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History > 2017 > USA > Health, Health care (I)

 

 

 

Trump’s Budget

Cuts Deeply Into Medicaid

and Anti-Poverty Efforts

 

MAY 22, 2017

The New York Times

By JULIE HIRSCHFELD DAVIS

 

WASHINGTON — President Trump plans to unveil on Tuesday a $4.1 trillion budget for 2018 that would cut deeply into programs for the poor, from health care and food stamps to student loans and disability payments, laying out an austere vision for reordering the nation’s priorities.

The document, grandly titled “A New Foundation for American Greatness,” encapsulates much of the “America first” message that powered Mr. Trump’s campaign. It calls for an increase in military spending of 10 percent and spending more than $2.6 billion for border security — including $1.6 billion to begin work on a wall on the border with Mexico — as well as huge tax reductions and an improbable promise of 3 percent economic growth.

The wildly optimistic projections balance Mr. Trump’s budget, at least on paper, even though the proposal makes no changes to Social Security’s retirement program or Medicare, the two largest drivers of the nation’s debt.

To compensate, the package contains deep cuts in entitlement programs that would hit hardest many of the economically strained voters who propelled the president into office. Over the next decade, it calls for slashing more than $800 billion from Medicaid, the federal health program for the poor, while slicing $192 billion from nutritional assistance and $272 billion over all from welfare programs. And domestic programs outside of military and homeland security whose budgets are determined annually by Congress would also take a hit, their funding falling by $57 billion, or 10.6 percent.

The plan would cut by more than $72 billion the disability benefits upon which millions of Americans rely. It would eliminate loan programs that subsidize college education for the poor and those who take jobs in government or nonprofit organizations.

Mr. Trump’s advisers portrayed the steep reductions as necessary to balance the nation’s budget while sparing taxpayers from shouldering the burden of programs that do not work well.

“This is, I think, the first time in a long time that an administration has written a budget through the eyes of the people who are actually paying the taxes,” said Mick Mulvaney, Mr. Trump’s budget director.

“We’re not going to measure our success by how much money we spend, but by how many people we actually help,” Mr. Mulvaney said as he outlined the proposal at the White House on Monday before its formal presentation on Tuesday to Congress.

Among its innovations: Mr. Trump proposes saving $40 billion over a decade by barring undocumented immigrants from collecting the Child Tax Credit and adding additional measures to ensure they cannot collect the Earned Income Tax Credit. He has also requested $19 billion over 10 years for a new program, spearheaded by his daughter and senior adviser Ivanka Trump, to provide six weeks of paid leave to new parents. The budget also includes a broad prohibition against money for entities that provide abortions, including Planned Parenthood, blocking them from receiving any federal health funding

The release of the document, an annual ritual in Washington that usually constitutes a marquee event for a new president working to promote his vision, unfolded under unusual circumstances. Mr. Trump is out of the country for his first foreign trip, and his administration is enduring a near-daily drumbeat of revelations about the investigation into his campaign’s possible links with Russia.

The president’s absence, which his aides dismissed as a mere coincidence of the calendar, seemed to highlight the haphazard way in which his White House has approached its dealings with Congress. It is just as much a sign of Mr. Trump’s lack of enthusiasm for the policy detail and message discipline that is required to marshal support to enact politically challenging changes.

“If the president is distancing himself from the budget, why on earth would Republicans rally around tough choices that would have to be made?” said Robert L. Bixby, the executive director of the Concord Coalition, a nonpartisan organization that promotes deficit reduction. “If you want to make the political case for the budget — and the budget is ultimately a political document — you really need the president to do it. So, it does seem bizarre that the president is out of the country.”

The president’s annual budget — more a message document than a practical set of marching orders even in the best of times — routinely faces challenges on Capitol Hill. Lawmakers jealously guard their prerogative to control federal spending and shape government programs. But Mr. Trump’s wish list, in particular, faces long odds, with Democrats uniformly opposed and Republicans already showing themselves to be squeamish about some of the president’s plans.

