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Why 'CBO' Is Showing Up All Over the Place

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What You Need to Know

  • The overall level of health policy expertise on Capitol Hill is lower than it used to be.
  • That's increased the influence of a key congressional research arm, the Congressional Budget Office.
  • One issue: COVID-19 has changed the way policymakers think about some key numbers, such as the number of uninsured people.

The Congressional Budget Office is playing a bigger role in shaping federal health care and health insurance policy these days, because that’s where more of congressional health policy expertise is.

Jamease Kowalczyk, a senior policy associate at Acumen LLC, talked about that trend Monday, during a session at the Society of Actuaries’ 2021 Health Meeting.

Actuaries are professionals who have shown that they have the math and risk analysis skills to understand insurance operations, pension plans, and other financial arrangements that involve many different types of risk.

The SOA is holding a three-day online conference this week, and it’s offering additional on-demand sessions throughout the month.

Kowalczyk — who spent 12 years working at the CBO as a health policy analyst and has also worked with congressional aides — briefed meeting participants on how health care policymaking in Washington really works.

When Things Changed

Before the 1980s, Democratic and Republican members of committees often drafted and shaped legislation in a bipartisan way, through the process described in the old Schoolhouse Rock video about how bills get through Congress, Kowalczyk said.

In the early 2000s, when members of Congress were holding the discussions that led to the drafting of the Affordable Care Act, Congress was full of experienced health care content experts,, according to a session slidedeck prepared by Kowalczyk and the session moderator, Kirsten Kari Staveland, an actuary with Lewis and Ellis.

Former President Barack Obama signed the two bills that created the ACA in early 2010.

“After the ACA was passed, there was an exodus of seasoned content experts” from the ranks of congressional aides, and many of the successors were former interns, who tended to lack the kind of expertise the seasoned experts had, Kowalczyk and Staveland reported.

Since Kowalczyk has been involved with health care policy, “The New Normal” system has prevailed, and party leaders have dominated the drafting and shaping legislation, she said.

The New Normal System

The New Normal system, and veteran health care aide brain drain in Congress, have increased the influence of lobbyists and trade groups, Kowalczyk said.

Kowalczyk noted that the true drafters of legislation are usually lawyers in the Office of Legislative Counsel or lawyers at outside interest groups, not the lawmakers themselves or ordinary staffers.

In one case, Kowalczyk said, when she was at the CBO, she saw a bill, that had passed through a committee, the came in on the letterhead of a lobbying firm.

The CBO’s influence also has increased, partly because of the expertise of CBO analysts, and partly because of lengthy, behind-the-scenes discussions between legislation drafters and CBO scoring analysts before the official analyses come out, Kowalczyk said.

Actuaries and the CBO

For actuaries, she said, one challenge is that the CBO has focused mainly on hiring analysts from economics doctorate programs and master of public policy programs. Most of the actuaries it works with are on advisory panels.

“CBO is very protective of its non-partisan status,” Kowalczyk said. “A lot of times, actuaries get viewed, because of where they work, as not being able to maintain that status.”

But Kowalczyk said she often wanted to get actuaries’ advice when she was working at the CBO.

Staveland said actuaries have a responsibility to help policymakers draft health care and health insurance legislation and help them understand the many types of unintended consequences the legislation could have.

The Uninsured

Gregory Fann, an actuary with Axene Health Partners, spoke at another session about efforts to track the number of uninsured people in the United States.

The COVID-19 pandemic has made counting the uninsured, and understanding what being uninsured really means, more difficult, and some of the tracking efforts are now focusing more on what uninsured people are thinking, rather than the number of uninsured people, Fann said.

One thing surveys have found is that as many as 4 million people who say they are uninsured because health insurance is too expensive may be eligible for free coverage, Fann said.

(Image: Andrey_Popov/Shutterstock)