Friday, December 18, 2009

Health Care Should Be Driven by Mission, Not Money

Philip Caper, M.D.

As health care reform legislation enters a critical phase in Congress, it's important to keep our eye on the ball - elements essential to the success of any reform effort. In order to define those elements, we must have a clear understanding of the nature of the pathology in our dysfunctional health care system.

Modern high-tech health care is a right of the residents of most wealthy countries in the world - except the United States. America is exceptional in this regard. It is also exceptional in being the only wealthy nation where health care is considered to be a business.

To read a PDF of the full article, click here.

The Heart of Power: Health and Politics in the Oval Office

A Book Review by Philip Caper, M.D.

In many ways, the new book by David Blumenthal and James Morone is a fine dissertation on the role of the presidency and a succession of American presidents, stretching back to FDR, in the formulation of health care policy in the United States. But it does not address a central question. What are the barriers to reform of the American health-care system? Why has it been so difficult for American politicians to create a statutory right to health care for Americans - a right that every other affluent democracy created years ago?

To read a PDF of the full review, click here.

Thursday, October 15, 2009

Can the Time Value of Money Save Long Term Care?

John Cutler
Senior Policy Analyst, United States Office of Personnel Management

Often left behind instead of going to the dance, long term care may finally see its opening in health care reform. Until now, few reform proposals bothered with long term care (LTC) in spite of the fact that a much greater share of the population is at risk compared with the scope of the “uninsured” for general health care. In addition, social insurance advocates and private insurance supporters often were in an uneasy alliance around how to approach any LTC reform, further hindering chances to address it. But with the reform of health care likely this year, LTC supporters have, for the most part, coalesced around Senator Kennedy’s CLASS Act as the most likely ticket to the dance.

More on that later but it would be remiss not to mention the previous ideas that have been out there on the dance floor. For instance, adding an expanded chronic care benefit to health care or to Medicare has been suggested. While this could “medicalize” long term care, it increases the chance of LTC being included in health care reform. In fact even the nomenclature would change, with long-term services and supports (LTSS), the new term of art. Other interesting LTC reform proposals have been advanced by the provider trade groups, most notably AAHSA. And the exercise by Georgetown/RWJ a few years ago generated several innovative proposals, for instance Lambrew and Tumlinson authored a proposal to expand the home health care component of Medicare. And this author (with Shulman and Litow) developed a "Medi-LTC" idea which incorporated both Medicare SNF and home health along with private LTC insurance.

Whatever LTC – or LTSS -- reform looks like, advocates of social insurance and the private market are still talking past each other. Both believe the other is a necessary evil and the debate between them is how best to limit the other in their favored universe. Instead, what should take place is an attempt to find the best features in each others’ approach.

This thought piece suggests one important idea from the private insurance world that has been missing in social insurance -- the time value of money. Most insurance products (public and private) are delivered on annual basis. Money comes in this year and claims get paid. This is true of Medicare and Medicaid as well as private health insurance. Private LTC insurance offers a different option – it takes advantage of the time value of money by pre-funding future risks.

By collecting a premium at the outset which represents the actuarial value of total claims which will need to be paid for the covered cohort, risk is pooled across a diverse population in terms of time as well as age. Absent exogenous events that might lead to a class-wide rate increase, individual insureds will pay the same premium every year even as they age, until they need benefits. This means LTC insurance is actually deflationary: while the product's value keeps up with inflation the premium does not increase with inflation (assuming the insured elected this option, which more and more do).

One means of integrating this aspect of private LTC insurance into social insurance is via a “trade” between the LTC insurance carriers and Medicare where both come out ahead. Under this concept, the LTC insurers would pay for all SNF and home health care instead of providing this via Medicare. The savings to Medicare could result in a lower cost from removing short-term benefits for LTC needs that it now covers. Unlike the government, insurers would recognize additional revenue through investment income. The accumulation of investment income and the time value of money would allow all to "win" if Medicare could be brought into the mix directly. (Currently although one can argue that Medicaid savings accrue when people use LTC insurance, Medicare gains almost nothing from the existence of private insurance.)

Another variant – and the most promising to date -- would be to include private insurance within other vehicles as is done in the CLASS Act. Senator Kennedy’s proposal provides a flat amount for covered individuals that satisfy the cognitive or ADL triggers. Although it might look like a term product because it is financed on an annual basis out of employment, it also anticipates a level premium price that allows for the build up of reserves across time to pay for care in future years. What is exciting about the CLASS Act as a “public” insurance product then is its use of this powerful compounding process.

However, the bare bones of the legislation do not address other issues. For instance, the design of the program provides a claimant essentially half of what the true cost of care will be, hence the authors of the CLASS Act envision gap-filling by private insurers for those that wish it. One should worry that private insurers will attempt to underwrite healthy lives into their product while off-loading those with less health into the CLASS Act. A more integrated product where the private insurance subsumes or explicitly supplements the CLASS Act benefit (ala Medigap) would allow the CLASS Act to more successfully survive what will otherwise become these competitive attacks by private sector products. If not, we will be back where we were at the beginning.

Tuesday, September 22, 2009

Recent Changes in Dutch Health Insurance

Kieke Okma
Adjunct Associate Professor of Health Policy and Management, New York University

In 2006 the Netherlands implemented a new health insurance system that requires all citizens to buy health insurance from a regulated insurance company of their choice; insurers must accept all applicants; the government subsidizes children and low-income families. Recent Changes in Dutch Health Insurance analyzes the new Dutch system and considers whether it might serve as a model for the U.S. The working paper emphasizes some of the major differences between the Netherlands and the U.S., including the extensive role of the Dutch government in regulating the health sector and the egalitarian tradition in Dutch social policies.

