More than a week after the House passed its healthcare reform bill, members of the US Senate still have yet even to see their final bill.
Senate majority leader Harry Reid confirmed Tuesday that he is waiting on the Congressional Budget Office (CBO). But “waiting” doesn’t begin to capture the complex and highly interactive process going on behind the scenes.
The leadership team drafting the Senate bill are using CBO estimates of how much various potential healthcare reforms will cost to rejig their draft bill. The goal is to get the score – and the mix of policy – necessary to get a bill through the Senate.
It’s not a negotiation. The nonpartisan CBO, after all, works for the Congress: It’s the impartial scorekeeper for the cost of laws that Congress passes. But the Senate leadership team can use CBO estimates of various policy options to rework the draft – and that’s what’s taking so much time.
“You only get one shot at this,” says a leadership aide close to the process.
It’s critical that the final plan meet President Obama’s pledge to not add a dime to the federal deficit, and the CBO is the arbiter of whether
that pledge is met. House leaders went through a similar process of using CBO estimates to rework their bill before passing health care reform on Nov. 7, by a narrow 220-215 vote.
“The CBO does not want this to be seen as any pressure or inducement – or anything but applying their complicated models,” says Norman Ornstein, resident scholar at the American Enterprise Institute in Washington. "But it is a process of fine-tuning: You give them policy options, and they give back numbers, then you re-jig those estimates to see if you can get different numbers.”
Some CBO estimates are counterintuitive. In an Aug. 9 blog, CBO director Douglas Elmendorf challenged the view that wellness programs and preventive care necessarily lower federal healthcare costs – a theme in both House and Senate healthcare proposals.
“Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services,
expanded utilization leads to higher, not lower, medical spending overall,” he wrote.
Critics say the CBO may be underestimating the cost savings from prevention and wellness programs.
At the same time, the final version of the bill also has to have the right mix of policies to win the 60 votes needed to clear the Senate and any potential filibuster. Moderate Democrats say that they will not commit to support the bill until they see the final version and have time to study it. And for some, the key concern is whether enough has been done to contain the rise of healthcare costs.
“I’m still very focused on the cost containment issues,” says Sen. Mark Warner (D) of Virginia.
Other moderates are balking at including a government run public healthcare option like the one passed in the House bill.
“One of the concerns of the centrists is that we’re not interested in something that’s government-run or government-funded,” says Sen. Thomas Carper (D) of Delaware.
The group expects to propose an amendment as an alternative to a fully fledged public option. If insurers fail to meet an affordability standard in any state, the plan would empower the Department of Health and Human Services to step in and help start a healthcare option there. But once the venture was up and running, the federal government would withdraw, according to the broad outlines of the plan discussed with reporters Tuesday. The details are still in flux.
For those senators not directly involved in final negotiations on the text of the bill – and that includes the vast majority of the caucus – "waiting" is an accurate term.
“This is probably the biggest, the most elaborate, hard-to-figure out score of any bill that’s been done in 40 or 50 years,” says Sen. Maria Cantwell (D) of Washington.
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