Showing posts with label Reform. Show all posts
Showing posts with label Reform. Show all posts

Tuesday, 16 July 2013

Can We Buy Our Way to Health Reform?

library C. Eugene Steuerle

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.

© TAX ANALYSTS. Reprinted with permission.

Note: This report is available in its entirety in the Portable Document Format (PDF).

The text below is a portion of the complete document.

No issue has stumped policymakers more than how to provide healthcare to its citizens in an efficient and fair manner. Healthcare costs spiral out of control, usurping other vital government functions. Those rising costs also lead to increased numbers of uninsured, as employers and employees both decide to avoid costs simply by neglecting health insurance altogether. Every recent health "fix" has involved trying to buy health reform by devoting even more dollars to it. Do we lack adequate drug care? Then spend more through a drug bill. Do tax breaks tend to discourage consumer involvement in their healthcare? Then spend more on health savings accounts. Yet each of those enactments adds cost to a system that already is unsustainable. Yes, they might get at some particular imbalance in the system — removing some bias against drugs or against spending out of pocket — but in simply throwing more money into the system, they add to, rather than subtract from, the fundamental problem that someone, somewhere, somehow has to decide what health spending is worthwhile and what is not.

Note: This report is available in its entirety in the Portable Document Format (PDF).


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A Blueprint for Tax Reform and Health Reform

library A Blueprint for Tax Reform and Health ReformLeonard E. Burman

Reprinted with permission of the Virginia Tax Review.

The text below is an excerpt from the complete document. Read the full report in PDF format.

This paper outlines a plan for a VAT dedicated to paying for a new universal health insurance voucher combined with a vastly simplified and much flatter income tax. Top income tax rates could be cut to 25% or less and most taxpayers would not have to file returns. The health care voucher would offset the inherent regressivity of a VAT, since the voucher would be worth more than the VAT tax paid by most households. Moreover, with the VAT rate tied to health spending, the public would have a vested interest in reining in the growth of health care costs.

The nation urgently needs tax reform for at least four reasons. First, under current law most of the tax cuts enacted since 2000 are set to expire at the end of 2010 and the Code will revert to that of 2000. In theory, this would trigger what tax cut advocates have called the largest tax increase in history. Neither political party seems inclined to let that happen, so a significant tax revision before 2011 seems almost certain. Second, the baby boomers are beginning to retire and the costs of providing their Social Security and medical care will strain available federal revenues. Third, under current law, the reach of the individual alternative minimum tax (AMT), a pointlessly complicated and unfair element of the current code, is scheduled to mushroom, hitting thirty-two million taxpayers by 2010, up from four million in 2007. Were that to happen, the middle class would scream in protest, but making up for the hundreds of billions of dollars in revenue that the AMT is projected to produce will be a huge challenge. Finally, there is growing public dissatisfaction with our federal tax system, which is complex, riddled with loopholes, and widely perceived to be unfair. It is hard to see how these challenges can be tackled without a major tax reform.

Nonetheless, there are good reasons to be skeptical of a major tax reform happening any time soon. George Yin catalogued a litany of reasons why tax reform is much less likely now than it was in 1986, when the last landmark tax reform was enacted. Committee chairs in Congress have less power than they once did, meaning that tax bills are controlled by leadership that does not have the specialized knowledge or resources to shepherd a complex tax bill through Congress. Representatives and Senators spend so much time fundraising and running for reelection that they have little incentive or ability to invest in a time-consuming, complicated, and politically risky tax overhaul. Consequently, the political environment is poisoned, making the bipartisan effort necessary to accomplish tax reform next to impossible.

(End of excerpt. The entire report is available in PDF format.)


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Health Reform: A Four-Tranche System : Updated and Revised

library Updated and RevisedStephanie Rennane, C. Eugene Steuerle

This package of tables considers interactions between four different provisions of government support for health care that exist under the new Health Reform law (the Patient Protection and Affordable Care Act, or PPACA): Medicare, Medicaid, Insurance Subsidies offered through the Exchange, and Employer Sponsored Insurance (ESI). The summary table estimates the value of health benefits to families and singles at various income levels under the four options, and the charts show how these benefit levels change as income rises. Estimates for Medicare benefits are from CMS; estimates of Medicaid premiums are from the Health Policy Center. Backup tables work through the calculations for the value of the exchange subsidy and the tax subsidy for ESI.

