A side-by-side comparison of Obamacare and the GOP’s replacement plans

By Noam N. Levey and Kyle Kim

MARCH 8, 2017

With revised legislation unveiled by Senate Republicans, this page has been updated to reflect the differences between the House and Senate attempts to roll back the Affordable Care Act. These updates do not include a Congressional Budget Office analysis of the revised bill. The latest CBO report focused on a "repeal-only" Senate plan. A previous version of this comparison erroneously included the "repeal-only" report.

More uninsured

The revised version of the Better Care Reconciliation Act (BCRA) maintains much of its original structure and intent. Like the House legislation, the Senate Republican bill introduced in June will produce major losses in insurance coverage that will mostly affect low- and moderate-income Americans, according to the CBO’s analysis of the bills. The centerpiece of the Senate bill is a series of major reductions in federal aid for poor Americans who rely on Medicaid and for consumers who currently qualify for federal subsidies to help them buy private health insurance through the Obamacare marketplace.

The CBO estimated that under the House bill, 23 million fewer people would have insurance over the next decade. The estimate is 22 million for the previous Senate version.

Percentage of uninsured could nearly double under GOP plans by 2026
0 5 10 15 20% uninsured 2026 2020 2010 2000 1990 Pre-Affordable Care Act Pre-Affordable Care Act House Senate ACA 2010ACA signed into law 2010ACA signed into law 2010ACA signed into law 10% 18% 19% Projected
Percentage of uninsured could nearly double under GOP plans by 2026
0 5 10 15 20% uninsured 2026 2020 2010 2000 1990 House Senate ACA 10% 18% 19% Pre-Affordable Care Act Pre-Affordable Care Act 2010ACA signed into law 2010ACA signed into law 2010ACA signed into law Projected

Note: Chart shows the percentage of U.S. residents under 65 who lack health insurance. Data from 1990 to 2016 come from the National Center for Health Statistics; projections for 2017 to 2026 come from the Congressional Budget Office.

Medicaid

Cuts to Medicaid spending totaled $834 billion in the House legislation. The new Senate legislation would likely include a large spending cut as well. Expanded Medicaid coverage would cease and the funding structure would change in both bills.


Under the Affordable Care Act

  • The federal government and states share the cost of insuring the poor. The amount of money that Washington gives each state varies depending on how much medical care that state's Medicaid patients receive
  • The federal government is picking up almost the entire cost of expanding Medicaid coverage to low-income adults without children in the 30 states (and the District of Columbia) that have chosen to expand their programs

Under the GOP proposal

Updated Senate version
  • Will replace current Medicaid with a fixed per capita cap or a block grant. Each state would have a fixed amount of money every year. That amount would increase annually by a percentage linked to the inflation rate, though the rate would be lower than in the House bill, meaning deeper cuts.
  • Provides $45 billion to states to combat the opioid addiction epidemic, an increase from $2 billion for one year in the previous version.
House version
  • A fixed per capita cap or a block grant would replace the decades-old current system. Each state would have a fixed amount of money every year. That amount would increase annually by a percentage linked to the inflation rate
  • The additional federal funding that covered expanding Medicaid would be eliminated by 2020.
States that adopted Medicaid expansion
AK HI MACTRINJDEMDDC WA MT CO NM AZ ND MN IA IL MI KY OH PA WV NY VT IN LA AR OR NV CA
States that adopted Medicaid expansion
AK HI MACTRINJDEMDDCWV WA MT CO NM AZ ND MN IA IL MI KY OH PA NY VT IN LA AR OR NV CA
Estimated annual cuts in federal Medicaid spending under House and previous Senate bills (in billions)
-150 -100 -50 0 2026 2025 2024 2023 2022 2021 2020 2019 2018 House Senate


Changes in insurance costs

The House and Senate GOP healthcare bills would make major changes to health insurance markets, reducing requirements on health plans and changing the structure of financial subsidies that the current law provides to low- and moderate-income Americans.

Those changes would make health plans less expensive, on average, for some consumers, according to the Congressional Budget Office. But older and lower-income Americans would see their insurance premiums soar under the GOP plans.

The updated version of the Senate healthcare bill includes an amendment crafted by Sens. Ted Cruz (R-Texas) and Mike Lee (R-Utah), which would allow insurers to provide lower-cost, stripped-down insurance plans, as long as they offer one plan that meets Obamacare standards. Experts and moderates warn that such a provision could cause premiums to soar for sicker people if healthy people move to the cheaper options.


