In what is rapidly becoming a sort of Capitol Hill tradition, the Congressional Budget Office on Thursday released yet another analysis of the impact a Republican plan to repeal and replace the Affordable Care Act, reporting that it would save the government money while dramatically reducing the number of Americans who have health insurance, and lowering the quality of that insurance for millions of others.
Because it’s getting hard to be sure just which version of the GOP’s ACA repeal bills is being discussed at any given time, here is a quick rundown of what’s still in play right now.
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On the House side of the Capitol, there is the American Health Care Act, which actually passed the House in May. CBO has estimated that, while it would save the government $119 billion over ten years, at the end of that period there would be 23 million fewer Americans with health care.
Things are more complicated on the Senate side.
There is the Obamacare Repeal and Reconciliation Act, released yesterday, which would repeal the ACA over the course of two years, but would not replace it. Senate Republicans would argue that it makes no sense to score the bill as though it will play out over ten years, because they intend to craft a replacement before the ACA is fully repealed. CBO scored it anyway and found that it would save the government $473 billion over a decade, but at the cost of 32 million fewer Americans with coverage, much higher premiums, and 75 percent of Americans living in counties with no options for health insurance on the individual marketplace.
There are also two versions of the Better Care Reconciliation Act in play at the moment. Both would not so much repeal the Affordable Care Act as tweak it into a version that Republicans find more appealing. Both would do away with the individual and employer mandates that the ACA put in place, replacing the former with a waiting period that could leave people who choose to go without insurance unable to access it if they suddenly find that they need it.
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Both would also restructure the subsidy system put in place by the ACA, with the result that premiums for plans sold on the health care exchanges would be nominally lower at each coverage level, but would cover less than they do under the current system.
One version of the BCRA contains a provision offered by Texas Sen. Ted Cruz that would allow insurers to offer plans that do not meet the essential health benefits described by the ACA, so long as the same insurers offer at least one plan at each of the ACA tiers that does comply with the law’s rules.
The version of the BCRA without the Cruz provision was scored by CBO on Thursday. The agency found that the proposal would produce a net savings to the federal government of $420 billion over ten years. However, it also found that the bill would reduce the number of Americans with health insurance by 15 million in 2018, 19 million in 2020 and 22 million in 2026. The total estimated savings and coverage losses are not dramatically different from some of the earlier repeal and replace proposals floated by the Senate.
After a brief period of higher premiums, the average cost of individual health care plans would start to fall in 2020, CBO found. But one of the prime drivers of that decline is that the level of coverage provided by plans in different tiers would be lower than they are under current law. In other words, people would be paying less, but they would be getting less in return.
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One thing that stands out in the analysis of the most recent version of the BCRA is the impact it has on the cost of even basic insurance coverage for poor Americans. Some living near the poverty line, even accounting for government subsidies, would face crippling costs. A “silver” tier plan, which covered about 70 percent of expected costs under the ACA, would cover 58 percent under the BCRA. And annual deductibles would be extremely high, with annual out-of-pocket expense rising to well above $10,000.
According to the agency’s report, “many people with low income would not purchase any plan even if it had very low premiums—on net, after accounting for premium tax credits—CBO and JCT estimate. Under this legislation, in 2026, that deductible would exceed the annual income of $11,400 for someone with income at 75 percent of the FPL. For people whose income was at 175 percent of the FPL ($26,500) and 375 percent of the FPL ($56,800), the deductible would constitute about a half and a quarter of their income, respectively.”
Senate Majority Leader Mitch McConnell said on Wednesday that he expects the Senate to begin debating a bill next week, but he was either unwilling or unable to explain which one of the three current proposals being considered it would be.
In truth, it may not matter much. All of the Obamacare replacement plans that have been published and offered to the CBO for review are extremely unpopular with the public, and it’s not even clear that McConnell will be able to muster the votes he needs to simply begin debate on one of them.
