For example, the CBO projection includes about 5 million people who’d leave Medicaid rolls, even though Medicaid is free. Other, previous analyses have found that the mandate helps ease the stigma of enrolling in Medicaid, a means-tested program traditionally viewed as welfare. They’ve also found it helps spread awareness about coverage options to low-income people and their children. What’s more, diminishing risk pools on the exchanges—the result of an imbalance between high- and low-cost patients—raise premiums and can influence insurer decisions to pull out of markets.
It’s hard to imagine those changes would leave stable, working exchanges in the years ahead. Again, insurers make decisions based on risk, and it seems the Trump administration and a Republican Congress are presenting them with plenty of risk.
The bill’s potential effect on Americans’ health doesn’t stop at the mandate. The CBO also reports that if the projected deficit increase of $1.5 trillion isn’t mitigated through additional legislation, it’ll trigger automatic cuts in mandatory spending, including up to $25 billion a year from Medicare. That alone wouldn’t be enough to close the deficit gap, but it’d have serious implications for the decades-old program. Twenty-five billion dollars is only 4 percent of its annual budget, but as Vox’s Sarah Kliff explained, for life-saving therapies and programs requiring expensive drugs and devices, that 4 percent makes all the difference.
Additionally, as my colleague James Hamblin noted, the overall health effects from income inequality run deeper and broader than coverage numbers suggest. With the bill expected to increase relative disparities between upper- and lower-income tiers, some researchers predict that the stress of trying to make it out of the working class will only increase, and with it, so will health disparities.
In short, the legislation would put incredible strains on the remaining infrastructure of the health law, just as another blow is potentially around the corner. As more and more senators, including Maine’s Susan Collins, have been coaxed to get on board with the GOP’s tax plan, a reauthorization bill for the Children’s Health Insurance Program has languished since Congress allowed the program to lapse in September. States have been relying on reserve funding to keep the 9 million children insured through the program covered, but for many states that money will soon run out. The lack of a deal on CHIP is baffling for a program that has long enjoyed bipartisan support, and all the more so because the holdup appears to be the cost of the program. CHIP, which costs roughly $15 billion annually, is in limbo while a $1.5 trillion tax plan consolidates GOP support.
Nothing is a sure thing at this point. Obamacare sign-ups could rally over the next two weeks. A final tax plan could still be defeated in either chamber, or lawmakers could ditch the individual-mandate provision. And CHIP could still get reauthorized, even if it takes a bit of congressional brinksmanship to get there. But with markets already wracked by instability and uncertainty, damage to the greater health-care landscape has already been done.