Category: Health Insurance

A Discussion of the Biden Health Care Plan

The health insurance debate in the United States has revolved around three perspectives — repeal and replace the ACA, modify and improve the ACA, and replace the existing system with a single payer plan.   Vice President Biden’s proposal aims to modify and improve the ACA.

I understand the view that the most politically feasible and sustainable way to improve health insurance outcomes in the United States is to build on and improve the ACA.  However, whether Vice President Biden’s actual plan would improve health insurance outcomes in the United States is a specific question requiring a thorough analysis of the detailed plan.  

This memo evaluates and proposes changes to the Biden health care plan.

Summary of the Biden Health Care Plan:

The Biden health plan seeks to expand health insurance coverage and reduce financial exposure for people with health coverage by modifying and extending the Affordable Care Act.  The plan is outlined in two papers, one on the Biden campaign web site and the other in a paper titled the Healthy American Program, written by economists at the Urban Institute.  

Specific elements of the Bide approach to health care reform outlined in these two papers include:

• Giving Americans a new choice, a public insurance option like Medicare,
• Increased value of tax credits to lower premiums for health plans sold on state exchanges,
• Expansion of coverage to low-income households,
• An expansion of the premium tax credit for the purchase of state exchange health insurance to middle-class families with income over 400 percent of the federal poverty line,
• An increase in the size of the premium tax credit for the purchase of state exchange health insurance for households with income less than 400 percent of the federal poverty line, 
• A reduction in out-of-pocket costs by linking premium tax credits for state exchange health insurance plans to the purchase of a gold health plan rather than a silver plan, 
• A potential elimination of the employer mandate requiring large employers to provide health insurance to their employees, (This proposal was mentioned in the Urban Institute paper but not mentioned in the Biden proposal.)
• A rule barring surprise medical bills for out-of-network services,

The Biden campaign also has several proposals to deal with other issues including high drug prices, the level of competition, and reproductive rights.  

The two central aspects of the Biden health care plan involve the addition of a public and changes to the tax code designed to make the purchase of health insurance more affordable.  The proposed public option and proposed tax change are inter-related.

Discussion of the proposed public option: 

The public option debate has two components – the use of existing public health programs like Medicaid and/or a new public option to provide health insurance to low-income adults and a new public option both for middle-income people who might not be able to afford health insurance or people who are dissatisfied with their current health insurance.  

The discussion of the public option for low-income households is a follow up to a provision in the ACA to expand Medicaid to all adults earning up to 138 percent of the federal poverty line.  The Medicaid expansion was originally intended to be a nationwide expansion; however, a 2012 Supreme Court ruling allowed states to opt out of the expansion.  The Medicaid expansion has been adopted by 38 states and the District of Columbia as of August 2020.  States that had not yet expanded Medicaid like Texas, Oklahoma and Georgia, tend to be states with the highest uninsured rates.  However, even in states which expanded Medicaid enrollment by low-income adults is not automatic and many remain uninsured.

Medicaid expansion has ramifications for state budgets and there is intense political resistance to Medicaid expansion in some states.   Also, Congress cannot force states to expand Medicaid because of the Supreme court ruling that this decision belonged to the states.  

The proposed Biden public option for low-income people requires states currently providing Medicaid expansion to continue to fund a premium-free public option.  It is not clear why states that have refused the Medicaid expansion should get a better financial deal than states that have expanded Medicaid.  

Enrollment into Medicaid is not automatic for all people without health insurance under the Biden plan.   Biden’s plan mentions automatic enrollment for people interacting with public schools and programs for low-income populations like SNAP.  Many states that have expanded Medicaid already use such enrollment procedures and still miss some low-income people who are eligible for Medicaid.  Moreover, the enrollment programs would be immediately cut once a new Administration that was not supportive of the new public option gained political power.   The reduction in resources for Medicaid enrollment is one reason for the increase in the number of uninsured during the Trump Administration. 

The Biden plan contains language indicating that all Americans should be allowed to choose a public option.

“Giving Americans a new choice a public health insurance option like Medicare.   If your insurance company isn’t doing right by you, you should have another better choice.  Whether you’re covered through your employer, buying your insurance on your own or going without coverage altogether, Biden will give you the choice to purchase a public health insurance option like Medicare.”

Issues related to the creation of a public option, which would be available to anyone who lacks health insurance regardless of income and anyone with health insurance who is unhappy with their current plan is a more complex issue than the expansion of health insurance exclusively for low-income people.   

There are many middle-income people with and without private health insurance who might benefit from a public option. Some young adults without employer-based health insurance cannot afford comprehensive health insurance on state exchanges.   Some comprehensive private health plans have deductibles and coinsurance rates that are substantially higher than public plans.   Some private short-term health plans do not cover essential health services and leave consumers with substantial medical bills.  Many middle-income people who either go uninsured or underinsure could improve their health care situations through access to an affordable public option.  

The largest potential problem with a public option is that it could crowd out private health insurance, especially private state exchange insurance.  Crowding out of private state exchange would reduce competition and choice in state exchange markets, which currently cover only around 6 percent of the working-age population.  Currently state-exchange markets in many counties only provide access to one or two private health care providers.  A robust widely available public option could further reduce competition in state exchange markets.   The actual impact on competition in state exchange markets would also be impacted by Biden’s proposed changes to market and tax rules.

The brief description of the Biden plan on the campaign web sited quoted above appears to give workers with employer-based insurance greater access to the public option than to private insurance on state exchanges.  The affordability rule prevents people with an offer of “affordable” health insurance from claiming health insurance the premium tax credit on state exchanges.   