Average annual insurance premiums for a silver-level plan under the current law and the House and previous Senate repeal bills
Current law
House
Senate
0 5 10 15 $20,000 Senate House (states not requesting waivers for market regulations) current law 21 years old 40 64 For an individual with an annual income of: Poorer, older individuals would see their premiums skyrocket under Republican bills Poorer, older individuals would see their premiums skyrocket under Republican bills $26,500
0 5000 10000 15000 20000 25000 Senate House (states not requesting waivers for market regulations) current law 21 years old 40 64 Middle-income individuals under 60 would see cheaper costs under Republican bills Middle-income individuals under 60 would see cheaper costs under Republican bills 0 10 5 15 20 $25,000 For an individual with an annual income of: $68,200
Note: Figures for the House bill are for states that do not seek waivers from the federal government to further weaken Obamacare insurance regulations, an option provided by the House legislation.

Under the Affordable Care Act

  • People using healthcare marketplaces and making less than $48,000 a year receive subsidies to help them buy insurance
  • The amount of the subsidy is tied to a person's income and to the cost of insurance in the person's area
  • The subsidies are automatically applied to the consumers’ monthly insurance bills rather than having to wait for a rebate

Under the GOP proposal

Senate version
  • Would still link aid to consumers’ income, though it would stop at 350% of poverty level, compared with 400% under the current law
  • A new formula for setting the amount of subsidies would tie them to the cost of less comprehensive health plans. That means many consumers would get substantially less assistance than under Obamacare.
  • Cost-sharing subsidies for insurers to help cover deductibles and co-payments for poorer customers would end in 2020, but could be cut off earlier.
  • Provides $70 billion to help insurance companies cover patients with high medical costs.
House version
  • People would still receive subsidies, which would phase out at incomes of $75,000 per year
  • The amount would be tied to a person's age, not income, so younger low-income people would get less help.
    • Tax credit proposal
    Age Credit 0 500 1000 1500 2000 2500 3000 3500 4000 60+ 50-59 40-49 30-39 20-29 $2,000 $2,500 $3,000 $3,500 $4,000
  • The subsidies would not vary with the cost of insurance, so people in high-cost areas would also not get as much help, proportionally

Insurance mandate

Obamacare, for the first time, required Americans to have health insurance. That would no longer be the case.

Under the Affordable Care Act

  • A person is required to purchase health insurance or pay a tax penalty

Under the GOP proposal

Senate version
  • The Senate bill would eliminate the tax penalty
  • Does not include financial penalties for people who do not maintain coverage. People who haven’t been continuously covered would have to wait six months before they can purchase a new plan.
House version
  • The House bill would also eliminate the tax penalty
  • Anyone who goes without insurance for more than two months would face a six-month waiting period to get coverage when they buy a new plan

Guaranteed coverage

People with preexisting conditions could see substantial changes in what kind of coverage they could receive.

Under the Affordable Care Act

  • Americans are able to get health insurance even if they’re sick. This put an end to insurers denying coverage to people who have preexisting medical conditions
  • Insurers are barred from charging sick consumers more for coverage
  • Insurers cannot impose annual or lifetime limits on coverage
  • Insurers must offer a basic set of benefits, including mental health, prescription drugs and maternity care
  • Insurers cannot charge older consumers more than three times more than younger consumers

Under the GOP proposal

Senate version
  • States would be allowed to scale back conditions that they require insurers to cover. Because of the way the law is structured, that could allow insurers to reimpose annual and lifetime limits on some coverage
  • Unlike the House bill, the Senate bill would not allow insurers to charge sick people more
  • Insurers would be able to charge older consumers five times more than younger consumers
House version
  • Would not explicitly eliminate guaranteed coverage, but would allow states to seek waivers from several consumer protections
  • States would be allowed to scale back conditions that insurers must cover. Because of the way the law is structured, that could allow insurers to reimpose annual and lifetime limits on some coverage.
  • States would also be able to allow insurers to charge sick people more, potentially making coverage unaffordable for some
  • Insurers would be able to charge older consumers five times more than younger consumers

Insurance marketplaces

The insurance marketplace would be intact, but would change dramatically.

