Health Care's History of Fiscal Folly

Expanding health coverage busted state budgets. Will it bust the federal budget too?

The Affordable Care Act—otherwise known as ObamaCare—isn't the first attempt to expand health insurance coverage in America. Before Washington passed its law, a number of states took smaller-scale cracks at the job—each of which proved far more expensive than planned. As the nation dives further into debt, the destabilizing fiscal effects of those programs don't bode well for how ObamaCare will shape the U.S. budget.

As spectacular failures go, it's hard to do worse than Tennessee. This early state attempt to dramatically increase health coverage, dubbed TennCare, started off promisingly. In 1994, the first year of its operation, the system added half a million new individuals to its rolls. Premiums were cheap—just $2.74 per month for people right above the poverty line—and liberal policy wonks loved it. The Urban Institute, for example, gave it good marks for "improving coverage of the uninsurable or high-risk individuals with very limited access to private coverage." At its peak, the program covered 1.4 million individuals—nearly a quarter of the state's population and more than any other state's Medicaid program—leaving just 6 percent of the state's population uninsured.

But those benefits came at a high price. By 2001, the system's costs were growing faster than the state budget. The drive to increase coverage had not been matched by the drive to control costs. Vivian Riefberg, a partner at consulting firm McKinsey & Company, described it as having "almost across the board, no limits on scope and duration of coverage." Spending on drug coverage, in particular, had gone out of control: The state topped the nation in prescription drug use, and the program put no cap on how many prescription drugs a patient could receive. The result was that, by 2004, TennCare's drug benefits cost the state more than its entire higher education program. Meanwhile, in 1998, the program was opened to individuals at twice the poverty level, even if they had access to employer-provided insurance.

In other words, the program's costs were uncontrolled and unsustainable. By 2004, the budget had jumped from $2.6 billion to $6.9 billion, and it accounted for a quarter of the state's appropriations. A McKinsey report projected that the program's costs could hit $12.8 billion by 2008, consuming 36 percent of state appropriations and 91 percent of new state tax revenues. On the question of the system's fiscal sustainability, the report concluded that, even if a number of planned reforms were implemented, the program would simply "not be financially viable." 

Democratic Gov. Phil Bredesen declared the report "sobering," and, rather than allow the state to face bankruptcy, quickly scaled the state back to a traditional Medicaid model, dropping about 200,000 from the program in a period of about four months. Though the state still calls its Medicaid program TennCare, Bredesen's decision to scale back effectively shut the program down. In 2007, he told the journal Health Affairs, "The idea of TennCare, as it was implemented, failed."

Maine took a different route to expanding coverage, but it also resulted in failure. In 2003, the state started Dirigo Care, which, it was promised, would cover each and every one of the state's 128,000 uninsured by 2009. The program was given a one-time $53 million grant to get things started, but was intended to be eventually self-sustaining. It wasn't. Indeed, the program managed the neat trick of drastically overshooting cost projections while drastically undershooting coverage estimates.

In 2009, the year in which the program was to have successfully covered all of the uninsured, the uninsured rate still hovered around 10 percent—effectively unchanged from when the program began. Taxpayers and insurers, however, had picked up an additional $155 million in unexpected costs—all while the state was wading deeper into massive budget shortfalls and increased debt. The program has not been shut down, but because expected cost-savings did not materialize, it's been all but abandoned. As of September 2009, only 9,600 individuals remained covered through the plan.

And then there is the Massachusetts plan, the model for ObamaCare. The state's health care program has successfully expanded coverage to about 97 percent of the state's population, but the price tag may be more than the state can bear.

When the program was signed into law, estimates indicated that the cost of its health insurance subsidies would be about $725 million per year. But by 2008, those projections had been revised. New estimates indicated that the plan was to cost $869 million in 2009 and $880 million in 2010, an upwards increase of nearly 20 percent. More recently, the governor's office announced a $294 million shortfall on health care funds, and state health insurance commissioners have warned that, on its current course, the program may be headed for bankruptcy. According to an analysis by the Rand Corporation, "in the absence of policy change, health care spending in Massachusetts is projected to nearly double to $123 billion in 2020, increasing 8 percent faster than the state’s gross domestic product (GDP)." The state's treasurer, a former Democrat who recently split with his party, says that the program has survived only because of federal assistance.

