bentley parent lecture series: economics of healthcare reform and the affordable care act
TRANSCRIPT
Economics of Healthcare Reform &
the Affordable Care Act
Dhaval M. Dave
Department of EconomicsBentley University
Parent Lecture Series, FALL 2014
A little about me…
Rutgers University◦ B.S. in Finance / Economics
Rutgers University◦ M.A. in Economics
City University of New York◦ Ph.D. in Economics
Wharton, Univ. of Pennsylvania◦ Post-doctoral Research Fellowship
Bentley University◦ Professor of Economics
National Bureau of Economic Research (NBER)◦ Research Associate
Current Research
Rx advertising
Effects of Medicaid expansions
Substance abuse policies
◦ Alcohol, smoking, e-cigarettes
Effects of the business cycle on health behaviors
Broader effects of welfare reform on health and human capital
Juvenile crime & recidivism / human capital
Outline
What ails the U.S. healthcare system?
“Two-headed Beast”
Rising costs
Number of uninsured
Affordable Care Act (ACA) as the ‘remedy’ (?)
I. Rising Healthcare Costs
0.0
2.0
4.0
6.0
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0
1000
2000
3000
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% G
DP
NH
E p
er
cap
ita
$9142
5.6%
$216
17.2%
Driving force behind rising costs is Technology
Source: Congressional Budget Office 2008
Rising Healthcare Costs
Ultimately paid out of wages
◦ Stagnant wage growth over the past 40
years
50% of costs borne by government
◦ Opportunity cost – funds diverted from other
services (education; infrastructure)
U.S. vs other OECD countries (2012) ?
US
72.0
74.0
76.0
78.0
80.0
82.0
84.0
86.0
0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
Lif
e E
xp
ec
tan
cy
HC Spending per capita
Source: Data from OECD Health Data
McAllen vs. El Paso, TX Redux?
New York Times, September 8, 2009
Rising Healthcare Costs
Inefficiencies / Waste in the current
system
◦ Unnecessary procedures
◦ Excessive compensation
◦ Ineffective management
II. Rising Uninsured
49 million (16%) in 2011
20,000 die each year due to lack of
insurance
Medical expenses largest cause of
individual bankruptcies
II. Rising Uninsured
But I am insured. Why should I care?
Everyone is at risk of becoming uninsured
◦ Declining trend in employer-provided insurance
Non-group insurance market is broken
$50 billion in uncompensated care passed on to the insured
Insured come only into healthcare system at a later stage when they need it, as opposed to getting preventive care – no usual source of care
Affordable Care Act
Reduce Number of Uninsured
I. Fix ‘broken’ non-group market
Guaranteed issue
Community rating
Affordable Care Act
Reduce Number of Uninsured
II. Individual mandate
Everyone required to obtain healthcare
coverage or pay a penalty
Risk adjustment
Affordable Care Act
Reduce Number of Uninsured
III. Make insurance affordable Employer mandate (>50 FTEs)
Expands Medicaid to cover all individuals/families <138% of
FPL
Provides subsidies on a sliding scale for those between 138-
400% FPL
Administers Exchanges giving consumers easy-to-understand,
one-stop shopping for insurance options
Affordable Care Act
Reduce Number of Uninsured
I. Fix ‘broken’ non-group market
II. Individual mandate
III. Make insurance affordable
Affordable Care Act
Taking on Cost Control
Cadillac tax◦ For many, insurance is far too generous due to tax
deductibility/subsidy
◦ Induces over-spending on healthcare
◦ Larger tax breaks for higher-income
Health insurance exchanges◦ Encourages price/quality competition across insurers to
reduce administrative costs & wastes
Medicare IPAB◦ Make recommendations on how to improve quality of medical
care & lower costs by improving the program’s efficiency
Affordable Care Act
Taking on Cost Control Comparative Effectiveness Research
◦ Head-to-head comparisons between alternate treatments/drugs
◦ Whether expensive treatments work better than cheaper alternatives
Accountable Care Organizations (ACO)◦ System where care is coordinated across providers
◦ Coordinated groups that provide all patient care for one global reimbursement amount
◦ Doctors & hospitals have to figure out the best way to deliver care to make ends meet under their fixed payment
Expand access to preventive care◦ Eliminates all cost-sharing / copays / deductibles
Medicare reimburse providers based on services & QUALITY◦ Reward high-quality hospitals/doctors & penalize low-quality providers
What’s the solution?
Insuring everyone requires money, but it
can be done
More complicated: how do we change
the way the health care delivery system
works so we get high quality care at
lower cost?
ACA addresses head-on the problem of uninsured
◦ 14 million newly insured
◦ 26 million by 2019
ACA takes first “baby” steps towards cost control that might work and could translate into a future plan to build on what works
Reduces “job-lock”
ACA is fiscally-responsible - may well result in a net reduction in the deficit
Potential labor supply effects (?)
◦ But likely small (?)
Potential crowd-out (?)
Question is do you do coverage first & cost-containment second or vice versa (?)
Verdict ?
BACK
Cyclicality of Medical-Loss Ratio
(Benefits Paid / Premiums)
0.81
0.82
0.83
0.84
0.85
0.86
0.87
0.88
0.89
0.9
0.91
0.92
Medical-Loss Ratio
Typical loading fees by group size
Number of workers Loading fee as % of
benefits
Individual policies 60-80
Small group (1-10) 30-40
Moderate group
(11-100)
20-30
Medium group (100-200) 15-20
Large group (201-1000) 8-15
Very large group (more than 1,000) 5-8
Overall for all plans 15-25
US vs. OECD Countries (1980)
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0 200 400 600 800 1000 1200
Lif
e E
xp
ecta
ncy
HC Spending per capita
Life Expectancy
us