The latest version of House Republicans’ health care bill will lower the cost of insurance for many Americans compared with what they would pay under Obamacare, but would leave 23 million fewer people with health insurance a decade from now, the Congressional Budget Office said Wednesday.
Healthy people could see “significantly lower premiums” in some states that waive Obamacare requirements, letting insurers sell plans that cover fewer services, some of which people don’t want or need. But the sick or elderly could struggle to find affordable plans in those states, the CBO said.
Republican leaders touted the savings, saying it bolsters their “rescue mission” to save the country from the 2010 Affordable Care Act, which is quickly losing insurers.
The latest blow came Wednesday when Blue Cross Blue Shield of Kansas City said it would pull out of the marketplace in 32 counties spanning 67,000 customers in Missouri and Kansas next year.
“This CBO report again confirms that the American Health Care Act achieves our mission: lowering premiums and lowering the deficit. It is another positive step toward keeping our promise to repeal and replace Obamacare,” said House Speaker Paul D. Ryan, Wisconsin Republican.
The analysis should also clear the path for the Senate to take up the bill, after analysts said it showed enough savings to meet budget rules that allow the legislation to be fast-tracked, avoiding a Democratic filibuster.
But Democrats and some rank-and-file Republicans said the numbers were a grim indictment of the GOP plan, leaving far too many people without the coverage that was the chief goal of Obamacare.
“I have never seen a health care bill which throws 23 million Americans off of health insurance. That’s not a health care bill,” said Sen. Bernard Sanders, Vermont independent.
The 23 million figure includes people who, without Obamacare’s “individual mandate,” would choose not to get health insurance, though the largest chunk consists of people affected by cuts in federal subsidies to state Medicaid programs.
Scorekeepers said that thanks to changes in Medicaid and other programs, the Republican bill will reduce federal deficits by $119 billion over the next decade. That’s less than the $150 billion in savings from a previous version of the bill.
Yet the number of people who would lack insurance by 2026 is just a slight improvement over the 24 million the CBO projected in March, based on the earlier version of the bill, meaning the figure will remain a public relations headache for the GOP.
The White House hit back at the report’s figures, saying the CBO is unreliable in evaluating health care legislation.
“History has proven the CBO to be totally incapable of accurately predicting how health care legislation will impact health insurance coverage,” a White House official said.
House Republicans pushed the bill through their chamber on a 217-213 vote earlier this month, after making changes to win over holdouts who had sunk the first effort in March.
Among the more significant changes, leaders agreed to allow states to waive the Affordable Care Act’s main strictures requiring insurers to cover an expansive list of services. The new bill also pours billions of federal dollars into risk programs that subsidize sicker customers who would end up paying more.
Budget analysts said starting in 2020, the bill’s effect on premiums will depend on where someone lives.
About half of Americans — those living in states that won’t request waivers — will see a small drop in premiums, averaging 4 percent by 2026, the CBO said.
Another third of the country resides in states that will waive Obamacare’s “essential benefits” like maternity and mental health, resulting in rates that average 20 percent lower than current law — though actual savings will vary by region and age of customers.
One-sixth of the country lives in places that would also waive essential benefits and rules requiring insurers to charge healthy and sicker people the same amount.
The CBO said it is too difficult for it to estimate how much lower premiums will be for healthier people, but said, over time, it will “become more difficult” for sicker ones in those states to purchase insurance “because their premiums would continue to increase rapidly.”
The CBO said the markets should remain stable under Obamacare in most areas, but that pockets of the country will have limited choice due to the exodus of insurers such as Blue Cross of Kansas City.
Those insurers say they can’t turn a profit or worry the Trump administration won’t implement key parts of the 2010 law, namely the “individual mandate” requiring people to hold insurance or pay a tax, and cost-sharing subsidies that help insurers who lose money by picking up low-income customers’ costs.
Democrats are unanimously opposed to the GOP bill, and said Republicans won’t be able to spin the latest cost estimate as good news.
“Republicans will crow about the premiums going down in the outer years, but the decrease in premiums only occurs because the quality of insurance will plummet. Cheaper insurance isn’t going to help anyone if it doesn’t actually lead to the health care people need,” said Senate Minority Leader Charles E. Schumer, New York Democrat.
As written, the House bill repeals most of Obamacare’s taxes and its individual mandate, replaces its generous subsidies with refundable, age-based tax credits and reins in and caps spending on the Medicaid program for the poor.
It also strips Planned Parenthood of federal funding as punishment for its abortion practices.
Senate Republicans have said they’ll write their own bill, hoping to soften the transition for states that expanded Medicaid or provide more generous tax credits to poorer and older Americans who could struggle to afford coverage under the House plan.
Senate Majority Leader Mitch McConnell, Kentucky Republican, signaled Wednesday he sees a tough road ahead.
“I don’t know how we get to 50 [votes] at the moment,” he told Reuters. “But that’s the goal.”
The CBO’s findings should guide senators who are trying to address regulations and consumer protections baked into Obamacare, with conservatives preferring a more direct strike at the law.
In the House, the waiver plan negotiated by Rep. Thomas MacArthur, New Jersey Republican, and the House Freedom Caucus would let states opt out of a series of “essential” health benefits, such as maternity and mental health care, and allow insurers to charge healthier people less than sicker ones, so long as the states set up high-risk pools to pick up their higher costs.
States can tap $115 billion in federal “stability” funding over 10 years for the high-risk pools and an additional $15 billion for a risk-sharing mechanism to pay for sicker consumers who could be priced out of the market.
A late amendment by Rep. Fred Upton, Michigan Republican, added $8 billion to risk-pool funding to get more centrists on board with the plan.
“The report places a great deal of emphasis on the effects the MacArthur amendment would have on destabilizing state insurance markets in waiver states and see the additional $8 billion in funding provided by the Upton amendment as having very little effect,” said Timothy Jost, a law professor at Washington and Lee University in Virginia who closely tracks the debate.
The CBO said scrapping essential health benefits would also come with tradeoffs. Premiums would decline, on average, though people who need the optional services would have to pay more.
“In particular,” it said, “out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for the nongroup enrollees who would use those services.”
• Dave Boyer contributed to this report.