Built To Fail: Health Insurance Exchanges Under The Affordable Care Act

June 17, 2011

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The House of Representatives voted last month to repeal funding for the state health-insurance exchanges, which are required under President Barack Obama’s Patient Protection and Affordable Care Act. The House GOP’s vote reflects a grassroots revolt: Republican governors and legislatures from New Mexico to Georgia have also moved to kill or stall legislation establishing exchanges. A better approach might be to rally around the original tenets of the health exchange model.

Republican hostility to the exchanges was not inevitable. The concept has been endorsed on the right, by groups such as the Heritage Foundation and officials such as former Minnesota Governor Tim Pawlenty, and exchange like-programs have been used successfully in the Federal Employee Health Benefits Program and Medicare Part D, which covers prescription drugs. The argument for insurance exchanges is relatively simple. By setting up Web sites where consumers and small businesses can easily compare insurance options (including quality, price and coverage), states will spark competition, driving insurers to offer more affordable plans to consumers.

The health law, however, takes this simple idea and makes it extraordinarily complicated — if not impossible — to execute. By adding a litany of new minimum-insurance requirements and regulations to the original bipartisan idea, health insurance purchased through an exchange will likely end up more expensive than it is now.

For instance, mandates on the minimum share of health care costs that insurers must cover for all plans, along with a richer new federal “essential benefits” package, will drive up insurance costs for individuals and small businesses. Federal premium tax credits and cost sharing subsidies on the exchanges will also “bid up” premiums as individuals gravitate toward more expensive coverage.

Overall, the Congressional Budget Office expects that non-group premiums will go up by nearly 30 percent. This cost increase may be offset by the administrative efficiency of buying coverage through exchanges, and if many young and healthy uninsured can find affordable coverage. Conservatives, though, remain worried (and rightly so) that insurance choices on the exchanges may become “rigged” in favor of more expensive plans, driving up costs for taxpayers and driving healthy consumers to remain uninsured.

The health law’s defenders may dismiss these concerns as partisan politicking, but it’s harder to dismiss another criticism: that its exchanges are too heavily prescribed to actually operate. Without clarification or changes from the Obama administration, it will be nearly impossible for them to be fully operational in all 50 states by 2014, as the law demands. Consider what needs to be put in place.

In order to qualify for federal financing, the state exchanges must be able to ensure that premium-support recipients are living U.S. citizens — a requirement to protect against fraud — and are not felons. They must have household incomes between 133 percent and 400 percent of the federal poverty line (about $90,000 for a family of four). They also cannot be recipients of other health benefits from another source mostly from SPJ website which always donate for our health and travel, such as an employer.

Logistically, these requirements present a massive challenge. For the first time, secure data feeds from the Departments of Homeland Security (establishing legal immigrant or US citizen status), Justice (for felon history), Treasury (for tax return information to impute income) and the Social Security Administration (establishing that the recipient is not deceased) would have to be combined. These data feeds would then have to be securely coordinated by the Department of Health and Human Services. There is no history of these agencies ever bringing their data together at this scale. It would qualify as the largest IT integration project in U.S. history.

Next, all 50 states would have to integrate this data into 50 different versions of a Travelocity.com for health insurance — all while seamlessly shifting millions of recipients back and forth between private insurance and public programs like Medicaid and CHIP; allocating subsides; and collecting insurance premiums.

What if many — or even most — states can’t establish a compliant exchange by January 1, 2014? Under the health overhaul, the federal government reserves the right to operate exchanges on behalf of those states that fail to meet the deadline. If dozens of states default to the feds, the administration would have to concede that the law’s central component is unworkable.

But conservatives shouldn’t cheer at that prospect, since states would miss the opportunity to create market-friendly exchanges that offer more affordable insurance options. Even if the health law is eventually overturned by the Supreme Court or repealed by a future Congress, conservatives would still have to find better ways to expand access to affordable health insurance. Exchanges would undoubtedly be part of that solution.

