In March, when House Republicans rolled out their long-awaited American Health Care Act, it was a real turd. Democrats naturally disliked it because it rolled back the Affordable Care Act's Medicaid expansion and pared back subsidies in order to cut taxes for the rich; conservatives were peeved that it didn't completely dismantle the ACA. That version of the AHCA sputtered and failed, but Republican moderates and conservatives were able to compromise and agree on a new version of the bill, which passed the House earlier this month.
But because the nonpartisan Congressional Budget Office didn't score that version of the bill, it was far from certain what the effect of that Republican-on-Republican dealmaking was. On Wednesday, the CBO finally released its assessment of the new AHCA, and the picture became a little clearer: Conservatives' changes to the bill could be devastating to sick people who happen to live in the wrong states.
The revised bill would result in 1 million more people having insurance in 2026 than the original bill, according to the CBO—but that's still 23 million fewer people with insurance than would have it under the ACA. The new AHCA would save the federal government $119 billion over that time, compared to $150 billion in the original. There's an additional $38 billion allocated to a fund that states could use to "stabilize" private insurance markets and keep costs down. But the big, scary change is that the new bill would allow states to waive various regulations on insurers, hastening a return of the bad old pre-ACA days.
The CBO report cautions that it can't make "explicit predictions about which states would make which decisions," but estimates about half of Americans live in states where no waivers would be issued. A third of Americans live in states where "moderate changes to market regulations" would result in premiums on nongroup plans (i.e. not Medicaid, Medicare, or employer-provided insurance) being "roughly 20 percent lower in 2026 than under current law, primarily because, on average, insurance policies would provide fewer benefits." And a sixth of Americans would be in states where insurers would be free to do pretty much whatever they liked—that would mean young, healthy people could buy cheap plans that don't provide much coverage since they don't need much healthcare, but people who do need care would be out of luck.
In this last group of states, the CBO says, insurers would be free to offer plans that don't include things like "maternity care, mental health and substance abuse benefits, rehabilitative and habilitative services, and pediatric dental benefits. In particular, 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."
Worse still, the additional money in the stability fund wouldn't be able to stop the markets failing these people in these states:
People who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all—despite the additional funding that would be available under H.R. 1628 to help reduce premiums. As a result, the nongroup markets in those states would become unstable for people with higher-than-average expected health care costs.
The AHCA is a long way from becoming law, since the Senate needs to pass its own version and the two chambers of Congress need to hammer out the differences between those versions. If the AHCA is ultimately passed, it might take years for some of these effects to occur. And hey, maybe the CBO is wrong about its estimates.
But assuming the report is broadly correct, some states will choose to scrap current regulations about what insurers have to offer, making life harder for people who most need care. That's the upshot of months of dealmaking among House Republicans—more uncertainty and danger for the country's vulnerable. The bill's still a turd.
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