Governing is hard

The Republican Party has an ACA problem.  The ACA is deficit reducing.  Most of that was because it raised taxes on upper income families and cut back Medicare reimbursement rates for Medicare Advantage.  The Republicans are ideologically indifferent to cutting back Medicare Advantage reimbursement rates especially as Medicare Advantage has continued to grow in popularity so it has not harmed core Republican votes or donors.  But the Republican Party is ideologically committed to lower taxes on high income families.

The Republican Party has a policy problem.  It needs to offer something that is close enough to coverage to minimize blowback of sympathetic figures crying on camera that the Republican health policy bill will kill them.  So that means some type of coverage.  And that means spending some money.  That money has to be found from somewhere.  It can either be found from raising a different set of taxes after the taxes that hit high income individuals are cut or borrowing.

So here is what the Republican Party’s wonks are proposing:

Republicans are considering capping the U.S.’s tax break on job-provided health insurance, a major change to the tax system that could be used to finance their efforts to repeal and replace Obamacare.

This is a big pool of money.  The CBO believes the ESI tax exclusion is worth a quarter trillion dollars a year.  It is regressive tax benefit where the benefits mostly accrue to upper income individuals.  There is a good economic argument that the tax incentive favors one form of compensation (health insurance) over another (cash) when the efficient incentive structure is to be indifferent where both forms are treated the same by the tax code.  Most liberal wonks (myself included) will agree that building a system from scratch, ESI tax exclusion would never be part of an ideal package.

BUT HERE IS THE PROBLEM.  It pisses off voters who receive coverage through work.  And we already sort of tried this route before:

A similar idea was proposed by Senator Ron Wyden, a Democrat, during debate over the Affordable Care Act, and went nowhere. Obamacare already includes a levy on high-cost health insurance plans, known as the Cadillac tax, that begins in 2020. Republicans didn’t say where they would set the cap.

The Cadilliac tax set a fairly high rate (40%) excise tax on a fairly high exclusion limit.  It was supposed to have gone into play for 2018 but a large, bi-partisan coalition (including union friendly Democrats) pushed to force it back another two years.  There is still a large blocking coalition in place to continue to push the Cadillac tax back.  It will become the health care tax equivalent to the AMT re-indexing.

If the Republicans need to raise serious money from this exclusion being rolled back ($50 to $100 billion a year is serious), it means the tax hits most employer sponsored health plans to some degree.  If they don’t raise serious money because they fear blowback, it is a high income earner only tax and it still leaves their plan with a massive hole.

The easiest solution for Republicans looking for money to paper over their plan is to do what they did for Medicare Part D.  Just borrow it as that means no hard choices are needed.

But I can’t see how this proposal would get 150 votes in the House or 40 in the Senate.

HSAs, tax deductions and help for those who don’t need it

Health Savings Accounts (HSA) are going to be a big component of whatever passes as Republican health policy over the next couple of years. An HSA is a tax advantaged savings account that can be used to pay for out of pocket expenses and premiums. They are initiated and contribution eligible when the owner is covered under a high deductible health plan (HDHP). One of the primary tax advantages for an HSA is that contributions are tax free. Growth (as long as it is used for qualified medical expenses) is also tax free. I want to focus on the first part though.

My wife was notified of her bonus yesterday. Her firm also gave her a cost of living and merit based pay bump. She’ll see her bonus in the first check in January. I was sitting in a meeting where I barely needed to pay attention so I started sketching out my family’s 2017 budget. 2017 is looking good for us. I figure that I’ll still do some soccer but the four year plan to trade quantity for quality will continue as I value my family time more than soccer time as I no longer need it to pay the mortgage. My son will be out of daycare this summer so we are seeing a major expense drop and our incomes are going up. As my son leaves daycare, we’ll lose the value of the tax free benefit of the flexible spending account and that thought made me angry. Not angry at losing a tax benefit but angry at getting a lot of help when my family really does not need a lot of help.

We are able to contribute tax free a significant chunk of his day care costs. In 2016, we are doing well for ourselves so our marginal income is taxed at a fairly high marginal rate. I’m okay with paying a high marginal rate as I like civilization and the public sphere. I thought back to 2009 and 2010. Those years were lean. I was either out of work or consulting and my wife was working but unable to find full time work. We were tight and paying the mortgage was an adventure some months. If we were able to afford to put money away, we would have seen a tax benefit that is significantly less than what we are getting now. And those were the years when we really needed help as we had an infant daughter and a fraction of total income in 2016 or projected for 2017.

