Beginning to Stem the Red Ink Tide: Health Care Concepts for a Conservative Congress
A PDF version of this paper is available on the Paragon Health Institute website…
Donald Trump’s answer in September’s presidential debate that he had “concepts of a plan” regarding health care drew derision from the left. But the former president’s re-election in November, coupled with the election of Republican majorities in the House and Senate, provides an opportunity not just to formulate a more conservative vision of health care but to enact it into law.
One prime concept should define this new conservative vision: When you’re in a hole, stop digging.[1] Over the past decade-plus, Barack Obama and Joe Biden took concerted efforts to expand the welfare state via Obamacare—but the new Congress provides an opportunity to begin to turn the tide.
Legislative efforts should focus first on pausing and freezing the myriad new regulatory and entitlement expansions created by the Obama and Biden administrations. Congress should also repeal the most egregious examples of wasteful and inefficient government spending on health care. These preliminary steps would restore a pattern of lawmakers regularly taking steps to rein in federal spending, laying down a precedent for a more comprehensive approach to right-size the federal budgetary commitment to health care.
Prevent Further Extension of Enhanced Subsidies
Consistent with the Hippocratic Oath’s advice to “First, do no harm,” conservatives in Congress should not extend the enhanced exchange subsidies first enacted by Democrats in 2021 and instead allow them to expire at the end of 2025 as scheduled. For multiple reasons, allowing the enhanced subsidies to sunset would benefit taxpayers and the health insurance system as a whole.
First, extending the enhanced subsidies comes with a significant cost. The Congressional Budget Office (CBO) found that a 10-year extension would cost $335 billion over a decade—along with $48.3 billion in added interest costs over the same period.[2] At a time when the national debt exceeds $36 trillion, and the federal government’s health care spending continues to grow at an unsustainable rate, this nearly $400 billion expenditure represents a sizable expenditure of scarce taxpayer dollars.
Moreover, the expenditure constitutes an unwise use of taxpayer funds that would accelerate the deterioration of employer-sponsored health coverage. CBO concluded that a permanent extension of the enhanced subsidies would lead to “a 3.5 million decrease in enrollment in employment-based coverage,” largely due to a “reduction in offers of employment-based coverage.”[3] In CBO’s opinion, a permanent extension of the enhanced subsidies would mean that “more employers would change their offers of health insurance,” dropping their employer plans and sending workers to the exchanges.[4] As a result, more individuals would lose their existing coverage from their employers than would become newly insured due to the enhanced subsidies.[5]
This phenomenon of crowd-out—whereby government subsidies encourage more employers to drop private coverage—represents one of many inefficiencies created by the enhanced exchange subsidies. Fraud and abuse constitute another source of government waste, with more individuals signing up for zero-premium (i.e., “free”) benchmark plans than are eligible for such plans in many states.[6] Other reports indicate that the zero-premium plans created by the American Rescue Plan Act have encouraged unscrupulous insurance brokers to unsuspectingly enroll individuals and change their plan selections without their knowledge or consent, allowing the brokers to receive commissions from insurance companies.[7]
Supporters of the enhanced federal subsidies may cite CBO estimates indicating that the number of uninsured might rise by a modest amount—in the range of 3-4 million—should the higher subsidy amounts not get extended.[8] However, CBO also indicated that approximately 40 percent of the increase in the number of uninsured would come over a year after the increased subsidies expire: “CBO assumes enrollees would need time to fully respond to the expiration, for example, because of automatic renewal policies.”[9] That estimate suggests that a sizable percentage of subsidy recipients are effectively “zombie enrollees”—that is, they receive subsidies because they enrolled at some prior point, because the subsidies do not require them to pay premiums out of pocket and because the federal government automatically renews this “free” subsidized coverage.[10] The fact that CBO believes 1.5 million individuals would take no action for a year should the enhanced subsidies expire suggests that many of these recipients find the coverage of little value or benefit.
The structure of Obamacare has created an insurance package that most beneficiaries do not value, as the federally mandated package of benefits means that health insurers have but two levers to control premiums. Insurers can (and most do) create narrow networks of medical providers, making access to actual care a challenge for beneficiaries.[11] When patients do find doctors that accept their insurance, high deductibles often make that coverage “all but useless.”[12] While exchange enrollees will sign up for insurance that federal subsidies make “free,” or nearly so, most will not spend much of their own money on plans providing little actual coverage for the things they value—namely, robust access to care and financial protection.
As it happens, the debate around coverage expansions, while important, distracts from the decidedly mixed effects of those coverage expansions on patients’ health. Most studies suggest that expansions of health insurance provide little measurable improvement in health care, in part because uninsured patients can obtain charity care or apply for and receive coverage if they suffer catastrophic medical events.[13] As a result, newly insured individuals derive little value from gaining coverage, with most of the benefit going to external entities (such as hospitals) that would otherwise provide uncompensated care.[14] This dynamic explains why hospitals and health insurers strongly support extending the enhanced subsidies, because those federal payments benefit their own bottom lines—as opposed to those of beneficiaries—while insulating beneficiaries from the effects of premium increases.
In arguing for the enhanced subsidies, supporters might also cite CBO estimates noting that gross benchmark premiums would rise by about 8 percent should the enhanced subsidies lapse, largely because some healthy people would disenroll from exchange coverage absent the higher premium subsidies.[15] However, supporters’ warnings of increased premiums directly contradict their own focus on the number of enrollees who qualify for federal premium subsidies, meaning they would not bear the financial impact of any premium increases.[16] Lawmakers should not spend billions of dollars throwing money at exchange enrollees to get them to maintain their coverage just to lower a theoretical premium amount that most enrollees do not pay anyway.
Congress should not extend a package of costly and inefficient subsidies that weakens employer-sponsored coverage, encourages employers to drop their insurance offerings to place more individuals on the government rolls, promotes fraud, and provides coverage that many enrollees do not appear to value. Instead, because many beneficiaries pay little or nothing out-of-pocket in monthly premiums (unlike Medicare or employer-provided coverage), Congress or the new administration should end automatic renewal for subsidized exchange enrollees, just as most states require annual eligibility determinations of Medicaid recipients. And Congress should increase subsidy repayment amounts for individuals who misstate their income when originally applying for subsidized coverage, reducing a source of the fraud that has plagued many exchanges in recent years.[17]
Repeal Harmful and Costly Regulations
The new Trump administration will undoubtedly engage in efforts to rewrite, rescind, withdraw, or otherwise cancel many of the more onerous and controversial regulations promulgated by the Biden administration. However, Congress also has a role to play in these deregulatory efforts. Rescinding rules via statute, rather than through unilateral executive action, would preclude a future administration from reinstating any Biden-era regulations.
