Roughly 23 million more people would be uninsured over a decade if the House-passed Republican Obamacare repeal bill becomes law, according to a long-awaited CBO analysis that could complicate GOP hopes of getting a companion measure through the Senate.
That’s nearly identical to the coverage losses that CBO forecast for an earlier version of the bill — despite the addition of new provisions and billions of dollars in funding aimed at keeping more people insured.
The nonpartisan scorekeeping office also forecast the GOP plan would cut the deficit by $119 billion over a decade, primarily because of its cuts to Medicaid and private insurance subsidies. That exceeds $2 billion of minimum projected savings the bill needed to hit, which should clear an important hurdle and help the bill’s prospects of getting to the Senate. Senate GOP aides are still checking the analysis to ensure the bill can travel safely across the Capitol.
“It improves the number of people who would be covered and premiums continue to come down even more,” House Energy and Commerce Committee Chair Greg Walden (R-Ore.) told reporters. “This is the first big plan out there that really brings premiums down, or has the potential to bring premiums down.”
But the prediction of coverage losses is expected to add more fuel to Democratic arguments that the people who signed up for coverage under Obamacare would be much worse off under the GOP bill. The CBO in March projected that an earlier version of the legislation would leave roughly 24 million more people uninsured over a decade, prompting a backlash that forced GOP leaders to abandon a planned vote.
House Republicans narrowly advanced a revised version of their American Health Care Act six weeks later, making a controversial decision to vote without waiting for a revised CBO score. The legislation now includes an additional $38 billion in funding aimed at keeping people covered — but also gives states the option to waive key Obamacare protections.
This new coverage prediction will likely re-energize opposition to the GOP plan, after CBO concluded those changes would barely make a dent in the long-term effect on coverage. Fourteen million more people are still likely to end up uninsured under provisions rolling back Obamacare’s Medicaid expansion and enacting deep cuts to the program serving low-income and disabled Americans. The projected coverage number would also include roughly six million fewer people purchasing insurance on the nongroup market than under Obamacare, in large part because there would be less financial aid to help people buy coverage.
Those who remain insured would pay less than overall under Obamacare by 2026, an aspect that Republicans seized on soon after the report’s release. But the savings would largely benefit younger enrollees at the expense of older, more expensive Americans — the very demographic that helped President Donald Trump win the White House.
And much of the long-term reduction would be aided by provisions that allow insurers to sell less generous plans under the AHCA in states that choose to opt out of Obamacare’s minimum benefit requirements. CBO estimates that roughly one-third of the population resides in states that may eliminate at least some of Obamacare’s protections under new flexibility that the law grants states — leading to roughly 20 percent premium declines. Still, the agency warned that the lower prices would come with worse benefits — meaning people could be stuck with skyrocketing out-of-pocket costs.
CBO also warns the GOP’s health plan could jeopardize coverage for people with pre-existing conditions in states that opt out of Obamacare’s limits on charging certain people with pre-existing conditions higher premiums. That exposes a legislative weakness that could prove particularly troublesome in the Senate, and could make the market “unstable” for sicker individuals across several states.
“That instability would cause some people who would have been insured in the nongroup market under current law to be uninsured,” the report said.
The predictions of market instability, despite the GOP’s plan to earmark more than $100 billion to help keep coverage affordable and accessible, brings to life some of Republicans’ biggest political fears about the bill.
Senate Republicans quickly downplayed the CBO’s conclusions.
“Although our Senate bill will be different, we will carefully analyze this CBO report,” Sen. James Lankford (R-Okla.) said in a Facebook post. “But nothing about this CBO score changes my approach to health care reform — we need a smooth transition from the Affordable Care Act to a better health care system and better coverage options for everyone.”
And Senate Majority Leader Mitch McConnell earlier in the day called the score a simple “procedural step” that will allow the GOP to get on with its work.
Indeed, the CBO score’s main function is to clear the way for the Senate to take up the House’s legislation. The bill needed to save at least $2 billion to qualify for consideration under a reconciliation process that is filibuster-proof by requiring only 51 votes in the Senate, not the typical 60-vote threshold.
But the report highlights the central dilemma that Republicans are grappling with now — how to write a health care bill that preserves peoples’ coverage at a reasonable price, without resorting to government mandates and billions in federal spending. And it drops that problem right on the Senate’s doorstep. Despite weeks of work, GOP lawmakers remain split on fundamental, yet high-stakes, decisions like how quickly to roll back Medicaid expansion and the amount of financial aid older and sicker enrollees should receive.
The CBO score could jump start those talks by giving the Senate a concrete starting point. But it also threatens to ratchet up public scrutiny of a process that Democrats argue is bound to eliminate the major health gains achieved under Obamacare.
House Republicans, in a break with traditional bill-writing practices, jammed their bill through the chamber without waiting for CBO’s updated score — assuring both lawmakers and the health care community alike that their revisions would keep more people covered. But the coverage projections barely budged, leaving the Senate to shoulder whatever fallout is yet to come.
“It was irresponsible for the House to vote for the GOP health bill before a CBO analysis was available,” said Ron Pollack, the founding executive director of advocacy group Families USA. “Now that it exists, however, anyone still supporting the bill is probably a prime candidate for a conscience implant.”
Republican senators largely panned the House bill when it passed, emphasizing that the chamber planned to start from scratch on its own repeal proposal. Still, early discussions have centered more on potential tweaks to the AHCA rather than a wholesale renovation.
The GOP has largely coalesced around ending Medicaid’s entitlement status and capping its federal funding, despite sharp disagreements over how drastically to cut the program’s financing. Sen. John Thune (R-S.D.) is also heading up work aimed at tweaking the House bill’s tax credits, in a bid to better subsidize older Americans buying insurance in the individual market.
But in a sign of the broadly diverging viewpoints that still exist within the Senate GOP, Sen. Lindsey Graham (R-S.C.) used the CBO report as an opportunity to resume his call for holding off on replacing Obamacare until the current system fails completely.
"With today’s news, the ‘Collapse and Replace’ of Obamacare may prove the most effective path forward," he tweeted. "After Obamacare collapses, we should challenge Democrats to work with us to fix the mess they created."