The CBO is poised to tell Senate Republicans this week that their health plan will leave millions more uninsured than Obamacare — with the losses estimated from 15 million to 22 million over a decade, according to a half dozen budget analysts polled by POLITICO.
"What I can say with confidence is that the Senate bill will lead to very large coverage losses," predicted Matt Fiedler of the Brookings Institution, which had previewed the CBO score of the House bill in March but declined to do so for the Senate. "The only question is how large."
And that could complicate GOP leaders’ attempts to corral wavering moderates as they race to lock down votes ahead of a possible vote by week’s end to give President Donald Trump his first legislative victory.
Still-uncommitted moderates like Sens. Rob Portman (R-Ohio), Lisa Murkowski (R-Alaska) and Shelley Moore Capito (R-W.Va.), will face increasing pressure to oppose the bill. All hail from states that have expanded Medicaid, where hundreds of thousands of newly covered Americans may lose coverage.
Some senators have already staked out opposition to significant declines in coverage. "I cannot support a bill that’s going to result in tens of millions of people losing their health insurance," Sen. Susan Collins (R-Maine) said on Thursday.
Senate Republicans can only afford to lose two votes to pass their bill through the budget reconciliation process on a party-line vote.
The CBO score of the House bill — which was released 10 days before an initially planned floor vote and projected a coverage decline of 24 million people — was a factor in House Speaker Paul Ryan’s decision to cancel the vote in late March, as many moderates said they couldn’t vote for the legislation as written and needed more time to review it. Ryan Costello (R-Pa.), who voted for the bill in committee, was among the handful of House Republicans who ended up deciding to vote against the bill after the CBO score.
But nearly all House members ended up backing the final bill without waiting for an updated score. Several weeks later, the budget analysts found a coverage decline of 23 million over a decade for that plan.
The CBO score of the Senate bill, expected as early as Monday, is a near-certainty to project major declines in coverage because of the bill’s significant funding cuts to Medicaid, budget experts said.
Given the bill’s myriad waiver possibilities and the time crunch, some organizations said they aren’t bothering to run formal analyses this time.
“We gave up,” said one budget expert who has analyzed the Republican bill. “Too much uncertainty.”
By all accounts, there is no threshold uninsured number that would kill the bill. GOP senators are already attempting to inoculate themselves from political blowback by assailing the budget office’s reliability, which has been a running attack from the party since the health care process began.
"I have a lot of questions about the accuracy of the CBO," said Wyoming Sen. John Barrasso.
Republican budget experts have bemoaned those attacks. "Should Republicans take CBO seriously? Somewhat tongue-in-cheek, they have no choice," said Bill Hoagland, who was an early employee of the budget office and later worked for former Senate Majority Leader Bill Frist (R-Tenn.). "The rules and procedures under the Budget Act require that cost estimates be prepared by CBO."
Doug Holtz-Eakin, the former head of the CBO and the leader of the conservative American Action Forum, says he’s upset by some of the criticism but understands where it comes from, too.
"I believe it’s reasonable for people to disagree where CBO comes down sometimes," Holtz-Eakin said. "I don’t like it when people attack the integrity of CBO or somehow accuse them of tilting the playing field. But they’re just going to struggle with this. They are."
Some Republicans like Ryan have attacked the CBO’s projections but also touted numbers published by the office — when it suits them.
"The CBO does a great job, by and large, on how much something costs,” HHS Secretary Tom Price said on Sunday. “They do a relatively poor job on what the coverage consequences of a health plan are.”
Hoagland observed that Republicans "like the spending savings associated with the reduction in Medicaid, but they don’t like the number estimated to reduce coverage."
"You can’t have it both ways," he said.
While the Senate bill includes many similar provisions as the House bill, it also includes changes to Obamacare subsidies and other insurance market reforms that could make the decline slightly smaller.
Some Senate Republicans have spent years praising the CBO’s reliability and accuracy; Iowa Sen. Chuck Grassley has repeatedly said that CBO is "like God" in Washington.
"There are those who will want to discount a CBO score,” said Sen. Jerry Moran (R-Kan.). But "it’s what we have here, it’s what we utilize, and I think it’s an important discussion."
Several senators said they’re explicitly waiting for the CBO report to understand the broader implications of the bill. "There is a possibility when we see the CBO score that the Republican plan spends more than the Democrats have been spending," said Sen. Rand Paul (R-Ky.), who has been a critic of the GOP health care effort.
"My analysis is that [consumers’] out-of-pocket costs would increase under the Senate bill," Collins said. "That’s one of my major concerns, we’ll have to see what CBO says."
That kind of scope is one reason the CBO projections are so important, budget analysts say.
"I would be very, very worried for Republicans to dismiss the CBO estimates," Hoagland said. "It was established specifically for the purpose of what we’re going through — an objective analysis of [major] Congressional legislation."