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CBO: 22 million fewer Americans would have insurance under Senate health care bill

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.

Under the Senate Republican health care bill, 22 million fewer Americans would have health insurance in 2026, compared with Obamacare, according to new estimates from the Congressional Budget Office.

As soon as next year, 15 million more Americans would be uninsured, the office found in its analysis of the latest Senate GOP plan. Senate leaders are hoping to press forward with a vote on the bill by the end of the week.

By eventually ending the generous federal funding for Obamacare’s Medicaid expansion and overhauling the entire program’s financing, the Senate bill would cut the program’s spending by $772 billion over 10 years, versus what would be expected under current law.

CBO’s projections would represent an abrupt turn from the trends under Obamacare; the US uninsured rate had dropped below 11 percent in late 2016. The office has estimated that there are currently 26 million uninsured Americans; that would increase to 49 million by 2026 under the Senate Republican plan, according to CBO.

The Senate revamped the House GOP, incorporating more of Obamacare’s infrastructure while cutting Medicaid more deeply in later years. The House bill had been estimated to lead to 23 million fewer Americans having health insurance.

Why the CBO’s projection is so important

CBO represents the official analysis of the Senate’s bill, though some Republicans have sought to cast doubt on its accuracy. Several swing votes in the Senate, such as Sen. Susan Collins (R-ME), have said they could not vote for a bill that would lead to tens of millions fewer Americans having health insurance. The new numbers from CBO could make them more skittish about supporting the Senate plan.

Its projections will also help determine what provisions can and cannot be included under the procedural rules Senate Republicans are using to pass a bill with only 50 votes. The bill is supposed to be limited to policies that directly affect federal spending or revenue; CBO’s score helps make those determinations.

More changes could be made to the legislation in the next few days, as Senate leadership presses ahead for a vote by the end of the week. So Monday’s CBO report may not reflect the actual bill that senators will eventually vote on.

The bill would reduce the federal deficit by $321 billion over 10 years, according to CBO. Under the Senate’s rules, the plan only needs to meet the House bill’s savings, which were $119 billion. So Senate Republicans could significantly boost the spending in their bill over the next few days.

Average premiums will eventually decline, but out-of-pocket costs would go up for many people

The Senate’s bill allows insurers to charge older people five times as much as younger people, gives states more flexibility to waive Obamacare’s insurance regulations, and scales back the financial assistance people receive to buy private insurance. Lowering premiums is a priority for many Republicans, and the bill’s supporters argue that these policies would help achieve that.

Average premiums would be about 20 percent lower under the GOP plan, compared to Obamacare, in 2026, CBO found.

But that would be in part because the GOP’s financial assistance is pegged to plans with higher out-of-pocket costs. Most Americans who buy insurance on the individual market would actually end up paying more for health care, even if their premiums went down.

“Because nongroup insurance would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law,” CBO’s analysts wrote.

The loosening of state waivers created by Obamacare would also increase health care costs for many Americans, CBO found. The Senate bill allows states to roll back more of Obamacare’s insurance regulations and makes it easier for states to get the waivers.

About half the US population lives in states that would seek waivers from the Obamacare requirement that health plans cover certain essential health benefits, CBO estimated. If states narrowed what services plans are required to cover, people could end up paying more for those services and insurers could again impose annual or lifetimes limits on how much they would pay for those services.

“People who used services or benefits no longer included in the EHBs would experience substantial increases in supplemental premiums or out-of-pocket spending on health care, or would choose to forgo the services,” CBO said, adding of lifetime and annual limits: “some enrollees could see large increases in out-of-pocket spending because annual or lifetime limits would be allowed.”

15 million fewer people would be enrolled in Medicaid, including people currently eligible

The Senate bill eventually ends Obamacare’s generous federal funding for Medicaid expansion, which covered millions of poor Americans, in 2024. It also overhauls the entire program’s financing, placing a federal spending cap on the program for the first time. CBO estimates that, under the Republican plan, Medicaid spending would be cut by $772 billion by 2026, versus current law.

As a result, about 15 million fewer people would be enrolled in Medicaid in 2026 — including about 10 million people currently eligible for the program. The other 5 million are people who would have enrolled had Obamacare remained the law of their land and if their state eventually expanded Medicaid.


Under the spending caps, states would make up for the loss in federal funding by adding their own dollars, cutting spending or restricting eligibility — CBO projects that states would adopt a mix of those policies.

If states chose to leave their Medicaid program unchanged and instead found other ways to offset the loss of federal funds, enrollees would notice little or no change in their Medicaid coverage.


If states reduced payment rates, fewer providers might be willing to accept Medicaid patients, especially given that, in many cases, Medicaid’s rates are already significantly below those of Medicare or private insurance for some of the same services.


If states reduced covered services, some enrollees might decide either to pay out of pocket or to forgo those services entirely. And if states narrowed their categories of eligibility or used administrative procedures that made it more difficult to enroll, some enrollees would lose access to Medicaid coverage, although some would become eligible for subsidies for nongroup coverage through the marketplaces or could choose to enroll in employment-based insurance, if it was available.

Though it did not provide specific estimates, CBO projected that Medicaid enrollment would continue to fall after 2026 under the Senate bill’s spending caps.