By Billy Dering, Amy Killelea, and Christine Monahan
The recently enacted federal budget law is set to significantly roll back critical provisions of the Affordable Care Act (ACA) that have expanded health insurance coverage to millions. The law takes aim at health care programs that primarily serve low- and moderate- income Americans. As experts at CHIR have discussed, the law and complementary regulatory changes tighten eligibility rules and add new administrative barriers to enrolling in and maintaining Medicaid and Marketplace coverage. The Congressional Budget Office estimates that over 10 million people will lose health coverage due to the federal budget law. The law also fails to extend enhanced premium tax credits, which have made coverage significantly more affordable for Marketplace enrollees following the COVID-19 pandemic. An additional 4.2 million are projected to lose coverage if Congress decides not to extend enhanced premium tax credits. Congress could still extend the enhanced subsidies, but time is running out.
The anticipated loss of coverage will make care less accessible and affordable for people across the country, particularly those with chronic conditions for whom access to health care is a matter of life and death. People with insulin-requiring diabetes are a prime example of a population who will be hit hardest by the upcoming changes. One such person from Illinois recently recounted what losing the enhanced health insurance premium support would mean for him as part of a Center on Budget and Policy Priorities project collecting enrollee stories from all over the country:
“I would have to consider switching to a cheaper plan which has a higher deductible which means that at the beginning of the year I’d have to pay my medications out of pocket which would be difficult of course. And maybe I would have to hold back on some of those medications, eat less, so take less insulin to treat my diabetes. And also it’s possible I’d have to switch to cheaper versions of my medications that don’t work as well.”
He will not be alone. People with insulin-requiring diabetes, a population of around 2 million in the United States, need regular access to insulin, glucose monitors, pumps, and many other items and services. They depend on health insurance to make that care accessible and affordable. For those that can’t get coverage through their employer, Medicaid and the ACA Marketplaces are a critical backstop. National survey data from 2019 revealed that adults aged 18-64 years living with diabetes (many but not all of whom use insulin) were significantly more likely to have Medicaid, Medicare, or other public coverage than those without diabetes. The data also show that individuals with diabetes purchase private health insurance through the ACA Marketplaces at a higher rate (10.6%) than people without diabetes (6.9%). For people with diabetes, the upcoming changes threaten their ability to secure comprehensive and affordable health insurance coverage, and expose them to dangerous disruptions in care and treatment and financial hardship.
As people with diabetes are affected by the loss of coverage caused by the new restrictive eligibility rules and the possible expiration of premium tax credits, they may face significant challenges finding affordable health insurance that will meet their needs. Unsubsidized premiums in the ACA Marketplaces can be very expensive, and are likely to become much more expensive as a result of the recent policy changes. Insurers expect the average health insurance participant will be sicker than in previous years. Those with chronic or complex conditions, including insulin-requiring diabetes, are more likely to endure the extra hurdles federal policymakers are imposing, while those who are healthier may drop out of the market. This will leave insurers with a smaller pool of enrollees that use, on average, more health care services, requiring them to increase premiums. And indeed, in the wake of federal policy changes, they are proposing to do just that: a preliminary analysis of Marketplace insurer filings found premiums increasing by a median of 15%, with some states seeing average rate increases above 20%.
In the longer term, restrictions on Medicaid and Marketplace eligibility, increased paperwork to access and maintain coverage, and higher premiums and cost-sharing will mean individuals with insulin-requiring diabetes could face reduced coverage continuity and for many, the loss of coverage. As CHIR authors highlighted in a recent Health Affairs Forefront post, patients with insulin-requiring diabetes cannot afford gaps in their insurance coverage. Any coverage change requires considerable effort to assess what insulin, monitors, and pumps are covered, what copays they are responsible for, and what prior authorization a new plan will require, among other diabetes-specific considerations. Gaps in access to care can have serious, life threatening implications. Yet, just when patients and consumers will need help navigating the new red tape, CMS has cut the ACA Navigator program by almost 90%.
The federal budget law and related regulatory changes also imperil efforts of states across the political spectrum to increase affordability and accessibility of care for individuals with insulin-requiring diabetes through insurance reforms. States across the country with political environments as different as Utah and Illinois have implemented coverage requirements, limits on cost sharing, and prior authorization reforms that affect cost and availability of diabetes services. Even as more states introduce and enact reforms to follow in their footsteps, the disruptions under the new federal budget law could very well limit their progress as attention and funding turns to responding to coverage churning, reductions in individual market enrollment, and skyrocketing premiums.
The looming changes to Medicaid and the ACA Marketplaces as a result of federal legislative and regulatory actions represent a disproportionate threat to Americans with insulin-requiring diabetes who rely on affordable health insurance to manage their conditions. With the expiration of enhanced premium tax credits, new restrictions on insurance eligibility and enrollment, and increases in red tape, these people will face ever greater barriers to accessing needed items and services.
