Microsimulation of Demand for Health Insurance: A Method Based on Elasticities
By Jessica S. Banthin
AcademyHealth Annual Research Meeting, Congressional Budget Office, June 9, 2014
CBO’s Health Insurance Simulation Model (HISIM)
- The first version was developed in 2002 to model various proposals for expanding coverage, including direct subsidies, changes to tax incentives, and insurance market reforms.
- The model is updated regularly to incorporate new data, the most recent economic forecast, changes in law or regulations, and technical improvements.
Major Outcomes Modeled by CBO’s HISIM
- Effects on the federal budget
- Changes in coverage by source of coverage
- Uninsured
- Employment-based coverage
- Medicaid
- Exchange(Subsidized and unsubsidized)
- Other(Including nongroup coverage outside of the exchanges, Medicare, and military health care)
- Occasional analyses of premiums, individual out-of-pocket spending, and outcomes by relationship to the Federal Poverty Level
By simulating behavior for each individual and family unit, the estimates capture the distribution of responses rather than average response by cell or subgroup, as in a simpler spreadsheet-type approach.
By taking advantage of detailed information collected in household surveys such as the SIPP on individuals and families and the relationships between key variables such as income, health status, employment status, and coverage, the estimates better reflect outcomes under new policies.
Individual behavior is modeled using an elasticity approach, not an expected utility approach.
Estimated Effects of the Affordable Care Act on Health Insurance Coverage, 2024 (non-elderly people):
UNINSURED:
- Without the ACA: 57 million
- Under the ACA: 31 million
INSURED:
Without the ACA
- 35 million – Medicaid and CHIP
- 166 million – Employment-Based
- 27 million – Nongroup and Other
Under the ACA
- 25 million – Exchanges
- 48 million – Medicaid and CHIP
- 159 million – Employment-Based
- 22 million – Nongroup and Other
Estimated Budgetary Effects of the Insurance Coverage Provisions of the Affordable Care Act, 2015 to 2024: ~ $1,400 billion
http://www.cbo.gov/sites/default/files/cbofiles/attachments/45427-AcademyHealth.pdf
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Comment:
By Don McCanne, MD
Imagine how complex it is trying to estimate who will be eligible for and how many will select each of the various sources of coverage, how many will end up uninsured, and what impact that will have on the federal budget. The few excerpts above from the CBO presentation, “Microsimulation of Demand for Health Insurance: A Method Based on Elasticities,” provide an inkling of the complexity of that task.
Now imagine how simple it would be to estimate coverage under a single payer system. To the total population, estimates of births and immigration would be added and estimates of deaths and emigration would be subtracted. The CBO microsimulation serves as a proxy for the profound unnecessary administrative complexity and waste in our system.
The CBO is tasked with making projections for our federal budget. They estimate that the increase in federal spending on health care over the next decade due solely to the insurance coverage provisions of the Affordable Care Act will be ~ $1.4 trillion! This does not include the fact that individuals will be paying more because of the decrease in actuarial value of plans within and outside of the exchange, including especially the declining actuarial value of the largest sector of all – employer-sponsored plans. Our total national health expenditures is a much more important number than is the portion in the federal budget.
As we’ve said repeatedly, the ACA model falls short on most of the goals and it is the most expensive of the comprehensive models of reform. In contrast, the single payer model meets essentially all goals and is the least expensive of comprehensive models.
Because of the great number of variables and interdependent complexity of our health care financing, the CBO has declared that in the future it can no longer give a reasonable estimate of the changes in the federal budget due to the implementation and perpetuation of the provisions of the Affordable Care Act. That should tell you something. It’s time for single payer.