A new online publication launched this week called the Fiscal Times (a million laughs, I know). But, it has some interesting stuff, including the first of a 5-part series on the cost of care at the end of life. I talked with the author about his series and some of my research that shows that hospice saves Medicare money while improving quality of life (there aren't so many examples of this dual occurrence).
Other interesting items include this one on tax expenditures in the federal budget such as the exclusion of employer paid insurance premiums from income, an article on bipartisan indifference to slowing health care cost inflation, a profile of Paul Ryan, and lots of other stuff.
It appears to have a variety of voices/views with columnsts/bloggers ranging from Cato Institute types to former Gore staffers. Check it out.
Wednesday, March 3, 2010
President's Speech
Has just been completed....I watched as I cleaned my office. This is the first time I have heard him couch the proposal in terms of the wide variation of possibilites: on the left a 'gov't run health care system' and on the right a 'reduction of regulation in the hopes that things would improve' and placing 'his proposal' in the center. In policy terms, the Senate bill is quite center and he invoked the notion of building on the current system.
Update: here is text.
The only other thing that caught my ear was his saying something along the lines of 'the cost of our approach is about $100 Billion per year but it is paid for primarily from within the system because much of what we spend in non productive.' Something like that....I can't find the text yet. I was thinking, 'thanks for the set up Sen. Coburn' on that one. As I wrote last week, the most puzzling part of the Summit for me was Sen. Coburn absolutely hammering away that one in three dollars spent on health care is non-productive, which actually helps make the case for financing coverage expansions via Medicare cuts.
I thought the President was also effective at asking for an up or down vote on health care. This is of course laying the stage for a clean up bill after the House passes the Senate bill. I found him persuasive. Someone who thinks all of this is a socialist plot will not. The question is what will folks in the middle think? I really don't know.
Finally, I thought his statement that he wasn't sure of how the politics of this work out, but that he thinks that it is the right thing to do at this time regardless of the politics. Amen.
Update: interesting article focusing not only on the politics and policy of health reform but the need to explain/make the case to skeptics and what reform says about first year of Obama presidency.
Update: here is text.
The only other thing that caught my ear was his saying something along the lines of 'the cost of our approach is about $100 Billion per year but it is paid for primarily from within the system because much of what we spend in non productive.' Something like that....I can't find the text yet. I was thinking, 'thanks for the set up Sen. Coburn' on that one. As I wrote last week, the most puzzling part of the Summit for me was Sen. Coburn absolutely hammering away that one in three dollars spent on health care is non-productive, which actually helps make the case for financing coverage expansions via Medicare cuts.
I thought the President was also effective at asking for an up or down vote on health care. This is of course laying the stage for a clean up bill after the House passes the Senate bill. I found him persuasive. Someone who thinks all of this is a socialist plot will not. The question is what will folks in the middle think? I really don't know.
Finally, I thought his statement that he wasn't sure of how the politics of this work out, but that he thinks that it is the right thing to do at this time regardless of the politics. Amen.
Update: interesting article focusing not only on the politics and policy of health reform but the need to explain/make the case to skeptics and what reform says about first year of Obama presidency.
The Definition of a Republican
is the main thing that has changed since 1993-94 when the main Republican alternative to the Clinton plan was an individual mandate, setting up a private market, income based subsidies to help persons purchase cover, and national regulation of what insurance covered. This according to Dave Durenberger, a Republican Senator from Minnesota, back in the day in an interesting interview with Kaiser Health News about a week ago. I wrote this back in October on this issue.
As this health reform discussion comes to a conclusion one way or another, I think the big picture of what has happened is this. As the policy details of reform moved center, the rhetoric in opposition moved toward the apocalyptic. Has there been a true change in what Republicans/Conservatives think on reform? Or was this just blocking President Obama? Time will tell.
As this health reform discussion comes to a conclusion one way or another, I think the big picture of what has happened is this. As the policy details of reform moved center, the rhetoric in opposition moved toward the apocalyptic. Has there been a true change in what Republicans/Conservatives think on reform? Or was this just blocking President Obama? Time will tell.
Fundamental difference
As the reform discussion has waxed and waned, different arguments against the Senate bill framework (individual mandate, set up private market for uninsured to buy in) have been in vogue. I think the most fundamental objection at the end of the process is that an individual mandate limits personal freedom. Of course it does, just as every law ever passed does. You have to decide if the limit of freedom is worth it.
