Tag Archives: Immigration

Will the “Byrd Bath” Turn Into a Tax Credit Bloodbath?

While most of official Washington waits for word—expected early this week—from the Congressional Budget Office (CBO) about the fiscal effects of House Republicans’ “repeal-and-replace” legislation, another, equally critical debate is taking place within the corridors of the Capitol. Arcane arguments behind closed doors about the nuances of parliamentary procedure will do much to determine the bill’s fate in the Senate—and could lead to a final product vastly altered compared to its current form.

In recent days, House leaders have made numerous comments highlighting the procedural limitations of the budget reconciliation process in the Senate. However, those statements do not necessarily mean that the legislation released last week comports with all of those Senate strictures. Indeed, my conversations with more than half a dozen current and former senior Senate staff, all of whom have long expertise in the minutiae of Senate rules and procedure, have revealed at least four significant procedural issues—one regarding abortion, two regarding immigration, and one regarding a structural “firewall”—surrounding the bill’s tax credit regime.

Those and other procedural questions explain why, according to my sources, Senate staff will spend the coming week determining whether they will need to write an entirely new bill to substitute for the House’s proposed language. The stakes involved are high: Guidance from the parliamentarian suggesting that the House bill contains fatal procedural flaws, meaning it does not qualify as a reconciliation bill, could force the House to repeat the process, starting again with a new, “clean” reconciliation measure.

It is far too premature to claim that any of these potential flaws will necessarily be fatal. The Senate parliamentarian’s guidance to senators depends on textual analysis—of the bill’s specific wording, the underlying statutes to which it refers, and the CBO scores (not yet available)—and arguments about precedent made by both parties. Senate staff could re-draft portions of the House bill to make it pass procedural muster, or make arguments to preserve the existing language that the parliamentarian accepts as consistent with Senate precedents. Nevertheless, if the parliamentarian validates even one of the four potential procedural problems, Republicans could end up with a tax credit regime that is politically unsustainable, or whose costs escalate appreciably.

In 2009, Democratic Senator Kent Conrad famously opined that passing health care legislation through budget reconciliation would make the bill look like “Swiss cheese.” (While Democrats did not pass Obamacare through reconciliation, they did use the reconciliation process to “fix” the bill that cleared the Senate on Christmas Eve 2009.) In reality, it’s much easier to repeal provisions of a budgetary nature—like Obamacare’s taxes, entitlements, and even its major regulations—through reconciliation than to create a new replacement regime. The coming week may provide firsthand proof of Conrad’s 2009 axiom.

“Byrd Rule” and Abortion

The Senate’s so-called “Byrd rule” governing debate on budget reconciliation rules—named after former Senate Majority Leader and procedural guru Robert Byrd (D-WV)— in fact consists of not one rule, but six. The six points of order (codified here) seek to keep extraneous material out of the expedited reconciliation process, preserving the Senate tradition of unlimited debate, subject to the usual 60-vote margin to break a filibuster.

The Byrd rule’s most famous test states that “a provision shall be considered extraneous if it produces changes in outlays or revenues which are merely incidental to the non-budgetary components of the legislation.” If the section in question primarily makes a policy change, and has a minimal budgetary impact, it remains in the bill only if 60 senators (the usual margin necessary to break a filibuster) agree to waive the Byrd point of order.

One example of this test may apply to the House bill’s tax credits: “Hyde amendment” language preventing the credits from funding plans that cover abortion. Such language protecting taxpayer funding of abortion coverage occurs several places throughout the bill, including at the top of page 25 of the Ways and Means title.

Over multiple decades, and numerous parliamentarians, Republican efforts to enact Hyde amendment protections through budget reconciliation have all failed. It is possible that Republicans could in the next few weeks find new arguments that allow these critical protections to remain in the House bill—but that scenario cannot be viewed as likely.

The question will then occur as to what becomes of both the credit and the Hyde protections. Some within the Administration have argued that the Department of Health and Human Services (HHS) can institute pro-life protections through regulations—but Administration insiders doubt HHS’ authority to do so. Moreover, most pro-life groups publicly denounced President Obama’s March 2010 executive order—which he claimed would prevent taxpayer funding of abortion coverage in Obamacare—as 1) insufficient and 2) subject to change under a future Administration. How would those pro-life groups view a regulatory change by the current Administration any differently?

Immigration

A similarly controversial issue—immigration—brings an even larger set of procedural challenges. Apart from the separate question of whether the current verification provisions in the House bill are sufficiently robust, ANY eligibility verification regime for tax credits faces not one, but two major procedural obstacles in the Senate.

