Basics of Budget Reconciliation and the Connection to Health Policy

February 11, 2021

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Budgetary and spending pressures heavily influence the design of Congressional policy changes, especially in health care. Budget Reconciliation is a special legislative process, created in the 1970s, that is intended to facilitate tax and spending changes to meet a recommended Congressional Budget Resolution cost or saving target. However, because the process allows members of Congress to circumvent standard rules and procedures, it has been increasingly used as a mechanism by both political parties to enact significant policy changes.

This briefing provided a high-level overview of the budget reconciliation process, including unique rules and restrictions, historical uses, and its use as a tool to advance legislative priorities in Congress. Panelists also discussed potential applications of reconciliation to address national economic and health policy concerns of the 117th Congress and the new administration, such as COVID-19 relief, economic stimulus, and equitable health care access and affordability.


  • Sarah Kuehl Egge, MPP, Principal, SplitOak Strategies
  • Purva Rawal, Ph.D., Principal, CapView Strategies
  • Rodney L. Whitlock, Ph.D., M.A., Vice President, McDermott+Consulting
  • Kate Sullivan Hare, Vice President for Policy and Communications, Alliance for Health Policy (moderator)

Presentation: Basics of Budget Reconciliation and the Connection to Health Policy

Event Resources

Key Resources

(listed chronologically, beginning with the most recent)

“S.Con.Res.5: The Budget Resolution FY2021.” Lynch, M., Saturno, J. Congressional Research Services. February 8, 2021. Available at

“McDermott+ Healthcare Preview: Week of February 8.” McDermott+Consulting. February 8, 2021. Available at

“The Role of Reconciliation in Advancing President Biden’s Health Agenda.” Egge, S., Fowler, E., Nuzum, R. The Commonwealth Fund. February 5, 2021. Available at

“The Budget Reconciliation Process: Stages of Consideration.” Lynch, M., Saturno, J. Congressional Research Service. January 25, 2021. Available at

“Budget Reconciliation: The Basics.” U.S. House of Representatives Committee on the Budget. October 28, 2020. Available at

“The Budget Reconciliation Process: Timing of Legislative Action.” Lynch, M. Congressional Research Service. February 23, 2016. Available at

“The Budget Reconciliation Process: The Senate’s ‘Byrd Rule’.” Keith, R. Congressional Research Service. July 2, 2010. Available at

Additional Resources

“Financial Services Report 2/8.” Thorn Run Partners. February 8, 2021. Available at

“9 Questions About Budget Reconciliation You Were Too Afraid to Ask.” Scott, D. Vox. January 25, 2021. Available at

“Reconciliation 101.” Committee for a Responsible Federal Budget. January 22, 2021. Available at

“Introduction to Budget ‘Reconciliation’.” Kogan, R., Reich, D. Center on Budget and Policy Priorities. January 21, 2021. Available at

“Introduction to The Federal Budget Process.” Saturno, J. Congressional Research Services. February 26, 2020. Available at

“Heritage Explains: Budget Reconciliation.” Heritage Foundation. 2017. Available at

“Medicaid and the Budget Reconciliation Debate.” Rosenbaum, S., Rothenberg, S., Gunsalus, R. The Commonwealth Fund. January 7, 2016. Available at

“The Good, The Bad, and The Ugly of the Budget Conference.” Committee for a Responsible Federal Budget. April 29, 2015. Available at

“Budget Reconciliation Measures Enacted Into Law: 1980-2010.” Lynch, M. Congressional Research Services. September 2, 2010. Available at



Sarah Kuehl Egge
SplitOak Strategies, Principal

Purva Rawal
Capview Strategies, Principal

Rodney Whitlock
McDermott+Consulting, Vice President

Experts and Analysts

James C. Capretta
American Enterprise Institute, Resident Fellow; Milton Friedman Chair

Greg D’Angelo
The Nickles Group, Vice President

Marc Goldwein
Committee for a Responsible Federal Budget, Senior Vice President and Senior Policy Director

Seth Hanlon
Center for American Progress, Senior Fellow

Larry Levitt
Kaiser Family Foundation, Senior Vice President for Health Reform

Nina Owcharenko Schaefer
The Heritage Foundation, Senior Research Fellow, Domestic Policy Studies, Health Policy

Paul N. Van de Water
Center on Budget and Policy Priorities, Senior Fellow

David Wessel
Brookings Institute, Director, Hutchins Center on Fiscal and Monetary Policy, Senior Fellow – Economic Studies


Brian Gillis
Office of Management and Budget, Budget Officer

Theresa A. Gullo
Congressional Budget Office, Director, Budget Analysis Division

Megan S. Lynch
Congressional Research Services, Specialist on Congress and the Legislative Process



Thank you for joining today’s webinar, Basics of Budget Reconciliation and the Connection to Health Policy.


I am Kate Sullivan Hare, Vice President for Policy and Communications at the Alliance for Health Policy.


For those of you who aren’t familiar with the Alliance, Welcome, we are a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issues.


The Alliance for Health Policy, gratefully acknowledges the support of Arnold Ventures and the Commonwealth Fund for supporting today’s webinar, and I’m pleased to have representatives from each organization here today to give brief opening remarks before we get started.


Now, let me turn it over to Erica Socker, Vice President, Healthcare, and Payer Reform at Arnold Ventures.


Alright, thank you so much, Kate. And let me first start by saying thank you to the Alliance team for putting together this event today, and to the Commonwealth Fund for co funding it for, for co funding it with us, and thanks to all of you for joining us.


So, for those of you not familiar with …, for those of you that are not familiar with Arnold Ventures or philanthropy that’s focused on providing evidence based solutions to important domestic policy problems, whether this is in criminal justice and higher education, or in the topic that everyone here today really cares about health policy.


