More than 4 million people could potentially enroll in association health plans if President Donald Trump follows through on a pledge to expand eligibility in the programs, but most enrollees would likely receive less generous benefits than currently available, according to an analysis of the proposal commissioned by America's Health Insurance Plans.

AHIP is only one of several associations in recent weeks that have submitted comments to the U.S. Department of Labor on the proposal. Last year Trump instructed the agency to explore ways to expand eligibility in association health plans, which would allow many businesses to skirt certain Affordable Care Act coverage requirements in the insurance they offer to employees.

AHIP is an opponent of the proposal. The group hired the health care consulting firm Avalere Health to research the effects the plan would have on the insurance marketplace. The report's authors concluded that association health plans would likely push up premiums in the individual and small-group market, increase the number of uninsured, and result in higher out-of-pocket costs for enrollees with significant health care needs, according to the association.

The authors forecasted that an additional 2.4 million to 4.2 million people would enroll in association health plans that would offer lower premiums because they offer less generous benefits. Those same people would likely face higher out-of-pocket medical costs because of the less generous benefits.

The AHIP report also forecasted that as many as 122,000 individuals could lose insurance coverage by 2022 because of premium increases in other plans, resulting from healthier individuals shifting to cheaper association health plans.

Medical groups also have been wary of expanding access to association health plans. In comments to the Labor Department, the American College of Rheumatology said the proposal could lead to " weak and insufficient" coverage for Americans living with rheumatic diseases.

"Our patients require continuous access to specialized care to manage pain and avoid long-term disability," ACR President David Daikh said. "Therefore, it is imperative that the Administration ensure that Americans living with rheumatic diseases be afforded adequate protections under these new rules."

Other associations have urged the administration to enact the proposed changes. In its comments, ASAE said expanding association health plans would be a boom for small businesses facing rising health insurance costs.

"Small businesses could thus offer more competitive benefits, allowing them to compete with large employers and international competitors to retain and recruit employees, and expend more of their limited managerial resources on the important business of running their businesses," ASAE said.

The International Franchise Association supports the proposed rule because it would expand the definition "employer" to allow businesses to join together through association health plans. However, the group is requesting the franchise business model be included in that change.

"The franchise model is the best example of how economies of scale can be utilized to make the delivery of products and services more affordable for small business owners, and their customers," said Matt Haller, IFA's senior vice president of government relations and public affairs. "If businesses engaged in franchising can form AHPs, they are poised to improve access to coverage at an accelerated rate."

The National Association of Realtors also voiced support because the proposed rule would broaden definition of "employer" to include "working owners." The association noted the change would allow it to offer coverage to members through the large group insurance market.

Most Realtors are independent contractors, not employees, of their real estate brokerages, NAR said.

"As an independent contractor, many typically don't have access to traditional employer-provided benefits, such as 401K plans and health insurance, since these types of benefits could jeopardize their independent contractor status," NAR said. "As a result, self-employed professionals are forced to purchase insurance in the individual insurance market, which tends to offer fewer choices at higher costs."

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