New Health Bills Unlikely to Boost Coverage: Ex-CBO Chiefs

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By Jonathan Nicholson and Alex Ruoff

The bills House Republicans hope to pass alongside their repeal of the Affordable Care Act won’t improve coverage, according to two former Congressional Budget Office directors.

Republican leaders have been touting the additional proposals they plan to advance in addition to the repeal of the ACA after the repeal came under fire for increasing the number of uninsured. But the Congressional Budget Office said— in 2009—some of those ideas won’t increase coverage either.

When the full House votes on the repeal measure, it’s also expected to consider bills to permit the sale of health insurance across state lines, cap medical malpractice claims, permit businesses to create association health plans and make other policy changes. These bills will help stem the expected rise in the national uninsured rate by making insurance cheaper, lawmakers have said.

“This is just part one of a three-part plan, and that’s why I’m excited,” House Speaker Paul Ryan (R-Wis.) said March 13, referring to the repeal bill.

Ryan’s three-part plan starts with his repeal bill and continues with regulatory changes made by the Department of Health and Human Services, followed by the additional legislation.

After the CBO said 24 million Americans would lose health insurance under the ACA repeal bill over a decade, some Republican lawmakers have become skeptical about the bill’s passage as well as the planned follow-on bills. “If it requires a 60-vote threshold, we can’t get those votes,” Sen. Bill Cassidy (R-La.) said.

Bills Under Consideration

The third part of the three-prong plan could contain as many as six bills, all recently considered by various House committees. Nearly all the bills are opposed by Democrats, meaning they could pass the House but are unlikely to pass the Senate where Democrats could filibuster them.

The medical malpractice bill House leaders are slated to bring to the floor (H.R. 1215), sponsored by Rep. Steve King (R-Iowa), would cap damages for medical injuries that aren’t based on economic losses at $250,000. Supporters of the bill say it would help lower health-care costs because doctors wouldn’t have to practice defensive medicine by ordering more tests and procedures than necessary. Detractors of tort reform say it wouldn’t reduce health-care costs meaningfully.

Ryan has repeatedly praised a bill approved March 1 by the House Education and Workforce Committee (H.R. 1101) that would allow businesses to create association health plans, groups of employees of member companies that band together to negotiate better health plans.

A bill to allow insurers to sell plans across state lines has not yet been introduced. However, Ryan and President Donald Trump have praised the change.

The problem is the CBO has seen those ideas before and did not score them as significantly increasing the number of insured Americans.

Old CBO Score

As the House considered the bill that would be the first of two laws that make up the Affordable Care Act in early November 2009, two amendments to it were allowed on the House floor. One was sponsored by then-Rep. Bart Stupak (D-Mich.) dealing with the bill’s abortion coverage provisions. The other was the Republican substitute sponsored by then-Republican Leader John Boehner (R-Ohio).

The Boehner substitute included medical malpractice overhaul, association health plans and easing the ability of insurance companies to sell plans across state lines by allowing states to make interstate compacts. The result: little change in the number of insured or the percentage of insured compared to the then-current law.

“By 2019, CBO and JCT [Joint Committee on Taxation] estimate, the number of nonelderly people without health insurance would be reduced by about 3 million relative to current law, leaving about 52 million nonelderly residents uninsured. The share of legal nonelderly residents with insurance coverage in 2019 would be about 83 percent, roughly in line with the current share,” wrote Douglas Elmendorf, who was CBO director at the time, in a Nov. 4, 2009, letter to Boehner and other congressional leaders.

Elmendorf, now dean of the John F. Kennedy School of Government at Harvard University, said March 14 he did not expect the CBO’s opinion to have changed much since the 2009 score because those three ideas would not make much difference in the cost of health care. “These three changes in policy would have only small effects on coverage because they would not change total health-care spending or the cost of health care very much,” Elmendorf told Bloomberg BNA.

`Something They Want.’

Elmendorf said many states already allow interstate insurance sales but it has been hard for insurers to sign up and manage health-care networks in other states. Malpractice changes also would not save that much money, he said, and in December 2016 the CBO said it would only cut the deficit by about $61.9 billion over 10 years.

His view was echoed by Doug Holtz-Eakin, who was director of the CBO from 2003 to 2005. Holtz-Eakin is president of the conservative American Action Forum think tank. Referring to the follow-on bills, Holtz-Eakin told Bloomberg BNA, “Their remainder of this looks like attempts to get the margins where across states might matter. That, to me, doesn’t seem as big.”

An economist with the conservative Heritage Foundation disagreed. Rachel Bovard, director of policy services for the Heritage Foundation, told Bloomberg BNA March 14 the CBO report proved that many young, healthy Americans only purchased health insurance under the ACA because of the health law’s individual mandate, which levies a penalty for anyone who fails to have coverage.

Bovard said having affordable insurance and incentives to purchase insurance could convince many of these Americans to buy insurance. “Most people would buy something they want, rather than something they’re forced to buy,” she said.

Two Other Bills

Holtz-Eakin said Republicans should not focus on coverage. “I have always felt that if you want to have a competition about coverage, you’re on the wrong playing field, because, as we’ve seen, Democrats are willing to make being uninsured illegal and throw trillions of dollars of taxpayer money at covering people and Republicans are uncomfortable with both of those,” he said.

In addition to the ideas in the 2009 Boehner amendment, Republicans are looking at other proposals to include in follow-on legislation.

The House Education and the Workforce Committee also recently approved a controversial bill (H.R. 1313) that would allow employers to require workers to either submit medical information for wellness plans or be disqualified from certain discounts. Democrats have panned the bill as allowing employers to evade disability discrimination law.

Legislation (H.R. 372) that would expose health insurers to more antitrust lawsuits and federal enforcement actions could also reach the House floor around the same time as the repeal bill.

The measure could change how health insurers conduct business with one another by subjecting them to federal charges of price fixing or improper coordination in the development of policy forms. Backers say the industry can abuse the antitrust exemption by stating that its coordination practices fall within “the business of insurance,” which is immune from federal enforcement.

To contact the reporters on this story: Jonathan Nicholson in Washington at; and Alex Ruoff in Washington at

To contact the editor responsible for this story: Paul Hendrie at

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