Additionally, congressional action to rescind regulations would in many cases generate sizable budgetary savings, which could be passed on to the American people by renewing the tax relief provisions of the Tax Cuts and Jobs Act (TCJA) of 2017, major portions of which are currently scheduled to expire in December 2025. Under Senate rules and procedures outlined in the Congressional Budget Act, a budget reconciliation measure can provide permanent tax relief without becoming subject to the usual 60-vote margin needed to overcome a Senate filibuster—but only if the tax relief provisions are paid for outside the 10-year budgetary window, preferably by reducing federal spending.[18]
Between legislation enacted under unified Democratic control of Congress in 2021-2022 and regulatory proposals enacted via unilateral executive action, the Biden administration has increased federal spending to such a degree that cancelling this spending would fund most, if not all, of the cost of permanently extending the expiring TCJA provisions.[19] Much of that spending, such as climate subsidies and student loan “forgiveness,” lies outside of the scope of this paper. However, several costly Biden administration regulations will increase spending on federal health care programs. Congress should rescind these regulations as part of a budget reconciliation measure, yielding sizable budgetary savings.
Medicaid Eligibility and Renewal
In April 2024, the Centers for Medicare and Medicaid Services (CMS) released a final rule enacting a series of changes regarding Medicaid eligibility and renewal policies.[20] Among many other new requirements, the rule prohibits several policies designed to ensure program integrity within Medicaid, including eligibility determinations more frequently than every 12 months, in-person interviews, and waiting periods for enrollees in the Children’s Health Insurance Program.[21]
According to the most recent estimates, Medicaid suffered from $31.1 billion in improper payments in fiscal year 2024.[22] While not all improper payments constitute fraud, the $31.1 billion figure represents a substantial underestimate of the level of improper payments in Medicaid, because states could not verify eligibility—a prime source of payment errors—for three years due to the COVID pandemic. The more accurate number of Medicaid improper payments—$86.49 billion, or 21.36 percent of all Medicaid spending—comes from November 2020, the last year the estimates incorporated states’ Medicaid eligibility reviews that were suspended during the COVID public health emergency.[23] Given the sizable level of improper payments within Medicaid on both an absolute and a percentage basis, the rule’s new limits on state flexibility to ensure program integrity seem particularly unwise.
In addition, the rule will impose costs on federal and state governments alike. CMS estimates that the new requirements will increase federal spending by a net of $22 billion between 2024 and 2028.[24] As a result, the Office of Management and Budget (OMB) had to waive a new requirement, included in the April 2023 debt ceiling agreement, federal spending must be coupled with rules that decrease federal spending.[25] The same CMS estimates indicate that the rule will raise the state portion of Medicaid spending by $23.2 billion through 2028, or nearly $50 billion within a decade.[26]
Congress should repeal a rule that contains new unpaid-for spending, imposes additional unfunded mandates on state governments, and undermines not just state flexibility but efforts to improve Medicaid program integrity and combat fraud.
Medicaid Managed Care Rule
Shortly after releasing the Medicaid eligibility rule, in May 2024 CMS also published a final regulation regarding Medicaid managed care.[27] The regulation imposes myriad new requirements on state Medicaid programs and managed care plans regarding quality improvement, financing, and other metrics.
Those requirements will prove burdensome to states and managed care plans alike. According to the CMS estimates, the rule will require a total of 1,880,356 man-hours to comply with all the new federal requirements.[28] Excluding one-time burdens, the annualized cost of compliance will come to an average of 112,648 man-hours per year.[29] These higher compliance costs will raise premiums and also impose a burden on the taxpayers that fund state Medicaid programs.
Other estimates in the managed care rule also indicate that the proposals will raise Medicaid spending. For instance, CMS estimates that one series of proposals regarding state-directed payments, by explicitly authorizing states to pay providers at rates up to the average of commercial insurance, will raise Medicaid spending by at least $27 billion ($17.6 billion federal, $9.4 billion state) through 2028, and it could raise Medicaid spending by as much as $129.6 billion ($83.9 billion federal, $45.7 billion state) over the same time period.[30] Another series of proposals—these related to paying for non-medical services (e.g., nutritious meals, respite services for caregivers, and services related to social determinants of health)—could raise Medicaid spending by as much as $8.4 billion ($5.3 billion federal, $3 billion state) through 2028.[31] As with the Medicaid eligibility rule, the likelihood of increases in federal mandatory spending directly attributable to the managed care rule required OMB to waive the Administrative Pay-As-You-Go Act.[32]
While the Biden administration’s OMB waived away the impact of the new spending in the Medicaid managed care rule, taxpayers will have no such option. For this reason, Congress or the new administration should at minimum remove the rule’s incentives for state Medicaid programs to raise payment levels up to the average of commercial insurance, which could cost the federal government up to $200 billion over the coming decade. Lawmakers should also consider whether to repeal the entire rule outright, which would save managed care plans and state Medicaid programs from its myriad new administrative burdens.
Nursing Home Rule
On the same day it published the Medicaid eligibility and managed care rules, CMS also issued the final version of another major rule, this one regarding nursing home standards.[33] This regulation imposed new requirements regarding staffing levels for all nursing homes that accept Medicare and Medicaid patients. CMS claimed that it needed to impose the new mandates to increase safety for nursing home residents, but Congress, as CMS acknowledged, had previously laid out explicit staffing requirements for nursing homes in federal law.[34] In the rule, CMS claimed it had “separate authority” to lay out additional staffing requirements over and above the ones Congress had previously prescribed.[35]
Those additional requirements will place significant new costs on the nursing home industry. In the final rule, CMS calculated their impact at $43 billion over a decade while conceding that outside estimates arrived at higher amounts.[36] Even the lower CMS estimates understate the rule’s costs once fully implemented, because they assume significantly lower implementation costs in the rule’s first two years.[37]
Because government programs such as Medicare and Medicaid pay for the overwhelming portion of nursing care provided nationwide, those programs face sizable potential costs from the rule. Assuming that the rule’s $43 billion in costs over its first decade are allocated proportionately according to the share of nursing home residents covered by the two programs, Medicaid faces nearly $28.2 billion in costs ($11.7 billion state, $16.5 billion federal), while Medicare faces over $4.7 billion in costs.[38] While the rule’s higher costs to Medicaid programs would impose fiscal burdens on state budgets, the higher costs to the Medicare Hospital Insurance Trust Fund, which funds skilled nursing home care for Medicare patients, would undermine the trust fund’s solvency.
