WASHINGTON, D.C. — The road to passage for the Senate Republican health care bill got a little steeper on Monday after the Congressional Budget Office determined the embattled draft legislation would cause 22 million people to lose health coverage by 2026.
The legislation would cause 15 million more people to lose coverage in 2018, and Medicaid enrollment would fall by 16 percent by 2026 under the proposal. In all, 49 million Americans would lack health coverage under the legislation in 2026, compared with 28 million under current law.
The bill would save the government $321 billion over 10 years, mainly by cutting Medicaid spending by 26 percent, the CBO estimated.
The disappointing numbers will complicate an already difficult task for Senate Majority Leader Mitch McConnell, who needs 50 senators to vote for the widely criticized legislation to pass the upper chamber in a possible vote later this week.
Four conservative GOP senators have said they won’t support the legislation as written: Ted Cruz of Texas, Ron Johnson of Wisconsin, Mike Lee of Utah and Rand Paul of Kentucky. Among Republican moderates, Sen. Dean Heller of Nevada — facing a tough re-election race in 2018 — said he opposes the legislation as-is, while Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and Shelley Moore Capito of West Virginia are considered to be on the fence.
With 52 members in the Senate, Republicans can only lose two members and still pass the bill under budget reconciliation rules that prevent filibustering by Democrats. Vice President Mike Pence would cast the deciding vote in the event of a 50-50 tie.
In order to win more support, McConnell’s team is expected to amend the legislation significantly this week in a furious effort to meet President Donald Trump’s goal of bringing the measure to a floor vote before the July 4 congressional recess.
But adding legislative sweeteners to woo conservative and moderate senators alike will prove tricky, since changes to appease one side will likely alienate the other.
The legislation, known as the Better Care Reconciliation Act, was revealed by the Congressional Budget Office to be very similar to its counterpart, the American Health Care Act, which narrowly passed the House of Representatives last month. The CBO estimated the AHCA would cause 23 million people to lose health coverage by 2026.
Like the AHCA, the Senate legislation would cut subsidies that help purchase marketplace insurance, would phase out the Medicaid expansion and would slash funding for Medicaid more deeply than the 10-year, $834 billion cut in the House legislation.
Sens. Tammy Duckworth, D-Ill., and Ron Wyden, D-Ore., asked the Congressional Budget Office to project the cost of the bill over 20 years instead of the usual 10-year span.
That’s because in 2025 — the final two years of the CBO budget window — the legislation would limit Medicaid spending increases to the slower-growing rate of inflation instead of the faster-growing rate of increasing medical costs to which program spending is now pegged.
“Such budgetary gaming and gimmicks” would mask the full effect of long-term cuts in program funding, Duckworth argued in a letter to the CBO.
The American Medical Association said the proposed change in Medicaid’s funding formula “threatens to limit states’ ability to address the health care needs of their most vulnerable citizens,” adding “it would be a serious mistake to lock into place another arbitrary and unsustainable formula that will be extremely difficult and costly to fix.”
The Senate legislation also abolishes most of the taxes that funded the Affordable Care Act’s coverage expansion. Most of the lost tax revenue would fund tax breaks that disproportionately benefit wealthy individuals.
The bill also would make coverage more expensive for older people and those with pre-existing medical conditions, while allowing states to waive the Affordable Care Act’s requirement that individual insurance cover 10 essential health benefits.
On Monday the legislation was amended to include, beginning in 2019, a six-month waiting period for coverage to begin for people who went without insurance for 63 days or more in the previous year. Enrollees would not have to pay their premiums during the waiting period.
Insurers lobbied for the change because the bill, as originally written, would have repealed the ACA’s mandatory coverage requirement without imposing a new penalty for people who let their coverage lapse. That would have allowed people to game the system by waiting until they were sick to enroll in coverage.
Ten patient and provider advocacy groups, including the American Heart Association, the March of Dimes and United Way Worldwide, sent letters to all 50 state governors asking them to contact their senators and state representatives about the bill’s “potentially devastating consequences.”
The American Medical Association gave their thumbs-down to the legislation on Monday, as well, saying the bill violates a basic tenet of medicine: “first, do no harm.” The draft legislation “violates that standard on many levels” said Dr. James L. Madara, CEO of the AMA, in a Monday letter to Senate leaders.
