The Congressional Budget Office estimates that U.S. President Donald Trump's proposed health-care legislation would save the government $337-billion (U.S.), but result in 24 million fewer people having health insurance by 2026 than if Obamacare were retained.
That stark assessment – released Monday by the independent financial watchdog – comes as the President promises he can simultaneously get rid of the Affordable Care Act, popularly known as Obamacare, and ensure no one loses access to care.
Mr. Trump's bill is already creating divisions within the GOP and shining a spotlight on one of the United States' most confounding paradoxes: that the richest country in the world is one of the few developed societies not to have all its citizens' health insured.
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How Mr. Trump and Congress deal with these tensions – if they can – will have a sweeping effect on both the country's poorest and sickest, and shape the debate over the fraying social safety net in the United States.
What Obamacare did
At Mount Sinai hospital in Chicago, Dr. Ihab Aziz can enumerate the ways a lack of insurance hurts his neediest patients and burdens the system.
The diabetics who can't afford to see a doctor until their disease is so far advanced they end up in the emergency room with failing kidneys. People with heart conditions who are readmitted repeatedly. Patients requiring a course of antibiotics or blood-thinners who have to be kept in hospital for several days to finish their treatment because they have no family doctor to follow up with them.
Obamacare went some way toward fixing the problem. The percentage of uninsured patients at Mount Sinai fell by more than half.
"We were helping them get coverage for the first time in their lives. Patients were in tears," Dr. Aziz, the hospital's chair of family medicine, said in an interview. "They were baking cookies for the people who were helping them sign up. All they knew about health care before was the ER."
And Dr. Aziz has no doubt what the effect of Mr. Trump's proposed changes will be on his patients.
"People will lose hope and lose care after a very good thing," he said.
The Affordable Care Act is a complicated series of health reforms then-president Barack Obama pushed through in his first term in his office. Collectively, the ACA's policies have helped 20 million previously uninsured Americans get coverage but caused premiums to rise for some people who already had insurance.
One component of the ACA imposed new rules on insurance companies, forcing them to cover people with pre-existing conditions, mandating which health services must be insured and allowing people to stay on their parents' health plans until the age of 26. To mitigate the spike in premiums this would cause, the ACA also made it illegal for people not to have insurance – a rule called the "individual mandate."
Other pieces of Obamacare include an expansion of Medicaid, a government-funded health-care plan for the poorest in the country; a series of subsidies for low-income people to purchase private insurance; and the creation of "exchanges" – government websites where people can compare insurance plans and apply for subsidies.
During and after the presidential election campaign, even as Mr. Trump promised to repeal Obamacare, he vowed to simultaneously push premiums down and ensure that no one loses insurance coverage. It is a virtually impossible task, as illustrated by the CBO's analysis, but it is an important part of the President's appeal to blue-collar voters in the country's industrial heartland.
On Monday, at a health-care roundtable with supporters at the White House, the President repeated this pledge.
"We're going to be working to unleash the power of the private marketplace to let insurers come in and compete for your business," he said. "And you'll see rates go down, down, down, and you'll see plans go up, up, up."
Trumpcare, and a divided caucus
The American Health Care Act, the proposed repeal bill drafted by Republican Congressional leaders in consultation with Mr. Trump's White House, is something of a compromise. It scraps the individual mandate and begins cutting back the Medicaid expansion in 2020, but leaves in place the new rules on insurance companies. It also replaces the income-tested subsidies of Obamacare with age-tested tax credits that are available in full to anyone earning up to $75,000 a year.
But if Mr. Trump believed the legislation would forge a consensus within his own party and give him political cover with working-class supporters, he was entirely mistaken.
Some Republicans argue the bill goes too far and are particularly alarmed at the curtailing of the Medicaid expansion.
Four GOP senators last week wrote an open letter to Senate Majority Leader Mitch McConnell warning that "reform should not come at the cost of disruption in access to health care for our country's most vulnerable and sickest individuals." Ohio Governor John Kasich, one of Mr. Trump's rivals for the party's presidential nomination last year, said the roll-back would particularly hurt people with mental-health or drug-addiction problems. "This country better be careful we're not losing the soul of our country," he said Sunday on Meet the Press.
Ideological purists, meanwhile, argue the proposal preserves too much of the ACA and want the law rolled back completely.
Senator Rand Paul has derided Mr. Trump's plan as "Obamacare lite" for offering tax credits to help subsidize insurance costs. Senator Ted Cruz has called for all the rules on insurance companies to be repealed, arguing that this would help bring the cost of premiums down.
With a slender majority in the Senate, the Republicans need their caucus to hang together to get the bill through.
The problems with repeal
Health-policy experts say some provisions of the AHCA are also simply unworkable. Chief among them is the decision to keep the popular rules on insurance companies, but get rid of the individual mandate. Such a move would cause young and healthy people to opt out of insurance, driving up premiums for the older and unhealthy people who remain.
"Everybody likes the benefits and nobody likes the costs," said Jocelyn Johnston, a professor of public policy at American University in Washington, who contended the dislike for the mandate is misplaced. "We are regulated in other insurance areas: If you want to drive, you have to have insurance; if you own a house, you have insurance."
The individual mandate is itself a free-market solution to the health-care problem – first implemented by Republican Mitt Romney when he was governor of Massachusetts – meant to push the country toward universal health coverage without creating a fully taxpayer-funded system. Conversely, health-policy expert Jonathan Weiner points out, the AHCA still provides more coverage than the U.S. had before the ACA.
"There's bluster on all sides. If [the AHCA] proposal had been put forward by President Obama and got passed, people would be extremely pleased – it was better than what we had before," said Prof. Weiner, who teaches at Johns Hopkins University in Baltimore. "And Obamacare itself was a moderate Republican proposal."
The structure of the proposed GOP bill does, however, speak to the concerns of the party's base: It rolls back health-care subsidies from low-income people while expanding them for the middle- and upper-middle class.
"Most Americans are pretty well insured: They are satisfied with what they've got and are more worried about losing it than with getting something more," said Henry Aaron, a Brookings Institute economist who worked in the federal health department in the 1970s. The AHCA, he said, represents "a pretty brazen transfer of money up the income scale."
Randi Abramson, chief medical officer at Washington charity Bread for the City, said the Republicans' proposed tax credits aren't going to do anything for the people she treats. Her clinic sees 1,500 patients and has to turn away about 50 more every week because they don't have the resources to help them.
"These tax credits they talk about are for the wealthy. For people who are struggling paycheque to paycheque, that's not going to help them," she said. "People are concerned about losing their benefits. When you're struggling for food, struggling for rent, it's just one more stress to get through the day."
At Mount Sinai, meanwhile, Dr. Aziz said one of the hospital executives has a simple saying that sums up the problem facing the front lines of health care as the repeal moves ahead: "People are not going to stop being poor in 2020."