At least in Serbia, people know that politicians’ promises are ridiculous. NPR reports on a satirical candidate named Ljubisa Beli Preletacevic, or just Beli for short:

A new politician is here to save you. I’m pure and clean. Whatever the other politicians promise you, I will promise you three times more.

I’ll give jobs to everyone and big pensions to everyone. I’m going to move the sea here because we need a beach.

Satire it may be, but his new party won 12 council seats in his home town, and most of his party’s candidates are seriously seeking election. Reporter Joanna Kakissis continues:

There will be no corruption, excluding my own of course, he declares to one crowd. Please send all money directly to my pockets. Drama student Danka Svetilova laughs and asks for a selfie. She says mainstream politicians have lied to Serbs for years.…

So that’s why she and her schoolteacher mom are voting for Beli in this Sunday’s presidential election. Better a fake candidate who tells the truth about lying, she says, than a real one who lies about telling the truth.

I sometimes feel like a broken record about entitlement programs. How many times, after all, can I point out that America is on a path to become a decrepit European-style welfare state because of a combination of demographic changes and poorly designed entitlement programs?

But I can’t help myself. I feel like I’m watching a surreal version of Titanic where the captain and crew know in advance that the ship will hit the iceberg,

yet they’re still allowing passengers to board and still planning the same route. And in this dystopian version of the movie, the tickets actually warn the passengers that tragedy will strike, but most of them don’t bother to read the fine print because they are distracted by the promise of fancy buffets and free drinks.

We now have the book version of this grim movie. It’s called The 2017 Long-Term Budget Outlook and it was just released today by the Congressional Budget Office.

If you’re a fiscal policy wonk, it’s an exciting publication. If you’re a normal human being, it’s a turgid collection of depressing data.

But maybe, just maybe, the data is so depressing that both the electorate and politicians will wake up and realize something needs to change.

I’ve selected six charts and images from the new CBO report, all of which highlight America’s grim fiscal future.

The first chart simply shows where we are right now and where we will be in 30 years if policy is left on autopilot. The most important takeaway is that the burden of government spending is going to increase significantly.

Interestingly, even CBO openly acknowledges that rising levels of red ink are caused solely by the fact that spending is projected to increase faster than revenue.

And it’s also worth noting that revenues are going up, even without any additional tax increases.

The bottom part of this chart shows that revenues from the income tax will climb by about 2 percent of GDP. In other words, more than 100 percent of our long-run fiscal mess is due to higher levels of government spending. So it’s absurd to think the solution should involve higher taxes.

This next image digs into the details. We can see that the spending burden is rising because of Social Security and the health entitlements. By the way, the top middle column on “other noninterest spending” shows one thing that is real, which is that defense spending has fallen as a share of GDP since the mid-1960s, and one thing that may not be real, which is that politicians somehow will limit domestic discretionary spending over the next three decades.

This bottom left part of the image also gives the details on built-in growth in revenues from the income tax, further underscoring that we don’t have a problem of inadequate revenue.

Here’s a chart that shows that our main problem is Medicare, Medicaid, and Obamacare.

Last but not least, here’s a graphic that shows the amount of fiscal policy changes that would be needed to either reduce or stabilize government debt.

I think that’s the wrong goal, and that instead the focus should be on reducing or stabilizing the burden of government spending,

but I’m sharing this chart because it shows that spending would have to be lowered by 3.1 percent of GDP to put the nation on a good fiscal path.

Some folks think that might be impossible, but I’ll simply point out that the five-year de facto spending freeze that we achieved from 2009–2014 actually reduced the burden of government spending by a greater amount. In other words, the payoff from genuine spending restraint is enormous.

The bottom line is very simple.

We need to invoke my Golden Rule so that government grows slower than the private sector. In the long run, that will require genuine entitlement reform.

Or we can let America become Greece.

