The number of uninsured Americans would rise by a total of 24 million by 2026 under the Republican American Health Care Act, according to a key independent analysis – but the end goal was never about the number of people covered, President Trump’s budget point-man says.

Really? How can coverage not be the point?

It comes down to a philosophical difference between Republicans and Democrats on the role of government in health care, observers explain. And then it comes down to a whole lot of other things, including division among Republicans about their philosophy, and the workability – and politics – of the GOP plan itself.

On Monday, the independent Congressional Budget Office estimated that the GOP legislation to repeal and replace the Affordable Care Act (ACA) would reduce federal deficits by $337 billion over 10 years, a point that's sure to cheer many.

But the strong increase in the number of uninsured under the plan is sure to invigorate the plan's opponents. Next year, according to the report, 14 million more people would lack insurance than under the current law.

Most of that would be because the GOP plan removes the penalties in connection with the "individual mandate." Some would choose to drop forced insurance and some would drop it because of higher premiums, the report said.

Longer term, however, that number would jump by another 10 million and would occur mostly among those who would have been covered by Medicaid, which is health care for the poor.

The ACA, popularly known as Obamacare, allowed for the expansion of Medicaid enrollment, but the GOP plan would phase that out starting in 2020 and would also cap federal Medicaid payments to the states. The estimate of uninsured is a politically problematic number for Republicans and one that the GOP has been working to undermine in anticipation of the report.

For several days, President Trump’s chief budgeteer, Mick Mulvaney, has been saying that the GOP plan is not about the numbers covered but about Americans’ access to quality care they can afford – and allowing them to make their own health care choices.

Democrats, on the other hand, want government to guarantee that all Americans have coverage – requiring them to sign up for it – while using private markets in that effort.

Under Obamacare, Americans “can afford to have a little plastic piece of paper that says they have an insurance policy, but they can’t afford to go to the doctor” because of impossibly large deductibles, Mr. Mulvaney said on ABC’s "This Week" on Sunday. So what good is that?

“Insurance is not really the end goal,” Mulvaney said last week – despite the fact that his boss, President Trump, has promised that “everyone” will have “beautiful” coverage.

What Mulvaney is getting at is a conservative view, shared, for instance, by House Speaker Paul Ryan (R) of Wisconsin, that free markets and competition will drive down costs to such an extent that everyone who wants health care will be able to afford it, says Dan Holler, spokesman for Heritage Action. This is a conservative advocacy group that backs the hard-line Freedom Caucus in the House that wants the GOP plan to go even further. Mulvaney belonged to this group when he was a congressman just last year. Both Speaker Ryan and Mulvaney back some government help – in the form of tax credits – as part of that equation. Freedom Caucus members object to those tax credits, calling them a new entitlement.

Democratic minority leader Rep. Nancy Pelosi’s description of health care as a “right” and not a “privilege” avoids the fundamental question of whether the government can mandate coverage and decide what should be in policies – as it does in Obamacare, says Mr. Holler.

“The fundamental divide is what is the government’s role.”

In the very broadest sense, that’s true, but Heritage Action does not speak for all conservatives and neither are the White House nor Republicans in Congress speaking with one voice on GOP repeal and replace plans, notes Joseph Antos, a health policy expert at the conservative American Enterprise Institute think tank in Washington.

In an interview ahead of the CBO report, Mr. Antos says that millions of people without insurance as a result of the GOP plan will be politically devastating for Republicans. They will “take an unbelievable amount of grief which will be very difficult to deal with in the next election.” There will also be “negative consequences” for people who may have benefited from Obamacare coverage but who would lose it under the GOP plan.

Antos is particularly concerned that the Republican plan would give poor Americans tax credits to purchase insurance that are much lower than the federal subsidies provided to consumers under Obamacare.

“Sick people spend a lot of money on health care and they need help with it," Antos says. "I don’t think it’s any harder than that.”

In addition to decreasing the federal deficit, there was some more good news for Republicans in the CBO assessment: Markets would be generally stable under this change, and average premiums would increase until 2020 and then decrease — though older Americans would pay "substantially" more.

The selling of the GOP’s American Health Care Act is complicated by the fact that it is only the first stage of a three-pronged strategy designed to reduce costs – without any detailed spelling out of the other two stages or guarantee that they will work.

Ryan points to the other phases of repeal-and-replace: rules changes by Tom Price, Trump's new secretary of Health and Human Services, and then separate legislation that will need to pass a 60-vote bipartisan threshold in the Senate.

Ryan likes to cite the 1,442 items in Obamacare that are subject to action by the health secretary – actions that Ryan said can “dramatically lower the price of health insurance.” Experts give as an example the possible redefinition of maternity coverage.

Ryan told reporters last week, however, that Secretary Price “can’t tell you what he’s thinking about doing” because of “legal reasons.”

The speaker was a bit less cryptic about the GOP’s legislative ideas, including a bill to allow health insurance competition across state lines – like auto insurance – and a bill to allow associations, such as farmers’ groups, to purchase health insurance.

Still, it is far from certain that Senate Democrats would help Republicans in their repeal-and-replace effort by passing such bills.

Without the two other pieces in place, “this bill can’t stand on its own,” says Antos. “It doesn’t fully add up.”

Republicans may try to differentiate between “universal access” to health care, as Ryan puts it, and the “universal coverage” of the Democratic vision. But that distinction will be meaningless to Americans if millions of people are deprived of coverage under a GOP plan.

Get the Monitor Stories you care about delivered to your inbox. By signing up, you agree to our Privacy Policy

“What is the purpose of health reform? Most Americans agree that expanding is the purpose and that the number who are uninsured or without coverage should not rise because of repeal,” writes Lawrence Jacobs, a political science professor and health-care policy expert at the University of Minnesota in Minneapolis, in an email.

“President Trump promised that everyone would continue to be covered.”