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Imagining a time before the Affordable Care Act is like trying to imagine a time before cellphones—it was only a few years ago, but it was a completely different world, and not necessarily one that anyone wants to go back to. Though estimates vary on how many people Obamacare gave insurance to, even those who aren't fans of the law admit it's well over 10 million. And as Republicans prepare to repeal the law without a concrete replacement, many of those people are rightfully worried about whether they'll lose the insurance they just got.There are many people whose lives are affected by the battle over repeal. Some have preexisting conditions that insurers may not have to cover if Obamacare goes away. Others, who are healthy enough not to worry about that, haven't bothered to get insurance and might be unsure about whether they should bother with major changes coming soon. Still others may be contemplating leaving their insurance-providing jobs but now are concerned they won't be able to buy affordable individual plans.To sort out the best course of action for people who either don't have insurance or at risk of losing it, I called up Paul Keckley, a healthcare policy analyst. (I interrupted his viewing of the confirmation hearing for Department of Health and Human Services head Tom Price, which he said was making him angry.) He took a few minutes to explain what he thinks will happen to insurance premiums after Obamacare is dismantled, as well as what young people should do in anticipation of the new system.VICE: What should someone do if they don't have healthcare right now?
Paul Keckley: You really end up with two options. Let's assume you're in the "young and invincible" category, and you're employable. The first option: If you're employed, your employer is going to offer you a high-deductible product that's going to carry about a $1,000 out-of-pocket and a premium depending on what state you're in—somewhere between $100 and $400 a month. That's gonna be the safety net. Some will actually choose a deductible as high as $2,500 or $5,000, if they can go to mom or dad for that if they end up in the emergency room.The second option is you kind of take your chances and go without, which there's an expectation that large numbers of folks will actually do. There are 6.1 million who got coverage who are 19 to 25 under the provision of the law, and it's likely that about half will simply go without, because they won't transition into a job where they're able to access that high-deductible product and they're not earning enough income that they can afford any premium. They'll take their chances on emergency rooms and walk-in clinics. That's the bottom line, that's where we are.So with the executive order that Trump signed, no one's going to be penalized for not having health insurance at least, right?
What he's done is suspend the penalty. The current mechanisms that are being taken off the table are the individual mandate, and the mechanisms by which the IRS can come back at somebody and say, "You should have bought insurance, and you didn't."What they're struggling with is finding out the mechanism to get all these flat bellies into the insurance market. How do you encourage that? And no one is coming up with that out of the five Republican plans. If you look at them, three say the way to do that is to let all the young, healthy people buy insurance across state lines. One of them, the Cassidy-Collins one, says, "Let's have everyone automatically enrolled unless they opt out." States would have the ability to throw you into the insurance market, and there would be some subsidies for people who don't make a lot of money. And Trump's plan is kind of mute, and basically says, "We'll cover everyone, and keep these folks under 26," but it doesn't say how. So we're kind at that starting line of finding out what they're gonna settle on between these five plans—Rand Paul's, Tom Price's, Cassidy-Collins, and then the Trump one. And there might be another two or three before we're through.Do people with Obamacare need to worry that their benefits will be reduced or that their premiums will go up, or is that all locked in?
In 2018, people will have access to cheaper products that cover a lot less. That's the bottom line. Because that's what the view is of how a Republican model of health insurance would keep the insurance companies in the game. They would be able to say in the 2018 election cycle that they slowed down the growth of insurance premiums. The way to do that is to cover less and get people to pay more out of pocket and check the box and move on. Will people lose coverage? No. They'll just have a plan that covers less. One of the sticking points in the [ACA] was essential health benefits—there were ten categories that every plan had to address. What the [new] plans will do is say, "You don't need mental health coverage," or "You don't need obstetrics coverage," or "You don't need dental coverage." So skinner coverage and lower premiums.What if you're 26 and on your parents' plan, but you'll turn 27 likely before there's an ACA replacement? Should you jump into the exchanges now or ride it out?
The quick answer is we're not sure what's gonna happen to the exchanges. The Republicans say they're going to have the states manage the exchanges that exist. Healthcare.gov handles about 40 right now, and there are ten states that do it on their own. So we don't know how these plans are going to dispose of the responsibilities of Healthcare.gov, but in all likelihood, it will be to let the states decide. If I was in a state where the exchange had been relatively good, like Kentucky, where it seemed to work pretty well, then I would want to stick with it. You would want to move to the exchange while you can. If I was in a state where there had been a lot of political garbage, and it's likely that the legislature is not gonna support it in any form, then I'd likely start looking for one of these high-deductible skinny products outside of the exchange.What if someone is working part-time or freelancing and relies on Obamacare? Should they be looking for any shitty full-time job, so they can get coverage ASAP?
