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United States Government Accountability Office
The Nation’s Long-TermFiscal Outlook
 April 2008 Update
GAO
Health Care Cost Growth andDemographic Trends Drive theLong-Term Fiscal Challenge
Our updated simulations continue to illustrate that the long-term fiscaloutlook is unsustainable. (See fig. 1) Despite some improvement in thelong-term outlook for federal health and retirement spending, the federalgovernment still faces large and growing structural deficits driven primarily by rising health care costs and known demographic trends. Infact, the oldest members of the baby boom generation are now eligible forSocial Security retirement benefits and will be eligible for Medicarebenefits in less than 3 years. According to the Social Security Administration nearly 80 million Americans will become eligible for SocialSecurity retirement benefits over the next two decades—an average of more than 10,000 per day. Although Social Security is important becauseof its size, the real driver of the long-term fiscal outlook is health carespending. Medicare and Medicaid are both large and projected to continuegrowing rapidly in the future.
Figure 1: Unified Surpluses and Deficits as a Share of GDP under Alternative FiscalPolicy Simulations
GAO’s Long-Term FiscalSimulations
Since 1992, GAO has publishedlong-term fiscal simulations of what might happen to federaldeficits and debt levels under varying policy assumptions. Wedeveloped our long-term model inresponse to a bipartisan requestfrom Members of Congress whowere concerned about the long-term effects of fiscal policy.Our simulations were updatedwith the Trustees 2008intermediate projections andcontinue to indicate that the long-term federal fiscal outlookremains unsustainable. Thisupdate combined with our analysisof the fiscal outlook of state andlocal governments demonstratesthat the fiscal challenges facing alllevels of government are linkedand should be considered in astrategic and integrated manner.We update our simulations threetimes a year as new estimatesbecome available from
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the Congressional BudgetOffice’s (CBO)
 Budget and Economic Outlook
(January),
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Social Security and Medicare
Trustees Reports
(spring), and
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CBO’s
 Budget and EconomicOutlook: An Update
(latesummer).This product responds tocongressional interest in receivingupdated simulation results. Additional information about theGAO model, its assumptions, data,and charts can be found athttp://www.gao.gov/special.pubs/longterm/. For more information,contact Susan J. Irving at (202)512-9142 orirvings@gao.gov.
GAO-08-783R
 
 
Figure 1 shows two alternative fiscal paths. The first is “BaselineExtended,” which follows the CBO’s January baseline estimates for thefirst 10 years and then simply holds revenue and spending other than largeentitlement programs constant as a share of gross domestic product(GDP). The second is the “Alternative simulation” based on historicaltrends and recent policy preferences. Under these alternative assumptions,discretionary spending grows with the economy rather than inflationduring the first 10 years, Medicare physician payments are not reduced asin current law,
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and revenues are brought down to their historical level.Simulations are not forecasts or predictions. They are designed to ask thequestion “what if?” Our “what ifs” include what if discretionary spending islower than the 20-year historical average and revenue higher than thehistorical average (as in Baseline Extended) or nearly at the historicalaverages (as in the Alternative). Although the timing of deficits and theresulting debt buildup varies depending on the assumptions used, bothsimulations show that the federal government is on an unsustainable fiscal path.By definition, what is unsustainable will not be sustained. The question ishow and when the nation’s current imprudent and unsustainable path willend. At some point, action will be taken to change the nation’s fiscalcourse. The longer action to deal with the nation’s long-term fiscal outlookis delayed, the greater the risk that the eventual changes will be disruptiveand destabilizing. Acting sooner rather than later will provide more time to phase in gradual changes, while also providing more time for those likelyto be most affected to make compensatory changes.The long-term fiscal outlook results from a large and persistent gapbetween expected revenues and expected spending. The spending thatdrives the outlook is primarily spending on the large federal entitlement programs (i.e., Medicare, Medicaid, and Social Security), especially healthcare programs. The retirement of the baby boom generation is one keyelement of this. Already the first members of the baby boom generationhave begun receiving Social Security retirement benefits and in 2011 willbecome eligible for Medicare benefits. In the next two decades America’s population will age dramatically, and relatively fewer workers will beasked to support ever-larger costs for retirees.
What Drives OurNation’s Bleak Long-Term Fiscal Outlook?
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Under the sustainable growth rate system in current law, physician payments arescheduled to be reduced by 10 percent in 2008 and 2009 and by 5 percent for nearly every year from 2010 through 2016.
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GAO-08-783R Long-Term Fiscal Outlook April 2008
 
 
 
 Although Social Security is a major part of the fiscal challenge, it is farfrom the biggest challenge. Spending on the major federal health programs(i.e., Medicare and Medicaid) represents a much larger, faster growing,and more immediate problem. In fact, the federal government’s futureobligations for Medicare Part D alone exceed the unfunded obligations forSocial Security. Over the past several decades, health care spending percapita has grown on average about 2.5 percent faster than average annualGDP per capita, absorbing increasing shares of the nation’s resources, andthis rapid growth is projected to continue. For this reason and others,rising health care costs pose a fiscal challenge not just to the federalbudget but to American business and our economy and society as a whole.Figures 2 and 3 look behind the deficit path to the composition of federalspending under the two scenarios. Both figures show that the estimatedgrowth in the major entitlement programs leads to an unsustainable fiscalfuture—whether revenues as a share of GDP are above historical levels, asin Baseline Extended, or at about historical levels, as in the Alternativesimulation. In these figures the category “all other spending” includesmuch of what many think of as “government”—discretionary spending onsuch activities as national defense, homeland security, veterans healthbenefits, national parks, highways and mass transit, and foreign aid, plusmandatory spending on the smaller entitlement programs such asSupplemental Security Income, Temporary Assistance for Needy Families,and farm price supports.
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The growth in Social Security, Medicare,Medicaid, and interest on debt held by the public dwarfs the growth in allother types of spending.Under Baseline Extended (see fig. 2) we follow CBO’s January baseline forthe first 10 years: tax provisions that are scheduled to expire are assumedto do so (including the temporary increase in the alternative minimum tax(AMT) exemption amount) and discretionary spending is assumed to growwith inflation. At the end of the 10-year period, revenues in BaselineExtended are at 20.3 percent of GDP—a couple of points above the 20-yearhistorical average. Discretionary spending is at 6.1 percent of GDP—somewhat below the 20-year historical average of 7.6 percent of GDP. Forthe remainder of the simulation period, levels of revenues anddiscretionary spending as shares of GDP are held constant, and for SocialSecurity and Medicare, we use the Trustees’ 2008 intermediate estimates.The Medicare estimates assume the continuation of current law, under
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Discretionary spending refers to spending based on authority provided in annualappropriations acts. Mandatory spending refers to spending that Congress has authorizedin legislation other than appropriations acts that entitles beneficiaries to receive paymentor that otherwise obligates the government to make payment.
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