As debate rages in Washington and insurers consider a move to the Obamacare turnstiles, Tennessee is on the front lines of a national battle. Holly Fletcher, Kyleah Starling/The Tennessean

One of the biggest consumer complaints about U.S. health insurance is that there are too many out-of-pocket costs. Unfortunately, this problem doesnt seem to be going away anytime soon.(Photo: Getty Images/iStockphoto)

Health policy is complicated for every decision, there are equal and opposite reactions. If the American Health Care Act (AHCA) becomes law, there will be both winners and losers in Tennessee. In other words, some consumers will benefit, and others will be worse off.

This makes it tricky for policymakers to strike a balance. The Affordable Care Act certainly didnt figure this out perfectly, and the Republican Obamacare repeal bill probably wont, either. The AHCA, which passed the U.S. House of Representatives last month, still has to make it through the Senate. But based on the first pass at repealing Obamacare,we can make some predictions on the AHCAs winners and losers.

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The Tennessee consumers who most stand to benefit from the AHCA are people who have individual health plans but make too much money to receive ACA subsidies. Because of the double-digit premium increases over the last few years, the sticker price of ACA coverage can be hundreds or even thousands of dollars per month. More than 80 percent of ACA consumers receive subsidies to offset these costs, but some consumers do not. If you make more than 400 percent of the federal poverty line, you receive no assistance, and premiums have been unaffordable for many of these consumers. The AHCA strives to cut premium costs by reducing what plans have to cover, and allowing insurers to charge people with pre-existing conditions higher rates. If you are pretty healthy, and frustrated by paying so much for ACA health insurance, you will likely benefit from the AHCA. If the AHCA passes, another group of higher income consumers may benefit the uninsured. Lets say Tom is in the situation described above. He makes too much for a subsidy, and paying the penalty for being uninsured is cheaper than paying his premiums all year. Hes healthy, so he decides to be uninsured. But then, he receives a cancer diagnosis. Hes suddenly facing hundreds of thousands of dollars in medical bills. He wants to get coverage, but under the ACA, he cant. Obamacarerequires consumers to sign up for coverage at a certain time of year, called open enrollment. If they dont, theyre locked out until the next year, even if they get sick. On the other hand, the AHCA would allow Tom to sign up at any time. The AHCA would replace open enrollment with whats called continuous coverage, or financial incentives to stay insured. He may pay more for coverage because he went without insurance and because of his diagnosis, but he can sign up.

The Tennessee consumers at risk if the AHCA passes are those who most benefited from the ACAs protections. The Houses version of the AHCA would allow states to opt out of Obamacareinsurance regulations that prohibited carriers from charging sick consumers more than healthier ones and capping coverage after a certain threshold. According to the Kaiser Family Foundation, 30 percent of Tennesseans have pre-existing conditions. If Tennessee were to opt out of the community rating regulation, these consumers could be charged more for insurance. Insurers would not be able to deny coverage to people with diabetes, canceror asthma, for example, but they could increase their premiums. This will be a particular issue for lower-income, older consumers with pre-existing conditions. The other type of consumer most at-risk is those with extremely expensive medical conditions. The AHCAs waiver could lead to the return of coverage caps for people in the individual market and with employer plans, which means carriers could stop paying after a certain threshold.

Before the ACA, the majority of consumers never hit their threshold. But those who did were back on the hook for all bills after the cap, often $50,000 or $75,000 per year, for example. The policies that these consumers benefited from are partially responsible for healthy consumers increased costs. This is why striking the healthcare policy balance is so challenging. Whether more Tennesseans would benefit from the AHCA than the ACA remains to be seen.

Alex Tolbert is the founder of Bernard Health, a company that provides non-commissioned, expert advice on health, Medicare and COBRA insurance and medical bill consulting. To learn more, visit http://www.bernardhealth.com.

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The American Health Care Act's winners and losers in Tennessee - The Tennessean