In news that will likely change the way some lawmakers view the Senate’s proposal to gut and replace much of the Affordable Care Act, the Congressional Budget Office has estimated that this latest effort would ultimately leave 22 million Americans without insurance on top of those that would be uninsured under the current law, while trimming $321 billion from the federal deficit over ten years.
The projected number of uninsured is virtually identical to the CBO analysis of the American Health Care Act (AHCA), the bill that passed the House on May 4.
The CBO estimated that the AHCA would result in an estimated 23 million additional Americans being without insurance by 2026, while only shaving $119 billion off the federal deficit, about one-third of what the GOP had originally proposed when it introduced the bill.
Today’s score [PDF] for the Better Care Reconciliation Act (BCRA) estimates that an additional 15 million Americans would go uninsured in 2019, mostly because the BCRA repeals the so-called “individual mandate” — the requirement that most individuals have some sort of health insurance — and the “employer mandate,” which requires that larger businesses provide employees with qualifying coverage.
By 2020, the number of additional uninsured would grow to 19 million, and finally to 22 million by 2026, according to the CBO.
The BCRA appears to pare down the AHCA’s uninsured number by delaying the end of Medicaid expansion. Given that the Senate bill allows expansion to continue through 2021, there are fewer years in the CBO scoring window (which only projects out 10 years) for people to drop off of Medicaid after the burden of paying for this program is shifted primarily to the backs of the individual states.
As with the House version of the bill, the Senate version allows insurance companies to charge older Americans significantly more than they do now for insurance. Currently, insurers can only charge older policyholders up to three times what they charge to young adults. Under the BCRA, that would increase to five times.
Pay Less; Get Less
As with previous CBO scores of the Republican repeal plans, insurance premiums are expected to increase through 2020 before dropping thereafter. However, one of the reasons for this decline in costs is that the policyholder will have to spend more out of pocket.
The “benchmark” plan under the Affordable Care Act covers around 70% of the individual’s annual medical expenses. However, the benchmark set by the BRCA is significantly lower, with plans only required to cover 58% of medical costs. So premiums might go down, but you’ll have to pay for more if you get sick.
That means higher deductibles. The current benchmark plans (known as “silver” plans on the Obamacare exchanges) have average deductibles of around $3,600 per year for one person. The CBO says the standard deductible on the Senate plan would be closer to $6,000 per year for an individual. Or if you want to get a plan with a lower deductible, you’ll have to pay a higher premium.
Because of these projected higher out-of-pocket costs, the CBO predicts that “few low-income people would purchase any plan,” even though they would qualify for the tax credits to help them pay for the insurance.
In addition to higher deductibles and less coverage, about half the U.S. population could also face costs for “essential health benefits” if their state decides to exercise its right under the BCRA to waive the current law’s requirements on certain benefits that all health insurers must currently provide. These include mental healthcare, prenatal and maternity care, lab tests, pediatric care, rehabilitative services, and more.
Even if an insurer chooses to include these benefits in a standard policy in a state where they are no longer deemed essential, the current law’s ban on annual and lifetime limits for these benefits would be waived. So a policy could still cover your visit to the hospital to deliver your new baby, but if there is difficulty — say the newborn is premature or needs to stay in the NICU — you may have to go out of pocket because your insurer has placed a cap on how much it will spend to cover that care.
“The CBO confirmed what every public interest, medical, hospital and patient group has been saying — this bill would take insurance away from millions, decimate Medicaid, cost consumers more in premiums and out-of-pocket costs, and leave the lucky few that can afford insurance with skimpy plans that aren’t required to cover basic care like emergency, maternity and prescription drug coverage,” says our colleague Betsy Imholz, Special Project Director for Consumers Union. “This bill is simply a bad deal for consumers’ health and financial security — and no amendments nor tweaks can change that harsh reality.”
Waiting Period
Even though it was only a few hours ago that the Senate released a version of this bill that includes a 6-month waiting penalty for people who let their coverage lapse, the CBO score includes this provision that was not in the draft bill.
Under this change, starting in 2019 insurers on the individual market would be required to impose a waiting period of up to six months before providing coverage to a new applicant who had gone without insurance for more than 63 days.
The CBO says this has a slight positive effect on keeping some people from dropping service but not in the initial years “when the incentives to obtain coverage would be weak because premiums would be relatively high.”
Will It Pass?
All eyes will now turn to both moderate and hardline conservatives in the Republican party to see if the CBO score nudges them toward supporting or turning against this bill.
The conservatives — led by Ted Cruz and Rand Paul — had concerns that this bill didn’t do enough to cut support to Medicaid or trim the deficit. The moderates, like Lisa Murkowski, Dean Heller, and Susan Collins, had taken a more wait-and-see approach, saying they wanted to see how it would impact lower-income and older Americans.
Because the BCRA is technically a budget resolution and not a law, opponents can not hope to block a vote through filibuster. Thus, rather than the 60 votes generally needed to invoke cloture, this bill would only need a simple majority to pass through the Senate. However, the GOP can not afford to lose more than two votes. Since Vice President Mike Pence — a supporter of the BCRA — is the tiebreaker, the GOP can still pass the legislation with only 50 votes.
If the bill does pass, it would still need to go back to the House, since it’s not the same resolution passed by that chamber. The House narrowly passed the AHCA by a vote of 217-213, with 20 Republicans voting against it.
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