Republicans are bracing for a report Wednesday expected to say their Obamacare repeal plan would leave millions of Americans without health insurance, further complicating their efforts to pass legislation quickly.
The CBO’s analysis of the bill comes three weeks after House Republicans rushed to vote on the legislation without an update on its cost, or its impact on the nation’s uninsured. The agency’s score will serve as the unofficial framework for Senate lawmakers negotiating their own version of repeal and will likely help those eager to make big changes. It’s also expected to become a rallying point for Democrats critical of an effort that could strip health care from millions.
The original House bill would have meant 24 million more Americans would be uninsured in a decade, with older Americans hit hardest by skyrocketing premiums. The new version may not fare much better.
“I would be shocked if we didn’t wind up with a CBO score that showed more than 20 million people lose insurance,” said Doug Holtz-Eakin, who served as CBO director during George W. Bush’s administration.
The labyrinth-like task of scoring the GOP’s extremely complex revised bill will also be a game of survival for the politically bruised agency.
The steadfastly nonpartisan office, disparaged by GOP officials trying to preemptively discredit brutal CBO forecasts, is now entangled in what many former CBO staffers describe as the toughest possible legislative analysis.
The bill gives states a menu of choices on health care; that gave CBO the formidable task of trying to game out the most likely scenarios and their rippling effect on cost and coverage in 50 separate states, each with its own health care ecosystem, for a decade to come.
If the updated score shows the House bill doesn’t match the precise savings targets required under Senate budget rules, the House will have to tinker more — and vote again. Speaker Paul Ryan has downplayed that scenario. But he can’t be certain it’s moot until the agency speaks.
CBO’s assessment of the first bill — that shocking 24 million more uninsured — complicated House Republicans’ sprint toward a vote. Moderates in particular got nervous, and the heated town halls focused public attention, especially on the weakened protection for those with pre-existing conditions. Lacking the votes, House leaders pulled that bill in late March, an embarrassing setback for their pledge to uproot Obamacare which they had made to voters for seven years.
The reworked version that passed in early May included a pair of amendments that increased the bill’s complexity — and maybe its price tag, too. And there’s little assurance it’ll make a dent in the CBO’s coverage projections, or throw a lifeline to Republicans navigating an even more difficult path in the Senate. They need to get 50 of 52 Senate Republicans to vote for it; the current list of potential defectors has a lot more than two names on it.
“The Republicans don’t have any options that will maintain the high level of insurance coverage under the ACA while moving in a sharply conservative direction,” said Douglas Elmendorf, who served as CBO director for six years during the Obama administration. “The point is that tens of millions of people will lose health insurance. There’s no chance that won’t be true.”
Senate leaders haven’t pounded the CBO’s credibility with the same intensity as some House and Trump administration officials. But they are emphasizing that the budget score will be just one of many factors that go into crafting their Affordable Care Act replacement. Republican talks so far are centering on bringing down premiums — not on keeping everyone covered.
“We need to listen to their advice and their counsel,” Sen. John Thune (R-S.D.) said of the CBO. “But I think they’re one of many that we’ll be paying attention to.”
Still, it’s likely shift the Senate’s already-tricky health care discussions into overdrive.
“It’s an incredibly important score,” said Sen. Bill Cassidy (R-La.) a critic of the House bill who is pushing his own, more centrist alternative for replacing Obamacare. “We put a lot of importance on the CBO score of the ACA. Now, it would be hypocritical of us not to put similar importance upon it now.”
Since the CBO first scored their repeal plan, House Republicans added at least $38 billion in federal spending. Perhaps more importantly, they included provisions allowing states to opt out of key Obamacare protections.
That forces CBO to do the most complicated type of government budget math — predicting the politically fraught decisions of all 50 states. The nonpartisan budget scorekeeper must decide not only which protections each state could decide to keep or scrap, but also what those choices will mean for cost and coverage.
And even the best budget scorekeepers will have to rely on some guesswork, according to multiple former CBO officials, and raises the prospect that the agency may not be able to come up with a one definitive score.
“It’s just too complex and too political,” Alice Rivlin, the founding director of CBO who is now a senior fellow at the Brookings Institution. “I just don’t see how they do this. It will cause complications but the idea that they could come up with a number seems to me, just a bridge too far.”
Most other experts to expect the CBO will make a call, even if it’s laden with caveats. The agency could bypass a state-by-state analysis in favor of a broader brush approach that estimates how groups of states with similar politics and economies might act on the waivers. Or it could pluck final numbers from the midpoint of two scenarios—the first assuming that most states opt in, and the second assuming most opt out.
“There are a lot of tough judgment calls here,” Holtz-Eakin said. “They’ll come up with a number. They’ll have to.”
Some CBO staffers are calling individual states “just to get an impression” of the political reaction there so far, said Bill Hoagland, a former agency staffer who is now vice president of the Bipartisan Policy Center.
The complexity means CBO’s projections will invariably be closer to rough estimates than pinpoint predictions– a reality that Republicans turned into an attack on the agency’s credibility after its initial score showed millions losing coverage.
“I don’t believe the facts are correct,” OMB Director Mick Mulvaney said in March, adding that the agency ran its own numbers separately from CBO. “I’m saying that based upon a track record of the CBO being wrong before, and we believe the CBO is wrong now.”
That strategy did little to dull the report’s impact. In the weeks afterward, coverage concerns convinced nearly every major health care group to oppose the bill.
Senate Republicans seem intent on a more circumspect approach, avoiding direct criticism of the CBO while pre-emptively dismissing both its analysis and its likely conclusions.
Their health care philosophy is focused on choice and affordability, GOP lawmakers argued, rather than requiring people purchase insurance. By design, that difference will result in fewer people overall having coverage — without accounting for the broader improvements that Republicans say they’re committed to delivering.
“They have to judge it based on what would happen if Obamacare were to continue for the next 10 years, and recall that Obamacare has failed so dramatically that it’s not sustainable for the next 10 years,” said John Barrasso (R-Wyo.), one of the Senate’s leading anti-Obamacare crusaders. “So you put some credibility into it, but not as if it were a real number.”