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The bipartisan deal to raise the debt ceiling would claw back billions of dollars meant to enable a large-scale refurbishment of the IRS, which has withered over the last decade due to budget cuts, outdated technology and loss of staff. No less than a quarter of the $80 billion in new funding awarded to the IRS in Democrats’ Inflation Reduction Act (IRA) would be taken back from the agency in a deal struck by the White House and House Republicans over the weekend. The White House has emphasized that all the new initiatives at the IRS — laid out in an ambitious operating plan released in April — are still full-steam ahead and that the agency will be able to make good on the Treasury Department’s promise to go after rich tax cheats. Even so, the debt ceiling deal puts extra stress on the regular appropriations bills for the IRS and rattles the foundation of its long-term restructuring. “Look at the strategic operating plan — so much of it has been laid out in terms of steady investments,” Janet Holtzblatt, a former Senate Budget Committee analyst and former deputy director of the Individual Taxation Division in the US Treasury Office of Tax Analysis, said in an interview with The Hill. “My worry is that this gives an incentive to spend money more quickly.” What happens to IRS money now? The $20 billion excision from the IRA’s $80 billion boost is not an explicit budgetary provision in the text of the House bill itself. Rather, it is an oral agreement between the White House and House Republicans about money that will be taken away from the IRS and spent elsewhere in appropriations bills in 2024 and 2025. Of that excision, $10 billion will be “repurposed” throughout the course of the fiscal 2024 appropriations process, along with another $10 billion in 2025 to be allocated toward more resources for nondefense priorities, White House officials said Sunday. That leaves a total effective funding boost of about $60 billion for the IRS. If appropriations negotiations preserve the $8 billion investment in taxpayer services and systems modernization that Republicans approved of in their own debt ceiling bill passed earlier this month, that total boost could fall as low as $52 billion. That means that roughly $29 billion could now be spent on additional enforcement and auditing over the next 10 years as opposed to the $45 billion originally allocated. The $25 billion boost to operations could fall as low as $16.25 billion under this scenario. The White House said the IRS will pull forward some of its IRA funding to keep the agency on track to deliver its updates. But experts in U.S. tax administration say the funding modifications could still pull the rug out from under these initiatives. The IRS is piloting new enforcement techniques using data and analytics tools that have yet to be assessed. The debt ceiling deal removes funding for years in which some of the pilots — including the test of a free online filing system for regular taxpayers — are already planned. For fiscal 2025, the IRS is working on “new tailored treatments developed and piloted based on data and analytics” to help fix “issues and omissions” on tax returns, according to the agency’s new operating plan. Why the ‘tax gap’ could widen The funding cut could also limit new hires of seasoned accountants and auditors, who are perhaps the most crucial component of the agency’s increased enforcement capacity.

Social Security and Medicare are both programs that are household names, but do you know the true difference? Both programs help safeguard millions of Americans as well as improve the quality of life for their family and friends. While Social Security offers retirement, disability, and survivors benefits, Medicare provides health insurance.

Medicare is our country’s health insurance program for people age 65 or older and younger people receiving Social Security disability benefits. The program helps with the cost of health care, but it doesn’t cover all medical expenses or the cost of most long-term care.

Many of Medicare's administrative shortcomings result from a significant disparity between its responsibilities and resources, both in personnel and dollars. At the inception of the Medicare program, providers expressed apprehension about governmental intervention into health care.4 As a result, the government created a different structure for administering Medicare than for administering Social Security. The Social Security Administration (SSA), with an in-house staff of 63,000,' processes Social Security payments directly to over forty-five million beneficiaries according to a schedule of benefits that is easy to administer. 6 By contrast, the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA),7 currently has an in-house staff of fewer than 5,000. CMS, however, must administer a much more complex set of payments for Medicare services for almost as many beneficiaries through numerous third parties that together employ another 22,500 people.8

In 2023, when you work, about 85 cents of every Social Security tax dollar you pay goes to a trust fund that pays monthly benefits to current retirees and their families and to surviving spouses and children of workers who have died. About 15 cents goes to a trust fund that pays benefits to people with disabilities and their families.4 From these trust funds, we also pay the costs of managing our programs. We’re one of the most efficient agencies in the federal government, and we’re working to make it better every day. Of each Social Security tax dollar you pay, we spend less than 1 penny to manage the program. The entire amount of Medicare taxes you pay goes to a trust fund that pays some costs of hospital and related care for all Medicare beneficiaries. The Centers for Medicare & Medicaid Services, not Social Security, manages Medicare.

