Congressional Budget Office Estimates Research Articles

Health Insurance For People Younger Than Age 65: Expiration Of Temporary Policies Projected To Reshuffle Coverage, 2023-33.

The Congressional Budget Office estimates that in 2023, 248million people in the US who are younger than age sixty-five have health insurance coverage (mostly through employment-based plans), and twenty-three million people, or 8.3percent of that age group, are uninsured-with significant variations in coverage by income and, to a lesser extent, by race and ethnicity. The unprecedented low uninsurance rate is largely attributable to temporary policies that kept beneficiaries enrolled in Medicaid and enhanced the subsidies available through the health insurance Marketplaces during the COVID-19 pandemic. As the continuous eligibility provisions unwind in 2023 and 2024, an estimated 9.3million people in that age group will transition to other forms of coverage, and 6.2million will become uninsured. If the enhanced subsidies expire after 2025, 4.9million fewer people are estimated to enroll in Marketplace coverage, instead enrolling in unsubsidized nongroup or employment-based coverage or becoming uninsured. By 2033 the uninsurance rate is projected to be 10.1percent, which is still below the 2019 rate of about 12percent.

Health Policy Was Bustin' Out All Over.

The Trump administration refused to defend important provisions of the ACA in court and pursued rules that could open the door to less-regulated insurance options.

On the Benefits and Costs of Public Access to Data Used to Support Federal Policy Making

Congress is considering two bills that would require the Environmental Protection Agency (EPA) to make publicly available all data from studies that it relies on as it develops regulations. The Congressional Budget Office estimates that it would cost $250 million per year for the EPA to comply with such a requirement. As an alternative to these bills, the Obama administration points to an Office of Science and Technology Policy directive requiring that agencies spending more than $100 million per year on research issue plans to maximize public access to federally funded data. We show that this directive has not been implemented by the EPA and that there is good reason to question the validity of scientific research when the data used to create it is not publicly available. Furthermore, there is good reason to believe that the CBO significantly overestimated the cost of the bills. We recommend that all regulatory agencies generally provide public access to the data they rely on to develop economically significant regulations.

THE AFFORDABLE CARE ACT, LABOR SUPPLY, AND SOCIAL WELFARE

This paper converts Congressional Budget Office estimates of the labor supply effects of the Affordable Care Act (ACA) into social welfare effects for each of the major individual provisions of the law. The sum of these negative, individual welfare effects can be reduced, almost to zero, by utilizing alternative assumptions about labor supply elasticities and the ability of individuals to perceive changes in marginal tax rates. Incorporation of previous estimates of the welfare-enhancing aspects of the ACA would likely outweigh the small, negative (and possibly negligible) welfare losses caused by the law's labor supply distortions.

CBO’s Outlook for the Economy in February 2014

These remarks summarize the economic forecast and budget outlook that the Congressional Budget Office (CBO) published in February 2014. The discussion has not been updated to reflect subsequent economic and budget data or subsequent projections by CBO. Under an assumption that current laws governing federal taxes and spending remain in place, CBO projects that real GDP will expand by roughly 3 percent between the fourth quarter of 2013 and the fourth quarter of 2014—the largest rise in nearly a decade. Similar annual growth rates are projected through 2017. Nevertheless, CBO estimates that the economy will continue to have considerable slack for the next few years. To a large degree, the slow recovery of the labor market since the official end of the recession in 2009 reflects slow growth in the demand for goods and services. To a smaller degree, that slow recovery is the result of structural factors that stem from the recession and the subsequent weak growth of output but that are not directly related to the economy’s current cyclical weakness. The unemployment rate is expected to remain above 6.0 percent until late 2016. Moreover, labor force participation is projected to move only slowly back toward what it would be without the cyclical weakness in the economy. Beyond 2017, CBO expects that economic growth will be well below the average seen over the past several decades, primarily because of slower growth in the labor force arising from the aging of the population. Inflation, as measured by the change in the price index for personal consumption expenditures, is expected to remain at or below 2.0 percent throughout the next decade. Interest rates on Treasury securities are projected to increase in the next few years as the economy strengthens. The federal budget deficit has fallen sharply during the past few years, and it is on a path to decline further this year and next year. However, if current laws remain unchanged, the deficit will increase again after a few years because revenues are expected to grow at roughly the same pace as GDP whereas spending is expected to grow more rapidly. Federal debt held by the public is expected to equal 74 percent of GDP at the end of this year and close to 80 percent a decade from now.

