Everyone is entitled to his own opinion, but not his own facts. Founded by Mark Kleiman (1951-2019)
Author: Don Taylor
Don Taylor is an Associate Professor of Public Policy at Duke University, where his teaching and research focuses on health policy, with a focus on Medicare generally, and on hospice and palliative care, specifically. He increasingly works at the intersection of health policy and the federal budget. Past research topics have included health workforce and the economics of smoking. He began blogging in June 2009 and wrote columns on health reform for the Raleigh, (N.C.) News and Observer. He blogged at The Incidental Economist from March 2011 to March 2012. He is the author of a book, Balancing the Budget is a Progressive Priority that will be published by Springer in May 2012.
The debate about whether health insurance improves health has been ushered into prominence by the need of proponents and detractors of the ACA to make their case against the other side. It is an important discussion, regardless of why is has popped up (examples of good debate: one | two). Much of the best debate has been technical in nature, hinging on issues of research design, internal versus external validity, statistical power and the choice of measures. The latest round of skirmishes has ventured into the area of whether the benefits outweigh the costs, always a fair question in public policy as is seeking to fully identify the costs and benefits.
Midnight was the enrollment deadline, but people who were in process with applications can complete the process through the first two weeks of April. This is a big milestone in the law, but no matter how much everyone wants an instant assessment of the ACA as “working great” or “sucking” that answer is not forthcoming based on how many signed up. I will, however, go out on a limb and predict the answer is somewhere between “working great” and “sucking”.
I didn’t blog about it because the Medicaid portion of the document is really quite bad given that the report was hyped as the precursor to a major policy push by Rep Ryan and House Republicans. It is essentially a poorly done annotated bibliography that would get about a C- in my intro U.S. health system course. The biggest problem with the Medicaid portion of the document is not even the one-sided summary of the literature that is cited that could be forgiven in such a document, but ignoring the issue of the dual eligibles almost completely in something that is meant to set up the need for Medicaid reform is quite a big miss. So, the document is not serious enough on the Medicaid issue to warrant much blogging time.
I didn’t read the remainder of the report (on other federal poverty programs) after looking at the Medicaid parts. Here is a blog tag on the many things I have written about the dual eligibles and the need for reform.
The CBO Budget Outlook (2014-24) is out today, and much of the focus is on their revised estimate of the ACA’s impact on the labor market (Appendix C, pp. 118-27). CBO is projecting that “the ACA will cause a reduction of roughly 1 percent in aggregate labor compensation over the 2017-2024 period, compared with what it would have been otherwise” (p. 117). This is basically CBO’s estimate of the impact of the marginal tax rate on labor income created by the various policy structures of the ACA that Casey Mulligan has written about. As I wrote in this post, you get less of something if you tax it, so if that is not your goal (it is with tobacco taxes, for example) then you are left to decide whether the reduction is worth achieving an alternative goal(s). That can be a difficult question to answer, because you are trading off important things–labor market participation, rates of uninsured, and the system reform provisions of the ACA.
First off, lets just say that the rage machine that has been perfected to argue against the ACA could get plenty cranked up from the these results. There is a breathless Americans for Prosperity Ad running in North Carolina talking about a nice lady losing her doctor in an Obamacare plan, in health policy speak, due to the rise of the narrow network. Yep, this score says PCARE will have a slight increase in persons covered by 2023 compared to the ACA, but most of that arises from a shift of people into narrow network plans. Continue reading “Private Score of Senate Republican Health Proposal”
It acknowledges gravity, while making changes. While PCARE talks of repeal of the ACA, it locks in a good deal of the structure of the ACA, and addresses changes from that new status quo. For example, no lifetime limits (sec 201) is retained from the ACA, as is keeping people up to 26 on their parents health insurance, while the current 3-to-1 age banding premium regulation is replaced with 5-to-1 (now a 64 year old could not be charged more than 3 times what a 20 something could be charged;now they could be charged 5 times as much). Winner 20-somethings, loser 60-somethings. Eventually they say they plan to allow States to set these rules with a looser federal touch, meaning a state could decide to stick with the 3-to-1 premium banding by age, for example. I want to hear more about guaranteed renewability and related insurance market regulations as the 2nd full paragraph of page 2 is a bit slippery. For example, it contains this quote: “Insurance companies would also be banned from makingÂ unfairÂ coverage terminations of health coverage.” (emphasis mine). What might “fair” ones be? Continue reading “Thoughts on Burr, Coburn, Hatch Health Reform Plan”
I was a discussant of Casey Mulligan’s paper Average Marginal Labor Income Tax Rates Under the ACA at the UNC Tax Symposium hosted in Chapel Hill, NC by Doug Shackelford this past Saturday. His figure 3 summarizes changes in the marginal tax rate of labor income over the past 7 years, accounting for both explicit and implicit taxes for someone with median wages. For example, in 2014, there is an increase in the marginal rate due to a reduction in work incentive that occurs for someone with median wages because premium subsidies are based on a income-linked sliding schedule–an implicit tax on earning more because you lose insurance subsidy as you earn more income. The paper also identifies increased implicit incentives to work more, for example, the fact that exchange subsidies cannot flow to those below 100% of poverty.
WaPo had a story on Dec 27, 2013Â with a nearly irresistible click baitÂ headline “Hospice firms draining billions from Medicare.” Like much health policy that focuses on the end-of-life, the story raises some valid points, but gives in to the sensational and turns away from the far more difficult reality of the counterfactual: current hospice policy as compared to what?
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