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Now what? Hurdles for CBO and the governors

Steve Cannon / AP

Now that the House has acted (and left town), the Congressional Budget Office has to find a useful way to estimate what will happen with the state waivers in the health care bill — more useful than the way it has tried to predict state decisions in the past. And we need a better sense of what the governors are planning to do.

Here's what we ought to be looking for:

CBO has a different job: It can't be useful if it does its usual scoring, because the number of people likely to lose what it defines as comprehensive insurance depends wholly on which states, if any, opt to seek waivers to allow insurers to underwrite for pre-existing conditions and/or cut back on essential benefits. (The waivers were created by Rep. Tom MacArthur's changes to the first bill.)

Instead, it should provide a series of scores based on hypothetical scenarios of which states seek the waiver. For example, one score would guess that Texas, Florida, and other southern states would seek a waiver, perhaps by assuming that all those that opted not to expand Medicaid would allow the waiver.

Then it could project how many more people nationally would lose comprehensive insurance because they cannot afford the rates to be charged in the high risk pools, versus how many more healthy people would opt to get insurance because the rates in the regular pool get lower as a result of the sick being kicked out.

That would then also allow CBO to project how much lower those non-high-risk rates would be.

A second score would assume that no state opts to allow waivers (because the political pressure on governors not to pull the trigger — both from voters and the state's hospitals and doctors — is likely to be so strong).

A third score might assume that just the most conservative governors — perhaps Greg Abbott in Texas and Rick Scott in Florida — seek waivers.

The CBO faced a similar dilemma in July 2012, after the Supreme Court ruled that states could opt out of expanding Medicaid. In reissuing an estimate of how many people would now be covered by Medicaid and what it could cost, CBO declined to sketch multiple scenarios, or to predict which states would do what.

Instead the auditors vaguely cited "many factors that states are likely to take into account," and projected that only one third of the Medicaid-eligible population would end up being fully covered, half would end up being partially covered, and only a sixth would not get coverage at all.

This time, a state-by-state projection seems doable because the "factors" and the decision are so binary.

Besides, the CBO's post-Supreme Court estimate was simply an update to a law already passed, not guidance for how Congress should vote. They need to do better this time. If CBO doesn't do that multi-tiered estimate, the Kaiser Family Foundation or some other non-partisan group ought to.

Which reminds me: Why aren't reporters going state by state to see which governors, if any, will touch the new third rail of politics — eliminating the pre-existing condition restriction?

Which, in turn, demonstrates the illogic of the explanation some Republicans gave for switching their positions and voting for the bill because, they said, they were now satisfied that it would lower premiums and deductibles for most by putting those with pre-existing conditions into the high risk pools.

Does Republican John Faso of New York really think Democratic Gov. Andrew Cuomo is going to seek a waiver? If not, how does the new bill lower premiums and deductibles? Same question for New Jersey's Rodney Frelinghuysen. Did he switch his position because he thinks Chris Christie, who expanded Medicaid, is going to seek a waiver?