actuary


The Repeal Windfall

As November approaches, Obamacare’s defenders are quite plainly desperate. They see public opinion solidly against them, and a devastating election fast approaching. Their latest gambit to protect what was jammed through Congress in March is to claim that repeal would be so costly to the federal budget that it would be impossible to pass, even with overwhelming popular support. That’s the spin some on the left put on a recent letter from the Congressional Budget Office (CBO) to Senator Mike Crapo.

But unfortunately for these advocates, that’s not what the CBO letter says. CBO’s message to Senator Crapo actually just states what is already obvious: If an effort were made to repeal just the Medicare cuts in the new law, it would, on paper, increase Medicare spending, and thus the federal budget deficit, by about $450 billion over ten years. Moreover, enacting a real “doc fix” to avoid deep and unrealistic cuts in Medicare physician fees will cost another $300 billion or so over the coming decade.

What this communication from CBO actually confirms, however, is that, contrary to White House assertions, Obamacare is a budget buster of the highest order. The claim that it would reduce the budget deficit over the coming decade has always rested on a series of gimmicks, implausible assumptions, and sleights-of-hand that have been exposed repeatedly over the past year, most especially by Congressman Paul Ryan in the presence of President Obama. Among the most egregious deceptions is the double- counting of cuts in Medicare’s reimbursement rates for hospitals and other providers of care — cuts so deep that they would push Medicare’s rates below those paid by Medicaid by the end of the decade. Even if these cuts were realistic — which they aren’t — they can’t both be used to pay for a new entitlement and to improve Medicare’s solvency, as the White House claims. The same money simply can’t be spent twice. Moreover, this money is almost certainly never going to materialize anyway because, as Medicare’s chief actuary has warned repeatedly, they would seriously reduce access to care for seniors by driving hospitals and physicians out of the program. It is all but inevitable, therefore, that Congress will step in at some point to reverse the “cuts,” and probably sooner rather than later. When that happens, it will only confirm what’s already abundantly clear — that these unsustainable payment reductions should never have been allowed to grease the way for a permanent and massively expensive entitlement program.

Indeed, contrary to latest spin from the left, not only would repeal not bust the budget, it would in fact produce a budgetary windfall of such enormous size that it could pay for a sensible reform of American health care and for deficit reduction too.

The centerpiece of Obamacare is the largest expansion of entitlement spending in a generation. CBO estimates that the new law will add 35 million people to the federal government’s health entitlement rolls by decade’s end — and that’s almost certainly a lowball estimate. Gross federal spending for this added entitlement burden, plus various other spending provisions in the bill, is expected to reach $233 billion in 2019 alone, and then grow at a rate of about 7 percent annually every year thereafter. That means Obamacare’s spending will total at least $3.4 trillion over its second decade, on top of the $1.1 trillion it will cost between now and 2019. And it’s likely to be much more than that when more realistic assumptions about employer dumping of coverage are factored into the estimates.

So that’s at least $4.5 trillion in federal spending that would be avoided over the next twenty years if Congress moved ahead with repeal. Even in Washington that’s a lot of money. So much in fact that it should be more than enough to gut Obamacare’s most egregious tax hikes and spending “offsets” while still paying for a sensible reform of American health care that actually cuts costs and covers more people. And even after enacting this kind of “replacement” program, there should still be something left over to put a real dent in the massive deficits projected to occur under the Obama budget plan.

A couple of weeks ago, the left’s message gurus put out the word to Democratic candidates to abandon talk of the supposed cost-cutting that would occur under Obamacare.

They now understand that the public has not, and will not, buy the argument that a government takeover of American health care will somehow lower costs. Americans have long understood that Obamacare is a massive new spending commitment, piled on top of the unaffordable ones already on the federal books. That’s a recipe for financial disaster, not deficit cutting. The solution is repeal coupled with a reform that puts consumers, not the government, in charge of controlling costs. That’s the way to fix health care—and the budget too. And, yes, it can be done.

posted by James C. Capretta | 6:47 pm
Tags: actuary, budget, doc fix, repeal, deficit
File As: Health Care

A Fraud Exposed and Ignored

“Law Will Extend Medicare Fund, Report Says,” was the New York Times headline. “Medicare Funds to Last 12 Years Longer Than Earlier Forecast, Report Says,” was the similar take of the Washington Post. Those two stories were upbeat summaries of what the latest report on Medicare’s long-term financial outlook supposedly revealed.