Since the rule’s publication, the largest trade association for nursing homes has filed suit in federal court, claiming the regulation exceeds CMS’s statutory authority.[39] Members of both the House and the Senate have filed resolutions of disapproval seeking to strike down the new requirements.[40] While neither measure has received a floor vote, the Energy and Commerce Committee approved the House measure in September, and the Senate resolution has amassed 35 bipartisan co-sponsors.
Given the bipartisan opposition to this rule, the new Congress should complete the work of the last Congress and strike it down. If fully implemented, the rule would raise Medicare and Medicaid spending, undermine Medicare’s solvency, place an unfunded mandate on states, and exacerbate existing workforce shortages within the nursing home and long-term care industry.
Unilateral “Fix” to Family “Glitch”
In October 2022, the Treasury Department issued final regulations changing the affordability test to qualify for exchange subsidies.[41] Under the new Biden rule, dependents (i.e., spouses and children) can qualify for taxpayer-funded exchange subsidies if they are offered employer coverage, but that family coverage is “unaffordable,” as defined by Obamacare.
However, this interpretation violates the plain text of the law, which states that all members of a household, including dependents, do not qualify for subsidies if an employee in the household has an “affordable” offer of self-only coverage from an employer—irrespective of whether that employer-based coverage is “affordable” for the entire family.[42] While Democrats have called this provision the “family ‘glitch,’” implying that the law was not working as designed, it constituted nothing of the sort—the provision blocking dependents from qualifying for subsidies was part of an by congressional Democrats to reduce Obamacare’s total cost at the time of its passage.[43]
In the years leading up to the rollout of the exchanges, the Obama administration concluded it did not have the statutory authority to make dependents without offers of “affordable” employer coverage eligible for subsidies. However, the Biden administration subsequently overrode the Obama administration’s interpretation and rewrote the law unilaterally to expand subsidy eligibility.[44]
President Biden made no bones about his desire to overturn the prior—and correct—interpretation of this provision of law, directing officials in an executive order issued in his administration’s first days to reassess “policies or practices that may reduce the affordability of coverage or financial assistance for coverage, including for dependents.”[45] Unfortunately, Treasury Department and Internal Revenue Service officials succumbed to the President’s political pressure and acquiesced.[46] To top it off, Biden administration officials promulgated the rule in a procedurally flawed way, whereby OMB officials cancelled meetings scheduled with a group of analysts concerned by the legal and economic implications of the proposal.[47]
On top of its many legal flaws, the rule represents an inefficient use of scarce taxpayer resources. According to the Urban Institute, only about 4 percent, or 190,000, of the roughly 4.8 million individuals eligible for subsidies under this policy would gain access to coverage after being uninsured.[48] Instead, most of the federal spending would come from individuals dropping their private, employer-based coverage to receive taxpayer-funded exchange subsidies. The same Urban Institute analysis confirmed how the policy would substitute public dollars for private ones, noting that federal spending would increase by an average of $3.2 billion per year, even as employer contributions declined by roughly $2 billion annually.[49]
While it did not contain a full cost estimate, the final rule stated that the Treasury’s Office of Tax Analysis assessed the change as costing “an average of $3.8 billion per year over the next 10 years,” or $38 billion over a decade.[50] According to its most recent estimate, CBO estimated that the regulation would cost $45 billion over that same time frame.[51] Rescinding the Biden administration rule should generate “scorable” savings roughly consistent with those two estimates.
Congress should repeal this unwise—and arguably illegal—rule for multiple reasons. It does not comport with the text or intent of the law and therefore spends money that the legislative branch has not authorized. It also undermines private, employer-based coverage to make more individuals dependent on taxpayer-funded subsidies.
Exchange Subsidies for Undocumented Immigrants
In May 2024, CMS released a final rule allowing individuals participating in the Deferred Action for Childhood Arrivals (DACA) program to qualify for exchange coverage.[52] The Treasury regulation re-defined the term lawfully present to encompass DACA recipients, making them eligible for taxpayer-funded subsidies, even though most already have health insurance coverage.[53]
In August 2024, a group of state attorneys general filed suit in federal court to block the rule.[54] The complaint alleged that the Biden regulations violate the 1996 welfare reform law, which included a provision preventing non-qualified aliens from receiving taxpayer-funded benefits. It also accused the Biden administration of violating the text of Obamacare itself by redefining lawfully present to include “the class of individuals whom [the Department of Homeland Security] is deferring removal action based on their unlawful presence.”[55] The states objected to the higher immigration enforcement costs—and higher administrative costs to those states that run their own exchanges—stemming from the rule and sought judicial relief on that basis.
In December, a federal judge in North Dakota granted a stay and a preliminary injunction barring enrollment in the 19 states that challenged the Biden administration regulation in court.[56] Even if the new Trump administration refuses to defend the Biden administration’s regulation in court, Congress should still take action to repeal it outright—to provide policy certainty to all states in light of the legal dispute, to respond to the executive branch’s attempts to rewrite congressional statutes unilaterally, and to discourage additional illegal migration.
As part of the final rule, the Treasury Department estimated its financial impact at $1.15 billion over five years.[57] However, CBO believes this change would generate higher budgetary costs of at least $7 billion over a decade.[58] The higher cost estimate comes from CBO’s belief that more DACA recipients (at least 110,000) would obtain subsidized coverage than the Treasury estimated (roughly 86,000).[59] The Treasury’s lower numbers stem largely from its assumption that none of the nearly three-quarters (73 percent) of DACA recipients who already have health insurance would switch or cancel their current coverage to obtain subsidized policies on the exchanges.[60]
End Wasteful Spending
Over and above repeal of existing regulations, lawmakers should also begin to work to rein in the health care spending that has made the federal government’s budget unsustainable in the long term. The announcement by the Trump transition team creating a putative Department of Governmental Efficiency (DOGE) represents a step in the right direction, as it identifies wasteful spending and unnecessary regulations as impediments to strong economic growth.[61] However, DOGE’s efforts can succeed only if Congress follows through to eliminate unnecessary government spending, including those on ineffective and wasteful health care programs.
