Eight billion dollars might be enough to persuade a few reluctant Republicans to vote for the latest Obamacare repeal bill. But it won’t come close to covering the costs for millions of Americans with serious and expensive pre-existing medical conditions.

The extra money for “high-risk pools” in states that choose to opt out of Obamacare is the key change that might get the House bill over the finish line in a high-stakes vote now set for Thursday. But industry experts say it may cost billions more to cover sick patients who might otherwise see their premiums skyrocket to levels they cannot afford.


“Short answer, this does not make any meaningful difference,” said Chris Sloan, a senior manager at consultant Avalere Health, who did an analysis of the legislation’s stability fund. “High-risk pools are incredibly expensive and an additional $8 billion over five years doesn’t lead to that [many] more people being able to be covered.”

Even Rep. Fred Upton (R-Mich.), the lawmaker who got the extra money in the bill, said he didn’t know if $8 billion extra money — added to the $130 billion already included in the bill — was the right number.

“Is it enough money? I don’t know,” Upton told reporters Wednesday afternoon. “I asked if this is going to get it covered and the answer was yes — that’s what I needed.”

But the extra cash was politically significant. It was negotiated by Upton and Rep. Billy Long (R-Mo.), two high-profile holdouts who are now backing the bill. Their switch could be a key to winning over shaky centrists worried about keeping their constituents covered through so-called high-risk pools. Lots of states tried those pools in the years before the Affordable Care Act — and they generally did a poor job of helping high-cost patients with life-threatening or disabling conditions.

The House Republicans are now putting more money than they ever have into helping lower premiums and keeping people insured. They say their legislation is full of protections meant to avoid a return to the bad old days when health plans just wouldn’t cover the sick.

Still many experts and health advocacy groups disagree. Without the patient protections of Obamacare, millions could fall through the gaps.

"The GOP repeal bill still drops the coverage guarantee for people with pre-existing conditions, strips coverage from millions, and drives up costs for millions more," consumer advocacy organization Families USA said. "The Upton $8 billion is a non-solution."

The $138 billion fund sits at the core of the repeal bill’s central aims — encouraging states to customize their health care markets while at the same time maintaining people’s access to insurance.

That’s crucial now that the House legislation would give states the option to waive key Obamacare provisions like the requirement that insurers charge the same regardless of health status. The opt-out undermines Obamacare’s pre-existing condition protections and potentially prices some people out of the market. States that do so would have to set up high-risk pools or similar backstops to keep coverage affordable.

But high-risk pools are costly — far more costly than the money the GOP wants to set aside. And not all of the bill’s funding would go into those pools. Some of the cash would have to go toward supporting specific services like maternity care or mental health — another portion could be range of initiatives beyond helping the sickest.

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“If you put all the high-risk people in a single pool, by definition it’s going to be very expensive.” said Ralph Tyler, who supervised Maryland’s pre-Obamacare high-risk pool as state insurance commissioner. That, he added, is “contrary to the basic concept of how insurance is supposed to work.”

Maryland spent nearly $204 million on just 20,000 high-risk pool enrollees in 2011 alone — and that was after requiring them to pay above-market premiums and accept lifetime benefit caps and temporary coverage exclusions for the pre-existing conditions that forced them into the pool in the first place.

It was one of the most successful of the nearly three dozen programs run by red and blue states prior to Obamacare. Altogether, states that ran risk pools paid out a combined $1.2 billion that year — or more than $5,500 per enrollee.

Under the GOP’s repeal bill, state high-risk pools may need to cover far more people than before — and with lower-priced, more generous plans — to fulfill Trump’s pledge not to leave behind people with pre-existing conditions.

“This has been tried over and over again,” said Mario Molina, the recently axed CEO of Molina Healthcare. “They have not worked because they haven’t been adequately funded, and this bill will not provide adequate funding.”

Republicans insist otherwise, especially with Upton’s newly won $8 billion is added to the pot.

Rep. Tim Murphy (R-Pa.) called it a big improvement. “It’ll make a significant difference for a lot of people.”

But there’s little chance all that money will go toward supporting sick Americans. Only $23 billion is earmarked specifically to help states establish high-risk pools. A further $15 billion, secured in part by Murphy, is to support maternity care, substance abuse and mental health services.

The biggest chunk — $100 billion — would be distributed to states for them to use for any number of initiatives aimed at customizing their health care markets. That could include activities vaguely directed at “incentivizing” insurer participation, and even allows the direct payment of health care providers.

If states opt not to create their own program, they’d simply receive the funds as “reinsurance” to be distributed among companies on the individual insurance market — a mechanism nearly identical to one of the temporary Obamacare programs panned by Republicans for ”bailing out” insurers.

“At the end of the day, it’s just easy to sit back and say, we’re going to let the feds run the reinsurance,” Avalere’s Sloan said. “I don’t necessarily think of it as a safety net for patients.”

That could be especially true once states find out how much of the $100 billion they’re actually getting. The bill allocates the money based largely on how big a state’s total insurance market is — not just how many people are in the individual insurance market.

The legislative quirk means that blue states with relatively stable markets — like Massachusetts and Connecticut — could receive more than $1,000 per enrollee in funding, among the biggest per-capital windfalls in the nation.

Deep red states like Tennessee and Texas, meanwhile, would be in line for just a fraction of that payout.

“Obviously there are huge problems in controlling health care costs,” Taylor said. “This model doesn’t purport to do that.”

Paul Demko contributed to this report.