That's the estimate by the Office of Management and Budget
The tax bill, which increases the deficit while delivering huge benefits to corporations and the wealthy, polls poorly and has sparked repeated protests against Susan Collins. Students have staged sit-ins while religious leaders were arrested after occupying one of her offices.
After Susan Collins' votes against the "Obamacare" repeal, some Maine residents have struggled to understand why she would support a tax bill that slashes corporate rates while repealing the Affordable Care Act's mandate for most Americans to carry health insurance or pay fines.
The individual mandate repeal is expected to result in 13 million more uninsured Americans, and health care advocates say that even if they do end up becoming law, the health bills Susan Collins supports will not make up for that.
"It's the last vote that counts. You can say 'no' 53 times in a row but if the 54th is the 'yes' that puts the thing over the line, that's going to be your legacy," said Steve Butterfield, policy director of Consumers for Affordable Health Care in Augusta, Maine.
In this case, Butterfield added, Susan Collins' legacy would be millions of Americans losing their health insurance.
Doctors, hospitals, patient advocates and others who work in the nation’s healthcare system are growing increasingly alarmed at the Republican tax bill, warning that it threatens care for millions of sick Americans.
The legislation – which GOP leaders are rushing to pass this week – will eliminate beginning in 2019 the Affordable Care Act penalty on consumers without health coverage, a move many experts warn will weaken insurance markets in parts of the country.
The tax bill, which includes huge tax cuts for corporations, may also force tens of millions of dollars in cuts to the Medicare program under federal budget rules, though congressional leaders say they are confident they can waive the rules as they have in the past.
Most worrisome to many, the bill will open a $1.5-trillion hole in the federal deficit over the next decade. That will put substantial new pressure on government healthcare programs such as Medicare and Medicaid and has already ignited a renewed Republican campaign to cut them back.
“This is a horrid bill,” said John Baackes, chief executive of L.A. Care, a public insurance plan that covers more than 2 million mostly low-income residents of Los Angeles County.
“They haven’t been able to repeal and replace [the healthcare law], so they’ll attack it through the budget by looking for ways knock down the money that’s needed to cover people.”
The GOP tax package – which would reduce the corporate tax rate from 35% to 21% – may mean more money for drug makers and for-profit insurance companies and hospital systems.
But across the country, dozens of healthcare groups, including every major physician association and patient advocacy organization, have urged GOP lawmakers to slow down and at least preserve the insurance requirement.
“This bill leaves too many patients behind and saddles millions more with higher premiums,” said Harold P. Wimmer, chief executive of the American Lung Assn., which was among 16 patient organizations that sent a letter to congressional leaders this month warning that the tax bill could erode sick patients’ access to medical care.
The groups include the American Diabetes Assn., the American Heart Assn., the Cystic Fibrosis Foundation, the Arthritis Foundation, the March of Dimes, the National Multiple Sclerosis Society and the advocacy arm of the American Cancer Society.
Last week, the American Academy of Actuaries sent congressional leaders a similar warning that if the mandate is eliminated, “premiums would increase as a result, reducing affordability and eroding preexisting condition protections.”
At highest risk may be consumers in regions of the country where there are few insurers selling plans now and where premiums are already very high.
Republican leaders have dismissed the objections of healthcare groups and others, arguing that eliminating the penalty on people who don’t get health insurance will remove an unfair government requirement.
“Obamacare’s coercive individual mandate represents perhaps the worst example of the federal government violating individual freedom and liberty,” Rep. Mark Walker (R-N.C.), chairman of the conservative Republican Study Committee.
GOP lawmakers have also rejected analyses by the nonpartisan Congressional Budget Office, independent economists and others that the massive tax cuts in the legislation will drive up the federal deficit. President Trump and his congressional allies say the cuts will fuel economic growth.
But senior Republicans have made no secret of their interest in renewing a push to cut government healthcare programs next year to control the ballooning government debt.
"We're going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit," House Speaker Paul D. Ryan (R-Wis.) said during a recent appearance on “The Ross Kaminsky Show,” a conservative talk radio program in Denver.
“Frankly, it's the healthcare entitlements that are the big drivers of our debt, so we spend more time on the healthcare entitlements, because that's really where the problem lies, fiscally speaking," Ryan said.
Ryan has long advocated major changes to the federal Medicare program.
And each of this year’s leading Republican bills to roll back the Affordable Care Act – commonly called Obamacare – would have slashed hundreds of billions of dollars of federal healthcare aid to low- and middle-income Americans.
