By Sara R. Collins, David C. Radley, and Jesse C. Baumgartner
The Commonwealth Fund, November 21, 2019

Abstract

Issue: With 2020 elections coming up, some Democratic presidential candidates and members of Congress have suggested ways to reduce costs of insurance and care, including proposals for employer plans, which cover roughly half the population of the United States.

Goal: Examine trends in employer coverage over the past decade to determine how much workers are spending on premiums and deductibles and compare costs to median household income in each state.

Methods: Data from the Medical Expenditure Panel Survey–Insurance Component (MEPS–IC), which surveyed more than 40,000 private-sector employers in 2018 on their health insurance plans.

Key Findings and Conclusions: Average annual growth in the combined cost of employees’ contributions to premiums and deductibles outpaced growth in U.S. median income between 2008 and 2018 in every state. Middle-income workers spent an average 6.8 percent of income on employer premium contributions in 2018; per-person deductibles across single and family plans amounted to 4.7 percent of median income. Recent proposals would enhance the affordability and cost protection of Affordable Care Act marketplace plans, allow people with employer plans to buy coverage on the marketplaces, or replace private insurance with a public plan like Medicare.

Conclusions and Policy Implications

For U.S. families, the growth in employer health insurance costs has outpaced average growth in median income over the past decade. In addition, as costs have climbed, families haven’t received higher-quality insurance. In 18 states, the average health plan deductible is now 5 percent or more of income, meeting the threshold for underinsurance. While this study only considered families with middle incomes, lower-income families with employer coverage devote an even larger share of their income to health insurance and related costs.

People across the United States are not experiencing health care costs equally. Worker cost burdens are driven by four factors: the size of the overall premium, the share that employees contribute to those premiums, the size of their deductibles, and their income. In Mississippi, for example, people could spend more than 16 percent of their incomes on premiums and meeting deductibles, compared to an average cost burden of 8.4 percent in Massachusetts. In Mississippi, combined premiums and deductibles are higher than those in Massachusetts and Mississippi has the second-lowest median income in the country ($47,800). In contrast, median income in Massachusetts is among the nation’s highest ($81,913).

Higher costs for insurance and health care have consequences. People with low and moderate incomes may decide to go without insurance if it competes with other critical living expenses like housing and food, which consumed 36 percent of average family income in 2018. Research indicates that high deductibles lead people to delay or skip needed health care and prescription medications.

The Affordable Care Act (ACA) provides some cost protection to people with employer coverage. First, people with low incomes — less than 138 percent of poverty (or just under $17,000 for an individual) — are eligible for Medicaid in the 33 states, as well as D.C., which have expanded eligibility under the ACA. This is true regardless of whether or not they are offered a plan through their job. People enrolled in Medicaid pay no premiums or very limited premiums and face low or no cost-sharing. Second, people with employer premium expenses that exceed 9.86 percent of their income are eligible for marketplace subsidies, which trigger a federal tax penalty for their employers. This penalty is also triggered if the actuarial value of their plan is less than 60 percent (i.e., covers less than 60% of their costs on average). There’s a catch: these provisions only apply to single-person policies, leaving many middle-income families caught in the so-called family coverage glitch, where they have an expensive family plan but do not qualify for marketplace subsidies. The data in this report show that the average employee contribution to a family plan is 10 percent or more of median income in nine states.

What is the right level of premiums and cost-sharing for Americans? The ACA set standards for the marketplaces: required premium contributions for marketplace plans begin at 2.08 percent of income at the poverty level ($12,140 for an individual and $25,100 for a family of four) and rise to 9.86 percent for people at 300 percent to 400 percent of poverty ($36,420 to 48,560 for an individual and $75,300 to $100,400 for a family of four). The law also set standards for the benefits plans must cover and the amount that patients pay providers when they use their plans, with subsidies for people with lower incomes.

Congress could extend these marketplace requirements to employer plans or allow all people with employer plans to buy coverage in the marketplaces. But are the marketplace premiums and cost-sharing subsidies set at affordable levels for people across the income scale? Survey research indicates that many people, especially those with incomes just over the threshold for premium subsidies and cost-sharing reductions, may struggle to afford their premiums and deductibles.

