National Expert in Health Law Shows How ‘Money Changes Everything’

While most Americans are by now fluent in the politics of the health care debate, few understand the critical role played by the congressional budget process. Nothing in government gets done without money, and that money is subject to many rules and limitations. Timothy M. Westmoreland, professor at Georgetown University Law Center and former congressional counsel, argues that this complex process “distorts legislative policy even as it appears to be agnostic about outcome.”

Westmoreland was the featured speaker Oct. 19 at the health law discussion “Money Changes Everything – The Congressional Budget Process and Health Reform,” co-sponsored by Center for Health, Science & Public Policy and the Office of Alumni Relations. Calling on his experience as counsel to the Subcommittee on Health and the Environment in the U.S. House of Representatives, and later as director of the Medicaid program at the Health Care Financing Administration, Westmoreland gave the audience an abbreviated lesson on the federal budget. There are three types of money in the budget, he explained: discretionary, mandatory, and tax spending, and there is a layer of scorekeeping conducted by the Congressional Budget Office to ensure that a balance remains whatever actions are taken.

Westmoreland illustrated the human impact of a seemingly dry process with an anecdote from his time working for Rep. Henry Waxman on the Subcommittee on Health and the Environment. At the time, during the Reagan administration, Medicare did not pay for prescription drugs. Waxman wanted to legislate an exception to force Medicare to pay for a new vaccine that could prevent thousands of premature deaths from a strain of pneumonia. The cost estimate that came out of the budget process was a prohibitive $100 billion, based on the fact that the people who did not die from pneumonia would eventually need other expensive services like hip replacements and heart surgery.

“The CBO eventually withdrew that estimate and said they made a mistake,” said Westmoreland. “But it’s not a mistake. The fact that more people would need services is something the government needs to know. But it’s a lousy way to make policy.”

Westmoreland also faced this issue when he served as counsel to the Koop-Kessler Advisory Committee on Tobacco Policy and Public Health in the 1990s. He worked on a bill to regulate tobacco as a drug and aimed to reduce smoking through new labels, warnings, and cessation programs that would be paid for by an excise tax on cigarettes. The CBO, which only considers the potential effects of legislation within the decade after it is passed, said this program would lose the government $1 billion by reducing revenues brought in by cigarette purchases, unable to take into account future savings that a drop in smoking would bring.

Both the vaccine coverage and tobacco bill ultimately passed, but not without protracted fights.

“My criticisms are not about the CBO,” Westmoreland said. “The process is just so one-dimensional that it only looks at what something costs, and when you get right down to it, it costs money to keep people alive.”

A Q&A with Professor Karen Porter, executive director of the Center for Health, Science and Public Policy, and Dean Nick Allard followed the presentation.