Of the six tests under the Byrd rule, some are more fatal than others. For instance, if the Hyde amendment restrictions outlined above are ruled incidental in nature, then those provisions merely get stricken from the bill unless 60 Senators vote to retain them—a highly improbable scenario in this case.

But two other tests under the Byrd rule—provisions outside a committee’s jurisdiction, and provisions making changes to Title II of the Social Security Act—are fatal not just to that particular provision, but to the entire bill, potentially forcing the process to begin all over again in the House. The eligibility verification regime touches them both.

Page 37 of the Ways and Means title of the bill requires creation of a verification regime for tax credits similar to that created under Sections 1411 and 1412 of Obamacare. As Joint Committee on Taxation Chief of Staff Tom Barthold testified last week during the Ways and Means Committee markup, verifying citizenship requires use of a database held by the Department of Homeland Security’s Bureau of Citizenship and Immigration Services (CIS).

That admission creates a big problem: The tax credit lies within the jurisdiction of the Senate Finance Committee—but CIS lies within the jurisdiction of the Senate Homeland Security and Governmental Affairs Committee. And because the Finance Committee’s portion of the reconciliation bill can affect only programs within the Finance Committee’s jurisdiction, imposing programmatic requirements on CIS to verify citizenship status could exceed the Finance Committee’s scope—potentially jeopardizing the entire bill.

The verification provisions in Sections 1411 and 1412 of Obamacare also require the use of Social Security numbers—triggering another potentially fatal blow to the entire bill. Senate sources report that, during when drafting the original reconciliation bill repealing Obamacare in the fall of 2015, Republicans attempted to repeal the language in Obamacare (Section 1414(a)(2), to be precise) giving the Secretary of HHS authority to collect and use Social Security numbers to establish eligibility. However, because Section 1414(a)(2) of Obamacare amended Title II of the Social Security Act, Republicans ultimately did not repeal this section of Obamacare in the reconciliation bill—because it could have triggered a point of order fatal to the legislation.

If both the points of order against the verification regime are sustained, Congress will have to re-write the bill to create an eligibility verification system that 1) does not rely on the Department of Homeland Security AND 2) does not use Social Security numbers. Doing so would create both political and policy problems. On the political side, the revised verification regime would exacerbate existing concerns that undocumented immigrants may have access to federal tax credits.

But the policy implications of a weaker verification regime might actually be more profound. Weaker verification would likely result in a higher score from CBO and JCT—budget scorekeepers would assume a higher incidence of fraud, raising the credits’ costs. House leaders might then have to reduce the amount of their tax credit to reflect the higher take-up of the credit by fraudsters taking advantage of lax verification. And any reduction in the credit amounts would bring with it additional political and policy implications, including lower coverage rates.

Firewall Concerns

Finally, the tax credit “firewall”—designed to ensure that only individuals without access to other health insurance options receive federal subsidies—could also present procedural concerns. Specifically, pages 27 and 28 of the bill make ineligible for the credit individuals participating in other forms of health insurance, several of which—Tricare, Veterans Administration coverage, coverage for Peace Corps volunteers, etc.—lie outside the Finance Committee’s jurisdiction.

If the Senate parliamentarian advises for the removal of references to these programs because they lie outside the Finance Committee’s jurisdiction, then participants in those programs will essentially be able to “double-dip”—to receive both the federal tax credit AND maintain their current coverage. As with the immigration provision outlined above, such a scenario could significantly increase the tax credits’ cost—requiring offsetting cuts elsewhere, which would have their own budgetary implications.

Senate sources indicate that this “firewall” concern could prove less problematic than the immigration concern outlined above. While the immigration provision extends new programmatic authority to the Administration to develop a revised eligibility verification system, the “firewall” provisions have the opposite effect—essentially excluding Tricare and other program recipients from the credit. However, if the parliamentarian gives guidance suggesting that some or all of the “firewall” provisions must go, that will have a significant impact on the bill’s fiscal impact.

Broader Implications

Both individually and collectively, these four potential procedural concerns hint at an intellectual inconsistency in the House bill’s approach—one Yuval Levin highlighted in National Review last week. House leaders claim that their bill was drafted to comply with the Senate reconciliation procedures. But the bill itself contains numerous actual or potential violations of those procedures—and amends some of Obamacare’s insurance regulations, rather than repealing them outright—making their argument incoherent.

