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CBO Report: GOP Bill Could Leave 24M More Without Health Coverage By 2026


Let's ask what the numbers in a Republican health insurance bill really mean.


A nonpartisan budget office calculated the effects of a replacement for the Affordable Care Act. Some are so jaw-dropping that President Trump's top health care official says he just doesn't believe them.

INSKEEP: Other numbers prompted House Speaker Paul Ryan to say he's encouraged. Democrats are using the word disaster. NPR congressional correspondent Susan Davis is here to work through all the numbers with us. Hi, Sue.


INSKEEP: So what are the major numbers?

DAVIS: So think of them in three very broad categories. In terms of coverage, CBO says the plan would see about 14 million fewer people insured as soon as next year. And that number climbs to 24 million over the course of the next decade, through 2026.

INSKEEP: So that's coverage.

DAVIS: That's coverage. In terms of costs, it does save the government money. It would reduce the federal budget deficit by over 300 billion in that same period of time.


DAVIS: And that brings us to what it changes and that - this legislation will fundamentally reshape the way the Medicaid system works in this country.

INSKEEP: OK. Coverage, costs and changes, you've given us the three C's there. Let's go with coverage first, go through these numbers. Millions of people drop their insurance, including 14 million in the first year. Tom Price, the secretary of Health and Human Services, doesn't buy this at all. In fact, he says that number is, quote, "virtually impossible." Let's listen to some more of what he says.


TOM PRICE: We believe that the plan that we're putting in place is going to insure more individuals than currently are insured. So we think that CBO simply has it wrong.

INSKEEP: Simply has it wrong, that actually more people will end up with insurance instead of millions fewer, how?

DAVIS: Well, Republicans like the Health and Human Services secretary say the CBO estimate just doesn't see the entire picture and that the coverage losses come from the fact that they get rid of the individual mandate that tells people they have to have insurance.

But Republicans are arguing that is the whole point of this legislation. Price argues that the Republican plan will allow for more affordable insurance plans and more options in the private market, and that it will be more tailored to individual needs. So people will choose to have insurance. They won't be told they have to have insurance.

INSKEEP: Even though subsidies are also going down for a lot of people, that people will choose to have insurance because Republicans hope they'll have cheaper options. Is that right?

DAVIS: Yes. And, you know, this is at the core philosophical disagreement here between the two parties. Republicans simply do not believe it is the government's job to tell you you have to have insurance. They see it as their job to make sure people have access to insurance.

And Republicans also say that they - CBO can't account for their entire strategy, which is a three-pronged strategy that also includes new HHS regulations as well as they have plans to do further legislation down the road to do things like let states buy insurance across state lines. Of course, they can't guarantee that those things will happen. But that's their plan.

INSKEEP: Now, Paul Ryan, the speaker of the House, is a fan of this bill even though there is some grim news in this analysis. And here's some of what he said about it.


PAUL RYAN: I'm excited about this analysis. And yeah, I think they sort of overestimate the uninsured number just like they overestimated who would be insured by Obamacare. But I do believe that if we're not going to force people to buy something they don't want to buy, they won't buy it. And that's kind of obvious.

INSKEEP: So he's acknowledging the basic point. Fewer people will be insured, but he likes it. And he likes the next number. We said there was coverage costs and changes.

DAVIS: And change.

INSKEEP: Costs here - $337 billion less in the federal budget deficit over the course of a decade. He says he's encouraged. What's he mean by that?

DAVIS: Well, you know, part of this, too, that the speaker - who's been probably the most passionate defender of this law because much of it has come from his own ideas - is that he's also saying to his colleagues that what they're trying to do with Medicaid is a once-in-a-generation shot for conservatives to reshape an entitlement program. And if you've spent any time paying attention to Paul Ryan's career, I mean, this has been one of the driving forces of his purpose in Washington.

INSKEEP: They're going to take hundreds of billions of dollars out of Medicaid, the health program for the poor. How do they do that?

DAVIS: So right now, the federal government essentially guarantees to the states that they'll make up the difference in what their Medicaid costs are. And going forward, the federal government will essentially cap those costs to the states and tell states that they have to come up with the difference. So that saves money on the federal government end. What their argument is, they'll give states more flexibility to - with what they can do with those federal dollars and will, in theory, allow for more innovative ways to spend money in the Medicaid system.

INSKEEP: And we should emphasize part of this plan is tax cuts, tax cuts for wealthier people. They'll roll back tax cuts - tax increases on the wealthy that were part of Obamacare. Less money for Medicaid, but they're insisting that the states can work it out. How comfortable are Republican senators with all of this?

DAVIS: Not particularly comfortable. One Republican to look at that I think tells the story of this bill and the conflicts they're going to have is Arkansas Republican Tom Cotton. He is a conservative by any measure and any definition, a supporter of Donald Trump. And he has been one of the most publicly skeptical Republicans about this legislation. Why is that? Arkansas has seen one of the sharpest drops in uninsured rates in the country.

And Democrats can make a case that Obamacare has been a success story in a state like that. So he is saying, as are many Republicans in the Senate, we really need to put the brakes on this. And specifically on the Medicaid part, there's a lot of skepticism among Republicans that this is the right thing to do.

INSKEEP: Can Democrats stay unanimous against this as they've said they want to be?

DAVIS: Yes. This is an easy vote for Democrats. There's not a single wavering Democrat against this. This is really an internal Republican argument. And Republicans are going to have to find votes on their own to pass it.

INSKEEP: Sue, thanks as always.

DAVIS: You bet.

INSKEEP: That's NPR congressional correspondent Susan Davis. Transcript provided by NPR, Copyright NPR.

Susan Davis is a congressional correspondent for NPR and a co-host of the NPR Politics Podcast. She has covered Congress, elections, and national politics since 2002 for publications including USA TODAY, The Wall Street Journal, National Journal and Roll Call. She appears regularly on television and radio outlets to discuss congressional and national politics, and she is a contributor on PBS's Washington Week with Robert Costa. She is a graduate of American University in Washington, D.C., and a Philadelphia native.