The “new-and-improved” American Health Care Act looks little improved

As the CBO reports that the AHCA could result in million of Americans losing healthcare insurance, Allan M. Joseph and William H. Seligman assess what impact this will have

A small, technical, apolitical office of the United States government might have just dealt a serious blow to one of the biggest partisan efforts in recent memory: Republicans’ plans to repeal and replace the Affordable Care Act (ACA). The Congressional Budget Office (CBO) acts as Congress’ referee, using detailed modeling to estimate the effects of pending legislation. CBO had modeled earlier versions of President Donald Trump and House Speaker Paul Ryan’s healthcare plans—the American Health Care Act (AHCA)—and estimated that they would cause 24 million Americans to lose insurance over a 10-year window, while closing the budget deficit by between $150 and $337 billion over that same period.

These earlier models, however, did not account for the major amendments that allowed House leadership to cobble together a coalition sufficient to pass the bill, as we outlined in a previous article. As we also mentioned when discussing those developments, lawmakers traditionally wait for CBO to analyse major changes to legislation before voting. In this case, however, House leadership prioritised speed above all else in an attempt to get the bill out of the House. So intent on delivering on promises made to constituents in recent elections, House Republicans passed the AHCA and took it to the Senate before understanding what impact the MacArthur and Upton Amendments would have.

Republicans may now have second thoughts about such haste. Despite lawmakers’ claims to the contrary, CBO estimates that the AHCA, as passed by the House, would result in 23 million Americans losing insurance over the next decade, with 14 million of those losses occurring in 2018 alone. The budget deficit would still shrink, but by $119 billion instead of the $150 to $337 billion estimated in earlier versions of the bill. Most troubling for Republicans, however, CBO also estimates that changes introduced by the MacArthur Amendment would destabilise the market for individual insurance (individual insurance is purchased by those who do not receive insurance through their employer or through government programs e.g. Medicare/Medicaid) for approximately one-sixth of the country, making premiums unaffordable for many. Though the legislation would, in the long run, lower the average premium in that market, it would do so by excluding the old and sick.

The Republicans’ promises now ring hollow. In debating the AHCA, Republicans (particularly moderates such as Rep. MacArthur) had claimed that protecting the sick was a top priority, along with lowering premiums. Yet the changes MacArthur introduced did little to protect the sick, and may have made the situation worse for some. MacArthur himself has chosen to attack CBO for false precision; though of course any exercise in modeling is fraught with peril, CBO is a widely-respected, unbiased, and generally-accurate institution.

Attention now shifts to Congress’ upper chamber, where Senate Republicans are under an extraordinarily pressing set of constraints. Republicans hold only 52 seats in the Senate (as well as the Vice President’s tie-breaking vote), and can thus only afford to lose three votes. Moderates will balk at the CBO score, particularly at the prospect of millions losing their insurance in a midterm election year. Meanwhile, hard-line conservatives are uneasy about any government subsidies for health insurance and will resist any efforts to soften the bill’s impact. All the while, the White House has shown fitful interest in the bill. It appears for now that the Senate will deliberate over the summer and begin writing its own bill. If it manages to pass such a bill, then the House and Senate will have to negotiate a compromise between the House and Senate-passed bills—which must then pass each chamber again.

Overall, a tricky, narrow journey remains to overturn the ACA. And as the CBO analysis reminds us, the reason this task is so difficult is because millions of lives are at stake. Republicans would do well to heed its warnings. There are ways of making the ACA work better. Could “repeal and replace” soon become “fix and improve?”

Allan M. Joseph studies health policy at the Harvard T.H. Chan School of Public Health and is a medical student at the Warren Alpert Medical School of Brown University.



William H. Seligman completed his Foundation Programme training in the Severn region before embarking on the Master of Public Health program in health policy at the Harvard T.H. Chan School of Public Health. He was previously a Legislative Intern in the United States Senate.

Competing interests: None declared.