It is difficult to forecast what President Trump’s fiscal legacy will be. He’s sought credit for a recent reduction in public debt, but pledged not to touch the entitlement programs which are its key long-term driver, while also cutting taxes. His team has talked of the need for high-quality infrastructure investment to boost productivity, but leaked memos suggest priority projects must be “shovel ready” and “direct job creators” – different short-term aims.

Anybody hopeful that the fiscal conservative lines of this muddled agenda might win out might want to think again. It looks as if Trump has “stimulus” rather than a supply-side agenda in mind. Here’s an interview excerpt from The NYT:

Trump seemed much less animated by the subject of budget cuts than the subject of spending increases. “We’re also going to prime the pump,” he said. “You know what I mean by ‘prime the pump’? In order to get this” — the economy — “going, and going big league, and having the jobs coming in and the taxes that will be cut very substantially and the regulations that’ll be going, we’re going to have to prime the pump to some extent. In other words: Spend money to make a lot more money in the future. And that’ll happen.”

Let us presume for the sake of argument that Trump is a Keynesian who believes that government spending can be used to re-inflate the economy from downturns. Let us also assume that this kind of agenda works as Keynesian theory predicts. We can still ponder: why does the U.S. economy need a fiscal stimulus now? Theory (even Keynesian) and evidence suggests it does not.

1. Theory would suggest fiscal stimulus is not effective when there is little “spare capacity.” Whatever Trump thinks about the veracity of the statistics, the US economy is close to “full employment.” The civilian unemployment rate currently stands at 4.7 percent, only slightly above the Congressional Budget Office’s estimate for the “natural rate of unemployment.” The job openings rate is now running above that seen pre-crisis, quit rates are about the same as they were prior to the crash. The U5 unemployment rate (which adds marginally attached workers to the official rate) and the U6 unemployment rate (which adds those who are part-time for economic reasons) are at levels seen in the middle of the 2000s and construction unemployment is lower than in 2007. In such an environment, any attempted macroeconomic stimulus through infrastructure investment would be highly likely to crowd out private sector activity.

2. Theory suggests fiscal stimulus will be offset by monetary policy. Given the Fed has begun to raise its target rate, Keynesian theory would suggest monetary policy would offset any expansionary fiscal policy. Paul Krugman spelled this argument out clearly when he wrote “spending can be withdrawn later on without hurting employment, because once you’re out of the liquidity trap the Fed can offset the contractionary effects of a fiscal tightening by holding off on the monetary tightening it would otherwise have pursued.

3. Evidence suggests that any effect of government spending is very small when countries are highly indebted. US federal public debt stands at 105 percent of GDP. The long-term outlook for the public finances is dire on unchanged policies, driven by rising entitlement spending given demographic trends and rising health care costs. The federal deficit is already projected to be 2.9 per cent in 2017, but if current policies remain largely unchanged, the Congressional Budget Office projects estimates the annual deficit would rise to 5 per cent of GDP over the next decade (even with tax revenues above their average over the past five decades). In such an environment, consumers are more likely to foresee future tax increases when the federal government borrows more, and hence rein in activity today.

4. The assumptions necessary for short-term spending improving the debt-to-GDP outlook are incredible. Trump talks about spending money now to make a lot more in the future, but Larry Summers and Brad Delong outlined back in 2012 the conditions under which short-term borrowing could hypothetically improve the longer-term debt-to GDP path. As I wrote at the time, “the paper does an important public service, however. It lays out in detail the scale of the assumptions required.” They presume fiscal multipliers are large, monetary policy does not work, and that absent short-term borrowing workers and capital will become much less productive. All of these conditions are even less likely now than they were in 2012. As the FT’s Chris Giles said: “you have to have a rather weird faith in the notion that raising capital spending a bit today provides a much more powerful boost than the hit that inevitably comes next year when that temporary support is removed.”

