The GOP’s Penny-wise, Pound-Foolish Spending Cuts
Let’s say that for every dollar you gave me, I gave you a crisp $10 bill in return. Good deal, right? Almost too good. But before you start to ask questions, I’ll remind you that this is my thought experiment. Perhaps I just love dollar bills. Or perhaps I just love you. At any rate, there are no strings attached, and you can take advantage of it more than once.
Now let’s say that you’re in debt and you need to get your finances in order. Do you start handing me more dollar bills? Or fewer?
If you’ve got any sense, you’ll give me more. Converting dollar bills into $10 bills is an excellent way to pay off your credit card. Except, it seems, if you’re a House Republican.
On March 1, House Republicans voted to cut $600 million from the budget of the Internal Revenue Service for the remainder of 2011, and they want even deeper cuts in 2012. Perhaps that doesn’t surprise you: Republicans don’t like spending — at least when they’re not in power — and they don’t like taxes. Why would they fund the IRS?
Well, as the Associated Press reported, “every dollar the Internal Revenue Service spends for audits, liens and seizing property from tax cheats brings in more than $10, a rate of return so good the Obama administration wants to boost the agency’s budget.” It’s an easy way to reduce the deficit: You don’t have to cut heating oil for the poor or Pell grants for students. You just have to make people pay what they owe.
But deficit reduction is not the GOP’s top priority. It’s a bit lower on the list, somewhere between “get Styrofoam cups back into Congress” — an actual push the Republicans took up to thumb their nose at Nancy Pelosi’s environmental policies — and make “Sesame Street” beg for money. In fact, if you listen to Speaker John Boehner, he’ll tell you himself. “The American people want us to focus on creating jobs and cutting spending,” he has said. And that comment wasn’t a one-off: “Our goal is to cut spending,” he said in another speech.
Cutting spending is related to, but in important ways different from, cutting deficits. For one, it rules out tax increases. That’s how Republicans can lobby to make the Bush tax cuts permanent, at a cost of $4 trillion over 10 years, and yet say they’re fulfilling their campaign promises by making much smaller cuts to non-defense discretionary spending. If you add up what Republicans have offered since the election, the policies they’ve endorsed would increase deficits but also decrease spending, at least in the short term. The IRS example shows that spending cuts don’t always reduce the deficit. But it’s worse even than that: Spending cuts don’t always reduce government spending.
There are three categories of spending in which cuts lead to more, rather than less, spending down the line, says Alice Rivlin, former director of both the Congressional Budget Office and the Office of Management and Budget. Inspection, enforcement and maintenance. The GOP is trying to cut all three.
Let’s begin with the costs of cutting inspection — for example, the Food and Drug Administration and the Agriculture Department. Together, the agencies are charged with ensuring that the nation’s food is safe. That’s increasingly crucial as our interconnected, industrialized system makes contaminated food a national crisis rather than a local problem. In recent years, we’ve seen massive recalls stemming from E. coli in spinach, salmonella in peanut butter and melamine in pet food. Each required the recall of thousands of tons of food and alerts to consumers who, in many cases, were screened or treated.
The problem was bad enough — and the people and pets sick enough— that Congress passed a bipartisan food-safety bill during last year’s lame-duck session. But now Republicans want big cuts in the agencies’ budgets, meaning fewer inspectors and a higher chance of outbreaks and food-borne illness. And those don’t come cheap. They show up in our health-care costs, disability insurance and tax revenue, not to mention in the pain and suffering and even death they cause.
Next up: enforcement. As any budget wonk will tell you, cracking down on “waste, fraud and abuse” won’t cure all our fiscal ills. But waste, fraud and abuse do happen, particularly in Medicare and Medicaid, where they can be costly. Republicans are looking for big reductions in the Department of Health and Human Services, meaning fewer agents to conduct due diligence on health-care transactions. Costs will go up, not down.