Health Insurance Is Not Health Care

Thanks to theAffordableCareAct (ACA), low-incomeAmericans (thoseearning less than 139%of the federal poverty level) living in 25 states and theDistrict of Columbia gained eligibility to Medicaid on January 1, 2014.1 The Congressional Budget Office estimates that by 2022 there will be 12 mill ion new enrollees into Medicaid.2 Although this is anunprecedented leap forward in providing low-income Americans with health insurance, it is important to remember thathealth insurance isnothealthcare. Health insurance is a financialmechanismforpaying forhealth care. It is not the care itself, or even a guarantee of care.

LTC-Vital Medicaid Is on the Bargaining Table

LTC-Vital Medicaid Is on the Bargaining Table

Are Higher or Lower Medicare Rates Ahead?

Are Higher or Lower Medicare Rates Ahead?

THE IMPORTANCE OF COMMITTEE ASSIGNMENT: HEALTH CARE INDUSTRY POLITICAL ACTION COMMITTEE CONTRIBUTIONS AND THE HOUSE OF REPRESENTATIVES

I. INTRODUCTION The Congressional Budget Office estimates that total spending on health care will increase from 16% of gross domestic product (GDP) in 2007 to 25% in 2025 even as almost 15% of Americans lack health insurance. The debate surrounding health care financing and access has been around for almost 75 years since the Social Security Act was passed in 1935, but the issue of health care reform received more attention as rising health care costs and limited access to health care services became a campaign issue and later a failed domestic policy objective during the Clinton administration. The current system of health care is not sustainable. Reform of the health care system will create winners and losers, particularly among consumers, taxpayers, and members of the health care industry. Unlike the average consumer and taxpayer, however, members of the health care industry may have the ability to influence the outcomes of health care legislation through political action committee contributions. This paper explores the relationship between House committee membership and campaign contributions from political action (PACs) representing specific sectors of the health care industry over three election cycles, 1997-1998, 1999-2000, and 2001-2002. Although there have been a few papers dealing with PAC contributions from the American Medical Association (AMA) and voting on particular pieces of legislation affecting the health industry and one paper dealing with PAC contributions from sectors of the health industry and voting on medical liability legislation, the role of committee membership and PAC contributions has not been examined with respect to the health industry. Economic theory suggests that individual have more power than the entire Congress over their areas of jurisdiction. Individual legislators, recognizing the power of committees, seek legislative assignments that benefit their constituents' interest and the congressperson's own chance of reelection. Bennett and Loucks (1994, 1996, 2008) provide evidence that committee membership is one of the most important determinants of PAC contributions from different sectors of the financial services industry to members of the House of Representatives. In this paper, we extend that analysis to the health industry. In particular, we examine the relationship between PAC contributions from four sectors of the health industry to individual legislators over the 1998-2002 election cycles using a sample selection model. We expect to find that membership on that have significant oversight responsibilities for the health care industry, the Appropriations Committee, the Committee on Energy and Commerce, the Veterans' Affairs Committee, and the Committee on Ways and Means, is positively and significantly related to contributions from PACs representing different sectors of the health care industry. We expect that committee membership matters to health industry PACs, and health industry PACs will contribute disproportionately to those legislators who sit on committee with oversight responsibilities for the health care industry. II. LITERATURE REVIEW As discussed in Weingast and Moran (1983) and Weingast and Marshall (1988), individual have more power than the entire Congress over their areas of jurisdiction. As noted by Grier and Munger (1991, p. 25), committees in Congress, and particularly in the House of Representatives, possess disproportionate power over the policy areas in their respective jurisdictions, have the right to hold hearings, and recommend budget allocations for the bureaus in their district. Committee members determine the nature and content of any legislation that reaches the floor and have the power to prevent legislation from ever reaching the floor. Krozner and Stratmann (2000) also note that the relationship between PACs and congressional standing committee members may be particularly strong because the committee structure gives PACs the ability to build long-term relationships with members of because of the near permanent nature of standing and the ability of legislators to keep their committee assignments for as long as they are in the House (p. …

