Tag Archives: Health Policy

What Makes Singapore’s Health Care So Cheap?

Posted on by • Posted in Uncategorized • Tagged , • Leave a comment

What Makes Singapore’s Health Care So Cheap?

Image result for singapore's healthcare

Singapore’s health care system is distinctive, and not just because of the improbability that it’s admired by many on both the American left and the right.

It spends less of its economy on health care than any country that was included in our recent tournament on best health systems in the world.

And it spends far, far less than the United States does. Yet it achieves some outcomes Americans would find remarkable. Life expectancy at birth is two to three years longer than in Britain or the United States. Its infant mortality rate is among the lowest in the world, about half that of the United States, and just over half that of Britain, Australia, Canada and France. General mortality rates are impressive compared with pretty much all other countries as well.

When the World Health Organization ranked health care systems in 2000, it placed the United States 37th in quality; Singapore ranked sixth.

Americans tend to think that they have a highly privatized health system, but Singapore is arguably much more so. There, about two-thirds of health care spending is private, and about one-third is public. It’s just about the opposite in the United States.

Singapore’s health system also has a mix of public and private health care delivery organizations. There are private and public hospitals, as well as a number of tiers of care. There are five classes: A, B1, B2+, B2 and C. “A” gets you a private room, your own bathroom, air-conditioning and your choice of doctor. “C” gets you an open ward with seven or eight other patients, a shared bathroom and whatever doctor is assigned to you.

But choosing “A” means you pay for it all. Choosing “C” means the government pays up to 80 percent of the costs.

What also sets Singapore apart, and what makes it beloved among many conservative policy analysts, is its reliance on health savings accounts. All workers are mandated to put a decent percentage of their earnings into savings for the future. Workers up to age 55 have to put 20 percent of their wages into these accounts, matched by an additional 17 percent of wages from their employer. After age 55, these percentages go down.

The money is divided among three types of accounts. There’s an Ordinary Account, to be used for housing, insurance against death and disability, or for investment or education. There’s a Special Account, for old age and investment in retirement-related financial products. And there’s a Medisave Account, to be used for health care expenses and approved medical insurance.

The contribution to Medisave is about 8 percent to 10.5 percent of wages, depending on your age. It earns interest, set by the government. And it has a maximum cap, around $52,000, at which point you’d divert the mandatory savings into some other account.

A second health care program is Medishield Life. This is for catastrophic illness, and while it’s not mandatory, almost all of the population is covered by it. It’s really cheap, from $16 a month for a 29-year-old in 2019 to $68 a month for a 69-year-old, without subsidies.

Medishield Life kicks in when you’ve paid the deductibles for the year, and after you’ve paid your coinsurance. Deductibles vary by your age and the class of care you choose, and range from $1,500 to $3,000. Coinsuranceranges from 3 percent to 20 percent, varying by the size of the medical bill. Medishield Life has an annual limit of $100,000 but no lifetime limit.

Medishield Life is managed so that it covers most of a hospitalization in a Class B2 or C ward. Patients would cover the rest out of their Medisave accounts. Patients also have the option to pay for additional insurance, which would cover a higher class of care. Some plans are offered by the government, and people can use Medisave money to pay for those. Other plans are purely private, and sometimes offered by employers as benefits.

A third health care program is Medifund, which is Singapore’s safety net program. Only citizens are eligible; it covers only the lowest class of wards; and it’s available only after people have depleted their Medisave account and Medishield Life coverage. The amount of help someone could get from Medifund depends on a patient’s and family’s income, condition, expenses and social circumstances. Decisions are made at a very local level.

A number of people hold up Singapore as an example of how conservative ideas of competition and consumer-directed spending work. Unfortunately, the story isn’t so clean when you look at the data. In a 1995 paper in Health Affairs, William Hsiao looked at how health spending fared in Singapore before and after the introduction of Medisave. He found that health care spending increased after the introduction of increased cost-sharing, which is not what most proponents of such changes would expect. Michael Barr had similar thoughts in his “critical inquiry” into Singapore’s medical savings account, published in The Journal of Health Politics, Policy and Law in 2001.

But why is Singapore so cheap? Some think that it’s the strong use of health savings accounts and cost-sharing. People who have to use their own money usually spend less. But that’s not the whole story here. There’s a lot of government regulation as well.

Through the tiered care system and its public hospitals, the government has a great deal of control over inpatient care. It allows a private system to challenge the public one, but the public system plays the dominant role in providing services.

Initially, Singapore let hospitals compete more, believing that the free market would bring down costs. But when hospitals competed, they did so by buying new technology, offering expensive services, paying more for doctors, decreasing services to lower-class wards, and focusing more on A-class wards. This led to increased spending.