I’m angry about this because the tax deduction racket shovels most of the benefits towards people who don’t need the additional help. Someone who is in the top bracket this year will see the federal government subsidize their $1,000 contribution with a $400 tax break. Someone who is making $10,000 a year will not be able to afford to make a $1,000 contribution and in the odd case that they could, the federal subsidy administered through the tax code is only worth $100. That is wrong on a moral basis. More help goes to people who really don’t need it as the marginal value of their last dollar is fairly low.

One of the policies I want to see advanced is a flipping of tax deductiblity towards an open ended credit so it is more of a sliding scale based on either income or contribution. Here is how I think it could work:

The first $200 of a contribution to an HSA or an FSA would have credit equal to the size of the contribution times the top income tax marginal rate.
The next $500 contributed would have a credit equal to the size of the contribution times the second highest income tax marginal rate
The next $500 would have a credit equal to the increment times the third highest marginal rate

This would continue until a threshold is reached where any contributions to a tax advantaged account receive a federal subsidy equal to the lowest marginal rate. It still encourages savings but it gives more help to people who need it and less help the the people who are in pretty good to really good shape.

Repeal and Delay with the Norquist problem

Right now, the current Republican plan is Repeal and Delay as the NY Times reports:

Republicans in Congress plan to move almost immediately next month to repeal the Affordable Care Act, as President-elect Donald J. Trump promised. But they also are likely to delay the effective date so that they have several years to phase out President Obama’s signature achievement.

This emerging “repeal and delay” strategy, which Speaker Paul D. Ryan discussed this week with Vice President-elect Mike Pence, underscores a growing recognition that replacing the health care law will be technically complicated and could be politically explosive.

The mechanics of the repeal bill are fairly straightforward. A reconciliation bill would be written to sunset subsidies and Medicaid Expansion money after two (or three) years while a Replace bill is cobbled together. The individual mandate tax would be dropped to zero even if it was not technically repealed and all of the taxes that fund the ACA would be dropped immediately. This blows up the insurance market fast. There are discussions and rumblings that some Republican wonks are trying to make this point to Republican leaders. Someway of shoveling a massive amount of cash to insurers would be needed that would perform the same function as risk corridors and reinsurance but called something else is the most likely response.

And then there would be some type of Replace bill that would offer skimpier subsidies and much higher cost sharing than current law.

That Replace bill will cost money. It won’t cost as much money as the ACA but it will cost money.

That is a major problem as the major funding streams from the ACA (Cadillac Tax and high income tax surcharges) are gone. Nicholas Bagley at the Incidental Economist flagged this very early on:

You’ve got to bear in mind that passing the reconciliation bill would represent an immediate $346 billion tax cut over ten years to the wealthy—$123 billion from the Medicare tax surcharge and $223 billion from the tax on investment income. All of that money—every dime—will go to people making more than $200,000 a year.

The other major source of funding for the ACA is the Cadillac tax in the out years and Medicare Advantage payment equalization. The Cadillac tax is popular with health economists who, when they concentrate for an annual convention, might have sufficient political power to elect a county commissioner in an NFL market and no one else. The Republican Replace plans use modified Cadillac plans that usually apply regular income tax rates to health insurance benefits at far lower thresholds than the Cadillac tax. But I digress.

The Replace plan will cost money. And here is where we run into the Norquist problem. It is Republican orthodoxy that once a tax cut is passed it can never be re-enacted. The Replace Bill would not be signed for at least six months (absurdly optimistic case scenario) after the Repeal bill that wiped out the high income taxes that fund the ACA. The Congressional Budget Office (CBO) would score Replace based on current law which means no high income surcharges as offsets. Republicans can’t vote for higher taxes per Norquist even if those are taxes that just got cut.

Assuming Norquist is still a major political enforcer of Republican orthodoxy, my best bet is that any Replace Bill will be like the 2003 Medicare Modernization Act (MMA) in that it is almost completely deficit financed.

Double D’s and Subsidies

I always like to look at the 12-DD box on my W-2.

This box tells me how much my employer sponsored insurance (ESI) actually costs between premiums and Health Savings Account (HSA) contributions. The 12-DD box was a requirement of PPACA and its goal is to make people slightly more aware that their health insurance at work really costs them more than $47.56 every two weeks.

My employer is starting the annual open enrollment education process. We’ll get weekly e-mails from Human Resources about all of the different options and how the networks interact. There are no major changes to network or plan design for employee insurance this year. There is a small diabetes disease management program and a reference pricing experiment but for most people there will be very few visible differences between the 2016 policies and the 2017 policies. For people at my pay grade, we are seeing a 4.2% increase in premiums explicitly taken out of our paychecks. The company is “covering” roughly 85% of the cost of 85% Actuarial Value coverage for my family. Economically, the company contribution is “just” cash income transformed into a tax advantaged compensation but I don’t see the money so it does not feel like I am paying the full price of my insurance coverage for my family.