That's 20 percent of the workforce, and it's 30 percent of kids under 35. So it's real. You take a job in a bar, and you're working 20 hours, and you take a job at the Gap, and you take another 30 hours, and you hope you can pay your rent. Honestly, you're taking the highest-deductible product you can, which is about a $5,000 product, and you hope you stay well. That's it.What if that person has a preexisting condition? Getting employer-provided insurance should be their top priority, right?
Yeah, but here's where how the law plays out will be kind of interesting. Depending on which study you read, anywhere from as few as 1 percent to as much as 10 percent of the population qualifies for a high-risk pool today. And 30 percent of the population has a preexisting condition. The magnitude of that number is what stumbles people up. So these Republican plans have to figure out how to fund the pool of those that currently have a major medical problem, which is this 1 to 10 percent of the population. So how do you fund that? Direct federal funding? Do you just pay the states to manage those high-risk pools? And then for this 30 percent that has a preexisting condition, which can be something like Type II diabetes, or heart disease, or whatever, then do you create a second risk pool where individuals pay a premium for that coverage? That first group, they can't afford to pay for their coverage. The next group can pay something. So how much of that can you recover from them as a policy, and how will the states do that?How about someone who is working a job they hate and wants to quit as part of a New Year's resolution? Should they jump ship now or wait to see where the chips fall?
Well, the exchange market closes on Tuesday. So if they were gonna jump into the exchanges, they've got from now until then.What about someone who only got insurance through Medicaid expansion? Are they totally screwed now?
There were 31 states that expanded Medicaid, and the Republicans proposed that they're simply going to send a check to the states and let them manage the fund. So they're not gonna be thrown off, but you can expect the state will skinny the coverage for a little bit. Or they may contract with one group of doctors in the state to manage all of them. There will be a lot of latitude at the state level. And the ACA set that threshold [for receiving Medicaid] of at 138 percent of the federal poverty level, and states will in all likelihood, or at least Republican ones, lower that to 100 percent, which does mean that fewer people will be eligible.I think a lot of people's fears might be alleviated if they knew what plan the GOP was going to go with. What's Tom Price saying on C-SPAN, and what's making you mad?
He believes that the answer for Medicare is to do premium support, or let people essentially get money from the federal government to buy private-insurance products for their Medicare. So he says to allow people to buy insurance across state lines to drive premiums down, and essentially, he says to leave the doctors alone and let them treat the patients. He's a doctor, and his view of everything is that this is about doctors and let them do their thing and the rest takes care of itself. Get the suits out the way.He has one of those five plans. He introduced it last year, and it's called the Empowering Patients First Act. It basically says, "Let's get rid of all this crap that gets in the way of the doctors, and get the government out of it, and let the states figure out who need obstetrical coverage or Planned Parenthood." He'll be confirmed, but here's the reality: There are inconsistencies between the proposed plans, and all of them have to be scored [by the Congressional Budget Office]. We have to figure out what they're gonna cost, and [House Speaker] Paul Ryan is more likely to push for ways to reduce Medicare spending. That really flies in the face of Trump saying we need to keep everybody on their insurance and that nobody is gonna lose theirs. So the sausage-making is now happening.This interview has been condensed and edited for the sake of clarity.Follow Allie Conti on Twitter.
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Paul Keckley: You really end up with two options. Let's assume you're in the "young and invincible" category, and you're employable. The first option: If you're employed, your employer is going to offer you a high-deductible product that's going to carry about a $1,000 out-of-pocket and a premium depending on what state you're in—somewhere between $100 and $400 a month. That's gonna be the safety net. Some will actually choose a deductible as high as $2,500 or $5,000, if they can go to mom or dad for that if they end up in the emergency room.
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What he's done is suspend the penalty. The current mechanisms that are being taken off the table are the individual mandate, and the mechanisms by which the IRS can come back at somebody and say, "You should have bought insurance, and you didn't."What they're struggling with is finding out the mechanism to get all these flat bellies into the insurance market. How do you encourage that? And no one is coming up with that out of the five Republican plans. If you look at them, three say the way to do that is to let all the young, healthy people buy insurance across state lines. One of them, the Cassidy-Collins one, says, "Let's have everyone automatically enrolled unless they opt out." States would have the ability to throw you into the insurance market, and there would be some subsidies for people who don't make a lot of money. And Trump's plan is kind of mute, and basically says, "We'll cover everyone, and keep these folks under 26," but it doesn't say how. So we're kind at that starting line of finding out what they're gonna settle on between these five plans—Rand Paul's, Tom Price's, Cassidy-Collins, and then the Trump one. And there might be another two or three before we're through.