Click here to download the full working paper, commissioned by a joint study panel of the National Academy of Social Insurance and the National Academy of Public Administration on Administrative Solutions in Health Reform. For a list of other papers and study panel members, click here. The project is funded by the Robert Wood Johnson Foundation.

Monday, September 21, 2009

Designing Administrative Organizations for Health Reform

Paul N. Van de Water
Senior Fellow, Center on Budget and Policy Priorities

Many proposals for expanding health coverage involve the creation of organizations to produce information on comparative effectiveness, make coverage decisions, manage the marketplace for health insurance, or offer a public health insurance plan. Designing Administrative Organizations for Health Reform describes proposals to create new entities or agencies as part of a reformed health coverage system, catalogs the major types of federal executive agencies and non-governmental entities, and considers some of the issues involved in choosing an appropriate organizational design. It concludes that organizations that use governmental powers and funds and make public policy need to be accountable as well as effective.

Click here to download the full working paper, commissioned by a joint study panel of the National Academy of Social Insurance and the National Academy of Public Administration on Administrative Solutions in Health Reform. For a list of other papers and study panel members, click here. The project is funded by the Robert Wood Johnson Foundation.

Friday, September 18, 2009

Re-Figuring Federalism: Nation and State in Health Reform's Next Round

Lawrence D. Brown
Professor of Public Health, Columbia University

Health reform must recognize the extensive role of states in U.S. health policy and reconcile national consistency with sub-national diversity. Re-Figuring Federalism: Nation and State in Health Reform's Next Round draws lessons both from federal-state relations in Medicaid and from the experiences of three other federal countries—Canada, Germany and Switzerland. It concludes that universal health coverage is compatible with a federal system, but that the federal government needs to establish central rules of the game.

Click here to download the full working paper, commissioned by a joint study panel of the National Academy of Social Insurance and the National Academy of Public Administration on Administrative Solutions in Health Reform. For a list of other papers and study panel members, click here. The project is funded by the Robert Wood Johnson Foundation.

Thursday, September 17, 2009

Designing a Mixed Public and Private System for the Health Insurance Market

Bryan Dowd
Professor, University of Minnesota

Designing a Mixed Public and Private System for the Health Insurance Market considers design features of a health care reform proposal that would offer a government-run health insurance plan alongside competing private plans in a government-run insurance exchange. The Medicare program provides a practical guide to the problems and opportunities offered by such a mixed public and private system. Since both public and private plans have inherent advantages and disadvantages, both plans can be offered on a relatively level playing field. Among the items to be considered in creating a level playing field are the benefit package, advertising and consumer information, risk selection and risk adjustment, the choice environment, default enrollment, provider payment rates, and the administrative structure.

Click here to download the full working paper, commissioned by a joint study panel of the National Academy of Social Insurance and the National Academy of Public Administration on Administrative Solutions in Health Reform. For a list of other papers and study panel members, click here. The project is funded by the Robert Wood Johnson Foundation.

Wednesday, September 16, 2009

Cost Containment and Coverage Expansion

Mark Merlis
Health Policy Consultant

Choices about covering the uninsured have implications for the feasibility of different approaches for controlling health care costs, and vice versa. In practice, some combinations may work together better than others and the interplay of different approaches to coverage expansion and cost containment is the focus of Cost Containment and Coverage Expansion. It begins with a brief review of whether coverage expansion and cost controls must go hand-in-hand. It then lays out the menus of commonly proposed coverage approaches and available cost control measures and considers how the two might go together.

Click here to download the full working paper, commissioned by a joint study panel of the National Academy of Social Insurance and the National Academy of Public Administration on Administrative Solutions in Health Reform. For a list of other papers and study panel members, click here. The project is funded by the Robert Wood Johnson Foundation.

Tuesday, September 15, 2009

Timothy Stoltzfus Jos
Robert L. Willett Family Professor of Law and Ethan Allen Faculty Fellow, Washington and Lee University: School of Law

The Regulation of Private Health Insurance examines the current role of health insurance regulation and the role that it could play in a reformed health care system. It begins by exploring the nature of health insurance and alternative approaches to regulation. It next considers the current status of state and federal health insurance regulation, both describing the development of health insurance regulation and examining arguments in support of and in opposition to regulatory interventions. Finally, it considers the kind of insurance regulation that will be needed in a reformed health care system, as well as the question of whether authority for insurance regulation should be placed at the federal or state level. It concludes that the best approach would be to develop national standards for health insurance enforced primarily at the state level.

Click here to download the full working paper, commissioned by a joint study panel of the National Academy of Social Insurance and the National Academy of Public Administration on Administrative Solutions in Health Reform. For a list of other papers and study panel members, click here. The project is funded by the Robert Wood Johnson Foundation.

Monday, July 13, 2009

Simplifying Administration of Health Insurance

Mark Merlis
Health Policy Consultant

The high administrative costs of the U.S. health insurance system have been a focus of discussion for decades. Simplifying Administration of Health Insurance finds ways to define and classify administrative costs, both of insurers and of other participants in the system, and summarizes the fragmentary estimates of how large these costs are. It discusses current efforts to reduce administrative costs, many of which have focused on standardizing and simplifying transactions among insurers, providers, and employers. Finally, it considers how various reform proposals, whether or not directly targeted at administrative costs, might reduce—or add to—the complexity of the current system.

Click here to download the full working paper, commissioned by a joint study panel of the National Academy of Social Insurance and the National Academy of Public Administration on Administrative Solutions in Health Reform. For a list of other papers and study panel members, click here. The project is funded by the Robert Wood Johnson Foundation.