Several Democratic members of Congress and presidential candidates have proposed enhancing the marketplace premium and cost-sharing subsidies and extending them further up the income scale. Others also would give people in employer plans the option of enrolling in a public plan offered through the marketplaces. Other members and candidates have suggested eliminating all private insurance and replacing it with a public plan like Medicare, and ending or reducing premiums and cost-sharing. Republican health reform ideas tend to favor replacing the ACA with market-oriented approaches that give states more discretion over insurance markets and the Medicaid program. We are certain to hear from voters on this issue in the coming year.

https://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

In spite of the Affordable Care Act, “For U.S. families, the growth in employer health insurance costs has outpaced average growth in median income over the past decade.”

Something needs to be done. On “policy implications” this article suggests expanding the provisions of the Affordable Care Act and perhaps adding a public option to the marketplaces. Such an approach would perpetuate much of the deficiencies and injustices of our current system of financing health care.

There is one sentence buried in the last paragraph that describes an approach that would correct most of the deficiencies in our health care financing system: “Other members and candidates have suggested eliminating all private insurance and replacing it with a public plan like Medicare, and ending or reducing premiums and cost-sharing.”

It is unfortunate that The Commonwealth Fund along with other organizations and media sources seem to have delegated this approach to a category of “aspiration” which can be dismissed because of a supposed lack of political feasibility.

Our task? Change the perception about political feasibility. Take to the streets if we have to.

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By Adam Gaffney, Steffie Woolhandler, and David Himmelstein
Journal of General Internal Medicine, Online November 19, 2019

Abstract

Most analysts project that a reform like Medicare-for-All that lowers financial barriers to care would cause a surge in the utilization of services, raising costs despite stable or even reduced prices. However, the finite supply of physicians and hospital beds could constrain such utilization increases. We reviewed the effects of 13 universal coverage expansions in capitalist nations on physician and hospital utilization, beginning with New Zealand’s 1938 Social Security Act up through the 2010 Affordable Care Act in the USA. Almost all coverage expansions had either a small (i.e., < 10%) or no effect on society-wide utilization. However, coverage expansions often redistributed care—increasing use among newly covered groups while producing small, offsetting reductions among those already covered. We conclude that in wealthy nations, large-scale coverage expansions need not cause overall utilization to surge if provider supply is controlled. However, such reforms could redirect care towards patients who most need it.

From the Methods

We identified all rapid universal coverage expansions in high-income capitalist nations. In brief, we considered a nation to have undergone a rapid universal coverage expansion if it experienced a ≥ 10 percentage point reduction in uninsurance rates over a 2-year period that brought it to ≥ 95% population coverage. Our final sample included the following: New Zealand—1938, Great Britain—1946, Sweden—1947/1953, Canada’s hospital insurance—1957, Finland—1963, USA/Medicare—1965, Canada’s physician insurance—1966, Australia—1974, Portugal—1979, Greece—1983, Spain—1986, Taiwan—1994, and the USA/ACA—2010 (although neither US expansion achieved 95% coverage, we include them because of their policy salience).

From the Discussion

Thirteen UHC expansions in 11 affluent nations spanning eight decades were mostly associated with small (< 10%), or no, increases in society-wide hospital and physician utilization. However, many redistributed care from well-off populations to more disadvantaged ones. These findings suggest that healthcare supply may constrain utilization increases, even when financial barriers are lifted. Most, but not all, cost projections of Medicare-for-All have failed to account for such supply constraints.

Milton Roemer famously noted that “a hospital bed built is a hospital bed filled,” and conversely that a limited bed supply constrains utilization. Many studies — and our finding that UHC rarely caused a surge in hospital utilization — support “Roemer’s law.”

Many, but not all, econometric analyses have similarly found that doctors provide slightly less care to the previously insured when coverage expands — and slightly more care to those remaining insured when coverage shrinks. Several studies suggest that such utilization reductions among insured populations predominantly affect low-value services, with no evidence of harm. Similarly, an oversupply of hospital beds in a community apparently does not improve health and may increase overutilization of low-value services.

In summary, history suggests that coverage expansions such as Medicare-for-All redirect care to the poor and sick, but need not drive up overall utilization if growth in supply is regulated.

https://link.springer.com…

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Comment:

By Don McCanne, M.D.