The thing that really drives our health care work isn’t interested in making health care more affordable. And to us, that means making coverage more affordable for families, for employers, and for the government.


Just as an example of some of the issues that we’re focused on at the moment, this includes things like addressing excessive prices for prescription drugs, do for other health care services, like hospital care, and doing things like improving the long-term sustainability of the Medicare program.


Budget reconciliation, The topic of today’s event, is one tool that both Parties and Congress have used to advance their fiscal policy agenda over the years.


The thing could include policies like the one I just meant, like the ones I just mentioned, that affect health care spending and have real implications for access and affordability.


It sounds like an obscure and complex process, which it can be in many ways, but can also be a powerful way for Congress to make policy change.


I hope you find this discussion useful.


I think it’s really timely as Congress is going through the reconciliation process for a CCO Literally feel right now potentially considering additional reconciliation bills, I’m later on in this Congress.


Thanks, Kate.


Great, thank you so much, Erica.


Now we’ll, I’ll turn it over to Rachel Nuzum, vice president for Federal and State Health Policy at the Commonwealth Fund.


Thanks so much, Kate. Thanks to the Alliance team and thanks Darnall Ventures for joining us and partnering on this really important, timely event.


And thanks to our panelists, they are former staffers who are going to walk us through this process and help all of us understand what might be possible, what might not be possible through the use of budget reconciliation, The Commonwealth Fund, we are a 100 year old on, private foundation focused on improving our health care system and health care delivery in an equitable way. And a key component of that is ensuring affordable access to health insurance coverage.


And one of the key strategies that we have is making sure that we’re connecting our evidence and our research and our analysis to end users. And that’s you, all that are on the call with us today, policymakers and policy influencers, at the federal level, and the congressional, on the congressional side, in the, in the administration, as well as, our colleagues that are making really critical health policy decisions at the state level. So, we’re thrilled to be a regular partner with the Alliance, and connecting you off with really timely as evidence based information. So please, be interactive today. Please use this as an opportunity to ask your questions about the process about the policy. Nothing is a, is a crazy question.


And really take this opportunity to let us know how we can help you do your jobs as you work to expand access to affordable coverage for American. So, thanks again, and we look forward to the conversation today.


Great, Thank you so much, Rachel. Now, I just wanted to go over a few quick housekeeping items and introduce and then introduce our panelists.


I want to remind everyone that you can join today’s conversation on Twitter, using the hashtag all health Lives, and follow us at all health policy, as well as on Facebook and LinkedIn.


We want you to be active participants, so please get your questions ready.


You should see a dashboard on the right side of your web browser that has a speech bubble icon with a question mark.


You can use that speech bubble icon to submit questions you have for the panelists at any time.


We’ll collect those, and address them during the broadcast. You can also chat any technical issues you may be experiencing, and someone will attempt to help.


Please be sure to check out our website, all health policy dot org, where you can find background materials, including a resource list and an expert list.


A recording of today’s webinar, including today’s slide decks, will be made available on our website soon.


Finally, be sure to mark your calendars for Thursday, February 25th for a discussion on Medicare insolvency and potential solutions.


OK, now to get into the topic at hand here with me today to further explore the challenges and opportunities of budget reconciliation or a group of former staffers, as well as Xtina experts.


First, I would please, I’m pleased to be joined by Sarah Kuehl Egge, a former partner of split, a founding partner of Split Hooks Strategies, and Washington, DC, which is a bipartisan consulting firm.


She focuses on health care policy across a wide range of sectors and federal programs.


Sarah possesses over a decade of **** experience including as a legislative assistant policy analyst to Senator Bob Kerrey and later served as health and the title that’s analyst for the Senate Budget Committee.


She also served as Deputy Staff Director to the Joint Committee on Deficit Reduction.


Next we have Dr. Purva Rawal, principal at CapView Strategies where she develops evidence based public policy and business strategies and conducts policy research on health system transformation, transformation and sustainability issues.


She’s also an adjunct assistant professor at Georgetown University and as an active writer and public speaker.


Previously, you, Dr. Rawal served as a professional staff on the Senate Budget Committee during the passage of the Affordable Care Act and as the health and social policy advisor to former Senator Joseph Lieberman.


Finally, we have Dr. Rodney Whitlock, Vice President at McDermott+ Consulting.


Rodney is an accomplished healthcare executive with more than two decades on health on Capitol Hill where he has specialized in rural health, the health care safety net and disability policy, while working in Congress, Rodney surface the former US. Rep, Charlie Horwitz Health Policy Director.


He then went on to serve Senator Chuck Grassley in the Senate.


He first joined the Senate Finance Committee staff as a Health Policy Advisor to Chairman Grassley and ultimately joined the Senators Personnel Office of Health Policy Director.


Thank you all for being here with us today.


Sarah, let’s start with you to provide a quick level set of the budget reconciliation process.


Excellent. Thanks so much, Kate.


And thanks to the Alliance for Health Policy, the Commonwealth Fund, and Arnold Ventures, for giving us this opportunity to come talk about reconciliation.


Perhaps it’s no surprise. I started my career as a congressional intern back in the summer of 97 attending markups, that the Ways and Means Committee, for the two big reconciliation bills. Known as BBA and the Taxpayer Relief Act of 1987. And then was lucky enough to go spend the next 15 years of my life working in and around tax and budget, and healthcare related items at the Senate Budget Committee.


So if we could go to the next slide.


Stepping sort of back to the actual slide after that, if we could skip to the next slide. Stepping back out to the 50,000 foot level, the federal budget process has five basic components And I’m gonna focus the presentation today on the three and italics because those are the three pieces that really are part of the congressional budget process. But typically in Washington, the Federal budget process kicks off with the submission of the President’s budget. Now we’re currently waiting for President Biden to submit his budget for fiscal year 20 22.


