The mas­sive Fur­ther Con­sol­i­dat­ed Appro­pri­a­tions Act, passed in the wan­ing days of Decem­ber, made sev­er­al sub­stan­tive changes to the Afford­able Care Act, a goal Pres­i­dent Trump first trum­pet­ed in his cam­paign and has con­tin­ued to pur­sue since he began his office term.

  • Repeal of the Cadil­lac Tax — a clas­sic case of “now that we have it, what do we do with it” giv­en that it was going to charge many med­ical plan pol­i­cy­hold­ers a tax for hav­ing a “rich” plan.  Rev­enue was sup­posed to pay for ACA reduc­tions, so now what?
  • Repeal of the 2.3% med­ical excise tax (will the man­u­fac­tur­ers reduce their pric­ing by a com­men­su­rate amount?)
  • Repeal of the Health Insur­ance Pre­mi­um Tax (HIT) after 2020 (which car­ri­ers have been pass­ing along two pol­i­cy­hold­ers since it was imposed – and now?)

There is no waiv­er or end to the PCORI (Patient Cen­tered Out­comes Research Insti­tute) tax, though no one is quite sure what the insti­tute is doing.  This only applies to self-fund­ed plans.

It is also appar­ent that the Trump admin­is­tra­tion, fol­low­ing an exec­u­tive order filed ear­ly in the term, has no inten­tion of pur­su­ing any fur­ther action on dis­crim­i­na­tion testing.

The repeal of the three tax­es, designed to pay for ACA cov­er­age expan­sion, result in a col­lec­tive loss of $373.3 bil­lion over ten years.  No replace­ment for the rev­enue is suggested.

There is also some­thing in the bill regard­ing “sil­ver load­ing” which deals with allowances for the pre­mi­um tax cred­it for those who qual­i­fy for the sub­sidy.  The pre­mi­um for the sec­ond low­est cost mar­ket­place sil­ver plan is used to deter­mine the cred­it allowance.  As a result, car­ri­ers loaded the cost of the sil­ver plan, despite the actu­al actu­ar­i­al con­sid­er­a­tions.  If sil­ver load­ing were pro­hib­it­ed, it is spec­u­lat­ed that car­ri­ers would spread the load among all med­ical plans.  The expect­ed increase was 11% for non-sil­ver plans with a 5% reduc­tion in sil­ver plans.