Two weeks after introducing their bill to overhaul the Affordable Care Act to heated criticism, House Republicans unveiled amendments to the plan. Here's what you need to know about the legislation and its changes. (Bastien Inzaurralde,Sarah Parnass,Jenny Starrs/The Washington Post)

The Post reports, “House Republicans on Monday released long-anticipated legislation to supplant the Affordable Care Act with a more conservative vision for the nation’s health care system, replacing federal insurance subsidies with a new form of individual tax credits and grants to help states shape their own policies.” However, let’s be clear how little we know — and how little members will know — about what this entails. For example, “it is unclear what the size of the tax credits will be compared to the ACA’s subsidies.” We don’t know whether tax credits “would be restricted to people under a certain income threshold — perhaps $75,000, according to the House member briefed on the plan — or whether the subsidy would taper off after a specific income level but not end entirely.” In what must be the understatement of the year, it seems, “several House Republicans expressed concerns that the committees might start to work on the legislation without a complete fiscal assessment.” That’s putting it generously.

House Speaker Paul D. Ryan’s (R-Wis.) office says it has no Congressional Budget Office score for the bill to repeal Obamacare. Well, I asked, how then do you know:

  • What the impact will be on the deficit?
  • What the increase would be in out-of-pocket costs?
  • How many people will lose coverage?
  • How many people will be eliminated from Medicaid?

The answer: We don’t have a CBO score.

For starters, I frankly don’t believe that. Ryan can direct the CBO to score whatever he pleases, and it defies common sense to think he doesn’t have a very, very good idea how CBO would score this, even with recent changes to reintroduce income as a consideration in calculating the size of the tax credit. Moreover, the notion that House Republicans would vote to end legislation on which tens of millions of people depend for health-care coverage without knowing critical facts about their bill arguably is the most irresponsible display of governance in my lifetime. House Minority Leader Nancy Pelosi (D-Calif.) was berated for saying members would have to vote for the Affordable Care Act to find out what was in it, but members knew far more about what was in that bill than Republicans now know about the American Health Care Act (AHCA) — and Republicans are taking coverage away.

Conservative health-care guru and Obamacare critic Avik Roy bluntly criticizes “the bill’s stubborn desire to make health insurance unaffordable for millions of Americans, and trap millions more in poverty.” He notes the “critical” flaw in the bill, namely “its insistence on flat, non-means-tested tax credits. The flat credit will price many poor and vulnerable people out of the health insurance market.” The bill is far more generous to upper-income people than the ACA is, provided that the new tax credit does not phase out entirely for a single 40-something individual before $105,000 in earnings. Roy’s conclusion should bring smiles to Democrats’ faces:

It’s not clear why they’re proceeding without a [CBO] score, but it means that members of the House Energy & Commerce and Ways & Means Committees will not have the information they need to make informed decisions about how best to revise the bill.

The CBO is likely to score the AHCA as covering around 20 million fewer Americans than Obamacare. There are flaws in the way the CBO models health reform legislation, but the AHCA itself contains enough flaws that there can be little doubt that the plan will price millions out of the health insurance market.

Expanding subsidies for high earners, and cutting health coverage off from the working poor: it sounds like a left-wing caricature of mustache-twirling, top-hatted Republican fat cats.

Another conservative commentator agrees that the House bill will look horrible upon closer inspection, including: “significant erosion of up to 10-20 million individuals with employer-provided health coverage; a new entitlement — the refundable tax credits — that by and large wouldn’t expand coverage, but instead cause individuals currently in employer plans to switch to the credits; more federal spending via the refundable tax credits; a tax increase — a cap on the current exclusion for employer-provided health coverage — to pay for the new spending on the credits; and an increase in the uninsured (compared to Obamacare) of at least 15 million — nearly as much as repealing the law outright.” He speculates that 10 million to 20 million could lose coverage.

Meanwhile, in the grown-up world, four GOP senators already have staked out a clear position on Medicaid. Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.) and Lisa Murkowski (Alaska) sent a letter to Senate Majority Leader Mitch McConnell (R-Ky.) outlining concerns that the House will not “provide stability and certainty for individuals and families in Medicaid expansion programs or the necessary flexibility for states.” Not unreasonably, they argue:

We are concerned that any poorly implemented or poorly timed change in the current funding structure in Medicaid could result in a reduction in access to life-saving health care services. The Medicaid population includes a wide range of beneficiaries, many of which cycle on and off Medicaid due to frequent changes in income, family situations, and living environments.  The Department of Health and Human Services reports that nearly one-third of individuals covered under the Medicaid expansion have a mental health or substance use disorder. As the largest payer of mental health and substance use services in the United States, it is critical that any health care replacement provide states with a stable transition period and the opportunity to gradually phase-in their populations to any new Medicaid financing structure.

We believe Medicaid needs to be reformed, but reform should not come at the cost of disruption in access to health care for our country’s most vulnerable and sickest individuals

Well, from what we can gather about the House bill, they are right to be concerned. (The Post reports, “Starting in 2020, however, the GOP plan would restrict the government’s generous Medicaid payment — 90 percent of the cost of covering people in the expansion group — only to people who were in the program as of then. States would keep getting that amount of federal help for each of those people as long as they remained eligible, with the idea that most people on Medicaid drop off after a few years.” The rest of the states would get a lump sum of $10 billion over five years.) What about those who lose Medicaid coverage, the poorest and sickest? House Republicans do not bother to ask, let alone provide a satisfactory answer.

Interestingly, the House drops its bill on a day we find that the vast majority of Americans want to repair, not repeal, Obamacare. The Hill reports, “According to a national poll from the liberal-leaning Hart Research Associates, 68 percent of voters favor keeping what works in the healthcare law and fixing what doesn’t. Meanwhile, 32 percent say ObamaCare should be repealed and replaced with a new law.” And while Republicans may not care about the details of Medicaid, their base does. “60 percent of voters polled viewed changing Medicaid’s funding to block grants unfavorably, while 40 percent view it favorably. Among people who voted for President Trump, 33 percent view the proposal unfavorably.” Oh, and, “58 percent of voters said they would be less likely to support their senator or congressman for reelection if they voted for block grants and cuts to the program.”

Senate Minority Leader Charles E. Schumer (D-N.Y.) put out a perfunctory statement last night excoriating the House plan. It read in part, “Trumpcare doesn’t replace the Affordable Care Act, it forces millions of Americans to pay more for less care. This plan would cut and cap Medicaid, defund Planned Parenthood, and force Americans, particularly older Americans, to pay more out of pocket for their medical care all so insurance companies can pad their bottom line.” We think that is correct, but frankly, neither we nor the members of Congress voting for it know for sure. And that is a disgrace.