In other words, Singapore discovered that, as we’ve seen many times before, the market sometimes fails in health care. When that happened in Singapore, government officials got more involved. They established the proportion of each type of ward hospitals had to provide, they kept them from focusing too much on profits, and they required approval to buy new, expensive technology.

Singapore heavily regulates the number of physicians, and it has some control over salaries as well. The country uses bulk purchasing power to spend less on drugs.

The most frustrating part about Singapore is that, as an example, it’s easily misused by those who want to see their own health care systems change. Conservatives will point to the Medisave accounts and the emphasis on individual contributions, but ignore the heavy government involvement and regulation. Liberals will point to the public’s ability to hold down costs and achieve quality, but ignore the class system or the system’s reliance on individual decision-making.

Singapore is also very small, and the population may be healthier in general than in some other countries. It’s a little easier to run a health care system like that. It also makes the system easier to change. We should also note that some question the outcomes on quality, or feel that the government isn’t as honest about the system’s functioning.

There is a big doctor shortage, as well as a shortage of hospital beds. As Mr. Barr noted in a longer discussion of Singapore’s system, “It seems to be highly likely that if one could examine the Singapore health system from the inside, one would find a fairly ordinary health system with some strong points and many weaknesses — much like health systems all over the developed world.” This concern about how much we can really know about Singapore’s true outcomes is one of the reasons it didn’t fare so well in our contest.

States Gird for Worst as Congress Wrestles with Children’s Insurance Program

Posted on by • Posted in Uncategorized • Tagged , • Leave a comment

Image result for pennies for children

Federal officials on Monday approved a $3.6 million emergency infusion for Minnesota after the state’s human services chief warned that pregnant women and some children were at imminent risk of losing health care coverage under the Children’s Health Insurance Program.

Utah, meantime, has formally requested authority to “eliminate eligibility and services under CHIP” if the state does not have enough money to continue coverage.

In statehouses around the country, officials are preparing for the worst as lawmakers in Washington struggle to find money for the popular Children’s Health Insurance Program, which insures nearly nine million children but lost its spending authority on Sunday, with the start of the new fiscal year.

Congress has known for two years that federal funds for the Children’s Health Insurance Program were expiring this fall. But only on Wednesday are two congressional panels — the Senate Finance Committee and the House Energy and Commerce Committee — tentatively scheduled to vote on legislation that would provide money for the program for another five years.

And the two chambers have not agreed on how to pay for the measures.

“We know that there is a desire in Congress to provide the funds, but we have heard that same sentiment all through the spring and the summer,” said Nathan Checketts, the deputy director of the Utah Health Department. “Congress needs to get this done as soon as possible, so states do not have to begin notifying people that their coverage may end.”

The Utah program covers 19,000 children.

Most states still have unspent funds that will last several months. But some are drafting contingency plans in case Congress does what it has done so often: fails to reach an agreement. A federal panel that advises Congress on the Children’s Health Insurance Program says that more than half the states are expected to exhaust all their CHIP funds within six months.

By the end of this year, Arizona, Minnesota and North Carolina are likely to run out of money for their programs, according to the panel, the Medicaid and CHIP Payment and Access Commission.

By March 2018, it said, CHIP funds will be exhausted in 27 additional states, including California, Colorado, Connecticut, Florida, Massachusetts, New York, Ohio, Oregon and Pennsylvania. Another 19 states are expected to use up their money from April to June 2018, with one state exhausting its funds from July to September 2018.

Gov. Andrew M. Cuomo of New York, a Democrat, said Tuesday that Congress’s failure to act jeopardized coverage for 330,000 children in the state.

Representative Pete Sessions, Republican of Texas, said the need was “not dire or urgent.” Republicans, he said, intend to provide the funds, so “the money that is necessary to keep this program going is not in jeopardy.”

But Democrats accused Republicans of willful inattention.

“If making sure that every child in America has access to health care, if that is not a priority, what is?” asked Representative Jan Schakowsky, Democrat of Illinois. “Families are waiting anxiously while their health security is hanging in the balance.”

Action in the Senate was delayed for several weeks as Republicans made repeated unsuccessful attempts, in July and September, to pass legislation that would have repealed much of the Affordable Care Act.

CHIP is for children in families that make too much to qualify for Medicaid but not enough to afford other coverage. Nearly 90 percent of children in the program had family incomes less than twice the poverty level (less than about $40,000 a year for a family of three).

Even if congressional committees can agree, it is not clear how soon legislation will emerge from Congress. The Senate plans to be in recess next week, and the House is expected to be in recess in the following week.

