Chairman Ryan Gets Roughly Two-Thirds of His Huge Budget Cuts From Programs For Lower-Income Americans
House Budget Committee Chairman Paul Ryan’s budget plan would get about two-thirds of its more than $4 trillion in budget cuts over 10 years from programs that serve people of limited means, which violates basic principles of fairness and stands a core principle of President Obama’s fiscal commission on its head.
The plan of Erskine Bowles and Alan Simpson, who co-chaired President Obama’s National Commission on Fiscal Responsibility and Reform, established, as a basic principle, that deficit reduction should not increase poverty or inequality or hurt the disadvantaged. The Ryan plan, which the chairman unveiled in a news conference, speech, and Wall Street Journal op-ed today, charts a different course, turning its biggest cannons on these people.
This finding emerges from a Center on Budget and Policy Priorities analysis of the Ryan plan. Table S-4 of the plan shows that it proposes net program cuts of $4.3 trillion over ten years. The plan shows a $5.8 trillion cut in outlays from the Congressional Budget Office baseline, but $446 billion of that is interest savings and another $1.04 trillion is simply an assumption that the Iraq and Afghanistan wars will phase down on the Obama Administration’s timetable. Actual program cuts produce net savings of $4.322 trillion.
Cuts in low-income programs appear likely to account for at least $2.9 trillion — or about two-thirds — of this amount. The $2.9 trillion includes the following three categories of cuts:
- $2.17 trillion in reductions from Medicaid and related health care. The plan shows Medicaid cuts of $771 billion, plus savings of $1.4 trillion from repealing the health reform law’s Medicaid expansion and its subsidies to help low- and moderate-income people purchase health insurance.
- $350 billion in cuts in mandatory programs serving low-income Americans (other than Medicaid). The budget documents that Chairman Ryan issued today show that he is proposing $715 billion in cuts in mandatory programs other than Medicare, Medicaid, and Social Security, but do not specify how much will be cut from various programs (although they imply that cuts in the food stamp program will be large). In this analysis, we make the conservative assumption that savings from low-income mandatory programs (other than Medicaid) would be proportionate to their share of spending in this category. Thus, we derive the $350 billion figure from the fact that about half of mandatory spending other than for Medicare, Medicaid, and Social Security goes for programs for low- and moderate-income individuals and families. This likely substantially understates the cuts that the plan would make in low-income programs. The Ryan documents show that $380 billion in cuts would come from programs in the income security portion of the budget (function 600), and the overwhelming bulk of the mandatory spending in that category goes for low-income programs. The documents also show $126 billion in mandatory cuts in the education, training, employment, and social services portion of the budget (function 500), which, based on the discussion in those documents, would likely come mainly from cuts in the mandatory portion of the Pell Grant program for low-income students.
- $400 billion in cuts in low-income discretionary programs. The Ryan budget documents show that he is proposing $1.6 trillion in cuts in non-security discretionary programs, but again do not provide details about the size of cuts to specific programs. (The documents do identify some major low-income program areas, including Pell Grants and low-income housing, as prime targets for cuts.) Here, too, we make the conservative assumption that low-income programs in this category would bear a proportionate share of the cuts. Thus, we derive the $400 billion figure from the fact that about a quarter of non-security discretionary spending goes for programs for low- and moderate-income individuals and families.
Our numerical assumptions are conservative in another way as well. That’s because, when faced with the choice of which specific programs to cut, policymakers are unlikely to cut much from a number of non-low-income programs in these budget categories that are popular, such as veterans’ disability compensation and the FBI. That means that other programs — including low-income programs — would have to be cut by more than their proportionate share.
By: Robert Greenstein, Center on Budget and Policy Priorities, April 5, 2011
Congressional Budget Office Looks At “RyanCare” Rationing And It Ain’t Pretty
The Congressional Budget Office has released its preliminary analysis (PDF) of House Budget Committee Chairman Paul Ryan’s budget, and I wouldn’t say it’s pretty. According to the CBO, Medicare beneficiaries will be left paying more for less. The CBO goes about this in a bit of a confusing way, setting a “benchmark” that corresponds to the cost of purchasing a private plan equivalent to Medicare, and then seeing how much more that plan would cost than Medicare under two different scenarios. Compared with either scenario, RyanCare costs a lot more than Medicare:
Under the proposal, most elderly people would pay more for their health care than they would pay under the current Medicare system. For a typical 65-year-old with average health spending enrolled in a plan with benefits similar to those currently provided by Medicare, the CBO estimated the beneficiary’s spending on premiums and out-of-pocket expenditures as a share of a benchmark: what total health-care spending would be if a private insurer covered the beneficiary. By 2030, the beneficiary’s spending would be 68 percent of that benchmark under the proposal, 25 percent under the extended-baseline scenario, and 30 percent under the alternative fiscal scenario.
