The Congressional Budget Office (CBO) projected yesterday that 24 million fewer people will have coverage a decade from now than would under current law. The Trump administration has objected to the CBO's score as implausible—but an internal analysis found that an even larger coverage decline, according to a report in Politico.
It's hard to square either estimate with Republican rhetoric about the replacement plan. In January of this year, Senate Majority Leader Mitch McConnell criticized Obamacare for leaving tens of millions of Americans without health coverage. "What you need to understand is that there are 25 million Americans who aren't covered now," he said. "If the idea behind Obamacare was to get everyone covered, that's one of the many failures."
According to President Trump and his team, the idea behind the GOP's Obamacare replacement plan was to cover everyone affordably. "We're going to have insurance for everybody," Trump told The Washington Post in January. "There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us." Around the same time, one of Trump's senior advisers, Kellyanne Conway, also said no one would lose coverage. "We don't want anyone who currently has insurance to not have insurance," she said.
Yesterday, however, the CBO released an estimate projecting that the House GOP's plan to partially repeal Obamacare and replace it with a new system of tax subsidies would result in 24 million people losing coverage over the next decade. The CBO pinned much of the coverage decline on the repeal of the individual mandate penalties, and an associated rise in health insurance premiums in the initial years of the bill.
The Trump administration, which had spent the weekend criticizing the CBO, objected rather strongly to the report.
"We disagree strenuously with the report that was put out," Health and Human Services Secretary Tom Price said. "It's just not believable is what we would suggest."
"We believe that the plan that we're putting in place is gonna insure more individuals than currently are insured. So we think that CBO simply has it wrong," he said, adding that it is "virtually impossible" to come up with a coverage decline that high.
Virtually, perhaps, but not totally. An administration projection based on a version of the House bill projected 26 million fewer would have coverage as a result of the law, according to Politico, which viewed a draft of the estimate.
Now when it comes to health policy, coverage is an important factor, but it isn't the only one that matters. Yet in the lead up to the release of the GOP health care bill, the White House and other top Republicans have often focused on coverage, and promised to maintain Obamacare's coverage levels, or even expand further, despite their own analysts finding that the bill would result in a large decline. The disconnect is revealing.
And there are, of course, reasons to critique the CBO's estimates. It is frequently wrong, and in particular, it has been wrong on estimates related to the Affordable Care Act, which the GOP bill is intended to partially repeal and replace. It relies assumptions that are not always universally shared—for example, that the particular penalties associated with the individual mandate have a powerful effect on insurance coverage. (In a 2016 report for The New England Journal of Medicine, for example, a group of health policy professors "assessed the mandate's detailed provisions" including "income-based penalties for lacking coverage and various specific exemptions from those penalties" and found "that overall coverage rates responded to these aspects of the law," though the paper suggested that the mandate might have some effect irrespective of the particular penalties.)
But forecasting the effects of complex legislation is difficult for any institution. That CBO sometimes misses the mark isn't a reason to simply not try at all, and to rely on the rhetoric of self-interested politicians instead. CBO is a worthy institution that provides directionally useful estimates that aren't intended to help one party or another. And the existence of those estimates forces those who have issues with its scores to respond with evidence backing up their claims.
In pushing back against CBO's numbers, the White House has provided no evidence. Indeed, the internal analysis reported by Politico suggests that the administration's own experts expect a similar decline in coverage. The White House's shabby efforts to discredit the CBO have only discredited itself.