November 26, 2015

Posts on health care

Subscribe to this feed Subscribe to this feed


Monday, June 13, 2011 - 9:33 AM

A shorter version of this column is featured on

It is often said that the most expensive piece of medical equipment is the doctor’s pen. Unfortunately, after more than two years of intense debate about health care costs in Washington, politicians still seem stuck debating who should pay for the pen instead of focusing on how to make the pen less expensive.

Republicans want private insurers to make health care payments along with substantially higher cost-sharing by individuals. Democrats and the President want retirees to continue in a system where the government is the predominant payer.

However, in either vision of the world, the primary decisions driving the costs of medical care will be made based on what the doctor says to a patient in an office visit or laying on a hospital bed. This is destined to be the case for as long as doctors train and build up extraordinary expertise. 

This is why the Independent Payment Advisory Board (IPAB), created by the 2010 Affordable Care Act (ACA), is so important in the effort to control costs. The IPAB will be made up of 15 experts, some suggested by congressional leaders and all confirmed by the Senate, appointed to represent the major...

Tuesday, May 17, 2011 - 7:48 AM

Anyone wondering why Social Security and Medicare should be “on the table” in budget negotiations need look no further than the 2011 Trustees’ Report issued on May 13.

As is usually the case, media accounts of the trustees’ report tended to focus on trust fund balances rather than on the cash balances and growing costs of the two programs. Viewed from a trust fund perspective, the financial condition of Social Security and Medicare may appear troubling but of no immediate concern. Social Security’s combined trust funds are projected to remain solvent until 2036 and the Medicare HI trust fund [Part A] is solvent until 2024. The Medicare SMI trust funds [Parts B and D] are permanently solvent, but only because they have an automatic draw on general revenues.

So why worry about these programs now? Why not wait another 10 years before making changes in Medicare and 20 years or more for Social Security?

One reason is that both programs are straining the federal budget now because they are paying out more than they are taking in from dedicated resources, including payroll taxes, taxation of...

Thursday, December 16, 2010 - 3:55 PM

The legal term severable normally gets little notice outside the world of constitutional law -- yet now it has become a big buzzword amongst health care analysts and federal budget wonks. The reason has to do with the numerous legal challenges to the Accountable Care Act's individual mandate to purchase health insurance. 

A U.S. District Court Judge in the Eastern District of Virginia recently declared the mandate unconstitutional. He also declared it severable from the rest of the health care reform legislation. This means that even though he found that one provision is unconstitutional, he held that the rest of the legislative package is constitutional and can continue on its path to full implementation. If the courts ultimately agree with this judge's interpretation, the budgetary results could become disastrous without congressional action.

While we have discussed the primacy of the individual mandate in making health care reform work (here and here,) it makes sense to revisit the issue of...

Monday, September 13, 2010 - 1:56 PM

The Center for Medicare and Medicaid Services recently updated its estimate of National Health Spending. This unusual mid-year update, delivered in an article in Health Affairs, reflects changes due to the passage of the health care reform law in March, along with a few smaller legislative changes since then.

The overall picture is that within the 2009-2019 time period, projected total national health care spending will slightly increase relative to where it would have been without passage of reform. Annual spending growth will average 0.2 percent higher over the projection period. As a nation, we will go from spending 17.3 percent of GDP on health care in 2009 to 19.3 percent of GDP in 2019, a figure 0.3 percent of GDP higher than it would have been without health care reform.

Within these small overall changes, however, there will be major differences in the number of insured and the payers for health insurance. By 2019, approximately 32.5 million more individuals will have health insurance, which will mean coverage of 92.7 percent of the population (compared to 83 percent prior to passage of the legislation). Within that, Medicaid and the Children’s Health Insurance Program (CHIP) enrollment will be one-third...

Tuesday, August 10, 2010 - 1:45 PM

Good news comes and goes rather quickly in the 2010 Medicare Trustees’ Report. It begins with the optimistic news that Medicare’s finances have improved substantially as a result of this year’s health care reform bill, the Affordable Care Act (ACA). However, the report then goes on to explain in great detail why this apparently good news is probably not as good as it sounds.

According to the trustees, “actual future Medicare expenditures are likely to exceed the intermediate projections  shown in this report, possibly by quite large amounts.” A separate memo prepared by the Center for Medicare and Medicaid Services (CMS) Office of the Actuary bluntly states that “the projections in the report do not represent the ‘best estimate’ of actual future Medicare expenditures.”

For those seeking solutions to our nation’s long-term structural deficit, understanding the complex message of the trustees’ report is crucial. Despite the buoyant headlines, the trustees warn, “The financial projections in this report indicate a need for additional steps to address Medicare’s remaining financial challenges.”

On paper, Medicare’s finances have indeed improved. The ACA reduced future non-physician Medicare provider reimbursements and added dedicated...