In sum, theory and evidence suggests more government borrowing at the current time is unnecessary and would have little effect on GDP but would worsen the debt-to-GDP ratio. Sure, there might be a case for some infrastructure investment for other reasons (maintenance, alleviating damaging congestion, enabling new transport modes etc.), which I will explore in future posts, but that is a very different rationale from the pump priming put forward by the President.

In the political hullabaloo over efforts to shift costs of health care to someone else, the argument for keeping Obamacare’s compulsory insurance and ever-expanding Medicaid enrollment relies naïvely on notoriously comical Congressional Budget Office (CBO) 10-year “projections.” 

CBO claims the initial House Republican plan would eventually cause 3 million to “lose” health insurance simply because they would no longer be fined up to 2.5% of income for not buying a policy designed by and for politicians. This not a loss, but a gain – in freedom of choice.

CBO claims the GOP plan would “lose” another 14 million by not expanding Medicaid enrollment as rapidly as Obamacare hopes to. The federal government pays about 57% of the cost of Medicaid for poor people, but 90–93% (until 2022) to the 31 states that provide Medicaid to those earning up to 138% of the poverty line. That has added 17 million to the Medicaid rolls, and enriched big health insurers and Kaiser Permanente.

Since expanded Medicaid added only 17 million, how could the Republican plan’s modest frugality possibly subtract 14 million? Only because CBO assumes that if nothing changes then more and more states will leap on this stalled bandwagon, thus shoving millions more on Medicaid. This seems politically unlikely (few Republican governors have done so), but also unhealthy. All those new patients on Medicaid may have to drive very far to find an MD who accepts Medicaid. Having a third-rate health insurance card is not “health care.” It’s a card. 

Some of the biggest public policy blunders of recent years resulted from taking CBO’s crystal ball far too seriously. Higher 1991 tax rates on high incomes and luxuries worsened the recession and lost revenue, for example, yet seemed courageous by the low standards of faulty CBO bookkeeping. 

An even better example of CBO dominating policy decisions was the foolishly phased-in and poorly-targeted 2001 Bush tax cuts.

In January 2001, CBO predicted that budget surpluses would add up to $5.6 trillion by 2011. That absurd CBO forecast made their (overestimated) $1.35 trillion 10-year revenue loss from look puny – merely nibbling away at 24% of projected surpluses. Little wonder the 2001 law was a grab-bag of feel-good giveaways (10% tax rate, refundable credits, etc.) thanks in large part to the CBO’s blurred vision of endless surpluses.

Why does this have anything to do with health insurance policy? Because CBO projections for the Affordable Care Act (ACA) have also been embarrassingly wrong. In March 2010 CBO estimated only 21 million would be uninsured by 2016, but the actual number turned out to be 27 million. CBO expected 21 million policies on the Exchanges by 2016, but the actual number turned out to be 12 million. 

By using CBO projections as the baseline, as is being done with the GOP plan, it could be said that Obamacare “lost coverage” for 6 million people in 6 years –compared with 2010 CBO projections.

In short, the CBO has always grossly overestimated the success of Obamacare. And they still do. They appear to underestimate how much larger federal subsidies to Medicaid and the Exchanges “crowd out” other insurance – luring people out of unsubsidized insurance into subsidized insurance, or into seemingly “free” expanded Medicaid in 31 states. 

The CBO’s rosy scenario about the future success of Obamacare exchanges, and about future growth of expanded Medicaid coverage, results in a grossly exaggerated estimate of the number of policies to be “lost” by reducing compulsion, mandates and taxpayer subsidies. Good policy requires more good judgment, not more bad estimates.

Yesterday, the Los Angeles Times noted that reports of sexual assault and domestic violence are down in Latino-dominated areas of Los Angeles. NPR also published a story yesterday about four cases of domestic violence dropped by four Latina women in Denver, Colorado. The underlying factor blamed in both stories is federal enforcement of immigration laws at local courthouses.

I wrote about the fallout of this abhorrent practice last month in the Washington Post.