Defenders of the program argue that it's not really a budget buster because the state's budget was already in trouble. But for those worried about ObamaCare's potential effects on the federal budget, that's hardly comforting. The Congressional Budget Office (CBO) has warned that, without significant change, the U.S. fiscal situation is "unsustainable," with publicly held debt likely to reach a potentially destabilizing 90 percent of GDP by 2020. Democrats managed to get the CBO to score ObamaCare as a net reduction in the deficit, but those projections are tremendously uncertain at best. As Alan Greenspan warned last weekend, if the CBO's estimates are wrong, the consequences could be "severe".

The history of health coverage expansion should make us worry. If ObamaCare's actual fiscal effects look anything like previous efforts to expand health coverage, the federal budget is in for a world of hurt.

Peter Suderman is an associate editor at Reason.

Editor's Note: We invite comments and request that they be civil and on-topic. We do not moderate or assume any responsibility for comments, which are owned by the readers who post them. Comments do not represent the views of or Reason Foundation. We reserve the right to delete any comment for any reason at any time. Report abuses.

  • ||

    Too bad nobody in the media wanted to tell us about all of these failed plans.

  • PersolMan||

    Media can not be trusted anymore

  • OC Home Renters||

    When could the media ever be trusted. The media was invented to sell advertising for profit.

  • Amit @ big booty||

    Since, when was the media trustable??

    All they care is about money.. nothing else

  • Don||

    LOL. Could they ever be trusted to report anything not fully biased?

  • seo mexico||

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  • Computer Repair Union Mo||

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  • sage||

    The Affordable Care Act—otherwise known as ObamaCare

    NO. It's Obamacare. He owns this turd.

  • ed||

    Yep. It's his baby. History will judge him by name.

  • PR||

    when it implodes, I'm sure the I didn't do it kid will take responsibility.

  • ||

    It is set to implode after 2012, when Obama may be a private citizen again.

  • ||

    Since the fiscal "case" for ObamaCare was always either a po-faced assertion or an out-right lie, arguing the fiscal effects seems moot at this point.

    The leftist strategy is very clear. Move toward single-payer by kicking over the shaky health care structure put in place by past stupid government policy making. Then the flow of money from the producing to the the non-producing classes will become as free as wrist-blood in a warm bath.

    They are sick of flinging leeches and having them only land on extremities. They want it to latch right on the jugular.

  • ||

    Bloodletting was an acceptable form of medical therapy for a very long time, and lingered around long enough in Abe Lincoln's time (and contributed to his death).

    Apparently, they wish to resurrect the practice on the body politic.

  • ||

    Bloodletting by bullet to the head then?

    I think you mean Washington.

  • ||

    No I meant Lincoln.

    When he was shot the bullet was lodged into his brain and resulted in a subcranial hematoma in occipital region of the cranium leading to cranial encephaly secondary to shock. The first responder, Dr. Charles Leade, upon realizing that the insulting wound was a GSW, bled Lincoln at regular intervals to relieve the intracranial pressure. The modern TX had Lincoln presented today would be a craniotomy with a wound-vac and exploratory surgery with excision of the offending object, provided no major blood vessels were insulted and depending where the bullet ultimately resulted. It is quite possible Lincoln could have survived the assasination as he was in a coma for nine hours following the assault.

    Bloodletting didn't fall out of favor until the later part of the 19th century due to the perceived benefits of sedation from bloodletting and the treatment of shock and circulatory management.

    Bloodletting in modern medicine is indicated in the TX of hemochromatosis and severed limb reattachment via leeching.

  • bonsoir||


  • OC Home Renters||

    Nice post, I'm impressed! But what was the significance of the coma as related to Lincoln's potential for survival?

  • ||

    Actually, it's worse than that. The Left's REAL strategy is to create massive new entitlements and run the national debt up to catastrophic levels. This in turn, will FORCE massive tax hikes (the only alternative would be to cut the entitlements which voters will never allow). Once this occurs...Voila!!...we have a socialist state. After the election, I predict the Left will fear-monger 24/7 about the national debt and use this as a pretext to create a national sales (VAT) tax.