But was that really the most newsworthy headline here?

It might actually have been more newsworthy that the person who compiled all of the data for this report, and knows its contents better than anyone else, utterly repudiated its findings.

That’s right. Richard Foster, the chief actuary of the Medicare program and the man responsible for overseeing the production of the data which forms the basis of this annual report’s forecast, has advised the public — in his official “Statement of Actuarial Opinion” printed at the end of the trustees’ report — not to believe any of the modestly rosy conclusions contained within it.

It’s hard to overstate the importance of this development. Here is the president’s point man for assessing the financial status of Medicare declaring that much of the claimed benefits for Medicare from the recently passed health-care law — benefits that the president himself again touted on Saturday — are not to be believed. You’d think it might be news if the top expert in government essentially said the president of the United States is basing his public assertions on one of the most important issues of the day on flawed and misleading data. But apparently not.

Foster and his staff began exposing the fraudulent nature of the Medicare claims months ago. In their April analysis of the final health legislation, they agreed with the Congressional Budget Office and every other commonsense person that the same dollar can’t be spent twice. If the Medicare cuts in Obamacare are to be believed (a big “if”), they could be used to improve Medicare’s financial outlook, or to pay for another entitlement program, but not both. But of course Obamacare’s apologists continue to argue that both were financed by the Medicare cuts. The unfortunate consequence of this duplicity is that, eventually, taxpayers will be left holding the bag. At some point, they will be asked to pay higher taxes to finance Medicare spending as well as a new entitlement for health insurance, both of which were supposedly covered by the Medicare cuts.

But it’s actually far worse than just that. As Foster notes, the Medicare cuts upon which the president’s claims of additional Medicare solvency rest are so absurdly unrealistic that they can hardly be taken seriously at all. Despite all of the talk of painless “delivery-system reform” in Medicare, the big cuts come, as usual, from arbitrary and deep across-the-board payment-rate reductions for hospitals and other institutional providers of care.

Each year, these institutions get an inflation increase in their payment rates, to reflect a rise in their input costs. Under Obamacare, those inflation increases will now be cut by an amount averaging a little over a half of a percentage point every year, in perpetuity. The compounding effect of cuts of this size is truly massive, and entirely implausible. As Foster and his colleagues document in an accompanying analysis released on the same day as the annual report, these payment-rate reductions simply widen the gap between the cost of providing care and what the government will pay. Even before the cuts become operational, Medicare’s rates stand at only about 80 percent of what private insurers must pay to secure access to care for patients. But under Obamacare, by 2020, Medicare’s rates would have already fallen below 75 percent of private insurers’ rates, and below what Medicaid pays as well. By the end of the projection period, Medicare’s rates would cover only about one-third of the payments that private insurers would be making to secure access to services.

Obamacare’s apologists would like Americans to believe they have set in motion a sophisticated and carefully considered plan to slow cost growth in Medicare — and the rest of the health system for that matter. But the truth is that all they have done is put into law a formulaic requirement for deeper price cuts in Medicare. That’s it. Presto! Problem solved!

But of course, the problem is not solved. Arbitrary price controls always and everywhere drive out willing suppliers of services. Who will see Medicare patients at 33 cents on the dollar?

When more realistic assumptions are employed by the Medicare actuaries, the supposed improvement in Medicare solvency all but vanishes. In the annual report, the unfunded liability of the Medicare fund for hospital services is said to have fallen to “just” $2.4 trillion over 75 years. But if more realistic payment-rate assumptions are used, the unfunded liability rises to $7.0 trillion.

Even correcting for the implausibility of payment-rate cuts does not offer a realistic scenario. The other key Medicare provision in Obamacare is the return of Carter-era “bracket creep” in the tax system. Initially, the law’s steep payroll-tax hike of 0.9 percent of wages will apply only to individual taxpayers with annual incomes exceeding $200,000 and couples with incomes exceeding $250,000. But those income thresholds will not increase with general inflation in the economy. Consequently, as the years pass, more and more Americans, including the middle class, will pay it — at least that’s the theory. Overall, the Medicare tax hikes in the new law are expected to raise about $1.4 trillion over 75 years, in present-value terms. But that assumes America’s middle class will placidly accept the return to the bad-old days of “bracket creep.” A more realistic assumption would be that elected leaders will come under pressure in short order to prevent such a massive tax hike on the middle class and respond accordingly, much as they do today in trying to minimize the tax hikes associated with the alternative minimum tax.