Then there’s deferred maintenance. In 2009, the Society of Civil Engineers gave America’s existing infrastructure a grade of D. They estimated that simply maintaining America’s existing stock would require up to $2.2 trillion in investment. But Republicans have been cool to Obama’s calls to increase infrastructure investment. Just “another tax-and-spend proposal,” Rep. John Mica (R-Fla.) said when the initiative was announced. But a dollar in maintenance delayed — or cut — isn’t a dollar saved. It’s a dollar that needs to be spent later. And waiting can be costly. It’s cheaper to strengthen a bridge that’s standing than repair one that’s fallen down.
And there are plenty of examples beyond that. Republicans have proposed massive cuts to the Securities and Exchange Commission, which would make another financial crisis that much likelier. They’ve proposed cuts to the National Oceanic and Atmospheric Administration, which conducts tsunami monitoring. In their zeal to cut spending, they’re also cutting the spending that’s there to prevent overspending. Just as you have to spend money to make money, you also have to spend money to save money — at least sometimes.
There are all sorts of reasons Republicans are being penny-wise and pound-foolish. Cutting $100 billion in spending in one year sounded good on the campaign trail but turned out to be tough in practice. Curtailing the IRS and cutting the Department of Health and Human Services — and, particularly, its ability to implement health-care reform — is a long-term ideological objective for Republicans.
Whatever the reason, the effect will be the same: a higher likelihood of pricey disasters, an easier time for fraudsters, and bigger price tags when we have to rebuild what we could’ve just repaired.
By: Ezra Klein, The Washington Post, March 15, 2011
What Wisconsin Democrats Can Teach Washington Democrats
Consider the contrast between two groups of Democrats, in Wisconsin and in the nation’s capital.
Washington Democrats, including President Obama, have allowed conservative Republicans to dominate the budget debate so far. As long as the argument is over who will cut more from federal spending, conservatives win. Voters may think the GOP is going too far, but when it comes to dollar amounts, they know Republicans will always cut more.
In Wisconsin, by contrast, 14 Democrats in the state Senate defined the political argument on their own terms – and they are winning it.
By leaving Madison rather than providing a quorum to pass Gov. Scott Walker’s assault on collective bargaining for public employees, the Wisconsin 14 took a big risk. Yet to the surprise of establishment politicians, voters have sided with the itinerant senators and the unions against a Republican governor who has been successfully portrayed as an inflexible ideologue. And in using questionable tactics to force the antiunion provision through the Senate on Wednesday, Republicans may win a procedural round but lose further ground in public opinion.
Here’s the key to the Wisconsin battle: For the first time in a long time, blue-collar Republicans – once known as Reagan Democrats – have been encouraged to remember what they think is wrong with conservative ideology. Working-class voters, including many Republicans, want no part of Walker’s war.
A nationwide Pew Research Center survey released last week, for example, showed Americans siding with the unions over Walker by a margin of 42 percent to 31 percent. Walker’s 31 percent was well below the GOP’s typical base vote because 17 percent of self-described Republicans picked the unions over their party’s governor.
At my request, Pew broke the numbers down by education and income and, sure enough, Walker won support from fewer than half of Republicans in two overlapping groups: those with incomes under $50,000 and those who did not attend college. Walker’s strongest support came from the wealthier and those with college educations, i.e., country club Republicans.
Republicans cannot afford to hemorrhage blue-collar voters. In a seminal article in the Weekly Standard six years ago, conservative writers Reihan Salam and Ross Douthat observed: “This is the Republican Party of today – an increasingly working-class party, dependent for its power on supermajorities of the white working-class vote, and a party whose constituents are surprisingly comfortable with bad-but-popular liberal ideas like raising the minimum wage, expanding clumsy environmental regulations, or hiking taxes on the wealthy to fund a health care entitlement.”
Put aside that I favor the policies Douthat and Salam criticize. Their electoral point is dead on. In 2010, working-class whites gave Republicans a 30-point lead over Democrats in House races. That’s why the Wisconsin fight is so dangerous to the conservative cause: Many working-class Republicans still have warm feelings toward unions, and Walker has contrived to remind them of this.
Which brings us to the Washington Democrats. Up to now, the only thing clear about the budget fight is that Democrats want to cut less from discretionary spending than Republicans do. Quietly, many Democrats acknowledge that they have been losing this argument.
