The healthcare bill Senate Republican leaders unveiled last week would increase the number of people in the U.S. without health coverage by 22 million and push up medical costs for millions of other poor and sick Americans, according to a new analysis by the nonpartisan Congressional Budget Office.
The grim analysis immediately called into question whether Senate Republican leaders will have the votes to proceed with the bill this week as the majority leader, Sen. Mitch McConnell of Kentucky, has planned. He can lose only two GOP senators.
One key undecided lawmaker, Sen. Susan Collins (R-Maine), announced a few hours after the report was issued that she would oppose bringing the bill up this week, joining Sen. Dean Heller (R-Nev.), who said last week he opposes the legislation.
"I want to work w/ my GOP & Dem colleagues to fix the flaws" in the Affordable Care Act, Collins wrote in a Twitter message. "CBO analysis shows Senate bill won't do it."
Several other senators have said they are uncomfortable with voting this week on the bill. "They're trying to jam this thing through," Sen. Ron Johnson of Wisconsin said in an interview with conservative radio host Hugh Hewitt. "All I'm asking is let's give ourselves a few more days. Maybe a week or two."
The budget office report -- which comes just days after President Trump called for a bill "with heart" -- outlines how the GOP plan would cause a widespread erosion in basic health protections, driven by more than $1 trillion in cuts to federal healthcare spending over the next decade.
Some consumers "would experience substantial increases in what they would spend on health care," the budget office analysis said. Because individual insurance under the Senate bill "would pay for a smaller average share of benefits," it found, "most people purchasing it would have higher out-of-pocket spending on health care than under current law."
And although budget analysts predicted that average insurance premiums in 2020 would be lower under the Senate bill, analysts noted that would be because insurance would pay for less medical care.
The coverage losses in the Senate bill would completely reverse historic gains in recent years under Obamacare. Over the last four years, the share of people without coverage in the U.S. has been cut in half, dropping to the lowest levels ever recorded, data show.
The Senate bill has spurred widespread condemnation from patient advocates, physicians, hospitals and others.
On Monday, the American Medical Assn. added to the pressure on senators, sending the chamber's leaders a blunt warning: "Congress should be working to increase the number of Americans with access to quality, affordable health insurance instead of pursuing policies that have the opposite effect," the medical group said.
In the face of such criticism, McConnell and his allies have been scrambling to lock down the remaining votes they need.
A key moment could come as early as Tuesday with a procedural vote allowing the Senate to begin debate on the bill.
Senators have said the report from the budget office, which Congress has traditionally relied on for estimates of the impact of major legislation, would be important to their decision on how to vote.
Monday, Sen. John Thune (R-S.D.), a Republican leader, celebrated the budget report's predictions of lower premiums.
The White House pushed back at the budget office, however, claiming that its past analyses have shown a "history of inaccuracy" and should "not be trusted blindly."
In reality, the budget office's predictions about the Affordable Care Act accurately projected the increase in the number of Americans who would gain insurance, although analysts overestimated the number of people who would get insurance through the marketplaces the law created and underestimated the number who would be covered on their jobs.
The new budget office report suggests the effects of the Senate bill would be particularly hard on millions of low- and middle-income Americans, as it forces states to scale back their safety nets and prompts insurers to pare down benefits and raise deductibles in response to weakened regulations.
"The share of services covered by insurance would be smaller," the report concludes. That, coupled with high deductibles, would drive many consumers from the market. "Few low-income people would purchase any plan," the analysts concluded.
For example, a 40-year-old American with an income of $26,500 a year would see his or her annual insurance premiums nearly double to $3,000, the budget office found. A 60-year-old with the same income would see premiums nearly quadruple to $6,500.
Americans making even less might only be able to buy health plans with deductibles that were half their annual incomes.
By contrast, higher-income Americans and a number of industries, including health insurers and medical device makers, would reap windfalls as the bill wipes out about $700 billion in taxes over the next decade, according to the budget analysis.