Citizenship Verification in Federal Health Programs
Verification of eligibility to receive health benefits has its roots in a 2005 report that found that 46 states, plus the District of Columbia, relied on self-attestation of citizenship status, 27 of which made no attempts to verify this self-attestation.[62] Shortly thereafter, the Republican-controlled Congress created a verification regime in Section 6036 of the Deficit Reduction Act (DRA), which required state Medicaid programs to verify identity and citizenship on the basis of appropriate documentation.[63]
When Democrats regained control of Congress in January 2007, they created an alternative verification regime as part of a children’s health insurance reauthorization, which relies primarily on matching an applicant’s name and Social Security number. Although President George W. Bush vetoed two versions of the children’s health insurance legislation in late 2007, and Congress sustained his veto, Barack Obama signed a similar version into law in February 2009 shortly after taking office.[64]
Obamacare’s exchanges use a similar verification regime.[65] By relying on a Social Security number match, this regime verifies that a named individual is a citizen—but it provides little verification that the applicant is the person he purports himself to be. [66]
Lawmakers have a vested interest in ensuring that individuals illegally present in the country do not receive taxpayer funded benefits, both to ensure wise use of taxpayer resources and to discourage additional migration. As none other than Hillary Clinton testified before Congress in the fall of 1993:
We do not think the comprehensive health care benefits should be extended to those who are undocumented workers and illegal aliens. We do not want to do anything to encourage more illegal immigration into this country. We know now that too many people come in for medical care, as it is. We certainly don’t want them having the same benefits that American citizens are entitled to have.[67]
For the reasons Clinton outlined over three decades ago, Congress should repeal the more lenient verification regime enacted in 2009 and replace it with a requirement that all insurance exchanges and state Medicaid programs use the verification regime created as part of the DRA.[68] Such measures would ensure that government resources are spent wisely and dedicated to the recipients for whom they were designed.
Incentives for States to Expand Medicaid to Able-Bodied Adults
A prime source of budgetary savings should come from the repeal of Section 9814 of the American Rescue Plan Act, Democrats’ COVID-era spending legislation. This provision offers states that have not already accepted Obamacare’s Medicaid expansion a five-percentage-point increase in the federal Medicaid match rate for their existing Medicaid populations (e.g., pregnant women, children, and individuals with disabilities) for two years should they accept the Obamacare expansion to able-bodied adults.[69] According to one liberal think tank, this provision offers $13.1 billion in higher federal matching funds to the 10 states that have not accepted Medicaid expansion.[70]
While it might appear generous to give additional federal funds to states that have yet to expand, Section 9614 effectively offers states temporary increases in their federal match rates if they accept permanent increases in their fiscal obligations via Medicaid expansion. Given how many Medicaid expansion states have seen the financial costs of expansion vastly exceed their original projections, the non-expansion states should not accept what amounts to a raw deal from Washington.[71]
Moreover, a temporary increase in the federal match for existing Medicaid populations does not disguise the fact that Obamacare’s Medicaid expansion effectively discriminates against these individuals by offering states a higher federal match to cover able-bodied adults than to provide care to vulnerable populations, including individuals with disabilities.[72] Congress should reject this flawed—and immoral—sense of priorities by repealing Section 9614’s incentive for states to expand Medicaid to able-bodied adults.
Make Waivers and Demonstration Projects Budget Neutral
In recent years, the executive branch has engaged in a series of questionable decisions regarding Medicaid waivers established under Section 1115 of the Social Security Act and Medicare demonstration projects established under Section 402 of the Social Security Act amendments.[73] Government policy states that Medicaid waivers and Medicare demonstration programs should be approved on a budget-neutral basis—that is, federal taxpayers should not incur additional costs as a result of these reform proposals—but this policy is not codified in federal law or regulations.
In several instances, the Obama and Biden administrations have violated this budget-neutrality principle. Government auditors have repeatedly criticized their actions as lacking a proper legal basis and wasting taxpayer dollars:
- In August 2014, the Government Accountability Office (GAO) reported that the Obama administration approved a Medicaid expansion waiver for Arkansas with a spending limit that was $778 million (or nearly 25 percent) higher than it should have been and improperly permitted Arkansas to adjust that spending limit even higher.[74] The decision by the Obama administration came as it attempted to convince Republican-leaning states such as Arkansas to accept Obamacare’s expansion of Medicaid to able-bodied adults.
- In March 2012, GAO recommended that the Obama administration cancel a Medicare Advantage demonstration program that gave bonus payments to Medicare Advantage insurers, stating that its $8 billion cost “dwarfs all other Medicare demonstrations … conducted since 1995” and that it was “unlikely that the demonstration will produce meaningful results.”[75] Four months later, GAO reiterated that “we remain concerned about the agency’s legal authority to undertake the demonstration.”[76] Notwithstanding GAO’s criticisms, the Obama administration retained the program. Critics charged that this demonstration program effectively undid much of Obamacare’s reductions to Medicare Advantage payments in advance of Obama’s 2012 re-election bid.[77]
- In July 2024, the Biden administration announced a “premium stabilization demonstration” for the Medicare Part D program covering 2025 and potentially beyond.[78] The program, designed to offset effects of the Inflation Reduction Act that will raise Medicare prescription drug premiums in 2025 and succeeding years, will increase federal Medicare spending by $5 billion in 2025 alone, according to CBO, along with an additional $2 billion in interest costs over the coming decade.[79] While GAO has not yet formally commented on the legality of the Biden administration’s demonstration, it contains several of the same characteristics of the Obama administration demonstration that GAO criticized in 2012, including the lack of a comparison group from which Medicare can draw policy conclusions. Critics have again charged that the Biden administration created this $5 billion demonstration for ostensibly political purposes—namely, to avoid hitting seniors with a major increase in Medicare premiums just ahead of the November 2024 election.[80]
GAO has on multiple occasions called for Congress to codify specific requirements that the Department of Health and Human Services must undertake to ensure the budget neutrality of state Medicaid waivers.[81] Lawmakers should do exactly that—and require that Medicaid waivers and demonstration programs be undertaken on a budget-neutral basis with clear criteria for determining a program’s costs. While the executive branch should have flexibility to innovate within the Medicare and Medicaid programs, such flexibility should not become a justification for presidents of either party for politically motivated giveaways.[82]
Restrict Provider Taxes
Congress should begin work to end a mechanism that amounts to little more than of an at best questionable legality. Through these taxes, a group of medical providers within a state—for instance, hospitals, nursing homes, or managed care plans—agree to an assessment on their organizations. The state uses these funds to receive federal Medicaid matching dollars from Washington and then distributes those dollars back to the respective providers.