Particularly when it comes to Obamacare’s costly insurance regulations, there seems little reason not to make the “ol’ college try,” and attempt to repeal the major mandates that have raised premium levels. According to prior CBO scores, other outside estimates, and the Obama Administration’s own estimates when releasing the regulations, the major regulations have significant budgetary effects. Republicans can and should argue to the parliamentarian that the regulations’ repeal would be neither incidental nor extraneous—their repeal would remove the terms and conditions under which Obamacare created its insurance subsidies in the first place, thus meeting the Byrd test. If successful, such efforts would provide relief on the issue Americans care most about: Reducing health costs and staggering premium increases.

When it comes to the tax credit itself, Republicans may face some difficult choices. Abortion and immigration present thorny—and controversial—issues, either one of which could sink the legislation. When it comes to the bill’s tax credits, the “Byrd bath,” in which the parliamentarian gives guidance on what provisions can remain in the reconciliation bill, could become a bloodbath. If pro-life protections and eligibility verification come out of the bill, a difficult choice for conservatives on whether or not to support tax credits will become that much harder.

This post was published at The Federalist.

The Republican Party Split That Donald Trump’s Nomination Won’t Resolve

The general election campaign has not begun, but preliminary polling suggests that Donald Trump is a decided underdog against Hillary Clinton. For the Republican Party, there is an issue beyond the Election Day outcome–and one that, at least right now, looks unlikely to be resolved no matter who wins in November.

More so than reports of John Kasich suspending his campaign, it was Sen. Ted Cruz‘s withdrawal from the Republican primary race Tuesday night that sparked reactions from Republicans ranging from begrudging acceptance to continued hostility. Mr. Trump’s ascendance illustrates a split within the Republican Party, between the “establishment” and the “tea party” lanes, that has been widening for years. It is likely to persist, as both factions disagree on the elements that led to Mr. Trump’s meteoric rise.

A core point in the internal GOP dispute is whether political confrontation or ideological conservatism most motivates voters, including the party’s base. Steve Schmidt, a consultant to John McCain‘s presidential campaign in 2008, said on MSNBC Tuesday night that Mr. Trump’s rise was fueled by voter frustration stoked by the tea-party wing. He and other establishment figures view anger as a poor substitute for substantive policy solutions and a dead-end political strategy in general.

On the other hand, those aligned with tea-partyers view the Trump phenomenon as rising from discontent with an insufficiently conservative leadership. They see voters’ frustration and anger rooted in an establishment that overpromised and underdelivered, for example by promising to fight President Barack Obama’s executive orders on immigration “tooth and nail” in November 2014 but, just a few months later, ruling out a partial government shutdown over the issue as “not an option.”

A Cruz nomination would have left little doubt about the party’s ideological direction. Mr. Cruz often echoed Ronald Reagan’s desire to speak “in bold colors, not pale pastels,” and relying on motivated conservatives to help drive general election turnout. A Cruz-Clinton match-up would have made clear the potential, and potential limits, of a “base strategy.”

Conversely, Trump’s ideological heterodoxies—on health careabortion and even about Hillary Clinton herself—reshuffle the political landscape. Mr. Trump falls outside the “establishment” and “tea party” labels, as neither side fully embraced his ascent. Mr. Trump said Wednesday that “As far as the Republican Party coming together, it will, maybe not 100%, but it’ll come together 99% and the 1% I don’t want and it won’t have any impact.” What shape the GOP takes as some elements rally behind him and others consider different directions will definitely have an impact on the Republican Party as we have known it.

This post was originally published at the Wall Street Journal’s Think Tank blog.

CBO, Transparency, and Obamacare’s Deficit Impact

Before a House rules change in January, CBO generally had not applied “dynamic scoring” to major legislation, or considered likely macro-economic effects when analyzing a bill’s potential impact on the deficit. On Friday, in response to follow-up questions from a January congressional hearing, CBO said that had it conducted such an analysis of Obamacare, it would have found that the bill reduced the federal deficit by less than its original projections.

In short: Because CBO believes the health-care law will discourage work, it would lower federal revenues—but the agency did not consider the revenue impacts of these effects in 2010, when it projected that the law would reduce the federal deficit.

Although CBO does not usually estimate macroeconomic effects of major bills, it has done this. In 2013 the agency “relaxed” its score-keeping convention with respect to immigration legislation in the Senate, concluding that the bills under consideration would increase the labor supply and economic growth and thus federal revenues. Both the 2013 Senate immigration bill and Obamacare would have altered the U.S. workforce by millions of workers. That CBO went to great lengths to estimate the macroeconomic and fiscal effects of Senate legislation never enacted but has yet to do so with Obamacare raises questions about the agency’s policies for scoring legislative measures.

