Analysis of the Abraham and Strain Student Debt Argument

A recent article authored by Abraham and Strain arguing against a debt relief proposal under consideration by the Biden Administration was inaccurate. The proposal under consideration mostly benefits middle-income borrowers and the program could be means tested. Existing IDR programs have proven to be ineffective. Bankruptcy reform won’t pass Congress. Student debt discharge is the only realistic way to stop the increase in student debt burdens and reduce the number of people foregoing higher education.

Introduction:

Abraham and Strain claim a debt relief proposal for student borrowers considered by President Biden is regressive.  They cite research indicating that a blanket forgiveness of $10,000 in student debt relief would offer $3.60 in debt relief to households with the highest 10 percent of income compared to $1.00 for the bottom 10 percent.  The research they cite also found that ¾ of the benefit from the proposal under consideration would flow to households with income over the median.  They argue that expansion of Income Driven Replacement (IDR) loan programs and alteration in the treatment of student debt in bankruptcy would be a more effective way to assist students with excessive student loans.

Comments on arguments advanced by Abraham and Strain:

I am not surprised that student debt does not provide much benefit to households with income in the bottom ten percent because education is the best way to avoid poverty. Most of the advantages of the current student loan discharge proposal appear to go to middle income people with income between the 25th and 75thpercentile.  The percent of people receiving benefits in the middle of the income distribution is a much more interesting portrayal of the equity of the proposal than the percent of benefits going to people with income over the median. 

IDR programs have proven to be ineffective at providing debt relief to student borrowers, especially middle-income borrowers.  The Public Service Loan Forgiveness loans, which are tied to IDR loans were not discharged in a timely fashion and it is likely that borrowers in long-term IDR programs will experience a similar fate.  People in IDR loan programs often can’t qualify for a home mortgage because of uncertainty about their income and loan payment. The relative merits of an IDR versus a conventional loan are unknowable immediately after the student borrower finishes school and starts repayment.  IDR loans can be negatively amortized, and many IDR borrowers pay substantially more on their loan than if they took out a conventional loan.

Abraham and Strain argue for allowing the discharge of student loans in bankruptcy, an action that would not pass Congress.  Alternatively, it would be useful to modify chapter 13 bankruptcy payment rules to allow for increased student debt payments and decreased payments on other consumer loans during the chapter 13 bankruptcy period.  This proposal also probably lacks the 60 votes needed to get through the Senate. 

Abraham and Strain argue that it is inappropriate to treat student borrowers from people who borrowed for other purposes.  However, this is exactly what current bankruptcy law does and Congress is not going to change this situation.  A second-best answer is to provide debt relief.

The $10,000 immediate student loan debt discharge strikes me as excessively generous.  I agree that it could encourage increased future borrowing.  I would structure debt relief at the greater of 20 percent of outstanding loans per year or $3,000 per borrower per year for five years.  I would exclude borrowers with household income greater than the 90th percentile.

Concluding Remark

These has been a constant increase in the trend growth of the number of entrants to the workforce with student debt, the average student debt burden for new workers, and the number of older workers leaving the workforce and entering retirement with unpaid student loans. 

I understand that most people with student debt are better off than people who never went to college but increases in the burden of going to college will almost certainly increase the number of people foregoing higher education.  Congress is not going to act on this problem.  Many of the proposed solutions won’t work.  Some unilateral debt relief is the only way to avoid worsening debt burdens and increases in the number of people foregoing higher education.

David Bernstein, an economist living in Denver Colorado is the author of A 2024 Health Care Reform Proposal.  Use promotion code REFORM101 for a discount on the paper.

True-False Questions from the 2024 Health Care Reform Proposal

Test your knowledge on the continuing health insurance reform debate.


The true-false questions presented here are fully explained in the memo A 2024 Health Care Reform Proposal.

Questions:

  1. High-deductible health plans coupled with health savings accounts are more likely to prevent a $25,000 to $50,000 out-of-pocket health expense than short-term health insurance.
  2. The sum of deductibles and worker share of premiums has decreased since the passage of the ACA.
  3. Tax preferences associated with health savings accounts are smaller for low-income people than for high-income people.
  4. The Senate could make major changes to the tax-treatment of employer-based insurance and the premium tax credit based on a majority vote.
  5. Short-Term health plans provide great protection if total health expenditures remain below the annual cap.
  6. The ACA guarantees that people purchasing state-exchange health insurance have access to top cancer hospital if they get cancer.

Answers and Discussion:

  1. True. High-Deductible health plans cap out-of-pocket health expenditures. The current out-of-pocket limits are $7,050 for an individual policy and $14,100 for a family policy. The arbitrary benefit exclusions on short-term health plans can lead to large out-of-pocket expenses for relatively minor health problems.
  2. False. The sum of deductibles and worker shares of premiums has risen since passage of the ACA.
  3. True. HSA contributions are deductible. The value of the deduction is determined by marginal tax rates. This disparity could be eliminated by replacing the HSA tax deduction with a tax credit.
  4. True. if done through the tax reconciliation process. Several tax changes are proposed in the book including the tax credit discussed above and the replacement of the tax subsidy for employer-based health insurance with an employer subsidy of state-exchange insurance.
  5. False: A three-day stay in the hospital could result in thousands of dollars of health expenses for people covered by a short-term health plan. The book points the reader to some papers that found problems associated with short-term health plans could be rectified through reinsurance subsidies or by allowing automatic access to Medicaid for people covered by a policy with an annual cap.
  6. False. In fact, state-exchange health insurance policies tend to have narrower provider networks than employer-based health insurance policies. The book discusses how issues related to narrow network policy might be addressed through network adequacy regulation, expansion of the No-Surprises Act and new subsidies.

