Who’s Going to Pay for This Obamacare Wish List?

I wrote in this space last June that supporters of the president’s health-care law had not made many specific suggestions about how to amend or otherwise change the Affordable Care Act. Last week, the advocacy group Families USA attempted to change that, releasing its “Health Reform 2.0” agenda of how to expand on Obamacare. But the paper also raises an important question for the law’s supporters—including presidential candidates running in 2016: How to pay for the myriad promises that liberal groups want to add to the health-care agenda?

The Families USA paper includes a full—and costly—wish list of new spending programs related to the law, including:

* Fixing the “family glitch,” in which families are ineligible for federal insurance subsidies if one member of the family has an offer of “affordable” employer-sponsored health coverage;

* Extending funding for children’s health insurance, a program that Obamacare funded only through September;

* Increasing federal cost-sharing subsidies—raising the amount of subsidies, currently provided to families with incomes under 250% of the federal poverty level, so as further to reduce deductibles and co-payments, and potentially raising the income cutoff for subsidies;

* Making permanent an increase in Medicaid reimbursement rates included in Obamacare that expired on Dec. 31, 2014;

* Extending coverage to immigrant populations (the report does not specify whether such coverage should also apply to the undocumented); and

* Increasing federal premium subsidies. Amending the current subsidy set-up in this way would necessitate two changes to current law, both of which would require an increase in federal spending. Congress would need to repeal the provision, set to kick in after 2019, scheduled to reduce the subsidies’ annual rate of growth; then lawmakers would have to pass the subsidy increase that Families USA advocates.

The proposal also contains numerous mandates on insurance plans—for instance, to cover adult dental care, all forms of pediatric care, and expand access to provider networks. These would come at a cost, raising insurance premiums for individuals and families—and raising costs for the federal government as well, related to the 87% of exchange participants receiving premium assistance subsidies.

While specific cost estimates for these proposals are unavailable, they are likely to be substantial. Cost concerns meant that the children’s health insurance program received funding for just a two-year extension in Obamacare. Likewise, the Medicaid reimbursement bump was so expensive—$8.3 billion—that lawmakers financed it for only 2013 and 2014 as part of the law. And Families USA’s proposed changes to the subsidy regime could cost far more: a 2011 study found that fixing just the “family glitch” could increase spending by nearly $50 billion per year.

In other words, a liberal group has proposed spending hundreds of billions—at minimum—on expanding Obamacare programs. And other than some suggestions about using government-imposed price controls—“direct intervention in pricing may ultimately be necessary”—the Families USA report contains precious little on paying for these expanded entitlements. It may have answered the “What?” when it comes to proposed “fixes” to the law, but it did not answer the “How much?” And as the law remains divisive, and federal debt continues to rise, the latter question must remain on the public agenda for some time to come.

This post was originally published at the Wall Street Journal Think Tank blog.