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The Congressional Budget Office released their updated score for the American Health Care Act (AHCA), the House GOP health bill, on Wednesday.

The report from the CBO on the amendments added just before the AHCA was passed by the House shows that 23 million more Americans could be uninsured by 2026 compared to the current healthcare system, slightly lower than the 24 million estimated under the previous iteration of the bill.

Importantly, the score projects that the AHCA will cut the federal deficit by $119 billion, $32 billion less than the $151 billion cut in the previous report.

This was key because Republicans plan to consider the bill under the reconciliation process in the Senate. By these rules, the bill must shave off at least $2 billion from the federal deficit in order to be considered.

House Speaker Paul Ryan has yet to send the AHCA to the Senate in anticipation of this CBO score. In the event that it did not shave off $2 billion, an amendment would have been needed to move the bill to the upper chamber, but would have likely viewed as a referendum on the totality of the bill.

Given the razor thin margin on the AHCA vote when it passed, a second vote would have likely been nerve wracking for GOP leadership.

Despite the new score, the Senate is expected to craft their own version of a healthcare bill instead of using the current form of the AHCA.

The CBo also confirmed one of the biggest worries of health experts and constituents that the bill co udl undermine protections for people with preexisting conditions.

The CBO looked at the impact of the MacArthur amendment added to the bill after the previous score. This provision would allow states to apply for a waiver to repeal Obamacare’s essential health benefit and community rating protections.

Around one-sixth of the population in the US lives in a state that the CBO projects would receive a waiver for community rating. This provision makes it so that insurers must charge people of the same age living in the same area the same amount fo premiums. Health policy experts have worried that by repealing community rating, insurers could charge more to those with preexisting conditions and possibly price them out of the market.

This possibility was echoed in the CBO projections. From the report:

“In addition, premiums would vary significantly according to health status and the types of benefits provided, and less healthy people would face extremely high premiums, despite the additional funding that would be available under H.R. 1628 to help reduce premiums. Over time, it would become more difficult for less healthy people (including people with preexisting medical conditions) in those states to purchase insurance because their premiums would continue to increase rapidly.”

The CBO said that roughly one-third of the population lives in states that would recieve waivers for the essentially health benefits, which impose a mandatory set of procedures and care that an insurer must cover such as maternity care and emergency room visits. This would drive down premiums by 20% from the current baseline in those states, according to the CBO, because “insurance policies would provide fewer benefits.”

In those states that waive EHBs, said the CBO, more people could have coverage but end up paying higher costs.

“Although premiums would decline, on average, in states that chose to narrow the scope of EHBs, some people enrolled in nongroup insurance would experience substantial increases in what they would spend on health care,” said the report. “People living in states modifying the EHBs who used services or benefits no longer included in the EHBs would experience substantial increases in out-of-pocket spending on health care or would choose to forgo the services.”

The report says that out-of-pocket costs for things like maternity care, substance abuse, and mental health care would increase substantially for some people.


How to Read the C.B.O. Score of the Health Bill Like an Expert

Today, the Congressional Budget Office will issue important numbers about the House-passed version of the American Health Care Act, the Republican bill to repeal and replace portions of the Affordable Care Act.

Although the budget office had analyzed an early version of the bill, the House on May 4 took the unusual step of voting before the budget office could gauge how several last-minute amendments might affect the deficit or the number of uninsured.

Senate leadership has vowed to make major changes to the House bill. But a detailed accounting of the House bill’s effects will still guide the legislative process. As we did when the budget office first scored the Republican proposal, we sought the advice of a panel of former C.B.O. directors, consultants and other budget experts to help us predict what the budget office would say.

We also asked them the No. 1 question they’d be looking for the score to answer. Here are their big questions and best guesses at answers. They will help you read the report like an expert, too.

Will it lower the deficit?

In practical terms, this is the most important question that the C.B.O. needs to answer for the bill to move forward. Republicans are passing their health overhaul bill through a special budget process in order to avoid a filibuster in the Senate. That process comes with a number of special rules.

One is that the bill must not increase the federal deficit beyond a 10-year window. Our entire panel thought the bill would still hit that target.

But the measure also must comply with specific instructions from an earlier budget resolution. That legislation said that the health bill had to save at least $1 billion from portions of the bill overseen by the Senate Finance Committee and at least $1 billion from portions of the bill overseen by the Senate Health, Education, Labor and Pensions Committee. There is a small chance that it could miss. Bloomberg News reported last week that the House is waiting to send the bill over to the Senate, just in case it fails to comply with the budget instructions.