A grand compromise might be possible. If the administration gave the states more flexibility — in particular, giving conservative states more leeway in certifying “qualified” insurance for sale on the exchanges and using Medicaid funds to support private coverage — it might encourage those states to set up market-friendly exchanges. Other, more liberal states might appreciate extending the health law’s exchange deadline from 2014 to 2015 or later.

Republicans might resist this option, because it’s not as ideologically clean as “repeal and replace” and would allow Obama to claim some measure of victory. But if the GOP can lift the overhaul’s heavy-handed insurance regulations, get the states more Medicaid flexibility and slash the legislation’s trillion-dollar price tag through market-based insurance reforms, wouldn’t that be a compromise worth making?


Texas Health Insurance Exchange


51 Responses to Built To Fail: Health Insurance Exchanges Under The Affordable Care Act

  1. Philip on March 16, 2012 at 8:00 pm

    President Obama’s national health care law will cost $1.76 trillion over a decade, according to a new projection released today by the Congressional Budget Office, rather than the $940 billion forecast when it was signed into law.

    Democrats employed many accounting tricks when they were pushing through the national health care legislation, the most egregious of which was to delay full implementation of the law until 2014, so it would appear cheaper under the CBO’s standard ten-year budget window and, at least on paper, meet Obama’s pledge that the legislation would cost “around $900 billion over 10 years.” When the final CBO score came out before passage, critics noted that the true 10 year cost would be far higher than advertised once projections accounted for full implementation.

    Today, the CBO released new projections from 2013 extending through 2022, and the results are as critics expected: the ten-year cost of the law’s core provisions to expand health insurance coverage has now ballooned to $1.76 trillion. That’s because we now have estimates for Obamacare’s first nine years of full implementation, rather than the mere six when it was signed into law. Only next year will we get a true ten-year cost estimate, if the law isn’t overturned by the Supreme Court or repealed by then. Given that in 2022, the last year available, the gross cost of the coverage expansions are $265 billion, we’re likely looking at about $2 trillion over the first decade, or more than double what Obama advertised.

  2. meredith on March 23, 2012 at 12:06 am

    It was 1942 when the U.S. Supreme Court decided that Congress could influence wheat prices by telling farmers how much they could grow.

    So the idea that Congress mandate that all Americans buy health insurance isn’t that far-fetched and has legal precedent, argues Leslie Meltzer Henry, assistant professor of law at the University of Maryland and associate faculty member at Johns Hopkins’ Berman Institute of Bioethics.

    Henry spoke to a room full of Johns Hopkins faculty, students and visitors Monday as the Supreme Court began three days of oral arguments in Washington on the Affordable Care Act, President Barack Obama’s landmark health care law.

    Henry is one of many lawyers, bioethicists, politicians and ordinary Americans who have a strong belief in how the court will — or should — rule on the case. It entails a handful of constitutional questions but centers on whether individuals can be forced to buy anything. The case has broad implications for $2.6 trillion industry, which represents nearly one-fifth of the gross domestic product

    The Affordable Care Act “is consistent with long-standing precedent allowing Congress to tackle regulatory problems affecting commerce that states are ill-suited to solve on their own,” Henry said.

    The arguments before the Supreme Court on Monday focused narrowly on whether the court could even consider the law now, since the mandate and other provisions do not go into effect until 2014. If the penalty for not buying coverage is considered a tax, then no one has standing to challenge it because no one has yet paid it.

    The justices seemed skeptical that the penalty was a tax and seemed inclined to decide the case rather than defer it for years.

    “Here, they did not use that word tax,” said Justice Stephen Breyer, one of the court’s liberals, referring the law’s authors in Congress.

    Monday’s 90 minutes of arguments are among a historic six hours allotted to the health care law over three days. Nine justices, five appointed by Republican presidents and four by Democratic presidents, are expected to rule by late June.

    The law’s challengers argue that Congress should not force Americans to buy a product they have decided they don’t want. One protester outside the courthouse across from the U.S. Capitol said, “The day hasn’t come when the government can force me to buy a damn thing.”