CBO has conducted two analyses of the health-care law’s impact on labor markets, but these did not say that the law’s effects on the labor force would impact its potential deficit reduction. The first analysis, released in August 2010, said that Obamacare would reduce the workforce by about half a percent, or approximately 800,000 workers, by 2021. The second analysis, released in February 2014, roughly tripled that estimate, to 1.5% to 2% of the labor force—the equivalent of approximately 2.3 million workers in 2021. CBO could have publicly stated that these labor-force changes, and the related revenue effects, would negatively affect the deficit, even if it could not specify by how much.

CBO said last summer that it would no longer produce estimates for the fiscal impact of the health law as a whole. It also declined to release a score of legislation repealing the law before last month’s House vote. In a blogpost last June, Mr. Elmendorf wrote that CBO and the Joint Committee on Taxation “have no reason to think that their initial [March 2010] assessment that the ACA would reduce budget deficits was incorrect.” But the agency’s statement on Friday illustrates that the 2010 deficit assessment was incomplete and could be incorrect. CBO appears to have no intention of correcting this flaw or revealing Obamacare’s true fiscal impact.

CBO’s statement Friday was released to select congressional offices the same day Keith Hall was named as Mr. Elmendorf’s replacement. As CBO’s past analyses of Obamacare’s impact on the labor market received much press fanfare, the down-playing of this information seems straight out of “The West Wing.”

One hopes that under Dr. Hall’s leadership CBO will address a few issues, including a revised score of Obamacare that accounts for the legislation’s impact on labor markets and a broader discussion about the need to consider macroeconomic effects when analyzing bills as large in size and scope as the 2,700-page health-care law. CBO is accountable to Congress and taxpayers; it can act accordingly starting with more transparency.

This post was originally published at the Wall Street Journal’s Think Tank blog.

Who’s Going to Pay for This Obamacare Wish List?

I wrote in this space last June that supporters of the president’s health-care law had not made many specific suggestions about how to amend or otherwise change the Affordable Care Act. Last week, the advocacy group Families USA attempted to change that, releasing its “Health Reform 2.0” agenda of how to expand on Obamacare. But the paper also raises an important question for the law’s supporters—including presidential candidates running in 2016: How to pay for the myriad promises that liberal groups want to add to the health-care agenda?

The Families USA paper includes a full—and costly—wish list of new spending programs related to the law, including:

* Fixing the “family glitch,” in which families are ineligible for federal insurance subsidies if one member of the family has an offer of “affordable” employer-sponsored health coverage;

* Extending funding for children’s health insurance, a program that Obamacare funded only through September;

* Increasing federal cost-sharing subsidies—raising the amount of subsidies, currently provided to families with incomes under 250% of the federal poverty level, so as further to reduce deductibles and co-payments, and potentially raising the income cutoff for subsidies;

* Making permanent an increase in Medicaid reimbursement rates included in Obamacare that expired on Dec. 31, 2014;

* Extending coverage to immigrant populations (the report does not specify whether such coverage should also apply to the undocumented); and

* Increasing federal premium subsidies. Amending the current subsidy set-up in this way would necessitate two changes to current law, both of which would require an increase in federal spending. Congress would need to repeal the provision, set to kick in after 2019, scheduled to reduce the subsidies’ annual rate of growth; then lawmakers would have to pass the subsidy increase that Families USA advocates.

The proposal also contains numerous mandates on insurance plans—for instance, to cover adult dental care, all forms of pediatric care, and expand access to provider networks. These would come at a cost, raising insurance premiums for individuals and families—and raising costs for the federal government as well, related to the 87% of exchange participants receiving premium assistance subsidies.

While specific cost estimates for these proposals are unavailable, they are likely to be substantial. Cost concerns meant that the children’s health insurance program received funding for just a two-year extension in Obamacare. Likewise, the Medicaid reimbursement bump was so expensive—$8.3 billion—that lawmakers financed it for only 2013 and 2014 as part of the law. And Families USA’s proposed changes to the subsidy regime could cost far more: a 2011 study found that fixing just the “family glitch” could increase spending by nearly $50 billion per year.

In other words, a liberal group has proposed spending hundreds of billions—at minimum—on expanding Obamacare programs. And other than some suggestions about using government-imposed price controls—“direct intervention in pricing may ultimately be necessary”—the Families USA report contains precious little on paying for these expanded entitlements. It may have answered the “What?” when it comes to proposed “fixes” to the law, but it did not answer the “How much?” And as the law remains divisive, and federal debt continues to rise, the latter question must remain on the public agenda for some time to come.

