Gas Prices are High, But Don’t Blame the Usual Suspects: Implications for Policy

A.  Introduction

Gasoline prices in the US (and indeed elsewhere) are certainly high.  Given that in the US much of the voting population views cheap gas as much of a right as life, liberty, and the pursuit of happiness, this has political implications.  It is thus not surprising that politicians, including those in the Biden administration, are considering a range of policy measures with the hope they will bring these gas prices down.  And while fuel prices have indeed come down some in the last few weeks from their recent peak, they remain high, and their path going forward remains uncertain.

One of the most common such measures, already implemented in six states (as of July 6) and under consideration in many more, has been to reduce or end completely for some period state taxes on fuels.  And President Biden on June 22 called on Congress to approve a three-month suspension of federal gas and diesel taxes.  The political attraction of such proposals is certainly understandable.  A Morning Consult / Politico public opinion poll in March found that 72% of those surveyed would favor “a temporary break from paying state taxes on gasoline”, and 73% would favor a similar “temporary break from paying federal taxes on gasoline”.  It is hard to find anything these days that close to three-quarters of the population agree on.

But would this in fact help to reduce what people are paying at the pump?  The answer is no.  One has to look at what led to the recent run-up in gas and other fuel prices, and only with a proper understanding of that can the appropriate policy response be worked out.  Cutting taxes on fuels should not be expected to lead to a reduction in what people pay at the pump for their gas.  Indeed, what could lower these prices would be to raise fuel taxes, and then use the funds generated to cover measures that would, in the near term, reduce the demand for these fuels.

This post will first examine the recent run-up in fuel prices, putting it in the context of how that market has functioned over the last decade and what is different now.  Based on this, it will then look at what the impact would be of measures such as cutting fuel taxes, releasing crude oil from the nation’s Strategic Petroleum Reserve, encouraging more drilling for oil, and similar.  None of these should be expected, under current conditions, to lead to lower prices at the pump.

Rather, one could raise fuel taxes and use these funds to support measures that would reduce the nation’s usage of gas.  For example, an immediate action that would be effective as well as easy to implement would be to encourage ridership on our public transit systems by simply ending the charging of fares on those systems.  One could stop charging those fares tomorrow – nothing special is needed.  Some share of those driving their cars for commuting or for other trips would then switch to transit, which would lead to a reduction in fuel demand and from this a reduction in fuel prices.  The lower price will benefit all those who buy gas, including those in rural areas who have no transit options.  And as will be discussed, the cost to cover what is being collected in fares would be really quite low.

A note on usage:  All references to “gas” in this post are to gasoline.  They are not to natural gas (methane) nor indeed any other gas.  Fuels will refer to gasoline and diesel together, where statements made with a specific reference to gas will normally apply similarly to diesel.

B.  The Rise in Fuel Prices and the Factors Behind It

Fuel prices have certainly gone up in the first half of 2022.  As shown in the chart at the top of this post, despite the fall in recent weeks fuel prices (the line in red) are still 75% above where they were in early-December (in June they were more than double), with those December 2021 prices double what they had been in October / November 2020.  Crude oil prices (the line in black) have also been going up, and have been since late 2020 (following the dip earlier in 2020 due to the Covid lockdowns).  This rise in the price of crude oil can explain the rise in the retail prices for fuels up through early this year.  But as we will discuss, the factors behind the more recent rise in fuel prices changed in late February 2022 – coinciding with Russia’s invasion of Ukraine.

First, some notes on the data.  The figures all come from the Energy Information Administration (EIA), part of the US Department of Energy, and weekly averages are used.  For reasons to be discussed below, the price of “fuel” is a 2:1 weighted average of the prices of regular unleaded gasoline (unleaded) and diesel (ultra low-sulfur no. 2), both wholesale FOB spot prices and for delivery at the US Gulf Coast.  While it is an average, this does not really matter much in practice as the wholesale prices of gas and diesel have not, at any point in time, differed by all that much from each other.  They move together.  Nor have their average prices over time differed by all that much.  For the period since the start of 2014, the average wholesale cost of gas was $1.81 per gallon while that for diesel was $1.90 – a difference of just 9 cents.  While there can be larger differences at various points in time, for the purposes here the distinction between the two fuels is not central.

