CBO Releases Score For House-Approved American Health Care Act

The Congressional Budget Office gave its projections Wednesday on the costs and impact of the version of the American Health Care Act passed by the House earlier this month.

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We now have a score of the health care bill recently passed by House Republicans. That's what the analysis from the nonpartisan Congressional Budget Office is called. Economists have estimated how much the bill will cost and how many Americans it's expected to cover. NPR congressional correspondent Susan Davis has read the report. She joins us now to talk about those numbers and what they mean as the bill heads to the Senate. And Susan, to start, what does the CBO say the budget impact would be if this House bill actually became law?

SUSAN DAVIS, BYLINE: Well, the first news that I think will be good news for Republicans is that it saves money. It says that it would reduce the federal deficit by about $120 billion over the next 10 years. The original forecast on the bill earlier this year said that it would leave 24 million fewer Americans insured over that same period of time, that 10-year period. This report is slightly better. It estimates only 23 million fewer Americans will be insured over the next decade. And it also forecasts that premiums on the individual market would be lower.

Now, the caveat of course, Audie, is they say premiums would be lower because of the changes Republicans made to the bill that would give states options to get waivers from the current law mandates on what insurance plans have to cover as well as how pre-existing conditions are covered.

CORNISH: Let's talk more about pre-existing conditions. How will they be affected according to this report?

DAVIS: Audie, I think this is one of the most notable parts of this update and something that we're going to be hearing a lot more about. Republicans said the changes they were making to the bill would not hurt people with pre-existing conditions or their access to coverage. Their argument is that their plan would give states more flexibility, and they included more money in what they were calling stability funds to help people buy those premiums if they needed to. CBO says very clearly that's not the case. In this report, it states that premiums for up to one-sixth of the people in the individual market could see their premiums go up, and they wouldn't be able to afford them.

In the very nerdy, wonky CBO language, they say, quote, "instability would cause some people who have been insured under current law to be uninsured." Now, the pre-existing condition protections are arguably the most popular part of Obamacare, and Republicans campaigned on keeping those protections in place. So if this is seen as an effort to weaken them, this is an area where I think we could see a huge backlash, at least politically.

CORNISH: When it comes to the politics, I know the CBO has been a bit of a political football for lawmakers. How are they reacting to the report?

DAVIS: You know, it doesn't really shift the debate. This is, as you know, one of the most partisan debates on Capitol Hill about this health care bill. You know, there's a lot of fodder in here for Democrats to continue to oppose the legislation. Republicans have been largely dismissive of it. They note that in the past, CBO forecasts have been wrong, and many of them think they'll be wrong again. For - that 23 million fewer insured, you know, Republicans will say that's because the repealing the individual mandate. And that is what they promised to do.

Their argument is that fewer people will have to buy something they don't want in the first place. House Speaker Paul Ryan put out a statement on it, and he said that the bill accomplishes their mission. And the mission as he defines it is, quote, "lowering premiums and lowering the deficit." And if that is Republicans' goal this bill does that.

CORNISH: And in the meantime, what does this mean for the Senate? They're still writing their version of the bill.

DAVIS: You know, Senate Majority Leader Mitch McConnell gave an interview to Reuters today in which he said he does not know yet how he's going to get to 50 votes. We don't know a lot about what's happening in the Senate because it's all happening behind closed doors. There's a 13-member Republican working group. They're meeting at least twice a week in private to try and craft a bill that can pass the Senate. We don't know what that bill's going to look like, but the goal is to try and have a bill and to pass it by the August recess. We do know that senators do not see the House bill as where they need to go and are going to write their own very different bill.

CORNISH: NPR congressional correspondent Susan Davis. Thanks so much.

DAVIS: Thank you, Audie.

Copyright © 2017 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.</s>Candidate Donald Trump promised better and more affordable health care, but as president his first full budget calls for deep cuts to popular insurance programs. And it omits any proposal for negotiating prescription drug prices, a frequent Trump talking point.

While not addressing Medicare's long term financial problems, the budget targets the much smaller Children's Health Insurance Program, or CHIP. And Trump's Medicaid cuts appear even bigger than those in the health care bill recently passed by House Republicans, above what would be needed to fulfill the GOP vow to repeal "Obamacare."

Both safety net programs are federal-state collaborations, and such cuts would leave states with hard choices: spend more of their own money; restrict enrollment; cut benefits, or reduce payments to hospitals and doctors.

