CBO: 32 million to lose their health coverage by 2026 under repeal-and-replace bill

Updated at 5:18 pm

Senate Republicans' repeal-and-delay bill would cause 32 million to lose their health coverage by 2026 and 17 million to become uninsured next year, according to a new projection released today the Congressional Budget Office.

Under the Senate GOP's initial bill, which proposed a replacement for the Affordable Care Act, the CBO projected that 22 million would be uninsured by 2026 as a result of the law. Lacking support for that bill, the Better Care Reconciliation Act, Majority Leader Mitch McConnell pulled the plug on a repeal-and-replace strategy and is now considering the repeal-and-delay tactic. President Donald Trump today urged senators to send him a bill, even if it means further delaying their August recess.

"For seven years you promised the American people that you would repeal Obamacare. People are hurting. Inaction is not an option and frankly I don't think we should leave town unless we have a health insurance plan," he said during a lunch with GOP lawmakers.

Three Republicans senators already said on Monday they would not even agree to start debating a repeal-and-delay approach. Sen. Susan Collins of Maine voted against the same bill in 2015, and Alaska's Lisa Murkowski and West Virginia's Shelley Moore Capito also said they are not going to vote for repeal without knowing whether they can live with the replacement.

McConnell (R-Ky.) needs 50 of the 52 Republicans to vote yes to get the bill passed, because Vice President Mike Pence would be the tiebreaker.

The repeal-and-delay bill cuts less out of Medicaid than the BCRA because while it ends the enhanced match for Medicaid expansion—which led to 12 million people getting coverage—it does not change the financing to Medicaid for the children, disabled adults, parents of young children and elderly people on the program. The enhanced match would only last until 2019 and 2020. The 6 percentage point increase for home healthcare waiver activities would also disappear at the beginning of 2020.

However, repeal and delay leaves the fate of the individual market completely in the dark, because it's unknown what kind of subsidies would be available for low and moderate income people to buy insurance in the yet-to-be written replacement. The bill would appropriate cost-sharing reduction payments to insurers through the end of 2019.

The CBO estimate assumes nothing is done to replace the ACA, which would mean premiums would increase by 50% more than would be expected under current law by 2020, and they would about double by 2026.

Next year, the CBO projected, about 10 million fewer people would be in the individual market, mostly because they don't want to buy insurance, and without a mandate, they'd stop buying policies. However, the CBO also projects that 10% of the population would live in counties that have no insurer willing to sell individual policies.

It would get worse quickly. The nonpartisan budget shop projects that half the U.S. population would not be able to buy individual plans at all by 2020, and 75% would have no willing seller by 2026, because it would be so unprofitable to sell such high-priced insurance with no help to pay premiums. Only the sickest people would find it worthwhile to pay in that scenario.

The 17 million increase in uninsured next year also includes about 4 million fewer people going into Medicaid, because they wouldn't hear about the mandate, visit the exchange, and find out they qualify for free health insurance. It also includes roughly 2 million fewer people on employer-sponsored insurance next year without the employer mandate.

The repeal-and-delay approach does add a little spending in healthcare.

Hospitals would get $21 billion back over 10 years in the disproportionate-share hospitals program.

The bill would also appropriate $1.5 billion in the next two fiscal years for grants to states for substance abuse or mental health needs. It would add $422 million to federally qualified healthcare center spending in the current fiscal year.

The bill gives senators two years to figure out a replacement. In the nearly seven months since controlling both the executive and legislative branches, they've been unable to find middle ground between conservatives and moderates in the Republican Party.

Some Republican senators are meeting Wednesday night to try to bridge the divide, after the president exhorted them to at lunch today. HHS Secretary Dr. Tom Price and CMS Administrator Seema Verma will also attend.