Showing posts with label Budget Cuts-US. Show all posts
Showing posts with label Budget Cuts-US. Show all posts

August 2, 2018

Puerto Rico's Bleeding Out Medicaid Program Faces New Cuts from Trump




Blue tarps still dot rooftops, homes lack electricity needed to refrigerate medicines, and clinics chip away at debts incurred from running generators. Yet despite these residual effects from last year's devastating hurricanes, Puerto Rico is moving ahead with major cuts to its health care safety net that will affect more than a million of its poorest residents.
The government here needs to squeeze $840.2 million in annual savings from Medicaid by 2023, a reduction required by the U.S. territory's agreement with the federal government, as the island claws its way back from fiscal oblivion.
Overall, Puerto Rico faces a crushing debt of more than $70 billion — much of it due to the territory's large Medicaid expenses. That's on an island where the average household earns $20,000 annually and diabetes and hypertension are widespread.
But physicians, health insurers and former government officials say the drastic cuts demanded provide far too little money to care for a population still traumatized by Hurricane Maria.




The cutbacks do nothing to address the underlying fiscal imbalance at the root of Puerto Rico's health care woes, which stem from the fact that the federal government already contributes a much smaller fraction of the U.S. territory's Medicaid budget, compared to what it contributes to the 50 U.S. states.
"We are rearranging the chairs on the Titanic," says Dr. Jaime Torres, whose jurisdiction included Puerto Rico when he served as a regional director of the Department of Health and Human Services.
Already health plans have been forced to lay off social workers and nurses like Eileen Calderón, who once visited dozens of chronically ill Puerto Ricans each month, finding them specialists, supervising medicine compliance and arranging rides to doctor appointments.
"These people who have been under our service for the last four or five years — all of a sudden I have to abandon them," says Dr. José Joaquín Vargaspresident and chief medical adviser for VarMed, the Bayamon-based company that operated the program that employed Calderón.
Health care crippled by debt
If Puerto Rico were a state, the federal government would pay 83 percent of its Medicaid costs. (It pays upward of 70 percent of Medicaid expenses in 10 states, according to a formula that takes a state's economy into account.) But because of a 1968 law capping the amount of Medicaid money Washington sends to U.S. territories, the federal government pays only about 19 percent of Puerto Rico's Medicaid costs, and as a fixed annual payment, or block grant.
In February, Congress approved $4.8 billion in additional funds to help pay the island's Medicaid bills. But the additional payments are widely viewed as a stopgap measure; health economists say that extra money is likely to run out in September 2019, a grim estimate shared by the territory's fiscal oversight board. That's a federal control board established by Congress in 2016 to oversee Puerto Rico's budget, negotiate with its creditors and help restructure at least some of the island's debt.
Gov. Ricardo Rosselló's administration aims to reduce Puerto Rico's Medicaid spending and improve access to care by putting an end to years of regional monopolies by private health insurance companies. The insurers have locked patients into narrow networks of health care providers. Later this year, under Rosselló's plan, the companies will be forced to offer island-wide insurance plans and compete for customers.
"We do not have the luxury" of continuing to spend inefficiently, says Ángela Ávila Marrero, executive director of Puerto Rico's Health Insurance Administration.
If Rosselló's overhaul fails to achieve adequate savings — as most observers predict — drastic cuts are in the offing. Among those cuts: Some 1.1 million of the 1.6 million Puerto Rico residents on Medicaid are at risk of losing coverage next fall, their health held hostage to the island's need to pay back its crippling debt.
Puerto Rico's government effectively defaulted on more than $70 billion in debt. Economists blame a decades-long recession, a corporate tax break that ended in 2006,and reckless spending by a bloated government.
But also to blame, they say, and largely unnoticed in discussions of the debt, is Puerto Rico's staggering Medicaid burden.
Poverty is so pervasive here that nearly 50 percent of residents qualify for public health insurance; Medicaid expenses in 2016 totaled $2.4 billion.
Residents suffer from higher rates of chronic conditions like diabetes and asthma, and the percentage of people who are elderly is quickly rising.
Footing medical bills without the kind of federal assistance dispensed to states has effectively doomed the island's fiscal health, health economists say.
Researchers of health care say that, putting aside interest on Puerto Rico's debt, the territory's primary fiscal deficit would have been erased had Congress paid the same share of Medicaid bills that it pays the 50 states and Washington, D.C.
"The main issue is that we are not yet a state," says Rep. Jenniffer González-Colón, the territory's nonvoting member of Congress. The island must pay for Medicaid, she adds, "with local funds that we don't have."
