December 1, 2015

Posts on health care

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Friday, November 6, 2015 - 10:44 AM

Rep. Scott Rigell (R-Va.) recently offered the America First Act, a bill to replace 75 percent of the sequester cuts scheduled under current law with a mix of reforms in mandatory spending and revenue increases from limiting tax expenditures.

In the aftermath of the bipartisan budget agreement, ideas like those in the Rigell plan could serve as models for long-term, bipartisan fiscal reform efforts in Congress.

The Rigell plan proposes a new framework that would achieve substantial deficit reduction while replacing the sequestration-level spending caps that are in place under current law. The plan comes at a time when a number of fiscal experts and lawmakers have concluded that the sequester caps are unrealistically tight.  

According to Congressional Budget Office (CBO) estimates, the Rigell bill would save $2.5 trillion over the 10-year budget window. It would do so by implementing a three-to-one mix of spending cuts to revenue increases, making major reforms to Social Security and Medicare to improve their long-term finances.

On the...

Monday, October 12, 2015 - 11:30 AM

There has recently been a renewed focus on a key provision in the Affordable Care Act (ACA) -- the so-called “Cadillac tax.” The tax, which will take effect in 2018, attempts to limit the tax-free treatment of employer-provided health insurance benefits by taxing them above a certain amount.

The “Cadillac” terminology arises because only the most expensive, generous insurance plans are initially projected to be hit by the tax. As insurance costs rise along with health care costs, more plans will gradually become partly subject to the tax, and thus the amount of fully tax-free health insurance in the country will fall.

This is good, because the exclusion of health insurance from taxation is widely considered economically inefficient and regressive tax policy. It is very expensive for the government, only provides benefits to some workers, distributes those benefits primarily to those who earn the highest incomes, and encourages higher health care spending. Economists believe that as the tax-based preference for health insurance over employee wages dissipates, employee wages will rise.

The Cadillac tax was always a suboptimal and clunky method through which to limit the health care tax exclusion because it does so indirectly (Concord’s...

Monday, July 27, 2015 - 10:44 AM

The message from the Social Security and Medicare trustees last week could not have been more blunt: the two programs’ long-term costs “are not sustainable with currently scheduled financing and will require legislative action to avoid disruptive consequences for beneficiaries and taxpayers.”

This conclusion should take no one by surprise. The pressures on both programs from population aging and rising health care costs have been warned about many times by many nonpartisan sources.

What is surprising is that so few lawmakers seem to take these warnings seriously.

After all, Social Security and Medicare are not insignificant programs. In 2014, 59 million Americans received Social Security benefits, and Medicare covered 54 million. At a cost of nearly $1.5 trillion, the two programs alone accounted for 42 percent of federal program spending last year.

Given their size and importance for so many American families, the fact that Social Security and Medicare are on an unsustainable track should place them high on the legislative agenda for both...

Tuesday, July 14, 2015 - 9:58 AM

Last week the Department of Health and Human Services (HHS) proposed a new method of paying for health care services, using its authority under the Affordable Care Act (ACA) to scale up payment reforms that have been shown to save money while maintaining the quality of care.

In 75 metropolitan areas, Medicare will use “bundled payments” for hip and knee replacements  -- meaning that every aspect of an intervention, from the surgeon’s work to the artificial joint to post-surgery rehab, will be covered in a single payment. Ultimately, providers will both share in any cost savings or risk penalties if there are cost overruns or quality falls short.

For the first time these payment changes will be mandatory. This is an important step in furthering the Obama administration’s goal to make most Medicare payments through alternative models (not fee-for-service) by 2018.

Starting with hips and knees for such mandatory changes makes sense because there is a wide cost variation for these procedures, but no evidence linking cost to quality. Furthemore, this...

Friday, November 7, 2014 - 12:55 PM

Last Wednesday, President Obama requested approximately $6.2 billion to combat the Ebola epidemic. As Congress examines and debates this proposal, it is an important opportunity to reexamine our government’s budgetary policies.

Whether it’s Ebola, ISIS, or the child migrant crisis, our nation faced a number of unforeseen challenges this year that required action (and emergency spending) by the federal government. These challenges serve as reminders of a key underlying purpose of fiscal responsibility: To enable the country to deal with the unexpected.

We can’t predict the future. But having lower debt and deficits can give us the fiscal flexibility to act quickly when crises arise. Alternatively, irresponsible budget policies leave the government with higher borrowing costs and fewer resources to deal with changing circumstances.

