MONEY long term care

The Retirement Crisis Nobody Talks About: Long-term Care

If you become disabled, you may face huge bills for daily help. And, no, Medicare doesn't cover it.

When you try to gauge the biggest risks to your financial security in retirement, health care costs usually top the list. But there’s even bigger danger that doesn’t get as much attention: long-term care costs.

By whatever measure you use, many Americans aren’t saving enough for retirement. In its latest annual retirement readiness study, the Employee Benefit Research Institute found that some 57% to 59% of Baby Boomer and Gen X households are on track to retire comfortably. But if you factor in long-term care costs, the percentage of households running short of money in retirement soars by 100% or more after 20 years for those in middle-class or upper-income quartiles, according to new study by EBRI. The analysis assumes that Baby Boomer and Gen X households will retire at 65 and spend average amounts for food, housing and other living expenses, in addition to long-term care costs.

The risk of falling short financially is highest for those in the lower-income quartile—by the 10th year of retirement, some 70% in this group would have run short of money, according to EBRI, though the majority were already headed for trouble because of lack of savings. But even households in the highest-income quartile saw the percentage falling short reach 8% by the 20th year of retirement vs. just 1% without accounting for long-term care.

If you become disabled, the costs of assistance with daily living tasks (what’s commonly referred to as long-term care) aren’t generally covered by Medicare. That’s something many people don’t realize. A nursing home in the Midwest might run you $60,000 a year, while the median salary for a home health aide may be $45,000 annually. Some 70% of Americans age 65 and older are expected to need long-term care at some point in their lives. And studies have found that many families end up paying huge amounts out of pocket, as much as $100,000 in the last five years of life.

Planning ahead can help, but unfortunately there are few solutions to the long-term care dilemma. One alternative is to purchase long-term care insurance, but it’s pricey, so few can afford it. “Long-term care insurance is something that nobody wants to buy and the insurance industry doesn’t want to sell,” says Howard Gleckman, senior fellow at the Urban Institute and author of “Caring for Our Parents.” In recent years, many insurance companies have raised premiums on long-term care policies. And other insurers have gotten out of the business—that’s mainly because fewer buyers than expected are dropping policies, and low interest rates have reduced profits.

Another option is Medicaid, which many seniors end up relying on to pay for long-term care. But in order to qualify you will have to spend down most of your assets—not anyone’s idea of a dream retirement. And as more aging Boomers and Gen X retirees require care, Medicaid programs will come under increasing financial pressure, Gleckman says, so it’s not clear what the programs will provide in 20 years.

Until more options develop—perhaps some kind of private-public partnership for long-term care—your best strategy is to stay healthy, save as much as you can, and build a community network. People with strong social ties, research shows, live longer, happier lives.

This article was updated to clarify the percentage of households facing shortfalls in retirement due to long-term care costs.

MONEY Health Care

The Mystery Behind Your Doctor’s Charges, Unveiled

Illustration of man unlocking filing cabinet of doctors
Medicare is providing consumers with a new way to research health care pricing. Paul Blow

A quick peek into some Medicare data can help you reduce your medical bills. Here's how to use the new tool.

Medicare has pulled back the veil on what doctors, physician assistants, physical therapists, and other health care providers charge, letting everyone see the rates for a wide variety of procedures in advance for the first time. “This is a big step forward and will be very enlightening,” says Jean Mitchell, a health economist at Georgetown University.

Health care researchers and fraud investigators are salivating over the data—already it’s revealed that some doctors favor the most expensive in-office intravenous drug treatments, likely because Medicare pays them a percentage of the cost, says ­Gerard Anderson, a professor at Johns Hopkins University.

As a patient, you can use the numbers, which are from 2012, to conduct your own research into prices and practices. Even if you’re under 65, you can glean valuable insights. Head to the Medicare Physician and Other Supplier Look-Up Tool to find your doctor. You’ll see how many times he or she did a particular service and the average charges. Then here’s what to make of the information:

If you’re facing surgery
See how often your doctor operates; for complicated procedures, frequency pays. “Research shows doctors who perform more than 50 hip replacements a year have fewer complications,” says Andrew Fitch of Nerdwallet Health. Yet about half of orthopedic surgeons did fewer than 20 a year on traditional Medicare patients, a Nerdwallet analysis of the data found.