It is often claimed that if we expanded health care coverage to include everyone, as would happen with implementation of the single payer model of Medicare for All, we would not be able to afford the costs of the surge in health care utilization, plus the increased demand for care would require greater rationing with resulting impairment of access. Today’s report assures us that neither one of these claims constitute a real threat to access or affordability.

This important study looked at 13 large coverage expansions in 11 nations and found that, by and large, utilization increases were fairly negligible, thus increases in costs and rationing were also negligible. The change that did seem to occur was that there was a limited redistribution of care from low-value care for the healthy and wealthy to essential care for the sick and poor – an actual improvement in health care delivery.

Thus, when you hear that we cannot afford the increase in costs of Medicare for All, you can respond that we will not be spending more, but we will be spending better (keeping in mind that we will recover hundreds of billions of dollars in administrative waste that can be spent on health care).

Also, when you hear that people will not be able to get health care because of rationing, you can respond that the value in health care will improve because we will target our health care resources to providing more effective care (keeping in mind that all universal systems place a priority on emergency services).

This study further confirms that expanding health care coverage to include everyone will provide greater value and higher quality in our health care. We can’t afford not to do it.

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By Mark Shepard, Katherine Baicker, and Jonathan S. Skinner
National Bureau of Economic Research, November 2019

Abstract

There is increasing interest in expanding Medicare health insurance coverage in the U.S., but it is not clear whether the current program is the right foundation on which to build. Traditional Medicare covers a uniform set of benefits for all income groups and provides more generous access to providers and new treatments than public programs in other developed countries. We develop an economic framework to assess the efficiency and equity tradeoffs involved with reforming this generous, uniform structure. We argue that three major shifts make a uniform design less efficient today than when Medicare began in 1965. First, rising income inequality makes it more difficult to design a single plan that serves the needs of both higher- and lower-income people. Second, the dramatic expansion of expensive medical technology means that a generous program increasingly crowds out other public programs valued by the poor and middle class. Finally, as medical spending rises, the tax-financing of the system creates mounting economic costs and increasingly untenable policy constraints. These forces motivate reforms that shift towards a more basic public benefit that individuals can “top-up” with private spending. If combined with an increase in other progressive transfers, such a reform could improve efficiency and reduce public spending while benefiting low income populations.

From the Introduction

In this paper, we focus on the design of the current Medicare program for the elderly to assess its tradeoffs and provide insights about the implications of using it as a foundation for expanding coverage. We first ask about the efficiency and equity tradeoffs involved with its current generous, uniform design. Second, we address the question of how rising income inequality, ongoing medical technology innovation, and the budget pressures imposed by an aging population affect the efficiency of the current benefit structure. Finally, we examine the effects of an alternative, non-uniform benefit structure on economic efficiency and equity.

To study these questions, we build on a rich literature in health economics and social insurance design to develop a simple economic model of Medicare that incorporates income inequality, medical technology growth, and distortionary taxes. The model allows us to assess how the welfare consequences of Medicare’s uniform benefit structure have evolved, as well as the welfare effects of potential alternative public insurance designs.

The model suggests that while Medicare’s uniform benefit has the advantages of simplicity and lower administrative costs, it also comes with a cost of uniformity. While high-income households would likely prefer a very generous plan, low-income households would likely prefer lower health care spending and higher take-home pay or more generous non-medical benefits such as food stamps or housing assistance. A uniform program pools everyone into the same plan, creating an inefficiency due to mismatch between the public benefit and privately optimal generosity.

Our central argument is that three macro trends have increased this cost of uniformity appreciably since Medicare’s creation in 1965. First, income inequality has risen substantially. Rising inequality leads to growing divergence between rich and poor in willingness (and ability) to pay for generous medical care. Second, there have been dramatic innovations in medical technology: there was much less health care available to buy in the 1960s, and even advanced technologies of the day were relatively inexpensive. Third, average marginal tax rates have increased from less than 25% in 1965 to 30% in 2012, commensurately increasing the deadweight loss (or economic cost) associated with publicly financed benefits – a trend that will likely continue with the budget pressures from population aging.

