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美國的復(fù)蘇與再投資法案
2007年12月全球的經(jīng)濟(jì)已陷入衰退,但直到2008年11月下旬才正式宣布。衰退定義為“基于大量的經(jīng)濟(jì)指標(biāo),如就業(yè)和收入，經(jīng)濟(jì)各領(lǐng)域的活動持續(xù)超過了幾個月顯著減少” (CRS,2009)。2009年的財政年度預(yù)算赤字為1.4萬億美元，占國內(nèi)生產(chǎn)總值(GDP)的10%,而全國的失業(yè)率飆升到1月份的7.6%,高于2007年12月開始衰退時的4.9%,對于大多數(shù)的國家來說，2011財年嚴(yán)重的預(yù)算赤字將達(dá)到3500億美元(Kaiser基金會,2009年)。
聯(lián)邦政府對國家的財政援助項目并不是一個新的方法。在1973年到1975年的經(jīng)濟(jì)衰退時期,美國國會頒布了《重振經(jīng)濟(jì)的財政援助項目》(ARFA)以及通過了全面就業(yè)和培訓(xùn)法案(CETA)為美國提供基礎(chǔ)建設(shè)的資金。布什政府最近頒布了美國就業(yè)及經(jīng)濟(jì)增長的稅收減免和解法案(JGTRRA)來應(yīng)對在過去十年的早期的緩慢復(fù)蘇(馬頓等,2010)。連續(xù)的伊拉克和阿富汗戰(zhàn)爭的同時啟動成本,同時上屆政府為了尋求經(jīng)濟(jì)迅速惡化以及任期內(nèi)的巨額赤字的直接影響而制定了減稅政策 (國會預(yù)算辦公室,2010)。
American Recovery And Reinvestment Act Economics Essay
The economy was in recession in December 2007, but was not officially declared until late November of 2008. Recession is defined as a “significant decline in economic activity spread across the economy, lasting more than a few months and based on a number of economic indicators, such as employment and income (CRS, 2009). The budget deficit for the fiscal year 2009 in the amount of $ 1.4 trillion, 10 % of the Gross Domestic Product (GDP), and the spike in the national unemployment rates to reach 7.6 % in January of that year, up from 4.9 % at the beginning of the recession in December of 2007, in addition to the severe budget deficits for the majority of the states to reach $ 350 billion through the 2011 fiscal year (The Kaiser Foundation, 2009).
The fiscal assistance programs of federal support to the states are not a new approach. During the recession period of 1973 to 1975, the Congress enacted the Anti-recession Fiscal Assistance (ARFA) program and passed the Comprehensive Employment and Training Act (CETA) to provide infrastructure funding for the states. Most recently the Bush Administration had enacted The Jobs and growth Tax Relief Reconciliation Act (JGTRRA) for the states to deal with the slow recovery during the early years of the past decade (Mattoon et al, 2010). The cost of the two consecutive wars in Iraq and Afghanistan which were initiated simultaneously, along with the enactment of the tax cuts during the previous administration were sought to have a direct impact on the rapid deterioration of our economy and the huge deficits during this term (CBO, 2010).The estimated impacts of the changes in tax laws during the Bush Administration started by the enactment of the Economic growth and Tax Relief Reconciliation Act (EGTRRA), and later, by the enactment of the Jobs and Growth Tax Relief reconciliation Act of 2003 (JGTRRA); nevertheless, the stimulus package of the 2008, altogether accounted for the 1.7 trillion in extra deficits from 2001 through 2008, and a total of $ 3.4 trillion over the period from 2009 to 2019 (CBO, 2010).
The enactment of ARRA was intended to provide the states with the immediate, but temporary, fisc
al relief. It was the first economic stimulus to infuse $288 billion in tax cuts for individuals and businesses, $224 billion for education, health care, and unemployment insurance, and $275 billion to improve the infrastructure spending targeted to job creation and investment in the form of federal contracts, grants, and loans (Mattoon et al, 2010). The overall package was then expected to cost a total of $787 billion. It included significant funding for health care , $ 149 billion in health spending of which $ 87 billion was for a temporary increase in the federal share of Medicaid cost, $ 25 billion for temporary (COBRA) subsides, and $ 19.2 billion on Health Information technology (HIT) (The Kaiser Family Foundation, 2009).
