With House Republicans prepared to take a vote Thursday on yet another version of a plan to overhaul the 2010 Affordable Care Act, attention has been especially focused on whether Obamacare’s popular prohibition against denying coverage based on preexisting medical conditions will remain in place. Republicans, from President Trump to lawmakers pushing for the bill, insist that it remains intact, just in different form. Democrats and opponents of the bill say the guarantee is gone or greatly weakened. 
 
 Here’s a tweet by House Speaker Paul D. Ryan (R-Wis.), referring to an amendment added to the bill to attract votes. 
 
 VERIFIED: MacArthur Amendment strengthens AHCA, protects people with pre-existing conditions. https://t.co/6W7bDEO40r — Paul Ryan (@SpeakerRyan) May 2, 2017 
 
 The reality is more nuanced and complicated, as is often the case in Washington policy debates. Despite Ryan’s tweet that people with preexisting conditions are protected, there is no guarantee that they will not face higher costs than under current law. The impact of recent tweaks to the proposed legislation is especially unclear because lawmakers are rushing ahead without an assessment by the nonpartisan Congressional Budget Office. So here’s The Fact Checker’s guide to the debate. 
 
 What’s the issue? 
 
 Before the Affordable Care Act, insurance companies could consider a person’s health status when determining premiums, sometimes making coverage unaffordable or even unavailable if a person was already sick with a problem that required expensive treatment. The ACA prohibited that, in part by requiring everyone to purchase insurance. 
 
 But that “individual mandate” was unpopular and Republicans would eliminate that requirement in their proposed American Health Care Act. As a replacement, the AHCA initially included a continuous coverage provision that boosted insurance rates by 30 percent for one year if he or she has a lapse in coverage. (We explored this interaction between the provisions earlier.) 
 
 As part of an effort to attract more votes, Republicans have added an amendment, crafted by Rep. Tom McArthur (R-N.J.), that instead allows states to seek individual waivers from the law. One possible waiver would replace the continuous coverage provision so that insurance companies for one year could consider a person’s health status when writing policies in the individual market. Another possible waiver would allow the state to replace a federal essential benefits package with a more narrowly tailored package of benefits, again limited to the individual and small-group markets. 
 
 The theory is that removing sicker people from the markets and allowing policies with skimpier options would result in lower overall premiums. 
 
 Who would be affected? 
 
 If the law passed, a person generally would not be affected unless they lived in a state that sought a waiver. Moreover, they would need to have a lapse in health coverage for longer than 63 days and they would need to have a preexisting condition. Finally, they would have to purchase insurance in the individual market – such as the health exchanges in Obamacare – that currently serves about 18 million Americans. 
 
 Someone who got their insurance from an employer – and that’s about half of Americans under 65 (155 million) – presumably would not be affected, though the CBO did project that under the initial version of the AHCA 7 million fewer people would be covered by employers than under current law by 2026. 
 
 Then, for a period of one year, a person who fell into this category would face insurance rates that could be based on their individual condition. But states that seek a waiver are required to operate a risk mitigation program or participate in what is called an invisible risk sharing program. Alaska currently has such a program that helps cover the bills for one of 33 conditions (such as HIV/AIDS or metastatic cancer). The individual with the condition still submits bills to the insurance company, which then turns around and bills the state. But then the insurance company does not consider the cost of this care as part of its calculation for premiums to other individuals in the state. 
 
 All told, the AHCA would allot $138 billion over 10 years for a variety of funds that would seek to keep premiums lower or to assist with cost-sharing. Just this week, $8 billion over five years was added to the pot to woo wavering lawmakers, with the idea that the additional funds could be used for so-called high-risk pools. Many states had such pools to help people with preexisting conditions before the ACA. But the proposal does not require a state with a waiver to set up such a pool. 
 
 What could go wrong then? 
 
