The Senate healthcare receded into the shadows on Tuesday when it was announced that a planned vote will now be delayed until after the July 4 recess. But it's far from dead. Away from harsh media scrutiny, Republican senators are wheeling and dealing their way to what the leadership hopes will be an eventual yes vote.
If they can pull it off, the consequences could be enormous—including 22 million more people without insurance a decade from now, according to the nonpartisan Congressional Budget Office (CBO).
Supporters of the bill have claimed that the bill will cause premiums to fall, and that it doesn't cut Medicaid funding. That is false. Here's the CBO's graph of Medicaid spending between now and 2026 if the bill passes:
But the bill impacts a whole lot more than Medicaid spending. It represents a series of major changes to the American healthcare system that are parceled out over time, and you can't understand it until you understand how these changes will be rolled out.
Long story short, it wouldn't be a sudden flood of coverage cuts, but a slow titration of budget tweaks at the national and state levels, dripping and dripping, over the course of years. What follows is a timeline of those changes, based on the CBO report. Republicans want a new CBO score, and will likely make changes to the bill, but this is their plan as of right now.
What happens the day the bill passes:
The individual mandate no longer applies, but that doesn't mean much... yet.
Right now, under the Affordable Care Act, the average deductible (what someone pays for healthcare before his or her insurer starts covering costs) is $6,000 under what's called a "bronze" plan and $3,600 under a "silver" plan. If and when this bill passes, the average consumer probably won't notice no matter what their plan is, because insurance companies won't jump in and reset their prices immediately.
But the individual mandate, which penalized people who didn't have insurance, will go away. You could be like, Cool, I don't have to pay for health insurance anymore! and immediately cancel it for the rest of the year if you really wanted to. "There are probably some people who would do that," said Matthew Fiedler, a Brookings Institute fellow working at the Center for Health Policy and former member of Barack Obama's Council of Economic Advisers.
"I suspect that by the time this would have actually worked its way through the process to become law, we'd be far enough into the year that the magnitude of that would be fairly small, and the big effects would be in 2018," Fiedler added.
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The next year:
About 15 million people stop being covered. Premiums increase by about 20 percent on average.
A lot of people have decided they don't need health insurance—and most of these are on the healthier side. Having lost all those cheap-to-cover (and therefore profitable) customers, insurers would set much higher premiums "in anticipation of the fact that the risk pool they're going to be facing is meaningfully sicker," Fiedler told me.
So the decrease in coverage in 2018 is less because of changing subsidies and more because insurers will set their prices based on there not being an individual mandate anymore. This means "average premiums for benchmark plans for single individuals would be about 20 percent higher in 2018 than under current law," according to the CBO report.
Meanwhile, the midterm elections take place. Republicans will have to answer for their support of an incredibly unpopular bill. Democrats are unlikely to retake the Senate, but they have a good chance of winning the House.
Premiums that have gone up go back down a little. The number of new uninsured probably doesn't climb much higher than 15 million quite yet.
In 2019, insurance companies will benefit from what Fiedler calls "a large pot of money" for insurers. "The federal government would basically pay a significant portion of the claims associated with very high-cost enrollees," he explained.
This will help keep costs down for a while. Insurers will be less worried about patients getting really sick—since the federal government is going to pick up part of the tab. "The premium decline in 2019 is being driven by that very large pot of additional subsidy dollars," Fiedler explained.
An important 2019 rule change will, in certain cases, allow companies to charge older people premiums that are up to five times higher than the premiums for younger people. "That would cause a lot of older people who pay higher premiums to exit the market, and a lot of younger people who pay lower premiums—or at least some younger people who pay lower premiums—to come into the market, so that would contribute to reducing the average premium in the market," Fiedler explained.
So even though average premiums will go down, premiums will rise drastically for some old people, so much so that they'll go uninsured and hope they don't have serious healthcare problems before they turn 65 and qualify for Medicare.
Democrats may attempt to craft healthcare legislation, but even if they control the House, they won't be able to get anything past the Senate—and even if they could, Donald Trump will probably veto any Democratic bill.
Premiums go down in theory, and a premium tax credit kicks in for people at or below the poverty line. But at the same time, people also start ditching coverage because it's getting too expensive. The number of new uninsured reaches about 19 million people.
"The premiums lower, but the out of pocket costs are a lot higher," Fiedler told me.
