The Health 202: The CBO is caught in a health-care tug of war


Senate Minority Leader Charles E. Schumer (D-N.Y.) spoke to journalists about the GOP health-care bill. (Melina Mara/The Washington Post)

The Congressional Budget Office — a six-story, gray stone building a few blocks from the U.S. Capitol where analysts crunch numbers — isn’t exactly a government agency that’s top of Americans’ minds. Yet the CBO’s work has become central in the debate over repealing and replacing Obamacare as both Democrats and Republicans seek for its projections to support their own health-care narrative.

Republicans want to be able to tell the public a positive story about their health-care bill and how it would reshape the Affordable Care Act. Democrats want to further their negative narrative that the Better Care Reconciliation Act would cause fewer Americans to have coverage. But they can’t just pull the numbers out of thin air. It’s up to the CBO to estimate how many people would be covered under the Senate bill, how it would affect insurance costs and how much it would cost altogether.

Yesterday, the CBO released a new, longer-term analysis of the Senate health-care bill at the prodding of the Finance Committee’s senior Democrat from Oregon, Ron Wyden. It hammers home the point that the measure would cause sweeping cuts to Medicaid, even beyond the next decade. Twenty years from now, the GOP measure would lower federal Medicaid spending by a whopping 35 percent, the agency said.

The extra analysis punctuates an initial score from the CBO, which had originally looked forward only a decade. It found that federal Medicaid spending would dip by 26 percent in 2026, resulting in $772 billion less funding for states to run the program and 15 million fewer Americans covered by it. Democrats had already been criticizing those figures. But Wyden requested the longer-term outlook so he’d have an even more dramatic figure to use for bludgeoning Republicans. He was basically training a spotlight on what some Republicans have sought to bury, my colleague Amy Goldstein reports.

“Eliciting a longer view from the budget office was part of a strategy by the Senate’s minority party to ratchet up pressure on moderate Republicans,” Amy writes. “The Democrats drew new attention to parts of the health-care bill that already have made many of their GOP counterparts uncomfortable.”

Wyden sought to spread the new analysis far and wide yesterday:

He accused Republicans of trying to hide the long-term effects of the Medicaid spending reductions:

Wyden called it a “heartless scheme,” per The Post’s Greg Sargent:

From top Senate Democrat Charles E. Schumer (D-N.Y.):

And Maryland Democrat Sen. Chris Van Hollen:

Of course, if you’re a conservative who is worried about how entitlement programs like Medicaid are consuming the government’s resources, the projection of deeper cuts is a good thing, the Washington Examiner’s Phil Klein noted:

–Yet some Republicans have their own beef with the CBO and how it scored the Senate health-care bill. The agency assumed a cheerier but outdated outlook of the current situation under the Affordable Care Act when it estimated how the Senate bill would reduce insurance coverage. Sen. Ron Johnson (R-Wis.) has been arguing that if the CBO had compared the Senate bill to the more recent, and more pessimistic, estimation of coverage under the ACA, the Senate bill would look a bit better, appearing to reduce the insured rate by a smaller margin.


Watch Johnson’s remarks on MSNBC’s “Morning Joe”:

“If we use up-to-date CBO baselines on the individual group market…it’s 19 million,” Johnson told MSNBC’s “Morning Joe” on Wednesday. “That from my standpoint is big news…the distortion of the original CBO report is just wrong because it’s comparing against a very old baseline.”

The CBO has said the Senate bill would cause 22 million fewer people to be uninsured by 2026. But to make that projection, it used an old assumption from March 2016 that 18 million people would buy on the marketplaces and 25 million would buy nongroup plans off the marketplaces in that year. 

The CBO has since downgraded those estimates, after the marketplaces suffered a challenging year amid premium spikes and insurer exits in some areas. In January this year, the agency said only 13 million people would buy on the marketplaces and 20 million would buy non-group plans off them in 2026. Johnson was noting that if the CBO had compared the Senate bill to that more recent assumption about insurance coverage under the ACA, it would have resulted in a less harsh appraisal of the Senate health-care bill’s effect on coverage.