The most popular aspect of the Senate bill is the ban on pre-existing conditions and ending recission (denying cover after someone gets ill due to say there was a pre-existing condition that wasn't disclosed). The individual mandate and the insurance reforms go together. And the general approach of reform normatively assumes that everyone should be covered. This assumption could be based on some notion or morality, or could be more practical. If the uninsured get care eventually, we might as well cover them in a more straightfoward manner. I believe the only way to ever have a hope of controlling the rate of cost inflation is to first cover everyone and end the cost shifting. There are a variety of reasons in this vein.
Republican opposition to a mandate based on limits to freedom is a coherent argument, meaning you could believe such a mandate is a limit of freedom (of course it is, just like every other law), and that this limitation is not worth it. Fine. You will never get to anything near universal coverage without a mandate of some sort, but you could decide freedom was more important than universal coverage.
But this logic should then lead to a denial of care to persons who are uninsured. With freedom comes responsibility. If you are free from having to purchase insurance, shouldn't I be free from having to pay for you if you are not covered? Republicans aren't quite ready to go this far, at least not many of them or those who have to get elected. The hardest thing for them politically is how to appeal to the fact that even persons who don't like mandates like bans of pre-existing conditions. The Republican answer is high risk pools. If you took Republican opposition at their word, you could say their policy is to be opposed to mandates on freedom grounds. But, to say those who are uninsured/uninsurable due to health conditions are worthy of being helped, and their preferred method is high risk pools. This implies a sort of 'freedom with a net' approach in which some are worthy of extra help depending upon the reason they find themselves uninsured.
The biggest problem with high risk pools comes from the basics of insurance. The best way to deal with risk is to aggregate as much risk together in one pool in order to spread/share the risk. High risk pools do the opposite, and put the sickest worst risks together. Even adding more cases of high risk to a high risk pool is not likely to reduce the premiums because risk pooling of anything (health, car, homeowners) works because the healthy (or those who don't crash) subsidize those who are sick (and do crash). Here is a useful entry about the inevitable problems is high risk pools (30 states have them now). They are not only chronically underfunded, but they likely also serve as adverse selection magnets as people forego and wait until they get sick.
It is useful sometimes to pull back from the gory details and think about what you think.
The most popular aspect of the Senate bill is the ban on pre-existing conditions and ending recission (denying cover after someone gets ill due to say there was a pre-existing condition that wasn't disclosed). The individual mandate and the insurance reforms go together. And the general approach of reform normatively assumes that everyone should be covered. This assumption could be based on some notion or morality, or could be more practical. If the uninsured get care eventually, we might as well cover them in a more straightfoward manner. I believe the only way to ever have a hope of controlling the rate of cost inflation is to first cover everyone and end the cost shifting. There are a variety of reasons in this vein.
Republican opposition to a mandate based on limits to freedom is a coherent argument, meaning you could believe such a mandate is a limit of freedom (of course it is, just like every other law), and that this limitation is not worth it. Fine. You will never get to anything near universal coverage without a mandate of some sort, but you could decide freedom was more important than universal coverage.
But this logic should then lead to a denial of care to persons who are uninsured. With freedom comes responsibility. If you are free from having to purchase insurance, shouldn't I be free from having to pay for you if you are not covered? Republicans aren't quite ready to go this far, at least not many of them or those who have to get elected. The hardest thing for them politically is how to appeal to the fact that even persons who don't like mandates like bans of pre-existing conditions. The Republican answer is high risk pools. If you took Republican opposition at their word, you could say their policy is to be opposed to mandates on freedom grounds. But, to say those who are uninsured/uninsurable due to health conditions are worthy of being helped, and their preferred method is high risk pools. This implies a sort of 'freedom with a net' approach in which some are worthy of extra help depending upon the reason they find themselves uninsured.
The biggest problem with high risk pools comes from the basics of insurance. The best way to deal with risk is to aggregate as much risk together in one pool in order to spread/share the risk. High risk pools do the opposite, and put the sickest worst risks together. Even adding more cases of high risk to a high risk pool is not likely to reduce the premiums because risk pooling of anything (health, car, homeowners) works because the healthy (or those who don't crash) subsidize those who are sick (and do crash). Here is a useful entry about the inevitable problems is high risk pools (30 states have them now). They are not only chronically underfunded, but they likely also serve as adverse selection magnets as people forego and wait until they get sick.
