Health care groups that represent doctors and patients are warning members of Congress that the House Republicans' plan to overhaul the Affordable Care Act would hurt people who need insurance most.
The groups are responding to the latest assessment by the nonpartisan Congressional Budget Office, which concluded that the proposed American Health Care Act would leave 23 million more people without health insurance than under current law and would cut the deficit by $119 billion over 10 years.
The latest CBO analysis came after House Republicans made changes to the bill earlier this month to try to ensure that people with pre-existing medical conditions can still get insurance.
"Last-minute changes to the AHCA made by the House offered no real improvements," said Andrew Gurman, president of the American Medical Association, in a statement. "Millions of Americans will become uninsured --with low-income families on Medicaid being hit the hardest."
Those concerns were echoed by group after group, including AARP, the American Hospital Association, the American Academy of Family Physicians, the Association of American Medical Colleges and the March of Dimes.
The Republican plan would roll back the requirement under the Affordable Care Act, also known as Obamacare, that everybody has to have insurance. It also would replace the ACA's income-based tax credits and subsidies with age-based credits that most analysts say are less generous.
Older, low-income people would be hit hardest by the changes, the CBO says, because the proposed tax credits are less generous than those in Obamacare, while insurance for those older than 50 is the most expensive.
As NPR's Danielle Kurtzleben reported, a 64-year-old making $26,500 would pay $1,700 in premiums annually under Obamacare. In a state making those "moderate" changes to its market under the proposed law, that 64-year-old would pay $13,600, and in a state with no waivers, the cost would be $16,100.
But premiums would fall overall, the report said, because policies would offer fewer benefits and sicker people would leave the market because they wouldn't be able to afford insurance.
The bill also would roll back the ACA's expansion of Medicaid. As a result, the CBO analysis estimates that 14 million people would lose Medicaid coverage, which accounts for most of the savings under the bill, $834 billion over 10 years.
"The CBO confirmed the American Health Care Act will further lower premiums, deliver more immediate tax relief for individuals and families, and decrease the deficit," said Rep. Kevin Brady, R-Texas, the chairman of the House Ways and Means Committee.
But Georges Benjamin, executive director of the American Public Health Association, called the bill "dangerous, deadly and deeply flawed."
He said the proposal, which is now in the hands of the Senate, would eliminate the Prevention and Public Health Fund, which helps promote immunization, smoking cessation and other public health initiatives and makes up 12 percent of the budget of the Centers for Disease Control and Prevention.
The CBO reports that the bill could destabilize individual insurance markets in some states, leaving unhealthy Americans unable to buy insurance.
But the CBO also acknowledges that its analysis includes some uncertainty, in part because the AHCA would allow states to get waivers that would exempt their insurers from many Obamacare coverage rules. This includes what are called essential health benefits, a list of medical services, such as mental health care or prescription drugs, that plans are required to cover under the current law.
The CBO estimated how many states might accept those waivers and what they might put in place of the current rules. It figures that states making up about half the population would apply for a waiver of some sort, reducing the benefits that insurers in those state will offer.
"Services or benefits likely to be excluded from [essential health benefits] in some states include maternity care, mental health and substance abuse benefits, rehabilitative and habilitative services, and pediatric dental benefits," the report said.
States could also get waivers that would allow insurers to charge more for people with pre-existing conditions, a practice banned under the ACA.
"Over time, it would become more difficult for less healthy people (including people with pre-existing medical conditions) in those states to purchase insurance because their premiums would continue to increase rapidly," the CBO wrote.
Republicans argue that by allowing insurers to sell less comprehensive insurance, premiums will fall and more people will buy basic coverage. And their bill includes money for states to create so-called high-risk pools in which people with medical conditions can buy coverage if commercial insurers refuse them.
But two small-business groups, the Main Street Alliance and the Small Business Majority, said the bill could hurt their members, many of whom rely on the individual insurance market for their coverage.
"Many solo entrepreneurs would likely be forced out of the insurance market entirely. This means many small firms would close up shop while others would never get off the ground," said John Arensmeyer, founder of Small Business Majority, which represents 55,000 small businesses.
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