Normative Narratives


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How to Compromise and Fix the ACA

 

Time to Replace Those Repeal Attempts

The Senate’s latest attempts to repeal and replace the Affordable Care Act (ACA) have all failed to pass.

The most comprehensive attempt, the Better Care Reconciliation Act, was voted down 43-57. Defections came from both sides of the GOP–some thought the bill was too hard on low and middle income people, while others thought it left too much of the ACA in place.

With repeal and replace off the table, President Trump changed his tune from “repeal and replace” to “repeal, then [try to] replace”. The Congressional Budget Office (CBO) forecast that “a plan to repeal Obamacare without replacing it could cost 32 million Americans their health insurance by 2026…at the same time, premiums on individual insurance plans would rise 25 percent next year and double by 2026 if Obamacare is repealed.” This effort also failed to gain enough support in the Senate, as it was defeated 45-55.

These CBO projections and Senate votes reflect the fact that people do not want to go back to the pre-ACA days when they could be denied coverage due to pre-existing conditions. As the reality of the modern economy pushes back the typical age of financial independence, the ACA provision allowing young adults to stay on their parents health insurance until 26 has bipartisan support. Minimum standards ensure people who pay for coverage are actually covered when it is time to receive treatment. The individual mandate, while unpopular, ensures a reasonably healthy risk pool for insurers.

All this is to say that the ACA, while imperfect, was designed the way it was for a reason. “A la carte ACA” or the “skinny repeal” would not work, particularly without the individual mandate. Sicker risk pools would lead to a “death spiral“, driving up premiums for middle class customers and subsidy costs for the Government, all while increasing the number of uninsured. For those still keeping score at home, the CBO estimated the “skinny repeal” would result in 16 million Americans losing health insurance over a decade and raise insurance premiums by 20 percent in January. Thankfully, the “skinny repeal” also failed in the Senate, 49-51.

[In other news, the GOP wants to gut the CBO–talk about shooting the messenger]

With so many failed repeal efforts, it is clearly time to try to work towards improving the ACA. Many of the ACAs problems are the result of a lack of competition (see the map above)–private insurers are simply not participating in certain markets, particularly in rural areas (a problem that is expected to get worse in 2018).

The solution to this market failure is to create competition by allowing people to buy into the Medicaid “Public Option”.

I can already hear the outrage from Conservatives–“of course a liberal’s answer is more government”–but hear me out. The Public Option need not increase government spending drastically; people would receive healthcare at cost, but they would still pay–this is not a Medicaid for all as an entitlement proposal. Sure, administrative costs for the government would rise as the program absorbed more people, but the marginal cost of providing care for people who are currently ineligible for Medicaid should be close to zero (some scaling would be needed to smooth costs for people just above Medicaid thresholds).

Furthermore, with the Public Option in place, Medicaid would be in even better position to negotiate lower drug prices with pharmaceutical companies, a cost-saving idea championed by many, including President Trump.

Of course, in order to garner support for a Medicaid Public Option, concessions must be made to conservatives.

Removing the employer mandate:

With a reliable, affordable option that covered all essential health benefits, people would have a much clearer economic decision to make–accept a job that pays less but offers insurance, or take a job that pays more knowing they have to set aside a certain amount for insurance. The Public Option would make buying health insurance a predictable financial choice for the first time in American history.

This concession tackles a major criticism of the ACA–small businesses would no longer be required to factor in the cost of providing health insurance when deciding whether or not to hire more employees.

A higher employee threshold could also be kept in place to ensure larger corporations offer a health insurance option to their employees

Reviving Ted Cruz’s Essential Benefits Plan:

For those not familiar with it, Ted Cruz proposed a plan in which health insurers would be able to offer non-ACA complaint plans–ones that do not cover all essential health benefits–as long as they offer a plan that does cover them as well.

Clearly marking which plans do and do not cover all essential health benefits would be important, but it would also be easy enough. The real issue with Cruz’s plan was there was no way to ensure the ACA-compliant plan was being offered at a reasonable rate, and not just as a token to unlock the right to sell non-compliant plans. 

