Next year is the year President Barack Obama's signature health care law goes into high gear, covering millions of uninsured Americans by a mix of private plans and government programs infused with tens of billions of dollars in taxpayer money.
You'd think there'd be a chapter in the new 2014 budget that lays it all out. Wrong.
Well, maybe a table? Wrong again.
A box? Nope.
It turns out that the costs of the Affordable Care Act — Obamacare to its unyielding Republican foes— are sprinkled here and there through hundreds of pages of budget books. It's partly due to the arcane ways of government budgeting. It may also be an effort to avoid giving foes more of a target.
"I'm sure somebody has a spreadsheet somewhere, but clearly they are not publishing it in this budget," said Bill Hoagland, senior vice president at the Bipartisan Policy Center. "There is a political aspect to this and there is literally a green-eyeshade part. Once you have adopted a policy it's difficult to just pull it out."
Even some of the major spending in the new law isn't easy to find. Starting Jan. 1, people who don't have health insurance through their jobs will be able to get coverage in two main ways. Low-income people will be eligible for an expanded Medicaid program, provided their state government accepts. Uninsured middle-class people in every state will eligible for subsidized private plans through new state health insurance marketplaces that go live online this fall.
So how much will the new coverage cost the government? Hard to tell.
The Health and Human Services Department administers the new program. Its Medicaid budget calls for a nearly $38 billion increase for 2014. Most of that is due to the Medicaid expansion. But how much? Department officials said Wednesday they can't really tell.
Well, how about the subsidies to help middle-class uninsured people buy private insurance plans? Those are actually packaged as tax credits and not in the HHS budget at all. A footnote in another part of the budget estimates that "premium assistance credits" will cost $32.3 billion in 2014, rising to $82.2 billion by 2018.
Presidential budgets typically highlight new proposals and the cost of programs already on the books just gets blended in to one big fiscal stew.
The cost of the health care overhaul — at least for the foreseeable future — is not contributing to the federal deficit. Obama and congressional Democrats made sure it was paid for through a combination of Medicare cuts, tax increases borne largely by the wealthy and an assortment of new taxes and fees on health care industries.
HHS Secretary Kathleen Sebelius is being very specific about one aspect of funding for the new health care law. Her department needs Congress to approve $1.5 billion for it to operate and support new state-based insurance markets. Republicans in the House blocked last year's funding request, causing Sebelius to scrimp on administrative costs and tap into other accounts legally available. But those options will run out over the long haul.
"As this act is fully implemented and Americans begin to take advantage of its benefits, I'm hopeful Congress will see it as the law of the land," Sebelius said Wednesday. "Millions of Americans are looking forward to full implementation."