WASHINGTON -- The Senate bill to replace the Patient Protection and Affordable Care Act would increase the number of people without health insurance by 22 million by 2026, a figure that is only slightly lower than the 23 million more uninsured that the House version would create, the nonpartisan Congressional Budget Office said Monday.
As of late Monday, at least four GOP senators had threatened to vote against even starting debate on the bill.
The White House lambasted the budget office in a statement, saying it has a "history of inaccuracy" in projecting coverage. Democrats said the report confirmed their own analysis of the GOP measure.
President Donald Trump's administration says the Senate Republican bill would not cut Medicaid because spending would still grow from year to year. But the Congressional Budget Office said the bill would reduce Medicaid spending by $772 billion in the coming decade and that the number of people covered by Medicaid in 2026 would be 15 million lower than under current law.
[INTERACTIVE: Compare House, Senate bills with Affordable Care Act]
Next year, 15 million more people would be uninsured overall compared with the numbers under current law, the budget office said, and compared with 14 million in the House bill.
The budget office report said the Senate bill "would increase the number of uninsured people substantially." It said that would especially apply to people between 50 and 64 and with incomes below 200 percent of the poverty level, or around $30,300 for a single person. Those ages are just shy of when people begin qualifying for Medicare coverage.
The legislation would decrease federal deficits by a total of $321 billion over a decade, the budget office said.
The report said that under the bill, most insurance markets around the country would be stable before 2020. It said that similar to the House bill, average premiums around the country would be higher over the next two years -- including about 20 percent higher in 2018 than under the current health law -- but lower beginning in 2020.
The office said that overall, the Senate legislation would increase out-of-pocket costs for deductibles and co-payments. That's because standard policies would be skimpier than those currently offered, covering a smaller share of expected medical costs.
The budget office also warned that in some rural areas, either no insurer would be willing to participate in the individual market or the policies offered would be prohibitively expensive.
Two Republicans, Sens. Susan Collins of Maine and Rand Paul of Kentucky, said Monday that they would vote against even debating the health care bill, joining Sen. Dean Heller of Nevada, who made the same pledge Friday. Sen. Ron Johnson of Wisconsin that hinted he, too, would probably oppose taking up the bill on a procedural vote expected as early as today, meaning a collapse could be imminent.
"It's worse to pass a bad bill than pass no bill," Paul told reporters.
Collins wrote on Twitter on Monday evening that she wanted to work with her colleagues from both parties to fix flaws in the Affordable Care Act and that the budget office's report showed that the "Senate bill won't do it."
At least some of Collins' concerns could be shared by Sens. Lisa Murkowski of Alaska and Shelley Moore Capito of West Virginia, whose rural states would face effects similar to those in Maine.
"If you were on the fence, you were looking at this as a political vote, this CBO score didn't help you," said Sen. Lindsey Graham, R-S.C. "So I think it's going to be harder to get to 50, not easier."
He added, "I don't know if you delayed it for six weeks if anything changes."
Five Republican senators, including Paul and Johnson, have said they cannot support the version of the bill that was released last week, and Senate Majority Leader Mitch McConnell, R-Ky., can afford to lose only two. Democrats are united against it.
The additional deficit savings gives GOP leaders plenty of room to add more spending to win votes from skeptical moderate Republicans. Senate budget rules require that the final legislation save more than was saved in the House bill, at least $133 billion, giving senators $188 billion to make the bill more palatable.
Any extra spending risks alienating conservatives, however, and some moderates have said they will decide whether they can support the Senate's Better Care Reconciliation Act based on how it will affect Americans who have gained coverage under the Affordable Care Act during the past few years.
Democrats immediately seized on the estimates to criticize Republicans for planning a vote on a bill that would lower the number of people on insurance rolls and drive up premiums for seniors. Senate Minority Leader Charles Schumer, D-N.Y., said the bill cannot be fixed despite McConnell's plan to allow senators to make changes before a final vote.
Bill alterations
Earlier Monday afternoon, Senate Republican leaders altered the health bill to penalize people who go without health insurance by requiring them to wait six months before their coverage would begin. Insurers would generally be required to impose the waiting period on people who lacked coverage for more than about two months in the previous year.
The change, intended to satisfy insurers and minimize the number of Americans who may drop their plans if the bill becomes law, received measured praise from some industry officials but sharp criticism from patient advocates.
Under one of the most unpopular provisions of the Affordable Care Act, the government can impose tax penalties on people who go without health coverage. Republicans have denounced this as government coercion.
The bill passed by the House last month has a different kind of incentive. It would impose a 30 percent surcharge on premiums for a year for people who have gone without insurance. But the Congressional Budget Office said that provision could backfire. As a result of the surcharge, it said, 2 million fewer people would enroll and the people most likely to be deterred would be those who are healthy.
The Senate proposal for a waiting period could also have problems. For someone with cancer or a severe illness, a six-month waiting period could be a death sentence.
"Being denied critical and potentially lifesaving health care for six months is not a fair punishment for someone who is a few hundred dollars short on insurance payments because they lost their job and finances are unexpectedly tight," Schumer said.
Calls to slow down
Before the budget office released its report Monday, the American Medical Association officially announced its opposition to the bill, and the National Governors Association urged the Senate to slow down.
The American Medical Association, the nation's largest physicians organization, declared Monday: "Medicine has long operated under the precept of primum non nocere, or 'first, do no harm.' The draft legislation violates that standard on many levels."
The National Governors Association sent a bipartisan letter to McConnell on Monday, signed by association Chairman Terry McAuliffe, D-Va., and its vice chairman for health and human services, Charlie Baker, R-Mass.
"The nation's governors are ready to work with leaders in Washington to make health care more accessible and affordable to the people we serve," they wrote. "However, governors must be given adequate time to determine the impact any health care bill will have on their states and residents, and ensure that the bill does not adversely harm the people we were elected to serve."
In response to questions before the budget office's report was released, Arkansas Gov. Asa Hutchinson said the bill was an improvement over the House version.
Flexibility to states, a lower income cap for tax credits, more innovation funds and income-based tax credits made for a better bill, he said.
"It's not perfect, but it is a step in the right direction in terms of some of the changes that they've made," he said. "In my conversation with Sen. [Tom] Cotton -- and I have a call in to Sen. [John] Boozman as well -- they're continuing to look at this as I am and I shared some concerns from an Arkansas standpoint on it, but I also recognize that the status quo is not taking us in the right direction, either, and there has to be changes."
Top Republicans showed no signs of yielding to the pressure.
The No. 2 Senate Republican, John Cornyn of Texas, had previously left the door open to voting on the bill sometime in July. But Monday he wrote on Twitter: "I am closing the door. We need to do it this week before double-digit premium increases are announced for next year."
Trump struck a tone of resignation Monday on Twitter, noting that Republican senators were working hard to pass their repeal bill.
"Not easy! Perhaps just let OCare crash & burn!" Trump wrote, reiterating his assertion that President Barack Obama's signature health care law will be doomed if Congress does not come to its rescue.
Information for this article was contributed by Thomas Kaplan, Robert Pear, Reed Abelson and Emmarie Huetteman of The New York Times; by Amy Goldstein, Kelsey Snell, Juliet Eilperin, Sean Sullivan and David Weigel of The Washington Post; by Alan Fram, Erica Werner, Ricardo Alonso-Zaldivar and Andrew Taylor of The Associated Press; and by Brian Fanney of the Arkansas Democrat-Gazette.
A Section on 06/27/2017