"If states get fewer dollars from the federal government, there are only so many options, because states have to balance the budget every year," said Elizabeth Carpenter, a health policy expert with the consulting firm Avalare Health.

Trump's budget was silent on bargaining with the pharmaceutical industry to reduce the cost of prescription drugs, a topic the president has often touched on. But the budget repeated Trump's previous proposals for double-digit percentage cuts to the National Institutes of Health and the Centers for Disease Control and Prevention, considered nonstarters even by Republican lawmakers.

The trillion-dollar-plus Department of Health and Human Services, whose programs cover more than 130 million people, did not hold its customary budget briefing on Tuesday. From Europe where he is attending a world health conference, HHS Secretary Tom Price released a statement that said the budget "outlines a clear path toward fiscal responsibility by creating efficiencies that both improve services and save money."

As a candidate and as president Trump has frequently talked about making health care more affordable for regular folks, including by lowering premiums and deductibles. He promised not to cut Medicare, and initially, Medicaid as well. But to some experts, Trump's budget looks more like a cost shift from the federal government to the states and to people now benefiting from coverage expansions in the Obama years.

"I think it will be challenging for states to try to figure out what to do," said Trish Riley, executive director of the nonpartisan National Academy for State Health Policy, which advises states.

Coverage for children previously had not figured as a major issue for the administration, which separately is calling for paid parental leave. The CHIP health program covers about 7 million children, and traditionally enjoyed bipartisan support. While Trump's budget would extend CHIP for another two years, it would also cut $5.8 billion.

"It's a big impact," said Riley. States would receive significantly lower overall payments from the federal government, and Washington would no longer match state spending on coverage for kids whose families make more than two-and-a-half times the federal poverty level, about $51,000 for a family of three.

More than half the states now cover children above the administration's proposed cutoff, Riley said. Administration officials say that the limitation proposed in the budget would focus taxpayer money on families who need it the most.

Medicaid is facing even bigger cuts. Already, the House GOP bill would roll back former President Barack Obama's Medicaid expansion while also capping future federal financing for the program. The Congressional Budget Office estimates that would reduce federal Medicaid spending by $839 billion over 10 years.

Trump's budget would squeeze additional savings beyond that, but congressional aides say how much is not exactly clear. White House Budget Director Mick Mulvaney has indicated that the budget uses a lower growth rate for the federal government's share of future Medicaid spending.

"The Trump budget assumes hundreds of billions more in Medicaid cuts than the House bill," said Edwin Park, a health policy expert with the Center on Budget and Policy Priorities, which advocates for low-income people.

On Capitol Hill, Trump's budget won polite praise from some Republicans, but Democrats were dismissive. "This is the budget you write if you think working families have it too easy," said Sen. Ron Wyden of Oregon, ranking Democrat on the committee that oversees health care financing.</s>President Donald Trump's new budget plan calls for deeply cutting Medicaid over the next decade, a proposal that was swiftly slammed by top Pennsylvania Democrats.

The administration's new budget blueprint, released Tuesday morning, would slash $610 billion from the program, which provides health coverage for 2.8 million low-income, disabled, and elderly Pennsylvanians, including some seniors who are eligible for both Medicare and Medicaid.

It would do so by either capping the amount that states receive for each Medicaid enrollee, or offering states a block of funding with more flexibility in how state officials provide health care to their beneficiaries.

Currently, the federal government pays states based on the health care services used by their Medicaid enrollees. Those costs are roughly split between the two levels of government, but a flat contribution from the federal government would leave states to fill in any gaps or adjust services if costs rise.

"We are not spending less money one year than we spent before," said White House budget director Mick Mulvaney. "What we are doing is growing Medicaid more slowly over the 10-year budget window than the Congressional Budget Office says that we should or says that we will under current law."

Gov. Tom Wolf criticized the Trump administration's approach, which is similar to a bill approved by House Republicans earlier this month, as one that would "force seniors to pay more for health care."

"Medicaid is a lifeline for seniors across Pennsylvania that helps pay the costs of nursing home care," Wolf said in a statement. "The Trump budget proposes deep and devastating funding cuts over the next ten years, which would force many seniors out of nursing homes."

U.S. Sen. Bob Casey said the proposed Medicaid changes would "devastate Pennsylvanians living in rural communities."



The administration's budget proposal also lists $250 billion in savings from undoing the Affordable Care Act, which expanded who is eligible for Medicaid. Trump "supports a repeal and replace approach that improves Medicaid’s sustainability and targets resources to those most in need," the budget document states.

