G.O.P. Health Bill Would Leave 23 Million More Uninsured in a Decade, C.B.O. Says

WASHINGTON — A bill to dismantle the Affordable Care Act that narrowly passed the House this month would leave 14 million more people uninsured next year than under President Barack Obama’s health law — and 23 million more in 2026, the Congressional Budget Office said Wednesday. Some of the nation’s sickest would pay much more for health care.

Under the House bill, the number of uninsured would be slightly lower, but deficits would be somewhat higher, than the budget office estimated before Republican leaders made a series of changes to win enough votes for passage. Beneath the headline-grabbing numbers, those legislative tweaks would bring huge changes to the American health care system.

In many states, insurance costs could soar for consumers who are sick or have pre-existing conditions, while premiums would fall for the healthy, the new estimate concludes.

The forecast by the nonpartisan Congressional Budget Office, Capitol Hill’s official scorekeeper, is another potential blow to efforts to undo Mr. Obama’s signature domestic achievement. Republican senators have said they will make substantial changes to the measure passed by the House, but even Senator Mitch McConnell of Kentucky, the majority leader, sounds uncertain about his chances of finding a majority to repeal and replace the health law.

In states that obtain waivers from certain health insurance mandates, “premiums would vary significantly according to health status and the types of benefits provided, and less healthy people would face extremely high premiums,” the budget office said.

In addition, it said, “out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars.”

The new report is sure to influence Republican senators, who are writing their own version of the legislation behind closed doors. The report provided fresh ammunition for Democrats trying to kill the repeal bill, which they have derided as “Trumpcare.”

House Republican leaders, who pushed the bill through their chamber before the budget office could complete its final estimate, focused on the deficit reduction still on offer. The House bill would reduce federal budget deficits by $119 billion over a decade, less than the $150 billion in savings projected in late March for an earlier version of the bill, but still substantial, Republicans said.

Republicans in Congress generally focus more on reducing health costs than on expanding coverage. Their proposals will inevitably cover fewer people than the Affordable Care Act, they say, because they will not compel people to buy insurance.

But critics zeroed in on a bifurcated health care system that the bill could create: Those who are sick, at risk of getting sick or nearing retirement would pay more, while those who are young and healthy would pay less. In states that obtain waivers from rules mandating essential health coverage at uniform rates, the legislation could put insurance economically out of reach for some sick consumers.

“Unless you’re a healthy millionaire, Trumpcare is a nightmare,” said Senator Chuck Schumer of New York, the minority leader. “This report ought to be the final nail in the coffin of the Republican effort to sabotage our health care system.”

Insurance is, by definition, a pooling of risks, but the budget office said the House bill could cause a fragmentation of the market.

The budget office report indicates that the House bill would wipe out gains in coverage made in the last three years.

“In 2026,” it said, “an estimated 51 million people under age 65 would be uninsured, compared with 28 million who would lack insurance that year under current law.”

Republicans have been trying to repeal Mr. Obama’s health law since the day he signed it in March 2010. But the task is proving more difficult than they expected. Many parts of the law have become embedded in the nation’s health care system, and consumers have risen up to defend it, now that they fear losing its protection. At the same time, other consumers, upset about the mandate to buy insurance they can barely afford, are demanding changes in the law.

The budget office issued two reports on earlier versions of the House bill in March. Both said that the legislation would increase the number of uninsured by 14 million next year and by 24 million within a decade, compared with the current law.

But Republican senators appear as determined as ever to replace the Affordable Care Act.

“The status quo under Obamacare is completely unacceptable and totally unsustainable,” Mr. McConnell said Wednesday, a few hours before the budget office issued its report. “Prices are skyrocketing, choice is plummeting, the marketplace is collapsing, and countless more Americans will get hurt if we don’t act.”

The instability of the health law’s insurance marketplaces was underscored again on Wednesday when Blue Cross and Blue Shield of Kansas City, a nonprofit insurer, announced that it would not offer coverage under the law for 2018. The insurer lost more than $100 million in 2016 selling individual policies under the law, said Danette Wilson, the company’s chief executive.

Senator Chuck Schumer of New York, the minority leader, speaking to reporters in Washington on Tuesday.CreditAl Drago/The New York Times

“This is unsustainable,” she said in a statement. “We have a responsibility to our members and the greater community to remain stable and secure, and the uncertain direction of the market is a barrier to our continued participation.”

While a vast majority of people the company covers get insurance through an employer or a private Medicare plan, Blue Cross of Kansas City covers about 67,000 people in Kansas City and western Missouri under the federal health law. The company’s departure could leave 25 counties in western Missouri without an insurer, said Cynthia Cox, a researcher at the Kaiser Family Foundation.

Democrats say much of that instability stems from Republican efforts to repeal and undermine the Affordable Care Act.

The House repeal bill was approved on May 4 by a vote of 217 to 213, with no support from Democrats. It would eliminate tax penalties for people who go without health insurance and roll back state-by-state expansions of Medicaid, which have provided coverage to millions of low-income people. And in place of government-subsidized insurance policies offered exclusively on the Affordable Care Act’s marketplaces, the bill would offer tax credits of $2,000 to $4,000 a year, depending on age.

A family could receive up to $14,000 a year in credits. The credits would be reduced for individuals making more than $75,000 a year and families making more than $150,000.

The new report tends to validate criticism of the House Republican bill by AARP and other advocates for older Americans. “For older people with lower income, net premiums” — after tax credits — “would be much larger than under current law, on average,” the budget office said. As an example, it said, for a typical 64-year-old with an annual income of $26,500, the net premium in 2026 would average about $16,000 a year, compared with $1,700 under the Affordable Care Act.

The bill would reduce projected spending on Medicaid, the program for low-income people, by $834 billion over 10 years, and 14 million fewer people would be covered by Medicaid in 2026 — a reduction of about 17 percent from the enrollment expected under current law, the budget office said.

In a separate report, the congressional Joint Committee on Taxation said Wednesday that the House bill would cut taxes for high-income people by $230 billion over 10 years. The bill would repeal provisions of the Affordable Care Act that increased the payroll tax rate for many high-income taxpayers and imposed a surtax on their net investment income.

Under the House bill, the budget office said, uninsured people could keep $38 billion that they would otherwise have to pay in penalties over the next 10 years. The bill would also eliminate penalties for larger employers that fail to offer coverage to their employees, and as a result, the budget office said, the government would lose $171 billion in penalty payments from them.

Senior Republican senators say they want to reconfigure tax credits in the House bill to provide more financial assistance to low-income people and to older Americans, who could face much higher premiums under the House bill.

The House bill would roll back a number of insurance requirements in the Affordable Care Act, which Republicans say have driven up the cost of coverage.

In the weeks leading up to passage of the House bill, Republican leaders revised it to win support from some of the most conservative members of their party.

Under the House bill, states could opt out of certain provisions of the health care law, including one that requires insurers to provide a minimum set of health benefits and another that prohibits them from charging higher premiums based on a person’s health status.

These waivers could lower premiums, the budget office said, because insurance plans “would cover fewer benefits and therefore a smaller share of total health care costs.” If a state excluded maternity care from its definition of “essential health benefits,” such coverage could be offered separately as a rider, for an additional cost, just as it was in many states before the Affordable Care Act, the budget office said.

In states taking full advantage of the waivers, the budget office said, less healthy people could face higher premiums and “might not be able to purchase coverage at all.” In other words, it said, some “less healthy people would become uninsured.”

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