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The Republican plan to repeal and replace Obamacare with the American Health Care Act continues to worry advocates seeking to ensure access to health care for LGBT people and people with HIV — a concern that a recent report from the Congressional Budget Office has validated.

According to CBO, 14 million people would lose insurance coverage in 2018 if the American Health Care Act were to become law as a result of the elimination of the individual mandate under Obamacare. But that number would climb to 21 million in 2020, then to 24 million in 2026 following repeal of the Medicaid expansion under Obamacare. In 2026, CBO estimates 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.

As President Trump pushes for the proposal and continues to call Obamacare a “disaster,” a major source of fear for advocates of LGBT people and people with HIV is the rollback of Medicaid, which as health coverage for low-income Americans provides care for more than 40 percent of people with HIV and many transgender people.

CBO estimates the American Health Care Act would decrease direct spending in Medicaid by $880 billion over the 2017-2026 period resulting in 14 million fewer Medicaid enrollees by the end of that period.

Carl Schmid, deputy director of the AIDS Institute, said he couldn’t overstate the calamity passage of the American Health Care Act would mean for people with HIV.

“I hate to use the word devastating, other people have used it,” Schmid said. “The CBO score is not surprising at all because it’s what we had said that the biggest impact, they’re really cutting back, scaling back coverage in Medicaid. They’re removing all these people from the Medicaid rolls.”

Schmid said the American Health Care Act would also remove the Medicaid requirements that the states provide 10 essential health benefits, including prescription drugs, which means “we don’t know what the states will provide” to people with HIV.

Also at risk under the plan, Schmid said, is access to preventative services, like HIV testing, or access to PrEP as a means of HIV prevention for low-income people on Medicaid.

“PrEP is covered by most plans right now,” Schmid said. “Medicaid plans and qualified health plans. If people don’t have coverage, they can’t access the medications, and the federal government’s not paying for PrEP by the CDC or the Ryan White program. Ryan White is just for people who are HIV positive.”

One aspect of Obamacare that LGBT supporters value is Section 1557, which prohibits discrimination on the basis of sex in health care. The Obama administration interpreted that provision to bar discrimination in health care against transgender people, including by denying them gender reassignment surgery. A court order has enjoined enforcement of that regulation, but advocates insist transgender people can sue under the underlying law if they face discrimination in health care.

Mara Keisling, executive director of the National Center for Transgender Equality, said the provision is safe for the time being because it couldn’t be eliminated through the budget reconciliation process planned for the American Health Care Act, but nonetheless transgender people would face other problems.

“That really doesn’t matter because the repeal bill would make it so much harder for trans people to get insurance though the continuous coverage requirement, the gutting of Medicaid and several other aspects, that protecting from discrimination would move to a lesser concern,” Keisling said. “Trans people would be among those most hurt.”

In the individual market, CBO estimates the Republican plan would reduce premiums by an average of 10 percent, but there’s a wide fluctuation in estimated payments for older people and younger people. For a person making $26,500 a year, the yearly net premium would be $1,450 if that person were 21 years old, $2,400 if that person were 40 years old and $14,600 if that person were 64 years old.

Under the legislation, premiums for older people could be five times larger than those for younger people in many states, but the size of the tax credits for older people would only be twice the size of the credits for younger people.

CBO estimates the American Health Care Act would result in greater cost savings than Obamacare for the federal government. Under the Republican proposal, the agency projected a reduction in the federal deficits by by $337 billion over the 2017-2026 period.

White House Press Secretary Sean Spicer defended the American Health Care Act on Tuesday by dismissing the CBO’s estimates that the number of uninsured people would increase, asserting its estimate during the Obama era that 24 million people would have coverage under Obamacare in 2016 was “way off.”

“They were off by 13 million people — over 50 percent,” Spicer said. “In fact, only 10.4 million people were actually covered. Reports now suggest that that number has dwindled down to 9 million. CBO coverage estimates are consistently wrong and, more importantly, did not take into consideration the comprehensive nature of the three-pronged plan to repeal and replace Obamacare with the American Health Care Act.”

The second prong to the administration’s approach to health care reform is regulatory relief aimed at reducing costs by 10 percent in the individual markets. The third is additional legislation to undo Obamacare that can’t be done through the regulatory process, which only requires a majority vote for passage in the U.S. Senate as opposed to 60 votes to overcome as a filibuster.

