CBO score of Republican health care plan spells trouble for Florida, health experts say

Florida's health care future will look a lot like its past — with one of the nation's highest uninsured rates and an underfunded safety net system — if the Congressional Budget Office's projections for the American Health Care Act prove accurate, economists and industry experts said this week.

They predict that:

• Most of the 1.74 million Floridians signed up for coverage through the Affordable Care Act exchange at healthcare.gov will be unable to afford their plans under the Republican proposal.

• An estimated 4.3 million children, pregnant women, low-income elderly and disabled Floridians covered by Medicaid would see reductions in care and access to programs.

• Hospitals with high numbers of uninsured and Medicaid patients will be forced to cut back on services and pass along cost increases to other, insured patients.

"There are significant consequences for Florida," said Steven Ullmann, a University of Miami expert on health policy.

The CBO score released this week predicts that 14 million Americans — many of whom earn low incomes — will lose their coverage if the AHCA is enacted. CBO projects that number will rise to 21 million in 2020 and 24 million in 2026.

The nonpartisan agency's estimate for the Republican bill also predicts that health insurance premiums for those who buy their own coverage outside of work will drop on average after 2020 — but mostly for younger people, and only after a dramatic price spike of as much as 20 percent in the interim.

Health and Human Services Secretary Tom Price, a Georgia Republican, issued a written statement Tuesday that the CBO estimates "defy logic."

"For there to be the reductions in coverage they project in just the first year, they assume five million Americans on Medicaid will drop off of health insurance for which they pay very little, and another nine million will stop participating in the individual and employer markets," Price said in a written statement. "These types of assumptions do not translate to the real world, and they do not accurately estimate the effects of this bill."

Health experts said the biggest impact to Florida would come from the AHCA's elimination of financial aid for low- and moderate-income Americans to buy health plans through the ACA, also known as Obamacare. More than 90 percent of Floridians with an ACA plan in 2016 received financial aid from the government to lower their costs, according to the Department of Health and Human Services.

"You will see large numbers of people — I would say hundreds of thousands in Florida — who no longer are going to be able to afford coverage," said Judy Solomon, vice president for health policy at the nonprofit Center for Budget and Policy Priorities.

Of the 1.63 million Floridians with coverage through healthcare.gov in 2016, more than 50 percent had an annual household income that was less than $17,820 for an individual or $30,000 for a family of three. At that income level, the ACA qualifies Floridians for financial aid to pay their premiums and to lower their deductibles, copayments and other out-of-pocket costs.

"With that many people in the marketplace with very low incomes, I think you will see a spike in the uninsured rate under the AHCA," Solomon said.

But not all Floridians will feel changes in the same way. Younger people with moderate incomes and higher are likely to get some relief under the Republican plan.

The CBO report says that a 21-year-old person earning $26,500 a year would pay $1,700 in annual premiums for coverage under Obamacare compared to $1,450 in annual premiums under the AHCA.

But a 64-year-old person with the same annual income would pay much more — from $1,700 a year under Obamacare, to as much as $14,600 under the Republican plan. What's more, Solomon pointed out, the CBO report predicts that deductibles also will rise under the Republican plan.

"The sticker price is fine for people who can afford to pay the whole amount," Solomon said. "But it doesn't do the people who need a subsidy a lot of good, particularly older people."

With such high prices for health insurance, said Ullmann, the UM health policy expert, the AHCA would thrust the health insurance market for individuals into a so-called death spiral.

"What happens is that the people who will be buying insurance will be people who will tend to be more prone to illness, perhaps a little higher in age, and as a result because those are higher-cost users, premiums will go up," Ullmann explained.

For Florida hospitals, the prospect of fewer insured patients is bad enough, said Bruce Rueben, president of the Florida Hospital Association. But the Republican proposal's planned cuts to Medicaid, the public health insurance program for the poor and disabled, will deliver a one-two punch to the very medical centers that provide care to the state's most vulnerable residents, he said.

Though Florida did not expand eligibility for Medicaid as prescribed under Obamacare, Rueben noted that after the ACA exchange launched in 2014, Florida's uninsured rate dropped to 16.6 percent in 2015 — from about 25 percent in 2013, when the state trailed only Texas in the share of residents who lacked coverage

"To go back to that," Rueben said, "at the very time that the federal government would also cut funding to the states for Medicaid means you have double jeopardy here. ... It's going back to the way it was, only worse, potentially."

Hardest hit will be hospitals with high numbers of Medicaid and uninsured patients, and rural hospitals, Rueben said.

"They'll cut a program like a maternal care program or something like that," he said. "But when they cut it, they can't just cut it to Medicaid patients. They cut it out completely. So it's not available to anyone. You're harming access for everyone when you get to that point, and that's the concern that we have with a bill that cuts so much out of Medicaid at the very same time that it apparently is going to leave a whole lot of people uninsured who are insured today."

But Medicaid caps also will force the state to make difficult choices about who gets care under Medicaid, said Miriam Harmatz, a senior health attorney with Florida Legal Services, a nonprofit legal aid group.

Under the AHCA, the federal government's spending on Medicaid will be capped for each person enrolled in the program. Any spending above the cap will be the responsibility of each state.

Harmatz said that a Medicaid cap per person would force children's healthcare needs to compete with those of the elderly in the program. If a new drug is approved to treat Alzheimer's, she theorized, the cost is likely to be very high and the state would have to make a difficult choice about whether to withhold the drug from seniors or cut spending for children to cover the added expense.

"That's the really horrible rationing scenario that we'll be faced with if the AHCA passes," she said.

Contact Daniel Chang at dchang@miamiherald.com.