Almost every lawmaker remembers their first “bad” score from the Congressional Budget Office, the nonpartisan entity that estimates the budgetary and economic impacts of legislation. 

For Rep. Diana DeGette, D-Colo., it was when she tried to get a bill passed that would mandate Medicare and Medicaid coverage of tobacco cessation services, including counseling and drugs. 

At the time, the CBO told her that such a provision would raise the bill’s costs, despite her view that, as a preventive health measure, it would cost money upfront but save money in later years by reducing cancer and disease. 

That frustration is part of what spurred her to join Rep. Michael C. Burgess, R-Texas, to regularly sponsor legislation that would allow chairs and ranking members of health and budget committees to request that CBO score preventive health measures over a longer period of time — up to 30 years.

Burgess and DeGette are now working to get their bill on the House suspension calendar after the House Budget Committee approved it 30-0 earlier this month. The bill has been named after Burgess, who is retiring at the end of this term. 

“I think it will be a very potent shift in the way we look at health care policy,” DeGette said. 

DeGette’s experience reflects the importance of receiving a ‘good’ CBO score — seen as no or minimal increases in spending — in order to get legislation through Congress. 

A CBO estimate that a bill would raise spending can be a legislative death knell, forcing lawmakers to find a way to pay for it, reduce costs or change the legislation’s scope.

It’s also spurred some lawmakers and health care organizations to complain that the importance of CBO scores makes it difficult to pass health care legislation.  

Health care groups like the American Medical Association and the American Academy of Family Physicians have lobbied in support of the bill, seeing it as a gateway to getting Congress to pass more health interventions that prevent chronic disease.  

“As we look to increase the overall investment in primary care in this country, this is a component of that process,” said Stephanie Quinn, senior vice president of advocacy, practice advancement and policy at AAFP.  “You can’t look at making additional investments in primary care without being able to visualize the longer-term benefits.”

Still, some budget experts caution that preventive health care doesn’t always save money.

“I don’t think it’s going to accomplish what the members think it will accomplish,” said Joshua Gordon, director of health policy for the Committee for a Responsible Federal Budget. “Any large-scale interventions wind up costing more in aggregate than they save because it’s very expensive to screen everyone in the country for something.” 

DeGette’s bill with Burgess would allow the chair and ranking member of health or budget-related committees to request that the CBO estimate the budgetary effects over a 30-year period for legislation related to preventive health care services. While committees are already allowed to make these requests, according to the CBO, they rarely do. 

A DeGette spokesperson said passing the bill would make the process more streamlined. An extended score isn’t the default and “can leave a committee arguing over the actual costs of the bill and which CBO score” should be used. 

The bill’s definition of preventive health care is fairly broad. It would include any action that would focus on the health of the public, individuals or defined populations in order to protect, promote and maintain health and wellness and prevent disease, disability and premature death. 

Weight loss drugs 

In arguing for her CBO legislation, DeGette specifically cited the advent of drugs used for weight loss, like Wegovy, which shows promise in reducing heart attacks and strokes. Medicare currently doesn’t cover drugs for weight loss. 

“There’s a question about whether Medicare can cover those drugs and what the cost would be,” DeGette said, adding that CBO’s current limitations hamper its ability to answer those questions. 

The CBO said it expects the costs of Medicare coverage of “anti-obesity” medications “would be significant over the next 10 years.” At their current prices, the drugs would cost the government more than it would save from reducing other health care spending in the same time period, it said.

CBO Director Phillip Swagel similarly told the House Budget Committee in 2020 that even if the cost of a preventive service is low, costs can accumulate when many people receive it. Costs can also accumulate from false positives from screenings, and people living longer could also increase costs to the government.  

“We shouldn’t be so certain in the common sense idea that preventive care always saves money,”  said Jackson Hammond, health care policy analyst at the American Action Forum, a center-right think tank.

For example, preventive care services might save more money when directed at specific populations that would be at highest risk for diseases. 

“It’s not a bad idea,” he said of DeGette and Burgess’s bill, but added, “ I think there are some folks in Congress expecting a lot of savings out of preventive care that might not be there, or it might be in more select areas.”

‘Everyone has some beef with it’

Congress created the CBO by law in 1974 to analyze the budgetary and economic impacts of legislation amid distrust of the Nixon administration and its own budget entity, called the Office of Management and Budget. 

But what was probably unknown at the time was how much weight CBO’s scores would carry in determining what makes it into law. 

Questioning CBO’s methodology and reminiscing over times they have “gotten it wrong” have become something of a hobby for lawmakers over the years. 

“Everyone has some beef with it because it didn’t score the way they wanted it to,” Hammond said. 

Gordon, of the Committee for a Responsible Federal Budget, said Congress should ultimately find ways to pay for policies that are worthwhile. 

But it is becoming increasingly difficult to find offsets to pay for health care legislation, and policies that would save money are often controversial because they impact some industry’s bottom line.   

“There are so many options to reduce health care spending to pay for some of these investments and initiatives,” he said. “There’s just so many options, but everything has a little bit of political challenge to it. And this Congress doesn’t seem up for those challenges.”

The idea of tweaking the way CBO scores legislation ignores the underlying problem, said Charlie Ellsworth, a partner at Pioneer Public Affairs and former budget and appropriations staffer for Sen. Charles E. Schumer, referring to the climate on Capitol Hill

“Anything that creates a deficit is bad and anything that creates savings is good,” he said. “We need to stop viewing health policy as budget policy.”

Ellsworth suggested that public health be viewed as its own public policy goal.

“We need to understand the consequences of health care benefits on the budget, but ultimately they need to be judged by what it means for a healthier, longer-living population. Full stop.”

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