“It probably is the most conservative budget that we’ve had under Republican or Democrat administrations in decades,” said Representative Mark Meadows, Republican of North Carolina and the chairman of the conservative House Freedom Caucus.

But in a signal that some proposed cuts to domestic programs are likely to face resistance even from conservatives, Mr. Meadows said he could not stomach the idea of doing away with food assistance for older Americans.

“Meals on Wheels, even for some of us who are considered to be fiscal hawks, may be a bridge too far,” Mr. Meadows said.

Republicans balked at Mr. Trump’s demand for money for the border wall in negotiations over a spending package enacted last month. Many were deeply conflicted over voting for a health care overhaul measure that included the Medicaid cuts contained in the budget to be presented on Tuesday. Now the president is proposing still deeper reductions to the federal health program for the poor, as well as drastically scaling back a broad array of social safety net programs that are certain to be unpopular with lawmakers.

“The politics of this make no sense to me whatsoever, in the sense that the population that brought them to the dance are the populists out there in the Midwest and South who rely on these programs that he’s talking about reducing,” said G. William Hoagland, a former senior Republican congressional budget aide. Referring to Representative Paul D. Ryan, he said: “I don’t see how Speaker Ryan gets anywhere close to 218 votes in the House of Representatives if this is the model. It’s an exercise in futility.”

Senator Chuck Schumer, Democrat of New York and the minority leader, said Monday that the Medicaid cuts would “carry a staggering human cost” and violate Mr. Trump’s campaign promise to address the opioid epidemic.

“Based on what we know about this budget, the good news — the only good news — is that it was likely to be roundly rejected by members of both parties here in the Senate, just as the last budget was,” Mr. Schumer said on the Senate floor.

The budget itself avoids some of the tough choices that would be required to enact Mr. Trump’s fiscal vision. The huge tax cut was presented but without any detail about its elements or cost. Mr. Mulvaney said the tax plan would not add to the deficit, implying that its cost would be made up with other changes, such as eliminating deductions.

To balance the budget, Mr. Trump’s budget relies on growth he argues will be generated from the as-yet-unformed tax cut.

The blueprint also steers clear of changing Social Security’s retirement program or Medicare, steps that Mr. Mulvaney, a former South Carolina congressman who has backed entitlement cuts, said he had tried to persuade Mr. Trump to consider.

“He said, ‘I promised people on the campaign trail I would not touch their retirement and I would not touch Medicare,’ and we don’t do it,” Mr. Mulvaney said. “I honestly was surprised that we could balance the budget without changing those programs, but we managed to do that.”

But budget experts argued that was little more than fiction, and the plan could never deliver the results it claims to.

“The central inconsistency is promoting a massive tax cut and spending increases in some areas and leaving the major entitlement programs alone,” Mr. Bixby said. “You don’t have to be an economist to know that that doesn’t add up, and that’s why there’s a great deal of concern about the negative fiscal impact that this budget will have.”

While past presidents have often launched a road show with stops around the country to promote the components of their inaugural budgets, Mr. Trump is spending the rest of the week overseas, leaving his staff to explain his plan while Republicans prepare their own response.

“This budget is dead before arrival, so he might as well be out of town,” said David A. Stockman, a former budget director under President Ronald Reagan.

Mr. Stockman said both political parties had grown comfortable with running large annual budget deficits. “There’s not a snowball’s chance that most of this deep deficit reduction will even be considered in a serious way.”

 

 

Correction: May 24, 2017

An article on Tuesday about President Trump’s budget proposals, using information from Mick Mulvaney, the White House budget director, misstated a proposal to bar undocumented immigrants from receiving certain tax credits. A Social Security number is already required to claim the Earned Income Tax Credit. The proposal would impose this requirement for the Child Tax Credit, and the Child and Dependent Care Credit is not affected. The article also referred incorrectly to one effect on Social Security. The budget proposes cutting Social Security disability benefits, not reducing retirement benefits.