Thus the importance of a speech on Wednesday by Sen. Charles E. Schumer, a New York Democrat, intended to “reset the debate.” As Schumer noted, the current battle, focused on “one tiny portion of the budget,” evades the real causes of long-term budget deficits.
Schumer dared to put new revenue on the table – including some tax increases that are popular among the sorts of blue-collar voters who are turning against Walker. Schumer, for example, spoke of Obama’s proposal to end subsidies for oil and gas companies and for higher taxes on “millionaires and billionaires.” Yes, closing the deficit will require more revenue over the long run. But right now, the debate with the House isn’t focusing on revenue at all.
Schumer, who spoke at the Center for American Progress, also suggested cuts to agriculture subsidies and in unnecessary defense programs. He proposed changes in Medicare and Medicaid incentives that would save money, including reform of how both programs pay for prescription drugs. The broad debate Schumer called for would be a big improvement on the current petty argument, which he rightly described as “quicksand.”
To this point, Washington Democrats have been too afraid and divided to engage compellingly on the fundamentals of what government is there to do and how the burdens of deficit reduction should be apportioned. Wisconsin Democrats have shown that the only way to win arguments is to take risks on behalf of what you believe. Are Washington Democrats prepared to learn this lesson?
By: E. J. Dionne, Op-Ed Colunist, The Washington Post, March 10, 2011
It’s Not Just Entitlements, The Real Issue: Controlling All Health Care Costs
The current cry to reduce Federal deficits and debt growth by reducing Medicare and Medicaid entitlements is totally missing the key issue: the need to moderate all health care inflation. This should be the time for a national debate on how to best tackle the underlying cost problem, for the sake of our future, the economy, and access to health care.
The June 13-19, 2009 Economist editorialized: “America has the most wasteful [health] system on the planet. Its fiscal future would be transformed if Congress passed reforms that emphasized control of costs as much as the expansion of coverage that Barack Obama rightly wants.”
Health reform failed to get an adequate handle on all health care costs. Now there are constant calls by various expert commissions and many in Congress for entitlement spending reductions. Such cuts will create enormous new problems by failing to address the underlying, real problem of health costs and inflation.
Cutting just Medicare and Medicaid without addressing the whole problem is like squeezing a balloon—the balloon starts looking very strange very fast. While it is difficult to tell how much cost-shifting may occur and it will vary from market-to-market, some Medicare and Medicaid cuts probably get passed through in higher costs to the private sector—hardly a helpful action. (Congressional Budget Office, December 2008, Key Issues in Analyzing Major Health Insurance Proposals, p. 116) Cuts that are too deep in Medicare will also end up causing providers to be reluctant to see seniors and people with disabilities—as happens all too often today in Medicaid. In time, quality may be threatened.
And Medicare and Medicaid are not particularly driving the problem of soaring health care costs. As various studies have shown, over the long haul, Medicare has probably inflated slightly less rapidly for a comparable package of services than the private sector has. Recent reports by the Medicare Payment Advisory Commission (MedPAC) show that high quality, efficient hospitals have made a little money on Medicare, while private insurers have often failed to control costs, and have paid less effective hospitals 132 percent of the costs of running an efficient hospital. (See, for example, MedPAC’s March 2009 Report to Congress, Section 2A.)
A Comprehensive Approach To Health Care Cost Containment
It is past time for a comprehensive solution to ensure the affordability of a fundamental need: access to health care. We should say that access to reasonably affordable health care is a basic national need, like access to clean water and air, and treat it like a regulated utility—like your water–where cost growth is kept within a reasonable range and where a reasonable quality service is widely available (but if you want to go buy Perrier, you can).
Instead of squeezing one part of the health care cost balloon (Medicare and Medicaid), we need an “all saver” system. Under this system, any provider in the health care sector which inflates its billings faster than the growth in the CPI plus, say, one percent (adjusted for changes in population, new technologies, increased productivity, and changes in the severity of the cases that provider treats) would owe a rebate of the excess amount to its customers—both private and public. If the rebate were not provided, that excess income would face a 100 percent tax. The Federal government could do this under the Commerce clause, or, to enable providers and patients to opt out, could require participation by those accepting payment from Medicare, Medicaid, and payers claiming tax-deductible medical expenses.
