The way health care coverage works in America—those who can afford insurance and those who cannot—is once again changing.

With the passage of the American Health Care Act, the U.S. House of Representatives proposes to change the rules of the road for anyone who can't get health insurance through their job, and who is too young for Medicare.

Much has been written about these changes. My goal here is to highlight the Americans who are most at risk—and point you to good places to learn more.

So, who stands to pay more for their coverage—or even go without it—under the American Health Care Act?

1)    Older adults with low and middle incomes will pay more, thousands of dollars more.

Premiums will go up for more than 6 million adults aged 50 to 64 who buy their own insurance. Meanwhile, financial assistance to help pay for those higher premiums will go down for older people with low or middle incomes.

The AARP, a respected voice for older Americans, says that premiums could rise by $2,000 to $3,000. At the same time, tax credits to help cover premium costs will be thousands of dollars lower for older adults who earn less than $75,000 a year.

An example from AARP shows what this double whammy will cost older adults with lower incomes. Out-of-pocket costs for health insurance could go up by as much as:

  • $3,600 for a 55-year old earning $25,000 a year
  • $7,000 for a 64-year old earning $25,000 a year
  • $8,400 for a 64-year old earning $15,000 a year

You read that right:  64-year olds who earn less will pay more.

The American Health Care Act is driving these changes in several ways. The AARP explains these in this letter to Congress.

Would you like to compare your insurance premium costs now to what they could be in 2020? Check out the Kaiser Family Foundation's interactive map for an educated estimate.

2)   People with pre-existing health conditions will have weaker guarantees and may pay more.

The big question mark here is left up to the state in which you live.

Under the American Health Care Act, people with pre-existing conditions who buy their own coverage and maintain it, without breaks, will be able to continue to get that coverage without paying more.

But, that guarantee could go up in smoke if your state applies for a waiver to get more flexibility.

With a waiver, people with pre-existing conditions who have a break in their coverage for at least 63 days could be charged more when they try to get their coverage back.

State waivers could also be used to:

  • Charge even higher premiums for older adults
  • Reduce the health benefits (such as mental health care) that insurers must cover

The Kaiser Family Foundation has a good summary of the ins and outs of this complex issue.

3)    Adults with low incomes may well be forced to go uninsured.

The American Health Care Act phases out federal funding for the Affordable Care Act's expansion of Medicaid for adults with low incomes.

In Pennsylvania, more than 700,000 people are covered through Medicaid expansion.

These newly insured earn $33,600 a year (or less) for a family of four ($16,400 or less for a household of one). Co-pays and other out-of-pocket costs are minimal.

Most (72%) Medicaid expansion enrollees are in working families. Many live in rural Pennsylvania.

In a few years, Pennsylvania will have to decide whether to continue Medicaid expansion and find a way to pay for this coverage mostly out of state funds.  To do that, the governor's office has said that Pennsylvania will need to come up with $2.5–$3 billion.

Difficult, for sure. For the last several years, Pennsylvania has struggled with an ongoing "structural" budget shortfall of about $3 billion that has been passed from one budget to the next. That's an obligation that eventually will have to be paid.

For more about this challenge to Medicaid expansion, read this analysis from The Hospital and Healthsystem of Pennsylvania.

Most likely you know someone whose coverage is at risk because of these changes. Fortunately, this legislation is not a done deal. The U.S. Senate is now considering the House bill and is said to be working on its own proposal.

Now is the time to learn more, and to share your concerns with the elected officials who are changing the way health care coverage works in our state and nation.

The coverage you save may one day turn out to be your own.