This paper will address the fiscal aftermath of the ARRA on the state fiscal budgets and its implications on the long term costs in the United States.
Analysis of ARRA
John W. Kingdon’s “Stream Theory” model of policy process is instructive to the analysis of this paper. According to Kingdon, agenda setting is the first stage in the Policy Process. The policy agenda is the list of issues or problems to which government officials, or those who make policy decisions (including the voting public), pay serious attention. Moving an idea onto or higher up on that agenda involves three processes: problems, proposals, and politics (Harvard Family Research Project, 2007). Kingdon opines that a policy soup of three streams (problem, policy and politics) converge to create a metaphoric window of opportunity in which change can occur. (Citation) This paper will discuss the problem streams, political streams and policy streams that converged creating the opportunity to enact and implement of ARRA.
The 2009 Environment that defined the Problem, Policy and Political Streams
President Obama’s’ theme song during his 2008 presidential campaign was “Signed, Sealed, Delivered” by Artist and composer Stevie Wonder. That theme song was a poignant premonition to the passing of the American Recovery and Reinvestment Act (ARRA) on February 17, 2009. The new administration “signed, sealed, and delivered” a stimulus package promising to boost a Recession driven deflated economy. It can be argued that without this unprecedented action, the economy would have continued in a fast moving downward spiral possibly ending in a Depression.
Key indicators of the magnitude of the problem within the context of healthcare: Problem Stream.
Kingdon’s Problem Stream of policy analysis involves focusing on and defining the problem. In 2009, the United States was faced with the largest economic crisis since the Great Depression (Whitehouse.gov, 2011). ARRA
was created not as reform but as an immediate temporary economic relief. (Citation) It was enacted at a time when the U.S. gross domestic product (GDP) was decreasing at a yearly rate of 6 percent and employment was dropping at a rate of 750,000 jobs per month, (Council of Economic Advisers, 2010). According to The Kaiser Foundation, (2009) a 1% increase in unemployment can lead to one million more Medicaid and CHIP enrollees plus 1.1 million additional uninsured, which will create a greater pressure on the state spending and the long term care costs. Not to mention the trillion dollar scale national budget deficit.
Politics that played a role in the passage of ARRA: Political Stream.
The Political Stream of Kingdon’s policy analysis theory causes the development a list of issues to be resolved. Additionally, the visible cluster of policy actors is active and bargaining occurs in this stream (Henry, N., 2007). President Obama and the Democratic controlled Congress and House along with two Republican Senators from Maine were the major players in the passage of the ARRA (citation). The Act provided for an infusion of state funding for spending on health care, the extension of unemployment benefits, tax cuts for the middle class, educational improvement and infrastructure rebuilding that would provide employment (citation). The “Recovery Act” was the largest countercyclical (define) fiscal stimulus in American history (citation)
The financial crisis involving the explosion of the housing market and the ensuing collapse of major Wall Street firms in 2007-2008 was a key reason for the economic downturn. (citation). The collapse of Lehman Brothers and other large financial institutions caused credit spreads to rise and key sources of credit to dry up (citation). Swift action was clearly needed by someone in order to avoid a complete collapse of the U.S. financial market (citation). The entire financial system was in a state of peril and swift economic decline (citation). A policy change was needed to create long lasting financial stability for the US (Citation).
Opposing Political Views Agenda
There were other visible players in this swift policy change that opposed ARRA, conservatives had many criticisms for the new Act, and they had their own solution to the declining economic status. The agenda for conservatives and republicans alike was to say “No” to all that the President was trying to accomplish with ARRP. Conservative pundits and leaders believed tax cuts to small businesses and reduced governmental spending was the answer. According to the Economic Policy Institute, in Sept. 2010 former House Minority Leader John Boehner introduced a two step job creation plan that would result in a full extension of the Bush-era
tax cuts changes and changes to domestic policy. Boehner proposed a two year freeze on all tax rates and return to spending similar to the fiscal year 2008. Although Boehner’s claim that returning to Bush's economic policies would "create jobs," it was determined that it would have prevented over a million jobs to be created The Congressional Budget Office (CBO) and the Economic Policy Institute both agree that it was not the best way to promote growt. The Economic Policy Institute reported that Boehner’s proposal would have ultimately increased the overall deficit by 30 million. Moreover, Boehner’s plan would have been detrimental to the investment deficit and long term growth.