Battered even before the storm
Puerto Rico's health care system was already convulsing in September 2017 when Hurricane Maria struck. The federal government had issued warnings that the island would soon run out of additional Medicaid funds provided by the Affordable Care Act, and that 900,000 Puerto Rican residents would lose coverage.
Insurance companies, hospitals and physicians complained that the government was chronically late paying its bills. That frustration forced hospitals to defer maintenance and investments in new technology, and fueled the exodus of thousands of physiciansto the mainland in search of better incomes.
Today, Medicaid patients face long waits to see doctors on the island.
"If your kid needs a neurologist, for example, the waiting period is around six to 12 months," says Dr. Jorge Rosado, a pediatrician in San Juan. "For a genetics specialty, it's two to three years."
The $4.8 billion in relief funding from Congress is propping up Medicaid while the Rosselló administration negotiates new contracts with health insurance companies and enacts other measures mandated by the fiscal oversight board. Those include a new Medicaid fraud detection system and enhanced data collection.
There is little time to waste
Barring the unlikely passage of bills that would eliminate the cap on federal Medicaid spending in Puerto Rico, the disaster relief fund is projected to run out in the fall. González-Colón also has authored a bill calling for statehood, which would eliminate the federal government's unequal treatment toward the island's Medicaid program.
The fiscal control board established by Congress openly acknowledges the impending disaster. In an April 19 report (p. 97 of "New Fiscal Plan For Puerto Rico: Restoring Growth and Prosperity") the board projects monthly costs per Medicaid patient will rise nearly 40 percent over the next six years, barring any changes, and that Puerto Rico "will hit a 'Medicaid cliff.' "
Beginning this fall, Medicaid patients in Puerto Rico will be able to pick from at least four insurers, instead of being assigned to the one that had covered their ZIP code.
Puerto Rico has long capped the monthly payments insurers receive for Medicaid patients regardless of how many medical services they use — a form of managed care. But the government in San Juan believes that the insurers — without their regional monopolies — will be forced to compete, offering better care and more efficient delivery. They could save money by reducing unnecessary emergency room visits or hospital stays and by negotiating discounted payment rates to providers.
The island's government has vowed to pay private insurers extra money to care for those patients that have expensive or chronic medical conditions. Insurers have cautiously welcomed the changes.
"I support the government on what they're trying to do, but they didn't price it properly," says Dr. Richard Shinto, the president and chief executive of InnovaCare, an insurance company that sells plans in Puerto Rico.
"The oversight board is fixated on cuts," he says, "but we're never going to improve health care unless more money is put into the system."
Government health officials argue that their changes mean Medicaid patients, especially those outside the San Juan metropolitan area, will gain access to more specialists, who are concentrated in the capital. But staff at the island's clinics and hospitals fear they will be squeezed by insurers seeking to reduce costs, even as the clinics are still reeling from hurricane-related expenses.
For example, Hospital General de Castañer spent $5,000 every five days for gasoline to power the generators at its three sites for seven months; Health Pro Med, a community health center, spent at least $2,000 a day in added expenses, including private flights to ferry doctors to the storm-battered island of Vieques.  
Many experts are skeptical that managed-care companies will hire the army of social workers and nurses needed to trudge up hillsides, knock on doors and do the tedious work that entails solving the daily problems of poverty.Viewed through a narrow lens, with an eye for cutting expenses, such problems can seem far outside the purview of medicine.
Many people displaced by the storm haven't yet been able to return home, and that, too, can complicate health care delivery. Carmen Ramos, executive director of Redes del Sureste, a conglomerate of 22 medical groups in Puerto Rico, says 60 percent of the letters she recently sent to patients on her mailing list were returned.
"The managed-care companies need to produce revenue," says Victoria Sale, a senior director at Camden Coalition, a pioneer of social and health programs for the chronically ill. "That's a setup for concern."
Bottom line? The economic overhaul doesn't rectify Puerto Rico's fundamental problem — it can't sustain its Medicaid program so long as Congress treats the territory differently than it treats states.
"Next year, we will go back to Congress demanding the funding we deserve as U.S. citizens," says Torres. But, he adds, "it's time the local government started thinking about a Plan B."
Kaiser Health News, a nonprofit news service, is an editorially independent program of the Kaiser Family Foundation, and not affiliated with Kaiser Permanente.