I am not looking forward to a 2024 debate between advocates of Medicare for all and people who want to tinker around the edges of the ACA.  The memo A 2024 Health Care Reform Proposal makes the case for a centrist-flavored overhaul of health insurance in the United States.

Will Congress Change Retirement Savings Rules?

Retirement plan proposals currently under consideration by Congress will increase profits for Wall Street firms by increasing the use of high-cost 401(k) plans. These proposals do not assist the people having the hardest time saving for retirement. This memo evaluates the pension changes under consideration by Congress and presents alternative proposals.


Introduction:

recent CNN article describes several bills before Congress designed to change rules governing retirement plans including the Secure Act 2.0, a bill that has been passed by the House, and several proposals drawn up in the Senate. This memo outlines these legislative proposals and evaluates their potential financial impacts.

Features of the House Secure Act 2.0 bill:

  • Requires automatic enrollment in 401(k) plans, sets an initial contribution rate at 3.0 percent of salary, and increases contribution rate by 1.0 percent per year of service,
  • Increases catch-up contributions for people aged 62-64 and invest catch-up contributions in Roth accounts.
  • Allows employer matching 401(k) contributions on student loan payments,
  • Increases initiation age for required minimum distributions (RMDs) from retirement plans,
  • Require employers cover part-time workers working at least 500 hours per year for two years,

Discussion of bills in the United States Senate: 

The CNN article discusses several Senate bills addressing pension issues, which could be coupled with the bill that has already passed the House.

  • A bill offered by Senator Cardin and Senator Portman differs from the Secure Act 2.0 bill by excluding the automatic enrollment provision and its tax treatment of catch-up contributions.
  • A bill under construction by Senator Murray and Senator Burr may include provisions for new emergency savings options and annuity purchases by workers.
  • The starter K-bill offered by Senator Carper and Senator Barrasso facilitates creation of low-cost retirement plans, for small businesses and startups.  Proposed plans would have a $6,000 annual contribution limit and would allow automatic enrollment.

Analysis:

Comment One:  The automatic enrollment provisions in Secure Act 2.0 could lead to suboptimal savings outcomes for some workers.  It could lead to workers placing funds in a high-cost 401 (k) rather than a low-cost IRA.   (High 401(k) fees can decimate retirement savings as discussed here.)  Workers with substantial debt may be better off foregoing retirement contributions and rapidly repaying loans as discussed here. Many workers need to prioritize contributions to health savings accounts over additional contributions to 401(k) plans as discussed here.   This article makes the case for investments in Series I bonds outside of a retirement account instead of conventional bonds inside a retirement account.

Automatic enrollment into suboptimal financial options is bad policy.  The Cardin-Portman bill without an automatic enrollment provision would be preferable to the House bill.   A compromise bill would limit automatic enrollment to the amount needed to maximize receipt of the employer match and automatically enroll workers at firms without an employer match into IRAs.

Comment Two: An empirical analysis of the finances of people choosing to currently make catch-up contributions could determine if an expansion of catch-up contributions helps people who need to catch up or people already ahead.  It is likely expanded catch-up contributions for people in the 62-64 age group will primarily assist people who have little or no debt and are already well prepared for retirement.  People with debt should retire debt rather than increase contributions to their 401(k) because one of the worse financial outcomes is to enter retirement with outstanding debt and all financial asset inside a 401(k) plan.  

Comment Three:  It seems unusual to require catch-up contributions near retirement be made in Roth rather than conventional accounts.  I generally favor the use of Roth accounts instead of conventional account, but Roth contributions are most effective for young workers in low marginal tax brackets, not older workers nearing retirement.

Comment Four:  The proposal to increase the age of mandatory RMDs will benefit wealthier households capable of living by consuming from assets outside their retirement plans.  Less wealthy households will disburse their retirement assets earlier in life out of necessity. Households that delay distributions from their retirement plan because of the change in RMD rules will have to increase distributions and could pay higher tax later in life.

Comment Five:  The Secure Act 2.0 provision allowing employer matching contributions for workers making student debt payments will have a limited impact on savings incentives for most student borrowers and is not the most effective way to assist student borrowers.  Many young adults with student debt work at firms that either do not offer 401(k) firms or offer a plan without an employer match.  Young student borrowers that switch jobs prior to the employer contribution vesting will lose the contribution.  A rule allowing employer matching contributions into an IRA and allowing matching contributions for student debt payments would assist more student borrowers than the student-debt provision in Secure Act 2.0.

Comment Six:  The goal of increasing retirement savings for part-time workers would be better achieved by automatic IRA contributions instead of expanded 401(K) eligibility and automatic 401(k) contributions.   It would also be useful to change IRA rules to allow employer contributions into an IRA.   The participation of part-time workers into 401(k) plans will increase 401(k) fees.   Workers that use IRAs are free to select a low-cost highly diversified fund.

Comment Seven:  The goal of increasing retirement saving for workers at small firms that do not have a 401(K) plan would be better achieved through automatic enrollment in IRAS than by the creation of streamlined 401(k) plans.  Workers could seek out a low-cost IRA and are less likely to close the IRA than the 401(k) when they move to a new position. Also, the streamlined 401(K) option created by the Carper/Barrasso bill could displace more comprehensive 401(k) plans both among new and existing firms.  

Comment Eight: Many people currently withdraw a substantial portion of their retirement funds prior to retirement.  Around 60 percent of young adults have borrowed from their 401(k) plan.  It is unclear how the Murray/Burr bill will facilitate savings for emergencies while increasing saving for retirement.  One way to address this tradeoff is to encourage a shift in retirement savings from conventional accounts to Roth accounts.  Roth accounts allow disbursements of contributions without penalty and tax prior to age 59 ½ while conventional accounts apply penalty and taxes to all early disbursements.