According to The Economic Policy Institute, the Center on Budget and Policy Priorities, and the Center for American Progress other areas of the ARRA that were opposed by the Republicans, included, an increased investment in Clean Energy Technology, healthcare reform and extension of the Temporary Assistance for Needy Families; all areas that create jobs (citation). When the Americans United for Change, a liberal funded labor group, accused House Republicans of opposing middle class Americans Factcheck.org asserted that it’s all a matter of opinion, “Congressional Republicans didn’t oppose the stimulus bill or the budget because they hate middle-class tax cuts, working families and economic recovery. They opposed the budget because it would increase spending and add to the deficit, and the ARRA because it would increase spending and because of a concern that it won’t change the gross domestic product (or could reduce it slightly) in the long term” (Factcheck.org, 2009).
It can be argued that the two main political factions and many advocacy groups may have been divided on the cause of our failing economy and how to fix the problem. However, we opine that it was evident that the national media, political, public and private opinion agreed that something had to change. State governments faced insurmountable fiscal challenges that had to be averted due to a loss of revenue due to job losses and decreased tax collections and an increase in the number of people who would be able to qualify for state funded programs like Medicaid (citation). Policy entrepreneurs like newly appointed heads of federal agencies; State governments and community advocates had a personal stake in the matter. Heads of agencies had a professional reputation to protect and state’s had worsening budget crisis to end. More importantly, President Obama won on the platform of change. This was the impetus for the convergence of the three of Kingdon’s streams of policy process (Problem, Policy and Political). It is evident from the facts that the metaphoric window of opportunity opened just in time to effect fiscal change on such a large scale and enact ARRA.
In terms of Kingd
on’s Phases, both parties were ultimately able to undergo what Kingdon calls the softening up phase in which alternative solutions were able to be discussed. Kingdon believes that these three streams meet, a public policy can result.
Policy solutions significant to economic relief: policy stream.
The agenda is formulated in Kingdon’s policy stream of policy analysis. The policy behind ARRA was to stimulate job creation and strengthen State budgets (citation). A major hurdle was going to be costs and accountability for the spending. Was it technically feasible? Could it be sustained? What was going to be the costs and cost effectiveness? Retrospectively, the answers are in the affirmative. The following discusses the impact of the Stimulus Plan on state budgets.
The short term effect of the ARRA created a positive outlook by creating more jobs and thereby increasing the GDP; however, the long term effect is dependent on the availability of additional funds. According to U.S. Budget Watch (2009), over time the economic impact of the act would increase the economic growth on yearly basis until the FY 2013, by creating 1.2 million to 3.6 million jobs by the end of the FY 2010, and by improving the GDP to 3.3 % (citation). Moreover, it has been estimated that the costs of this act would pass the original $787 billion by incurring an additional total cost of $ 50 billion by the year 2018 (CBO, 2009).
The Council of Economic Advisers (CEA) to the President in September of 2009 reported that a very important element of the ARRA has been the impact it has made on state budgets and fiscal relief. According to CEA, aid to the states helped to avert large tax increases and slashes to important social programs and services provided to persons in need by the state governments (Citation). Because of the great loss of employment in many states, it increased the number of people eligible for Medicaid services, deepening the burden to most states budgets crisis. Those states received more of the ARRA money.