Why would Republicans have directed the CBO to use the older baseline in scoring their health-care bill? They may have calculated it would work to their advantage in other areas, conservative policy wonk Yuval Levin wrote in National Review earlier this month.

“I think that using the more recent baseline would have yielded (modestly) better projections of insurance coverage but also somewhat higher projections of cost, so the decision to use the earlier baseline may tell us something about the priorities of the relevant policymakers — or of those whose votes were most in doubt,” Yuval wrote.

Most Republicans haven’t adopted the baseline details as a political message — it’s a bit in the weeds and a hard one to make to the average voter. But they’ve done plenty of criticizing of other methods used by the CBO. White House Office of Management Director Mick Mulvaney even told the Washington Examiner recently that the CBO’s day has “probably come and gone.” 

The bottom line is that the CBO is the only real nonpartisan scorekeeper that Congress has right now to evaluate the effects of big legislation it tries to pass — even though some have noted its methods can be confusing.

Sen. John Cornyn (R-Tex.) tweeted a funny quip by Sen. Steve Daines (R-Mont.):

Senate Majority Leader Mitch McConnell (R-Ky.) walks away after speaking with reporters. (Photo by Jabin Botsford/The Washington Post)

AHH: For decades, McConnell has been celebrated (and bashed) as an obstructionist, a leader who was effective at derailing the other side’s initiatives, without much of a track record in achieving big things for his own team. But now McConnell is under pressure to put some points on the board on big-ticket issues such as health, tax reform and infrastructure. Whether he can do that will depend on his ability to pivot from blocking to building, The Post’s Marc Fisher and Sean Sullivan write, in a deep, probing look at the Kentucky Republican.

“Mitch McConnell never particularly took offense when his opponents branded him America’s No. 1 obstructionist, the Darth Vader of Capitol Hill. Call him dark, call him evil, he embraced it all, even posting the most biting cartoons on his office wall,” Marc and Sean write.

“Based on the electoral math alone, this should be the Senate majority leader’s moment, the veteran lawmaker finally in command with an inexperienced president and a young House speaker as his partners in a united Republican government,” they continue. “Despite this week’s embarrassing decision to slam the brakes on the replacement of Obamacare…McConnell may yet push through some version of the Senate’s health-care plan. But even if he does, it’s clear that the man who titled his autobiography ‘The Long Game’ faces an extended period of ideological division within his party, deeply damaged relations with the Democrats, and an uncertain bond with an impatient and impetuous president.”

OOF: Republican negotiations over how to overhaul Obamacare centered sharply yesterday on a divisive and ideological question: How much money should the Senate health-care bill spend on protecting vulnerable Americans, and how much on providing tax relief to the wealthy?

“Senate Majority Leader Mitch McConnell, in an effort to strike a balance between centrists and conservatives, is now making concessions to both factions of his caucus,” my colleagues Kelsey Snell, Sean Sullivan and Juliet Eilperin write.

“McConnell is rewriting his proposal to provide tens of billions more for opioid addiction treatment and assistance to low- and ­moderate-income Americans, in part with a major policy shift that has already alarmed conservatives who oppose it — potentially preserving a 3.8 percent tax on investment income provided under the ACA that the current draft of the Senate bill would repeal….At the same time, the Republican leader hopes to placate the right by further easing the existing law’s insurance mandates and providing higher tax deductions for the health savings accounts that conservatives favor, several Republicans said.”

(The Post’s Carolyn Y. Johnson has a great explainer here of why Republicans are thinking of keeping an Obamacare tax on the rich.)

Nevada Gov. Brian Sandoval (R) is one of several Republican governors who expanded Medicaid and doesn’t want to see it rolled back. (Chase Stevens/Las Vegas Review-Journal via AP)

OUCH: Nearly all of Nevada’s rural counties will lack even a single marketplace insurer in 2018, the Reno Gazette-Journal reports. Blaming uncertainty over the future of the Affordable Care Act, insurers have withdraw entirely from Carson City and other regions of the states, leaving about 8,000 Nevadans without marketplace options next year. Marketplace director Heather Korbulic called the situation a “health-care crisis for rural Nevada.” Gov. Brian Sandoval (R) called the situation “unacceptable.”