Provider taxes represent one of the few government-imposed levies that any individual or organization enjoys paying. As a recent Politico article notes, a provider “tax” amounts to “a tax no one really pays,” because it ultimately leads to more revenue for the medical profession.[83] Provider taxes have proven lucrative for both state Medicaid programs and the health care industry. Even prior to Obamacare’s enactment, an entire industry of consultants—many of them funded by contingency fees—emerged that focused solely on advising state Medicaid programs on how to bilk the federal government into paying a larger share of the states’ Medicaid costs via provider taxes and other funding schemes.[84]
Many states that have accepted Obamacare’s expansion to the able-bodied have funded the 10 percent state share of expansion costs through new or expanded provider taxes—using a budget gimmick to shift costs back to Washington rather than taking general revenue dollars from education or other state priorities. One liberal advocacy organization noted that 14 states funded some or all of their expansion costs in 2018 via some type of provider or insurer tax, effectively advertising that states could pay their costs with “free” federal money using this funding gimmick.[85]
Numerous independent budget experts, including the Simpson-Bowles Commission and the Rivlin-Domenici commission in 2011, have recommended phasing out and eliminating Medicaid provider taxes.[86] Journalist Bob Woodward noted that when serving as vice president, Joe Biden himself reportedly took a dim view of provider taxes during negotiations over the debt limit in 2011:
It’s a scam, Biden agreed. The states were gaming the system, taxing doctors and hospitals so they could get federal reimbursements and then returning the money to the providers. Let’s call it like it is, and let’s just do this…. It could save $40 billion. “If we can’t do this—” the Vice President said, “come on!”[87]
The quotes from Woodward suggest that Biden understood the abusive nature of these schemes and appreciated the need for reform—or at least he did in 2011. Since then, unfortunately, the “scam” has only increased among states, with the percentage of state Medicaid funds generated by provider taxes more than doubling from 2008 through 2018.[88]
Given Biden’s use of the “scam” terminology, restricting provider taxes would not “cut” federal dollars from Medicaid so much as address a marginally licit funding source that states never should have utilized in the first place. Doing so would properly restore the balance between federal and state governments, whereby the latter do not depend on bailouts and budget gimmicks from the former.
At minimum, lawmakers should put a moratorium on any new provider taxes—that is, prohibit states from creating new taxes or extending or expanding any existing levies. This move would prevent states from causing additional damage to the federal government’s fiscal position from this abusive mechanism. At that point, Congress can consider ways to scale back the provider taxes already in place, with an eye toward eliminating this scheme of legalized fraud over a longer period.
Similarly, lawmakers should also crack down on intergovernmental transfers, wherein state governments receive funding from local or county entities—often publicly owned hospitals and nursing homes—to draw down additional federal Medicaid dollars. In 2000, the left-leaning Center on Budget and Policy Priorities called these transfers “Rube Goldberg-like accounting arrangements that “use complex accounting gimmicks to secure additional federal funds for states without actual state matching contributions.”[89] As with provider taxes, Congress should at minimum place a moratorium on new intergovernmental transfers in the hopes of eliminating this major budgetary gimmick over time.
Establish a Culture of Efficiency
The steps outlined above would complement DOGE’s efforts to make government leaner, more effective, and more efficient. Enacting some or all of these proposals as part of a budget reconciliation measure would establish a precedent for Congress and the executive to work together to begin tackling structural budget deficits, including the rising levels of spending on federal health care programs.
Lawmakers interested in more comprehensive reforms could certainly go further to achieve budgetary savings. For instance, reforming the federal Medicaid matching rate—which encourages wealthier states to over-expand their programs and provides states with a higher federal match to cover able-bodied adults than to care for individuals with disabilities and the most vulnerable—would yield both better policy and potential fiscal savings.[90] Other reforms in this vein could include Medicaid block grants and work requirements for able-bodied beneficiaries.
But more than anything else, Congress should begin to address the rising tide of red ink within the federal government—a movement that should start by halting the welfare state expansions of the past dozen-plus years. From there, conservatives can work to right-size the federal budgetary commitment to health care and enact more policies that move the health care system toward a patient-centered—rather than government-focused—model.
This post was originally published by the Paragon Health Institute.
[1] Chris Jacobs, “Health Care Concepts for a GOP Congress,” Wall Street Journal, November 13, 2024, https://www.wsj.com/opinion/healthcare-concepts-for-a-gop-congress-trump-second-term-out-with-taxes-regulations-in-with-fiscal-responsibility-8d783e78.
[2] CBO, letter to Reps. Jodey Arrington and Jason Smith regarding permanent extension of enhanced premium tax credit, June 24, 2024, https://www.cbo.gov/system/files/2024-06/60437-Arrington-Smith-Letter.pdf.
[3] CBO, letter to Reps. Arrington and Smith.
[4] CBO, letter to Reps. Arrington and Smith.
[5] Chris Jacobs, “Biden’s Health Insurance Plan Would Grow the Deficit by $335 Billion in Ten Years,” The Federalist, July 15, 2024, https://thefederalist.com/2024/07/15/bidens-health-insurance-plan-would-grow-the-deficit-by-335-billion-in-10-years/. The June 24, 2024, CBO letter to Reps. Arrington and Smith notes that 3.5 million individuals would lose their existing employer plans should the subsidies get permanently extended, while only 3.4 million individuals would newly gain health insurance.
[6] Brian Blase and Drew Gonshorowski, “The Great Obamacare Enrollment Fraud,” Paragon Health Institute, June 2024, https://paragoninstitute.org/wp-content/uploads/2024/06/The-Great-Obamacare-Enrollment-Fraud_FOR_RELEASE_V1.pdf.
[7] Julie Appleby, “ACA Health Insurance Plans Are Being Switched without Enrollees’ OK,” Kaiser Health News, April 1, 2024, https://www.npr.org/sections/health-shots/2024/04/01/1241747442/aca-health-insurance-brokers-obamacare-fraud.
[8] CBO, letter to Reps. Arrington and Smith; CBO, letter to Sen. Ron Wyden et al. regarding effects of expiration of enhanced premium tax credits, December 5, 2024, https://www.cbo.gov/system/files/2024-12/59230-ARPA.pdf.
[9] Ibid.
[10] Chris Jacobs, “Congressional Budget Office Admits Obamacare ‘Zombie Enrollees’ Waste Billions of Taxpayer Dollars,” The Federalist, December 12, 2024, https://thefederalist.com/2024/12/12/congressional-budget-office-admits-obamacare-zombie-enrollees-waste-billions-of-taxpayer-dollars/.
