(By Donald Marron) Last week I argued that budgeting for Medicare's hospital insurance program is flawed. Today, I offer two ways to fix it (and reject a third).
Medicare Part A is one of several federal programs that control spending through a "belt and suspenders" combination of regular program rules (the belt) and an overall limit (the suspenders). But it's the only one that allows legislated savings to offset the costs of policy changes in other programs and extend the time before the overall limit constrains operations.
Congress can't increase Social Security payroll taxes to pay for increased health care spending or reduce flood insurance subsidies to pay for tax cuts; in both cases, the resources stay within the affected programs. And when it cuts spending on Medicare Parts B and D to pay for other spending, no one claims those cuts will also postpone the day when trust fund exhaustion will disrupt their operations.
Such double counting is possible only in Medicare Part A. And it's a real problem, creating needless confusion and reinforcing the sense that Washington plays fast and loose with budget numbers.
Happily, Congress knows how to fix this problem. All it needs to do is apply to Medicare A the practices used by one of the other programs that have "belt and suspenders" budgeting but avoid potential double counting.
One approach would be the rules used by the National Flood Insurance Program. As I discussed in more detail last week, those rules require that any legislated savings remain in the program. Lawmakers can't reduce NFIP subsidies to pay for new spending in other programs. Instead, any savings are automatically earmarked to pay future NFIP claims that would go unpaid because of the program's borrowing limit. (For an example, see here.)
This approach brings the overall limit explicitly into the budget. But it makes for weird budgeting. For example, the budget baseline would show Medicare A breaking even over the long run, since the trust fund limit would take precedence over its fundamental deficits.
A better approach would adopt the rules used by Social Security. Those rules show Social Security running deficits far into the future in the budget baseline, but they still take the trust fund seriously when examining new legislation. Any proposed cuts to the program's spending or increases in its revenues are "off budget". The Congressional Budget Office reports them, but Congress can't use them to pay for other spending.