The Congressional Budget Office released a report on the American Health Care Act this week, coming to the conclusion it would significantly reduce the number of insured people across the country.

And in Pennsylvania, it could be worse.

We could see our uninsured population rise at even greater rate, thanks to an aging population and, in Philadelphia, a high dependence on Medicaid. We’re potentially talking about twice as many PA residents uninsured by 2026 as there are now.

Here’s a primer of how Trumpcare would impact the state.

400K Pennsylvanians could lose health insurance next year

America has about 28 million uninsured people right now. The CBO expects that number to rise under the AHCA to 42 million by 2018. According to the CBO report, the majority of the rise in uninsured would come from people who opt not to purchase insurance because they won’t face a fine, as they will now because of Obamacare.

If the AHCA bill passes, Pennsylvania could see its uninsured rise by 400,000. How’d we get this number? According to recent Census estimates, about 800,000 Pennsylvanians are uninsured right now, and that’s 6.4 percent of the population. A proportional rise in uninsured people to the CBO’s estimate would puts Pennsylvania at 1.2 million uninsured in 2018, about 9.4 percent of the population.

The 2020 elimination of Medicaid expansion as part of the AHCA is predicted to further reduce the number of insured Americans. Nationwide, the CBO expects uninsured Americans to reach 52 million in 2026 — or 24 million higher than the current estimate. In Pennsylvania, the number would be 1.5 million, nearly twice the number of uninsured right now and 11.8 percent of the state’s population.

These are projections based on the CBO report. No study has been done on Pennsylvania in particular. But David Grande, director of policy at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, said that given Pennsylvania’s sizable expansion of insurance under the ACA, Medicaid and private coverage the last few years it’s reasonable to think the state would see a proportional reduction.

“The big picture,” Grande said, “is there is a lot here for Pennsylvania to lose in terms of coverage.”

Basically by 2026, Pennsylvania would be slightly behind where it started in terms of covered residents. Pre-ACA, per the Census, about 10 percent of the state was uninsured.

Medicaid and Philadelphia

Pennsylvania ranks at about the national average in terms of Medicaid recipients. About 18 percent of the population uses Medicaid, or 2.3 million total residents. But with a low-income population, Philadelphia has a disproportionate number of Medicaid recipients. North Philly alone has an estimated 300,000 residents on Medicaid — 13 percent of the approximate 2.3 million Pennsylvanians using it.

The cap on Medicaid in 2020 would potentially shut out people who would have been newly-eligible under Obamacare. Grande said Medicaid recipients also tend to be fluid. An eligible recipient might get temporary extra income and have regular health care for a while and then lose that income, requiring Medicaid again. Such a person would possibly be unable to return to Medicaid if the cap has been reached. And Philadelphia would be among the hardest hit areas of Pennsylvania.

Trump country will get slammed

Many experts and politicians have pointed out the adverse effect the AHCA could have on the older population. William Aaronson, chair of Temple’s College of Public Health, explains that under Obamacare measures were in place to minimize the amount older people were charged. The AHCA doesn’t do that to the same extent. People in the 55-to-64 age group could now be paying five times the premiums of younger people, compared to three times more under the ACA.

This could be an outsized issue for Pennsylvania. We’re the one of the oldest states in the US, with our median age of 40.7 about three years above the United States median. Our share of population over 50 has risen from 34.4 percent in 2005 to 38.3 percent in 2015, the latest year for which data is available.

“I would make the assumption that we could be very adversely affected by the AHCA,” Aaronson said of Pennsylvania.

And where will Pennsylvanians be particularly slammed because of age reasons? Trump country. Over the last decade or so, Philadelphia has gotten slightly younger. The median age here is 34.1 and only about 30 percent of the population is above 50. Nearly every other county in the state, particularly in Central and Western PA, has gotten older. In Cambria County, for instance, about 44 percent of the population is above 50.

Auditor General Eugene DePasquale said rural hospitals and rural patients dependent on Medicaid would both suffer.

“The working poor would lose coverage,” he said, “especially in rural Pennsylvania. The blow will be enormous.”