THE PROGNOSIS

The final word is in: The House Republican bill to replace large parts of the Affordable Care Act would save $119 billion over a decade but cost 23 million Americans their health coverage.

Those figures are actually pretty similar to initial estimates for the House's American Health Care Act -- before Republicans added in some last-minute amendments changes.

Yet when the CBO released its score late Wednesday afternoon, it reignited a heated debate in Washington over the ongoing GOP effort to ditch big provisions in President Obama’s health-care law – an issue that took a temporary back seat amid all the drama over President Trump’s relationship with Russia and his treatment of former FBI Director James B. Comey.

Democrats and ACA backers ripped into the GOP measure, noting that it would roll back most of the progress made toward reducing the country’s uninsured and could result in plans becoming impossibly expensive for some people, especially older Americans.

Democrats were quick to start bashing the numbers:

Republicans were less unified -- when they responded at all, that is -- with House leadership defending the bill while some moderate lawmakers said it falls far short.

Speaker Paul D. Ryan (R-Wis.) championed the fact that the bill is estimated to lower the deficit, and premiums -- which, as we've noted before, is a new focus for Republicans as they've set aside some of their other Obamacare criticisms.

House Majority Leader Kevin McCarthy (R-Calif.) chimed in:

Senate Republicans were far more muted, however. Majority Leader Mitch McConnell (R-Ky.) did not even issue a statement, and downplayed expectations in a Reuters interview yesterday:  "I don't know how we get to 50 (votes) at the moment. But that's the goal. And exactly what the composition of that (bill) is I'm not going to speculate about because it serves no purpose," he said.

But at least one outspoken Senate Republican seemed to suggest that Republicans would be better off leaving Obamacare in place:

Here's what some other Republican lawmakers said, according to my colleagues Juliet Eilperin and Kelsey Snell: 

  • Sen. David Perdue (R-Ga.) in a statement: “Regardless of any CBO score, it’s no secret Obamacare is collapsing under its own weight. Doing nothing is not an option.”
  • New York Rep. John Faso (R) questioned whether the waivers would affect one-sixth of the population, as the CBO projected: “Frankly I doubt any state would try to take advantage of that provision,” he said. “I think that is completely out of the ballpark.”
  • House Freedom Caucus Chair Mark Meadows (R-N.C.), who helped craft the House-passed measure, warned that any changes the Senate might concoct still have to pass the House.

But mostly, Republicans were pretty silent, as noted by my former colleague Jen Haberkorn at Politico:

Although Tom Price seems to think the scores are, well, wrong.

Medical associations, who have panned the GOP bill, also were not impressed:

See how Washington reacted to the big health-care news:

Here at The Health 202, we’re mostly relieved the CBO didn’t wait until 8:15 p.m. to release the score, as some had rumored on Twitter. Just in case you don’t have time to read the entire 41-page report, we’ve got five takeaways right here:

1. The GOP plan would lower monthly insurance premiums, but probably not by enough for Republicans to make a strong case for their bill.

A big, swirling question has been how many states might opt out of Obamacare requirements that insurers ignore health status when pricing premiums (called “community rating”) and cover certain essential health benefits outlined by the federal government.

In order to get conservatives on board with their legislation, House Republicans added an amendment giving states this opt-out possibility, with the idea that easing insurer mandates would help lower premiums. To score the bill, the CBO had to estimate how many states might go this route. Here’s what it found:

--About half the U.S. population lives in states that would keep the essential health benefits and community-rating requirements. Average premiums for people buying plans on their own would be about 4 percent lower in 2026 compared to current law, mostly because younger, healthier people would buy plans.

--About one-third of the population lives in states that would partially opt out. Average premiums in those states would be 20 percent lower in 2026 compared to current law, mostly because plans would cover fewer services.

--About one-sixth of the population lives in states that would entirely opt out. Premiums in these states would be lower on average but vary significantly because insurers could charge those with preexisting conditions much, much more.

2. Even if premiums go down, many Americans would still pay more under the GOP plan because they would receive fewer government subsidies.

The CBO estimated staggering cost increases for older Americans who don’t earn much, especially those in their 60s who aren’t yet eligible for Medicare. For example, a 64-year-old earning $26,500 a year would have to pay about 850 percent more for their plan under the GOP bill compared to under the ACA.

 

Here's a handy visual:

And some pointed reaction from other health-care wonks. From the Kaiser Family Foundation's Larry Leavitt:

From Sarah Kliff at Vox:

Fair point about millenials from the Huffington Post's Elise Foley:

3. The ACA fell far short of expectations in expanding health coverage. But now Democrats have a fresh opportunity to focus on how the GOP bill would do even worse in that department.