That would have left some 20 million more Americans without health coverage, according to independent analyses of the GOP repeal bills.
A new push to slash federal support for Medicare, Medicaid and other health programs risks a similar erosion in health protections, warned Dr. Ashok Rai, president of Prevea Health, a medical system in northern Wisconsin.
“We should be looking for ways to control healthcare spending,” said Rai, incoming chairman of the American Medical Group Assn., a leading advocate for making healthcare more efficient. “But when you are talking about blanket cost reductions, that affects a lot of needy people. … The consequences for the health of America would be serious.”
State leaders and healthcare officials in California and other states that rely heavily on state taxes to support their healthcare safety nets worry they will face even more pressure under the tax legislation.
The GOP bill would cap how much taxpayers can deduct in state and local taxes from their federal tax returns, effectively penalizing many taxpayers in states such as California, which has among the highest state income taxes in the country.
Although about 14 million California taxpayers are expected to see a tax cut in 2019 — most of less than $2,000 — nearly 2 million taxpayers will see their taxes increase, driven largely by this new cap, according to an analysis by the Washington-based Institute on Taxation and Economic Policy.
“The fact that Californians would be paying more in federal taxes would inevitably put new pressure on our state and municipal governments to reduce their taxes,” California Health Care Foundation president Sandra R. Hernández noted in a recent blog post.
“Under that scenario, it is not hard to imagine a new wave of painful state and local budget cuts.”
WASHINGTON — After a year in which Obamacare's fate hung by a thread, 2018 is likely to feature fewer mortal threats. But the next 12 months could still be a tumultuous period as insurers, customers and elected officials react to major changes to the law by the Trump administration and the Republican Congress.
Republicans tried without success throughout 2017 to repeal and replace Obamacare, but there's little indication they plan on pursuing another serious push next year.
President Donald Trump told supporters after the last health bill failed that Republicans had the votes to pass repeal in 2018 once a hospitalized senator — who was neither hospitalized nor a decisive vote — returned, but it was a face-saving bluff. Now with Sen.-elect Doug Jones, D-Ala., set to take office and midterms getting closer, the math is even harder.
"I think we'll probably move on to other issues," Senate Majority Leader Mitch McConnell, R-Ky., told NPR last week.
Instead, the Affordable Care Act — which Trump has pronounced "dead," "finished," "gone," and, as he put it earlier this month, "essentially repealed" —continues to chug along.
About 8.8 million people have signed up for 2018 coverage through HealthCare.gov, only a modest decline from the previous year despite a 90 percent cut in advertising by the administration and an enrollment period that was half as long. Insurer profits improved, suggesting companies have learned to price plans better. Millions more continue to get care through the law's Medicaid expansion.
"The ACA is living and breathing right now, which was hardly the expectation a year ago when Republicans took control of the federal government," Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation, said in an e-mail.
But the law's insurance exchanges are also fragile and face big changes next year.
The new tax bill eliminates the individual mandate, a key pillar of the ACA. Trump's White House is pursuing new regulations that could undermine Obamacare plans with cut-rate alternatives. Some states are struggling to attract insurers, a problem that's carried over from the Obama era. Republicans are still debating whether to give the ACA a bipartisan tune-up or purposefully "let Obamacare fail," as the president has put it. And nobody is sure what surprises the year might bring.
"The individual insurance market is one big question mark right now," Levitt said.
End of the mandate
While they fell short of full repeal, Republicans did manage to make a major change to Obamacare by passing a tax bill that eliminates the individual mandate, a penalty for people who go without insurance that was created by the Affordable Care Act.
At the time it was passed, the mandate was considered a critical part of the law's protections for people with pre-existing conditions. The goal was to push more young and healthy customers into the system to offset the cost of sicker patients insurers would now have to take on. Without the mandate, the Congressional Budget Office estimates that 4 million more people will go without insurance in 2019 and 13 million after a decade, while insurance premiums shoot up 10 percent annually.
Health experts are watching the mandate change closely, but they're not sure how much it will affect the insurance market. Some analysts already viewed the mandate as too weak to achieve its intended effect and insurers may have already priced in the assumption that they'll have fewer healthy customers than expected when the ACA passed.
Deep Banerjee, an analyst at S&P who tracks the insurance industry, said he expected higher premiums without the mandate and potentially some loss of customers and insurers, but not "mass exits" from the market.
