Health Care's Little Known Decider

Washington Matters

Health Care's Little Known Decider

For all the marquee names in the health care reform debate - Obama,  Kennedy, Pelosi, Baucus, Grassley, Sebelius, Rangel, Daschle -- there's one crucial player who most Americans have never even heard of. 

He is Douglas W. Elmendorf, hardly a household name, yet nonetheless he has the power to affect health care in every household for years to come.

As director of the Congressional Budget Office, Elmendorf signs off on the economic analyses and projections used to "score", or put a price tag, on all legislation moving through Congress, from gargantuan bills like health care and energy to small policy initiatives that may never even move out of committee.

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His name is popping up only peripherally even now,  CBO's sobering cost analysis of Obama's overall health care plan and his office's cost scoring body slam of the Ted Kennedy-backed plan. CBO concluded the plan would leave tens of millions without insurance despite huge costs, a verdict that may kill off Kennedy's preferred approach. 


It's not just that the  opinion of the nonpartisan CBO is respected, it's that Congress must use its projections in squaring the cost of legislation with budget requirements. That why the White House quickly distanced itself from Kennedy's plan after CBO scored it, and close Kennedy colleagues like Sen. Chris Dodd, D-Conn., instead of issuing a scathing opinion of CBO's math, simply said he and Kennedy would be working on revisions and changes to the plan to control costs.

Also this week, CBO scored a draft of the plan prepared by Senate Finance Committee Democrats. Its cost: a whopping $1.5 trillion over 10 years. Finance Chairman Max Baucus swiftly put out word that he'll modify the plan to cost no more than $1 trillion over 10 years. 

CBO doesn't have a lock on accuracy, especially with legislation costing hundreds of billions over several years. They were well off on their 2003 projection of the Medicare Prescription Drug Benefit, saying it would cost $633 billion over 10 years (the more accurate 2009 Medicare Trustees report put the cost at $377 billion). Any projection can only fairly be called a ball park figure because it is based on numerous economic factors and assumptions, as well as changing demographic projections in the case of health care.

But even so, the little known, number-crunching agency does have quite a say in what legislation swims or sinks. While many reasons are cited for the failure of Hillary Clinton's top-heavy health care plan in 1993, certainly one reason was then CBO-director Robert Reischauer's less than generous scoring of her plan, which came shortly before Democrats threw in the towel on the entire "Hillary-care" package.

Sixteen years later, we're already seeing some of the impact Elmendorf is having on this important national policy debate on the future of health care for every American.