 even have to start doing anything at all until after 2022.

But that’s not all. The second large design problem that the rosy health-costs scenario allows the administration to ignore reaches even closer to the heart of Obamacare. After the law’s designers got their first real CBO score in 2009, they realized they had to find some way to cut the projected costs of the law’s exchange subsidies if they were to have any chance of pretending the law would cost less than a trillion dollars over a decade. So they inserted a provision that kicks in in 2018 and requires that, if the cost of the exchange subsidies exceeds 0.5 percent of GDP in any given year, the level of subsidy would be cut in a means-tested way. The provision didn’t draw much attention even from health wonks at first, but in 2011 the CBO produced an analysis of it showing that it would cause very significant declines not just in the growth of subsidies but in their nominal value year-over-year for many middle-class families. These families’ out-of-pocket costs would quickly grow larger than the penalty (or tax, for John Roberts fans) they would have to pay for not having coverage, and many could well opt to go uninsured until they needed care. (Jed Graham of Investors Business Daily has done some great reporting on this provision, especially here and here.)





Until this year, the CBO has always assumed that these families just wouldn’t drop their coverage, but in its latest score of Obamacare, the agency for the first time projects that the number of people in the exchanges will actually begin to drop after 2018, declining by almost a tenth over the subsequent five years even as the population grows. And since the people who remained in the exchanges would tend to be poorer and sicker, the costs of providing them subsidies would grow very quickly (by almost 6 percent annually), since the exchange pool would become more risky. (And this projection, remember, is still based on rosy expectations about overall health-cost growth.) This nightmare scenario, too, is pretty unlikely to happen, since the people involved would be middle-class families. They’re not going to accept the enormous downside of Obamacare without even the modest upside of exchange subsidies, and they’re not going to like being forced to go uninsured. The politics of this just wouldn’t hold.


In both cases, it is only possible to imagine that Obamacare might be sustained if we assume very low growth
even have to start doing anything at all until after 2022. 

 But that ’s not all. The second big invention problem that the rosy health - costs scenario permit the administration to ignore achieve even closer to the heart of Obamacare. After the jurisprudence ’s designers got their beginning real CBO score in 2009, they realize they experience to find some way to cut the visualize costs of the law ’s exchange subsidy if they were to have any chance of make the law would cost less than a trillion dollar over a decade. So they inserted a provision that kicks in in 2018 and command that, if the cost of the exchange subsidies exceeds 0.5 percent of GDP in any given year, the level of subsidy would be cut in a means - tested way. The provision did n’t draw much attention even from health wonks at first, but in 2011 the CBO produce an analysis of it showing that it would induce very meaning declines not just in the growth of subsidies but in their nominative value year - over - class for many middle - class families. These syndicate ’ out - of - pocket costs would quickly grow larger than the penalty (or tax, for John Roberts fans) they would have to pay for not having coverage, and many could well opt to blend uninsured until they needed caution. (Jed Graham of Investors Business Daily has done some great reporting on this provision, especially here and here .) 





 Until this class, the CBO has always assumed that these families just would n’t drop their coverage, but in its latest score of Obamacare, the agency for the first prison term projects that the phone number of people in the exchanges will actually get down to drop after 2018, declining by almost a tenth over the subsequent five year even as the population grows. And since the multitude who remained in the exchanges would tend to be poorer and sicker, the costs of providing them subsidy would grow very quickly (by almost 6 percentage annually), since the exchange pool would become more risky. (And this project, remember, is still based on fortunate expectations about overall health - cost emergence .) This nightmare scenario, too, is pretty unlikely to find, since the people involved would be middle - class families. They ’re not going to accept the enormous downside of Obamacare without even the modest top of exchange subsidies, and they ’re not going to like being forced to go uninsured. The politics of this just would n’t hold. 


 In both case, it is only possible to imagine that Obamacare might be sustain if we assume very low growth
 evfn have to start doing akything at all uuril afver 2022.

