August 2, 2017
The House Budget Resolution for Fiscal Year (FY) 2018 would make cuts to the Medicare, Medicaid and Social Security programs and repeal and replace the Affordable Care Act (ACA), actions which would be harmful to millions of Americans.
The House Budget Resolution for FY 2018, H. Con. Res. 71, introduced by House Budget Committee Chairwoman Diane Black (R-TN), was approved by the House of Representatives Budget Committee on July 20, 2017. This budget proposes drastic cuts in federal spending for programs of importance to most low- and middle-income Americans while proposing tax breaks to benefit the very wealthy and large profitable corporations. This paper summarizes some of the key proposals in the House Republican FY 2018 budget resolution that would affect seniors and people with disabilities who rely on Medicare, Medicaid and Social Security.
The budget resolution proposes $487 billion in cuts to Medicare which would be achieved by ending traditional Medicare and increasing health care costs for beneficiaries. Chairwoman Black's plan privatizes Medicare and achieves savings for the federal government by shifting costs to Medicare beneficiaries.
Privatizing Medicare with Vouchers/Premium Support Payments
Beginning in 2024, when people become eligible for Medicare they would not enroll in the current traditional Medicare program which provides guaranteed benefits. Rather they would receive a voucher, also referred to as a premium support payment, to be used to purchase private health insurance or traditional Medicare through a Medicare Exchange. The amount of the voucher would be determined each year when private health insurance plans and traditional Medicare participate in a competitive bidding process. Seniors choosing a plan costing more than the average amount determined through competitive bidding would be required to pay the difference between the voucher and the plan's premium. In some geographic areas, traditional Medicare could be more expensive. This would make it harder for seniors, particularly lower-income beneficiaries, to choose their own doctors if their only affordable options are private plans that have limited provider networks. Wealthier Medicare beneficiaries would be required to pay a greater share of their premiums than lower-income seniors.
The House budget resolution requires private plans participating in the Medicare Exchange to offer insurance to all Medicare beneficiaries. However, it is likely that plans could tailor their benefits to attract the youngest and healthiest seniors and still be at least actuarially equivalent to the benefit package provided by fee-for-service Medicare. This would leave traditional Medicare with older and sicker beneficiaries. Their higher health costs would lead to higher premiums that people would be unable or unwilling to pay, resulting in a death spiral for traditional Medicare. This would adversely impact people age 55 and older, including people currently enrolled in traditional Medicare.
Raising the Medicare Eligibility Age
Beginning in 2024, H. Con. Res. 71 would gradually increase the age of eligibility for Medicare to correspond with Social Security’s retirement age which is increasing from 65 to 67. Raising the Medicare eligibility age is a benefit cut. Although this proposal would save money for the federal government, it would increase system-wide health spending by increasing costs for everyone else, including:
- 65 and 66 years olds who would have to buy private insurance, which can be age rated;
- younger people buying health insurance coverage in an older risk pool;
- Medicare beneficiaries left in an older and less-healthy risk pool;
- employers providing health insurance to workers and retirees; and
Increasing Beneficiaries’ Out-of-Pocket Costs
The House budget resolution assumes savings from redesigning the Medicare benefit beginning in 2024 by combining the Part A and Part B deductibles and making changes to supplemental insurance (Medigap) policies, changes that would likely increase costs for people with Medigap policies. Instead, Medicare should be improved for beneficiaries by simplifying its cost-sharing and adding a catastrophic cap.
The National Committee opposes a proposal in H. Con. Res. 71 to expand income-related premiums under Medicare Parts B and D until 25 percent of beneficiaries are subject to these premiums. A Kaiser Family Foundation study found that this proposal would affect individuals with incomes equivalent to $45,600 for an individual and $91,300 for a couple in 2013.
Repealing and Replacing the Affordable Care Act
The House budget resolution assumes the reforms included in the House-passed “American Health Care Act” (AHCA) that would reduce the federal deficit by $204.1 billion between fiscal year 2018 and fiscal year 2027.
According to the Congressional Budget Office (CBO), over the next decade 23 million people would lose health insurance under the AHCA compared to current law. These losses would occur due to the proposal’s repeal of the Medicaid expansion, restructuring of the Medicaid program into per capita caps, changes to the Affordable Care Act’s (ACA) individual market reforms, and repeal of the individual mandate. Seniors and near retirees would make up the largest demographic group to lose health care coverage under the AHCA.
By assuming the enactment of the ACA repeal, H. Con. Res. 71 would destroy the current Medicaid program and slash benefits for low-income individuals. These changes would be detrimental to seniors and others who rely on Medicaid.