Furthermore, responsible budgeting isn’t just about keeping spending in line with revenue. It’s about making sure our tax and spending policies reflect our priorities as a nation.

If federal investment in hospital and emergency preparedness is important to us, for example, we must be...

Tuesday, September 23, 2014 - 8:18 AM

In 2011, Medicare spent $170 billion, or 28 percent of its total expenditures, on services for beneficiaries in their last six months of life. But a new report says many of these patients are not receiving the care they want and are undergoing costly and unnecessary tests, procedures, and hospital visits.

Revamping the end-of-life care system in the U.S. could better satisfy the wishes of patients and families and make health care more affordable.

The report, “Dying in America,” was put together by a 21-member commission of doctors, nurses, religious leaders and aging experts. The panel was appointed by the Institute of Medicine, an independent research arm of the National Academy of Sciences that provides information to the public and policymakers.

The commission’s co-chairs are David Walker, former Comptroller General of the United States and former CEO of the Comeback America Initiative, and Dr. Philip A. Pizzo, a former dean of the Stanford University School of Medicine.

The report points...

Tuesday, June 17, 2014 - 8:19 AM

The Congressional Budget Office (CBO) cost estimate for the Senate’s expansion of veterans’ health care has been getting a lot of attention from budget groups and members of Congress. As illustrated by the Committee for a Responsible Federal Budget, when fully implemented, the part of the legislation that provides broad access to care providers outside the VA system might cost up to $50 billion a year -- more than doubling what is currently spent for veterans’ health. This new “mandatory appropriation” would increase the deficit by more than the prescription drug benefit under Medicare Part D.

While there has been a lot of misplaced consternation among members of Congress about CBO’s scoring accuracy, there has also been some constructive discussion about the need to find offsets for the new spending. However, there has not been nearly enough discussion about whether the entire congressional strategy and this rushed “fix” are misguided.

The first problem is that Congress, in trying to rapidly...

Tuesday, April 8, 2014 - 8:39 PM

Yesterday, the Centers for Medicare and Medicaid Services (CMS) released the 2015 government payment levels for the Medicare Advantage private insurance plans that are offered to seniors as an alternative to traditional Fee-for-Service (FFS) Medicare. In a bit of a surprise, CMS projects that total payments will increase by about 0.4 percent despite earlier CMS guidance suggesting payments would be cut by 1.9 percent.

The change follows months of lobbying by the private insurance industry -- fearful of lost profits -- along with members of Congress from both parties who are fearful of being attacked for cutting benefits to seniors.

Medicare Advantage plans have seen annual cuts to their payments from the government through a process set in motion by the Affordable Care Act (ACA), and cuts are scheduled to continue (despite the slight increase for next year). The payment reductions were intended to fix a fundamental financing disparity between FFS Medicare and the Medicare Advantage program; insurers are paid more per beneficiary than it would cost the government if the beneficiaries remained in FFS. 

The negative reaction from politicians and interest groups to these continual cuts...

Wednesday, March 26, 2014 - 9:34 AM

The growth in health care spending has slowed in recent years but could speed up again as the economy strengthens and the population ages. Even with slower growth rates, however, federal and state governments need to pursue reforms and innovations to keep public health programs sustainable.

Massachusetts and Maryland are at the forefront of such efforts. Officials in other states and the nation’s capital should watch how the experiments in these two states turn out and consider what lessons they may hold.

Maryland regulators recently received approval from the Center for Medicare and Medicaid Services (CMS) to limit the growth in hospital spending for each of the next five years to 3.58 percent. That is the state’s average annual rate of per capita economic growth since 2002.

Maryland already has successful experience restraining growth in health care spending relative to other states because of a unique commission that...

Friday, January 24, 2014 - 3:47 PM

As more people obtain health insurance through the Affordable Care Act’s exchanges and its expansion of Medicaid -- the federal-state program for low-income individuals -- policymakers should focus on ensuring that the health care system can meet the increased demand for services.

As people gain insurance, they tend to increase their utilization of health care. (See, for example, this report from the Medicare and Medicaid actuaries.)

Thus federal and state policymakers need to work together to make the health care system more efficient so that expenditures on health care don’t crowd out other important government programs. Possible solutions to this challenge can be found in Oregon, which has experimented with payment and delivery reforms in Medicaid in ways that could serve as a model for the rest of the country.

Reforming the delivery of care for Medicaid patients is not an easy task. An analysis of a landmark...