I do get two explicit subsidies. The entire premium of the policy is tax deductible. That is worth 4% of my families income. We also put away some money into a tax advantaged savings account that is worth another .5% of my family’s income for the year. So we get a total of 4.5% of family income subsidy help to pay for a good insurance package.

This is important because most poeple who get ESI don’t think they are getting subsidized. Everyone is getting subsidized. People with higher incomes and ESI get a larger dollar figure subsidy than people at a lower income because tax deductions are valued at the marginal tax rate. People with higher incomes also tend to have richer benefits, higher actuarial value coverage and fewer gatekeepers so total premiums are higher.

Medicare is heavily subsidized. Part A and Part B premiums pay for roughly a quarter of the program. The rest of society subsidizes the rest of the cost of Medicare.

CHIP has subsidies ranging from 0% to 25% to 100%.

Medicaid is almost entirely subsidized.

The individual market is heavily subsidized for people earning under 200% FPL. For people who earn between 200% and 400% FPL it is modestly subsidized. For people who earn more than 400% FPL there are no explicit subsidies like the advanced premium tax credits available between 100% FPL and 400% FPL nor any implicit subsidies through the tax code.

Let’s keep that in mind when we talk about health insurance. Almost everyone is subsidized except for a narrow segment of the PPACA individual market. It is just that some of the subsidies are well hidden and non-obvious.

Federalizing Medicaid funding

And another story from Oklahoma:

Facing a $1.3 billion budget hole, the Oklahoma House has passed legislation that would cut 111,000 Oklahomans from Medicaid.

House members on Wednesday passed the bill 65-34 mostly along partisan lines and sent it to the state Senate for action.

The measure would instruct the Oklahoma Health Care Authority to seek a federal waiver allowing the state to exclude from Medicaid all able-bodied adults under 65 with dependents.

That bill failed in the Oklahoma Senate.

Oklahoma is heavily dependent on oil revenue to make their budget work. Oil prices have cratered so state revenues have crashed. At the same time as oil prices have collapsed, economic activity in the state is decreasing which means more people don’t have jobs, more people don’t have employer sponsored insurance, and more people have become Medicaid eligible. The Medicaid eligible pool is counter-cyclical. As the economy does well, the eligible pool shrinks, and as the economy does poorly, the pool grows. So the number of people who are eligible for Legacy Medicaid grows just as the state revenue needed to pay for Medicaid services drops.  This is a problem.

Legacy Medicaid is financed by the state and the Feds splitting the bill.  Oklahoma pays 41% of the cost of the medical services component of the program.  The Feds pick up 59% of the medical side and a bit more on the administrative side.  Oklahoma has a balanced budget constraint.  the Federal government does not.  That means the Feds are willing and able to spend money to meet increased Legacy Medicaid demand in a downturn but the state can not.  Instead, the state needs to cut expenses to meet its balanced budget constraint and Medicaid is a very large line item in every state budget, so that means Medicaid is often one of the major areas of cut-backs in either eligibility, services allowed or provider payments.

So what is the solution?

The long term solution is that the Federal government should take on more and more of the cost of Legacy Medicaid.  The Feds can spend in a downturn when the states have to be 50 mini-Hoovers who have to cut during a recession.  This does three things.  The first it makes sure that people can get the medical care that they need and that the continuity of care is maintained.  Continuous care is usually better and cheaper  than people getting dropped and then added back to insurance months or years later.  Secondly, it transforms Medicaid financing from a pro-cyclical activity into a counter-cyclical macro-economic stability policy.  One of the major components of the stimulus in 2009 was a Federal Match rate bump.  This moved $87 billion in Medicaid expenses from the states’ books to the Federal books.

The Stimulus bump was a short term solution that required massive supermajorities from a party that believes that the federal government faces a different budget constraint than a typical household.  The long term solution is to have the Feds continually increase their share of the costs until Legacy Medicaid is funded on the same bases as Medicaid Expansion. The Feds pick up 90% of the tab and the states pay 10%.  This will still allow for state control  which allows Massachusetts to cover different services than Mississippi but it allows for a much stronger counter-cyclical automatic stabilizer to be in place.

The attraction this should have to a significant number of Republican state level elites is that by taking Medicaid off of their books, it frees up a lot of money for easy to justify tax cuts.