As Congress considers options to repeal and replace the Affordable Care Act (ACA), it will need to confront how the federal budget scoring process can affect the fate of legislation. The Congressional Budget Office (CBO) is required to produce a “score,” or budget estimate, for most bills approved by a full committee in both the House of Representatives and the Senate. Each score represents CBO’s best estimate of the 10-year impact of legislation on the federal deficit. Bills scored as deficit-increasing may be difficult to pass given certain statutory and procedural rules intended to prevent new legislation from increasing the federal deficit.
Under the plans currently being discussed, repeal of the ACA’s coverage expansions may be delayed for two to three years to avoid immediately ending coverage for the 20 million people who became newly insured through the ACA.1 Another rationale for the potential delay is to allow Congress time to coalesce around a single replacement policy. Yet the repeal-and-delay approach could also set up a budgetary cliff by taking credit for the savings and leaving the costs of any replacement for future legislation.
CBO evaluates legislation relative to a baseline that reflects existing law. Under a repeal-and-delay approach, Congress would partially repeal the ACA in 2017 using budget reconciliation, a process that allows expedited consideration of legislation that affects the federal deficit. To do so, the House and the Senate would need to pass a budget resolution requiring Congress to reconcile the budget to achieve specific changes to revenues or spending. (So far, the Senate has passed such a resolution.) Congress could then repeal provisions of the ACA that directly affect the federal budget, including federal funding for Medicaid expansion and marketplace tax credits, with a simple majority of votes, avoiding the potential of a filibuster in the Senate.
With this approach, lawmakers would be able to act quickly and decisively on a key promise made by president-elect Donald Trump, namely to repeal the ACA within the first 100 days after taking office. But disagreement among lawmakers about appropriate replacements for the ACA could cause disruption for insurers and health care providers, who would face uncertain regulatory and marketplace environments.
Moreover, the repeal-and-delay approach could make it difficult for any replacement legislation to be budget neutral. In a score of a previous partial repeal bill, H.R. 3762, CBO projected that repealing the coverage provisions in the ACA would reduce federal spending by $1.4 trillion between 2016 and 2025. Once repealed, the savings associated with eliminating the ACA’s coverage expansions would be part of current law and hence the baseline budget. This means that a future replacement bill could be scored as deficit-increasing, even if it cost less than $1.4 trillion.
HENRY KOTULA 