The Congressional Budget Office (CBO) has been in the news a lot during the health care debate, most recently today when all eight of its former directors signed a letter refuting accusations that the agency’s work is partisan or based on bad methodology. Reporters, advocates, and experts eagerly anticipate CBO’s report every time a new proposal is released, and those findings are playing a huge role in how the different proposals are received. That means it is important to understand what CBO is and where the agency came from.
CBO’s job is to provide an independent analysis of policy proposals without making any policy recommendations – it is sometimes called the referee of Congress. It was created during the Nixon Administration so that members of Congress did not have to rely on findings from an agency controlled by the President (the Office of Management and Budget or OMB) when debating policy. The director of CBO is appointed by the Speaker of the House and the Senate’s President pro tempore (a person chosen by the rest of the Senate). The current director, Keith Hall, was appointed by Senator Orrin Hatch and Speaker John Boehner in 2015 and had previously served as the Chief Economist on President George W. Bush’s Council of Economic Advisors.
CBO starts its assessment of policy changes by calculating what it calls a baseline. The baseline shows what will happen in the next ten years with no policy changes. This is important because spending will look different ten years from now even without policy changes. For example, our population is getting older so even with no changes to Medicare, spending on Medicare may change. It would not be accurate to assess a proposal related to Medicare and assume that we’ll still have the same proportion of elderly people as we do today. Once CBO has developed its baseline, it performs its calculations again and includes the proposed change. When CBO reported that the health bills would increase the number of people without insurance, it is in comparison to leaving the ACA as it is.
When CBO and OMB develop different findings, it is not always because someone is being partisan. Sometimes it is simply because the work they do is very complicated. However, CBO has a track record of making people from all parties uncomfortable. It also has a better track record on accuracy than other government bodies that are more exposed to partisanship, like OMB. The eight former CBO directors who signed today’s letter were appointed by Republicans and Democrats, and each released findings that were upsetting to both Republicans and Democrats during their tenure.
CBO works for Congress as a whole, not for one party. It is certainly possible that the final number of people who go uninsured because of these bills won’t add up exactly to CBO’s 22 million or 32 million. But the margin of error for those reports is not so large that they can be dismissed outright. Whether it turns out to be slightly more or less than the exact numbers in CBO’s reports, tens of millions of people will lose their health insurance under either of the health proposals circulating right now.
The past three days have been a roller coaster for the health bills under consideration by the Senate. As of now, we have two possible bills and a promise from Senate Republicans to vote on something next week. We described some of the fights we anticipated yesterday – and quite a few of them are already here. There aren’t really many new ideas floating around besides something called the Cruz amendment and some worrisome signs that the Trump Administration is going to make it difficult for people to sign up for ACA plans. So below is a review of some of the important ideas we’ve been discussing for the past few months and an explanation of the two newest concerns.
Repealing the ACA without Replacing It
One bill is the straight repeal bill that was discussed in January and February. That bill is now being called the Obamacare Repeal Reconciliation Act or ORRA. ORRA sticks to repealing the parts of the Affordable Care Act that can be repealed using what’s called budget reconciliation. Bills that strictly address raising or spending money cannot be filibustered. ACA opponents do not have enough seats to survive a filibuster, so any major piece of legislation Republicans propose has to stick to spending or raising money. (And of course, they could write a bill that Democrats would find it possible to support!) So that means they cannot repeal the entire law, just things like premium subsidies, the individual mandate, taxes, and the bonus given to states that expanded Medicaid to childless adults. The Congressional Budget Office (CBO) analyzed that bill and found that compared to leaving the ACA alone it would cause 32 million more people to be without insurance (more than were uninsured before the ACA), premiums would double, and most of the United States would be left without any insurance companies to buy from.
Repealing the ACA, Replacing Some of It, and Dismantling Medicaid
The other bill is the Better Care Reconciliation Act (BCRA) first proposed by the Senate a couple of weeks ago and similar to the House bill that passed in May. Some people are referring to it as the repeal and replace option. BCRA repeals or changes many spending aspects of the ACA and adds massive changes to the Medicaid program. It keeps premium subsidies but greatly reduces their value and allows states to get rid of the pre-existing conditions protections and Essential Health Benefits if they choose. BCRA would cap spending on Medicaid, forcing states to ration care by either dropping people from the program or denying them coverage once the cap is reached. States like New York that have chosen to spend more on Medicaid over the years would fare the worst, because the caps would be based on national averages that include states that do not invest in Medicaid.
When CBO analyzed that bill (in a new report released today), it found that 22 million more people would be uninsured compared to leaving the ACA in place. New York would not be a state that chooses to undo the pre-existing condition protection or the Essential Health Benefits. But this provision could have disastrous effects for employer-provided coverage, since employer-sponsored plans are not regulated by states and might not have to abide by New York’s consumer protections if they don’t exist in federal law. Older people in New York State would likely find themselves priced out of the market. The chart below, from page 40 of the CBO report, shows what CBO thinks would happen to New Yorkers – older people would go from paying $1,700 for premiums to $16,100.)