Richard Gottfried, the legislative sponsor of the single-payer proposal in New York, dismisses the ERISA challenge as unlikely to succeed, noting that (1) the state has clear authority to impose payroll taxes; (2) the proposed law does not require any firm to provide coverage but, in fact, does just the opposite, relieving firms of any such obligation; and (3) firms could still maintain their employer-based coverage, although it would be irrational for them to do so because they also would be contributing to the cost of the single-payer program.6 There is no clear precedent suggesting how the courts would rule in the inevitable ERISA challenge to a state-based single-payer initiative. It is quite likely, however, that the litigation would drag on for years, complicating at a minimum any effort to implement such a program.

In the 2016 Democratic presidential primary, Senator Bernie Sanders (D-VT) ran an insurgent campaign against front-runner Hillary Clinton. Sanders's signature proposal was a call to establish “Medicare for All,” replacing the byzantine web of public and private insurance sources from which Americans obtain health coverage—and that leaves millions of people without any coverage at all—with one government-run program. Medicare for All promised to remedy the myriad shortcomings and consequences of America's health insurance arrangements: inequity, inefficiency, insecurity, unaffordability, complexity, poor health outcomes, and more. Sanders's invocation of Medicare for All, rather than the more opaque single-payer insurance label that reformers had previously bandied about, swaddled sweeping change within the familiar grasp of a popular, long-established program (namely, Medicare); instantly conveyed the core, seemingly straightforward idea behind the plan (extending Medicare's federal insurance to all Americans); and, crucially, located the model for reform within the United States rather than across the borders of a foreign country (since the 1970s, American reformers have often touted Canada's universal health insurance arrangements, also known as Medicare, as an exemplar). If, as some critics alleged, it seemed politically or culturally unthinkable and a contravention of American values for the United States to import another nation's national health insurance system (Marmor 1994: 184–85), even one as geographically and culturally proximate as Canada, what was so impossible about building on a Medicare program that had operated in the United States for more than five decades and drew strong support from its beneficiaries and the public?

Sanders lost the 2016 primary to Clinton. However, he did much better than pundits expected, and his Medicare for All campaign raised the issue's profile substantially, far beyond Sanders's voters. In 2016, the Kaiser Family Foundation reported that for the first time, 50% of Americans “favor[ed] a national health plan in which all Americans would get their insurance from a single government plan” (KFF 2020). In the ensuing years, the momentum for Medicare for All grew. In 2017 and 2019, Sanders introduced Medicare for All bills in the Senate (with 14 Senate cosponsors in 2019). Meanwhile, in the House of Representatives Congresswoman Pramila Jayapal (D-WA) introduced similar Medicare for All legislation, with more than 100 members of the House cosponsoring it. Between 2017 and 2020, 53% to 59% of respondents in Kaiser polls continued to favor a national Medicare for All plan, with much higher support among Democrats (KFF 2020).

More than double the national debt to 203 percent of the economy. Federal debt held by the public currently totals about $17 trillion, or 80 percent of GDP. Under current law, debt is projected to reach 98 percent of GDP by 2030. Assuming no changes in projected interest rates or economic growth, deficit-financing Medicare for All over the next decade would require nearly $34 trillion of new borrowing including interest, which is the equivalent of 105 percent of GDP by 2030. As a result, debt would rise to 203 percent of GDP, more than double its currently projected level. This would put debt in 2030 at almost five times its historic average of 42 percent and nearly twice the historic record of 106 percent (set after World War II). Under different cost assumptions, debt could rise by as little as 89 percent of GDP and as much as 124 percent of GDP. Debt would continue to grow rapidly beyond 2030.

WASHINGTON — Paying for "Medicare for All" could require raising payroll taxes by 32 percent on workers and businesses, among other options, according to a new report from a think tank that advocates for balanced budgets.

But the report, released Monday by the Committee for a Responsible Federal Budget, also suggested that middle class families could save money overall, even with significantly higher taxes.

By any definition, a pandemic is an exogenous shock that substantially alters the needs, incentives, and capacities of many components of local, regional, and national healthcare systems. In a pandemic, disruptions to limited staffing pools (e.g., callouts, forced quarantine, etc.) can have outsized effects upon RHS ability to deliver care to patients and can mean that they prematurely reach patient saturation, particularly during times of heightened disease incidence. Existing heightened risk factors within rural populations could result in health systems becoming suddenly and unexpectedly inundated with new cases – overstretching bed and labor availability (Vestal, 2020). RHS often lack access to larger, more resilient, supply chains. Many have limited testing capacity and send tests to commercial labs that can take multiple days to return results. Often understaffed outside crisis, they can face serious workforce problems. RHS that lack slack can consequently experience system collapse and suboptimal and dangerous triage-based health care decision-making (Vestal, 2020). States like North Dakota, which has less than 20 ICU beds in the state (limited to hospitals in Dickinson, Fargo, and Bismark) saw the consequences of these concerns when patients had to be transferred as far as South Dakota or Montana to get the level of care needed (Vestal, 2020).