“My administration is working diligently to identify solutions to ensure there is, at the very least, a safety net available to rural Nevada residents who will be left without any options for coverage in the wake of these devastating and unfortunate decisions,” Sandoval said in a written statement.

Sen. Dean Heller (R-Nev.), who is opposing the Senate health-care bill in its current form, notably said yesterday that his position hasn’t changed, per Politico’s Burgess Everett: 

President Trump. (AP Photo/Susan Walsh)

President Trump tweeted his health-care strategy this morning:

–The tweet comes a day after Trump was criticized deeply — by even some Republicans — for attacking “Morning Joe” co-host Mike Brzezinski in another tweet.


–At least one Republican lawmaker suggested the tweet was an attempt to distract from the GOP health-care effort. Rep. Tom Reed (R-N.Y.) said in an interview with CNN on Thursday morning he was “concerned” about the language in the president’s tweet.

“Well, obviously, I was just made aware of that tweet. I don’t know the context of the exchange. But obviously, I’m concerned about that type of language,” Reed said. “Maybe the intent is to distract from the health-care debate. But I want to be part of the debate that’s impacting the American people.”

Watch Reed’s interview below: 

The Post’s Aaron Blake also pointed out that of the several Republican lawmakers who condemned the president’s remarks, three were female senators who are on the fence about the health-care bill:

From Sen. Susan Collins (R-Maine): 

From Sen. Lisa Murkowski (R-Alaska): 

CNN’s Manu Raju caught Sen. Shelley Moore Capito’s (R-W.Va) remarks:

President Trump and Vice President Mike Pence arrive for a meeting with Republican senators about health care. (Photo by Jabin Botsford/The Washington Post)

–Yesterday, Vice President Pence cruised down Pennsylvania Ave. to the Capitol building to try to exert his influence over Republican senators refusing to support the health-care bill. His tweet:




Photos shared by the vice president show him chatting with a few senators who are insisting on changes to the Senate bill as it currently stands, including Sens. Susan Collins (R-Maine), Shelley Moore Capito (R-W.Va.) and Ted Cruz (R-Texas). The photos don’t seem to depict Pence slipping them any cash, so The Health 202 is still wondering exactly what he promised them. Whatever he said doesn’t appear to have swayed them, at least yet.

The theory that the two defectors on the health-care measure will be Collins and Sen. Rand Paul (R-Ky.) still stands. Collins, for her part, yesterday called for a “major overhaul” of the Senate draft. “From my perspective, the bill needs a lot more than tweaking or tinkering around the edges,” she said on MSNBC. “It needs a major overhaul.”

Sen. Rob Portman (R-Ohio) on the left. (AP Photo/Bryan Woolston) Sen. Patrick J. Toomey (R-Pa.) on the right. (Photo by Chip Somodevilla/Getty Images) 

–If Republican Sens. Rob Portman (R-Ohio) and Patrick J. Toomey (R-Pa.) can’t agree, the Senate can’t pass its health-care bill, my colleague Paul Kane writes. Portman has become the de facto leader of moderates and mainstream conservatives from states that accepted the ACA’s expanded federal funding for Medicaid coverage. Toomey has galvanized conservatives behind his proposal to cut that program and provide what some consider the most dramatic curtailment of an entitlement program in a generation.

Yet the two men are more alike than they are different. They took the Senate’s oath of office on the same day. They’ve both been intellectual forces inside the Republican caucus. They both got picked for a special committee to cut the debt. They sit next to one another on the Finance Committee. And they both found ways to win reelection from neighboring states by building a unique coalition of suburban professionals and rural conservatives.