The Senate bill is a bipartisan measure, drafted by Senators Orrin G. Hatch, Republican of Utah, and Ron Wyden, Democrat of Oregon. Mr. Hatch, now the chairman of the Finance Committee, helped create the child health program in 1997 and says he is eager to extend it.

In the House, some Democrats have expressed concerns about the bill drafted by House Republicans because, they say, it would pay for continuation of the CHIP program by cutting other health spending. Some House Democrats have suggested offsets that would instead reduce payments to pharmaceutical companies.

Under federal law, states receive annual allotments of federal CHIP funds. They have two years to spend their allotments, and unspent money is then available for redistribution to other states. The money sent to Minnesota this week came from that pool of unspent funds.

The Senate and House bills would each provide a total of $118.5 billion over five years, but under arcane budget rules, Congress needs to offset less than 10 percent of that cost. The Congressional Budget Office assumes that if the program ended, some children would become uninsured, but the federal government would help provide coverage for others, through Medicaid or through private insurance subsidized under the Affordable Care Act.

The federal government and the states have historically shared the cost of CHIP, with Washington paying approximately 70 percent of the cost in a typical state. The Affordable Care Act increased the federal share by 23 percentage points, with the result that the federal government has been paying the entire cost in 11 states.

The Senate and House bills would continue the 23 percentage point bonus in 2018 and 2019, cut it in half in 2020 and eliminate it in 2021 and 2022.

With Affordable Care Act’s Future Cloudy, Costs for Many Seem Sure to Soar

Posted on by • Posted in Uncategorized • Tagged , , , , , • Leave a comment

Image result for cost sharing reduction payments

Health insurers are aggressively increasing prices next year for individual policies sold under the federal health care law, with some raising premiums by more than 50 percent.

By approving such steep increases for 2018 in recent weeks, regulators in many states appeared to be coaxing companies to hang in there, despite turmoil in the market and continuing uncertainty in Congress about the future of the law, the Affordable Care Act.

In Georgia, the state insurance commissioner, Ralph T. Hudgens, an outspoken critic of the law, often referred to as Obamacare, said the rates he approved would be up to 57.5 percent higher next year. The state had already lost Anthem, the large insurer that offers for-profit Blue Cross plans in several states, which left many markets in Georgia.

“Obamacare has become even more unaffordable for Georgia’s middle class,” Mr. Hudgens said in a statement. “I am disappointed by reports that the latest Obamacare repeal has stalled once again and urge Congress to take action to end this failed health insurance experiment.”

In Florida, the average rate increase will be about 45 percent, according to state regulators. And in New York, where officials said prices would still be below where they were before the law took effect, premiums were expected to increase by an average of about 14 percent. Many states have not made insurers’ rate increases public, and experts said the rise in costs for consumers could run from 10 percent to nearly 60 percent.

There are exceptions. Minnesota, which sought a federal waiver to address the high cost of premiums, said this week that prices for plans sold on the state exchange there would remain stable or drop significantly in 2018.

Those who qualify for federal subsidies, a group that accounts for about 85 percent of the roughly 10 million people who buy insurance through the marketplaces created under the health law, will largely be shielded from the higher prices.

Regulators in Florida and New York said that residents of those states who qualified for the most generous subsidies could see lower prices next year, depending on which plan they buy. In some places, the least expensive plans could become free after customers apply their subsidies. (Deficit hawks will probably complain about the higher federal outlays for subsidies.)

People who earn too much to qualify for financial assistance will feel the brunt of any increases. Because many insurers raised prices most sharply on plans that are attractive to people who receive the most generous subsidies, those unable to get subsidies may have to shop for plans that are not affected or look beyond their state marketplaces for lower-priced options.

The final prices and policies available for all plans may not be public until Nov. 1, leaving many consumers confused about coverage costs as a shortened period of open enrollment for health care insurance under the Affordable Care Act begins.

The insurance companies have defended the rate increases, saying they were unavoidable under the current circumstances. After the latest Senate effort to repeal the health law collapsed, insurers still have no commitment about whether the government will continue to allocate millions of dollars in critical financing. Some lawmakers have renewed talk of a bipartisan solution to guarantee that the money keeps flowing, but there is no resolution — forcing insurers to set rates without an agreement.

The Trump administration has sent mixed signals about whether it will enforce key elements of the law like the individual mandate, which encourages healthy people to sign up for insurance or be charged a tax penalty. If insurers cannot spread out the cost of coverage for people with high medical bills over a large enough group, they may be inclined to raise premiums even higher.

“We’re all pricing up for it,” said Dr. Martin Hickey, the chief executive of New Mexico Health Connections, one of the few remaining insurance start-ups created by the federal law. New Mexico Health Connections recently expanded an existing partnership with Evolent Health, a public company, which will provide additional capital.