Many RHS lack resilience against external and internal stressors, so adding additional labor and resources can improve the capacity for the system to recover from spikes in demand for care that are inevitable in current and future crises. Because of potentially significant costs associated with adding a resilience component to RHS, careful resilience analytics and tradeoff analyses should be driving resource allocation. However, resilience is difficult to quantify due to the complex and diverse nature of its definition especially in attempting to compare across distinctly different communities.

As Americans look hopefully toward the end of the pandemic, many aspects of life are returning to normal, including routine health care. Still abnormal, though—and likely to remain so, are wait times for emergency care, which grew perilously long during the pandemic because of staff shortages and patient overload.

“Patients will suffer with that in the short term,” observed Arjun Venkatesh, MD, MBA, associate professor and administration section chief at Yale School of Medicine’s department of medicine. “It will take years to layer in the necessary changes. I doubt next year you’ll be reporting that things have improved. I hope we’ll be improving, but there are not that many people to staff the emergency departments (EDs) out there. There are shortages everywhere.”

The American College of Physicians joins the American Nurses Association, the American Medical Association’s Medical Student Section, and at least a dozen other medical professional groups who have called for the United States to implement a single-payer health care system.

These doctors may soon regret their decision. “Medicare-for-all” would saddle physicians with pay cuts, long hours, and rolls of regulatory red tape. That would cause even more doctors to burn out — and leave millions of Americans without access to quality care.

However, the RUC does not have the ability to push prices up to whatever level its members wish, because Part B is subject to a budget-neutrality rule, meaning that any changes to the MPFS that result in an increase or decrease in Medicare Part B outlays exceeding $20 million will trigger automatic adjustments. Consequently, if the RUC recommends payment increases for certain services, it is forced to recommend cuts for other services. A long-standing problem stemming from the budget-neutrality rule is that it encourages the RUC to propose cuts on relatively low-priced, high-volume services, namely E/M codes that broadly apply to all physician visits and services intended to evaluate and manage a patient’s health. Although E/M services are billed by all physicians, they constitute a larger share of primary care physicians’ bills, because specialists perform procedures more frequently than primary care doctors do. Conversely, procedure-code rates are easier to increase, because they are billed less often than E/M codes and increasing them is less likely to cause Medicare spending to balloon out of control. In addition, most of the members of the RUC are specialists, and just a handful are primary care physicians; this has been cited as a factor that may contribute to procedure-code rate increases. Analyses have shown that Medicare reimburses physicians three to five times more for common procedural care than for E/M care, and some have warned that this could exacerbate the current shortage of primary care providers.

Payment cuts are generally reflected through the RVUs for PW and ultimately the CF. In calendar year (CY) 2023, the CF announced in the MPFS final rule was $33.067, down from $34.6062 in 2022.21 The proposed cut was met with considerable opposition from physician groups, which warned that it threatened the financial stability of practices in the face of soaring inflation and growing rates of physician burnout. Congress subsequently passed the Consolidated Appropriations Act of 2023, which mitigated the cuts set to begin on January 1, 2023. Consequently, CMS announced on January 5, 2023, that the conversion factor would be $33.8872 in CY 2023, a reduction of $0.72 from the CY 2022 rate.

Projecting a dramatic 40 percent reduction in provider reimbursement relative to private insurance, Charles Blahous, a former Medicare trustee, observes, "The cuts in the Sanders M4A bill would sharply reduce provider reimbursements for treatments now covered by private insurance, which represent a substantially greater (more than 50 percent larger) share of national health spending than does Medicare."

True, American physicians are among the most highly paid medical professionals in the world. Overall, in 2018 the average American primary care physician earned $223,000, while specialists earned $329,000. In 2018, American staff nurses earned $73,287 on average, clinical nurse specialists earned $88,271, and nurse anesthetists earned $150,833.

The United States is projected to face a shortage of up to 124,000 physicians by 2034 as the demand outpaces supply, according to the Association of American Medical Colleges.

The workforce shortage means “we’re really not prepared” for another pandemic, Sanders said.

According to new data published today by the AAMC (Association of American Medical Colleges), the United States could see an estimated shortage of between 37,800 and 124,000 physicians by 2034, including shortfalls in both primary and specialty care.

“The COVID-19 pandemic has highlighted many of the deepest disparities in health and access to health care services and exposed vulnerabilities in the health care system,” said AAMC President and CEO David J. Skorton, MD. “The pandemic also has underscored the vital role that physicians and other health care providers play in our nation’s health care infrastructure and the need to ensure we have enough physicians to meet America’s needs.”