These changes imply that demand among the rich for generous medical care increasingly diverges from what a uniform public system can afford to fund. While a universal, generous Medicare program may have been efficient in 1965 when options for treatment were both limited and relatively inexpensive, tax rates were lower, and income more evenly distributed, the efficiency cost of maintaining uniform coverage has grown over time. The current benefit design thus may not be a sustainable foundation upon which to expand public health insurance.

We describe an alternative insurance benefit design in which the government provides basic insurance but allows higher-income households to “top up” by purchasing additional coverage for additional services. (Medicare does have in place supplemental “Medigap” plans, but these are primarily designed to cover copayments and deductibles, rather than cover additional services.) The basic plan is intended to be similar to public insurance provided in many other countries – with low patient copayments and deductibles but with more modest provider payment rates and with coverage of treatments restricted to those with proven effectiveness relative to lower-cost alternatives.

Supplemental “top-up” plans are also common in other countries. Governments often underwrite a basic insurance plan (or mandate the purchase of regulated and subsidized private plans), but then allow households to add on private supplemental insurance.

Our calibrated model suggests that switching from a uniform Medicare benefit to a top-up structure could generate substantial cost reductions and efficiency gains in the long term. The distributional implications of such a policy change would depend on the alternative uses to which the resources saved on public insurance would be devoted. Many European countries spend substantially more on other social insurance programs than the U.S., and some of those non-medical programs themselves are likely to yield health benefits. We show in the model that there exists a redistribution of the “Medicare dividend” that would raise wellbeing across all income groups.

While our model considers benefit design solely for people age 65 and over, the implications for Medicare benefit design are clearly amplified under proposals to expand the eligible population. For example, while the cost of “Medicare for All” proposals depends crucially on the details of eligibility, coverage, and provider payment rates, most proposals require additional tax revenues that would substantially raise marginal tax rates. The implication of our simple model is that a more basic public benefit – closer to “Medicaid for All” than to “Medicare for All” – with the option for individuals to top up to more generous private coverage, coupled with increased transfers to the poor, could prove to be a higher-value, more sustainable alternative to many proposals that seek to expand the current Medicare program.

From the Discussion and Conclusion

Means-tested in-kind transfers of housing, food, and health care are the predominant form of income redistribution to low-income households. Medicare is a prominent example of a uniform in-kind benefit provided to both high- and low-income populations. In this paper, we develop a model that allows us to gauge the tradeoffs involved in this uniform benefit design.

Using a stylized model, we show how tax distortions, income inequality, egalitarian preferences, and technology growth affect the efficient structure of the program. Our results suggest that in 1965 when Medicare was first created, its uniform generous structure was relatively well suited to the economic and technological environment. But by 2019 it has become much less efficient relative to a “top-up” health insurance program where more basic public coverage can be supplemented by private health insurance. Our results are consistent with policies seen in many other developed countries, which provide a basic universal public insurance plan and where many citizens take advantage of the opportunity to pay extra for amenities and additional services.

We explore the implications of an alternative “basic” form of public insurance that provides more restricted benefits with regulated prices and allows higher income households to top-up their coverage with privately financed plans. Under such a plan, lower income households would consume less health care than their higher income counterparts, and perhaps less care than they do now. This naturally raises concerns about equity. Many who support a uniform benefit structure point to the “right to health care” as a foundational rationale. It is worth noting, however, that a uniform benefit is likely to result in a substantially higher share of income being devoted to health care (rather than, for example, food, education, or housing) than the typical lower-income household might choose. It is also likely to result in fiscal pressures over time that not only raise taxes but also crowd out spending on other public goods and transfer programs. We demonstrate in our model that it is possible to offset some of the equity effects of the top-up redesign by appropriate redistribution of the taxpayer savings generated by scaling back the public benefit.

This top-up structure is not only similar to that seen in some other countries, but is also related to other proposals discussed in the U.S. context, including value-based insurance design and premium support plans.

Moving to a basic benefit-plus-top-up plan would of course pose both practical and political challenges because of the reliance on potentially controversial determinations of cost-effectiveness. Political pressures might, though, play out differently with different plans and different eligible populations.

As new technologies arrive with ever-larger price-tags, pressure will continue to mount on public budgets; and equality of access to care, rather than guaranteed access to a minimum level of care, will become increasingly costly. It is vital that policymakers consider how alternative program designs affect the overall wellbeing of households across the income distribution as they debate Medicare’s future.

https://www.nber.org…

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Comment:

By Don McCanne, M.D.