February 13, 2018

Domestic Cuts on the New Budget Are So Extreme They Reflect a Disdain for Working Class and the Poor


Looking at this budget it will remind some of the budgets of a nation on a major war or a totalitarian government in which the money goes for weapons and for judges to jail people in this case is to kick people out of the country, not for a strong society but the opposite with a government not accountable to anyone.    Adam

                                                                             $


 President Donald Trump proposed a budget on Monday that calls for cuts in domestic programs and seeks a sharp increase in military spending and funding for a wall on the Mexican border.

Presidential budgets are rarely enacted by the U.S. Congress, which controls federal purse strings, but they allow the White House to lay out its priorities for the year.

In a bid to show conservatives that the administration is embracing some fiscal discipline, the plan calls for deep cuts in non-military spending that would lower the federal budget deficit by more than $3 trillion over 10 years.

But those cuts fly in the face of a two-year budget deal passed last week by Congress that raised spending limits on both military and domestic programs by $300 billion.

That agreement makes the president’s budget request even less relevant than it would be normally because Congress has already locked in its own spending priorities.

The Trump administration says, however, that Congress need not spend all of the money called for by the deal, particularly with regard to domestic spending.

The budget plan calls for spending $57 billion less in the fiscal year 2019 than the bipartisan agreement allows. If ever brought into force, the cuts could slash programs for the poor that provides housing and healthcare.

The proposal also calls for overhauling Medicare and Medicaid, two government-funded healthcare programs that are widely popular. Trump vowed on the campaign trail to leave them untouched, but the budget plan argues they can be made more efficient without harming recipients.

The proposed cuts drew a rebuke from the top Democrat on the House of Representatives Budget Committee, John Yarmuth.

”These cuts to critical federal investments are so extreme they can only reflect a disdain for working families and a total lack of vision for a stronger society,” he said in a statement.

The budget forecasts annual gross domestic product growth of at least 3 percent over the next three years, an aggressive target that is crucial to help cover the cost of the $1.5 trillion tax cuts passed by the Republican-controlled Congress in December.

Still, given the swelling of the federal debt in the wake of the tax bill and the two-year budget agreement, Trump’s proposal notably abandons the objective of eliminating the federal budget deficit after 10 years, a longstanding goal of fiscal conservatives.

MILITARY, INFRASTRUCTURE

Trump’s $4.4 trillion budget proposal provides for $716 billion in spending on military programs and for maintaining the U.S. nuclear arsenal,

It includes $200 billion for rebuilding the nation’s infrastructure and outlays $23 billion for border security -- most of it for the building of a wall on the border with Mexico to stop illegal immigration.

The wall is a key item for Trump’s political base of supporters but is opposed by Democrats. The issue has become a sticking point in talks to keep alive a federal program to spare from deportation so-called “Dreamers”-- children brought to the country by illegal immigrant parents.

Also on border security, Trump’s budget calls for $571 million in additional funding to hire 2,000 more Immigration and Customs Enforcement officers and agents.

Pentagon's $686 billion budget proposal backs National Defense Strategy
Pentagon's $686 billion budget proposal backs National Defense Strategy
It also requests funding for more judges and attorneys to handle cases of illegal immigration.

In keeping with another Trump campaign promise, the budget provides for $200 billion in federal funds intended to spur $1.5 trillion in infrastructure investments with state, local and private partners over the next 10 years -- an ambitious program that will have to be approved by Congress.

The budget also seeks some $13 billion in new funding over the next two years to combat the opioid epidemic.

The proposal increases U.S. contributions to the United Nations, an organization that Trump has repeatedly criticized, by 4.5 percent. The budget explains the increase as supporting American interests, including “drug control, crime and terrorism prevention, and trade promotion.”