How would the plan work? Complicated? Yes, but soon very doable with today’s health information technology systems and the coding systems developed by Medicare and others. It would take several years to set the system up, but it would work like this. Let’s say a hospital in a base year of 2013 had $100 million worth of billings. If consumer inflation were 4 percent and if the system allowed another 1 percent (just because we do highly value health care and some extra growth is a reasonable choice), then in 2014, the hospital could bill $105 million. (Let’s assume that an expensive new technology is available that costs an extra $1 million, but let’s also assume that increase is coincidentally offset by a national increase in productivity of 1 percent that saves about $1 million.)
If the hospital bills its customers $110 million in 2014, yet those customers are no sicker or more complicated to treat than in 2013 (as proven by the audited billing codes or adjusted for coding creep), the hospital will owe its customers $5 million in rebates. If Medicare paid 40 percent of the bills ($44 million), it would receive back 40 percent of the $5 million excessive inflation ($2 million). If a large employer’s health plan paid 20 percent of the provider’s bills, it would get $1 million back, and so forth.
If a provider did not want to participate, they could insist on only after-tax cash customers, and individuals would be free to use such doctors and hospitals.
Changing The Debate
Instead of focusing on Medicare/Medicaid cuts, Congress should be debating ideas of how to moderate all health care spending while minimizing interference in the practice of medicine. The plan I’ve described is just one option, and of course it would have to be adjusted to deal with many complexities. For example:
- How could the plan be made fair to new doctors and facilities with one-time extra start-up costs and no history of billings?
- How could the plan use quarterly payments or rolling averages to avoid many providers shutting down in December?
- How could society encourage further innovation, perhaps by offering more inflation for drugs certified as breakthroughs by the Food and Drug Administration?
- What cosmetic-type services could or should be exempt?
- What MedPAC-like advice and constitutional governance would be best?
Of course, if over the next decade reforms such as electronic medical records, comparative effectiveness research, and new bundling of the way we pay for services sufficiently ‘bends’ the spending curve downward, this system could be suspended. But it is doubtful those changes will do enough, and it is time to act on a comprehensive solution.
Incidentally, slowing all health care inflation would not only save enormous amounts in Medicare and Medicaid; over time it should achieve huge extra CBO/Joint Tax scorable savings, because the private sector and individuals will claim less in tax-deductible expenses for health care.
Budget reform that gets a handle on all health care inflation will solve most—or at least the toughest–of the ‘entitlement and future debt problems facing the nation. The entitlement problem is overwhelmingly a Medicare problem, driven not so much by more seniors or an aging population as by constantly soaring per capita costs of care. If we try to solve the entitlement problem just by cutting Medicare and Medicaid, we will destroy those programs. We need a total solution, because soaring health care costs are distorting the economy and our future as a successful nation.
Now is the time for this debate.
By: William Vaughan, Health Affairs Blog, Originally published March 3, 2011
Republicans Stampede Toward The Cliff
Interesting findings from the NBC/WSJ poll. Asked about deficit reducing options, the options the public overwhelmingly favors are ones Democrats favor, and the options they overwhelmingly oppose are ones Republicans are promising to propose:
[The survey] listed 26 different ways to reduce the federal budget deficit. The most popular: placing a surtax on federal income taxes for those who make more than $1 million per year (81 percent said that was acceptable), eliminating spending on earmarks (78 percent), eliminating funding for weapons systems the Defense Department says aren’t necessary (76 percent) and eliminating tax credits for the oil and gas industries (74 percent).
The least popular: cutting funding for Medicaid, the federal government health-care program for the poor (32 percent said that was acceptable); cutting funding for Medicare, the federal government health-care program for seniors (23 percent); cutting funding for K-12 education (22 percent); and cutting funding for Social Security (22 percent).
But the public demands deficit reduction, right? Well, actually, they care more about jobs:
In the poll, eight in 10 respondents say they are concerned about the growing federal deficit and the national debt, but more than 60 percent — including key swing-voter groups — are concerned that major cuts from Congress could impact their lives and their families.
