• Job lock: What the ACA does

    Links to all posts in the series to which this post belongs are in the introductory post. This post is jointly authored by Nicholas Bagley and Austin Frakt.

    As the posts in this series have shown, the available studies provide ample support for the theoretical prediction that many people will experience job lock. In an ideal world, the fear of losing employer-sponsored health insurance shouldn’t drive decisions about where, whether, or how much to work. Attentive to that concern, the drafters of the ACA took a number of steps to mitigate job lock.

    Most fundamentally, the Act prohibits any health plan—employer-sponsored or not—from refusing to cover a preexisting condition. (Only grandfathered plans get a pass.) Employers can still impose up to a 90-day “waiting period” before a group health plan kicks in, but that’s it. The elimination of preexisting-condition exclusions should ease somewhat the concerns of workers who might have hesitated to switch jobs because, if they had a gap between jobs of more than two months, a new employer could have declined to cover such a condition for up to a year.

    Of even greater importance, the Act revolutionizes the individual market for private insurance. By prohibiting medical underwriting and guaranteeing issue, the ACA makes it more likely that those with preexisting conditions or high anticipated medical expenses can find affordable insurance in the private market. That should encourage those workers to retire earlier, to switch to firms that don’t offer health coverage, or to become entrepreneurs. The overall effect on job lock will be mixed, however. Community rating will make exchange plans more expensive for the young and healthy, which may discourage them from ditching their employer-sponsored coverage.

    In any event, employer-sponsored coverage will still be tax-advantaged, meaning that many people will still prefer to get coverage through their employers. That’s particularly true for higher-income individuals for whom the tax exclusion is especially valuable. As a result, job lock won’t go away altogether. On the other hand, the Cadillac tax will gradually claw back some of the tax advantages of more plans over time, beginning with those with very high premiums.

    For those under 400% of the poverty line, however, the ACA extends tax credits and cost-sharing subsidies to buy exchange plans. Those credits and subsidies will partly offset the exclusion, mitigating job lock. For low-income workers, the effect could be particularly dramatic: the subsidized cost of insurance on an exchange may be lower than the wage reduction necessary to purchase employer-sponsored coverage. For those workers, exchange coverage could be a better deal than employer-sponsored coverage. Indeed, such workers might shy away from jobs that offer such coverage and pay commensurately less than alternative employment with fewer benefits.

    For those under 133% of the poverty line, the expanded availability of Medicaid coverage—at least in states that have expanded their Medicaid programs—could also diminish job lock. Consider the breadwinner in a family of four making just $30,000 at a job that offers health coverage. Prior to the ACA, he or she may have been unable to afford a job at a comparable wage that didn’t offer health coverage. With Medicaid as a fallback, a different job at the same wage would be considerably more attractive.

    The ACA also encourages small employers to provide employer-sponsored coverage, which could make it more attractive for workers to take a job with a small firm. The Act extends sizeable tax credits to employers with fewer than 25 employees that offer health coverage. By eliminating medical underwriting, the Act should make it easier for small firms with bad claims experience to secure affordable coverage. (Some firms with good claims experience, however, will see their premiums go up.) The Act also organizes the market for small-business coverage onto an exchange—a SHOP exchange—which, by encouraging price transparency and making it easier to shop for coverage, may encourage small employers to offer health coverage to their workers.

    Finally, the ACA broadens a rule that makes the tax exclusion available only to those employers that don’t discriminate in favor of highly compensated workers. Previously, the rule only applied to self-insured employers, which allowed fully insured employers to offer health plans to only a slice of their workforce and still take advantage of the tax exclusion. Once the IRS issues rules to implement the non-discrimination rule, those fully insured firms will have a tax incentive to offer coverage to most of their workforce—including to lower-income workers who might otherwise have been reluctant to take a job with the firm.

    Putting all these and other ACA reforms together, the law should substantially reduce job lock. At the same time, we can confidently say it won’t eliminate it. For some people—particularly those with incomes too high for exchange subsidies and who also benefit substantially from the exclusion of employer-sponsored insurance premiums from income taxation—coverage through work will still be the best deal possible. And a lot of small firms still won’t offer coverage, which may lock those people into jobs that offer health coverage.

    Quantifying how much the ACA will remove job lock requires extrapolating the research findings to a post-ACA world. That involves some educated guesswork, but Linda Blumberg, Sabrina Corlette, and Kevin Lucia have taken a run at one aspect of the problem and based estimates of what the ACA will do for entrepreneurship and self-employment on some of the entrepreneurship-lock literature covered earlier in the series. They “make a rough estimate that the number of self-employed individuals will increase by about 1.5 million, a relative  increase of more than 11 percent.”

    That’s a step in the right direction. Even after the ACA, however, job lock will remain an issue. Indeed, it will remain an issue, at least to some extent, so long as employer-sponsored coverage is subject to different rules than coverage secured in the private market. When it comes to job lock, the ACA is just the latest chapter. It’s not the end of the story.