Seizing a person who is seeking refuge from violence subverts the protective function of police officers. If individuals fear as much from law enforcement as they do the criminals living among and victimizing them, they will not come forward to report crimes or cooperate with criminal investigations.

While immigration enforcement is often done under the banner of “public safety,” victims of crimes will be less likely to come forward if doing so risks breaking up their families by deportation. This puts more people in harm’s way and enables abusers and predators free rein among people too fearful to ask for the help that they need.

Moreover, despite the “law and order” rhetoric touted by the Trump Campaign and now Administration, these efforts make police officers’ jobs more difficult.

One Los Angeles Police Dept. detective told the Los Angeles Times, “It is my job to investigate crimes.… And if I can’t do that, I can’t get justice for people, because all of a sudden, I’m losing my witnesses or my victims because they’re afraid that talking to me is going to lead to them getting deported.” When he recently approached a group of Latino workers to investigate a crime, they stood up and walked away. Even though Los Angeles has repeatedly asserted its self-appointed status as a “sanctuary city” for immigrants, one of the workers uttered “Trump is coming,” as he left.

All the pro-police rhetoric in the world cannot make-up for the real-world problems that misguided immigration enforcement can cause. Emboldening violent criminals by making large swaths of the population too scared to come forward not only makes police work more difficult, it can make it more dangerous.

Supporting the police means respecting their jobs and enforcement priorities, not just reciting tough-on-crime pablum. If the Administration really cares about police officers, it should start listening to what they have to say. Immigration agents can find other ways to enforce the law than to pick on the most vulnerable at their time of need.

President Donald Trump’s budget issued last week would cut $54 billion from nondefense spending. Budget director Mick Mulvaney did a nice job assembling an array of sensible cuts, as I discuss in this CNN op-ed and this blog.

Recipients of handouts and pro-spending activists are not happy with the proposals. But many of Mulvaney’s proposed cuts are for local activities, such as housing and schools. If programs are important, then local governments can fund them with their own taxes, which would be a more efficient, transparent, and democratic fiscal approach.

Some GOP members of Congress are not happy about the cuts either. Republicans generally consider themselves to be fiscal conservatives. But for some members, their oft-expressed concerns about deficits might be just philosophical musings, not a guide to their actual policy positions:

• Senator Rob Portman (R‑OH) responded to Trump’s cuts by coming to the defense of federal funding for Lake Erie restoration, which he called “critical.” Yet the senator’s official website complains about the federal “spending spree, piling up new deficits onto our massive debt … Washington’s fiscal irresponsibility passes the problem to future generations.”
• Representative Michael Conway (R‑TX) opposes farm subsidy cuts, saying “Agriculture has done more than its fair share” in restraining deficits. (That’s not true—farm aid has risen in recent years). Yet on his website, Conway says, “Our nation is in a budgetary crisis … As a CPA and fiscal conservative, I am committed to working with my colleagues to cut spending and put our fiscal house in order. Congress does not have a blank check; it is vitally important that we balance the federal budget.”
• Senator Lisa Murkowski (R‑AK) complained about the Trump budget as well. She “attacked plans to cut or eliminate programs that help the poor pay heating bills, provide aid for localities to deal with wastewater and subsidize air travel in rural areas like her home state of Alaska.” Yet her website says, “Senator Murkowski believes one of the most essential functions of Congress is to pass a balanced budget that sets a responsible spending plan for federal government services. For too long, the U.S. government has been spending more than it takes in and borrowing large sums of money to make up the difference. To set the nation on a more stable financial path, it is critical for Congress to set sustainable funding levels for the federal government, reduce overall spending levels.”
• House appropriator Hal Rogers (R‑KY) complained about Trump’s proposed cuts to foreign affairs activities. Yet his website says that he will “remain steadfast in fighting against government waste and any bills that increase the government’s reach on your dime.” As it turns out, foreign affairs has greatly increased its reach on our dime, and so Trump’s proposed cuts make a lot of sense.

