WASHINGTON – Health-care legislation adopted by House Republicans earlier this month would leave 23 million more Americans uninsured by 2026 than under current law, the Congressional Budget Office projected Wednesday – only a million fewer than the estimate for the House's previous bill.
The nonpartisan agency's finding, which drew immediate fire from Democrats, patient advocates, health industry officials and some business groups, is likely to complicate Republicans' push to pass a companion bill in the Senate.
The new score, which reflects a series of last-minute revisions that Republicans made to win over several conservative lawmakers and a handful of moderates, calculates that the American Health Care Act would reduce the federal deficit by $119 billion between 2017 and 2026. That represents a smaller reduction than the $150 billion CBO estimated in late March, largely because House leaders provided more money in their final bill to offset costs for consumers with expensive medical conditions and included language that could translate to greater federal spending on health insurance subsidies.
As Republican senators quickly distanced themselves from the updated numbers, what became apparent is the difficult balancing act congressional leaders face as they seek to rewrite large portions of the Affordable Care Act. Some GOP senators are eager to soften portions of the House bill, including cuts to entitlement programs and provisions that would allow insurers in individual states to offer fewer benefits in their health plans or to charge consumers with costly medical conditions higher premiums.
Senate Majority Leader Mitch McConnell, R-Ky., who did not issue a statement in response to the new budget score, suggested in an interview with Reuters on Wednesday that he still harbored doubts over whether his party could muster enough votes to pass any kind of health-care bill this year.
"I don't know how we get to 50 [votes] at the moment," he said, referring to a situation in which Vice President Mike Pence would cast the deciding vote. "But that's the goal."
To avoid a filibuster by Democrats, Senate Republicans plan to take the bill up under budget reconciliation rules – which only require a majority vote but mean the legislation cannot increase the federal deficit within a 10-year window. The Republicans have been working for weeks on their own health-care bill and emphasize that they do not intend to simply follow the House's lead.
"Exactly what the composition of [our legislation] is, I'm not going to speculate about because it serves no purpose," McConnell told Reuters.
Some, like Sen. David Perdue, R-Ga., said the CBO score would have no impact on his chamber's efforts to write its own bill.
"Regardless of any CBO score, it's no secret Obamacare is collapsing under its own weight," Perdue said in a statement. "Doing nothing is not an option."
Instead of addressing the future number of uninsured Americans under the Republican plan – projected to immediately jump in 2018 by 14 million – House Speaker Paul Ryan, R-Wis., on Wednesday chose to focus on the CBO's estimate that premiums overall would fall under the AHCA.
"This CBO report again confirms that the American Health Care Act achieves our mission: lowering premiums and lowering the deficit," Ryan said in a statement. "It is another positive step toward keeping our promise to repeal and replace Obamacare."
Congressional analysts concluded that one change to the House bill aimed at lowering premiums, by allowing states to opt out of some current insurance requirements, would encourage some employers to maintain coverage for their workers and get younger, healthier people to buy plans on their own. But those gains would be largely offset by consumers with preexisting conditions, who would face higher premiums than they do now.
"Their premiums would continue to increase rapidly," the report found.
The CBO estimated that states seeking waivers to strip these essential benefits would affect roughly one-sixth of the population and that obtaining maternity coverage outside a basic plan "could be more than $1,000 per month."
But Rep. John Faso, R-N.Y., who supported the House bill, called the CBO's assumption that waivers would affect that many Americans "grossly wrong."
"Frankly I doubt any state would try to take advantage of that provision," he said. "I think that is completely out of the ballpark."
Asked why the House included the provision if no state would seek such waivers, he replied, "I'm sure it will be stripped out in the Senate."
The administration's reaction came from Health and Human Services Secretary Tom Price, who questioned the congressional analysts' latest numbers while noting that many Americans on the independent insurance market are paying significantly higher premiums than they were before the Affordable Care Act passed in 2010.
"The CBO was wrong when they analyzed Obamacare's effect on cost and coverage, and they are wrong again," Price said.
Joseph Antos, a resident scholar at the libertarian American Enterprise Institute who specializes in the health care, said the new estimate "is the same signal repeated," conveying that the changes congressional Republicans envision would cut the price of premiums and trim the decifit while leaving more Americans without insurance.
The AHCA's proposal to cut spending on Medicaid – a federal program that covers roughly 69 million Americans – by $834 billion over the next decade is the thorniest political issue facing the Senate, Antos said.
"They're going to have to do something on Medicaid, and that something is a real question," he said.
Rep. Mark Meadows, R-N.C., chairman of the conservative House Freedom Caucus, said he was confident the Senate would be able to craft a bill that could pass muster in the House – even in light of the CBO's analysis.
He said that he expected senators to address the situation of the roughly 10 million Americans who now enjoy Medicaid coverage under the ACA "in a less conservative way" than the House and that the measure "would still have conservative support in the House when it came back."
Senate Democrats seized on the new budget estimate, arguing that their GOP counterparts would be foolhardy to press ahead with a bill along the lines of the House. "These were cosmetic changes. They thought they could put lipstick on a pig," said Sen. Ron Wyden, D-Ore., adding that it's now obvious "we're going to have well over 20 million people uninsured."
Several key outside groups, including those representing physicians, hospitals and patients, said the updated projections underscored the need for the Senate to shift course.
The president of the American Medical Association urged the Senate to take a different approach. The CBO estimates "show that last-minute changes to the AHCA made by the House offered no real improvements," Andrew Gurman said in a statement.
Rick Pollack, president and chief executive of the American Hospital Association, said in a statement that the new numbers "only reinforce our deep concerns about the importance of maintaining coverage for those vulnerable patients who need it."
The Washington Post's Mike DeBonis and Sean Sullivan contributed to this report.