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  • Zombie Medicaid arguments

    The following is co-authored by Aaron and Austin.

    They just won’t die. Evidently, the House Republican budget is going to take another whack at Medicaid reform. Today, from the WaPo:

    Medicaid, which provides health coverage to low-income families, is the object of a sharply worded review. “Medicaid coverage has little effect on patients’ health,” the report says, adding that it imposes an “implicit tax on beneficiaries,” “crowds out private insurance” and “increases the likelihood of receiving welfare benefits.”

    There are studies documenting circumstances under which Medicaid can substantially “crowd out” private insurance. But, as has been explained on TIE, those circumstances don’t necessarily apply to the ACA. Moreover, many people at the low end of the socio-economic spectrum have the option of Medicaid or nothing. They make less than 138% of the poverty line. They aren’t able to afford insurance without massive subsidies.

    But, as always, we want to focus on the first statement, the one that declares that Medicaid doesn’t improve patients’ health. That’s not true.

    Does anyone really dispute that having health insurance is better than not having health insurance? Anyone who does should put their money where their mouth is. Mediaid isn’t welfare. You don’t get cash. It pays for health care if you need it. And, like all health insurance, it makes people healthier and saves lives. Lots of people say so.  Studies confirm this.

    A lot of the research that “shows Medicaid is bad” is flawed or misunderstood

    That research could be improved with the use of better research design, and methodologically stronger studies have shown that Medicaid is good for HIV mortalitychild healthinfant mortality, and more.

    Which brings us to the Oregon Health Study, an actual randomized controlled trial of Medicaid. We have both written on early results. We’ve also commented on the later results, which are the ones people often seize upon to discredit Medicaid. Again.

    People say that it does little to improve the health of people who have diabetes, who are at risk for heart disease, who have high cholesterol, or who have high blood pressure. There are real problems with those assertions. The Oregon study was not powered to detect improvements in those domains. We’re sorry, but it wasn’t. Here’s Austin explaining how it wasn’t set up to detect major changes in cholesterol or the Framingham Risk Score. Here’s Aaron talking about how it couldn’t detect changes in hypertension because the vast majority of people didn’t have it, and the assumptions that underlie arguments for being able to see a change aren’t on point. Same goes for diabetes.

    Here’s a summary of those issues.

    Why do people have insurance? Most people have it to protect themselves from financial ruin should they get really ill. But they also get it because it provides them the ability and incentive to get health care if they need it. Medicaid is about access. It’s just the first step in the chain of events that leads to better health and wellbeing. It’s not sufficient, but it is often necessary.

    Many who argue that insurance should immediately and significantly make a population healthier are glossing over these other issues. They also seem not to care that there are no good RCTs proving that private insurance (or Medicare) do this.

    There are lots of legitimate claims to make against Medicaid. It under-reimburses physicians, for instance, causing access problems in some areas and for some beneficiaries. (Guess what. Those problems are even worse for the uninsured, though.) But the natural response to saying docs don’t get paid enough would be to increase Medicaid funding to improve that. Gutting the program will do the opposite.

    And let’s live in the real world here. Cutting Medicaid will be hard and painful. It will have serious consequences.

    We look forward to a continuing and lively debate on how to reform the health care system. But declaring that health insurance in the form of Medicaid hurts people or “doesn’t work” ignores the real good that it does for so many people. (And, come on, health insurance is just pushing money around—it isn’t medicine or procedures.) Let’s listen to each other’s arguments and respond to them, instead of repeating talking points past each other.

    @aaronecarroll and @afrakt

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  • On CMMI and our tendency to “over-mythologize” RCTs

    The following is jointly authored by Adrianna and Austin.

    Randomized controlled trials are the gold standard in empirical research, but that doesn’t mean they’re the only standard worth paying attention to. If we only find value in RCTs, researchers are wasting an awful lot of time and headspace on alternate methods. So, that recent NYTimes hit piece on the Center for Medicare and Medicaid Innovation strikes us as troubling.

    Aaron covered some important technical points yesterday. RCTs can have fantastic internal validity—when they’re conducted well, we can say with relative certainty how treatment did or did not affect the study population—but our capacity to generalize those results is often limited. Dan Diamond has a piece worth reading, too:

    CMMI’s approach isn’t totally above reproach; the data that the center is seeing from its pilots could be confused by secular trends, like changes in population, practices, and so on. That’s why, Harvard’s Jha acknowledged, it’s important to design studies with a contemporary control group and statistical testing.

    But under CMMI’s ambitious charter, researchers are attempting to track a range of payment and delivery reforms. And it’s hard to think of how the center could use an RCT for some of its projects.

    For example, I asked a half-dozen different researchers to construct a hypothetical RCT to test how accountable care organizations would work. All were stumped.