Current retirement plan rules allow the worker to disburse all funds at any age if she is willing to pay an additional tax and penalty.  My view is any expansion of the use of retirement funds for emergencies without penalty or tax should be combined with a rule change that requires a portion of funds contributed to the retirement plan remain allocated for use after age 59 ½. 

Comment Nine:  An alternative to the Murray/Burr proposal for the purchase of annuities in a retirement plan is a program, like Oregon Saves, that allows workers to contribute to the state pension fund.  The Oregon Saves program also obviates the need for creation of retirement plans by small businesses.

Concluding Remark:  Proposals altering the retirement savings system currently in Congress favor the use of high-fee 401(k) plans over low-fee IRAs. The primary beneficiary of these changes is Wall Street, not households experiencing the most difficult saving for retirement.

The comments presented here support the view that rules allowing employer contributions into IRAs and automatic enrollment into IRAs instead of 401(k) plans are superior to the enlarged role of 401(K) plan offered by current Congressional proposals.   

Authors Note:  David Bernstein recently published a 2024 Health Care Reform Proposal, which differs substantially from the ACA modifications favored by the Biden Administration and the Medicare for All proposal favored by the progressives.  The program outlined in this paper available on Kindle would bring the United States close to universal coverage and would substantially improve health and financial outcomes for people with low-cost health insurance policies.

Appeasing Russia Will Fail

Many pundits and analysts, including Jeffrey Sachs in a recent CNN article, are arguing against sanctions and weapons for Ukraine. Sachs favors a peace deal that ends NATO growth and creates a neutral Ukraine. This unenforceable approach would lead to further aggression against Ukraine and neighboring states.


Introduction:

In a recent CNN opinion peace, Jeffrey Sachs argues against sanctions and military support for Ukraine and for a quick peace deal.

The two-pronged US strategy, to help Ukraine overcome the Russian invasion by imposing tough sanctions and by supplying Ukraine’s military with sophisticated armaments, is likely to fall short. What is needed is a peace deal, which may be within reach. Yet to reach a deal, the United States will have to compromise on NATO, something Washington has so far rejected.

The specious arguments used by Sachs to advance this policy will lead to a future of war and genocide.  This approach will not alleviate the economic issues from the invasion.

Analysis:

Russia is committing war crimes in Ukraine and Putin is supportive of these actions. Putin does not believe Ukraine is a real state. How can Ukraine make a deal with Russia given Putin’s stated aim and current actions?

Russia could sign a peace deal, regroup, and reinvade.  The starting part for the new invasion would the parts of Ukraine that Ukraine cedes to Russia, a lot closer to Kyiv.  The best way to deter Russia from a future invasion is admitting Ukraine into NATO, the very action Sachs opposes.

Sachs correctly points out there are holes in sanctions. Sanctions on imports are not the only tool needed to combat Russian aggression.  The west can end all scientific cooperation including space, all travel and tourism to Russia, remove Russia from the WTO, ban Russians from international sporting and cultural events, and stop exporting technology to Russia.

Sachs pointed out that countries representing most of the world’s population did not vote for resolutions against Russia.   The countries that are not unequivocally opposed to Russian aggression have a relatively small percent of the world’s GDP and the GDP share may be a better measure of likely effectiveness of sanctions.  Countries that have not supported resolutions condemning Russia do not parrot the Russian line on the invasion and may come around with more evidence of atrocities.

Sanctions and disruptions from the war are impacting the world economy.  The war is preventing planting of grain, and Russian ships are preventing the delivery of Ukrainian grain to the world.  Russia could control around 30 percent of the world grain supply if it takes control of part of Ukraine.  Any peace deal should be constructed so Russia does not have more power over the world’s food supply.

Western nations need to plant more grain. The United States should end the ethanol mandate and covert corn farms to wheat farms.  See the U.S. subsidy that powers Putin.

Sachs points out that higher oil and grain prices could increase export revenue to Russia in the short term despite sanctions.  The Ukrainians may have to disrupt Russian exports at some point.  The west could ration and substantially reduce consumption of gas perhaps through a COVID type shut down.

Sachs seems to accept Putin’s concerns about NATO expansion.  NATO nations have not invaded either the Soviet Union or Russia.  There are numerous examples of the Soviet Union and Russia invading its neighbors.  

Sach’s deal with Russia is outlined in the second to last paragraph of his essay.

“The key step is for the US, NATO allies and Ukraine to make clear that NATO will not enlarge into Ukraine as long as Russia stops the war and leaves Ukraine. The countries aligned with Putin, and those choosing neither side, would then say to Putin that since he has stopped NATO’s enlargement, it’s now time for Russia to leave the battlefield and return home. Of course, negotiations might fail if Russia’s demands remain unacceptable. But we should at least try, and indeed try very hard, to see whether peace can be achieved through Ukraine’s neutrality backed by international guarantees.”

It seems a bit late for this deal.  Russia has already killed a lot of civilians and seized a lot of land.  What type if international guarantees would support Ukraine’s existence?  The Budapest memo?  That worked out so well.

The end of the war does not end the problem.  The peace must be enforced somehow.  Ukraine must be rebuilt.  Western funds should not contribute to rebuilding areas seized by Russia.  Any peace that does not end in a defeat by Russia will result in even more aggression.

David Bernstein is an economist living in Denver Colorado.  He is the author of A 2024 Health Care Reform Proposal.  This plan available on Kindle will move the United States close to universal health coverage, would enable continuous coverage during periods of unemployment and would improve health and financial outcomes for people with low-cost insurance coverage. 

Health Policy Memos: Elimination of short-term health plans

People with short-term health plans often experience catastrophic financial losses despite their insurance coverage. Alternative insurance plans and cost-sharing arrangements that reduce insurance premiums and provide more complete financial protection are considered here.

