Question 1: Is public policy like homework, meaning if you expend all your energy on the easy fix (Social Security), then you might not have anything left for the harder part (Medicare)?
- Maybe. If we could only do one thing, we would be better off addressing Medicare. In the end, if we do NOTHING on Social Security, what we are saying is that in 2039 (or so) when the reserve funds collected the past quarter Century and redeemed by the government over the next 30 years are exhausted, that the outlays of Social Security must equal the payroll taxes in a given year (that is current law). The worst year is probably around 2045 or so, when this would mean that around 80% of the promised benefits would be paid out in that year, when I will be 77 if still alive, so this is not theoretical for me! So, the default is a large benefit cut (but anyone saying there will be nothing when you retire etc. either doesn't know what they are talking about or is being purposefully misleading).
- If we have a Social Security fix, I am imagining it to be more of a 'lets hold hands and jump together' type of fix coming out of the Deficit Commission, and not a long protracted 'war'. This would seem to come relatively quickly or not at all. This is what I mean by we need momentum around the Deficit Commission....make some compromises and find some solutions, holds hands and jump and then fight it out over health care (implement v. repeal, how to amend and improve, etc).
- The next step in addressing Medicare cost inflation is to implement PPACA, and especially the IPAB. Culturally, we need to begin asking the following questions in Medicare (and the rest of the system). Does it improve quality of life? Does it extend life? If no to both questions, we need to ask, why again are we doing it? And regardless of the answer to these questions, how much does it cost? There is obviously uncertainty in answering these questions, and mistakes will be made, but we must start asking them, and move to use the answers to make policy. The IPAB is a first step to all of this. I am not sure of the calculus of how we eventually use the answers to these questions to make policy both in Medicare and private insurance; we will have to work that out and it will take time. This is a cultural issue as much as a health policy one: will we grow up and learn to talk thoughtfully about limits and then make some practical decisions? I am rambling....my point is that we won't crack these profound health policy questions this year (or even this decade), but we could shore up Social Security this year.
- Any changes/alterations to PPACA that address cost inflation should be seriously considered and supported. The big enchilada is changing the tax treatment of employer paid insurance. Interestingly, I believe every single Republican member of the Deficit Commission has at one point or another favored eliminating the tax exclusion of employer paid insurance. This is what made their (Republicans, generally) opposition to the tax on high cost health insurance so preposterous, which of course in a roundabout way accomplishes the same thing. And of course the President pushed for this, obviously over the wishes of organized labor a key Democratic Party constituency. The tax was delayed until 2018 and the trigger level made to apply only to policies over $27,000 in value I believe (for families). The fact that this tax on high cost insurance remained in the final legislation is in my opinion, the least reported 'big deal' of PPACA. The delay and increase in trigger point was in the reconciliation bill, which of course expires in 10 years. Inside the Senate bill is a tax with a lower threshold level that is being updated at 1 point above CPI that will come into force in a decade, and will apply to a good number of policies since health care cost inflation is going up lots faster than 1 point above CPI. The pay-for to get rid of it (repeal it in 10 years) will be very large. So, the tax treatment of employer paid insurance is likely going to change in a decade or so one way or another. That is one of the best aspects of long range PPACA in terms of cost control. I would rather cap the tax exclusion in a straightforward manner and at a lower level, much sooner.
- Austin's comment about lack of momentum after PPACA casting doubt about my notion that a Social Security fix could add momentum for general policy movement is a fair point....I am an optimistic person. And I keep thinking that at some point the seriousness of the issue facing our nation will mean that the grown ups will rise up and work things out.....
- I think this is a bad idea, because it undermines Social Security as a Social Insurance program. A payroll tax is regressive, which means that for 83% of the US population, 100% of their wages are subject to the OASDI tax; for someone with $1 Million in wages, only 11% of their wages are subjected to the tax. It is the opposite of our income tax structure that is progressive. However, having a payroll tax be a first-dollar tax also means that each person with wages chips in something to Social Security (and also Medicare). And while it is true that Social Security has a redistributionist aspect (floor below which no one can fall; non retirement protection such as survivor benefits); it is also true that your wage history (what you paid in) is important in setting your retirement benefit level. I don't think that it is romantic to be poor, but it is the case that even someone with very low wages today has contributed something to Social Security, and I think that provides them with a measure of dignity, and helps explain the high level of support for the program: everyone contributes, everyone benefits.