This post was originally published at the Wall Street Journal’s Think Tank blog.

What’s Behind the Latest Obamacare “Glitch”

An Associated Press story Wednesday detailing how at least 2 million individuals have data discrepancies in their applications for Affordable Care Act insurance subsidies provides another example of executive implementation gone awry.

The issue lies with verification of income, citizenship and immigration status for those applying for health insurance subsidies. Legislation that reopened the federal government last fall included a requirement (Section 1001 here) for the secretary of health and human services (HHS) to certify that only eligible individuals would receive insurance subsidies.

The 16-page HHS report complying with that requirement has more than a dozen pages of references to federal regulations, statutory requirements, government agencies and administrative processes—suggesting that taxpayer funds would be spent wisely.

Except the processes weren’t ready at all. The Washington Post reported last month that the federal computer systems central to the verification process had yet to be built—meaning that verification documents sent in by Americans have been gathering dust.

Wednesday’s AP story cited an administration official saying that about 60% of exchange applications with discrepancies remain in the 90-day window provided under the law to adjudicate disputes. The implication is that 40% of applications—or about 800,000 individuals’ paperwork—haven’t been resolved, and it’s not known when they might be.

All this means that those Americans receiving subsidies in error—who may later be forced to pay back sizable sums as the verification process drags on—and all taxpayers, who will ultimately foot the bill for any fraud, could face nasty surprises in future months.

This post was originally published at the Wall Street Journal’s Think Tank blog.

Harry Reid, the Constitution, & Obamacare

Speaking on the Senate floor during leader time this afternoon, Majority Leader Reid offered comments on this morning’s Supreme Court decision regarding Arizona’s immigration law.  Sen. Reid called it “disturbing” that anyone would consider the Arizona law a policy model.  He continued:

Anyone who thinks such an unconstitutional law should serve as a model, their national reform is clearly outside the mainstream and the United States Supreme Court agreed with that today.

So on Monday of this week, Sen. Reid said that an immigration bill ruled unconstitutional by the Supreme Court is “clearly outside the mainstream” and not a model for national reform.  Of course, we know Sen. Reid will apply exactly the same standard to the health care bill as well.  That’s why, should the Court decide to strike down some or all of Obamacare on Thursday, we eagerly await Sen. Reid’s remarks admitting that the bill he and his Democrat colleagues rammed through two years ago is “clearly outside the mainstream,” not a model for national reform, and should be repealed in its entirety for those reasons.

Obamacare & Identity Fraud

This morning the Treasury’s Inspector General for Tax Administration testified before two Ways and Means subcommittees about the prevalence of identity theft and fraud within the tax system. Although the IRS identified 1.1 million incidents of identity theft affecting the tax system in 2011 alone, the Inspector General’s testimony found that even this level of fraud was merely the tip of the iceberg:

However, the IRS does not know how many identity thieves are filing fraudulent tax returns or the amount of revenue being lost….Our analysis found that, although the IRS detects and prevents a large number of fraudulent refunds based on false income documents, there is much fraud that it does not detect. We identified approximately 1.5 million additional undetected tax returns with potentially fraudulent tax refunds totaling in excess of $5.2 billion. If not addressed, we estimate the IRS could issue approximately $26 billion in fraudulent tax refunds resulting from identity theft over the next five years.

These findings have troubling implications for the president’s unpopular 2,700-page health care law, on several levels:

  1. Rather than increasing efforts to combat identity fraud in the existing tax system, much of the IRS’ time over the next few years will instead be spent on creating and implementing a brand new entitlement — health insurance subsidies administered through the tax code.
  2. The massive amounts spent on Obamacare’s insurance subsidies — $632 billion between now and 2022, according to the Congressional Budget Office’s most recent baseline – will only provide further incentives for identity thieves to engage in tax fraud, so they can receive insurance subsidies to which they are not entitled.
  3. Obamacare will only require applicants for insurance subsidies to verify citizenship, NOT identity; the verification process will check that John Doe is a citizen, but will not confirm that the applicant is in fact John Doe. Today’s inspector general report highlights that identity fraud is rampant within the current tax system. Therefore, it is not unreasonable to conclude that non-citizens will commit identity theft — as millions already do by filing bogus tax returns every year — to obtain subsidized insurance. This scenario would violate the President’s promise made before a joint session of Congress in 2009, that individuals illegally present would not be able to obtain insurance under his plan.

