Almost every lawmaker remembers their first “bad” score from the Congressional Budget Office, the nonpartisan organization that estimates the budget and economic effects of legislation.
Rep. Diana Daggett, D-Colo. For, when she tried to pass a bill mandating Medicare and Medicaid coverage of tobacco cessation services, including counseling and drugs.
At the time, the CBO told him that such a provision would increase the cost of the bill, despite his view that, as a preventive health measure, it costs money upfront but saves money in later years by reducing cancer and disease.
That disappointment made him Rep. Michael C. Burgess, R-Texas, was prompted to join as the chair and ranking members of the Health and Budget Committee routinely sponsored legislation that would have allowed the CBO to request that long-term preventive health measures be scored. Time – up to 30 years.
Burgess and Daggett are now working to get their bill on the House suspension calendar after it was approved 30-0 by the House Budget Committee earlier this month. The bill is named after Burgess, who will retire at the end of this term.
“I think it’s going to be a very powerful change in the way we look at health care policy,” Daggett said.
DeGette’s experience reflects the importance of getting a ‘good’ CBO score—seen as no or minimal increases in spending—in order to get legislation through Congress.
The CBO estimates that the bill could be a legal death knell for raising spending, forcing lawmakers to find ways to pay for it, cut costs or change the scope of the law.
This has prompted some lawmakers and health care organizations to complain that the significance of the CBO score makes it difficult to pass health care legislation.
Health care groups such as the American Medical Association and the American Academy of Family Physicians have lobbied in support of the bill, seeing it as a gateway for Congress to pass more health interventions to prevent chronic disease.
“We’re looking to increase overall investment in primary care in this country, this is part of that process,” said Stephanie Quinn, senior vice president of advocacy, practice advancement and policy at the AAFP. “You can’t see the long-term benefits of making more investments in primary care until you’re able to imagine.”
Still, some budget experts caution that preventive health care doesn’t always save money.
“I don’t think it’s going to accomplish what the members are going to accomplish,” said Joshua Gordon, health policy director of the Committee for a Responsible Federal Budget. “Any large-scale interventions cost more overall than they save because it’s so expensive to screen everyone in this country for something.”
DeGette’s bill with Burgess would allow chairmen and ranking members of health or budget-related committees to request CBO estimate the budget impacts over a 30-year period for legislation related to preventive health care services. While committees are already allowed to make these requests, according to CBO, they rarely do.
A spokesman for Daggett said the passage of the bill would streamline the process. The expanded score is not prescriptive and may leave the committee debating “the actual cost of the bill and which CBO score” should be used.
The bill’s definition of preventive health care is quite broad. It includes any action that focuses on the health of the public, individuals or defined populations in order to protect, promote and maintain health and well-being and to prevent disease, disability and premature death.
Weight loss medicine
In arguing for her CBO legislation, Daggett specifically cited the advent of drugs used for weight loss, such as Wegovy, which show promise in reducing heart attacks and strokes. Medicare does not currently cover weight loss medications.
“There is a question about whether Medicare can cover those drugs and what the cost will be,” Daggett said, adding that the CBO’s current limitations hinder its ability to answer those questions.
The CBO said it expects the cost of Medicare coverage of “anti-obesity” drugs “will be significant over the next 10 years.” At their current prices, drugs would cost the government more than it would save by cutting other health care spending over the same period, it said.
CBO Director Philip Swagel told the House Budget Committee in 2020 that even if the cost of preventive services is low, the costs may accumulate as more people receive them. Costs can also accrue from false positives from screening, and people living longer can also increase costs to the government.
“We shouldn’t be so sure of the common-sense idea that preventive care always saves money,” said Jackson Hammond, a health care policy analyst at the American Action Forum, a center-right think tank.
For example, preventive care services can save more money when directed at specific populations at high risk for diseases.
“It’s not a bad idea,” he said of Daggett and Burgess’ bill, but added, “I think some people in Congress are expecting a lot of savings from preventive care that might not be there, or it might be in more select areas.”
‘Everybody has a beef’
Congress created the CBO by law in 1974 to analyze the budgetary and economic effects of legislation amid distrust of the Nixon administration and its own budget unit, called the Office of Management and Budget.
But what was probably not known at the time was how much weight the CBO’s score would take in determining what would make it into law.
Questioning the CBO’s practices and periodically reminding them that they “got it wrong” has become a topic of interest for lawmakers over the years.
“Everybody has some beef because it didn’t score the way they wanted it to,” Hammond said.
Gordon, of the Committee for a Responsible Federal Budget, said Congress must eventually find ways to pay for worthwhile policies.
But finding offsets to pay for the health care law is getting harder, and policies that save money are often controversial because they affect some industries’ bottom lines.
“There are many options to reduce health care spending to pay for some of these investments and initiatives,” he said. “There are many options, but everything has some political challenge. And this Congress is not up for those challenges.
The idea of tweaking the way CBO makes laws ignores the underlying problem, said Charlie Ellsworth, a partner at Pioneer Public Affairs and Sen. Charles E. Schumer’s former budget and appropriations staff said, referring to the climate on Capitol Hill.
“Anything that creates a deficit is bad and anything that creates savings is good,” he said. “We need to stop looking at health policy as a budget policy.”
Ellsworth suggested that public health should be viewed as its own public policy goal.
“We need to understand the consequences of health care gains on the budget, but ultimately judge what they mean for a healthier, longer-living population. Full stop.”
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