[11] Daniel Cruz and Greg Fann, “It’s Not Just the Prices: ACA Plans Have Declined in Quality Over the Past Decade,” Paragon Health Institute, September 2024, https://paragoninstitute.org/wp-content/uploads/2024/09/Its-Not-Just-the-Prices_Dan-Cruz_Greg_Fann_FOR-RELEASE_V1.pdf.
[12] Robert Pear, “Many Say High Deductibles Make Their Health Law Insurance All but Useless,” New York Times, November 15, 2015, https://www.nytimes.com/2015/11/15/us/politics/many-say-high-deductibles-make-their-health-law-insurance-all-but-useless.html.
[13] Joel Zinberg and Liam Sigaud, “What Matters for Health: Insurance Is Less Than You Think,” Paragon Health Institute, December 3, 2024, https://paragoninstitute.org/wp-content/uploads/2024/12/Zinberg-Sigaud_What-Matters-For-Health_Insurance_FOR-RELEASE_V3.pdf.
[14] Amy Finkelstein et al., “The Value of Medicaid: Interpreting Results from the Oregon Health Insurance Experiment,” National Bureau of Economic Research, June 2015, https://www.nber.org/system/files/working_papers/w21308/w21308.pdf.
[15] CBO, letter to Sen. Wyden et al., pp. 3-4.
[16] For instance, a recent CMS fact sheet advertises that “four in five HealthCare.gov customers will still be able to find health care coverage for $10 or less per month for 2025 after subsidies.” CMS, “Marketplace 2025 Open Enrollment Fact Sheet,” October 25, 2024, https://www.cms.gov/newsroom/fact-sheets/marketplace-2025-open-enrollment-fact-sheet. The dynamic whereby few exchange enrollees paid the full premium occurred long before enactment of the subsidy increases in March 2021. A 2014 Department of Health and Human Services (HHS) analysis of the exchanges’ first year concluded that 85 percent of individuals who signed up for exchange coverage qualified for federal subsidies. See HHS, Office of the Assistant Secretary for Planning and Evaluation (ASPE), “Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period,” May 1, 2014, Table 5, p. 15, https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//44226/ib_2014Apr_enrollment.pdf. A separate HHS analysis of 2014 enrollments found that nearly seven in ten (69 percent) of federal exchange enrollees who qualified for subsidies paid $100 or less per month for coverage. See Amy Burke et al., “Premium Affordability, Competition, and Choice in the Health Insurance Marketplace, 2014,” ASPE, June 18, 2014, Table 3, p. 7, https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//44246/2014MktPlacePremBrf.pdf.
[17] Since passage of the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 (Pub. L. No. 112-9), repayment amounts have been capped at fixed amounts, adjusted annually for inflation. In 2024, per Internal Revenue Service Revenue Procedure 2023-34, those repayment amounts were capped at $375 for individuals and $750 for households with incomes at or below two times the federal poverty level ($31,200 for a family of four in 2024), $950 for individuals and $1,900 for households with incomes between two and three times poverty, and $1,575 for individuals and $3,150 for households with incomes between three and four times poverty. Section 9662 of the American Rescue Plan Act of 2021 (Pub. L. No. 117-2) suspended repayments for the 2020 tax year for all individuals who filed income tax returns.
[18] Chris Jacobs, “If Republicans Want to Extend Trump’s Tax Cuts, They Should Cut Spending to Do It,” The Federalist, August 19, 2024, https://thefederalist.com/2024/08/19/if-republicans-want-to-extend-trumps-tax-cuts-they-should-cut-spending-to-do-it/.
[19] Chris Jacobs, “CBO Gives Republicans a Chance for Real Tax Reform,” Wall Street Journal, February 9, 2024, https://www.wsj.com/articles/republicans-chance-for-real-tax-reform-federal-spending-545ef881; Chris Jacobs, “Cancel Biden’s Spending to Pay for Tax Cuts,” Wall Street Journal, May 14, 2024, https://www.wsj.com/articles/cancel-bidens-spending-to-pay-for-tax-cuts-bf6a9eea. For instance, repealing the roughly $1.2 trillion in green energy subsidies from the Inflation Reduction Act, a 2021 change to food stamp policy costing $425 billion, and more than $500 billion in student loan “forgiveness” would generate more than half the $3.8 trillion in savings necessary to pay for a full TCJA extension.
[20] CMS, “Medicaid Program: Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes,” 89 Fed. Reg. 22780-22878 (Apr. 2, 2024), https://www.govinfo.gov/content/pkg/FR-2024-04-02/pdf/2024-06566.pdf.
[21] Jackson Hammond, “Biden’s Medicaid Changes: High Costs, Misguided Policy,” Paragon Health Institute, November 6, 2024, https://paragoninstitute.org/wp-content/uploads/2024/11/Bidens_Medicaid_Changes_Jackson-Hammond_FOR-RELEASE_V2.pdf.
[22] CMS, “Fiscal Year 2024 Improper Payments Fact Sheet,” November 15, 2024, https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2024-improper-payments-fact-sheet.
[23] CMS, “Fiscal Year 2020 Improper Payments Fact Sheet,” November 16, 2020, https://www.cms.gov/newsroom/fact-sheets/2020-estimated-improper-payment-rates-centers-medicare-medicaid-services-cms-programs.
[24] CMS, “Medicaid Program: Streamlining,” Table 25, p. 22864. Reflects an increase in federal Medicaid spending of $36.2 billion, an increase in CHIP spending of $1.2 billion, and a decrease in federal spending on Exchange subsidies of $15.4 billion.
[25] CMS, “Medicaid Program: Streamlining,” p. 22865; Statutory Administrative Pay-As-You-Go Act of 2023, Title III of Fiscal Responsibility Act, Pub. L. No. 118-5.
[26] CMS, “Medicaid Program: Streamlining,” Table 24, p. 22863. Includes $22.7 billion in state Medicaid spending and $490 million in state CHIP spending.
[27] CMS, “Medicaid Program: Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality,” 89 Fed. Reg. 41002-41285 (May 10, 2024), https://www.govinfo.gov/content/pkg/FR-2024-05-10/pdf/2024-08085.pdf.
[28] CMS, “Medicaid Program: Medicaid and Children’s Health Insurance Program,” Table 7, p. 41256.
[29] CMS, “Medicaid Program: Medicaid and Children’s Health Insurance Program,” Table 7, p. 41256.
[30] CMS, “Medicaid Program: Medicaid and Children’s Health Insurance Program,” Table 10, p. 41260.
[31] CMS, “Medicaid Program: Medicaid and Children’s Health Insurance Program,” Table 12, p. 41263.
