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On May 4, the House of Representatives narrowly approved — on a 217 to 213 vote — H.R. 1628, the American Health Care Act of 2017 (AHCA). Every Democrat and 20 Republicans voted against the bill. This legislation would reverse the progress that California and the rest of the nation have made in extending health coverage to millions of people under the framework of the Patient Protection and Affordable Care Act (ACA), which President Obama signed into law in 2010.

The AHCA would make several changes that would damage the health and economic security of millions of Americans. These include, but are not limited to, 1) phasing out the Medicaid expansion, through which California and many other states have extended health coverage to millions of low-income adults under age 65; 2) shifting huge new costs for Medicaid to the states by capping annual federal funding for the program; 3) restructuring federal premium assistance — which lowers the cost of monthly health insurance payments — in a way that disadvantages people who are older and/or have lower incomes; 4) eliminating federal subsidies that reduce the cost of copays and deductibles for people with low or moderate incomes; and 5) ending nationwide protections for people with pre-existing health conditions. At the same time, the AHCA would provide massive tax breaks for the wealthy and for drug and insurance companies.

Republicans in the House approved the AHCA even though the final version of the bill had not been analyzed by the nonpartisan Congressional Budget Office (CBO), which estimates the potential impacts of proposed legislation. Today — nearly three weeks after House Republicans approved the AHCA — the CBO released its assessment of the bill.

On a nationwide basis, the CBO estimates that if the AHCA were signed into law:

  • By 2026, an additional 23 million people would be uninsured compared to current law. This includes 14 million fewer Medicaid enrollees by 2026, a reduction of 17 percent relative to the number expected to be enrolled under current law. The CBO notes that the increase in the number of uninsured “would be disproportionately larger among older people with lower income — particularly people between 50 and 64 years old with income of less than 200 percent of the federal poverty level.”
  • Federal spending for Medicaid would be reduced by $834 billion over the 2017-2026 period compared to what the CBO projects under current law.
  • Less healthy people in states that fully opt out of certain health care regulations would face particularly difficult challenges in purchasing health coverage on the individual (or “nongroup”) market. About one-sixth of the US population lives in states that would obtain waivers — as allowed by the AHCA — to 1) narrow the scope of benefits that must be covered by health insurance and 2) let insurers charge premiums based on an individual’s health status if they fail to maintain continuous coverage. (The CBO does not indicate which states it presumes would fall into this category.) As a result of these changes, the CBO anticipates that “people who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all — despite the additional funding that would be available under H.R. 1628 to help reduce premiums.” Consequently, the nongroup markets in these states “would become unstable for people with higher-than-average expected health care costs,” according to the CBO.

The CBO does not assess the potential impacts of the AHCA on individual states. However, state-level research from other organizations shows that the House-passed bill would:

  • Shift nearly $6 billion in Medicaid costs from the federal government to California in 2020, rising to an annual cost-shift of $24.3 billion by 2027, according to the state Department of Health Care Services.


