of the medicaid expansion was likely to result in a loss of healthcare for poorer americans. estimated impact of the republican ahca and bcra cbo estimated in may 2017 that under the republican ahca, about 23 million fewer people would have health insurance in 2026, compared with current law. ahca (republican healthcare bill) impact on income distribution, as of the year 2022. net benefits would go to families with over $50,000 income on average, with net costs to those below $50,000. impact on the budget deficit of the republican healthcare bills (ahca and bcra). cuts to medicaid more than offset tax cuts, resulting in moderate deficit reduction. changes in medicaid spending under the better care reconciliation act compared with cbo's extended baseline share of nonelderly adults without health insurance coverage under current law and the better care reconciliation act, by age and income category, 2026 cbo projections of persons without health insurance under 65 years of age (%) under various legislative proposals and current law. the nonpartisan congressional budget office has evaluated ("scored") the ahca (initial and revised) and bcra with respect to health insurance coverage, impact on the annual budget deficit, cost of insurance, and quality of insurance (i.e., the actuarial value, or percent of costs a given policy is expected to cover). other groups have evaluated some of these elements, as well as the distributional impact of the tax changes by income level and impact on job creation. the results of these analyses are as follows: health insurance coverage according to each of the cbo scores, passage of the republican bills would result in a dramatic reduction in the number of persons with health insurance, relative to current law. persons with healthcare insurance coverage would be reduced by 14 million in 2018, 21 million in 2020, and 24 million in 2026 relative to current law. in 2018, most of the reduction would be caused by the elimination of the penalties for the individual mandate, both directly and indirectly. later reductions would be due to reductions in medicaid enrollment, elimination of the individual mandate penalty, subsidy reduction, and higher costs for some persons. by 2026, an estimated 49 million people would be uninsured under the senate bcra, versus 28 million under current law. non-cbo coverage estimates according to a report viewed by politico, the white house office of management and budget's own analysis of the ahca estimated that 26 million people would under ahca lose coverage over the next decade. according to white house communications director michael dubke, the analysis tried to use similar methodology as the cbo. other individuals and organizations such as the brookings institution and s&p estimated sizable coverage losses due to the ahca. according to a report published by the center on budget and policy priorities, the legislation would lead to 3 million more children (defined as persons under 18 years old) losing healthcare coverage. budget deficit cbo has evaluated the impact on the budget deficit in each of its scores, generally finding a moderate reduction relative to current law: cbo ahca march 13: the ahca would reduce the deficit relative to current law by $337 billion over a decade. approximately $1.2 trillion less would be spent over that time, while $900 billion less in tax revenue would be collected. medicaid spending would be cut considerably. taxes on the roughly top 5% of income-earners under current law would considerably drop. cbo ahca revised march 24: in negotiations after the initial report, the law was modified such that the cbo estimated the deficit reduction would total about $150 billion over a decade. cbo bcra june 26: a reduction of $321 billion over a decade. for scale, cbo has estimated that the u.s. will add approximately $9.4 trillion to the debt total over the 2018-2027 period, based on laws in place as of january 2017. the $321 billion therefore represents a reduction of about 3.5% of the total debt increase over the decade, while the $150 billion is about 1.6%. insurance costs and quality there are many variables that affect premiums, deductibles, and out-of-pocket amounts, including (among others) age and health of plan participants, availability of subsidies, funding for high-risk pools, required insurance coverage elements, lifetime limits, maximum ratio of prices charged to older persons versus younger, and the quality of insurance offered. regarding quality, the "actuarial value" is an estimate of the percentage of total cost that a particular insurance plan is expected to cover. cbo reported that: cbo ahca march 13: insurance premiums would rise initially relative to current law, but would be reduced in the future moderately: "starting in 2020, the increase in average premiums from repealing the individual mandate penalties would be more than offset by the combination of several factors that would decrease those premiums: grants to states from the patient and state stability fund (which cbo and jct expect to largely be used by states to limit the costs to insurers of enrollees with very high claims); the elimination of the requirement for insurers to offer plans covering certain percentages of the cost of covered benefits; and a younger mix of enrollees. by 2026, average premiums for single policyholders in the nongroup market under the legislation would be roughly 10 percent lower than under current law..." cbo ahca march 13: premium changes would vary significantly by age: "under the legislation, insurers would be allowed to generally charge five times more for older enrollees than younger ones rather than three times more as under current law, substantially reducing premiums for young adults and substantially raising premiums for older people." this would lead to a mix of younger enrollees, one of the reasons for the lower overall premiums over the longer-term. cbo bcra june 26: "in 2020, average premiums for benchmark plans for single individuals would be about 30 percent lower than under current law. a combination of factors would lead to that decrease—most important, the smaller share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums. that share of services