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The CBO report on AHCA has grim news for pregnant women and people in recovery

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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The American Health Care Act wouldn't just lead to people with higher medical costs being priced out of health insurance, as the Congressional Budget Office found in its new report yesterday.

The bill could also expose pregnant women and people receiving treatment for substance abuse to exorbitant medical bills.

As part of the last-minute compromise that got the bill through the House, the AHCA allows states to waive two central Obamacare regulations: the prohibition on insurers charging sick people more than healthy people and the requirement that health plans cover certain essential health benefits.

Nixing the latter rule could have devastating effects for women who are pregnant and for people struggling with addiction, according to CBO. (The US, remember, is in the midst of the worst drug crisis in a generation.)

Some states — where one in six Americans live — would probably seek substantial waivers from the essential health benefits requirement for insurance sold on the individual market, according to CBO. Under the AHCA, those states would then be allowed to set their own requirements for what insurance must cover.

The office projected that maternity care and mental health and substance abuse benefits were among the most likely services to be excluded if states set their own requirements. Obamacare had required that both be covered by private insurance sold in the individual market.

"Out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for the nongroup enrollees who would use those services," the CBO's analysts wrote.

Less than half of states mandated maternity coverage (18) and some mental health coverage (23) in the individual market pre-Obamacare — and CBO expects it would be those states with fewer requirements before the health care law that would seek waivers under the AHCA.

Even if insurers in those states did provide some coverage for those services, CBO noted, they would be allowed to set annual or lifetime limits on what they would pay for. Obamacare's ban on those limits applies only to things that are considered essential health benefits.

"Some enrollees could see large increases in out-of-pocket spending because annual or lifetime limits would be allowed," CBO wrote.

Some plans could offer separate coverage for maternity care, CBO theorized. But those additional benefits would likely cost upward of $1,000 a month — again putting pregnant women on the hook for higher costs. A $15 billion funding pool provided in the bill for maternity coverage and substance abuse services would not fully offset these increased costs, based on the CBO report.

Advocates, particularly those focused on drug addiction, are primarily concerned with what the AHCA would do to Medicaid ($834 billion cut, 14 million fewer people enrolled, more state leeway to trim benefits). But the risks to vulnerable people who buy coverage on the individual market were made plain by the final CBO score.

House Republicans touted the CBO's findings that some people in states with AHCA waivers would see lower premiums. But the report makes clear that would be achieved by driving sick people out of the market and leaving these populations with higher medical bills.

Meanwhile, in North Carolina...

Sarah and I have written a lot about Trump's "nuclear option" to stop essential Obamacare subsidies, sabotaging the market. Trump is ready to press the button, according to a report last week.

Insurers are taking these threats seriously, and they may be enough, on their own, to destabilize the market. New proposed premium increases by Blue Cross Blue Shield in North Carolina demonstrate the effect.

The insurer said it planned to raise premiums 22.9 percent in 2018 — but would have proposed only an 8.8 percent increase if the Trump administration had guaranteed the Obamacare subsidies would be paid.

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Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

Today's top news

  • "Andy Slavitt can’t stop: How a health care wonk became a rabble-rouser": “Slavitt, 50, insists that he is not an advocate or an activist — 'If the Republicans came out with a good bill, I would be out here actually supporting it,' he said — but he has become one of the strongest voices in the fight against the dismantling of the Affordable Care Act.” —Eric Boodman, STAT
  • "Indiana adds Medicaid work requirement to waiver request": “The state posted an amendment to its pending request to renew its conservative Medicaid expansion model known as Healthy Indiana Plan 2.0 for an additional three years. Under the plan, Medicaid enrollees would have to be employed or searching for work in order to be eligible for the program.” —Virgil Dickson, Modern Healthcare
  • "The GOP Health Bill Would Make Zika the Newest Preexisting Condition": "Multiple health care experts told Mother Jones that the GOP bill would almost certainly mean a host of insurance problems for both pregnant women who have had Zika and infants born with microcephaly, a condition where a child has a smaller brain and other health defects." —Rebecca Leber, Mother Jones

Analysis and longer reads

  • "The Republican Health Care Debacle": "Even more striking is that these changes emerged from a legislative process that blatantly violated the norms of professional policymaking. Indeed, the development and passage of the AHCA is a case study in how not to make public policy." —Douglas Elmendorf, Foreign Affairs

"Three Strategies to Defend GOP Health Bill: Euphemisms, False Statements and Deleted Comments": "We’re back with more examples of how legislators are interacting with constituents about repealing Obamacare, whether online or in traditional correspondence. Their more controversial tactics seem to fall into three main categories: providing incorrect information, using euphemisms for the impact of their actions, and deleting comments critical of them." —Charles Ornstein, ProPublica

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