Democrats were swift to respond to the CBO estimate yesterday, blasting Republicans for trying to reverse the ACA’s advances.

“It was irresponsible for the House to vote for the GOP health bill before a CBO analysis was available,” said Ron Pollack, former director of Families USA and one of the ACA's biggest proponents. “Now that it exists, however, anyone still supporting the bill is probably a prime candidate for a conscience implant.”

Some former Obama administration officials held a call late Wednesday to highlight what they see as its biggest shortcomings – and warn the Senate to go a different route.

“This report is a warning shot to the Senate, because they are marching down the same disastrous repeal path the House did,” said Leslie Dach, former senior counselor to Health and Human Services Secretary Sylvia Mathews Burwell.

4. Now Senate Republicans can really get to work on their own health-care bill. But if they want to beef up its coverage provisions, they only have $119 billion to work with.

The next steps for replacing Obamacare are complicated for Republicans. If they want to make subsidies for low-income Americans more generous, or restore some of the Medicaid cuts, they’ll have to dip into the bill’s deficit reduction or perhaps keep some of the ACA’s taxes.

And the CBO score is likely to motivate moderates to press leadership even harder for a health-care bill that preserves coverage for more people. They were quick to distance themselves from the House bill yesterday, criticizing its coverage shortcomings and promising they’ll come up with something better.

Sen. Susan Collins (R-Maine) touted her efforts with Sens. Bill Cassidy (R-La.) to work toward a bipartisan compromise. Cassidy, for his part, issued just about the shortest press release we at The Health 202 have ever seen, making a reference to his recent appearance on Jimmy Kimmel in which he said any ACA replacement must take care of people with preexisting conditions.

“Congress’s focus must be to lower premiums with coverage which passes the Jimmy Kimmel Test,” Cassidy said. “The AHCA does not. I am working with Senate colleagues to do so.”

AHH, OOF and OUCH

AHH: A small Christian school under fire recently for banning pregnant senior Maddi Runkles, a 4.0 student, from walking at graduation is not backing down, the Post's Joe Heim reports. In a letter to parents Tuesday evening, the school's principal said Runkles is being banned not because she is pregnant but "because she was immoral...The best way to love her right now is to hold her accountable for her morality that began this situation.”

Runkles told the Post in a telephone interview that the school is "missing out on an incredible opportunity to set an example for the pro-life community and Christian schools about how to treat guys and girls like me." "There have been kids who have broken the student code and they could have hurt people or even gone to jail and they only received an in-school suspension and they’re allowed to walk this year," she said. "The school is worried about its reputation."

--Antiabortion groups have been protesting the school's decision too. Students for Life of America is asking activists to write the school and ask for it to reconsider the decision and to donate to a scholarship and baby supply fund for Maddi. Susan B. Anthony List said the school "is heaping guilt and shame on a young woman who has made a life-affirming decision when she did not have to."

OOF: For one reporter, asking about the CBO score of the Republican health-care bill was hazardous to his health. Montana GOP congressional candidate Greg Gianforte appears to have body-slammed and broken the glasses of a journalist covering his special election contest, which is today.

"Gianforte was charged with misdemeanor assault Wednesday after allegedly assaulting a reporter for the Guardian who had been trying to ask him a question," my colleague Dave Weigel reports from Montana. "Gianforte, who is seen as the slight favorite in a race that ends Thursday, left what was supposed to be a final campaign rally at his Bozeman headquarters without making remarks."

The episode was caught on audio:

This former anti-Trump GOP presidential candidate had a word of warning for Republicans on health care:

OUCH: If any insurer has been doing well in the Obamacare marketplaces, it's been Blue Cross Blue Shield, whose plans were already deeply entrenched in communities and accustomed to covering lower-income patients. So it's particularly disturbing news that BCBS Kansas City is pulling completely out of the exchanges, affecting about 67,000 enrollees and putting a region in northwestern Missouri in danger of having no marketplace plans next year. The company says it has lost more than $100 million on plans in the marketplaces since they launched in 2014. 

"This is unsustainable for our company,” said CEO Danette Wilson, per the Kansas City Star. “We have a responsibility to our members and the greater community to remain stable and secure, and the uncertain direction of this market is a barrier to our continued participation.”

Consumers already faced a shortage of plan options in the past year in Missouri's marketplace, where just one plan was available in 97 of the state's 114 counties. Sen. Roy Blunt (R-Mo.) jumped on the latest news, saying it's evidence that "Obamacare is collapsing." Missouri's other senator, Democrat Claire McCaskill, said the news points to a need for more insurance options for people. McCaskill has introduced legislation allowing people in counties with no Obamacare plans to access the same plans offered to members of Congress.