President Trump recently signed an Executive Order requiring agencies to eliminate two regulations for each new one imposed. He should ask members of Congress to be similarly responsible on spending. For each proposed spending cut they disapprove, they should identify and pursue two similar-sized cuts elsewhere in the budget. 

Responding to conservative protests that the American Health Care Act would immortalize ObamaCare rather than repeal it, the House Republican leadership has announced several amendments. (See my initial analysis of the bill here, and my analysis of the Congressional Budget Office score).

The amendments do not even come close to fixing the problems with this fatally flawed bill. Indeed, by expanding the AHCA’s tax-credit entitlement, it will make the bill resemble ObamaCare even more.

ObamaCare’s Medicaid Expansion 

Original AHCA provisions:

As introduced, the AHCA includes language that supposedly repeals ObamaCare’s expansion of Medicaid to able-bodied, childless adults. In fact, it would expand the Medicaid expansion and make it permanent.

The original bill would have allowed the 19 non-participating states to implement the expansion until 2020, allowed participating states to expand enrollment until 2020, and would have kept paying states the enhanced, 90 percent federal “match” for each expansion enrollee until that enrollee disenrolled. Expansion advocates in those 19 states hailed the bill for removing obstacles to those states implementing the expansion.

The bill thus would have repealed the Medicaid expansion in name only. By 2020, there would have been so many more Medicaid expansion states and enrollees, that Congress would rescind the repeal and keep the expansion in perpetuity.

Amendment:

The amendment would prevent the 19 states that have not implemented the expansion from doing so. This is a welcome change—but it is not nearly sufficient.

Even with this change, there would more Medicaid-expansion enrollees after “repeal” than before. The 31 expansion states could keep adding new enrollees to the expansion until 2020, and keep receiving the enhanced, 90 percent federal “match” for those enrollees after 2020. The AHCA would still reward state officials who did the wrong thing (expanding Medicaid) and punish state officials who did the right thing (refused to implement the expansion). The bill would still create increased pressure on Congress to rescind this “repeal” before 2020.

The amendment would allow states to impose work requirements for able-bodied Medicaid enrollees. Again, this is a welcome change, but not nearly sufficient.

Work requirements could reduce dependence on Medicaid, reduce Medicaid spending, and reduce pressure for Congress to preserve the expansion. Yet work requirements are only (politically) feasible for able-bodied adults. And the states where work requirements are most needed—the 31 states that have implemented the Medicaid expansion—are the least likely to impose a work requirement. Why would they? States that use work requirements to help Medicaid-expansion enrollees achieve financial independence would see only 10 percent of the savings. The other 90 percent goes to Washington. The amendment’s optional work requirements are a fig-leaf proposal that does little if anything to improve the AHCA.

Medicaid “Reforms”

Original AHCA provisions:

Under current law, the federal government provides unlimited matching grants to states for their Medicaid programs. For every dollar a state spends on its “old” Medicaid program, the federal government gives the state from $1 to $3. For every dollar a state spends on ObamaCare’s Medicaid expansion, the federal government generally will give the state $9. These provisions create incentives for states to expand Medicaid to able-bodied adults and to cut care for more vulnerable residents—children, expectant mothers, the aged, blind, and disabled.

As introduced, the AHCA would change how the federal government funds the “old” Medicaid program in a way that likewise encourages states to expand the program to able-bodied adults and to cut care for the disabled and other vulnerable residents.

The AHCA would convert the current unlimited matching-grant system to a system where states can receive unlimited grants so long as they keep expanding eligibility and enrolling more people in Medicaid.

States would continue to receive matching federal dollars for every dollar they spend until federal grants reach a variable “cap.” Beyond that cap, states get no more money from the feds. But the cap rises if states expand enrollment.

