At Least 21 Million Would Lose Coverage in GOP Bill, Brookings Says

  • Brookings Institution estimates losses from 2020-2026
  • Group says number likely underestimates uninsured under bill

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At least 21 million fewer Americans would have health-care coverage from 2020 to 2026 under the Senate Republicans’ latest plan to repeal and replace parts of Obamacare, according to an estimate by the Brookings Institution.

The number “likely underestimates the reductions in insurance coverage” because it doesn’t take into account difficulties states may face setting up their own health systems, said the nonprofit policy group, which has been supportive of the Affordable Care Act.

The Brookings estimate is the first look at what the bill, backed by Republican senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, would mean for millions of people covered under Obamacare by Medicaid or private plans. The estimate could add to concerns about Republicans’ last-ditch attempts to round up enough votes to get the bill on the Senate floor next week. One of the key GOP holdouts, Senator John McCain of Arizona, said Friday he will oppose the bill, dealing the proposal a major blow.

The Congressional Budget Office, Congress’s official policy analyst, has said it won’t have its own estimate for some time. A CBO estimate of a previous “skinny repeal” proposal projected that 15 million more people would be uninsured under that bill than under current law by 2026. That legislation, called the Healthcare Freedom Act, failed to pass the Senate.

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Other independent reports have found that the legislation would cut tens of billions of dollars from states that expanded Medicaid to low-income people under Obamacare, and would also result in broad spending reductions compared with current law.

The Graham-Cassidy bill would take money used to fund coverage under Obamacare and turn it over to states, which would decide how to cover their citizens. Not all states would benefit: Those that expanded Medicaid under the ACA would lose federal funding while states that didn’t expand stand to receive extra billions.

The bill also eliminates a requirement that everyone in the U.S. have health-care coverage and moves Medicaid funding to a fixed, per-enrollee amount instead of paying for a set percentage of states’ costs. And states would be allowed to apply for a waiver to allow insurers to charge more for people with pre-existing conditions -- the center of heated criticism.

Pre-Existing Conditions

States haven’t been able to offer much detail yet on how they’d use the money. But some GOP governors who support the measure have signaled they’d consider options including how to cover people with pre-existing conditions.

In South Dakota, one of the 19 states that haven’t expanded Medicaid, the conversation would include how to create more competition and how to help people with pre-existing conditions afford coverage, Tony Venhuizen, chief of staff for Republican Governor Dennis Daugaard, said Friday. He pointed out that, before Obamacare, South Dakota had 17 private health insurers offering plans -- now down to a few -- and a successful high-risk insurance pool for patients with pre-existing conditions.

Kansas, also a non-expansion state, would consider using the funds for a high-risk pool as well, according to Lieutenant Governor Jeff Colyer.

“We want more control to design a program that is for Kansans,” said Colyer, a Republican. “Kansans can make their own decisions about health care; those decisions don’t need to be in the hands of a faceless bureaucrat in Washington.”

Broad Opposition

States may be tempted to use the funding, in the form of block grants, for unrelated purposes, said Matthew Fiedler and Loren Adler, the authors of the Brookings report.

The bill contains “no apparent legal barriers to diverting funds to unrelated uses,” they wrote. States could use it to fund existing health programs and free up those dollars to be used elsewhere or to pay for health benefits for state employees, they said.

The bill has generated broad opposition among doctors, hospitals and health insurers, as well as state Medicaid plans. On Thursday, the National Association of Medicaid Directors, a group representing the state plans, said it was concerned the Graham-Cassidy bill would undermine “efforts in many states and fail to deliver on our collective goal of an improved health-care system.”

John Baackes, chief executive officer of L.A. Care Health Plan, which offers coverage options through Medicaid and via California’s Obamacare exchange, anticipates the repeal of the individual mandate and a reduction in funds will throw the state’s health programs “into a tailspin.”

“The unintended consequences are going to be horrendous,” Baackes said in an interview. “It’s as if the thinking is, ‘We’re going to cut the federal share and throw all the money to the states to figure out.’ You’re not giving them flexibility to print money.”

California would lose $61.7 billion in federal funding from 2020 to 2026 if the Graham-Cassidy legislation passes, according to the Kaiser Family Foundation. He predicted that under the Graham-Cassidy bill, young, healthy people who purchased insurance to comply with the coverage rule would likely drop their plans, leaving insurers with older, sicker people. That would likely destabilize the insurance markets.

L.A. Care is a member of the Washington lobby group America’s Health Insurance Plans, which along with the Blue Cross Blue Shield Association, another insurer trade group, came out Wednesday in opposition to the Senate bill.

— With assistance by Zachary Tracer, and Natasha Rausch

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