The tally excludes operations on patients with private insurance or a Medicare Advantage Plan. Still, a low number compared to other MDs should prompt you to ask how often your doctor does the job, particularly for hip and knee replacements, says Fitch. If the figure is high, keep in mind that at times every physician in a group practice bills under one name.

If you’re on traditional Medicare
For a price preview, calculate the difference between the “average Medicare allowed amount” and the “average Medicare payment.” That’s your share of the bill before supplemental insurance kicks in. One caveat: What you see in the Medicare database are charges per service. So ask if you’ll face other bills or a facility fee if you’re cared for at a hospital or surgical center.

If you have private insurance
Check out the “average submitted charge,” which is the doctor’s full retail price. If you go outside your network, you’ll owe the difference between this amount and what your insurer deems a “customary and reasonable” rate (get that from your insurer), on top of your co-insurance.

You should negotiate with out-of-network docs, and the Medicare allowed amount is a good starting point. If the provider balks at that, go as high as 35% more, which is the national standard for a reasonable charge, says Anderson.

MONEY The Economy

The Shrinking Role of Wages

Senior woman looking at Social Security check
A social security check arrives in the mail Donald Higgs—Getty Images

As the population ages and workers get displaced, a smaller portion of income is derived from actual work.

For Americans, work is becoming less and less important.

Today, wages and salaries make up only 50.5% of overall personal income, according to a new Wells Fargo Securities report. That’s down from almost 60% in 1980.

You can blame some of this on changing demographics, including the aging of the population and government programs that direct transfer payments to certain groups.

Take Medicare and Social Security. In the beginning of 2007, 80% of people between the prime working ages of 25 to 54 was employed. Today that number is down to 76%.

image (1)
Source: St. Louis Federal Reserve and the Labor Department

While the Great Recession lowered demand for workers, “the aging of the baby boomers and longer life expectancies have pushed the share of the population age 65 and older to a record high,” writes Wells Fargo economists John Silvia and Sarah House.

Almost one in seven Americans is 65, according to the U.S. Census, compared to 12.4% in 2000. More Americans over the age of 65 means more Americans receiving Social Security and Medicare.

Then there’s help for the disabled and poor. “Increased eligibility and use of social insurance programs such as disability insurance and food stamps have also prompted the rise in transfer payments,” note Silvia and House.

Right now there are more than 14 million Americans who are deemed disabled by the Social Security Administration.

Consider this from NPR’s Planet Money’s excellent series on disability:

Part of the rise in the number of people on disability is simply driven by the fact that the workforce is getting older, and older people tend to have more health problems.

But disability has also become a de facto welfare program for people without a lot of education or job skills. But it wasn’t supposed to serve this purpose; it’s not a retraining program designed to get people back onto their feet. Once people go onto disability, they almost never go back to work. Fewer than 1 percent of those who were on the federal program for disabled workers at the beginning of 2011 have returned to the workforce since then, one economist told me.

Or take food stamps. Since 1969, the number of people on food stamps has increased by a factor of 16.

The share of income derived from transfers has increased from 12.5% in 2000 to 17.3% today, according to Wells Fargo Securities.

A lousy job market in the aftermath of the recession has left millions without work — 36% of today’s unemployed have been without a job for over 27 weeks, compared to 12.1% in 2000. And that abundance of available labor, writes Silvia and House, “has kept wage growth muted, restraining labor income even as hiring has improved.”

image (2)
Sources: St. Louis Federal Reserve and the Labor Department

For the overall economy, “the general diversification of income sources adds to the stability of consumer spending over time,” House says. “In particular, transfer payments have becoming an increasingly important share of income and have helped to smooth income/spending throughout the business cycle and Americans’ life cycle.”

MONEY Social Security

The Real Reason Social Security Won’t Be There

Congress won't cut your monthly check to shreds, but rising health care costs may well do the job.

You may be worried that Social Security will disappear by the time you retire. It won’t. Here’s the real problem: In 10 years the typical payment won’t be enough to cover medical bills for most middle-class retirees, according to a recent analysis by data tracker HealthView Services.

