Twenty days after the House passed a bill to repeal and replace Obamacare with a revised version of the American Health Care Act, the nonpartisan Congressional Budget Office has scored the plan. What we now know is that by 2018, 14 million more people would be uninsured than under current law, reaching 19 million in 2020 and 23 million in 2026. That would bring the total number of uninsured people under the age of 65 up to 51 million by 2026. But the federal deficit would be reduced by $119 billion, which may give us the clearest equation yet for how much someone's life is worth to the GOP.
That 14 million human beings will lose insurance next year and 23 million over ten years seems like the sort of information that would have been good to know before the House voted to make the AHCA the law of the land, especially since a pre-Obamacare American Journal of Public Health study analyzed CDC data and found that 44,789 people die unnecessary deaths just because they don't have health insurance.
"The purpose of having a Congressional Budget Office is to give Congress information about legislation before it votes," says Doug Elmendorf, the Director of the Congressional Budget Office from 2009 to 2015. "The shocking development is the House voted on the bill without having an estimate in hand for a bill of this consequence."
Like many things in the administration, no, this was not normal, and yes, there is a hypocritical tweet for this occasion: On March 18, 2010, the GOP put out a press release that insisted then-Speaker Nancy Pelosi wait for the CBO score before moving forward with the ACA. But Deputy White House press secretary Sarah Huckabee Sanders said the AHCA would be impossible to score. Was the White House lying to us, or do they have no idea what they're doing with matters of life and death? Now that may be impossible to know.
That the revised AHCA would lead to millions of Americans losing health insurance people was easy to predict, according to Elmendorf. "We know what happened with the passage of ACA—millions more Americans got health insurance," he says. "The further you try to go back to before the ACA, the more health insurance you're likely to lose."
The revised AHCA replaces Obamacare in especially cruel ways: It takes away affordable health insurance from people who need it the most, somehow even more extensively than the original bill. One way it does so is through the MacArthur Amendment, which allows states to obtain three waivers: It allows older Americans to be charged more than 5 times what younger Americans pay, it brings back higher premiums for people with pre-existing conditions if their coverage lapses, and it lets insurers opt-out of essential health benefits, which include things like emergency services and maternity care. While the CBO writes that any "specific state's actions would be highly uncertain," the ultimate result seems clear: reduced premiums for young, healthy adults and higher and rapidly increasing premiums for older and sicker Americans who need more expensive health coverage.
The other way that the ACHA undoes affordable health coverage, which remains unchanged from the original bill, is by eliminating Medicaid expansion; doing so is, once again, estimated to take health insurance away from 14 million people who are among the poorest and most vulnerable.
"What matters is not just total number of people who are insured, but whether people who most need health insurance can get it," Elmendorf says. "Under [the] revised AHCA, the people who would lose health insurance will tend to be those who have the greatest need for health care, because when you free up the individual insurance market so that insurers can avoid people who have high health care costs, they try to do that."
And while most attention will be on the difference between the CBO score from the original version and the revised one, this isn't the right comparison. The better comparison remains between how the AHCA changes things from the status quo of Obamacare, which brought down the uninsured rate to the lowest on record. "The bottom line," Elmendorf says, "is that tens of millions of Americans will lose health insurance."
Jason Silverstein is a lecturer and writer-in-residence in the department of global health and social medicine at Harvard Medical School and an Instructor at the Harvard TH Chan School of Public Health.
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