The American people have already questioned why, at a time of trillion-dollar deficits, Democrats want to spend $2.6 trillion creating massive new entitlement programs. Today’s inspector general report raises the further question of whether and why such spending will be diverted for fraudulent purposes by identity thieves preying on unsuspecting American families and taxpayers alike.

208 Things in Obamacare That Democrats Support

Last week, former HELP Committee staffer John McDonough wrote a list of “50 provisions I ask the media to ask Romney et al. if they are committed to repealing as President.”  McDonough noted that “there are [Obamacare] provisions opponents could pick out to create an alternative list for elimination.”

We know a challenge when we hear one; our list is submitted below, with sections from the statute duly noted.  Remember when reading this list:  We KNOW that President Obama and Democrats all support these provisions in Obamacare – because they all voted to enact them into law.  So members of the media can readily ask President Obama and Democrat Members of Congress why they supported a law that…

  1. Imposes $800 billion in tax increases, including no fewer than 12 separate provisions breaking candidate Obama’s “firm pledge” during his campaign that he would not raise “any of your taxes” (Sections 9001-9016)?
  2. Forces Americans to purchase a product for the first time ever (Section 1501)?
  3. Creates a board of 15 unelected and unaccountable bureaucrats to make binding rulings on how to reduce Medicare spending (Section 3403)?
  4. Pays over $800 billion in subsidies straight to health insurance companies (Sections 1401, 1402, and 1412)?
  5. Requires all individuals to buy government-approved health insurance plans, imposing new mandates that will raise individual insurance premiums by an average of $2,100 per family (Section 1302)?
  6. Forces seniors to lose their current health care, by enacting Medicare Advantage cuts that by 2017 will cut enrollment in half, and cut plan choices by two-thirds (Section 3201)?
  7. Imposes a 40 percent tax on health benefits, a direct contradiction of Barack Obama’s campaign promises (Section 9001)?
  8. Relies upon government bureaucrats to “issue guidance on best practices of plain language writing” (Section 1311(e)(3)(B))?
  9. Provides special benefits to residents of Libby, Montana – home of Max Baucus, the powerful Chairman of the Senate Finance Committee, who helped write the law even though he says he hasn’t read it (Section 10323)?
  10. Imposes what a Democrat Governor called the “mother of all unfunded mandates” – new, Washington-dictated requirements of at least $118 billion – at a time when states already face budget deficits totaling a collective $175 billion (Section 2001)?
  11. Imposes reductions in Medicare spending that, according to the program’s non-partisan actuary, would cause 40 percent of all Medicare providers to become unprofitable, and could lead to their exit from the program (Section 3401)?
  12. Raises premiums on more than 17 million seniors participating in Medicare Part D, so that Big Pharma can benefit from its “rock-solid deal” struck behind closed doors with President Obama and Congressional Democrats (Section 3301)?
  13. Creates an institute to undertake research that, according to one draft Committee report prepared by Democrats, could mean that “more expensive [treatments] will no longer be prescribed” (Section 6301)?
  14. Creates a multi-billion dollar “slush fund” doled out solely by federal bureaucrats, which has already been used to fund things like bike paths (Section 4002)?
  15. Subjects states to myriad new lawsuits, by forcing them to assume legal liability for delivering services to Medicaid patients for the first time in that program’s history (Section 2304)?
  16. Permits taxpayer dollars to flow to health plans that fund abortion, in a sharp deviation from prior practice under Democrat and Republican Administrations (Section 1303)?
  17. Empowers bureaucrats on a board that has ruled against mammograms and against prostate cancer screenings to make binding determinations about what types of preventive services should be covered (Sections 2713 and 4104)?
  18. Precludes poor individuals from having a choice of health care plans by automatically dumping them in the Medicaid program (Section 1413(a))?
  19. Creates a new entitlement program that one Democrat called “a Ponzi scheme of the first order, the kind of thing that Bernie Madoff would have been proud of” – a scheme so unsustainable even the Administration was forced to admit it would not work (Section 8002)?
  20. Provides $5 billion in taxpayer dollars to a fund that has largely served to bail out unions and other organizations who made unsustainable health care promises to retirees that they cannot afford (Section 1102)?
  21. Creates a tax credit so convoluted it requires seven different worksheets to determine eligibility (Section 1421)?