Deficit reduction matters politically, too, of course. After the C.B.O. evaluated an earlier version of the House bill, House leaders promoted the bill’s estimated $337 billion in budgetary savings. But later, in the hectic scramble to win votes from conservatives and then moderates, leaders agreed to amendments that are likely to erode those savings substantially. Now, our experts estimate, the bill that passed the House will probably save only $25 billion to $150 billion over the decade.

Bottom line: Any number less than $2 billion in savings is a huge problem. But even a bigger number could spell trouble, depending on where the savings come from.

What happens to the uninsured number?

The initial version of the bill would have resulted in 24 million fewer Americans with health insurance in a decade, the C.B.O. estimated. Most of our experts think that number will fall a little bit with the recent changes.

Here’s why: The majority of the estimated reductions in coverage come from cuts to the Medicaid program. The recent bill amendments didn’t change those much. But the MacArthur Amendment, which would allow states to eliminate certain Obamacare insurance regulations, might lower the price of insurance premiums enough to prompt more Americans to sign up.

Those cheaper plans, however, are likely to cover fewer medical benefits, and may cost more for people with a history of serious illnesses. Many of our experts said the crucial changes would come not from the total number of uninsured Americans, but who they are.

The version of the bill that passed the House is likely to exclude more people who are older and sicker, while covering more who are younger and healthier. “Focus will be on premiums and on coverage, but there is a shift from sick to healthy and from good insurance to bad that needs to be emphasized as well,” wrote Jonathan Gruber, a health economist at M.I.T.


Soon the Congressional Budget Office will weigh in on the Republicans’ replacement of the Affordable Care Act. Protesters outside the Capitol in early May had already made up their mind.CreditGabriella Demczuk for The New York Times

Four of our experts thought the uninsured number would decline slightly. One thought it would be unchanged. And one thought it would increase slightly. The numbers ranged from 20 million to 25 million.

Bottom line: The topline number will be the one everyone is talking about. But shifts in who gets insurance coverage are important, too.

How will premiums change?

When the C.B.O. released its first report, Republican leaders seized upon estimates that the average insurance premium would be 10 percent lower in a decade than it would be under the Affordable Care Act. That number obscured a lot, since it reflected a younger pool of insurance customers, and plans with higher deductibles and other forms of out-of-pocket spending for customers.

The MacArthur Amendment could push premiums down even more by allowing plans that cover fewer benefits and by discouraging sicker customers from buying insurance.

Bottom line: The average insurance plan is likely to get slightly cheaper, but cover less.

Who will waive the insurance rules?

The hardest job for the C.B.O. is estimating the effects of the MacArthur Amendment, which allows states to waive several insurance regulations. In order to make calculations, the office’s economists must first estimate how many states will decide to pursue the waivers, how many people live in those states, and which rules they will choose to waive. To figure that out, C.B.O. employees have probably spent the last few weeks speaking with state officials and studying how states have previously tried to change program requirements.

Some experts have said the waivers will be unpopular, and only a few states will pursue them. Others have argued that they are likely to become widespread. Our panel estimated a wide range of effects, saying as few as 10 percent of Americans would be affected or as many as half.

“One could argue 100 percent, depending if the definition is just one provision and Secretary [Tom] Price is lenient in granting waiver requests,” wrote G. William Hoagland, the senior vice president at the Bipartisan Policy Center and a former director of the Senate Budget Committee. The answer matters, both politically and in terms of the report’s headline numbers.

Bottom line: If few states pursue waivers, then the Senate is dealing with a bill that’s much like the one scored in the early C.B.O. report. If many do, then the amendment will broadly reshape what health insurance covers and who can afford it.

About these estimates

The Times asked 20 experts in health economics and budget policy, including former directors of the C.B.O., to assess the version of the American Health Care Act that passed the House. Seven responded, including people who have served in both Democratic and Republican administrations.

Panel of experts


Resident scholar and Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute


Senior economist, RAND Corporation


Professor of economics, M.I.T.; former health care consultant for the Obama administration


Senior vice president, Bipartisan Policy Center, and former Senate budget director


Former director of the Congressional Budget Office


Former director of the Congressional Budget Office and the Office of Management and Budget


Senior vice president for policy and strategy, Avalere Health