It is useful sometimes to pull back from the gory details and think about what you think.
Tuesday, March 2, 2010
Conrad and Reconciliation
Ezra Klein with interview of Sen. Conrad, chair of budget committee on reconciliation, and what he did and did not say.
President Obama's Next Step
The White House released a letter this afternoon identifying several Republican ideas that they seem to be willing to add to the President's proposal. The text, released on the White House blog is here. The President had been set to make a speech or statement regarding the way forward sometime tomorrow. It is not clear, but this could imply there have been some discussions with select Republican on different ideas, and this letter is one last chance to stimulate some final negotiation/agreements on add ons.
The items highlighted in the letter are noted in terms of Republican ideas that he is open to, or adopting. They include:
(1) Senator Coburn's waste, fraud and abuse notion of undercover 'stings' on doctors and providers. The President notes that his document of last week adopted several Republican proposals on waste, fraud and abuse, which is correct.
(2) Increasing money to states for medical malpractice demonstrations....the Pres notes his proposal has $23 Million for grants to states for medical courts, and today says he will appropriate $50 Million more toward this. He places this all in the context of agreeing with/adopting provisions of the Patients' Choice Act (PCA) which Sen Coburn and Burr and Rep. Ryan and Nunes sponsored. While I expect many will say this is not that much or not enough, it is the case that it is in line with the PCA, the most comprehensive Republican alternative. In many ways, the most puzzling aspect of the PCA was that it didn't propose more on medical malpractice. The appropriation lanugage v. authoriziation means guaranteeing these demonstration grants will be funded.
(3) Says he is open to Sen. Grassley's suggestion/worry that if expanding Medicaid by 15 Million persons, need to expand physician payment for Medicaid in a way that will make it more attractive for doctors to treat Medicaid beneficiaries.
(4) Says he is open to including language that will ensure that high-deductible plans are able to be offered in exchanges per Sen. Barrasso's comments at the summit about catastrophic coverage. The Pres says he thinks they are now allowed, but willing to clarify. This is the biggest of the developments here (more on that below).
(5) Says he will include language to end the Florida Medicare Advantage deal that Sen. McCain pointed out at the Summit. In addition, he already had included an end to the special deal for Nebraska Medicaid.
The biggest deal is #4. If there is a move to make clearer or easier a route to high deductible plans, then such plans may plausibly be more palatable to younger persons, the persons that might be most likely to not follow an employer mandate. As I noted in my last News and Observer column, a move to let an individual mandate only apply for catastrophic cover would be the likely direction of an actual negotiation on policy terms between the Senate bill and the Patients' Choice Act, for example. There is not really any evidence such a negotiation is underway behind the scences. However, moves toward making a high deductible plan more readily available in exchanges could help entice younger, healthier individuals act on an individual mandate.
The President also clearly stakes out his position that 'piecemeal reform' is not the best way forward. This stands in contrast with Sen. Alexander's notion at the summit that we don't do comprehensive well.
Next step is the President laying out the way forward, presumably tomorrow. Then, can the House find 216 votes to pass the Senate bill? At this point, based on how members of the House voted in November on the House bill, they should be 1 vote short. 220 voted yea (1 Republican, Cao who says he will vote no; Murtha died; 3 Dems who voted yes have resigned to run for other offices since) so based on how they voted in November, that is 215 for, 216 against.
The President and the Speaker have to find 1 Democrat to change their vote yes, while maintaining all those who voted yes in November. Leading candidates to switch would be 3 retiring Democrats, and Dennis Kucinich, who is a single payer guy and voted no because the House bill didn't do enough....and in his terms, the Senate bill does even less (no public option, etc). Does he prefer the status quo to the Senate bill? We will see.
Any blue dog who voted yes in November will get the full monty on being a socialist, wanting to kill your grandmother, hating America, etc. based on that vote....if they switch to no they will also get 'he was for it before I was against it' and will generally be (rightfully) understood to be wusses (this is a technical term). And the Senate bill should be much more to their liking in any event as it is more center than the House bill. So, I think those who voted yes should hold.
