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Even though House Republicans voted to approve the American Health Care Act on Thursday, there are still many open questions—including what the legislation could mean for consumers if it passes the Senate and ultimately becomes law.

"My guess is that it will cover even fewer people and cost even more than the previous version," says Vivian Ho, the chair in health economics at Rice’s Baker Institute for Public Policy and director of the institute’s Center for Health and Biosciences.

The GOP says that the Affordable Care Act needs to be repealed and replaced because of rising premiums and a lack of consumer choice.

Speaker Paul Ryan, in his speech before the House voted, said “Let’s make it easier for people to afford their health insurance, let’s give people more choice and more control over their care."

The bill's future impact is unknown because the legislation was passed without being evaluated by the Congressional Budget Office. The CBO determines the cost and the number of people whose insurance will be affected. An earlier version of the AHCA was scored by the CBO, which estimated 24 million Americans would lose their health insurance.

Some consumers say they're worried about their ability to afford good quality health care. In CR’s Consumer Voices survey in January 2017, 55 percent of consumers said they lacked confidence that they or their loved ones would be able to afford insurance to secure that care.

“The House of Representatives today failed their constituents and the American health system by passing the American Health Care Act. In a field where ‘do no harm’ is the standard, this bill does nothing but harm American families,” says Betsy Imholz, Special Projects Director for Consumers Union, the policy and mobilization arm of Consumer Reports. “Each iteration has only made this bad bill worse.”

How You May Be Affected By the AHCA

Here's what we expect will happen next, and what we know now.

Q: What’s next?
The AHCA will move on to the Senate for a vote. There the legislation is expected to undergo major changes before a vote happens—if it ever does. A number of Senators have already said they oppose the legislation in its current form.

Sen. Rand Paul (R-KY), and Ted Cruz (R-TX) have said they won’t vote for anything that doesn’t repeal the ACA completely. If the Senate changes the bill significantly, the House and Senate might have a hard time reconciling the bill.

The Senate can’t vote on its version of the bill before the Congressional Budget Office scores it to estimate the cost and how many people it will affect. That is expected to take a few weeks.

Q: Does this legislation repeal Obamacare?
Not entirely. There’s only so much that Congress can do to change the ACA through the reconciliation process that Republicans are using, which only requires a simple majority to approve a bill instead of the 60-vote threshold needed for most legislation.

The AHCA still retains the basic ACA structure, but the AHCA makes vast, substantive changes. Chief among them: The GOP bill in effect, removes the Medicaid expansion implemented by 31 states; allows insurers to charge older Americans five times what they charge younger people, as opposed to three times as much under current law; and enables insurers to hike premiums by 30 percent for people who don’t remain continuously covered.

It also shifts how tax credits used to help people pay their premiums are structured. Under the ACA, you can get tax credits to subsidize premiums based on your income and where you live. The less you make, the bigger your credit. Under the AHCA, tax credits are based on age, not income. And the credits are a set amount: from $2,000 to people under 30 up to $4,000 for people older than 60.

The net result: Under the House plan, if you’re younger and healthy and live in places where healthcare is relatively inexpensive, insurance could be less expensive for you than under the ACA. But if you’re older, poorer, or live in an area where healthcare is more expensive, the cost of insurance will likely be less affordable.

Q: What’s the biggest difference in this bill from the earlier version that Republicans couldn’t get enough support to vote on last month?
There are two major revisions, says Chris Sloan, a senior manager in the policy practice at Avalere Health, a healthcare consulting firm that has analyzed the GOP legislation. The first would allow states to let insurers charge higher premiums to sicker people if their coverage has lapsed, provided the state has set up a so-called "high-risk pool," or other special health insurance program to help sicker people pay for higher premiums. The AHCA calls for more than $130 billion over 10 years to fund a Patient and State Stability Fund for states that apply for waivers.

At the last minute, Republicans added another $8 billion to that fund, which helped sway moderate Republicans worried about the AHCA's impact on the premiums of people with pre-existing conditions.

But critics say the programs will be woefully underfunded, even with that extra cash. About 27 percent of Americans have pre-existing conditions, according to Kaiser Family Foundation, a non-profit, non-partisan health policy research organization. If most states apply for waivers, that won’t be enough money to cover all the people who will need financial assistance, says Larry Levitt a senior vice president at Kaiser.