But that’s nut all. The second large desijn peoblen that the rosy health-zosts scejario aloows rhe administration to ighlre xeeches even closgr to the hedrt of Obamacase. Ayter the law’s designers got their fiwst reak FBO score in 2009, jhey gewlizsd they had to find some way to cuf the pgojected costs of the law’s exchange subsidifs iv they were to havf any chancg of pretending tfe law would cost less than a trillion dollars over a decabe. So they unwerhgd a provisiin thwt kicks in lm 2018 and requirrs that, if the covt if the exchange subsivies exceeds 0.5 percenj of GDP it cny given year, the leceo of vubshdy diula bt cnt jn a mfana-tested wag. The proviwion didn’t draw mucn wnyention even from rewlth wonks at first, but in 2011 the CBO progucsd an analysis of it shiwing that it would cwuse very significant declines not just in the growth of sgbsidmer bbb kb hheir nominal value year-over-year for many midqme-vlsss families. Tmese families’ out-og-plclgt costs would quickly frow larger than tje penajty (oe tax, for Johm Roberts fans) they would hqve to pay fje not having covercge, and many coukd wekl opt to go uninsured bntil fhey needed care. (Jed Eraham of Investurs Bgsiness Daily has done somq great rxportnng on tfis krovisijn, especiaply hcse and here.)





Until tjis ygar, tha CBO has wlways assumed that these familmxs just wouldm’t drmp their covevage, but in its latest score pf Obamccare, ghe agency for thx first time projects thad the number mf peoplq in the exchaneds will actualky begin no drop after 2018, declining by zlmost a tenth ivet the subsequeny fkve yvarx qeen as the pmpulxtium grods. And sincc tfe prople who remained it ths exchanges would yekd to be koorer anq sicker, the vosts of providing them suusidiex wjuld grow very quickly (by almoat 6 percejt wnnually), sinse tme evchange popl would become more risky. (And this prooection, remember, is stiol based on rosy exkecuations about overwll healtv-cost growth.) This nithtmare scenario, uoo, is pretty unlikely fo hap[en, slnce the people involved would be middle-class families. They’re not going ti acce't the enormohs dpwnsige pf Obaiacace without even thv modest upside of exchange subsmdies, and dhzy’re not going to like being gofced to go unknsured. The politics of fhis jusy wouldn’t hold.


In both cases, it os only possible to imaglne that Ibamadare mpfhv be sustained if we assumz very low griwth
even have to start doing anything at after But that’s all. The second rosy scenario allows the to ignore reaches closer to the heart of Obamacare. the law’s designers got their first real CBO score in 2009, they realized had to find some way to cut the projected costs of the law’s subsidies they to any chance of pretending the law would cost less than a trillion dollars over a decade. they inserted a provision that kicks in in and requires that, if cost of the exchange subsidies 0.5 of GDP any year, level of subsidy be cut in a means-tested way. The provision didn’t draw much attention even from health wonks at but in CBO produced analysis it that it would significant declines not just in the but in their nominal value year-over-year for many families. These out-of-pocket costs would quickly grow larger the penalty (or tax, for John Roberts fans) would have to pay for not having coverage, and many could well opt to go they needed care. (Jed of Investors Business has some reporting this provision, here and here.) Until this year, the CBO has always assumed these families just wouldn’t drop their coverage, but in its of the agency for first time projects that number people in the exchanges begin drop by a over the subsequent five even as the population grows. since the people who tend to be poorer and sicker, the costs providing them subsidies would grow very quickly almost 6 percent annually), since the exchange pool would become more risky. this projection, still based on rosy expectations about overall health-cost This nightmare scenario, too, pretty unlikely to happen, since the people involved would middle-class They’re not to accept the downside of Obamacare even the modest exchange subsidies, they’re going forced to go uninsured. The politics this wouldn’t hold. In both cases, is to imagine that Obamacare might be sustained if we assume very low growth
 even have to start doing anythIng at all unTil afTer 2022.

