Market Competition as a Path to Making Medicare Available for All

A.  Introduction

Since taking office just two years ago, the Trump administration has done all it legally could to undermine Obamacare.  The share of the US population without health insurance had been brought down to historic lows under Obama, but they have now moved back up, with roughly half of the gains now lost.  The chart above (from Gallup) traces its path.

This vulnerability of health cover gains to an antagonistic administration has led many Democrats to look for a more fundamental reform that would be better protected.  Many are now calling for an expansion of the popular and successful Medicare program to the full population – it is currently restricted just to those aged 65 and above.  Some form of Medicare-for-All has now been endorsed by most of the candidates that have so far announced they are seeking the Democratic nomination to run for president in 2020, although the specifics differ.

But while Medicare-for-All is popular as an ultimate goal, the path to get there as well as specifics on what the final structure might look like are far from clear (and differ across candidates, even when different alternatives are each labeled “Medicare-for-All”).  There are justifiable concerns on whether there will be disruptions along the way.  And the candidates favoring Medicare-for-All have yet to set out all the details on how that process would work.

But there is no need for the process to be disruptive.  The purpose of this blog post is to set out a possible path where personal choice in a system of market competition can lead to a health insurance system where Medicare is at least available for all who desire it, and where the private insurance that remains will need to be at least as efficient and as attractive to consumers as Medicare.

The specifics will be laid out below, but briefly, the proposal is built around two main observations.  One is that Medicare is a far more efficient, and hence lower cost, system than private health insurance is in the US.  As was discussed in an earlier post on this blog, administrative expenses account for only 2.4% of the cost of traditional Medicare.  All the rest (97.6%) goes to health care providers.  Private health insurers, in contrast, have non-medical expenses of 12% of their total costs, or five times as much.  Medicare is less costly to administer as it is a simpler system and enjoys huge economies of scale.  Private health insurers, in contrast, have set up complex systems of multiple plans and networks of health care providers, pay very generous salaries to CEOs and other senior staff who are skilled at operating in the resulting highly fragmented system, and pay out high profits as well (that in normal years account for roughly one-quarter of that 12% margin).

With Medicare so much more efficient, why has it not pushed out the more costly private insurance providers?  The answer is simple:  Congress has legislated that Medicare is not allowed to compete with them.  And that is the second point:  Remove these legislated constraints, and allow Medicare-managed plans to compete with the private insurance companies (at a price set so that it breaks even).  Americans will then be able to choose, and in this way transition to a system where enrollment in Medicare-managed insurance services is available to all.  And over time, such competition can be expected to lead most to enroll in the Medicare-managed options.  They will be cheaper for a given quality, due to Medicare’s greater efficiency.

There will still be a role for private insurance.  For those competing with Medicare straight on, the private insurers that remain will have to be able to provide as good a product at as good a cost.  But also, private insurers will remain to offer insurance services that supplement what a Medicare insurance plan would provide.  Such optional private insurance would cover services (such as dental services) or costs (Medicare covers just 80% after the deductible) that the basic Medicare plan does not cover.  Medicare will then be the primary insurer, and the private insurance the secondary.  And, importantly, note that in this system the individual will still be receiving all the services that they receive under their current health plans.  This addresses the concern of some that a Medicare-like plan would not be as complete or as comprehensive as what they might have now.  With the optional supplemental, their insurance could cover exactly what they have now, or even more.  Medicare would be providing a core level of coverage, and then, for those who so choose, supplemental private plans can bring the coverage to all that they have now.  But the cost will be lower, as they will gain from the low cost of Medicare for those core services.

More specifically, how would this work?

B.  Allow Medicare to Compete in the Market for Individual Health Insurance Plans

A central part of the Obamacare reforms was the creation of a marketplace where individuals, who do not otherwise have access to a health insurance plan (such as through an employer), could choose to purchase an individual health insurance plan.  As originally proposed, and indeed as initially passed by the House of Representatives, a publicly managed health insurance plan would have been made available (at a premium rate that would cover its full costs) in addition to whatever plans were offered by private insurers.  This would have addressed the problem in the Obamacare markets of often excessive complexity (with constantly changing private plans entering or leaving the different markets), as well as limited and sometimes even no competition in certain regions.  A public option would have always been available everywhere.  But to secure the 60 votes needed to pass in the Senate, the public option had to be dropped (at the insistence of Senator Joe Lieberman of Connecticut).

It could, and should, be introduced now.  Such a public option could be managed by Medicare, and could then piggy-back on the management systems and networks of hospitals, doctors, and other health care providers who already work with Medicare.  However, the insurance plan itself would be broader than what Medicare covers for the elderly, and would meet the standards for a comprehensive health care plan as defined under Obamacare.  Medicare for the elderly is, by design, only partial (for example, it covers only 80% of the cost, after a modest deductible), plus it does not cover services such as for pregnancies.  A public option plan administered by Medicare in the Obamacare marketplace would rather provide services as would be covered under the core “silver plan” option in those markets (the option that is the basis for the determination of the subsidies for low-income households).  And one might consider offering as options plans at the “bronze” and “gold” levels as well.

Such a Medicare-managed public option would provide competition in the Obamacare exchanges.  An important difficulty, especially in the Republican states that have not been supportive of offering such health insurance, is that in certain states (or counties within those states) there have been few health insurers competing with each other, and indeed often only one.  The exchanges are organized by state, and even when insurers decide to offer insurance cover within some state, they may decide to offer it only to residents of certain counties within that state.  The private insurers operate with an expensive business model, built typically around organizing networks of doctors with whom they negotiate individual rates for health care services provided.  It is costly to set this up, and not worthwhile unless they have a substantial number of individuals enrolled in their particular plan.

But one should also recognize that there is a strong incentive in the current Obamacare markets for an individual insurer to provide cover in a particular area if no other insurer is there to compete with them.  That is because the federal subsidy to a low-income individual subscribing to an insurance plan depends on the difference between what insurers charge for a silver-level plan (specifically the second lowest cost for such a plan, if there are two or more insurers in the market) and some given percentage of that individual’s household income (with that share phased out for higher incomes).  What that means is that with no other insurer providing competition in some locale, the one that is offering insurance can charge very high rates for their plans and then receive high federal subsidies.  The ones who then lose in this (aside from the federal taxpayer) are households of middle or higher income who would want to purchase private health insurance, but whose income is above the cutoff for eligibility for the federal subsidies.

The result is that the states with the most expensive health insurance plan costs are those that have sought to undermine the Obamacare marketplace (leading to less competition), while the lowest costs are in those states that have encouraged the Obamacare exchanges and thus have multiple insurers competing with each other.  For example, the two states with the most expensive premium rates in 2019 (average for the benchmark silver plans) were Wyoming (average monthly premium for a 40-year-old of $865, before subsidies) and Nebraska (premium of $838).  Each had only one health insurer provider on the exchanges.  At the other end, the five states with the least expensive average premia, all with multiple providers, were Minnesota ($326), Massachusetts ($332), Rhode Island ($336), Indiana ($339), and New Jersey ($352).  These are not generally considered to be low-cost states, but the cost of the insurance plans in Wyoming and Nebraska were two and a half times higher.

The competition of a Medicare-managed public provider would bring down those extremely high insurance costs in the states with limited or no competition.  And at such lower rates, the total being spent by the federal government to support access by individuals to health insurance will come down.  But to achieve this, Congress will have to allow such competition from a public provider, and management through Medicare would be the most efficient way to do this.  One would still have any private providers who wish to compete.  But consumers would then have a choice.

C.  Allow Medicare to Compete in the Market for Employer-Sponsored Health Insurance Cover

While the market for individual health insurance cover is important to extending the availability of affordable health care to those otherwise without insurance cover, employer-sponsored health insurance plans account for a much higher share of the population.  Excluding those with government-sponsored plans via Medicare, Medicaid, and other such public programs, employer-sponsored plans accounted for 76% of the remaining population, individual plans for 11%, and the uninsured for 14%.

These employer-sponsored plans are dominant in the US for historical reasons.  They receive special tax breaks, which began during World War II.  Due to the tax breaks, it is cheaper for the firm to arrange for employee health insurance through the firm (even though it is in the end paid for by the employee, as part of their total compensation package), than to pay the employee an overall wage with the employee then purchasing the health insurance on his or her own.  The employer can deduct it as a business expense.  But this has led to the highly fragmented system of health insurance cover in the US, with each employer negotiating with private insurers for what will be provided through their firm, with resulting high costs for such insurance.

As many have noted, no one would design such a health care funding system from scratch.  But it is what the US has now, and there is justifiable concern over whether some individuals might encounter significant disruptions when switching over to a more rational system, whether Medicare-for-All or anything else.  It is a concern which needs to be respected, as we need health care treatment when we need it, and one does not want to be locked out of access, even if temporarily, during some transition.  How can this risk be avoided?

One could manage this by avoiding a compulsory switch in insurance plans, but rather provide as an option insurance through a Medicare-managed plan.  That is, a Medicare-managed insurance plan, similar in what is covered to current Medicare, would be allowed to compete with current insurance providers, and employers would have the option to switch to that Medicare plan, either immediately or at some later point, as they wish, to manage health insurance for their employees.

Furthermore, this Medicare-managed insurance could serve as a core insurance plan, to be supplemented by a private insurance plan which could cover costs and health care services that Medicare does not cover (such as dental and vision).  These could be similar to Medicare Supplement plans (often called a Medigap plan), or indeed any private insurance plan that provides additional coverage to what Medicare provides.  Medicare is then the primary insurer, while the private supplemental plan is secondary and covers whatever costs (up to whatever that supplemental plan covers) that are not paid for under the core Medicare plan.

In this way, an individual’s effective coverage could be exactly the same as what they receive now under their current employer-sponsored plan.  Employers would still sponsor these supplemental plans, as an addition to the core Medicare-managed plan that they would also choose (and pay for, like any other insurance plan).  But the cost of the Medicare-managed plus private supplemental plans would typically be less than the cost of the purely private plans, due to the far greater efficiency of Medicare.  And with this supplemental coverage, one would address the concern of many that what they now receive through their employer-sponsored plan is a level of benefits that are greater than what Medicare itself covers.  They don’t want to lose that.  But with such supplemental plans, one could bring what is covered up to exactly what they are covering now.

This is not uncommon.  Personally, I am enrolled in Medicare, while I have (though my former employer) additional cover by a secondary private insurer.  And I pay monthly premia to Medicare and through my former employer to the private insurer for this coverage (with those premia supplemented by my former employer, as part of my retirement package).  With the supplemental coverage, I have exactly the same health care services and share of costs covered as what I had before I became eligible for Medicare.  But the cost to me (and my former employer) is less.  One should recognize that for retirees this is in part due to Medicare for the elderly receiving general fiscal subsidies through the government budget.  But the far greater efficiency of Medicare that allows it to keep its administrative costs low (at just 2.4% of what it spends, with the rest going to health care service providers, as compared to a 12% cost share for private insurance) would lead to lower costs for Medicare than for private providers even without such fiscal support.

Such supplemental coverage is also common internationally.  Canada and France, for example, both have widely admired single-payer health insurance systems (what Medicare-for-All would be), and in both one can purchase supplemental coverage from private insurers for costs and services that are not covered under the core, government managed, single-payer plans.

Under this proposed scheme for the US, the decision by a company of whether to purchase cover from Medicare need not be compulsory.  The company could, if it wished, choose to remain with its current private insurer.  But what would be necessary would be for Congress to remove the restriction that prohibits Medicare from competing with private insurance providers.  Medicare would then be allowed to offer such plans at a price which covers its costs.  Companies could then, if they so chose, purchase such core cover from Medicare and additionally, to supplement such insurance with a private secondary plan.  One would expect that given the high cost of medical services everywhere (but especially in the US) they will take a close look at the comparative costs and value provided, and choose the plan (or set of plans) which is most advantageous to them.

Over time, one would expect a shift towards the Medicare-managed plans, given its greater efficiency.  And private plans, in order to be competitive for the core (primary) insurance available from Medicare, would be forced to improve their own efficiency, or face a smaller and smaller market share.  If they can compete, that is fine.  But given their track record up to now, one would expect that they will leave that market largely to Medicare, and focus instead on providing supplemental coverage for the firms to select from.

D.  Avoiding Cherry-Picking by the Private Insurers

An issue to consider, but which can be addressed, is whether in such a system the private insurers will be able to “cherry-pick” the more lucrative, lower risk, population, leaving those with higher health care costs to the Medicare-managed options.  The result would be higher expenses for the public options, which would require them either to raise their rates (if they price to break even) or require a fiscal subsidy from the general government budget.  And if the public options were forced to raise their rates, there would no longer be a level playing field in the market, effective competition would be undermined, and lower-efficiency private insurers could then remain in the market, raising our overall health system costs.

This is an issue that needs to be addressed in any insurance system, and was addressed for the Obamacare exchanges as originally structured.  While the Trump administration has sought to undermine these, they do provide a guide to what is needed.