But in the interim, because Congress didn’t complete its work on the Fiscal Year 20 21 budget, Congress was able to adopt last Friday in the House and Senate, a joint Congressional Budget Resolution that is kicking off a reconciliation process This week over in the House.


We’ll talk a little bit about what the components of a budget resolution are, what reconciliation really is, how the budget resolution is enforced. And then I would be remiss if I didn’t also mention that the Executive Branch has a, has a component to the enforcement actions as well, related to statutory deficit control measures. But we’re not going to spend too much time in this presentation talking about that.


Please skip to the next slide, please.


So, what is a budget resolution? I mean, put, most simply, a budget resolution is, essentially, a governing blueprint that provides an annual plan for the Government’s finances.


And it really provides structure for Congress to revisit old spending and revenue decisions at the macro level, and develop and enforce fiscal targets.


According to the budget plan, the Congressional Budget Act, 1974, is what really spells out what has to be included in a budget, and at a macro level, and include spending revenues, deficits, and debt levels that are then going to be enforced throughout the, the, the next fiscal year, spending is further broken down into sub categories. That are broad in nature as, you know, defense, Medicare, spending income, security spending, and each committee ends up getting an allocation for spending, and then the ways and means, and finance committee is getting revenue allocation.


Um, a budget resolution may also include, what is known as a reconciliation instruction, and that is essentially a legislative tool to expedite action by the authorizing committees to bring spending and revenue policies in line, what was envisioned in the budget resolution.


It can also include reserve funds, which highlight particular spending priorities that Congress might want to work on in the coming year. And it’s an important tool for getting around 60 vote budget points of order on the Senate.


Typically, a budget resolution covers 5 or 10 fiscal years. It’s at the discretion of the Chairman of the Budget Committee. This particular budget resolution that passed last week is for 10 years.


What, what is unique about a budget resolution is its privileged nature, which means there are limitations on the amount of debate in the Senate. So limited to 50 hours.


It cannot be filibustered, and it takes only a simple majority to pass.


In years in which Congress doesn’t adopt a conference budget resolution, typically, a deeming resolution is adopted that is used to enforce the budget rules. And that very often occurs when a different party is in charge of both the House and the Senate.


If we can go to the next slide?


So what exactly is reconciliation instruction?


I mean, as we discuss, reconciliation is an optional component of a budget resolution, but in recent years, it’s pretty much been the driving force to accomplish and adopt a budget resolution in both chambers. Because it unlocks the opportunity to advance legislation in the Senate with only a simple majority vote and get around the filibuster.


A reconciliation directive and a budget resolution is really quite simple. It includes, you know, directions to particular committees, in the resolution passed last week. 12 committees were instructed in the House, 11 in the Senate.


They are instructed to achieve a particular budgetary target and to report back their recommendations to the budget committee by a date certain, and in this case, it’s the last resolution was for February 16th.


It’s important to note reconciliation. Instructions can’t dictate a particular policy outcome. That is really up to the authorizing committees to decide how they want to use their instructions.


But included here, I just put an example so we can see what a reconciliation instruction looks like.


As you can see here, you know, the Committee on Ways and Means was directed to submit changes that achieved nine hundred forty point seven billion dollars in deficit, increasing measures And they’re instructed to report back to the budget committee by February 16th and in fact, they are in day two right now of their markup.


If we can advance to the next slide.


Reserve funds are also an important part of a budget resolution that essentially create a placeholder for future policy actions by the By the authorizing committees.


The most recent budget resolution included reserved funds for everything from preventing tax increases on small businesses during a pandemic to cope with 19 vaccine administration and a public awareness campaign.


They’re important because they give the chairman of the budget committee flexibility to adjust committee allocations and other budget levels to accommodate legislation and get around 60 vote points of order.


They can allow flexibility within a committee or across committees on how bills are offset. So, for example, you know, create some fungibility within the Finance Committee to use revenues to offset spending or vice versa. Could allow a committee like the Help Committee to, to advance spending legislation, but offset with maybe something from the Finance committee.


The most recent budget resolution included, as an example here, a reconciliation reserve fund that essentially gives the chairman of the budget committee, the ability to change the allocations and the aggregates and the PAYGo ledger to help get around the Senate PAYGo point of order.


And also, basically, said, Any legislation that meets this test, according to the chairman Budget committee, could also avoid the short term, and long term, deficit points of order, which would otherwise create a 60 vote point of order against a reconciliation bill in the Senate.


If we can move to the next slide.


So, reconciliation is, is really, you know, part of a two step process, The first being the passage of the budget resolution, that’s the enabling document that allows the House and the Senate to move forward with reconciliation legislation.


And right now, as we discussed, the House committees are already very busily working on, their meeting, their reconciliation recommendations, which they’re going to send to the House Budget Committee. You know, Congress has passed probably 26 reconciliation bills since 19 80. The first time reconciliation was ever used, and 21 of those bills have been enacted into law, you know, in the eighties and nineties. Reconciliation. Legislation was really use to advance deficit.


Reduction measures starting in sort of 1999 to 2000 a number of Congresses have used reconciliation to advance tax legislation that has that reduced significant surpluses.


Yes we actually used to have surpluses back in the day back in the early two thousands or to increase the deficit in the case of the 2017 tax cut.


In the Senate, while reconciliation bills are a privileged vehicle, which means you can’t filibuster getting on the bill and you can’t filibuster getting off the bill.


And they do get expedite consideration.


There are a number of budget enforcement tools that really kind of constrain what can be included in a reconciliation bill.


Know, generally, 60 vote points of order, against amendments that are non domain Or that we put a committee out of compliance or that touches anything having to do with Social Security Title II benefits.