Senate Republicans have been working on their own Obamacare replacement bill after the House Republican approved their approach this month.

U.S. Sen. Pat Toomey, R-Pa., is part of the Senate GOP working group on health care, and has been working directly on Medicaid changes. He's seeking to limit the program's future cost increases.</s>Republicans have argued that the bill’s waivers would not hurt insurance access for people with pre-existing health conditions, thanks to state funding devoted to high-risk pools subsidizing their coverage. The C.B.O. essentially dismissed that idea, saying that the state funds would not be enough to protect sick customers from huge bills.

Premiums for healthier customers would go down in those states, though some people might end up buying plans so flimsy that the budget office said they didn’t count as insurance. A second set of states that pursued more limited waivers of insurance rules could enjoy premiums some 20 percent lower than expected under the Affordable Care Act in exchange for more limited benefits, it said.

Republicans have argued that letting states waive the insurance rules would lead to a more robust and attractive insurance market. The C.B.O. disagreed with that argument, too. It said that markets in the states with waivers would become smaller than under an earlier version of the bill that did not include the waivers. In response, more employers would offer workers coverage, it said, since they would see individual coverage as an unattractive alternative.

Over all, the budget office found that the law would mean 23 million more people would lack insurance than under current law, a slight decrease from its assessment of an earlier draft that did not include the waivers. But it noted that the group without insurance would not be precisely the same as it would under the earlier bill. The uninsured would be more likely to be the kind of patients who rely on health insurance most.</s>People who are pregnant, mentally ill or have pre-existing health conditions could face skyrocketing premiums under the Republican health care plan, according to a new Congressional Budget Office report.

The CBO projects that several states will waive the Obamacare rules that prevent insurers from raising prices on people due to their individual health circumstances, and this will lead to rapid cost increases for people facing health problems.

The CBO found that the American Health Care Act, which was passed by the House but still needs to be approved by the Senate, will save $119 billion over the next decade at a cost of 23 million more uninsured people than under Obamacare.

The state waivers allow insurers to offer bare bones insurance plans and charge higher rates to people with pre-existing conditions, all in the hopes of slashing premium costs everyone else.

Republicans were hoping for a boost in the projection of insured people. They did not get it.

The CBO projected the original AHCA to cause 24 million more uninsured people over the next decade. For the amended bill, that number drops by just one million to 23 million new uninsured.

The CBO expects less healthy people to face "extremely high premiums" in states that exercise the waivers.

"Over time, it would become more difficult for less healthy people (including people with preexisting medical conditions) in those states to purchase insurance because their premiums would continue to increase rapidly," says the report.



The CBO projects about one sixth of the American public to be affected by the waivers. It expects several benefits that currently are mandated to be part of all insurance plans to be dropped. These include maternity care, mental health services, substance abuse treatment, 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," says the report.

The CBO says the AHCA will lower premium costs on average, but this is tied to plans covering a smaller percentage of total health care costs.



The CBO projects the amended AHCA to cut $834 million from Medicaid over the next decade, most of which is redirected into tax cuts. The CBO projects Medicaid rolls to shrink by 14 million people over the next decade as the Obamacare Medicaid expansion is rolled back.

Premiums will rise for plans that do not discriminate against people with pre-existing conditions in states that adopt the waivers, according to the report. The theory is that healthier people, who are less expensive to cover, will move into the cheaper health plans that only they are eligible for. This will raise costs on everyone, sick or healthy, in other plans.

This is a developing news story. Check back for updates or follow BuzzFeed News on Twitter.</s>There are 2 comments on the The San Diego Union-Tribune story from 11 hrs ago, titled Congressional Budget Office. In it, The San Diego Union-Tribune reports that:

The Congressional Budget Office says the health care bill Republicans pushed through the House this month would leave 23 million additional people uninsured in 2026, compared with former President Barack Obama 's health care law. The nonpartisan office also says that compared with Obama's 2010 overhaul, average premiums for people buying individual policies would be lower.

Join the discussion below, or Read more at The San Diego Union-Tribune.</s>WASHINGTON (AP) – The health care bill Republicans have pushed through the House would leave 23 million additional people uninsured in 2026 compared to President Barack Obama’s health care law, the Congressional Budget Office said Wednesday.

The GOP bill would lower average premiums, but in part that would be because coverage would typically be skimpier.