Specifically, all insurers on the Obamacare exchanges are required to take on anyone in the geographic region who chooses to enroll in their particular plan, even if they have pre-existing conditions.  This is the key requirement which keeps private insurers from cherry-picking lower-cost enrollees, and excluding those who will likely have higher costs.  However, this then needs to be complemented with: 1) the individual mandate; 2) minimum standards on what constitutes an adequate health insurance plan; and 3) what is in essence a reinsurance system across insurers to compensate those who ended up with high-cost enrollees, by payments from those insurers with what turned out to be a lower cost pool (the “risk corridor” program).  These were all in the original Obamacare system, but: 1) the individual mandate was dropped in the December 2017 Republican tax cut (after the Trump administration said they would no longer enforce it anyway);  2) the Trump administration has weakened the minimum standards; and 3) Senator Marco Rubio was able in late 2015 to insert a provision in a must-pass budget bill which blocked any federal spending to even out payments in the risk corridor program.

Without these measures, it will be impossible to sustain the requirement that insurers provide access to everyone, at a price which reflects the health care risks of the population as a whole. With no individual mandate, those who are currently healthy could choose to free-ride on the system, and enroll in one of the health care plans only when they might literally be on the way to the hospital, or, in a less extreme example, only aim to enroll at the point when they know they will soon have high medical expenses (such as when they decide to have a baby, or to have some non-urgent but expensive medical procedure done).  The need for good minimum standards for health care plans is related to this.  Those who are relatively healthy might decide to enroll in an insurance plan that covers little, but, when diagnosed with say a cancer or some other such medical condition, then and only then enroll in a medical insurance plan that provides good cover for such treatments.  The good medical insurance plans would either soon go bankrupt, or be forced also to reduce what they cover in a race to the bottom.

Finally, risk sharing across insurers is in fact common (it is called reinsurance), and was especially important in the new Obamacare markets as the mix of those who would enroll in the plans, especially in the early years, could not be known.  Thus, as part of Obamacare, a system of “risk corridors” was introduced where insurers who ended up with an expensive mix of enrollees (those with severe medical conditions to treat) would be compensated by those with an unexpectedly low-cost mix of enrollees, with the federal government in the middle to smooth out the payments over time.  The Congressional Budget Office estimated in 2014 that while the payment flows would be substantial ($186 billion over ten years) the inflows would match the outflows, leaving no net budgetary cost.  However, Senator Rubio’s amendment effectively blocked this, as he (incorrectly) characterized the risk corridor program to be a “bailout” fund for the insurers.  But the effect of Rubio’s amendment was to lead smaller insurers and newly established health care coops to exit the market (as they did not have the financial resources to wait for inflows and outflows to even out), reducing competition by leaving only a limited number of the large, deep pocket, insurers who could survive such a wait, and then, with the more limited competition, jack up the insurance premia rates.  The result, as we will discuss immediately below, was to increase, not decrease, federal budgetary costs, while pricing out access to the markets of those with incomes too high to receive the federal subsidies.

Despite these efforts to kill Obamacare and block the extension of health insurance coverage to those Americans who have not had it, another provision in the Obamacare structure has allowed it to survive, at least so far and albeit in a more restrictive (but higher cost) form.  And that is due to the way the system of federal subsidies are provided to those of lower-income households in order to make it possible for them to purchase health insurance at a price they can afford.  As discussed above, these federal subsidies cover the difference between some percentage of a household’s income (with that percentage depending on their income) and the cost of a benchmark silver-level plan in their region.

More specifically, those with incomes up to 400% of the federal poverty line (400% would be $49,960 for an individual in 2019, or $103,000 for a family of four) are eligible to receive a federal subsidy to purchase a qualifying health insurance plan.  The subsidy is equal to the difference between the cost of the benchmark silver-level plan and a percentage of their income, on a sliding scale that starts at 2.08% of income for those earning 133% of the poverty line, and goes up to 9.86% for those earning 400%.  The mathematical result of this is that if the cost of the benchmark health insurance plan goes up by $1, they will receive an extra $1 of subsidy (as their income, and hence their contribution, is still the same).

The result is that measures such as the blocking of the risk corridor program by Senator Rubio’s amendment, or the Trump administration’s decision not to enforce (and then to remove altogether) the individual mandate, or the weakening the standards of what has to be covered in a qualifying health insurance plan, have all had the effect of the insurance companies being forced to raise the insurance premium rates sharply.  While those with incomes up to 400% of the poverty line were not affected by this (they pay the same share of their income), those with incomes higher than the 400% limit have been effectively priced out of these markets.  Only those (whose incomes are above that 400%) with some expensive medical condition might remain, but this then further biases the risk pool to those with high medical expenses.  Finally and importantly, these measures to undermine the markets have led to higher, not lower, federal budgetary costs, as the federal subsidies go up dollar for dollar with the higher premium rates.

So we know how to structure the markets to ensure there will be no cherry-picking of low risk, low cost, enrollees, leaving the high-cost patients for the Medicare-managed option.  But it needs to be done.  The requirement that all the insurance plans accept any enrollee will stop this.  This then needs to be complemented with the individual mandate, minimum standards for the health insurance plans, and some form of risk corridors (reinsurance) program.  The issue is not that this is impossible to do, but rather that the Trump administration (and Republicans in Congress) have sought to undermine it.

This discussion has been couched in terms of the market for individual insurance plans, but the same principles apply in the market for employer-sponsored health insurance.  While not as much discussed, the Affordable Care Act also included an employer mandate (phased in over time), with penalties for firms with 50 employees or more who do not offer a health insurance plan meeting minimum standards to their employees.  There were also tax credits provided to smaller firms who offer such insurance plans.

But the cherry-picking concern is less of an issue for such employer-based coverage than it is for coverage of individuals.  This is because there will be a reasonable degree of risk diversification across individuals (the mix of those with more expensive medical needs and those with less) even with just 100 employees or so.  And smaller firms can often subscribe together with others in the industry to a plan that covers them as a group, thus providing a reasonable degree of diversification.  With the insurance covering everyone in the firm (or group of firms), there will be less of a possibility of trying to cherry-pick among them.

The possibility of cherry-picking is therefore something that needs to be considered when designing some insurance system.  If not addressed, it could lead to a loading of the more costly enrollees onto a public option, thus increasing its costs and requiring either higher premia to subscribe to it or government budget support.  But we know how to address the issue.  The primary tool, which we should want in any case, is to require health insurers to be open to any enrollees, and not block those with pre-existing conditions.  But this then needs to be balanced with the individual mandate, minimum standards for what qualifies as a genuine health insurance plan, and means to reinsure exceptional risks across insurers.  The Obamacare reforms had these, and one cannot say that we do not know how to address the issue.

E.  Conclusion

These proposals are not radical.  And while there has been much discussion of allowing a public option to provide competition for insurance plans in the Obamacare markets, I have not seen much discussion of allowing a Medicare-managed option in the market for employer-sponsored health insurance plans.  Yet the latter market is far larger than the market for private, individual, plans, and a key part of the proposal is to allow such competition here as well.

Allowing such options would enable a smooth transition to Medicare-managed health insurance that would be available to all Americans.  And over time one would expect many if not most to choose such Medicare-managed options. Medicare has demonstrated that it is managed with far great efficiency than private health insurers, and thus it can offer better plans at lower cost than private insurers currently do.  If the private insurers are then able to improve their competitiveness by reducing their costs to what Medicare has been able to achieve, then they may remain.  But I expect that most of them will choose to compete in the markets for supplemental coverage, offering plans that complement the core Medicare-managed plan and which would offer a range of options from which employers can choose for their employer-sponsored health insurance cover.

Conservatives may question, and indeed likely will question, whether government-managed anything can be as efficient, much less more efficient, than privately provided services.  While the facts are clear (Medicare does exist, we have the data on what it costs, and we have the data on what private health insurance costs), some will still not accept this.  However, with such a belief, conservatives should not then be opposed to allowing Medicare-managed health insurance options to compete with the private insurers.  If what they believe is true, the publicly-managed options would be too expensive for an inferior product, and few would enroll in it.

But I suspect that the private insurers realize they would not be able to compete with the Medicare-managed insurance options unless they were able to bring their costs down to a comparable level.  And they do not want to do this as they (and their senior staff) benefit enormously from the current fragmented, high cost, system.  That is, there are important vested interests who will be opposed to opening up the system to competition from Medicare-managed options.  It should be no surprise that they, and the politicians they contribute generously to, will be opposed.

The Savings from Lower Administrative Costs in a Medicare-for-All System

 

A.  Introduction

One of the most important issues facing the US is our high cost of health care.  We have a terribly inefficient system, with the highest costs in the world (reaching 18% of GDP, which is 50% more than in the second most expensive country and close to double the average of the OECD countries), yet with only mediocre results compared to other countries.  It is a market-based system, with competing health care providers (doctors, hospitals, and so on) and competing private health insurance companies.  However, the extremely wide variation in prices for the same treatments and procedures (often varying by a factor of ten or more) is a clear sign that this market is not working as it should.  And those skilled at exploiting these inefficiencies are able to profit handsomely, with CEOs and other senior staff of the major private insurance companies paid well.  Indeed, total compensation packages have occasionally even topped $100 million.

Despite so much spending, the US is still far from providing affordable access to health care for our entire population.  While the situation improved substantially following the introduction of Obamacare (with the share of the US population without any form of health insurance falling by about 40% after Obamacare went into effect), the Trump administration is doing all it can to reverse these gains.

Faced with these issues, a number of analysts and politicians (Senator Bernie Sanders as just the most prominent) have proposed that the US move to what is termed a “single-payer” system, such as what they have in Canada, France, and a number of other countries.  In a single-payer system, doctors, hospitals, and healthcare service providers remain as they are now, as independent and typically private agents serving their patients.  The only difference is that there is only one insurer, run as a government agency.  This is what the US has in the popular Medicare system, but Medicare is restricted only to those aged 65 and above.  Hence in the US context, a single-payer system for all is often referred to as “Medicare-for-All”.

A key question is whether a Medicare-for-All system would reduce the high cost of healthcare in the US.  Those opposed to any such government managed programs have argued that costs would rise.  And they have issued reports with headline findings that can only be interpreted as being deliberately misleading.  For example, in late July, Charles Blahous (a former Bush administration official) issued an analysis through the Mercatus Center of George Mason University (a center that has received major funding from the Koch Brothers) that concluded government spending would rise by $32.6 trillion over ten years under a Medicare-for-All system.  This has received a good deal of press coverage, and is being used (as I write this) in a number of ads being televised by Republican candidates in the 2018 midterm elections.

But while worded carefully, this claim is misleading in the extreme.  First of all, that such high amounts will be spent on health care should not be a surprise, when added up over ten years.  Total US health care spending is expected to reach $3.7 trillion this year, would rise to $5.7 trillion by 2026 if nothing is done, and would total $45.0 trillion over the ten-year period of 2017 to 2026 (using National Health Expenditure data and forecasts, which will be discussed in detail below).  The portion of this covered by various forms of personal health insurance (both private and public, such as Medicare, but excluding the military and the VA) is expected to reach $2.7 trillion this year, $4.2 trillion by 2026, and would sum to $33.1 trillion over the ten years 2017 to 2026.

So high amounts will be spent on health care, unless measures are taken to improve efficiency and reduce costs.  In per capita terms, the US population will be spending in 2018 an average of $8,190 per person through the various forms of personal health insurance our system currently employs.  This is, without question, a lot.  It will be an estimated 17.9% of the median wage this year.  But if we had the far lower administrative costs that Medicare has been able to achieve for the health insurance it manages directly, instead of the significantly higher administrative costs incurred under a variety of mostly private health insurance plans (discussed below), the average per capita cost would be just $7,480 per person in 2018.  There would also be other savings (such as what health care providers will enjoy from a simplified system, which we will also discuss below), but the savings from those sources, while certainly significant, are harder to estimate.  The $7,480 figure simply reflects savings from lower administrative costs on the part of the insurers if we were able to achieve what Medicare already does.

Thus the correct question is whether we should prefer sending a check for $8,190 per person to Aetna, Cigna, United Healthcare, and the other insurers (and including what is paid through taxes for Medicare and other publicly managed insurance), or a check for $7,480 just to Medicare under a Medicare-for-All system.  The doctors we see would be the same, and the treatments and procedures would also be the same as what we have now.  The savings here is purely from more efficient administration of our health insurance.  That the check in one case goes just to the government, and in the other to a mix of private and public insurers, should not be, in itself, of consequence.  But the Blahous argument, in saying that we cannot afford the $32.6 trillion he forecasts for healthcare spending over ten years, is that for some reason a larger check (of $8,190) to our current mix of insurers is fine while we cannot afford to send instead a smaller check (of $7,480) if that check goes to a government entity.  This is silly.