This scary prospect is the result of simple math. Healthcare expenses are projected to rise 5% to 7% a year, while Social Security cost-of-living increases are expected to grow just 2% annually, says Ron Mastrogiovanni, CEO of HealthView.

A healthy couple who retires a decade from now will need their entire Social Security paycheck just to cover their healthcare expenses, up from 69% today, according to HealthView’s Retirement Health Care Cost index. In 20 years, it won’t even be enough: Healthcare costs will equal 127% of the typical Social Security check.

HealthView’s calculations take into account Medicare premiums, supplemental Medicare plan payments and services Medicare doesn’t cover such as dental and vision care.

Related: How does Social Security work?

One potentially expensive item that isn’t factored in: Long-term care costs. An estimated 70% of people over 65 will need some kind of long-term care to help with the tasks of daily living, such as dressing or bathing. Long-term care isn’t covered by Medicare, and it can be very expensive—the median cost of a home health aide is $45,000 a year, while a private nursing home room averages $87,000 a year according to the Genworth 2014 Cost of Care survey.

Of course, these numbers are just averages and your actual costs will vary widely, depending on your health and where you live. And there’s no way to accurately predict what your health care needs will be as you age. But there are a few tools that can help you develop a rough estimate. HealthView just launched a basic healthcare expense calculator that you can use to gauge your out-of-pocket expenses when you retire based on your current health status. For a more informed estimate, try the Livingto100.com calculator, which lets you add data about your family history, marital status, income and exercise habits.

Build healthcare expenses into your retirement spending plan, and you won’t have to worry as much about whether Social Security will be enough for you.

 

TIME Medicare

Strike Force Arrests 90 for $260 Million in Medicare Fraud

Wifredo Ferrer, Tyler Smith, George Piro
Wifredo Ferrer, left, U.S. Attorney for the Southern District of Florida, announces the arrest of 90 individuals in a Medicare fraud sting operation on May 13, 2014 in Miami. AP

A Medicare fraud strike force has arrested 90 people, including 16 doctors along with nurses and other medical professionals in six different cities, who stand accused of issuing false medical bills for unwanted medical services

A Medicare fraud strike force has arrested 90 people for allegedly defrauding the program of $260 million, law enforcement officials said Tuesday.

The Federal Bureau of Investigation announced that agents in six different cities arrested 16 doctors along with nurses and other medical professionals who stand accused of padding medical bills with unwanted or undelivered services.

The largest batch of arrests occurred in Miami, where 50 defendants were charged with defrauding the system of $65.5 million by falsely billing home health treatments, mental health services and prescription drugs that were never dispensed, according to the FBI.

Investigators said one physician in Los Angeles charged with $23 million in fraudulent bills had ordered hundreds of power wheelchairs for able-bodied patients.

“The fraud was rampant, it was brazen and it permeated every part of the Medicare system,” Acting Assistant Attorney General David O’Neil said in a statement.

The arrest marks the seventh sting operation in the strike force’s history, which has charged almost 1,900 defendants since it was established in 2007.

MONEY Health Care

Hear Better for Less: How to Save Big on Hearing Aids

New competitors mean more ways to save money. But should you really buy hearing aids at Costco?

Most technology gets cheaper over time — think about what you used to pay for a flat-screen TV or a laptop.

Not so with hearing aids, which can set you back as much as $6,000 a pair and last only three to five years, according to the Better Hearing Institute. What’s more, Medicare doesn’t cover aids, and private insurance typically hasn’t either.

Times are changing. While buying a hearing aid has often meant visiting an audiologist, new competitors are shaking up the industry. With players like Costco and online sellers gunning for more of the action, you can reap significant savings.

“How aids are traditionally sold through audiologists isn’t affordable for a lot of people, so new devices and shopping avenues are gaining traction,” says Frank Lin, an ear, nose, and throat surgeon and assistant professor at Johns Hopkins.

Insurers are starting to change their tune too. UnitedHealthcare, the nation’s largest insurance company, has added discounted and even free aids to its plans. A small number of other plans will pitch in $500 to $1,000 toward the cost.