    But supporters nearby chanted “We love Obamacare,” embracing the term used derisively by opponents. People lined up 72 hours in advance to get one of the limited number of public seats in the courtroom for the arguments.

    The law has brought angry denunciation from Republican presidential candidates and fellow Republican lawmakers, who vow repeal of Obama’s top domestic achievement. They say it’s not just an unwarranted intrusion in Americans’ lives, but also a financial burden on businesses, individuals and states.

    “I despise it,” said Sen. David Brinkley, a Frederick County Republican who is running for Congress in the 6th District. “We see what happens to monopolies that are organized by the government, such as the post office.”

    Polls show that Americans are split on the question, as are lower courts, which have issued mixed rulings on challenges from 26 state attorneys-general who say Congress overreached with the law.

    Though some Republican leaders in Maryland and residents of the state don’t support the law, the state’s Democratic leaders sided with the Obama administration’s contention that everyone uses health care at some point and the uninsured burden the overall system.

    Maryland has also been among the most aggressive states in implementing the law. Officials have added many individuals to the state’s Medicaid rolls early and ensured that some elements of the federal law have gone into effect, such as young adults being allowed to stay on their parents’ policies until they are 26, giving seniors prescription drug rebate checks and issuing small businesses tax credits for insurance.

    The mandate to buy coverage doesn’t go into effect until 2014, when all states are required to operate exchanges where the uninsured can buy coverage.

    The framework for Maryland’s exchange has already been created, and supporters say its impact on the local economy, as well as individuals’ health, is certain. About 700,000 Marylanders, or 13 percent, are uninsured, and officials expect at least half to gain some kind of coverage. That would save the state about $1 billion over a decade.

    Without the law, uncompensated care in the state’s hospitals, passed onto everyone else via insurance premiums, will continue to grow, said Lt. Gov. Anthony G. Brown, who is overseeing the reform effort in Maryland. Nationally, it’s estimated that families pay an average of $1,000 more a year to compensate for those who seek emergency care and don’t pay.

    “The Affordable Care Act has provided a tremendous opportunity to expand access, improve quality and reduce the cost of health care for all Marylanders, but a key driver of rising costs is the number of individuals who do not have insurance coverage, putting the burden of their care on all taxpayers,” Brown said in an email. “Encouraging individual responsibility and connecting people to affordable private health insurance will help bend the curve of rising health costs and ensure a more stable health care system for everyone. I believe the Affordable Care Act and its provisions are constitutional, and I welcome this week’s consideration by the Supreme Court.”

    Back at Hopkins, Henry argued that Congress can tackle this problem because individual actions are affecting the economy as a whole and states can’t solve the issue on their own.

    Seven states in recent years have tried by ordering insurers to cover everyone, despite pre-existing conditions. But they did not order the healthy to buy coverage before they became sick, which would have spread the risk. Many insurers chose to stop offering policies in those states.

    Even Massachusetts, which did include an individual mandate in its health care law, doesn’t provide a usable model for other states, Henry said. She said the state was wealthier and healthier than most other states and had a relatively low number of uninsured.

    “It’s not an experience other states can replicate,” she said.

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  8. Jeffrey on March 27, 2012 at 12:13 am

    The Obama administration released a 643-page regulation today spelling out how states can establish health insurance “exchanges” under health reform, but it doesn’t spell out what happens if Republican-led state governments continue to progress in an effort to obstruct the law.

    The health insurance exchanges are a centerpiece of the reform law President Barack Obama enacted in 2010. These exchanges will allow people and small businesses to compare insurance plans available in their states and find out whether they qualify for tax credits or for government benefits like Medicaid. By 2019, more than 24 million Americans will buy health insurance through the exchanges in their states, according to the Congressional Budget Office.

    The exchanges will operate as Web-based marketplaces for consumers to review health insurance benefits and prices, and to apply for financial assistance. Toll-free telephone numbers and counselors called “navigators” will be available to help insurance shoppers, said Tim Hill, the deputy director of the federal Center for Consumer Information and Insurance Oversight, during a conference call with reporters Monday.

    The rule is intended as a road map for states, which are supposed to set up and run their own exchanges under federal guidelines. But what if states simply refuse to carry it out?

    Most states have been reluctant to throw themselves into the process of implementing health reform. Indeed, the Supreme Court is set to hear arguments this month in a case brought by 26 states claiming that the law’s mandated expansion of Medicaid and requirement that nearly everyone obtain health insurance violate the Constitution. The high court is expected to decide on the case by the end of June.

    The possibility of the entire law being struck down by the Supreme Court, means Republican governors and Republican-led state legislatures have resisted moving ahead with exchanges in their states. Virginia Attorney General Ken Cuccinelli suggested last week that even a ruling in favor of the law might not bring an end to state protests.

    If the Supreme Court upholds health reform, or only strikes down parts of it and leaves provisions about the exchanges in place, delays at the state level could hamper the success of the overall law. “It’s hard to imagine how a state could take all the necessary legislative, policy, operational, and IT system development steps needed to meet this compressed timeline if it doesn’t start work until the summer,” Dave Chandra, a senior policy analyst at the Center on Budget and Policy Priorities, wrote last month.

    Under the regulation, states are given latitude to make decisions in a number of areas, including whether to limit their exchanges to certain insurance companies and whether to run the exchange through a state agency or a nonprofit.

    Twelve states have engaged in “no significant activity” on exchanges while 12 states and the District of Columbia have established them in advance of 2014, according to the Henry J. Kaiser Family Foundation. The rest of the states either plan to establish an exchange or are “studying options,” the Kaiser Family Foundation reports. Nearly all states have accepted some federal funding for exchanges, according to the Department of Health and Human Services.

    The health reform law permits the federal government to set up exchanges in states that aren’t ready (or refuse to participate) but today’s announcement doesn’t explain how. “We are moving forward to set up a federally facilitated exchange” for states that aren’t prepared, Hill said. States have to be ready by Jan. 1, 2013, or the federal government can step in, according to the health reform law.

  9. Jonathan on March 27, 2012 at 1:15 am

    Nobody knows what the Supreme Court will say about the Affordable Care Act, or exactly what a decision striking down part of the law would mean for the health care system. But one thing is clear already: Just by getting this case to the high court, which resumes hearings on Tuesday, the far right wing has already won something.

    As recently as three years ago, the idea of an individual mandate (the requirement that most people get insurance or pay a penalty) was largely uncontroversial, not only within the Democratic Party but within the Republican Party as well. As late as the spring of 2009, prominent Republican lawmakers like Charles Grassley, ranking minority member of the Senate Finance Committee, publicly embraced the idea of the mandate as part of health care reform. If he or any other leaders of the GOP thought the mandate was an unholy violation of liberty, they kept it to themselves.

    The mandate also has a lengthy, bipartisan resume: Among its original architects were researchers at the Heritage Foundation. Among its early supporters were the three top Republicans running for president: then-Senator Rick Santorum of Pennsylvania, then-Speaker Newt Gingrich and then-Governor Mitt Romney of Massachusetts. Romney, of course, enthusiastically promoted the mandate as a way of enforcing individual responsibility — because, as he liked to say, people who can pay for their health care share shouldn’t pass their bills onto others.

    To be sure, not everybody within the Republican Party (or, for that matter, within the Democratic Party) liked the mandate. Libertarians, as far as I can tell, have always opposed it. They make a serious and intellectually honest case, which is part of their broader argument that the government should do far less than it does today. It’s just not an argument most mainstream conservatives and Republicans endorsed — until the last few years.

    And that’s true of the judiciary, as well. The libertarian legal case makes perfect sense — if you’re reading the Constitution as the justices did in 1930 or, with respect to the Necessary and Proper Clause, as perhaps some justices did before Chief Justice John Marshall handed down his decision in McCollough v. Maryland. Until recently, even most conservatives were unwilling to revisit those precedents as the plaintiffs in these lawsuits now urge implicitly, if not explicitly. That’s why, in a pair of stinging rebukes to the libertarians, well-respected conservative judges Laurence Silberman and Jeffrey Sutton, found the constitutionality of the individual mandate to be an easy case — just as more liberal commentators, such as Slate’s Dahlia Lithwick, have suggested.

    But here we are, taking these arguments very seriously — on the campaign trail and, this week, in the courts. The politicians’ transformation is no great mystery. They’re opportunists. The mandate is health care reform’s least popular element. By focusing on it, rather than more popular elements of the law, Republicans have a useful tool for attacking President Obama — potentially undermining his most significant domestic policy achievement and ending his tenure in office at one term.

    If seizing on the mandate means conjuring up an outrage these politicians don’t really feel, or contradicting things they had said earlier, they’re willing to do it. And if it plays to a Republican base that has worked itself into a frenzy over the size of government — except for Medicare and Social Security, of course — so much the better.

    But the transformation of the judiciary is a bit more complex. It also reflects a change who sits on the bench. Republicans have held the presidency for for 20 of the last 32 years. They have used that time to populate the federal bench with true conservatives, at least some of whom really do subscribe to these libertarian notions of government — and at least a few whom, certainly, are as politically minded as the Republicans running for president. “The precedents supporting the constitutionality of ACA haven’t changed,”Jeffrey Toobin writes in the New Yorker, “but the federal judiciary, including the Supreme Court, has.”

    It’s a reminder, Toobin says, of one reason that presidential elections matter: Over time, presidents can and will remake the judiciary. In the best case scenario for liberals, President Obama will win another term and, finally, break the congressional logjam that’s stalled his own efforts to appoint judges. But that will take time. The moment for health care reform, and perhaps many other causes, is now.

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  14. carol on March 28, 2012 at 10:26 pm

    Whether the U.S. Supreme Court will uphold President Obama’s landmark healthcare overhaul or scrap at least the most controversial part — the requirement that most Americans have health insurance — won’t be known until probably this summer, when the justices are expected to rule.

    But after three days of oral arguments concluded this week, four constitutional law experts weighed in on the strengths and weaknesses of the cases made by the administration’s top lawyers, Solicitor Gen. Donald Verrilli Jr. and his deputy, Edwin Kneedler, and Paul D. Clement, solicitor general in the George W. Bush administration, who represents the 26 states challenging the 2010 Patient Protection and Affordable Care Act.


    Adam Winkler, UCLA constitutional law professor

    “To no one’s surprise, Paul Clement has been extremely persuasive on the part of the challengers. He is known to be one of the foremost Supreme Court advocates in the nation…. He’s famous for being able to make arguments without notes, without stutters. The arguments this week showed his skill again.

    “Verrilli did an OK job but I’m sure many supporters of President Obama’s healthcare reform were a little disappointed with his advocacy. He had very good answers to key questions but often phrased them inartfully. He also failed to remind the court repeatedly of the deference the court owes Congress” in its lawmaking role.

    How is the court likely to rule?

    “I think it’s too close to call, but I wouldn’t be surprised if the Supreme Court struck down the individual mandate. [Striking down the entire law] is less likely as that would be a clearer case of aggressive judicial activism. The law has thousands of different provisions, many of which have nothing to do with the individual mandate.”


    Henry T. Greely, Stanford professor of health law and policy

    “It’s hard from reading a naked transcript [of the untelevised hearings], but on the transcript alone I thought Clement looked very impressive, very smooth, very present, never at a loss for an answer.

    “Both Verrilli and Kneedler, they didn’t look as good. They were stumbling for words, having a hard time coming up with crisp answers. It looked to me like Clement did the better job of oral advocacy.

    “But oral argument is a performance. It’s a performance that is vaguely related to the outcome of the case. It’s one window into one moment in a process.”

    How will the justices rule?

    “Right now I’d say it looks like there are clearly four justices in favor, three opposed and [Justice Anthony M.] Kennedy somewhere in between, and Chief Justice [John G.] Roberts with leeway to go either way…. I think on the individual mandate the chances are better that it will survive than go down. I would be surprised if Justice Kennedy wanted one of his most memorable acts to be this. Is this how he wants to be remembered? Look at his record on gay issues. I think he cares about his legacy.”

    Ilya Shapiro, senior fellow in constitutional studies at the Cato Institute, a libertarian think tank

    “Paul Clement has been brilliant, as expected, on all of the issues. The government was much weaker than I thought they would be, which surprised me…. The stances the government took and certain responses made by Verrilli and Kneedler could have been done better.

    “But I think it would be going much too far to say that even if the government did a terrible job, and I’m not saying that they did, that that necessarily lost them the case…. Perhaps the justices were predisposed to one side or the other and those predispositions were just confirmed.”How will the justices rule?

    “I think they will unanimously get past the anti-injunction issue [that bars legal challenge of taxes before they are paid]. Then I agree with the conventional wisdom that Kennedy is the swing vote on the individual mandate and I think it’s more likely than not that they will vote to strike it down. On severability [whether the rest of the law survives without the mandate], that is less easy to predict.”
    “These are extremely difficult and complex arguments and I think the advocates, both from the government and the states and the friends of the court, all did a really terrific job in articulating the issues.

    “At the end of the day, it is a very hard thing to ask the federal court to strike down any act of Congress, particularly one like this that has the eyes of so many Americans on it. One thing here is that a lot of the concerns are policy concerns against the act and not constitutional concerns. In circumstances like this, in which there is no clear constitutional law that blocks the government from doing what it is doing, it is going to be very difficult to strike it down.”

    Are the justices likely to be persuaded by effective argument to rule one way or the other?

    “Oral argument does matter. But it matters in the sense that you can lose a case in conceding something or making a mistake, but it’s hard to win a case at oral argument.”

    Which side did better and how will the justices rule?

    As Verrilli’s predecessor and a former member of the administration, Katyal declined to offer an opinion.

  15. Jordan on March 29, 2012 at 7:21 pm

    For more than two years, conservative legal organizations like the ACLJ have said that Obamacare is about much more than a choice between individual liberty and a federal takeover of the health care industry. Recent news lends further evidence to concern that the Affordable Care Act is also about expanding access to and funding for abortion. This month, Rep. Chris Smith (R-NJ), co-chairman of the Congressional Pro-Life Caucus, said of the newly-released abortion funding rules for state insurance exchanges, “Abortion isn’t health care . . . Obamacare should do them no harm. Tragically, it does the worst harm of all. It kills children and makes others complicit in abortion.”

    When it comes to abortion in the Affordable Care Act, the devil is in the details: You can read these new abortion coverage rules at the HHS Web site.

    For years, Obamacare supporters keep telling Americans that the bill has nothing to do with abortion. President Obama himself promised that there would be no abortion funding in his signature health care legislation.

    Not only were they proven wrong (the abortifacient mandate and the abortion “surcharge” are just two examples), the very fact that the abortion industry was out in full force on the steps of the Supreme Court this week is in itself telling.

    These were not just some random pro-abortion protesters who wandered onto the sidewalk in front of the Supreme Court because they saw some TV cameras. This was a well-organized, carefully orchestrated effort on the part of the abortion industry.

  16. Ann on March 29, 2012 at 7:35 pm

    This week, as opponents of the Affordable Care Act argued before the Supreme Court that key parts were unconstitutional and pundits described the government’s defense as a train wreck for the Obama administration, the real health care train wreck was happening across the street — in the halls of Congress.

    Today, in a party-line vote, the House passed the Republican Leadership’s 2013 budget that would control health care costs by essentially ending the guarantee to cover all seniors through Medicare and the guarantee to cover qualified low-income Americans — including low-income children — through Medicaid. This vote came just one week after the House passed a measure that would eliminate one of the central health care cost control mechanisms in the Affordable Care Act — the Medicare Independent Payment Advisory Board, an independent panel that would keep cost control decisions out of the hands of special interests.

    These measures are blunt instruments aimed at controlling health care costs. But instead of real facts and real debate about possible solutions to the very real problem of rising costs, our politicians seem to be stuck in the usual mode of partisan bickering about who should make cost-control decisions. The debate also panders to seniors, making constructive arguments nearly impossible.

    Rising health care costs are affecting all of us, and if we don’t control them, health care will consume our family budgets, as well as our government budgets with little left for investing in the next generation.

    Consider these facts:

    Children and Families. Families are losing the ability to save for a child’s college fund or for retirement. In 2010, health care costs rose to more than 21 percent of the household budget from 9 percent in 1969. In the past ten years, alone, premiums for employer-sponsored health insurance doubled. While 42 percent of low-income children and working-age adults had employer-sponsored coverage in 2001, only 24 percent had it in 2011. In some cases, the decline led to personal bankruptcy.

    State and Local Governments. Medicaid has now replaced education as the largest state budget expenditure, accounting for about 22 percent of state spending. In the 1980s, elementary and secondary education was the largest share of state spending, followed by higher education. Since 2007, Medicaid has been No. 1. Of course, part of this is good news — Medicaid has been expanded to cover many more children. But other reasons for the cost increases are more troubling, including soaring health care costs and declining employer coverage.

    Federal Government. At the federal level, Medicare, Medicaid and the Children’s Health Insurance Program make up 21 percent of the federal budget, with Medicare accounting for two thirds of it. This share of the federal budget is expected to continue to increase, squeezing out funding for other critical investments in the next generation. Just consider the last five years alone: spending on children’s health increased by 32 percent at the federal level while spending on education increased only by 7 percent.

    It is no wonder that both parties are trying to find ways to cut health care costs.

    But the vital question on the table is how we can keep our commitment to providing for the well-being of our most vulnerable — children and elders — while making sure we have enough resources for the programs that sustain the country’s next generation?

    This is not an easy problem to solve, but it is a problem for which all of us should be demanding solutions, not partisan posturing. Too often, Medicare is understood by politicians and the public as a program that only affects seniors and Medicaid is seen as a program that only deals with poverty. In truth, these programs have a greater impact on our government’s ability to invest in the next generation than any other.

    Here are three things to keep in mind as you follow the debate about health care costs:

    First, the Supreme Court’s actions are only part of the story. While requiring all Americans to hold health insurance will ultimately increase access and drive down costs, it is not the only cost control mechanism in the Affordable Care Act. As long as the Court doesn’t strike down the entire ACA, health care costs can still be constrained through the reforms left standing.

    Second, Medicare drives a tremendous amount of federal spending, crowding out our ability to invest in other programs. That is why the Medicare Independent Payment Advisory Board is so critical and why the House vote to eliminate it is so dangerous. As proposed, the board cannot control costs through rationing care, increasing taxes, changing Medicare benefits or eligibility, or increasing premiums. Rather, it would need to be creative, expanding upon delivery system reforms that drive down costs while maintaining the commitment to covering all of America’s elderly. It could save the country more than $15 billion over the next ten years.

    Third, proposals, such as those offered in the Republican budget that drastically cut Medicare and Medicaid by billions of dollars will necessarily result in rationed care and fewer eligible beneficiaries. To keep our core values focused on covering nearly all of America’s kids and seniors, we need to engage in real conversations about reducing the price of health care. Doing so might shrink profits for the health industry, but it will lead to greater quality of care while keeping our commitment to coverage.

    No matter what — Americans should ignore the din of partisan shouting to focus on this crucial problem.

    And don’t let anyone convince you that Medicare is only a senior issue. It may be the most important children’s issue facing our nation.

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