The Congressional Budget Office released its estimates of the impact of House Republicans’ American Health Care Act — which would repeal and replace parts of the Affordable Care Act — on Monday. So in lieu of this week’s politics chat, on Tuesday we convened a crew of FiveThirtyEight policy lovers to talk through the numbers (and some of the politics) of the proposed legislation. The transcript below has been lightly edited.
ben (Ben Casselman, chief economics writer): Last week, the regular crew chatted about the politics of the Republican replacement for Obamacare. So this week we thought we’d shake things up by inviting people who actually know something about health care. Welcome!
Shoutout to Perry, though, who somehow understands both politics and health care. You must be fun at parties.
anna (Anna Maria Barry-Jester, lead health writer): I’m not sure what you’re implying, Ben. What do you talk about on Friday nights if not risk corridors and block grants?
perry (Perry Bacon Jr., senior writer): Great to be here on what must be known as “Day After CBO Day.”
ben: Right, Perry. In addition to having different personnel this week, we also have something else new: facts! Or at least, estimates of facts. The Congressional Budget Office on Monday released its analysis of the GOP plan. So for this week’s chat, we’re going through some of the key numbers in the CBO report and talking about their significance for politics and policy.
First up: 24 million, which is how many more Americans the CBO says will be uninsured in 2026 under the GOP plan than under the Affordable Care Act. Anna, pretty much everyone knew that millions of people would lose insurance under the GOP plan, but the 24 million estimate is a surprise, right?
anna: Yeah, that was higher than many people expected, though keep in mind that’s by 2026. The CBO estimates 14 million fewer people will be uninsured next year.
perry: 24 million = bad for Republicans. That is just undeniable.
anna: Though it’s lower than the White House estimate of 26 million. (The White House did tell Politico that wasn’t a report, but rather their attempt to estimate what the CBO would say.)
But, yeah, that’s a lot of people. It takes us back to the pre-Obamacare uninsured rate: 19 percent uninsured among people under age 65.
perry: From Nov. 9, the GOP should have been saying, “We don’t judge based on how many are covered. We care about costs, access, choice.” They discovered that message maybe 10 days ago.
ben: OK, but let’s take a quick step back here. After we wrote about this Monday, a ton of people responded by saying, “People won’t lose insurance, they’ll be able to choose not to get it!” What’s wrong with that line of thinking?
anna: What’s not wrong with that line of thinking? Sure, some people will decide they’d rather not pay for insurance, but not being able to afford something does not equal choosing not to buy it.
ben: An analogy I’ve seen in different forms: Just because I can theoretically choose to buy a Ferrari doesn’t mean I can afford one in practice.
perry: Well, 14 million of the 24 million are in Medicaid. People are choosing to get Medicaid in record numbers right now. The GOP is trying to limit that choice.
anna: Yeah, we’re talking about people earning about $16,000 a year or less. That’s not enough for food and housing in many areas.
perry: And the report makes clear that some people will face higher premiums (older, low-income people) and they will “choose” not to buy insurance because it is unaffordable. We already have that problem under the Affordable Care Act. Many plans are unaffordable, particularly in terms of deductibles. That will continue and for some get worse.
anna: It’s true that some people really do choose not to get coverage now and pay a penalty at tax time. That penalty goes away under the GOP plan. The CBO thinks millions of people will not buy insurance without that federal mandate to buy coverage. If many of those are younger people, who tend to use less health care, plans would likely get even more expensive for the first couple of years.
perry: But how many of that 24 million are young opt-out people (not the worst problem) versus people who won’t get insurance who want it?
anna: Certainly some — but probably not the majority.
ben: I want to spend another moment on that “14 million fewer people on Medicaid” figure that Perry mentioned. A major factor in the ACA’s coverage gains has been the expansion of Medicaid — Anna, as you’ve explained to me before, the ACA basically took a program that was focused on a few narrow groups (children, the disabled, pregnant women) and broadened it to cover low-income people more generally. The GOP bill would not just undo that, but actually impose further limits on Medicaid, right?
anna: Right. So you’ve got Medicaid pre-Obamacare, which was a program for a very specific group of people. Then you’ve got Medicaid expansion, which in theory opened up the program to all people with low incomes. The AHCA basically brings Medicaid back to that original group, but also limits how much money states can get from the federal government, which everyone expects will limit how much is spent on Medicaid.
perry: Essentially, under Obamacare, the federal government is matching about 90 percent of every state dollar spent on Medicaid. Outside of Obamacare, feds match on average 57 percent of state Medicaid spending.