But the Byrd Rule, which can be raised against provisions that are considered to be extraneous, is really probably the most commonly discussed. Point of order that applies in the Senate.


It can be waived with 60 votes. But if not waived, the provisions can be struck from the bill.


There are plenty of examples of provisions that have been included in past reconciliation bills that would have been verbal, but didn’t end up getting burned out because those bills advanced any more bipartisan way.


As we more recently have seen examples of really partisan reconciliation approaches, we tend to see a lot more issues challenged through the Byrd Rule.


The bird rule is really a six part test and the six pieces are are listed out here, A through F, but I would really call your attention to a couple of bird rule provisions in particular because they’re the most commonly discussed.


And there’s a lot of discretion involved in how they reply.


The first is, you know, if a provision can violate the Byrd Rule, if it doesn’t produce a changing out laser revenues, that may seem very straightforward.


But for a number of provisions, you can have a sort of sub clause that’s considered a terminal condition.


That, in and of itself, doesn’t have a score, you know, associated with it, but is considered to be a term and condition of an underlying provision that does produce and outweigh our revenue effect.


Those those are not necessarily considered vertical items and the staff will spend a lot of time in front of the Parliamentarian debating what is a term condition and what is not a term and condition.


I’d also draw your attention to Part D, which essentially says, you, you, It’s considered extremely nice if you have a provision that changes outlays or revenues, but it’s merely incidental to the underlying, you know, budgetary components of the provision.


A lot of that is in the eye of the beholder on what is merely incidental.


I think we’re going to probably have a very robust discussion on this coming reconciliation built around, whether provisions, like the minimum wage are truly budgetary in nature, or whether they are really more mandates on private business and don’t necessarily meet the test of a budgetary item.


Another key component is at Section E, which, if you have a provision that increases net outlays or decreases net revenues outside of the budget window in this case, 10 years, if those provisions aren’t otherwise offset by other provisions within that title, they have to be sunset. And this is something we’ve seen a lot in tax reconciliation bills in recent years.


I’m going to order or not self executing a senator and it has to stand up and raise a bird real point of order.


And the parliamentarians role in all of this is to advise the presiding officer in the Senate on whether a Byrd rule applies.


Key players in this whole reconciliation efforts are really threefold.


First is the Parliamentarian who plays a really critical role, as I said, in advising the presiding officer, a half weeks of order are applied, particularly with respect to the application of the verb rule.


The Parliamentarian looks to precedent, no reasonableness the Senate rules, defer to the budget chairman often on matters of scoring.


But on many issues, applying the rule is an art and not a science.


CBO and JCT are also critical to the process, because they provide very detailed information about the revenue, and spending, and deficit impact of these various provisions in a reconciliation bill, which then helps determine whether points of order apply. And then, of course, the budget committee chairman is authoritative on on scoring issues, on the underlying reconciliation bill, and plays a really critical and important role.


If we can go to the next slide.


Finally, I would be remiss to point out that, you know, budget enforcement provisions don’t just apply to reconciliation bills, They apply to all bills, and it’s a way of enforcing the the budget numbers that were agreed to in the budget resolution.


There are some points of order that apply only to budget reconciliation bills and budget resolutions, but many apply to all legislation.


Many can be waived with a simple majority. Some require 60 votes to waive.


Some of the most common, you know, points of order, you know, that are raised against bills have to do with committees exceeding their allocations.


Or violating the Senate PAYGo rule, which requires direct spending and revenue legislation to be fully offset.


Just like with reconciliation points of order, in general, budget, points of order are not self executing a, Senator has to go to the floor, and raise a point of order in order for that to apply. And, Of course, another Senator would have to stand up and wave that point, the corner. I know we’re gonna get into a lot more discussion about how reconciliation, and the application of vertical has applied in the real world, and the politics around reconciliation, but I’m gonna pause there, because I know I threw a lot of information, and turn it over to our next presenter.


Sir, Thank you so much for that helpful context.


Definitely. I learned a few things, left them to a few of the yourself. A little scary.


I’d like to now turn it over to Purvey for heartache.


Just want to say thank you to the Alliance Arnold Venture from the Commonwealth Fund for making this event possible, and for the opportunity to participate, especially with my former colleagues. I feel like I had a tough at sandwiched between Romney, who are two real budget and health policy experts. So Sarah walked through the complicated rules governing reconciliation. And I think helps us all, including myself, understand, better what types of provisions or policies may make it through the process, over the next month. or a month. and a half. My brief remarks are really gonna focus on how the reconciliation bill, may address some of the Biden Administrations and Congressional Democrats Health Policy Priorities. Next slide.


So for the health policy wonks, in the audience, we know there are countless challenges facing on our health system today and the Biden administration, you know, even dating back to the campaign. And even in the first few weeks of this Administration. Which, you know, I think it’s only been three weeks, and I feel like a year. And, you know, they outlined to many of these challenges. They talked about a lot of these challenges, and, you know, in many cases, you know, a number of proposals on many of which are expansive nature, to address them. So now, we’re thinking about coverage gaps, affordability challenges, that are facing consumers, and patients, both insured and uninsured. And then, you know, of course, the priority issue is containing the pandemic, And that’s the driving reason for this. First relief fell under the Administration.


So, you know, today and for the next 4 to 6 weeks in the Congress, the new administration and many of us in Health Policy world are going to be focused on that first. Chevron. Coven 19 and And And how this really fill me address a lot of the health and economic needs. That the pandemic has kind of pushed to the forefront.


But, you know, I think this is also an opportunity for us to think about how this reconciliation bill and this effort, may impact or lay the groundwork for action on some of these other priority issues down the road as well.


Next slide.