Overall, Foster and his team make clear in their alternative projection scenario that Medicare spending remains on a completely unsustainable trajectory. In last year’s annual report, Medicare spending was expected to reach 11.2 percent of GDP in 2080, up from just over 3 percent today. Now, using what the actuaries consider reasonable assumptions, Medicare spending would “only” rise to 10.7 percent of GDP. So much for the Obamacare solution.

posted by James C. Capretta | 3:01 pm
Tags: actuary, Medicare, annual Trustees report
File As: Health Care

The President Caves In to Union Pressure Shamelessly

As a candidate, Barack Obama promised an audacious presidency. If nothing else, he’s delivering on that.

For a year now, the president has argued that the health-care bill he is pushing will “bend the cost-curve.” Of course, his own Chief Actuary of the Medicare program — the man charged with actually running the numbers for the administration — has said repeatedly that there’s no curve-bending going on in the bills being written in Congress. His estimates show both the House and Senate-passed versions of Obamacare would increase overall health-care costs, not decrease them (see here and here). And that’s assuming all of the implausible assumptions written into the bills actually pan out, which they won’t.

But no matter. The president and his team have continued to press the argument nonetheless, citing in particular provisions in the Senate-passed bill that they believe will do the trick.

Among the most cited “game changers” is the so-called “high-cost insurance tax” — which was the subject of yesterday’s day-long, backroom deal-making in the White House. As passed by the Senate, the new 40 percent excise tax would apply to any insurance plan, including those sponsored by employers, with premiums exceeding $23,000 for family coverage and $8,500 for policies sold to individuals. The idea is to force insurers and employers to develop and sell policies that stay under the premium threshold, almost certainly by pushing more cost-sharing requirements (deductibles and co-payments) onto the plans’ enrollees. In the Senate bill, the high-cost plan excise tax would become effective in 2013 — conveniently after another presidential election.

It was always a stretch to say this provision — which would have applied to a very few plans for most of this decade — was robust enough to offset the massive cost pressures unleashed by expanding health entitlement promises to tens of millions of people. But if there were any optimistic holdouts still hoping cost discipline would eventually emerge from this unbecoming legislative process, they almost certainly have given up all hope today. Because yesterday, the president showed he is not only shameless but utterly weak as well. In the face of withering pressure from liberals in the House and labor unions, the president essentially caved by gutting one of his signature “bend the curve” ideas in the name of political expediency. In the deal struck between the White House and labor unions, employer-sponsored health insurance plans that are collectively bargained will be exempted from the tax until 2018 — well past the time when the president will have exited the White House. The deal also raised the thresholds to $24,000 for family coverage and $8,900 for individuals and exempted dental and vision plans beginning in 2015.

It’s takes a special kind of audacity to go behind closed doors and strike a deal using the taxpayers’ money to pay off political supporters at the expense of everyone else (no wonder they don’t want C-SPAN to record it for history!). But caving into to the unions is likely to unravel the entire high-cost tax idea before all is said and done. The administration will argue that the deal still leaves in place 60 percent of the Senate-passed bill. But that assumes no further backpedaling — which seems highly unlikely given the track record. What could possibly justify applying to this tax only to non-union workers? What will companies with a non-union workforce think about the federal government providing special favors to their unionized competitors? News of this deal is already producing a backlash, just like the Cornhusker Kickback did. And that backlash is only going to become more intense as the negotiators look to raise taxes on others to make up for the payoff they have promised only to their union patrons. In the end, pressure will build to exempt even more people from the tax. And, when that occurs, on what basis will the president be able to resist?

For a year now, the president has said he is willing to make the tough decisions to slow the pace of rising health-care costs. But he showed yesterday that he has absolutely no capacity to do so. This health-care bill is a runaway entitlement program, piled on top of an unreformed health-care system. It’s never been anything more than that. And it’s getting worse by the hour.

posted by James C. Capretta | 4:55 pm
Tags: unions, labor, Obamacare, cost curve, actuary, C-SPAN
File As: Health Care