The cost of crude oil (the line in black) is for West Texas Intermediate (FOB spot price, for delivery at Cushing, Oklahoma), the benchmark crude most commonly used in the US and also the basis for the main financial contracts used to hedge the price of oil in the US.  It is presented here on a per-gallon basis to make it comparable to the other prices, where one barrel of oil is equivalent to 42 gallons.

A refinery will purchase crude oil and then through various processes refine that oil into gasoline, diesel, and other petroleum products that can then be used as fuels by our cars and trucks as well for other purposes.  The difference in price between what the refinery can sell these finished products for and the cost of the crude it buys as the primary input is called the “crack spread”.  While the crack spread will be unique for each refinery, as it will depend on the technology it has (how modern and efficient it is), what types of crude it has been designed to process most efficiently (as different crudes have different characteristics, such as viscosity and sulfur content), the mix of specific products it produces (the share ending as gas or diesel, but also jet fuel, heating oil, etc.), and the location of the refinery (as the crude oil must be delivered to it, and it then must arrange for the delivery of its products to the ultimate purchasers), a simplified standard spread is often calculated to provide an indication of how market prices are moving.  The most common such standard spread is called the “3-2-1 crack spread”.

The 3-2-1 crack spread is calculated for a refinery that would process 3 barrels of crude oil into 2 barrels of gasoline and 1 barrel of diesel.  For the calculations here, all were expressed on a per-gallon basis, and the specific fuels and delivery locations are as specified above.  The 3-2-1 crack spread is then simply calculated as the value of two gallons of gasoline plus one gallon of diesel, minus the cost of three gallons of crude oil, with that total then divided by three as three gallons of fuel are being produced.  It is a gross spread, as a refinery will of course have other operational costs (including the cost of labor), plus the refinery will need to generate a return on the capital invested for it to be viable in the long term.  But this simple gross spread is often used as an indicator of what is happening in the market.

That calculated 3-2-1 crack spread is presented as the blue line in the chart at the top of this post.  From 2014 through 2021, it rarely moved above $0.50 per gallon, and it averaged just $0.36 per gallon over the period.  In 2021 it was not much higher, averaging $0.42 per gallon over the year.  But from late February 2022, coinciding with the Russian invasion of Ukraine, it has shot upward.  As of the week ending June 24 it had reached $1.46 per gallon, but as of the week ending July 8 it had come down to $1.02.  That is still high – it is still close to three times what it had averaged before.

To understand the factors that led to this jump in the crack spread this year, one should first consider how prices are determined in these markets.  The key is that the crack spread is not itself an independently determined price, but rather a spread between the price of the final product (gasoline and diesel fuels) and the price of crude oil, both of which are determined independently.

Start with the final products – gasoline and diesel:  These are sold in highly competitive markets of numerous gas stations pricing their product to sell at the best prices they can get, but where for the nation as a whole, stocks of the fuels are kept within a narrow range.  One can calculate (again from EIA data), that in recent years (2017 through 2022H1), the nation’s stocks of motor gasoline have averaged 236 million barrels, with no clear upward or downward trend.  While the stocks will vary over the course of the year due to seasonality, at comparable weeks in the year they have been kept in a relatively narrow range, with a standard deviation of just 2.1% of the weekly averages over this period.  This means (assuming a normal distribution, which is reasonable) that in about two-thirds of the weekly cases, the stocks will be within +/- 2.1% of the average for those weeks (one standard deviation), and in 95% of the cases will be within +/-4.2% of the averages (two standard deviations).  That is, the stocks are managed to stay within a relatively narrow range, although at a target level that depends on the season of the year.

In such a market, if producers (either directly or through the gas stations they contract with) price their gasoline at too low a price for the conditions of the time, they will find that their stocks will be running down – soon to unsustainable levels.  They would need to ration what they sell, either by long lines at the pumps or by some direct rationing system.  And if they price their gasoline at too high a price, they will find their stocks accumulating to levels that exceed what they can store.  They sell their gas for the highest price they can get, but that price will be constrained to be such that they will be able to manage their inventories of refined gasoline (and similarly for diesel fuels) to within a certain range.  And as noted above, that range is a narrow one of normally just +/- 2% or so.

