President Trump and House Speaker Paul Ryan, to his left, celebrating the House passage of the AHCA on May 4. Evan Vucci/AP
While the score was not dramatically different from an earlier one, it nonetheless drew a significant amount of news coverage. Countless articles talk about the AHCA’s dramatic effects on insurance coverage and premiums.
However, this focus is decidedly too narrow and missed the larger endeavor by President Trump and Speaker Paul Ryan to initiate a dramatic disinvestment from the nation’s disadvantaged, particularly in terms of health care.
Working in one of the nation’s poorest states, West Virginia, I encounter the challenges of poverty firsthand. It complements my academic work on the historic development of the American safety net and the historic role of public hospitals. The combination of the AHCA and the Trump administration’s budget would hollow out America’s safety net that has evolved since the New Deal and the Great Society.
The Congressional Budget Office and the American Health Care Act
The Congressional Budget Office (CBO) is a nonpartisan congressional agency created in the early 1970s during the Nixon administration. It was envisioned as a counterweight to the dominance of the executive branch and the president in policymaking, particularly when it comes to budgeting. It was also supposed to infuse policy decisions with nonpartisan, analytical information. The assumption is that policymaking is better when it is informed by facts and when we are aware of the effects of the legislation before passing it.
By and large, the CBO has lived up to its expectations. While far from perfect in its projections, it is generally held in high regard by politicians and scholars alike. As such, it has held a dominant role in some of the nation’s major legislative efforts, including the Clinton-era Health Security Act, the Affordable Care Act and now the American Health Care Act.
In March, the CBO had scored a previous version of the American Health Care Act, saying 24 million Americans would lose their insurance under the AHCA. The score also showed that insurance premiums in the individual market would actually increase because fewer benefits would be included.
At the same time, the AHCA would provide a massive tax cut to America’s wealthiest and reduce the federal deficit just over US$100 billion over 10 years. It would do so because of massive cuts to Medicaid and the ACA’s insurance premium subsidies.
However, the version ultimately passed by the House of Representatives had not been scored until yesterday. Some have argued that Speaker Paul Ryan (R-WI) deliberately rushed the bill to a vote to avoid being confronted with what experts expect to be abysmal numbers by the CBO.
And the numbers were bad indeed. The most recent CBO estimate expects 23 million Americans to lose insurance coverage. Moreover, it shows reduced savings, higher premiums if benefit design and age distribution remain constant, and inadequate protections for Americans with preexisting conditions.
Importantly, the CBO also expects one-sixth of the nation’s individual insurance market to collapse due to the newly added provisions in the AHCA allowing states to eliminate the ACA’s Essential Health Benefits and charge higher premiums for individuals with preexisting conditions. Overall, 51 million Americans are expected to be without insurance in 2026.
The bigger picture: Disinvesting in the disadvantaged
Not surprisingly, the focus of countless media articles and TV news has been on the CBO’s scoring of the American Health Care Act. However, while important, this loses sight of larger, more concerning developments.
Indeed, the CBO’s dire prediction for America’s uninsured under the American Health Care Act is made significantly worse by the Trump administration’s recently released budget.
While the AHCA’s drastic $834 billion cuts to the Medicaid program are estimated to cost 14 million Americans their coverage, the Trump budget will cut an additional $610 billion. This would basically slash the current Medicaid program in half and destroy a mainstay of America’s safety net since the Great Society.
While the dramatic cuts to the Medicaid program will affect more than 70 million Americans, there is more. The bipartisan and popular Children’s Health Insurance Program (CHIP) is slated for a 21 percent cut as well as significant reductions in eligibility. Some states like Arizona and West Virginia have automatic triggers that would eliminate CHIP with these funding reductions.
Moreover, the proposed budget cuts or eliminates funding to agencies and programs helping the most vulnerable in our communities beyond the immediate provision of health care.
It cuts funding to the Substance Abuse and Mental Health Services Administration (SAMHSA), tasked with reducing the ill effects of substance abuse and mental illness.
It cuts funding to the National Center on Birth Defects and Developmental Disabilities (NCBDDD), which addresses birth defects and improves the health of individuals with disabilities.
It cuts funding to the National Asthma Control Program (NACP), intended to “help the millions of people with asthma in the United States gain control over their disease.”
It cuts funding to the Supplemental Nutrition Assistance Program (SNAP), which provides food for million of Americans.
It cuts funding to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides nutritious food for pregnant women, young children, and half of all infants in the country.
It cuts funding to the Appalachian Regional Commission, which provides loans to improve sewers and provide safe drinking water in rural Appalachia.
The list, unfortunately, goes on.
Just months ago, the nation reached a milestone when the uninsured rate fell to a historic low. Meanwhile, Republicans and Democrats are heatedly debating the future of the nation’s health care system.
What often gets lost in the numbers and the public debate is that they involve people’s lives and livelihoods. With all its shortcomings, the Affordable Care Act has brought relief to millions of Americans who are no longer scared to fall sick.
When a person loses health care, it often means having to choose between food and medications. It means delaying necessary care, exacerbating medical conditions with at times irreversible consequences.
Much remains to be done to improve the American health care system. But the changes proposed by President Trump and Speaker Ryan would reverse decades of gains made for America’s disadvantaged since the 1920s.
Perhaps most importantly, both the AHCA and the Trump administration’s budget would cause tremendous amounts of suffering and pain across all of our communities.
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