By Andrew Kreighbaum

The Republican replacement plan for the Affordable Care Act will have negative consequences for both adjuncts and other employees at many colleges, as well as for low-income students and academic medical centers, say observers of health care policy in higher education.

The elimination of the employer mandate means that some institutions may choose not to continue offering health insurance to adjunct instructors who aren’t full-time employees. The weakening of subsidies for Obamacare exchanges and — eventually — federal support for state Medicaid expansion will hurt the ability of many students to obtain insurance coverage, experts said.

How those effects play out for each student will likely differ campus by campus and state by state. And details of the proposed replacement plan could change. Meanwhile, the House plan, dubbed the American Health Care Act, has come under attack from both advocates for expanded health care and critics on the right who are referring to it as Obamacare 2.0.

But advocates say the bottom line of the bill released this week is that it shifts more costs to states while potentially leaving millions of students uninsured and making the existence of part-time workers more precarious.

“What you’ll see is a cut in coverage — not just who’s covered but the type of coverage provided,” said Amy Ellen Duke-Benfield, a senior policy analyst at the Center for Law and Social Policy.

The bill provides less generous subsidies to those in lower- and middle-income brackets to purchase insurance through state exchanges. It ends federal support for state expansion of Medicaid — a key feature to the Affordable Care Act’s drive to provide health insurance to the poorest Americans — after 2020. And it converts Medicaid funding from an open-ended commitment to a “per capita” system, which observers say will mean less support for the program.

Weaker federal support for Medicaid in particular could put more pressure on states to find money elsewhere in their budgets. And it could have negative consequences for college completion, Duke-Benfield said, because one of the top reasons students drop out of college is financial difficulties.

Sam Leitermann, president and CEO of the National Association of Graduate-Professional Students, said the bill maintains some important components of the Affordable Care Act, including a ban on denial of coverage for pre-existing conditions and a provision that allows individuals to remain on their parents’ health insurance plan until age 26. But he said the penalty for a lapse in coverage was concerning — if an individual goes more than 60 days without insurance, when they do buy coverage again they could see their premiums go up by 30 percent.

“It removes good parts of the ACA and doesn’t replace them,” Leitermann said. “It’s ACA light, which means we have lost something.”

Maryann Haytmanek, director of the New Choices/New Options Program at Northampton Community College, works with students to help them obtain coverage through Medicaid or the state insurance exchange. Haytmanek said students at the Bethlehem, Pa., college who did not earn enough to qualify for subsidies on the exchange were able to get insurance coverage when the state expanded Medicaid in 2014. Without that access to coverage, it would be more difficult for students to persevere with medical challenges and complete their degree plan, she said.

“It’s really a retention issue,” she said. “You don’t have to miss class. You can be comfortable knowing you are healthy and that you can go see the doctor when you need to.” 

Johnetta McNeil, a second-year Northampton student majoring in nursing, said she was able to qualify for coverage through Medicaid after realizing she could no longer work full time and pursue her academic program. McNeil, who is asthmatic and has seasonal allergies, said her coverage makes it possible to afford medication like an inhaler without paying out of pocket.

“It makes a difference knowing that if I go to the doctor, I know my inhaler or my Flonase will be covered instead of trying to come up with the money,” she said. “That money that didn’t come out of pocket you can put toward your books or utilities for classes — paper, pens, pencils.” 

Impact on Adjuncts

Ending the employer mandate won’t necessarily mean large numbers of adjuncts lose insurance. But that’s because of the way many colleges responded to the health-care law. Many of them, noting that they had to cover those who worked more than 30 hours per week, cut adjunct hours. Had colleges not done so, the Affordable Care Act might have been a major advance for adjuncts seeking health insurance, although some did gain.

Maria Maisto, president of adjunct advocacy group New Faculty Majority, said those employees at institutions that cut their hours could see a return to the higher course loads they were assigned prior to the health law’s implementation. And for some adjuncts who did get heath insurance under the law, that could go away.

“The bottom line is it’s going to depend by institution whether or not this has any impact whatsoever,” said Andy Brantley, president and chief executive officer of CUPA-HR, which advises colleges on human resources issues. “At this point, all of that is to be determined on an institution-by-institution basis.”

National higher education organizations that advise colleges and universities on federal policy changes also say the impact on contingent faculty and other employees will depend on the course staked out by individual institutions.

It also remains to be seen how student health insurance plans offered by colleges and universities may be affected by this bill, said Steven Bloom, director of government relations at the American Council on Education.

“This is really one of those issues where the devil is in the details,” Bloom said. “A word changed here or there can make an enormous difference.”

On Thursday, a group of seven hospital groups, including the Association of American Medical Colleges, released a statement expressing concern that the legislation would weaken Medicaid and result in a loss of coverage through the program. Karen Fisher, the AAMC’s chief public policy officer, said the increase in the uninsured population that would result from changes to Medicaid would put pressure on academic medical centers, which act as safety net institutions for those patients.

“Clinical revenues help offset the costs associated with graduate medical education,” Fisher said. “To the extent that there is less clinical revenue, there’s going to be pressure on the other missions of academic medical centers, including their medical education and their research missions.”