Medicaid is a government plan that provides health insurance for persons and families with incomes below certain levels; this level varies according to the state you reside. The Federal government provides x amount of dollars for their Medicaid expenses as determined by the Federal Medical Assistance Program or FMAP to each state for each person enrolled in the Medicaid program (CEA, 2009). The more people enroll in the program, the more the state has to spend x amount of dollars per person. ARRA made changes to the FMAP calculations and allowed states to maintain budget shortfalls for a short period of time, states would still need to make important decisions and budget cuts in order to balance their budgets, this was only a temporary fix. Pursuan
t to it’s healthcare provisions, ARRA provided for a temporary increase in the FMAPs ($86.6 billion), Extension on the moratoria on Medicaid regulations ($105 million), Prompt pay requirements ($680 million), Extension of Transitional Medical Assistance ($1.3 billion), COBRA provision subsidy ($24.7 billion), HIT ($19.2 billion), Community Health Centers ($1.5 billion), Comparative Effectiveness Research ($1.1 billion), Expansion of primary care workforce ($500 million), Blocking of payment reduction to teaching hospitals and hospice providers and make technical corrections for long term care payments ($338 million). (American Recovery and Reinvestment Act: Medicaid and Healthcare Provisions, KFF, March 2009). The purpose for this relief was to support the state with funds during the increase demand as the unemployment rate continued to spike. Although, the national unemployment rate hit 7.6 % in January 2009, some states were at much higher levels (citation).
Accountability and Transparency
States and ARRA
A Regional look at how ARRA funds were used: Success Stories
States, counties, cities and suburbs are important economic agents that not only provide services important to functioning of regional economies, but also serve as major employers to the state residents (citation). The ARRA provided a much needed partnership between state and federal governmental services to ease the state fiscal crisis (citation). The ARRA provided temporary fiscal assistance to stabilize state budgets; it provided employment for its residents as a response to the consequences of the economic downturn, it strengthened and stabilized the housing market, it provided investment into local transportation and transit, and it also enhanced municipal credit (Muro, M. & Hoene, C., 2009).
Most states and the Virgin Islands have formed or projected ways to track, present oversight, and give out information relating to federal stimulus funds. Governors have created ways, state agencies are recording projects, and legislatures are forming commissions or committees to manage the American Recovery and Reinvestment Act (ARRA) (National Conference of State Legislatures, NCLS, 2010).
New Jersey Funding
New Jersey’s distributions of funds are represented in figure 2.
According to the states website New Jersey will collect about $17.5 billion in total reimbursements over the three years from ARRA. (This $17.5 billion estimate is based on an analysis that accounts for about 70% - or $550 billion - of the total cost of the recovery package (NJ Recovery and Reinvestment, 2010). According to figure 2, 42% of New Jerseyans will receive tax benefits from ARRA.
The rest of the funds will be used for road and rail network and energy projects; education and job preparation; saving jobs and protecting vital services; Medicaid and other social safety net programs. According to the states website New Jersey will obtain roughly $2.2 billion in supplementary Medicaid support over three federal fiscal years. This added money will help to prevent the worst cuts in service and allow the state to guard the most at risk populations through this fiscal crisis. The increase is in recognition of the State’s growing health care costs, including the increasing numbers of uninsured. Medicaid enrollment grew by 8 percent or 84,000 people last year.
Figure 4.
Pennsylvania Funding
In Pennsylvania, according to the states website, the economic recovery plan provides about $5.3 billion to increase access to quality health care for vulnerable populations. The funding will help to create the Pennsylvania Health Information Exchange (PHIX), health information technology through electronic health or medical records, (emr, ehr). The objectives in Pennsylvania with ARRA are to ease the impact of rising health care costs without reducing coverage to those in need of coverage.
New York Funding
New York has been no different than the two previous states with the use of the ARRA funds. According to the New York State figure 5
Economic Recovery and Reinvestment Cabinet, 2009, New York will receive about $420 billion in stimulus money over the projected period, of that $11.1 billion will go to Medicaid funding to offset the cost of the Medicaid program (citation). The state will use approximately $549 million to stabilize the state’s budget and reduce a need for budget cuts, layoffs and increased taxes.