But with the Public Option, it wouldn’t really matter; if the ACA plan was offered at an unaffordable rate, people would have the choice to opt-in to the Public Option. 

This concession tackles another major criticism of the ACA–people would no longer have to buy insurance covering care they don’t feel they need.

President Trump said “Obamacare is Death”, while Senate majority leader McConnell called it a “nightmare”–empty hyperbole meant to scare people who do not know better. In the darkest of ironies, their very replacement ideas would have truly be a living nightmare for millions, and would have lead to many preventable deaths.

In defeat, President Trump tweeted (of course he did) to just let Obamacare fail. There is much his administration can still do to undermine the laws effectiveness if it truly prioritizes political vendettas over the well-being of American citizens. The GOP has (thankfully) proven it can still be the party of “No” when it comes to Healthcare, even when it is the majority party. Now is the time to see if it can be the party of “Yes” for a stronger, bipartisan plan, the American people want and deserve.


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Economic Outlook: Inelastic Demand, Imperfect Competition, and Price Regulation

Talk is cheap, which is why makes sense for business owners to claim prices will increase and / or mass layoffs will result if regulations are put in place. What this really means is that profits will fall, so it is worth it to talk (which, remember, is cheap), and hire lobbyists (which are relatively cheap for big business compared to the benefits they deliver) to support these claims.

In most cases, markets decide pricing. Increase prices, and people can substitute your good for a competitors. Lay people off to make a political statement, and you forego market-share that will be readily snapped up by competitors. In competitive markets, these problems tend to regulate themselves. While true Perfect Competition doesn’t exist in reality, some markets are closer to this ideal than others.

Under perfect competition, there are many buyers and sellers, and prices reflect supply and demand. Also, consumers have many substitutes if the good or service they wish to buy becomes too expensive or its quality begins to fall short.

When a good is necessary for living (healthcare) or for social mobility (college), imperfect markets can price lower income people out.

bls data

Base Year 1978 (Prices = 100)

Healthcare:

ACA–companies justify price increases:

Rate Review helps protect you from unreasonable rate increases. Insurance companies must now publicly justify any rate increase of 10% or more before raising your premium.

Price controls imposed as part of the ACA are at least partially responsible for the dramatic slowdown in healthcare cost increases over the past few years (the Great Recession was another major factor).

But since health insurance is a composite of a number of inputs, including cost of being seen by a doctor and cost of prescription drugs, each of these inputs would need to be regulated to keep health insurance costs down.

The current approach used to try to keep prescription drug prices down–naming and shaming price gauging companies–does not work.

College:

While a college education is not a silver bullet, it is an important element of the social mobility puzzle. As the graph above shows, college costs have skyrocketed in recent decades, leading poorer students to take on increasing levels of debt to afford a degree.

Those who complete their degree still tend to realize a strong return on investment, but the high (and increasing) debt burden is a huge stressor, which likely contributes to poor graduation rates (especially among lower class students). The combination of non-completion (and related low earnings) and high debt can result in an inescapable debt cycle.

A good proxy for the “necessity” of a good or service is it’s elasticity of demand:

Products that are necessities are more insensitive to price changes because consumers would continue buying these products despite price increases.

The availability of substitutes…is probably the most important factor influencing the elasticity of a good or service. In general, the more substitutes, the more elastic the demand will be.

Imperfect markets result in a lack of substitutes, as barriers to entry result in little competition. Policymakers can start with a matrix of competitiveness and necessity (elasticity of demand); goods and services that are both necessities and exist in highly imperfect markets are primary candidates for price regulation. Two obvious tools for regulating these markets are:

  1. Price controls (making companies justify price increases over a certain threshold)
  2. Tying federal funding to price oversight

 

Price controls may seem like a blunt tool, but they can actually be quite nuanced. Take the ACA’s “Rate Review”. A company can has an opportunity to make its case that a price increase is justified; if it justified is, the government will allow it. It is in no ones interest to see businesses fail in the name of price control regulation. Such failures hurt the economy, and undermine support for the regulatory policies that lead to their failure.

