Two of the biggest names in the health insurance policy, President Trump and Secretary of Health and Human Services Tom Price. Source: AP

The Congressional Budget Office’s analysis of the second major draft of the GOP’s Affordable Care Act repeal bill, the American Health Care Act, threw more gas on the fire in an already raging health care debate in Washington.

The medical community slammed it. A big group of medical associations led by the American Heart Association, said it “puts patients last.” In the Senate, the bill does not look promising, as Senate Majority Leader Mitch McConnell told Reuters: “I don’t know how we get to 50 at the moment.”

The key number: 23 million people who would have health insurance under current law would lose their coverage by 2026, an improvement over the last version by 1 million.

That improvement also comes at a remarkable cost: the savings to the deficit has gone down considerably from $337 billion in the first CBO review to $119 billion. That means that while the new bill is estimated to cover 1 million more people, it does so at the cost of $218,000 each.

Beyond these initial numbers that cast a shadow over its current form in the Senate, the CBO highlights one thing above others: significant uncertainty.

Under this new version, the CBO tried to estimate how many states will ask for waivers from the Department of Health and Human services, which has indicated its willingness to give them. (The more recent version of the AHCA allows states, in 2020, to apply for a waiver to change the 10 essential benefits required under Obamacare to be included in nearly all insurance plans.)

The CBO, which surveyed states, estimated that half of the population would be in states that would seek waivers to loosen the essential health benefits (EHBs) or allow insurers to charge substantially more for people with pre-existing conditions who had a lapse in coverage—around 6.3 million currently.

Maternity care, mental health and substance abuse care, rehabilitative services, and pediatric dental benefits would likely be the EHBs that get the axe in some states, the CBO noted.

“In particular, out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for the [people buying insurance on the individual market] who would use those services,” the CBO said.

These loosened restrictions, however, may not simply affect the 7% of the population that buys insurance on the open individual market and the 20% that gets it through Medicaid, including the expansion. Any changes to the system through the AHCA could affect everyone who gets their insurance through their employer, which represents 49% of the US population.

Here’s what can happen, according to the CBO: Larger employers that operate in multiple states can choose a specific state to base its plan’s EHBs. This means if an employer wanted to lower costs, it “could base all of the plans it offers on the EHB requirements in a state with the waiver,” the CBO wrote. “That decision could allow annual and lifetime limits on benefits not included in the state’s EHBs.”

The report noted that estimating outcomes in these situations is “especially uncertain” given the complexity of how states could implement market regulations with waivers. However, it forecasts that states’ actions wouldn’t “noticeably” affect benefit offerings for employee-based coverage—especially by smaller employers with small insurance pools.

With this uncertainty opening up for what insurance plans may or may not cover, should this portion of the bill make it into law, reading the fine print would assume even more importance for consumers as to what the health plans would pay for and how much they would pay.

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Ethan Wolff-Mann is a writer at Yahoo Finance focusing on consumer issues, tech, and personal finance. Follow him on Twitter @ewolffmann. Got a tip? Send it to tips@yahoo-inc.com.

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