Will Cutting the Payroll Tax Increase Jobs? (Empirical Evidence from the EU VAT)

Red Ink Rising, the Peterson–Pew Commission on Budget Reform’s report presents the country with a fiscal/employment dilemma – Congress must act immediately to stem the federal debt, but it must move carefully lest it harm employment in the fragile economy. In short, we must act fast and slow – we must decrease the debt and increase employment. This is a difficult task. The Peterson-Pew dilemma (notably its jobs-creation aspect) was taken to heart by both of the reform commissions that issued reports soon thereafter (National Commission on Fiscal Responsibility and Reform, The Moment of Truth and The Debt Reduction Task Force (Domenici/Rivlin), Restoring America’s Future). The dilemma also appears to be have played a role in President Obama’s compromise with the Republican leadership in the Tax Relief, Unemployment Insurance Reauthorization, and Jobs Creation Act of 2010 (P.L. 111-312) – particularly the 2% payroll tax cut enacted at section 601. The Congressional Budget Office (CBO) places the payroll tax at the intersection of the policies that Peterson-Pew examines. Empirical evidence from the EU suggests that P.L. 111-312 got it right (as between general reductions in the employees’ and employers’ payroll taxes). The evidence gathered in a two-year policy experiment conducted in nine EU Member States also suggests that the CBO estimates of employment gains from employers’ payroll tax cuts cannot be supported (if they are targeted generally). In addition, EU macro-economic simulations based on these findings also suggest that the best way to use payroll tax incentives to increase employment is to use them to directly reduce the cost of labor. This can be accomplished either (1) under mechanisms used in the HIRE Act or (2) by targeting specific categories of workers (the unemployed) for an employees’ payroll tax cut that would be tethered to (used in conjunction with) an employers’ tax incentive to significantly reduce the cost of labor. This paper endeavors to bring EU analysis into the US payroll tax debate. Five options are considered: •(1) Employers’ payroll tax holiday. •(2) Employees’ payroll tax holiday. •(3) Targeted employers’ payroll tax holiday. •(4) Targeted employees’ payroll tax holiday. •(5) Tethering an employers’ payroll tax holiday to a targeted employees’ payroll tax holiday.

Controlling Costs Poses Hurdle to Reforming Health Care System

Back to table of contents Previous article Next article Government NewsFull AccessControlling Costs Poses Hurdle to Reforming Health Care SystemMark MoranMark MoranSearch for more papers by this authorPublished Online:6 Feb 2009https://doi.org/10.1176/pn.44.3.0009aFederal spending on Medicare and Medicaid will rise from about 4 percent of gross domestic product in 2009 to nearly 6 percent in 2019 and 12 percent by 2050.Most of that increase will result, however, from rising per-capita costs rather than from the aging of the population.That projection comes from a comprehensive report by the Congressional Budget Office (CBO) outlining the urgency of health system reform, the pros and cons of various health reform proposals, and the obstacles they will encounter.The report, “Key Issues in Analyzing Major Health Insurance Proposals,” focuses on large-scale proposals, provides extensive background information, and explains the CBO's analysis of numerous issues that could arise should the Congress seek to enact major changes in the health insurance system.“Without changes in policy, a substantial number of nonelderly people (those younger than 65) are likely to be without health insurance,” said Robert Sunshine, acting director of the CBO, in a Weblog he writes called the Director's Blog. “CBO estimates that the average number of nonelderly people who are uninsured will rise from at least 45 million in 2009 to about 54 million in 2019,” according to Sunshine.“Those problems cannot be solved without making major changes in the financing or provision of health insurance and health care. In considering such changes, policy-makers face difficult trade-offs between the objectives of expanding insurance coverage and controlling both federal spending and total costs for health care.”For instance, Sunshine noted that serious concerns exist about the efficiency of the health care system, but no simple solutions are available to control the growth of health care costs. Steps to restructure the insurance market and to encourage people to purchase less extensive coverage could reduce the use of treatments that provide minimal benefits, but enrollees would face higher cost sharing or tighter management of their care, he wrote.“In many cases,” he added, “the current health care system does not give doctors, hospitals, and other providers of health care incentives to control costs. Significantly reducing the level or slowing the growth of health care spending would require substantial changes in those incentives.”The CBO report is posted at<www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf>. Robert Sunshine's Director's Blog is posted at<http://cboblog.cbo.gov>.▪ ISSUES NewArchived

