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WASHINGTON -- The long awaited scoring of the American Health Care Act (AHCA) is in and scores show the uninsured losing to deficit reduction.

An estimated 14 million more people under 65 would be uninsured in 2018 compared with current law and by 2026, that number would rise to 23 million, the report said.

The AHCA, which the House passed on May 4th, also would decrease the deficit by $119 billion from 2017-2026, CBO said Wednesday.

These numbers are in contrast to the CBO's score on an earlier version of the House bill, which the agency estimated would result in 24 million fewer people having health insurance by the year 2026 and decrease the federal deficit by $141 billion over 10 years, largely by making changes to the Medicaid program and cutting subsidies to individual enrollees on the ACA's health insurance exchanges.

The new numbers probably won’t do much to change the political debate, experts said. “These are very modest differences, well within any reasonable person’s confidence interval around any prediction,” said Gail Wilensky, PhD, senior fellow at Project HOPE in Bethesda, Md. and former administrator of the Centers for Medicare & Medicaid Services under President George H.W. Bush. “For moderates concerned about the hit on the uninsured, they should be equally concerned. For conservatives who wanted more deficit reduction or lowering of premiums, it’s a pretty modest difference.”

The small degree of change in the score “is not unexpected,” said Thomas Buchmueller, PhD, professor of business economics and public policy at the University of Michigan, in Ann Arbor. “The tweaks they made to get the votes weren’t very substantive … Getting outside of Washington, people are going to have the same concerns. Hospitals will dislike it for the same reasons they did before; physicians are going to have the same reason to be opposed, and a huge number of people are [still] going to lose Medicaid coverage — that’s been a constant throughout.”

The initial response from the medical community remained overwhelmingly negativem, including the American Medical Association, as it did when the CBO score on the earlier bill was released.

“Today’s announcement by the [CBO] confirms that the House-passed American Heath Care Act will strip healthcare away from millions of Americans,” Harold Wimmer, national president and CEO of the American Lung Association, said in a statement. “The American Lung Association urges the Senate to reject the American Heath Care Act and instead protect the millions of Americans with lung disease, lung cancer and other healthcare needs.”

“The CBO score confirms what we already know: the American Health Care Act would deal considerable damage to our health care system, and move millions of people back into the ranks of the uninsured,” Margaret Murray, CEO of the Association for Community Affiliated Plans, said in a statement. “There are opportunities all around us to improve the healthcare system. We hope the deliberations in the Senate represent a fresh start.”

The Back Story

The House had planned to vote on the earlier version of the AHCA on March 24th, but House Speaker Paul Ryan (R-Wisc.) pulled the bill from the floor at the last minute when it became evident that the measure wouldn't have the votes to pass.

Under both the old and the revised bill, the current Medicaid program -- under which states are given matching funds by the federal government which vary depending on how much each state spends on its Medicaid program -- would be changed to a "per-capita cap" program, in which states would get a fixed amount of federal funds for each Medicaid beneficiary. It would also end the Medicaid expansion launched under the ACA by freezing enrollment in that program starting in 2020.

Both versions of the bill also repeal many of the taxes -- including an increase in the Hospital Insurance payroll tax rate for high-income taxpayers and annual fees imposed on health insurers -- that were used to pay for implementing the ACA. They also would eliminate the taxes and mandates that financed the ACA -- including the individual and employer mandate penalty -- and allow insurers to charge older adults more and young people less, and replace subsidies based on need with flat tax credits based primarily on age.

The new bill, which passed by a vote of 217-213, adds several amendments to appease both moderate and conservative Republicans, including:

• An that would allow states to opt out of requiring insurers to cover the ACA's list of "essential health benefits"; instead, states could develop their own lists of what benefits they considered essential. The amendment also would allow states to charge more for 1 year to patients with preexisting conditions if they have been without insurance coverage for 63 days or more. This type of medical underwriting would be done in lieu of a 30% penalty called for under the law for patients who re-enroll in health insurance after such a lapse in coverage. States who opt to allow medical underwriting also would have to set up high-risk pools for patients with high costs due to preexisting conditions.
• An that would provide states with an extra $8 billion over 5 years to set up high-risk pools to cover patients with high costs due to preexisting conditions, in addition to the $130 billion already in the bill that states could use for that purpose.
• An to prevent members of Congress from being exempted from the AHCA. The AHCA originally exempted Congress members from being affected by state waivers.

The Senate is now working on its own version of the bill; they are not starting with the House version but are instead developing their own bill from scratch. Ryan has held off on formally sending the House bill to the Senate for consideration, as is required by congressional procedure; that although he didn't expect the CBO score to change anything, he would wait until the score was released "out of an abundance of caution." Because the new CBO report did not suggest an increase in the deficit with the revised measure, the House will not need to change or re-vote on the bill.

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