What’s more, while Americans find some budget cuts acceptable, they are adamantly opposed to cuts in Medicaid, Medicare, Social Security and K-12 education.
And although a combined 22 percent of poll-takers name the deficit/government spending as the top issue the federal government should address, 37 percent believe job creation/economic growth is the No. 1 issue.
Republican pollster Bill McInturff, who conducted the survey with Democratic pollster Peter D. Hart, says these results are a “cautionary sign” for a Republican Party pursuing deep budget cuts.
He points out that the Americans who are most concerned about spending cuts are core Republicans and Tea Party supporters, not independents and swing voters.
“It may be hard to understand why a person might jump off a cliff, unless you understand they’re being chased by a tiger,” he said. “That tiger is the Tea Party.”
By the standards of these things, those are extremely sharp comments from McInturff. Leaders are usually more worried about internal threats than external threats. Boehner needs to make sure he doesn’t get deposed as speaker before he worries about winning a showdown with Democrats.
The specifics of the fight — Republicans promising to cut overwhelmingly popular programs, being willing to shut down the government, and pushing a plan that private analysts predict will reduce jobs — put them in a very tough position. Republicans are working really hard to buck each other up and ignore data about public opinion. Democrats have the upper hand here. President Obama may decide to cut a deficit deal, but both the politics and the policy say he should hand the Republicans their head first.
By: Jonathan Chait, The New Republic, March 3, 2011
Mr. Obama’s Health Care Challenge-The Ball Is In Your Court GOP
President Obama had a splendid idea this week. He challenged governors who oppose his health care reforms, most of whom are Republicans, to come up with a better alternative. He has agreed to move up the date at which states can offer their own solutions and thus opt out of requirements that they oppose, like the mandate that everyone buy health insurance and that most employers provide it.
Let as many states as possible test innovative approaches to determine which works best.
The president told the nation’s governors on Monday that he supported a bipartisan bill — sponsored by Senators Ron Wyden, Democrat of Oregon, Scott Brown, Republican of Massachusetts, and Mary Landrieu, Democrat of Louisiana — that would allow states to fashion solutions right from the start of full-scale reform in 2014, rather than waiting until 2017, as the law requires.
The catch is that a state’s plan must cover as many people as the federal law does, provide insurance that is as comprehensive and affordable, and not increase the deficit. That won’t be easy for the governors to accomplish, and House Republicans seem unlikely to pass the bill to let them try. They would much rather repeal the reform law — or have it declared unconstitutional by the Supreme Court — than join Mr. Obama in improving it.
The decision to set the date at 2017 was based on a desire to get the reform elements up and coverage greatly expanded before allowing states to start changing the law. There also were concerns that the early start would be more costly. That’s because the states would be given money for alternatives equal to the cost of insuring their citizens under health care reform. Without three years of experience to get firm figures, those block grants would probably be set too high.
Neither rationale still seems compelling. It would be wasteful to require states to set up exchanges and other elements of the reform only to abandon them for an alternative system three years later. The pending bill would wisely allow states to submit proposals in the near future and, if approved, put them into effect in 2014.
Alternative approaches might include replacing the mandate to buy insurance with a system to automatically enroll people in health plans, reformulating tax credits for small businesses and low-income individuals to encourage near-universal coverage, adopting such liberal approaches as a single-payer plan or a public option, and even moving all or part of the enrollees in Medicaid into new health insurance exchanges. These would all have to be done without driving up the federal deficit or reducing benefits, affordability and coverage.
Reaction among Republican governors has been mixed. The vast majority are focused on their immediate need to reduce Medicaid spending to help close their budget gaps, not on fashioning alternatives for 2014. For the near-term budget problems, the administration is already advising states on ways to reduce Medicaid costs and the president asked the governors to form a bipartisan group to work on further cost-reduction.
The president’s new olive branch is not apt to change the legal arguments over whether the mandate in the reform law is constitutional. But it can’t hurt to bring forcefully to everyone’s attention that there are alternatives to the mandate if states want to pursue them. Republicans ought to rise to the challenge.
By: The New York Times-Editorial, Published March 1, 2011
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