"Looking forward to 2018, I'm not expecting any meaningful increase or decline (in enrollment)," Banerjee told NBC News. "What that means is the market seems to be stabilizing at this level."
While the mandate's full impact isn't yet known, insurers have not taken well to unpredictability in the past. The change, along with other moves, will add more of it in 2018 as insurers decide their rates for the following year and whether to participate in Obamacare's exchanges at all.
Last year, providers cited confusion over GOP repeal efforts and Trump's threats to cut off cost-sharing reduction payments (CSR), which he did in October, in announcing higher rates and pulling out of some markets. The CBO credited "short-term uncertainty" with driving premiums up 15 percent.
Adding to the confusion next year, the Trump administration is considering new rules, which could take months to develop and finalize, that would allow people to buy less comprehensive short-term or association plans. This could siphon more young and healthy customers from Obamacare's exchanges, which could further raise premiums and potentially spook more insurers away from the exchanges for 2019 enrollment.
"I think there's a lot of uncertainty remaining in the market and that's something that some insurance companies may find they can no longer tolerate," said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University.
The result could be to worsen an already large divide in Obamacare's exchanges between lower-income and higher-income customers.
Most Obamacare customers qualify for subsidies that rise with premiums, meaning they won't feel the effects of rate increases. But customers who make too much to qualify for federal help, which cuts off at 400 percent of the federal poverty level, face much higher premiums and could struggle to find a plan they can afford.
"I think very quickly those folks will be priced out of coverage if they haven't been already," Corlette said.
More action in Congress
While full repeal may be unlikely, Congress could potentially take action on health care in other ways.
Sen. Susan Collins, R-Maine, tied her vote for tax cuts to assurances that Republicans would consider bipartisan bills to help shore up Obamacare's markets.
One of the bills, Alexander-Murray, would temporarily restart CSR payments to insurers, which experts are skeptical would have much effect now that insurers have priced the changes into their plans. Another bill, Collins-Nelson, would provide seed money for reinsurance programs to help insurers handle more expensive customers. Outside analyses by private firms have estimated reinsurance could help lower premiums by as much as 20 percent, potentially offsetting increases from ending the mandate.
But passing either bill would require Republicans to declare a temporary truce in the Obamacare wars and risk being tagged by conservatives with "bailing out" the law. Trump himself has seemed torn over the issue, initially encouraging talks on Alexander-Murray before abruptly rejecting the bill.
If action stalls in Congress, states might step in. In Virginia, where Democrats made major gains in the state legislature in November, lawmakers could make a push to expand Medicaid. Maine passed a ballot measure in 2017 backing Medicaid expansion. In Nevada, officials are looking at switching to a state exchange rather than Healthcare.gov, which would give them more control over enrollment. Other states might pursue new reinsurance plans on their own.
What is clear, though, is that Obamacare's status remains highly unsettled heading into the new year.
The Trump administration is turning to regulations as their last, best hope of chipping away at ObamaCare in 2018, with congressional Republicans unlikely to pass full repeal.
A proposed rule released Thursday targeting the health law is likely the first step in a new effort to undermine the law. And advocates for the health law worry that another forthcoming rule could cause even more damage.
The administration on Thursday eased rules on small businesses that band together to buy health insurance, through what are known as association health plans (AHPs).
The proposal retains ObamaCare protections for people with pre-existing conditions and prohibits lifetime limits on benefits.
But it would allow associations to purchase cheaper health insurance that won't cover the ten "essential health benefits," which include mental health, substance abuse treatment, maternity care and prescription drugs.
A second proposed rule, yet to be unveiled, could have an even greater impact, with much broader exemptions from ObamaCare.
That rule is expected to lift the Obama administration's restrictions on skimpy, short-term health insurance plans. The changes would allow the plans to last for 12 months and be renewed.
Experts expect the short-term plans to also be exempt from all of ObamaCare's protections, meaning insurers would be able to charge higher premiums to people with pre-existing conditions.
The proposal on association plans is "aimed at putting AHPs on same footing as large employer plans. But large employer plans are still subject to various ACA requirements," said Edward Leeds, an attorney at Ballard Spahr in Philadelphia.
The expected rule on short-term plans "would really go beyond that," he added.
Together, the proposed rules have advocates for the health law worried about massive instability in the law's insurance marketplace.
Experts and advocates warn the rules would lead to skyrocketing premiums and a major fragmentation of the insurance markets.