Background on Short-Term Health Plans:

A short-term health plan is a health plan that does not provide the essential minimum benefits offered by ACA compliant health plans on state exchanges or through employers.  

Unlike state-exchange and employer-based health plans, insurance companies can refuse to sell short-term plans to people with pre-existing conditions.

Also, unlike state-exchange and employer-based health plans insurance companies can base premiums on a person’s health status.

recent report by the Democratic staff of the House Energy and Commerce Committee and a paper by the Kaiser Family Foundation paper  identify several general problems with short-term health plans. These problems include:

  • Denials of benefits for life-saving procedures including treatments for cancer and heart surgery.
  • Strict limits on reimbursements for hospital stays, surgeries and for doctors. Limits include $500 per policy period for doctor visits, a $1,000 daily limit on hospital reimbursements, a $500 maximum for emergency services, and a $2,500 maximum for surgery services. 
  • Denial of benefits by requiring extensive documentation after a procedure has been conducted,
  • Rescission of coverage
  • Lack of automatic renewability.  By contrast, since 1996 federal law guaranteed renewability for all other individual health insurance plans.
  • Existence of annual and lifetime benefit caps. Caps on other plans are prohibited by the ACA. 
  • No annual cap on cost sharing, another departure from ACA rules.
  • No minimum loss ratio.  ACA plans have a minimum loss ratio of 80 percent.  

second paper by the Kaiser Family Foundation discusses the extent to which short-term health plans covered mental health services, substance abuse, outpatient prescription drugs and maternity care.  The paper found that:

  • 43 percent of plans lacked coverage for mental health services, 62 percent did not cover substance abuse, 71 percent did not cover out-patient prescription drugs and no plans covered maternity care. In seven states all available short-term health plans lacked coverage in all categories.

An issue brief written by IHPI concludes increased use of short-term health plans will result in increased coverage gaps for pregnant women.

The literature provides numerous examples of people with short-term health plans being responsible for large bills despite ostensibly having insurance.

  • The report by the Energy and Commerce committee describes several situations. In one a patient received a $14,000 bill for two-day hospital stay for pneumonia.  In another the short-term policy only paid $7,000 on a $35,000 bill for an emergency procedure. 
  • CBPP paper citing work by the American Cancer Society Action Network found that a person with a short-term health plan diagnosed with breast cancer would pay $40,000 to $60,000 out-of-pocket compared to less than $8,000 for a person with an ACA marketplace plan.

Are short-term health plans beneficial?

Most economists oppose government restrictions on financial products that leave low-income people exposed to substantial financial risk.  This laissez-faire attitude resulted in the use of subprime mortgages large levels of mortgage defaults and a catastrophic financial collapse.   

Most economists also do not oppose the use of short-term health plans based on their view that some insurance is better than no insurance. 

My view is that many people with short term health insurance plans including the person with a $60,000 out-of-pocket bill for breast cancer and the person with a $25,000 bill for emergency room services are de-facto uninsured.

Short-term health plans with arbitrary benefit packages and large gaps of coverage do not effectively limit household financial risk.  By contrast, high deductible health plans HDHPs, discussed here, require considerable cost sharing do cap total risk.  

The expansion of short-term health plans facilitated by the Trump Administration executive order does more than unnecessarily increase financial risk for households that choose short-term health plans.  The plans will attract younger healthy adults who receive pay all or most of their state exchange health insurance premium.  (The premium tax credit for state exchange health insurance is age-rated leaving many middle-income young adults are responsible for their entire premium.  Go here for a discussion of this issue.) 

Short term health plans are a bad product that creates additional problems for society.

The growth of short-term policies creates unmanageable risk for policy holders, creates coverage gaps for women who get pregnant, and weakens state-exchange markets.

Alternatives to short-term health plans:

A strong case can be made for prohibiting insurance contracts with vague arbitrary features or contracts that often fail to protect individuals from catastrophic losses.  Such a prohibition would increase the number of uninsured but decrease the number of people with insurance who are de-facto without protection.   

The most effective way to reduce use and problems from short-term health plans is to create viable lower-cost comprehensive alternatives to short-term health plans.

A lower-cost catastrophic but comprehensive option:

A proposal offered by Senator Alexander and Senator Murray for a  new catastrophic health plan offered on state exchanges would substantially reduce premiums and would provide much better coverage than short-term plans.  The catastrophic option would have high deductibles and higher cost sharing but would not allow for the arbitrary benefit exclusions that characterize short-term plans.    Catastrophic plans of this type could be improved by the expansion in health savings accounts proposed here.

Reinsurance or Medicaid above an annual cap.

Short term health plans reduce costs by imposing annual and lifetime limits on reimbursed health expenditures; however, the annual limits eliminate access to health services and increase financial risk for people with health expenditures above the limit.   

One way to keep premium reductions achieved from annual and lifetime reimbursement limits and still protect patients that reach the limit is to allow access to Medicaid once the limit on the health plan is reached. This type of cost-sharing arrangement was first described in this SSRN paper.   

It should be possible for the Biden Administration and certain states to implement cost sharing through a Medicaid waiver, which allows states to use Medicaid funds to pay health expenditures for people with health expenditures over their annual cap.   

A Public Option:

Another way to eliminate inadequate short-term health insurance plans is the creation of a public option through increased access to Medicaid or Medicare.   

Existing public options provide comprehensive health insurance and quick reimbursements to health care providers.  Medicaid and Medicare reimbursement rates are low compared to many private insurance plans and some providers do not accept Medicaid or Medicare.  

There is also concern that a widely available public option could crowd-out private insurance.  However, the combination of a public option and a more generous subsidy for health savings account contributions would likely not crowd out private insurance if the HSA subsidies were only available for people with private insurance.  