Data Exclusivity Period Length and Federal Government Savings from Enactment of the Biologics Price Competition and Innovation Act of 2007

Senate Bill S.1695, the Biologics Price Competition and Innovation Act of 2007 would establish an abbreviated regulatory procedure for the Food and Drug Administration (FDA) to license follow-on biological (FOB) drugs. The motivation for the bill is to save money for the Federal government and other purchasers of biologics. The Congressional Budget Office estimates Federal savings of $5.8 billion over the ten year scoring window covering 2009-2018. The length of data exclusivity to be awarded to innovator biologics upon FDA approval also is under debate. We show that by setting the data exclusivity period below 14 years, the government saves at most an additional $1.4 billion over ten years which represents only 0.11 percent of expected Federal drug spending, and 0.012 percent of Federal healthcare spending over the scoring window. Furthermore, we show that adopting a data exclusivity period of less than 14 years will have significant impacts on research and development (R&D) spending and thus, fewer, innovative biologics used to treat patients will be brought to market. This is because innovative biotechnology firms will lose a significant portion of their sales to copycat FOB firms. The average biologic does not cover its costs until 17 years after it starts selling the product. Because firms rely heavily on cash flow from sales to fund their R&D, fewer sales imply less R&D spending. We show that biotechnology R&D is likely to fall by at least $41 billion. The long-run effect is likely to be much larger due in part because the high-cost, high-sales breakthrough biologics will face greater FOB competition. Innovator firms may fund more lower-cost, less-innovative biologics because they will face fewer FOBs, allowing them to retain a greater proportion of sales.