For the nation as a whole, the savings from the greater efficiency of a Medicare-for-All system is substantial.  As we will see, it would add up to $204 billion in 2016, had this system been in place that year, growing to $365 billion by 2026.  For the ten year period from 2017 to 2026, the savings would sum to $2.9 trillion.  This is not a small sum.

This main point is that we should look at the data, and not presume certain outcomes based on ideology or political beliefs.  We will thus start in this blog post with an examination of what administrative costs actually are, for Medicare and for private insurance.  We will see that the cost for administering Medicare, for the portion of Medicare managed directly by government, is far less than what is spent to administer other health insurance, including in particular private health insurance.  There are many reasons for this, where the most important is the relative simplicity and scale of the Medicare system.  An annex to this blog will discuss in detail what these various factors are for the different health insurance systems that could be folded into a Medicare-for-All system.  We will also discuss in that annex why Medicare is able to achieve its far lower administrative costs, and address some of the arguments that have mistakenly asserted that this is not the case, despite the evidence.

Taking the administrative costs that Medicare has been able to achieve as a base, we will then calculate what the savings would add up to, per year for the US as a whole, under a Medicare-for-All system.  The basic result is depicted in the chart at the top of this post, and as noted above, the savings from greater administrative efficiency would rise from $204 billion in 2016 (had the system been in place then) to $365 billion in 2026.

These savings are substantial.  But there are also other savings, which are, however, more difficult to estimate.  The penultimate section of this post will discuss several.  They include savings that will be possible in the administrative and clerical costs at doctor’s offices and at hospitals and other healthcare facilities.  Doctors, hospitals, and other facilities must hire specialist staff to deal with the complex and fragmented system of insurance in the US, and the costs from this are substantial.  There will also be savings on the part of employers, who must now manage and oversee the contracts they have with private insurers.

A final, concluding, section will summarize the key issues and discuss briefly why such an obvious and large saving in costs has not been politically possible in the US (at least so far).  The short answer:  Vested interests profit substantially under the current fragmented system, and it should not be a surprise that they do not want to see it replaced.  With extra spending in the hundreds of billions of dollars each year, there is a lot to be gained by those skilled at operating in this fragmented system.

B.  The Cost of Administering Current Health Insurance Plans

It is often difficult to estimate what costs and savings might be under some major reform, as we do not yet know what will happen.  But this is not the case for estimating administrative costs for health insurance.  We already have excellent data on what those costs actually are for a variety of different health insurance providers, including Medicare.

The primary sources of the data are the National Health Expenditure Accounts (NHE), produced annually by the Centers for Medicare and Medicaid Services, and the Annual Report of the Medicare Trustees.  The current NHE (released in February 2018) provides detailed historical figures on health expenditures (broken down in numerous ways) through to 2016, plus forecasts for many of the series to 2026.  And the Annual Report of the Medicare Trustees (with the most recent released in June 2018), provides detailed financial accounts, including of government administrative costs, for the different components of Medicare and the supporting trust funds (with past as well as forecast expenditures and revenues).

Table 19 of the historical tables in the most recent NHE provides a detailed break down of health care expenditures in 2016 by payer (mostly various insurance programs, both public and private).  The expenditures shown include what is spent on administration by government entities (separately for state and federal, although I have aggregated the two in the table below), and for what they term the “net cost of health insurance”.  The net cost of private health insurance includes all elements of the difference between what the private insurer receives in premium payments, and what the insurer pays out for health services provided by doctors, hospitals, and so on.  Thus it includes such items as profits earned by the insurer.  For simplicity, I will use “administrative costs” to include all these elements, including profits, even though this is a broad use of the term.

Table 19 of the NHE shows Medicare expenditures for all components of Medicare on just one line.  While it shows separately the administrative costs incurred by government in the administration of Medicare (with all of it federal, as states are not involved), and the administrative costs (as defined above) incurred by private insurers for the Medicare programs that they manage, the NHE does not show separately which of those costs (government and private) are linked to which Medicare programs.

For those figures one must turn to the Medicare Trustees Annual Report.  Medicare Parts A and B are managed directly by Medicare officials, and provide payments for services by hospitals (Part A) and doctors (Part B).  Medicare Part C (also now called Medicare Advantage) is managed by private insurers on behalf of Medicare, and cover services that would otherwise be covered by Medicare directly in Medicare Parts A and B.  And the relatively recent Medicare Part D (for prescription drugs) is also managed by private insurers, either as a stand-alone cover or folded into Medicare Advantage plans.

Any such combination of numbers from two separate sources will often lead to somewhat different estimates for those figures that can be compared directly with each other.  There might be slight differences in definitions, or in concepts such as whether expenses are recorded as incurred or as paid, or something else.  But the figures which could be compared here were close.  In particular, the figure for total Medicare expenditures in calendar year 2016 was $678.8 billion in the Trustees report and $672.1 billion in the NHE, a difference of just 1%.  Of greater relative importance, the Trustees report has a figure for government administration (for all Medicare programs combined) of $9.3 billion, while the NHE has a figure of $10.5 billion.  However, while the difference between these two figures may appear to be large, what matters is not so much the difference between these two, but rather the difference (as a share of total costs) between either of these and the much higher cost share for privately managed insurance (as we will see below).  We will in any case run scenarios in Section C below with each of the two different estimates for government administrative costs in Medicare, and see that the overall effect of choosing one rather than the other is not large.

Based on these sources, the costs paid in 2016 under most of the major health insurance programs in the US were:

Current Expenditures for Health Care and for Administrative Costs 

   2016 data ($ billions)

Gross Cost

Gov’t Admin

Private Admin

Total Admin

Total   as %

Private Health Insurance

$1,123.4

$129.6

$129.6

11.5%

Medicare:

$678.8

    Gov’t Administered

$390.7

$9.3

$9.3

2.4%

    Privately Administered

$288.1

$36.3

$36.3

12.6%

Medicaid

$565.6

$24.2

$36.1

$60.3

10.7%

CHIP (Children’s Health Insurance Program)

$16.9

$1.5

$1.4

$2.9

17.3%

Worker’s Compensation

$50.7

$2.3

$16.4

$18.8

37.0%

Total: 

$2,435.3

$37.4

$219.8

$257.2

10.6%

* Medicare Gov’t Admin –   NHE estimate

$390.7

$10.5

$10.5

2.7%

Sources:  Medicare expenditures, other than private administrative costs, are from the 2018 Medicare Trustees Annual Report.  All other figures are from the NHE accounts, Table 19 (historical), released in February 2018.

 

The table leaves out the health care programs of the Department of Defense and the Veterans’ Administration (as they operate under special conditions, with many of the services provided directly), as well as a number of smaller government and other programs (such as for Native Americans, or worksite or school-based health programs).  Those programs have been set aside here due to their special nature.  But while significant, the $2,435.3 billion of expenditures in the programs listed in the table account for 89% of the total spent in the US in 2016 on all health care services to individuals covered through either some form of health insurance or third-party payer.  While some portion of the remaining 11% could perhaps be folded into a Medicare-for-All system (thus leading to even higher savings), we will focus in this post on the 89%.

The table shows that the administrative cost ratios vary over a wide range, from just 2.4% for the health insurance Medicare administers directly (using the Medicare Trustees figures, or 2.7% based on the NHE figures), up to 37% for the administration of the health portions of Workers’ Compensation.  The administrative cost for direct private health insurance is 11.5% on average, while the administrative cost for the privately managed portions of Medicare (Medicare Part C and Part D) is a similar, but somewhat higher, 12.6%.

This wide variation in administrative cost ratios provides clues on what is going on.  These will be discussed in the Annex to this post for those interested.  Briefly, the programs (other than government-administered Medicare) are complex, fragmented, have to make case by case assessments of whether the claim is eligible (as for Workers’ Compensation plans) or whether the individual meets the enrollment requirements (as for Medicaid and CHIP – the Children’s Health Insurance Program), and do not benefit from the scale economies that Medicare enjoys.

But while such explanations are of interest in understanding why Medicare can be provided at such a lower cost than private and other insurance, the key finding, in the end, is that it is.  The data are clear.  The next section will use this to calculate what overall savings would be at the national level if we were to move to a system with the cost efficiencies of Medicare.

C.  National Savings in Administrative Costs from a Medicare-for-All System

Medicare (for the portion managed directly by government) costs far less to administer than our current health insurance system with its complex and fragmented mix of plans (most of which are privately managed).  Only 2.4% of the cost of the portion of Medicare managed directly by government was needed for administration of the program in 2016, while the costs to administer the other identified health insurance programs range between 10.7% (for Medicaid) and 11.5% (for private health insurance) to 37% (for workers’ compensation plans).  With $2.4 trillion spent on these health insurance plans (in 2016), the savings from a more efficient approach to administration will be significant.

An estimate of what the nation-wide savings would be can then be calculated based on figures in the NHE forecasts of health expenditures (by health insurance program) for the 2017 to 2026 period (Table 17 of the forecasts), coupled with the Medicare system forecasts provided in the Medicare Trustees Annual Report.  Applying the share of administrative costs in the portion of Medicare managed directly by government (2.4% in 2016, but then using the year by year forecasts of the Medicare trustees for the full forecast period), rather than what the administrative cost ratios would have been for the other programs that would be folded into a Medicare-for-All system (private health insurance, Medicaid, CHIP, and Workers’ Compensation), using their 2016 cost ratios, yields the savings shown in the chart above.

Had a Medicare-for-All system been in effect in 2016, we would have saved $204 billion in administration, with this growing over time (with the overall growth in health expenditures over time) to an estimated $365 billion by 2026.  The savings over ten years (2017 to 2026) would be $2.9 trillion, and would by itself bring down the cost of health care (for the programs covered) from a ten year total of $33.1 trillion forecast now, to $30.2 trillion with the reform.  There would be other savings as well (discussed in the next section below), but they are more difficult to quantify.  However, a very rough estimate is that they could be double the magnitude of the savings from the more efficient administration of health insurance alone.  See the next section below for a discussion.

The calculations here required a mix of data from the NHE and from the Medicare Trustees report, and as I noted above, the estimates of the cost of government administration in these two sources were not quite the same.  The Medicare Trustees report gave a figure for government administrative costs of the overall Medicare system of $9.3 billion in 2016 (and then year by year forecasts going forward to 2026), while the NHE estimate was $10.5 billion in 2016.  As shown in the last line of the table above, the $10.5 billion figure would lead to an administrative cost share of 2.7%, compared to the 2.4% figure if the cost was at the NHE figure of $10.5 billion.  The savings in moving to a Medicare-for-All system would then not be as large.

But the impact of this would be small.  One can calculate what the cost savings would be assuming government administration would cost 2.7% rather than the 2.4% figure in the Medicare Trustees report (with also its forecasts going forward), using the same process as above.  The total national savings would have been $199 billion in 2016 rather than $204 billion, growing to savings of $345 billion in 2026 rather than $365 billion.  The ten-year total savings would be $2.7 trillion rather than $2.9 trillion.  The savings under either estimate would be large.

D.  Other Efficiency Savings in a Medicare-for-All System 

The $2.9 trillion (or $2.7 trillion) figure for savings over ten years from moving to a Medicare-for-All system comes solely from the lower administrative costs that we know can be achieved in a Medicare type system – we know because we know what Medicare in fact costs.  But there are other savings as well that will be gained by moving to this simpler system, and this section will discuss several of them.  How much would be saved is more difficult to estimate, so we have kept these savings separate.  But some rough figures are possible.

But before going to these other sources of efficiency gains, we should mention one possible source of lower costs which has often been discussed by others, but which I would not include here.  It has often been asserted that Medicare pays doctors, hospitals, and other health service providers, less than what other insurance plans pay.  But first, it is not clear whether this is in fact true.  It might be, but I have not seen reliable data to back it up.  The problem is that most of what is paid to doctors, hospitals, and others by private health insurance plans is now at network negotiated rates, and these rates are kept as trade secrets.  It is not in the interest of the doctors and other health care providers to reveal them (as it would undermine their bargaining power with other insurers), nor in the interest of the insurance companies to reveal them (as other insurers would gain a competitive advantage in their negotiations with the providers).  Indeed, secrecy clauses are common in the negotiated agreements.

In the absence of such publicly available data, one is limited to citing either anecdotal cases, or statements by various health care providers who have a vested interest in trying to persuade Medicare to pay them more.  Neither will be reliable.

But second, and aside from this difficulty in knowing what the truth really is, the focus in this blog post is solely on the gains that could be achieved by moving to a more efficient system.  If doctors and hospitals are indeed paid less under Medicare, costs would go down, but this would be in the nature of what economists call a transfer payment, not an efficiency gain.  Efficiency gains come from being able to do more with less (e.g. administer more at a lower cost).  Transfers are a payment from one party to another, with no net gain – the gain to one party is offset by a loss of the same amount to the other.