Friday, July 10, 2009

Restructuring Health Insurance Markets

Elliot K. Wicks
Senior Economist, Health Management Associates

Restructuring Health Insurance Markets examines six structural changes that could expand health insurance coverage, with special focus on the administrative issues: changes in rating rules, high risk pools, standard benefit plans, reinsurance, Section 125 plans, and insurance exchanges. It considers what benefits these changes might produce, how they can be most effectively structured, and how they can be implemented. From an administrative standpoint, it is critical that any set of policies be considered as a whole, with careful attention to their interactions, both to enhance their chances for success and to avoid unnecessary administrative burdens and duplication.

Click here to download the full working paper, commissioned by a joint study panel of the National Academy of Social Insurance and the National Academy of Public Administration on Administrative Solutions in Health Reform. For a list of other papers and study panel members, click here. The project is funded by the Robert Wood Johnson Foundation.

Monday, June 29, 2009

Business and Retirement Income – What Role in the Future?

Anna M. Rappaport
President, Anna Rappaport Consulting

I have been very pleased to spend the last few days in Washington, DC and to participate in several meetings about retirement security. On Wednesday, June 17, I joined a group at the National Academy of Social Insurance at “The Quest for Adequate Retirement Income” a symposium focusing on current issues in the retirement system.

On Thursday [July 18th], I had the opportunity to meet with a number of plan sponsors who were discussing challenges in the retirement income system from their perspective. These large organizations were interested in providing retirement security to their employees, and frustrated at what often seems to be a stream of endless roadblocks.

What I heard from the two sets of people presented a very sharp contrast. At NASI, there were no representatives of the business community and none of the presenters had lived through the challenge of operating pension plans. Further, when asked what business thought about the issues and whether the financial crisis reinforced the importance of DB plans, the response was that business was not interested in offering this type of benefit. I was very frustrated to hear this from a researcher has not been a part of the discussions in the business community. The correct answer should have been to talk to someone in the business community and get their views. While this might seem difficult to an academic or policy person not in touch with benefit managers, there are ways to access this information.

There are groups that represent plan sponsors in Washington and provide business perspective to Congress. They include the ERISA Industry Committee and American Benefits Council. There are also groups that represent public sector plan sponsors. Another way to gain insight on business perspectives is to talk with consultants who work with plan sponsors. One of the great values of NASI is that it brings together people with diverse viewpoints.

Employers have long been an important part of retirement security in America. My view is that many employers have worked for a long time to protect employee security, and that they have endured many roadblocks. The success stories are hidden from view while failures are the focus of the news. How many more roadblocks they are willing to face is not clear, but we reduce the chances if we make it more difficult for them. It is vital for other stakeholders to have a dialogue with the employer community, and not to just make assumptions about it.

Friday, June 26, 2009

Administering Health Insurance Mandates

C. Eugene Steuerle
Vice President, Peter G. Peterson Foundation

Paul N. Van de Water
Senior Fellow, Center on Budget and Policy Priorities

Mandates form an integral part of many proposals to expand health insurance coverage. Often, however, too little attention is paid to how and whether they can be administered. Administering Health Insurance Mandates finds that a mandate will be easier to administer when some or all of the following conditions are met: The mandate emphasizes facilitating compliance rather than penalizing noncompliance; It operates as a simple play-or-pay arrangement; It can accurately take advantage of regular withholding for most workers; It involves penalties that are moderate and collectable; It is coordinated with any subsidies and other public programs, including Medicaid; It is based upon other government payments that can be denied, such as tax benefits; It is applied only to those with more than low incomes, unless the penalty is denial of other benefits; Its size does not vary greatly with fluctuations in income, so any penalty can be collected currently and accurately.

Click here to download the full working paper, commissioned by a joint study panel of the National Academy of Social Insurance and the National Academy of Public Administration on Administrative Solutions in Health Reform. For a list of other papers and study panel members, click here. The project is funded by the Robert Wood Johnson Foundation.

Wednesday, June 24, 2009

Paying a Fair Share for Health Coverage and Care

Jill Bernstein
Health Policy Consultant

Expanding health coverage will involve changes in the premiums and taxes people pay for health insurance and the amounts they pay out-of-pocket for specific health care services. Payment arrangements must generate sufficient revenue, promote efficiency in health care delivery, assure access to care for people who have low income or are in poor health, and minimize administrative costs and burden. Paying a Fair Share for Health Coverage and Care evaluates alternative approaches—including social insurance programs, means-tested premium assistance, and income-related cost sharing—according to these criteria.

Click here to download the full working paper, commissioned by a joint study panel of the National Academy of Social Insurance and the National Academy of Public Administration on Administrative Solutions in Health Reform. For a list of other papers and study panel members, click here. The project is funded by the Robert Wood Johnson Foundation.

Friday, June 19, 2009

Don't Worry, Be Happy: Characterization of Social Security Trust Funds

A. Haeworth Robertson
Former Chief Actuary, Social Security Administration, 1975-78

The nature and significance of Social Security trust funds is sometimes misrepresented to the public. This appears to be the case in Social Security Brief #30 issued on May 12, 2009 by the National Academy of Social Insurance. The section of this brief entitled “Where does the Social Security surplus go?” states essentially the following:

“Some people worry when they hear that Social Security annual cash surpluses are loaned to the U.S. Treasury and the government spends the cash on other activities.” Don’t worry, be happy, because when a Social Security surplus is loaned to the government it reduces the debt owed to the public by the amount of the surplus and thereby makes it “easier to afford Social Security and other activities of the government in the future.” (Emphasis added)

I believe that this conclusion is incorrect and that it is an inappropriate way to characterize the nature and value of the trust funds.

