HHS Budget FY 2023

House Budget: Department of Health and Human Services FY 2023 Budget, April 6, 2022

Ways and Means: Proposed Fiscal Year 2023 Budget with Health & Human Services, April 28, 2022

Finance: The President’s Fiscal Year 2023 Health and Human Services Budget, April 5, 2022

There have been more than a few hearings this spring to set the stage for the release of this budget. I will briefly restate some of our comments. Links to our comments can be found on our Fiscal Equity blog and YouTube channel. These hearings include:

Senate Finance: Behavioral Health Care When Americans Need It: Ensuring Parity and Care Integration, March 30, 2022 Video

Ways and Means: America’s Mental Health Crisis, February 2, 2022 Video See also: Finance: Mental Health Care in America: Addressing Root Causes and Identifying Policy Solutions, June 15, 2021

Ways and Means, Worker and Family Support:  Improving Family Outcomes through Home Visiting, March 16, 2022 Video

Ways and Means, Health:  Bridging Health Equity Gaps for People with Disabilities and Chronic Conditions, February 3, 2022 Video

Please also see our many Pandemic related comments, which took the Centers for Disease Control to task for not correctly assessing the early symptoms of the virus.  See especially

Ways and Means,  Health: The Path Forward on COVID-19 Immunizations, February 26, 2021

We agree with the President’s proposals to add funding to prepare for a future pandemic and to fund the ARPA-H Cancer Moonshot. Discoveries relating to the former will likely help the latter.

Part of ARPA-H is the funding for research on orphan drugs and the lingering problem of their cost once research leads to product development. In comments to Senate Finance on March 16th of this year, we repeated our proposal in this area for NIH to retain ownership in any such drug and contract out its further development and manufacture. Keeping ownership in public hands ends the need for drug companies to charge extreme prices or increase prices for its existing formulary to fund development.

PhARMA would still make reasonable profit, but the government would eat the risk and sometimes reap the rewards. NIH/FDA might even break even in the long term, especially if large volume drugs which were developed with government grants must pay back a share of basic research costs and the attached profits, as well as regulatory cost.

On the pandemic, we urge that there be a public examination of lessons learned - particularly mistakes. The largest mistake was to not identify COVID-19 as being spread like a cold.

Subsequent variants identified sneezing and a runny nose as early signs of the virus. This was true in the first round, but to save face, it was not mentioned and is still not admitted. Job one of preparing for the next coronavirus pandemic is to list cold or supposed allergy symptoms as the signal to self-quarantine (if not be quarantined). 

Donald Trump did not kill a million people. Trying to downplay original symptoms did - which led to a loss of credibility among some populations. This social aspect must also be explored - especially if these populations are to comply with later instructions.

The President's proposals  to expand behavioral health are most welcome, although only a start. Replacing mental health facilities - as well as policies which allow longer-term mandatory stays are what is needed - including conditions whereby readmission to a more controlled environment is automatic in the event of relapse or medication non-compliance.

Such a change in the rules of the game will demand 50-state cooperation, as local laws are impacted. The Department of Justice and state and local police agency participation is also required. Reform cannot only be for those with insurance - it must be for everyone. Parity is not enough - and is impossible without not only more beds - but more dedicated hospitals.

The Visiting Nurses program is worthy of expansion - not only in public sector funding, but in the private sector as well. When my daughter was born, a visiting nurse to screen for depression and help with lactation coaching would have been a godsend, although we were lucky for generous family leave policies and good health insurance through my wife’s employer. Health Insurance Reform will allow an even greater expansion of the pilot program to all. I will come back to this shortly.

New mothers and their partners have unmet needs beyond the particular programs listed in the House Budget Committee Summary. We cannot take our eye off of the Child Tax Credit ball. It must be both refundable and more generous. So that families are not simply living off of their CTC, the minimum wage needs to go up - although with a higher Child Credit a lower amount can be agreed to. Childcare subsidies are also as essential now as they were last year.

We have attached a portion of our comments from last year having to do with the Affordable Care Act, enacting a public option, how the issue is related to Student Loan forgiveness (here’s a clue - baselines) and how to reform Medicaid and Medicare to remove the biggest Medicaid contingent liability from state budgets.

Considering the problems getting Build Back Better over the line, I can see where opening discussions on the Public Option and Medicare for All might prove difficult - especially given the lack of agreement between the relevant committees.

I hope I am not shocking anyone by saying this. With that said, it is time for both CMMS and the Budget and Revenue Committees to start discussing what might be done in the next Congress on a bipartisan basis.

Please allow me to offer questions for research and discussion:

Would a public option be more likely to pass if Affordable Care Act surtaxes (SMI) were repealed?

What would be the impact on passage and operation of a public option of ending pre-existing condition reform with automatic enrollment in the public option, with subsidies, if coverage were denied?

How large would subsidies have to be to hold those who cannot get insurance due to a pre-existing condition harmless?

Are Affordable Care Act deductibles and premiums too high? (It seemed so to me when I had them and suffered a broken rib - for which the provider was never paid).

Can a public option, or even the ACA as it exists, meet all of its goals without either immigration reform or ending the prohibition on covering undocumented workers?

To what extent is sick leave (Building Back Better), essential for the ACA to really cut prices?

To what extent would the public option replace Medicaid?

Would reform be easier to pass if long term care were funded as Medicare Part E rather than being operated and funded by the states? (This would also require 50-state cooperation).

What is the best way to fund a public option (or Medicare for All)? Is some form of border adjustable goods and services tax better than a payroll tax? Would an employer-paid subtraction VAT be better?

SVAT would burden profits and would replace current funding of the Affordable Care Act and the tax exclusion for employer-provided health insurance. Corporate Income Taxes and Schedules C and F for Form 1040 would be replaced with this tax. See the second attachment for details.

How long would it take for insurance companies to deny anyone who is sick coverage, thus forcing them into a subsidized public option? Would this become Medicare for All, given that much private managed care, Medicaid and Medicare Parts B and D or Part C are all offered by the same list of providers, albeit with different copays?

Income Security is also in need of advanced study..

While Social Security 2100 is the school solution preferred by most mainstream analysts, should some form of expanded employee-ownership be part of the solution?

To study this, HHS, the IRS and the Department of Labor - as well as their authorizing committees, should look at how to expand employee-ownership.

The same bodies must also explore the impact of increasing the minimum wage on benefit levels, assuming that any increase lead to a rebasing of employment history.

What is the impact of crediting the employer contribution on an equal dollar basis rather than as a match to the employee contribution?

Would rebasing income history with a higher minimum wage and an equal dollar employer contribution end poverty among the low income elderly and disabled? Is it a matter of degree? How much would the minimum wage have to change to make a significant impact?

How would addressing such questions impact Social Security 2100?

Attachment: HHS Budget, F Y 2022 Video

Attachment: Tax Reform with attached videos