Crude oil prices are determined differently.  Here there is a world market, where OPEC producers (as well as a few producers who cooperate with OPEC, where the most prominent is Russia) set production ceilings by OPEC member (and cooperative partner) with the aim of achieving some price target.  They do not always succeed in achieving that target, as global conditions can change suddenly.  Recent examples include conditions triggered by the Covid crisis in 2020, or by the global financial crisis that began in the US in 2008.  OPEC also responds sluggishly to changes in the markets, particularly when crude oil prices are rising – which many OPEC members are rather pleased with – as the production quotas must be negotiated among the members.  But it is correct to say that the market for crude oil is a managed one, although often not a terribly well managed one due to the inherent difficulty in forecasting global demands and then responding on a timely basis to unexpected changes.

With the retail price of the fuels determined on the one side by conditions in the competitive markets for fuels, and the price of crude oil determined on the other side by the actions of OPEC and those who cooperate with it, the crack spread will be a margin that has now been determined.  That is, it is not a price that the refiners themselves will normally be able to set.  There is a lower limit, as a gross crack spread that is too low to cover their other operating costs (and is expected to stay that low for some time), will lead refiners to shut down their operations.  But based on what we observe for the period from 2014 in the chart at the top of this post, it appears that a crack spread of $0.36 per gallon (the average from 2014 through 2021) is sufficient to cover such costs as well as provide a return on the capital invested, as refineries stayed open and continued to produce over this period with such a spread.

This spread then jumped in late February of this year – coinciding with the Russian invasion of Ukraine – to a level that has been between three and four times what it was before.  What happened?  While the Russian invasion was clearly significant, one should look at this in the context of where the market was just prior to the invasion.  It was tight, and the Russian invasion should be seen as a tipping point where refinery supplies of these fuels could no longer meet the demand.

First of all, demand has been growing, both in the US and in the rest of the world, as economies have recovered from the lockdowns that were necessary at the start of the Covid crisis.  The US enjoyed a particularly strong recovery in 2021, with real GDP growing by 5.7% – the fastest such growth in any calendar year in the US in close to 40 years.  And the personal consumption component of GDP rose by 7.9% in 2021 – the fastest such growth in any year since 1946!  But it should be recognized that this was coming after the sharp falls in 2020 due to Covid (of 3.4% for GDP and 3.8% for personal consumption).  The rest of the world recovered similarly in 2021, although at various different rates.

This raised the demand for gas, diesel, and other fuels.  Petroleum refineries could keep up in 2021, as this followed the lower demands they had for their products in 2020.  But the lower demands (and hence lower refinery throughputs) in 2020 due to Covid did have an effect.  It led to decisions to close some of that refinery capacity, leading to a reduction in capacity in 2021 for the first time in decades.  Albeit small, worldwide, refinery capacity fell from 102.3 million barrels per day in 2020 to 101.9 million barrels in 2021 (a fall of 0.4%).  Refinery capacity in the US fell similarly, from 18.1 million barrels per day in 2020 to 17.9 million barrels in 2021 (a fall of 1.1%).  With the recovery in demand for fuel products in 2021, this placed producers at closer to their limits.

But the limit to how much petroleum refineries can produce is pretty rigid.  They normally operate on a continuous, 24-hours a day, basis – at a rate as close as possible to their design capacity.  Thus they cannot increase production by adding an extra work shift or by running processes at a faster rate.  They do need to shut down periodically for preventive maintenance, as their systems are complex and they must deal with flammable liquids that are being processed at often high temperatures and pressures, where a failure of some part can lead to a catastrophic explosion.  They must also shut down on occasion for safety reasons, such as when a hurricane or other major storm threatens (an increasingly frequent occurrence in recent years in the US Gulf Coast, where much of the US refinery capacity is located, due to climate change – such weather-related shutdowns are discussed further below).  In general, then, refinery throughput is highly constrained in the short run by existing available capacity, which is being run continuously at as high a rate as they can.