If Medicare’s beneficiaries are getting less for more, Medicaid’s are simply getting less, period:
Federal payments for Medicaid under the proposal would be substantially smaller than currently projected amounts. States would have additional flexibility to design and manage their Medicaid programs, and they might achieve greater efficiencies in the delivery of care than under current law. Even with additional flexibility, however, the large projected reduction in payments would probably require states to decrease payments to Medicaid providers, reduce eligibility for Medicaid, provide less extensive coverage to beneficiaries, or pay more themselves than would be the case under current law.
As the CBO recognizes, a lot of what Ryan is doing isn’t saving money so much as shifting costs. Poor people and seniors don’t need less health care because Medicare and Medicaid are providing less health care. They just have to pay for more of it on their own. And as the CBO says, it’s hard to imagine Congress simply ignoring their pleas for help:
Under the proposal analyzed here, debt would eventually shrink relative to the size of the economy — but the gradually increasing number of Medicare beneficiaries participating in the new premium support program would bear a much larger share of their health care costs than they would under the current program; payments to physicians and other providers for services provided under the traditional Medicare program would be restrained (as under the two scenarios); states would have to pay substantially more for their Medicaid programs or tightly constrain spending for those programs; and spending for federal programs other than Social Security and the major health care programs would be reduced far below historical levels relative to GDP. It is unclear whether and how future lawmakers would address the pressures resulting from the long-term scenarios or the proposal analyzed here.
By: Ezra Klein, The Washington Post, April 5, 2011
Implosion: Paul Ryan’s Radical, Ridiculous, Rip-Off Roadmap
While the process of crafting a budget plan for this fiscal year implodes under the weight of GOP intransigence, today also happens to be the day next year’s budget fight begins in earnest. And if you think the current fight is a mess, prepare to have Republicans take your breath away.
And if you’re a disabled senior on Medicaid, relying on an oxygen tank, that expression should probably be taken literally.
Today, House Budget Committee Chairman Paul Ryan (R-Wis.) unveils his plan for fiscal year 2012. He promised a truly radical approach to our entire system of government, and he wasn’t lying — Ryan’s budget is based on his radical “roadmap” and effectively rewrites the American social contract.
Medicare would be eliminated and replaced with a voucher system. Medicaid would be gutted and sent to the states as a block grant. The Affordable Care Act would be scrapped, tax rates on corporations and the wealthy would be slashed, and all told, Ryan’s plan intends to slash roughly $6 trillion from the federal budget over the next 10 years.
This is madness.
There’s obviously no way Democrats in the Senate or the White House will even consider such extremism, but House Republicans don’t much care. This is the plan they want; this is the plan they’ll pass; and this is the plan that will set a truly ridiculous benchmark for future negotiations. If a shutdown seems inevitable this week, wait until the House GOP votes to eliminate Medicare as part of their next budget pitch.
Those of us hoping the chattering class will recognize the Republican plan as extremist nonsense are likely to be disappointed. David Brooks gushed today about the radical roadmap.
The country lacked that leadership until today. Today, Paul Ryan, the Republican chairman of the House Budget Committee, is scheduled to release the most comprehensive and most courageous budget reform proposal any of us have seen in our lifetimes. Ryan is expected to leap into the vacuum left by the president’s passivity. The Ryan budget will not be enacted this year, but it will immediately reframe the domestic policy debate.
His proposal will set the standard of seriousness for anybody who wants to play in this discussion…. Paul Ryan has grasped reality with both hands. He’s forcing everybody else to do the same.
Jonathan Zasloff’s point-by-point takedown of the Brooks column is worthwhile, but my biggest fear is that the D.C. establishment will start to assume that Brooks is correct. He’s not. Ryan’s budget plan is stark raving mad.
“Courageous”? To the extent that a major political party and House majority is actually willing to rally behind such extremism — without a hint of shame or trepidation — I’ll gladly give Republicans credit for actually putting their ridiculous wish list on the table.
But in this context, real, meaningful courage requires sound judgment, not just a willingness to fight for millionaires and corporations, while screwing over the elderly, the poor, the disabled, and working families.
By: Steve Benen, Washington Monthly, April5, 2011
Cutting Medicaid Means Cutting Care For The Poor, Sick And Elderly
The part of Paul Ryan’s budget that’s going to get the most attention is his proposal to privatize and voucherize Medicare. But the part that worries me the most is his effort to slash Medicaid, with no real theory as to how to make up the cuts.
Ryan’s op-ed introducing his budget lists Medicaid under “welfare reform,” reflecting the widespread belief that Medicaid is a program for the poor. That belief is wrong, or at least incomplete. A full two-thirds of Medicaid’s spending goes to seniors and people with disabilities — even though seniors and the disabled are only a quarter of Medicaid’s members. Sharply cutting Medicaid means sharply cutting their benefits, as that’s where the bulk of Medicaid’s money goes. This is not just about the free health care given to some hypothetical class of undeserving and unemployed Medicaid queens.
