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Introducing the Budget Offsets Bank

Oct 16, 2019 | Budgets & Projections

The federal debt is at a post-war record high, deficits are set to exceed the trillion-dollar mark this year, and new initiatives are being proposed regularly.

In order to help policymakers offset the cost of new spending programs and tax cuts and slow the growth of the national debt, the Committee for a Responsible Federal Budget will begin publishing a Budget Offsets Bank of options to raise revenue and reduce spending.

Our Budget Offsets Bank shows ranges of potential saving for types of policy changes – readers can contact us to learn more about understanding and designing specific policy changes. These estimates are largely based on those from the Congressional Budget Office and other reputable sources, with adjustments from our staff as needed to account for the passage of time or subsequent legislation.

Our first installment focuses on health care policies that reduce the cost of Medicare, Medicaid, or other federal health spending or increase health-related revenue. We will be publishing additional options in the coming weeks and months. Prior options lists are available here or in the list below. View the full Budget Offsets Bank at crfb.org/Offsets.

Health-Related Offset Options

Health Policy Ten-Year Savings
Medicare Provider Payments  
Reduce excessive payments for post-acute care Up to $85 billion
Equalize hospital and physician payments regardless of site of service $15 to $90 billion
Expand use of bundled payments $10 to $50 billion
Reduce Medicare's coverage of bad debt $10 to $50 billion
Reduce and reform payments for Graduate Medical Education $5 to $50 billion
Reduce and reform payments for uncompensated care (DSH) $5 to $100 billion
Replace sequester with rebased Medicare payments Long-term savings
Reduce and reform payments to rural hospitals $5 to $30 billion
Reduce payments growth to hospitals by 1% $20 billion
Reform Medicare hospice payments $10 billion
Expand penalties for preventable readmissions and unnecessary complications Up to $10 billion
Expand competitive bidding for medical equipment and labs Up to $10 billion
Reform and tighten "Stark rule" to limit self-referrals $5 billion
   
Prescription Drugs  
Allow HHS to negotiate Part D drug prices, but not exclude drugs from coverage less than $10 billion
Require HHS to negotiate Part D drug prices with a cap based on international prices and a large penalty for manufacturers who walk away from negotiations $350 billion
Redesign Medicare Part D benefit, including by adding a catastrophic cap, eliminating the donut hole coverage gap, and reducing government re-insurance for high-cost drugs $35 to $75 billion
Require drug companies to pay “rebates” to reduce costs in Medicare Part D $50 to $200 billion
Restrict drug price increases in excess of inflation in Part B and Part D $70 billion
Tighten Medicaid drug rebates $5 to $20 billion
Allow for drug re-importation Up to $25 billion
Encourage use of generics by low-income Medicare beneficiaries Up to $20 billion
Modify Part B physician administered drug payments that promote high-cost drugs Up to $10 billion
Increase flexibility of the Part D drug formulary $10 billion
Encourage entry of generic drugs and biosimilars $10 billion
Prohibit pharmacy benefit manager spread pricing $5 billion
   
Medicare Beneficiary Responsibility  
Restrict Medigap plans from offering generous wrap-around coverage $100 billion
Restrict TRICARE for life from offering generous wrap-around coverage $35 billion
Restrict employer and other wrap-around coverage Up to $100 billion1
Reform Medicare benefit design to establish unified Part A and B deductible, co-insurance, and a catastrophic cap $0 to $70 billion
Establish cost sharing for home health $5 to $20 billion
Increase Medicare Part B deductible $10 to $20 billion
Increase base Medicare premiums by 10 percent of costs $450 billion
Increase Medicare premiums for high earners $50 to $100 billion
Increase the Medicare eligibility age $20 to $30 billion
   
Medicare Advantage and Private Medicare Plans  
Allow private plans to compete with Medicare, set subsidy based on average bid $50 to $350 billion
Allow private plans to compete with Medicare, set subsidy based on 2nd lowest bid $150 to $800 billion
Set Medicare Advantage payments using competitive bidding $30 to $100 billion
Modify risk adjustment payments to Medicare Advantage plans $50 to $80 billion
Reduce excessive quality bonus payments to Medicare Advantage plans $20 to $110 billion
   
Affordable Care Act  
Reduce Medicaid match in expansion population to match ordinary FMAP $400 billion
Restore Cost Sharing Reduction subsidies $100 billion2
Phase out ACA exchange subsidies above 300 percent of poverty up to $50 billion
Recapture excessive premium subsidies $50 billion
Establish a public option for health exchanges $100 billion
Repeal the Prevention Fund $10 billion
Allow states to apply Medicaid asset tests to expansion population $5 billion
   
Medicaid  
Establish Medicaid spending cap and/or block grant Medicaid $200 to 900 billion
Limit states from inflating the federal Medicaid match through “provider taxes” $5 to $400 billion
Reduce the Federal Medical Assistance Percentage (FMAP) floor Up to $450 billion
Reduce federal Medicaid matching rates for base Medicaid program $50 billion/pp
Match all administrative costs at 50% $65 billion
Establish work and “community engagement” requirement in Medicaid $25 to $100 billion
Encourage states to re-determine Medicaid eligibility more frequently $50 billion
Subject Medicaid managed care plans to medical loss ratio rules $10 billion
Require states to deny personal care payments for duplicative/inappropriate services Up to $10 billion
   
Other Health Savings  
Restrict out-of-network “surprise billing” $20 to $25 billion
Reform medical malpractice law Up to $30 billion
Replace the Federal Employees Health Benefits (FEHB) program with a voucher Up to $35 billion
Introduce TRICARE for Life enrollment fee $15 billion
Extend CHIP programs beyond 2027 $5 billion
   
Health-Related Tax Preferences  
Cap the employer sponsored insurance (ESI) income tax exclusion $100 to $700 billion
Cap the ESI payroll tax exclusion (at median to 90th percentile) $30 to $250 billion
Replace the ESI exclusion with a credit or deduction dialable
Eliminate the ESI exclusion for the Medicare payroll tax   $250 billion
Limit the ESI exclusion for higher income workers $50 to $200 billon
Repeal Cadillac Tax (subtract from options above if replacing Cadillac Tax) -$200 billion
Eliminate income tax deduction for health-related cafeteria plans contributions $400 billion
Eliminate payroll tax deduction for health-related cafeteria plans contributions $200 billion
Limit or end medical expense deduction Up to $75 billion
Limit or repeal health Flexible Spending Accounts (FSAs) Up to $50 billion
Limit or repeal Health Savings Accounts (HSAs) Up to $50 billion
Limit or repeal private activity bonds for nonprofit hospitals $10 to $25 billion
Eliminate orphan drug tax credit $20 billion
Repeal small business tax credit for offering health benefits $10 billion
Repeal Blue Cross/Blue Shield deduction $5 billion
   
Health-Related Revenue  
Raise Medicare payroll tax rate $900 billion/point
Expand the 3.8% Medicare Tax to all passthrough income $200 billion
Apply Medicare payroll tax to all business income from material participants $125 billion
Equalize and increase alcohol taxes $20 to $100 billion
Increase cigarette taxes $40 to $100 billion
Expand cigarette taxes to include vaping $10 billion
Impose tax on sugary drinks $50 to $200 billion
Double employer mandate penalty $50 billion
Establish a food safety user fee $10 billion

1 No official estimate is available for this option, and savings would vary substantially based on design.
2 CBO scores restoring CSRs with no savings due to technical reasons, however they would reduce deficits by about $10 billion per year relative to CBO’s baseline.

Previously Published Offset Options