Changing the Structure of Medicaid from an Entitlement to Per Capita Caps or a Block Grant
Medicaid provides funding for health care to help the most vulnerable Americans, including low-income seniors, people with disabilities, children and some families. The House budget resolution would end the current joint federal/state financing partnership and replace it with per capita caps (or a block grant, at state option) giving states less money than they would receive under current law.
Based on the House-passed AHCA, H. Con. Res. 71 would cap the growth in federal per-enrollee payments for most children and nondisabled adults enrolled in Medicaid at the medical care component of the consumer price index (CPI-M) beginning in 2020. For most enrollees who are disabled or age 65 or older, the capped amount would be the CPI-M plus one percentage point, starting in 2020. Historically, the CPI-M has grown more slowly than the rate at which Medicaid expenditures have grown. Alternatively, the House budget resolution would allow states an option to convert the federal Medicaid payment to a block grant. This would change Medicaid, making it more like the Children’s Health Insurance Program (CHIP) block grants to the states.
While block grants or per capita caps would give state governments greater flexibility to manage and design their Medicaid programs, such discretion in no way compensates for the significant reductions that beneficiaries, including nursing home residents and their families, could face.
The House budget resolution would further cut Medicaid by applying work requirements to Medicaid recipients under 65 who are not disabled or pregnant.
Repealing the Medicaid Expansion under the Affordable Care Act (ACA)
Beginning in 2014, states have had the option to receive federal funding to expand Medicaid coverage to uninsured adults with incomes of up to 138 percent of the federal poverty level ($16,242 for an individual in 2015). Thirty-two states have expanded their Medicaid programs.
H. Con. Res. 71 would repeal the Medicaid expansion in the ACA by January 1, 2020. This proposal would hurt states and low-income individuals by:
- Eliminating billions of federal dollars to states to provide their residents with health care and financial protection. Under the ACA, the federal government paid 100 percent of the cost for newly eligible low-income adults in Medicaid for the first three years (2014-2016), phasing down to 90 percent by 2020.
- Preventing low-income adults from receiving access to health care services. Repealing the Medicaid expansion would result in 14-17 million people losing coverage. In total, the House budget resolution would cut $1.5 trillion from Medicaid and “other programs.”
The House budget resolution calls for the President to submit a plan to be considered under "expedited procedures" to reform Social Security if the Social Security Trustees determine the Trust Funds do not meet a 75-year actuarial balance. This "fast track" procedure has been proposed previously by those seeking a way to circumvent public scrutiny of proposals to reduce Social Security programs.
Moreover, the National Committee believes that issues relating to the solvency of the Social Security Trust Funds and benefit adequacy should be considered separate and apart from any discussion of the nation’s debt or deficit. In addition, the Congress should develop changes to Social Security in the full light of day, through the use of regular order and procedures in both bodies, rather than depriving Americans of their right to full participation in the development of reform proposals.
Additionally, H. Con. Res. 71 proposes reforming the Social Security Disability Insurance (SSDI) program and includes a plan to eliminate concurrent receipt of Unemployment Insurance and SSDI. This proposal would affect SSDI beneficiaries who work, but get laid off – and as a result – qualify for Unemployment Insurance. These are benefits that Americans have earned through their contributions while working and it is unfair to deny them their earned benefits in an effort to balance the budget.
NATIONAL COMMITTEE POSITION
The National Committee opposes provisions included in the House budget resolution that would reduce health care coverage through Medicare, Medicaid and the Affordable Care Act, as well as proposals that would be detrimental to the Social Security program, particularly the following:
- Ending traditional Medicare by converting it from a defined benefit to a defined contribution program;
- Raising the Medicare eligibility age;
- Increasing costs for Medicare beneficiaries through higher cost sharing and income-related premiums and by restructuring the program and Medigap in ways intended to reduce federal spending;
- Repealing the Affordable Care Act, which has extended the solvency of the Medicare Part A Hospital Insurance trust fund;
- Transforming the Medicaid program from a federal/state partnership into either per capita caps or a block grant program, which would result in arbitrary cuts to vulnerable seniors and other individuals;
- Repealing the Medicaid expansion, which would hurt states financially and negatively affect low-income adults who need access to health care services;
- Proposals to reform Social Security through program changes that are enacted through “fast track” legislative procedures, depriving Americans of their right to full participation in the development of reform proposals affecting their lives.
Government Relations and Policy, August 2017
The House Budget Committee approved H. Con. Res. 71 before July 28, 2017 when the Senate rejected the AHCA and other ACA repeal bills. However, the Senate could decide to resume consideration of ACA repeal legislation or lawmakers could include provisions of the AHCA in FY 2018 budget reconciliation legislation.