So it’s time you stopped ignoring missed conversations and garbled movie scenes. First, to rule out other medical conditions, get a checkup from an audiologist or an ear, nose, and throat or primary-care doctor. Then pick from these options.

Over-the-counter devices

What you get. Personal sound amplification products are the drugstore reading glasses of the hearing world. These gadgets, sold online and in electronics stores, are technically meant to help normal hearing people catch every word in places like restaurants.

At one time PSAPs did little more than amplify all sounds, but recent improvements to the technology have made them better at reducing background noise, says David Copithorne, who publishes the industry site HearingMojo.com.

Who it’s best for. Someone with mild hearing loss — meaning you miss a word here and there — could benefit from a PSAP.

“Go for the higher-end version, not the $50 or $100 pair,” says Copithorne.

The Sound World Solutions CS10, which costs $300 and looks like a Bluetooth headset, or the $200 RCA Symphonix, which goes over your ear, may boost sound enough for you to get by at a crowded dinner table, he says.

Drawbacks. Wear a PSAP without an exam, audiologists warn, and you might miss treatable causes of poor hearing, such as wax buildup or an infection.

Another potential pitfall: You try out a PSAP, conclude aids won’t work, and never trade up to the real deal. In case a PSAP is no help, make sure whatever you buy can be returned.

An audiologist’s office

What you get. The most handholding from a pro with the most training — four years of postgraduate study. In addition to testing, audiologists can customize aids for your ear shape and hearing condition and tweak them in follow-up visits, says Bettie Borton, a Montgomery audiologist and the president of the American Academy of Audiology.

You’ll pay $2,500 to $6,000 for a pair of aids depending on the features you want. High-end add-ons include Bluetooth to sync aids with your phone. But since aids aren’t expensive to make, says Lin, a lot of what you’re paying for is service.

Who it’s best for. Anyone with severe hearing loss or different levels of loss in each ear. Stick with an audiologist if you want the most advanced features or in-person help. Find one at audiology.org.

Drawbacks. The price. The costs of the follow-up visits and the aid are typically bundled. Ask for a breakout so that you can negotiate on both, says Nancy Macklin of the Hearing Loss Association of America, a consumer group supported by members, including audiologists.

A trip to Costco

What you get. The big-box retailer stocks discounted hearing aids in 94% of its stores, often from manufacturers affiliated with the ones audiologists use.

Costco’s nine models sell for $1,000 to $3,000, including fitting and follow-up care. The biggest difference from the audiologist’s office is that you’ll probably be seen by a hearing aid specialist, who has a state license and on-the-job training, not a degree.

Who it’s best for. “They’re a good-quality product for someone with mild to moderate loss,” says Copithorne.

Drawbacks. Costco doesn’t carry the right aids for severe loss, concedes Richard Chavez, who runs Costco’s hearing aid business.

Shopping online

What you get. At websites like Americahears.com and Audicus.com, you can pay as little as $800 for a set of aids. First you’ll need to get a hearing exam from a local audiologist or storefront hearing center (expect to pay $50 to $200). Once you submit the results, you can talk to a phone rep about what types of environments you have trouble in and then get a programmed device. Any adjustments are DIY, or you can mail back the aids.

The website Hi HealthInnovations has local audiologists and specialists who will do in-person tests and fittings — go to hihealthinnovations.com to see if there’s one near you. Aids at this site, owned by the parent of insurer UnitedHealthcare, go for $1,600 to $2,000, less if you’re in a UnitedHealthcare plan.

Who it’s best for. If you’re comfortable teaching yourself to adjust and clean your aid — perhaps this is your second set — you’re a candidate. Same goes if you’re near a Hi Health location. Many sites offer free returns without the 5% or so restocking fee you may face elsewhere.

Drawbacks. Limited choice in models. And did we mention do-it-yourself adjustments? True bargains come at a price.