The analysis was similar to what the budget office said regarding the version of the bill that passed the House last month. That bill would reduce insurance coverage by about 23 million people over the next decade, the budget office said. The Senate measure would have slightly less impact on overall coverage, but would involve a deeper, long-term cut in Medicaid spending than the House measure.
A last-minute change to the Senate bill added Monday that would replace Obamacare's insurance mandate with an alternative penalty would have little impact, the budget office concluded. The Senate measure would impose a six-month waiting period for coverage on consumers who go without health insurance for more than two months.
Much of the gain in insurance coverage under Obamacare has been driven by expanding Medicaid.
The centerpiece of the Senate Republican bill is a series of measures that would reverse that trend, imposing a $772-billion cut in Medicaid spending over the next decade.
The federal government under the Republican bill would pull back aid to states for the half-century-old government health plan, which currently covers some 75 million low-income people, including children and the elderly in nursing homes.
The bill would end the expansion of Medicaid coverage made possible by the current law. Federal assistance for expanded Medicaid would be phased out beginning in 2020 and shut down completely by 2023.
To date, 31 states have expanded Medicaid eligibility through Obamacare, helping to drive a historic reduction in the number of uninsured Americans -- including many struggling with opiate addiction.
Even more revolutionary, the GOP bill would fundamentally transform Medicaid by capping future federal Medicaid assistance to states.
Since Medicaid's founding in the mid-1960s, the federal government has paid a share of all medical expenses incurred by Medicaid patients. But under the GOP plans, that would be replaced by fixed payments to states, regardless of how much patient care costs.
Because the cap on federal help would increase only at the rate of inflation, states would bear an increasingly large share of medical costs, which have traditionally increased faster than inflation, according to the CBO analysis.
"With less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to finance the program" or "reduce spending by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility" or "arriving at more efficient methods for delivering services" to the extent that is feasible, the budget analysts noted.
The budget office warnings were amplified Monday by the nonpartisan National Assn. of Medicaid Directors, the organization of officials in the 50 states who run Medicaid programs. The group's board warned that the Senate bill represents "a transfer of risk, responsibility, and cost to the states of historic proportions" and was "insufficient and unworkable."
The bill's provisions would bring even greater retrenchments after 2026, as the caps on spending take effect, though that is not reflected in the budget analysis, which focuses on the impact over the next decade.
Separately, the Senate bill would make major changes to health insurance markets. The CBO report forecasts that a growing number of health plans would not cover basic benefits such as maternity care or mental health services. That would be possible because the bill loosens a series of current requirements on insurers.
The proposal also restructures the system of subsidies that helps Americans pay for private insurance on the Obamacare marketplaces.
These tax credits, which about 8 million Americans receive, lower the cost of insurance plans that consumers can buy on HealthCare.gov, Covered California and other insurance marketplaces.
Currently, the amount of assistance a person gets is linked to how much he or she earns as well as to the cost of a relatively robust health plan that covers a basic set of benefits.
The Senate GOP measure continues to link the subsidies to consumers' incomes, though it makes the aid available only to people making up to 350% of the federal poverty line, compared with 400% under current law.
But the amount of the subsidy would be tied to the price of cheaper health plans, which cover less of patients' medical expenses. That would reduce the value of aid available to most consumers.
The GOP plan would also eliminate, after 2019, the extra assistance that Obamacare provides that reduces deductibles for low-income consumers. Without that, many low- and moderate-income Americans could be left to buy health plans with deductibles that reach $6,000 or higher, effectively putting most medical care out of reach.
At the same time, the bill would loosen requirements in Obamacare that health plans cover a basic set of benefits, a change that patient advocates and consumer groups have warned would once again leave many sick Americans with inadequate or unaffordable coverage.
"If this bill passes as written, we will likely return to the days before the Affordable Care Act, when many patients with heart disease had to pass around the plate for surgery, " said Dr. John Warner, president-elect of the American Heart Assn.
5:00 p.m.: This article was updated with additional detail and reaction.
4:20 p.m.: This article was updated with reaction from Sen. Susan Collins of Maine.
3:05 p.m.: This article was updated with additional detail and reaction to the CBO report.
1:47 p.m.: This article was updated with additional details from the budget office report.