The Patient Protection and Affordable Care Act (PPACA) does include provisions that will allow the purchasing of health insurance across state lines. However, these provisions are structured somewhat differently than earlier proposals advocated by some members of Congress and Senator John McCain during his 2008 presidential run. The differences are intended to protect states with more consumer protections from having those regulations undermined by cross-state sales of health insurance.1

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Summary

Interstate sales of health insurance are permitted under PPACA, but only between states entering into explicit joint insurance compacts developed for this purpose. The law’s minimum levels of insurance regulations, which will apply to all states and its limitation of cross-state sales to those joining compacts, will provide greater consumer protections than would have been the case under prior proposals.

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Impact on the Federal Budget in the First Decade

As a result of changes in direct spending and revenues, CBO expects that enacting H.R. 2 would probably increase federal budget deficits over the 2012–2019 period by a total of roughly $145 billion (on the basis of the original estimate), plus or minus the effects of technical and economic changes that CBO and JCT will include in the forthcoming estimate. Adding two more years (through 2021) brings the projected increase in deficits to something in the vicinity of $230 billion, plus or minus the effects of technical and economic changes.

Those projections do not include any potential savings in discretionary spending, which is governed by annual appropriation acts. By CBO’s estimates, repeal of the health care legislation would probably reduce the appropriations needed by the Internal Revenue Service by between $5 billion and $10 billion over 10 years. Similar savings would accrue to the Department of Health and Human Services.

There is no clear basis for projecting other effects of H.R. 2 on discretionary spending. PPACA contained a number of authorizations for future appropriations, which, if left in place, might or might not result in additional appropriations. For example, most of the authorizations were for activities that were already being carried out under current law or that were previously authorized and that PPACA authorized for future years. Thus, repeal of the PPACA authorizations might or might not result in discretionary savings associated with those authorizations.

Impact on the Federal Budget Beyond the First 10 Years

CBO estimates that enacting H.R. 2 would increase federal deficits in the decade after 2019 by an amount that is in a broad range around one-half percent of GDP, plus or minus the effects of technical and economic changes that CBO and JCT will include in the forthcoming estimate. For the decade beginning after 2021, the effect of H.R. 2 on federal deficits as a share of the economy would probably be somewhat larger.

As with all of CBO’s cost estimates, these estimates—both for the first 10 years and beyond—reflect an assumption that the provisions of current law would otherwise remain unchanged throughout the projection period and that the legislation being considered would be enacted and implemented in its current form. CBO’s responsibility to the Congress is to estimate the effects of proposals as written and not to forecast future legislation. However, current law now includes a number of policies that might be difficult to sustain over a long period of time. If those policies or other key aspects of the original legislation would have subsequently been modified or implemented incompletely, then the budgetary effects of repealing PPACA and the relevant provisions of the Reconciliation Act could be quite different—but CBO cannot forecast future changes in law or assume such changes in its estimates.

Effects on the Federal Budgetary Commitment to Health Care

CBO uses the term “federal budgetary commitment to health care” to describe the sum of net federal outlays for health programs and tax preferences for health care. H.R. 2 would roughly reverse the outcome projected for the original legislation, diminishing the federal budgetary commitment to health care over the next decade and increasing it in subsequent years.

Effects on the Number of People with Health Insurance

Under H.R. 2, about 32 million fewer nonelderly people would have health insurance in 2019, leaving a total of about 54 million nonelderly people uninsured. The share of legal nonelderly residents with insurance coverage in 2019 would be about 83 percent, compared with a projected share of 94 percent under current law (and 83 percent currently).

Effects on Health Insurance Premiums

If H.R. 2 was enacted, premiums for health insurance in the individual market would be somewhat lower than under current law, mostly because the average insurance policy in this market would cover a smaller share of enrollees’ costs for health care and a slightly narrower range of benefits. Although premiums in the individual market would be lower, on average, under H.R. 2 than under current law, many people would end up paying more for health insurance—because under current law, the majority of enrollees purchasing coverage in that market would receive subsidies via the insurance exchanges, and H.R. 2 would eliminate those subsidies.

Premiums for employment-based coverage obtained through large employers would be slightly higher under H.R. 2 than under current law. Premiums for employment-based coverage obtained through small employers might be slightly higher or slightly lower (reflecting uncertainty about the impact of the enacted legislation on premiums in that market).

You don't get to wave around huge savings "missed". The COST of those savings, in human terms, are not being mentioned. And that cost is a lot higher than the "savings".