Those who believe the brief’s conclusion is correct appear to rely on the assumption that “intragovernmental debt” is different from “public debt.” Perhaps it is, but no matter how the debt is labeled:

  • the U.S. government’s responsibility to pay interest and eventually repay the loans is no different.
  • the amount of future taxes required to pay interest and eventually repay the loans is no different.

Collecting surplus Social Security taxes and loaning the funds to the government and calling it “intragovernmental debt” does not “make it easier to afford Social Security and other activities of the government in the future” than if the government borrowed that same amount from someone else and called it “public debt.”

There are, however, other consequences to collecting surplus Social Security taxes and loaning them to the government:

  • The government uses Social Security taxpayer money to finance other government programs during the years that surplus Social Security taxes are added to the “trust fund,” and thereafter uses general revenue to finance Social Security benefits. This results in a subtle cost-shifting between one generation of the Social Security taxpaying population and a later generation of the general taxpaying population.
  • By the time the trust fund is nearly exhausted, say in 2037, Social Security benefits and administrative expenses will be financed 76% by payroll taxes and 24% by general revenue (to redeem Treasury securities). Therefore, this financing procedure is, in effect, an ingenious method of gradual transition from payroll tax financing to significant general revenue financing.
  • After 2037 when the trust fund has no more Treasury securities to be redeemed, the government could--with a change in the law--finance the deficit between payroll taxes and benefits by simply continuing to use general revenue or by borrowing, just as it will have been doing since 2016 to pay interest on or redeem Treasury securities. The result would be a seamless shift to still more general revenue financing after 2037.
  • Labeling some of the government’s debt as intragovernmental debt (the part borrowed from the trust funds), and thus reducing the acknowledged public debt, may lead some people to believe the government’s fiscal condition is stronger than it really is. Accordingly, the government may be able to offer lower interest rates than otherwise required to induce the general public to buy Treasury securities. However, this will work only so long as the voluntary purchasers of Treasury securities fail to recognize the true government debt. (It may be relevant to note that at the beginning of 2009, 24 percent of the total national debt was owed to the Social Security trust funds; and another 19 percent was owed to other federal trust funds or accounts.)
  • By requiring Social Security taxpayers to pay excess taxes that are then used to buy Treasury securities (using the ruse of building up a “trust fund” to finance Social Security benefits), the government may be able to pay a lower interest rate on such securities than if it had to sell them on the open market. (An effective subsidization of government operations—and general taxpayers-- by Social Security taxpayers?)
  • By requiring Social Security taxpayers to pay excess taxes that are then used to buy Treasury securities, the government takes funds from the hands of such taxpayers that are thus not available for alternative uses. Such taxpayers might well have made more productive use of these funds if they’d had a choice.
  • For the unsophisticated, all the rhetoric frequently used to describe the “trust funds” tends to bestow on the trust funds an undeserved significance; to obscure the fact that funds purportedly collected to pay Social Security benefits are diverted to other government programs; and to suggest that Social Security is more financially viable, during the period the “trust funds” exist, than it really is.

Acknowledgment of the true nature and significance of the Social Security trust funds will be important as the nation considers alternative ways to make the program viable. It will be of particular significance when considering proposals to increase payroll taxes at a time they are not needed to pay current benefits. Such tax increases might put the system’s income and outgo into “arithmetic balance,” but they would result in a trust fund buildup of questionable value.

Wednesday, April 22, 2009

Strengthening Social Security Wage Reporting For Farm Workers

Barbara Robles
Associate Professor, School of Social Work, Arizona State University

Farm workers are at risk of not having their work count toward Social Security benefits because their employers may erroneously classify them as independent contractors or simply fail to pay Social Security taxes and report wages. Strengthening Social Security for Farm Workers: The Fragile Retirement Prospects for Hispanic Farm Worker Families supports legislation introduced in the 110th Congress, along with stronger enforcement of existing laws, to strengthen wage reporting. The proposal also notes that the changes would increase tax receipts and benefit the Latino farm worker population by increasing their Social Security benefits, providing better access to the Earned Income Tax Credit, and easing the burden on adult children of farm workers who have the triple burden of school debt, raising children and supporting aging parents.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Monday, April 20, 2009

Increasing Social Security Benefits for Low-Wage Single Retirees

Patricia E. Dilley
Professor of Law, University of Florida Levin College of Law

Single retirees (that is, never married, divorced or widowed) are at high risk of being poor in old age. The decline in private pensions, rising out-of-pocket health costs, and declining housing values can be expected to make the already precarious financial situation of unmarried retirees even worse. Restoring Old Age Income Security to Low-Wage Single Workers proposes a change to the basic Social Security retired-worker benefit formula that would increase benefits for single retirees with at least 30 years of covered employment and low lifetime earnings. A second change would target single beneficiaries over age 85. Those who had at least 30 years of covered work, and received relatively low benefits (less than 75 percent of the average benefit), would receive a 10 percent benefit increase at age 85.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Friday, April 17, 2009

A New Social Security Minimum Benefit For Low Lifetime Earners

Melissa Favreault
Senior Research Associate, The Urban Institute

Despite a lifetime of hard work, many workers end up poor or near poor in retirement. A New Minimum Benefit for Low Lifetime Earners examines a new minimum benefit that targets workers with long careers and low lifetime earnings, along with a modest credit that compensates for up to three years of low (or no) earnings due to care giving, unemployment, or poor health. The benefit at the full retirement age would pay 60 percent of the poverty threshold for a worker with 20 years of Social Security covered work and increase to 110 percent of the poverty threshold for a worker with 40 years of work. Caregiver credits would be available only in years when a child is under age 4 and only to one parent. The credit would be 60 percent of the average wage in the first such year, 50 percent in the second year and 40 percent in the third year.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Wednesday, April 15, 2009

Why Do We Call Taxes a `Burden'?