The Biden plan does not specify the price of the public option for middle-income people choosing a public option over private plans.  A public option that is too inexpensive would likely crowd out private insurance and could lead to a single-payer plan.  A public option that is too expensive would not provide a reasonable alternative to inadequate private insurance.

Lower compensation rates to providers give public options a cost advantage over private insurers.   However, the lower compensation rates under the public option reduce health care provider income.  Some health care providers, especially specialists, refuse to serve patients with the public option.  Some rural hospitals in states that have not expanded Medicaid would receive greater revenue.  Some hospitals serving large Medicaid populations could also realize higher revenues if the compensation rate on the new public option was larger than the Medicaid compensation. 

The lower costs of the public option could reduce costs to the taxpayer if the alternative is the subsidization of private insurance.

The financial impact of a new public health option on both taxpayers and medical care providers depends on the details of the public option and the details of incentives for the purchase of private insurance.

Tax Issues:  

The Biden plan makes three major changes to the premium tax credit. It increases premium subsidies for people with income less than 400 percent of the federal poverty line. For example, the premium limit at the 400 percent threshold is reduced from 9.86% of income to 8.5% of income.  It eliminates the current income eligibility threshold for claiming the premium tax credit.  Under the Biden proposal, no person purchasing state exchange insurance would pay more than 8.5 % of their income on premiums regardless of their income.  It links the premium tax credit to a gold health plan with lower out-of-pocket costs than the silver health plan.

Currently, employers offer employer-based insurance to attract qualified workers.  The availability of a more generous state exchange health insurance policy, which is free to the employer, reduces the need for employers to offer this fringe benefit.  The more generous premium tax credit offered under the Biden proposal creates incentives for businesses to drop employer-based coverage.

The more generous premium tax credit increases the number of employees who are better off with state exchange health insurance than with employer-based insurance.  However, an ACA rule prohibiting employees at firms with an affordable health care option from claiming the premium tax credit will make some people worse off if the firm offers employer-based coverage.  

Whether a firm will drop employer-based health insurance coverage due to the more generous Biden premium tax credit depends on the proportion of workers who would be eligible for premium tax credits and the dollar value of premium subsidies employees of the firm will lose if the firm offers employer-based insurance to its employees.  The magnitude of the premium tax credit varies with the age, household income, and size of the household of workers in the firm.  Firms with a large share of workers eligible for large premium tax credits would still be able to hire workers and would reduce expenditures on worker compensation by dropping employer-based coverage and allowing their workers to claim the premium tax credit.

A firm with a mix of workers with varied ages and incomes has a difficult decision to make.  The decision to eliminate employer-based insurance could leave some workers worse off and other workers better off.  The changes to the premium tax credit proposed by Biden are more generous to older more established families seeking family coverage than to young adults seeking single coverage.   

This tradeoff can be illustrated by considering a two-worker firm.  One worker is 60 years old, has a has a family of four, and earns $75,000 per year.  The second worker is 30 years old, single with no dependents and makes $60,000 per year.  The first worker would likely receive a subsidy of $1,468.75 per year and pay $531.25 towards premiums on a state-exchange health insurance policy.   The second worker will pay $409 for coverage and will not receive any subsidy.

Proponents of the Biden plan argue that more generous premium tax credit will result in large savings for many households. Calculations supporting this view are based on a comparison of insurance premiums under the existing premium tax credit to insurance premiums under the new tax credit. This comparison is appropriate for people who are currently obtaining state exchange health insurance and will continue to do so after the tax change.   The comparison is not appropriate for people who will move from employer-based insurance to state exchange insurance because their employer eliminated employer-based coverage to allow their employees access to state exchange markets.  

Many employers currently pay all or a substantial share of health insurance for their employees.  The 2019 employer health insurance survey conducted by the Kaiser Family Foundation found the average employee share of employer-based insurance was 18 percent for self-coverage and 30% for family coverage.  The average employee share of an employer-based health insurance policy is $1,294 for single coverage and $6,173 for family coverage.  Some workers who currently work at firms that offer and highly subsidize health insurance to their employees will be worse off once the firm eliminates employer-based coverage.

The actual impact of the Biden proposal on the size of state-exchange and employer-based insurance markets depends on whether the final proposal includes the employer mandate. The employer mandate fines firms with more than 50 employees that do not provide health insurance to their employees.  The retention of the employer mandate would limit the reduction of employer-based insurance to firms with fewer than 50 employees.  The elimination of the employer mandate would allow larger employers with more than 50 full time employees to also eliminate employer-based coverage. 

The combination of a more generous employee tax credit and the elimination of the employer mandate could result in a large number of firms dropping employer-based health insurance coverage and increased costs for many households.

The Biden plan has several other tax implications.

Under current tax rules, the premium tax credit is entirely phased out once household income reaches 400 percent of the federal poverty line.  People who claim the advanced premium tax credit and end up earning more than 400 percent of the federal poverty line will lose the entire tax credit and end up with a large end of year tax bill.   The Biden plan, by removing the phase out of the tax credit at 400 percent of the federal poverty line eliminates unanticipated tax bills from this ACA feature. 

The current and proposed premium tax credit increases with income for people with household income below the 400 percent of the federal poverty line.  The marginal tax rate also increases with income.  The increase in both insurance costs and taxes for households with income below 400 percent of the poverty line penalizes and discourages work.