Congress OKs Funding for Mentally Ill in Justice System

Back to table of contents Previous article Next article Government NewsFull AccessCongress OKs Funding for Mentally Ill in Justice SystemRich DalyRich DalySearch for more papers by this authorPublished Online:21 Nov 2008https://doi.org/10.1176/pn.43.22.0010A law funding federal grant programs to help people with mental illness who become entangled with law enforcement was reauthorized and expanded for five years in October.The measure came up short of APA's goal for this legislation, which was to increase funds for the law's existing programs, but it did add $10 million to train police how to recognize and respond appropriately to situations involving mentally ill persons.Moreoever, the law requires the Justice Department to report the rate of serious mental illness among people in custody or on parole and the rate of those who are eligible to receive Supplemental Security Income benefits.“The existing grant program has been useful, and now we will build on it by providing resources to help law enforcement and the courts better understand how to address and handle the problems and situations posed by defendants who have mental health problems,” said Sen. Pete Domenici (R-N.M.), the bill's sponsor, in a written statement.The measure is titled the Mentally Ill Offender Treatment and Crime Reduction Reauthorization and Improvement Act (S 2304, PL 110-416). Other members of Congress who led the effort for its passage included Sen. Edward Kennedy (D-Mass.) and Reps. Bobby Scott (D-Va.) and Jim Ramstad (R-Minn.).Other grants are earmarked for creating “specialized receiving centers” to assess the mental health requirements and suicide risk of recently arrested people, computerized information systems to improve police response to likely mentally ill suspects, and programs to train campus security personnel to identify and respond appropriately to incidents in which individuals thought to be mentally ill are involved.One of the programs that the law reauthorizes provides federal grants to states and local communities for jail-diversion initiatives, community-reentry services, and other efforts to address the needs of people with serious mental illness and cooccurring substance use disorders who are accused of nonviolent offenses. The law also reauthorizes support for preincarceration programs that provide counselor intervention for individuals with mental illness.Jail-diversion programs employ mental health professionals to screen new nonviolent detainees for mental disorders and offer treatment-based alternatives to incarceration.“Mental health courts are not a panacea for addressing the needs of the growing number of people with mental illnesses who come in contact with the criminal justice system,” Domenici said. “But they should be one part of the solution.”The 2004 law authorized spending up to $50 million per year for Fiscal 2006 and Fiscal 2007, but only $5 million was actually provided in each of those years.Advocates of the measure fought to increase the annual funding level to $75 million through 2014, but they failed to garner enough support for the higher number; thus, annual funding limits remain at $50 million. Advocates must still seek allocation of funds—up to their full authorized levels—through the federal budget process.The need for the reauthorization and expansion of the law was described in a House committee report that cited Justice Department statistics from 2006 that identified likely mental illness in 56 percent of state prisoners, 45 percent of federal prisoners, and 64 percent of local jail inmates.In addition, research findings have shown that state prisoners with a mental health problem are twice as likely as those without a psychiatric condition to have been homeless in the year before their arrest, according to the legislation.“Many of these individuals are not violent or habitual criminals,” said Domenici in a speech on the Senate floor. “Most have been charged or convicted of nonviolent crimes that are a direct consequence of not having received needed treatment and supportive services for their mental illness.”On any given day, at least 284,000 seriously mentally ill people are incarcerated, while just 187,000 such individuals are in mental health facilities, said Scott in a 2007 hearing on the legislation.“Jails and prisons require extra staffing and treatment resources for inmates with mental illness,” said Rep. J. Randy Forbes (R-Va.).Supporters of the measure said that communities that have taken advantage of past grants have seen their mental health and criminal justice systems work collaboratively on solutions and have achieved a considerable impact in fostering recovery, improving treatment outcomes, and decreasing recidivism.The measure passed over the objections of Sen. Tom Coburn (R-Okla.), who said that the law would duplicate other sources of funding for mentally ill prisoners. It ultimately passed by a simple voice vote.The Congressional Budget Office estimates that the law will cost about $565 million through 2014.The text of the Mentally Ill Offender Treatment and Crime Reduction Reauthorization and Improvement Act can be accessed at<http://thomas.loc.gov> by searching on the bill number, S 2304. ▪ ISSUES NewArchived