The backup tables provide a comparison of health subsidies in the employer-provided system and the subsidy exchange in the Health Care and Education Reconciliation Act that was signed into law on March 30, 2010. This is an update to tables that compared health subsidies under the employer-provided system and the subsidy exchange in the earlier versions health reform proposals. The main provisions of the law are found in the Patient Protection and Affordable Care Act (PPACA), originally passed by the Senate on December 24, 2009. The changes in the latest Reconciliation Act that are relevant to this analysis include: (1) premium contributions range from 2% of income for people earning up to 133% of the federal poverty line to 9.5% of income for earners in the 300%-400% FPL range; (2) the employer penalty for not providing coverage in 2014 is $2,000 per full time worker and is indexed in subsequent years; and (3) cost share subsidies ensure an actuarial value of the health premium of 94% for those under 150% FPL; of 85% for 150-200% FPL; of 73% for 200-250% FPL and of 70% for 250% and higher.

We made several assumptions when calculating these estimates. First, we assume that the employer provides only cash wages and health insurance benefits (where applicable), and pays the appropriate employer payroll taxes. Secondly, our starting point was to set the employee's cost to the employer equal under the subsidy and ESI scenarios; this represents the amount of extra or less subsidy to be shared by employee or employer by adding or removing employer-provided insurance. In a simple case where the employer gives the employee the extra benefits from switching to the exchange, for instance, those benefits would be net of any employer penalty that had to be paid. Finally, the two earner scenario assumes that both employees either: (1) both have ESI available; or (2) are both eligible for the exchange. In the exchange situation, we assume that both employers incur a penalty that is passed on to the employee. A family with two earners where only one worker's employer incurs a penalty would resemble the one-earner situation at an equal income level.


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Social Security Reform: The Budget Debate All Over Again

library C. Eugene Steuerle

"Economic Perspective" column reprinted with permission.
Copyright 1998 TAX ANALYSTS

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.

Social security and Medicare reform suffer from the same problem that for so long made budget reform difficult. They measure gains and losses, winners and losers, from a base of a system that is imbalanced and whose promises don't add up. If our elected representatives convert the system to one that is more sustainable, however, they are accused of creating only losers—those who get smaller increases in benefits or higher taxes than are currently scheduled. But this is simply bad political accounting.

In budget policy, reducing future deficits was never given any formal credit for creating winners. Little recognition was given for all those who would get to pay fewer taxes, or receive additional benefits, if future interest costs on the federal debt were lower. Instead, the politics of budget reform implied there were only losers: those who would pay more taxes or receive fewer expenditures to keep the deficit lower.

Sometimes the list of losers would show up on distributional or other tables. For example, the 1982, 1984, 1990, and 1993 budget agreements all had some tax increases attached to them. In each case, the Joint Committee on Taxation would dutifully produce distributional tables by income class showing who would pay the additional taxes under the new law. Similarly, in many of the Medicare and other expenditure reforms that were debated as part of these budget efforts, calculations would sometimes be made of the additional cash burden for those individuals who might face some increased premium or copayment or lose some other benefit.

The problem with these calculations was not so much that some "losers" were identified; it was that the corresponding set of winners were ignored. Half the balance sheet was never calculated.

Ignore for the moment whether any particular tax and expenditure policy is good or bad for the economy in terms of behavior, incentives, poverty reduction, and so forth. Those are vital economic issues, but not usually part of the presentation of winners and losers. Absent those particular economic effects, the sum of losses plus gains to taxpayers from government action is exactly zero. That is, for every dollar paid in tax, there is a dollar that is expended for some purpose. This is easiest to see in the case of a direct cash transfer. One person pays, another receives. One dollar of loss to one is a dollar of gain for the other. The sum of transfers paid equal the sum of transfers received. If the expenditure is some good or service rather than a cash transfer, then each dollar's worth of that good or service for some people still represents a dollar of cost to other people.