The Biden plan attempts to insulate households from high out-of-pocket costs by linking the premium tax credit to the cost of a more expensive gold plan instead of a silver plan.  This decision increases taxpayer expenditures on the premium tax credit.   The more generous premium tax credit would not assist many young adults earning around 400 percent of the federal poverty line who because of their income and age are not eligible for the premium tax credit.   Changes to rules governing health savings accounts and high-deductible health plans might be a more effective way to insulate households from out-of-pocket costs.

The decision to link the premium tax credit to a gold plan with lower deductibles and lower out-of-pocket costs than the silver plan will lead to higher premiums.   The cost of the higher premiums is borne by taxpayers when households can claim the premium tax credit and is borne by households for households that are not eligible for the premium tax credit.

Suggestions and Concluding Remarks:

The two key elements of the Biden health plan involve the creation of a public option and a more generous premium tax credit.   

The part of the plan involving the creation of a public option appears intentionally vague.  To better understand the economic impact of an expanded public option we need to have information on who is eligible to purchase the option and the cost of the option for different people.  The public option would be more effective if people without private coverage were automatically enrolled.   

Tax returns and tax penalties could be used to facilitate automatic enrollment.  Taxpayers without health insurance could be automatically enrolled in a public option. The cost of the public option would be loss of some of the taxpayer’s standard or itemized deduction with the actual amount linked to adjusted gross income.  Enrollment in the public option would be free for all low-income households without private health insurance coverage.  Individuals with income over a particular threshold (perhaps 200 percent of the federal poverty line) could choose a public health plan over a private health plan but would lose some or all deductions.

This loss of a tax deduction for enrollment in the public option would replace the individual mandate.

Currently, some people who cannot afford essential health plans on state exchanges often enroll in short-term health plans that do not provide adequate coverage.   Short-term health plans of this type could be eliminated and replaced with a public option paid for by a reduction in the taxpayer’s standard or itemized deduction.   Even if comprehensive health care reform cannot be immediately achieved it should be possible to quickly enact a reform eliminating current short-term health plans are replacing it with access to a public option. 

Around 156 million people currently obtain health insurance from their employer compared to around 11 million people obtaining health insurance from state exchanges.  Many current state exchange markets are small and served by only one or two insurance markets. The impact of the Biden proposal on the relative size of employer-based and state exchange health insurance markets is uncertain.  A public health insurance option would increase competition among private firms in state exchange markets.  Biden’s more generous premium tax credit could expand state exchange markets if it resulted in employers eliminating employer-based coverage.   

The Biden health plan does not address problem caused by the continued dominant role of employer-based insurance.   The current system results in employees routinely losing access to coverage if they become unemployed, an especially difficult problem now because of the loss of jobs from the COVID pandemic.  ACA rules governing access to affordable health care prevents employees with an offer of affordable health care from claiming a premium tax credit even when state exchange insurance would provide the household with a better outcome than employer-based coverage.   A merger of employer-based and state-exchange health insurance markets could in addition to solving these problems increase competition among private insurance firms.

The revised Biden plan should maintain the current linkage of the premium tax credit to silver plans rather than the more expensive gold plan.   The economic burden of high out-of-pocket costs to low-income households would be mitigated through other subsidies including a tax credit for contributions to health savings accounts.  This approach is likely to be less expensive to taxpayers and could provide greater benefit for people who are not eligible for the premium tax credit and must pay the entire health insurance premium.

A more detailed health insurance plan building on these observations will be available shortly.

David Bernstein, the author of this post an economist, retired from the U.S. Treasury in 2012 and is now living in Denver Colorado.  He is the author of a policy primer Defying Magnets:  Centrist Policies in a Polarized World. 

The 2017 Tax Reconciliation Act repealed fines for violating the individual mandate and created a set of legal and economic problems impacting health insurance markets. These issues must be dealt with by the new Administration and new Congress.

The ACA guaranteed access to health insurance for people with pre-existing conditions and mandated that health insurance companies not consider health status when setting health insurance rates.  The individual mandate discouraged healthy people from opting out of insurance coverage and quickly purchasing health insurance should their health status change.  

In the absence of the individual mandate, fewer healthy people would obtain health insurance and more people would take out short-term health plans leaving themselves underinsured.  The decision of healthy people to forego continuous comprehensive health insurance coverage increases insurance premiums and impacts the viability of state-exchange health insurance markets.  

Litigation now before the Supreme court, supported by a Trump Administration amicus brief, seeks to have all or part of the ACA declared unconstitutional based on the view that the individual mandate is central to the law.  The Trump Administration brief argues the individual mandate is essential for the successful implementation of guarantee-issue and community-rating rules and that these provisions impact other aspects of the law including the premium tax credit, annual and lifetime benefit caps, and the employer mandate. 

The ACA states that provisions of the law are severable and that the removal of one provision does not invalidate the rest of the law. However, the elimination of fines for the individual mandate alters the risk pool of people seeking health insurance, has a large impact on insurance firms, and was not the outcome desired by many in Congress when they voted for the ACA.  

The Supreme court could rule either way on this issue.   The chief justice pointed out that it was hard to argue Congress wanted to repeal the entire law when zeroing out the individual mandate because it did not vote on a repeal at that time.

A ruling by the Supreme court on behalf of the plaintiffs in this case would allow insurance companies to base insurance premiums on health status.  The actual regulatory authority over premiums might even revert to state governments. These changes would result in either the denial of insurance coverage or prohibitively expensive insurance for people with pre-existing conditions.   Insurance companies would also reimpose annual and lifetime caps on benefits.  

