Republicans have a point that their Obamacare replacement plan is particularly hard for the Congressional Budget Office to score, budget experts say.
The bill, which Democrats are sharply criticizing for its lack of a CBO score, gives states much more leeway in how they would provide — or not provide — health insurance for people. And predicting how states will behave over the next decade is a time-consuming and tricky task for the agency.
The agency ultimately will release a score estimating how much the plan would cost and how many people it would cover, likely early next week. House Republicans refused to wait for it, instead plunging ahead Wednesday with committee markups on their bill to repeal some big parts of the Affordable Care Act, reshape its health insurance subsidies and change the way Medicaid is funded.
They have political reasons to move forward quickly, as the CBO score could open them up to even more criticism if it shows the measure is too expensive or would result in fewer people being covered.
But House Ways and Means Committee Chairman Kevin Brady also blamed the nature of the legislation itself for why there’s no CBO score yet when queried by conservative radio host Hugh Hewitt this week.
“The CBO is having trouble getting their heads around the states, not Washington, controlling healthcare,” Brady said. “So there’s a good reason they don’t have a score yet.”
Brady has a point, say former CBO directors and employees. To come up with a score, the agency must gather as much information as possible about how states might respond to the measure.
For example, some states might keep their Medicaid programs expanded — although with less federal funding — while others might pull back, resulting in fewer people with coverage. And there are all sorts of ways states could use the $100 billion the law provides for innovation. All of those decisions would affect how much the law costs and the extent of its coverage.
To reach their estimate, CBO staffers spend time talking to analysts at the state level to make their best guess about how states would act. That’s a hefty task, said Doug Holtz-Eakin, who headed the Congressional Budget Office under President George W. Bush.
“It takes time, you have to get some sense of what the range of likely outcomes would be and how fast it will happen,” Eakin said. “That is time consuming.”
Take the state innovation grants. There’s a smorgasbord of ways states could use the funding. For example, if they use it to set up a reinsurance program to help pad insurer losses, that would lead to lower premiums, which could lead to greater enrollment and more demand for federal tax credits.
“That’s a complicated, interconnected web of decisions,” Eakin said.
Democrats spent Wednesday’s committee markups demanding that Republicans postpone movement on the legislation until CBO releases a score.
“You should indicate why you are trying to pass legislation through the committees without hearing from CBO,” said Rep. Sander Levin, D-Mich., at a House Ways and Means Committee markup. “I think the answer may be you’re fearful the CBO might provide answers to questions you don’t like.”
Republicans responded by noting that Democrats marked up the Affordable Care Act in 2009 without CBO scores, although the agency had given some preliminary analyses.
Brady said there will be a “thoughtful, thorough, comprehensive” CBO score before the measure gets a House vote.
“We are going to allow CBO to have a thorough, deliberate analysis of this 50-plus page provision,” Brady said.
Often described as Congress’ official scorekeeper, the CBO is in charge of evaluating bills for how much they would cost and what their widespread effects would be. The agency typically gives estimates for a 10-year window, starting from a baseline assumption based on current law.
It’s a requirement that bills get a CBO score before they come to the House or Senate floor, but it is not mandated prior to committee votes. Bills are often moved in committee without a score, although Democrats argue that a bill of this impact and size should have a score first.
Republicans almost certainly have a good idea of what the bill’s score will be, as staff typically receive informal estimates from the agency while writing legislation. But there have been several iterations of the legislation, and changes were likely being made up until leadership announced the plan Monday evening.
“The problem is words probably didn’t stabilize until I would guess Monday afternoon,” said Joe Antos, who has served as assistant director for health and human resources at the CBO. “That’s the holdup.”
