The Congressional Budget Office released its assessment of the bill. CBO reports that the bill’s biggest costs come from reducing payroll and investment income taxes for high-income individuals and insurance companies, and its new age-based tax credits. Its biggest spending reductions come from cutting Medicaid and subsidies for people who buy their own insurance.
The Medicare Rights Center expressed concern over the “secretive and rushed manner” in which the bill was developed, and concern about the negative effects it will have on people with disabilities and the elderly.
The American Hospital Association does not support the bill, arguing that the Medicaid caps will lead to “significant reductions in a program that provides services to our most vulnerable populations” and reminding Congress that progress on our substance abuse crisis is linked to the progress we’ve made on insurance coverage. America’s Essential Hospitals also opposes the bill, arguing that capping Medicaid spending and de-funding the Medicaid expansion to childless adults would force them to reduce services and staff.
The American Medical Association opposes the bill overall. The organization particularly highlighted the bill’s age-based, instead of income-based, financial assistance; its roll-back of the Medicaid expansion; capped funding for Medicaid; its elimination of the Public Health and Prevention Fund; and its de-funding of Planned Parenthood.
The AARP has come out against the idea of allowing insurers to charge older people five times more than younger people in a video. The ACA allows insurers to charge older people three times more.
Initial estimates of coverage losses range from 6 to 10 million newly uninsured to 20 million. Standard & Poor’s estimates 6 to 10 million, assuming that in wealthier states like New York, tax payers will begin paying more to cover the federal cuts.
The Commonwealth Fund examined the history of proposals to change Medicaid into a block-grant program or to fund it based on per-capita caps. They argue that both would “divorce funding considerations from the real-life needs that have informed federal and state Medicaid policy for half a century.”
Health Savings Accounts
The Center on Budget and Policy Priorities examined whether health savings accounts are a suitable replacement for the ACA, finding that the accounts “do little or nothing to help the uninsured afford coverage but offer high-income people lucrative tax-sheltering opportunities.”
The Commonwealth Fund examined the results of the national high-risk pool that existed before the ACA’s pre-existing condition protections, and concludes that the pools are “prohibitively expensive” for both states and consumers while offering “much less than optimal” coverage.
The Kaiser Family Foundation found that the national high-risk pool and the 35 high-risk pools run by states before the ACA covered only a fraction of the people who could not buy insurance because of their pre-existing condition, typically did not cover services related to the person’s pre-existing condition for some period of time, and charged premiums “substantially in excess of what a typical person would pay in the non-group market.”
A group of health advocates including Health Care for American Now! produced a New York state fact sheet finding that 1.1 million New Yorkers would lose coverage.
Governor Cuomo provided county-by-county estimates of coverage losses (totaling about 14 percent of the state’s population) and direct budget impacts of a repeal ($3.7 billion).
The Commonwealth Fund estimates that an ACA repeal will kill around 131,000 jobs in New York.
Families USA estimated that New York would lose $57 billion over ten years and that 124,000 New Yorkers will lose premium assistance. They also provide estimates of coverage losses and the numbers of New Yorkers benefiting from things like the ban on lifetime limits, guaranteed issue, the closure of Medicare’s “donut hole” and the medical loss ratio.
The Kaiser Family Foundation estimates that around 25 percent of New Yorkers (over 3 million people) have a pre-existing condition that could exclude them from purchasing plans without the ACA’s protections.
The New York State of Health provided county-level totals for people who enrolled in Medicaid, Child Health Plus (CHP), the Essential Plan (EP), or Qualified Health Plans (QHPs) during 2017’s open enrollment.
Statements from New York’s Leaders
Governor Andrew Cuomo asked the House Majority Leader to “do no harm,” and to reject the ACA repeal and any plan to turn Medicaid into a block grant program or cap its funding on a per-capita basis.
Department of Financial Services Superintendent Maria Vullo argued that repealing the ACA with no replacement would be “disastrous” for our insurance markets and discussed the importance of the individual mandate and tax credits for keeping premiums down. She also argued that allowing insurance sales across state borders would create a ‘race to the bottom’ and “violate a fundamental principle of state sovereignty.”
National Estimates and Commentary
The Congressional Budget Office estimates that repealing the individual mandate, premium assistance, and the Medicaid expansion would cause premiums to double and 32 million people to become uninsured by 2026. They also estimate that in the first year, half of Americans would live in places with no individual plans available at all and this would increase to 75 percent of Americans by 2026.
The American Academy of Actuaries sent a letter to Speaker Ryan and Leader Pelosi saying that a repeal without replacement would cause the individual market to deteriorate immediately, even with a delayed implementation, and that taking away the cost-sharing reduction payments to insurers would lead to “solvency challenges.”
The American Hospital Association estimates that an ACA repeal will result in a loss of $289.5 billion to hospitals if it maintains cuts to disproportionate share payments, and a loss of $165.8 billion if those cuts are reversed. In a letter to President Trump, the AHA said that “losses of this magnitude cannot be sustained and will adversely impact patients’ access to care, decimate hospitals’ and health systems’ ability to provide services, weaken local economies that hospitals help sustain and grow, and result in massive job losses.”
The Urban Institute estimated that providers would be hit by an additional $84 billion in uncompensated care in 2019 provided to patients who no longer have health insurance, and an additional trillion dollars in uncompensated care over 10 years.
The American Enterprise Institute argues that the ACA should not be repealed without a comprehensive replacement in place, that “health insurance is a necessity of modern life,” and that “households with low incomes will never be able to pay the premiums for health insurance without government assistance.” They recommend allowing people with ACA-subsidized coverage and people who are newly eligible for Medicaid to keep their existing coverage indefinitely.
The Office of the Assistant Secretary for Planning and Evaluation (within the Department of Health & Human Services) found that expanding Medicaid to childless adults improved access to primary care and preventive services, helped people with chronic conditions get diagnosed, and reduced the risk of personal bankruptcy.
The Center on Budget and Policy Priorities estimates that the Medicaid expansion implemented through the ACA provided 11 million Americans with health insurance. They also point out that the expansion helped states save money by eliminating the need for state programs that provided emergency care for people who now get care through Medicaid.
Medicaid Block Grants
The Center for Budget and Policy Priorities argues that changing Medicaid into a block-grant program would lead to “draconian cuts to eligibility, benefits, and provider payment rates.” They cite Urban Institute data suggesting that between 14 and 21 million people would lose coverage.