TIME Medicare

The Return of Mediscare

In Arkansas, Democrats dust off an old tactic in order to retain control of the U.S. Senate

Tom Cotton is your basic republican red-state fantasy candidate. He is 36 years old, a former Army captain who served in both Iraq and Afghanistan, and a graduate of Harvard University and Harvard Law. He is a member of the House running for the U.S. Senate from Arkansas. His opponent is an unflashy Democratic moderate, Mark Pryor, who spent the first months of the campaign barraged by an estimated $2 million in Obamascare ads provided by Americans for Prosperity, the Koch brothers’ super PAC. Not surprisingly, Cotton has been leading–and is one of the reasons the Republicans may retake the Senate in 2014. Or maybe not: the polls suddenly turned around in March, and Pryor is now narrowly ahead. What happened?

Meet Linda … who joins Harry and Louise, and dozens of other average Americans–some real, some conjured–in the long, sordid history of political ads designed to scare the bejeezus out of other average Americans over health care. Linda appears to be real. She’s from Little Rock. She’s been married to the same lucky fellow for 37 years, and they have two “great” kids. We know this because a black-and-white family photo is shown prominently at the beginning of the ad. Then we see Linda, who seems to be in her 50s, with tightly curled gray hair and glasses, sitting in her breakfast nook gazing at her Apple computer. Retirement is just around the corner, she says. “That’s why I was so concerned when I read”–and here she seems to be reading off her computer–“that Tom Cotton voted to turn Medicare into a voucher system” that would allow insurance companies to “increase rates, cut benefits and cost seniors thousands more each year.”

It’s a brilliant ad, classic Mediscare. The fact that Linda seems to be reading the horrific news about Cotton off her computer lends a subtle authority to the information. Is it accurate? Well, yes and no. Cotton and 218 of his colleagues in the House did indeed vote for the Paul Ryan budget, which would slash costs by moving to a privatized “premium support”–or voucher–system of health care delivery for senior citizens. Is that a bad idea? Probably not. In fact, a more generous version already exists in the form of Medicare Advantage, the private-sector Medicare alternative that seems to be going great guns in the Obamacare era: an estimated 30% of seniors have signed up, an increase of 38% in recent years. The brute force of competition (plus some federal subsidies that both parties want to diminish) has allowed increased benefits like gym memberships and free medication. The fact that many of these plans are based within systems where doctors are paid salaries makes it potentially more cost-effective than classic fee-for-service Medicare. It would be very valuable to have a serious conversation about this. Pryor is a fiscal conservative. He’s said that all programs (including Medicare, presumably) should be on the table. He could be part of the solution, rather than hiding behind traditional Democratic battlements.

Democrats will say, Oh, come on. It’s about time we started playing hardball again. The Republicans strolled into a tornado by voting–symbolically, since it never had a chance of passage–for the Ryan budget. The Koch brothers have spent gazillions putting sketchy Obamascare ads on the air, including one starring Jerry, an Arkansas truck driver who “lost” his health coverage because of Obamacare, although maybe he didn’t, because the Arkansas insurance commissioner put a two-year delay on that ruling and now Jerry is “confused” by all these newfangled government machinations. This was one of the less toxic Koch ads–and “Jerry” has been smoked by “Linda” in the court of public opinion.

Of course, next month there could be a killer Obamascare ad starring “Arnie,” an Arkansas druggist whose health care premiums have skyrocketed. And later we may get to know “Marge,” who survived breast cancer because Obamacare saved her health insurance. We could go back and forth, Obamascare vs. Mediscare, all the way until November. It’s happened before. It’s worked before. But is it what you really want this election to be about? Isn’t it precisely the sort of campaign that turns people off politics? Don’t we have more important things to talk about? “I think the Republicans will still win the House and Senate,” says Steve Schmidt, a GOP consultant. “But when you have no real governing agenda, it becomes very easy to get caught up in entitlement issues.”

That is true for Democrats as well. They are proud of their demographics, especially the favor bestowed on them by younger voters. But younger voters may decide they don’t like paying for an unreformed Medicare system as we baby boomers live on and on and on. Those who live by the anecdote can die by the anecdote.

MONEY Ask the Expert

If You’re on Medicare, Do You Also Need Medigap?

If you're considering getting supplement insurance, or Medigap, sign up within six months of enrolling in Medicare.

My father just went on Medicare. Should he buy Medigap insurance? Which policy is best? — Joe, Houston.

If your dad isn’t insured by a former employer, he should buy supplement insurance, or Medigap, which pays for some costs not covered by Medicare.

