Harold Pollack is a professor at the University of Chicago School of Social Service Administration and Special Correspondent for The Treatment.
Democratic senators and staff are still crowing about the latest Congressional Budget Office scores. According to CBO, the Senate bill costs out at $848 billion, and is estimated to reduce the federal deficit by $130 billion by 2019. Mazol Tov to Senator Reid for the good numbers. Before the high-fives get too wild, let's all take a deep breath and remind ourselves that CBO scoring is a heroic back-of-the-envelope calculation whose faux precision borders the tragicomic.
That’s nobody’s fault. CBO staff operate with integrity under great political and time pressure to score bewilderingly complex 2,000-page bills. The scoring process provides genuine accountability and judicious analysis. It places an essential roadblock that stops much stupid or venal legislation. We are just asking the impossible.
Most obvious within the comical category are the instructions CBO receives from its Republican and Democratic overseers to accept obviously false assumptions about future policies. Congress will not impose steep and sudden cuts in Medicare physician reimbursement, steep and sudden estate tax increases, or any number of other political absurdities captured in the phrase "under current law."
Then there are the heroic extrapolations required to estimate the budgetary impact of huge changes in government policy. The best welfare policy experts--and some others--made huge mistakes in guessing the likely impact of the 1996 welfare reform. Experts extrapolated from the extensive literature to predict what would happen if one abolished traditional welfare and replaced it with an avowedly transitional program. Nobody was stupid. It's not clear what else the experts could have done. You just can't reliably forecast the impact of a massive policy change by scaling up results from more modest experiments and state policy changes that have come before.
The 2009 health reform is an even more massive change, applied to a $2.4 trillion healthcare economy. Truckloads of scholarly reports and foundation white papers discuss how reform will alter medical practice and the demand for medical services. Large, perhaps inherently unpredictable changes seem inevitable. Analysts badly underestimated the budgetary impact of prospective payment and other reimbursement changes. They may do so again.
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COMMENTS (2)
Of course, the whole point of scoring is political not policy. After all, if the policy decision, once made, is (near) universal coverage (for humanitarian or other reasons), what's the point of scoring the legislation to achieve it? Unless, of course, one is comparing different models to achieve it, which is not what is being done with the scoring discussed here. As to the specifics of overall health care spending, scoring any "reform" is next to impossible. For example, many "breakthroughs" in cancer have converted many concers to chronic conditions rather than death sentences. How does one score that? Compare the increase costs for treating a chronic condition against the lost outp ... view full comment
Of course, the whole point of scoring is political not policy. After all, if the policy decision, once made, is (near) universal coverage (for humanitarian or other reasons), what's the point of scoring the legislation to achieve it? Unless, of course, one is comparing different models to achieve it, which is not what is being done with the scoring discussed here. As to the specifics of overall health care spending, scoring any "reform" is next to impossible. For example, many "breakthroughs" in cancer have converted many concers to chronic conditions rather than death sentences. How does one score that? Compare the increase costs for treating a chronic condition against the lost output resulting from an early death of an otherwise economically productive person? Mr. Pollock's ambivalence about scoring health care legislation is understandable, even if he doesn't appreciate the reason for it.
Doing double duty this evening because I just happened upon this Nov article by Professor Pollack.
I have been wondering why a national single payer proposal has not been scored when all manner of projected, potential and possible reform scenarios have been costed out.
In a report issued in Dec 2008, Key Issues in Analyzing Major Health Insurance Proposals, the CBO authors say single payer cannot be seriously assessed because it can't be compared to any existing program! Gimme a break!
I have heard that certain backers of HR 676 are reluctant to ask CBO to score the bill because of high early costs--but surely it could be scored over the decade--as is the case with both current Senate and Hou ... view full comment
Doing double duty this evening because I just happened upon this Nov article by Professor Pollack.
I have been wondering why a national single payer proposal has not been scored when all manner of projected, potential and possible reform scenarios have been costed out.
In a report issued in Dec 2008, Key Issues in Analyzing Major Health Insurance Proposals, the CBO authors say single payer cannot be seriously assessed because it can't be compared to any existing program! Gimme a break!
I have heard that certain backers of HR 676 are reluctant to ask CBO to score the bill because of high early costs--but surely it could be scored over the decade--as is the case with both current Senate and House proposals. And the huge savings to be recouped under a Medicare-for-all system are surely just as easy to predict as possible gains due to the implementation of medical IT or comparative effectiveness.
Here is the link to the report:
http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf
The report is a long but interesting read now that we know so much more about the possible reforms discussed. There is a lot of info on Medicare proposals, Medicaid, and reference made to a Medicare-like public plan aka public option. I find it interesting that component parts of reform legislation were all in the sights of the CBO before Congress even started to debate.
A search for "single-payer" (hyphenated) yields mention on pp.
5, 12, 20, 20, 28, 103, 118, 121, 131, 135, and 183.