By Chris Jacobs
According to the Congressional Budget Office’s most recent baselines, the federal government will spend a total of $6.87 trillion on Medicare and $4.36 trillion on Medicaid over the next ten years – that’s $11.2 trillion total, not even counting additional state spending on Medicaid. Yet President Obama’s budget, released today, contains net deficit savings of only $152 billion from health care programs. That’s a total savings of only 1.35 percent of the trillions the federal government will spend on health care in the coming decade. Sadly, it’s another sign the President isn’t serious about real budget and deficit reform.
Overall, the budget:
- Proposes a total of $401 billion in savings, yet calls for $249 billion in unpaid-for spending due to the Medicare physician reimbursement “doc fix” – thus resulting in only $152 billion in net deficit savings. (The $249 billion presumes a ten year freeze of Medicare physician payments; however, the budget does NOT propose ways to pay for this new spending.)
- Proposes few structural reforms to Medicare; those that are included – weak as they are – are not scheduled to take effect until 2017, well after President Obama leaves office. If the proposals are so sound, why the delay?
- Requests a more than 50% increase – totaling $1.4 billion – for program management at the Centers for Medicare and Medicaid Services, of which the vast majority would be used to implement Obamacare.
- Includes mandatory proposals in the budget that largely track last year’s budget and the President’s September 2011 deficit proposal to Congress, with a few exceptions. The largest difference between this year’s budget and the prior submissions is a massive increase in savings from reductions to nursing and rehabilitation facilities – $79 billion, compared to a $32.5 billion estimated impact in September 2011.
A full summary follows below. We will have further information on the budget in the coming days.
When compared to Fiscal Year 2013 appropriated amounts, the budget calls for the following changes in discretionary spending by major HHS divisions (tabulated by budget authority):
- $37 million (1.5%) increase for the Food and Drug Administration (not including $770 million in increased user fees);
- $435 million (4.9%) increase for the Health Services and Resources Administration;
- $97 million (2.2%) increase for the Indian Health Service;
- $344 million (5.7%) increase for the Centers for Disease Control;
- $274 million (0.9%) increase for the National Institutes of Health; and
- $1.4 billion (52.9%) increase for the discretionary portion of the Centers for Medicare and Medicaid Services program management account.
With regard to the above numbers for CDC and HRSA, note that these are discretionary numbers only. The Administration’s budget also would allocate an additional $1 billion mandatory spending from the Prevention and Public Health “slush fund” created in Obamacare, further increasing spending levels. For instance, CDC spending would be increased by an additional $755 million.
Obamacare Implementation Funding and Personnel: As previously noted, the budget includes more than $1.4 billion in discretionary spending increases for the Centers for Medicare and Medicaid Services, which the HHS Budget in Brief claims would be used to “continue implementing key provisions of [Obamacare].” This funding would finance 712 new bureaucrats within CMS when compared to last fiscal year – a massive increase when compared to a request of 256 new FTEs in last year’s budget proposal. Overall, the HHS budget proposes an increase of 1,311 full-time equivalent positions within the bureaucracy compared to projections for the current fiscal cycle, and an increase of 3,327 bureaucrats compared to last fiscal year.
The budget includes specific requests related to Obamacare totaling over $2 billion, including:
- $803.5 million for “CMS activities to support [Exchanges] in FY 2014,” including funding for the federally-funded Exchange, for which the health law itself did not appropriate funding;
- $837 million for “beneficiary education and outreach activities through the National Medicare Education program and consumer support…including $554 million for the [Exchanges];”
- $519 million for “general IT systems and other support,” including funding for the federal Exchange;
- $3.8 million for updates to healthcare.gov;
- $18.4 million to oversee the medical loss ratio regulations; and
- $24 million for administrative activities in Medicaid related to “implement[ing] new responsibilities” under Obamacare.
Exchange Funding: The budget envisions HHS spending $1.5 billion on Exchange grants in 2013. That’s an increase of over $300 million compared to last year’s estimate of fiscal year 2013 spending – despite the fact that most states have chosen not to create their own Exchanges. The budget anticipates a further $2.1 billion in spending on Exchange grants in fiscal year 2014. The health care law provides the Secretary with an unlimited amount of budget authority to fund state Exchange grants through 2015. However, other reports have noted that the Secretary does NOT have authority to use these funds to construct a federal Exchange.
Abstinence Education Funding: The budget proposes eliminating the abstinence education funding program, and converting those funds into a new pregnancy prevention program.
Medicare Proposals (Total savings of $359.9 Billion, including interactions)
Bad Debts: Reduces bad debt payments to providers – for unpaid cost-sharing owed by beneficiaries – from 65 percent down to 25 percent over three years, beginning in 2014. The Simpson-Bowles Commission made similar recommendations in its final report. Saves $25.5 billion.
Medical Education Payments: Reduces the Indirect Medical Education adjustment paid to teaching hospitals beginning in 2014, saving $11 billion. Previous studies by the Medicare Payment Advisory Committee (MedPAC) have indicated that IME payments to teaching hospitals may be greater than the actual costs the hospitals incur.
Rural Payments: Reduces critical access hospital payments from 101% of costs to 100% of costs, saving $1.4 billion, and prohibits hospitals fewer than 10 miles away from the nearest hospital from receiving a critical access hospital designation, saving $700 million.
Anti-Fraud Provisions: Assumes $400 million in savings from various anti-fraud provisions, including limiting the discharge of debt in bankruptcy proceedings associated with fraudulent activities.
Imaging: Reduces imaging payments by assuming a higher level of utilization for certain types of equipment, saving $400 million. Imposes prior authorization requirements for advanced imaging; no savings are assumed, a change from the September 2011 deficit proposal, which said prior authorization would save $900 million.
Pharmaceutical Price Controls: Expands Medicaid price controls to dual eligible and low-income subsidy beneficiaries participating in Part D, saving $123.2 billion according to OMB. Some have expressed concerns that further expanding government-imposed price controls to prescription drugs could harm innovation and the release of new therapies that could help cure diseases.
Medicare Drug Discounts: Proposes accelerating the “doughnut hole” drug discount plan included in PPACA, filling in the “doughnut hole” completely by 2015. While the budget claims this proposal will save $11.2 billion over ten years, some may be concerned that – by raising drug spending, and eliminating incentives for seniors to choose generic pharmaceuticals over brand name drugs, this provision will actually INCREASE Medicare spending, consistent withprior CBO estimates at the time of PPACA’s passage.
Post-Acute Care: Reduces various acute-care payment updates (details not specified) and equalizes payment rates between skilled nursing facilities and inpatient rehabilitation facilities, saving $79 billion – a significant increase compared to the $56.7 billion in last year’s budget and the $32.5 billion in proposed savings under the President’s September 2011 deficit proposal. Equalizes payments between IRFs and SNFs for certain conditions, saving $2 billion. Adjusts payments to inpatient rehabilitation facilities and skilled nursing facilities to account for unnecessary hospital readmissions and encourage appropriate care, saving a total of $4.7 billion. Restructures post-acute care reimbursements through the use of bundled payments, saving $8.2 billion.
Physician Payment: Includes language extending accountability standards to physicians who self-refer for radiation therapy, therapy services, and advanced imaging services, saving $6.1 billion. Makes adjustments to clinical laboratory payments, designed to align Medicare with private payment rates, saving $9.5 billion. Expands availability of Medicare data for performance and quality improvement; no savings assumed.
Medicare Drugs: Reduces payment of physician administered drugs from 106 percent of average sales price to 103 percent of average sales price. Some may note reports that similar payment reductions, implemented as part of the sequester, have caused some cancer clinics to limit their Medicare patient load. By including a similar proposal in his budget, President Obama has effectively endorsed these policies. Saves $4.5 billion.
Medicare Advantage: Resurrects a prior-year proposal to increase Medicare Advantage coding intensity adjustments; this provision would have the effect of reducing MA plan payments, based on an assumption that MA enrollees are healthier on average than those in government-run Medicare. Saves $15.3 billion over ten years. Also proposes $4.1 billion in additional savings by aligning employer group waiver plan payments with average MA plan bids.
Additional Means Testing: Increases means tested premiums under Parts B and D by five percentage points, beginning in 2017. Freezes the income thresholds at which means testing applies until 25 percent of beneficiaries are subject to such premiums. Saves $50 billion over ten years, and presumably more thereafter, as additional seniors would hit the means testing threshold, subjecting them to higher premiums.
Medicare Deductible Increase: Increases Medicare Part B deductible by $25 in 2017, 2019, and 2021 – but for new beneficiaries only; “current beneficiaries or near retirees [not defined] would not be subject to the revised deductible.” Saves $3.3 billion.
Home Health Co-Payment: Beginning in 2017, introduces a home health co-payment of $100 per episode for new beneficiaries only, in cases where an episode lasts five or more visits and is NOT proceeded by a hospital stay. MedPAC has previously recommended introducing home health co-payments as a way to ensure appropriate utilization. Saves $730 million.
Medigap Surcharge: Imposes a Part B premium surcharge equal to about 15 percent of the average Medigap premium – or about 30 percent of the Part B premium – for seniors with Medigap supplemental insurance that provides first dollar coverage. Applies beginning in 2017to new beneficiaries only. A study commissioned by MedPAC previously concluded that first dollar Medigap coverage induces beneficiaries to consume more medical services, thus increasing costs for the Medicare program and federal taxpayers. Saves $2.9 billion.
Generic Drug Incentives: Proposes increasing co-payments for certain brand-name drugs for beneficiaries receiving the Part D low-income subsidy, while reducing co-payments for relevant generic drugs by 15 percent, in an attempt to increase generic usage among low-income seniors currently insulated from much of the financial impact of their purchasing decisions. Saves $6.7 billion, according to OMB.