REUTERS


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May 24, 2017

Trump's FY18 Budget Puts LGBT Lives in Jeopardy





GLAAD Condemns Drastic Proposed Cuts to Ryan White HIV/AIDS Program, CDC, and Planned Parenthood 
NEW YORK – GLAAD, the world’s largest LGBTQ media advocacy organization, responded after President Donald Trump released the administration’s 2018 fiscal year budget, which highlights their key objectives and priorities in the upcoming fiscal year. The budget includes proposed slashes to programs and departments critical to the LGBTQ community, including Medicaid, Planned Parenthood, and the Center of Disease Control’s HIV and AIDS programs.
Further, the Trump Administration proposed additional cuts in the FY 2018 Budget that could also endanger policies geared to assist transgender women of color and their access to quality HIV-related health care.
“This budget would pull the rug from under some of America’s most marginalized communities, including transgender women of color, at a time when they need our help the most,” said Sarah Kate Ellis, President and CEO of GLAAD. “President Trump’s budget is heartless and the latest example of the Administration working to systematically erase LGBTQ Americans from the fabric of this nation.”
Moreover, the proposed budget also slashes dollars to the Health and Human Services’ Office of Civil Rights. This office is charged with helping marginalized communities, including LGBTQ Americans, gain access to health care and human services providers without discrimination. Roger Severino, who has a long history of anti-LGBTQ activism and remarks, was appointed to lead the Office of Civil Rights earlier this year.
GLAAD has been documenting the administration’s systematic erasure of the LGBTQ community and policies intended to support LGBTQ Americans. Click here to visit GLAAD’s Trump Accountability Project.
BACKGROUND INFORMATION: How the Trump Administration’s Proposed Budget Harms LGBTQ Americans
Health and Human Services Cuts to LGBTQ Health Care Access
Eliminates $59 million from the Ryan White HIV/AIDS Program. [Health and Human Services FY 2018 Budget, Page 24]
Proposed discontinuing the Ryan White HIV/AIDS Part F AIDS Education and Training Programs and Special Projects of National Significance. [Health and Human Services FY 2018 Budget, Page 24]
The Special Projects of National Significance features a program geared toward transgender women of color https://hab.hrsa.gov/about-ryan-white-hivaids-





Cuts $186 million in HIV/AIDS, Viral Hepatitis, STIs, and TB prevention CDC funding [Health and Human Services FY 2018 Budget, Page 28]

Drops $6 million in funding for HHS Office of Civil Rights [Health and Human Services FY 2018 Budget, Page 95]
Cutting Medicaid Harms People with HIV and AIDS
Advocate: Trumpcare Could Bring HIV Roaring Back: By gutting Medicaid expansion and other benefits, the proposal could complicate PrEP access and promotion in the states that adopted Medicaid expansion. If passed, the new bill will begin to eliminate money for Medical expansion in 2020, potentially blocking new applicants and access to critical medication…
WGBH News: Trumpcare Would Harm LGBT People And Those Living With HIV: “Changes to Medicaid proposed by the AHCA would put many people with HIV at risk of losing access to life-saving medicines and treatment” […] Trumpcare would also reverse ACA-related changes to Medicaid eligibility that have benefitted LGBT people. Previously, only low-income adults with dependent children or low-income adults with a disability were eligible for Medicaid. Now people are eligible for Medicaid on the basis of income alone. Since many LGBT people do not have children, this change has made it easier for them to enroll in Medicaid.”
Defunding Planned Parenthood Harms Trans Americans
HEADLINE: Trump’s Budget Proposes Kicking Planned Parenthood Out of All Federal Programs [New York Magazine, 5.23.17]
Daily Beast: The Attack on Planned Parenthood Hurts Transgender People, Too: “But a lesser-known consequence of the attack on Planned Parenthood is its potential impact on transgender people like Burns who rely on the organization for transition-related medical care. Elizabeth Clark, Planned Parenthood’s director of health media, told The Daily Beast that health centers in 16 states—including California, Florida, New York, and Illinois—currently offer hormone therapy to transgender patients. From 2013 to 2015, she added, there was an 80 percent increase in affiliates that reported offering that treatment.”
The Guardian: How defunding Planned Parenthood could wipe out transgender healthcare; “Unbeknown to many, Planned Parenthood is one of the largest sources in the US of transgender healthcare. The embattled provider offers hormone replacement therapy, which helps a person’s body appear more masculine or feminine, at dozens of its locations, and a growing share of its staff are trained to perform routine sexual health exams for trans patients.
Planned Parenthood in recent years has sought to address that problem. And it has made its clinics a magnet for thousands with few other options. Starting with Planned Parenthood of the Southern Finger Lakes, in upstate New York, a growing number of its health centers have become places where trans people can begin to transition medically, as well as get basic reproductive services. Its centers use a newer model for gender transitioning that gives the patient input on whether to start their transition, rather than turning the decision over entirely to a psychiatrist. Some clinics have staff with detailed knowledge of how to update driver’s licenses, passports and social security cards to reflect someone’s name and gender.”
###

