"At this point, there's so much uncertainty. We're still talking about state waivers. It's not clear what the states are going to do as a consequence of that," said Dr. Robert Pearl, CEO of the Permanente Medical Group, a unit of Kaiser Permanente.
The AHCA also gives states the option of taking some high-cost enrollees with pre-existing conditions who may have to drop coverage, and creating a separate high-risk pool to cover them. The bill provides up to about $15 billion a year in funding for the high-risk pool through 2026.
Analysts at Avalere Health estimate that funding could cover about 600,000 people. Yet, in Texas alone, there are nearly 200,000 people with pre-existing chronic conditions who'd qualify.
"If any large states receive a waiver, many chronically ill individuals could be left without access to insurance," said Caroline Pearson, senior vice president at Avalere.
Kevin Counihan, who served as chief of HealthCare.gov under the Obama administration, said there's too much uncertainty in the way the opt-in program is outlined to know whether the funding is adequate.
"We just don't know how big the number of states are [that will opt in]. Two is fine. Fifteen — not close to enough," said Counihan.
Actuaries say the flexibility the bill gives states when it comes to using federal funds for creating high-risk pools could help bring overall premiums down for healthy people in the state market individual health-care policies.
"About one percent of the population incurs 30 percent of the costs," explained David Dillon, a fellow with the Society of Actuaries. "The premiums are going to come down. However, those 30 percent of the claims aren't going away. They have to be funded somehow."
At the individual level, there will be new winners and losers. The House bill would leave Obamacare credits tied to premium costs in place for next year. After that, individuals on the exchange would get tax credits ranging from $2,000 to $4,000 depending on their age; the credits get phased out for those earning over $75,000 a year.
For healthier younger people in rural states with lower health costs, the new credits could be more generous. For lower-income, older enrollees in higher cost states, the new credits could mean a big cut in premium assistance.