---
type: claim
domain: health
secondary_domains: [internet-finance, grand-strategy]
description: "CBO and ASPE diverge by $35.7B on GLP-1 Medicare coverage because budget scoring rules structurally discount prevention economics"
confidence: likely
source: "ASPE Medicare Coverage of Anti-Obesity Medications analysis (2024-11-01), CBO scoring methodology"
created: 2026-03-11
---

# Federal budget scoring methodology systematically undervalues preventive interventions because the 10-year scoring window and conservative uptake assumptions exclude long-term downstream savings

The CBO vs. ASPE divergence on Medicare GLP-1 coverage reveals a structural bias in how prevention economics are evaluated at the federal policy level. CBO estimates that authorizing Medicare coverage for anti-obesity medications would increase federal spending by $35 billion over 2026-2034. ASPE's clinical economics analysis of the same policy estimates net savings of $715 million over 10 years (with alternative scenarios ranging from $412M to $1.04B in savings).

Both analyses are technically correct but answer fundamentally different questions:

**CBO's budget scoring perspective** counts direct drug costs within a 10-year budget window using conservative assumptions about uptake and downstream savings. It does not fully account for avoided hospitalizations, disease progression costs, and long-term health outcomes that fall outside the scoring window or involve methodological uncertainty.

**ASPE's clinical economics perspective** includes downstream event avoidance: 38,950 cardiovascular events avoided and 6,180 deaths avoided over 10 years under broad semaglutide access scenarios. These avoided events generate savings that offset drug costs, producing net savings rather than net costs.

The $35.7 billion gap between these estimates is not a minor methodological difference—it represents a fundamentally different answer to "are GLP-1s worth covering?" The budget scoring rules structurally disadvantage preventive interventions because:

1. **Time horizon truncation**: The 10-year scoring window captures drug costs (immediate) but truncates long-term health benefits (decades)
2. **Conservative uptake assumptions**: CBO assumes lower utilization than clinical models predict, reducing both costs and benefits but asymmetrically affecting the net calculation
3. **Downstream savings discounting**: Avoided hospitalizations and disease progression are harder to score with certainty than direct drug expenditures, leading to systematic underweighting

This methodological divergence has profound policy consequences. The political weight of CBO scoring often overrides clinical economics in Congressional decision-making, even when the clinical evidence strongly supports coverage expansion. The same structural bias affects all preventive health investments—screening programs, vaccines, early intervention services—creating a systematic policy tilt away from prevention despite strong clinical and economic rationale.

The GLP-1 case is particularly stark because the clinical evidence is robust (cardiovascular outcomes trials, real-world effectiveness data) and the eligible population is large (~10% of Medicare beneficiaries under proposed criteria requiring comorbidities). Yet budget scoring methodology produces a "$35B cost" headline that dominates policy debate, while the "$715M savings" clinical economics analysis receives less political weight.

## Evidence

- ASPE analysis: CBO estimate of $35B additional federal spending (2026-2034) vs. ASPE estimate of $715M net savings over 10 years
- Clinical outcomes under broad semaglutide access: 38,950 CV events avoided, 6,180 deaths avoided over 10 years
- Eligibility: ~10% of Medicare beneficiaries under proposed criteria (requiring comorbidities: CVD history, heart failure, CKD, prediabetes)
- Annual Part D cost increase: $3.1-6.1 billion under coverage expansion

## Challenges

The claim that budget scoring "systematically" undervalues prevention requires evidence beyond a single case. However, the GLP-1 divergence is consistent with known CBO methodology (10-year window, conservative assumptions) and parallels similar scoring challenges for other preventive interventions (vaccines, screening programs). The structural bias is well-documented in health policy literature, though this source provides the most dramatic single-case illustration.


### Additional Evidence (confirm)
*Source: 2024-11-01-aspe-medicare-anti-obesity-medication-coverage | Added: 2026-03-16*

The CBO vs. ASPE divergence on Medicare GLP-1 coverage provides concrete evidence: CBO projects $35B in additional spending (2026-2034) using budget scoring methodology, while ASPE projects net savings of $715M over 10 years using clinical economics methodology that includes downstream event avoidance. The $35.7B gap between these estimates demonstrates how budget scoring rules structurally disadvantage preventive interventions. CBO uses conservative uptake assumptions and doesn't fully count avoided hospitalizations and disease progression within the 10-year window, while ASPE includes 38,950 CV events avoided and 6,180 deaths avoided. Both are technically correct but answer different questions—budget impact vs. clinical economics.


### Additional Evidence (challenge)
*Source: 2025-01-01-gimm-hoffman-chw-rct-scoping-review | Added: 2026-03-18*

IMPaCT's $2.47 Medicaid ROI within the same fiscal year demonstrates that at least one category of preventive intervention (CHW programs) generates returns fast enough to be captured within annual budget cycles, not just 10-year windows. This suggests the scoring methodology problem may be less severe for interventions with rapid return profiles.


### Additional Evidence (confirm)
*Source: [[2024-10-31-cms-vbid-model-termination-food-medicine]] | Added: 2026-03-18*

VBID termination was driven by $2.3B excess costs in CY2021-2022, measured within a short window that could not capture long-term savings from food-as-medicine interventions. CMS cited 'unprecedented' excess costs as justification, demonstrating how short-term cost accounting drives policy decisions even for preventive interventions with strong theoretical long-term ROI.

---

Relevant Notes:
- [[the healthcare cost curve bends up through 2035 because new curative and screening capabilities create more treatable conditions faster than prices decline]]
- [[GLP-1 receptor agonists are the largest therapeutic category launch in pharmaceutical history but their chronic use model makes the net cost impact inflationary through 2035]]
- [[proxy inertia is the most reliable predictor of incumbent failure because current profitability rationally discourages pursuit of viable futures]]
- [[value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk]]

Topics:
- domains/health/_map
- core/mechanisms/_map
- foundations/teleological-economics/_map