House Republicans can’t say they weren’t warned.
As party leaders rushed to pass their American Health Care Act earlier this month, they ignored a chorus of calls—from Democrats, yes, but also from independent analysts and some in their own party—to wait for a final assessment from the Congressional Budget Office, a customary step before voting on any major legislation. The nonpartisan fiscal scorekeeper had run the numbers on two previous versions of the bill, but it had not had time to examine the impact of two late amendments. One would weaken Obamacare’s protections for people with preexisting conditions by allowing states to opt out of federal mandates, and the other sought to plug a hole that change could create by setting aside $8 billion to help cover costs for the affected population.
Critics sounded an immediate alarm, warning that $8 billion over five years, even when added to a $130 billion “stability fund” already in the legislation, would be woefully short of the amount needed to protect medically-expensive people who could be priced out of insurance as a result. Republicans went ahead anyway. House Speaker Paul Ryan had finally locked up the votes he needed, and with a 10-day House recess looming, he did not want to take a chance by waiting.
On Wednesday, the CBO confirmed what Republicans didn’t want to hear: Their changes to the bill had made only modest improvements to the number of people who could lose coverage (23 million instead of 24 million) and to the average cost of premiums, but they had made insurance all but unaffordable for people with preexisting conditions in states that wriggled out of Obamacare’s requirements. “Less healthy people would face extremely high premiums, despite the additional funding that would be available under H.R. 1628 to help reduce premiums,” the CBO wrote.
Republicans professed surprise. Representative Mark Meadows of North Carolina, the conservative House Freedom Caucus chairman who helped write the waiver amendment, initially doubted reporters who showed him CBO’s findings on Wednesday. Then, according to both the Independent Journal Review and the Washington Examiner, he grew emotional as he recalled losing both his father and his sister to cancer. “If anybody is sensitive to preexisting conditions, it’s me,” the congressman said. “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.”
Meadows suggested he’d be open to having the Senate add more money to bolster the high-risk pools. “In the end what we’ve gotta do is make sure there is enough funds there to handle preexisting conditions and drive down premiums,” Meadows told the reporters. “If we can't do those three things then we will have failed.”
Another supporter of the bill, Representative Pete Sessions of Texas, told reporters he assumed no state would take advantage of the waivers—a sentiment other House Republicans voiced in justifying their votes for the legislation. The CBO disagreed, projecting that as much as one-sixth of the nation’s population resides in states that would seek the maximum exemptions from Obamacare’s federal mandates.
The idea behind a high-risk pool is that instead of forcing younger, healthier people to pay higher premiums to cover the costs of the sickest, most expensive consumers of health care in a general insurance market, the government would heavily subsidize people with preexisting conditions in the separate pool while spending less money on the broader population. Some health policy analysts have said this arrangement could work—but only if the government provides enough funding for the high-risk pools. And in that regard, the money Republicans set aside in the AHCA wasn’t nearly enough. In a report released last week, the Urban Institute found that under the most conservative projection, the high-risk pools in the GOP bill would need at least $359 billion over 10 years—about three times as much as Republicans allocated. It could potentially be much more.
Not everyone was taken aback by the CBO’s findings. Ryan largely embraced them, saying he was “comforted” that the report confirmed that the GOP had achieved its goal of lowering average premiums and reducing the deficit (a requirement for the Senate’s budget rules). As for people with preexisting conditions, the speaker reminded reporters that states have been running high-risk pools for years—including in his own Wisconsin—and would be contributing substantially to their funding as well. “Remember, the states will also do some of the lifting,” Ryan said. “We will have federal resources and state resources, which taken together will improve the situation.”
Ryan is correct that states will have to pony up half of the costs in order to access matching funding from the federal government’s stability fund for high-risk pools. But CBO accounted for that split and found the money would still come up short. Moreover, states will also feel the strain of more than $800 billion in cuts to the federal contributions to Medicaid, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. “This is a net substantial withdrawal of financial resources out of the health-care system,” Pollitz told me, “and we’ve never seen states all of a sudden spending that kind of money.”
To the GOP’s critics, the point is not that they couldn’t dispute the CBO’s analysis; it’s that they didn’t seem interested in seeing it or waiting around to debate it. Republicans never invited experts to testify about the implications of their amendments to the AHCA, nor did they spend more than a couple hours debating them on the floor of the House. A few members admitted they didn’t even read the final bill before the vote—confessing to the very sin they alleged of Democrats in passing the much longer Affordable Care Act in 2010. “Even more striking is that these changes emerged from a legislative process that blatantly violated the norms of professional policymaking,” Doug Elmendorf, a former director of the CBO, wrote on Thursday on the website of Foreign Affairs. “Indeed, the development and passage of the AHCA is a case study in how not to make public policy.”
Republicans were desperate to pass their bill out of the House three weeks ago, unwilling to tolerate the lingering embarrassment of having failed on their core campaign promise of repealing and replacing Obamacare. Aware of the measure’s flaws, they reasoned that the Senate would rewrite it, that it would never become law. With insurers fleeing the individual market in some states, they argued, they couldn’t afford to wait. That all may be true. But on Wednesday, the arrival of the CBO’s damning, if unsurprising, report reminded Republicans that the danger of rushing can be even be even greater than the risk of delay.