Rushing a major piece of legislation that involves a complicated set of interconnected working parts onto the floor of the House of Representatives without a proper score and analysis from the Congressional Budget Office is worse than a crime — it’s a mistake.
Democrats, when writing their own complicated health care law eight years ago, arguably ended up getting too hung up on the details of CBO scoring. Decisions about when to phase in certain provisions, in particular, were at times excessively driven by the 10-year scoring window. Delaying the rollout of benefits by a year, for example, didn’t really save any money in the long run — but pushing some spending into year 11 changed the headline number that came out of the score.
This, in turn, spawned a worldview on Capitol Hill — among both backbench members and many reporters — that the CBO process is a kind of obstacle course whose main purpose is to give the opposition ammunition to hit you with.
BREAKING: Politicians like the CBO when it says things they like and think it's stupid when it doesn't— Benjy Sarlin (@BenjySarlin) March 8, 2017
But the procedural gamesmanship is far and away the least important aspect of the CBO’s role in the legislative process. It exists, fundamentally, for the same reason that Congress has an IT department and a janitorial staff: to help members get their work done.
A reasonable person trying to decide whether to vote for a piece of health care legislation would want to know what the bill actually does. She’d want to know how it affects her constituents and American politics broadly. She’d also want a sense of whether relatively small modifications to the legislation could generate large changes to the real-world outcomes. She’d find that her in-house staff simply lacks the resources to generate credible models about this.
And she’d be glad to learn that Congress has its very own in-house think tank full of smart people and smart models to help her think it through.
Deciding the CBO is wrong is one thing; ignoring it is another
Predictions are hard, especially about the future, and the CBO has certainly gotten some things wrong over the years. There’s nothing wrong with political leaders making a calculated decision that they think the CBO’s team of experts is wrong and some other experts have it right.
The architects of the Affordable Care Act, for example, included in the legislation a number of reforms to America’s health care payment and delivery system. The goal was to restrain the growth of national health care spending. The CBO took a dim view of this idea, and decided that the only cost control measures it would score were cruder efforts to reduce the quantity of health care consumed by encouraging higher-deductible plans. Legislators ultimately ended up including both kinds of reforms — enough of the latter to get a score they were happy with, but also a lot of delivery system reforms they believed in on the merits.
As it turns out, the legislation’s drafters were correct, and the cost curve bent significantly more than the CBO believed it would.
But this isn’t what Republicans are doing. They aren’t saying that the CBO score of the legislation is wrong and they have some other model demonstrating the real impact on coverage, the federal budget, household income, and other matters. Nor are they saying that the CBO score is irrelevant because they are so confident in some other model. Indeed, the current CBO director was handpicked by Paul Ryan and Health and Human Services Secretary Tom Price, who, until recently, headed the House Budget Committee.
Republicans don’t have any specific problem with the CBO’s methods or a specific alternative they want to use. They’re just saying they don’t want to know.
The problem is the bill might pass
The purpose of rushing the votes, it seems, is to ensure that bad news from the CBO doesn’t slow down the repeal-and-replace train.
But that’s exactly what makes it such a crazy idea. An analysis from Standard & Poor’s predicts that AHCA will cost 6 million to 10 million people their health insurance. Credible experts have told me the real number might be as high as 15 million. Other experts tell Sarah Kliff the AHCA scheme will create death spirals and collapse entire states’ individual insurance markets.
Six million people is a lot of people, but 15 million people is way more. Republican leaders seem to be vaguely asserting that both figures are too high. The screams of opposition from America’s organized lobbies for doctors, hospitals, and other health care providers ought to provide a clue. People with a direct interest in knowing whether this law is going to make it harder for Americans to pay for health care services seem to think that it will. But the providers’ lobbies haven’t had time to do a really rigorous model either.
A reasonably prudent backbencher would want to have some sense of who is correct about this before committing the country to a course of action for which he is going to be held accountable on Election Day.