  22. Imposes multiple penalties on those who marry, by reducing subsidies (and increasing taxes) for married couples when compared to two individuals cohabiting together (Sections 1401-02)?
  23. Extends the Medicare “payroll tax” to unearned income for the first time ever, including new taxes on the sale of some homes (Section 1402)?
  24. Impedes state flexibility by requiring Medicaid programs to offer a specific package of benefits, including benefits like family planning services (Sections 2001(a)(2), 2001(c), 1302(b), and 2303(c))?
  25. Requires individuals to go to the doctor and get a prescription in order to spend their own Flexible Spending Account money on over-the-counter medicines (Section 9003)?
  26. Expands the definition of “low-income” to make 63 percent of non-elderly Americans eligible for “low-income” subsidized insurance (Section 1401)?
  27. Imposes a new tax on the makers of goods like pacemakers and hearing aids (Section 9009)?
  28. Creates an insurance reimbursement scheme that could result in the federal government obtaining Americans’ medical records (Section 1343)?
  29. Permits states to make individuals presumptively eligible for Medicaid for unlimited 60-day periods, thus allowing any individual to receive taxpayer-funded assistance ad infinitum (Section 2303(b))?
  30. Allows individuals to purchase insurance on government exchanges – and to receive taxpayer-funded insurance subsidies – WITHOUT verifying their identity as American citizens (Section 1411)?
  31. Gives $300 million in higher Medicaid reimbursements to one state as part of the infamous “Louisiana Purchase” – described by ABC News as “what…it take[s] to get a wavering senator to vote for health care reform” (Section 2006)?
  32. Raises taxes on firms who cannot afford to buy coverage for their workers (Section 1513)?
  33. Forces younger Americans to pay double-digit premium increases so that older workers can pay slightly less (Section 1201)?
  34. Prohibits states from modifying their Medicaid programs to include things like modest anti-fraud protections (Section 2001)?
  35. Includes a special provision increasing federal payments just for Tennessee (Section 1203(b))?
  36. Allows individuals to purchase health insurance across state lines – but only if politicians and bureaucrats agree to allow citizens this privilege (Section 1333)?
  37. Allows the HHS Secretary and federal bureaucrats to grant waivers exempting people from Obamacare’s onerous mandates, over half of which have gone to members of union plans (Section 1001)?
  38. Creates a pseudo-government-run plan overseen by the federal government (Section 1334)?
  39. Removes a demonstration project designed to force government-run Medicare to compete on a level playing field with private plans (Section 1102(f))?
  40. Gives the Secretary of HHS an UNLIMITED amount of federal funds to spend funding state insurance Exchanges (Section 1311(a))?
  41. Creates a grant program that could be used by liberal groups like ACORN or AARP to conduct “public education activities” surrounding Obamacare (Section 1311(i))?
  42. Applies new federal mandates to pre-Obamacare insurance policies, thus proving that you CAN’T keep the insurance plan you had – and liked – before the law passed (Sections 2301 and 10103)?
  43. Prohibits individuals harmed by federal bureaucrats from challenging those decisions, either in court or through regulatory processes (Sections 3001, 3003, 3007, 3008, 3021, 3022, 3025, 3133, 3403, 5501, 6001, AND 6401)?
  44. Earmarks $100 million for “construction of a health care facility,” a “sweetheart deal” inserted by a Democrat Senator trying to win re-election (Section 10502)?
  45. Puts yet another Medicaid unfunded mandate on states, by raising payments to primary care physicians, but only for two years, forcing states to come up with another method of funding this unsustainable promise when federal funding expires (Section 1202)?
  46. Imposes price controls that have had the effect of costing jobs in the short time since they were first implemented (Section 1001)?
  47. Prohibits individuals from spending federal insurance subsidies outside government-approved Exchanges (Section 1401(a))?
  48. Provides a special increase in federal hospital payments just for Hawaii (Section 10201(e)(1))?
  49. Imposes new reporting requirements that will cost businesses millions of dollars, and affect thousands of restaurants and other establishments across the country (Section 4205)?

And instead of including a 50th item on our list, we’re going to include 159 separate items.  These are the 159 new boards, bureaucracies, and programs created by Obamacare.  You can find the list here.

No matter which way you look at it, this list provides 208 easy reasons why the American people still continue to reject Democrats’ unpopular 2700-page health care law.

