How Congressman Ryan’s Radical Health Care Proposals Would Impact DC

April 12, 2011

Now the answer to a question I’ve been asking myself ever since I looked at Congressman Paul Ryan’s proposals for federal health care programs. What would they mean for the District of Columbia and its residents?

Families USA has just issued a report with state-by-state impact figures for each of the major health care parts of Ryan’s Fiscal Year 2012 budget resolution — his so-called Pathway to Prosperity.

Here’s what we learn.

Medicaid Block Grant. As you may recall, the Ryan plan would convert Medicaid to a block grant. Grants would be adjusted according to a formula that reflected neither rising health care costs nor the aging of the population. The latter is important because state Medicaid programs spend more for low-income seniors than for most other covered groups.

Under the block grant, the District’s existing program would lose $4.4 million next year. Losses would grow exponentially every year thereafter. For the entire first 10-year period, 2012-2021, they would total more than $3.4 billion.

Funding for Medicaid Expansion. Under the health care reform act, states must expand their Medicaid programs to include all people with incomes at or below 133% of the federal poverty line. The federal government will pay all the costs of the expansion for the first three years and most of the costs thereafter.

The Ryan plan would repeal both the expansion requirement and the related funding. Losses to the District by 2021 would reportedly total well over $1.2 billion.

“Reportedly” because Families USA assumed that the District would undertake the expansion in 2014, as the law requires. I understand it’s decided to move at least some eligible residents into Medicaid earlier. This might affect the estimate.

Tax Credits for Insurance Premiums. The health care reform act includes tax credits to help moderate-income families purchase health insurance in the exchanges that will be created. Credits will be available to families up to 400% of the federal poverty line.

The Ryan plan would repeal this provision also. District residents eligible for the tax credits would lose $37.4 million in 2014, the year they’d become available under the current law.

Here again, losses would dramatically escalate. During the 2012-21 period, they’d total close to $1.3 billion.

The health care reform act also provides tax credits for small businesses and some other incentives to encourage employers to provide health insurance. These too would be repealed under the Ryan plan.

Loss of all the tax credits, plus the loss of federal funding for expansion of Medicaid would mean that at least 46,600 District residents would have no health insurance 10 years from now.

Medicare Privatization. Under the Ryan plan, people now under 55 would be subject to an altogether different health insurance scheme when they reached Medicare eligibility age or became severely disabled before that.

Instead of enrolling in the fairly comprehensive, low-cost insurance plan we know as Medicare, they’d get the equivalent of a voucher to purchase health insurance in the private market. As I noted earlier, the value of the voucher would increase at a much lower rate than health care costs.

Families USA doesn’t provide state-by-state figures for the budget crunch that seniors and people too disabled to work would face. The Congressional Budget Office, however, did some preliminary national estimates.

According to these, typical 65 year olds enrolled in a private insurance plan similar to the current Medicare would pay 68% of their health insurance premiums and out-of-pocket costs in 2030. This is 43% more than what they’d pay under Medicare as it exists today.

And the total costs would be much greater because Medicare delivers more health care bang for the buck than private insurance plans.

Bottom Line. If the Ryan proposals for Medicaid, Medicare and health insurance tax credits were all adopted, the District and its residents would lose more than $6 billion in the first 10 years alone.

And for what? So that $4.2 trillion could be used to finance extended and expanded tax breaks that would make the wealthiest even wealthier.


Congressman Ryan’s Radical Attack On Our Health Care System

April 7, 2011

Republicans in Congress made a big deal of the fact that the health care reform legislation was more than 1,000 pages long. A large portion of those pages spelled out initiatives aimed at controlling health care costs.

Congressman Paul Ryan, Chairman of the House Budget Committee, has a simpler way of cutting federal health care spending. Just stop paying for the health care people need.

His just-released Fiscal Year 2012 budget resolution, The Pathway to Prosperity, would make two radical changes in our health care system.

It would convert Medicare from a health insurance program for seniors and severely disabled people to subsidies that would partially cover the costs of health insurance they purchase on the private market.