The Future of ARRA: A Strategic Plan
A little over two years ago, ARRA held the promise of fiscal recovery. However, the first part of the federal FY 2011 still showed that the United States continued to live in the midst of the worst economic downturn since the Great Depression manifested by high unemployment, severely depressed revenues and increased demand for services, such as Medicaid (citation). While most states expect to see the impact of the recession endure for the next few years, some are hoping that 2011 will be a turning point moving toward economic recovery (The Kaiser Family Foundation, 2010). In 2009, the United States had at least 50.7 million people without health insurance coverage (citation). What is the number now? Those without adequate health insurance often forgo needed care, endure preventable illnesses, suffer complications that could have been avoided if diagnosed and treated earlier (ACP, 2011). As a res
ult, some states have planned for an extension by Congress of FMAPs in their FY 2011 budgets. As of April, 2010, most states had declared an intension to plan their budgets as if Congress will approve a six month extension (FMAP extensions and the Impact on States, National Conference of State Legislatures, 2010). New Jersey planned the state budget considering an extension in the amount of approximately $490 million but has no contingency plan. New York has also budgeted on an extension assumption in the amount of $1.1 billion and Pennsylvania in the amount of $848.5 million without a contingency plan.
Only nine states have contingency plans in the case Congress fails to grant the extension (National Conference of State Legislatures, 2010). Some contingency plans include eliminating eligibility categories, depleting reserves, reducing allotments and the transfer of funding allocations. (National Conference of State Legislators, April 29, 2010).
On the heels of ARRA, almost one year ago, on March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act (ACA), into law (The Kaiser Family Foundation, 2010). The ACA, according to The Kaiser Family Foundation is expected to extend health insurance coverage to 32 million more people, covering 95% of the U.S. population by 2019. It can be argued that some ACA provisions extends some of the ARRA healthcare provisions long term. According to CBO (2010), the President’s budget deficits will reach a total of $9.8 trillion in 2011 through year 2020. However, if president Obama’s was to extend the inherited policy, the actual deficits would then have reached more than $11 trillion; the difference of $ 1.3 trillion in savings (citation). Despite this reduction, the federal government will continue to generate serious deficits in the decades to come (citation). To address this dilemma, the policymakers will need to take a serious approach to stabilize the federal debt as a percentage of GDP by reducing the annual deficits to about 3% of GDP (CBO, 2010).
The proposed savings of $ 1.3 trillion will occur during the next decade, as $ 500 billion will be saved during the period of 2011 and 2015 and the remaining will be saved over the next decade (CBO, 2010). The health care costs have been the largest cause of expenditures over the long term. The two main reasons of the risings expenditures are the health care costs per person and the aging population through the three big programs: Medicare, Medicaid, and Social Security. It has been estimated that the growth in these programs will account for all of the increases in the federal spending as a huge share of GDP for the next forty years (CBO, 2010).
The impact of ARRA on the long term fiscal budget can not be quantified, and for mo
re than one reason. Firstly, the ARRA’s budgetary effects is addressing the period during the FY2009 through FY 2011, which will only account to a 3% of the long term budget gap estimated to run until 2050 (citation). According to CBO, the long term fiscal gap projected is an end result of other budgetary policies and other factors that have led to the recession. Secondly, the rapid growth of the health care costs, the aging of the population and the expensive tax cuts in 2001 and 2003 are mainly the primary reasons that pre-existed and thought to have a major contribution on the increased expenditures and the loss in revenues.
To control costs, 46 states implemented at least one new policy (what does this mean?) in FY 2011, with some states reporting program reductions in multiple areas. While many states mentioned that ARRA helped to avoid or mitigate provider rate cuts, 37 states have planned provider rate restrictions.
More than any other area, provider rates are linked to economic conditions. (citation). Under budget pressure, states turn to rate cuts to have an immediate budget impact and when conditions improve states are able to restore or enhance rates (citation). Moreover, 20 states implemented benefit restrictions in FY 2010, and 14 states have planned to have done the same in FY 2011 (Citation). These benefit restrictions include the elimination of covered benefits as well as the application of utilization controls or limits for existing benefits (citation). For example, several states eliminated all or some adult dental services including Arizona, California, Hawaii and Massachusetts. A number of states also imposed limits on benefits such as imaging services, medical supplies or durable medical equipment, therapies or personal care services (The Kaiser Family Foundation, 2010).
