By Thomas P. Miller

Part I of “Here Today, Forgotten Tomorrow” budget projections recounted the sorry history of CBO’s soothsaying about the employer mandate of the Affordable Care Act (ACA). Now let’s review its related recent work on estimates for various types of insurance coverage and the effects of the seemingly permanent “temporary” public health emergency, as well as what is too often left unsaid. More of these “gems” are tucked away in the late-June CBO report on federal subsidies for health insurance for people under age 65.

CBO acknowledges that estimates of enrollment in new
Individual Coverage Health Reimbursement Arrangements (IHCRAs)—finalized under
a June 2019 Trump administration rule and first available in 2020—now are
“lower” and those for employer-sponsored “group” insurance coverage are
“higher.”

CBO and the Joint Committee on Taxation previously estimated
that roughly 2 million people would enroll in ICHRAs outside of the ACA
marketplaces by 2032. Some other sources suggest larger magnitudes of the
differences between ex ante optimism and more recent skepticism.

The Trump administration’s Treasury Department estimated that 1.1 million individuals would receive an ICHRA in 2020, growing to 11.4 million in 2029. (However, this total included ICHRA enrollment in ACA marketplace plans.) Conversely, the number of individuals in traditional group health plan coverage would fall by an estimated 0.6 million in 2020 and 6.9 million in 2029.

The initial years of the COVID-19 pandemic provide some excuses for slow implementation and take up, but enrollment in ICHRAs has been much lower than either the initial Trump administration or CBO forecasts imagined. An updated estimate of current enrollment by HealthSherpa (a web-based health insurance broker that most recently accounted for half of broker-assisted ACA exchange enrollment on Healthcare.gov) is that about 100,000 to 200,000 people have ICHRA coverage today, most likely on the lower end of that estimate. Like many previously touted “innovations” in health insurance, it’s usually easier initially to forecast rapid growth than to achieve it. The reduced expectations and downward revisions tend to surface later rather than sooner.

Or consider Medicaid enrollment during the federally
designated Public Health Emergency (PHE). CBO now acknowledges that nearly 13
million of the 73.6 million people enrolled in Medicaid in 2022 were due to
continuous eligibility provisions passed in 2020 that were tied to a 6.2
percentage point increase in the federal share of Medicaid reimbursement as
well as the continuing declaration of a PHE. Neither the current Congress nor
the Biden White House shows any signs of wishing to end this cash flow bonanza
to Medicaid’s state officials, insurers, and health care providers. About 4.2
million, or one-third, of the “extra” Medicaid enrollees due to continuous
eligibility were ACA expansion population adults.

The continuous eligibility handcuffs on state scrubbing of
their Medicaid programs for otherwise ineligible enrollees shows up in another curious
finding: People with multiple sources of coverage jumped up from 12 million in
CBO’s July 2021 forecast to 19 million in this latest one. Perhaps CBO should
term these insured individuals as double-covered receivers or at least another
type of “dual eligible.”

There’s more than rounding errors elsewhere between the
lines, including evidence that a host of other political messaging claims by
ACA advocates are wildly exaggerated at best. Did the ACA substantially boost overall
insurance coverage? Just a bit, and almost exclusively for lower cost, lower
quality Medicaid. Must recent “temporary” expansions of ACA tax subsidies be
extended or made permanent? Two wrongs don’t make a permanent right. Are insurers
still on shaky ground due to pandemic disruptions? Check out their current balance
sheets and medical loss ratios.

Then again, there’s nothing as permanent as a “temporary”
government program.

But one should not misconstrue the operational role of the
budgetary entrail readers at CBO. Their work provides “cover” to other public
officials who can claim, on alternate days of the week, that their hands are
tied due to budgetary score projections or that their inflated promises under
current law have to be taken, mostly, at face value once enacted—regardless of
how they are implemented. CBO’s work helps sustain the status quo, and agents
of Congress usually can figure out what their bosses really want.

CBO budget scores work as a double-edged sword. They provide narrow gates through which new legislation and programs can “pass.” Then, those aging and shaky forecasts provide protection against changing substantially whatever finally managed to get through. Don’t shoot the CBO forecasters; they are really just the piano players.

The more honest and transparent budgetary scores in far too
many cases really should include: “Your guess is about as good as ours!” The “major
questions” legal doctrine, if not non-delegation of political accountability, could
be expanded to the legislative branch, too.

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