A little on how this will work: Under the Affordable Care Act, silver plans are the plans that receive certain subsidies. These plans cover an average of 70 percent of a consumer's out-of-pocket healthcare costs. But the Republican bill in effect cuts those subsidies, making silver plans more expensive—and unaffordable to lots of poorer people. In 2020, the cheapest plans that receive subsidies will cover just 58 percent of out-of-pocket costs on average.
The CBO says deductibles for those plans will be around $6,000, and few families living around the poverty line could afford to pay that kind of medical bill. According to the CBO, "As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan."
The CBO also says that there'll be reductions in the number of Americans with insurance beginning in 2020 "because the average subsidy for coverage in that market would be substantially lower for most people currently eligible for subsidies—and for some people that subsidy would be eliminated."
"On some level  is the sweet spot for the bill," Fiedler told me. "The reinsurance subsidies are at their peak, and the generosity of the benchmark plan has fallen," so while that may suck for low-income people, the bill will seem to be working as advertised. Some people's premiums will have fallen. But Fiedler added that there will be some "challenges" heading into the 2020 presidential election, including a lot of uncertainty about insurance companies being reimbursed for Obamacare-era cost-sharing reductions.
Speaking of the 2020 election, healthcare will be a major issue in that contest, as the real effects of the bill don't kick in until:
Fewer and fewer people will qualify for Medicare, and they will lose coverage as a result.
In these years there are two areas to look at. "On the private side," Fiedler said, "you've got reinsurance funding falling substantially over those years." That will mean a slow ramping up of insurance costs for consumers.
Then there's the public side. Under the Affordable Care Act, states that expanded Medicaid to cover more people were given enough money to cover that expansion entirely—in other words, new Medicaid enrollees were cheaper for states than their old Medicaid enrollees. But starting in 2021, those states will see that money from the feds slowly decrease.
"You've got states gradually winding down their expansions," Fiedler told me. "There are actually some states whose expansion laws are written such that the moment the funding for the state—the matching rate that the state gets from the federal government—falls, those states would discontinue their expansion."
That means the Medicaid expansion, which insured more people than any other provision of the ACA, will come to an unambiguous and abrupt end in many places. "Other states are going to hold on a little longer, and wait until 2024," Fiedler added.
Additionally, Medicaid funding will be limited based on how many people a state has enrolled in the program—as opposed to right now, where the federal government picks up a set percentage of a state's cost. That cap will rise year by year, but spending will go up more slowly than it would have. In other words, Medicaid will be cut, and states will have to decide whether to raise taxes or else provide fewer benefits to their citizens.
If Democrats have clawed back control of the government, maybe there will be efforts to reverse these effects. But at this point, it's pretty much pointless to predict the political aspect.
Also, in 2023 the OSIRIS REx space probe will return to Earth with samples from a distant asteroid, so hey, maybe we'll get a space plague.
ACA funding for Medicaid finally goes away completely.
For all intents and purposes, 2024 is the end of the Obamacare Medicaid expansion, but it will go out with a whimper, not a bang, since state Medicaid programs will have already been tightening their purse strings over the past few years. "You may also have a couple states who hang on a year beyond 2024 with their expansions," Fiedler told me.
According to the CBO, the number of people who won't have Medicaid as a result of this bill will go from 12 million in 2023 to 14 million in 2024.
Another presidential election happens this year. If Trump won a second term in 2020, he'll be out for good now. Who will take his place, and what the healthcare debate will be like, is anyone's guess.
The increase in the number of uninsured reaches 22 million people.
We're way in the future now, so there's a lot of uncertainty. By 2026, we might be able to stream all five Avatar movies straight to our VR contact lenses, with devastating mental health consequences for millions. Who knows?
This is as far as the CBO report projects. It's taken a while, but the combination of lower Medicaid spending and reduced subsidies has taken a big toll.
Here's a key passage from the CBO report: "By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law."
Here's another key passage: "Even with the net premium of $300 shown in the illustrative examples for a person with income at 75 percent of the [federal poverty line] ($11,400 in 2026), the deductible would be more than half their annual income." That's barely better than no insurance at all.
What's on the other side of the scale? A total of $321 billion in deficit reduction, according to the CBO. And according to CNN, those in the top 0.1 percent tax bracket, meaning people earning at least $5 million, would get on average about $250,000 in tax savings in 2026. So there's that.
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Note: A previous version of this article incorrectly spelled Matthew Fiedler as "Matthew Fielder."