This working paper is important because it comes from noted academics in the health policy community. The theme is not original. In a somewhat arcane economic disposition they rationalize a two-tiered or multitiered system of health care financing:

“We explore the implications of an alternative ‘basic’ form of public insurance that provides more restricted benefits with regulated prices and allows higher income households to top-up their coverage with privately financed plans. Under such a plan, lower income households would consume less health care than their higher income counterparts, and perhaps less care than they do now.”

In one of my earliest ventures into health policy, in response to the failure of the Clinton reform effort, I composed a health care proposal advocating for a basic plan for everyone and supplemental coverage for those who could afford it. I sent it in to PNHP, and Claudia Fegan was kind enough to return it, saturated in red ink. I learned two lessons. I realized how poorly informed I was on the topic of health policy, and it motivated me to study the topic more intensively, which I continue to do so to this day. More importantly, I developed a more acute sense of health care justice – that we can easily devise a health care system that ensures that everyone receives the health care they should have.

So why do so many in the policy community believe that lower income households should be restricted to only basic health care benefits while allowing higher-income households to top-up their benefits? I did further research to try to answer this question, and I found an article by the lead author of this working paper, Mark Shepard, titled, “Surprised by Jesus: how he found me at Harvard.” But the historical Jesus was a prophet of social change, which leads to the age-old question: What would Jesus have done?

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FTI Consulting, November 2019

Key Findings

• Introducing a public option could create a “two-tier” health system where employer- based insurance provides access to a different set of hospitals or services than those available to enrollees in public insurance.
• The government would be expected to set premiums for the public option approximately 25 percent below market value for comparable private insurance plans, squeezing out private competition and diminishing consumer choice. The significant discrepancy in premiums would cause the eventual elimination of all private plans in the individual market.
• By 2028, 20 percent of state marketplaces would not offer a single private insurance option as a result of the introduction of the public option.
• In the first year following introduction of the public option, over 130,000 Americans enrolled in ACA coverage would be forced off of their existing health plan as private insurers exit the marketplaces. Over a decade, up to two million marketplace enrollees could experience a loss of private coverage.

Conclusion

The success of the ACA in expanding affordable coverage through increased private sector competition is one reason why it remains popular today. For years, politicians have toyed with the idea of introducing a public option into our nation’s health care system. Time and time again, efforts have failed when it became clear that doing so would destabilize health coverage for the millions of Americans satisfied with their existing coverage. The results of FTI’s analysis demonstrate that introducing a public option to the ACA marketplaces would not serve to build upon the existing system, but would instead displace private insurance plans in most markets. Instead of bearing the risks associated with public option plans, several states have implemented market stabilization measures, such as reinsurance, that have successfully reduced costs to consumers and state governments. Such programs offer a potential alternative to the public option for policymakers seeking to reduce health care costs while preserving consumer choice.

Acknowledgments: This work was supported by the Partnership for America’s Health Care Future.

https://americashealthcarefuture.org…

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Comment:

By Don McCanne, M.D.

This consultant’s report was supported by the Partnership for America’s Health Care Future – “an ad hoc alliance of American hospital, health insurance, and pharmaceutical lobbyists committed to preventing legislation that would lead to single payer healthcare, expanding Medicare, or creating Medicare for All in particular” (Wikipedia). So what bias does the report demonstrate?

The consultants conclude that introducing a public option (a publicly administered insurance program) to the ACA insurance exchanges (marketplaces) would place the private plans at a considerable competitive disadvantage and drive them out of the exchanges.

What could the public option do that would be more appealing to patients than the private plans? Rather than the narrower provider networks of the private plans, the public option might be open to all current Medicare providers, which constitute most of our health care delivery system. Also they expect premiums for the public option to be 25 percent lower than private plans, likely representing both administrative efficiencies and administered pricing that would be features a public option.

The public option does sound like a much better deal for beneficiaries than the private plans. In fact, driving out the more expensive private plans through competition is touted to be a benefit of markets. The risk under market theory would be that the single plan remaining would be a monopoly that could drive prices up and reduce services. But in this case the public option would not be driven by profits and shareholder demands; instead, it would continue as a public service providing appropriate health benefits at a fair cost.