    • These massive annual cost-shifts would result from several AHCA provisions. These include 1) the substantial reduction in the federal government’s share of costs for people who sign up for coverage through the Medicaid expansion; and 2) the proposal to cap federal funding for the entire Medicaid program — through a “per capita cap” or a block grant — at a level that would fail to keep pace with anticipated Medicaid spending growth, resulting in federal funding cuts that would grow every year.
    • California’s state budget would not be able to absorb these sizeable annual cost-shifts. As a result, state policymakers would face the very real prospect of having to repeal the Medi-Cal expansion. Such an action would eliminate the only viable source of health coverage for nearly 4 million nonelderly adults, who live in every Congressional district in the state (see table below). Moreover, Medi-Cal coverage and benefits would be put at risk for the nearly 10 million additional Californians — including children, people with disabilities, and adults age 65 or older — who qualify for Medi-Cal through other eligibility pathways (i.e., not through the expansion).
  • Disproportionately harm women, according to the Center on Budget and Policy Priorities (CBPP). Women and girls comprise more than half of Medi-Cal enrollees (54 percent as of December 2016), and women “are much more likely to use Medicaid’s long-term services and supports as they age,” the CBPP notes. Medi-Cal also plays a significant role in women’s health by financing roughly half of all births in California (50.4 percent as recently as 2011). Federal cuts to Medicaid could require California to scale back the state’s investment in these and other critical services for women. In addition, family-planning services would be threatened because the AHCA would prevent states — including California — “from reimbursing Planned Parenthood for its preventive health and family planning services” for people enrolled in Medicaid, according to the CBPP.
  • Hurt military veterans, according to Families USA. Medicaid is a critical source of health coverage for veterans, who are “at a higher risk than most for unique and sometimes serious or complicated health care issues as a result of their service.” Nationwide, more than 1.7 million veterans (nearly 1 in 10) were enrolled in Medicaid in 2015, with roughly 183,000 of these former servicemen and -women receiving services through California’s Medi-Cal program. (A California-specific estimate is not available.) For some veterans, Medicaid supplements the health coverage that they receive through the federal Department of Veterans Affairs; for others, Medicaid “is their only source of coverage,” Families USA notes. By cutting and capping federal Medicaid funding, the AHCA would threaten access to health coverage for tens of thousands of veterans in California.
  • Increase total health costs by an average of $2,800 in 2020 for people who buy coverage through Covered California, the state’s health insurance marketplace, according to the CBPP. This increase “would be larger for people who have lower incomes, are older, or live in high cost counties,” with average increases projected to exceed $4,000 in 32 counties. This analysis does not account for “additional premium increases and benefit reductions” that could occur under the AHCA proposal to end nationwide protections for people with pre-existing health conditions.

Number of Adults Enrolled in Medi-Cal Due to the
Expansion of the Program as Allowed by the
Federal Patient Protection and Affordable Care Act (ACA)
*Updated as of February 2017.
Note: Data exclude 67,110 Medi-Cal enrollees who had addresses that could not be coded to specific congressional districts.
Source: Department of Health Care Services
Representative Party Expansion Enrollees,
October 2016*
1 LaMalfa, Doug R 69,181
2 Huffman, Jared D 62,679
3 Garamendi, John D 61,765
4 McClintock, Tom R 44,486
5 Thompson, Mike D 55,931
6 Matsui, Doris O. D 78,376
7 Bera, Ami D 55,658
8 Cook, Paul R 81,201
9 McNerney, Jerry D 76,139
10 Denham, Jeff R 77,822
11 DeSaulnier, Mark D 52,303
12 Pelosi, Nancy D 67,507
13 Lee, Barbara D 75,685
14 Speier, Jackie D 54,092
15 Swalwell, Eric D 44,768
16 Costa, Jim D 101,106
17 Khanna, Ro D 44,527
18 Eshoo, Anna G. D 34,569
19 Lofgren, Zoe D 74,367
20 Panetta, Jimmy D 65,022
21 Valadao, David R 93,600
22 Nunes, Devin R 73,624
23 McCarthy, Kevin R 66,484
24 Carbajal, Salud D 53,134
25 Knight, Steve R 63,067
26 Brownley, Julia D 57,414
27 Chu, Judy D 74,873
28 Schiff, Adam D 90,122
29 Cárdenas, Tony D 100,398
30 Sherman, Brad D 70,467
31 Aguilar, Pete D 82,223
32 Napolitano, Grace D 86,643
33 Lieu, Ted D 34,498
34 Vacant 115,306
35 Torres, Norma D 87,226
36 Ruiz, Raul D 75,981
37 Bass, Karen D 98,485
38 Sánchez, Linda D 63,061
39 Royce, Ed R 54,800
40 Roybal-Allard, Lucille D 90,716
41 Takano, Mark D 77,855
42 Calvert, Ken R 53,283
43 Waters, Maxine D 88,496
44 Barragán, Nanette D 97,286
45 Walters, Mimi R 38,097
46 Correa, J. Louis D 84,859
47 Lowenthal, Alan D 75,946
48 Rohrabacher, Dana R 55,746
49 Issa, Darrell R 39,735
50 Hunter, Duncan D. R 54,675
51 Vargas, Juan D 90,616
52 Peters, Scott D 37,064
53 Davis, Susan D 59,101

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