    These aren’t clinical trials where you can pass out pills and placebos and carefully record individual health outcomes; CMMI is all about changing institutional practices. And just because health policy is closer in proximity to medicine (and its many RCTs) doesn’t actually make health policy more amenable to this kind of study than any other policy domain.

    Take ACOs as an example. What would we supposedly randomize: patients, physicians, or entire hospital systems? Can you imagine the backlash if Medicare tried to foist the program on randomized-but-disinterested providers? Patients would be tricky, too. The way ACOs work now, a Medicare beneficiary is passively “assigned” to an ACO if their physician belongs to that ACO. But that beneficiary isn’t required to limit their care to the ACO—an acknowledged wrinkle—and they may not actually realize that they’re taking part in a new delivery paradigm. (That, itself, is a source of natural (and imperfect) randomness that could be exploited.) According to one Health Affairs brief, critics “believe that patients should have a choice about participating in an arrangement that could reward providers for reducing services.” That sort of rhetoric hardly bodes well for implementing randomized trials in the health services delivery setting.

    Moreover, CMMI wasn’t designed to focus on cumbersome, time-consuming, and relatively static experiments. This is a good thing.

    These demonstrations aim to do two things to health services delivery: improve quality while maintaining or decreasing costs, or reduce costs while maintaining or improving quality. The emphasis is on “rapid-cycle” evaluation—collecting and analyzing data in near-real time, providing feedback on the programs. Far from wasting resources, CMMI is actually bound by law to modify or terminate demonstrations that have insufficient evidence of success.

    Well-conducted policy trials are important and we can learn a lot from them. That said, they don’t come easy or cheap, so they’re not very common. Nor are they immune to threats to internal validity from contamination/crossover/attrition, problems that can be addressed by—wait for it—observational study techniques.

    The Oregon Medicaid experiment was a terrific empirical exercise. It’s also paradigmatic of limitations that policy RCTs face—an entire methods course could probably be taught on it. In order to correct potential biases inherent in the design, the authors employed instrumental variables, an observational technique. A constrained sample size meant power problems. A focus on Portland restricts the results’ external validity. Scholars have (and will continue to) debate the study’s findings and their generalizability.

    Empirical science, and every technique thereof, is imperfect and incremental. But it’s the best we have. Insisting on only one research modality—the RCT—and overlooking the potential gains and relevance of other approaches is costly, both in dollars and applicable knowledge.

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  • Helping research inform legislation

    The following post is coauthored by Sarah Jane Reed, Sarah K. Emond, and Austin Frakt. Sarah Jane Reed serves as Program Director for the Institute for Clinical and Economic Review (ICER), where she oversees operations and strategic planning for the New England Comparative Effectiveness Public Advisory Council (CEPAC).  She holds a Masters of Science in International Health Policy from the London School of Economics. Sarah K. Emond is responsible for the strategic direction of ICER as its Chief Operating Officer, including the implementation of ICER’s research through its flagship initiatives, CEPAC and the California Technology Assessment Forum (CTAF).  Sarah has a Masters of Public Policy from the Heller School at Brandeis University.

    Disclaimers: The views expressed here are the authors’ own and do not necessarily represent the views or opinions of ICER or CEPAC. Austin serves as a member of CEPAC.

    Increasingly, lawmakers are influencing medical policy through patient notification laws and insurance coverage mandates. Such laws are intended to benefit patients, but their inflexibility can cause them to be out of step with sound interpretations of clinical research.

    Consider breast cancer screening. Thirteen states have recently passed breast density notification legislation requiring radiologists to inform women when their mammogram results reveal they have dense breast tissue, which may mask abnormalities. (Approximately 50% of women have dense breasts.) Dozens more states have similar legislation pending. Some states have gone further, requiring insurance coverage of supplemental ultrasound screening for women with dense breasts.

    The issue has also caught the attention of Congress, where similar breast density notification legislation has been introduced.

    Notably, no states with laws such as these and none of the legislation introduced in Congress stratify their requirements by patient risk. Yet sensitivity to risk may, in fact, be what’s best for patients.

    We often think more health information is better. However, notifying women at low risk of breast cancer of their density status may raise more questions than it helps answer. To make informed decisions about future screening options for women with dense breasts, patients and providers need to weigh the benefits and risks of additional screening. Does supplemental screening catch more cancers? Does it help save lives?

    The New England Comparative Effectiveness Public Advisory Council (CEPAC) recently addressed these questions. CEPAC is an independently recruited Council of 18 practicing physicians, methodologists and public representatives from all six New England states who meet in public to discuss and vote on evidence reviews covering test and treatment options in high-impact clinical areas.

    Through its process, CEPAC discusses how evidence can be interpreted on a regional basis, taking into consideration factors such as prevalence, workforce issues, and utilization patterns that are unique to New England but affect how evidence can best be applied in policy and practice. The body also accepts and considers public comments, thereby incorporating a diverse range of stakeholder views and concerns.