 There are many uncertainties about this path. The health insurance market has a lot of churn, so many people may experience a gap in coverage of just a few months. One estimate, by the Commonwealth Fund, indicated that 30 million adults would have had such a gap in 2016, potentially exposing them to a surcharge or being placed in a high-risk pool. On top of that, the Kaiser Family Foundation estimated that 27 percent of the people in the individual market have existing conditions that would have been uninsured before the ACA. 
 
 The AHCA eliminates cost sharing and offers a stingier tax credit to defray premium costs, likely resulting in higher overall health costs that may make insurance unaffordable for many people. (The CBO projected that 24 million more people would be without health insurance than under current law by 2026.) 
 
 Then, if people get sick, they may suddenly find themselves for a year being priced on their illness if they live in a state that sought a waiver. Depending on the approach taken by a state, some people might find it difficult to keep up their coverage for a full year before they qualify for prices at the community rate. 
 
 A big question is whether the funding to cover these folks is adequate. High-risk pools were big money losers and underfunded in the pre-Obamacare days, even though many had restrictions, high premiums and waiting lists. A $5 billion federal pool, established by the ACA as a bridge to the creation of the exchanges in 2013, covered about 100,000 people but was suspended when it ran out of money. 
 
 The Center for American Progress, a left-leaning group that opposes the AHCA, produced an analysis that indicated that even with the additional $8 billion, the maximum enrollment the AHCA’s funds would cover is about 700,000 people. If just 5 percent of the people currently in the individual market ended up in high-risk pools – and all states sought a waiver – that would overwhelm the proposed funding. 
 
 Avalere Health, a consulting firm, said in an analysis that $23 billion is specifically allocated in the bill for helping people with pre-existing conditions. That would cover about 110,000 people. If states allocated all of the other available funding, that would cover 600,00 people. “Approximately 2.2 million enrollees in the individual market today have some form of pre-existing chronic condition,” the analysis said. 
 
 When states had high-risk pools, people in those pools represented just 2 percent of the non-group health insurance participants. But given the limitations of those funds, that percentage may not be a good guide for what would happen under the AHCA. 
 
 Whenever health-care laws are changed, there are unknown and unintended consequences. The current system does not take into account a person’s health status when assessing premiums. But, as a Brookings Institution analysis suggested, under the AHCA’s provisions, healthy people might have an incentive to join plans based on health status. That would leave sicker people in the community rated plans, which in turn would face higher premiums. Over time, that could make the community rating meaningless. (Update: The CBO in its revised report on the AHCA said this was quite possible for states representing about one-sixth of the U.S. population. We explored that in detail in this article.) 
 
 Another possible outcome: If the pool of money is used to pay insurance companies for the difference in costs for patients with preexisting conditions, there may be little incentive for companies to keep their prices low; the difference would be made up by U.S. taxpayers. 
 
 The Bottom Line 
 
 When it comes to health care, readers should be wary about claims that important changes in health-care coverage are without consequences and that people are “protected” – or that the changes will result in massive dislocation and turmoil. There are always winners and losers in a bill of this size. In this case, if the bill ever became law, much would depend on unknown policy decisions by individual states – and then how those decisions are implemented. 
 
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 Sign up for The Fact Checker weekly newsletter ||||| WASHINGTON—The House of Representatives moved closer Thursday to vote on a bill to replace most of the Affordable Care Act, a first step toward fulfilling a promise that Republican leaders have made to voters for more than seven years. 
 
 The bill easily passed a procedural vote on Thursday morning, its first test of whether the GOP leadership has enough votes to deliver the first major legislative win to President Donald Trump. Only one Republican defected. House leaders are expected to hold a vote on final passage in the early... ||||| This is the web version of VoxCare, a daily newsletter from Vox on the latest twists and turns in America’s health care debate. Like what you’re reading? Sign up to get VoxCare in your inbox here. 
 
 The House of Representatives will vote on the American Health Care Act, the bill to repeal and replace Obamacare, on Thursday in the early afternoon. House Republicans are hurtling toward a vote on a bill that is disliked by most Americans, opposed by nearly every major health care group, and not yet scored by the Congressional Budget Office. 
 
