Some Reactions to the Senate Health Care Bill

With the Senate’s passage of its version of health care reform, I’d like to compare it against what I described earlier this year as my ideal reform. That reform included four elements:

  1. Community Rating
  2. Guaranteed Issue
  3. Ex Post Risk Adjustment
  4. An Individual Mandate (with Medicaid for a fee as the backup option)

I think the first two elements are well represented in the Senate bill, and, importantly, they apply to all health insurance plans. I have a personal preference for more latitude for insurers in charging different premiums to those of different ages, particularly in the individual market. I am just averse to any program that further takes from the young to give to the old, given how much we already do through existing old-age entitlement programs.

The ex post risk adjustment and reinsurance in the Senate bill seems to be quite extensive, but I wish they went beyond the individual and small group markets and included all health insurance plans.

On a related note, I am not a fan of the excise tax on so-called “Cadillac” health plans. I would need to be convinced that the reason why the premiums are so high is unrelated to the health characteristics of the insured group. What if the premiums are so high because the insured group is old or has large families? Simply including all plans in the ex post risk adjustment and reinsurance aspects of the bill is the right way to even out premium costs in the face of differences in the insured group. And if people want to spend more on their own health insurance, through high-quality services or (to my thinking) inefficiently low deductibles and co-pays, why stop them?

The individual mandate in the bill, summarized here by The New York Times, seems a bit weak to me. If you were determined to avoid having coverage, you now do have to pay a penalty in most cases, but those penalties are still well below what others would be paying for coverage. I think the individual mandate ought to be combined with Medicaid-for-all.

Specifically, I’d like to see everyone enrolled in Medicaid via the tax return as the default, unless they can prove that they had alternative coverage. They could then be charged an income-related premium for Medicaid on the tax return. I think this gets us to universal coverage more directly — there is no need to separately impose penalties for those who violate the individual mandate and no need to provide a complicated system of incentives for those of modest means to be able to afford coverage through traditional markets.

I don’t miss the public option or Medicare-for-a-fee. There is no evidence that the federal government can operate a public option without borrowing large sums of money from future taxpayers. So I see no reason, given what I’ve outlined above, to expand that model of coverage.

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About Andrew Samwick 89 Articles

Affiliation: Dartmouth College

Andrew Samwick is a professor of economics and Director of the Nelson A. Rockefeller Center at Dartmouth College in Hanover, New Hampshire.

He is most widely known for his work on the economics of retirement, and his scholarly work has covered a range of topics, including pensions, saving, taxation, portfolio choice, and executive compensation.

In July 2003, Samwick joined the staff of the President's Council of Economic Advisers, serving for a year as its chief economist and helping to direct the work of about 20 economists in support of the three Presidential appointees on the Council.

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1 Comment on Some Reactions to the Senate Health Care Bill

  1. Are you, or have you ever been, on medicaid?
    Are you aware that private doctors cannot usually afford to take medicaid patients? (They are lucky to get a dime on the dollar for them, and they cannot stay in business that way. Many private doctors take charity patients, but it is hard to find many who take medicaid, especially for more intensive needs.)

    Indeed, almost the entirety of the burden of the medicaid patient populace falls to the hospitals.

    What then would happen if instead of reforming the broken medicaid system, you expanded it to include everyone? Where would those people go, when no doctor could afford to take them? You cannot reasonable force the doctors to take them, for the doctors would go out of business! Certainly capping litigation costs against doctors and reforming the wastes and beaurocracy of medicaid would do much to encourage doctors to take on more medicaid patients – but as it stands now, medicaid forces all of its patients into one corner of the market.

    With -everyone- a patient, the extremely long waiting lists on medicaid would become deathly unbearable. (And yes, they are long. Many many months for the same service private insurance might take a few days.) And flooding the hopsitals would be bad – as hospitals provide our much needed emergency services! If they become flooded with requests for clinical care and chronic care under medicaid, they will have to devote all their resources to that, and then what will everyone do when they have an emergency? Sign up on a year long wait list to have their heart attack looked at, because the hospital no longer can provide EMTS? Or if the hospital chooses to keep providing emergency services, wait lists become five years instead! (This is medicaid for -everyone- after all.)

    And on a last note, a mandate that people must buy private health insurance or be fined is not constitutional. I suggest you do a story asking where the Speaker and others thought they found a right in our founding document for congress to force anyone to enter into a contract with a private entity simply to remain a law abiding citizen.

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