"Both of these rules would have the effect of seriously undercutting the viability of ObamaCare's consumer protections by driving up premiums, and weakening the risk pools," said Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities.
President Trump has made no secret of his desire to undo as much of ObamaCare as possible. He's said the law is failing, and on numerous occasions said the inevitable collapse of the insurance markets would bring Democrats to the negotiating table to work on a replacement.
When he signed an executive order loosening ObamaCare protections in October, Trump said he was "starting that process" to repeal the law.
It will be the "first steps to providing millions of Americans with ObamaCare relief," he said of the order.
Administration officials said the order was just the beginning of their efforts to target ObamaCare, with Congress seemingly unable to repeal the law.
Republicans failed to repeal ObamaCare after a months-long struggle in 2017, and the obstacles now appear greater. The election of Sen. Doug Jones, a Democrat from Alabama, cut the GOP majority to a single seat, 51-49.
GOP lawmakers did get one win - repealing ObamaCare's individual mandate in the Trump tax reform package.
It's not yet clear what the mandate repeal will mean, but most expect it will also make premiums in the ObamaCare marketplace rise.
The individual mandate likely pushed some healthy individuals to buy insurance on the exchange. Without that financial penalty, they may not return.
"The repeal of the mandate and expansion of association health plans and the rise of short term plans will certainly send premiums rising for middle class people with pre-existing conditions, whose only option is the ACA-regulated market," said Larry Levitt, a vice president at the Kaiser Family Foundation.
The new regulations can't go as far as the policies in the various repeal bills, but Park said they can still do a lot of damage to the law.
"They're all steps to undermine the market," Park said.
Levitt said the administration appears to want to use regulations to create a parallel insurance market that "largely doesn't have to follow the rules" of ObamaCare.
The administration has high hopes for their new effort.
In a recent interview in The New York Times, Trump said the ObamaCare regulations, combined with the repeal of the mandate, could accomplish his goal of bringing Democrats and Republicans together for a bipartisan compromise on a replacement bill.
"I believe that because of the individual mandate and the associations, the Democrats will and certainly should come to me and see if they can do a really great health care plan for the remaining people," Trump said.
"This is the administration's strategy, make it look like market reforms and marketplaces aren't successful," said Park.
"And that's used as justification for further changes."
Democrats are coming up with their own health care plans to help fix the sabotaging of ACA from Trump and the GOP.
I have absolutely zero respect for any of the republicans today.
Not only do they not do anything about the clear obstruction of justice the president committed (firing Comey and admitting the reason was Russian related, helping to write the response for his son's and the other's Trump tower meeting)
Democrats are coming up with their own health care plans to help fix the sabotaging of ACA from Trump and the GOP.
On Health Care, Democrats Are Shifting to Offense
Thanks for posting this link. The democrats are coming up with some good ideas. It is wonderful to see the democrats propose real solutions to fixing healthcare. The republicans will never go along with any of these good ideas.
There were no good ideas or fixes for Obamacare in that article. Every single proposal was a variation of the single payer delusion.
Complete single-payer (Medicare for all) is the best idea and the best fix to healthcare.
If we can't get that, any variation of some type of single-payer is better than nothing.
Some may believe that healthcare should be a privilege. I believe healthcare should be a right.
The only way I can see every man, woman, and child being guaranteed AFFORDABLE ACCESSIBLE healthcare is single-payer.
We have always had market based healthcare. Market based healthcare has gotten completely out of control. The market based healthcare is what forced us into Obamacare. By the way, Obamacare with all of it's flaws is way better than the market based healthcare that preceded Obamacare. Prior to Obamacare, the market based healthcare was rapidly getting worse and worse over time. Also, the market based healthcare that preceded Obamacare had way many more flaws than Obamacare.
Let me repeat that: Market based healthcare had way many more flaws than Obamacare. That was the reason we needed and got Obamacare.
As far as fixing Obamacare, the next logical step would be single-payer.
World experience shows that there are other systems that work just as well, including market-based systems that are a much better fit for America's values and America's current system.
Yes you are correct that Obamacare is (partially) market based. Because of these mandatory protections and rights is why Obamacare is not entirely market based.
At this time, I am not convinced that there are other systems that would work better than single-payer for America. Admittedly, I am not really knowledgeable of the many healthcare systems of other countries.
As far as American value goes, our American values currently provide single-payer to our seniors. As you already know that being Medicare. If our American values provide single-payer to our seniors, how is that not American values to provide the same thing to everyone else?