Medicare Part D

Medicare Part D

Postpartum Depression Research Could Get Funding Boost

Back to table of contents Previous article Next article Government NewsFull AccessPostpartum Depression Research Could Get Funding BoostRich DalyRich DalySearch for more papers by this authorPublished Online:16 Nov 2007https://doi.org/10.1176/pn.42.22.0007The House of Representatives passed APA-supported legislation last month to expand services and research that target postpartum depression.The Melanie Blocker-Stokes Postpartum Depression and Care Act (HR 20) would promote research and treatment for appropriate care of women with postpartum depression and postpartum psychosis through grants from the National Institutes of Health (NIH).The bill, sponsored by Rep. Bobby Rush (D-Ill.), passed 382-3.“The causes of postpartum depression are complex and unknown at this time,” said Rep. Frank Pallone Jr. (D-N.J.) during a May congressional hearing on the bill. “However, if diagnosed properly and treated with social support, therapy, and medication, relief is highly attainable.”The measure also aims to improve the dissemination of guidelines for diagnosing and treating postpartum depression and related disorders to“ health care professionals and the public.”Postpartum mood and anxiety disorders affect up to 18 percent of new mothers, and postpartum psychosis strikes 1 in 1,000 new mothers, according to the Centers for Disease Control and Prevention and other researchers.The legislation is designed to address the range of postpartum mental health problems, which include the relatively mild “maternity blues” or “baby blues” to “devastating” postpartum psychosis. Between these two extremes is postpartum depression, the bill notes, which complicates 10 percent to 15 percent of all births and 26 percent to 32 percent of births by adolescents.The legislation would authorize $3 million in research grants in the first year and unspecified sums thereafter. The Congressional Budget Office estimates that $18 million in grants would be awarded between 2008 and 2012.The bill would support research such as epidemiological studies, the development of improved diagnostic techniques, clinical research, and information and education programs.Although research suggests that many factors may contribute to the onset of postpartum depression, including hormonal changes, situational risks, and life stresses, more study is needed to clarify the condition's etiology, according to the bill's authors.Stotland Testifies on Bill“The bill lays out a straightforward agenda for research, resource coordination, and improved services to improve the diagnosis and treatment of postpartum depression, and—most importantly—to fund programs to establish and operate programs and systems of care for treating postpartum depression and postpartum psychosis,” said Nada Stotland, M.D., APA president-elect, in testimony on the bill in May.Stotland stressed that the type of clinical depression that may occur after childbirth can be an agonizing and disabling disorder impacting the general and mental health of the mother as well as the entire family.The legislation also aims to increase detection of postpartum depression by improving clinicians' training and awareness of signs and symptoms and encouraging more women to seek treatment, rather than avoid it because of social stigma or embarrassment.The bill urges a new national awareness campaign, in addition to NIH's current efforts, to inform the public about emerging research from the field. Both the NIH and the Health Resources and Services Administration sponsor Web sites on postpartum depression.Treatment Programs Also SupportedIn addition, the bill would establish a funding mechanism for establishing and operating systems of care for treating patients with postpartum depression and postpartum psychosis through grants to public and nonprofit programs that provide health care and support services. These programs would provide postpartum mental health care through inpatient and outpatient treatment, screenings, and case-management services.The legislation also includes language that calls for a study on abortion- and miscarriage-related depression, which was added as a compromise amendment to satisfy some Republican lawmakers who raised the issue during a hearing on the bill.The Senate companion bill (S 1375), which does not include the abortion provision, has not yet begun to advance.The text of the Melanie Blocker-Stokes Postpartum Depression and Care Act can be accessed at<http://thomas.loc.gov> by searching on the bill number, HR 20. ▪ ISSUES NewArchived

Vaccines against Avian Influenza — A Race against Time

Avian influenza A (H5N1) virus poses an important pandemic threat. A study by the Congressional Budget Office estimates that the consequences of a severe pandemic could, in the United States, include 200 million people infected, 90 million clinically ill, and 2 million dead.1 The study estimates that 30 percent of all workers would become ill and 2.5 percent would die, with 30 percent of workers missing a mean of three weeks of work — resulting in a decrease in the gross domestic product of 5 percent. Furthermore, 18 million to 45 million people would require outpatient care, and economic costs . . .

Assessing the Impact of Hurricanes Katrina and Rita

In the summer of 2005, while the U.S. economy was growing comfortably despite a few longstanding concerns about deficits and outsourcing, storms were brewing off the Gulf Coast. On August 25, 2005, Hurricane Katrina blasted New Orleans, Louisiana, and the surrounding coastal areas on the Gulf of Mexico. Barely a month later, a second storm, Hurricane Rita, swept through the Gulf region, making landfall between Sabine Pass, Texas, and Johnson's Bayou, Louisiana. Speculation about their likely impact on world energy markets and the U.S. economy began as soon as the hurricanes were forecast to strike the oil-rich Gulf region. This case documents the paths of the storms and provides a summary of the Congressional Budget Office's estimates of the storms' impact on the U.S. economy. It is designed for use in teaching the concept of national income accounts. It can also be used to analyze the impact of exogenous shocks.