Rashi Fein

This 1996 op-ed, originally published in The Washington Post, is as timely as ever.

******

I learn a lot watching C-SPAN. The other night, one of Washington's leading economists was asked about using the tax system to help reduce environmental damage. The response? It certainly would be difficult, because it would increase the `tax burden.'

`Tax burden' is a phrase with which we are all so familiar that we don't stop to think what it means--nor what it implies. At first blush it seems value-free. But plainly a `burden' is something to be lifted. We don't refer to the monies we spend on movies, popcorn, milk or shoes as `burdens.' We refer to them--and think of them--as expenditures, some (movies and popcorn) optional, others (food, shoes) necessary. We don't speak of our `consumption burden.' Why, then, a `tax burden'?

Is it that our tax payments are not optional but our food expenditures are? That can't be it: We have to buy food. We can choose between steak and hamburger (or yogurt and tofu), but we can't choose between eating and starving. Indeed, the penalty for not eating far exceeds the penalty for nonpayment of taxes. yet we do not speak of the `food burden.'

More likely, we think of taxes as a burden because we're not quite certain what it is we're buying when we pay them. We miss, somehow, the connection between our tax dollars and the fire protection, the highways, the security against foreign powers and the biomedical research that our dollars buy. The problem is that few of the benefits we derive can be seen, touched or smelled. Moreover, the benefits we derive from government expenditures most often accrue to everyone; they do not come packaged in discrete units--this box of defense for me, this piece of highway for you.

And many of us assume that we'd continue to get whatever it is we're getting from government even if we didn't pay our taxes. Without spending our dollars, we'd have no milk on our tables, but we can't really imagine that schools and roads would disappear if you and I didn't buy them with our tax dollars. Clearly, government doesn't determine how many potholes to fill only after it deposits our tax dollars. If I don't buy that book, that restaurant meal, that aspirin--or if I cheat on my taxes--does government really subtract from the pothole-fixing budget or the salaries of judges? That's a tough connection to make--but without that connection, my taxes come to seem irrelevant, hence unnecessary, hence a `burden.'

Of course, no government program would suffer if you or I consumed less (and thus paid less in sales tax) or if I cheated on my return (and thus paid less in income tax). But if you and I both underpaid, everyone else would have to pay more. And it surely stretches language beyond acceptable usage to call not taking advantage of one's neighbors a `burden.'

Burdens are by definition oppressive, and our facile use of the term in connection with our taxes thereby encourages us to do everything we can (within the law) to ease them. Cheating on our taxes comes to seem acceptable (at least understandable), even though tax evasion is precisely analogous to shoplifting. If we take fire protection, guarantees on educational loans, clean air and water but fail to pay for them, we are stealing.

Our language shapes our attitudes. To weigh appropriate tax and expenditure policies in difficult when our language encourages us to think of our taxes as burdens not connected to the benefits we derive from them.

Some weeks ago, I received a brochure encouraging me to open an IRA. In that brochure, a 1040 tax return was labeled `pain,' while the application for an IRA was labeled `pain killer.' By implication, taxes (like pain) are to be avoided. By implication, I can continue to enjoy the benefits of government expenditures without paying for them.

We can debate `value for money,' the wisdom of particular government policies, programs and expenditures. We can argue as to whether we're spending too much here, not enough there. But that debate is distorted if we enter it with the view that any government expenditure--which means my tax dollar--is inherently burdensome.

I feel as I do because I remember what Justice Holmes wrote in 1904: `Taxes are what we pay for a civilized society' and what Franklin Delano Roosevelt said in 1936, `Taxes, after all, are the dues that we pay for the privileges of membership in an organized society.'

Now, at century's end, our economists tell us taxes are a burden, and our pension funds tell us taxes are a pain. Is it any wonder that our leaders vie to reduce the burden and the pain, even if in so doing our society becomes somewhat less organized and less civilized?

Monday, April 13, 2009

Improving Benefits for Widowed Spouses of Low-Earning Couples

Joan Entmacher
Vice President for Family Economic Security, National Women’s Law Center

Social Security is especially important to older women, particularly widows. Most poor elderly women are widows. Social Security survivor benefits help to bridge the transition to widowhood, but the benefits are less adequate when both the husband and wife had worked at low pay. Strengthening Social Security Benefits for Widow(er) s: The 75 Percent Combined Worker Benefit Alternative proposes to increase benefits for widowed spouses of low-earning dual-earner couples. The new widowed-spouse benefit would be 75 percent of the combined retired-worker benefits of the husband and the wife, but would be capped to not exceed the benefit for one person who had earned the average wage over a career.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Friday, April 10, 2009

Increasing Social Security Benefits at Advanced Ages

John Turner
Director, Pension Policy Center

People who live into their 80s and 90s face a growing risk of becoming poor. They rely more and more on Social Security because their other sources of income decline as they age: private pensions, if received, are eroded by inflation; income from work is very rarely an option; and financial assets may have been spent. Longevity Insurance, Strengthening Social Security at Advanced Ages proposes increasing benefits at age 82 (about the average life expectancy at age 65) for beneficiaries with low Social Security benefits and long work histories. This longevity insurance would improve financial security for individuals who live longer than the average life span.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Wednesday, April 8, 2009

