It's finally here, but it has a long way to go.
Republicans unveiled their long-awaited alternative to Obamacare on Monday night, after years of fighting the former president's signature domestic legislative achievement.
The key change in the House Republicans' plan is the elimination of the individual mandate that forced people to buy health insurance (the foundation of Obamacare) in favor of a new system of individual tax credits to incentivize people to buy insurance on the open market.
The Republican plan will likely go through plenty of revisions before it reaches President Trump's desk— especially because Republicans did not give a cost estimate or project how many Americans would be left without insurance.
Here's a rundown of the expected winners and losers under the Republicans' American Health Care Act, if it passes.
- Younger and wealthier people: The revised plan relies on a system of tax credits based primarily on age. This is a significant departure from Obamacare, which gave people tax credits mostly based on income and provided more of a benefit to people who earn less. So under the Republican plan, younger people who cost less to insure or people who make more money get the exact same tax benefit as sicker people their same age who earn less (more on that later).
- People under 26: The Republican plan keeps the popular provision of Obamacare that allows people under 26 to stay on their parents' insurance plans.
- People with pre-existing conditions: The Republican plan also would keep the popular Obamacare provision that bans insurance companies from discriminating against people based on how sick they are.
- Lifetime limits: The Republican plan also keeps in place the ban on insurance companies' setting a cap on how long they have to insure someone.
- Old people: Obamacare prevented insurance companies from charging their oldest enrollees more than three times as much as their youngest. The Republican plan removes this regulation and allows companies to charge their oldest enrollees as much as they want. In most cases, this would not outweigh the greater tax credit they receive.
- The Republican plan offers the biggest tax credit to everyone who makes less than $75,000, regardless of age. But these subsidies are lower than what is currently offered under Obamacare and likely won't offset the higher premiums that insurance companies will be allowed to charge older people.
- Low-income people: The House Republican bill would roll back the Medicaid expansion, which gave approximately 11 million poor people coverage under Obamacare. (This won't be immediate, though; it continues the Medicaid expansion until 2020).
- People who go without insurance: The Republican plan does not impose a fee on people who choose to not buy insurance. Instead, it imposes what is essentially a huge fine on those who do not maintain "continuous coverage": i.e. people who try to reenter the market after going without coverage for a period of time. Insurance companies will now be allowed to increase their premiums by 30 percent for an entire year for those who let their insurance lapse.
- Planned Parenthood: The AHCA would cut off funding to the reproductive health organization because it also provides abortions, something Republicans have long promised to do.
- Zero federal funds currently go toward paying for abortions. So by cutting off federal reimbursements to Planned Parenthood (mostly in the form of Medicaid payments), this mostly hurts poorer women who rely on the organization for routine coverage like STD testings, cancer screenings, and maternity healthcare, currently subsidized by the government.
- People who want to get an abortion: The House Republican plan threatens to cut off funding to any private insurance company that offers abortions. This forces women to pay out of pocket for the procedure, which can cost anywhere from $500 to thousands of dollars.
- People who live in areas where insurance is more expensive: People who live in high-premium areas (like Alaska and Arizona) will not receive any more of a tax benefit than people who live in places where insurance is cheaper (like Massachusetts and New Hampshire). Obamacare took geographic location into account when calculating the tax subsidies. So under the Republican proposal, a 60-year-old making $20,000 a year could receive a tax credit that is nearly 80 percent less than what they received under Obamacare, depending on what part of the country they live in, according to calculations by the Kaiser Family Foundation,
Even for a Republican Party in charge of both the House and the Senate, revisiting the complicated business of healthcare legislation promises to be a fraught exercise.
The rollback of federal funding for the expansion of Medicaid that took place in 31 states under Obamacare looks to be particularly contentious; on Monday, Republican senators from three states where Medicaid provisions were expanded said they could not support moves to strip federal funding from the expansion.
Democrats also denounced the bill, saying it would lead to Americans paying more for healthcare – to insurance companies' benefit – and millions of Americans being stripped of their coverage.
Two House committees — Ways and Means and Energy and Commerce — will take up the health proposal on Wednesday.
Follow Olivia Becker on Twitter: @oliviaLbecker