According to a new report by Avalere Health, 2.2 million enrollees in the individual market have pre-existing conditions. Only 660,000 people would be covered by the money allocated by the AHCA.

The AHCA also calls for allowing states to waive a requirement that insurers cover 10 essential health benefits, including mental health, emergency services, maternity care and prescription drugs. The result, says Ho, is that insurance companies would be able to offer much skimpier policies. “Those policies would be cheaper but wouldn’t cover as much,” she says.

Q: If I get my insurance from my employer, will anything change for me?
It’s possible. More than half of Americans get health insurance through their work and most of those covered—86 percent—- work for large employers.

If states are allowed to redefine the essential health benefits insurers must cover, large employers could reduce their coverage to match the standard of a state with less coverage, according to Matthew Fiedler at the Brookings Institute. That could also put another important ACA protection in jeopardy: A ban on private insurance plans imposing annual or lifetime limits on the dollar amount of care covered and caps on how much any individual has to spend out-of-pocket for healthcare annually.

The ACA’s ban on annual and lifetime limits only applies with respect to care that is considered essential health benefits, according to Fiedler. That didn’t matter because the ACA required all states to provide standard benefits. Now, even if you live in a state that continues to cover all 10 essential health benefits, your employer could choose to apply the standards from another state that limits what benefits it covers. Lifetime and annual coverage limits only apply to those essential benefits. So, an employer could cap what it covers on medical care outside of what that state considers essential.

Some health policy experts think it’s unlikely many large employers will do this. “Health insurance benefits are a big part of how employers attract and retain workers, especially large companies,” says Sloan of the consulting firm Avalere Health. “We don’t expect a lot of companies to change that.” But it would be possible, and as costs rise may become a more attractive option.

Q: Will anything change if I'm already enrolled in an ACA plan for 2017?
Maybe. Even though the AHCA was passed, that milestone hasn’t removed the biggest near-term uncertainty hanging over the ACA: Whether the Trump Administration or Congress will reimburse insurers for the critical cost-sharing subsidies that six million low-income people get to pay out of pocket costs for health insurance. Without those funds –$7 billion this year— insurers would be on the hook for billions of dollars.

The cost-sharing reductions (CSRs) are funded monthly, and the Trump administration could pull the plug on the funds at any time. If that happens, insurers could hike premiums mid-year or exit the market entirely, according to the Kaiser Family Foundation. Already a number of major insurers have pulled out of ACA exchanges or warned that they will if the CSRs aren’t funded. If that happens, consumers would qualify for a special enrollment circumstance to sign up for another ACA insurance plan. If none is available in their marketplace, they could go off-exchange but wouldn’t get the tax credits the ACA provides to help pay premium costs.

Q: What does this mean for people on Medicaid?
Under the current version of the AHCA, the biggest group of people expected to see changes are those on or hoping to be on Medicaid, the government health insurance program for lower-income Americans. More than half of the 20 million people who gained health insurance through the ACA lived in one of the 31 states that expanded Medicaid coverage. Under the AHCA, Medicaid funding is significantly cut back in two ways. If you’re getting health insurance through the Medicaid expansion program now, you’ll be grandfathered in and still receive it. But starting in 2020, if you have a break in coverage for more than one month you won’t be able to re-enroll.

The CBO estimates that under the House plan, 14 million people will drop out of Medicaid coverage in the next decade because of changes to how the program is funded.

Q: If I am on Medicare, how will it affect me?
Medicare is separate and apart from the ACA insurance marketplaces, so the AHCA won’t cause Medicare premiums or co-pays to change.

But the AHCA still has implications for people on Medicare, or at least those who hope to be in the future. That’s because the House bill eliminates virtually all taxes used to fund the ACA starting in 2018, including a 0.9 percent payroll tax on higher-income workers that funnels money into Medicare.

Without those funds, Medicare Part A (which pays for hospital, hospice and skilled nursing facility care) could be insolvent in 2024 and have to start reducing the amount of benefits it pays out—four years sooner than previously predicted, according to the AARP, a nonprofit organization that advocates on behalf of people 50 and older.

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