But what exactly does the CBO’s work entail, and why is its scoring important? In lieu of a report from the office itself, I spoke with former CBO Director Doug Holtz-Eakin on the agency’s role and his own analysis of the amended AHCA. He was a director during the George W. Bush administration and is now president of the center-right think tank American Action Forum. The following interview, conducted before the House vote, has been edited for length and clarity.
Vann R. Newkirk II: Can you walk us through what the traditional CBO scoring process is like for a major health-reform bill like the AHCA?
Douglas Holtz-Eakin: As the legislation is being developed, the staff on the Hill will be in contact with CBO describing what they’re going to do, so CBO has some notion of what’s coming their way. Congress will then provide them, typically, with some sort of outline of the structure of the bill, and CBO will give some sort of estimate of the implications. Then they’ll actually have to write the legislative language and send that to CBO, and there will be several iterations on that. Then there will be final legislation as well, and CBO will write a formal cost estimate. That describes the budgetary impact of the legislation—what does it do to revenues coming in and spending going out?—and often, for health legislation, provides some supplementary information on premiums and coverage implications of the bill.
The Budget Act of 1974 said that if you’re going to consider language that contains a congressional authorization, there should be a CBO score that accompanies it—so that’s the basis for which this process was set up. Congress can waive the CBO score at any time. It gets done differently in every circumstance.
Newkirk: In your tenure, did you have any situation where Congress decided, on a final bill, to waive or bypass the CBO scoring?
Holtz-Eakin: We did a lot of things with the Medicare Modernization Act, the Part D program; we put a score out for that, of course. But people would put up amendments on the floor without having any CBO score and without knowing. That’s not uncommon at all. In this circumstance with the AHCA, Congress isn’t waiting for the final score, but CBO did put out the score on the base bill a couple weeks ago, and these three amendments don’t really change that. They’re really tiny tweaks in my view. And we know what adding $15 billion and $8 billion costs: $23 billion. So I don’t think there’s any real big mystery here.
Newkirk: And knowing the spending is the most important part of the CBO process.
Holtz-Eakin: Right. The CBO’s job is budget, and the budget stuff is clear. When it goes over to the Senate, I’ll expect modifications, and CBO will have to score it again, otherwise they can’t get reconciliation protection and they can’t roll it out with 51 votes.