Health-care Rashomon

By Ezra Klein

The Congressional Budget Office serves a very particular purpose in our political system: They provide politically independent, fairly cautious estimates and explanations of legislation so that when we debate, we can at least work off the same basic set of facts, or, if not facts, then educated guesses. They've safeguarded this reputation quite effectively over the years, repeatedly disappointing Republicans and Democrats alike. Many blame them for killing Bill Clinton's health-care bill by deciding to count payments to private insurers as part of the federal budget, which vastly expanded the apparent size of the budget. Democrats were pretty angry at the CBO in 2009, too, as the scorekeeper refused to give them credit for delivery-system reforms and technological improvements that they -- and many health-care experts -- believed would save the system a lot of money. That meant Democrats had to include blunter, surer financing mechanisms, like Medicare cuts and taxes. They may not have agreed with the CBO's estimate, but they recognized it as a legitimate and credible guess, and responded.

But the Republicans have refused to play by those rules. They have claimed, as Doug Holtz-Eakin, Joseph Antos and James Capretta do in today's Wall Street Journal, that the CBO's work is now the product of "budget gimmicks, deceptive accounting, and implausible assumptions used to create the false impression of fiscal discipline." They have created a separate world for themselves when it comes to this bill, a world where there are no accepted estimates except the ones they choose to accept (notably, they regularly mention the CBO results that they think help their case), where there is no neutral arbiter who can be relied on to set the premises of the debate, and thus, where policy debate is not really possible.

It doesn't take long for the bad-faith arguments underlying the case against the CBO to present themselves. Holtz-Eakin, Antos and Capretta mockingly wonder how "the ACA magically convert[s] $1 trillion in new spending into painless deficit reduction," knowing full well that the deficit reduction isn't painless at all: It's more than $500 billion in Medicare cuts that Republicans used to slaughter Democrats in the midterm election, and it's a tax on expensive health-care plans that almost drove unions out of the Democratic coalition on the bill.

They say that the Medicare cuts -- which are smaller than the cuts we successfully made to Medicare in the 1990s -- can't possibly be sustainable, but they know full well -- and admit in the op-ed -- that Medicare requires cuts that are many orders of magnitude larger over the coming decades. And notice how this argument, that these cuts are implausible, conflicts with another common conservative argument, that these cuts represented the "low-hanging fruit" that should've been saved for a future deficit-reduction bill.

And then there are the straightforwardly wrong and dishonest arguments that get tossed around: that the costs of fixing a disastrous Medicare reform that Republicans passed in 1997 should be attached to the Democrats' health-care reforms in 2010. That the $115 billion of discretionary spending that is either already in the budget or won't be appropriated without further action from Congress has been unfairly left out of the bill. That the CBO is "double-counting" Medicare savings, when it's doing nothing of the kind (something even Rep. Paul Ryan admits).

You could spend all day knocking these arguments around. Trust me: I've done it. But the point isn't the arguments themselves, but their cumulative effect. If you're a conservative and you consume conservative media, you now live in a world where it's simultaneously preposterous to believe that the health-care law saves money and commonly asserted that it cuts Medicare to the bone and raises taxes all across the country. You live in a world so different from the one that Democrats share with the CBO that no argument is really possible. Democrats say the bill reduces the deficit. Republicans say that the bill explodes the deficit. And when the scorekeeper tries to intervene, Republicans take aim at the scorekeeper.

Real debate isn't possible under those circumstances. But that's not the only danger here: When you have a scorekeeper respected by all sides, legislation ends up being more fiscally responsible. Fear of a bad score is why Democrats, though they disagreed with the CBO's modeling and thought their reforms would save more money with less pain, went back to the drawing board and include cost-saving provisions that they didn't like and that they knew might hurt them in the polls. The end result? A vastly more fiscally responsible bill. The process worked.

But since that put Republicans in a bind -- after all, how bad could this legislation be if it fulfilled its goals while paying for itself? -- they've turned on the process. That's not only left the two sides arguing from different sets of facts, but undermined the incentives of future congressional majorities to work with the CBO to release fiscally responsible legislation in the future. After all, if no one cares about the score, why kill yourself chasing it?