How many more people would lack coverage under Cassidy-Graham? We can guess

Published Sept. 22, 2017

WASHINGTON — It's safe to say the new Obamacare rollback measure toward which the Senate is charging would mean fewer Americans have health coverage. Exactly how many is unclear. Some argue it could be more than 22 million people. Others say it could be fewer.

Why is 22 million an important figure? It's how many more people would lack coverage under the Better Care Reconciliation Act — the health care bill the Senate tried and failed to pass back in July. That unsavory figure haunted Republicans as they tried to defend already unpopular legislation. They found out the hard way that it's not so easy to win over the public on a policy that nudged up the uninsured rate.

Republicans won't have to combat a similar number if they vote on the Cassidy-Graham bill next week, which Senate Majority Leader Mitch McConnell, R-Ky., has announced he intends to bring to the floor. That's because the Congressional Budget Office — the official scorekeeper for the legislative branch — says it will release only a partial analysis by then. It will take several more weeks to estimate the bill's costs and how many more people may be uninsured than under Obamacare.

On one hand, voting without this key information just means Republicans will endure more criticism that they're ignoring the measure's impact on a sizable segment of the U.S. population. On the other, it means they're not up against another big, scary number from the CBO at the moment.

Yet the question remains: How would the bill repealing and replacing parts of the Affordable Care Act, advanced by Sens. Bill Cassidy, R-La., and Lindsey Graham, R-S.C., affect coverage?

We have a few clues.

A big reason for the coverage reductions under the BCRA was because it would have trashed the requirement to buy coverage or pay a fine (the individual mandate). The CBO has previously estimated that would result in about 15 million fewer people buying plans right off the bat (although many conservatives feel the agency overestimated the mandate's effect).

Cassidy-Graham also gets rid of the individual mandate. So it appears the measure would result in at least 15 million fewer insured Americans, if the CBO uses the same methods.

But how would cuts to Medicaid and marketplace subsidies further affect coverage rates? Cassidy-Graham actually enacts cuts to traditional Medicaid that are comparable to those envisioned under BCRA, reducing spending on the program by about 8 percent by 2026.

And, up until 2027, when there's a big funding cliff, Cassidy-Graham appears to maintain more of the funding for subsidies and Medicaid expansion than BCRA.

Under BCRA, the federal government would spend $389 billion less on subsidies between 2020 and 2026, according to the CBO. But under Cassidy-Graham, it would spend $243 billion less during the same period on subsidies and Medicaid expansion combined, according to a projection by the left-leaning Center on Budget and Policy Priorities. Avalere Health set the figure at $215 billion in an analysis it released Wednesday. (Neither group had figures for subsidy spending alone).

So some conservatives argue that Cassidy-Graham could feasibly result in more people receiving coverage than under BCRA, depending on how states implement it.

"States could take the fact they've regained control of the insurance rules in their markets and have a lot of money from the federal government and could end up with something that covers a lot more people," former CBO director Doug Holtz-Eakin told me. "I can make the case they could beat that number."

Assumptions about how states will behave are key here. Under Cassidy-Graham, the federal dollars used for subsidies and Medicaid expansion would go to the states in a lump sum they could use in a huge variety of ways. That makes calculating the coverage effects of the Cassidy-Graham bill decidedly difficult, experts say.

For the CBO to come up with a ballpark figure for how many people would have health coverage under the GOP measure, the agency must make a whole lot of assumptions about how states would spend the money. They could do a heck of a lot of things with it, like setting up high-risk pools or covering cost-sharing subsidies — or even continuing premium subsidies. To top it off, 36 states are electing new governors next year, making it incredibly difficult to predict how they'd all act.

These reasons are why health policy firm Avalere hasn't yet released an estimate of how many people would have coverage under Cassidy-Graham, said the group's founder, Dan Mendelson. It's a little easier to make assumptions about how states like California or New York, which are more actively involved in providing care to residents, would act than to guess the behavior of less-involved states like, say, Mississippi or Kansas.

"It is very dependent on state decision-making," Mendelson said.

Of course, you could also assume states would use the money in ways that would result in many fewer people getting coverage — potentially meaning Cassidy-Graham would get a CBO score even worse than the 22 million figure we've already discussed.

The Commonwealth Fund's Sara Collins says the bill has the potential for massive coverage losses, especially when you consider states would have only a short time frame (until 2020) to set up their own coverage schemes.

"You kind of have this black hole where states are going to have some money but they don't have the administrative structures in place," she said.