  • virginia||

    Masshole Care is finito santiago.

    "A half-dozen health insurers yesterday filed a lawsuit against the state seeking to reverse last week’s decision by the insurance commissioner to block double-digit premium increases — a ruling they say could leave them with hundreds of millions in losses this year."

    "The stand-off between Massachusetts regulators and health insurance companies intensified today as most insurers stopped offering new coverage to small businesses and individuals..."

  • Jeffersonian||

    One thing is certain: Massachusettes needs a lot more state intervention in its insurance markets to fix this. That's always the answer.

  • fit in facts, don't fit over ||

    "Rep. Mazie Hirono (D-Hawaii) got her state’s existing health program exempted by what the Honolulu Advertiser called the “Hirono Amendment.” As a result, the reform measures will be a non-event for many people in Hawaii.

    ...Lawmakers from Massachusetts ensured that their state’s universal coverage program, the Health Insurance Connector, could continue operating independently. The program was a model for the “exchanges” in the Democrats’ national bill, but some drafts of the healthcare bill would have left the program’s future in question or might have weakened its ability to negotiate with insurers. Massachusetts officials say the program is working well and should be left alone."

  • ||

    Hawaii has a vested interest in being exempted.

    Regarding Hawaii's SCHIP Program.

    From the Galen Institute:

    MIT economist Jonathan Gruber says his studies "clearly show that crowd-out is significant" - on the order of 60 percent. In other words, SCHIP coverage replaces private health insurance 60 percent of the time, and the rate will be greater if we extend eligibility to higher-income families.

    Universal coverage in any form is an increasingly elusive goal. Several states (including California, Pennsylvania, Illinois and Wisconsin) have attempted major efforts to advance toward health coverage for all citizens. All have had to turn back because the costs were prohibitive.

  • learn from any mistakes||

    and make hcr work. For instance, close the high-income/covered child loophole.
    They also have had success:
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  • ||

    I will look into those stats as the article cited was lacking details.

  • bonsoir||

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  • ||

    Yeah, but we're still living the dream here in the Volunteer State. Even with Bredesen's cuts (you should have heard the whining) we had to use a significant amount of our federal "stimulus" money to keep it afloat the last fiscal year.

    Bredesen (even though a Democrat I like him) was one of the few governors who complained publicly about the mandates which will be placed on the states by ObamaCare. I've read that Tennessee's costs will come in at about $700 million annually. These types of estimates are always low-balled and judging from the accounts of cost increases Suderman offers here it won't take many years before the whole thing implodes.

    SugarFree, you are right on about the underlying agenda. The bill was nothing more than a tactical move to bring about federally run healthcare. What else to you think the little o said to Kucinich to get him to change his vote?

  • Steff||

    Ha! It took nothing but a plane ride to get Kucinich's vote. Because he's a dope. Take it from an Ohioan.

  • ||

    I thought his wife was promised some cush job.

  • Steff||

    I'm not sure, but it wouldn't shock me. All I know is that he was a Born Again Dumbass when he stepped off of Air Force One.

  • ||

    I'll bet he would have either gotten permanent couch duty or would have been flat out cock blocked from his towering, fiery ginger siren of a wife.

    Hot ginger lovin' or following one's convictions? We have our answer and Little Dennis still has use for those crampons and climbing gear he got as a wedding present.

  • ||

    He was a certified dumbass long before that.
    But as someone who lives in the community that elected that hag Pelosi, I can't gripe too much.

  • President Brain Slug||

    I simply introduced him to my cousin, Congressman Brain Slug.

  • Jimmy 'Crack' Corn||

    Obama, a lying piece of shit.

  • ||

    This is GREAT!:
    "Defenders of the program argue that it's not really a budget buster because the state's budget was already in trouble."

    IOWs, we can't afford *this*, but it doesn't matter since we couldn't afford *that*, either.

  • Rick||

    Another little piece of this health care debacle is:

    The CLASS Act – an acronym for the Community Living Assistance Services and Supports Act

    Another entitlement program that will likely be unsustainable. Not sure if I have seen this covered here at Reason yet.

