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Public Health: How to Read the C.B.O. Score of the Health Bill Like an Expert

Will it lower the deficit?

In practical terms, this is the most important question that the C.B.O. needs to answer for the bill to move forward. Republicans are passing their health overhaul bill through a special budget process in order to avoid a filibuster in the Senate. That process comes with a number of special rules.

One is that the bill must not increase the federal deficit beyond a 10-year window. Our entire panel thought the bill would still hit that target.

But the measure also must comply with specific instructions from an earlier budget resolution. That legislation said that the health bill had to save at least $1 billion from portions of the bill overseen by the Senate Finance Committee and at least $1 billion from portions of the bill overseen by the Senate Health, Education, Labor and Pensions Committee. There is a small chance that it could miss. Bloomberg News reported last week that the House is waiting to send the bill over to the Senate, just in case it fails to comply with the budget instructions.

Deficit reduction matters politically, too, of course. After the C.B.O. evaluated an earlier version of the House bill, House leaders promoted the bill’s estimated $337 billion in budgetary savings. But later, in the hectic scramble to win votes from conservatives and then moderates, leaders agreed to amendments that are likely to erode those savings substantially. Now, our experts estimate, the bill that passed the House will probably save only $25 billion to $150 billion over the decade.

Bottom line: Any number less than $2 billion in savings is a huge problem. But even a bigger number could spell trouble, depending on where the savings come from.

What happens to the uninsured number?

The initial version of the bill would have resulted in 24 million fewer Americans with health insurance in a decade, the C.B.O. estimated. Most of our experts think that number will fall a little bit with the recent changes.

Here’s why: The majority of the estimated reductions in coverage come from cuts to the Medicaid program. The recent bill amendments didn’t change those much. But the MacArthur Amendment, which would allow states to eliminate certain Obamacare insurance regulations, might lower the price of insurance premiums enough to prompt more Americans to sign up.

Those cheaper plans, however, are likely to cover fewer medical benefits, and may cost more for people with a history of serious illnesses. Many of our experts said the crucial changes would come not from the total number of uninsured Americans, but who they are.

The version of the bill that passed the House is likely to exclude more people who are older and sicker, while covering more who are younger and healthier. “Focus will be on premiums and on coverage, but there is a shift from sick to healthy and from good insurance to bad that needs to be emphasized as well,” wrote Jonathan Gruber, a health economist at M.I.T.

Photo

Soon the Congressional Budget Office will weigh in on the Republicans’ replacement of the Affordable Care Act. Protesters outside the Capitol in early May had already made up their mind.

Credit
Gabriella Demczuk for The New York Times

Four of our experts thought the uninsured number would decline slightly. One thought it would be unchanged. And one thought it would increase slightly. The numbers ranged from 20 million to 25 million.

Bottom line: The topline number will be the one everyone is talking about. But shifts in who gets insurance coverage are important, too.

How will premiums change?

When the C.B.O. released its first report, Republican leaders seized upon estimates that the average insurance premium would be 10 percent lower in a decade than it would be under the Affordable Care Act. That number obscured a lot, since it reflected a younger pool of insurance customers, and plans with higher deductibles and other forms of out-of-pocket spending for customers.

The MacArthur Amendment could push premiums down even more by allowing plans that cover fewer benefits and by discouraging sicker customers from buying insurance.

Bottom line: The average insurance plan is likely to get slightly cheaper, but cover less.

Who will waive the insurance rules?

The hardest job for the C.B.O. is estimating the effects of the MacArthur Amendment, which allows states to waive several insurance regulations. In order to make calculations, the office’s economists must first estimate how many states will decide to pursue the waivers, how many people live in those states, and which rules they will choose to waive. To figure that out, C.B.O. employees have probably spent the last few weeks speaking with state officials and studying how states have previously tried to change program requirements.

Some experts have said the waivers will be unpopular, and only a few states will pursue them. Others have argued that they are likely to become widespread. Our panel estimated a wide range of effects, saying as few as 10 percent of Americans would be affected or as many as half.

“One could argue 100 percent, depending if the definition is just one provision and Secretary [Tom] Price is lenient in granting waiver requests,” wrote G. William Hoagland, the senior vice president at the Bipartisan Policy Center and a former director of the Senate Budget Committee. The answer matters, both politically and in terms of the report’s headline numbers.

Bottom line: If few states pursue waivers, then the Senate is dealing with a bill that’s much like the one scored in the early C.B.O. report. If many do, then the amendment will broadly reshape what health insurance covers and who can afford it.

About these estimates

The Times asked 20 experts in health economics and budget policy, including former directors of the C.B.O., to assess the version of the American Health Care Act that passed the House. Seven responded, including people who have served in both Democratic and Republican administrations.

Panel of experts

JOSEPH ANTOS

Resident scholar and Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute

CHRISTINE EIBNER

Senior economist, RAND Corporation

JONATHAN GRUBER

Professor of economics, M.I.T.; former health care consultant for the Obama administration

G. WILLIAM HOAGLAND

Senior vice president, Bipartisan Policy Center, and former Senate budget director

DOUGLAS HOLTZ-EAKIN

Former director of the Congressional Budget Office

PETER ORSZAG

Former director of the Congressional Budget Office and the Office of Management and Budget

CAROLINE PEARSON

Senior vice president for policy and strategy, Avalere Health

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