 This is an unusual situation, and a puzzling one. Republicans will vote tomorrow for a health care bill without knowing how many people it covers or how much it would cost. They risk setting themselves up for embarrassment when the numbers actually do come out and don't look good. 
 
 As leadership scrambles to whip the votes for the American Health Care Act, it's worth stepping back to ask: What the heck is the rush? 
 
 The best explanation I've found comes from my colleague Andrew Prokop. When Republicans started this year, they had a strategy to move two big policy packages, one on health care and another on tax reform. There would only be two chances to use the budget reconciliation process that allows a bill to pass with only 51 Senate votes (for complex procedural reasons explained here), so each would get one shot. 
 
 Health reform would go first, they thought, because it would be simpler. It was a legislative strategy built when the Republican health care plan looked markedly different: 
 
 They thought it would be legislatively easier to write an Obamacare repeal bill than tax reform, because they intended to put off the hard work of creating an actual replacement for Obamacare until later. This was the “repeal and delay” strategy — pass a quick repeal, set it to go into effect in a few years, and write the replacement in the meantime. But then GOP leaders encountered a problem. Their members, in both the House and the Senate, turned out to really hate the “repeal and delay” strategy, because it meant getting rid of Obamacare and its benefits without the “replacement” the party had long promised they’d offer being ready. 
 
 Republicans want to move quickly on health care so they can fit in tax reform too, another immense and complex policy lift. 
 
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 Adding to that pressure, it's also the case that this current frenzy began as Trump was nearing his 100th day as president and pressuring Congress to schedule a vote. Although the 100-day mark has come and gone, some of that residual momentum seems to have hung around. 
 
 This all explains why, in general, there is a desire to move relatively quickly. 
 
 The part that Republicans haven't explained: Why move so quickly that they don't get a score from the Congressional Budget Office? 
 
 A legislator deciding whether or not to support the American Health Care Act would likely wonder what the bill actually does. This is the role CBO has traditionally played, providing nonpartisan estimates of who would gain coverage, who would lose it, and how much the whole thing would cost. 
 
 The whole point of CBO scoring is to figure this out before you decide whether a piece of legislation is good or bad. This also gives legislators some space to make changes to parts of a bill that don't seem to work. CBO scores are meant to be a tool for legislators, a way to game out the consequences — both politically and policy-wise — of moving laws forward. 
 
 It's notable that we haven't heard one member of Congress say, "I like the idea of this bill, but I'll wait until we see the CBO score to make up my mind." 
 
 But so far, the CBO score has been treated as unnecessary — certainly nice to have, but not a prerequisite for holding a floor vote. Here's how Rep. Fred Upton (R-MI) put it earlier today to a reporter: 
 
 Upton said he'd like to see a CBO score, like most members say, but apparently it's not a condition for him voting for the bill, which, ah. — Matt Fuller (@MEPFuller) May 3, 2017 
 
 There are very few people telling Republican legislators at this point that the American Health Care Act is a good bill. Basically every health care interest group you can think of – hospitals, doctors, insurers, patients — don't support it. The most recent polling data finds most voters don't like it either. There is not a CBO score that suggests this bill achieves House Republicans' objectives. 
 
 At this point, Republicans seem more concerned with moving something out of their chamber than they do with what that something is. That is a risky and potentially embarrassing move. The CBO score will come out sooner or later, and Republicans might be faced with defending a bill they don't like much at all. 
 
 Meanwhile, in Iowa: insurer threatens to leave 94 of 99 counties with no Obamacare insurer 
 
 The health insurance plan Medica announced Wednesday that it was considering pulling out of Iowa's insurance marketplace. It is the only insurer signed up to sell coverage in all the dark pink areas of the map below, from Margot Sanger-Katz at the New York Times: 
 
 In a statement, Medica said the uncertainty in Washington makes it difficult to commit to sticking with the marketplaces in 2018: 
 
 Without swift action by the state or Congress to provide stability to Iowa’s individual insurance market, Medica will not be able to serve the citizens of Iowa in the manner and breadth that we do today. We are examining the potential of limited offerings, but our ability to stay in the Iowa insurance market in any capacity is in question at this point. 
 
