CBO analysis of Republican replacement legislation

Cost Estimate: American Health Care Act

Congressional Budget Office, March 13, 2017

The Congressional Budget Office and the staff of the Joint Committee on Taxation (JCT) have produced an estimate of the budgetary effects of the American Health Care Act.

Effects on the Federal Budget

CBO and JCT estimate that enacting the legislation would reduce federal deficits by $337 billion over the 2017-2026 period. That total consists of $323 billion in on-budget savings and $13 billion in off-budget savings. Outlays would be reduced by $1.2 trillion over the period, and revenues would be reduced by $0.9 trillion.

The largest savings would come from reductions in outlays for Medicaid and from the elimination of the Affordable Care Act’s (ACA’s) subsidies for nongroup health insurance. The largest costs would come from repealing many of the changes the ACA made to the Internal Revenue Code—including an increase in the Hospital Insurance payroll tax rate for high-income taxpayers, a surtax on those taxpayers’ net investment income, and annual fees imposed on health insurers—and from the establishment of a new tax credit for health insurance.

Effects on Health Insurance Coverage

CBO and JCT estimate that, in 2018, 14 million more people would be uninsured under the legislation than under current law. Most of that increase would stem from repealing the penalties associated with the individual mandate.

Later, following additional changes to subsidies for insurance purchased in the nongroup market and to the Medicaid program, the increase in the number of uninsured people relative to the number under current law would rise to 21 million in 2020 and then to 24 million in 2026. The reductions in insurance coverage between 2018 and 2026 would stem in large part from changes in Medicaid enrollment — because some states would discontinue their expansion of eligibility, some states that would have expanded eligibility in the future would choose not to do so, and per-enrollee spending in the program would be capped. In 2026, an estimated 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.

Although the agencies expect that the legislation would increase the number of uninsured broadly, the increase would be disproportionately larger among older people with lower income; in particular, people between 50 and 64 years old with income of less than 200 percent of the FPL would make up a larger share of the uninsured.

Effects on Premiums

In 2018 and 2019, according to CBO and JCT’s estimates, average premiums for single policyholders in the nongroup market would be 15 percent to 20 percent higher than under current law, mainly because the individual mandate penalties would be eliminated, inducing fewer comparatively healthy people to sign up.

Starting in 2020, the increase in average premiums from repealing the individual mandate penalties would be more than offset by the combination of three main factors. First, the mix of people enrolled in coverage obtained in the nongroup market is anticipated to be younger, on average, than the mix under current law. Second, premiums, on average, are estimated to fall because of the elimination of actuarial value requirements, which would result in plans that cover a lower share of health care costs, on average. Third, reinsurance programs supported by the Patient and State Stability Fund are estimated to reduce premiums. If those funds were devoted to other purposes, then premium reductions would be smaller. By 2026, average premiums for single policyholders in the nongroup market under the legislation would be roughly 10 percent lower than the estimates under current law.

Although average premiums would increase prior to 2020 and decrease starting in 2020, CBO and JCT estimate that changes in premiums relative to those under current law would differ significantly for people of different ages because of a change in age-rating rules. Under the legislation, insurers would be allowed to generally charge five times more for older enrollees than younger ones rather than three times more as under current law, substantially reducing premiums for young adults and substantially raising premiums for older people.

Major Changes to Medicaid

CBO estimates that several major provisions affecting Medicaid would decrease direct spending by $880 billion over the 2017-2026 period. That reduction would stem primarily from lower enrollment throughout the period, culminating in 14 million fewer Medicaid enrollees by 2026, a reduction of about 17 percent relative to the number under current law. Some of that decline would be among people who are currently eligible for Medicaid benefits, and some would be among people who CBO projects would be made eligible as a result of state actions in the future under current law (that is, from additional states adopting the optional expansion of eligibility authorized by the ACA). Some decline in spending and enrollment would begin immediately, but most of the changes would begin in 2020, when the legislation would terminate the enhanced federal matching rate for new enrollees under the ACA’s expansion of Medicaid and would place a per capita-based cap on the federal government’s payments to states for medical assistance provided through Medicaid. By 2026, Medicaid spending would be about 25 percent less than what CBO projects under current law.

Changes to Actuarial Value Requirements

Actuarial value is the percentage of total costs for covered benefits that the plan pays when covering a standard population. Under current law, most plans in the nongroup and small-group markets must have an actuarial value that is in one of four tiers: about 60 percent, 70 percent, 80 percent, or 90 percent. Beginning in 2020, the legislation would repeal those requirements, potentially allowing plans to have an actuarial value below 60 percent. However, plans would still be required to cover 10 categories of health benefits that are defined as “essential” under current law, and the total annual out-of-pocket costs for an enrollee would remain capped. In CBO and JCT’s estimation, complying with those two requirements would significantly limit the ability of insurers to design plans with an actuarial value much below 60 percent.

