The GOP's last-ditch effort to repeal Obamacare would redistribute hundreds of billions of dollars in federal financing for insurance coverage, creating winners and losers among individual Americans and states in ways not yet fully clear.
Independent analysts say the latest Senate Republican bill is likely to leave more people uninsured than the Affordable Care Act, and allow states to make changes that raise costs for people with health problems or pre-existing medical conditions.
After closed-door meetings Tuesday, supporters seemed confident but acknowledged they're not sure if the bill can pass. There's only a narrow window for the Senate to act under special budget rules that expire at the end of the month.
The Congressional Budget Office has said it doesn't have time to complete a full analysis of the impact on coverage before the deadline.
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The biggest changes would start in 2020 — the next presidential election year. That's a political risk for Republicans, since health care changes often involve unforeseen problems.
A key feature of the legislation from Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana would put the ACA's financing for subsidized private health insurance and Medicaid expansion into a giant pot and redistribute it among states according to new formulas. States could obtain federal waivers allowing them to modify insurance market safeguards for consumers. For example, states could let insurers charge higher premiums for older adults.
The 31 states that expanded Medicaid are likely to see a funding reduction over time, as well as states, like Florida, where many residents received subsidies for private health insurance, said Larry Levitt of the nonpartisan Kaiser Family Foundation.
"Every state has to start from scratch creating its own health insurance program, in some cases with reduced federal funding and in some cases with increased federal funding," Levitt said. "I don't think at this point anybody knows what states are going to do."
Following the framework of previous Republican bills, the new legislation would also limit overall federal financing for Medicaid, which serves more than 70 million low-income people. That feature affects the entire program, not just former President Barack Obama's expansion to cover more low-income adults. It would change the current open-ended nature of Medicaid financing, a move that prompts deep concern from hospitals, doctors, nursing homes, consumer groups, and some state officials.
"The bottom line is most states will experience a reduction in federal funding under the bill," said Caroline Pearson of the consulting firm Avalere Health. "States that expanded Medicaid are likely to see some of the biggest cuts."
Graham says his bill will allow states to take the initiative on health care, designing programs that work best under local conditions. "I believe that most Republicans like the idea of state control of health care rather than Washington, D.C., control," he said. "We've come upon an idea that is uniquely Republican."
But Sen. Susan Collins, R-Maine, sees problems. "It seems that it has many of the same flaws as the bill that we rejected previously," said Collins, one of three GOP senators whose opposition derailed the last Republican legislation.
Here's a look at some winners and losers under the bill:
• People who don't believe the government should require individuals to purchase a costly private service like health insurance. The bill would repeal Obamacare's unpopular requirements for individuals to have coverage and for larger employers to offer coverage. The trade-off is that without such a legal requirement, more people are likely to be uninsured. And an accident or unexpected illness can make that a costly decision.
• Medical device manufacturers. The bill would repeal an ACA tax on the industry. But it would leave in place Obama's tax increases on upper-income individuals, a feature that may cause problems among some conservatives.
• People who use tax-sheltered health savings accounts for health care expenses. Contribution limits would be raised and consumers could use their accounts to pay insurance premiums, not just out-of-pocket costs such as copays and deductibles.
• People with health problems or with pre-existing medical conditions could be charged more if the state they live in obtains a waiver from current requirements that forbid insurers from charging higher premiums based on health status. States could also seek waivers from the current requirement that insurers cover 10 basic kinds of services, such as maternity and childbirth, or mental health and substance abuse treatment.
• States that expanded Medicaid, including 17 with Republican governors. The more generous federal match for the expansion would be phased out, and some of the money would be redistributed to states that did not expand their programs.