Last week President Obama announced that he will try to keep his oft repeated promise to Americans in the individual market that they can keep their plans if they like them … for a year. The media have done an excellent job explaining why President Obama’s temporary patch to the ACA may endanger its existence; in the process the American public has learned more than it ever wanted to about adverse selection, cream skimming, and most importantly crass politics. Though the full costs of adverse selection will be muted in the first year by risk corridors and reinsurance, it is clear that the failing website, the bad press, and the recently announced delay are placing maximal stress on even those backup provisions of the bill.
Even if the ACA survives this additional insult against the economics that support its very existence, we have witnessed yet another missed opportunity for positive reform to President Obama’s signature legislative achievement. And this time we can’t just blame intransigent tea-party Republicans and their quixotic efforts at repeal; here the buck stops at 1600 Pennsylvania Ave, NW.
While many of the plans that are affected by the President’s temporary patch might actually be plans that don’t qualify as “insurance” (i.e. they have low lifetime caps on expenditures or don’t cover hospital services), numerous others actually offer quite good coverage that just don’t meet the exceptionally high standards of the newly developed minimum essential health benefit (EHB). In many ways, the first dollar coverage for preventive care and the wide ranging number of services covered by the ACA aren’t truly insurance either. Instead, these features amount to a very generous pre-payment plan for medical services supported by the United States treasury.
These elements of the EHB are too costly and unnecessary. Perhaps even more concerning, they are just the ante. As time goes on, vested interests for everything not included in the EHB will work tirelessly to insure that their favorite benefits are included. If you want evidence of this eventuality, you need look no further than the remarkably long and growing list of benefits mandated by most states. Keep in mind that as the EHB grows more generous the premiums and subsidies on the exchanges will also grow. And we know who will pay their “fair share” of those increases.
Given these facts, the President should have used the recent attention on the individual market as an excuse to pause, and carefully reconsider whether the EHB has actually been set far too high. Doing so would allow insurers to develop innovative benefit designs to create health insurance plans that provide quality coverage without exacerbating the growth of medical spending. Instead, the President chose the easy path. Let’s kick the can down the road and perhaps we can delay the next round of news stories about policy cancellations in the individual market until after the 2014 mid-term elections.
Beyond simply delaying the inevitable, the “policy” change announced last week could threaten the very existence of the ACA. To understand why, we provide a short history lesson. Stanford Professor Alain Enthoven described a prototype for health insurance exchanges in 1978. Over the next two decades, the idea for exchanges was fully developed; the estimable Jackson Hole Group of leading academics, policy wonks, and industry executives produced at least two serious national health insurance (NHI) proposals centered on exchanges. A bipartisan NHI proposal featuring exchanges was debated during President Reagan’s tenure, and again at the time of President Clinton’s ill-fated NHI proposal. Finally, in the mid-2000s, Massachusetts launched its exchange.
During this time, academics came to understand what it would take to have a viable exchange. The young and healthy would have to participate, which in turn meant there would have to be a complex system of subsidies and penalties. And while it would do a world of good to end employer- sponsored insurance (see our previous blogs), the short term disruption and political roadblocks would be severe. So exchanges would have to compete side-by-side with other insurance options, which would have to be regulated lest bare bones plans skim the healthy enrollees from the exchanges. This, in turn, would surely force many individuals to lose their current coverage, and a number of those individuals who don’t qualify for subsidies will likely face much higher premiums. This is how we ended up with the hybrid ACA proposal and, because the plain economic truth was hidden from us, the broken promises.
From the beginning, opponents of the exchanges fell into two camps. The first and by far the larger camp offered a purely political reaction to any proposal offered by President Obama. We could expect such a reaction from tea party Republicans who are still searching for the President’s birth certificate. But we are disappointed by the moderate, supposedly pro-business Republicans who failed to see how moving away from employer-sponsored insurance could unshackle America’s businesses, especially small companies and entrepreneurs. We would have hoped that the establishment members of the Republican Party would have taken the opportunity then, or at least now when President Obama appears to be more amenable to compromise, to make the exchanges into a positive economic force. For example, they could have crafted a compromise to lower the EHB and expand the availability of high deductible health plans on the Bronze tier of the exchanges.
Exchanges and their many rules may sound crazy, but there is method to the madness. The President may have lied about the implications of these rules, but they are at least internally coherent. At least they were internally coherent before the latest delay.
And that brings us to the second camp. From the beginning, we joined with many free-market economists and other skeptics in opposing the ACA because we feared that ugly politics would trump sensible economics. The heavy hand of politics appeared early on, when a variety of budgeting tricks were employed to make the ACA appear to be revenue neutral. (Does anyone recall that the tax increases to fund the exchange subsidies began fully three years before the first dollar in subsidies would be paid out?) States were supposed to launch their own exchanges, but the federal option was introduced to deal with political realities. Efforts to rein in spending on high cost/low value medical technologies were abandoned to avoid any notions of “death panels.” Finally, and more recently, the employer mandate for insurance was delayed by a year because of difficulties in implementation. We can now add to this list the “you can keep your plan” lie and the temporary patch for those who did not keep their plans. All of these are example of how the ACA has become much more about politics than about sensible policy. Both sides must take the blame for this result.
And so the greatest danger of large scale government intervention is laid bare for all to see. We greatly admire our colleagues who have diagnosed the ills of the U.S. health insurance system. We agree with them that “properly implemented” exchanges can assure that nearly all Americans obtain insurance coverage, promote competition among insurers, and liberate Americans from the yoke of tying insurance to employment. But in a two party system, especially with today’s two and a half (we can’t count the tea party as a distinct party but it is hard to lump them in with more sensible Republicans) parties, national politics continues to trump economic theory. Exchanges may be working reasonably well in Massachusetts, but nationwide? Good luck to that. (Wasn’t that Romney’s message? Like him or not, he sure got it right that solutions that work well in one state might not translate to the nation.)
As each day brings sadder news about the exchanges, we are reminded that it is easier for a camel to pass through the eye of a needle than it is for politicians to properly implement complex economic policies.