Binyamin Appelbaum and Thomas Kaplan
contributed reporting.

Trump’s Budget Cuts Deeply Into Medicaid and Anti-Poverty Efforts,
NYT,
May 22, 2017,
https://www.nytimes.com/2017/05/22/us/
politics/trump-budget-cuts.html

 

 

 

 

 

The Fake Freedom

of American Health Care

 

MARCH 18, 2017

The New York Times

The Opinion Pages | Opinion

By ANU PARTANEN

 

Last week the nonpartisan Congressional Budget Office estimated that the new Republican health plan would increase the number of uninsured Americans by 24 million people within a decade, mostly because changes in regulations, subsidies and Medicaid coverage would make insurance too expensive for them.

Republican leaders seem unfazed by this, perhaps because, in their minds, deciding not to have health care because it’s too expensive is an exercise of individual free will. As Representative Jason Chaffetz, Republican of Utah, put it: “Americans have choices. And they’ve got to make a choice. And so maybe, rather than getting that new iPhone that they just love, and they want to go spend hundreds of dollars on that, maybe they should invest in their own health care.”

There is an appealing logic to such thinking. The idea is that buying health care is like buying anything else. The United States is home to some of the world’s best medical schools, doctors, research institutes and hospitals, and if you have the money for the coverage and procedures you want, you absolutely can get top-notch care. This approach might result in extreme inequalities and it might be expensive, but it definitely buys you the best medical treatment anywhere. Such is the cost of freedom. As House Speaker Paul Ryan put it in a tweet: “Freedom is the ability to buy what you want to fit what you need.” Vice President Mike Pence picked up that baton: “Obamacare will be replaced with something that actually works — bringing freedom and individual responsibility back to American health care.”

In practice, though, this Republican notion is an awfully peculiar kind of freedom. It requires most Americans to spend not just money, but also time and energy agonizing over the bewildering logistics of coverage and treatment — confusing plans, exorbitant premiums and deductibles, exclusive networks, mysterious tests, outrageous drug prices. And more often than not, individual choices are severely restricted by decisions made by employers, insurers, doctors, pharmaceutical companies and other private players. Those interest groups, not the consumer, decide which plans are available, what those plans cover, which doctors patients can see and how much it will cost.

And I haven’t even mentioned the millions of Americans who don’t earn enough to pay for insurance or a lifesaving treatment. If you can’t afford it, not buying it is hardly a choice.

Eight years ago I moved to the United States from Finland, which like all the Nordic nations is a wealthy capitalist economy, despite the stereotypes you may have heard. And like all those countries, Finland has invested in a universal, taxpayer-funded and publicly managed health care system. Finns constantly debate the shortcomings of their system and are working to improve it, but in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes — which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City — and if I needed to see a doctor, I had several options.

For minor medical matters, I could visit a private physician who was provided as a perk by my employer. Or I could call the public clinic closest to my home. If I saw the private doctor, my employer picked up the tab, with the help of public subsidies. If I went to the public clinic, it might cost me a small co-payment, usually around $20. Had I been pregnant, most care would have been free.

If I had wanted to, I also could have easily paid to see a private doctor on my own, again with the help of public subsidies. All of this works without anyone ever having to sign up for or buy health insurance unless he wants additional coverage. I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.

Republicans are fond of criticizing this sort of European-style health care. President Trump has called Canada’s national health care system “catastrophic.” On CNN recently, Senator Ted Cruz gave multiple examples of how patients in countries with universal, government-managed health care get less care than Americans.

In Europe, he said, elderly people facing life-threatening diseases are often placed in palliative care and essentially told it’s their time to go. According to the Republican orthodoxy, government always takes away not only people’s freedom to choose their doctor, but also their doctor’s ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.

But are Republicans right about this? Practically every wealthy capitalist democracy in the world has decided that some form of government-managed universal health care is the most sensible and effective option. According to the latest report of the O.E.C.D. — an organization of mostly wealthy nations — the United States as a whole does not actually outshine other countries in the quality of care.