So Sarah already referenced that. I think we’re in a second day of markup. So, you know, these are just some of the examples of the types of policies that are under consideration. Starting with the house side, you know, they’ve gotten underway already, finished the last couple of days, have been kind of flipping through, I’m sure many of you on the line, then flipping through the legislative tax emerging from ways and means, and health and labor, and an energy and commerce. But these are some examples of the types of policies that are under consideration. And, you see that, you know, Congress is really trying to address a broad range of health and economic issues that are facing folks.


So, you know, obviously, front and center, in our cover testing, your vaccine policies and money to kind of, you know, for the CDC to distribute on vaccines addressed, vaccine confidence and hesitancy issues, really creating a robust testing capability. You know, technical assistance to states, making sure your tests are being developed, distributed, and we have the capacity to do that, hefting, There’s also potential investments in workforce. So, you know, building a real contact tracing workforce, mainly on community health workers, who are often the folks on the frontline and are really key to addressing vaccine hesitancy epidemiologists.


There’s, there’s a long list, and in some alliterative text, and then also focusing on health care settings, where, you know, lucene outbreaks like skilled nursing, you know, another, obviously, big bucket of policy issues.


Congress is trying to address coverage expansion. So, we’re looking at, you know, potentially significant changes, even if they are short-term for now, in all segments of the population. So, you know, and I think policymakers are really trying to your members available to both shore up and expand coverage. So, ACA, you know, looking at making subsidies more robust employer ESI, extending cobra subsidies and then, again, thinking about Medicaid. And, you know, achmat potential map enhancements to get non expansion or coverage gap states to expand. And also think incentives for post-partum coverage up to 12 months.


Then I think one of the other issues that co-operatives really, you know pushed to the forefront, which, you know, everyone here as well aware, is, you know, the issues with at risk and vulnerable populations and really push those issues to the forefront of the big focus.


President Biden and Vice President, Harris’s campaign and even in the early weeks of their administration we’ve seen them you know stand a covered health equity taskforce or a meeting later this month. And so, you know, I think we’re seeing Congress prioritize those populations as well.


In some of the early legislative efforts for, for Medicaid, it’s not just getting some of the eligible enrolled in coverage gap state, but also are there specific parts of, you know, the Medicaid program that can be strengthened? So, you know, 100% F map to states for vaccine administration increased enhanced snap for home and community based services.


In the last few days, we’ve seen a lot of news about community health centers, increasing funding to say today’s, making sure vaccines are getting there, and then also took note of additional funds for the Indian Health Service.


We know its population and many of those communities have been disproportionately impacted by the virus then Last, I added a couple of bullets on social services and support because, you know, those of us in health policy world, we’ve been talking more and more about social determinants of health issues and social risk factors over the last few years. And you know, I think when we’re thinking about the health policy impacts of this Kobe Relief though, it’s also an opportunity for us to look at social. Howdy. These Investments, Congress makes these investments and social services and supports, you, know, trust, and connect that back to, maybe, potentially, you know, hopefully, having some positive health impacts from you as well.


Next slide.


And then I’m gonna close it out by just saying, you know, depending on what is in a final reconciliation, voluntarily walkthrough. You know, it’s not easy to maintain, you know, all of the provisions that Congressional Democrats. The dividing ministration may want to see, given all the rules governing the process. But I think we can also look forward to be thinking about the longer term implications. For provisions, I do make it in, or even provisions that have been, you know, that are being debated, and what that means for longer term policymaking and some of the longer term coverage, and affordability, and public health goals for this administration and Congress.


So, you know, in terms of the ACA, for instance, if we are looking at more robust subsidies for the time, limited period, is actual thing, that kit, that maybe gets extended, or are, made more permanent. You know, if actually, you know, were to receive an enhanced F map for moving forward on Medicaid expansion. If they haven’t yet, for a quarter, is that something that they would walk back from, after after a couple of years, you know, hard to take coverage away.


Then workforce issues, for instance, you know, the the cell can really provide a new foundation to rebuild and kinda re-invigorate our public health workforce, which we know it’s been really which covenants I think has really illustrated has been quite depleted. Some questions for us to be thinking about. You know, one of the other thing Sarah mentioned was, you know, if there is bending or increase the deficit outside of the 10 year budget window, the spending increases have to be have to be offset. And, so, you know, depending on the offset that are needed in this, Reconciliation Bill could also affect future legislation, negotiation for potential legislation that does move to the regular order.


So, I’ll just close it out by saying, there’s a lot happening in our lot of moving pieces.


lethal already, But, you know, for many of us who are, you know, in the policy world and researchers as well, it’s really also an opportunity, I think, to measure and assess the impact of some of the shorter term changes. To think about, you know, what we can learn to address some of the longer term challenges and priorities.


Thank you and I will turn it over to Rodney.


Great. Thank you. And I would like to invite, that is extremely helpful. And I would like to now turn it over to Rodney.


Alright. So I get to follow those two. And man, they’re smart. There’s a reason why, when I argue before the Parliamentarian on the other side of their argument I lost.


And I lost, so, let’s talk about this from the perspective of, you know, some nuts and bolts, nitty gritty things. Some politics.


Reconciliation is necessarily parts, The last reconciliation processes, oh, 5, 10, 15, and 17, or all partisan, not one minority member on either side, cross the aisle. To vote with. Go, back to the old one tax bill was the last time we get there, Sarah can correct me as she will know that we’ve had a even a hint of bipartisanship and reconciliation.


I think that we have very, very, very low expectations on whether or not there’s going to be any bipartisanship within these reconciliations.


So the role of the minority in these efforts is to try to make it as difficult as possible for the majority, Don’t hate the players, take the game. That’s the role.


Their job is to come in and try to make it difficult to make it hard for the majority to get around the filibuster in the Senate through using reconciliation, which is why all of those nattering little rules set forth by Robert Byrd, are so important.