HEALTH ON THE HILL

--As we've already written, there was a range of responses and emotions on Capitol Hill yesterday when the final CBO score on the Republican health-care bill was released. Some Republicans even appeared to tear up.

Told that the measure doesn't contain enough high-risk pool funding for people with preexisting conditions (according to the CBO), House Freedom Caucus Chairman Mark Meadows told reporters he'd go through the analysis more thoroughly to make sure they're properly funded. Then he got emotional, according to the Independent Journal Review, saying this: "Listen, I lost my sister to breast cancer. I lost my dad to lung cancer. If anybody is sensitive to preexisting conditions, it’s me. I’m not going to make a political decision today that affects somebody’s sister or father because I wouldn’t do it to myself." 

--For a core group of Senate Republicans, the CBO projection that 23 million people would lose coverage may be all they need to bury the House version of a health-care overhaul once and for all, the Post's Paul Kane writes. These Republicans also highlight just how high the hurdle is to get a health-care bill to President Trump’s desk.

"After Wednesday’s updated estimates, those Senate Republicans, predominantly from states with large populations of people who benefited from Medicaid expansion, dug in even further against the House bill because millions of their constituents would be left in the lurch by the GOP proposal," Kane writes.

Here are some more interesting reads:

Anthem said Wednesday that its plans for selling 2018 Obamacare individual plans are still up in the air because of political and regulatory uncertainty, making it the latest health insurer to say questions about continued funding of government subsidies will affect consumers next year.
Reuters
Insurance regulations created by Obamacare led to higher premiums in every state, finds a government analysis.
Washington Examiner
Senate Republicans are under mounting pressure to pass an ObamaCare repeal-and-replace bill before the congressional recess in August.
Sen. Lamar Alexander wants Congress to save Obamacare before it dismantles it, and he's in a position to push hard for that.
Roll Call
MALPRACTICE

--My fact-checking colleague Glenn Kessler has awarded two "Pinnochios" to the right-leaning American Action Network for a new ad supporting the Republican health-care bill. In one of the ads, a California woman named Elizabeth Jacinto says she suffered under Obamacare and expresses enthusiasm for the American Health Care Act. Kessler takes a look at this statement:

“As a mom, rising health-care costs are a big concern. My family lost our insurance and doctor because of the Affordable Care Act. But now, we have hope.”

The details: Jacinto had been kicked off her plan with Covered California, the state health-care exchange. But Kessler notes that the Republican health-care bill wouldn't eliminate the marketplaces, so it wouldn't really fix what Jacinto considered broken.

And would the plan give her "hope?" As backup for the ad's claims, the American Action Network cited an analysis that the establishment of a Patient and State Stability Fund will inspire states to set up efforts to encourage insurance companies to “provide consumers with an array of options.” ANN also cited the Congressional Budget Office report that “by 2026, average premiums for single policyholders in the nongroup market would be roughly 10 percent lower than under current law.”

But that doesn't mean costs will decrease, only that they'll increase more slowly than under the ACA, Kessler notes. Costs will especially increase for older Americans under the GOP bill because insurers would be allowed to charge them more. And while the Republican plan would expand the universe of people who would qualify for tax credits, it would also make the credits less generous for many people.

The conclusion: "The ultimate shape of the Republican replacement for Obamacare is still uncertain, if it even emerges from the Senate," Kessler writes. "But this ad glosses over many details to paint a rather rosy picture of reality. Jacinto — and readers — should be aware that rising health costs are unlikely to be halted under the [bill] as currently drafted."

DAYBOOK

Today

  • All eyes will be on Montana tonight, as Republican Greg Gianforte faces off against Democrat and folk singer Rob Quist to fill Interior Secretary Ryan Zinke’s congressional seat. The race will be read for signs of a Democratic wave election, partially tied to health care, in 2018.
  • The House will vote today on two bills aimed at protecting children who are subjected to exploitation or sexual abuse.
  • The House’s Appropriations Committee will also hold their budget hearing on the FDA at 10 a.m.

Coming up

  • Congress will recess for a week starting Friday, and progressive activists have already started planning health-care town halls during the break. 
SUGAR RUSH

Democratic National Committee Chairman Tom Perez went on Last Night with Seth Meyers to slam the GOP health-care bill:

Watch Stephen Colbert test the president's arithmetic skills with an elementary-level math pop quiz, since his budget shows a $2 trillion error:

We fact check whether insurance premiums will fall under the health-care bill: