 Originally published at Real Clear Health.
By Deane Waldman & Vance Ginn February 20, 2017 Most people have heard the aphorism, “if it sounds too good to be true, it probably is.” Referring to the GOP’s cure for Medicaid, “If it sounds too good to be true, it might be true; but guaranteed, it won’t be good.” A Feb. 6, 2017 report on Medicaid makes this point perfectly. The GOP commissioned a study by Avalere Health, a health care consulting group, to assess the fiscal impact of federal block grants to state Medicaid programs. They evaluated two funding approaches: a lump sum to be negotiated and a per capita, i.e., per enrollee, formula. Their study showed that block grants could save Washington between $110 billion and $150 billion over five years depending on which formula was used. Roughly half the states would get a small increase in their federal contribution and half would get less, sometimes a lot less. The biggest loser, Arizona Medicaid, would receive 62 percent less than it is currently receiving from Washington. With the present Medicaid state-federal matching scheme, the more a state spends, the more money it gets from Washington. This produces a classic perverse incentive: rewarding the outcome you don’t want. We want states to reduce spending, yet Washington rewards them—with federal dollars—when they spend more! With a block grant, this perverse incentive goes away. This is a good thing. Medicaid block grants could save $110-150 billion and would eliminate the perverse incentive. Sounds like a great idea. It makes wonderful sound bytes, and the GOP seems to want to run with it. There is just one teeny, tiny problem with block grants as proposed: no health care. The federal government can, and in recent years does, spend more than it takes in as tax revenue. The federal government is able to do this because Washington has the option to issue debt and finance it by printing dollars through the Federal Reserve’s open market operations. States cannot, print money that is. Because states must live within their means, Medicaid programs will have to cut services to patients in order to balance their budgets. For a specific example, simple financial arithmetic shows that the GOP plan for block grants to Medicaid will reduce access to care. Whether a lump sum or per capita contribution, the block grant approach gives a fixed amount to the state. That is the state’s Medicaid income from Washington. Federally mandated spending—the state’s Medicaid cost—is constantly increasing and exceeds available funds. Between 2011 and 2015, spending on Texas Medicaid increased from $27.7 billion to $30.4 billion. That is a 13.5 percent increase in the state’s cost compared with only an 11.8 percent increase in population growth plus inflation. Texas, just like other states, cannot spend more money than it takes in. Unlike most other states, Texas has had a robust economy and was able to compensate for its yearly Medicaid shortfalls by routinely passing supplemental spending bills. States such as Illinois, Connecticut, and Massachusetts that flirt with bankruptcy cannot do this. What occurred in New Mexico, another cash-strapped state, demonstrates the effect of Washington’s spending mandates on the state’s Medicaid program. New Mexico expanded its Medicaid program and received an additional $3 billion from the federal government. However, the Land of Enchantment was required by federal law to spend $417 million more on insurance benefits and bureaucracy in 2017 than the state had in its bank account. Without the luxury of Texas’ exuberant economy, New Mexico had to cut spending somewhere while remaining compliant with federal regulations. Thus, they cut reimbursements to providers. Now think about all those states—26 of them and the District of Columbia according to the Ayalere study—that will receive less money under the GOP block grant scheme. They will still have to spend according to federal mandates. And just like New Mexico, they will be forced to cut services in order to balance their budgets. Half of the nation will be filled with Medicaid-insured patients who expect to get the care they need but can’t get it, for lack of doctors. Apparently, the GOP can’t do simple fiscal arithmetic. Enamored with their fundamentally flawed, one-size-fits-all block grant, they will cut costs, and cut care without fundamental health care reform to focus on improving patient care. There is a way to make this work. Along with block grants, repeal the federal Medicaid mandates. That would put control of spending where it belongs—at the state level, closer to patients. Administrative processes could be streamlined. Resources would be apportioned more closely in accordance with local needs. Healthcare dollars could actually be spent on health care. We can fix Medicaid using block grants, but only by giving control of both income and spending to the states. The latest report from the Bureau of Economic Analysis (BEA) shows that many states’ economies improved in the third quarter of 2016. Real gross domestic product (GDP), a measure of inflation-adjusted economic output, increased in 48 states and the District of Columbia. This contributed to a faster U.S. annualized economic growth rate of 3.5 percent that quarter but then slowed to a 1.9 percent pace in the fourth quarter, which aligns with this national economic expansion’s growth rate that’s the slowest since WWII.
Faster GDP growth rates indicate increased economic activity that typically includes more job opportunities, higher pay, and other benefits. Although the U.S. reported unemployment rate averaged 4.9 percent in 2016, which some economists consider to be at or near full employment, the more accurate underutilization rate (U6) that includes the unemployed, underemployed, and discouraged workers of 9.6 percent suggests slack in the labor market. The figure below shows that Texas’ real GDP increased by 4.3 percent in the third quarter, which ranks 12th highest nationally. This translates into an increase in economic output by $28 billion to $1.65 trillion, or 9 percent of the U.S. economy. Economic growth contributed to an average unemployment rate in 2016 of 4.5 percent with a U6 rate of 8.6 percent in the Lone Star State. Sectors of the Texas economy that contributed to the 4.3 percent growth rate were dominated by the wholesale trade (0.78 percentage points), finance and insurance (0.56 percentage points), and real estate and rental and leasing (0.46 percentage points). The only industry that was a drag on economic growth was the mining industry (-0.11 percentage points) from continued contraction in the oil and gas sector. However, that sector looks to get some reprieve as oil prices have increased since the third quarter. Texas is the second largest state economy only behind California ($2.59 trillion), which expanded at a slower 3.3 percent rate in the third quarter. Regarding sectoral growth differences between these two states, Texas’ faster overall growth rate was driven primarily by sectoral positive growth differences in nondurable-goods manufacturing, wholesale trade, real estate and leasing, and agriculture. On a larger scale, if Texas and California were separate economies, they would rank 11th and 6th, respectively, worldwide. By a private estimate of the cost of living, the Golden State has a 49 percent higher cost of living than Texas. This means greater purchasing power for many Texans compared with Californians. Despite the declines in oil and gas-dominated areas statewide for the past two years, including the third quarter of 2016, Texas’ diverse economy and relatively limited government has supported economic expansion in most quarters during that period. While things look to improve with potentially higher oil prices and pro-growth federal policies, there’s much that the Texas Legislature can do to unleash economic growth by limiting spending and cutting taxes, especially eliminating the business margins tax. http://www.texaspolicy.com/blog/detail/texas-economy-picks-up-steam This commentary originally appeared in The Gilmer Mirror on February 14, 2017.
Texas Governor Greg Abbott recently released his 2018-19 state budget proposal. He noted in that proposal, “Spending restraint must always be practiced, especially when the revenue projection is tight. While there are difficult choices to be made, the Governor’s budget funds the state’s priorities without issuing new debt, raising taxes, or utilizing the Economic Stabilization Fund.” Some will claim that restraining or cutting government spending will slow economic growth. This point fails basic economics. Given that the state budget is funded by taxpayer dollars, fewer budgeted dollars means less takings from you, and more opportunities to prosper. Of course, there are essential services provided by the government, but those limited, effective provisions are far fewer than we have today. An indicator of this is the fact that the state’s current total budget—the footprint of government—is up 11.8 percent compared with compounded population growth plus inflation since 2004. This amounts to families of four paying roughly $1,600 more in taxes this year alone, thereby hampering your ability to satisfy desires and support economic activity. The Governor gets it right that “spending restraint must always be made.” Like tightening your home budget when there’s less income and more essential expenses, so must state government. However, unlike your home budget, state government must collect tax dollars without generating income, so they must also consider how to leave more money in your pocket. Fortunately, there are opportunities to achieve these goals of restraining spending through the Sales Tax Reduction (STaR) Fund and reducing tax burdens by eliminating the business franchise tax. Texas House rules allow legislators to appropriate money cut from one program to another more preferred agency. This provides little opportunity for legislators to actually cut ineffective or excessive areas of the budget, leaving many legislators understandably frustrated with the budget process. The STaR Fund, passed as ALEC model legislation in 2015, would be a budget-cutting mechanism to resolve this issue. It would operate by aggregating state surplus dollars from various sources (i.e., budget cuts, budget surpluses, and funds above the Economic Stabilization Fund cap) to temporarily reduce the state sales tax rate for a specified period. This would restrain the growth of government while keeping more money in your pocket. As legislators consider which tax is the most costly for Texans, the reformed franchise tax, often called the margins tax, would top that list. It has been a failure since its reform in 2006 by restraining economic growth and job creation from the tax liability and cost of compliance. Since it is based on the gross revenue of a business with more than $1 million, businesses can have high revenues but be running net losses and be pushed further in the red by paying the margins tax. Research shows that every year the margins tax is in place, Texans lose tens of billions of dollars in personal income and tens of thousands of new job opportunities. This leaves fewer opportunities for you to prosper. This must end. By eliminating the margins tax, the Tax Foundation shows that the state’s business tax climate could increase from 14th highest nationally to third best. The combination of higher personal income, more job creation, and increased economic competitiveness makes abolishing this tax a no-brainer for legislators. While it may not be possible to entirely eliminate it this session, the largest cuts in the tax rates possible would be the best choice. As the data make clear, Texas doesn’t have a revenue problem, it has a spending problem. By achieving the goals outlined by Governor Abbott to restrain spending, the 85th Legislature can take steps to create the STaR Fund and put the margins tax on a path to death as quickly as possible. These steps along with meeting the needs of Texas will hopefully allow for what could be a historic second consecutive conservative budget and better support the success of the Texas model. The Conservative Texas Budget Coalition, which includes the Texas Public Policy Foundation and 13 other member organizations, recently presented our agenda for the 2017 Texas Legislature. You can view the press conference here and the press release with statements from most members.
Here is my statement: “The Conservative Texas Budget limits increases in the budget to no more than $147.5 billion in state funds and $218.5 billion in all funds,” said Vance Ginn, Ph.D., economist in the Center for Fiscal Policy at TPPF. “These limits are based on a 4.5 percent increase in population growth plus inflation during the previous two fiscal years. By limiting government spending to just meeting the needs of Texans, legislators can do more to increase the entrepreneurial spirit and job creation in Texas.” The Coalition welcomes the newest member of the Coalition, Citizens Against Government Waste. Here’s the updated one-pager with all 14 member organizations and our agenda items. Regarding the CTB agenda items, the Foundation has recently released the following publications:
Through these efforts, we hope to reduce the size and scope of government in Texas so Texans have the best opportunity to flourish. |
Vance Ginn, Ph.D.
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