Because that’s the real mechanism that the minority has to try to at least create limits on what the majority will do in this bill.


And in future reconciliations.


Because as would be inappropriate question for this panel, No. This is not the only time we’re going to be doing reconciliation between now and the 22 election.


Good chance, we might be doing it again, And again.


And how we could do that, is going to be really important. And, then, learning all those nattering little rules, is very important.


We’ll talk a little bit about, well, I’ll talk a little bit about the process, literally, how it works, when we have these disagreements, over what can be in a reconciliation bill.


So, in, when the bill comes before the Senate floor, this reconciliation Bill is on a fast track, and it will be to the Senate floor, soon, like, weeks away, soon.


It certainly appears that the all intents are to get this to the President’s desk, before the ides of March. So, this has happened.


When it hits the Senate floor, when the Senate Budget Committee calls this up on the Senate floor, it starts a process, a process, where the majority and the Minority, will, go, before the Senate Parliamentarian to take a look at the bill to show what it is, potentially, oh, a violation of the Byrd Rule.


And what should fall out? This is referred to. for those of us then. I’ve done this on the Inside the Bird bath, which then, produces bird droppings. I wish I was kidding. We really do talk that way.


And so, with the bird bath and the bird droppings, you have provisions that just may simply not be able to be included in a reconciliation bill.


But understand this, the majority has very, very distinct advantages. The advantages are, that one, the majority has language.


The minority only gets to see the final language, when the majority is ready for them to see that the majority has time to plan. The minority does not.


The majority has access access to CBO, does not say the minority doesn’t have access to CBO, the majority knows what they’re having scored.


The minority is sort of playing a guessing game, what we think they might be doing this, and how much you react.


And then, of course, there’s access to the Parliamentarian hope to be sure both sides have access, but the majority knows what they’re talking about. Minority is guessing.


As long as the majority has time to use those advantages, they have a clear advantage when it comes to arguing before the Parliamentarian over whether or not something is legitimately bird rule violation or is arguable.


Those advantages, though, are limited.


The limitation is Robert Bird, of course.


Well, those rules are in place, and it makes it very difficult to do complicated public policy under reconciliation.


There’s a reason: Republicans failed in 20 17 to take on repeal and replace two reconciliation.


Moving the policy necessary through budget reconciliation was improbable.


Remember the 2010, Affordable Care Act?


Sometimes you might have to be reminded that actually didn’t move by reconciliation, Healthcare, and Education Reconciliation Act it, but that was what we lovingly referred to as the Sidecar, the main bill moves the regular order, and that’s because in a million years, a lot of the ACA could not have gotten through reconciliation in 2003. Republicans and Democrats, Republicans, particularly the majority at that point, never remotely consider trying to do Part D through reconciliation.




Because Robert’s book, Robert Byrd rule basically says, if you’re trying to do complicated public policy through reconciliation, that’s not what it’s for.


His intent, the creation of the …, you can go back and read the 19 85 first Board role hearings lovingly written by Bill Doused. Her who now currently serves on the Senate Budget Committee for the majority. That the intent was to protect ultimately, the filibuster and it’s, frankly, all inspiring power in the Senate by not allowing reconciliation to get around it, to do complex public policy.


So we have these arguments. And these arguments are over what we would consider to be the gray area.


Just what is extraneous and what is not, what can be included, what meets with those definitions?


And those are arguments held before the Parliamentarian my friends and I have done. So we have argued over whether or not something was consistent with the Budget Act.


But at the end of the day, that is a process that is ultimately considered legitimate for those of us in the room.


Am I happy that I lost arguments?


Of course not.


Oh, am I going to get over it?


I’m probably never. Well, I continue to wake up, in the middle of the night, arguing with Mary Naylor over whether or not a formula is extraneous to the savings found through a disk Provision.


Yeah, probably, But am I really, at the end of the day? Kidding about that.


Of course, I.


At the end of the day, we who do this and have done this on a professional level, we depend upon the legitimacy of the process. We depend upon an agreement that what we’re doing here is consistent with the rules of the game.


And that’s, I think, one of the things we’ll watch for most carefully in 20 21, which is, as we get to points where the rules getting in the way of the public policy interests, oh, will the majority being able to live with that and be able to take the losses, or when we begin to bend the rules. Bruce: The rules are concerning Lee, break the rules. That’s something we’ll watch for. I think there’s one conversation to be had in this bill.


But then we move to other bills. We move sorta toward the agenda, the Perfect discussed.


Now, we’re moving into areas where it’s much more complicated in terms of policy, and those arguments are going to become much more important as we move into complicated policy areas. And so this is the first conversation we’re having, probably not the left. And how that is treated and how that is respected is really critical for public policy moving forward.


And with that, I’ll turn it back over.


That’s great. Thank you, Rodney, that.


We could do a whole a whole hour just listening to us inside the beltway terms like bird droppings and Bird Beth, or, I guess, the other.


Learning lots of things inside the beltway. So glad to have all of our panelists back on camera for some questions.


And we’ve already had quite a few around the virtual if I could just jump into some of these.


Um, one is from, uh, from Craig Smith.


He wants to know about how, often, in a budget reconciliation, how often this session budget reconciliation, can be used.


Normally, I think it’s once, but this year, as twice, And we’re just one who’s wondering if this is possible because of budget wasn’t approved for the prior session.


But if someone could answer that question about why it is that we have to reconciliation bills this year, yeah, I’m happy to to tackle that first. So the reason.


So the answer is complicated. the reason we are taking up a Reconciliation Bill, so quickly before President Biden has submitted a budget is because Congress never completed action last year on its FY 21 budget resolution. And so following in the footsteps of the Republican Congress from 20 17, who advanced in January, a budget resolution that sort of enabled the whole repeal and replace reconciliation fight, they had taken a beat because the previous year in 20 16 no budget resolution have been adopted.