Debt only confuses the issue, but the calculation is the same. Spend one dollar today and pay for it tomorrow. The present value—the sum of all values over time, discounted to the present—of all losses still equals the present value of all gains. Deferred taxes are still taxes. Similarly, if taxes are in excess of expenditures, then losses to current taxpayers or beneficiaries is made up for by gains to future taxpayers and beneficiaries.

This is simply basic accounting. If one looks only at a point in time, then it's easy to miscalculate winners and losers. Suppose one tries to calculate who wins by paying off current interest on the debt. At first it may look as if there are only losers—those taxpayers who fork over the extra money each year. That's because the winners likely were in the past—those who avoided paying the taxes to cover the cost of the benefits or expenditures they received.

From a measurement standpoint, it is obvious why only half the balance sheet is usually presented. Although we know that they must exist, the eventual winners from deficit reduction or bringing a system into balance are hard to identify. For example, reducing expected deficits allows the country to sell less debt. The future interest and principal payments that eventually have to be paid are lower. Nobody has to pay these amounts, and just who is "nobody" is vague at best. So, winners are hard to identify, and this side of the balance sheet is hard to create. It's not filled in, and it is hard to introduce it into the debate.

In contrast, losers from deficit reduction appear easy to identify. They are the ones who bear the lower benefits or higher taxes (the losses) from changing items already scheduled into the law. So, this side of the balance sheet is easy to fill in. It is the one that likely will be presented to the public and debated by the politicians because it is filled in.

That brings us back to taxes and expenditures in social security and Medicare. These systems promise higher and higher levels of benefits in the future, much more than current taxes can reasonably support. If one assumed that social security taxes were to support all of the promised increase in social security and Medicare benefits, those tax rates would almost have to double. Whether done through increased taxes or reduced expenditures, whether within social security and Medicare or through the general budget and general revenues, the shortfall must be covered. Promises must be reduced, taxes must be increased, or other programs must be cut back in size and scale. Identifying exactly who will bear these burdens is considered a political liability because it fills out the long-term accounting sheet.

What deters action on social security and Medicare, therefore, are precisely the same factors that kept the deficit reduction debate going without resolution for so many years. The only real difference is that the budget debate usually centered around deficits in the current year and the next few years. For social security and Medicare, the deficits of consequence are years, even decades, into the future—especially once the baby boomers more fully occupy the ranks of the retired.

Are there ways around this problem? Although not perfect, there are alternative ways to show changes over time. One need not show only differences from a set of promises that cannot be met. One alternative is to show changes from existing levels of benefits, rather than those benefits that are scheduled to grow over time. For instance, in today's dollars social security promises an insurance policy worth approximately $1/4 million in lifetime benefits to an average-income couple retiring today and $1/3 million to an average-income couple retiring in 30 years. If Congress cuts the growth in lifetime benefits so that the future couple only gets $300,000, that can be shown either as a $33,000 cut from "current law" promises, or an increase of $50,000 from "current levels" of benefits.

On the tax side of the budget, one could argue that the existing benefit schedule implies a future "tax" rate of, say, 15 percent to fund social security alone rather than about 10 percent. If the tax rate is kept at 10 percent for the future, then that could be shown as equivalent to a 5 percentage point reduction from the level of taxation implied in current law.

None of these measures is perfect, but at least they do a better job of balancing the tendency to look on only one side of the accounting sheet. The danger is that the political cost of identifying only losers will deter action by most of our elected officials, and that the country will be forced once again to go through years, even decades, of effort to get this longer term deficit into order. Along the way, most other policymaking will continue to be tied into knots.


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A Blueprint for Tax Reform and Health Reform : Before the Senate Committee on Finance

library A Blueprint for Tax Reform and Health ReformLeonard E. Burman

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.

In this testimony Burman outlines a plan for tax reform that would maintain progressivity, raise enough revenues to finance the government, and dovetail with plans to provide universal access to health insurance. It would combine a value-added tax (VAT) dedicated to pay for a new universal health insurance voucher with a vastly simplified and much flatter income tax. With a new financing source for health care, income tax rates could be cut sharply—the top rates could be cut to 25 percent or less. The health care voucher would also offset the inherent regressivity of a VAT. And, under the simplified system, most Americans would not have to file income tax returns.