And, says Bonnie Burns, a policy specialist with California Health Advocates, he should sign up within six months of enrolling in Medicare, when he can’t be rejected for health reasons (some states let you qualify later on for a similar six-month window if your employer plan is canceled).

Since switching policies later may involve a physical, your dad’s best plan is one that suits him over time, not just one that meets his needs cheaply now.

Related: What is Medicare?

All policies must match one of Medicare’s 10 standardized plans — from basic coinsurance to coverage of skilled nursing. Learn more at Medicare.gov.

TIME Healthcare

Tiny Share of Doctors Get Big Slice of Medicare Pie

Newly released data that details how Medicare pays doctors for specific procedures shows the top 2% of the highest-paid doctors who accept Medicare accounted for a significant portion of the federal program's costs, likely leading to changes in insurance practices

A single Florida ophthalmologist was paid $21 million by Medicare in 2012, according to federal data released Wednesday that shows a tiny sliver of U.S. doctors who accept Medicare account for an outsize proportion of the insurance program’s costs.

Medicare payments to 880,000 doctors nationwide totaled roughly $77 billion in 2012. But the top 2 percent of highest-paid doctors who accept Medicare accounted for about $15 billion in payments under the system, almost a quarter of the total not including commercial entity payments, according to data analyzed by the New York Times.

The data shows in detail for the first time how Medicare pays doctors for specific procedures. Fraud investigators, health insurance plans and researchers will sort through the new data with a fine-tooth comb in the upcoming weeks, likely leading to lawsuits and changes in insurance practices.

“There’s a lot of potential for whistle-blowers and justified worry for fraudsters,” Steven F. Grover, a lawyer who represents whistle-blowers who sue doctors they claim have committed Medicare fraud, told the Times. “There’s going to be a lot of litigation over this.”

In 2012, 100 doctors received a total of $610 million from Medicare payouts, and about 3,300 ophthalmologists were paid $3.3 billion from Medicare, the Times reports. Medicare paid $12 billion for 214 million office and outpatient visits—most of them outpatient visits between 15 and 25 minutes long. The doctors and nurse practitioners were paid an average of $57 per visit.

Ophthalmology and oncology both accounted for a large chunk of Medicare spending.

The doctor’s group the American Medical Association has withheld Medicare data for decades, but a federal judge ruled last year the information could be made public. This release marks the first time since the 1970s that detailed figures on Medicare reimbursements have been made available.

[NYT]

 

TIME Budget

New Paul Ryan Budget Cuts Trillions in Spending, Faces Difficult Vote

Paul Ryan
House Budget Committee Chairman Rep. Paul Ryan, R-Wis., speaks at the Conservative Political Action Committee annual conference in National Harbor, Md., March 6, 2014. Susan Walsh—AP

House Budget Committee Chairman Paul Ryan has released his fiscal year 2015 budget that would cut $5.1 trillion in spending by repealing Obamacare, eliminating USAID and set aside less funding to fight climate change, among other big reductions

Updated at 4:50pm to include comment from Paul Ryan.

House Budget Committee Chairman Paul Ryan on Tuesday released his fiscal year 2015 budget, in which he cuts $5.1 trillion in spending, mostly from health care, to balance the budget by 2024.

The budget would repeal ObamaCare, including the money-saving Independent Payment Advisory Board, cutting $1.2 trillion in federal outlays. It turns Medicaid into a block grant program for states, which would save $732 billion over 10 years. It essentially aims to privatize Medicare, offering enrollees in 2024 the choice of a private plan, while raising the age of eligibility and means tests for high income seniors. All told, more than half of the $5.1 trillion would come from health care savings. The document, provided on an embargoed basis to reporters, did not provide detailed budgetary outlays, but rather an overview of the budget’s goals.

As in past budgets, Ryan leaves the Pentagon and the Veterans Affairs Department largely untouched, including only those cuts recommended by the Pentagon itself. In fact, he criticizes President Obama from cutting too much in military spending in his 2015 budget, calling the President funding level “irresponsible.”

