As Congress gets set to pause, repeal or replace the Affordable Care Act (ACA, also known as Obamacare), people with chronic conditions may be concerned about specific Medicare benefits that might be eliminated or significantly altered. Among these are prescription drug benefits, Medicaid, and limits on Premiums.

Prescription Benefits

The ACA expanded prescription drug benefits for Medicare patients, closing the “donut hole,” or the point at which Medicare would stop paying for drugs and patients would have to buy them at full price. This can be especially burdensome for patients under Chronic Care Management (CCM), which typically face multiple medications, some of them very costly.

A 2011 study conducted by the Kaiser Family Foundation found that patients were likely to skip medications when forced to pay the full price, which can result in worsened health and ultimately higher Medicare costs.

A study by the National Institutes of Health found that “Medication nonadherence is widespread and varied by disease, patient characteristics, and insurance coverage, with nonadherence rates ranging from 25 percent to 50 percent.” The study estimated that “Between $100 and $300 billion of avoidable healthcare costs have been attributed to nonadherence in the U.S.”


Medicaid is the last safety net in our healthcare system. It is often seen as health insurance for the poor, but is it also a benefit used by the chronically ill, especially elderly patients. Medicaid pays for the long-term care of the chronically ill, including nursing home patients.

The ACA expanded Medicaid in states that would participate in the program. Some 12 million people obtained health insurance through the ACA’s Medicaid expansion, according to the White House Council of Economics Advisors. New leaders in Washington have suggested making Medicaid a block grant program. This would mean funding would be sent to each state as a standard fixed sum, and state governments would then determine program eligibility.

ACA advocates are concerned that states could ignore federal laws that provide for the most vulnerable and older patients, and that in the event of an economic downturn when demand increases, no additional funds will be available.

Insurance Premiums

The ACA put a limit on how much insurers could charge seniors–previously insurance companies charged higher premiums to older age groups that used more services. The current limit is that premiums for people in their 50s and older can only be charged 2-3 times the amount of younger people. New administration proposals have suggested doubling those limits or eliminating them entirely. A study by the Rand Corporation found if premium caps are eliminated, “400,000 individuals between the ages of 50 and 64 lose insurance.”

The ACA has been controversial since its inception. Proponents claim that 20 million people that couldn’t afford health insurance are now covered, thanks to the program. Opponents point out that insurers have opted out because of the high costs involved, which has led to higher premiums. For people with chronic conditions, the stakes are high around prescription drug benefits, Medicaid expansion, and premium costs.

The latest message from legislators is, “if you like Obamacare, you can keep it,” meaning that no one will be forced to adopt whatever replaces it. Whether this is political gamesmanship or a workable policy remains to be seen. What is recommended is that if you like your ACA coverage and want to keep it, let your representatives know.

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