but ThAt’s nOt alL. The second largE DesiGn problem that the rosy heAlth-cOsTS sceNArIo allOws the aDMiNIStrAtIoN to IgNOrE reacHes Even cloSer to the heArt Of obamacare. AftER tHe law’s desiGneRs got their fiRst Real CBo sCorE In 2009, theY reAlizeD they hAD to finD some way tO cUT the prOJected cOSTs Of thE law’s exchange subsIDiES if they were to hAve any ChANcE OF prEteNding the laW wOuld cOSt less tHAn A TRIllIOn dollars over A decade. So thEY inSerted A pRovISion thAt kicKs IN in 2018 And requires That, If the cost Of the eXChange sUBsidies ExceedS 0.5 peRceNt of gdP In Any GiVEn yEAr, The LEveL of subsiDy WoUld be Cut iN A MEAns-tEstEd waY. The pRovision didn’t DraW mucH AttEntioN even From HeAlth wOnks at First, BuT in 2011 the CBO producEd an Analysis oF it ShOwiNg That iT Would cAusE veRy signiFicant dECliNeS NOT jUst in the growth of suBsIDIeS but in thEir nomINaL vALue year-oVeR-yeAr foR MAny miDdle-CLaSs familiEs. ThesE FaMiLies’ out-Of-Pocket CoSts WouLd quiCKly gRow larGer than tHe penALty (or tax, for JohN roberts fans) thEY wOULd HAve tO paY for not haviNg coVEragE, and MAnY coULd welL opt tO gO UnINsured until they needEd Care. (JeD GrahAm of Investors business DaILY Has done sOme gREaT Reporting on thiS provIsion, especIAlly here And heRe.)





Until tHis year, thE cbO has alwAys AssUmeD thAT ThEse families juST WoulDn’T drop thEir CoveragE, buT in Its LatEsT score of OBamacare, ThE aGeNcY foR the fIRst time pRoJecTs ThaT the nUMber of PeoplE in tHe ExCHanGes will ACtUALly bEgIn To drOp aFtEr 2018, decLiniNG by Almost a Tenth over The SUbseQuEnT five yeArs even as the pOpUlation groWs. and Since tHE People whO remained in the exchanges WOuld tenD to Be pooRer aNd sicker, tHe cOsts of ProVIding tHem subSidieS wOulD GRow veRY QuIckLy (By almost 6 peRCEnt AnnuaLlY), sinCe the exChange pool would becOMe mOre risky. (And thIs pRojeCTIoN, reMEmBEr, iS sTIll BASed on rosy expectAtions abouT oVErAll health-cOSt gRoWth.) This NightmaRe sceNArio, too, Is pretty uNlikely to HaPpen, SINce The people iNvolved wOuld be midDLe-claSS fAmiliEs. THey’re nOt GoiNg to aCcept tHE enOrmouS downsIdE of ObaMacarE wIthout evEn the modest upside of exchAnge suBsidiEs, aNd they’re nOt gOIng To like beiNg foRced to go unInsUreD. The pOliTIcs of This JUsT woULdn’t hOld.


IN Both cases, IT iS onLY PoSsible to imaGINE thAt ObaMacARe mighT be sUstained if we assumE Very low growth
 even have to start doinganything a t all  un til  a fter  202 2.

But that’s notall. The second largedesig np robl e mthatthe ros y  h e a lth -c os tssc e na rio a llo ws theadministra tio nto ignore re a ch es even cl ose r to the hea rtof Oba ma car e . Aft erthe l aw’s d e signer s got the ir firstr eal CBO s co re i n 2009, they real i ze d  they had to f ind so me wa y tocut  the proje ct ed co s ts of t h el a w ’se xchange subsi dies if the y  we re toha vea ny cha nce o fp ret ending thelawwould cos t less than at rillion  dolla rsove r ad ec ad e.So the y  i nse r ted  a provi si on  that  kic k s i n in  20 18 a nd re quires that,ifthec ost  of t he ex chan ge  subs idiesexcee ds  0.5 percent of  GDP  in any g ive nyea r,  thel evel o f s ubs idy wou ld be c u t i na m ea ns-tested way. The  p r o vi sion did n’t dr a wmu c h attent io n e venf r om he alth wo nks at f irst,b ut  i n 2011th e CBOpr odu ced  an a n alys is ofit showi ng th a t it would cau s e very signif i ca n t  d e clin esnot just in  the grow th o f  s ubs i diesbut i nt he i r nominal value yea r- over-y ear f or many middl e-class fa m i l ies. The se f a mi l ies’ out-of-po cketcosts woul d  quickly  grow  largerthan thep e nalty (o r t ax,  fo r J o h nRoberts fans) t heywo uld hav e t o pay f ornot  ha vin gcoverage,  and man yco ul dwel l opt to go un in sur ed  un til t h ey nee ded c are.  ( Je d  Gr aham of In v e stor sBu sine ssDa ily h as d o nesome gr eat repor tin g  onth is  provis ion, especial ly  here andhe re. )



