Concern about patients spending too much of their own money onhealth care has driven the debate over repealing and replacing Obamacare. But thelatest Senate Republican health bill does little to address thosefears and may exacerbate them.

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The bill, rolled out anew on Thursday after a raft of Republicandefections threatened to sink the original legislation, faces anarrow road to passage despite alterations aimed at winning overlawmakers who balked at the earlier draft. Two Republican Senatorssignaled their opposition; a third dissent could doom the measure,and a long-held GOP vow to overturn the Affordable Care Act.

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Among other changes, including some specifically targeted atwavering GOP moderates, the bill now provides more money to statesto help cover some patient costs, and sets up a $45 billion fundfor treating opioid addiction.

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Doctors and hospitals quickly lined up against the plan, sayingit still will leave the most vulnerable Americans without viableoptions for health insurance. The American Hospital Associationtold lawmakers to “go back to the drawing board.”

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“The revised bill does not address the key concerns ofphysicians and patients regarding proposed Medicaid cuts andinadequate subsidies that will result in millions of Americanslosing health insurance coverage,” David Barbe, the president ofthe American Medical Association, said in a statement.

Pocketbook issue

High upfront costs for care have been a frequent line of attackfor critics of Obamacare. Earlier versions of the Senate billrelied on high deductibles to keep premiums down, and the new billdoes little to change that, creating a market that largely pushesindividuals into plans where their out-of-pocket costs could total thousands ofdollars.

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The Congressional Budget Office is expected to release itsevaluation of the rewritten legislation as soon as Monday.

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“I just don’t see the Republican Senate plan as creating a moreworkable market,” said Robert Laszewski, an insurance-industryconsultant and Obamacare skeptic. “And it makes things a lot worsefor many people.”

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Voters have signaled that their upfront spending on health careis a top concern. A Kaiser Family Foundation poll in January foundthat reducing the costs individuals have to pay for health care wascited as the top priority of about two-thirds of Democrats,Republicans, and independents. President Donald Trump promised“great health care for much less money" and in April touted “muchlower premiums & deductibles” in the Obamacare overhaul in apost on Twitter.

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The initial Senate health bill was criticized for loweringpremiums by raising deductibles. To address those concerns, the newbill adds $70 billion to a stabilization fund in order to helpstates control out-of-pocket expenses. But cuts elsewherecould still drive up upfront costs.

Medicaid worry

For lower-income Americans, the bill carves into Medicaid,shifting poor people out of the program and into private coveragewhere they could face deductibles reaching thousands ofdollars. One change to the bill pushed by Republican SenatorTed Cruz of Texas would let insurers create even skimpier plansthat could exclude coverage for an array of conditions.

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Maine’s GOP Senator Susan Collins has said that she’s opposed tothe measure because of its Medicaid cuts. Governors attending theirsummer meeting in Providence, Rhode Island, said they are studyingthe bill but are concerned about states having to assume more ofthe cost for Medicaid and their residents losing coverage.

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The Senate bill “still has meaningful cuts to the Medicaidprogram, with no explanation as to how you can accomplish thosecuts, except by reducing enrollment or services provided,” saidCraig Garthwaite, a professor at Northwestern University’s KelloggSchool of Management.

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“A lot of the difference in the bill is funneling more money tothe states,” Garthwaite said. “If a state chooses to use that moneyfor something else, it’s going to be tough to be a moderatelylow-income person covered by this plan.”

Subsidy shift

Poor patients benefit from Obamacare subsidiesthat lower their upfront costs, but the Senate plan cuts off suchcost-sharing reduction payments in 2020. That could boost theaverage deductible for someone making just more than the povertylevel from a few hundred dollars to more than $6,000, according tothe Kaiser Family Foundation.

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The Senate measure also reduces help available for individualsto buy health plans. Subsidies -- which are only available up to350 percent of the poverty level, rather than Obamacare’s 400percent limit -- would be based on plans that cover 58 percentof medical costs, compared with about 70 percent in Obamacare.

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According to the Brookings Institution, the reduced subsidiesand other changes mean individuals will pay 5 percent to 9 percentmore for their health insurance plans, compared to under Obamacare.That analysis is based on a previous version of the bill. Changesto the new version in an amendment backed by Cruz could make thesituation worse, according to Matt Fiedler, one of the authors ofthe analysis.

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“The Cruz amendment will significantly increase premiums in theACA-compliant market, and the additional stability funding isprobably not enough to offset that increase,” he said. “That willcause significant increases in premiums for sicker people noteligible for tax credits.”

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Healthier people could get cheaper coverage, but it might notcover care they need if they do get sick.

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“By enrolling people in skimpier plans, the GOP can say they aregiving people lower premiums,” said John Graves, a professor atVanderbilt University School of Medicine. “There is littleattention paid, if any at all, to the affordability ofout-of-pocket health expenses.”

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Copyright 2018 Bloomberg. All rightsreserved. This material may not be published, broadcast, rewritten,or redistributed.

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