In New Mexico, the average rate increase for plans sold on the state marketplace is about 30 percent. “Half of that increase is due to the uncertainty in Washington and the inability to lead,” said John G. Franchini, the state insurance regulator. The four insurers selling policies in the state marketplace are offering more types of plans.

After a slow start, many insurers have been making money in the individual market for the past year or so. Premiums have generally risen faster than underlying medical expenses, according to a recent analysis by the research firm Mark Farrah Associates. With rates set to climb much higher next year, insurers could see profits rise significantly too.

But questions about the insurance market’s future make it nearly impossible to come up with accurate projections. Regulators and actuaries said that the higher rates reflected a conservative approach as a cushion against potentially sizable losses.

“It’s very hard for a regulator to deny those rate increases when we can take a look at their bottom line and can tell they can’t continue if they can’t keep their head above water,” said Mike Kreidler, Washington State’s insurance commissioner and a supporter of the health law.

Actuaries said that the higher rates were justified. The insurers “are really struggling,” said Kurt Giesa, a partner with Oliver Wyman, a consultant that has worked with regulators to review rates. “They have been working hard to adapt to what they are faced with right now,” he said.

And although they have been raising prices aggressively, “it doesn’t mean that insurers couldn’t lose money,” said Deep Banerjee, an industry analyst for Standard & Poor’s who has been following the improved profitability of Blue Cross plans. “The trend has been improving but the market is still fragile,” he said.

The uncertainty over paying insurers for the so-called cost-sharing reductions, which limit out-of-pocket medical costs for people with low incomes, remains problematic. Most state regulators let insurers set prices to cover the cost of the required reductions, but several did not.

The Trump administration has been paying insurers on a month-to-month basis; a legal challenge over the payments by House Republicans has left the issue in limbo.

In the states that did not allow insurers to account for a loss of federal funding, the rates would be “inadequate” if that funding went away, said David M. Dillon, a fellow with the Society of Actuaries who has also worked with several state regulators. They “are just hopeful that something can be fixed later on,” he said.

Two insurers pulled out of the markets at the last minute because of the confusion. Medica stopped offering coverage in North Dakota next year because regulators said insurers had to assume the financing would continue; Anthem abandoned the Maine marketplace because the money had not been guaranteed.

Mr. Kreidler of Washington approved two sets of rates but is only allowing insurers to charge the lower set. If the government stops paying for the subsidies, he said, “It’s going to be a real challenge.”

If Congress or the administration decide to keep providing the subsidies, prices will be higher than necessary if insurers raised their rates to make up for a loss of the funding. “We’ll see if we can lower those rates with the permission” of the federal agency responsible for overseeing the marketplace, Mr. Franchini of New Mexico said.

Some insurers think a decision on the cost-sharing money could come too late.

CareFirst, a Blue Cross insurer, offers plans in Virginia and Maryland. Virginia allowed CareFirst to assume a lack of financing; Maryland regulators prohibited insurers from setting higher rates based on a loss of subsidies.

“You have this unbelievable contradiction,” said Chet Burrell, CareFirst’s chief executive. In Maryland, where the company is losing money on individual policies, it could sustain much deeper losses if the federal money stopped coming in.

“I don’t think you can work it out,” he said. “The workout is you will have to eat it this year.”

Like other insurance executives, Mr. Burrell worries that the higher prices will eventually discourage too many healthy people from enrolling. In Maryland, he said, only one-third of those buying coverage are eligible for subsidies. Everyone else pays full price. The most popular type of plan could come with premiums of $373 a month to $686 a month for a 40-year-old.

“Given the size of the rate increases, we think healthier people will continue to opt out of the risk pool,” he said, suggesting that would lead to rates being even higher in 2019. “If that occurs, then you’re in a death spiral,” he said, because as rates climb, more healthy people drop out, sending prices even higher. Mr. Burrell said he was working with regulators in Maryland to potentially create a fund that would help care for patients with the very high medical bills while possibly lowering overall premiums.

But even insurers in states that have allowed for the loss of funding are not sanguine.

“I think it’s going to be a stumbling in the dark next year because of all the uncertainties,” Dr. Hickey of New Mexico Health Connections said. The changing circumstances and inaction by Congress have forced insurers to raise rates and experiment with different plans for those who are not eligible for federal assistance.

“It’s almost like the beginning, again,” he said.

GOP gives ground in ObamaCare stabilization talks

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment

http://thehill.com/policy/healthcare/353671-gop-willing-to-give-ground-on-obamacare-subsidies

Image result for cost sharing reduction payments

Republicans are willing to provide insurers with two years of ObamaCare subsidies under a bipartisan market stabilization bill, according to the Senate Health Committee chairman.