Nevertheless, CBO and JCT estimate that repealing the actuarial value requirements would lower the actuarial value of plans in the nongroup market on average. The requirement that insurers offer both a plan with an actuarial value of 70 percent and one with an actuarial value of 80 percent in order to participate in the marketplace would no longer apply under the legislation. As a result, an insurer could choose to sell only plans with lower actuarial values. Many insurers would find that option attractive because they could offer a plan priced closer to the amount of the premium tax credit so that a younger person would have low out-of-pocket costs for premiums and would be more likely to enroll. Insurers might be less likely to offer plans with high actuarial values out of a fear of attracting a greater proportion of less healthy enrollees to those plans, although the availability of the Patient and State Stability Fund grants in most states would reduce that risk. The continuation of the risk adjustment program could also help limit insurers’ costs from high-risk enrollees.

Because of plans’ lower average actuarial values, CBO and JCT expect that individuals’ cost-sharing payments, including deductibles, in the nongroup market would tend to be higher than those anticipated under current law. In addition, cost-sharing subsidies would be repealed in 2020, significantly increasing out-of-pocket costs for nongroup insurance for many lower-income enrollees. The higher costs would make the plans less attractive than those available under current law to many potential enrollees, especially people who are eligible for the largest subsidies under current law.

Effects of Changes in the Nongroup Market on Employers’ Decisions to Offer Coverage

CBO and JCT estimate that, over time, fewer employers would offer health insurance because the legislation would change their incentives to do so. First, the mandate penalties would be eliminated. Second, the tax credits under the legislation, for which people would be ineligible if they had any offer of employment-based insurance, would be available to people with a broader range of incomes than the current tax credits are. That change could make nongroup coverage more attractive to a larger share of employees. Consequently, in CBO and JCT’s estimation, some employers would choose not to offer coverage and instead increase other forms of compensation in the belief that nongroup insurance was a close substitute for employment-based coverage for their employees.



By Don McCanne, M.D.

Since the CBO release yesterday of their analysis of the Republican replacement legislation - the American Health Care Act - major impacts have been widely reported. By 2026, an additional 24 million people would be uninsured compared to the projected uninsured under present law, whereas the federal budget deficit would be reduced by $337 billion. Some details of the analysis warrant a closer look.

Policies in the legislation that would result in leaving a total of 52 million uninsured are not applied evenly. Premiums would increase disproportionally for older individuals, who happen to have greater health care needs, thus this segment of the population would have a greater likelihood of being uninsured. Insured rates would increase for the younger, healthier population because of the lower premiums they would face. Thus the blunt targeting of the legislation would reduce coverage rates for those with greater needs.

Some are celebrating the fact that the legislation would eventually reduce premiums by 10 percent compared to what they would be under current law. But it is important to understand that the legislation removes the actuarial tiers under the Affordable Care Act and allows insurers to market plans below the minimum actuarial value of 60 percent - the patient pays over 40 percent of the costs. The analysis explains that the insurers would cluster their products in this low range (to maintain competitive premiums), which will leave patients exposed to greater cost sharing. Affordable premiums translate to unaffordable health care access. Also, as explained above, the premiums would be lower for younger, healthier individuals, but for older, sicker individuals the premiums would be higher than they are under the current law. When people with higher premiums drop out, the average premium becomes artificially lower.

Perhaps the greatest harm of this legislation is the attack on Medicaid - a program designed to help meet then health care needs of lower-income individuals and families. The largest reductions in federal spending would come from cuts to the Medicaid program. These reductions would result in 14 million fewer individuals being enrolled in the Medicaid program. Many of these would remain uninsured because of the lack of options that are affordable for them.

The legislation would also negatively impact the mainstay of health insurance in America - employer-sponsored health plans. The employer mandate to provide insurance would be eliminated, and employees would be eligible for the new tax credits under this legislation only if employers did not offer health care coverage. Since employers could offer wage increases in lieu of health care benefits, it is anticipated that the employer offer rate of health care coverage would decline. That would be unfortunate since the plans dominating the marketplace would have very low actuarial values that would make actual health care much less affordable.

Finally, since the CBO analysis is primarily concerned about the impact on the federal budget, it would seem to be good news that the federal deficit would be reduced by $337 billion. But when you look at what that means, that’s a number that only budget hawks could love considering what the real impact is on the citizens of this nation. That deficit reduction is the difference between a $1.2 trillion decrease in direct spending for health care - spending which is shifted to patients - and a $883 billion reduction in revenues - primarily a reduction in taxes paid by the wealthy. An important part of ACA was the progressive taxes that made health care more affordable for lower-income individuals and constituted a very modest correction of our problematic wealth transfer to the rich. Although the CBO was correct to calculate the difference in the numbers as far as the federal balance sheet is concerned, actually both of the numbers represent a negative impact on working families. Families have to pay more out-of-pocket for health care, and they have to make up the difference in the tax benefit received by the wealthy. Thus working families collectively are worse off by the sum of these two numbers - over $2 trillion!

This legislation has been characterized as representing health care cuts for the people and tax cuts for the rich. Paul Ryan dismisses that by saying, “Read the bill.” Well, we have. It’s even worse because it also leaves in place our profoundly expensive, highly dysfunctional, very inequitable method of financing health care - wasting over $500 billion in administrative excesses alone. We desperately need a much better designed financing system - a single payer national health program.