    (CEPAC, and its sister organization, the California Technology Assessment Forum, are the flagship implementation initiatives of the independent non-profit, the Institute for Clinical and Economic Review.)

    At its last meeting in December, CEPAC deliberated on the latest evidence on supplemental breast cancer screening for women with dense breasts. In weighing the benefits and risks of supplemental screening, CEPAC examined the evidence on additional cancers detected, reduced mortality rates and the risks of further testing, including the possibility of false alarms.

    A majority of CEPAC voted that for women at low-risk for breast cancer, the evidence does not demonstrate a benefit of supplemental screening. During the deliberation, Council members highlighted the dearth of evidence on long-term outcomes, such as mortality, for these women. However, in women at a moderate- or high-risk for cancer, CEPAC voted that the benefits of supplemental screening outweigh the risks, with the strongest evidence supporting additional screening in women at higher risk for breast cancer. You can read the full report here.

    A discussion at the December meeting of how the evidence should influence policy and practice focused on changes needed in guidelines, clinical practice workflow. A common refrain during this discussion was, “is the policy ahead of the science?” In other words, in light of CEPAC’s votes, are laws that mandate dense breast notification to low-risk women doing more harm than good? This touches on the divisive issue of just how much of medical care should be shaped by legislation. Though CEPAC cannot resolve that question, it is clearly relevant in the case of dense breast tissue notification, as well as others.

    As states in New England, and nationally, contemplate legislation mandating that women be notified if they have dense breasts, more attention should be paid by policymakers to expert, fair, transparent, and publicly deliberative assessments of the current state of the relevant evidence. There is a real danger of laws getting ahead of science. And, all good intentions aside, that is not to the benefit of patients.

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  • Reference pricing as a solution to “doc shock”

    The following post is co-authored by Austin Frakt and Nicholas Bagley.

    Spurred by intense competition on the new health-insurance exchanges, insurers have been casting about for new and better ways to offer their products at the lowest possible price. One way they’re cutting costs is by narrowing the networks of physicians and hospitals that their enrollees can visit for care. Consumers, finding that their preferred plan doesn’t offer coverage for their favorite doctors and hospitals, are experiencing “doc shock,” or soon may.

    It doesn’t need to be this way. Though “preferred” or “network” contracting – the establishment of networks of health care providers willing to accept lower payments – is a standard cost-reduction technique, it’s not the only approach. It’s certainly not the best for consumers.

    Reference pricing is an appealing alternative. With reference pricing, insurers set the price they’re willing to pay for a given service or procedure, typically pegging it to a price at which it can be obtained at good quality – the reference price. A policyholder can then obtain that service or procedure at zero out-of-pocket cost at any provider willing to match that price. For providers that charge more, the policyholder—not the insurer—pays the difference.

    Although reference pricing for medical services isn’t common, there are encouraging signs of good performance where it has been implemented. James Robinson and Timothy Brown studied CalPERS, California’s insurance program for public employees, when it set reference prices for knee- and hip-replacement surgery. They found the reference-pricing initiative had profound effects on the market. CalPERS patients shifted their site of knee- and hip-replacement surgeries to lower-priced hospitals. High-cost providers came under a ton of pressure to lower their prices.

    And that’s exactly what they did. As Robinson and Brown documented, higher-priced hospitals reduced their prices down toward the reference price. Meanwhile, no CalPERS policyholders were left without any coverage with their preferred providers. They were free to obtain knee and hip replacement surgeries at any facility they pleased. So much for doc shock.

    As it stands, there’s no legal impediment to reference pricing on the exchanges. The Affordable Care Act only requires exchange plans to cover essential health benefits. It doesn’t dictate how much plans have to pay for those benefits. It only dictates what proportion of health care costs plans have to cover overall — their “actuarial equivalence.”

    That legal flexibility, however, does present a risk that reference pricing could shift the risk of high costs to policyholders. What if the reference price were set so low that no providers would accept it as full payment? This is a serious concern, but one that should be mitigated by a provision of the ACA requiring plans to guarantee the adequacy of their provider networks. Specifically, plans must “assure that all [covered] services will be accessible without unreasonable delay.” Assuming that the rule is properly enforced—and it should be—insurers can’t set reference prices so low that benefits are effectively unavailable.

    If reference pricing offers a much-needed alternative to tightly restricted networks, why do so few exchanges plans do it? There are at least two reasons. First, reference pricing is hard. When an insurer offers a fixed price for hip-replacement surgery, what precisely does that cover? Does it include the costs of treating an infection acquired in the aftermath of surgery? Or can the hospital bill separately for that treatment? Resolving those sorts of line-drawing problems would require considerable innovation from insurers.