Lower Caps on Medicare Spending: Section 3403 of the health care law established an Independent Payment Advisory Board tasked with limiting Medicare spending to the growth of the economy plus one percentage point (GDP+1) in 2018 and succeeding years. The White House proposal would reduce this target to GDP+0.5 percent. The Medicare actuary has previouslywritten that the spending adjustments contemplated by IPAB and the health care law “are unlikely to be sustainable on a permanent annual basis” and “very challenging” – problems that would be exacerbated by utilizing a slower target rate for Medicare spending growth. According to the budget, this proposal would save $4.1 billion, mainly in 2023.
Medicaid and Other Health Proposals (Total savings of $41.1 Billion)
Limit Durable Medical Equipment Reimbursement: Caps Medicaid reimbursements for durable medical equipment (DME) at Medicare rates, beginning in 2014. The health care law extended and expanded a previous Medicare competitive bidding demonstration project included in the Medicare Modernization Act, resulting in savings to the Medicare program. This proposal, by capping Medicaid reimbursements for DME at Medicare levels, would attempt to extend those savings to the Medicaid program. Saves $4.5 billion over ten years.
Rebase Medicaid Disproportionate Share Hospital Payments: Proposes beginning DSH payment reductions in 2015 instead of 2014, and “to determine future state DSH allotments based on states’ actual DSH allotments as reduced” by PPACA. Saves $3.6 billion, all in fiscal 2023.
Medicaid Anti-Fraud Savings: Assumes $3.7 billion in savings from a variety of Medicaid anti-fraud provisions. Included in this amount are proposals that would remove exceptions to the requirement that Medicaid must reject payments when another party is liable for a medical claim. A separate proposal related to the tracking of pharmaceutical price controls would save $8.8 billion.
Transitional Medical Assistance/QI Program: Provides for temporary extensions of the Transitional Medical Assistance program, which provides Medicaid benefits for low-income families transitioning from welfare to work, along with the Qualifying Individual program, which provides assistance to low-income seniors in paying Medicare premiums. The extensions cost $1.1 billion and $590 million, respectively.
“Pay-for-Delay:” Prohibits brand-name pharmaceutical manufacturers from entering into arrangements that would delay the availability of new generic drugs. Some Members have previously expressed concerns that these provisions would harm innovation, and actually impede the incentives to generic manufacturers to bring cost-saving generic drugs on the market. OMB scores this proposal as saving $11 billion.
Follow-on Biologics: Reduces to seven years the period of exclusivity for follow-on biologics. Current law provides for a twelve-year period of exclusivity, based upon an amendment to the health care law that was adopted on a bipartisan basis in both the House and Senate (one of the few substantive bipartisan amendments adopted). Some Members have expressed concern that reducing the period of exclusivity would harm innovation and discourage companies from developing life-saving treatments. OMB scores this proposal as saving $3.3 billion.
State Waivers: Accelerates from 2017 to 2014 the date under which states can submit request for waivers of SOME of the health care law’s requirements to HHS. While supposedly designed to increase flexibility, even liberal commentators have agreed that under the law’s state waiver program “critics of Obama’s proposal have a point: It wouldn’t allow to enact the sorts of health care reforms they would prefer” and that “conservatives can’t do any better – at least not under these rules.” No cost is assumed; however, in its re-estimate of the President’s budget last year, CBO scored this proposal as costing $4.5 billion.
Implementation “Slush Fund:” Proposes $400 million in new spending for HHS to implement the proposals listed above.
FEHB Contracting: Similar to last year’s budget, proposes streamlining pharmacy benefit contracting within the Federal Employee Health Benefits program, by centralizing pharmaceutical benefit contracting within the Office of Personnel Management (OPM), saving $1.6 billion. However, this year’s budget goes further in restructuring FEHBP – OPM would also be empowered to modernize benefit designs (savings of $264 million); create a “self-plus-one” benefit option for federal employees and extend benefits to domestic partners (total savings of $5.2 billion, despite the costs inherent in the latter option); and adjust premium levels based on tobacco usage and/or participation in wellness programs (savings of $1.3 billion). Some individuals, noting that OPM is also empowered to create “multi-state plans” as part of the health care overhaul, may be concerned that these provisions could be part of a larger plan to make OPM the head of a de facto government-run health plan.
Other Health Care Proposal of Note
Tax Credit: The Treasury Green Book proposes expanding the small business health insurance tax credit included in the health care law. Specifically, the budget would expand the number of employers eligible for the credit to include all employers with up to 50 full-time workers; firms with under 20 workers would be eligible for the full credit. (Currently those levels are 25 and 10 full-time employees, respectively.) The budget also changes the coordination of the two phase-outs based on a firm’s average wage and number of employees, with the changes designed to make more companies eligible for a larger credit. The changes would begin in the current calendar and tax year (i.e., 2013). According to OMB, these changes would cost $10.4 billion over ten years – down from last year’s estimate of $14 billion over ten years. Many may view this proposal as a tacit admission that the credit included in the law was a failure, because its limited reach and complicated nature – firms must fill out seven worksheets to determine their eligibility – have deterred American job creators from receiving this subsidy. Moreover, the reduced score in this year’s budget compared to last year’s implies that even this expansion of the credit will have a less robust impact than originally anticipated.