House Majority Whip Steve Scalise, accompanied by House Majority Leader Kevin McCarthy, reads a letter from a constituent concerning health care May 2. | AP Photo What's actually in the GOP health care bill Peek under the hood of the GOP text and there are many changes that will have broad but unpredictable consequences for the American health care system.

Covering people with pre-existing conditions has been the hottest issue in the Obamacare repeal debate on the Hill. But peek under the hood of the GOP text and there are a whole lot of other changes — including some surprises — that will have broad but unpredictable consequences for the American health care system and the patients and families that rely on it. Many of the provisions don't take effect for several years.

Here are several:


Imposes a mandate by another name — The legislation expunges Obamacare’s unpopular individual mandate requiring most Americans to have health insurance. But in its place, the bill allows insurers to charge people who have been uninsured for about two months a 30 percent surcharge on their premiums, an incentive designed to encourage people to maintain insurance coverage.

Gives tax breaks to the wealthy — The bill gifts wealthy Americans with massive tax cuts in the hundreds of billions of dollars. It scraps most of Obamacare’s taxes that are used to fund the law — including two taxes on high-income earners.

The bill eliminates in 2018 the ACA’s 3.8 percent investment tax on people earning more than $250,000. It also slashes a 0.9 percent surcharge on individuals in the same high-income bracket. The two taxes together raised roughly $27 billion in 2015. The Tax Policy Center estimates eliminating these taxes would save the top 0.1 percent of income earners about $195,000 each year. The bill also rolls back Obamacare’s tax on health insurers, medical device manufacturers, drug manufacturers and tanning bed salons.

Defunds Planned Parenthood for one year — The bill includes a provision long-sought by Republicans to cut off federal funding from Planned Parenthood and other abortion providers. The measure would block Medicaid reimbursements to those organizations for one year after enactment. The bill also includes a measure that would prohibit federal tax credits from being used to pay for insurance that covers abortion services.

Allows older Americans to be charged more — Under Obamacare, insurers can’t charge a 64-year-old more than three times as much as it does a 21-year-old. The GOP plan would let insurers charge older customer five times as much. And in states that waive that rule, insurers could establish an even higher ratio. Low-income older Americans in particular would also receive far less generous subsidies to purchase insurance compared to what’s available in Obamacare.

Allows sick Americans to be charged more — States could opt out of Obamacare’s required set of benefits or — most significantly — allow insurers again to charge some sick patients more for coverage, if they take steps such as setting up high-risk pools so that people with pre-existing conditions would have access to coverage. The latest amendment would provide an additional $8 billion over five years to help people in such states cover premium spikes but analysts say that is likely to be woefully inadequate. The wild card here is how many states would actually opt out.

Likely will mean benefit cuts for Medicaid recipients — or cause states to cough up more money — The law cuts federal funding for Medicaid by $880 billion, or 25 percent, over 10 years, and states could choose a “per-capita cap” or block grants under the most dramatic changes in Medicaid financing since its creation. Many of the groups that rely on Medicaid, which covers about 75 million low-income people from babies to nursing home patients, are likely to see benefit cuts as a result.

Could cut school services for disabled children — School superintendents, who rely on $4 billion a year in Medicaid money to hire staff and provide services to children with disabilities, say the bill’s cuts to Medicaid could hamper their ability to employ nurses, social workers, occupational therapists and psychologists and to offer services such as hearing and eye tests.

Could weaken employer sponsored insurance — A single state’s decision to weaken or eliminate its essential health benefit standards could weaken the ACA’s guarantee of protection against catastrophic costs for people with coverage through large employer plans in every state, according to some health policy experts. The ACA prevents employer plans from putting annual limits on the amount of care they will cover, and it bars lifetime limits on 10 essential benefits. But the Obama administration said that employers aren’t bound by the benefits mandated by their state and can pick from another state’s list of required benefits. Employers would be free under the House bill to choose the benefits available in a state that sought a waiver from the ACA’s benefit requirements.

Dan Diamond, Joanne Kenen and Jason Millman contributed to this report.