WASHINGTON -- The Senate Republicans' bill to repeal and replace the Affordable Care Act (ACA) will result in 22 million fewer people having health insurance in 2026 compared with current law, .
That number is a million shy of the estimate of 23 million people that the CBO estimated would be cut from the insurance rolls during that same period under the House version of the bill, known as the American Health Care Act. That bill passed the House on May 4. The Senate bill -- known as the -- that was scored Monday by the CBO is a revised version of the discussion draft released last week.
The Senate repeal-and-replace bill would also cut the deficit by $321 billion through 2026, which is $202 billion more than the reduction in the deficit under the House bill, the CBO said. The reductions include a $772 billion cut in Medicaid spending -- a little lower than the $800 billion Medicaid cut in the House version of the bill -- and $408 billion in reduced subsidies for individual enrollees in the health insurance exchanges. Those spending reductions are partially offset by $541 billion in tax cuts and $210 billion in reduced penalties collected from employers and the uninsured, as well as $107 billion in increased spending to help some enrollees reduce their premiums and for other purposes.
The Senate bill has many similarities to the House bill, including the use of per-capita caps to lower Medicaid spending (with an option for states to chose block grants instead), the repeal of the ACA's individual and employer mandates, and a provision allowing states to impose work requirements on Medicaid recipients. However, while the House bill would allow insurers to levy a 1-year premium surcharge to enrollees in the individual health insurance marketplace who had a gap in insurance coverage of at least 63 days, the Senate bill did not include that option.
Instead, the revised version of the Senate bill would require those whose health insurance had lapsed for at least 63 days to before coverage under a new policy would become effective (they would not have to pay premiums during the waiting period). The waiting period could last up to 12 months depending on whether or not the individual involved signed up during an open enrollment period.
Compared with the House bill, the Senate bill “saves a lot more money and leads to 1 million fewer uninsured, but other than that, it has a similar impact,†said Chris Sloan, a health policy expert at Avalere, a consulting firm here. “You’ve still got 7 million fewer [insured] in the individual market, 15 million fewer in Medicaid, and [a total of] 22 million more uninsured. So the way they get to those numbers is a little different, but the results are effectively the same.â€
One reason the Senate bill would cut the deficit more than the House bill is that it would pay subsidies to enrollees in the health insurance marketplace plans based on the cost of a lower-priced bronze plan, rather than a silver plan, Sloan explained. “When you peg the subsidies to lower-cost plan, the subsidies cost less,†although from the enrollees’ standpoint, bronze plans have higher deductibles and more cost-sharing than silver plans, so they often end up paying more out-of-pocket for their care.
For providers, passing the bill will mean that fewer of their patients will be insured, Sloan said, noting that the ACA cut so-called disproportionate share (DSH) payments to hospitals that treat large numbers of low-income patients “predicated on the fact that hospitals and providers were going to see more insured patients, so they wouldn’t need [those payments]. This bill eliminates those DSH cuts starting in 2018 for states that did not expand Medicaid. And it also provides some funding for safety net hospitals in non-expansion states.â€
Rep. John Garamendi (D-Calif.) told ľֱ in a phone call thatthe Senate bill is “at least as mean if not meaner†than the House bill.
Cuts to the Medicaid program will leave states with the option of “back-filling†lost funding, which for California amounts to $16 billion, said Garamendi, a former insurance commissioner for the state.
Asked if this bill could be characterized as a “rescue†bill to save the allegedly collapsing insurance market, as Republicans have argued, Garamendi was skeptical.
By pulling away money for reinsurance and for advertising the administration is starving the insurance market and causing it to fail, he said. On top of that the repeal-and-replace bills from the legislature create even more uncertainty for the market, Garamendi continued.
“Insurers are indeed pulling out of the insurance market because they have absolutely no idea how to structure their policies or what to charge for them … because they don’t have any certainty,†he continued.
“[Republicans] created the problem and then they say they are solving the problem,†Garamendi said. “Only one of those things is true.â€
Both the House and Senate bills continue to rack up opposition from healthcare groups. On Monday, the National Association of Medicaid Directors (NAMD), a bipartisan organization representing leaders of state Medicaid agencies, saying that the per-capita caps in the Senate bill "would be a transfer of risk, responsibility, and cost to the states of historic proportions. While NAMD does not have consensus on the mandatory conversion of Medicaid financing to a per capita cap or block grant, the per capita cap growth rates for Medicaid in the Senate bill are insufficient and unworkable."
“This bill puts the protections and peace of mind that come with comprehensive health insurance out of reach for millions of people—including children, the elderly, and those with disabilities,†Richard Besser, MD, president and CEO of the Robert Wood Johnson Foundation, said in a statement. “Every member of Congress must weigh the policy and moral implications of taking insurance from 22 million people … Cutting a lifeline to affordable health care is a step in the wrong direction.â€
“The bill is a step backwards for the health of millions of American families,†said Harold Wimmer, national president and CEO of the American Lung Association, in a statement. “Healthcare legislation should put the health of Americans first, and this Senate bill puts the health of Americans last … The American Lung Association urges the Senate to scrap this bill and instead start again, focusing on improving care in a new, bipartisan process.â€
The American Medical Association (AMA) also opposed the bill Monday in the form of a . "Medicine has long operated under the precept of Primum non nocere, or 'First, do no harm,'" wrote James Madara, MD, the AMA's executive vice president and CEO. "The draft legislation violates that standard on many levels."
The AMA also objected to the bill's per-capita caps on Medicaid spending. "Per-capita caps fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation." And the association decried a provision in both the House and Senate bills which would take away funding for Planned Parenthood.
"We also continue to oppose Congressionally-mandated restrictions on where lower income women (and men) may receive otherwise covered healthcare services – in this case the prohibition on individuals using their Medicaid coverage at clinics operated by Planned Parenthood," wrote Madara. "These provisions violate longstanding AMA policy on patients' freedom to choose their providers and physicians' freedom to practice in the setting of their choice."