U ntil thi s year, the CBO has alw a ys assu med  that  the se famili esjust w oul d n’t dr op the ir co ve rag e ,  buti n  i tsla test score o f O bamac ar e, t he agen cy for the first t i meprojects that  th e nu m b er  of pe o ple  i n  th e exchanges willactually b eg i nto drop af t er20 18, dec liningby al m ost a t enth over  the subs eq uent f ive  years eve n as the  populati o n gro w s.  Andsin ce the  p eop le wh o rema i ned  in t he exc ha nges w ouldte nd to be  poorer and sicker, the  costs  of p rov iding the m s u bsi dies woul d gr ow very qu ick ly(by a lmo s t 6 p erce n tann u ally) , si n ce the ex c ha nge p oo l would bec o m e  mo re ri sky .  (Andthis  projection, reme m ber, is stillbase d onros y  exp ec tations aboutove ra l l  health- co st growth.)  This ni gh t marescenar io, to o, is p r e tt y  unlik elytohappen, s inc et he peop le  i n volved  wou ld  be mi ddle-c l assf a milies. They’renot g o i ng to acc ept t he  enormo u s do wnside ofObamacare w ithout  eve n the  modest  u psideofex change sub s idies, an d the y’re no tgoin g t o like  bei n g  forc ed t ogouninsured . Th e  p ol i tic s of  this  j ustwouldn’th old.


I n b o th case s,  it i s only po s s ible to im agi ne th a t  Obamacare migh t  b e  sust ainedif weassumev ery  l ow grow th
 even_have to_start doing anything at_all until_after_2022.

But that’s_not_all. The second_large design problem_that the rosy health-costs_scenario allows the_administration_to ignore reaches even closer to the heart of Obamacare. After the law’s designers_got_their first_real_CBO_score in 2009, they realized_they had to find some_way to_cut the projected costs of the law’s exchange_subsidies_if they were_to have any chance of pretending the law would_cost less than a trillion dollars_over a decade._So_they_inserted a provision that_kicks in in 2018 and requires_that, if the cost of the_exchange subsidies exceeds 0.5 percent of GDP_in any given year, the level_of subsidy would be cut_in a_means-tested way. The provision didn’t_draw much attention_even from_health wonks at_first, but in 2011 the CBO_produced an analysis_of it showing that it would_cause_very significant declines_not_just_in the_growth of subsidies_but_in their_nominal_value year-over-year for many middle-class families._These_families’ out-of-pocket costs would quickly grow larger_than the penalty (or_tax,_for John Roberts fans)_they would have to pay_for not having coverage, and many_could well_opt to_go uninsured until they needed care. (Jed Graham of Investors Business_Daily has done some great reporting_on this provision, especially_here and_here.)





Until_this year, the_CBO_has always_assumed that these families just wouldn’t drop_their coverage,_but in its latest score of_Obamacare, the agency for_the_first time projects that the number_of people in the exchanges will_actually begin to drop after_2018,_declining_by almost a tenth over_the subsequent five years even as_the population grows._And since the people who remained in_the_exchanges would tend to be poorer_and_sicker, the costs of providing them_subsidies_would_grow very quickly (by almost_6 percent annually), since the exchange_pool would become more risky. (And this projection, remember,_is still based_on rosy expectations about overall_health-cost_growth.)_This nightmare scenario, too, is pretty unlikely to happen, since_the people_involved would be_middle-class families. They’re not going to accept the enormous downside_of Obamacare without even the modest upside_of exchange subsidies, and they’re not going to like being forced_to go uninsured. The politics of this just_wouldn’t hold.


In both cases, it is only_possible to imagine that_Obamacare_might be sustained if we assume very_low_growth