“Now, six months into their second term, Portman and Toomey stand apart on the most critical issue preventing a deal to repeal the law that helped launch their careers, the Affordable Care Act,” Paul writes. “The dispute between Portman, 61, and Toomey, 55, has grown contentious behind closed doors. Neither senator lacks for self-confidence, and they have jousted over both the policy and the political fallout of those ideas, often talking past one another in a bid to win support from their fellow Republicans.”

“There are other issues that could still derail the proposal from Senate Majority Leader Mitch McConnell (R-Ky.), who has delayed an initial test vote on the nearly 150-page draft until at least mid-July,” Paul continues. “But there is simply no path for victory unless these two senators, so similar in many ways, bridge their divide on this core issue.”

Sen. Chris Murphy (D-Conn.) (AP Photo/Steve Helber)

–Post fact-checker Michelle Ye Hee Lee digs into claims from Democrats about how the Senate bill would treat patients with preexisting conditions. Some lawmakers are charging that it would repeal protections contained in the Affordable Care Act for people with preexisting conditions, which ban insurers from charging these patients higher premiums or denying them coverage altogether. Sen. Chris Murphy (D-Conn.) tweeted this last week:

What’s the reality? As with most things in health-care policy, it’s complicated. Here’s how things stand now and how’d they change under both versions of a Republican Obamacare overhaul.

World before the ACA: Insurance companies could consider a person’s health status when they decide whether and how much to charge premiums. If a person had a preexisting medical condition that would cost a lot of money, the insurance company could increase the cost of their premiums or even deny coverage.

World with the ACA: Insurers can’t consider health status in pricing premiums or enrolling patients under the health-care law, which also requires everyone to purchase insurance. It also requires insurance carriers to offer people in the individual and small group markets “essential health benefits,” such as maternity care, mental health services, prescription drugs, pediatric services and emergency services. 

World with the House GOP health-care bill: The measure the House passed in May provided waivers so states could replace a federal essential benefits package with a more narrowly tailored package of benefits and charge higher premiums to certain patients based on their health status. These changes would affect only people who meet the following criteria: lives in a state that seeks this waiver; has a lapse in health coverage for longer than 63 days; has a preexisting condition; and purchases insurance on the individual market.

World with the Senate GOP health-care bill: Similar to the House bill, the Senate version allows states to use a waiver to opt out of covering the essential health benefits package, along with removing other restrictions on how the waivers could be used. But states couldn’t use the waiver to deny insurance coverage because a person has a preexisting medical condition.

But remember: Even though the Senate bill explicitly prohibits waivers for preexisting condition protections, health analysts say waiving the essential health benefits package and eliminating waiver restrictions could weaken the types of services covered for people with preexisting conditions.

“If states aren’t required to ensure that their coverage is as comprehensive as the essential health benefits package, insurers can redesign plans that do not include certain services that otherwise would have been required under the ACA,” Michelle writes. “These services may be ones that people with preexisting conditions need….Insurers won’t be able to single out a person for a preexisting condition. But indirectly, insurers could design policies that could affect people with preexisting conditions.”

(AP Photo/J. Scott Applewhite)

Coming Up

  • The American Enterprise Institute is hosting a panel discussion on the broader role for health savings accounts on July 6.

  • The Bipartisan Policy Center is holding an event on solutions to long-term care financing on July 11. 

  • The Hill is hosting an event on “The Cost of Caring: Family Caregivers and Tax Reform,” featuring Sen. Tammy Baldwin (D-Wis.), Sen. Joni Ernst (R-Iowa), Rep. Dan Donovan (R-N.Y.) and Rep. Michelle Lujan Grisham (D-N.M.) on July 13.

Why health care is so hard for the GOP: 

Fact Check: Does the Senate health-care bill include cuts to Medicaid?

House Minority Leader Nancy Pelosi (D-Calif.) says Republicans have a “poor record” of accomplishments:

Trump’s ‘Morning Joe’ tweets are just the latest step in a years-long feud:

Stephen Colbert on President Trump’s tweets about “Morning Joe” co-host Mika Brzezinski:

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