 It's hard to know how much of a bellwether Medica is for the rest of the Obamacare marketplaces. On the one hand, all insurers are frustrated that Congress likely won't be appropriating funding for the cost-sharing reduction subsidies. 
 
 On the other hand, Iowa seems to be a bit of an exceptional situation. There is one patient in the marketplace who reportedly has $1 million in monthly claims (you can read more about the situation here). This has made the entire state an undesirable market for health plans, which know that if they're the last man standing, they will end up with that extremely high-cost patient. 
 
 Kliff’s Notes 
 
 Your daily top health care reads, with research help from Caitlin Davis 
 
 Today's top news 
 
 "Key Republicans Long, Upton say they now support Obamacare repeal with more money for pre-existing conditions" : “Two key Republican lawmakers say that they will support a bill to repeal and replace Obamacare after changes were proposed to provide additional funds for people with pre-existing conditions. Republican Reps. Fred Upton of Michigan and Billy Long of Missouri announced their decision to reporters outside the White House Wednesday after meeting with President Trump about the legislation.” —Kimberly Leonard, Washington Examiner 
 
 “Two key Republican lawmakers say that they will support a bill to repeal and replace Obamacare after changes were proposed to provide additional funds for people with pre-existing conditions. Republican Reps. Fred Upton of Michigan and Billy Long of Missouri announced their decision to reporters outside the White House Wednesday after meeting with President Trump about the legislation.” —Kimberly Leonard, Washington Examiner "No good GOP options if Obamacare repeal fails" : “If their latest Obamacare repeal efforts fail, Republicans really only have a few options. And each means political peril for President Donald Trump and Republican congressional leaders. House members made progress Wednesday on the repeal and replacement bill — but there are still many hurdles, including overcoming some of the same challenges in bringing together conservatives and moderates if the bill reaches the Senate.” —Adam Cancryn and Paul Demko, Politico 
 
 “If their latest Obamacare repeal efforts fail, Republicans really only have a few options. And each means political peril for President Donald Trump and Republican congressional leaders. House members made progress Wednesday on the repeal and replacement bill — but there are still many hurdles, including overcoming some of the same challenges in bringing together conservatives and moderates if the bill reaches the Senate.” —Adam Cancryn and Paul Demko, Politico "Insurer Aetna Posts Loss, Evaluates Obamacare Exposure": “Aetna Inc reported a quarterly net loss on Tuesday related to costs from its failed acquisition of Humana Inc and said it will cut exposure to money-losing Obamacare coverage in 2018. Like other U.S.-based health insurers including Anthem Inc and Molina Healthcare Corp, Aetna faces deadlines to file 2018 plans but is uncertain about components of premium rates such as the continuation of government subsidies and the mandate for Americans to have insurance.” —Reuters 
 
 Analysis and longer reads 
 
 "Why Democrats secretly want an Obamacare repeal vote" : “Democrats don’t actually want the law repealed. Under their dream scenario, House GOP leaders would muscle through their controversial health care bill only to watch it die a long, painful death in the Senate, where it has already received a lukewarm reception from Republicans. Obamacare would stay intact while the House Republicans who voted to gut the law have a big shiny target on their back heading into the 2018 midterms.” —Heather Caygle, Politico 
 