Excluding such transfers (if they in fact exist), what are other efficiency gains that one would obtain with a Medicare-for-All system (other than the gains from lower administrative costs for the health insurance itself, which we estimated above)?  There are several:

a)  Doctors offices now need to employ specialists in handling billing, who are able to handle the numerous (and often changing) health insurance plans their patients are enrolled in.  These specialists are critical, and good ones are paid well, as they are needed if the doctors want to be paid in full for the services they provided.  Based on personal experience, I am often amazed that the staff good at this are indeed able to stay on top of the numerous health insurance plans they must deal with (I find it difficult enough to stay on top of just my own).  While essential to ensuring the doctors can survive financially, such staff are a significant cost.  While one will still need to ensure proper billing under any Medicare-for-All system, it would be far simpler.

b)  Similarly, hospitals and other medical facilities need to employ such specialist staff to handle billing.  The same issues arise.  They must contend with numerous health insurance plans, each with its own set of requirements, and ensure the bills they file with the insurers will compensate the facilities properly (and from their perspective most advantageously) for the services provided.  This is not easy to do under the present highly complex system, and would be far simpler under Medicare-for-All.

c)  There are also costs that must be borne by employers in managing the primarily employer-based health insurance system used in the US.  The employer must work out which health insurance provider would work best for them, negotiate a complex but critical and expensive contract, and then oversee the insurer to ensure they are providing services in accordance with that contract.  Firms must often hire specialist (and expensive) consultants to advise them on how best to do this.  With the cost of healthcare so high in the US, these health insurance contracts are costly.  It is important to get them right.  But all this necessary oversight is also a major cost for the firm.

How much might then be saved from such sources by moving to a more efficient Medicare-for-All system?  This is not so easy to estimate, but one study looked at the costs in the US from such expenses and compared them to similarly measured expenses in Canada, which has a single-payer system.  As noted above, a Medicare-for-All system is a single-payer system, and thus (along with the other similarities between the US and Canadian economies, such as the similar levels of income) the difference between what the costs are in the US and the costs in Canada for the same services can provide an estimate of how much might be saved by moving to a single-payer, Medicare-for-All system.

The study was prepared by Steffie Woolhander (lead author – Harvard Medical School), along with Terry Campbell, and David Himmelstein, and was published in the New England Journal of Medicine, August 2003.  They drew from a variety of sources to arrive at their estimates, and some had to be approximate.  The data is also from 1999 – almost 20 years ago.  Things may have changed, but with the upward trend in costs over time in the US, the cost shares now are likely even worse.  The authors presented the basic figures in per capita terms (and all in US dollars), and I have scaled them up to what they would be in 2016 (assuming the shares are unchanged) in accordance with the overall growth in US personal health care spending (from the NHE accounts).

The results are:

Admin costs 1999/2016

Per capita in $

Per capita in $

Per capita     in $

Total in $ billion

US –    1999

Canada – 1999

US excess – 1999

US excess – 2016

Insurance overheads

$259

$47

$212

$156.9

Doctors, hospitals, other

$743

$252

$491

$363.3

    Doctors only

$324

$107

$217

$160.6

    Hospitals & other facilities

$419

$145

$274

$202.8

Employers’ admin costs

$57

$8

$49

$36.3

Total:

$1,059

$307

$752

$556.5

Total excluding Insurance overheads

$399.6

Source:  Calculated from Woolhander, Campbell, and Himmelstein, “Costs of Health Care Administration in the United States and Canada”, New England Journal of Medicine, 349: 768-775, August 21, 2003.

Note:  “Insurance overheads” exclude health insurer profits as well as certain expenses (such as for advertising and marketing).

 

The first three columns show the estimated spending in per capita terms (and in US dollars) for each category of costs, for the US, for Canada, and then for the difference between the two.  US spending is always higher.  Thus, for example, for the line labeled “doctors”, the authors estimate that doctor’s offices have to spend an average of $324 per every US resident for expenses related to billing and other dealings with health insurance companies in 1999.  The cost in Canada with its single-payer system, in contrast, is on average just $107 per resident (in US dollar terms).  The difference is $217 per person, in 1999.  Grossing this up to the US population, and rescaled to total health care expenditures in the US in 2016 relative to 1999, the excess cost in the US in 2016 is an estimated $160.6 billion.  This is what would be saved in the US in 2016 if doctor’s offices were able to manage their health insurance billings with the same efficiency as they can in Canada.

The other lines show the estimated savings from other sources.  The top line is for insurance overheads.  The estimate here is that the US would have been able to save $156.9 billion in 2016 if health insurance administration were as efficient as what is found in Canada with its single-payer system.  While on the surface this appears to be less than the $204 billion savings estimated (for 2016) if the US moved to a Medicare-for-All system, they are in fact consistent.  The estimate in Woolhander, et. al., of the excessive cost of health insurance administration excludes what is paid out in insurance company profits and certain other expenses (such as advertising and marketing).  As discussed in the Annex below, insurance company profits can add one-third to administrative costs, so a $150 billion cost would become $200 billion when one uses the same definitions for what is encompassed.  The two estimates are in fact surprisingly consistent, even though very different approaches were used for the estimation of each.

Overall, the US would have saved about $400 billion (excluding the savings from lower expenses at the insurance companies) had a single-payer system been in effect in 2016, according to these estimates.  That is double the estimated $204 billion in savings from lower administration costs at the health insurers alone, estimated in the section above.  These additional cost savings from moving to a Medicare-for-All system are clearly significant, but are often ignored in the debate on how much would be saved from efficiency gains in a Medicare-for-All system.  They are (I would acknowledge) rough estimates.  They cannot be estimated with the same precision as one can for the savings from the more efficient administration of health insurance alone under a Medicare-for-All system.  But neither should they be forgotten.

E.  Summary and Conclusion

Medicare is a well-managed and popular program.  It is a single-payer system, but currently restricted to those aged 65 and above.  And administrative costs, on that portion of Medicare managed directly by government, are only 2.4%.  This 2.4% is far below the 11.5% administrative cost share for regular private health insurance, or 12.6% for that portion of Medicare that is managed through private health insurance companies.

And even with such low costs, Medicare is a popular program, where numerous surveys have found Medicare to be more highly rated (including in terms of user experiences with the program) than private health insurance plans (see, for example, here, here, here, and here).

Creating a Medicare-like system to cover also those Americans below the age of 65 would not be difficult.  We already have the model of Medicare itself to see what could be done and how such a system can be managed.  And we also have the examples of other countries, such as Canada, that show that such systems are not only feasible but can work well.  It is also not, as conservative critics often assert, a government “takeover” of healthcare (a criticism also often used in attacks on Obamacare):  Under a single-payer system, the providers of health care services (doctors, hospitals, and so on) remain as they are now, as private or non-profit entities, competing with each other in the services they offer.

Nor would an extension of health insurance under a Medicare-like system to those below age 65 lead to issues for the current Medicare system.  This has now become an attack line being asserted in numerous Republican political campaigns this fall, including in a signed piece by President Trump published on October 10 by USA Today.  This was in essence a campaign ad (but published for free), which fact checkers immediately saw contained numerous false statements.  As Glenn Kessler noted in the Washington Post, “almost every sentence contained a misleading statement or a falsehood”.

There is no reason why extending a Medicare-like system to those below age 65 should somehow harm Medicare.  The cost for the health insurance for those below age 65 would be paid for by sending the checks we currently must send to private insurers (such as Aetna or United Healthcare), instead to the new single-payer insurer.  As noted above, with such an entity copying the Medicare management system and achieving its low administrative costs, we would have been able to reduce the average per person cost of healthcare in 2018 from the $8,190 we are paying now, to $7,480 instead, a savings of $710 for each of us.  That $7,480 would still need to be paid in, but it is far better to send in $7,480 to the single-payer (for the same health care services as we now receive) than to send in $8,190 to the mix of insurers we now have.

Furthermore, these savings are solely from the more efficient administration of health insurance that we see can be done in Medicare.  There will also be very substantial savings from other sources in a Medicare-for-All system, including in what doctors and hospitals must now spend to deal with our currently highly fragmented and complex health insurance system, and savings by employers in what they must spend to manage their employer-based private health insurance plans.  The magnitude of such additional savings are more difficult to estimate, but they might be on the order of double the size of savings from the more efficient administration of the health insurance itself.  That is, total savings in 2016 might have been on the order of $600 billion, or three times the $200 billion in savings from more efficient administration of health insurance alone.

And such savings (or rather the lack of it under our current complex and fragmented system) can account for a significant share of the far higher cost of health care in the US than elsewhere.  As noted before, health care costs about 18% of GDP in the US, or 50% more than in the second most expensive country where it is just 12%.  Had the US been able to save $600 billion in health care expenditures in 2016 by moving to a Medicare-for-All system, US healthcare spending would have been reduced from 18% of GDP to below 15% (more precisely, from 17.9% in 2016 to 14.7%).  This, by itself, would have gotten us over halfway to what other countries spend.  More should be done, to be sure, but such a reform would be a major step.

So why has it not been done?  While the lower costs under a Medicare-for-All system would be attractive to most of us, one needs also to recognize that those higher costs are a windfall to those who are skilled at operating within our complex and fragmented system.  That is, there are vested interests who benefit under the current system, and the dollar amounts involved are massive.  Private health insurers, and their key staff (CEOs and others), profit handsomely under this system, and it should not be surprising that they lobby aggressively to keep it.  Under a Medicare-for-All system, there would be no need (or a greatly reduced need, if some niches remain) for such private health insurance.

This is not to deny that there will be issues in any such transition.  Just the paperwork involved to ensure everyone is enrolled properly will be a massive undertaking (although for all those currently enrolled in some health insurance plan, mostly via employer-based plans, the paperwork could presumably be transferred automatically to the new program).  Nor can one guarantee that while on average health care consumers will save, that each and every one will.  But the same is true in any tax reform, where even if taxes on average are being cut, there are some who end up paying more.

One should also acknowledge that many doctors and hospitals are concerned that in a Medicare-for-All system they will have little choice but to agree to the Medicare-approved rates for their services.  However, it is not clear this is much different from the current system for the doctors, where they must either agree to accept the in-network rates negotiated with the private health insurers, or expect few patients.  And surveys of doctors on their support for a Medicare-for-All system show a turnaround from earlier opposition to strong support.  A survey published in August 2017 found 56% of physicians in support (and 41% opposed), a flip from the results of a similar survey in 2008 (when only 42% were in support, and 58% opposed).  A key reason appears to be the costs and difficulties (discussed above) doctors face in dealing with the multiple, fragmented, insurance plans they must contend with now.  Even the American Medical Association, a staunch opponent of Medicare when it was approved in the 1960s, and an opponent ever since, may now be changing its views.

Finally, 70% of Americans now support a Medicare-for-All system, according to a recent Reuters survey.  It is time for such a system.

 

 


Annex:  The Causes of the Wide Variation in Administrative Cost Shares

a.  The Wide Range of Administrative Cost Shares

Administrative cost shares vary enormously across different health insurance programs, from just 2.4% for government-managed Medicare to 37% for health insurance provided through Workers’ Compensation plans.  The figures are shown above in the top table in the post.  Some might say that this cannot be – that they are all providing health insurance so why should the differ by so much.  But they can and they do, and this annex will discuss why.

Take the case of Workers’ Compensation first.  Workers’ Compensation insurance was established by states in the US starting in 1902 (Maryland was the first).  Most states passed laws between 1910 and 1920 requiring businesses to arrange for such insurance, and by 1920 all but five states (all in the South) had such coverage (and by 1948 all states had it).  And in most (but not all) states, health care benefits are provided through the purchase of privately managed insurance.

But these programs are expensive to administer.  Each individual claim must be scrutinized to determine that it was in fact due to a covered workplace injury.  This leads to the extremely high (37%) administrative cost share.  If the injury is indeed covered, the workers’ compensation insurance arranged by the business will pay for the associated health care costs.  But if it is not, the injury will now normally be covered by the individual’s regular health care insurance.  The treatment is still needed, and is provided.  The issue is only who pays for it.

Hence the time and effort spent to ascertain whether the injury was in fact due to a covered workplace injury is a pure social cost, and would not be needed (at least for the health care treatments) in a Medicare-for-All system.  The injuries would still be treated, but funds would not need to be spent to see whether the costs can be shifted from one insurer to a different one.  And when each individual claim must be assessed (with many then rejected), the administrative costs for Workers’ Compensation plans can be a high share of what is in the end paid for healthcare treatments.

When workers’ compensation programs were first set up, in the early 20th century, individual health insurance was not common.  Such health insurance (set up through employers) only began to be widespread during World War II, when the Roosevelt administration approved favorable tax treatment of such insurance by businesses (who were trying to attract workers, but were subject to general wage and price controls).  But workers’ compensation programs continue to exist, despite their high administrative costs.  And from the point of view of the private insurer providing the workers’ compensation cover, spending such money to assess liability for some injury makes sense, as (from the private perspective of the individual insurer) they would gain if the health treatment costs can be shifted to a different insurer.  But such expenditures do not make sense from the perspective of society as a whole.  They are just a cost.  And under a Medicare-for-All system the injury would simply be treated, with no need to ascertain if one insurer or a different one was responsible for making the payment.  Overall costs would be less, with the same health care treatments provided.