Although it would seem that this report was produced to scare the public by threatening them with the loss of their private coverage, it seems that it might have the opposite effect of enticing them into supporting a public option. More likely, this report may be used internally to scare the members of the Partnership for America’s Health Care Future, causing them to intensify their lobbying efforts against the public option, and, by extension, especially against Medicare for All.

This report emphasizes the consequences of a public option since many consider it to be an incremental step towards Medicare for All. But merely enacting a public option would add yet one more player to our highly dysfunctional, fragmented health care financing system. It would be much more logical to move directly to a single payer system of Medicare for All.

Can you imagine what the members must think about the prospect of the government offering the entire nation superior benefits with spending moderated through administrative efficiencies and negotiation of fair prices that would be paid by a public universal risk pool? Unfair competition! Maybe the medical industrial complex would consider it unfair, but what could be more fair for the patients?

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By Elizabeth Warren
Medium, November 15. 2019

Every serious proposal for Medicare for All contemplates a significant transition period. Today, I’m announcing my plan to expand public health care coverage, reduce costs, and improve the quality of care for every family in America. My plan will be completed in my first term. It includes dramatic actions to lower drug prices, a Medicare for All option available to everyone that is more generous than any plan proposed by any other presidential candidate, critical health system reforms to save money and save lives, and a full transition to Medicare for All.

(Most of the report describes transitional steps including strengthening the Affordable Care Act, Medicare and Medicaid, and establishing a “true Medicare for All option.”)

Completing the Transition to Medicare For All

By pursuing these changes, we will provide every person in America with the option of choosing public coverage that matches the full benefits of Medicare for All. Given the quality of the public alternatives, millions are likely to move out of private insurance as quickly as possible.

No later than my third year in office, at which point the number of individuals voluntarily remaining in private insurance would likely be quite low, I will fight to pass legislation to complete the transition to the Medicare for All system defined by the Medicare for All Act by the end of my first term in office.

Moving to this system would mean integrating everyone into a unified system with zero premiums, copays, and deductibles. Senator Sanders’s Medicare for All Act allows for supplemental private insurance to cover services that are not duplicative of the coverage in Medicare for All; for unions that seek specialized wraparound coverage and individuals with specialized needs, a private market could still exist. In addition, we can allow private employer coverage that reflects the outcome of a collective bargaining agreement to be grandfathered into the new system to ensure that these workers receive the full benefit of their bargain before moving to the new system. But the point of Medicare for All is to cut out the middleman.

I believe the next president must do everything she can within one presidential term to complete the transition to Medicare for All. My plan will reduce the financial and political power of the insurance companies — as well as their ability to frighten the American people — by implementing reforms immediately and demonstrating at each phase that true Medicare for All coverage is better than their private options. I believe this approach gives us our best chance to succeed.

Why do we need to transition to Medicare for All if a robust Medicare for All option is available to everyone? The answer is simple and blunt: cost and outcomes. Today, up to 30% of current health spending is driven by the costs of filling out different insurance forms and following different claims processes and fighting with insurance companies over what is and is not covered. I have demonstrated how a full Medicare for All system can use its leverage to wring trillions of dollars in waste out of our system while delivering smarter care — and I’ve made clear exactly how I would do it. The experience of other countries shows that this system is the cheapest and most efficient way to deliver high-quality health care. As long as duplicative private coverage exists, we will limit our ability to make health care delivery more effective and affordable — and the ability of private middlemen to abuse patients will remain.

This final legislation will put a choice before Congress — maintain a two-tiered system where private insurers can continue to profit from being the middlemen between patients and doctors, getting rich by denying care — or give everybody Medicare for All to capture the full value of trillions of dollars in savings in health care spending. I believe that the American people will demand Congress make the right choice.

https://medium.com…

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Comment:

By Don McCanne, M.D.

As promised, Elizabeth Warren is proposing dramatic transitional steps in improving our health care financing system, ending in the third year with a full transformation into a bona fide single-payer improved Medicare for All program. The sketchy details of the transformation are spelled out in her article, but much more important is that the end goal of a single payer model of Medicare for All is not compromised. It really can be achieved.

PNHP does not endorse any political candidate for public office.

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