As a result, when states approach or exceed the cap, they will have two choices. They can expand enrollment (which allows the state to continue receiving federal matching dollars) or they can cut benefits and provider payments. The AHCA thus mimics the Medicaid expansion’s incentives to expand enrollment among able-bodied adults (who cost the state relatively little) and to cut care to vulnerable populations. Under the ACHA, cutting spending for vulnerable patients by $1 saves the state $1, as opposed to an average $0.43 under the current system.

The AHCA would give states the option of a block grant—a fixed federal payment, rather than matching grants. But making block grants an option assures higher federal spending, since each state will take whichever option maximizes the federal contribution to their programs.

Amendments:

The amendments would increase the rate of growth of the “cap” with respect to elderly and disabled enrollees. This change would increase federal spending on those groups, but do nothing to change the perverse incentives noted above.

Tax Provisions

Original AHCA provisions:

As introduced, the AHCA preserves much of ObamaCare’s entitlement spending by reshaping its subsidies for private health insurance. ObamaCare offers “refundable” tax credits for health insurance that are based on income. The “refundable” part means that these tax credits are mostly government outlays, not tax reduction. ObamaCare’s “tax credits” are 94 percent government spending.

The AHCA would convert those tax credits to smaller credits based on age. Crudely put, the AHCA would shift the benefits from ObamaCare’s tax credits from low-income people in the individual market to higher-income people in the individual market. At the same time, the AHCA would allow insurers to reduce premiums for younger enrollees and increase premiums for older enrollees. The combination of these changes means many older and lower-income enrollees will have to pay more out of pocket for less coverage.

The AHCA would have allowed tax-credit recipients who purchased coverage that cost less than the amount of the credit to deposit the balance in a tax-free health savings account (HSA).

ObamaCare increased the threshold above which taxpayers can deduct their medical expenses from 7.5 percent to 10 percent of income. This was literally a tax on the poor and the sick. As introduced, the AHCA would have reduced the threshold back to 7.5 percent.

Amendments:

The amendments provide additional funding for refundable tax credits, but punt to the Senate the task of devising a way to spend the extra money on low-income, near-elderly taxpayers. They would eliminate the “spillover” option of depositing the balance of one’s tax credit into an HSA. And they would further reduce the threshold above which taxpayers may deduct medical expenses to 5.8 percent of income.

These changes are cosmetic. They do not alter the fact that the CBO projects the AHCA will cause average premiums to rise by 20 percent. And they do not address the root problem of excessive health care prices.

Expanding the tax credits simply throws even more federal dollars after unaffordable care. Subsidizing third-party payment, as tax credits do, makes health care less affordable, not more. Eliminating the “spillover” option further subsidizes third-party payment by guaranteeing tax-credit recipients will buy coverage than they consider desirable. Reducing the threshold for medical deductions might move in the direction of tax neutrality between direct payment and third-party payment, but only negligibly.

In each case, Congress would do more to make medical care affordable by using those resources to expand tax-free health savings accounts (HSAs).

Conclusion

Indeed, all the changes made by these amendments are cosmetic. When the House GOP leadership unveiled the American Health Care Act, I wrote that it “merely applies a new coat of paint to a building that Republicans themselves have already condemned.” All these amendments do is paint the shutters a different color. Even with these amendments, the AHCA would be worse than doing nothing.

Some conservatives will like that the amendments would eliminate ObamaCare’s taxes (except the Cadillac tax) one year earlier than the original bill. Yet because the AHCA gets the policy wrong, it sets the stage for higher federal spending, which will create pressure for higher taxes in the future. If conservatives want the AHCA’s tax cuts to stick, they need to revamp the health care provisions drastically. 

To make those tax cuts stick, Republicans need to improve health care. To improve health care, Republicans need to bring premiums down immediately by fulfilling President Trump’s promise to repeal ObamaCare in full; give states a fixed federal contribution to their Medicaid programs plus full flexibility to target Medicaid funds to the truly needy; and bring health care prices down for all patients by expanding HSAs.