There are similar socially wasteful expenditures in other health insurance programs, which drive up their administrative costs.  CHIP (Children’s Health Insurance Program) has a relatively high administrative cost share (17.3% in 2016) in part because it is relatively small ($16.9 billion in expenditures in 2016, which can be compared to the $678.8 billion for Medicare), so it does not enjoy the economies of scale of other programs, but also because eligibility for the program must be assessed for each individual participating.  While rules vary by state, children and teens are generally eligible for CHIP coverage up to age 18, for families whose incomes are below some limit, but who are not receiving Medicaid (or in coordination with Medicaid in certain cases).  The CHIP insurance for the children and teens is then either free or low-cost, depending on family income.

Confirming that children to be enrolled under CHIP meet the eligibility requirements is costly.  Hence it is not surprising that this (along with the lack of the economies of scale that larger programs can take advantage of) leads to the relatively high share for administrative costs.  But this eligibility question would not be an issue that would need to be individually assessed in a Medicare-for-All system.  It is a socially wasteful expenditure that is required only because the program needs to confirm those enrolled meet the specific eligibility requirements of this narrow program.  And a Medicare-for-All system would of course enjoy huge economy of scale advantages.

Medicaid also has to bear the cost of assessing whether eligibility requirements have been met, and certain states are indeed now making those eligibility requirements even more burdensome and complex (in the apparent hope of reducing enrollment).  Most recently, the Trump administration in early 2018 issued new rules allowing states to impose work requirements on those enrolled in Medicaid, and several states have now started to impose such restrictions.  But such requirements are themselves costly to assess.  While enrollment in Medicaid may then fall (leading to the health care costs of those individuals being shifted on to someone else), administrative costs as a share of what is spent will rise.  But from the point of view of society as a whole, shifting the cost of health treatment for those individuals who would otherwise be enrolled in Medicare on to someone else does not save on the overall cost of health care.  And indeed, if it shifts such treatment from doctor’s offices to treatment in emergency rooms, the cost will go up, and probably by a lot.

This would no longer be an issue in a Medicare-for-All system.  There would be no need to waste funds on assessing whether the individual meets the eligibility requirements of some specific health insurance program or another.

Despite such special costs. the overall costs of administration for Medicaid were 10.7% in 2016.  This is a bit below the cost for regular private insurance of 11.5%, and probably reflects the significant economies of scale Medicaid is able to benefit from.  And while a significant share of the Medicaid administrative costs are incurred by private insurers contracted to manage the Medicaid programs in many of the states ($36 billion of the $60 billion total for administration according to the NHE figures), government itself takes on a significant share of the administration.  And the overall administrative cost combined is still less than what private health insurance requires (as a share).

b)  The Cost of Administering Private Health Insurance

Which brings us to the question of why private health insurance costs so much to administer, at 11.5% of the total paid for such insurance.  Medicare, when administered directly by government, has a cost of just 2.4%.  Why does private insurance cost so much more?

First, a note on terminology.  Up to this point, as we have discussed various government health insurance plans (such as Medicaid or CHIP), we have not had to distinguish the total cost of the health insurance plans (the total of what is paid out in benefits to health care providers, plus what is paid for administration) from the total paid for the insurance cover.  We need to be more precise for private insurance cover.  One has the total paid in any period (a year in these figures) in insurance premia by the subscribers, and the total in what is paid by the private insurer in each such period to cover benefits.  The NHE has estimates for each of these, and then calculates the difference between the two as the “net cost of health insurance”.  We have referred to this as a broad concept of administrative costs, as it includes any profits earned by the insurers as part of their current operations.  But private insurers have an additional source of earnings, and that is from revenues on invested capital.  Premia are paid upfront and benefits paid out later (in overall probabilistic terms), and an important source of income to insurers comes from what they earn on those funds as they are invested in various asset markets, such as stocks and bonds, real estate, commodities, and so on.

For private insurance we should therefore be clear that what we have so far referred to as the “total cost” of the health insurance is synonymous with the total premia paid (which some sources refer to as “underwriting revenue”).  Subtracting the total paid to health care providers under the insurance policies from the total paid in premia will then lead to the broad concept of administrative costs, including profits earned from the current period insurance operations.  On top of this, private insurers will generate earnings from investments on their accumulated capital (obtained, in part, from premia being paid in before benefits are paid out).  For the figures here we are excluding these latter earnings.  Such earnings will be on top of those obtained from their current insurance operations.

Why then, do private insurers incur administrative costs (as defined here) of 11.5% when government-administered Medicare has a far lower cost of just 2.4%?

There are a number of reasons.  First, private health insurance is a tremendously fragmented system, where health plans are mostly organized at the individual firm level.  This is costly, and the cost share varies systematically by firm size.  Administrative costs (including insurer profits) will typically range between 5 and 15% of the total paid for the insurance in firms with greater than 50 employees, between 15 and 25% in firms with fewer than 50 employees, and (in the period before the Obamacare market exchanges were set up) between 25 and 40% of the total for individuals seeking health insurance (see, for example, this report from the Commonwealth Fund).

These high and rising costs (in inverse direction to firm size) arise as there are significant fixed costs in setting up any such system at some firm, which leads to a high cost-share when there are fewer workers to spread it over.  Commissions paid to insurance brokers also play a role, as the use of brokers is typical and especially significant for the small-group market.  The Commonwealth Fund report cites figures indicating these commissions can account for 4 to 11% of the total in premia paid for insurance in such markets.  And in those cases where the insurers themselves take on the risk (as opposed to simply managing the claims process while the firm itself pays the claims – this is called “self-insurance”, and is typical in large firms with 1,000 employees or more, as it ends up cheaper for such firms), the insurers must then invest significant resources in assessing the risk of the pool of workers covered in order to price the policy appropriately.  The costs the insurance company will need to pay out will depend not only on the local cost of health care services (which can vary tremendously across different parts of the country), but also by the industry of the firm (as the health risks of the typical workers employed will vary by industry) and specifics of the firm being covered (such as the average age of the workers employed, the male/female ratio, and other such factors).

There are also high fixed costs of the insurers themselves under their business model.  They typically offer dozens of insurance plans, each with different features on what is covered and by how much.  And most of the plans are built around networks of care providers (doctors, hospitals, and so on) with whom they have individually negotiated “in-network” prices for subscribers of the particular health insurance plan.  These in-network prices can still vary tremendously (even by a factor of ten or more, for those I have been able to check with my own insurer, and all for the same metropolitan area), and are set through some negotiation process.  The price eventually agreed to reflects some balance in negotiating strength.  If you are a hospital chain that dominates in some metro area, you will be able to negotiate a price close to what you wish to charge as the insurer has to include hospital services.  Similarly, if you are an insurance company that dominates in some metro area, then the hospitals have to agree to charge something close to what you are willing to pay, as otherwise they will not have many patients.  And individual doctors operating in private practices will generally have very little negotiating power.

But such negotiations (for each and every health care provider, and then for each possible service) are expensive to carry out, regardless of the outcome.  And while some argue that such negotiations hold down the cost of health care, it is not at all clear that such is the case.  The US, after all and as noted before, has by far the most expensive health care services in the world (close to double the average in OECD countries, as a share of GDP), and yet achieves only mediocre results.  Furthermore, the actual volume of health care services provided in the US (as measured, for example, by doctor consultations per capita per year, or hospital beds per 1,000 of population, and so on) has the US at close to the bottom among OECD countries.  The problem is not excessive health care services utilized, but rather their high cost in the US.  Negotiated in-network pricing has not helped, and quite possibly (due to the resulting fragmentation into non-competing markets) has hurt.

This complex and fragmented system does lead, however, to high rewards to those who are good at operating in it.  Hence CEOs (and other senior staff) of insurance companies skilled at this are rewarded handsomely, with such CEOs typically receiving compensation of more than $10 million a year, and in some cases far more.  Indeed, as recounted in an earlier blog post, the CEO of UnitedHealth Care personally received total compensation of more than $1.3 billion over his 15-year tenure of 1991 to 2006 (even after the SEC forced him to forfeit stock options worth a further $620 million due to illegalities in how they were priced).  Such salaries are reflected in the administrative costs of the health insurance plans offered, and account for a substantial share of it.

Finally, this complex and fragmented market has also led to high profits for the private health insurance companies.  If this were due to the exceptional efficiency of certain of the health insurance firms as compared to others, all in a competitive market, then such high profits of such firms might be explained.  But there is no indication that health insurance markets operate anywhere close to what economists would call “perfect competition”.  The extremely wide variation in prices for the same health care services (often by a factor of ten or more) is a clear sign of markets that are nowhere close to perfectly competitive.

And the amount paid to cover such profits is high.  For example, an examination of health insurance markets in New York State found (in data for 2006) that profits from underwriting (i.e. excluding profits from capital invested) accounted for 4.9% of total underwriting revenue (the total premia paid) before taxes, or roughly one-third of the total 14.9% in administrative costs (including underwriting profits).  After taxes, it would be roughly one-quarter of the total.  Applying that ratio to the 11.5% administrative cost share found in the NHE accounts for the nation as a whole in 2016, the charge to cover profits would be close to 3% points.  That, by itself, would be greater than the 2.4% cost share for government-managed Medicare.

c)  The Cost of Administering the Portion of Medicare Managed Directly by Government

Why, then, does the portion of Medicare (Parts A and B) managed directly by government cost so little?  It is fundamentally because Medicare does not bear many of the costs discussed above for the other insurance plans, and can spread the costs that remain over a far larger enrollment base.  Specifically:

1)  Medicare enjoys huge economy of scale advantages:  The portion of Medicare managed directly by government is huge, at $390.7 billion spent in 2016 ($381.4 billion of which went to health care providers, and only $9.3 billion to administration).  And this is for a single plan.  Private health insurers instead each manage dozens of plans covering millions of firms (at rates which vary firm to firm, depending on the risk pool).

2)  Medicare does not have to make a determination for each individual claim as to whether it will be covered (as Workers’ Compensation plans must), nor whether the individual is eligible (other than whether they are of age 65 or more, and have paid the relevant premia and taxes).  That is, Medicare does not need to contend with the complex (and now being made increasingly complex) eligibility requirements for participants in Medicaid, CHIP, and other such programs.

3)  Medicare has one set of compensation rates, which doctors and hospitals accept or not.  The compensation rates vary by region and other such factors, but they are not individually negotiated each year with each of the possible providers.

4)  And Medicare does not have the costs private insurers need to pay to retain the CEOs and other senior staff who are skilled at operating within the fragmented US healthcare system, nor do they pay large amounts for marketing and such.  Nor does Medicare pay profits, and profits, as noted above, are high for private health insurers in the US.

It is this “business model” of Medicare which keeps its costs down.  It is a relatively simple model (relative to that of private insurers – no health care payment system is simple in an absolute sense), and enjoys great economies of scale.  Thus Medicare can keep its costs down, and needs to spend on administration only a fraction of what private health insurers spend.

d)  The Conservative Critics of Medicare Costs

There are critics who contend that Medicare costs are not in fact low.  These critics have issued analyses through such groups as the Heritage Foundation (conservative, with major funding from the Koch brothers), the Cato Institute (conservative – libertarian), lobby groups with a vested interest, and publications that link back to these analyses.  But these arguments are flawed.  Indeed, some of the responses to the assertions are so obvious that one must assume that ideology (a view that it is impossible for government to be more efficient) was the primary driver.

These critics make three primary arguments:

1)  First, several contend that Medicare does not pay for, nor include in its recorded administrative costs, the costs incurred by Social Security and other government agencies that provide services that are essential to Medicare’s operations.  For example, initial enrollment in Medicare at age 65 is handled through the Social Security Administration, and Medicare premia payments (for Parts B and D) are normally collected out of Social Security checks.

However, while it is true that Social Security provides such services to Medicare, it is not true that Medicare does not pay for this.  A simple look at the Medicare income and expenses tables in the Medicare Trustees Annual Report will show what those payments are.  For example, for fiscal year 2017, Tables V.H1 and V.H.2 (on pages 217 and 218 of the 2018 report) indicate that $980,805,000 was paid to the Social Security Administration under the Medicare HI Trust Fund (“Hospital Insurance”, for Part A) and $1,247,226,000 under the Medicare SMI Trust Fund (“Supplementary Medical Insurance”, for Parts B and D).  These are substantial amounts, and they are not hidden.

And the tables similarly show the amounts paid by Medicare (as components in its administrative costs) to other government agencies for services they provide to Medicare.  These include payments made to the FBI and the Department of Justice (for fraud and abuse control), to the Office of the Secretary of Health and Human Services (HHS, for oversight) as well as to other HHS offices (such as the Inspector General), to the US Treasury, and to a number of others.  They are all shown.  The conservative critics who assert Medicare expenses do not include payments for such services simply never looked.