    Second, providers may successfully resist reference pricing. If enough popular hospitals or physician groups refuse to accept reference prices as full payment for their services, people may be unwilling to purchase plans that reference price. Plans that reference price could lose customers—not attract them.

    These challenges notwithstanding, widespread agitation over constricted networks suggests that insurers should give reference pricing another look. Restricted networks are so unpopular that it’s possible—maybe even likely—that consumers would flock to plans that offer them more choices of hospitals and physicians. In the newly competitive market on the health-care exchanges, they should certainly have that option.

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  • A break from comments

    This is a joint post by Austin, Aaron, and Adrianna (the TIE admins and comment moderators).

    All TIE admins are in agreement that we need a break from comment moderation. It’s a lot of work and the benefits relative to costs have dwindled. We’d rather use our time in other ways. So, at least until the end of January, comments will be disabled on all TIE posts by default. We may open up comments now and then to solicit input on specific issues. We might invite comments on an occasional open thread, but we haven’t decided.

    This is an experiment, and we’ll revisit this decision at the end of January.

    This brief post doesn’t convey how much time and effort we’ve devoted over the past year or so in trying to find ways to make comment moderation less taxing on us. Our latest approach didn’t increase the burden,* but also wasn’t of substantial help in reducing it. The idea of shutting comments down altogether goes back at least a year; we would have done it long ago, but we recognize the value of comments to some readers, so we wanted to try other things first.

    Those other things are not working well enough. And so, after lengthy deliberation, we’ll try going (mostly) comment free.

    You are, of course, welcome to email us. Or, if you prefer a more public forum, you can tweet at us. And, you always have the option to start your own blog, start a comment thread on Reddit or similar sites, etc. We value feedback. We just need a break from the moderation duties. (And, no, we can’t run an unmoderated site. You would not believe the spam, even with a good spam filter running.)

    * As of this writing, Austin has received a grand total of zero inquiries about unpublished comments.

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  • Raising the Medicare eligibility age is now a REALLY bad idea

    This post is co-authored by Aaron Carroll and Austin Frakt.

    We’ve written so many times on how raising the Medicare eligibility age to 67 is a bad idea that we hesitate to do so again. (See the FAQ.) But a recent revision by the CBO of federal savings it would generate compels us to do this one more time.

    Implementing this option would reduce federal budget deficits by $19 billion between 2016 and 2023, accord to new estimates by CBO and the staff of the Joint Committee on Taxation (see Table 1). That figure represents the net effect of a $23 billion decrease in outlays and a $4 billion decrease in revenues over that period. The decrease in outlays includes a reduction in federal spending for Medicare as well as a slight reduction in outlays for Social Security retirement benefits. However, those savings would be substantially offset by increases in federal spending for Medicaid and for subsidies to purchase health insurance through the new insurance exchanges and by the decrease in revenues.

    Do you get that? Phasing this in starting in 2016 could save $19 billion over the next 8 years. That’s less than $3 billion a year. That’s… insane.

    Why isn’t it more? Well, once again, the more people you kick of Medicare, the more you get on Medicaid. That increases federal expenditures. More people will also need exchange insurance, too, which means more people needing subsidies. That will also increase federal expenditures. These expenditures reduce the savings to the federal government from the $63.5 billion it would have cost to cover the 65 and 66 year olds to only $23 billion in savings.

    And we’re not even counting the increase to state expenditures for the added Medicaid, the increased cost to employers who have to provide insurance, the increased cost to all Americans in higher premiums for adding those elderly people to the private risk pools, or the increased out of pocket expenses to those seniors. (We covered these costs in prior posts.) If this was a bad deal before, it’s worse now.

    The last time the CBO estimated the savings from increasing the Medicare eligibility age, they pegged the savings to the federal government at $113 billion over 10 years. The new report has the savings as much, much less. Why? It turns out the CBO made a bit of a mistake last time*:

    CBO’s analysis highlighted two points. First, at ages 65 and 66, beneficiaries who enrolled in Medicare when they turned 65 tend to be in much better health—and thus are substantially less expensive, on average—than beneficiaries who were already enrolled upon turning 65 (because of disability or end-stage renal disease). Second, the many 65- and 66-year-old beneficiaries who are workers (or workers’ elderly spouses) with employment-based health insurance are less costly to Medicare, on average, than other beneficiaries at those ages.

    Two things here. The first is more important. Some people who are 65 and 66 who are on Medicare have been on Medicare for some time. That’s because they have renal failure or some other major disability that qualifies them for Medicare before age does. It should go without saying that these people are way more expensive than your otherwise average 65- or 66-year old Medicare beneficiary. These people are also completely unaffected by raising the eligibility age. They’re not eligible due to age, but due to disability or renal failure.

    It appears to us that in their original analysis, the CBO looked at average spending of all 65 and 66 year olds, including all of those extra unhealthy people. But they aren’t relevant here. We want to know how much will be saved by the new policy. So when you look only at people who are new to Medicare at 65 and those that were and then turn 66, the savings from raising the eligibility age is much, much less.