The text below is an excerpt from the complete document.
Read the full written testimony in PDF format.

Chairman Baucus, Ranking Member Grassley, and members of the committee: Thank you for inviting me to testify on tax reform.

It is a great honor to speak to you on this topic. The last great tax reform effort lured me to Washington away from academia to work for the Treasury Department in 1985. I remember when Chairman Packwood rescued reform from the abyss with his “27-percent solution”—a top rate so low it caught the public’s attention and sustained momentum for what became the Tax Reform Act of 1986. The creativity and bipartisanship of this committee were key elements in the success of the 1986 Act.

In the mid-1980s, the tax system desperately needed fixing. Tax shelters were rampant, with investment decisions often motivated solely by the tax savings they could produce, rather than their underlying economics, which were often dubious. The public had lost confidence in the fairness of the tax system.

If anything, the need for tax reform is even greater now for at least four reasons. First, under current law most of the tax cuts enacted since 2000 are set to expire at the end of 2010 and the code will revert to that of 2000. In theory, this will trigger what tax cut advocates are already calling the largest tax increase in history, but extending the tax cuts seems fiscally reckless. Second, the baby boomers are beginning to retire and the costs of providing their Social Security and medical care will strain available federal revenues. Third, under current law, the reach of the individual alternative minimum tax (AMT), a pointlessly complicated and unfair element of the current code, is scheduled to mushroom, hitting 32 million taxpayers by 2010, up from 4 million in 2007. Were that to happen the middle class would scream in protest, but making up for the hundreds of billions of dollars in revenue that the AMT is projected to produce will be a huge challenge. Finally, there is growing public dissatisfaction with our federal tax system which is complex, riddled with loopholes, and widely perceived to be unfair. It is hard to see how these challenges can be tackled without a major tax reform.

Although tax reform is always a long shot, there are reasons for optimism. Politicians in both parties—and even current presidential candidates—understand that the current situation is unsustainable. A new president who had campaigned on a platform of working in a bipartisan way to advance objectives that matter to both parties may be willing to stake political capital on advancing tax reform. And the fact that both sides acknowledge that this is a “change election” bodes well for the next president’s willingness to take political risks.

(End of excerpt. The entire testimony is available in PDF format.)

The views expressed are those of the author and should not be attributed to the Urban Institute, its trustees, or its funders.


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The Future of Long-Term Care: What Is Its Place in the Health Reform Debate?

library The Future of Long-Term Care: What Is Its Place in the Health Reform Debate?Howard Gleckman

The text below is an excerpt from the complete document. Read the full report in PDF format.

More than 10 million Americans require long-term care supports and services. Yet the system for delivering and paying for this assistance is deeply flawed. While most of the frail elderly and those with disabilities prefer assistance at home, many must live in nursing homes to receive Medicaid benefits, care coordination for those with multiple chronic illnesses is poor, and the system for financing care impoverishes many middle-income families. The national health reform debate allows policymakers to reconsider long-term care as well. This paper assesses proposals to restructure the delivery and financing of long-term care services.

As the population ages, demand for long-term care supports and services is growing. Today, 10 million frail elderly and adults with disabilities require such care. Nearly 80 percent is provided at home, much of it by family members and friends. In 2007, the cost of paid services was estimated at $230 billion, while the economic value of informal care may have approached $375 billion. As the Baby Boomers age, both demand for this care and its costs are expected to increase dramatically.

Today, most paid care is funded by government, through Medicaid and other programs. Less than 10 percent is financed by private long-term care insurance, and much of the rest is paid for out-of-pocket by families themselves.

Despite the considerable resources devoted to long-term services, many continue to receive poor quality care. As a result, policymakers are pursuing major changes in the way assistance is both delivered and financed.

(End of excerpt. The entire report is available in PDF format.)


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Different Way to Pay for Health Reform

library Different Way to Pay for Health ReformLeonard E. Burman

Editorial as appeared in the Washington Times,on May 19, 2009

Expanding health-care access is a top priority for the Obama administration, and leaders in Congress are on board. Political leaders also agree that any health insurance expansion must not increase the deficit. So how do we pay for health care without sinking the economy? The best option would be to phase in a value-added tax (VAT) dedicated to paying for health care. Packaged with the right bells and whistles, the VAT would help revive the economy, offset the burden on low-income families, and help slow health-care costs.