Phill Wilson, CEO of The Black AIDS Institute, said in a statement the White House attack on the CBO’s calculations is “spin” because the American Health Care Act will increase premiums, reduce benefits and replace subsidies with tax credits.

“Particularly if you’re a person living with HIV/AIDS, a poor person, a person with other chronic illnesses, or an older American — regardless of what lie the administration or the Congress tries to sell to you — ask yourself this: Is my health insurance likely to be more robust, better and cheaper under the new plan than it was under the Affordable Care Act?” Wilson said. “Then mobilize accordingly.”

Under questioning from CNN’s Jim Acosta, Spicer conceded millions of people won’t have health coverage as a result of the American Health Care Act, but insisted “you have to look at the current situation.”

“If you could bring down cost and choices and allow people to find a plan that fit their budget, that was tailored to their needs, there is actually a higher likelihood that they will find something that they want at a price that they can afford — as to right now, which is I get a plan that I’m forced to buy that has a deductible that I can’t afford, but I’ve got a cute little plastic card that I can wave around,” Spicer said.

Schmid rejected the argument health care plans can’t be used now because premiums and deductibles are too high, noting for many people, such as those on Medicaid, it’s either this coverage or nothing at all.

“We agree that there are problems with high deductibles,” Schmid said. “That’s why we want to repair the Affordable Care Act, but taking away coverage from people is even worse. And he mixes up Medicaid. Medicaid doesn’t have premiums and deductibles and so that’s the biggest problem. They keep on saying it doesn’t work. You have deductibles. Well, that’s only the qualified health plans. Medicaid doesn’t have premiums, doesn’t have deductibles. They have minor co-pays and they’re limited by law, and they’re minimal.”

As part of an effort to derail repeal, Democrats, including Senate Minority Leader Chuck Schumer (D-N.Y.), have sought to vilify the proposal by calling it “Trumpcare” much like Republican opponents of Affordable Care Act dubbed the Democratic plan Obamacare — a nomenclature President Obama ultimately accepted as his own.

Spicer, however, sought to put some distance between Trump and the Republican proposal by rejecting the Trumpcare label for the American Health Care Act, saying the issue at hand isn’t labels, but health care reform.

“The Obama administration didn’t label it Obamacare, they called it the ACA,” Spicer said. “I mean, this is the American Health Care Act. The president is proud of it. The president is proud of the fact that we’re working with Congress. But this is a bill that is not his, it’s a joint effort that we’ve worked with the House and the Senate on. He’s proud of it. He’s proud of the impact that it’s going to have on American patients. So I don’t think this is about labels and names, this is about getting a job done.”

The office of U.S. House Speaker Paul Ryan (R-Wis.), who was the originator of the American Health Care Act before Trump endorsed it, didn’t respond to the Washington Blade’s request to comment on the impact the plan would have on LGBT people and people with HIV.

Gregory Angelo, president of the Log Cabin Republicans, said he’d withhold formal comment on the American Health Care Act, citing on ongoing review of the American Health Care Act on LGBT people and people with HIV.

“I will say that I continue to get messages from LCR members across the country whose premiums have skyrocketed or whose healthcare plans have been canceled as a result of Obamacare,” Angelo said. “Clearly there has to be a better way.”

Because of opposition on all sides, passage in the Republican-controlled Congress will be an uphill fight. Democrats, including the conservative Sen. Joe Manchin (D-W.Va.) seem locked in opposition to the American Health Care Act. On the other side of the aisle, the far-right House Freedom Caucus opposes the measure because it doesn’t go far enough, as do Sens. Tom Cotton (R-Ark.) and Rand Paul (R-Ky.), whose states have enacted some version of the Medicaid expansion.

Schmid said he doesn’t think the current version of the American Health Care Act would make it through Congress, saying Republicans are “running scared” over the prospects of the bill becoming law.

“I think what they’ll do is make some changes, but I don’t see how this is going to pass even in the House, let alone the Senate,” Schmid said. “It’s ripping coverage away from people with health care, and we can’t do that. What we say is people with HIV need consistent care, and you cannot risk taking away their medications or health care. Not even for a single day.”