Ryan claims that his plan will unleash competition by letting patients choose the plan that delivers high-quality services for the lowest cost.

But, of course, that’s how a vast number of people get their health insurance now — not only the members of Congress Ryan mentions, but others who get their health insurance through their employers or purchase it on their own. Yet health care costs are spiraling.

So how will the Ryan plan save money? Pathway to Prosperity makes the conventional references to waste and abuse, but is otherwise judiciously vague.

But Ryan’s earlier Roadmap for America’s Future certainly wasn’t. Nor was the similar plan he developed in partnership with Alice Rivlin, former head of the Congressional Budget Office and the Office of Management and Budget.

Ryan would reduce federal Medicare spending by adjusting the value of the subsidies according to an inflation index that doesn’t reflect rising health care costs. This produces an even bigger crunch than Ryan-Rivlin.

So, as the Center on Budget and Policy Priorities explains, seniors and other beneficiaries would have to shoulder more and more of their health insurance costs or switch to plans that provide significantly less protection.

Ryan would also convert Medicaid from a genuine federal-state partnership into a block grant — a different type of cost shift, but with similar results.

The federal government now covers a certain percentage of states’ Medicaid costs — somewhere between half and three-quarters, depending on a state’s average per person income.

Under Ryan’s plan, states would get a fixed amount of money — the same in good times and bad, somewhat more over time, but considerably less than would be needed to accommodate rising health care costs and the aging of the population.

States would get enormous “flexibility” (favorite Republican word). They’d no longer have to enroll everyone whose income was low enough to fall below a standard threshold — or indeed, any threshold at all. Nor would they have to provide a specified minimum package of essential services.

Ryan claims that the block grant would eliminate incentives that have led states to expand coverage to people who aren’t “truly in need” — as if people who now qualify for Medicaid aren’t.

States would also, he says, gain freedom from unspecified restrictions that keep them from making their programs “smart” and “efficient.”

We’ve already seen what happens when states face budget pressures due to a combination of lower revenues and rising safety net costs. They look for savings in Medicaid, which accounts for a large percentage of those costs.

And they exercise what’s actually considerable flexibility to eliminate benefits federal rules don’t require — home care that keeps frail elderly people out of nursing homes, hearing aids and eyeglasses, preventive dental care, even life-saving organ transplants.

They make further cuts in reimbursement rates, effectively denying Medicaid participants health care because doctors won’t treat them.

They seek permission to drop people from the program — something they wouldn’t have to do under Ryan’s plan because it would repeal most of the health care reform act, which bars states from rolling back Medicaid coverage.

And recall, this is all happening under the current funding formula.

Ryan says that his plan for Medicaid would save $1 trillion over 10 years. Only one way that could happen. Less federal funding than under the current system — probably progressively less relative to need as time goes on.

States could in theory pick up the difference. But it’s more likely that most would ramp up the kinds of cost-cutting measures we’re seeing now — and go in for others we’re not seeing, thanks only to federal rules.

The Ryan plan may be a pathway to prosperity for the wealthiest, who would enjoy a further 10% cut in their income tax rate. But it’s a pathway to unnecessary pain, suffering and economic insecurity for the rest of us.

UPDATE: The Ryan plan is more generous to the very wealthy than I realized. The Wall Street Journal reports that it would not only cut the top income tax bracket, but eliminate the recently-enacted surtax on high earners’ investment income.


Senate Health Care Bill Puts Cost Burdens On Low-Income People

December 5, 2009

Bear with me for a moment. There’s been such an over-plus of proposals, polls, pontificating and  propaganda that I’ve half-forgotten why we decided to plunge into health care reform to begin with. And it seems I’m not the only one.

As I recall, the idea was to make good health insurance affordable for everyone because most people can’t get the health care they need without it. Bringing down health care costs was a means to this end, though it’s taken on a life of its own.

I’ve gone back to the basics because I think they’re a lens for looking at what the bill the House passed and the bill the Senate’s debating will do to ensure that low-income people can get sufficient, affordable health care.