In fact, the United States has shorter life expectancy, higher infant mortality and fewer doctors per capita than most other developed countries. When it comes to outcomes in some illnesses, including cancer, the United States does have some of the best survival rates in the world — but that’s barely ahead of, or even slightly behind, the equivalent survival rates in other developed countries. In breast cancer survival, for example, the United States comes in second, after Sweden. Third-best is Norway, then Finland. All three countries have universal, government-run health care systems.

For colorectal cancer, the five-year survival rate after diagnosis in the United States brings it to a not very impressive ninth place in the O.E.C.D. statistics. Ahead of the United States are South Korea, Israel, Australia, Sweden and Finland, all with some form of government-managed universal health care. And when it comes to cervical cancer, American women are at a significant disadvantage: The United States comes in only 22nd. Meanwhile, life expectancy at age 65 is higher in 24 other developed nations, including Canada, Britain and most European nations.

Americans might still assume that long waits for care are inevitable in a health care system run by the government. But that’s not necessarily the case either. A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That’s a great achievement. But the Netherlands and Switzerland did better. When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.

It’s not just American patients who endure endless bureaucratic hassles. American doctors were also significantly more likely to report as major problems the amount of time they spent on dealing with administrative burdens related to insurance and claims, as well as on getting patients medications or treatment because of restrictions imposed by insurance companies, compared with doctors in most of the other 10 countries studied — including Sweden and Britain.

Overall, Americans spend far more of their hard-earned money on health care than citizens of any other country, by a very wide margin. This means that it is in fact Americans who are getting a raw deal. Americans pay much more than people in other countries but do not get significantly better results.

The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power. It is not like buying a consumer product, where choosing not to buy will not endanger one’s life. It’s also not like buying some other service tailored to individual demands, because for the most part we can’t predict our future health care needs.

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom. Arranging health care is an overwhelming task, and having a specialized entity do the negotiating, regulating and perhaps even much of the providing is just vastly more efficient than forcing everyone to go it alone.

What passes for an American health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven’t even been seriously sick or injured yet.

As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.

So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.

Here is my appeal to Republicans: If you really want to free Americans and unburden American employers, why not try, or at least seriously consider, some form of government-managed health care, like almost every other capitalist democracy? There are many ways of giving people choice and excellent care under government management. Universal publicly managed health coverage would even free America’s corporations and businesses to streamline their operations, releasing them from bureaucratic obligations that to me, coming from Finland, I have to say look weirdly socialist. Would this mean they would have to pay more in taxes? Possibly.

Many countries require employers and employees to contribute to the health care system through payroll taxes, more than the United States does. But again, Americans are paying far more for health care than anyone else, and America’s businesses are stuck managing this mess. It’s true that in countries with universal health care the cost of hiring a new employee can be significant, especially for a small employer. Yet these countries still have plenty of thriving businesses, with lower administrative burdens. It can be done.

In wealthy capitalist democracies all around the world the government itself also has an essential kind of freedom. It’s a freedom that enables the government to do work on behalf of the citizens who elect it, including negotiating the prices of health care with providers and pharmaceutical companies — a policy that has led to lower drug prices in those countries.

Americans today are paying vastly more in money, worry and hassle for the same, and sometimes worse, care than people in other wealthy capitalist democracies. Some Americans have coverage that serves them well, but judging by the current mood, the number of Americans who think the system needs to change is growing. No health care system is perfect. But in a nation that purports to champion freedom, the outdated disaster that is the United States health care system is taking that freedom away.

 

 

Anu Partanen is the author of “The Nordic Theory of Everything: In Search of a Better Life.”

A version of this op-ed appears in print on March 19, 2017,
on Page SR1 of the New York edition with the headline:
The Fake Freedom of American Health Care.

The Fake Freedom of American Health Care,
NYT,
MARCH 18, 2017,
https://www.nytimes.com/2017/03/18/
opinion/the-fake-freedom-of-american-health-care.html

 

 

 

 

 

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