The Supreme Court need not have the final word on the future of the ACA.  The current legal challenge to the ACA occurred because of a provision in a tax reconciliation bill.   Senate rules allow tax reconciliation bills to be passed with a simple majority of the United States Senate.  Several potential modifications to a new tax reconciliation bill could eliminate legal challenges to the ACA and improve health insurance outcomes.

The simplest tax change ending the legal challenge to the ACA is to restore fines for violating the individual mandate. The current Republican majority opposes the mandate and any restoration of fines for violating the mandate could easily be repealed by a new Congress.

Restoring the individual mandate is not the only way to stabilize insurance markets and protect people with pre-existing conditions.  The replacement of the individual mandate with other automatic financial incentives and enrollment procedures could result in substantial improvements in health insurance outcomes in the United States.

The number of people forgoing health insurance coverage would be reduced by the expansion of the premium tax credit for the purchase of state exchange health insurance coverage and by the reduction of standard or itemized deductions for people without coverage.  These new financial incentives would reduce the number of people who forego insurance coverage or underinsure and obviate the need for an individual mandate.

The goal of financial penalties imposed on those who lack health insurance coverage is not to punish people without insurance but is to rather prevent healthy people from gaming the system by waiting until they become sick to obtain health insurance.  Financial penalties, like an automatic reduction in tax deductions for not having insurance coverage, could be linked to automatic enrollment in a public option. Wouldn’t the creation of a robust public option linked to a financial penalty for failure to obtain private insurance be an ironic outcome of a court case seeking to eliminate the entire ACA?  This outcome is not imminent given the current political situation.

President Trump discussed the possibility of protecting people with pre-existing conditions with an executive order should the Supreme Court rule the ACA unconstitutional.  It is hard to understand how an executive order protecting people with pre-existing conditions is constitutional while a law passed by Congress attempting to achieve the same goals is unconstitutional.

Attempts to fix problems with the ACA, deal with issues raised by repeal of the individual mandate and improve health care in the United States require action by the U.S. Senate.  Even if a few Republicans want to join Democrats and fix problems, solutions could be blocked by the majority leader.  The two runoff Senate elections in Georgia may determine the future of the ACA and the likelihood of progress on a range of issues.

David Bernstein is an economist who worked for the U.S. Treasury between 1988 and 2012.   He now resides in Denver Colorado with his family.   He is the author of Defying Magnets: Centrist Policies in a Polarized World and is working on a new book on health insurance issues.

Is it time to merge employer-based and state exchange insurance markets?

The Affordable Care Act (ACA) created state-exchange health insurance markets to allow access to health insurance for people with pre-existing conditions, link premiums to age instead of health status, and provide subsidies for low-income households.  The ACA also maintained long standing tax preferences provided to employer-based insurance and includes rules favoring employer-based coverage over state exchange coverage. Currently around 11 million Americans obtain health insurance from state exchanges compared to around 157 million who obtain health insurance from their employer.  

The continued dominance of employer-based health insurance has resulted in several problems leaving many Americans uninsured or underinsured.  Many of these problems could be fixed by changes to regulations and tax laws which have employers subsidize the purchase of health insurance on state exchanges and have the government, through a tax credit, share part of the cost of premium payments.   

Economists have long favored separating the provision of health insurance from employers.  Senator John McCain, in his 2008 campaign favored replacing all employer-based insurance with a market where all individuals would pay insurance premiums with a tax credit.  The McCain plan would have provided the same subsidy to all households, which is a fairer outcome than the current system where some employers pay most or all of their worker’s health insurance premium and some workers receive little or no premium subsidy.   However, people with employer-based coverage and generous subsidies like and support the current system and there was little support for abolishing the employer-based system.  

The idea discussed here allows for direct contributions from employers for health insurance on state exchanges rather than having each employer select and administer a health plan exclusively for its own employees.   The employer contribution towards health insurance premiums would be deductible to the employer and untaxed to the household as in current law.  Part of the cost of state exchange health insurance would be funded with an individual tax credit.  Also, low-income people without employer contributions for health insurance or with an employee contribution that did not cover the entire premium could continue to claim the existing premium tax credit available for the purchase of state exchange insurance. 

These revised rules alleviate several problems impacting participants in U.S. health insurance markets.   

The partial separation of the responsibility of providing health insurance to employers greatly benefits workers who become unemployed or experience a job transition.  Potential benefits from a system which keeps people enrolled in their health insurance plan after becoming unemployed are vividly demonstrated by the current economic situation.  A recent study by the Economic Policy Institute found that around 9.2 million people have lost their health insurance due to the COVID pandemic.  Many of these people will be unable to maintain their current health insurance coverage, either because COBRA, the program used to continue coverage is unaffordable to many newly unemployed individuals, or the coverage is unavailable in a bankruptcy situation.  

People with employer-based health insurance who become unemployed can maintain health insurance coverage through COBRA, however, they are responsible for the entire insurance premium plus a 2 percent administrative fee.   By contrast, people with state exchange health insurance could claim the premium tax credit if their income fell below 400 percent of the federal poverty line and any newly created tax credit as advocated in this proposal.  Also, there would be no administrative costs or fees for simply maintaining coverage.  

Employers experiencing a Chapter 11 bankruptcy often eliminate coverage or reduce subsidies.   Chapter 7 bankruptcy generally results in the termination of all employer-based health insurance including COBRA.  State exchange health insurance is unaffected by corporate bankruptcy.

The migration of all employer-subsidized health insurance to state exchanges would benefit all people going through a job transition, not just the unemployed. People switching jobs would maintain the same insurance plan and would not have to meet a new deductible in the middle of the year prior to receiving new insurance benefits.

