Most people are focused on how many people would lose insurance under the Senate bill compared to current law: an estimated 22 million, according to the new Congressional Budget Office analysis. But the report digs deeper into the kind of insurance that people, especially poor people, would be able to access -- and finds that it would be so financially burdensome with high deductibles that many people would choose not to sign up.
Trump has criticized the insurance currently offered in the exchanges -- not only for sky-high premiums, but also because "deductibles are so high that it is practically useless."
Because of fundamental changes in how the Senate bill would provide support to people, those deductibles are virtually guaranteed to grow.
The Senate bill proposes providing federal assistance for premiums based on a benchmark plan that is fundamentally less generous than the status quo. What that means is that the assistance is calculated based on a plan shifts a greater portion of health care costs on to the person through deductibles, co-pays and other out-of-pocket costs. The bill also winds down federal payments that had significantly brought down lower-income Americans' share of their deductibles and co-pay.
Here's how CBO explains it: A 40-year-old who makes $26,500 a year in the year 2026 would pay an annual premium of $1,700 under the current law, for a plan that covers 87 percent of their health care costs. That same person would pay an annual premium of $1,600 a year -- slightly lower -- but for a plan that picks up only 58 percent of their health care costs.
Another change the bill makes is to extend the premium assistance to people who make less than the federal poverty level, while effectively phasing out the Medicaid expansion that allowed adults with incomes up to 133 percent of the federal poverty level to be eligible. Today, in states that expanded Medicaid, eligible people would typically pay no premiums and have few out-of-pocket costs. Since states are likely to curtail their Medicaid enrollment as they face budgetary pressure, this would leave a growing number of poor people the option to buy their own insurance with the tax credits.
But health policy experts have been skeptical about whether that insurance would be attractive to people.
Here's how CBO described the conundrum for someone who makes $11,400 a year in 2026: they'd benefit from tax credits and pay only $300 a year in premiums for their insurance. But their deductible would be more than half their annual income. Buying a more generous plan -- with a deductible that is a third of that person's income -- would cost $1,700 a year.
"Many people in that situation would not purchase any plan... although some people with assets to protect or who expect to have high use of health care would," the Congressional Budget Office report states.
Translation: healthy people who don't think they'll use health care much won't bother signing up, seeing that they'd be on the hook for thousands of dollars of medical costs even if they had insurance. And that means mostly sick people will be motivated to sign up for insurance -- a pattern that insurers have already complained makes the business of selling insurance untenable.