The Future of Health Insurance for Patients With Diabetes

Robert E. Ratner, MD; Mark Harmel, MPH


July 15, 2020

This transcript has been edited for clarity.

It's hard to believe that we're now 10 years out from the institution of the Affordable Care Act. Since its inception, the Republican side has been interested in seeing its demise. The question in 2020 is: Where are we vis-à-vis the Affordable Care Act?

Some Background

One of the very first formal efforts to get rid of it was the Graham-Cassidy-Heller-Johnson bill that was presented in the Senate back in September 2017. This was when the Republicans held the presidency, the House, and the Senate.

You may remember that this bill essentially voided the Affordable Care Act; it repealed it. You may also remember the thumbs-down vote that John McCain made in order to defeat the bill.

The judicial approach was started many years ago by a group of state attorneys general, led by the attorney general from Texas, which — following Congress removing the tax for the individual mandate — declared that the entire Affordable Care Act was unconstitutional because it didn't meet the requirement for taxes that the Supreme Court had instituted.

There was a countersuit from California, so the final Supreme Court case is California v. Texas, which was accepted by the Supreme Court on March 2, 2020.

The question before the court is whether the entire Affordable Care Act is unconstitutional because of the failure to tax to mandate individual coverage. Or can it be separated ("separability" is the legal term that's being used) so that perhaps you can take away the tax on the individual mandate, but the rest of the Affordable Care Act would stand?

Now, unfortunately, this is not going to be decided before the election. It will be argued before the court in its next session, which begins October 5, 2020. It's unlikely that any decision would come out before the election. There's even a good possibility that the justices would delay the arguments until after the election so as not to have an undue influence over the vote.

What 2021 Means for Patients With Diabetes

The question then remains, with the Affordable Care Act in limbo and awaiting Supreme Court decision: What is the Trump Administration going to do vis-à-vis their budget for the coming year?

On February 10, 2020, President Trump released his fiscal year 2021 budget. In it, he calls for the elimination of coverage for the expansions that are inherent within the Affordable Care Act. In particular, he calls for the elimination of federal subsidy, which is up to 90% for state Medicaid expansion.

He also calls for the institution of work requirements to qualify for Medicaid. He calls for the elimination of marketplace subsidies to support buying policies for low-income individuals. The market subsidies, along with the Medicaid subsidies, would result in approximately 22 million individuals losing insurance coverage, which they had gained through the Affordable Care Act.

In addition, Trump proposes per capita block grants for coverage of Medicaid. That would limit the amount of money that would ultimately go to Medicaid, with no changes in terms of medical inflation. He would also eliminate state requirements for specific coverage.

Currently, there is a concept called minimal essential benefits that the Affordable Care Act said all policies must include. Trump would call for its repeal and for allowing coverage at much, much lower levels. Some have called this "ghost coverage" because it looks as though you've got it, but when you need it, there's nothing really there.

It would also allow for the increase of premiums for preexisting conditions. What that could potentially mean is that individuals who have underlying conditions, like diabetes, could literally be priced out of the market.

It's Not All Bad

Now, not everything is negative for individuals with diabetes in Trump's budget. He also calls for the limit of out-of-pocket expenses for medications within Medicare, so that the donut hole would disappear and there would be a maximum of what you ultimately pay.

We don't know what's going to happen to the Affordable Care Act, just as we don't know what the impact is going to be of the election in November. What we can say is that individuals with diabetes have significantly benefited by the provisions of the Affordable Care Act, both in terms of absolute coverage through Medicaid expansion and subsidies for Medicare, and also through the extension of insurance coverage up to the age of 26 through their parents.

In addition to that, the exclusion of preexisting conditions was completely wiped out, so that leveled the playing field for premiums for individuals with diabetes vs those without.

For those of you who are particularly concerned about how health insurance and policy are going to change in the near future for people with diabetes, I would encourage you to read the budget, consider the arguments in the Supreme Court, and make sure you vote your conscience in November.

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