Expanding health-care access is a top priority for the Obama administration, and leaders in Congress are on board. The stakes are high; the Democrats remember only too well how the Clinton health-care debacle cost their party control of Congress, and they don't want to repeat the experience.

To their credit, political leaders also agree that any health insurance expansion must not increase the deficit. Given the $9 trillion of projected deficits over the next decade, more red ink is not what the doctor ordered.

The trick, of course, is how to pay for it. President Obama's campaign proposal would cost something like $1.5 trillion over 10 years. There are no painless options for raising that kind of money.

The president proposed covering a fraction of the cost by limiting deductions for high-income taxpayers. But that immediately drew fire from nonprofit groups (charitable deduction) and real-estate agents (mortgage interest). Others have proposed limiting tax breaks for employer-sponsored health insurance, but as a candidate, Mr. Obama skewered Republican John McCain for proposing to eliminate the popular tax break. Republicans would have a field day slinging that bit of campaign rhetoric back in the president's face.

And so it goes. Because new taxes and real program cuts are politically perilous, I worry that policymakers will simply assume the problem away - implement market reforms intended to cut waste and inefficiency and then instruct a skeptical Congressional Budget Office to take it on faith that the reforms will be fabulously successful. Alternatively, they might design some bogus trigger mechanism: "If we don't achieve the desired cost savings, we'll make really hard decisions then. Honest."

That trigger will never be pulled, and the deficit hole will be that much deeper.

To be sure, we must slow the growth of health-care costs. But an aging population, the cost of covering the uninsured and the fact that many medical advances really are worth paying for guarantee that health-care spending will go up over time.

So how do we pay for health care without sinking the economy? The best option would be to phase in a value-added tax (VAT) dedicated to paying for health care. A VAT, which nearly every country has, is basically a sales tax on all goods and services that is collected in stages from all the producers in the supply chain. A 10 percent VAT would add 10 percent to the price of all goods and services.

It might sound nuts to add a tax during a recession, but announcing a future VAT could help revive the economy. Suppose the administration announced that a 5 percent VAT would take effect in 2010 and rise to 10 percent in 2011. That would boost spending - and the economy - now and again in 2010, as people accelerate purchases, especially of such big-ticket items as cars and major appliances, to avoid the future tax increase.

The VAT would also provide long-term economic benefits by encouraging people to save, because it taxes spending but not saving.

The conventional wisdom is that a VAT would be political suicide. But a VAT earmarked to pay for health care might fly. Although people don't like taxes, states have found that sales taxes are more palatable than income taxes. What's more, if the VAT came with a voucher to pay for health insurance, most people would gain way more in insurance coverage than they'd pay in VAT.

A few bells and whistles would be needed to make the package work. For people who get qualifying insurance at work, the voucher would be transferable to the employer, who would have to give it back to employees in their paychecks.

To offset the burden of the VAT on low-income working families (who spend all of their incomes on necessities so can't afford higher prices), a refundable income-tax credit would cover the VAT that a family at the poverty threshold would expect to pay. This idea echoes the "prebate" proposed by advocates for a national retail sales tax (or "fair tax").

A 10 percent VAT would pay for the voucher and tax credit. Over time, the VAT could be expanded to cover the costs of other federal health programs, making real income-tax reform, including significantly lower rates, a possibility.

A VAT earmarked for health care would help slow health-care costs because, if health spending continues to grow unabated, the VAT rate will go up and up, building pressure on politicians and health-care providers to restrain costs. This dynamic contrasts with the current system, in which many people think that health insurance is almost free, paid for by employers or the government.

A new tax might sound like a political fantasy, but an outspoken advocate of this approach has been Ezekiel Emanuel, the brother of Obama Chief of Staff Rahm Emanuel and an adviser to the president on health care.

The worst thing we could do would be to create another expensive health-care entitlement without figuring out how to pay for it. That would be hazardous to our children's health.

(This editorial is also available in PDF format.)


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