There are, of course the 14 Dems who voted yes and linked their vote to the Stupak abortion language. I have no idea how that plays out. I have never gotten Stupak as an actual health policy consideration, since using the logic of Stupak means that the federal government has been subsidizing abortion via the tax exclusion of employer paid insurance if one woman has had an abortion paid for by employer sponsored insurance since Roe v. Wade came into effect. I have always assumed these folks were a mixture of people who wanted to kill reform but have an excuse and/or folks who thought this was a way to advance their advocacy of their abortion position. To the extent these folks are more conservative than average in the Dem caucus, they should like the Senate bill more than the House bill.
The morning of the state of the Union, I said 5% chance of a comprehensive bill when making the case for the Senate bill. Today, I say the chance is better, because of the belief that the President can convince 1 Democrat to change. However, I am not sure of how the abortion language plays out...that is the real wild card, and the way this all goes down if it does.
Update: 8:55pm: I heard a radio report with the AP saying there are 10 Dems who voted no on the House bill in November who are considering/open to voting yes on the Senate bill. It would seem very likely 1 of these will change.....but the 14 Stupak abortion votes remain the wild card.
The items highlighted in the letter are noted in terms of Republican ideas that he is open to, or adopting. They include:
(1) Senator Coburn's waste, fraud and abuse notion of undercover 'stings' on doctors and providers. The President notes that his document of last week adopted several Republican proposals on waste, fraud and abuse, which is correct.
(2) Increasing money to states for medical malpractice demonstrations....the Pres notes his proposal has $23 Million for grants to states for medical courts, and today says he will appropriate $50 Million more toward this. He places this all in the context of agreeing with/adopting provisions of the Patients' Choice Act (PCA) which Sen Coburn and Burr and Rep. Ryan and Nunes sponsored. While I expect many will say this is not that much or not enough, it is the case that it is in line with the PCA, the most comprehensive Republican alternative. In many ways, the most puzzling aspect of the PCA was that it didn't propose more on medical malpractice. The appropriation lanugage v. authoriziation means guaranteeing these demonstration grants will be funded.
(3) Says he is open to Sen. Grassley's suggestion/worry that if expanding Medicaid by 15 Million persons, need to expand physician payment for Medicaid in a way that will make it more attractive for doctors to treat Medicaid beneficiaries.
(4) Says he is open to including language that will ensure that high-deductible plans are able to be offered in exchanges per Sen. Barrasso's comments at the summit about catastrophic coverage. The Pres says he thinks they are now allowed, but willing to clarify. This is the biggest of the developments here (more on that below).
(5) Says he will include language to end the Florida Medicare Advantage deal that Sen. McCain pointed out at the Summit. In addition, he already had included an end to the special deal for Nebraska Medicaid.
The biggest deal is #4. If there is a move to make clearer or easier a route to high deductible plans, then such plans may plausibly be more palatable to younger persons, the persons that might be most likely to not follow an employer mandate. As I noted in my last News and Observer column, a move to let an individual mandate only apply for catastrophic cover would be the likely direction of an actual negotiation on policy terms between the Senate bill and the Patients' Choice Act, for example. There is not really any evidence such a negotiation is underway behind the scences. However, moves toward making a high deductible plan more readily available in exchanges could help entice younger, healthier individuals act on an individual mandate.
The President also clearly stakes out his position that 'piecemeal reform' is not the best way forward. This stands in contrast with Sen. Alexander's notion at the summit that we don't do comprehensive well.
Next step is the President laying out the way forward, presumably tomorrow. Then, can the House find 216 votes to pass the Senate bill? At this point, based on how members of the House voted in November on the House bill, they should be 1 vote short. 220 voted yea (1 Republican, Cao who says he will vote no; Murtha died; 3 Dems who voted yes have resigned to run for other offices since) so based on how they voted in November, that is 215 for, 216 against.
The President and the Speaker have to find 1 Democrat to change their vote yes, while maintaining all those who voted yes in November. Leading candidates to switch would be 3 retiring Democrats, and Dennis Kucinich, who is a single payer guy and voted no because the House bill didn't do enough....and in his terms, the Senate bill does even less (no public option, etc). Does he prefer the status quo to the Senate bill? We will see.
Any blue dog who voted yes in November will get the full monty on being a socialist, wanting to kill your grandmother, hating America, etc. based on that vote....if they switch to no they will also get 'he was for it before I was against it' and will generally be (rightfully) understood to be wusses (this is a technical term). And the Senate bill should be much more to their liking in any event as it is more center than the House bill. So, I think those who voted yes should hold.