Nursing Implications
It can be gleaned that the healthcare provisions of ARRA has the power to directly affect nursing. It provides for more autonomy and leadership roles for NP’s in the context of federally qualified community health clinics. The HIT provisions has the potential to create a surge in tele nursing and other IT nursing jobs. Nurses will have an opportunity to play a major role decreasing long term healthcare costs through the implementation of preventative care on a larger scale to populations who would otherwise enter the healthcare system in an acute state. However, since ARRA was really meant to be a short term fiscal relief policy, Nurses must also be at the forefront of advocacy for a broader more permanent and comprehensive healthcare reform and healthcare expansions (KFF, March 2009).
It can be also predicted that Nurses are in a great position to use ARRA and ARRA derivative funding (i.e., ACA) to make palpable differe
nces in the healthcare system. In addition to primary service, Nurses can also play a role in research utilizing NIH grants. The National Institute of Health plays a major role in empowering researchers to find solutions to major health challenges (HHS.gov/recovery, 2011) .
On February 17, 2011, HHS Secretary Kathleen Sebelius celebrated the second anniversary of the Recovery Act. Secretary Sebelius recalled how ARRA empowered the Department of Health and Human Services “to boost the nation’s economy, create or save jobs, maintain health care services, expand access to affordable health care, protect those in greatest need and provide for the elderly and young children” (hhs.gov/recovery, 2011),
In terms of health care relief, the following successes were noted:
Over $84 billion in federal payments helped maintain state Medicaid services and provided fiscal relief when the numbers of grew during the economic downturn exceeding State’s budgetary capacity.
Over 3.2 million new patients, including 1.8 million uninsured patients, have received health care at community health centers. (FQHC)
Starting on January 3, 2011, hospitals and eligible professionals began registering to receive Medicare and Medicaid incentive payments for the adoption and meaningful use of electronic health care records.
The NIH awarded over 20,000 grants for research
Thirty-nine states, the District of Columbia, two territories and eight tribes were awarded $1.3 billion from the Temporary Assistance for Needy Families Emergency Contingency Fund (TANF) to support employment programs, including transitional jobs, summer job programs for low-income youth and work programs for individuals with disabilities.
Over 7,800 American Indian and Alaskan Native homes gained access to safe drinking water and adequate waste disposal facilities.
Forty-four communities, reaching over 50 million Americans, received over $370 million in grants to reduce obesity and reduce tobacco use by implementing evidence-based preventions and wellness strategies.
The HHS has made program integrity a priority working hard to prevent waste, fraud and abuse.
(HHS.gov/recovery, 2/17/2011).
Were the Implementation guidelines followed?
Recipients of ARRA funds were required to use the money and report quarterly on how they used the funding. (Recovery.gov, 2011)
The CEA, 2010, reports following the implementation of the ARRA the course of the economy has improved, and as of the first quarter in 2010 “the tax relief and income support pro
visions of the Recovery Act have save or created more than 1 million and 1.4 million jobs, or roughly one-half of the total number of jobs saved or created by the ACT” pg 3 (CEA report, April 14, 2010).
Accountability and Transparency
Stop measures to reduce or eliminate fraud have been implemented. In terms of evaluation, all Recovery Act programs are assessed for risk and to assure appropriate internal controls are in place pursuant to the requirements of the Federal Manager’s Financial Integrity Act and the Improper Payments Information Act and the OMB’s Circular A-123 “Managements’ Responsibility for Internal Control. Accountability and Transparency will also be required of HRSA in dispensation of all Recovery Act funding, consistent with statutory and OBM requirements (Health Resources and Service Administration: Community Health Centers- Services, 2009).
Conclusion
In conclusion, the final question for analysis is whether the ARRA did what it was meant to do in such a short period of time? The short answer might be yes but it depends who you ask. In light of the fact that an extension is being considered, it can be argued that the final analysis is still open for interpretation. Proponents will argue that the federal government acted swiftly and responsibly to help relieve state budget’s. However, ARRA’s opposers may counter that it did not help solve Medicare’s long term solvency issues.