Concluding Remarks:

Most economists with their pro-market even laissez-faire approach do not support prohibitions against less than complete financial products.   These economists did not appreciate the damage done by the growth of the subprime mortgage market and do not currently appear to understand problems created by short-term health insurance plans.   

Short-term health plans undermine state-exchange insurance markets and have crowded out proposals for the creation of more viable low-cost insurance options.  The adage “some insurance is better than no insurance” is glib advice when arbitrary benefits do not cover serious health problems and the cheap insurance product undermines the market for comprehensive insurance.

Health Policy Memos: Expanded coverage for medically necessary out-of-network procedures

The No-Surprises-Act provides some protections to people receiving surprise medical bills from consumers inadvertently receiving out-of-network care but does not cover many medically necessary out-of-network procedures even when the procedure is not offered in a narrow medical network. An expansion of the No-Surprises Act and some additional federal subsidies for medically necessary out-of-network procedures would alleviate problems with narrow network health plans in a cost-efficient manner.

Background on the No-Surprises Act:

The No-Surprises Act provides protections against surprise medical bills, expenditures on health services inadvertently received out of network.  

The scope of the law is extremely limited because the definition of a surprise medical bill is narrow, and many medically necessary out-of-pocket procedures remain uncovered or subject to higher cost-sharing terms even when the procedures are not offered inside a network.  

The No-Surprises Act does not cover many medically necessary health care procedures that may not be offered or covered by a narrow-network health care plan.

Surprise medical bills usually occur when patients receive care from an out-of-network emergency room or are admitted to a hospital after the emergency room visit.

Other surprise medical bills include services performed by out-of-network providers who work at in-network hospitals.

The No-Surprises Act pertains to ambulance for air transportation but not for transportation for ambulance by ground transportation.

An article by the Kaiser Family Foundation describes the provisions of the No-Surprise Act. The No-Surprises Act does the following:

  • Requires insurance companies cover out-of-network claims for surprise medical bills and apply in-network cost sharing arrangements. 
  • Limits charges on surprise medical bills to the in-network cost sharing amount.
  • Creates negotiations and independent dispute resolution between the insurance firm and the provider on the remaining bill for the surprise medical bill.
  • Allows some providers to request patients waive their rights under the No Surprises Law.
  • Requires both the insurance plan and the provider to identify health expenditures that are surprise bills.  

The law does not guarantee the automatic elimination of all surprise medical bills. If a medical bill is not flagged as a surprise medical bill the patient must apply for protections under the act.  Go here for a CNBC discussion of the appeals process.

The No-Surprises Act pertains both to PPOs that require higher cost sharing for out-of-network health services and to HMOs that do not provide any compensation for out-of-network services.

Analysis of limits of Narrow-Network Health Plans:

The passage of the Affordable Care Act (ACA) created a trend towards the greater use of narrow-provider health plans, especially on the plans sold on state-exchange markets. One study found narrow plan substantially reduced both insurance premiums and federal subsidies on insurance premiums.  

However, the use of narrow network plans instead of broad network plans creates financial risks and impedes access to health care 

  • One study published in JAMA found that 15 percent of plans were deficient in at least one specialty.
  • One study published by the Journal of Oncology found that narrow-network health plans were more than twice as likely to exclude doctors affiliated with the top cancer hospitals.
  • One study published in Health Affairs found that narrow health plans had substantially fewer mental health providers and that the lack of coverage would likely lead to insufficient coverage for mental health conditions.

The growth of narrow-network plans may increase disparity between access to health care in rural versus urban or suburban areas.

Potential policy solutions to issues cause by narrow-provider networks:

Narrow-network health plans reduce costs and premiums but also result in reduced access to health care when the narrow network does not provide a service or higher costs when the patient obtains services outside of her network.   This paper discusses policies that would expand access to service to out-of-network medically necessary health care procedures when the services are not available in a narrow network, while retaining the cost efficiencies achieved by the narrow network plans.

This article by the USC-Brookings Schaefer Initiative for Health Policy looks at two policy initiatives – the regulation of the adequacy of provider networks and dispute resolution measures similar to those in the No-Surprises Act.

A network adequacy regulation might be based on maximum travel time to distance to see a specialist, the ratio of provider to enrollees, or the maximum appointment wait time.  

These regulations are insufficient for highly specialized health care procedures.   Many surgeries and procedure are best done by doctors with narrow skills including cardiac surgeons and doctors, pediatric surgeons, and eye surgeons.  It would be extremely difficult to create a regulatory procedure requiring inclusion of narrow specialists in each network, especially in small markets when few specialists were available.

Network adequacy regulation does not facilitate access to top cancer hospitals which are often excluded from narrow-network plans.

The Brookings paper favors a dispute resolutions procedure to allow for access to outside specialists for out-of-network services when medically necessary.  The dispute resolution process for medically necessary out-of-network procedures would be patterned after the dispute resolution procedures established in the No Surprises Act.

Both the proposed network adequacy regulations and the expanded dispute resolution procedures would increase costs for narrow network health plans.

An alternative or additional approach used to facilitate access to medically necessary out-of-network health care procedures involves a federal subsidy for medically necessary out-of-network procedures.   

The new subsidy would increase demand for less expensive narrow health care plan and this shift toward narrow plans would reduce federal subsidies on ACA state exchange health insurance thereby offsetting part of the cost of the subsidy.   The new subsidy could involve reinsurance compensating insurance companies for high-cost health care cases.

Concluding Remarks

Narrow-network health plans do a good job in reducing health expenditures, premiums, and federal subsidies on premiums; however, these plans deny many households access to medically necessary out-of-network health.  Expansion of the dispute resolutions measures created by the No-Surprise-Act and new federal subsidies for medically necessary out-of-network health procedures could mitigate some of the problems associated with narrow-network health plans and expand their use.

