The Costs of the Health Bills: Another Look

The Congressional Budget Office released a very helpful letter today that clarifies some of its thinking about the budget impacts of the health bills now pending in Congress. Most importantly, CBO offers a new metric for evaluating the health bills: how they affect the federal government’s budgetary commitment to health care. That’s a very useful metric because it reflects not only government spending on health care, but also the various tax subsidies (most notably for employer-sponsored health insurance) that the government provides.

CBO concludes that the House bill would increase the federal commitment to health care by seven times as much as would the Senate Finance Committee bill ($598 billion vs. $85 billion over ten years):

The top line in the table reflects the gross costs of the coverage expansions in each bill. As I noted yesterday, the correct figure for the House bill is $1.055 trillion. There was some confusion about this at first, but most commentators now appear to be referencing this figure (see this nice NYT piece discussing the confusion).

There are two additions I would make to this table:

• First, as I discussed yesterday and a few weeks ago, I think policy makers should unpack the second line item, changes in net spending for Medicare, Medicaid, and other programs. That line includes not only spending reductions but also important spending increases. Based on the individual line items in the two cost estimates, I estimate that those spending expansions are about $75 billion in the Senate Finance bill and about $217 billion in the House bill. As a result, I think the gross costs of the two bills are around $904 billion and $1.272 trillion, respectively. (But see the caveat below.)

• Second, the House bill includes the CLASS Act, whose budget accounting is misleading. As I discussed several months ago, the CLASS Act would create an insurance program for long-term care. It’s intended to be budget-neutral in the long-run, but premiums start faster and more robustly than do benefit payments. As a result, this budget-neutral proposal narrows the deficit by $72 billion over the next ten years, but then increases the deficit by a comparable amount in subsequent years. A better accounting would net this out, leaving the House bill with a deficit reduction of $32 billion over the next ten years, rather than $104 billion. (Speaker Pelosi and her team deserve credit for being very transparent on this point; the side-by-side they distributed comparing the bill to an earlier one highlights this issue in the very first entry, and some proponents of the bill have indeed referred to it as saving about $30 billion over ten years.)

Caveat: As I’ve previously noted, it’s difficult to get a precise estimate of the additional gross health spending in the bills because the plethora of provisions interact with one another. As a result, CBO reports some major cost impacts–including both deficit reducers and deficit increasers–as interactions that aren’t attributed to individual line items. In principle, those interactions could cause my $75 billion and $217 billion figures to be higher or lower. CBO briefly addresses this issue in today’s letter, noting: “The reductions in net spending for those programs could themselves be divided into provisions that would increase spending (and thus the federal budgetary commitment to health care) and provisions that would decrease spending (and thus that commitment). However, even some individual provisions of the proposal have elements that raise costs and elements that lower costs. Tabulating all of the aspects of the proposal that would, in isolation, increase federal outlays would be complicated and would require somewhat arbitrary judgments about how to allocate interactions among different elements of individual provisions and interactions among provisions.” I certainly agree. However, I also believe that it is important for everyone involved in this debate to remember that these other provisions are in there. And so, in the absence of more precise figures, I think the $75 billion and $217 billion figures are the best we can do.