They were able to move forward after discussions with the Parliamentarian that it was appropriate with a budget resolution in 20 17. And so that’s exactly what’s happening this year, is because Congress hadn’t passed an FY 21 budget resolution. That opportunity is still available to the next Congress. So they are moving forward a budget resolution and reconciliation process pursuant to the FY 21 budget resolution, even though we’re, who’ve already been in fiscal Year 21 for how many months? Now?


5? 4.5.


However, once the president submits his budget for FY 22 and the the budget committee start their work, you know, sort of on the regular budget resolution cycle process for FY 22. If they’re able to adopt a conference budget resolution in both chambers. That includes a reconciliation, or instruction or instructions, then they can move forward with a second bite at the apple.


I would also note that, you know, there is nothing that prevents a Congress from then adopting yet another budget resolution or a reconciliation reconciliation resolution. That would allow for yet a third. But later this year, in fact, you know, in the early days of reconciliation, Kate, I think I heard you talking about history recently, when you are on the Hill.


There were actually multiple years where, you know, Congress took up more than one reconciliation bill. That was in the early days. Now, we realize how difficult it is to even get one reconciliation bill done. So, it’s rare that we try to take more than one bite at the apple, but it is a possibility.


I just want to jump in, and I really would love my colleagues reaction to this. Was our mutual friend, Bill, Doused, are going back, I think we’re going to dust off something called debt limit reconciliation this summer. Wouldn’t shock me in the least, and that’s perfectly legit.


Yes. That’s that’s definitely true, although debt limit reconciliation has to also be triggered by a budget resolution. So when you do a budget resolution, you can do multiple reconciliation instructions. You can do spending instructions, revenue, instructions, some, combination, which is either deficit increasing deficit reducing.


And you can do a debt limit instruction per reconciliation. Absolutely.


We’ve had several questions about the number of years, that our budget reconciliation Bill may be other bird rules, specific to 1, 5, and 10 year effects on the budget.


I’m happy to tackle that one, too. So typically, I believe the Congressional Budget Act actually requires you to use the current year and then the next five years. But oftentimes, we end up doing 10 years, because CBO is a matter, of course, is 10 year budget projections.


And depending on what you’re trying to accomplish, you know, the budget committee chairman will decide whether it’s more appropriate for a five year versus a 10 year budget. rest of this one.


That was just adopted last Friday, is a 10 year budget resolution. The question about how to points of order apply, yes. Many of the points of order that are, you know, either in statute or or have been created as a result of past budget resolutions, have three time windows.


Look at the current year, the five year window, and the 10 year window.


The Deficit Reduction Act was five year, unless the last time that the Congress did a five year version, All the rest, the one sense of all been tenure.


Actually, technically, 2010 was the five year budget resolution.


Sarah was five or 2009, which enabled the 2010, OK, because the provisions were, obviously outs are just me, see how it goes.


To combine several questions, if I can, until I pip over the wondering what some of the different policy initiatives might be tax on to reconciliation, could we see something as large as a public infrastructure, Bell, or something more narrowly focused to health a public option?


ACA policy change as the parvo walked us through.


But what about something like Paid Family Leave? How could we see those in a second bill this year if they’re not added this week?


Perfect. Enough, do you want to try some of these?


Now, I mean, I think what we’re seeing here in this initial, I mean, I think of the policies, even in this covert really, fill, are pretty expansive, but they’re time limited, Which makes them, I think, a little bit easier to pass on the telco. Dialing up and down, you know, on existing programs on, existing policies, subsidies addressed, or talking about enhancing them, for instance, on. But, I think, the bigger, if we’re thinking about new program, completely new policies, those things become more difficult. for the reasons that Sarah and Rodney laid out. You know, it’s hard to do. True policymaking, especially de novo.


Know, through reconciliation in radio, noted that Republicans ran into trouble would repeal and replace. So, you know, I think there are going to have to be things that have to move through the regular order in terms of some of the big policy priorities of the administration, and this. Congress, you know, there, you are probably going to need a little bit of bipartisan support as well. And so, you know, this is a real balancing act, I think, for you, to try to push a, really feel through that, you know, that the country needs. But also thinking about how it could impact some of these other priorities down the road as well.


There gonna be some very tired budget committee staffers in the House, the Senate by the end of the year. They will be tired, they will also be in desperate need of an august recess, because they won’t have any of my August recess. Any guys just like to, know, sort of what the other, On the other hand, we’re looking at.


Some of these, if we’re looking at these areas of cuts, what are the areas spending that could be adjusted to fund health policies if we’re going to do some of that balancing.




I think one thing I’d just add, and this is very much playing off with what perfect discussing her presentation, I mean, there’s there’s a significant interest in finding a way to advance policies in this second reconciliation bill, to, you know, expand affordable coverage to more or individuals.


And so not only might we see an extension of the ACA tax credit subsidy policies that are sort of being done for two years in this first, you know, they’ll get extended permanently in a second bill, but there’s also been discussion about potentially a version of a public option that might expand health insurance opportunities, too.


Those, under 100% of the federal poverty levels in non expansion states, none on Medicaid expansion states. There’s also been some discussion about potentially lowering the eligibility age for Medicare, from 65 down to 60.


But, I think what’s critically important to note is if, no, If they’re trying to advance those in a permanent way, um, those policies are going to have to be offset in some way, shape, or form.


And they have to be offset with provisions that are in the jurisdiction of the committee that, that, you know, has jurisdiction over tax.


Policies and Medicaid policies and Medicare policies, which of course is Finance Committee in the Senate, and then, of course, joint jurisdiction over on the House.