Easing the Impact of Increasing the Retirement Age: Occupational Disability

Eric Klieber
Director, Retirement Actuary, Buck Consultants

Legislation in 1983 increased from 65 to 67 the age at which Social Security pays full retirement benefits. The change lowers retirement benefits at each age they are claimed. Disabled-worker benefits remain unreduced, but are not available to individuals who fail to meet a strict test – “inability to engage in any gainful activity” – yet are unable to continue in their jobs. Strengthening Social Security for Workers in Physically Demanding Occupations proposes a benefit for such individuals based on an occupational disability test – “inability to perform the essential duties of one’s current occupation.” Making such an occupational disability benefit available at age 62 could protect recipients from retired-worker benefit reductions (or part of such reductions) due to increasing the full benefit age.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Monday, April 6, 2009

Increasing Social Security Benefits for Family Elder Caregivers

Shelley White-Means
Professor of Health Economics, University of Tennessee Health Science Center

Rose Rubin
Professor, Department of Economics, University of Memphis

Informal care provided by family members improves quality of life for frail elders, allows them to remain in the community instead of in nursing homes, and saves Medicaid dollars. Providing the care also imposes opportunity costs on caregivers that weaken their own retirement security. Retirement Security for Family Elder Care Givers with Labor Force Employment proposes to provide up to four years of Social Security credit to individuals who provide care to elders. The elders must be certified to need levels of care that would qualify for Medicaid coverage. The value of the credit would be the caregiver’s average wage in the three years before care giving interrupted earnings. The authors suggest the credit could be financed based on the reduction in public spending for nursing home care.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Friday, April 3, 2009

Helping Homeless Individuals with Serious Mental Illness Get Disability Benefits

Yvonne Perret
Executive Director, Advocacy and Training Center

Deborah Dennis
Vice President, Policy Research Associates, Inc

Margaret Lassiter
Senior Project Associate, Policy Research Associates, Inc

Social Security and SSI disability benefits are often the main sources of stable income for people who have serious mental illness. Individuals who are homeless face particular barriers in navigating the application process. They typically lack a mailing address, transportation, and a treatment history from accepted medical sources (physicians or licensed psychologists). Improving Social Security Disability Programs for Adults Experiencing Long-term Homelessness proposes three strategies to address these barriers: (a) expand the acceptable medical sources to include professions likely to be available in publicly funded health and mental health care systems; (b) use SSA’s presumptive eligibility for SSI disability benefits for people with schizophrenia who are homeless for at least six months; and (c) modify the administrative process to accommodate homeless individuals consistent with SSA’s Homeless Plan of 2002.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Tuesday, March 31, 2009

Increasing the Social Security Special Minimum Benefit and Updating SSI

Laura Sullivan
Research Assistant, Institute on Assets and Social Policy, Brandeis University

Tatjana Meschede
Research Director, Institute on Assets and Social Policy, Brandeis University

Thomas M. Shapiro
Director, Institute on Assets and Social Policy, Brandeis University

A special minimum benefit was added to the Social Security program in 1974, but few receive it today because it does not keep up with wage growth. Enhancing Social Security for Low-Income Workers: Coordinating an Enhanced Minimum Benefit with Social Safety Net Provisions for Seniors examines ways to update the special minimum benefit so that individuals with 30 years of work covered by Social Security would receive benefits that meet the updated poverty measure of the National Academy of Sciences, which is about 125 percent of the current official poverty threshold. It also proposes to update SSI to reflect inflation since the program began – that is, increase the asset limit for individuals from $2,000 to $6,700 and increase the general income exclusion from $20 to $89.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Friday, March 27, 2009

A Social Security Supplement for Low-Income Working Parents

Pamela Herd
Assistant Professor of Public Affairs and Sociology, La Follette School of Public Affairs, University of Wisconsin

Social Security provides benefits for spouses and widowed spouses, but does not provide credit for raising children. A growing portion of retiring women will not qualify for spousal benefits because they are divorced (with less than 10 years of marriage) or never married, yet will have earnings records that are limited because of time spent caring for their children. Crediting Care in Social Security: A Proposal for an Income-Tested Care Supplement proposes to supplement Social Security benefits for retirees who have raised one or more children. The supplement would be an additional 75 percent of the worker’s benefit (80 percent if two or more children were raised) but would be capped to not push the retiree’s household income above 125 percent of the poverty threshold. The benefit and income testing would be administered through individual tax returns, similar to the Earned Income Tax Credit.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Wednesday, March 25, 2009

Reducing Eligibility Requirements for Retirement Benefits

Andrew Biggs
Resident Scholar, American Enterprise Institute for Public Policy Research

To qualify for Social Security retired-worker benefits, individuals must have worked at least 40 calendar quarters (ten years) in jobs covered by Social Security. The Effects of Reducing Eligibility Requirements for Social Security Retirement Benefits examines the impact of eliminating the 40-quarters eligibility requirement. A small group of individuals (about 6 percent of those born in 1950) would gain eligibility for Social Security retired-worker benefits. The increases in benefits would often substitute for means-tested SSI benefits. Much of the new benefits would flow to immigrants who are not otherwise eligible for Social Security.