CBO also pointed out that the ACA’s out-of-pocket limits, which cannot be changed using budget reconciliation, would prohibit the sale of insurance plans as they were designed in BCRA because the deductibles would be too high. The ACA says that the worst plans insurance companies can sell have to have an actuarial value of 60 percent, which means that the customer pays about 40 percent of their bills and the insurance company pays 60 percent. The amount of help people get to buy insurance under the ACA is based on a middle level plan that has an actuarial value of 70 percent. BCRA says that the middle level plan used to calculate assistance should have an actuarial value of only 58 percent, lower than anything legally sold on the marketplaces today. But CBO found that plans with an actuarial value of 58 percent would require customers to pay $13,000 out-of-pocket. The ACA only allows a maximum of $11,400.
Allow Insurance Companies to Sell Totally Deregulated Plans (the Cruz Amendment)
The idea proposed by Ted Cruz is an amendment that would let insurance companies sell completely de-regulated plans as long as they sell at least one plan that follows the rules. CBO has not yet analyzed that amendment and so far, there is no final version of a bill that includes it (we are not likely going to see a final version of any bill until the day of voting). This bill would mean that states like New York no longer have the power to protect people with pre-existing conditions. People with pre-existing conditions would get segregated into their own plans while everyone else purchases cheaper, skimpier plans that are not currently legal. Prices for people with pre-existing conditions would quickly outpace their ability to pay. The Essential Health Benefits protect people with pre-existing conditions because it blocks insurance companies from offering skimpy plans that siphon off younger, healthier people. People with pre-existing conditions cannot buy skimpy plans – they need plans that offer comprehensive benefits. The Cruz amendment sticks all of those healthier younger people into their own cheap plans that don’t actually cover much, while leaving people with pre-existing conditions and older people to pay more and more. CBO has not been able to analyze this proposal yet, and is unlikely to do so before any vote that might take place next week.
Sabotaging the ACA from Within
Finally, there are some troubling indications that the Trump Administration is actively working to hurt the ACA marketplaces that provide tens of millions of Americans with health insurance. Even though the Trump Administration insists that the ACA is failing on its own, it also seems to believe that it has to take an active role in making the ACA fail. One of the ways it is doing that is to use money meant to help people sign up for health insurance to instead to pay for anti-ACA advertisements. HHS is also removing information from its website that explains how the law works.
If fewer people sign up because the Administration has made it too difficult, the ACA marketplaces really could fail. We won’t experience that in New York because we pay for our own advertisements and programs to help people sign up. New York State does a phenomenal job of informing the public about their health care options and making it easier for people to sign up. But failures in other states could still mislead New Yorkers about whether or not they should sign up for ACA plans, which has occurred in some other states already given the amount of confusion people are experiencing over health care since November.
This is a tough week and next week probably won’t be any better. Hang in there! No one is fighting this alone. HCFANY will keep posting updates as things develop and we’ll post information about rallies and other actions as soon as the information is available.
The coverage gains and consumer protections achieved under the ACA and the Medicaid program that covers the most vulnerable New Yorkers are all at risk. The Senate could be voting on their Better Health Care Reconciliation Act that would take coverage away from more than 22 million people and end the Medicaid program as we know it as early as next week.
Join HCFANY MONDAY, July 17 at 1:15 PM for the “Take a Stand for Health Care” rally with Governor Andrew Cuomo at Mount Sinai’s Icahn School of Medicine in New York City to defend the ACA and Medicaid. Please register here.
Icahn School of Medicine
Mt. Sinai Hospital
1468 Madison Avenue
New York, NY 10029
A few weeks ago, more than 70 members of HCFANY, Health Care for America Now-New York (HCAN), and Medicaid Matters New York (MMNY) from across the state gathered in Albany for the first joint New York State Health Advocates Spring Meeting. More than 50 consumers and advocates attended the press conference in front of the State Capitol about the then secret Senate Better Care Reconciliation Act bill. Several State Legislators also attended including: Assembly Member Richard Gottfried and Assembly Member Patricia Fahy. We were honored to have Margarida Jorge, Co-Executive Director of HCAN and the HCAN Education Fund, as a speaker at the press conference and as our keynote speaker. You can view WNYT coverage of the press conference here.
We heard updates from HCFANY, HCAN-New York, MMNY, Coverage 4 All (immigrant health), disability rights groups, and women’s health and LGBTQIA groups to learn more about what they are doing to fight for New York’s health care and how consumers can get involved. You can view slides from the presentation here. The meeting concluded with break out groups to plan ACA and Medicaid defense actions in different regions throughout New York State.