The New Republic

House Budget Chairman Paul Ryan has published his proposal for downsizing the federal government. In the hours and days to come, you're going to hear a lot of different numbers from his proposal. But let me draw your attention to a figure that's not in there: 32 million. Based on the available information, that's roughly the number of people likely to lose health insurance, relative to current law, if the budget were to become reality.

The spending blueprint calls explicitly for repealing the Affordable Care Act. That means taking insurance away from all of the people who are supposed to get coverage in 2014, when the Act is fully implemented. And Ryan's budget document proposes no alternative mechanism for significantly expanding coverage or making insurance itself more secure.

Back in January, the Congressional Budget Office analyzed what such a change would mean when it produced an estimate of repeal for Speaker John Boehner:

...about 32 million fewer nonelderly people would have health insurance in 2019, leaving a total of about 54 million nonelderly people uninsured. The share of legal nonelderly residents with insurance coverage in 2019 would be about 83 percent, compared with a projected share of 94 percent under current law (and 83 percent currently).

Several experts I consulted confirmed that it was reasonable to assume repeal will have approximately the same effect in Ryan's plan. Quips David Cutler, the Harvard economist and co-architect of President Obama's campaign plan, "It's like Survivor: Health Care."

All of this may sound like old news, since Republicans proposed repealing the Affordable Care Act a long time ago. But repeal is an essential component of Ryan's plan. It's supposed to reduce spending by $1.4 trillion over ten years, providing about a quarter of the total savings Ryan claims to generate.

I have asked Ryan's office for a comment. They have not yet responded. If and when they do, I assume they will say what conservatives usually say in these kinds of conversations: That this blueprint reduces the cost of health care overall, making insurance more affordable for some people.

But even with fairly heroic assumptions about the impact of the changes Republicans have in mind, you'd have to weigh that effect against the loss of subsidies, improved benefits, and consumer protections that come with the Affordable Care Act. 

Here is an assessment from Jonathan Gruber, the MIT economist who advised Democrats on the Affordable Care Act and advised Republican Governor Mitt Romney on his state's health care reforms:

Repealing the ACA would not only mean leaving 32 million more Americans uninsured, ensuring thousands of additional deaths each year. It would also remove the critical gains in economic and health security for the rest of Americans who are subject to losing their employer-provided health insurance. These individuals now face a harsh and unpredictable non-group market where they are one gene or one bad accident away from being uninsurable. Given the steady erosion of employer-sponsored insurance in the U.S. it is unconscionable to expose individuals to this source of risk and stress.

And that's not to mention the massive changes to Medicare and Medicaid Republicans are proposing. As noted previously, those changes will shift more costs onto seniors and likely result in less coverage for the poor. Writes Edwin Park, of the Center on Budget and Policy Priorities, "the Ryan plan’s Medicaid changes would profoundly impair health care coverage for seniors, people with disabilities, and people with low incomes." In fact, it's entirely possible that the end result of the Ryan plan would be that proportionally fewer people have health insurance, relative not only to what's supposed to happen in 2014 but also relative to the situation this very day.

Fiscal results aren't the only way to measure a budget. The human toll matters too. Here's hoping that the debate over Ryan's proposal reflects that.

Note: The CBO is publishing an assessment of Ryan's plan this afternoon. If that assessment includes projections of health insurance coverage as well as cost, I will update this item.

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