By Clifton Leaf
March 9, 2017

Eight years ago, when a new American president swept into office with high hopes for health care reform, there was one cohort of citizens that public health experts were particularly worried about: people between the ages of 50 and 64.

Whichever sock-tongued epidemiologist out there christened this group “near elderly” is no friend of mine (I mean, don’t even…)—but we’ll leave that fight for another time. For now, let’s call them (er, us) “Generation Strong.”

Anyway, this group—who numbered around 55 million back then (accounting for nearly one-fifth of the U.S. population), and who likely total more than 63 million today—tend to be fairly robust consumers of health care services, but are too young to be covered by Medicare. During the Great Recession that began at the end of 2007, when many of Gen-Strong suddenly found themselves out of work—and, in some cases, unemployed for a frighteningly long time—a compounding fear for many was the loss of health coverage on top of everything else.

This was the harsh, unforgiving truth that greeted a not-yet-gray-haired President Obama as he took his oath of office. And the writers of the Affordable Care Act were especially mindful of protecting this group in their health reform plan.

So, yesterday, I asked the question, “What problem with Obamacare does the new GOP plan solve?” Today, I’m asking, “What happens to Generation Strong under Trumpcare?

Vox and others reported on Tuesday that annual premiums for people ages 55 to 64 would jump by $5,269 if the Republican plan were put in place immediately, and would rise to $6,971 in 2020. For those with incomes below 250 percent of the federal poverty line, premiums would increase by $2,945 today and by $4,061 in 2020. It’s also not clear from the rules, the way they’re written now, that insurers can’t raise premiums substantially more, or adjust copays and deductibles to put additional burden on consumers, or further restrict what they cover…or do all of the above.

Yet there’s an even bigger concern than these premium increases, as much of a hardship as they may be to some. And that’s the coverage “donut hole” penalty I mentioned in yesterday’s newsletter. Here’s the provision in the GOP bill: “If the applicant had a lapse in coverage for greater than 63 days, issuers will assess a flat 30 percent late-enrollment surcharge on top of their base premium based on their decision to forgo coverage.” (You’ll find this line under a subsection titled “Patient Relief…”)

First off, I’m hoping that the “based on their decision to forgo coverage” riff becomes a Twitter meme. And second, this line of potential law could be devastating to Gen-Strong, as many face longer periods out of work—or canceled employer coverage, forced-early retirement, COBRA expirations, or premiums that are simply too pricey to afford.

“More than one in four adults ages 50 to 64 spends at least 10 percent of their disposable income on health care,” says AARP. And this share includes those who are already insured. The Trumpcare provisions are likely only to add to that burden.

To be sure, this age cohort has always been a squeezed generation—the ones who take care of elderly parents and help their kids with a home downpayment or a job transition or a new baby. But this is one additional squeeze I don’t think Gen-Strong is going to take lightly.

That this group overwhelmingly voted Republican in the November election is beside the point. Honestly, ignore that fact. Forget I even mentioned it.

This essay appears in today’s edition of the Fortune Brainstorm Health Daily. Get it delivered straight to your inbox.

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