House Speaker Paul Ryan isn’t planning to make any major changes to Republicans’ Obamacare replacement plan despite a politically difficult estimate of its effect on health coverage, according to a GOP aide.

Ryan and House Majority Leader Kevin McCarthy (R-Calif.) are scheduled to speak with President Donald Trump by telephone Tuesday afternoon to discuss next steps.

An estimate from the non-partisan Congressional Budget Office released on Monday shows that 14 million Americans could be uninsured next year under the GOP Obamacare replacement plan, leaving House Republicans in a bind with its dire picture of the bill’s effects heading into the 2018 congressional elections.

Even as the Trump administration challenged the CBO estimate, concern is growing that the analysis suggests the party may need to rethink its plan.

“It is clear that this bill is not consistent with the repeal and replace principles for which I stand,” said Rep. Rob Wittman (R-Va.) in a statement Monday. “I do not think this bill will do what is necessary for the short- and long-term best interests of Virginians and therefore, I must oppose it.” Wittman said he supports repealing Obamacare and will work with colleagues “on legislation that expands choices, increases access, and reduces costs.”

In addition to decreasing coverage, insurance premiums will continue to rise in the near term and will only fall years later, CBO predicts.

“I suspect that the political consequences of those near-term changes means that the long term will never actually arrive,” said Sen. Tom Cotton (R-Ark.) on Tuesday. “That’s why I believe it’s so important that the House take a pause and try to fix some of these fixable problems in their committees, which is the easiest place in Congress to fix them, whereas the Senate floor is the hardest place to fix them.”

Sen. Roy Blunt (R-Mo.) said Tuesday that he believes the House will alter the bill before it gets sent to Senate, "and the plan will be open to change here."

The 2018 portrait is particularly challenging for Republicans heading into the 2018 elections. About 14 million more people would be uninsured next year under Ryan’s health plan, compared with the existing Obamacare plan. Although the CBO said the measure would eventually reduce the deficit by $337 billion over 10 years, cost figures would still be rising through 2018, while premiums would also still be going up.

The long-term picture also poses political risk to Republicans. The number of Americans without coverage would rise to 24 million in 2026 under the plan, bringing the U.S. uninsured rate to a record 19 percent, CBO estimates.

House Republican leaders and White House officials, who had been attacking the CBO even before it released its findings, immediately rejected the latest estimates. They said the legislation is only the first of three phases of their healthcare plan. For example, Price contends that the CBO didn’t analyze the entire plan for healthcare, including regulatory changes that can be made by HHS. “We disagree strenuously with the report that was put out,” said Price. “We believe that our plan will cover more individuals at a lower cost and give them the choices that they want, the coverage that they want for themselves and their families.”

But several Senate Republicans said the new estimate shouldn’t be dismissed.

“Rather than attacking the CBO as a way of moving forward, I think the prudent thing for the party to do is to look at the CBO report and see if we can address some of the concerns raised,” said Sen. Lindsey Graham (R-S.C.).

Sen. Susan Collins (R-Maine) said the CBO “estimate that millions of Americans could lose their health insurance coverage if the House bill were to become law is cause for alarm. It should prompt the House to slow down and reconsider certain provisions of the bill.”

Sen. Bill Cassidy (R-La.) and Collins have an alternative bill they say is intended to increase coverage. “Society is going to pay for healthcare, whether it is through insurance or not,” Cassidy, a physician himself, said. “Society will pay for it either through cost shifting to the privately insured or it will pay for it through enhanced disproportionate payments” to hospitals that treat indigent patients.

The coverage estimate is a setback for Trump, who promised that “insurance for everybody” would replace Obamacare, which used government subsidies and an expansion of Medicaid to expand coverage to 20 million people who previously had no health insurance.

Republicans trying to pass the legislation without Democratic support argued that any reduction in the rolls of the insured isn’t as important as what they say will be cheaper coverage. Ryan said there will be a stable transition if the bill is passed so “no one has the rug pulled out from under them.” House leadership is “working on getting that consensus” with Republicans in both chambers, Ryan said.

Insurance premiums will be 15 percent to 20 percent higher over the next couple of years, before the GOP replacement plan goes fully into effect, the CBO estimated. They’d fall after that, thanks to more young people signing up and insurers offering skimpier coverage, the CBO says. In a decade, premiums are estimated to be 10 percent lower than they would have been under Obamacare.

Democrats quickly used the CBO scores to attack the GOP plan. Sen. Ron Wyden (D-Ore.) said the report shows, “Trumpcare is an awful deal for the American people.”

“The CBO report should be a knockout blow for Republicans in Congress,” said Sen. Chuck Schumer (D-N.Y.). “They should heed this warning and turn back from their plan that would be a disaster for the country.”

The legislation, called the American Health Care Act, repeals Obamacare’s mandate that everyone must have insurance or pay a penalty. It also provides age-based tax credits to help people purchase coverage, although they’re lower than the income-based subsidies offered under current law. The bill will also wind down Obamacare’s expansion of Medicaid in 2020. About 12 million people gained coverage in the 31 states that expanded Medicaid.

Older, poorer people will be hit the hardest under Republicans’ plan. A 64-year-old earning $26,500 a year would have a $19,500 premium for health insurance and get a tax credit of $4,900, leaving a bill to pay of $14,600, the CBO estimated. That compares to a $15,300 premium under Obamacare with a $13,600 subsidy, leaving the cost to the individual at $1,700.

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