[32] CMS, “Medicaid Program: Medicaid and Children’s Health Insurance Program,” p. 41266.
[33] CMS, “Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting,” 89 Fed. Reg. 40876-41000 (May 10, 2024), https://www.govinfo.gov/content/pkg/FR-2024-05-10/pdf/2024-08273.pdf.
[34] Section 1819(b)(4)(C) of the Social Security Act (42 U.S.C. 1395i-3(b)(4)(C)) and Section 1919(b)(4)(C) of the Social Security Act (42 U.S.C. 1396r(b)(4)(C)).
[35] CMS, “Minimum Staffing Standards,” pp. 40890-40891.
[36] CMS, “Minimum Staffing Standards,” pp. 40949-40953.
[37] CMS, “Minimum Staffing Standards,” Table 22, p. 40970.
[38] CMS, “Minimum Staffing Standards,” Table 23, p. 40972, and Table 24, p. 40974.
[39] American Health Care Association et al. v. Xavier Becerra and Chiquita Brooks-LaSure, amended complaint available at https://www.ahcancal.org/News-and-Communications/Press-Releases/Documents/2024-05-23%20AHCA%20Complaint.pdf.
[40] H.J.Res. 139 (118th Congress) and S.J.Res. 91 (118th Congress).
[41] Department of the Treasury, “Affordability of Employer Coverage for Family Members of Employees,” 87 Fed. Reg. 61979-62003 (Oct. 13, 2022), https://www.govinfo.gov/content/pkg/FR-2022-10-13/pdf/2022-22184.pdf.
[42] Comment letter from 35 health policy experts to Treasury Secretary Janet Yellen and Internal Revenue Service Commissioner Charles Rettig regarding “Affordability of Employer Coverage for Family Members of Employees,” June 5, 2022, https://paragoninstitute.org/wp-content/uploads/2023/12/Comments-on-IRS-Regulation-114339.pdf.
[43] Brian Blase, “To Fix the Obamacare ‘Glitch,’ Biden Politicizes the IRS,” Wall Street Journal, April 8, 2022, https://www.wsj.com/articles/obamacare-politicizes-irs-internal-revenue-service-affordable-care-act-subsidies-families-tax-code-healthcare-biden-obama-11649337661.
[44] Ibid.
[45] Exec. Order No. 14009, 86 Fed. Reg. 7794 (Feb. 3, 2021), https://www.govinfo.gov/content/pkg/FR-2021-02-02/pdf/2021-02252.pdf.
[46] Blase, “To Fix the Obamacare ‘Glitch.’”
[47] Brian Blase, “With the New Obamacare Rule, Lack of Transparency Isn’t a Glitch,” Wall Street Journal, October 12, 2022, https://www.wsj.com/articles/transparency-family-glitch-oira-irs-tax-subsidy-obamacare-aca-exchange-health-insurance-regulatory-meeting-biden-revesz-11665610038.
[48] Matthew Buettgens and Jessica Banthin, “Changing the ‘Family Glitch’ Would Make Health Coverage More Affordable for Many Families,” Urban Institute, May 11, 2021, https://www.urban.org/sites/default/files/publication/104223/changing-the-family-glitch-would-make-health-coverage-more-affordable-for-many-families_1.pdf.
[49] Buettgens and Banthin, “Changing the ‘Family Glitch,’” Table 4, p. 10.
[50] Treasury, “Affordability of Employer Coverage,” p. 61999.
[51] CBO, letter to Sen. Mike Crapo regarding health insurance policies, July 21, 2022, https://www.cbo.gov/system/files?file=2022-07/58313-Crapo_letter.pdf.
[52] CMS, “Clarifying the Eligibility of Deferred Action for Childhood Arrivals Recipients and Certain Other Noncitizens for a Qualified Health Plan through an Exchange, Advance Payments of the Premium Tax Credit, Cost-Sharing Reductions, and a Basic Health Program,” 89 Fed. Reg. 39392-39437 (May 8, 2024), https://www.govinfo.gov/content/pkg/FR-2024-05-08/pdf/2024-09661.pdf.
[53] HHS, “HHS Secretary Xavier Becerra Statement on CMS Submission of Proposed Rule That Would Expand Access to Coverage for DACA Recipients,” press release, April 13, 2023, https://www.hhs.gov/about/news/2023/04/13/hhs-secretary-xavier-becerra-statement-cms-submission-proposed-rule-that-would-expand-access-coverage-daca-recipients.html.
[54] Chris Jacobs, “AGs Sue to Stop Biden-Harris Rule Giving ‘Free’ Health Care to Illegal Aliens,” The Federalist, August 12, 2024, https://thefederalist.com/2024/08/12/ags-sue-to-stop-biden-harris-rule-giving-free-health-care-to-illegal-aliens/.
[55] Quoted in Jacobs, “AGs Sue to Stop Biden-Harris Rule.” Emphasis in original.
[56] Tara Suter, “Federal Court Blocks ACA Coverage for Dreamers,” The Hill, December 9, 2024, https://thehill.com/policy/healthcare/5031527-federal-court-blocks-aca-coverage-for-dreamers/.
[57] CMS, “Clarifying the Eligibility,” Tables 4-5, pp. 39431-32.
[58] CBO, letter to Reps. Arrington and Smith, p. 7.
[59] CBO, letter to Reps. Arrington and Smith, p. 7; CMS, “Clarifying the Eligibility,” Table 3, p. 39428. CBO assumes that, if the enhanced exchange subsidies are extended, 140,000 DACA recipients would obtain subsidized coverage, and the cost of this policy would rise to $9 billion over a 10-year period. CBO also estimates that the change would generate an additional $2 billion in interest costs over the coming decade, which are not included in its formal cost estimates.
[60] National Immigration Law Center, “DACA Recipients’ Access to Health Care: 2023 Report,” May 2023, https://www.nilc.org/wp-content/uploads/2023/05/NILC_DACA-Report_2023.pdf.
[61] Elon Musk and Vivek Ramaswamy, “The DOGE Plan to Reform Government,” Wall Street Journal, November 20, 2024, https://www.wsj.com/opinion/musk-and-ramaswamy-the-doge-plan-to-reform-government-supreme-court-guidance-end-executive-power-grab-fa51c020.
[62] HHS Inspector General, Self-Declaration of U.S. Citizenship for Medicaid, July 2005, https://oig.hhs.gov/oei/reports/oei-02-03-00190.pdf.
[63] Section 6036 of the Deficit Reduction Act, 42 U.S.C. § 1396b(x).