2)  Second, the critics argue that while private insurers must raise the capital they need to fund their operations, and that that capital has a cost, the costs of funding Medicare’s “capital” are not counted but rather are hidden away in the overall government budget.

But this reflects a fundamental confusion on the capital requirements of established insurers, whether private or public.  Insurers are not banks.  Banks raise funds (at a cost) and then lends them out.  Insurers take in premia payments from those insured, and at some later time make payments out under the insurance policies for covered costs.  On average, the payments they make come later than the payments they receive in premia, and hence they have capital to invest.  That capital is invested in stocks and bonds, real estate, commodities, or whatever, they make a return on those investments, and that return is factored into, and can reduce (not raise), the premia they need to charge to cover their overall costs.

Private insurers hence generate earnings from their capital, as it is invested as an asset.  It is not a cost.  Furthermore, Medicare operates in fundamentally the same way as other insurers.  The Medicare Trust Funds (HI and SMI) reflect funds that have been paid in and not yet expended in covered claims or other expenses, and they earn interest on the balances in those trust funds (at the long-term US Treasury bond rate).  The accounting is all there to be seen, for those interested, in the Medicare Trustees Annual Report.

3)  Probably most importantly, the conservative critics of Medicare assert that it is incorrect to calculate administrative costs as a share of the total costs paid.  Rather, they say those costs should be calculated per person enrolled.  Since older people have far higher medical costs each year than younger people do (which is certainly true), they argue that the low administrative cost share seen in Medicare (when taken as a share of total costs) is actually a reflection of the high health care costs of the elderly.

But there are two problems with this.  First, when elderly people see doctors at a pace of say 10 times a year rather than perhaps once a year when younger, they will be generating 10 times as many bills that need to be recorded and properly paid.  Each bill must go through the system, checked for possible fraud, and then paid in the correct amount.  That will cost more, indeed one should expect it will cost 10 times as much.  And if anything, medical procedures are more complicated for the elderly (as they have more complicated medical conditions), so it should be expected that the costs to process the more complex bills will indeed go up more than in proportion to the amount spent.  The conservative critics assert the costs of administering this do not go up with the more frequent billing, but rather are the same, flat, rate per person regardless of how many, how complex, and how costly the medical interventions are that they have in any given year.

Second, one has data.  The Medicare Parts C (Medicare Advantage) and D (for drugs) are managed via private health insurers.  And this Medicare is for the same elderly population that government-managed Medicare covers.  If what the conservative critics assert is correct, then the cost of administering these privately-managed Medicare programs should be similar to the cost of administering the portion of Medicare that government manages directly.  But this is not the case.  Government-managed Medicare spent only 2.4% on administration in 2016, while privately-managed Medicare spent 12.6%.  These are far from the same.

Indeed, the 12.6% administrative cost share for the privately-managed portion of Medicare is similar to, but a bit more than, the 11.5% share seen with regular private health insurance.  This is what one would expect, where the somewhat higher cost share might well be because of the greater complexity of the medical interventions required for the elderly population.

The government-managed portion of Medicare has a far low administrative cost share than private health insurance.  The conservative critics have not looked at the data.

Health Insurance Coverage is Improving, Especially in States that Have Not Tried to Block It

health-insurance-cover-2008-to-2015-by-medicaid-states-census-bureau-sept-2016

 

A.    Introduction

The US Census Bureau released on September 13 this year’s editions of three reports which normally come out at about this time:  Its report on Income and Poverty in the United States, its report on Health Insurance Coverage, and its Supplemental Poverty Measure report, which provides figures on poverty when government transfer programs are taken into account.  They all cover the period through 2015.

The reports show exceptionally strong improvements in a range of measures of income and well-being.  To start, real median household incomes rose by an estimated 5.2% in 2015. There has never before been such a large jump in real incomes since this series first started being reported in 1967.  Perhaps more importantly than the overall gains, the Census Bureau data also show that the gains were widespread across income groups (with the poorest 10% decile in fact seeing the largest gains) as well as across race and ethnic groups.  It was not only the rich who saw an improvement.

I should hasten to add that these results are from just one year, and that they follow far less satisfactory results over the last several years.  Real household incomes plummeted in the 2008 downturn in the last year of the Bush administration, and were flat or fell further in most years since.  It should also be recognized that the Census Bureau figures are based on household surveys, and thus that there will be statistical noise (as the Census Bureau emphasizes).  It remains to be seen whether the positive news will continue.  But with labor markets now at or close to levels generally considered to be full employment, and with real wages now rising, it is likely there has been an improvement also in 2016. But we will only know a year from now what the survey results will be.

The Health Insurance Coverage report found that health insurance coverage also improved significantly in 2015, as it had also in 2014 but importantly not in the years before.  The big change in 2014 was of course the coming into effect of the Affordable Care Act (ACA, or ObamaCare) reforms, with the introduction of the market exchanges on which the previously uninsured could purchase insurance at a reasonable price, as well as the expansion of Medicaid coverage in a number of states (but not all).  There are now over 20 million more Americans who have health insurance coverage than had it in 2013, before ObamaCare went into effect.

Not surprisingly, the reports received a good deal of news coverage.  It was the lead front page article of the Washington Post the next day, for example.  Not surprisingly also, the White House released a summary of some of the key, highly positive, findings.  But while the news reports focussed on the strong income gains, and many also noted the health insurance gains, I have not seen a chart such as that above which shows the gains in historical context, and with the Medicaid expansion states and non-expansion states shown separately.  This post will discuss that chart and what is going on behind it.

B.  The Gains in Health Insurance Coverage Under ObamaCare

The chart above shows the percentage share of the population without health insurance coverage in each year from 2008 to 2015, with this shown separately for those states where Medicaid was permitted to expand (27 states plus Washington, DC, with the status taken as of January 1, 2015) and for those states that did not allow Medicaid to expand (23 states). The figures were calculated from the underlying data tables (the “HIC” series) used in the Census Bureau Health Insurance Coverage report.  The data series used here comes from the American Community Survey (ACS), which has an extremely large sample size which permits a meaningful state by state breakdown.  It asks whether the individual was uninsured at the time of the interview.

The Health Insurance Coverage report also presents figures at the national level obtained from a different survey called the Current Population Survey – Annual Social and Economic Supplement (CPS ASEC), which is undertaken each Spring. This survey has a smaller sample size than the ACS, which is fine for national level estimates but which does not suffice for state by state breakdowns (as one needs when looking at Medicaid coverage by state).  It also asks the somewhat different question of whether the individual had health insurance cover for the entire previous year, rather than on the date of the interview.

The share of the US population without health insurance coverage fell sharply in 2014 and again in 2015.  Using figures from the ACS, it had fluctuated modestly in the period from 2008 through 2013, rising from 14.6% of the population in 2008 to 15.5% as unemployment hit its peak in 2010, and then recovering slowly to 14.5% by 2013.  It then dropped sharply to 11.7% in 2014 and to 9.4% in 2015.  Critics of ObamaCare asserted at the start that the reforms did not and would not lead to more Americans being covered by health insurance.  That was certainly not the case.  By 2015, there were 20.7 million more Americans with health insurance cover than had it in 2013.  This is far from minor, and can make an immense difference in a family’s life.

The CPS ASEC figures also show a sharp drop in the share of the population without health insurance, with these figures quoted in many of the news reports one might see. With its differing definition of who is not covered (for the entire year, rather than on the date of the interview as in the ACS), the shares are somewhat lower, at 9.1% in 2015.  It fell from a 13.3% share in 2013 and a 10.4% share in 2014 in these estimates of the share of the population who did not have health insurance over the entire year.

By whichever measure, health insurance cover expanded sharply once the ObamaCare reforms entered into effect.  By the ACS measure, the share of the population without health insurance fell from 14.5% of the population in 2013 to 9.4% two years later, or by 5.1% points.  It can be expected to fall further, although not to zero.  Certain groups in the population (including certain immigrant groups) are not eligible for purchasing insurance through the ObamaCare market exchanges, and thus the non-insured rate will never go to zero.  While the floor is not certain, many analysts set the figure at perhaps 4 or 5% of the population.  If so, then the improvement seen so far is approximately half of what might ultimately be achievable, provided politically imposed roadblocks are all removed.

C.  Medicaid Expansion

The chart also shows the shares of the population without health insurance separately for the states that expanded Medicaid coverage (supported by the ACA and an integral part of it) and those that did not. The system as designed under the ACA has that the working poor and lower income classes would obtain health insurance under Medicaid, with eligibility expanded from those with income up to generally 100% of the federal poverty line previously, to 133% from 2014 onwards.  Those with incomes higher than this would purchase insurance from the market exchanges, with a subsidy that phases out as incomes grow and is phased out entirely at 400% of the federal poverty line.  Thus the entire population, no matter how poor, would be able to obtain health insurance.

However, the Supreme Court decided that Medicaid expansion could not be made obligatory on the states even if the federal government is paying for it (as it is here). Rather, the states could choose whether or not to allow Medicaid to expand cover to include those making up to 133% of the federal poverty line.  It would be financially foolish for the states not to, as the federal government would cover 100% of the cost of the expanded coverage in the first several years, with this then phasing down to 90% of the additional cost from 2020 onwards.  But even with the states covering 10% of the cost from 2020, a net gain can be expected for the state budget due to the increased incomes of hospitals, doctors, nurses, and other health car suppliers who would now be providing care to the poor when they need it (and be compensated for it), and the state tax revenues that would be generated by such higher incomes. The states would also save by being able to reduce state payments made to cover a portion of the costs incurred by hospitals to provide health services to patients who were not able to pay for their treatments, due to a lack of health insurance.

Despite this, 23 states (as of January 2015) decided that the low income earners in their states would not be allowed to receive health insurance cover from Medicaid.  Note that these families must indeed be working to be able to have an income of 100% of the federal poverty line (of $24,300 in 2016 for a household of four).  Assuming one wage earner, working 40 hours a week for 52 weeks a year (no vacations), they would need to earn a wage of $11.68 per hour to earn this much, or well above the minimum wage of $7.25 per hour.  More likely there would be two income earners in such a household, each earning a wage rate of closer to the minimum wage, but likely not able to obtain full time employment of 40 hours a week for 52 weeks a year.  These households are not slackers, but rather are working hard to get by.

Yet these states are refusing to allow such households to obtain health insurance cover from Medicaid, despite a net financial benefit to their state budgets.  And since the Affordable Care Act was structured that such families would obtain health insurance coverage from Medicaid, and not purchased (with a partial subsidy assistance) through the health insurance market exchanges, they are now left with nothing.  These states have deliberately created a gap where their low income workers are effectively denied access to health insurance.

The reason these states have done this is of course political.  The 23 states (as of January 1, 2015) that had not permitted Medicaid to expand were states with Republican governors or Republican legislatures (or mostly both) that refused to allow Medicaid in their states to serve such families.  And as noted above, this was done even at financial cost to themselves.  Nebulous arguments were given that while the federal government would be paying for most or all of the costs in the near term, the federal government might reverse this later, due perhaps to budget pressures.  But there is no reason why such a reversal should be expected, nor why, if there were indeed such budget pressures, it would apply to Medicaid but not to other federally funded programs that those states are taking advantage of.  Furthermore, if this did indeed happen at some uncertain point in the future, the Medicaid programs in the state could be cut then, rather than now in anticipation that this might somehow happen at some unknown point in the unknown future.

As shown in the chart at the top of this post, the share of the population without health insurance cover fell to just 7.2% in 2015 in the 27 states (plus Washington, DC) that allowed Medicaid to expand, far below the 12.3% in those states that blocked that expansion.  Compared to 2013, before the ObamaCare reforms went into effect, this was a reduction of 5.6% points in the states that allowed Medicaid to expand, versus a reduction of 4.5% points in the states where the expansion was blocked.  Put another way, the share of the population without health insurance fell by 43% in the states that allowed Medicaid to expand, versus a fall of just 27% in the states that blocked it.

Furthermore, the far better improvement in the Medicaid expansion states was from a lower starting point in 2013 (of 12.8% of their population without health insurance, versus 16.7% in the states blocking Medicaid expansion).  One should expect that improvement becomes more difficult as one comes closer to the achievable ceiling in coverage.

But the chart also serves to show that the states blocking Medicaid expansion historically had a high share of their populations without health insurance.  These were conservative states, often relatively poor, with political establishments that did not exhibit great concern over the fact that a high share of their population could not get health insurance.  But not all were poor.  Indeed, the state with the absolute worst share of any state was oil-rich Texas, with 22.1% of its population without health insurance in 2013, and still 17.1% without it in 2015 (where both figures were the highest in the US in the respective years). Out of 50 states (plus Washington, DC), Texas was the worst.  This was a political choice, not an economic one.

It should also be noted that the reduction in the shares of uninsured in those states that allowed Medicaid to expand was not due solely to the increased number of Medicaid enrollees.  Between 2013 and 2015, those states saw 12.2 million of their citizens obtain health insurance cover.  Of these, 7.6 million came from increased enrollment under Medicaid, while 4.5 million came from other health insurance cover (including through the ObamaCare market exchanges).  And as noted above, they were starting from a point where a relatively high share of their citizens (compared to the states where Medicaid expansion was blocked) enjoyed some form of health insurance cover previously.

