As CBO weighs in on AHCA, Senate urged to chart different course

Andis Robeznieks , Senior News Writer

Enacting the American Health Care Act of 2017 (AHCA) as currently amended would result in 23 million fewer Americans having health insurance by 2026, according to estimates released Wednesday by the Congressional Budget Office (CBO) and the Joint Committee on Taxation staff. Senators are being advised to take pragmatic steps to stabilize the individual market and give Americans access to affordable insurance coverage.

That 23 million figure equals 1 million fewer uninsured individuals than was estimated for a previous iteration of the bill and is “primarily attributable” to lower premiums being predicted in the individual market—though such plans would likely offer fewer benefits and so have higher out-of-pocket costs for those who use covered services.

Last month, AMA President Andrew Gurman, MD, described the AHCA as falling short “where it matters most”—which is in maintaining the gains in health care coverage made in recent years. On Wednesday, he maintained that this was still true.

“Today’s estimates from the nonpartisan Congressional Budget Office show that last-minute changes to the AHCA made by the House offered no real improvements. Millions of Americans will become uninsured—with low-income families on Medicaid being hit the hardest,” Dr. Gurman said. “We urge the Senate to ensure that any changes made to current law do not cause Americans to lose access to affordable, meaningful health insurance coverage.” 

The legislation’s immediate effect would be 14 million more people uninsured next year, the CBO report says.

In all, the CBO estimates that the direct revenue and spending effects of the legislation, H.R. 1628, would result in 51 million people not having health insurance in 10 years, compared with the 28 million uninsured projected for 2026 under current law. There were nearly 50 million uninsured patients in 2010, according to the U.S. Census Bureau.

The AHCA calls for granting waivers to states so they could modify federal essential health benefit requirements and allow payers to set premiums based on an individual’s health status. This differs from currently mandated community-rated premiums based on a region’s average health care costs for people of the same age and smoking status.

Though the legislation could result in “relatively low” premiums for healthier-than-average individuals, the CBO projected that it would ultimately lead to unstable individual markets by 2020 in states where one-sixth of the U.S. population lives.

Insurance premiums would rise by an average of 20 percent next year under the AHCA, according to the CBO. They would rise an average of 5 percent in 2019. Then rule changes would take effect resulting in lower premiums that vary widely from state to state depending on the changes in market regulations a given state undertakes.

In some states, though, sicker people could see “extremely high premiums” and others could see lower premiums but “substantial” increases in their out of pocket expenses. That is especially so if they live in states that modify required benefits, or cap annual or lifetime expenses, according to the CBO.

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The agency noted that services some states may exclude from essential health benefit requirements include maternity care, mental health and substance abuse treatment, rehabilitation services and pediatric dental care.

The CBO acknowledged that there is uncertainty in its estimates and in the direction individual states will take, but said some effects of the legislation are clear.

“The amount of federal revenues collected and the amount of spending on Medicaid would almost surely both be lower than under current law,” the CBO concluded. “And the number of uninsured people under the legislation would almost surely be greater than under current law.”

The most recent amendment to the AHCA provided for $8 billion in federal funding between 2018 and 2023 to help stabilize individual markets. The CBO said this should lower premiums and out-of-pocket expenses, but the impact would be small because the funding would not be enough to lower premium increases high-cost enrollees would face.

In contrast to House GOP leaders, who took heat for not listening to health care stakeholders while drafting their bill, Senate Finance Committee Chairman Orrin Hatch, R-Utah, sent a letter May 12 to organizations representing physicians, patients, employers and other stakeholders soliciting their input.

Hatch specifically asked for guidance on taxation, health savings accounts, Medicaid, tax credits for buying health insurance, and funding to stabilize state marketplaces.

AMA CEO and Executive Vice President James L. Madara, MD, replied in a letter to Hatch in which he called for reforms that reduce regulatory burdens, provide greater cost transparency and maintain safety-net programs. He also laid out some specific proposals. Among other things, Dr. Madara said policymakers should:

  • Fund cost-sharing reductions for 2017 and 2018.
  • Provide monthly tax credits of about $50 for young adult to boost coverage rates and balance risk pools.
  • Help those with high deductibles by “modestly” funding health savings accounts.
  • Encourage states to decrease Medicaid administrative burdens while using new payment models to promote efficiency and high-quality care.

“The AMA stands ready to work with you and your Senate colleagues on a bipartisan basis to address the shortcomings of the existing health care system and ensure that health insurance coverage is available and affordable for every individual and family in the nation,” Dr. Madara wrote.

Read more about the AMA's comprehensive vision for health-system reform, refined over more than two decades by the AMA House of Delegates, which is composed of representatives of more than 190 state and national specialty medical associations.

You can further explore the AMA’s health reform objectives at, an online platform designed to educate and engage patients and physicians on the current debate. The site makes it easy for patients and physicians to write their elected Congressional representatives and urge them to protect Americans’ access to quality care.