 “Democrats don’t actually want the law repealed. Under their dream scenario, House GOP leaders would muscle through their controversial health care bill only to watch it die a long, painful death in the Senate, where it has already received a lukewarm reception from Republicans. Obamacare would stay intact while the House Republicans who voted to gut the law have a big shiny target on their back heading into the 2018 midterms.” —Heather Caygle, Politico "Personal Tragedy Drives Deal-Making GOP Congressman on Health Care": “Since the Republicans' failed attempt to repeal and replace the Affordable Care Act, [Rep. Tom] MacArthur has nearly single-handedly breathed new life into an effort that could culminate in a vote on the GOP measure this week. But while the fight over health care has played out as political high drama in the halls of power in Washington, for MacArthur it's also a personal battle stemming from the loss of his 11-year-old daughter nearly two decades ago.” —Leigh Ann Caldwell, NBC 
 
 "As patients take hospital bill issues public, hospitals take stock of their practices": “Recently, four hospital systems in Colorado — Centura Health, Health One, SCL Health and UCHealth — found themselves on the defensive after 9News, based in Kusa, ran a piece that was critical of their billing practices. The news station had invited viewers to email copies of their medical bills to give reporters an idea of what consumers were dealing with when it came to their bills. The station then invited the four health systems to their newsroom to answer on-air questions based on patients' complaints.” —Jeff Lagasse, Healthcare Finance ||||| House Republicans are once again fast-tracking consideration of their ObamaCare replacement bill without knowing the full impact of the legislation they’ll vote on Thursday. 
 
 The nonpartisan Congressional Budget Office (CBO) is not expected to have completed its analysis detailing the effects of the latest changes to the legislation overhauling the nation’s healthcare system in time for the Thursday vote. 
 
 Leadership’s decision to press ahead with the floor action means lawmakers will be voting on the bill without updated figures from their nonpartisan scorekeeper on how many people would lose coverage under the bill or how much it would cost. 
 
 Some lawmakers acknowledged that it would be helpful to have an analysis, known as a “score,” from the CBO, but said they could not wait for it. 
 
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 When asked why the vote would not wait for the score, Rep. Fred Upton (R-Mich.) — the lead sponsor of a new amendment to the bill that might push it over the finish line — said, “Because I don’t expect it probably for a couple weeks.” 
 
 “I wish that we had it, all right?” Upton added. “I wish that we had had it in committee. I said so at the time.” 
 
 The lack of a score comes despite years of GOP attacks on Democrats for what Republicans argued was a rushed process that rammed through the Affordable Care Act in 2010. 
 
 The latest bill text was posted Wednesday, just one night before the vote. 
 
 Upton’s amendment adds $8 billion over five years aimed at helping people with pre-existing conditions afford their premiums in states that choose to repeal ObamaCare protections preventing sick people from being charged exorbitantly high premiums. 
 
 Many health policy experts doubt that $8 billion is enough money. And Upton himself said Wednesday that he doesn’t know for sure that it will be. 
 
 “Is it enough money? I don’t know,” Upton said. “That’s the question that I asked and was led to believe that $5 billion would be enough, which is why it’s $8 billion.” 
 
 He noted that “at some point, this will be scored by CBO,” and said that if the analysis finds there is not enough money, more could be added by the Senate or at another point. 
 
 The CBO also has not provided an analysis of the amendment authored by centrist Rep. Tom MacArthur (R-N.J.) and Freedom Caucus Chairman Mark Meadows (R-N.C.) that lets states apply for waivers from ObamaCare provisions preventing insurers from charging sick people higher premiums and mandating minimum insurance coverage requirements so long as high-risk pools are offered. 
 
 When asked if there are concerns the process is being rushed without a CBO score and limited time to review late-breaking changes, Meadows said Republicans have waited long enough to fulfill a nearly decadelong campaign promise. 
 
 “We’ve been talking about repealing and replacing ObamaCare for seven years. That’s the first time that I’ve had anybody say that we rushed anything,” Meadows said. 
 
 At the same time, he conceded, “It’s a valid point.” 
 
 The CBO score of the underlying bill gave many moderates pause when it found that 24 million more people would become uninsured under the measure over 10 years. 
 
