House Speaker Paul Ryan's proposal to revise the Affordable Care Act would lower the number of Americans with health insurance by 24 million while reducing the federal deficit by $337 billion by 2026, congressional budget analysts said Monday.
According to a Congressional Budget Office projection, 14 million fewer people would have health insurance next year alone. Premiums would be 15 percent to 20 percent higher in the first year compared with the Affordable Care Act and 10 percent lower on average after 2026. By and large, older Americans would pay "substantially" more and younger Americans less, the report said.
The report from the Congressional Budget Office fueled concerns that the GOP health-care plan would prompt a dramatic loss in health-insurance coverage, potentially contradicting President Donald Trump's vow that health-care reform would provide "insurance for everybody" and threatening support from moderate Republican lawmakers.
Yet it also boosted House leaders' efforts to persuade skeptical conservatives, who felt that the measure did not go far enough in repealing the Affordable Care Act, to support what the CBO now predicts will be deficit-reducing legislation.
The analysis immediately prompted a clash of reactions between the White House and Republican leaders. Trump's budget director, Mick Mulvaney, said the report is "just absurd," and Health and Human Services Secretary Tom Price said: "We disagree strenuously" with it.
Ryan defended the report, saying that it proves that the proposal will "dramatically" reduce the deficit and usher in "the most fundamental entitlement reform in a generation."
"Our plan is not about forcing people to buy expensive, one-size-fits-all coverage," he said. "It is about giving people more choices and better access to a plan they want and can afford. When people have more choices, costs go down. That's what this report shows."
The release of the CBO's report marks the beginning of a new phase in the debate over the week-old health-care bill, which is moving through the House on an accelerated timetable despite opposition from Republicans, Democrats and virtually every sector of the U.S. health-care industry. Conservative Republicans, in particular, have demanded changes to the measure in exchange for their support.
The CBO report offered conclusions that might neutralize some conservative concerns, perhaps softening those members' opposition to the measure.
The conservative House Freedom Caucus did not immediately provide a response to the report.
At the same time, some moderate Republicans expressed concerns about the number of people who would lose coverage.
"These kinds of estimates are going to cause revisions in the bill, almost certainly," said Sen. Susan Collins, R-Maine.
"I don't think that the bill that is being considered now is the bill that ultimately will be the one that we vote on in the Senate."
Democrats cited the CBO numbers to support their flat-out opposition to the plan.
"The CBO score shows just how empty the president's promises, that everyone will be covered and costs will go down, have been," said Senate Minority Leader Charles Schumer, D-N.Y. "This should be a looming stop sign for the Republicans repeal effort."
"I would hope that this would make the Republicans say 'we can't do this," said Sen. Patty Murray, Wash., a member of Democratic leadership.
"Twenty-four million people lose their coverage, it is total chaos to the country and I hope they pause, say 'This is not what we should be doing,' and move on."
The White House has spent the past week engaged in a charm offensive aimed at bringing conservatives on board, as well as an effort to discredit the CBO before it released numbers that might cast the plan in a negative light.
"If you're looking to the CBO for accuracy, you're looking in the wrong place," White House spokesman Sean Spicer said last week.
Ryan had predicted that the CBO would forecast a loss in coverage, but he had also suggested that those affected would be exercising their choice not to buy health plans, a choice that is penalized under the Affordable Care Act.
"CBO will say, 'Well, gosh, not as many people will get coverage,' " Ryan said Sunday in an appearance on CBS's "Face the Nation." "You know why? Because this isn't a government mandate."
"It's up to people," he said. "People are going to do what they want to do with their lives because we believe in individual freedom in this country."
The Affordable Care Act has increased coverage by 20 million to 22 million - almost half of those through the insurance markets the law created for people who cannot get affordable coverage through a job, and the rest through an expansion of Medicaid in 31 states and the District of Columbia.
According to the report, an estimated 52 million people would be uninsured in 2026, compared with 28 million who would lack insurance that year under the current law.
"Obviously, we want to improve those coverage numbers," said Senate Majority Whip John Cornyn, R-Texas. "But when you don't punish people for their refusal to buy a government-approved insurance [plan], some people are going to make the decision not to buy it."
This reasoning would only account for the immediate increase in the uninsured, according to the CBO.
Eventually, many people would lose health insurance because the legislation's tax credits would be less generous than those in the current law and because some states might undo the expansion of their Medicaid programs.
"All I can tell you it is a work in progress," Cornyn said of the bill.
The Trump administration led a broad effort to undercut the Congressional Budget Office over the weekend, including pointing out flaws in its forecasts for the Affordable Care Act.
"If the CBO was right about Obamacare to begin with, there'd be 8 million more people on Obamacare today than there actually are," said Mulvaney, director of the White House Office of Management and Budget. "Sometimes we ask them to do stuff they're not capable of doing, and estimating the impact of a bill of this size probably isn't the best use of their time."
"The CBO estimate five, six, seven years ago when this started, they estimated that over 20 million people would have coverage at the end of the ten-year window," Price said on NBC's "Meet the Press." "In fact, it's about half of that right now. So CBO has been very adept in not providing appropriate coverage statistics."
Price, the former chairman of the House Budget Committee, had previously celebrated the selection of CBO Director Keith Hall in 2015, saying he would bring an "impressive level of economic expertise and experience."
In private meetings last week, Trump suggested he was open to significant changes to the bill to appease hardliners skeptical of the bill. By the end of the week, however, the White House clarified it was siding with House Republican leaders on at least one request from the hardliners: speeding up cuts to Medicaid eligibility.
"Right now, the date that's in the bill is what the president supports," Spicer told reporters. "It's not a question of negotiation," he added.
On Friday, members of the House Freedom Caucus remained split over which elements more urgently needed change. Some called for changing the Medicaid timetable, while others urged the elimination of basic benefit requirements for health plans.
On Sunday, a growing group of conservatives was still threatening to kill the plan unless GOP leaders agreed to renegotiate parts of it.
"He will not have the votes," Sen. Rand Paul, R-Ky., said of Ryan on CBS' "Face the Nation." "Everybody is being nice to everybody because they want us to vote for this, but we're not going to vote for it."
In January, Trump had promised to replace the ACA with a plan that provided "insurance for everybody."
"There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us," Trump said in a Jan. 15 interview with The Washington Post.
"It's not going to be their plan," Trump said of people covered under the Affordable Care Act. "It'll be another plan. But they'll be beautifully covered. I don't want single-payer. What I do want is to be able to take care of people."