Under the Affordable Care Act

  • The Obamacare marketplaces, such as HealthCare.gov, enable people who don't get health benefits at work to compare plans, just as they might compare hotel rooms or airline tickets online
  • All plans on the marketplaces must offer a basic set of benefits, such as hospital care, mental health services and prescription drugs

Under the GOP proposal

  • Under both the House and Senate bills, it is unclear how the marketplaces would work because insurers might potentially offer health plans that do not offer the same set of benefits

Women's health

Both the House and Senate Republican plans would impose new restrictions on health plans with abortion coverage, and would defund Planned Parenthood. Low-income women would be among the most seriously affected.

Under the Affordable Care Act

  • Insurance companies cannot charge women more than men for the same health plan
  • Insurers are required to provide a basic set of benefits including maternity care, pediatric care and contraception
  • Planned Parenthood receives federal funding for family planning and other medical services used by Medicaid recipients. Abortion cannot be funded with federal dollars

Under the GOP proposal

  • Insurance companies would still be banned from charging women more
  • States could seek waivers to allow insurers to drop some basic benefits, such as maternity care and contraceptives
  • Medicaid would no longer have to offer these benefits, which would more deeply affect low-income women. Nearly 80% of Planned Parenthood patients have incomes at or below 150% of the federal poverty level
  • Medicaid would be barred from providing funding for any health clinics that provide abortion services, including Planned Parenthood
Abortion services make up a small share of Planned Parenthood's overall health services, according to its most recent annual report
13% Pregnancy/prenatal 45% STD testing/treatment 1% Other 7% Cancerscreening/prevention 31% Contraception 3% Abortionprocedures
Federal subsidies make up the majority of Planned Parenthood's revenue
43% 27% Privatecontributions 6% Other Government grants/reimbursements 24% Non-government
Abortion services make up a small share of Planned Parenthood's overall health services, according to its most recent annual report
Abortion services make up a small share of Planned Parenthood’s overall health services 31% 7% 1% 45% 13% Other STD testing/treatment Cancer screening/prevention Pregnancy/prenatal services Contraception 3% Abortion procedures
Federal subsidies make up the majority of Planned Parenthood's revenue
27% Private contributions 24% Non-government 6% Other 43% Government grants/ reimbursements

Impact on deficit

CBO estimates the previous Senate version will cut the federal deficit by $321 billion by 2026. They estimate the House bill will cut the deficit by $118.7 billion. Both bills generate most savings by cutting Medicaid and reducing subsidies that help people pay for health insurance, the CBO found.

Taxes

Most of the taxes set up under Obamacare to pay for subsidizing insurance would be scrapped. The House and Senate GOP proposals do not include any new tax to offset the loss of revenue.

Under the Affordable Care Act

  • Insurance companies and medical device makers, which benefit from new customers under the law, pay more taxes
  • Taxpayers with incomes over $250,000 are also taxed more

Under the GOP proposal

  • Medical device makers, insurance companies and wealthy Americans would all receive a big tax cut as these taxes are eliminated
  • The Senate bill keeps two taxes on the wealthy, including an investment income tax and a payroll tax for high-income households.
  • The bill expands ability of Americans to use tax-deferred Health Savings Accounts to pay insurance premiums, a tax break that mostly benefits wealthier Americans

Sources: Census, Medicaid.gov, Kaiser Family Foundation, Congressional Budget Office, Planned Parenthood, Times reporting

Credits: Additional reporting and production contributions by Joe Fox

UPDATES:

July 13, 11:24 a.m.: This article was updated to include details of the revised version of the BCRA.

June 28, 2:14 p.m.: This article was updated to include insurance premium cost details between the current law and the House and Senate bills.

June 27, 12:34 p.m.: This article was updated to include details from the CBO's review of the Senate Republicans' bill.

June 22, 10 a.m.: This article was updated to include details from the Senate Republicans' version of the healthcare plan.

May 24, 2:31 p.m.: This article was updated to include details from the May 24 CBO cost estimate that assessed the latest version of the American Health Care Act.

May 4, 12:05 p.m.: This article was updated to include details from an amendment to the American Health Care Act. The amendment, introduced by New Jersey Rep. Tom MacArthur, would affect insurance marketplaces by allowing states to opt-out of specific Affordable Care Act requirements.

May 4 6:55 a.m.: This article was updated to include details from an amendment to the American Health Care Act. The amendment, introduced by Michigan Rep. Fred Upton, would set aside $8 billion over five years to pay for medical costs for people with preexisting conditions.