Sen. Lamar Alexander (R-Tenn.) said continuing cost-sharing reduction subsidies for two years is a key part of the stabilization package he is trying to negotiate with Sen. Patty Murray (D-Wash.).

Alexander and Murray are continuing to try to rally Republicans and Democrats around a short-term plan to lower ObamaCare premiums in 2018 and 2019.

“The elements of that are continuing cost-sharing payments for two years and to give states meaningful flexibility in the types of policies they can write,” Alexander said Tuesday.

Alexander initially only wanted to fund the payments for one year, while Democrats were pressing for two years.

Republicans pulled the plug on the bipartisan talks when it appeared their last-ditch ObamaCare repeal bill was gaining momentum, but the change in Alexander’s position could be a sign that he and Murray are closing in on an agreement.

The White House has been making the cost-sharing payments on a monthly basis, all while President Trump has continued to threaten to cancel them in a bid to make ObamaCare “implode.”

While Alexander and Murray may be close, the future of the bipartisan fix is unclear.

Many other Senate Republicans, including Senate Finance Committee Chairman Orrin Hatch (R-Utah), are more skeptical of a deal to stabilize ObamaCare than Alexander is.

And the House and White House are also uncertainties.

Alexander said the talks are continuing, and he and Murray plan to meet later on Tuesday.

Asked whether GOP leadership is urging him to continue the talks, Alexander said he thinks they have more important things to worry about.

“Well, I’m telling them that I am continuing the talks. They have lots of other things to worry about today,” he said.

 

The medical bill score: How the public judges health care

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , • Leave a comment

https://www.axios.com/the-medical-bill-score-2492012366.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=health-care

We track a lot of numbers in health care: how much we spend on health as a share of our economy; the number of uninsured; and the share of the federal budget allocated to health programs. What we don’t track — and a number the Congressional Budget Office cannot score — is the statistic that means the most to the American people: the share of the public having problems paying their health care bills.

Data: Kaiser Family Foundation/New York Times Medical Bills Survey (conducted August 28-September 28, 2015); Chart: Lazaro Gamio / Axios

The bottom line: The “medical bills score” is the single most important measure of how we are doing in health care from the public’s perspective. And ultimately, if Congress ever passes a new health care bill, it is how the public will evaluate that plan — from Graham-Cassidy to Medicare for All and everything in between.

The numbers that matter: As we found in a Kaiser Family Foundation poll in February:

  • 31% of Americans age 18-64 report they or a family member face problems paying their health care bills.
  • But that number shoots up to 57% for people who are sick.

It makes sense that people who use more care have more health care bills, but it also reveals how poorly our system performs from a consumer perspective when people who need care the most are protected the least by insurance coverage.

The impact: People are not just whining about necessary cost sharing. In a survey we did with the New York Times, we found that:

  • 70% of people with problems paying medical bills report cutting back on food, clothing and other basic necessities.
  • 59% report using up most of their savings.
  • 41% say they’ve taken an extra job to help pay for their health care.

Not surprisingly, the uninsured (41%) are more likely to have problems paying medical bills. But this is not a problem limited to the uninsured: 30% of the insured – think voters — have problems with medical bills.

The back story: The share of the public reporting problems paying their medical bills has not moved much in recent years. The Affordable Care Act has extended coverage and better financial protection to tens of millions, but it doesn’t have much of an impact on affordability beyond people covered by the Medicaid expansion and the marketplaces.

In the far larger employer-based health insurance sector, deductibles and other forms of cost sharing have been growing about five times faster than wages, and deductibles have been growing especially sharply for people who work for smaller employers. .

What to watch: Health care is a pocketbook issue for most of the public and the American people have their own scoring system. They may give this or that mostly partisan response about a health reform idea on a poll, but until they see how they’ll get help paying their health care bills, they will ultimately be disappointed by every health reform plan.

 

What the FY 2018 budget resolution means for ACA repeal

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

http://www.fiercehealthcare.com/aca/2018-budget-resolution-republicans-aca-repeal?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiTTJZNU4yTTNZV05sWm1FNSIsInQiOiJ2OXhPMHVRRk82MmRcL2llaVprUXFYSFJkbDBIS1lTcm1mRzVDSnFQQWRncUR5WmVDaFdFOGdTTkh4RWhIRTNHakR4Nm5Cd1hVYUIyZ1wveVl4ZTBpUXZqbkdYQldPTFpPazJqYlV4UGlNekw0QklMTHNwaEZtZVJGNHRXY2xVbzJPIn0=

The Senate side of the United States Capitol in Washington, D.C.