Several other problems with the U.S. health insurance system could be alleviated through the merger of ACA and state exchange insurance markets and the creation of additional subsidies separate from the employer for insurance premiums. 

Current ACA rules prevent a person with an “affordable” offer of employer-based coverage from accepting a premium tax credit on state exchanges even if the state exchange plan would offer better value.   The affordability rule is complex and as written leads to unaffordable outcomes for many households seeking family coverage.  Some health care reform proposals include a provision changing the definition of affordable in the statute to reduce burdens on households needing family coverage.  The creation of a single health insurance market would allow households to accept premium tax credits and choose the appropriate health plan if the employer contribution did not result in the health plan being affordable.    

Currently, health insurance choices at many small firms are extremely limited.  In 2020, around 75 percent of small firms offering health insurance to their employees offered only one plan.   In addition, 42 percent of self-only coverage at health plans offered by small firms had a deductible exceeding $2,000.  A large single market serving all people with or without an employer subsidy would increase choices for many people with employer-based coverage, especially employees of small firms. 

Many state exchange markets are not highly competitive. A report by the Kaiser Family Foundation found in 2020 two state exchanges were served by only one insurance company and another fourteen state exchanges had two insurance companies offering products.  Research has revealed that health insurance plans offered on state exchanges often lack access to top hospitals or specialists.    A larger market serving people both with and without employer-based subsidies would increase competition among insurance firms and would offer consumer more and better choices.  

The large single market would include current protections for people with pre-existing conditions.  Current state exchange markets are adversely impacted by people who delay the purchase of health insurance until they become sick. The repeal of fines for the individual mandate has led to litigation, which could abolish protections against pre-existing conditions.   A new tax credit funding part of the cost of health insurance premiums, which would only be available to people with health insurance would serve the same function as an individual mandate.  Regardless, people foregoing health insurance because of cost would likely have a negligible impact on the larger combined market serving the entire working-age population than they currently do in the small state exchange markets.

Currently, many small firms with low-income workers cannot afford and do not provide employer-based coverage for their employees.   The proposed premium tax credit for part of the cost of premiums will could result in more small firms subsidizing health insurance for their employees.

The new tax credit for and existing premium tax credits would only be available for people obtaining health insurance on state exchanges and would not be available for people obtaining health insurance at firms that self-insure.  Firms that self-insure are exempt from government regulations including protections against surprise medical bills.  The use of state exchange markets rather than self-insurance could improve consumer protections for many households. 

The current premium tax credit phases out at 400 percent of the federal poverty (around $50,000 for a person seeking individual coverage) leaving many self-employed workers and workers without an offer of employer-based insurance without tax subsidies for the purchase of health insurance.   The proposed tax credit for part of the health insurance does not phase out with income guarantees that all people have a partial subsidy for the purchase of health insurance.   

The combination of marginal tax rates which increase with income and a premium tax credit that decreases with income results in both health insurance costs and taxes increasing with income for many middle-income people.  A new tax credit that does not phase out would reduce the premium tax credit and the increase in health insurance costs caused by people working more and earning more. 

The combination of a merger of state exchange and employer-based health insurance markets and new tax credits for the purchase of health insurance will not make health insurance affordable to all Americans.   The achievement of universal coverage requires more ambitious actions, perhaps the creation of a robust public option coupled with automatic enrollment for people who cannot afford private health insurance.  The merger of employer-based and state exchange markets and the additional tax credits proposed here will assist many middle-income people and is a good first step toward improving the affordable care act.

David Bernstein is a retired economist, formerly employed by the U.S. Treasury.   He resides in Denver Colorado with his family, is working on a book on health insurance policy, and is author of a policy primer Defying Magnets: Centrist Policies in a Polarized World.

The health insurance system in the United States is in crisis.  The Affordable Care Act (ACA) reduced the number of Americans without health insurance coverage but still left many households without coverage or substantially underinsured.   The number of uninsured started increasing as soon as President Trump replaced President Obama and more recently skyrocketed due to the economic showdown caused by the COVID epidemic.   The number of people with insurance who are underinsured and face substantial financial exposure is larger than ever and problems associated with inadequate health insurance coverage were largely unaffected by the enactment of the ACA.

This memo describes problems impacting health insurance coverage in the United States.  Its purpose is to lay the groundwork for a health care reform addressing these problems.

Barriers to Health Insurance Access for Low-Income People

The ACA reduced the number of people without health insurance coverage; however, many people, especially low-income people, remained uninsured for three reasons.  

First, enrollment and reenrollment in both Medicaid and state exchanges is not automatic leaving many people who are eligible for health insurance uninsured. This report by Brookings discusses potential advantages of automatic enrollment both for public and private insurance programs. 

Second, the ACA Medicaid expansion was reduced by a Supreme Court decision, which found the decision to expand Medicaid belonged to the states not the federal government.  The Medicaid expansion has been adopted by 38 states and the District of Columbia as of August 2020.  States that had not yet expanded Medicaid like Texas, Oklahoma and Georgia, tended to be states with the highest uninsured rates.  

Third, even in states expanding Medicaid the income threshold for Medicaid benefits is quite low (138 percent of the federal poverty line or $17,608 in most states) leaving many low-income adults ineligible for the program.

The limited scope of Medicaid coverage and the lack of a universal public option leaves many relatively low-income people without employer-based health insurance coverage dependent on the premium tax credit for state exchange health insurance.   The premium tax credit is expensive to taxpayers, especially when insuring older low-income households.  A lower cost pubic option automatically enrolling people without private insurance would be substantially less expensive to taxpayers than subsidies for premium tax credits.

Loss of Health Insurance Coverage During Periods of unemployment:

The overwhelming majority of working-age people and their dependents obtain their health insurance from their employer.  The attachment between health insurance and employment often results in disruptions in coverage during periods of unemployment.  A recent study by the Economic Policy Institute found that around 9.2 million people have lost their health insurance due to the COVID pandemic.  

Many people who become unemployed lose employer-based health insurance either because COBRA, the program used to continue coverage for people with employer-based policies, is unaffordable or unavailable in a bankruptcy situation.  

The most obvious way to reduce the loss of health insurance coverage for people who become unemployed is to reduce the link between employment and health insurance coverage by having employers subsidize health insurance coverage for employers through state exchanges rather than sponsor firm-specific health plans.

Inadequate subsidies for middle-income people lacking employer-based health insurance coverage:

Middle-income people without an offer of employer-based insurance are usually charged much higher health insurance premiums on state exchanges than comparable people with an offer of employer-based insurance.  The current premium tax credit phases out at 400 percent of the federal poverty line, around $50,000 for a single person seeking self-only coverage.  Premium estimates obtained from the Kaiser Family Foundation Health Insurance Marketplace Calculator reveal that a single adult age 35 making around $50,000 per year would pay $5,288, the full health insurance premium for a self-only policy.  By contrast, most firms offering employer-based health insurance pay a substantial share of the insurance premium.  Statistics presented by the Employer Benefits Survey conducted by the Kaiser Family foundation indicate the average employee share of premiums for a single-only policy was around $1,250 in 2019. 

President-elect Biden plans to increase the generosity of the premium tax credit and eliminate the income threshold governing eligibility for the premium tax credit. This proposal would, like the current premium tax credit, leave many young adult single workers paying their entire health insurance premium.  This problem could be resolved by altering the premium tax credit to assure a minimum payment for all workers regardless of income.    

New public benefits or programs have the incentive to partially or totally crowd out private benefits.  For example, the more generous premium subsidies offered under President-elect Biden’s plan create an incentive for some firms to eliminate their offers of employer-based insurance.  The crowd-out incentive could be reduced or eliminated by having the government and employers share premium costs for all workers.

Lack of access to premium tax credit for people with offer of affordable health insurance:

ACA rules do not permit people with an affordable health care offer to claim the premium tax credit for health insurance on state exchanges if they have an offer of affordable health insurance from their employer.  The affordability rule creates an incentive for some firms to drop employer-based coverage in order for other workers to claim the premium tax credit.  A decision to drop employer-based coverage would adversely impact people who don’t qualify for the premium tax credit or are only eligible for a small tax credit.

The IRS definition of affordable health insurance, based on the cost of insuring a single individual, results in family plans from employer-based insurance being unaffordable for many households.   Analysis presented by the Center on Budget and Policy Priorities found the affordability rule increases costs of employer-based health care relative to potential costs for state exchange health care for some low-income households.  

The solution to this problem favored by President-elect Biden and Congressional Democrats involves altering the definition of affordable health insurance.  My preferred approach involves having employers subsidize employer-based insurance on state exchanges and the creation of a partial tax credit for the purchase of health insurance for all workers.  These changes would allow all workers access to the health plan that best suits their needs and budget. 

Increased Deductibles and out-of-pocket health expenses for people with comprehensive health insurance coverage:

Around four of ten employers now only offer a health savings account with a high-deductible health plan.  The higher deductibles reduce insurance plan premiums and provide substantial tax advantages for some households.  However, the deductibility of contributions to health savings accounts is much more favorable to higher-income taxpayers.

High out-of-pocket expenses under high deductible health plans encourage many people to forgo necessary medical procedures or treatments, resulting in future health problems or costs.  Studies have shown the use of health savings accounts and high-deductible health plans substantially reduce use of prescription drugs for chronic diseases. The lack of adherence to prescription drug treatments has contributes to 125,000 deaths, at least 10 percent of hospitalizations, and increased annual health costs ranging from $100 billion to $289 billion.

President-elect Biden proposes to reduce adverse impacts of high-deductible health plans by linking the premium tax credit for the purchase of state exchange health insurance plans to a health plan that imposes lower out-of-pocket expenses on households than the current default state-exchange health plans.   This approach increases premiums for all households purchasing state exchange health insurance.   A less expensive and more efficient way to assist people with high out-of-pocket expenses is through subsidies targeting low-income people and for extra benefits for some prescription drug regimens.

The growth of short-term health plans:

Many middle-income people without an offer of employer-based health insurance and with income near the eligibility threshold for the premium tax credit often cannot afford a comprehensive health insurance.  A Trump Administration executive order expanded the use of short-term health plans and made it easier for middle-income young adults to underinsure.  

Short-term health plans with arbitrary benefit provisions, large deductibles, and no out-of-pocket limits create substantial financial exposure for people they cover. The rules governing the purchase of short-term health plans do not guarantee coverage for people with pre-existing conditions and allow for premiums to be based on the health of the individual applying for insurance.    Since most people seeking short-term health plans are healthy, a shift towards short term health plans results in higher premiums for state exchange plans covering essential benefits.

There have been a number of cases where people covered by short term health plans have, despite their coverage, been responsible for large medical bills. Short term health plans need to be outlawed and replaced with automatic enrollment in either a public health insurance option or a lower-cost private option that covers all essential medical needs.

