clock menu more-arrow no yes mobile

Filed under:

Instead of a CBO score, here are 6 maddeningly unanswered CBO questions

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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 next shoe to drop — to borrow a phrase from Sen. John McCain — in the health care debate is a Congressional Budget Office analysis of the revised Senate bill.

It was supposed to be released Monday, but that has now been delayed. We're not sure for how long. In the meantime, here are some questions to get your brain gears turning:

1. Why was the CBO score delayed in the first place?

By all accounts, the office is taking the opportunity to fully analyze the legislation, now that there isn't the rush forced by an upcoming vote.

2. Will the CBO have time to analyze the Cruz provision?

The biggest change in the revised bill is Sen. Ted Cruz's proposal to allow health insurers to sell plans that don't comply with Obamacare's rules as long as they sell some that do.

Based on my conversations with experts, it's a really hard policy to untangle. "It really is very difficult to say, because it’s going to be such a state-by-state deal," Society of Actuaries expert Dave Dillon told me when I asked about the impact of the provision.

McCain's health scare gives the CBO more time, but it's not at all clear it will be enough. HuffPost's Matt Fuller reported it could take a month.

3. If so, what will the CBO project the Cruz proposal would do to the insurance market?

If the CBO can analyze the Cruz proposal, its findings will be crucial. Republicans are selling it as a policy that keeps the protections for people with preexisting conditions, while also lowering premiums for healthier people. The best of both worlds, which could also lead to more people with insurance — if it's true.

But outside experts, including health insurers themselves, have warned that premiums could skyrocket in the Obamacare market, as sicker people buy that more robust coverage and healthier people migrate to the skimpier non-Obamacare plans. Then there is the question of whether that causes people to lose coverage.

What will the CBO think? The office thought the House bill's unwinding of insurance regulations would have a slight positive impact on coverage, but also price some sicker people out of insurance.

Its assessment of how the Cruz plan would affect the market is the biggest question mark for the time being.

4. If so, what will be the difference between the CBO and HHS evaluations of the Cruz amendment?

I'm told an office inside the Department of Health and Human Services was asked to evaluate the Cruz provision, perhaps as a substitute for the CBO's analysis. It's not clear yet if that will continue now that the CBO has more time.

If we get two competing analyses — and HHS's would almost assuredly be rosier — expect it to be the biggest volley yet in the Trump administration's war on the CBO. They will have to then depend on wavering senators not being spooked by a bad CBO score and instead taking the HHS estimate to heart.

5. How much extra money does McConnell still have?

McConnell needs to hold every remaining gettable vote, now that Susan Collins and Rand Paul have defected. He may need some more Kodiak Kickbacks to keep wavering senators on board.

He should still have a lot of money to spread around, but we won't know exactly how much until the new CBO score comes out. The Senate bill ultimately needs to save only as much money as the House bill did, a bit more than $100 billion over 10 years. The versions we've seen so far have saved a lot more than that.

A budget expert and friend of VoxCare estimated (very roughly) that McConnell could have as much as $150 billion at his disposal.

6. The basics: What about coverage losses, market stability, premiums, and Medicaid cuts?

The above stuff is very important, if very wonky, but these findings will drive the press coverage and draw a sharp picture of the real-world impact of the Senate bill.

Remember the headlines from the original CBO score of the Senate plan:

  • 22 million fewer Americans with health insurance in 2026, versus Obamacare
  • $772 billion spending cut to Medicaid over 10 years, versus current law
  • 15 million fewer people enrolled in Medicaid, versus current law
  • Lower insurance premiums in the long run, but higher out-of-pocket costs

The bill with those consequences didn't have the votes to pass. Once the CBO lays bare the results of this new plan, will Republicans stand by it or run for the hills?

Chart of the Day

Urban Institute

State-by-state increases in uninsured under the BCRA. To answer our last question above, the Urban Institute has its own estimate already: 24 million fewer Americans with health insurance in 2022 under the revised Senate bill, compared with Obamacare. Though they, too, have not yet had time to fully untangle the Cruz plan. Read more from the institute here.

Kliff’s Notes

With research help from Caitlin Davis

  • "White House Takes Pitch for Health-Care Bill to U.S. Governors": “The Trump administration took its case directly to U.S. governors that the pending Senate health-care bill won’t hurt their residents with insurance, even as critics say it will cut billions in funding and leave millions more people without coverage.” —Mark Niquette, Bloomberg
  • "John McCain’s Recovery May Take Longer Than Expected, Dimming Prospects for GOP Health Bill": “The latest twist in the poorly scripted movie that is the current U.S. political system: The future of a bill that could take health insurance from millions of Americans may be decided by how quickly one senator recovers from an unexpected health problem.” —Margaret Hartmann, New York magazine
  • "Dems on health care delay: Maybe have some hearings?": “Top Senate Democrats have a suggestion for Republicans on how to use the extra time on the Senate health care bill: Hold some hearings on it. 'We request that you use this additional time to hold public hearings so that Senators can invite impartial experts, including patients, to testify on the policies in the bill,' Minority Leader Chuck Schumer and Sens. Patty Murray and Ron Wyden wrote in a letter to Majority Leader Mitch McConnell this morning.” —David Nather, Axios
  • "Note to Heller: Don't take away my health care or you die": “A note taped to Sen. Dean Heller’s campaign office was from someone asserting that he would lose his health care if the key senator voted yes on the health care bill and that he would die if that happened and would take Heller with him, a law enforcement source said.” —Jon Ralston, Nevada Independent

Join the conversation

Are you an Obamacare enrollee interested in what happens next? Join our Facebook community for conversation and updates.

Sign up for the newsletter Sign up for Vox Recommends

Get curated picks of the best Vox journalism to read, watch, and listen to every week, from our editors.