There are, of course the 14 Dems who voted yes and linked their vote to the Stupak abortion language. I have no idea how that plays out. I have never gotten Stupak as an actual health policy consideration, since using the logic of Stupak means that the federal government has been subsidizing abortion via the tax exclusion of employer paid insurance if one woman has had an abortion paid for by employer sponsored insurance since Roe v. Wade came into effect. I have always assumed these folks were a mixture of people who wanted to kill reform but have an excuse and/or folks who thought this was a way to advance their advocacy of their abortion position. To the extent these folks are more conservative than average in the Dem caucus, they should like the Senate bill more than the House bill.
The morning of the state of the Union, I said 5% chance of a comprehensive bill when making the case for the Senate bill. Today, I say the chance is better, because of the belief that the President can convince 1 Democrat to change. However, I am not sure of how the abortion language plays out...that is the real wild card, and the way this all goes down if it does.
Update: 8:55pm: I heard a radio report with the AP saying there are 10 Dems who voted no on the House bill in November who are considering/open to voting yes on the Senate bill. It would seem very likely 1 of these will change.....but the 14 Stupak abortion votes remain the wild card.
Monday, March 1, 2010
Excise tax and process
I understand the only way to pass a comprehensive reform this year to be for the House to pass the bill passed by the Senate on Christmas Eve. It will take 1 roll call vote to enact this into law (assuming the President signs it). This does not involve reconciliation.
Reconciliation would come into play to enact modifications to the Senate bill, essentially along the lines of the agreement that was emerging between the House and the Senate when Scott Brown's election took place in mid-January. For example, ending the Nebrasksa Medicaid deal had been agreed to by House and Senate leaders back in early January, and a deal to allow the tax on high cost insurance start later for labor Union health plans leaked out. This was basically undoing one deal that people hated, but creating another.
The Senate bill has been preferred by the President for some time, and it was functioning as the de facto starting point for House/Senate negotiations in early January. And the President clearly preferenced the Senate bill last week in the brief document he put out that listed a variety of tweaks to the Senate bill. Among them, ending the Nebraska Medicaid deal, adding some Republican ideas in the area of fraud and abuse, but also undoing the deal the preferenced labor Union insurance policies. But, in doing so, he proposed delaying the imposition of the tax on high cost health insurance for all plans until 2018 and raising the value at which the tax applies. This did away with the political problem of favoring unions, but also delayed one of the key aspects of the bill with promise to slow the rate of cost inflation.
In short, the tax on high cost plans has been delayed and the level at which it will be imposed has been raised (meaning fewer policies will be subject to the tax n 2018). This is not good from a cost saving standpoint, but I think that some are overstating the proof that this means such provisions will never come about. This is my take of how it would go.
First, the House passes the Senate bill and it is law. There is no reconciliation and therefore no sunsetting (provisions end after 10 years; this is why Bush tax cuts go away as default, because they were passed via reconciliation). Under the Senate bill, the tax on high cost insurance starts in 2014. The threshold is $24,000 for a family plan. It is indexed at 1 percentage point above the CPI, meaning much slower than actual health care inflation. Thus, over time, more and more policies will run up against this limit.
Second, a reconciliation bill will be passed that among other things, delays imposition of this tax until 2018 and with a higher value for the tax to apply.
Third, in 10 years, the reconciliation piece and provisions sunset, meaning, go away, cease to exist. The Senate bill, does not. And the tax of $24,000 will have been indexed at 1 percentage point above CPI for 10 years. This tax on high cost insurance will then be in effect, beginning Jan. 1, 2021. We don't know what the value that will trigger the tax will be, because we don't know what inflation will be over the next decade.
Fourth, Congress could pass a new law to do away with the tax on high cost insurance (say in 2020), but in doing so will presumably have to come up with 'pay fors' to offset the revenue that the CBO will say is going to be lost from the imposition of this tax. Read this as something else will have to go from somewhere, and it will be a lot of money.
So, I would prefer to not delay the imposition of the tax. In fact, I would prefer to just severely limit and move toward completely ending the tax exclusion of employer paid insurance, but something that radical would certainly take Republicans and Democrats working together and that seems impossible right now. However, folks saying the effect of the tax on high cost insurance is now essentially completely gone, I think, are incorrect. It is certainly delayed.