Per the CBO, “Under the legislation, the higher federal matching rate would apply for fewer than 5 percent of newly eligible enrollees by the end of 2024.” That was the money sentence on Medicaid.
ben: Right, so that means the Medicaid rollback is politically challenging too, right? Republican governors in states that expanded Medicaid aren’t eager to see those federal dollars disappear. Did Paul Ryan & Co. do enough to satisfy them?
anna: It’s hard to see how this makes the governors happy. Obamacare opened up Medicaid to everyone earning under 138 percent of the federal poverty line. But a Supreme Court case left it up to states whether or not to expand the program; 31 states and D.C. did. Among those states, there are several with Republican governors, and they have been pretty vocal that they don’t want to lose the money they get for Medicaid. We’re talking about a LOT of money. It’s hard to overstate what a big part of state budgets federal Medicaid dollars are.
perry: Ryan did not try to please GOP govs. Because they don’t have votes in the House.
ben: Oh, sure, get all “Schoolhouse Rock” on me, Perry.
OK — on to cost! Our next number is 15 percent to 20 percent, which is how much higher premiums would be, on average, for individuals buying insurance on the private market in 2019. But after that premiums would start going down, on average. What’s going on there?
anna: So many things are going on there!
ben: Who knew health care could be so complicated?
anna: First and perhaps foremost is something that’s pretty wonky, but important, so bear with me a second.
The GOP bill would let insurers charge older adults five times as much as they charge younger adults. Right now, they can only charge older adults three times as much. That makes insurance premiums higher for older people, but also lower for younger people. The CBO thinks that will make insurance so expensive for older people — who would get only $4,000 in subsidies from the federal government, no matter how much insurance cost — that many will drop out.
Also very important: There’s a little bit of an apples and oranges thing going on. The plans that would be sold under the GOP bill are likely not the same plans sold today. In all likelihood, they will be cheaper, but they will also cover less.
perry: So average premiums go down as 1) more young people are in system, 2) fewer older people are in system, 3) young people have different kinds of coverage.
anna: Thank you, Perry, for pulling us out of that weed patch I dumped us in.
perry: Ha. This part is peak complicated!
ben: So the key word here is “average,” right? Premiums would go down for some, up for others. Or let me put this another way: The eight-word summary of this bill, at least among liberal commentators, seems to be: better for young people, worse for old people. (Also better for rich people, worse for poor people, but we’ll get to that in a bit.) Is that an oversimplification? (I’m sure it’s an oversimplification, because this is health care.)
anna: No, though I’d add a rural/urban divide.
ben: Ooh, expand on that, Anna.
anna: So there are subsidies to help people buy insurance under Obamacare and under the GOP bill. But the subsidies are calculated very differently. Basically, it’s a set amount based on age in the GOP plan, available to everyone earning up to $75,000 a year for an individual. Under Obamacare, subsidies are calculated based on your income and how much insurance costs in your area. Insurance generally costs a lot more in rural places.
perry: This is a weird and obvious flaw. It was very well known that insurance costs and health care costs overall very widely by region, so not accounting for this was bizarre. Also, where do Trump voters live?
anna: I was hoping you could tell me what I was missing, Perry, ’cause the politics don’t add up.
perry: Yeah, if I were trying to get the votes of senators from Maine and Alaska, increasing health insurance costs there is maybe not the smartest policy plan.
anna: Or Oklahoma, Nebraska, Wyoming …
perry: Ryan has been talking about these kinds of tax credits for years. I think he views them as an incentive to keep costs down. Ideally, if the tax credit is X, eventually states/hospitals/etc. will adjust their costs to X. He might be right in the long term, but in the short term, this makes the bill hard to vote for.
ben: OK, on to our next number: $337 billion, which is how much the CBO says this would reduce the deficit over 10 years. As we explained Monday, that isn’t really a big deal in the context of the federal budget — it’s like a 4 percent reduction in the deficit — but it’s a very big deal in the legislative context, because if the bill added to the deficit, Republicans couldn’t use the reconciliation process to pass it. Perry, I just typed those words like I know what I’m talking about here, but let’s, uh, pretend for a second that I don’t. What’s the big deal about “reconciliation”?