[64] Section 211 of the Children’s Health Insurance Program Reauthorization Act, 42 U.S.C. § 1396a(ee).
[65] Section 1411 of the Patient Protection and Affordable Care Act, 42 U.S.C. § 18081.
[66] Chris Jacobs, “Health Care for Undocumented Immigrants,” Republican Study Committee, August 26, 2008, https://www.juniperresearchgroup.com/post/2008/08/26/health-care-for-undocumented-immigrants.
[67] James Crowler, “Hillary Clinton Discusses Reforming the Malpractice System,” YouTube, May 14, 2014, https://www.youtube.com/watch?v=WTVQQubdJ-w.
[68] Chris Jacobs, “GOP’s Border Security Bill Should Include Citizenship Verification for Health Care Handouts,” The Federalist January 9, 2025, https://thefederalist.com/2025/01/09/gops-border-security-bill-should-include-citizenship-verification-for-health-care-handouts/.
[69] Section 9814 of the American Rescue Plan Act, 42 U.S.C. § 1396d(ii).
[70] Laura Harker and Breanna Sharer, “Medicaid Expansion: Frequently Asked Questions,” Center for Budget and Policy Priorities, June 14, 2024, https://www.cbpp.org/sites/default/files/6-16-21health_series3-18-24.pdf.
[71] Hayden Dubois and Jonathan Ingram, “An Unsustainable Path: How Obamacare’s Medicaid Expansion Is Causing an Enrollment and Budget Crisis,” Foundation for Government Accountability, January 19, 2022, https://thefga.org/wp-content/uploads/2022/01/Medicaid-Enrollment-and-Cost-Hikes-2.0.pdf.
[72] Chris Jacobs, “How Obamacare Undermines American Values: Penalizing Work, Marriage, Citizenship, and the Disabled,” Heritage Foundation, November 21, 2013, https://static.heritage.org/2013/pdf/BG2862.pdf.
[73] Section 1115 of the Social Security Act, 42 U.S.C. § 1315, and Section 402 of the Social Security Act Amendments of 1967, 42 U.S.C. § 1395b-1.
[74] GAO, Medicaid Demonstrations: HHS’ Approval Process for Arkansas’ Medicaid Expansion Waiver Raises Cost Concerns, August 8, 2014, https://www.gao.gov/assets/gao-14-689r.pdf.
[75] GAO, Medicare Advantage: Quality Bonus Payment Demonstration Undermined by High Estimated Costs and Design Shortcomings, March 21, 2012, https://www.gao.gov/assets/gao-12-409r.pdf.
[76] GAO, Medicare Advantage Quality Bonus Payment Demonstration, July 11, 2012, https://www.gao.gov/assets/b-323170.pdf.
[77] Chris Jacobs, “Medicare Agency Just Gave Kamala Harris an In-Kind Contribution with Your Tax Dollars,” The Federalist, August 12, 2024, https://thefederalist.com/2024/08/12/medicare-agency-just-gave-kamala-harris-an-in-kind-contribution-with-your-tax-dollars/.
[78] CMS, “CMS Releases 2025 Medicare Part D Bid Information and Announces Premium Stabilization Demonstration,” July 29, 2024, https://www.cms.gov/newsroom/fact-sheets/cms-releases-2025-medicare-part-d-bid-information-and-announces-premium-stabilization-demonstration.
[79] CBO, letter to Rep. Jodey Arrington regarding developments in Medicare’s prescription drug benefit, October 2, 2024, https://www.cbo.gov/system/files/2024-10/Arrington_et_al_Letter_PartD_0.pdf.
[80] Jacobs, “Medicare Agency Just Gave Kamala Harris.”
[81] GAO, Medicaid Demonstrations.
[82] Chris Jacobs, “No, Trump Shouldn’t Hand Out $200 Prescription Cards Like Obama Would,” The Federalist, September 29, 2020, https://thefederalist.com/2020/09/29/no-trump-shouldnt-hand-out-200-prescription-cards-like-obama-would/.
[83] Rachel Bluth, “California Medical Lobby Ask Voters to Guarantee Billions in Annual Funding,” Politico, October 31, 2024, https://www.politico.com/news/2024/10/31/california-ballo-prop-65-health-care-00186322.
[84] GAO, Medicaid Financing: States’ Use of Contingency Fee Consultants to Maximize Federal Reimbursements Highlights Need for Increased Federal Oversight, June 2005, https://www.gao.gov/assets/gao-05-748.pdf.
[85] Families USA, “Options to Generate the State Share of Medicaid Expansion Costs,” January 2019, p. 5, https://familiesusa.org/wp-content/uploads/2019/09/MCD_States-Share-10-Percent_Fact-Sheet.pdf.
[86] National Commission on Fiscal Responsibility and Reform, “The Moment of Truth,” December 2010, p. 39, https://web.archive.org/web/20130530103543/http://www.momentoftruthproject.org/sites/default/files/TheMomentofTruth12_1_2010.pdf; Bipartisan Policy Center, “Domenici-Rivlin Debt Reduction Task Force Plan 2.0,” December 3, 2012, p. 5, https://bipartisanpolicy.org/download/?file=/wp-content/uploads/2019/03/D-R-Plan-2.0-FINAL.pdf.
[87] Quoted in Brian Blase, “Biden Was Right: Medicaid Provider Taxes a ‘Scam’ That Should Be Scrapped,” Forbes, February 16, 2016, https://www.forbes.com/sites/theapothecary/2016/02/16/biden-was-right-medicaid-provider-taxes-a-scam-that-should-be-scrapped/.
[88] Quoted in Medicaid and CHIP Payment and Access Commission, “Health Care-Related Taxes in Medicaid,” May 2021, p. 1, https://www.macpac.gov/wp-content/uploads/2020/01/Health-Care-Related-Taxes-in-Medicaid.pdf.
[89] Leighton Ku, “Limiting Abuses of Medicaid Financing: HCFA’s Plan to Regulate the Medicaid Upper Payment Limit,” Center on Budget and Policy Priorities, September 27, 2000, pp. 3-4, https://www.cbpp.org/sites/default/files/archive/9-27-00health.pdf.
[90] Brian Blase and Drew Gonshorowski, “Medicaid Financing Reform: Stopping Discrimination Against the Most Vulnerable and Reducing Bias Favoring Wealthy States,” Paragon Health Institute, July 2024, https://paragoninstitute.org/wp-content/uploads/2024/07/Medicaid-Financing-Reform_FOR-RELEASE_V1.pdf.