    I am seriously doing the math on whether I may soon be better off quitting my near 6-figure job to be "poor".

    I could pay in $5 a month for a few years on the CLASS act and get back 15-25K per year in benefits, use my existing medical conditions to collect disability, get free or subsidized health care, and a plethora of other government aid programs.

    Couple this with income I could earn in the underground economy, and I may double my take home pay without having to leave the house every morning.

    I have to imagine that there are tons of people out there who are being so disincentivized to actually work for a living that many will start looking seriously at this option.

  • LeftCoastRightBrain||

    CLASS will allow for the expansion of SEIU jobs in the healthcare arena. No big shock there as I'm sure Andy Stern's walking around with a big ol' smile on his face.

  • ||

    It is past time to return the Federal government to pre-1920 levels.

  • ||

    Will Rogers, sometime around 1928 or so, said, "Americans are lucky they don't get all the government they're paying for." I think we are getting closer.

    It's really simply human nature: more than 50% of the voters think they've figured out how to get whatever they want without having to pay for it out of their own pockets. And that is? To get the government to pay for it for them. So long and enough people believe that - and that particular piece of "theology" seems quite enduring - they will continue to vote for benefit increases. "Vox populi, vox dei" really means, "Oh, my God! How did we get into this pile of sh*t!"

  • TheNino85||

    "As spectacular failures go, it's hard to do worse than Tennessee."

    Even out of context, it has meaning!

  • ||

    "Will it bust the federal budget too?"

    Naah. We're all told this time it's different.

  • Larry Hastings||

    The Massachussetts thing is $880m in 2010, and it may "double to $123 billion in 2020"? That's not doubling, that's 150x. Did you mean "$1.23 billion"?

  • ||

    I was practicing in TN during the TennCare era. The gate keepers were supposed be primary care which paid by capitation IIRC. Anyway for marginal practitioners it was like a gold rush but there was no "care there".

    There is an OP-ED @ talking about the movement among primary care docs to refuse all insurance and medicare/medicaid. Cash on the barrel head, baby!

  • ||

    Given the impact of obesity on our national healthcare problems, did nobody in the fine state of Maine look at the name Dirigocare and engage their brains......

  • ||

    Of course it will bust the federal budget. To a Commie, that's not a bug, that's a feature. In fact, that's the goal.

    Don't forget what we're dealing with here.

  • ||

    Please take time to leave a comment and take note of H.R. 4903 which will repeal the healthcare bill.

  • ||

    So now it's "the affordable health care act"? Talk about futurespeak. Just like terrorism is now "man-made disasters" and the bailout bill was the "economic recovery act". The pathetic part isn't that pols pull this stuff...the really pathetic part is that they think we're so frigging stupid that it actually changes our opinions.

  • ||


    It's been going on for a long time; they can't help themselves. My favorite has always been "The Tax Simplification Act of 1986." 880 pages of simplification.

  • ||

    The largest cause of personal financial ruin for those in the middle class is lack of health insurance coverage once getting seriously ill. Does it make any sense to have health insurance through your job, when you get sick, you lose your job and your coverage (unless you have a UNION! to support you). Or a preexisting condition or lifetime spending cap? Where was the outrage over spending during the last eight years? At least with this spending, the largest cause of middle class financial ruin has been addressed.

  • ||

    This was the conclusion of a couple of tendentious studies from 2005-2007 that essentially assumed that if you went bankrupt owing a couple of medical bills, then the medical bills were the reason you went bankrupt. ( Since then, the real-estate cataclysm has forced medical bills as a cause for bankruptcy completely off the map. As for Obamacare "addressing" the problem, I guess you could say that, if "addressing" is taken to mean "throwing a billion of the taxpayer's dollars down a storm drain."

  • ||

    Because banks and real estate developers had a five year orgy- this eliminates a serious financial problem to the middle class? talk about backwards logic.

    BTW-"This" is paid for unlike Medicare D passed by a Republican congress and Republican President a couple of years ago was not paid for.