    Additionally, some 65 and 66 year olds still get insurance from their jobs and only use Medicare as a secondary source of coverage. This is much, much cheaper for the program, too. Savings from them will be less.

    Put these two things together, and the new estimate for federal savings is much lower than it was before. But all the non-federal costs (not in the CBO report but covered by us before — see links above) remain, as does the concern about the viability of the exchanges and the fact that Medicaid hasn’t expanded in all states. So if raising the Medicare eligibility age before was a bad idea (and it was), it’s an even worse idea now.

    *There are some who will use this opportunity to attack the CBO and their analyses. We will not be among those people. The CBO does amazing work, consistently and often thanklessly. The fact that they found this mistake and corrected it – publicly – is to be respected, if not lauded.

    @aaronecarroll and @afrakt

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  • The individual mandate penalty and Medicaid

    This post is jointly authored by Austin Frakt and Adrianna McIntyre. 

    In a post last week reminding readers how the individual mandate penalty works, Ezra Klein wrote

    That $95 floor [in 2014] is there to encourage people to sign up for Medicaid (in states where Medicaid isn’t being expanded, people making that little money will be exempted from the mandate on affordability grounds).

    Perhaps this is the designed purpose of the mandate penalty for Medicaid-eligible individuals, but explaining why relies a different logic than that for encouraging people to enroll in an exchange plan.*

    With respect to the exchange-eligible population, the purpose of the mandate penalty is twofold. First, it serves to manage risk selection, i.e., balancing premiums with expected health care costs. It does so by encouraging relatively healthier people to enroll. Relatively sicker individuals who will use more health services don’t need such an incentive. If the premium and cost sharing are lower than the cost of their care, they have ample motivation to purchase coverage. Encouraging those for whom this would not be the case to also purchase coverage will keep premiums, and therefore subsidy cost, lower than they would otherwise be. The mandate penalty is supposed to provide that encouragement.

    Second, the penalty will generate revenue from non-enrollees. This revenue will offset at least some of the cost of the uncompensated care they may use.

    Neither of these rationales for the mandate apply for the Medicaid population.** Medicaid enrollees don’t pay premiums; they aren’t permitted, with the exception of some beneficiaries above 150% FPL. Therefore, risk selection of the program is irrelevant. There are no premiums to balance against costs. With respect to program financing, every enrollee can only add cost. So, using a penalty to encourage Medicaid enrollment costs tax payers more, never less, and has no impact on the costs for other enrollees.

    Also, if a Medicaid-eligible but uninsured individual uses hospital services, s/he will be enrolled in Medicaid at that time. The ACA includes “presumptive eligibility” regulations that allow hospitals to enroll patients at point of service, given some basic information about household size and income. There is no limited open enrollment period for Medicaid. Therefore, the penalty does not recover a cost that the system must otherwise incur. (Hospitals cannot turn away patients requiring urgent care, but physicians can refuse them for office visits.)

    So, for the Medicaid eligible population, the penalty is just a penalty. It doesn’t serve to balance risk in an important way. It doesn’t recover costs, even though it would generate revenue. That’s just extra revenue. Of course the penalty will serve the role of encouraging additional enrollment. And that might be a benefit insofar as that causally increases the use of valuable, preventive or chronic condition management care.

    But recognize that for what it is: pure paternalism. Are we are penalizing Medicaid-eligible individuals just because we think they’d be better off with coverage?

    * What follows doesn’t apply to Arkansas, where the Medicaid expansion is operating under a waiver that caps contributions on an aggregate per capita basis; enrolling disproportionately sicker individuals could drive the expansion costs above that ceiling. More on that later.

    ** Some people who are eligible for Medicaid in expansion states will have incomes below the threshold for filing income taxes ($10,000 for someone filing individually in 2013) and will not have to pay the penalty because they have a “hardship exemption”. This also applies to all individuals below the poverty line in states not expanding Medicaid.

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  • The Republican Study Committee has a “replace” plan.

    The following is jointly authored by Aaron and Austin

    For years now, we have heard that those opposed to Obamacare had a plan to “repeal and replace” it. They’ve certainly been working on the “repeal” part. In fact, some House Republicans are willing to shut down the government, if not risk U.S. default on its debt obligations, if Obamacare is not repealed. So, we know what they’re against, but what are they for. We’ve not heard a word about “replace”.

    That’s not terribly surprising. Reforming the health care system to cover more people and to reduce the rate of growth of health spending is hard. The Affordable care Act (ACA), love it or hate it, was designed to do these things. It reforms the individual insurance market through exchanges and provides subsidies to those with low to moderate incomes to help them purchase insurance. It also includes some reforms aimed at lowering the rate of growth of health care spending, though it is not yet clear to what extent it will do so. The law was designed to balance its costs (coverage expansion) with reduced health care spending (Medicare payment cuts) and new revenue (taxes).