D.  The States That Allowed Medicaid to Expand Also Had Lower Premiums on ObamaCare Health Insurance Plans than on Company-Based Plans

There is also an interesting finding that the states that allowed Medicaid to expand not only saw greater improvements in the shares of their citizens who enjoyed health insurance cover, but also saw insurance premiums on their ObamaCare exchanges (as of 2016) which were lower than comparable company-sponsored plans in those states.

recent study by the Urban Institute (a non-profit think tank) found that for similar health insurance cover, the full prices (before subsidies) of health insurance purchased through the ObamaCare exchanges were 10% lower on average (at the national level), than the full prices of similar health insurance plans provided through employers. The calculations were made state by state, as costs varied by state, and varied widely.  But on average, the ObamaCare plans cost 10% less.

This may be come as a surprise to many.  The issue is that most employees do not know what the full cost of their company-sponsored health insurance plans in fact is.  The full cost includes not only what they pay directly, but also what they pay indirectly through the employer (which they typically never see) as part of their overall labor compensation package.  But it is part of their wages and a cost that must be covered.

The 10% lower cost is an average at the national level.  But the Urban Institute figures are calculated at the state level, and one can calculate from this how they vary between those states that expanded their Medicaid coverage and those states that blocked it. The results are interesting.  The simple unweighted averages (I did not have the underlying data necessary to calculate a weighted average properly) were:

Health Insurance Plan Costs:  ObamaCare Exchanges vs. Company Based

Unweighted averages

All States      

 -8%

Medicaid Expanded

-15%

Medicaid Not Expanded

   0%

The unweight average lower cost of the ObamaCare plans was 8% nationally.  This is different from the 10% figure the Urban Institute cited because the lower costs were especially large in some of the larger states, such as New York, Illinois, Pennsylvania, Michigan, and Ohio (all of which had lower costs of 18% or more).  In the unweighted averages, these larger states are weighted the same as smaller states.

But what is especially interesting is that the (unweighted) average lower cost of the ObamaCare plans compared to company based plans was 15% in the states that approved Medicaid expansion but was no different on average in the states that blocked Medicaid expansion.

Why would this be?  It was probably not due to the Medicaid expansion itself.  One would expect Medicaid expansion would lead to lower health insurance costs for those obtaining health insurance.  The reason is that hospitals and other health service providers will have lower costs due to less uncompensated care of patients without health insurance coverage (as more would have Medicaid coverage), and one can expect that these lower costs would then be reflected in lower health insurance costs for those who do pay. However, this should affect health insurance costs of policies purchased through the ObamaCare exchanges and company-based policies similarly, and hence would not likely affect the ratio in cost between the two.

However, the Medicaid expansion states were also the ones that encouraged competitive ObamaCare market exchanges to be established.  They did not seek to block these markets or keep them from functioning well.  They encouraged competition rather than did whatever they could to hinder it.

It was likely due to this greater degree of competition in those states that supported, rather than hindered, the ObamaCare exchanges that explains the lower costs in those states. This is also consistent with the fact noted above that many of the larger states saw especially low costs (relative to company-based plans) than were observed among the relatively smaller states.  The larger states will in general see greater competition, and competition drives down prices.

E.  ObamaCare Issues Remain

One can no longer dispute that ObamaCare has succeeded in its primary goal of making it possible for a higher share of the population to obtain the security of health insurance coverage.  But this certainly does not mean there are no issues with ObamaCare.

Republicans openly acknowledge that they continue to do whatever they can to block the expansion of access to health insurance under ObamaCare.  And these efforts to hinder ObamaCare have achieved some success.  As noted above, states that blocked Medicaid expansion have seen less of a reduction in their uninsured populations than was achieved in the states that allowed that expansion.  But the efforts to block access to ObamaCare went beyond blocking Medicaid.  Most of these states also decided not to implement directly the ObamaCare market exchanges in their states.  The Affordable Care Act envisioned that to best allow local control and adaptation to a state’s particular circumstances, state level authorities would be allowed and indeed encouraged to establish such exchanges.  Fortunately, the law also included a back-up provision that should a state choose not to establish such an exchange, the federal government could do it to allow the citizens of that state access to an affordable health insurance plan.  This was not without difficulties; recall the initial failure of the federal level computer systems when enrollment opened in October 2013 and the system was overwhelmed.

More recently, several of the larger health insurers have decided to withdraw from some of the markets in which they had previously offered health insurance plans on the ObamaCare market exchanges.  Most recently, Aetna announced in August that it would withdraw in 2017 from 11 of the 15 states where it had been offering such plans.  This followed earlier announcements by UnitedHealth and Humana that they also would be scaling back offerings significantly.  This will reduce competition among the insurers in a number of markets around the country, limiting the options enrollees in those markets will have.  Indeed, in some counties around the country there will be only one insurer offering coverage through the exchanges, and (unless something is now done) one county in Arizona where there will be no such insurer offering coverage through the exchanges.

The issues could certainly be addressed, if there is the will.  All major new social programs, including Medicare and Social Security were fine-tuned through new legislation following their launch to address issues that developed.  And this was done on a bipartisan basis. The problem now is that the Republican Party, for political reasons, is doing what it can to block any such adjustments, with the openly stated aim of trying to destroy ObamaCare.

It is still to be seen whether these efforts will succeed.  If they do, the US will revert to its previous system, with millions of Americans denied access to health insurance and with sharply rising health care costs that outpaced general inflation for decades.

An Update on Progress in the Labor Market Recovery Under Obama

Cumul Private Job Growth from Inauguration to Oct 2015

Cumul Govt Job Growth from Inauguration to Oct 2015

A)  Introduction

The Bureau of Labor Statistics released on November 6 its most recent report on the state of the job market.  It was a strong report, with net job gains of 271,000 in October and the unemployment rate falling to 5.0%.  One should not, however, put too much weight on the figures in just one month’s report.  Indeed, the report for October followed relatively weaker reports in the two previous months.  Rather, one should put all these reports in the longer term context of how the labor market has moved in recent years.  And what they show is continued, and remarkably steady, improvement.

This post will look at that longer term context by updating several labor market charts that have been discussed in previous posts on this blog.  It will look first at net job growth in the private sector and in the government sector in the period since Obama’s inauguration, with a comparison to the similar period during George W. Bush’s term.  The post will then look at the continued fall in the unemployment rate, with a comparison to the similar period under Reagan, and finally to the share of part time workers in total employment.  The last is to see whether there is any evidence to support the assertion coming from Republican critics that Obamacare has led to a shift by employers to part time workers so that they can avoid providing health insurance in the overall wage compensation package for their staff.  We will find that there is no indication in the data that this has been the case.

B)  Total Job Growth

The charts at the top of this post show total net job growth, in the private sector and in the government sector, in the period since Obama’s inauguration (up to October 2015) and under Bush (for his two full terms).  They update similar charts discussed in several earlier posts on this blog, most recently from June 2014.

Private sector job growth has been strong under Obama, and continues to be.  And the record is clearly far better than that under the George W. Bush administration.  There has been a net increase of 9.3 million new private jobs under Obama since the month he was inaugurated, versus just 4.0 million new private jobs over the similar period in the Bush administration.  Furthermore, this 4.0 million additional private jobs was close to the peak achieved in the Bush years, before it started to fall and then plummet as the housing bubble burst and the economy collapsed in the last year of his second term.  By the end of his presidency there were fewer private jobs than there were on the day he was inaugurated, eight years before.

Obama faced this collapse in the jobs market as he took office.  The economy was losing 800,000 private jobs per month, with the economy contracting at the fastest pace since the Great Depression.  The new administration was able to turn this around with the stimulus package and with aggressive Fed actions, with the fall in employment first slowing and then turning around.  The result has been a net growth of 13.5 million new private jobs from the trough just one year into the new administration until now.

Government jobs, in contrast, have been cut.  This hurt total job growth both directly (government jobs are part of total jobs obviously) as well as indirectly.  Indirectly, the government job cuts (as well as the fiscal austerity that began in 2010) reduced demand for goods and hence production at a time when the economy was still depressed and suffering from insufficient demand to keep production lines going.  As discussed in an earlier post on this blog, without the fiscal austerity introduced from 2010 onwards the economy would have recovered from the economic downturn by 2013 and perhaps even 2012.  The initial stimulus package in 2009 turned things around.  It is unfortunate that the government then moved to cuts from 2010 onwards, which reduced the pace of the recovery.

It should be recognized that government jobs as recorded here include government jobs at all levels (federal, state, and local), with federal government jobs only a relatively small share of the total (12.4%).  But government jobs have fallen at all three levels, federal as well as state and local.

The cuts on government jobs during Obama’s time in office stand in sharp contrast to the growth in government jobs during Bush’s two terms.  Yet Obama is charged with being a big government liberal while the Republicans claim to be small government conservatives.

C)  The Rate of Unemployment

Unemployment Rates - Obama vs Reagan, up to Oct 2015After peaking at 10.0% in October 2009, the rate of unemployment has fallen at a remarkably steady pace under Obama (aside from the monthly fluctuations in the reported figures, which will in part be statistical noise as unemployment estimates come from household surveys).  This was discussed in this earlier post on this blog.  The record is certainly better than that under Reagan.  The unemployment rate is now 5.0%, while it was still 6.0% at the same point in the Reagan presidency.

Furthermore, Reagan was not confronted, as Obama was, with an economy in collapse as he took office.  Rather, unemployment began to rise only about a half year after Reagan took office, as he began to implement his new budgetary and other policies.  The unemployment rate then rose to a peak of 10.8% in late 1982 before starting to fall.  And while the recovery was then rapid for a period, supported by rising government spending, it stalled by mid-1984 with unemployment then fluctuating in the range of 7.0% to 7.5% for most of the next two years.  One does not see the steady improvement as one has had under Obama.

With the unemployment rate now at 5.0%, it is expected that the Fed will soon start to raise interest rates.  This would be unfortunate in my view (as well as that of many others, such as Paul Krugman).  Inflation remains low (only 0.2% over the past year for personal consumption expenditures for all goods, or 1.3% over the past year if one excludes the often volatile food and energy costs).  And while wages ticked up by 2.5% over the year before in the most recent BLS labor market report, this is still below the roughly 3 1/2% increases that would be consistent (after expected productivity gains in a normally functioning job market) with the Fed’s 2.0% inflation target.  And if wages are not allowed to rise faster than inflation, then by definition there will be no increase in real wages.

It is of course recognized that the rate of unemployment cannot fall forever.  There will always be some slack in the labor market as workers transition between jobs, and if the unemployment rate is too low, there will be excessive upward pressure on wages, and inflation can become a problem.  But where that “full employment rate of unemployment” is, is not clear.  Different economists have different views.  It does not appear to be at 5.0% under current conditions, as the rate of inflation remains low.  But whether it is at 4.5% or 4.0% is not clear.  At some point, it would be reached.

When it is, the pace of job creation will need to fall to match the pace of labor force growth (from population growth).  Otherwise, by simple arithmetic, the rate of unemployment would continue to fall.  And this cut in employment growth would be the objective of the Fed in raising interest rates:  It would be to slow down the pace of job growth to the rate that matches labor force growth.

Once the Fed does start to raise interest rates, one should then not be surprised, nor criticize, that the pace of job growth has slowed.  That is the aim.  And it will need to slow sharply from what the pace of job growth has been in recent years under Obama.  Over the past two years, for example, employment growth has averaged 236,000 per month. The labor force has grown at a pace of 101,000 per month over this period.  As a result, unemployment has fallen at a pace of 135,000 per month (= 236,000 – 101,000), with this leading the unemployment rate to fall to 5.0% now from 7.2% two years ago.  If unemployment is now to be kept constant rather than falling, the pace of job growth will need to fall by more than half, from 236,000 per month to just 101,000 per month (or slightly more, to be precise, taking into account the arithmetic of a constant unemployment rate).

I have no doubt that when this happens, and the pace of job growth slows, that Obama will be criticized by his Republican critics.  But this will reflect a fundamental confusion of what full employment implies for the labor market.

D)  Part-Time Employment as a Share of Total Employment

Part-Time Employment #2 as Share of Total Employment, Jan 2007 to Oct 2015

Finally, it is of interest to update the graph in an earlier post to see whether there is now any evidence that the Affordable Care Act (Obamacare) has led employers to fire their regular full time workers and replace them with part-timers, in order to avoid the mandate of including health insurance coverage in the wage compensation package they pay to their workers.  Conservative politicians and media asserted this as a fact (see the earlier blog post cited for several references).  But as discussed before, and as confirmed with the more recent data, there is no indication in the data that this has been the case. Indeed, the share of part time workers in the total has been falling at an accelerated pace in the most recent two years, at a time when the Obamacare insurance mandate provisions have come into effect.