In one sense, this could be viewed as conceptually similar to many of the provisions that Rep. Paul Ryan (R-WI) has proposed for Medicare. There is essentially a 10 year warning that says come 10 years from now, things are really going to change. In the same way, 10 years from now a tax on high cost health insurance with a pretty big punch (meaning 40% rate on excess amount, with more and more policies above this limit because of how it is indexed) is coming on line. The point of this tax is to be avoided by folks with insurance having less insurance. The way you avoid it is to have less generous insuarance, which will slow cost inflation. So, this lead time could induce some of this of behavior in the private market as employers and employees negotiate around wages/benefit tradeoffs differently as we approach 2021 because of the coming of this tax. In this way, even the delayed tax could have more impact on cost savings in the first 10 years of the bill than most are saying.
Reconciliation would come into play to enact modifications to the Senate bill, essentially along the lines of the agreement that was emerging between the House and the Senate when Scott Brown's election took place in mid-January. For example, ending the Nebrasksa Medicaid deal had been agreed to by House and Senate leaders back in early January, and a deal to allow the tax on high cost insurance start later for labor Union health plans leaked out. This was basically undoing one deal that people hated, but creating another.
The Senate bill has been preferred by the President for some time, and it was functioning as the de facto starting point for House/Senate negotiations in early January. And the President clearly preferenced the Senate bill last week in the brief document he put out that listed a variety of tweaks to the Senate bill. Among them, ending the Nebraska Medicaid deal, adding some Republican ideas in the area of fraud and abuse, but also undoing the deal the preferenced labor Union insurance policies. But, in doing so, he proposed delaying the imposition of the tax on high cost health insurance for all plans until 2018 and raising the value at which the tax applies. This did away with the political problem of favoring unions, but also delayed one of the key aspects of the bill with promise to slow the rate of cost inflation.
In short, the tax on high cost plans has been delayed and the level at which it will be imposed has been raised (meaning fewer policies will be subject to the tax n 2018). This is not good from a cost saving standpoint, but I think that some are overstating the proof that this means such provisions will never come about. This is my take of how it would go.
First, the House passes the Senate bill and it is law. There is no reconciliation and therefore no sunsetting (provisions end after 10 years; this is why Bush tax cuts go away as default, because they were passed via reconciliation). Under the Senate bill, the tax on high cost insurance starts in 2014. The threshold is $24,000 for a family plan. It is indexed at 1 percentage point above the CPI, meaning much slower than actual health care inflation. Thus, over time, more and more policies will run up against this limit.
Second, a reconciliation bill will be passed that among other things, delays imposition of this tax until 2018 and with a higher value for the tax to apply.
Third, in 10 years, the reconciliation piece and provisions sunset, meaning, go away, cease to exist. The Senate bill, does not. And the tax of $24,000 will have been indexed at 1 percentage point above CPI for 10 years. This tax on high cost insurance will then be in effect, beginning Jan. 1, 2021. We don't know what the value that will trigger the tax will be, because we don't know what inflation will be over the next decade.
Fourth, Congress could pass a new law to do away with the tax on high cost insurance (say in 2020), but in doing so will presumably have to come up with 'pay fors' to offset the revenue that the CBO will say is going to be lost from the imposition of this tax. Read this as something else will have to go from somewhere, and it will be a lot of money.
So, I would prefer to not delay the imposition of the tax. In fact, I would prefer to just severely limit and move toward completely ending the tax exclusion of employer paid insurance, but something that radical would certainly take Republicans and Democrats working together and that seems impossible right now. However, folks saying the effect of the tax on high cost insurance is now essentially completely gone, I think, are incorrect. It is certainly delayed.
In one sense, this could be viewed as conceptually similar to many of the provisions that Rep. Paul Ryan (R-WI) has proposed for Medicare. There is essentially a 10 year warning that says come 10 years from now, things are really going to change. In the same way, 10 years from now a tax on high cost health insurance with a pretty big punch (meaning 40% rate on excess amount, with more and more policies above this limit because of how it is indexed) is coming on line. The point of this tax is to be avoided by folks with insurance having less insurance. The way you avoid it is to have less generous insuarance, which will slow cost inflation. So, this lead time could induce some of this of behavior in the private market as employers and employees negotiate around wages/benefit tradeoffs differently as we approach 2021 because of the coming of this tax. In this way, even the delayed tax could have more impact on cost savings in the first 10 years of the bill than most are saying.
Subscribe to:
Posts (Atom)