During the 1990s, Republicans mocked President Bill Clinton for his disingenuous statements on "the meaning of the word 'is.'" Nearly 20 years later, they're resorting to debating the meaning of "lose," in an attempt to explain away a Congressional Budget Office analysis showing that an estimated 23 million people will be without health insurance under the American Health Care Act recently passed by the House of Representatives. Congressional Republicans are also trying once again to attack the budget office's credibility, despite the fact that the agency's head is a Republican appointee.
The first version of the AHCA, which never made it even as far as being voted on by the House, was expected to leave 24 million people without insurance. To win over some wayward members, the House GOP leadership tossed in a few more billion dollars for "high-risk pools" to provide insurance for people who are less than healthy. It didn't make much of a difference in terms of coverage, however. In a report issued on May 24, the CBO estimated that the revised version of the Republican health care proposal would leave only a million fewer people uninsured.
The House bill's provision to end Obamacare's Medicaid expansion after several years is the primary way the new law is expected to save the federal government $119 billion over the next 10 years. But the proposed ending of Medicaid expansion is also the reason why the budget office has estimated that millions would be left without health insurance.
Under the AHCA, the budget bureau estimates within 10 years that 14 million people will not become eligible for Medicaid — who otherwise would, under existing law. The remaining 9 million are people the CBO expects to be priced out of the health insurance markets without being eligible for the "high risk pools" or who will simply opt to not purchase a policy at all, since the Republican proposal eliminates the current mandate to purchase health insurance.
Some Republicans, particularly on the House side, are completely ignoring the Medicaid cuts and the way the AHCA enables insurance companies to charge sky-high premiums for elderly people and extra premiums for women who want maternity care. Instead, they are trying to draw attention to a much smaller number of people who are expected to opt out of purchasing insurance altogether.
"Freedom is the ability to buy what you want to fit what you need," House Speaker Paul Ryan wrote on Twitter earlier this year. "Obamacare is Washington telling you what to buy regardless of your needs."
It's “basically a picture of when people are not forced to buy broccoli, they don’t eat it," Rep. Daniel Webster of Florida said on Thursday, executing a perfect hair split.
Webster is technically correct that people who choose to not buy insurance aren't losing their coverage; they're giving it up. But the vast majority of people who would be negatively affected by the GOP health care bill would have no choice about whether to have insurance. They simply won't have it.
Instead of trying to spin people's dropping their insurance coverage as a form of freedom, other Republicans are attacking the budget office's professionalism, claiming that the nonpartisan agency, whose leaders serve at the command of the House's and Senate's Republican leaders, cannot be trusted.
“The CBO’s crazy,” Rep. Roger Marshall, R-Kan., told HuffPost on Thursday. “I said for weeks I had zero confidence in the CBO. You would never hire them to manage your retirement plan, so it came out exactly what I expected it to be.”
Those sentiments were echoed by Rep. Tom McClintock, R-Calif. “The CBO is very good at crunching budget numbers,” he told HuffPost reporter Matt Fuller. “It has demonstrated it doesn’t have the first clue about how [health care] markets work.”
Attacking the CBO is nothing new for Republicans ever since the party fell under the thrall of supply-side economists who believe tax cuts will always increase government revenues. Even under Republican management, the budget agency must still follow sound economic methods, making it a thorn in the side of Republicans who subscribe to what President George H.W. Bush — a Republican of another era — once called "voodoo economics."
“If you are serious about real health reform, you must abolish the Congressional Budget Office because it lies,” Newt Gingrich, the former House speaker and GOP presidential candidate, said in 2011 at a debate sponsored by a conservative group.
The centerpiece in this latest Republican attack on the budget office is the notion that the agency was unable to correctly predict the number of people who would be insured under Obamacare.
In 2010 the office originally estimated that 92 percent of Americans would be insured by the end of 2016. After the Supreme Court decided that states could not be forced to expand Medicaid eligibility, the budget office lowered its estimate to 89 percent. According to a survey by the Centers for Disease Control, 89.5 percent of Americans were insured in 2015.
Instead of focusing on the overall number — which the budget office got almost exactly correct — Republicans have instead focused on the fact that it overestimated the number of people who would enroll in the subsidized individual insurance exchange markets established by Obamacare. The Trump administration has even forced the Department of Health and Human Services to get in on the act and attack another federal agency.
Whereas the budget office had predicted 23 million people would buy coverage via the Obamacare exchanges by the end of 2016, only 10.4 million had done so by the middle of last year. This was largely because more people had sought coverage under Medicaid than through the exchanges. And this happened because millions of people who were already eligible for Medicaid did not realize it until they were compelled to seek insurance under the Obamacare individual mandate. In most cases, the provider network is the same. While the budget office got the distribution of newly insured people wrong, it estimated the overall numbers correctly.
Notably, there is one error that the Congressional Budget Office made that Republicans are not talking about: The agency overestimated how much Obamacare would cost the federal government by a large margin, about one-third. The CBO's director, Keith Hall, admitted this in a March letter to Congress.
Not every Republican has been playing the spin game, however. Some Republicans from states that increased the income threshold to become eligible for Medicaid as provided for by Obamacare, including Sen. Shelley Moore Capito of West Virginia, have strongly criticized the AHCA's provision to return to the former cap.
“I’m from a state that has an expanded Medicaid population that I am very concerned about,” Capito told Talking Points Memo in November. “I don’t want to throw them off into the cold, and I don’t think that’s a strategy that I want to see."
Capito has retained her reservations about the House bill, telling The Washington Post on Thursday that the budget office's report “strengthens my resolve to say, what are we doing to people here, particularly to our most vulnerable or those that don’t have the wherewithal?”
The ultimate fate of the House GOP's health care bill is likely to rest in the hands of uncertain Republican senators like Capito. Will they be willing to risk a primary challenge from the right in order to have a chance at defeating a Democrat in the general election? (Capito is up for re-election next year and could be vulnerable both among those on her right and her left.) Or will they do nothing and risk offending GOP voters who haven't yet realized the downside of repealing Obamacare?