The most consequential revision Republicans made was to allow states to obtain a waiver exempting them from federal requirements that insurers cover a range of essential health benefits and a prohibition on charging higher premiums to people with preexisting conditions. The CBO’s task was to project how many states might take advantage of that flexibility, and what it would mean for insurance coverage and costs. The budget office estimated that about half the population lives in states—controlled by Democrats, presumably—that would not seek a waiver and adhere to the Obamacare regulations. In those states, average premiums would fall by a modest 4 percent. About one-third of the population lives in states, the CBO projected, that would opt out of some but not all of the requirements, and average premiums would fall by about 20 percent, with sharper drops for younger people and less change for older.

The biggest changes, however, would occur for the remaining Americans in states that obtained the maximum exemptions from the federal insurance standards. While the average premiums would go down overall, they would vary significantly based on health status and the types of benefits they provided. “Less healthy people would face extremely high premiums, despite the additional funding that would be available under H.R. 1628 to help reduce premiums,” the CBO wrote. “Over time, it would become more difficult for less healthy people (including people with preexisting medical conditions) in those states to purchase insurance because their premiums would continue to increase rapidly.” In those same states, the individual health insurance market would become unstable beginning in 2020, in part because people with higher medical costs would be unable to afford comprehensive insurance plans.

Democrats found validation in the findings, which backed up their warnings that the GOP bill would benefit younger, higher-income people at the expense of older and sicker Americans. “If you are sick, if you have ever been sick, you are at risk of losing your health care,” Senator Chris Murphy of Connecticut told reporters. “That’s plainly what CBO says.”

The fresh projection did bring relief to Republicans in one respect: The CBO found that the House-passed bill likely complied with budget reconciliation rules that it decrease the deficit after the first decade of enactment. The AHCA would cut the budget gap by $119 billion over a decade, according to the report.

At its heart, the Republican bill is a sharp reduction in the scope of the federal government’s role in health care. It cuts taxes on the wealthy that Democrats increased to pay for expanded coverage and benefits under Obamacare. And it reduces federal spending by about $1 trillion. An $834 billion cut to Medicaid and another $276 billion in lower subsidies accounts for the lower spending, overcoming the loss of $664 billion in revenue through tax cuts and another $210 billion in penalties from the repealed insurance mandate.