 Rep. Andy Harris (R-Md.) downplayed the notion that lawmakers didn’t have enough time to review the legislative text of the original bill or amendments authored by GOP Reps. Gary Palmer (Ala.), MacArthur and Upton. 
 
 “The bill has been out there for a while. I mean, the MacArthur amendment’s pretty short if you want to read it. The Palmer amendment’s pretty short. I assume this amendment that may be added before the final vote with the $8 billion will be short,” Harris, another Freedom Caucus member, said. 
 
 “Look, the bottom line is we’re going to deliver to the American public what we said, that premiums are actually going to go down,” he continued. 
 
 The Palmer amendment is four pages long, MacArthur’s is eight pages, and Upton’s is three pages. The original underlying bill was unveiled in March. 
 
 The lack of a CBO score isn’t the only sign of a markedly rushed process. 
 
 House GOP leaders gave themselves flexibility earlier this week to speed up consideration of the bill if they decided to bring it up for a vote. 
 
 The House voted along party lines in a Tuesday procedural vote to waive a rule requiring lawmakers to wait a day before considering a measure out of the Rules Committee, which determines how legislation is considered on the floor. 
 
 The move, known as “martial law,” is typically reserved for tight deadlines like avoiding an imminent government shutdown. 
 
 It’s highly unusual for leaders to invoke the procedure while trying to move legislation that doesn’t face a pressing need for passage, especially for something as far-reaching as healthcare reform. 
 
 If the rushed process sounds familiar, that’s because GOP leaders used the same tactics when they tried to bring the bill up for a vote in March. 
 
 As with this week, House Republicans voted to invoke martial law to speed up the floor vote. And GOP leaders also posted an amendment that would have repealed ObamaCare’s minimum insurance coverage requirements the night before they planned to vote on it. 
 
 GOP leaders ultimately canceled a vote when it became clear the legislation didn’t have the support to pass. 
 
 Thursday’s planned vote comes after years of Republicans mocking House Minority Leader Nancy Pelosi (D-Calif.), who was the Speaker when ObamaCare passed, for saying, “We have to pass the [healthcare] bill so that you can find out what’s in it.” 
 
 Now, on the eve of the vote on the GOP plan, Pelosi is charging that Republicans are deliberately trying to conceal the impact of their proposal. 
 
 “Forcing a vote without a CBO score shows that Republicans are terrified of the public learning the full consequences of their plan to push Americans with pre-existing conditions into the cold,” Pelosi said. 
 
 “But tomorrow, House Republicans are going to tattoo this moral monstrosity to their foreheads, and the American people will hold them accountable.”
– House Republicans promise to call a vote on their plan to replace ObamaCare on Thursday, but the Hill notes that lawmakers will cast those votes without an official estimate of how much the plan costs or how it will affect coverage for Americans. That is, the Congressional Budget Office hasn't had time to assess the American Health Care Act and score it. "I wish that we had it, all right?" said Rep. Fred Upton, a key figure who switched from no to yes when the White House agreed to add $8 billion for pre-existing conditions. But Upton said any such CBO estimate is probably weeks away, adding that the measure could be changed, perhaps by the Senate, at that point. At Vox, Sarah Kliff writes that the rush to vote is a risky move for the GOP. "The CBO score will come out sooner or later, and Republicans might be faced with defending a bill they don't like much at all." The sticking point over pre-existing conditions had threatened to derail the measure, and critics say the $8 billion amendment still won't do enough to ensure that people with pre-existing conditions will be adequately covered. An analysis by the Fact Checker blog at the Washington Post says the issue is so nuanced that the simplistic talking points coming from both sides on the issue are useless. "If the bill ever became law, much would depend on unknown policy decisions by individual states—and then how those decisions are implemented." Meanwhile, the Wall Street Journal reports that even if the vote is successful, it would "face uncertain prospects" in the Senate. Among other things, the House bill would reduce funding for Medicaid, which provides coverage for low-income and disabled Americans.