Senate Republicans’ fiscal year 2018 budget resolution suggests that they have put their goal of broadly unwinding the Affordable Care Act on the back burner—yet they could still use it to repeal key parts of the law.

The budget resolution (PDF), released by Senate Budget Committee Chairman Mike Enzi, R-Wyo., on Friday, contains reconciliation instructions that direct the Senate Finance Committee to “reduce revenues and change outlays to increase the deficit by not more than $1.5 trillion over the next 10 years.”

Since that reconciliation instruction is rather broad, the GOP could potentially use it to repeal some ACA-related taxes and other provisions that make health insurance affordable under the law, argued a post from the left-leaning Center for American Progress (CAP).

With their new budget resolution, Republicans could also still roll back other portions of the ACA, including the individual mandate, a Bloomberg article noted.

But because the budget resolution doesn’t include any instructions for the Senate Health, Education, Labor and Pensions Committee or the House Energy and Commerce Committee to craft reconciliation legislation, that may indicate that broader ACA repeal efforts are on hold, The Hill reported.

In addition to the reconciliation instructions, the budget resolution includes deficit-neutral reserve funds for legislation that would allow Congress to repeal or replace the ACA. This primarily just signals rhetorical support for rolling back the healthcare law, the CAP post noted, but that’s significant since it shows the GOP isn’t giving up on repeal.

Senate Budget Won’t Let GOP Pursue Full Obamacare Repeal

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

https://www.bloomberg.com/news/articles/2017-09-29/senate-budget-allows-1-5-trillion-tax-cut-not-full-aca-repeal

Image result for Obamacare Repeal

Senate Republicans unveiled a fiscal 2018 budget resolution Friday that they intend to use to push through as much as $1.5 trillion of tax cuts in the coming months, but it won’t allow the GOP to pursue a full repeal of Obamacare.

The budget proposal would still allow Republicans to pursue a much narrower attack on the Affordable Care Act, including repealing the individual mandate to purchase coverage. The resolution also would let the GOP use the fast-track process to open up drilling in the Arctic National Wildlife Refuge.

The budget, authored by Senate Budget Chairman Mike Enzi, forecasts a balance in nine years through $5 trillion in largely unspecified spending cuts. Unlike the House budget proposed in July, Enzi’s blueprint doesn’t call for cuts to Medicaid or a partial privatization of Medicare.

“A pro-growth tax plan will move the U.S. economy forward and help to produce better jobs and bigger paychecks for every American,” Enzi, of Wyoming, said in an emailed statement.

The Senate draft is to be voted on by the Budget Committee next week, with floor votes planned later in October and a conference to resolve differences with the House after that. The House plans a floor vote on its budget plan next week.

Tax Cut

Once in place, the budget resolution would allow Republicans to bring up a tax-cut bill that would increase deficits by as much as $1.5 trillion, compared with a Congressional Budget Office baseline. Under the fast-track process, the GOP-controlled Senate could pass the proposal with no Democratic votes.

The budget sets a target for the Senate Finance to report back with its draft tax bill by Nov. 13.

“The Senate budget resolution drafted by Budget Committee Chairman Mike Enzi is a critical step to advance President Trump’s agenda to provide tax relief for the middle-class and unleash economic prosperity for all Americans,” said White House budget director Mick Mulvaney in a statement. “I urge the Senate to pass this resolution and come to a swift agreement with the House so President Trump can sign America-first tax relief into law this year.”

Senate Democratic leader Chuck Schumer of New York said the GOP plan would “blow a huge hole in the deficit and stack up debt, leading to cuts in programs that middle-class Americans rely on.”

Individual Tax Rate

President Donald Trump and Republican leaders announced a tax-cut plan Wednesday that would cut the top individual rate to 35 percent from the current 39.6 percent. It would let Congress decide whether to create a higher bracket for those at the top of the income scale. The rate on corporations would be set at 20 percent, down from the current 35 percent. Under Senate rules, any tax cuts that increase the deficit would have to expire in 10 years because the budget process can’t be used for long-term deficit increases.

The provision making it easier for Congress to allow oil and gas drilling in part of the Arctic National Wildlife Refuge was sought by Alaska Republican Dan Sullivan. Under the proposal, royalties from oil and gas production in the wildlife refuge would be raise revenue that could help offset at least $1 billion in tax cuts over a decade.

The proposal’s instructions to the Finance Committee could allow a partial repeal of Obamacare, although panel Chairman Orrin Hatch has said he will keep that separate from a tax overhaul. Republican leaders have said they won’t try again on the health-care law until fiscal 2019.

Balanced Budget

When Republicans attempted to use the 2017 budget process to repeal Obamacare earlier this year, they didn’t provide a 10-year plan for reducing the deficit.

