During the debate over the Affordable Care Act in 2009, the budget office played a central role. Many Democratic lawmakers would not vote for the bill without knowing how many more people it would cover or that it would not increase the deficit. This time House Republicans, who have assailed the budget office’s calculations as inaccurate, were far less concerned about waiting for a score.
Lawmakers on Thursday didn’t vote entirely in the dark, of course. The budget office evaluated an earlier version of the bill, finding that it would save the federal government around $330 billion over a decade, while leaving around 24 million fewer people with health insurance. The budget office said the bill would raise insurance deductibles, and that it would lead to substantial rollbacks of state Medicaid coverage for the poor.
Changes made to the bill since that evaluation could change those numbers. Some are straightforward — lawmakers designated more spending for various programs. But many of the last-minute changes involved giving states the authority to rewrite the rules on insurance regulations. That means that the budget office’s task involves as much political science as economics. It will need to predict how many states would want to use the waivers allowed under the bill, and what they would choose to do with them.
“They’ll have to gauge the appetite on the ground, and make some sensible ballpark estimate of the implications,” said Douglas Holtz-Eakin, a former C.B.O. director who is now the president of the American Action Forum, a right-leaning policy research group. “It’s very, very hard.”
Mr. Holtz-Eakin pointed out that the office has to make difficult estimates all the time. He recalled a bill passed during the George W. Bush administration that established a federal backstop for private terrorism damage insurance. To estimate its cost, he needed to predict the likelihood and magnitude of coming terrorist attacks, and the way that private insurance companies might handle the claims.
Over all, it appears very likely that the revised bill will eat into the deficit reduction estimated in the original version. If the bill doesn’t save at least $2 billion over a decade, it will run into difficulties. The bill is being passed using a special budget procedure in order to avoid a Senate filibuster. To qualify, it needs the budget office to say it will achieve at least that amount of budget savings.
It’s unclear whether the mix of new changes will tend to increase or decrease insurance coverage. States that decided to pursue waivers of the normal insurance rules would be able to strip down benefit requirements and permit insurers to charge higher prices to some customers with prior illnesses.
Those provisions, taken together, are likely to lower the cost of insurance for healthier people, and those lower prices could lead more of them to buy insurance than they would under the original version of the bill. (Sicker people, who may find insurance less affordable, may exit.)
Edward Lorenzen, a senior adviser for the Committee for a Responsible Federal Budget, a research group, says the changes will cause fewer Americans to go without health insurance than the original bill. In an analysis of the changes, the group’s staff noted that any coverage increase would further erode any deficit savings from the bill.
Douglas Elmendorf, who led the budget office during the Obamacare debate, said he tended to think the changes would increase the number of Americans without health insurance, not decrease it. But he emphasized that the distribution of who gets coverage under the amended bill is likely to be different. On a relative basis, more young and healthy people could get insurance, while fewer older, sicker people could be able to afford coverage.
“What matters is not just how many people have insurance,” said Mr. Elmendorf, who is now the dean of the Harvard Kennedy School. “But whether people who really need insurance have insurance.”
We should find out next week. Perhaps the most politically salient new question the budget office will examine is what the bill means for Americans with pre-existing health conditions. Several reluctant Republican lawmakers were persuaded to vote for the bill after $8 billion was added to help lower costs for people who would face higher prices in waiver states.
Representative Fred Upton of Michigan told reporters that he had been assured the funding would be enough to make a difference. Some independent estimates have differed. The budget office’s answer may influence the future of the political debate.