Due to the demographic and socioeconomic composition of their patient populations as well as low patient volumes, small rural hospitals are inevitably more expensive and less efficient than other types of hospitals. Under a single-payer model in which the government has embraced the principle of universal access—as codified in the accessibility principle of the Canada Health Act, for instance—there is greater tolerance for the operational inefficiency of rural hospitals than is found in a largely market-driven system like that of the U.S. In an interview with the author (March 4, 2020), director of the Health Sector Models Branch of OMHLTC, Sherif Kaldas, confirmed the prioritization of access in the rural context: “We decided from a policy perspective . . . efficiency means little in this setting. It’s access. Are [rural residents] getting equitable access to [the level of hospital care that one associates with] large, urban centers?”

In 2012, Ontario introduced its Health System Funding Reform, a plan to transition hospital funding from simple global budgets to a Health Based Allocation Model based on patient populations and organizational performance. In doing so, however, the Ministry of Health recognized that small rural hospitals could not sustain the financial instability likely to result, and excluded such hospitals from the reform (Palmer et al. 2018). It must be emphasized that this kind of attention to and accommodation of the special needs of rural hospitals is not an inherent element of single-payer systems. Rather, it represents a hallmark of how single-payer health care originated and evolved in the Canadian context specifically.

Much has been made of the looming shortage of physicians. But there’s one place where the shortage is being felt acutely, is talked about even less, and the effects will ripple far into the future: the founding of new biomedical startups.

We live at a time when technology is dramatically transforming not just the field of biology but how biology-driven companies are built. It’s now entirely possible to create innovative and scalable new companies in the field with relatively modest initial funding. In other words, it’s salad days to be a bio startup, with so many new tools, data sources, and ideas at our disposal.

FTI Consulting examined the impact of Medicare for All on the supply of physicians, finding a significant increase in the projected shortage of both specialists and primary care physicians in future years as a result of rate setting and subsequent reductions in provider income. American physicians enter the workforce with an average student debt load of nearly $200,000,12 a factor that may drive graduates away from specialties with particularly low Medicare reimbursements, such as primary care, under the current system. For experienced physicians, declining Medicare reimbursements can play a role in the decision to retire early.13 FTI’s analysis demonstrates these factors would be amplified under Medicare for All, discouraging the next generation from entering the practice of medicine and prompting a greater number of older physicians to retire early.

IMPACT ON PHYSICIAN SUPPLY On average, Medicare reimbursements for physicians were about 75% of private insurance reimbursements for the same service in 201714 and are expected to fall to approximately 63% by 2025.15 Because Medicare for All’s most significant effect would be to replace private coverage, total reimbursements paid to physicians would also fall absent changes to the law. FTI estimates that, under Medicare for All, the U.S. could expect a loss of more than 0.13 physicians per 1,000 people once the policy is fully implemented. The current ratio in the United States is 2.46 physicians per 1,000, which translates to a nationwide loss of 44,693 physicians by 2050, compared to the projected number of physicians under current law.16

Physician and nursing shortages have become a major cause for concern affecting hospitals, clinics, and potential patients. The draining work environment and subsequent lifestyle physicians and nurses are subjected to, have led to physician burnout and an increased turnover rate which hospitals and clinics cannot afford. It is imperative that they find a way to retain these crucial healthcare workers to further improve patient access to much-needed health care. The physician shortage has plagued the healthcare industry for some time and is expected to continue growing exponentially by 2030, severely limiting patient care access.

A study released in March 2017 by the AAMC revealed that the United States could potentially find itself with a physician shortage upwards of 104,900 physicians by 2030. Due in part to population growth, an increase in the number of aging Americans and retirement of practicing doctors, this potential shortage has healthcare providers, hospitals, clinics, and private practices racing to discover and acquire long-lasting talent. Hopefully, this concerning effort will result in keeping the industry afloat throughout the next two decades, ensuring patient care access remains readily available for those who need it.

We were warned in 2012, when the Rand Corporation surveyed the international threats arrayed against the United States and concluded that only pandemics posed an existential danger, in that they were “capable of destroying America’s way of life.”

We were warned in 2015, when Ezra Klein of Vox, after speaking with Bill Gates about his algorithmic model for how a new strain of flu could spread rapidly in today’s globalized world, wrote that “a pandemic disease is the most predictable catastrophe in the history of the human race, if only because it has happened to the human race so many, many times before.” If there was anything humanity could be certain that it needed to prepare for to prevent the deaths of a lot of people in little time, it was this.