The new Senate plan proposes a balanced budget within nine years, while leaving it to other committees to figure out how to achieve that. The proposal calls for $4.8 trillion in spending cuts over 10 years and $1.635 trillion in revenue losses, including the tax cuts. Balance by 2026 is achieved by assuming $1.2 trillion in economic growth, in part due to the tax cuts. Enzi claims to achieve a $197 billion surplus in 2027.

The Republican assumptions of robust economic benefits from the budget were called into question by a separate CBO analysis. CBO predicted that the budget would reduce economic growth in the first two years and slightly increase it in later years.

CBO estimated that annual real GDP growth in the first two years would average 1.3 percent, down from an average of 1.6 percent in CBO’s baseline. In later years, real GDP growth would be 2.0 percent, compared with 1.9 percent in the CBO baseline.

The budget, unlike the one proposed by Trump in May, would hold defense spending at the current budget cap instead of the president’s proposed $489 billion defense increase over 10 years. Non-defense discretionary appropriations — which fund domestic agencies like the Agriculture Department and National Institutes of Health — would be cut by $632 billion over 10 years compared with $1.6 trillion in Trump’s budget request.

While the Trump and House budget proposals contain a number of nonbinding policy suggestions to carry out their spending cuts, Senate Republicans — weary of policy infighting — are keeping things vague.

Medicare, Medicaid

The House budget seeks to make $203 billion in cuts in entitlements such as Medicare, Medicaid and food stamps, and it could be used to fast-track changes to the Dodd-Frank financial law. The Senate plan avoids those options.

The Senate proposal does allow adjustments to increase the defense spending caps. It also urges senators to revise the Children’s Health Insurance Program, improve management of wildfire-prevention funding, prevent private-pension bailouts and improve services to veterans.

The budget resolution doesn’t address Social Security, which will run a trillion-dollar-plus deficit in the coming 10 years. In the past, Republicans have sought to balance a “unified budget” that includes the program. This time, they are keeping it “off-budget.”

CBO says that without the Social Security accounting move, Enzi’s budget would never balance and would show a $424 billion deficit in 2027.

The nonpartisan Committee for a Responsible Federal Budget said in a statement it prefers the House budget. “We encourage the Senate to look to the House Budget Committee, which passed a budget calling for revenue-neutral tax reform and at least $200 billion of mandatory spending cuts on top of that,” it said.

Dynamic Scoring

The Senate plan renews authority for the CBO and Joint Committee on Taxation to use so-called dynamic scoring when evaluating bills — a move allowing lawmakers to assume that tax cuts will cause economic growth that would offset some of the revenue loss.

And it changes several rules to allow senators to rush a tax bill through, including abolishing the need for a CBO analysis at least 28 hours before a vote.

The Senate plan avoids other tricks, though. Enzi included provisions to keep appropriators from using phantom cuts known as “changes to mandatory programs” to offset discretionary spending increases.

The chairman also rejected pressure from some lawmakers to use a baseline number for tax revenue that would allow $450 billion in additional tax cuts. Instead, he stayed with the baseline used by the CBO.

Is Health Care a Right?

Posted on by • Posted in Uncategorized • Tagged , , , , , • Leave a comment

https://www.newyorker.com/magazine/2017/10/02/is-health-care-a-right

Image result for is healthcare a right

It’s a question that divides Americans, including those from my home town. But it’s possible to find common ground.

Is health care a right? The United States remains the only developed country in the world unable to come to agreement on an answer. Earlier this year, I was visiting Athens, Ohio, the town in the Appalachian foothills where I grew up. The battle over whether to repeal, replace, or repair the Affordable Care Act raged then, as it continues to rage now. So I began asking people whether they thought that health care was a right. The responses were always interesting.

A friend had put me in touch with a forty-seven-year-old woman I’ll call Maria Dutton. She lived with her husband, Joe, down a long gravel driveway that snaked into the woods off a rural road. “You may feel like you are in the movie ‘Deliverance,’ ” she said, but it wasn’t like that at all. They had a tidy, double-wide modular home with flowered wallpaper, family pictures on every surface, a vase of cut roses on a sideboard, and an absurdly friendly hound in the yard. Maria told me her story sitting at the kitchen table with Joe.

She had joined the Army out of high school and married her recruiter—Joe is eleven years older—but after a year she had to take a medical discharge. She had developed severe fatigue, double vision, joint and neck pains, and muscle weakness. At first, doctors thought that she had multiple sclerosis. When that was ruled out, they were at a loss. After Joe left the military, he found steady, secure work as an electrical technician at an industrial plant nearby. Maria did secretarial and office-manager jobs and had a daughter. But her condition worsened, and soon she became too ill to work.