Click here to download the full policy proposal developed as part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Tuesday, March 24, 2009

Protecting Social Security Benefits from Garnishment

John Infranca
Judicial Clerk, The Honorable Berle M. Schiller, Federal Judiciary, Eastern District of Pennsylvania

Because Social Security and Supplemental Security Income (SSI) benefits are essential to meet basic needs, the Social Security Act protects the benefits from garnishment or attachment by creditors. Nevertheless, when benefits are deposited in a bank account, beneficiaries may find that their accounts have been temporarily frozen, or worse, permanently garnished at the behest of a creditor under provisions of state law. Because the government encourages direct deposit, over 80 percent of Social Security and SSI recipients receive their benefits electronically. Safer than the Mattress: A Policy to Ensure that Social Security and Other Exempt Federal Benefits Remain Safe From Garnishment, Attachment, and Freezes when Deposited in a Bank Account proposes a five-part legislative and administrative policy solution to ensure that Social Security and other exempt federal benefits remain safe from garnishment, attachment, and freezes when they are deposited in a bank.

Click here to download the full policy proposal developed as a part of the project, Strengthening Social Security for Vulnerable Groups.

The project was funded by the Rockefeller Foundation’s Campaign for American Workers.

Monday, March 9, 2009

Correcting David Broder on Social Security

Tom Bethell

Dear Mr. Broder,

If Bob Ball were still with us, I'm confident that he would be phoning or writing to you this morning re your Washington Post column of 2/5/09 in which you speak of "the looming bankruptcy" of Social Security, Medicare and Medicaid. He would be pointing out that all of these programs face challenges but none faces actual bankruptcy unless the full faith and credit of the United States is a meaningless phrase. In the case of Social Security in particular he would be dismayed to see you contributing to totally unjustified fears about the program's future. He would be pointing out that an estimated 2-percent-of-payroll shortfall over 75 years is hardly synonymous with bankruptcy and is in fact eminently manageable, and he would also be warning against casual assumptions that bipartisan commissions are panaceas (as he well knew from his experiences on many of them, particularly the Greenspan Commission). Bob is, of course, no longer with us, alas, but having worked with him off and on for 20 years I know he would want me to send you his plan for Social Security (as I know he did himself many times). He was in the process of updating his plan just weeks before his death, a year ago, and I've updated it to 2009 after checking with SSA's chief actuary to be sure that the plan's assumptions and data are valid. The Ball plan is available from the NASI website by clicking here.

Friday, March 6, 2009

Social Security is Shovel-Ready

Robert Hudson
Professor and Chair, Department of Social Welfare Policy, Boston University

There can be no question that the current economic crisis is emerging as the most dire that we have seen since the 1930s. And, in terms of both employment opportunities and retirement savings, it seems certain to hit older Americans as hard as it will everyone else. Looking for any silver lining in this situation, one finally occurs to me. In recent years, pressures on age-related programs have built as "the scope of conflict" around aging policy has expanded, meaning that programs that were once politically insulated are now under scrutiny and attack from those who see entitlement spending for older adults leading us toward fiscal doom.

Yet, the very challenge we face has allowed the scope of conflict to expand even wider and, in so doing, place aging policy on a side burner if not a back burner. Specifically in the case of Medicare, the issue is being recast, by President Obama and others, as being centrally about a health care financing and delivery system that is largely out of control and not as part of an entitlement crisis centered on older Americans.

Less certain, but possible, is that Social Security is coming to be seen as either a manageable problem or even as en economic stabilizer both meeting needs and protecting income. There is nothing more shovel-ready in America than Old Age, Survivors, and Disability Insurance.

Tuesday, March 3, 2009

A Bright Light in a Dismal Landscape

Alicia H. Munnell
Peter F. Drucker Professor of Management Sciences and Director of the Center for Retirement Research, Boston College
Original Published 3/25/09, The Boston Globe

President Barack Obama has said that overhauling Social Security and Medicare would be "a central part" of his administration's efforts to contain federal spending. But amid all the economic calamity, the Social Security program is functioning perfectly, meeting the crucial economic needs for millions of Americans. When older workers are losing their jobs and their 401(k) accounts are down about 30 percent, the ability to claim Social Security benefits serves as a backstop against severe economic hardship. Therefore, policymakers should tread carefully.

Social Security checks are not large, but they are reliable. For workers who claim benefits at age 66, the full retirement age, monthly benefits range from $850 for low-paid workers to about $2,200 for those who have consistently earned the maximum taxable amount. In fact, many workers claim early and receive reduced benefits. But Social Security benefits are increased each year to reflect changes in the cost of living, and they continue for as long as the recipient lives. So, despite the modest amounts, the benefits are predictable and people can count on them.

Are these valuable Social Security benefits endangered by the current economic crisis?

Certainly, a higher-than-predicted unemployment rate means that fewer people will be working and contributing to the system than originally projected. This shortfall could be a problem if Social Security operated on a pure pay-as-you-go basis, where today's contributions were the only source of funds for benefit payments. But the system has always had a contingency reserve to serve as a buffer in the event of economic downturns, and today's trust fund is more than adequate to ensure full benefit payments for decades.

How about Social Security's long-run outlook?

A worse-than-expected short-term economy will have only a tiny impact on Social Security's 75-year projections; the long-run costs of the program are driven mainly by the aging of the population, which has not changed. Over the next 75 years, the Social Security actuaries project a program shortfall equal to 1.70 percent of taxable earnings.

This number equals the size of the tax increase required to maintain solvency for 75 years. That is, if the payroll tax rate were raised immediately by roughly 1.70 percentage points - 0.85 percentage point each for the employee and the employer - the government would be able to pay the current package of benefits for everyone who reaches retirement age at least through 2082.

A lasting fix for Social Security would require a little more attention to the fact that the aging of the population will present an increasing financial challenge over the 75-year period. Thus, a lasting fix for Social Security could have smaller tax increases initially and larger ones later. This pattern would avoid the prospect of suddenly running short of money right after the end of the 75 years, and would achieve "sustainable solvency."

When crafting a solution to Social Security's long-term deficit, the lesson from the current financial crisis is that Social Security benefits are crucially important to older Americans.

This importance has increased with the shift in the private sector from traditional defined benefit pensions, which promised benefits for life, to 401(k) plans, which are exposed to the vagaries of the stock market. Americans, with little else to rely on in retirement, may be willing to pay up to maintain the country's successful Social Security program.

Building on Social Security’s Success

Virginia P. Reno
Vice President for Income Security, National Academy of Social Insurance

The United States needs a new conversation about how Social Security is part of the solution to the growing economic risks American workers face. The key question is: How can we build on the strengths of Social Security – its fiscally responsible design, its universality, progressivity, efficiency, and it effectiveness – to meet the needs of working families in the 21st century?

As employers’ shift away from traditional pensions to 401(k) plans, workers shoulder more financial risks. Social Security offers employers what they want – freedom from financial risk and fiduciary burdens, and it provides workers what they need – economic security.

Social Security has features of an ideal pension plan. It covers virtually everyone and is fully portable between jobs. Its retirement benefits last for life, keep up with the cost of living, and continue for widowed spouses in old age. Social Security provides family life insurance and disability protection. It has a permanent sponsor (the federal government) that will not go out of business or move its operations overseas. And Social Security is remarkably efficient – spending less than 1 percent of income on administration.

Social Security will continue to be affordable in the future. It is not part of an “entitlement crisis.” Its cost is projected to rise from 4.3 percent of gross domestic product (GDP) today to 6.0 percent by 2030, and then decline slightly and level off for the rest of the next 75 years. The increase in the share of GDP going to Social Security (1.8 percentage points) is smaller than the increase in national security spending in just the last 7 years (2.0 percentage points). It is also smaller than the increase in spending for public education (2.8 percentage points) when boomers were children and showed up in record numbers to enroll in kindergarten.

Social Security provides bedrock security for seniors. But benefits are modest. The case for improving Social Security benefits rests on the facts that:

  • U.S. seniors have lower replacement rates from Social Security and are more likely to be poor than are seniors in other advanced economies;

  • Benefit cuts already enacted and rising automatic deductions for Medicare premiums mean that seniors will need higher benefits in the future just to maintain replacement rates that retirees have had for the past 25 years; and

  • The rest of the retirement system is becoming less adequate and subjecting workers to more risks.

All these findings were true even before 2008 put in jeopardy all other resources that workers hope to have in retirement – home values, pensions, 401(k)s, savings accounts, and jobs.

Policymakers have an excellent tool at hand to strengthen retirement security. Social Security is well designed, secure, and efficient. With its proven track record, it holds the best prospect for using new money effectively to improve retirement security for American workers. Wise policy would first balance Social Security finances without cutting benefits. It would then make benefits more adequate before subsidizing other retirement income tools.


This post is based on a paper presented at an Economic Policy Institute briefing. The views are those of the author. The full paper can be downloaded here.

Longevity Insurance: Strengthening Social Security for People Age 82 and Older

John A. Turner
Director, Pension Policy Center

People in their 80's with low Social Security benefits are economically vulnerable. Few are able to compensate for a loss of non-Social Security income through work. People in this age group may not have sufficient resources to enjoy the last years of their lives with dignity.

Policymakers should add longevity insurance that targets beneficiaries age 82 or older with low Social Security benefits and long work histories to our current Social Security program. Age 82 is approximately the average life expectancy at age 65. Elderly poverty is high among this age group—a third higher than for people age 65-69. People in this age group are at risk of having fallen into poverty even though they had not been poor earlier in life. They have greater difficulty leaving poverty than people at younger ages. Strengthening Social Security for this group would provide cost effective social insurance.

Longevity insurance is a deferred annuity that starts at an advanced age. Much of the utility value to workers of annuitization comes from insuring against the possibility of running resources down to a very low level if one lives to be older than expected.

The longevity insurance benefit proposed here is a delayed annuity paid in the form of a minimum Social Security benefit or an enhanced Social Security benefit starting at age 82. Qualifying persons receiving a Social Security benefit below a minimum level would have their benefit raised at that age. Recognizing this enhanced insurance protection, Social Security OASI would be renamed Old-Age, Survivors and Longevity Insurance (OASLI). The renaming would inform people about the benefit. This “framing” would help people focus on and better understand the economic risk of living longer than their life expectancy.

In addition to serving as an enhanced insurance benefit, longevity insurance can simplify the problem of planning asset decumulation in old age. Some retirees have difficulty planning the spend down of their financial resources because of the uncertainty of age at death. With a longevity insurance benefit, that problem is simplified. Instead of planning for an uncertain period, they can plan for the fixed period from the date of their retirement to age 82, the date at which they start receiving the longevity insurance benefit.

Longevity insurance can be an important component of a policy package to restore Social Security solvency. Public policy changes likely will reduce the generosity of Social Security old-age benefits as part of a package to restore solvency. Most reform packages that cut benefits raise elderly poverty. To offset that effect, there will be a need to increase the generosity of some benefits to better target benefits to vulnerable groups. That goal could be achieved by providing longevity insurance benefits. This policy shifts Social Security resources toward persons who are both old and have low incomes.

As an alternative, survivors’ benefits could be raised, but that would be less targeted and thus more expensive for achieving the same results for vulnerable persons. Another alternative would be to raise minimum benefits, with the benefits being available at an earlier age, such as age 62. Longevity insurance would be better targeted by age. As life expectancy continues to increase, age 62 has become a relatively younger age compared to expected age at death. Further, providing minimum benefits at an earlier age would more likely affect labor supply.


To read the full proposal, click here.