Wednesday, June 16, 2010 - 12:23 PM

Debate on the so-called “extenders” bill has focused on the size and duration of unemployment benefits, health insurance assistance for those who recently lost their jobs, Medicare physician payments, state aid for health care and various offsets to mitigate the overall effect on the deficit.

Conspicuously missing from the debate is any scrutiny of the extenders themselves. It’s a missed opportunity to raise needed revenue while simplifying the tax code and broadening the tax base -- goals that economists of all ideological stripes have long advocated. 

Both the House and Senate versions of the extenders bill contain more than 60 narrowly targeted tax breaks that expired last year. Extending them just through this year will cost about $32 billion. The long-term cost runs to over $350 billion. That cost will add to the debt unless it is offset by corresponding tax increases or spending cuts that may prove more harmful to the economy than failing to renew some, or all, of the extenders. 

At a time when the President is commendably urging all federal agencies to identify their lowest priority and least effective items, Congress should devote the same level of scrutiny to the tax code. The extenders would be a good place to...

Wednesday, March 31, 2010 - 10:00 AM

According to a March 29 Roll Call article (subscription required), Senate Republicans have gone home for the two-week congressional recess with a strategy memorandum advising them to call for repeal of “Medicare cuts, tax hikes, mandates and sweetheart deals” in the new health care reform legislation.

Leaving aside the sweetheart deals, repeal of the other three items would amount to a fiscal catastrophe. One can legitimately argue that the law will end up costing more than anticipated or that some of the proposed savings will fail to materialize. Claims of big deficit reduction do indeed rest on some shaky assumptions, and the law certainly leaves a lot of work to be done on fiscal sustainability. However, the surest way to guarantee exploding deficits would be to leave in place all of the popular insurance reforms and repeal the politically difficult choices that have been made to pay for them.

Expanding health insurance coverage costs money. Unlike the 2003 Medicare prescription drug bill, this plan at least attempts to pay for its new spending by cutting future Medicare costs and raising new revenues. Constituents may not like these things but they are essential parts of the law. They are also protected by...

Friday, March 19, 2010 - 1:25 PM

It looks like we might be entering the final week(s) of (at least) this year's legislative push on health care reform.

Thursday brought us legislative text of the amendments to the Senate bill that the House will take up through the reconciliation process as well as an updated CBO score of the whole package. It is likely the House will vote on the bill package Sunday. If they do so, the Senate bill will become the law of the land, and the reconciliation amendments will then have to make it though the Senate before those become law.

The main fiscal takeaway from this week is that there really has not been any substantial change in what heath care reform is attempting to accomplish and whether it will ultimately be fiscally responsible legislation. Today we released a series of video discussions (see above) between Bob Bixby and I explaining the big picture and how the reconciliation tweaks effect that. One of the issues discussed is that clearly the most consequential fiscal change through reconciliation is the delay in implementation of the excise tax on cost insurance plans.

For a more complete view, our December Issue Brief, created as the Senate bill neared passage,...

Tuesday, March 2, 2010 - 9:47 AM

The end game for health care reform may finally have arrived. Some in Congress are suggesting that a decision should be made by the Easter break, which begins on March 26. Time is running short.

If we learned anything from last week’s health care summit, it is that the final end game negotiations will not take place between Democrats and Republicans but among various factions of Democrats.

Republicans now sense big gains coming in the November elections and thus have no motivation to move in Obama’s direction. Any attempt to draw them into a negotiation –- including the “start from scratch” option Republicans themselves are pushing -- will likely fail.

Democrats are split, with some fearing for their jobs if they support an unpopular bill while others believe that passing even a flawed bill will leave them better off in November.

One casualty of the situation may be cost containment. Democrats are mostly united around coverage expansion. That’s the easy part. Their biggest difference is on the more difficult question of aggressive cost containment. The two most promising cost-containment strategies still on the table are the tax on high-cost health care plans and the...

Sunday, January 24, 2010 - 8:06 PM

As the White House and congressional leaders rethink health care reform after the Republican upset in the Massachusetts Senate race, there is a growing danger that Congress will jettison comprehensive health care reform altogether. Even worse, they might pass stripped-down measures that eliminate politically difficult cost-containment, while popular but costly provisions are kept.

President Obama has suggested narrowing the focus of national reform, advising that Congress should “try to move quickly to coalesce around those elements of the package that people agree on.” Some members of Congress have also expressed support for a limited bill.

However, most policy experts agree that a limited bill is nearly impossible to construct without running into some major issues with short and long-term costs. That is because the easier elements -- the ones that “people agree on” -- are interlocked with elements whose benefits are far less apparent to many voters.

The key reforms for the health insurance industry are popular -- for instance, prohibiting discrimination based on pre-existing conditions. Yet, just doing that would lead to an insurance "death spiral" where only the sick would get insurance when needed, driving up the cost of premiums. The only way around this spiral is to have an individual mandate to...