But perhaps cutting it wouldn’t be so bad if there were a lot of waste in Medicaid. But there isn’t. Medicaid is cheap. Arguably too cheap. Its reimbursements are so low many doctors won’t accept Medicaid patients. Its costs grew less quickly than those of private insurance over the past decade, and at this point, a Medicaid plan is about 20 percent cheaper than an equivalent private-insurance plan. As it happens, I don’t think Medicaid is a great program, and I’d be perfectly happy to see it moved onto the exchanges once health-care reform is up and running. But the reason that’s unlikely to happen isn’t ideology. It’s money. Giving Medicaid members private insurance would cost many billions of dollars.
That’s why it’s well understood that converting Medicaid into block grants means cutting people off from using it, or limiting what they can use it for. You can see CBO director Doug Elmendorf say exactly the same thing here. There’s just not another way to cut costs in the program. You can, of course, work to cut costs outside of the program, either by helping people avoid becoming disabled or making it cheaper to treat patients once they become disabled or sick, but those sorts of health-system reforms are beyond the ambitions of Ryan’s budget.
To get around some of this, Ryan’s op-ed talks about state flexibility, with the implication being that states have some secret Medicaid policies they’ve been dying to try but that the federal government simply hasn’t let them attempt. But the truth is there’s been a tremendous amount of experimentation in Medicaid over recent decades. Indiana converted its Medicaid program into health savings accounts. Tennessee based its program around managed care. Massachusetts folded its Medicaid money into Mitt Romney’s health-care reforms. Oregon tried to rank treatments by value. Some of these reforms have worked well and some haven’t worked at all, but none have solved the basic problem that covering the sick and disabled costs money, and you can’t get around that by trying to redesign their insurance packages. For that reason, block-granting Medicaid ultimately means cutting health-care coverage to the poor, the elderly and the disabled, even as it doesn’t actually address the factors driving costs throughout the health-care system.
By: Ezra Klein, The Washington Post, April 5, 2011
When Lies Don’t Work, Try “Bait And Switch”: What Paul Ryan’s Budget Actually Does
Paul Ryan’s plan for Medicare and Paul Ryan’s plan for Medicaid rely on the same bait-and-switch: They use a reform to disguise a cut.
In Medicare’s case, the reform is privatization. The current Medicare program would be dissolved and the next generation of seniors would choose from Medicare-certified private plans on an exchange. But that wouldn’t save money. In fact, it would cost money. As the Congressional Budget Office has said (pdf), since Medicare is cheaper than private insurance, beneficiaries will see “higher premiums in the private market for a package of benefits similar to that currently provided by Medicare.”
In Medicaid’s case, the reform is block-granting. Right now, the federal government shares Medicaid costs with the states. That means their payments increase or decrease with Medicaid’s actual rate of spending. Under a block grant system, that’d stop. They’d simply give states a lump sum at the beginning of the year and that’d have to suffice. And if a recession hits and more people need Medicaid or a nasty flu descends and lots of disabled beneficiaries end up in the hospital with pneumonia? Too bad.
In both cases, what saves money is not the reform. It’s the cut. For Medicare, the cut is that the government wouldn’t cover the full cost of the private Medicare plans, and the portion they would cover is set to shrink as time goes on. In Medicaid, the block grants are set to increase more slowly than health-care costs, which is to say, the federal government will shoulder a smaller share of the costs than it currently does. The question for both plans is the same: What happens to beneficiaries?
Remember how the Affordable Care Act was really, really, really long? There was a reason for that. It was full of delivery-system reforms meant to make the health-care system cheaper and more efficient — things like bundling payments for illnesses and reducing reimbursements to hospitals with high rates of infection and creating a center tasked with seeding cost-control experiments throughout Medicare and encouraging the formation of Accountable Care Organizations. The hope is that those reforms will cut costs, which will make the rest of the bill’s cuts possible (more on that here). Republicans, notably, have been skeptical that these reforms will work, and have argued that the cuts won’t stick because beneficiaries will revolt.
To my knowledge, Ryan’s budget doesn’t attempt to reform the medical-care sector. It just has cuts. The hope is that those cuts will force consumers to be smarter shoppers and doctors to be more economical and states to be more innovative. But all that’s been tried, and it hasn’t been enough. That’s why the Affordable Care Act had to go so much further, digging deep into the delivery system, and why Republicans had at least a plausible case that some of its cuts wouldn’t stick. But now the GOP needs to apply the same skepticism to their own programs: Cuts aren’t enough, and if they somehow manage to distract people from the cuts by repeating the words “block grants” and “flexibility” and “premium support” over and over again, they’ll simply end up seeing their cuts ignored when it becomes clear that they’ll mean leaving the old and the poor without health care. What Ryan has here isn’t so much a plan to control spending as a plan to cut spending, whatever the consequences.
By: Ezra Klein, The Washington Post, April 4, 2011
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