    The law’s opponents have claimed it costs too much, will result in rationing, and limit freedom. Today, a group of House conservatives presented their version of a replacement plan, endorsed by the Republican Study Committee. In short, it throws poor Americans under the bus.

    The centerpiece of the plan is a universal, standard tax deduction of health insurance premiums, up to $7,500 for an individual and $20,000 for a family. This would level a playing field that is uneven today.

    Today, only insurance purchased through work is tax deductible. People who don’t get insurance through their jobs don’t get a deduction.

    There are two problems with the House plan though. The first is that it will obviously cost a lot of money. How much is not clear, but it won’t be insignificant. How will that be paid for? The second is that a tax deduction is much more valuable to someone who makes a lot of money than someone who makes little. But people with large incomes aren’t the ones who need help affording coverage. It’s those at the lower end of the socioeconomic spectrum who need the most assistance. Because of their low marginal tax rates, a tax deduction is of very little help.

    Sick Americans would receive very little help under the plan too. One of the ways the ACA helps the sick is by eliminating the ability of insurers to refuse to cover them (guaranteed issue) or to charge them more for being ill (community rating). The House plan weakens the guaranteed issue protection by extending it only to those who have continuous coverage. If you dropped (or were forced out) of prior coverage, you may not be able to get back in the market.

    For sick Americans, it replaces the ACA’s protections with a high risk pool in which premiums are capped at 200% of what healthy people pay in the rest of the market. To help offset the cost, the proposal sets aside $25 billion over 10 years. Still, sick people will pay very high premiums. If they become poor due to loss of work from their illness, they still have to pay those high premiums, or go uninsured.

    The plan includes a number of provisions that would encourage and expand the use of health savings accounts (HSAs). These are personal accounts that can be used to buy health care services or pay cost-sharing tax free. Again, the favorable tax treatment is of very little value to low income Americans. Moreover, low income Americans don’t have a lot of money to put aside for their future health care use. HSAs might be a helpful step. But they alone won’t help everyone.

    The rest of the proposal is a grab bag of old ideas that cannot work well as sketched out, won’t do very much, or are wasteful giveaways. For example, allowing insurers to sell policies across state lines would invite a “race to the bottom.” In time, all insurance would originate from states with the least regulation. The policies will be cheaper. But they’ll also be skimpier. They’ll be great if you’re young, healthy, or wealthy enough to afford to fill in the coverage gaps. They’ll be terrible if you are older, have a chronic condition, or, again, if you’re low income.

    The plan would reform medical malpractice by capping damages. However, studies show, malpractice suits doesn’t contribute as much to higher health spending as people think.

    Finally, the plan includes giveaways to the wellness industry, increasing the amount by which plans can increase premiums for those who don’t meet health standards. This is unlikely to do more than make sick people pay more for coverage. It would also permit gym memberships and nutritional supplements to be purchased tax free, up to a cap. These are giveaways to the fitness and supplements industry, as well as to people at the higher end of the socioeconomic spectrum who are more likely to go to gyms and use supplements anyway.

    There are some other provisions, including removing government support for comparative effectiveness research, but these are the high notes.

    The Affordable Care Act is intended to help people who don’t have insurance, especially those who are less than healthy, get it. The House proposal is intended to make insurance cheaper and easier to get if you are healthy.

    We understand that putting together a health plan is challenging. Nothing good comes without limitations and costs. That’s true of the House plan as well as the ACA. But if you’re committed to coming up with a way to expanding coverage while preserving the private insurance market, at least the ACA follows an established model. It happens to be how Massachusetts did it. It’s how Switzerland did it. And it’s how the conservative Heritage Foundation suggested doing it in 1989.

    The House is claiming it has a new way. But to us it only looks like a way back to the same problems that plague the system today.

    @aaronecarroll and @afrakt

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  • Singapore’s health system: commentary from the literature

    This post is coauthored by Austin Frakt and Aaron Carroll.

    We have already written many posts about Singapore’s health system (there’s a a tag for that), which is built around medical savings accounts (it’s Medisave program), though encompasses so much more. Unsurprisingly, we’re far from the first to comment on the system. But, contrary to what some have suggested, we’re not just interested in scoring political points. We want to know what data and evidence have to say about Singapore. This post summarizes a few points from some of the relevant literature from peer-reviewed journals.

    Scholarly literature on Singapore’s health system goes back at least as far as the 1995 Health Affairs paper by William Hsiao. (His paper is ungated. Ungated versions of those linked below may also exist. Use Google Scholar.) He described the country’s health spending trajectory just before and after Medisave was introduced. Medisave, you might remember, is the major source of cost-sharing for the people of Singapore:

    The per capita cost of health care in Singapore, in fact, rose faster after the introduction of the Medisave program in 1984 (Exhibit 2 [below]). Health expenditures per capita rose at an average rate of 13 percent per year-2 percent faster than the average before the introduction of Medisave. Part of this accelerated rate of increase was attributable to the upgrading of public hospital facilities but mostly caused by other factors. [...]