What is the American dream? Is it meritocracy and social mobility, or is it the freedom to charge whatever the market will bear regardless of the social cost?

Admitting their are limits to what perfect competition market models can achieve in the real world does not make you a socialist. It makes you a good economist and policy analyst. There is room for these industries to remain private and profitable. That does not mean we cannot regulate them in ways that make them work for society as a whole (considering the social benefits when they are widely available, and the social costs when they are not).

It is the job of politicians to identify these markets and call owners on their bluffs. Failure to do so reinforces power asymmetries that stifle social mobility. The Commerce Department’s mandate should be expanded to help balance the power asymmetry that exists between consumers and producers of necessities in the most imperfect markets.


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Transparency Report: Debt, Depression, and College Drop-Outs

The graphs in this blog come from a recent report co-authored by the Pell Institute and The University of Pennsylvania:

graduation rates

In addition to the direct (tuition, room and board, cost of living) and “opportunity cost” (foregone wages) of attending college, there is mounting evidence that suggests there is an emotional / psychological cost associated with taking out student loans.

Despite the intense interest in this issue among researchers, this is the first paper that attempts to understand the emotional cost of carrying student loan debt.  This question is, in fact, more fundamental than the others being posed in this genre of research, since it could help to explain the mechanism through which debt may be affecting other outcomes (i.e. emotional health, graduation rates).

Based on their analysis, the authors report, “cumulative student loans were significantly and inversely associated with better psychological functioning.”  In other words, individuals with more student debt reported lower levels of psychological health, when other things are held constant (including occupation, income, education and family wealth).  The effect is statistically significant, but it is quite small.  They also find that “the amount of yearly student loans borrowed was inversely associated with psychological functioning,” which implies that taking on debt is emotionally costly for students.

Unfortunately, this emotional / psychological “cost” seems to be affecting a greater number of incoming college students:

High numbers of students are beginning college having felt depressed and overwhelmed during the previous year, according to an annual survey released on Thursday, reinforcing some experts’ concern about the emotional health of college freshmen.

The survey of more than 150,000 students nationwide, “The American Freshman: National Norms Fall 2014,” found that 9.5 percent of respondents had frequently “felt depressed” during the past year, a significant rise over the 6.1 percent reported five years ago. Those who “felt overwhelmed” by schoolwork and other commitments rose to 34.6 percent from 27.1 percent.

Not coincidentally, the frequency and magnitude of student loan debt has increased greatly during this period of increasing student unease and depression, according to data released by the NY Fed:

More U.S. students continued to borrow larger sums for their college education last year, according to data from the Federal Reserve Bank of New York, while total student loan balances tripled over the last decade.

At 43 million, the number of student borrowers jumped 92 percent from 2004 to 2014, while their average balances climbed 74 percent, according to New York Fed researchers. The average balance was some $27,000.

Obviously correlation does not prove causation. But given the logical link between debt, depression, and dropping-out of school, these trends cannot be purely coincidental–more research on the subject is needed.

“It’s a public health issue,” said Dr. Anthony L. Rostain, a psychiatrist and co-chairman of a University of Pennsylvania task force on students’ emotional health. “We’re expecting more of students: There’s a sense of having to compete in a global economy, and they think they have to be on top of their game all the time. It’s no wonder they feel overwhelmed.”

While I cannot speak personally about the burden of student loan debt, I have experienced depression first hand, and understand how being depressed could make one more likely to drop out of school.

Depression is particularly difficult to battle in a college atmosphere. The pressure to maintain a social life, despite anxiety and financial issues, can reinforce negative feelings associated with depression. The abundance of drugs and alcohol certainly does not help the situation either.

The general pessimism which accompanies depression compromises a person’s ability to clearly assess long term goals, such as completing a degree. Depression also affects ones cognitive abilities, hampering academic outcomes.

I can only imagine the pressure on someone who is both depressed and has student loan debt to consider; some combination of the two surely accounts for more low-income drop-outs than is currently recognized.