Health Policy Memos: Improving Outcomes from Health Savings Accounts and High Deductible Health Plans

People using high-deductible health plans (HDHPs) are often unable to fund a health savings account (HSA), have substantial financial exposure, and often skip necessary medical procedures and regimens. This post explores proposals designed to reduce these problems.

Introduction:

High-Deductible Health Plans (HDHP) coupled with Health Savings Accounts (HSAs) are the only health plans offered by around 40 percent of employers. This combination can reduce premiums, provides a saving in taxes, incentivizes some people to save on health care, and creates a potential new source of savings for retirement.

This type of health insurance arrangement also creates health and financial tradeoffs, which are most severe for low-income and mid-income households.

  • HDHPs and HSAs often incentivize people to forego necessary health care procedures and regimens.  Studies have shown financial factors result in a lower utilization of prescription drugs for chronic health conditions,
  • The existence of HSAs to fund high deductibles causes some people to choose between funding their HSA or funding their 401(k) plan,
  • Some young healthy adults paying the full premium on their health plan may choose to go uninsured or may choose a short-term health plan creating financial risk.

These problems can be rectified by changes in the rules governing HSAs and HDHPs and the creation of additional financial incentives.

Potential Policy Responses:

Three policy changes designed to mitigate problems associated with HDHPs and HSAs are proposed and discussed.  Potential modifications include:

  • A refundable tax credit for HSA contributions, 
  • Expanded eligibility for HSA contributions for additional cost-sharing insurance plans,
  • Regulations expanding pre-deductible insurance payments for some prescription drugs 

These potential modifications are discussed in turn.

Tax Credit:

The current HSA subsidy allowing deductibility of contributions is more generous for households with high marginal tax rates.  There are multiple ways to modify the tax treatment of HSA contributions to augment and stimulate contributions to HSA plans by lower-income or middle-income households.

A refundable tax credit of $2,000 for HSA contributions up to $2,000 combined with the elimination of the tax-deductibility of HSA contributions would eliminate the disparity in benefits from HSAs across income groups.   The tax credit would cause other beneficial outcomes:

  • The increase in HSA contributions for low-income households would assist people most likely to have payment problems due to medical expenses.
  • The tax credit, which is only available for people with comprehensive private insurance, could reduce the number of people choosing to go uninsured or choosing Medicaid over private insurance. 
  • The proposed tax credit, if it did not vary with income, would not discourage work.

The economic impacts of the final tax credit depend on the details of the proposal and could impact and be impacted by other tax credits in existence and under consideration.

A tax credit for HSA contributions could be enacted through by majority vote through the tax reconciliation process.

Alteration of Eligibility Requirement for HSA Contributions:

Current tax law restricts HSA contributions to people with a qualified HDHP.  The proposed change to tax law would allow HSA contributions for people with high-coinsurance rates even if the plan had a modest deductible.

Health plans with high coinsurance rates are an effective and equitable cost-sharing mechanism.

People with high coinsurance rates and low deductible retain a partial incentive to economize on health expenditures even after the deductible has been met.   By contrast, people with a high deductible and a 0% coinsurance rate lose the incentive to economize on health as soon as the deductible is met. 

High deductible health plans do have one important advantage.   High deductibles are a highly effective way to reduce premiums and generally the high-deductible plan has a lower premium than the high-coinsurance-rate plan.

A high deductible health plan makes it extremely difficult to pay for health services until the deductible is met leading to possible bad health outcomes.

The choice of health insurance plan often depends on who pays the premium.  Households gravitate towards the more expensive plan if premiums are paid by an employer or through a government subsidy and the less expensive plan when they make premium payments.

This change like the proposed premium tax credit could be enacted by majority vote through the tax reconciliation process.   

Modification of regulations on HDHP reimbursement for some prescription drugs:

There is substantially variability in health insurance reimbursements for prescription drugs.

Some comprehensive low-deductible health plans make partial reimbursements for certain medicines even prior to the customer meeting her deductible.

Many high-deductible health plans do not reimburse any prescription drug costs until health expenditures reach the deductible.

The lack of reimbursement for prescription drugs until the deductible is satisfied causes some households to forego prescribe medicines.  The failure to take prescribed medicines for chronic conditions like diabetes can lead to kidney problems, eye problems, amputation, and heart issues.

A regulation classifying certain medicines as preventive medicines that are exempt from high deductibles under HDHP would reduce incentives for people with chronic health conditions to forego necessary prescriptions. The Department of Health and Human Services could mandate coverage for some prescriptions treating chronic diseases as a preventive method under current regulations.   

Financial Impacts:

The proposed modifications to HSA and HDHP rules impact the premiums paid for health insurance plans, tax revenue received by the government, and taxes paid by households.

The proposed tax credit for HSA contributions would increase demand for HDHPs by lower-income lower-marginal-tax rate households.  The shift in preferences towards HDHPs would reduce premiums and reduce the tax expenditures for insurance purchases in both the state-exchange and employer-based markets.  

The cost to the Treasury of the new tax credit for HSA contributions would be partially offset by a decrease in Treasury subsidies on health insurance premiums.  The elimination of deductibility of HSA contributions would also partially offset costs stemming from the new tax credit.

The proposed changes in rules governing insurance company reimbursements for drug payments would result in a modest increase in insurance premiums for HDHPs.  The change might increase demand for HDHPs, which could lower average premium payments since HDHPs would still be less expensive than low deductible plans.

Concluding Remarks:

The proposed changes to rules governing HSAs and HDHPs are beneficial for several reasons. The changes reduce financial risks associated with high out-of-pocket costs, reduce incentives for people to forego necessary medical treatments and may incentivize some health people to retain comprehensive health insurance.

The plans proposed here reduce out-of-pocket costs both for people insured in state-exchange and employer-based insurance markets.  By contrast, many of the reforms implemented by the Biden Administration and by Congress, including changes to the premium tax credit, the use of gold plans as a default, and cost-sharing subsidies only address problems in the state-exchange market.