March 20, 2017

Neil deGrasse Tyson”Trump Will Make America Weak,Sick/Stupid”









Astrophysicist Neil deGrasse Tyson believes President Donald Trump's first proposed budget could make America "weak," "sick" and "stupid."
"The fastest way to Make America Weak Again: Cut science funds to our agencies that support it," he tweeted Sunday as part of a social media rampage against the President. “The fastest way to Make America Sick Again: Cut funding to the National Institutes of Health." 
"The fastest way to Make America Stupid: Cut funds to programs that support education," Tyson added. "The fastest way to thwart Earth’s life-support systems for us all: Turn EPA into EDA — the Environmental Destruction Agency." 
In his first budget blueprint, the President proposed $54 billion in cuts to large parts of the federal government and popular programs big and small.
Trump's budget would cut off funding entirely for several agencies, including arts, public broadcasting and development groups, and also proposes steep cuts to agencies like the State Department and Environmental Protection Agency.
Nearly every agency will see some sort of cut, with only Defense, Homeland Security and Veterans Affairs getting a boost. 
"We can all imagine a land that provides no support for Art. But is that a place you'd want to Live? To Visit? To Play," Tyson tweeted.
"We all want to Make America Great Again. But that won’t happen until we first Make America Smart Again," he added.

March 17, 2017

$52.3 Defense Budget-What Can You Buy for This??

2017_03_16 TrumpBudgetPlan bars.r2

President Trump unveiled a partial $1.07 trillion budget blueprint on Thursday that cut overall discretionary spending by $2.7 billion but increased defense spending by $52.3 billion. He accomplished this by slashing budgets in other departments, including Health and Human Services, the State department (both of which lost the most funding in dollars) and the Environmental Protection Agency (which lost the largest percentage of its funding). Several agencies saw their funding cut entirely, including the National Endowment for the Arts, the National Endowment for the Humanities, and the Corporation for Public Broadcasting.

 United States already spends far more than the rest of the world on its military (at $56 billion, the United Kingdom’s entire military budget for 2015 was slightly more than Trump’s proposed increase alone) despite all of Trump’s campaign rhetoric about how the Obama administration decimated the “very weak” military. 
2017_03_16 TrumpBudgetPlan INFOGRAPHIC.r6

Perhaps that $52.3 billion could be better spent somewhere else. If you’re not into a well-funded National Endowment for the Arts or the various environmental programs and grants for people with lower incomes (including one that partially funds the Meals on Wheels program) that money was taken away from, here are a few more suggestions for how to spend $52.3 billion. Some may appeal to you; others will probably appeal more to Trump, who could buy his favorite social media platform five times over with that kind of money.
By Sara Morrison
vocativ.com

Trump’s Is The No1 Beneficiary of His Budget and GOP’s










Between the money he will recoup in taxes he wont have to pay, deductions on posh places to do business and the security expenses of his wife and sons, daughters and grandchildren plus the mopey they will making through benefis in tax law and freedom to do business around the world on the US dime this will probably be the most expensive presidency over. 

What would he do to say thanks? So far he has side tracked the government to bogus allegations of being wiretap by the Previous President (no tangible penalty for this but he got ugly discussions about him off the media and Congress for now) while we are involved in the crisis of North Korea’s nuclear missiles which will be directed to Japan first. Also the Russia’s interfering on our election and sanctions which he stop congress discussing anymore. I understand that Chaffeez was complaining is getting difficult to get information on Hillary’s server……….STILL..Not discussing what was behind the Presidents still assertions of being wiretap and  some reports the Vice President, staff still using private server as of 30 days ago or the connections of Trump and Putin and the emails between Flynn and the Turks and Russians.