  • ||

    It makes about as much sense to have your health "insurance" provided through your job, as it does to have your car insurance provided through your job, or to have your retirement plan provided through your job -- except for the tax breaks.

    Make all medical costs (insurance, co-pays, etc) deductible on your personal income tax return. Ditto for retirement savings and other little bennies -- replace 401(k) programs with a no-limits IRA. Make them not deductible to corporations (better yet, just abolish the corporate income tax, which would have the same effect).

    In a static analysis, shifting deductibility of medical plan from corporations to individuals has absolutely zero net effect on the federal budget. (Dynamic analysis is tricker, because you have to consider a bunch of mutually offsetting effects.)

    This has the virtue of simplicity, encourages decentralized decision-making, and allows people to keep their insurance as long as they want, rather than until they switch jobs. Just as you can with your car insurance today. The problem of "pre-existing conditions" only arises when you are forced to switch insurers.

  • The Big O||

    I want my FREE ObamaCare NOW

    I want my FREE ObamaMoney$$$ NOW

  • ||

    Better to you than to Blackwater.

  • Dollar Bill ||

    The number one problem facing the US Goverment when President Obama became President was the deficit. Since he became President, he has exacerbated the problem several fold. He is either inept or dangerous....probably both. Congress is to blame also. I can't believe our present course of deficit spending. God help us!

  • cost||

    Its not health care coverage that busted the budgets, its the monopoly pricing. Allow free competition in health care, and costs will be reasonable. An MRI in Japan costs $98, and here it costs $1600. Let Japan open MRI clinics staffed with Japanese trained personnel and the budget will be just fine. Lipitor costs $300 here, and $180 in Canada. Let people buy their Lipitor from Canada by mail, and the budget woes will be over. Better yet, let citizens just buy it OTC from Amazon the way they buy aspirin. Cheaper yet.

  • Chris||

    But then we won't have government making us safe from ourselves?

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    Health care is of vital importance to the people's livelihood. It should be emphasized and discussed again and again to a better and better solotion.

  • Henry||

    It would be better if it will be realized that Health Care Issues be responsive to the needs of the people. The issue of budget is another problem to solve by those who knows economy.

  • Gregg||

    I just can't understand sometimes that we cannot understand the laws that our lawmakers make. Isn't it that under the law, the profession to practice health cares are health professionals? then why is it that when making health laws which is I think the most critical activities of health planning and practice, non health professionals take charge? Is not maybe the reason why we have wrong health programs? from Gregg of sonic electric toothbrush

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  • snatur||

    That's serious problem

  • PersolMan||

    It is hard to trust media in our days

  • Credit pour des soins||

    Again, I think health comes first. Not even necessarily for yourself but for everyone you love. In France, the Public Health actually weighs very heavily in the national budget, it's true. But I'd rather see the courts are understaffed and the police in trouble rather than the services that care for my mother and I could never hope to pay, despite the fact that I work and I earn a significant amount of money . What would you think when you need care for your loved ones?
    Casaria -

  • snatur||

    It is hard to trust media in our days.

  • ปลวก||

    The leftist strategy is very clear. Move toward single-payer by kicking over the shaky health care structure put in place by past stupid government policy making. Then the flow of money from the producing to the the non-producing classes will become as free as wrist-blood in a warm bath.

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  • Cop Konteynerleri||

    " In other words, the program's costs were uncontrolled and unsustainable. By 2004, the budget had jumped from $2.6 billion to $6.9 billion, and it accounted for a quarter of the state's appropriations "

    These are very huge costs right ?

  • Bahce Mobilyasi||

    What is different between federal and state budget ?

  • K Nance||

    More people need to read this and understand this side of the story.
    Health care is a mess and the bias media won't acknowledge it.
    Good job!

  • Nerds Next Door||

    The problem is as a small business owner these issues are compounded greatly. What you find is that a small business owner has a tighter margin than larger companies and we are being squeezed by the costs of insurance. To be honest we have no idea what Obamacare will do for our company, will it make it better or worse?

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    Is it possible to have a budget enough to cover this? In a free market, costs will always go up once the "seller" determines that what he has is in demand. It's another vicious cycle.


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