    In spite of the high average rate of growth in GDP of 10 percent, Singapore’s health expenditures grew faster, rising from 2.5 percent to 3.2 percent of GDP between 1980 and 1993.

    NHE Singapore

    In other words, health care spending increased after the introduction of increased cost-sharing, which is not what most proponents of such changes would expect. These points are repeated in Michael Barr’s “critical inquiry” into Singapore’s medical savings account, published in the Journal of Health Politics, Policy and Law (JHPPL) in 2001. But this was not a randomized controlled trial, and causality is, of course, not proven.

    In an accompanying commentary, Mark Pauly responded with two valid points, among others. First, it’s been well established that the more something costs an individual, the less of it they buy. It’s even been established for health care. Cost sharing definitely matters. Second, casual, pre-post examination of time series is uninformative about the effects of an intervention. How would Singapore’s health spending have changed in the absence of the Medisave intervention? We don’t know.

    Compounding the difficulty in judging Medisave from a time series is that it was not the only intervention. It seems to be uncontroversial in Singapore that substantial government involvement (some may call it “intrusion”) in the health care market is necessary for good performance. Hsiao quoted a 1993 Singapore Ministerial Committee on Health Policy white paper, the first few pages of which can be viewed here:

    Market forces alone will not suffice to hold down medical costs to the minimum. The health care system is an example of market failure. The government has to intervene directly to structure and regulate the health system.

    Barr quoted a different passage of the same document justifies rationing, including by government intervention:

    We cannot avoid rationing medical care, implicitly or explicitly. Funding for health care will always be finite. There will always be competing demands for resources, whether the resources come from the State or the individual citizens. Using the latest in medical technology is expensive. Trade-offs among different areas of medical treatments, equipment, training and research are unavoidable.

    Intervene, the government did. In Health Affairs, Thomas Massaro and Yu-Ning Wong described some of the interventions, including control of physician and hospital supply, generous subsidization of hospital care, and hospital revenue caps. They wrote,

    Financing mechanisms alone do not define a health care system. Singapore has a clearly delineated policy that works in its setting. The state actively participates in every aspect of the delivery system, from physician supply to price setting and the establishment of service criteria. This willingness to intervene aggressively in the market (at levels probably unacceptable to most Americans) may be as important as the individual savings mechanism to its success.

    In a JHPPL commentary that accompanied Barr’s paper, Hsiao described other means of cost control.

    MediShield [Singapore's opt-out, catastrophic health plan] adopted the risk selection practices of private insurance schemes by excluding as enrollees persons aged seventy and older and by not covering some expensive services, such as treatments for congenital abnormalities, mental illness, and HIV/AIDS. [Some of these policies may have changed since the paper's publication in 2001.]

    Again, however, point granted to Pauly that some restrictions imposed by Singapore’s government are not altogether different from those imposed by commercial plans in the U.S., for better or worse. We take this to mean that there really aren’t all that many ways to control costs in all areas. Ultimately, you have to say “no” in some fashion.

    In another JHPPL commentary, Chris Ham makes what we think is the most important point:

    The broader lesson from Singapore is that health care reform continues to swing back and forth between a belief in market forces and the use of government regulation. In reality, health policy is replete with examples of market failures and government failures as policy makers experiment with different instruments. The variety of health care systems developed around the world indicates that the choice is neither pure markets nor government control but the balance to be struck between the two. And to return to our starting point, where the balance is struck will be shaped by social values and the political choices that follow from them.

    There’s one more challenge in assessing Singapore’s health system, raised by Barr.

    The government is highly secretive about the detailed operation of its system and has not made either the data source or method of its calculations available to anyone outside those in the Civil Service and the government who need to know—not to the public; not to academic researchers.

    This probably explains why, though there is a literature on the Singapore health system, it’s a modestly sized one. It should also cause anyone serious to hesitate before advocating that Singapore’s system, and its results, can be generalized without some concerns.

    By the way, JHPPL also published a letter to the editor by Meng-Kin Lim (we gather this is his homepage) and responses from Michael Barr and William Hsiao. Finally, here’s a paper that compares Shanghai’s experience with medical savings accounts to Singapore’s.

    The bottom line is that Singapore isn’t simply “cost-sharing”, “free market”, “competition”, and a “lack of government involvement”. If you endorse Singapore’s health care system, you’re buying into many things, and some truths, that libertarians and conservatives claim to dislike. We acknowledge that more cost sharing can reduce spending. But if that’s the only thing you endorse, then you’re not talking about Singapore.

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