covered by insurance would be smaller because the benchmark plan under this legislation would have an actuarial value of 58 percent beginning in 2020. that value is slightly below the actuarial value of 60 percent for "bronze" plans currently offered in the marketplaces." cbo bcra june 26: "under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. the deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income—also making such a plan unattractive, but for a different reason. as a result, despite being eligible for premium tax credits, few low-income people would purchase any plan..." cbo bcra june 26: cbo has provided a summary (table #5 on page 48) that compares premiums under current law (aca) with the bcra, for different ages and income levels, for bronze and silver plans. for example, a single individual 40 years old with annual income of $56,800 (375% of poverty level) would pay $5,000 for a bronze plan under bcra vs. $5,500 under current law, but receives a lower actuarial value plan of 58 versus 60. for that person, silver plans would be basically identical in terms of cost and quality. relative to current law, persons aged 64 years old would pay considerably more for either a bronze or silver plan under bcra, while a 21 year old would pay considerably less under bcra, due in part to relaxing the rules on how much more older persons can be charged relative to younger. non-cbo cost estimates the chief actuary of centers for medicare and medicaid services of the department of health and human services released a report on june 13, 2017 providing their estimates of the legislation's impact. they estimated that gross premiums would decrease by 13%, but net premiums, the amount paid by consumers after federal subsidies, would increase by 5% by 2026. taxation and income inequality the current law (aca) established two taxes on high-income individuals (defined as income over $200,000 for individuals or $250,000 for couples, roughly the top 6% of earners), via a 0.9% medicare payroll surtax on earnings over that threshold and a 3.8% tax on net investment income. the latter tax is steeply progressive, with the top 1% paying 90% of the tax, as investment income is highly concentrated with the wealthy. the aca also established a penalty tax (related to the individual mandate) for individuals without adequate insurance, an excise tax on employers with 50 or more workers who offer insufficient coverage, annual fees on health insurance providers, and the "cadillac tax" (yet to be implemented as of 2017) on generous employer-sponsored health plans. combined with subsidies that primarily benefit low-income households, the law significantly reduced income inequality after taxes and transfers. the republican bills (ahca and bcra) essentially repeal all of the taxes, penalties and fees and postpone the "cadillac tax" further. the tax policy center estimated in march 2017 that the ahca would significantly reduce taxes for the wealthy, with those irs tax units (an approximation for families) earning over $200,000 per year (the top 6%) receiving 70.6% of the benefit or a reduction of $5,680 in annual taxes on average. those with incomes over $1 million (the top 0.4%) would see a tax decrease of $51,410 on average, receiving 46% of the benefit. in general, those with incomes over $50,000 would see a tax cut, while those with income below $50,000 would see a tax increase. those with income below $10,000 would see a tax cut as well, but this benefit would be offset overall by reductions in medicaid availability. the effects overall would worsen income inequality. the center on budget and policy priorities (cbpp) reported that "the house bill would represent the largest transfer in modern u.s. history from low- and moderate-income people to the very wealthy." cbpp also wrote: "millionaires would gain roughly $40 billion in tax cuts annually...roughly equivalent to the $38 billion that 32 million households in poverty would lose from cuts to their tax credits and medicaid." medicaid medicaid is the u.s. program for low-income children, adults, seniors and people with disabilities, covering one in five americans. it is the primary payer of nursing home care. the aca (current law) expanded medicaid eligibility; 31 states and the district of columbia implemented the expansion. approximately 41% of medicaid enrollees are white, 25% are hispanic, and 22% are black. the proportion of white recipients in key swing states are 67% in ohio, 59% in michigan, and 58% in pennsylvania. about 48% of recipients are children (18 or under). most of the cost savings (deficit reduction) under ahca and bcra is due to reductions in medicaid spending and coverage relative to current law. cbo estimated that there would be 15 million fewer medicaid enrollees relative to current law by 2026, the largest component of the reduced coverage discussed above. cbo estimated that medicaid spending under bcra would be 26% lower in 2026 and 35% lower in 2036 relative to current law. this would reduce medicaid spending in 2036 from 2.4% gdp under current law to 1.6% gdp. the reductions are driven by reduced funding to states for those who became covered under the medicaid expansion in the current law (aca), reducing the inflation index used to compute per-enrollee payments to states, and eliminating coverage mandates. while the nominal spending amounts continue to rise but at a slower pace, adjusted for inflation the amounts are actually cut moderately relative to 2017 levels. jobs according to researchers at the milken institute school of public health at george washington university, the ahca legislation would lead to a loss of 924,000 jobs by 2026. the group also studied the bcra, which would cost an estimated 1.45 million jobs by 2026, including over 900,000 in healthcare. the stimulus effects from tax cuts would initially create jobs, but would be offset by the larger declines in spending as the various parts of the law take effect. further, gross state products would be $162 billion lower in 2026. states that expanded medicaid would bear the brunt of the economic impact, as government funds would be reduced more significantly. exchange stability under both the aca (current law) and the ahca,