While all of this may sound like a Republican, or at least Tea Party, dream, Ryan is expected to have a tough time getting his bill through the House. The measure assumes a 2015 spending baseline as prescribed in the deal he made with Senate Budget Committee Chair Patty Murray earlier this year. That baseline mitigates the sequester cuts and assumes a higher level of spending than House Republicans like. Sixty-two Republicans voted against that deal, which passed on Democratic support. There will be no Democratic votes for the Ryan budget as it includes drastic cuts to programs Democrats seek to protect, which means Ryan must convince those 62 nay votes to support his budget despite the short-term increase in spending.

“Members who may not have supproted the Ryan Murray deal will see this is a much bigger picture, balancing the budget and paying off the debt,” Ryan told reporters on a call Tuesday afternoon. “The good clearly outweighs any other concerns that they might have had.”

Of course, this budget is going nowhere in the Democratically-controlled Senate, which has already announced it would not pass a budget this year citing the two-year deal Murray and Ryan forged earlier this year. Democrats, meanwhile, were gleefully anticipating the Ryan budget, hoping to use some of its more extreme positions against GOP candidates in a midterm election where they are portraying Republicans as unsympathetic to the working class. “The Ryan budget wouldn’t do a thing to help the middle class, and simply attacking Obamacare won’t get them the political victory they seek,” Senator Chuck Schumer, a New York Democrat, said in response to Ryan’s budget on Tuesday. “We’ll put our agenda to give everyone a fair shot by creating jobs and raising wages, against a plan that guts the middle class and replaces Medicare’s guaranteed benefits any day of the week.”

The plan eliminates USAID, moving international aid to the Millennium Challenge Corporation. It also cuts international education exchanges and programs like the East-West Center. In a nod to Benghazi, it maintains increased spending on diplomatic security—8% over 2013 levels.

The budget drastically cuts clean energy and technology funds and funding to fight climate change, while expanding oil and gas drilling on and offshore. It also recommends approval of the controversial Keystone XL pipeline from Canada and drilling in the Arctic National Wildlife Refuge in Alaska.

It cuts $23 billion in agriculture subsidies and turns the food stamp program into a block grant program for the states. It trims funding to Low Income Home Energy Assistance Program, which Ryan says is being abused by the states. It would also slash federal pensions by $125 billion over 10 years. It would eliminate a program to repay federal employees’ student loans, and would encourage attrition in the federal workforce. It would cut welfare programs by $5 billion over 10 years. And it would bar people from receiving both unemployment and disability benefits at the same time, saving $5.4 billion over 10 years. It also eliminates printing costs by switching most records to electronic copies. And it would end election assistance.

The budget would cut funding to the Securities and Exchange Commission, restrict the FDIC’s authority to bail out bank creditors. It would privatize Fannie Mae and Freddie Mac, and slashes $19 billion from the struggling U.S. Postal Service.

Ryan did not include his “Road Map” recommendation from 2010 to essentially privatize Social Security. In this budget he simply notes the problem in long-term projected shortfalls and calls on Congress and the President to begin working on solutions.

It ends support for Amtrak, cuts some funding for the Transportation Security Administration, eliminates the Community Development Program, cuts funding to the Federal Emergency Management Program, noting that in the last three years 2,400 emergencies have been declared many of those decisions were “not made judiciously.” Ryan recommends reducing FEMA expenses by instilling per capita thresholds.

The budget would streamline job training by getting rid of nearly 50 duplicate and overlapping programs. It would cut funding to Pell Grants by imposing a maximum income eligibility cap, ending funding for less than half-time students and capping the maximum award to $5,730. It would streamline Education Department programs, particularly the 82 programs focusing on teacher quality and calls for major reform to elementary and secondary programs. It would end all federal funding to the National Endowment for the Arts, the National Endowment for the Humanities, Federal Institute of Museum and Library Services, and the Corporation for Public Broadcasting.

In a nod to Ryan’s anticipated move to become House Ways and Means Committee chairman, Congress’s top tax writing committee, Ryan included the bones of a tax reform plan he’s likely to push in the next session. That plan repeals the alternative minimum tax, cuts corporate tax rates to 25% and consolidates the seven personal income brackets to just three with a top rate of 25% and a bottom rate of 10%.

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