Monday, April 17, 2017

ACA/Obamacare: Before and After the Waiver of Pre-existing Conditions and the Advent of Community Rating

“As Republicans continue to debate the specifics of their plan to repeal and replace the Affordable Care Act (ACA or ObamaCare), two provisions have taken center stage: “Guaranteed Issue,” the requirement that insurers offer policies to all applicants, and “Community Rating,” the requirement that they offer all policies at the same price, regardless of risk factors like health, lifestyle, or even gender.

These rules were obviously designed to allow people with pre-existing conditions to purchase health coverage, and to equalize the premiums paid by everyone. But as nice as that sounds, the experience of different states shows that these rules don’t benefit many consumers and aren’t the best way to foster functional and fair insurance markets.”

“Before the ACA, everyone was guaranteed a policy in every state. First, employer-based or group carriers could not deny you coverage due to a pre-existing condition. Second, if you kept continuous coverage and followed the requirements of the 1996 Health Insurance Portability and Accountability Act (HIPAA), you had the right to buy an individual insurance policy with no exclusions for pre-existing conditions.

HIPAA required that a carrier could not raise your rates nor drop you if you developed a condition after the policy was in place. Sadly, the architects of the ACA misled people about these protections, saying they didn’t exist, and many people still believe that today.”

“While guaranteed issue and community rating may sound nice in theory, in reality, they don’t work out as intended. Unfortunately, these rules can create bad incentives. By raising the cost of insurance for healthy people, these rules can discourage some people from buying insurance until they become sick, when they will still be guaranteed a policy.”

“Before the ACA, 43 states allowed the sale of “true insurance.” Rates were based on your potential of claims, so carriers could inquire about your health conditions, occupation, and lifestyle choices. This provided an incentive to practice a healthy lifestyle because your premium would be lower if you did. Most applicants received very affordable rates since most people are healthy. Unlike the proponents of the ACA claimed, scores of common conditions like mild allergies and even elevated blood pressure and cholesterol were accepted. In fact, 87 percent of applicants received coverage, even with their pre-existing conditions.

Others who had delayed applying until they developed a serious condition or were expecting an expensive claim were offered a guaranteed plan through a carrier or through a high-risk pool. High-risk pools offer a variety of plans from different insurers to high-risk customers at subsidized rates. Those rates were typically up to 150 percent of standard rates and were funded partially through a state tax on carriers, the premiums of enrollees, and an occasional grant from the federal government.

These higher rates were only charged to a few people, and they were similar rates to what everyone is now paying under the ACA. As more people buy private plans before they develop a serious condition, rates will remain low and fewer people will be buying in the subsidized high-risk pools.” - Obamacare’s pre-existing condition rules sound nice but don’t work, 04/10/2017,

Link to the entire article appears below:

Friday, April 7, 2017

ACA/Obamacare: Cross Subsidy as a Hidden and Inefficient Tax

“But the great puzzle of health care policy: Just why is it, to accommodate this worthy goal, must your and my health care and insurance be so deeply regulated and so thoroughly dysfunctional? As one small example, why does a 20 minute skin check with the resident of my dermatologist generate a phoney baloney bill for over $1000, meaning a cash and carry market for such a simple, elastically demanded, and perfectly predictable service is impossible?

Why, in order to provide for the unfortunate, do we not simply levy taxes, and pay for charity care, and leave the rest of us alone? Regular Americans have jobs, buy houses, buy TVs, cars, and smartphones, negotiate the complexities of 401(k) and IRA plans, cell phone contracts, frequent flyer programs; hire the complex professional services of contractors, car mechanics, lawyers and accountants, and deal with the insane complexity of our tax system.”

“I think the answer is relatively simple. Our political system is allergic to the word "tax." Instead of straightforwardly raising taxes in a non-distortionary way (a VAT, say), and providing charity care or subsidies -- on budget, please, where we can see it -- our political system prefers to fund things by forcing cross subsidies.

Medicare and medicaid don't pay what the service costs, because we don't want to admit just how expensive that service is. So, large hospitals make up the difference by overcharging you and me instead. The poster child (though not really a cost driver) is emergency room care. The government passed a law saying hospitals must provide emergency room care for free. But money does not grow on trees, so again you and me (via private insurance) must get overcharged to cross-subsidize. The ACA tried to force young healthy wealthy (not getting subsidies) to vastly overpay for insurance, to cross subsidize the poorer and sicker.

This might seem like a wash. OK, if instead of paying taxes, it makes you feel good to pay business class prices for health insurance, what the heck. Economically, a cross-subsidy works the same as a tax. In fact, we do have Europe-size taxes and subsidies, we just hide them.

But it's not a wash. Cross-subsidies are dramatically less efficient than taxes. Choosing cross-subsidies over taxes is indeed the second original sin of health care and insurance regulation. Cross-subsidies cannot stand competition.

If as now you and I are grossly overpaying for health care and insurance, to cross-subsidize others, a competitive market would come along and peel us off. A local skin-check clinic could offer that service for $50.

Low prices, efficiency, and innovation in the provision of services like health care come centrally from competition, and especially disruptive competition. With no competition -- especially no entry by new doctors, hospitals, clinics, insurance companies -- costs spiral up. As costs spiral up, the cost of the charity care spirals up. As that spirals up, the size of the cross-subsidies spirals up. As that spirals up, the need to restrict competition spirals up.”

“Bottom line: Much of the pathology of health care and health insurance comes from this second original sin, choosing cross-subsidies rather than straightforward taxes. Cross-subsidies require the government to stop competition, so an initially clever way of hiding taxes eventually builds into a monstrously inefficient system. (That's a key point. Initially, it is about the same. But the cross subsidy system gets more and more inefficient over time.)

We would be far better off to admit this; raise explicit taxes enough to provide the charity end of our care, and let health insurers and care givers compete for the rest of us, as airlines, computer makers, and everyone else does. The politician's job is to explain to people that what they pay more in taxes they will more than make up in lower health care and insurance costs.” - The second original sin of healthcare regulation, John Cochrane, 04/05/2017

Link to the entire essay appears below: