Cadillac tax alternatives


TLDR: Changing the Cadillac tax from a fixed rate surcharge to elimination of deductible benefits workers with lower incomes but very high health insurance compensation while keeping the incentives aligned for better cost control measures. This tweak could get some unions back on board while also simplifying the tax code. Should be a double win. It won’t be.

HDHPs, HSA and no deductible Silvers

In yesterday’s thread that PPOs are merely a plan design and not an indicator of quality nor shittiness, Dr. Bloor restates a very important point about high deductible plans in response to another comment:

The High-Deductible Health Plans scare me. Are the prescription rates for these plans pre-negotiated, or do you eat the cost of prescriptions at retail rates until you hit the deductible?

You should never take on more of a deductible than you can assume you’ll spend in the course of a year. Folks who either opt for big deductibles or have them foisted on them by their employers for the sake of saving a few bucks on their monthly premium are aching to be victims of the penny-wise-pound-foolish approach to insuring their families.

High deductible health plans (HDHPs) are “consumer-driven” health insurance. The theory of change is that the consumer (not patient, and not person but consumer) will be able to effectively assess their healthcare needs and since they are paying the first several thousand dollars in expenses, they will not use healthcare that is low value to them. The IRS defines a HDHP as having a deductible of at least $1,300 for an individual in 2016.   A HDHP at $1,300 deductible and no other cost sharing has an actuarial value of 77% or 78% at a rough back of the envelope guess.

HDHPs are often tied to Health Savings Accounts (HSA) where people can put pre-tax money into an account to cover the deductible.  The money rolls-over year after year (unlike a Flexible Spending Account) and it can be placed on Red at the casino or invested.

I am not a big fan of high deductible health care as the evidence is good that they reduce utilization but the utilization reduction is not targeted at bad or low value care, it is not targeted at all.  Good care is excluded due to cost.  Recent evidence has shown that there is not a cost cascade two or three years out after employer sponsored insurance switches to HDHPs from low deductible health plans, but that study is fairly limited to a healthy population (employed individuals).

This is a problem with the ACA.  Catastrophic, Bronze and non-cost sharing Silver plans are low actuarial value plans when taken in the context of defining a HDHP.  Most of these plans have HSAs attached.  However I have a question about whether or not HSAs can be attached to some Silver plans?  Do no deductible Silvers qualify for HSAs?

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When a failure is a win and a win is a failure

From my days as a general policy wonk instead of a health policy wonk, there were two common sayings on optimal taxation policy:

“Lower rates, broader base”


“Tax the bads, subsidize the goods”

Yes, policy wonks are not wordsmiths, but I want to focus on the intersection of tax policy and healthcare policy that is implicit in the second shibboleth.

Taxing the bads usually means declining long term revenue as over the long term, fewer people consume the bad thing.  A classic recent example is the use of high levels of cigarette and other smoking tobacco taxes to fund the Childrens Health Insurance Program (CHIP).  In 2009, CHIP was reauthorized and expanded.  The federal share of the program was to be paid for with a $0.61 per pack increase in the federal cigarette tax.  There is a long term problem with using a tobacco tax to fund CHIP — tobacco usage is going down and has been going down for over a generation now as we as a society are starting to approach the point of having smokers fully internalize the costs of smoking.  This trend will continue as cigarettes and other tobacco products are more heavily taxed.

The basic mechanism is higher cash prices for cigarettes keeps non-smokers from becoming addicted smokers because they never try or they never quickly get to a pack a day.  Long term smokers will brand shift downwards or less likely quit if they are cash constrained, but cash constrained non-smoking 17 years olds will grow up to be non-cash constrained 51 year old non-smokers.  We’ve decided as a society that tobacco usage is a bad that we really want to significantly reduce or eliminate over the long term.  So we’ve been taxing a “bad” to subsidize a “good”, health insurance for kids.

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Taxing mission drifters

I’m of the opinion that things that look like ducks, quack like ducks, and taste like ducks are probably ducks even if they are called something else. The tax exemption was yanked because the California Franchise Tax Board thought Blue Shield of California had been acting like a for-profit company under its tax exempt status, so now it can act exactly like it has been operating for years but under a different tax status.

NPR has details:

California tax authorities have stripped Blue Shield of California, the state’s third largest insurer, of its tax-exempt status in California and ordered the firm to file returns dating to 2013, potentially costing the company tens of millions of dollars….
One likely explanation, however, is the $4.2 billion the company reports it is holding in financial reserves. That’s four times larger than the national trade organization, Blue Cross and Blue Shield Association, requires members to hold in surplus to pay out member claims….

If Blue Shield of California was acting like a for-profit entity under its tax advantaged status in 2013 and 2014, it will act like a for-profit entity under its taxable status in 2015 and 2016. I don’t think it will significantly change behavior or pricing as its current set of overpriced premiums that led to the reserve accumulation were sufficiently competitive with other for-profit and non-profit insurers pricing that people still bought their policies at a profitable rate. Their cost structure will change a bit, but the basic cultural push of the enterprise will be the same profit or retained earnings maximization.

I think it may have a deterrant effect on some other smaller medical non-profits as it could be enough of a shock to the boards that they focus on their mission and core values for several years or at least spend some serious time discussing what those core values are and should be. The successful, large and efficient non-profit insurers and medical providers are the ones that are extremely concerned about their values which becomes their mission. Mission drift is the concern not the tax status of large entities.

Paved With Bad Intentions

I wonder what my douchebag of a Congressman, Thomas Massie, is up to.

Wait, die-hard Glibertarian Thomas Massie sponsoring an infrastructure bill? What’s the catch?

Today, Congressman Thomas Massie introduced the DRIVE (Developing Roadway Infrastructure for a Vibrant Economy) Act of 2015 with Congressman Jim Jordan (R-OH), Congressman Justin Amash (R-MI), Congressman Jim Bridenstine (R-OK), and Congressman Ken Buck (R-CO) as original co-sponsors. The DRIVE Act (H.R. 1461) would help keep the Highway Trust Fund solvent and improve our national infrastructure, without raising the gas tax, by refocusing the Highway Trust Fund on its original and proper role of building and maintaining federal highways and bridges.

OK.  So again, what’s the catch?

“Currently, gas tax revenue is diverted from the federal Highway Trust Fund for bike paths, sidewalks, mass transit, and other local projects,” said Congressman Massie. “But due to inflation and fuel efficiency improvements of today’s vehicles, there is no longer enough money in the Highway Trust Fund to maintain our nation’s critical highways and bridges while also funding local projects that have no federal nexus. By eliminating diversion of gas tax revenues, the DRIVE Act ensures that the Highway Trust Fund can fulfill its namesake duty – to fund highways, without an increase in the gas tax rate.”

Oh I get it.  Let’s cut to the chase.

Annually, over $9 billion of the Highway Trust Fund goes to the Mass Transit Account, which provides funds for local public transportation projects, including subways, light rail, buses, and streetcars. Additional authorizations exist for sidewalks and bike paths to be funded from the Highway Trust Fund. The DRIVE Act repeals these authorizations and reduces Highway Trust Fund obligations by approximately $10 billion annually.

Ding ding ding!  So we’re going to fix the Highway Trust Fund by cutting $10 billion a year from mass transit projects, like, say, Cincinnati’s streetcar.

Oh well played, Mr. Massie.  Your bill has no chance in hell, but thanks for the heads up on what the GOP “fix” for the Highway Trust Fund is. Austerity for all the kids and trees and dogs and probably you too, because mass transit is the communist devil.

(Bonus: the Mass Transit Fund part of the Highway Trust Fund was created by Congress and signed into law by…*drum roll*…that known socialist collectivist Ronald Reagan in 1982. Orange Julius and the Gang That Couldn’t Legislate tried to kill the Mass Transit Fund in 2012 as part of their “JOBS” Act, which burst into flames the moment it was exposed to air and died miserably. Looks like they’re at it again.)

Cause and effect in Louisiana

A major hospital in Baton Rouge, Louisiana is closing its emergency room because it is hemorrhaging money:

 Baton Rouge General Medical Center-Mid City will close its emergency room within the next 60 days, a victim of continuing red ink and the Jindal administration withdrawing the financial support that kept it open….

The closest emergency rooms from Baton Rouge General’s Mid City campus is Lane Regional Medical Center, 30 minutes to the north in Zachary, and Our Lady of the Lake Regional Medical Center, 30 minutes to the south on Essen Lane. Mid-City’s ER recorded 45,000 patient visits last year…..

More and more poor and uninsured patients from the low-income neighborhoods of north Baton Rouge ended up at the Mid City hospital, which was the next-closest facility.

Mid City hospital reported losses of $1 million a month as more and more patients who could not pay arrived…. Officials projected losses would grow larger, reaching $25 million to $30 million in 2015.

Poor people can’t pay full freight nor are they likely to be covered by insurance. There just happens to be an extremely attractive offer to get lots of poor people covered by insurance. Medicaid expansion would help safety net hospitals in high poverty areas the most. Poor people covered by insurance will either be able to pay something towards their emergency room visits or divert to lower levels of appropropriate care.

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Like A Kansas Tornado

Storm system Brownback continues to ravage the state of Kansas unabated, and the next casualty involves some good old fashioned school austerity bombing.

Kansas Gov. Sam Brownback’s proposed budget cuts about $127.4 million from state support to local school districts, according to a report released Tuesday by the state Department of Education.

Some Senate Republican leaders dispute that the cut is that deep, saying the Education Department figure doesn’t account for spending on bonds and interest for school construction or payments to the state retirement fund.

The governor’s plan, released Friday, is to roll four major categories of spending into block grants to school districts. The block grants will include the money now spent in general state aid, supplemental state aid, capital outlay aid and the school district finance fund.

This year’s budget for those categories is almost $3.14 billion. The block grants proposed by the governor would total slightly more than $3 billion.

Block grants for schools that are already badly underfunded to the point where the state supreme court ordered Brownback to spend more, huh.  This should go over well.  Oh, but here’s the best part.

More broadly, Kansas state workers’ pension funds are also being used to patch Brownback’s fiscal gap. He is proposing to cut state payments to pension funds by $446 million over three fiscal years including the current one while also refinancing some of the funds’ debts. But the executive director of the Kansas Public Employees Retirement System says Brownback’s proposed tweaks will ultimately cost the state more than 8 times what they save in the short term.

The near-term cuts would raise long-term costs by $3.7 billion — nearly a quarter of the current size of the pension system. Reneging on pension obligations in the short term and creating larger retirement system problems in the long term helps create political pressure to cut workers’ retirement benefits down the road, according to critics of similar maneuvers in states like New Jersey.

Another big-ticket Brownback cut strips roughly $300 million in transportation department funding over the next couple years — a move that shares the penny-wise, pound-foolish DNA of Brownback’s schools and pensions cuts. The road repair cuts will save a little bit of money now, but “all you’re going to do is create bigger problems for yourself later,” the head of a trade group for heavy construction firms in Kansas City told the Star.

And that’s on top of his plan to raise cigarette and liquor taxes so he can keep cutting the state’s income taxes, which caused all this mess in the first place.

If you want to see what a Republican budget will do to the country should they get control of the whole playing field in 2016, look no further than the tornado ripping through Kansas right now.