The growth of narrow network plans and lack of access to top hospitals and networks:   

Many insurance plans have small provider networks and offer limited access to top hospitals and specialists.  The literature on this topic finds that health plans sold through state exchange markets are more likely to have small inadequate networks.   (See a study in JAMA which revealed one in seven ACA health plans did not provide access to in-network doctors in at least one specialty.  Also, see an Associated Press survey which found many top cancer hospitals do not accept people with state exchange coverage.)   The disproportionate number of narrow-network health plans in state exchange markets may be caused by the low number of firms serving many state-exchange markets.

Narrow network health plans with relatively few provider networks also exist in the employer-based market. Some small firms only offer a single possibly narrow-network health plan to their employees.

The problems of narrow networks in state-exchange health markets would be reduced if there were more competition and choice in state-exchange markets.   The level of competition in state exchange markets would be increased by combining state-exchange and employer-based health insurance markets where employers subsidize the purchase of health insurance for their employees on state exchange markets.

There may also have to be some regulation mandating insurance firms provide adequate medical networks because the prevalence of firms with inadequate networks is a factor contributing to surprise medical bill.  

Growth of surprise medical bills:

Surprise medical billing occurs when a person is treated in an in-network facility by a health care provider that is not inside the network.  Out-of-network medical bills can also occur when a person goes out of network because there are no available in-network options.

An analysis of surprise medical bills by the Kaiser Family Foundation, found 18 percent of emergency room visits and 16 percent of in-patient hospital stays involve at least one out-of-network charge.  Surprise medical billing was larger in rural areas and was also affected by differences in level of competition and state regulations. 

In theory, surprise medical billing could be a larger problem for HMOs than for fee-for-service insurance companies because HMOs are designed to provide all service inside their own exclusive network.  Some large HMOs like Kaiser are highly effective at working out these issues.

President-elect Biden as a candidate supported barring “health care providers from charging patients out-of-network rates when the patient doesn’t have control over which provider the patient sees.”   This approach does not reduce incentives for insurance companies to maintain insufficient provider networks or the incentive for specialists to join practices charging higher out-of-network fees.  An outright ban of surprise medical bills could result in the shortage of specialists in some rural hospitals.   Solutions to surprise medical billing probably require some regulation of insurance network adequacy and the creation of some incentives for doctors to refrain from charging high out-of-network prices.

Erosion of ACA during the Trump Administration:

The Trump Administration and the Republican Congress repeatedly voted to repeal the ACA and took several steps to undermine the law.  Effort to repeal the law failed but some Trump Administration actions have undermined the ACA.

The most notable success involved a provision of the 2017 Tax Reconciliation Act, which repealed fines for violating the individual mandate and created a set of legal and economic problems impacting health insurance markets.  The individual mandate discouraged healthy people from opting out of insurance coverage and quickly purchasing health insurance should their health status change.  In the absence of the individual mandate, fewer healthy people would obtain health insurance and more people would take out short-term health plans leaving themselves underinsured.  The decision of healthy people to forego continuous comprehensive health insurance coverage increases insurance premiums and impacts the viability of state-exchange health insurance markets.  The Supreme Court is considering a legal case seeking to invalidate part or all of the ACA because of the zeroing out of fines for the individual mandate.

The Trump Administration executive order allowing people to purchase short-term health plans increased demand for comprehensive health plans on state exchanges.  See discussion of short-term health plans above.

The Trump Administration reduced the budget for advertising and promoting enrollment in ACA state exchanges from $100 million to $10 million.  The best way to mitigate state exchanges from future budget cuts to enrollment efforts is to make the enrollment process automatic.

The Trump Administration cut off direct federal funding for cost sharing on state exchange health insurance plans, although, some cost sharing payments are still available.  Several court rulings have found that insurers are entitled to cost-sharing subsidies that were cut by the Trump Administration.   Future cost sharing payments would be better insulated from political pressures if the payments were made directly to households, perhaps through a tax credit for contributions to health savings accounts, than to insurance companies.

Several  Medicaid waivers approved by the Trump Administration increased premiums for Medicaid recipients, cut some Medicaid benefits and imposed a work requirement of eligibility for Medicaid.   The future role of state waivers to the Medicaid program could be reduced through creation of a public option entirely funded with federal funds.

The Trump Administration has cut risk-adjustment payments to insurers who took on a high number of high-cost patients.   Risk adjustment payments would be better insulated from political pressures if they were made directly to health care providers treating households incurring high health care costs than to insurance firms.

Concluding Remarks:

The ACA initially reduced the number of uninsured Americans by around 20 million people.  However, the number of uninsured increased early during the Trump Administration, largely due to Trump Administration policies, and skyrocketed during the pandemic.   

Moreover, the ACA did not reduce financial exposure of people with health insurance coverage.   Today, people with comprehensive health insurance have higher deductibles and higher out-of-pocket expenses than people 15 years ago because of the growth in the use of high-deductible health plans.  The Trump Administration executive order expanding the use of short-term health plans that fail to cover essential health benefits is creating substantial financial risk for people selecting these bare-bone health plans.

Many of the health insurance problems identified in this memo including the large loss of health insurance in periods of high unemployment and problems associated with the lack of competition in state exchange markets are caused by a tax code that favors employer-based insurance over state exchange insurance. These problems could be resolved or mitigated by tax reforms that partially decouple the responsibility of health insurance from employers.  This could be accomplished by a new rule allowing employers to subsidize health insurance for their employees on state exchange rather than pay for firm-specific health plans and a new tax credit where the Treasury would pay part of the cost of health insurance premiums.  The case for combining the employer-based and state-exchange health insurance markets is made here.