Promotion for book on centrist policies on student debt, pensions and health care.

Ideas on how pragmatic, politically feasible centrist policies can make a real difference.

Brief Discussion of Centrist Policies in a Polarized World:

Free Monday February 28 and Tuesday March 1, 2022.

Many Americans are experiencing increased financial stress even though the economy has performed well in the last several years. Student debt levels and the number of overextended borrowers continue to increase. Health Insurance premiums in state exchange health insurance markets are unstable and many state exchange markets have few providers. People are paying more for out-of-pocket for health care. High debt levels and the lack of funds for basic emergencies have persuaded many Americans to delay or reduce contributions to their retirement savings plan. 

The policy debates on student debt, health care, and retirement income in Washington follow a similar pattern. Conservatives offer a free market approach – reduction of financial assistance to student borrowers, repeal of the Affordable Care Act, and private accounts inside Social Security. Liberals offer expanded government programs – free or debt-free colleges, Medicare for all, and expansion of Social Security. In most cases, the conservative proposals would increase household financial risk while the liberal proposals are often unaffordable and poorly designed.  This book analyzes and compares conservative and liberal approaches to student debt, health care, and retirement income. 

The book also outlines a centrist economically feasible policy agenda in each area, with the goal of reducing household financial risk.  The centrist agenda on college costs and student debt targets financial assistance and debt relief to students and borrowers in greatest need.  The centrist health care agenda fixes problems with the Affordable Care Act and reduces distortions caused by high out-of-pocket costs and the most expensive health care cases. The centrist agenda seeks to expand health insurance and retirement benefits for contractors and workers at firms without employer-based benefit plans. The centrist agenda changes rules governing 401(k) plans and IRAs to facilitate increased savings by people with high debt levels and very little cash saved for emergencies. The centrist agenda includes an honest discussion on Social Security, which will likely infuriate both the left and the right.

The case for broad economic penalties on Russia

Targeted sanctions have not deterred the Russian invasion of Ukraine. Broader economic penalties outlined here – including a 100 percent tariff on all exports from Russia, the prohibition of all foreign direct investment, the eviction of Russia from the WTO, and severe restrictions on travel to Russia — are needed.

Introduction

In 1980, I had the privilege of asking Nobel Prize laureate Milton Friedman a question.

I asked why it was appropriate to prohibit virtually all trade with Communist countries while allowing substantial trade with non-communist authoritarian regimes.  

His response — that political change was possible in some authoritarian countries but impossible in countries that controlled the means or production — must be reconsidered.  

The Russian aggression in Ukraine teaches us that combatting communism is not the only reason for broad prohibitions against trade. 

Sanctions targeted towards the Russian elite is a grossly insufficient response to the current aggression.  

Money is fungible.   All funds obtained by Russia from exports, foreign direct investment, and tourism fuel for this invasion.

Analysis:

The Russian economy despite the size of the country is relatively small 

  • GDP $1.48 trillion
  • Exports around $332 billion, around 22 percent of GDP. 
  • Around $10.8 billion of these exports are purchased by the United States.

A decision by all countries sympathetic to Ukraine to put a 100 percent tariff on all exports from Russia would have a major impact on the Russian economy.  The tariffs can be phased in by some countries that are dependent on Russian oil and gas but countries that are not dependent on Russia for energy can implement the tariffs immediately.  

Russia entered the World Trade Organization on August of 2012 and was not expelled because of the 2014 invasion of Crimea. 

Ironically, WTO advocates claim that the WTO helps promote peace.   Seriously, this was listed as the number one benefit of the WTO. This time around Russia should be expelled from the WTO. 

The Russian economy is still receiving positive net foreign direct investment from the rest of the world. Interestingly, the United States is tied with China as the third largest source of foreign direct investment into China. 

Several restrictions on foreign direct investment could be implemented.  President Biden can probably immediately prohibit all foreign direct investment to Russia from the United States without legislation from Congress.  The President has broad authority with respect to foreign affairs and national security.  

Sanctions could be imposed on countries that continue investing in Russia.

Around 24.6 million foreigners visited Russia in 2018.  Foreign visitors contributed 3.8 percent to Russian Gross Value (GVA) added.  The Trump Administration imposed several restrictions on travel to Cuba.  The Biden Administration and America’s allies should now do the same for Russia.

Concluding Remarks:  Putin has prepared for the case of targeted sanctions by building up international reserves.  He has not prepared for large tariffs on all exports from Russia, the elimination of most foreign direct investment, the eviction of Russia from the WTO and the loss of funds from tourism.

Student Debt Proposal #4: Reducing tradeoff between retirement saving & student debt repayment

Reforms centered on increased use of Roth IRAs would better balance saving for retirement and student debt repayment than the Secure Act 2.0 reforms.

Introduction:   Tax and financial incentives are more generous for contributions to 401(k) plans than for the repayment of student debt.

  • Workers are allowed to to save untaxed dollars in a firm-sponsored retirement plan or an individual retirement account.
  • Firms can match employee contributions to the 401(k) plan. Two common 401(k) matching formulas are 50 percent of the dollar amount contributed by the employee up to 6.0 percent of the employee’s salary and 100 percent of contributions up to 3 percent of the employee’s salary. 
  • Student borrowers can deduct up to $2,500 of interest on student loans.  
  • The student loan tax deduction pertains exclusively to interest while the entire 401(k) or IRA contribution is exempt from taxes.
  • There are no matching contributions for student loan repayment.

The decision to prioritize 401(k) contributions over student debt repayment does not always work out well as discussed in a previous post.  Potential consequences include:

  • Higher total loan payments associated with selection of longer loan maturities.
  • Higher borrowing costs stemming from higher debt levels and lower credit ratings.
  • Early disbursements of 401(k) funds leading to penalty and tax payments.
  • Increased likelihood of having debt obligations in retirement.