And that’s going to involve some pretty significant, you know, discussions around potentially drug pricing policies. Could, you know, be a discussion around, you know, repealing the rebate rule that was finalized during the Trump administration could be a revisiting of tax policies from the 2017 tax bill to help offset some of these costs. Those are, Those are all tradeoffs. Either, I have to figure out what’s the right policy balance, but also what’s the right political balance to get us to 50 in the Senate.


If we’re going to try and tackle that challenge, I’ll say something simplistic.


If it spends money or saves money gamow, whether or not it can stay down to the last sentence, it is a different question. But if it spends money or it saves money, the games on, and you can try.


That’s a good point. Rodney, I’d like to ask another question that came up and it really comes to the role of the Senate.


Parliamentarian two is going to be making a lot of those decisions. And some after scoring comes into effect.


Can you tell me a little bit about the Parliamentarian who selects his Alexa Parliamentarian and what’s what their role is?


We all know Elizabeth McDonough. She’s the the current Parliamentarian. She is selected by the majority and she alum from the left and 13 and she took over since Do I have that right, guys? It was not long after two.


And wonderful person, Whip Smart and the arguments, when we go to her she’s representing the Budget Act and as the arbiter.


She doesn’t desperately care on about the policy.


It’s whether or not, what are the arguments that the three of us would make before her are consistent with her interpretation of the budget?


Yeah. I think that’s exactly right.


I mean, and she’s going to take into consideration things like precedent, no reasonableness.


I mean, She she has obviously you know of a finite knowledge of any particular Topic area that any of the Authorizing Committees might be coming to discuss with her.


And so she’s really going to use her good judgement based on the arguments that both both parties are bringing to the table to figure out, how does this really apply. And does this make sense.


That’s exactly what I was going to say, or the prep and you share some important, and we think back to the one reconciliation, but I wonder if you guys and Binder material, right, where you’re looking back at old reconciliation. Bellevue, guys, you know previous reference, ones that, you know, you’ve all this through and work on as well. But that is your profit is really important, because it’s not about policy. It’s about whether or not it, you know, here’s to the, to the world, and we’ve all been talking about. So you have to look at the path to see how it applies to, you know, a provision that might be, you know, potentially vertical.


OK, another question about the Federal from Julie Cantor Weinberg. She was wondering about non interference: with these: meet the requirements of budget reconciliation, or would it become a bird dropping after app or Beth?


Non non interference that That’s a very good question, and, you know, I know I, you know, when, when an interest in striking the non interference cause was first presented, back in movies that 2004, I can’t even remember when anymore. You know, CBO kind at the time that that would not have a budgetary impact unless Congress was going to attach other requirements to striking that inference class such as developing a formulary.


Um, I know letters have been sent from CVO in in the more recent times that hit. Basically, you know, re-affirmed that that continues to be there thinking.


I think the open question is if, you know, the Senate were to advance a proposal that required the Secretary of HHS to use some new tools to achieve savings.


And tied to that, a striking of the non interference clause.


Does that make the strength of the non interference clause a term and condition of the underlying provision that does have a scoring impact. And that is the kind of argument you would see playing out between Republicans and Democrats before the Parliamentarian.


I don’t think any of us know with certainty how that would turn out, but those are the kinds of arguments that would be presented.


I just got Sarah, what Sarah said. It was perfect in taking something that had a little bit of a black and white feel to it.


Well, it’s got those courts out, and then she started to make it a little grayer.


Now, it’s a fully open question, and that’s why she’s really, really good.


And but it’s true, and that’s, it’s long as you can start to make it a gray argument, knows what you accomplish, OK.


Well, you know, we could certainly dive into some of these issues for like I said, like another hour or if not the rest of the afternoon, but I just wanted to give each of you a minute to wrap up with any favorite memories that you might have from your years as a Congressional staffer. And working your way through reconciliation, any particular words of advice to staff and to our friends in the administration who are going through this for the first time?


Guess I’m kind of wondering as I get to know the Council in your office or the lawyers around you, which not a lot of folks are indispensable long term, but you know understanding legal precedent. And you know, really every word matters reconciliation Bill, on …, how you really have to read everything carefully go through with a fine tooth comb. So I found that those people are.


Keep, keep perspective. No person, I argued, in front of Allen, from an audit provision. Went back and forth and walked out Roman.


First deference, keep your perspective here, people.


That’s that’s important.


Right here.


I was gonna say, probably won that fight, but she might have won the fight. I don’t know if, ultimately, either of us have, won the war. But, my additional commentary is, find yourself, a friend like Bragi Whitlock, on the other side of the aisle, who you can still go laugh with and have a beer with at the end of the day.


But separate from that, you know, read, you know, build …, who’s now back at the Senate Budget committee, is that the Chief counsel has this great bird, rural, annotated document.


And for anybody who wants to get into the nitty gritty of how the Byrd rule has worked in the past on past bills, that is a great primer, too, to look at.


That’s terrific. Thank you so much for all of your insights. So we’ll see if we can get a copy of that primer for our website.


This has just been a terrific discussion, that I really appreciate it. Unfortunately, it’s all the time that we do have today. So I want to thank our panelists for joining us this afternoon.


Um, I just want to remind you again that February 25th is our discussion on Medicare and Solvency.


So please save that date and I’d like to see it right back here for that discussion.


Finally, we would like you to please, please take time to complete the brief evaluation survey that you’ll receive immediately after the broadcast, else, as well as by e-mail, later today, we really do listen to your comments, and take them seriously to improve our programming.


A recording of this webinar and additional materials will be available on the Alliance’s website staff, Parva, Rodney. Thank you so much for joining us. Appreciate it, and for everyone for joining us as well. Thank you.


Thanks so much.