The proposed tax changes differ from the approach outlined by the incoming Biden Administration.   The Biden approach increases the generosity of the premium tax credit but maintains separate employee-based and state-exchange markets.   

The dominant factor increasing the number of uninsured and underinsured people is affordability.   A successful health care reform effort requires the creation of a low-cost public option or a lower cost private option providing comprehensive health coverage.   A comprehensive low-cost private option could only be achieved through cost sharing arrangements with the government.

Abstract:   People with short-term health plans often experience catastrophic financial losses, despite their insurance coverage.  The Biden health plan would reduce but not eliminate demand for short-term health plans.  Problems with short-term health plans could be fixed through executive order and/or state Medicaid waivers.

Fixing Short-term Health Plans

Many people cannot afford comprehensive health insurance sold on state exchanges.   The Trump Administration responded to this affordability problem by expanding the use of short-term medically underwritten health plans, which are not compliant with ACA regulations and do not cover essential health benefits.   

A recent report by the Democratic staff of the House Energy and Commerce Committee found short-term health plans have arbitrary benefit packages, fail to cover many needed health care procedures and often provide households little or no financial protection when faced with an existential medical situation.  

Short-term health plans include several features that can lead to extremely adverse health or financial outcomes.   These plans do not cover treatments for pre-existing conditions and exclude coverage for many common medical treatments, preventive care and prescription drugs.   

Short term health plans often limit physician office visits, hospitalizations, emergency services and coverage for surgery.  Limits can take the form of number of days or visits of coverage or the reimbursement rate per day or visit.   Some short-term health plans have rescinded coverage for high-risk patients and for cancer patients.  

Arbitrary benefit limits often lead to unusual and unpredictable health care bills.  The report by the Energy and Commerce committee describes situations where one patient received a $14,000 bill for two-day hospital stay for pneumonia and another situation where the short-term policy only paid $7,000 on a $35,000 bill for an emergency procedure. 

Short-term health plans can cause physical or financial ruin for the customer.   In many situations, people with short-term health insurance plans are de facto uninsured. 

Short-term health plans with arbitrary health insurance provisions are fundamentally different than the high cost-sharing arrangements used in conventional catastrophic health plan.   A catastrophic health plan with high deductibles and coinsurance rates can result in high out-of-pocket health care costs and can cause a sick individual to forego some necessary health care treatments.   However, the existence of a high deductible will generally not result in financial ruin when the health plan covers essential services and has a reasonable maximum out-of-pocket limit.

Catastrophic health care plans are a potentially rational choice for people who are willing to tradeoff higher deductibles for lower premiums.   Short-term health plans with arbitrary benefit limits basically do not reduce risk.

President-elect Biden’s health plan attempts to reduce the demand for short-term health insurance plans by offering a more generous premium tax credit for the purchase of state exchange insurance and an affordable public option. The Center for Medicare Services projects that most people selecting short-term health plans have income over 400 percent of the federal poverty line and are ineligible for a premium tax credit.  The more generous premium tax credit offered by President-elect Biden’s plan does not provide much assistance to young adults with income slightly above 400 percent of the federal poverty line.  Young adults with income near 400 percent of the federal poverty line are unlikely to be eligible for the new public option.

There is a need for a low-cost insurance option for people who cannot afford comprehensive health insurance.   This need is likely to persist even if President-elect Biden’s health care reforms are fully enacted. However, the low-cost insurance option should not expose people to catastrophic losses even though on paper they have insurance coverage. 

The incoming Biden Administration can fix some of the more flagrant problems with short-term health plans through executive order.  The executive order would create a short-term health plan with higher deductibles and higher out-of-pocket limits than current state-exchange health plans similar to the copper plan considered by Senator Alexander and Senator Murray.   

New copper plans could attract healthier people and increase premiums for more generous plans.  This problem could be minimized by targeting copper plans towards people without access to premium tax credits.

The executive order would prohibit many or all of the arbitrary benefit limitations including limits on nights in hospital, use of emergency rooms and doctor visits. The executive order would require short-term health plans to cover all medically necessary health procedures.   The executive order would prohibit underwriting based on health status and any discrimination against people with pre-existing conditions in short-term insurance markets. 

The ACA prohibits insurance companies from imposing caps on annual and lifetime health care benefits on all comprehensive health plans with the exception of short-term health plans. Caps on health care benefits used by short-term plans reduce the cost of the health plans but create catastrophic health and financial situations for people who hit the benefit limit.  

The incoming Biden Administration and Congress needs to either prohibit short-term health plans from imposing annual benefit caps or consider innovative ways to provide additional coverage to people once they reached their annual or lifetime benefit caps on their short-term health plan. 

One approach would involve the government sharing costs above some benefit threshold.   Cost sharing could occur at any level perhaps the annual cap.   The cost sharing could be implemented by direct payments from the government to health care providers for a portion of the health care bill once annual expenditures reach the chosen threshold. Previous risk-sharing programs making payments to insurance companies with a large number of expensive health care cases were criticized as corporate welfare.  Direct payments to providers for servicers above the annual cap would be easier to defend than subsidies to insurance companies.  

A new broad cost-sharing subsidy would require Congressional approval.  It may 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.   This type of cost-sharing arrangement was first described in this SSRN paper.   

The focus of most health care reform discussions is on reducing the number of uninsured.   The growth of short-term health plans during the Trump era created a class of people with insurance on paper that would still be subject to potentially catastrophic financial losses or health outcomes.   Even if fundamental efforts for health care reform fail, the Biden Administration can fix some of the problems caused by the growth of short-term health plans through executive order or through the Medicaid waiver process.