Wall st Journal:

The first big tax cut moving through Congress under President Donald Trump would likely benefit the president himself, potentially saving him millions of dollars in taxes on his rental income next year and even more money on other income if he wins a second term.

Mr. Trump’s decision to continue owning his businesses as president without running them expands the tax’s effect on him and thus makes him benefit more from the proposed repeal, which would take effect in 2018, according to accountants and tax lawyers.

“In terms of his rental income, he would have been largely unaffected by repeal” if he were still a private citizen, said Tony Nitti, an accountant at Withum Smith & Brown. “There’s no just practical way he can qualify as a real estate professional now that he’s president of the United States.” 

President Trump's budget seeks increases in the military spending but deep reductions in domestic programs, such as funding for public television and the arts. WSJ's Gerald F. Seib says while these proposals reflect Trump's priorities, many targeted agencies may escape the ax. Photo: AP
The repeal of the 3.8% tax—known as the net investment income tax—is the largest tax cut contained in the Republican health-care bill moving through the House. It would reduce federal revenue by $157.6 billion over a decade, with most of that boost flowing to the top 1% of households.

Trump Budget Likely to See Major Rewrite in Congress

While Republicans lawmakers embraced President Donald Trump’s impulses to cut what some consider wasteful programs, they were quick to lodge objections to cuts in his budget plan that hit close to home. 
 
       
TRUMP'S FIRST 100 DAYS

Repealing the tax was part of the GOP health agenda long before Mr. Trump won the party’s nomination.

It is impossible to know how much Mr. Trump would actually benefit because he hasn’t released his tax returns and because his financial disclosures appear to conflate revenue and income in places.

But a previous Wall Street Journal review of his financial disclosures found that he had an estimated 2016 pretax income of $160 million, with $83.6 million of that coming from rental income. That would yield an annual tax savings of $3.2 million on rental income alone if the investment income tax were repealed.


The White House and a Trump Organization spokeswoman declined to comment. Mr. Trump’s representatives criticized the 2016 analysis, saying the income number was wrong.

Congress created the net investment income tax in the 2010 health law with two aims: to pay for the expansion of health insurance coverage and to subject what Democrats called “unearned income” to the same 3.8% tax imposed on top earners’ wages. It includes rent, capital gains, interest and dividends.

The tax, which applies to individuals with incomes over $200,000 and married couples with incomes over $250,000, took effect in January 2013. For instance, Democratic presidential candidate Hillary Clinton paid $3,517 because of the tax in 2015, according to her tax return.

But the tax’s structure also created a gap, one that the Obama administration tried but failed to close. Wage earners and investors paid it, but business owners could avoid the 3.8% tax on their profits, as long as they were actively involved in their businesses.

That is likely the gap Mr. Trump fell in before he became president, assuming his adjusted gross income was high enough.

He would have paid the investment income tax on any stock sales and some other income but likely avoided it on his business profits, which flow through to his personal tax return and are taxed as ordinary income.

“Up until he became president, he would have met the definition of being an active real estate professional,” said Joe Perry, partner-in-charge at the accounting firm Marcum LLP. Now, as president, “he would probably not meet the definition.”

Two different rules apply, depending on the underlying income. “He’s going to get hurt on both angles,” Mr. Nitti said.

Mr. Trump’s rental income, from office towers and retail stores he owns, is immediately subject to the tax. That is because owners of real estate who don’t meet certain tests about how much time they spend on the business don’t qualify and thus have to pay the tax.

“The case law has proven that it is extremely difficult for anybody with a full-time job outside the real-estate world to meet the real estate professional test,” Mr. Nitti said.

Mr. Trump’s other income—from hotel operations, branding deals and golf courses—likely wouldn’t face the tax until 2022, if he is still not actively running them. That is because of a different rule in the tax law for business profits, which says they are treated as active income if the taxpayer was active in five of the previous 10 years.

“He would be considered to be active for the next five even though he turned over management” of his business operations to his sons, said Mark Leeds, a tax partner at Mayer Brown LLP.

Beyond Mr. Trump, the repeal of the 3.8% tax is likely to deliver significant tax cuts very high-income households, according to an analysis by the nonpartisan congressional Joint Committee on Taxation.

In 2022 alone, the repeal would cut taxes by $10.8 billion for households making at least $1 million. That would be 69% of the total tax cut that year.

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