Plans by the Trump administration and Congress to cancel or alter the Affordable Care Act (ACA) could drastically affect those receiving Medicare coverage by eliminating tax credits to buy health insurance in state exchanges and rolling back Medicaid expansion. These changes would mean a loss of health coverage for many adults who need medical care the most, according to new research from the School of Public Health.

“It is important to understand the health and health care use by individuals at risk for losing insurance in such a scenario,” says study lead author and Associate Professor Pinar Karaca-Mandic.

The study was published in JAMA Internal Medicine.

Karaca-Mandic identified three groups of non-elderly adults at risk for losing health insurance if the tax credits and Medicaid expansion are repealed:

• Adults with incomes up to 400 percent of the federal poverty level (FPL) ($47,080 for a one-person household) who purchased insurance through exchanges. This group would experience substantial premium increases if premium tax credits were removed.
• Childless adults with incomes less than 138 percent FPL ($16,243 for one-person) who are covered through Medicaid and who do not receive Social Security income due to disability. This group represents newly eligible Medicaid adults under the ACA.
• Medicaid-enrolled parents or adults in families with children who did not receive disability income and whose income was 50-138 percent FPL. Before the ACA, the median eligibility threshold was 61 percent below FPL for parents or adult caretakers, so a large portion of this group could lose coverage.

All three groups were significantly more likely to be poor, unemployed, and minorities than adults in an employer-sponsored insurance group analyzed in the study. They also had lower education levels and higher rates of self-reported poor health.

Additionally, the research showed that these groups required more medical attention than the employer-sponsored insurance group, including treatment for chronic diseases, emergency room visits, hospitalizations, and doctor’s office visits in the past year.

“This tells us that groups at risk for losing insurance are socioeconomically vulnerable, and they have high rates of chronic disease and health care use,” says Karaca-Mandic. “The consequences of losing health insurance for these groups could be striking.”

Karaca-Mandic points out the research only examines the most expected legislative changes — not the worst-case scenario.

“Our analysis does not account for other things that could happen, such as elimination of the pre-existing conditions clause, moving further away from community rating, changes to state Medicaid block grant programs, or changes to the Medicare program,” says Karaca-Mandic.

Regardless of which path health care reform takes, Karaca-Mandic says that policymakers should take note of this research and take into account the vulnerability of these groups in the absence of health insurance when making coverage changes.