Student borrowers who quickly repay their loans would increase saving for retirement, realize lower borrowing costs, start the process of paying off their mortgage and would basically be much better off.  

There is general agreement that student debt significantly impedes saving for retirement by young households.  There is, however, no real consensus on how to fix this problem.

Proposed modifications to 401(K) plans in the SECURE Act 2.0, which would induce some student borrowers to begin saving through a 401(k) plan, don’t solve this problem. Expanded incentives for the use of Roth IRAs by student borrowers would be far more effective than expanded incentives for 401(k) contributions.

The Secure Act 2.0:

Wall Street favors and greatly benefits from incentives for 401(k) investing. The Secure Act 2.0 maintains the high priority attached to 401(k) saving and facilitates participation in 401(k) plans by student borrowers.  

The Secure Act 2.0 has the following features:

  • Requires automatic enrollment of employees in 401(k) plans
  • Requires all catchup contributions be designated as Roth contributions
  • Allows designation of matching contributions to a Roth account 
  • Delays mandatory distributions
  • Reduces waiting period for 401(K) contributions from 3 to 2 years for part-time workers.
  • Authorizes 401(k) matches for student borrowers even if they do not participate in a 401(k) plan.

The general purpose of the Secure Act 2.0 is to expand investments through 401(k) plans.

Many people who rely on high-cost 401(k) plans often end up paying a substantial portion of their savings to Wall Street. Go here for a discussion of the impact of 401(k) fees on retirement. 

The proposal only benefits student borrowers at firms with 401(k) plans, workers at firms with plans offering matching contributions, and workers eligible for the 401(k) plan.  

Many student borrowers will not benefit from this provision in Secure Act 2.0 including:

  • Self-employed workers and people employed by firms not offering a 401(k) plan.  Only 53 percent of small and mid-size firms offer a 401(k) plan.
  • People at firms with 401(k) plans that do not match employer contributions. Around 49 percent of all firms do not offer an employer match.
  • Employees who are ineligible for the firms-sponsored 401(k) plan.  Around 24 percent of firms require one year of service for entry to the firm-sponsored 401(k) plan.
  • Employees eschewing 401(k) plans due to  vesting requirements.

It is reasonable to anticipate that increased 401(k) contributions by young adults with student debt will fail to increase retirement wealth because, as evidenced by this CNBC article, around 60 percent of young adults end up raiding their retirement savings earlier in the career.

An Alternative Proposal, Incentives for Increased Use of Roth IRAs:

A more equitable and efficient way to balance the goal of saving for retirement with rapid repayment of student debt is through incentives to increase contributions to Roth IRAs instead of 401(k) plans

This could be accomplished by modifying the SECURE Act in the following fashion.

  • Mandate automatic contributions to Roth IRAs instead of automatic contributions to 401(k) plans 
  • Mandate automatic use of low-cost highly diversified IRAs unless person opts for a different investment strategy
  • Allow employers to match contributions to Roth IRAs or contributions to 401(k) plans
  • Allow employers to give employer matches to holders of Roth IRAs even if the student borrower does not contribute to the Roth IRA.
  • Prohibit distributions from investment income inside Roth IRAs prior to age 59 ½. 

A strong case can be made that many workers should maximize the use of Roth IRAs instead of traditional IRAs even under current law.

  • There are substantial tax savings in retirement from the use of Roth IRAs from two sources. First, the distribution for the Roth IRA is not taxed during retirement.  Second, the Roth distribution does not count towards the income limit leading to the taxation of Social Security benefits.  Households that rely primarily on Roth distributions in retirement often do not pay any tax on their Social Security benefits.
  • Distributions from Roth contributions prior to age 59 ½ are not subject to income tax or penalty.  This feature benefits young adults who tend to raid their account prior to retirement and pay taxes and penalty.
  • The Roth account does not allow 401(k) loans, a feature that causes people to distribute funds and even close the entire account prior to retirement. 

This proposal encourages student borrowers who are ready to save for retirement to choose a Roth IRA instead of a 401(k) plan.  The change will increase retirement saving for several reasons

  • Some firms without a firm-sponsored retirement plan may provide an employer match to an IRA because there should be no administrative costs imposed on the firm for this type of contribution
  • The automatic selection of a low-cost IRA will usually result in lower fees and higher returns compared to the default 401(k) option. 
  • The restriction on distributions from investment income until after age 59 ½ prevents people from distributing all retirement assets and closing the retirement plan prior to retirement. 
  • The IRA could receive matching funds from multiple employers.

Both the Secure Act 2.0 reforms and the alternative one presented here favor Roth accounts over traditional accounts.  The use of Roth accounts favors low-income student borrowers because their marginal tax rate and deduction for contributions to traditional 401(k) plans is low.  

The use of Roth accounts by low-income low-marginal-tax-rate workers facilitates diversion of some assets for debt repayment because the holder of the Roth requires less wealth to fund a sufficient retirement.  

Concluding Remarks:  Wall Street and financial advisors consistently advise their clients to prioritize 401(k) contributions over rapid repayment of student debt.  This approach is not leading to a secure financial life for many student borrowers who are paying more on student debt over their lifetime, incurring high borrowing costs on other loans, having trouble qualifying for a mortgage and raiding their 401(k) plan prior to retirement.   The use of Roth IRAs and rules allowing employers to match contributions into a Roth rather than contributions into a 401(k) will help student borrower better balance student debt repayment and retirement saving.

The more rapid repayment of student debt might also be facilitated by a partial discharge of student debt after around 60 on-time payments as describe in this post.

A list of student debt post presented here will be updated with new articles when available.