Access to Drugs Questionable for Medicaid Patients Under New Law

Back to table of contents Previous article Next article Government NewsFull AccessAccess to Drugs Questionable for Medicaid Patients Under New LawKate MulliganKate MulliganSearch for more papers by this authorPublished Online:16 Jan 2004https://doi.org/10.1176/pn.39.2.0001aAPA is on track to resolve a potentially serious problem raised by the recently passed Medicare legislation.Dual eligibles (individuals eligible for Medicare and Medicaid) will lose Medicaid prescription drug coverage on January 1, 2006. They will be expected to receive such coverage through enrollment in a Medicare Part D program.Under Medicaid, states that provide prescription drugs in their Medicaid program must cover all FDA-approved drugs of every manufacturer that has agreed to pay rebates to the states for the products they purchase.Part D plans, however, have broad flexibility to determine the array of drugs that will be covered. They can limit to two the number of drugs they will cover in any therapeutic class. The plans have authority to define what constitutes a therapeutic class.The change in coverage has the potential to decrease access to the full range of psychotropic medications.Michael Strazzella and Nicholas Meyers, deputy directors of APA’s Division of Government Relations, worked with the staffs of Sen. Pete Domenici (R-N.M.) and Rep. Jim Ramstad (R-Minn.) to ensure that the Senate and House conferees protected access to needed medication for people with serious mental illness.They secured agreement from the conferees on the following nonbinding language:“It is the intent of the conferees that Medicare beneficiaries have access to prescription drugs for the treatment of mental illness and neurological diseases resulting in severe epileptic episodes under the new provisions of Part D. . . .[T]he Centers for Medicare Choices shall take the appropriate steps before the first open-enrollment period to ensure that Medicare beneficiaries have clinically appropriate access to pharmaceutical treatment for treatments of mental illness, including but not limited to schizophrenia, bipolar disorder, depression, anxiety disorder, dementia, and attention-deficit disorder/attention-deficit hyperactivity disorder, and neurological illnesses resulting in epileptic episodes.”Meyers pointed out that implementation of the drug benefit does not take place until 2006. “We are a long way from enactment to implementation,” he said. “DGR will follow the drug plan implementation carefully, and physician-directed access to clinically appropriate medications for the treatment of mental illness is an area of particular and ongoing concern.”Medicare will pay the Part D deductible and premiums for all dual eligibles who enroll in an average- or low-cost Part D plan. The secretary of Health and Human Services is required to develop procedures that include means of enrolling dual eligibles in a Part D plan for which a premium subsidy is available, but the legislation does not provide any timeframe for enrollment of dual eligibles or guidance on how to identify dual eligibles in need of such subsidies.It is now apparent that the Medicare legislation does not provide the level of fiscal relief state legislators had wanted. All 50 governors were united in their view that Medicare-eligible people on Medicaid should be covered by the Medicare drug benefit (see page 6).States, which must provide matching funds for Medicaid, would have saved an estimated $115 billion over 10 years in prescription drug costs if Medicare, which is funded totally by the federal government, had picked up all prescription drug costs for the dual eligibles, according to the Congressional Budget Office (CBO), as reported on MEDLINE Plus on December 9, 2003.Instead, although the federal government initially will pay those costs, states must return to the federal government a significant portion of the savings. The federal government will use a formula to estimate what states must pay back each month based on their Medicaid spending for the dual eligibles in 2003.Because of the payback requirement (termed a “clawback”), the CBO estimates that the states will realize only 25 percent of the $115 billion savings over the 10-year period. New administrative costs will eat into those savings, leaving only an estimated $17 billion in savings, according to the CBO.Selby Jacobs, M.D., chair of APA’s Committee on Public Funding for Psychiatric Services, said, “This is the latest chapter in the cost-shifting saga between the federal government and the states. The states wanted relief from the costs of drugs for dually eligible persons as one strategy for solving their budget problems. It looks like the relief is limited in scope and far less than expected. This will put pressure on states to cut their budgets in other ways, which may impinge on seriously ill persons served through state departments of mental health.”“Slim Savings, Unknowns for States in New Medicare” is posted online at www.nlm.nih.gov/medlineplus/news/fullstory_15050.html. “Implications of the New Medicare Law for Dual Eligibles: 10 Key Questions and Answers” is posted at www.kff.org/medicaid/4160.cfm. ▪ ISSUES NewArchived