The nonpartisan analysts were also critical of 11th-hour provisions that GOP leaders had added to pick up votes and assure the bill’s passage. Letting states get federal waivers so insurers could charge higher premiums for people with pre-existing medical conditions would mean those consumers would “ultimately be unable to purchase” comprehensive coverage at prices comparable to today’s costs, “if they could purchase at all.”

The report was the budget office’s first analysis of the GOP health care overhaul that the House narrowly approved this month with only Republican votes. Two budget office reports in March on initial versions of the bill projected that 24 million people would lose coverage, and that premiums would rise over the next two years but fall by 2026.

Democrats have said the GOP bill would toss people off their coverage, threaten their benefits and jeopardize coverage for people with serious, costly to treat medical conditions.

Republicans have said they are largely focused on steps that will reduce premiums.

The House bill would also reduce the federal deficit by $119 billion over the next decade, according to the new projection. That’s slightly less than the $150 billion the office estimated in March.

The new estimates will serve as a starting point for GOP senators starting to write their own version of the legislation as they consider changing the House’s Medicaid cuts, tax credits and other policies.</s>The Congressional Budget Office reports the impacts of the new health care plan.</s>The revised Republican bill to repeal and replace the Affordable Care Act will leave 23 million more people uninsured in 2026 than if that act, also known as Obamacare, were to remain in place. The GOP bill would also reduce the deficit by $119 billion over 10 years.

That’s what the nonpartisan Congressional Budget Office reported on Wednesday in its latest score of the American Health Care Act. The CBO’s assessment shows that the deficit would fall and premiums would fall for some Americans, but the report also raises potential concerns about the bill. The agency reports that the bill could destabilize individual insurance markets in some states, leaving unhealthy Americans unable to buy insurance.

The bill will now move on to the Senate, and should it pass that chamber, it will not look like this current AHCA version. As NPR’s Susan Davis reported on Wednesday, the Senate will likely write their own version of the bill. Senate Majority Leader Mitch McConnell also told Reuters he doesn’t know what that path to passing the bill will look like.

“I don’t know how we get to 50 (votes) at the moment. But that’s the goal,” he said.

The $119 billion deficit reduction represents a decline from previous versions. When the CBO first scored the AHCA, it said the plan would save $337 billion over 10 years. Later revisions reduced those savings to $150 billion.

By far the biggest savings would come from Medicaid, which serves low-income Americans. That program would face $884 billion in cuts. Cutbacks in subsidies for individual health insurance would likewise help cut $276 billion. But those are offset in large part by bigger costs, including the repeal of many of Obamacare’s taxes.

Those tax cuts would overwhelmingly benefit the highest-income Americans, the Tax Policy Center, a Washington think tank, reported on Wednesday.

The increase in the number of uninsured is also slightly lower than in the CBO’s initial estimate. That report estimated that 24 million fewer would be insured in 2026 if this bill were to become law, putting the uninsured rate at around 18.6 percent. This revised bill would reduce that by around 1 million — a difference of less than half a percentage point.

In contrast, the uninsured rate in 2026 would be around 10 percent under Obamacare, the CBO reports.

More than half of that increase in the uninsured — 14 million — would come from reduced Medicaid enrollment.

The CBO also notes that the AHCA could mean some Americans would buy coverage that doesn’t cover “major medical risks.” Because of those policies’ skimpy coverage, the CBO doesn’t count those people as insured in this report.

The Trump administration responded by saying it believes the CBO’s numbers are unreliable.

“History has proven the CBO to be totally incapable of accurately predicting how healthcare legislation will impact health insurance coverage,” the White House said in a statement.

The CBO did indeed far overestimate the number of people who would sign up for the Obamacare exchanges, as FactCheck.org’s Brooks Jackson wrote in March. Likewise, it undershot on the number of Medicaid enrollees. (That said, Jackson added, the CBO predicted the uninsured rate relatively closely.)

Difficulties for some addicted, pregnant or sick Americans

The act could make obtaining health care coverage prohibitively expensive for some sicker Americans, the CBO found.

That’s because under the AHCA, states could get waivers exempting them from some Obamacare provisions, including what are called “essential health benefits” — a list of basics like mental health and prescription drugs that the Affordable Care Act required plans to cover. States could also get waivers that allow insurers to charge more for people with pre-existing conditions.