perry: It means they can pass this bill with 51 votes in the Senate, not 60 (which they’d typically need to avoid a filibuster), so they only need Republican votes. Reconciliation is the whole ball game.
ben: So on that score, at least, the CBO report was good news for Republicans.
perry: Yes. I would add, though, that the CBO is not the final major arbiter here. The Senate parliamentarian gets to determine if the bill follows reconciliation rules.
ben: More substantively, that $337 billion figure is the difference between a $1.2 trillion decrease in spending and a $900 billion reduction in tax revenue. On the revenue side, the reduction is driven by the elimination of Obamacare’s surcharges on high earners. I know Republicans will argue that they’re just reversing the tax increases imposed by Obamacare, but how does this not end up just looking like they’re cutting benefits for the poor to pay for tax cuts for the rich?
perry: I personally think that is not a huge problem for Republicans. Dems always say Republicans cut taxes for rich, cut benefits for the poor. If that message was working, Republicans wouldn’t control most statehouses, Congress and the White House.
ben: I’d like to note that while we are having this very serious health care conversation, our colleagues are debating whether Justin Trudeau is hotter than Paul Ryan.
anna: Getting back to why I’m no fun at parties, I’m quite happy here, thankyouverymuch.
perry: I feel like the answer to that question is so clear. Trudeau seems like 15 times cooler than Ryan. Am I missing something? Is Trudeau 5’2” or something?
(If Brendan Buck is reading this chat, I apologize! Paul Ryan is way cool.)
ben: OK, two numbers to go. First up: $178 million, which is how much federal funding Planned Parenthood would lose in the GOP bill in 2017. From the report:
To the extent that there would be reductions in access to care under the legislation, they would affect services that help women avert pregnancies. The people most likely to experience reduced access to care would probably reside in areas without other health care clinics or medical practitioners who serve low-income populations. CBO projects that about 15 percent of those people would lose access to care.
perry: This is a serious issue in terms of policy. Planned Parenthood provides important care to low-income women. This is hugely symbolic to Republicans to show their opposition to abortion (though existing federal law bars federal funding of abortions in almost all cases anyway). Not surprising, and don’t think it moves many votes.
anna: The CBO predicts that will mean more unwanted pregnancies, as women lose access to contraceptives.
perry: That was an interesting finding. I didn’t know CBO estimated pregnancies.
anna: The CBO’s job is not an easy one. They are trying to measure the economic impact of bills but have to take so much into account to try and do that!
In this case, nearly half of births are covered by Medicaid, so more pregnancies means more federal spending, in addition to the very real health care concerns.
ben: Amelia Thomson-DeVeaux had a good piece on this for us last week, which found that defunding Planned Parenthood could be a big deal, especially in rural areas.
OK, back to politics for our last number: 51 votes in the Senate. Which is admittedly not from the CBO report. But the ultimate question here is whether this bill can get through the Senate (assuming it can get through the House first, which isn’t a foregone conclusion). Perry, last week you were more bullish on the bill’s chances than some of the other people on the politics team. Has your thinking changed?
anna: *bows out of the conversation*
perry: Yeah, I think it has. I still think the bill can pass the House. But the premium increases, the Medicaid cuts and that 24 million — those are all really big. I just don’t see how it passes in the Senate without major changes, even if it gets through the House.
ben: What constituency does that hurt them with? I mean, among the constituencies they care about.
perry: Older, rural people. All these numbers show older rural people facing higher costs. I think Medicaid matters, too.
anna: I’m not going to pretend to understand the politics of this, but polling consistently shows that Medicaid is popular, among Republicans and Democrats.
perry: I guess overall, the CBO reports paints a large amount of disruption from the current system. The ACA did that. That made it unpopular.
anna: Another thing about the CBO report: It shows the cost of insurance going up in 2018 and 2019. That has to be a concern to people in Congress.
perry: Also, I think some Republicans are more supportive of Medicaid expansion than they can say publicly. (See Tom Cotton and Rand Paul).
ben: OK, so after all that talk about what the GOP bill would do, we’re now saying it won’t pass anyway. Good use of time, everyone! Tune in next week when we chat about the Democrats’ plan for free college!
All right, so, joking aside, there’s clearly much more still to come on this. But we’ll leave it here for now. Thanks, all!