“I didn’t even have enough energy to fry a pound of hamburger,” she said. “I’d have to fry half of it and then sit down, rest, and get up and fry the rest. I didn’t have enough energy to vacuum one room of the house.” Eventually, she was diagnosed with chronic-fatigue syndrome and depression. She became addicted to the opioids prescribed for her joint pains and was started on methadone. Her liver began to fail. In 2014, she was sent two hundred miles away to the Cleveland Clinic for a liver-transplant evaluation. There, after more than two decades of Maria’s deteriorating health, doctors figured out what the problem was: sarcoidosis, an inflammatory condition that produces hardened nodules in organs throughout the body. The doctors gave her immunosuppressive medication, and the nodules shrank away. Within a year, she had weaned herself off the methadone.

“It was miraculous,” she said. In middle age, with her daughter grown up and in the Army Reserves herself, Maria got her life back and returned to school. All along, she’d had coverage through her husband’s work. “They have amazing insurance,” she said. “I think one year the insurance paid out two hundred thousand dollars. But we paid out, too.”

This was an understatement. Between a six-thousand-dollar deductible and hefty co-pays and premiums, the Duttons’ annual costs reached fifteen thousand dollars. They were barely getting by. Then one day in 2001 Joe blacked out, for no apparent reason, at a Girl Scout meeting for their daughter and fell down two flights of stairs, resulting in a severe concussion. It put him out of work for six months. Given the health-care costs and his loss of income, the couple ran out of money.

“We had to file for bankruptcy,” Joe said. He told me this reluctantly. It took them more than five years to dig out of the hole. He considered the bankruptcy “pretty shameful,” he said, and had told almost no one about it, not even his family. (This was why they didn’t want me to use their names.) He saw it as a personal failure—not the government’s. In fact, the whole idea that government would get involved in the financing of health care bothered him. One person’s right to health care becomes another person’s burden to pay for it, he said. Taking other people’s money had to be justified, and he didn’t see how it could be in cases like this.

“Everybody has a right to access health care,” he allowed, “but they should be contributing to the cost.” He pointed out that anyone could walk into a hospital with an emergency condition, get treated, and be billed afterward. “Yes, they may have collectors coming after them,” he said. “But I believe everybody should contribute for the treatment they receive.”

Polling Spotlight: A silver lining for the GOP on Obamacare repeal

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

https://www.brookings.edu/blog/fixgov/2017/09/27/polling-spotlight-a-silver-lining-for-the-gop-on-obamacare-repeal/

Image result for silver lining

There is good reason to question the assumption that by failing once again to pass legislation repealing and replacing the Affordable Care Act, Republicans have shot themselves in the foot. Although the CBO (Congressional Budget Office) could not analyze in its usual detail the consequences of Graham-Cassidy, it was able to determine that the legislation would cut federal funding for Medicaid by more than $1 trillion over the next decade, throwing millions of low-income Americans off the rolls.

This outcome would have generated a huge political problem for Republicans. A Public Religion Research Institute poll released Monday found 69 percent of Americans opposed to cuts in Medicaid, with only 28 percent in favor. The opposition included 78 percent of Democrats, 69 percent of Independents—and 55 percent of Republicans. In a related finding, nearly 45 percent of Americans are worried that they or a member of their family will lose health coverage in the coming year.

No doubt, failing to act on Obamacare will anger a portion of the Republican base, adding fuel to the insurrection against the Republican establishment and depressing turnout in states and districts where Republican incumbents who support the party’s leadership are running for reelection. But in the long run, it would have been more politically damaging to deprive low-income Americans, including millions of Trump supporters in red states, of the Medicaid coverage they would otherwise have enjoyed.

As behavioral economists have shown, the fear of loss is more acute than the hope of gain. Health policy perfectly illustrates this proposition. Whoever moves to change the status quo must convince people that they will not lose what they already have. The larger the share of people who are satisfied with the status quo, the tougher the task. This is why President Obama put his personal credibility on the line to assure Americans that if they liked their current insurance policy, they could keep it under his proposed reform. When this turned out not to be entirely true, he and his party suffered.

But now, after almost eight years of public disapproval, Obamacare has become the new status quo, the baseline from which most people assess gains and losses. While opposition to Obamacare still exists writ larger, individual provisions—some of which have been under threat from Republican alternatives—are wildly popular among Americans. By threatening to take Medicaid away from millions of people, the Republicans poked a hornets’ nest. Whatever they did after this, they would have been hurt. But by running away, they at least minimized the number of stings. Their legislative failure was a blessing, very effectively disguised.