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In 2018, people will have access to cheaper products that cover a lot less. That's the bottom line. Because that's what the view is of how a Republican model of health insurance would keep the insurance companies in the game. They would be able to say in the 2018 election cycle that they slowed down the growth of insurance premiums. The way to do that is to cover less and get people to pay more out of pocket and check the box and move on. Will people lose coverage? No. They'll just have a plan that covers less. One of the sticking points in the [ACA] was essential health benefits—there were ten categories that every plan had to address. What the [new] plans will do is say, "You don't need mental health coverage," or "You don't need obstetrics coverage," or "You don't need dental coverage." So skinner coverage and lower premiums.What if you're 26 and on your parents' plan, but you'll turn 27 likely before there's an ACA replacement? Should you jump into the exchanges now or ride it out?
The quick answer is we're not sure what's gonna happen to the exchanges. The Republicans say they're going to have the states manage the exchanges that exist. Healthcare.gov handles about 40 right now, and there are ten states that do it on their own. So we don't know how these plans are going to dispose of the responsibilities of Healthcare.gov, but in all likelihood, it will be to let the states decide. If I was in a state where the exchange had been relatively good, like Kentucky, where it seemed to work pretty well, then I would want to stick with it. You would want to move to the exchange while you can. If I was in a state where there had been a lot of political garbage, and it's likely that the legislature is not gonna support it in any form, then I'd likely start looking for one of these high-deductible skinny products outside of the exchange.
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That's 20 percent of the workforce, and it's 30 percent of kids under 35. So it's real. You take a job in a bar, and you're working 20 hours, and you take a job at the Gap, and you take another 30 hours, and you hope you can pay your rent. Honestly, you're taking the highest-deductible product you can, which is about a $5,000 product, and you hope you stay well. That's it.What if that person has a preexisting condition? Getting employer-provided insurance should be their top priority, right?
Yeah, but here's where how the law plays out will be kind of interesting. Depending on which study you read, anywhere from as few as 1 percent to as much as 10 percent of the population qualifies for a high-risk pool today. And 30 percent of the population has a preexisting condition. The magnitude of that number is what stumbles people up. So these Republican plans have to figure out how to fund the pool of those that currently have a major medical problem, which is this 1 to 10 percent of the population. So how do you fund that? Direct federal funding? Do you just pay the states to manage those high-risk pools? And then for this 30 percent that has a preexisting condition, which can be something like Type II diabetes, or heart disease, or whatever, then do you create a second risk pool where individuals pay a premium for that coverage? That first group, they can't afford to pay for their coverage. The next group can pay something. So how much of that can you recover from them as a policy, and how will the states do that?
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Well, the exchange market closes on Tuesday. So if they were gonna jump into the exchanges, they've got from now until then.What about someone who only got insurance through Medicaid expansion? Are they totally screwed now?
There were 31 states that expanded Medicaid, and the Republicans proposed that they're simply going to send a check to the states and let them manage the fund. So they're not gonna be thrown off, but you can expect the state will skinny the coverage for a little bit. Or they may contract with one group of doctors in the state to manage all of them. There will be a lot of latitude at the state level. And the ACA set that threshold [for receiving Medicaid] of at 138 percent of the federal poverty level, and states will in all likelihood, or at least Republican ones, lower that to 100 percent, which does mean that fewer people will be eligible.I think a lot of people's fears might be alleviated if they knew what plan the GOP was going to go with. What's Tom Price saying on C-SPAN, and what's making you mad?
He believes that the answer for Medicare is to do premium support, or let people essentially get money from the federal government to buy private-insurance products for their Medicare. So he says to allow people to buy insurance across state lines to drive premiums down, and essentially, he says to leave the doctors alone and let them treat the patients. He's a doctor, and his view of everything is that this is about doctors and let them do their thing and the rest takes care of itself. Get the suits out the way.He has one of those five plans. He introduced it last year, and it's called the Empowering Patients First Act. It basically says, "Let's get rid of all this crap that gets in the way of the doctors, and get the government out of it, and let the states figure out who need obstetrical coverage or Planned Parenthood." He'll be confirmed, but here's the reality: There are inconsistencies between the proposed plans, and all of them have to be scored [by the Congressional Budget Office]. We have to figure out what they're gonna cost, and [House Speaker] Paul Ryan is more likely to push for ways to reduce Medicare spending. That really flies in the face of Trump saying we need to keep everybody on their insurance and that nobody is gonna lose theirs. So the sausage-making is now happening.This interview has been condensed and edited for the sake of clarity.Follow Allie Conti on Twitter.