One challenge the CBO faced in creating these estimates was figuring out how many states would get those waivers, and the report acknowledges that this creates some uncertainty in the estimates. In the end, they estimated that around one-sixth of the population lives in states that would seek both of those waivers. Around half of Americans live in states that would seek no waivers, meanwhile, and the remainder live in states that would make “moderate” changes.

In states that obtained both of those waivers, it would mean lower premiums for people buying individual insurance. But less healthy Americans in those states could face “extremely high premiums,” the report said.

“Over time, it would become more difficult for less healthy people (including people with preexisting medical conditions) in those states to purchase insurance because their premiums would continue to increase rapidly,” the CBO wrote.

Waiving essential health benefits could also make medical care much more expensive for people who are pregnant, addicted, or have other mental health issues, and who live in those states that waive those 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,” the report says of people living in those states.

Under current law, the CBO wrote, the markets will be “stable in most areas” because lower-income Americans buying individual insurance will be shielded from rising Obamacare premiums, thanks to subsidies.

However, the report acknowledges that insurers have reduced their participation in the exchanges, leaving some Americans with no options for buying insurance. “The Affordable Care Act doesn’t have a back-up plan for this situation,” as Vox’s Sarah Kliff and Sarah Frostenson reported Wednesday, so it’s not clear how this could play out.

Medicaid accounts for by far the biggest spending reductions under the American Health Care Act. The bill would roll back the Medicaid expansion instituted under the Affordable Care Act, which extended the program to cover some Americans with incomes up to 133 percent of the poverty line. That expansion grew enrollment by 10 million, as NPR’s Alison Kodjak previously reported. Rolling back that expansion would limit future enrollments.

The AHCA would also give states a choice: Receive Medicaid funding either via a block grant or receive a per capita amount per enrollee.

Together, these changes would create major cuts in enrollment for the program: 14 million fewer people by 2026, and $834 billion in spending cuts over a decade.

Average premiums would be lower in 2026 than they would be under Obamacare, both in states that do and don’t seek waivers. But it’s impossible to make a meaningful blanket statement about how premiums would change under this bill, as those changes differ vastly for different groups of people.

For example, older Americans who make little money and buy individual insurance would see their premiums climb far beyond what they would be under Obamacare. A 64-year-old making $26,500 would pay $1,700 in premiums annually under Obamacare. In a state making those “moderate” changes to its market, that 64-year-old would pay $13,600, and in a state with no waivers, the cost would be $16,100. That’s more than nine times that person’s premium under the Affordable Care Act.

However, younger Americans would see little change in their premiums, or even declines. Likewise, some people with higher incomes could see substantially lower premiums under this bill. For example, a 40-year-old paying $6,500 a year under current law could pay an estimated $2,100 in a state with “moderate changes” to its market.

The bill moves on to the Senate

The CBO’s newly estimated deficit savings mean the bill can safely move on to the Senate.

The future of the bill hinged upon this report, as House Republicans passed their most recent version of the bill without waiting for the CBO to report the bill’s estimated price tag. Three weeks after passing the bill, however, they have not sent the bill on to the Senate yet, because they were waiting on this score. Budget rules dictate that if the bill’s deficit savings had not reached $2 billion (and that $2 billion had to come from particular spending categories), the bill would be dead upon arrival in the upper chamber.</s>iStock/Thinkstock(WASHINGTON) — Republicans on Capitol Hill are preparing for the release of the Congressional Budget Office’s analysis of the GOP health care bill that passed the House earlier this month.

The estimate of the American Health Care Act impact on the federal deficit could determine whether the Senate will take up the measure, which passed with only one vote to spare in the House.

Senate budget rules require the AHCA to save $2 billion over 10 years in order to be taken up under reconciliation — a process that would allow Senate Republicans to pass the bill with only 51 votes.

If the nonpartisan CBO determines that the bill doesn’t pass muster for reconciliation, Democrats would be able to filibuster the measure, which could send the bill back to House Republicans to amend and hold another vote.

Republican leadership aides say it’s unlikely the bill won’t meet the Senate requirements.

The CBO score will also include an estimate of whether the number of Americans with health insurance would change and by how much.

An earlier analysis of the bill estimated that 24 million Americans would lose health insurance under the GOP’s AHCA, compared to Obamacare.
The Congressional Budget Office predicts that in the next decade, the new health care bill recently approved by the U.S. House of Representatives will reduce the federal deficit by $120 billion and leave 23 million more Americans uninsured, as opposed to current law.