I had to take a semester off to get myself back in the proper state of mind to complete my degree; not everyone has this luxury. However, everyone should have the support needed to realize their educational and emotional potential.

Due to my personal experiences and knowledge of economics, I vehemently support President Obama’s proposed Community College plan. Lower income students could learn if pursuing a bachelor’s degree is “for them” without taking out tens of thousands of dollars in loans, likely leading to better emotional, educational, and economic outcomes.

Furthermore, community colleges are more likely to have the the social counseling and financial advising services missing from for-profit universities, which predominantly attract low income students.

collegetypebyincome

The Obama administration is attempting break the vicious cycle of student debt, emotional suffering, and dropping-out of college. Dropping out of college with student loan debt in a competitive global economy is a poverty trap for low income individuals, and has become a drag on economic growth in the macro.

By expanding mental health parity through the ACA, getting treatment for depression is no longer a luxury reserved for the wealthy. If our lawmakers pass a free community college bill, the synergy between these two public policies would go a long way towards bringing equity to America’s higher education system and reinvigorating the American Dream.


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Transparency Report: The ACA, Mental Healthcare, and Mass Shootings

Despite reassurances by President Obama that “if you like your health insurance, you will not have to change it”, many people have been receiving letters notifying them that their current plans are being discontinued and they will be required to buy new ones. Perhaps Obama should have clarified his statement as follows; “if you like your health insurance, and it meets certain minimum requirements, you will be able to keep it.”

Why might a health insurance plan fail to meet these minimum standards? There are 10 “essential health benefits” that new policies must satisfy. The following analysis focuses on one essential service, mental health coverage, and its relationship to mass shootings:

The Obama administration issued a final rule on Wednesday defining “essential health benefits” that must be offered by most health insurance plans next year, and it said that 32 million people would gain access to coverage of mental health care as a result.

Kathleen Sebelius, the secretary of health and human services, said that in addition to the millions who would gain access to mental health care, 30 million people who already have some mental health coverage will see improvements in benefits.

White House officials described the rule as a major expansion of coverage. In the past, they said, nearly 20 percent of people buying insurance on their own did not have coverage for mental health services, and nearly one-third had no coverage for treatment of substance abuse.

Can we ever fully prevent mass shootings? No, there are elements of human will, technology, and finite security resources that make complete prevention impossible. However, there are steps that can be taken to drastically reduce the prevalence of such atrocities. One preventative measure would be to impose stricter gun control laws, which brings about the usual pro and con arguments. Less contentious ideas involve broader background checks (91% support) and increased government spending on youth mental healthcare (82% support).

One would be hard pressed to find an example of a mass-shooter who did not suffer from a mental illness. In fact, 48% of Americans think “failure of the mental health system to identify individuals who are dangers to others” shoulders a “great deal” of the blame for mass shootings (80% of people think this factor deserves a “great deal” or a “fair amount” of the blame). This is the number one factor Americans blame for mass shootings.

We often hear people say things such as “children are our most precious resource” or “I would give anything to protect my child”. The question I pose to my audience, and hopefully to the American public, is this. Do we want to be a country that makes a big deal about tragedies, a country that makes grand statements and then lets those statements fall to the wayside once the story isn’t recent news? Or do we want to be the country that puts its money where its mouth is, and actually implements the reforms we overwhelmingly believe in? One things is certain, mass shootings cannot be reduced by concentrated short term efforts directly after the fact followed by long periods of inaction.

True the survey says “increased government spending on mental healthcare”; however a great deal of people in the individual / uninsured market will receive free or subsidized healthcare, which is the equivalent of greater government spending on mental healthcare. Can we, as a nation, recognize this impact of expanded mental healthcare (not to mention the multitude of socioeconomic benefits associated with expanding healthcare coverage)? Are we truly willing to do anything to keep our children safe, or are we unwilling to even make the most basic investments to achieve this goal?

Update: Legislation is being finalized requiring equal coverage of mental healthcare by all health insurance. This is an important step in American healthcare reform, with untold socioeconomic and security benefits.