I’ve already put in my two cents on the employer responsibility provisions. So what about affordable health insurance for those who won’t be able to get it through their jobs?

On this score, the House bill does more for poor and near-poor people. It would extend Medicaid, which offers good coverage at very low cost, to individuals and families up to 150% of the federal poverty line. The Senate bill would cut off Medicaid eligibility at 133% of the FPL.

Above these thresholds come a range of actuarial values, i.e., levels of subsidized coverage provided by insurance purchased through the exchange. These decrease as income brackets go higher. Put them together with the Medicaid cut-offs and you’ve got significant cost differences.

The Center on Budget and Policy Priorities has updated its comparative table. As it shows, the Senate bill would keep costs lower for individuals and families at higher income levels by shifting the costs to those who have less.

  • Individuals and families who would be covered by Medicaid under only the House bill would pay nearly two-thirds more under the Senate bill–$613 more for families and $362 more for individuals.
  • Those at 150% of the FPL would pay somewhat over a third more under the Senate bill–$462 more for families and $252 more for individuals.
  • The situation reverses at 300% of the FPL, with families paying $100 less and individuals $65 less under the Senate bill.
  • By 400% of the FPL, the point spread has increased to $1,611 less for families and $953 less for individuals.

Similarly, the House bill would provide cost-sharing assistance to families up to 350% of the FPL, while the Senate bill would cut it off at 200% of the FPL. At the same time, actuarial values are lower under the Senate bill at all levels except for 400% of the FPL.

This means that low-income households would have to pay larger deductibles and co-pays than under the House bill. And again, the differences would be greatest for those in the lowest income brackets.

CPBB estimates that a family of three at 175% of the FPL would be responsible for $3,867 in deductibles and co-pays if the Senate plan were in effect now. That would be more than 10% of its annual income. And it would already have paid $2,307–6.3% of its income–for the premium.

Yes, the family would have insurance. But would it be able to afford the health care services it needs. I rather doubt it. And there goes one of the bill’s two main objectives–“to provide affordable, quality health care for all Americans.”

And if the family can’t afford the out-of-pockets, its members are likely, as now, to wind up in emergency rooms–a very costly alternative to preventive and maintenance care. Or it may decide simply to pay the relatively modest penalty for not having health insurance. One way or the other, there goes the bill’s other main objective–“to reduce the growth of health care spending.”

Will the bill that comes out of the Senate come closer to these objectives? More likely getting those precious 60 votes will mean even more compromises at the expense of those who need health care reform most.


Children’s Health Insurance Update

January 22, 2009

As expected, the U.S. House of Representatives passed its version of the State Children’s Health Insurance Program (SCHIP) reauthorization. The vote was 289-139, with 40 Republican voting in favor and two Democrats against.

The Senate Finance Committee completed work on the Senate version last Thursday. It added the House-passed provision that would allow states to immediately provide coverage to immigrant children and pregnant women who are in this country legally. It also added an option for states to provide dental care coverage for children who don’t have it through private insurance.

Now the full Senate will begin consideration of the SCHIP bill, possibly as early as today. Though Democrats are in a majority, passage is not a slam-dunk. The Republican leadership is strongly opposed to the current version of the bill. This means we are likely to see proposed amendments to narrow it.

Based on what Republican leaders have said, I’m guessing these could include:

  • Elimination of the legal immigrant children and pregnant women option
  • Reduction of income eligibiity from 300% to 200% of the federal poverty level
  • More onerous citizenship verification requirements
  • A provision designed to prevent “crowd out,” i.e., parents switching from private health insurance to SCHIP

The Democrats have the votes to defeat such amendments. But under Senate rules, they will need at least five Republicans to join them in voting to end debate. Without those votes, there can be no vote on the SCHIP bill itself.

Maybe those five votes are already there. If they aren’t, then the SCHIP bill could be weakened to get them.

So those of you who want to see SCHIP significantly expanded should consider contacting your Senators, especially if either or both are Republicans. The toll-free hotline is still open. It’s 1-800-828-0498.


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