共和党は木曜日、オバマケア：予算破壊雇用抹殺法“Obamacare: A Budget-Busting Job-Killing Law”というレポートを発表した。予算局の試算とは対照的に、医療制度改革法が実施されると2兆6000億ドルかかり、最初の10年で7010億ドルの赤字が追加されるとしている。予算局の試算は、連邦予算の赤字を2019年までに1430億ドル減らし、その後の10年で1兆ドル以上を減らすとしていた。
米連邦議会 医療制度改革法案を最終承認／米国医療事情 オバマ政権
In Battle Over Health Law, Math Cuts Both Ways
By DAVID M. HERSZENHORN
Published: January 7, 2011
WASHINGTON ― With the health care fight roaring back to life on Capitol Hill, questions that seemed settled last March, when President Obama signed his top domestic priority into law, are once again front and center.
So, will the health care law cost money or save money? Will it create jobs or eliminate jobs? Will it improve outcomes for patients or make medical care more difficult to get?
And, for the love of gravity and basic mathematics, how can the nonpartisan Congressional Budget Office, the official scorekeeper charged with keeping count of the nation’s fiscal condition, say that it would cost the government $230 billion over 10 years to repeal a law that would spend $930 billion to extend health insurance to 32 million people?
“I don’t think anybody in this town believes that repealing Obamacare is going to increase the deficit,” the House speaker, John A. Boehner, declared at a news conference on Thursday, dismissing a report by the budget experts concluding that a repeal would add $230 billion to federal deficits from 2012 to 2021.
But that is exactly what the budget office says, based on a complex thicket of calculations aimed at ascertaining the effect on the government’s bottom line of the law’s myriad tax increases, cuts in projected Medicare spending and costs of new benefits, including subsidies to help people buy insurance.
House Republicans on Friday pushed ahead with a measure to repeal the law. The House, by a vote of 236 to 181, approved the terms of debate for the repeal proposal, setting up a fierce floor fight next week ― the first major clash of the 112th Congress. The vote showed Republicans easily have the muscle to approve the repeal in a vote scheduled for Wednesday, but the bill is likely to go no further given the staunch opposition in the Democrat-led Senate.
Much of the health care debate will center on cost ― to the government and to employers. On Thursday, Republicans issued their own report, called “Obamacare: A Budget-Busting Job-Killing Law,” which concluded, “The health care law will cost the nation $2.6 trillion when fully implemented, and add $701 billion to the deficit in the first 10 years.”
The Republicans’ projections were in contrast to the budget office’s analysis of the health care law, and a related budget reconciliation measure, after they were adopted last March. The budget office said those laws would reduce federal deficits by $143 billion through 2019 and even more over the next decade, perhaps by more than $1 trillion.
Democrats have long registered their own complaints about the budget office projections, insisting that the law would do much more to reduce health spending, by the government and by individuals and private businesses. The Democrats said that normal budget scoring rules simply cannot account for many improvements in the way health care will be practiced and delivered in response to the law.
The disparities, while big, are not as hard to understand as they might seem.
There are uncertainties around all of the projections and predictions. And some questions, like whether the law will create or eliminate jobs, improve outcomes for patients or make medical care harder to obtain cannot be answered with any precision. Or at least no one on Capitol Hill seems to have the needed crystal ball.
Conceptually speaking, however, the budget office’s projection that the law would spend nearly $1 trillion on benefits and yet reduce deficits is easy to understand. As long as the revenue from new taxes and the savings from reductions in projected Medicare spending exceed the new expenditures by the government, the deficits are reduced.
The criticisms by House Republican leaders of those projections are also mostly straightforward. They say that the budget office should not have counted roughly $70 billion in revenue from premiums for a new long-term care insurance program, because the premiums would be used to pay benefits later and that it should not have counted $53 billion in increased revenue from Social Security taxes because that money must be used for Social Security benefits.
The Republicans also say that the budget rules effectively double-count nearly $400 billion in Medicare savings as both reducing the cost of the health care law and prolonging the life of the Medicare trust fund. They also complain that the projections omitted $115 billion in spending required to administer the law as well as $208 billion needed to prevent scheduled reductions in Medicare payments to doctors.
The director of the budget office, Douglas W. Elmendorf, is the first to acknowledge that there are many uncertainties around the projections. But he has also defended the agency’s numbers in public forums and numerous meetings with lawmakers and Congressional staff.
Mr. Elmendorf has stressed that the budget office used the “middle distribution of likely outcomes,” meaning that the health care law is just as likely to save the government more money as it is to cost more.
“Assessing the effects of making broad changes in the nation’s health care and health insurance systems ― or of reversing scheduled changes ― requires assumptions about a broad array of technical, behavioral and economic factors,” Mr. Elmendorf wrote in his report Thursday giving the preliminary estimate of the cost of repealing the law.
“However, CBO’s staff, in consultation with outside experts, has devoted a great deal of care and effort to the analysis of health care legislation in the past few years, and the agency strives to develop estimates that are in the middle of the distribution of possible outcomes,” he wrote. “As a result, CBO believes that its estimates of the net budgetary effects of health care legislation have a roughly equal chance of turning out to be too high or too low.”
Mr. Elmendorf and other experts have said that one of the major areas of uncertainty is the political difficulty Congress may face in carrying out the nearly $500 billion in reductions to projected Medicare spending called for in the law.
They note that Congress has acted repeatedly to avoid cuts in scheduled payments to doctors under a formula established in the 1990’s, stipulating that those payments should not exceed a “sustainable growth rate.”
The chief Medicare actuary, Richard S. Foster, has raised serious questions about whether Congress would be able to follow through with the cuts, which he said “could become unsustainable” driving some health care providers out of business.
Some of the Republicans’ criticisms are based on the longstanding budget scoring rules and conventions, like measuring the financial effects of legislation in a limited 10-year window. While spending will ramp up sharply after the first 10 years, the budget office says, the savings and revenue from taxes will accelerate even faster.
The Democrats designed the health care law so that most of the cuts and new taxes begin early while most of the spending, on insurance subsidies, for instance, begins in 2014. The new taxes include an increase in the individual hospital insurance payroll tax on income above $200,000 for individuals and $250,000 for couples, an excise tax on certain high-cost insurance plans and taxes on medical device manufacturers. The costs include a broad expansion in eligibility for Medicaid, the state-federal insurance program for low-income Americans, and new subsidies to help low- and middle-income Americans buy private health insurance.
Mr. Elmendorf, a respected economist and former Clinton administration official who has also worked at the Federal Reserve, was appointed director of the budget office in January 2009 to complete the term of Peter R. Orszag, who left the post to become Mr. Obama's budget director. The term ended on Jan. 3. The chairmen of the House and Senate budget commitees, Representative Paul Ryan, Republican of Wisconsin, and Senator Kent Conrad, Democrat of North Dakota, have said they support Mr. Elemendorf for a full four-year term. But Mr. Boehner has not said if he will back the appointment. The director is selected jointly by the House speaker and the Senate president pro tempore, currently Daniel K. Inouye of Hawaii. By law, Mr. Elmendorf can continue in the job until he is reappointed, a successor is named or either chamber of Congress votes to remove him.
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