The acceleration in the pace of this improvement is consistent with the improvement seen in the overall labor market over the past several years, as discussed above.  As the economy approaches full employment, those who are working part time (not by choice, but because they have no alternative) are able to find full time jobs.  The share of part-time workers in total employment is still somewhat above (at about 4%) what would be normal when the economy is at full employment (at about 3%), lending support to those arguing that while the labor market is improving, we are not yet at full employment (and the Fed should thus wait longer before it starts to raise interest rates).  But it is getting better.

I have also added to the graph a line (in red) showing what the share of part-time employment workers were in total employment during the Reagan years.  At the comparable time in his presidency, the share was higher than what it is now under Obama.  Furthermore, it had improved only slowly under Reagan over the three years leading up to that point.  Yet Reagan is praised by conservatives for his purportedly strong labor market.

E)  Conclusion

The labor market has improved considerably in recent years under Obama.  It could have been better had the government not turned to austerity in 2010, but even with the government cuts, job growth has been reasonably good.  The unemployment rate has now fallen to 5%, and it is expected the Fed will soon begin to raise interest rates in order to slow the pace of job creation.  One should not then be surprised if fewer net new jobs are created each month, nor criticize Obama when it does.  That will be precisely the aim of the policy.  But I strongly suspect that we will nonetheless hear such criticisms.

The Success of Obamacare: A Sharp Reduction in the Number of Americans Without Health Insurance

Health Insurance, % Without Coverage, 1999 to 2014, with 2013 -2014 scaled to US totals, ver 2 with gapA)  Introduction

The US Census Bureau released on September 16 its 2014 report on “Health Insurance Coverage in the United States”.  It provides the best estimate available on the share of the US population that is covered by health insurance, drawing on figures from both its Current Population Survey and its American Community Survey. The graph above was calculated from the underlying data used in the report (released by the Census Bureau along with it).

The new figures confirm that Obamacare has succeeded in sharply reducing the number of Americans who must suffer from lack of health insurance.  The results are consistent with those released earlier by other organizations, including from the commercial polling firm Gallup and from the non-profit Health Policy Center of the Urban Institute.  But the Census Bureau results are derived from larger and more comprehensive surveys than a commercial outfit such as Gallup or a nonprofit such as the Urban Institute can mount.

Gallup, the Urban Institute, and now the Census Bureau, have all found that health insurance coverage improved sharply in 2014, the first year in which the health insurance exchanges set up under Obamacare came into operation.  Also important was the expansion from the start of 2014 of Medicaid coverage in 26 of the 51 states plus Washington, DC.  The expansion, an integral part of the Obamacare reforms, raised eligibility from what had previously generally been 100% of the poverty line (there was some variation across states), to now include also the working close-to-poor who earn between 100% and 138% of the poverty line. Those earning more than 138% of the poverty line are eligible for federal subsidies (phased out with rising income) to purchase privately provided health insurance on the Obamacare market exchanges.

The improvement in health insurance coverage in 2014 (the decrease in the share with no insurance) is clear from these multiple sources.  And it should not be a surprise: The primary purpose of Affordable Care Act (aka Obamacare) was precisely to make affordable health insurance available to all.  Yet prominent political figures opposed to the act (such as the Republican Speaker of the House John Boehner, and Florida Senator Marco Rubio, now a candidate seeking the Republican presidential nomination) claimed that the Affordable Care Act had actually increased the net number of uninsured.  It was clear at the time that they did not understand some basics of insurance enrollment, and it is absolutely clear now that they were dramatically wrong in their assessments.  But I am not aware that any of these political critics have had the courage to admit that they had in fact been wrong.

There are some technical issues that arise in the Census Bureau numbers that should be understood, and these will be discussed below.  But the basic numbers are clear. Between 2013, before the Obamacare exchanges were in operation, and 2014, there was a sharp reduction in the share of the American population who had no health insurance cover.

This blog post will first review the basic results on improved health insurance cover with the start of the Obamacare reforms, and will then discuss some of the technical issues behind the numbers.

B)  The Reduction in the Number of Americans Without Health Insurance Following the Start of the Obamacare Reforms

The graph at the top of this post shows the Census Bureau numbers, as percentage shares of the population with no health insurance over the period 1999 to 2014. Unfortunately (and as will be discussed further below), the Census Bureau changed its methodology in 2013, so the 2013 and 2014 figures are not directly comparable with the figures for 1999 to 2012.  However, the 2013 and 2014 figures are directly comparable to each other, and show the sharp drop in the share of the population without health insurance in 2014 (the first year of the Obamacare market exchanges) compared to what it was before.

The share of the population without health insurance cover at any point in the calendar year fell from 13.3% in 2013 to 10.4% in 2014.  In terms of absolute numbers, the number of Americans without health insurance cover fell from 41.8 million in 2013 to 33.0 million in 2014, a reduction of 8.8 million or 21%.  The number of Americans with health insurance cover rose by 11.6 million, with this number different from the reduction in the number with no insurance cover (the 8.8 million) because the overall US population is growing. Furthermore, this was not (as some politicians have charged) solely a result of the Medicaid expansion.  While the Medicaid expansion was important, with an increase of 6.7 million enrolled in Medicaid (both under its prior program conditions, as well as under the expanded eligibility rules), the total number of Americans with some form of health insurance rose by well more than this.

The chart also shows the shares without health insurance separately for the group of states that as of January 1, 2014, had chosen not to take the federal money to expand Medicaid coverage to include the working close-to-poor (those earning between 100% and 138% of the poverty line).  Twenty-six states (all with a Republican governor or state legislature or usually both) decided not to expand Medicaid coverage to allow this segment of the population to obtain health insurance, despite the fact the additional costs would be covered 100% by the federal government for the first several years, with this then phased down to a still high 90% ultimately.  Even at the 90% federal cost share, the net cost to the state would not simply be small, but in fact negative.  Due to the higher state tax revenues that would be gained from what Medicaid would be paying hospitals, doctors, and nurses to provide health services to these close-to-poor, plus the lower state subsidies that would be needed at hospitals to cover a share of the cost of emergency room care that the uninsured must use when they have no alternative, the states would in fact come out ahead financially by accepting the Medicaid expansion.  Yet for purely political reasons, the Republican governors and legislators in these states refused to permit this Medicaid expansion, leaving this segment of the population with no health insurance cover.

It is also interesting to note from the chart at the top of this post that actions in this group of states to limit (or at least not facilitate access to) health insurance cover appear to have begun much earlier.  The shares of the population without access to any health insurance cover in those 26 states which as of January 1, 2014, had chosen not to expand Medicaid coverage, are shown as the red line in the chart.  The shares in the 25 states plus Washington, DC, that did decide to expand Medicaid coverage are shown in the blue line. In 1999 (the first year with comparable data in this series) and 2000, there was no such a discrepancy in health insurance cover between these two groups of states.  Indeed, in 1999 a slightly smaller share of the population had no insurance cover in the red states than in the blue states.  In 2000 the shares were almost identical.

But this then changed.  Starting in 2001, a consistent gap started to open up in the shares between the two groups of states, with fewer covered by insurance in the red states than in the blue.  The overall national trend for the share of those with no insurance cover was also upwards.  Why the gap between the two groups of states started to open up in 2001 and remain to this day is not fully clear, but it may reflect the trend to more conservative politics that started at that point (including the start of the Bush administration in 2001). The refusal to accept the Medicaid expansion (even at a cost to themselves), and other measures aimed at blocking Obamacare or at least make access more difficult (such as refusal to operate market exchanges at the state level), is in keeping with the observed deterioration in access to health cover in these states well prior to Obamacare ever being debated.

C.  Some Technical Notes

Estimates of the share of the population with or without health insurance cover come from surveys, and thus have the strengths and weaknesses of any surveys.  The accuracy of the results will depend on how well those being surveyed recall and answer correctly what they were asked.  The results will often depend on the way the questions are worded, and sometimes even on the sequence in which the questions are asked.  The Census Bureau recognizes this, continually tests its questionnaires, and periodically will change the way they ask their questions in a survey in an effort to obtain more accurate results.

Unfortunately, when there is such a change the new survey results will not be strictly and directly comparable with the responses provided in the past.  Often the Census Bureau will use various methods to try to link the different data series into one consistent whole, but this is not always done.  One way to do this, for example, would be to conduct two parallel surveys when there is to be a change, one following the old method and one following the new, and then with statistical methods to control for sample characteristics, seek to determine by how much the old series would likely need to be adjusted to become consistent with the new.

The Census Bureau did this when methodological changes were made in the series tracking health insurance coverage in 2007 and again in 2011.  When the 2007 changes were made, they went back and adjusted figures from 1999 onwards to approximate what they would be following the 2007 approach.  And when the 2011 changes were made, they again went back, to 1999 again, to produce a consistent series that eventually covered the period 1999 to 2012.

However, when the changes implemented in 2013 were made, the Census Bureau did not go back to adjust previous figures for consistency with the new approach.  I have found no explanation for why they have not, but would guess it might well be linked to budget cuts.  But for this reason, one cannot assume that the figures showing a reduced share of the population without health insurance in the 2013 figures compared to those in 2012, are necessarily due to more people enrolling in health insurance in 2013 relative to 2012. Hence the gaps in the lines in the graph as drawn above.

Indeed, other evidence suggests that coverage in 2013 was similar to that in 2012. Specifically, the Gallup numbers  previously cited indicate that share of uninsured in 2013 was actually a bit higher than where they were in 2012 (averaging what are quarterly estimates).  There was then a sharp fall in 2014 in the Gallup figures following the start of the Obamacare exchanges and the Medicaid expansion, consistent with the Census Bureau numbers.

It is unfortunate the Census Bureau did not try to work out a consistent series of estimates for health insurance coverage for this critical period.  But for whatever reason they did not (at least not yet).  But what we do know from the Census figures is that the share of the uninsured in the population was trending upwards over the 1999 to 2012 period, and that there was a sharp reduction in the share uninsured in 2014 compared to what it was in 2013.  And that is therefore all we could work with in this post.

Another issue is that the state by state figures were determined by the Census Bureau under one survey for the 1999 to 2012 period (the Annual Social and Economic Supplement to its Current Population Survey, or CPS-ASEC), but then a different survey for 2013 and 2014 (the American Community Survey, or ACS).  Both are large surveys, asking questions on a variety of issues.  But they ask somewhat different questions on the issue of health insurance coverage.  Specifically, the CPS-ASEC, which is undertaken between February and April of each year, asks the respondents whether they had had health insurance coverage at any point in the previous calendar year (separately for each household member).  The ACS survey, in contrast, is undertaken on a rolling basis throughout the year, and the question asked in that survey is whether each household member had health insurance cover at the time they were being interviewed.

These are of course different questions.  And by simple arithmetic, it should be clear that the responses to whether they had insurance at any point in the year will, for the sample as a whole, always be a higher figure than the share in response to the question of whether they have health insurance at the time of the interview.  Someone might not have health insurance at the time of the interview, but could have had it earlier in the year (or will obtain it later in the year).  The shares uninsured will be the mirror images of this.

The national figures for 2013 and 2014 were:

CPS-ASEC

ACS

No insurance at any

time in the calendar year

No insurance at the

time of the interview

2013

13.3%

14.5%

2014

10.4%

11.7%

The figures in the graph at the top of this post are based on the estimates of coverage at any point in the calendar year.  There was, however, a problem in determining on a consistent basis the underlying state figures, from which one could compute the shares for the states that had expanded Medicaid coverage and for those who had not.  The figures at the state level that the Census Bureau made available on its web site for the 1999 to 2012 period were from the CPS-ASEC series.  However, for some unexplained reason, but as part of the changes introduced with the new 2013 numbers, the state level figures for 2013 and 2014 were only made available under the ACS series.  I do not know why they did this, as it introduces another element of inconsistency when making comparisons across time.

Since the bulk of the state level series, for 1999 through to 2012, were published under the CPS-ASEC series, I used those as published.  But for 2013 and 2014, I determined the state totals for the Medicaid expansion and Medicaid non-expansion groups based on the ACS numbers (as they were the only ones available), and then rescaled the figures to fit the published national totals (working in terms of the underlying numbers, and then computing the shares).  The figures should be very close to what would have been worked out directly from the CPS-ASEC figures if they had been made available at the state level. One would expect the ratio of the figures of those without health insurance under the two different definitions (throughout the year or at the time of the interview) would not differ significantly between the two groups of states (those with and without the Medicaid expansion).

D)  Conclusion

Technical issues exist with any data set, and it is important to recognize what limitations such issues place on what one can infer from the figures.  Unfortunately, the Census Bureau numbers as published do not permit us to compare directly the 2013 and 2014 results to those of 1999 to 2012.  However, the 2013 and 2014 results are directly comparable to each other, and they clearly show that there has been a major improvement in health insurance coverage in 2014 after the Obamacare exchanges and Medicaid expansion came into effect.