What You Need to Know about Today’s Census Uninsured Numbers

The Census Bureau released their annual report on poverty, income, and the uninsured this morning; the report is now online and can be found here.  Important figures you need to know from the health insurance section of the report:

  • The total number of uninsured rose to 49.9 million, an increase of 919,000 compared to 2009’s REVISED estimate of 49.0 million uninsured.  (As previously noted, last year’s report claimed 50.6 million uninsured Americans in 2009—but was conducted using a different methodology, making the two reports not directly comparable.  This year’s report re-estimated the uninsured numbers for 2009 and earlier years using the new methodology; the re-estimated numbers are the ones cited below.)
  • The uninsured rate rose 0.2 percentage points to 16.3 percent.  As previously noted, this uninsured rate nearly matches the August total unemployment rate—including discouraged workers who have left the workforce and part-time workers who cannot find full-time employment—of 16.2 percent.
  • The number of individuals with private insurance fell by only 300,000, led by a decline in the number of individuals with employer-sponsored health insurance of 1.5 million.  This loss of employer-provided insurance was however offset by an increase of over 1 million buying direct purchase insurance (including insurance purchased on the individual market).
  • The number of individuals with government-provided health insurance rose by almost 1.8 million, led by an increase in Medicaid enrollment of about 800,000.  The Medicare population also rose by about 900,000, likely reflecting both the retirement of the first Baby Boomers and an increase in disability claims due to the recession.
  • While the losses in employer-sponsored insurance were more than offset by the combined increases in government coverage through Medicaid and in direct purchase insurance, they were not able to overcome the 1.8 million population increase, thus leading to a slight increase in both the number and rate of uninsured Americans.
  • The number of non-citizens (both legal and illegal) without health insurance rose totaled 9.7 million.  Non-citizens comprise just under one-fifth of the total number of uninsured.
  • The number of uninsured with household incomes under $25,000 rose by 846,000, to 16.1 million (or 32.3% of the uninsured).  Many of these individuals may be eligible for public assistance through Medicaid and SCHIP.  (Also, as noted in yesterday’s e-mail analysis, a significant number of uninsured may in fact already be enrolled in these programs, but their insurance status is not accurately reported by the Census data.)
  • The number of uninsured with household incomes over $75,000 totaled about 9.5 million (or about 19% of the total number of uninsured).  Many of these individuals may be able to obtain coverage on their own, but may choose not to do so if they do not consider the insurance policies offered to be of value to them.

It’s also important to note a significant change in the composition of insurance coverage for children.  From 2008 through 2010, the number of children enrolled in private insurance dropped by 2.8 million, while the number of children enrolled in Medicaid (which also includes SCHIP) rose by 3.5 million, or more than 15%.  As a reminder, 2009 was the year in which a significant expansion of SCHIP was enacted.  While it’s unlikely that the entire migration from employer-sponsored coverage to Medicaid was entirely caused by individuals voluntarily dropping out of employer coverage to enroll in government-sponsored coverage, it likely contributed to this migration.

As we’ve previously noted, it’s important to emphasize that, to the extent the increase in the number of uninsured reflects a drop in employer-sponsored coverage, this number reflects the continued lack of economic growth—and, more critically, jobs growth—under this Administration’s policies. Even liberal organizations have directly linked loss of insurance coverage to loss of employment.  However, such a link directly connects the rising number of uninsured to the Obama Administration’s failed predictions about the employment effects of their “stimulus” policies.

DREAM Act and Health Care

My judiciary colleague Gregg Nunziata has e-mailed your judiciary counterparts on the bill (S. 3992), but I just wanted to highlight one particular section of the CBO score of the bill that’s applicable to health care:

“Although the legislation would not have a large impact on deficits over the 2011-2020 period, the eventual conversion of some of the conditional non-immigrants to legal permanent resident (LPR) status after 2020 would lead to significant increases in spending for the federal health insurance exchanges, Medicaid, and the Supplemental Nutrition Assistance Program (SNAP).  Pursuant to section 311 of the Concurrent Resolution on the Budget for Fiscal Year 2009 (S. Con. Res. 70), CBO estimates that the bill would increase projected deficits by more than $5 billion in at least one of the four consecutive 10-year periods starting in 2021.”

Because the bill provides that conditional non-immigrants will not be eligible for health insurance subsidies or Medicaid, and because the bill requires conditional non-immigrants to wait ten years until obtaining legal resident status (at which point they would qualify for both Medicaid and insurance subsidies, if eligible based on income and other criteria), spending on health benefits for any individuals eventually granted legal status would not occur until 2020 (i.e., outside the budgetary window).  As noted above, however, CBO believes the fiscal effects after 2020 – which are not paid for – would be “significant,” although the score does not quantify their magnitude.  CBO also notes that the unpaid-for spending on insurance subsidies, Medicaid, and related programs after 2020 means the bill is subject to a budget point of order for increasing deficits by more than $5 billion in succeeding decades.