The CBO report on the House Republicans’ health care bill was released on Wednesday. If passed, the American Health Care Act would leave 23 million additional people uninsured and increase costs for the sickest and oldest Americans.
This version of the bill reduces the deficit even less than the last one, according to the CBO, with a net reduction of $119 billion in the deficit over that period—$32 million worse for the deficit.
Under this legislation, in 2026, the CBO estimates 51 million people under the age of 65 would be uninsured compared to 28 million under the ACA. The report found that even though the bill includes funding to help people with pre-existing conditions afford coverage, people who are less healthy would be unable to buy individual policies.
Under this bill, there would be wide latitude for states to make decisions about which features they would require health plans to offer. For states that decided to waive a requirement that plans have to provide “essential health benefits,” a signature feature of Obamacare, premiums would decline on average. But for many people, out-of-pocket spending on those essential benefits, including maternity care, mental health, and treatment for substance abuse or addiction, “could increase by thousands of dollars in a given year.”
Non-group insurance markets would “continue to be stable” in many parts of the country, according to the report, but uncertainty about implementation of the law could cause insurers to flee the markets. Still, many areas of the country — one-sixth of the population lives— would become unstable in 2020 because of market responses to states that waived the community ratings and essential health benefits provision.
Tax cuts disguised as health care
Jacob Leibenluft, senior advisor at the Center on Budget and Policy Priorities, said that the major takeaway from the CBO score is that Republicans’ talking points don’t hold up. AHCA supporters still claim that the waivers wouldn’t harm anyone who needed essential health benefits or anyone with preexisting conditions, but this bill doesn’t bear that out.
“What the changes of bills have effectively done is resulted in system where sicker and older people are even worse off in terms of how much they would pay and quality of insurance coverage they would get.” Leibenluft said. Those changes would do little to boost overall coverage numbers, either.
“I think what that points to is how deeply unfixable the basic structure is. The problem is they’re pursuing hundreds of billions in tax cuts in a bill that needs to reduce deficit and that requires deep cuts to health coverage. And it’s not possible to undo those cuts to coverage while maintaining that basic structure.”
Fundamentally, the bill’s failures come down to allowing states to waive essential protections the ACA put in place: No matter what approach states took to waivers, people’s health care coverage would adversely affected.
“It’s just a matter of how you distribute the pain,” Leibenluft said.
The last CBO score, released on March 13, found that 24 million more people would go uninsured by 2026 if Trumpcare became law. The report found that the largest reduction in outlays would come from changes to Medicaid — a reduction of $880 billion — and elimination of ACA subsidies for non-group health insurance. Premiums would climb in 2018 and 2019, then start to decrease in 2020. However, older people would still pay higher premiums.
Republicans have repeatedly downplayed the importance, and at times, accuracy, of the CBO score. After the CBO released its first analysis of the bill, Republicans added two amendments to the bill that would significantly change it by adding billions more in funding and gutting protections for people with pre-existing conditions. Nonetheless, House Speaker Paul Ryan decided not wait for a new CBO analysis before scheduling a vote last month. The bill barely squeaked through the House.
Ryan’s decision resulted in criticism from Democrats and nonpartisan policy experts. The former director of the CBO, Douglas Elmendorf, said it was a “terrible mistake” for House Republicans to vote on the bill without a CBO score because they had no idea what effects the legislation would have on people’s access to health care.
Republicans responded by saying that the CBO shouldn’t have to repeatedly score the bill, even after significant changes, and suggesting that people do the math themselves to find out what the results would be. On May 7, House Speaker Paul Ryan said on ABC’s This Week, “A three-page amendment is not going to dramatically alter that bill. It does a narrow change to the bill.”
On Wednesday afternoon, House Majority Whip Steve Scalise, (R-LA) told the Washington Examiner that he doesn’t see any reason for the House to take a second vote. He also said he was ready to “debunk” the most recent CBO score.
But there were two amendments that weren’t scored: the Upton Amendment and MacArthur Amendment. The MacArthur Amendment allows states to opt out of community ratings — which help people with pre-existing conditions afford coverage — and the essential health benefits requirement, which ensures plans cover things like prescription drugs, maternity care, and substance use treatment. The Upton Amendment would provide $8 billion in funding over five years to help subsidize expensive insurance for people with pre-existing conditions. Some health care experts have said that $8 billion is not nearly enough to address the needs of people with pre-existing conditions.
Still, Republicans needed the right kind of CBO score before the bill can move forward, because they’re hoping it will pass the Senate through budget reconciliation, a parliamentary maneuver doesn’t allow Democrats the opportunity to filibuster. But in order to qualify for reconciliation, the bill needed to include at least $2 billion in savings as certified by the CBO.
The Upton amendment complicated things by adding billions in spending to the bill. The MacArthur Amendment could also have proven costly because it’s possible that after states waive regulations, people would sign up for cheaper health care plans with less coverage, and that the government would have to increase the amount it spends on tax credits to help people afford higher premiums.