Aging in the 21st Century: A Call for Papers

T he aging of the world’s population has profound implications for medical care and health care systems. According to the United Nations, the number of people worldwide aged 60 years or older will increase from 1 in 10 currently to 1 in 5 by 2050. In some developed countries, that proportion will increase from 1 in 5 to 1 in 2 in 2050. The population 80 years or older is projected to increase from 11% of those older than 60 years now to 19% by 2050, and the number of centenarians is expected to increase 15-fold to 2.2 million. The rate of aging of the population is greatest in developing nations, a growing challenge for nations with few health care resources. By 2050, the ratio of people 65 years or older to those aged 15 to 64 years will double in developed nations and triple in developing nations. This demographic revolution will fundamentally affect both health care and society. As one example of the dramatic social and economic effects expected from this trend, the United Nations will hold the Second World Assembly on Ageing in April 2002. According to Nitin Desai, United Nations Under-Secretary-General for Economic and Social Affairs, “. . . Ageing is not a separate issue from social integration, gender advancement, economic stability or issues of poverty. It has developed a connection with many global agendas and will play, increasingly, a prominent role in the way society interacts with economic and social welfare institutions, family and community life and the roles of women. . . . Societies must respond to the extraordinary potential and range of variability in individual ageing, and seize the opportunity to rethink our notion of limits and recognize the farreaching benefits societies stand to gain from the continuing contributions of their older citizens.” The United States faces specific problems related to aging. The Congressional Budget Office estimates that Medicare spending will double in the next decade under existing laws (without a drug benefit), costing an estimated $3.3 trillion over the next decade—while 44 million people remain uninsured. The high cost of drugs for elderly patients is on the national agenda, with proposals for some drug benefits for the poorest individuals, even while some Medicare managed care organizations are discontinuing drug benefits. A federal study found that more than 90% of US nursing homes have too few workers to take proper care of patients but because of the cost involved, the federal government does not plan to set minimum staffing levels. The aging population will put further demands on this already stressed system. These demographic and societal trends have major and far-reaching implications for clinical care, medical research, and health care policy. Given the importance of these issues for physicians, JAMA and several of the Archives Journals will publish theme issues on aging in November 2002. We invite authors to submit manuscripts reporting original research, including randomized controlled trials and high-quality observational research; systematic reviews; and special communications and scholarly commentaries addressing aging issues. Topics may include interventions that prevent disease, reduce disability, or extend functional years, as well as interventions to improve the afflictions more frequent in older age: Alzheimer disease and other dementias, osteoporosis, frailty, mobility limitations, incontinence, cardiovascular disease, stroke, diabetes, and cancer. Other appropriate topics include providing high-quality care for older adults regardless of race/ethnicity, sex, or ability to pay, and care for persons nearing the end of life. Authors are advised to consult the JAMA Instructions for Authors for guidelines on manuscript submission and preparation. Manuscripts received before June 1, 2002, will have the best chance of acceptance for the November 13, 2002, JAMA theme issue.

Serving Competing Principals: The Budget Estimates of OMB and CBO in an Era of Divided Government

Battles over the federal budget have been at the heart of Washington politics over the past two decades. In assessing the potential consequences of fiscal policy choices, Congress and the president turn to the Congressional Budget Office (CBO) and the Office of Management and Budget (OMB) for spending and revenue estimates. While politicians carp about the partisanship of these agencies, previous scholarly research finds little evidence of bias. In this article, the authors systematically explore these estimates for signs of partisan bias. Specifically, the authors examine differences between OMB and CBO estimates of the president's budget since 1978 and find that agency differences are associated with party control of Congress and the presidency. During periods of divided government, when their principals may be expected to disagree most sharply about spending and taxes, these agencies' expenditure projections diverge.