Over the longer term, refinery capacity will depend on what investments are made to expand that capacity.  But new refineries cost billions of dollars, are rare, and when undertaken take many years to plan and then build.  Significant expansions in existing refineries are also very costly, and also require significant time to plan and then build.  Thus such investments are very carefully considered and are only made when they expect there will be a demand for the products of those refineries for many years to come – at least a decade or more.  It is not something they rush into.  Even if capacity is tight right now, such investments will not be made unless the owners expect those conditions to last for an extended time.  And even if the decision is made to make such an investment to expand capacity, it will normally take years before the added capacity will become available.

Thus in the near term, when one is already operating at close to the design limits of the refineries it will not be possible to supply much more than what the existing available capacity will allow.  Economists call this “inelastic supply”, as the percentage increase in supply of some product for some given percentage increase in the price that would be paid for that product (an “elasticity”) is low.  For refineries that are already operating at close to their technical limits, it will be very low.

The other factor in price determination is demand.  And for fuels such as gas or diesel, many will say the price elasticity of demand for such fuels is also low.  Indeed, a common view in the general population is that the price elasticity of demand for gas is zero – that they will have to buy the same number of gallons each week whatever the price is.  This is not really true (and contradicted by the assertion that they also cannot “afford” to pay more – if true, then at a higher price they will have to buy less).  But studies have found that while not zero, it is low.

For example, the Energy Information Agency in 2014 estimated the price elasticity of demand for gasoline in the US was just -0.02 to -0.04.  That is tiny.  It implies that if the price of gas were to rise by 10% (say from $4.00 to $4.40 per gallon), the demand for gas would decline only by 0.2 to 0.4%.  Other estimates that have been made have often been somewhat higher, although still low.  A widely cited review in 1998 by Molly Esprey, for example, examined 300 published studies, and found that the median estimate of this elasticity across those studies was -0.23.  This is still low.  It implies that a 10% increase in the price will be met by only a 2.3% fall in demand.

With a demand for fuel that does not go down by much when prices rise, and a supply for fuel that does not go up by much when prices rise (i.e. when refineries are already operating at close to their capacity), one should expect prices for fuels to be volatile.  And they are.  Even small shifts in the available supply or in the demand can lead to big changes in prices.

In these already tight markets of early 2022, Russia then invaded Ukraine on February 24.  The crack spread rose from $0.49 per gallon for the week ending February 25, to $0.64 the following week and to $0.74 the week after that.  It reached $0.88 by the end of March and $1.35 by the end of April.  As of the week ending June 24 it had reached $1.46, but then came down to $1.02 two weeks later.

The Russian invasion not only affected production at refineries in Ukraine, but international sanctions on Russia meant a significant share of Russian refineries would also no longer supply global markets.  While refineries in Ukraine are not a significant share of global capacity (just 0.2% in 2021), refineries in Russia are significant, with a 6.7% share of global capacity in 2021.  As a comparison, US refineries account for 17.6% of global capacity.

One should note that this does not mean that global capacity was effectively reduced by 6.7% of what it was.  Russian refineries continued to produce for their own markets, while also supplying others.  But the sanctions have reduced the volume effectively available by a significant amount.

In a market that was already tight, with refineries operating at close to capacity following the strong recovery demand in 2021 in the US and much of the world, such a reduction in effective supply acted as a tipping point.  The 3-2-1 crack spread shot up immediately.

C.  Policy Implications

What, then, can be done to reduce fuel prices?  I will take it as a given that that is the objective.  A case could well be made that to address climate change and the consequent need to reduce the burning of fossil fuels, high prices are good.  But while important, that is a separate issue I am not trying to address in this post.

First, where are gas prices now?:

The figures here are based on data gathered by the Bureau of Labor Statistics (BLS) for its calculations of the monthly CPI.  The figures are a consistent series going back to 1976 (further back than any other consistent series I have been able to find), are available in current price terms per gallon, and are not (here) seasonally adjusted so they reflect the actual prices paid that month.  And like the overall CPI that is commonly cited, it is an estimate of prices in urban areas.

As of June 2022, the average retail price of regular unleaded gasoline in the US was $5.058 per gallon.  For the chart, I have then shown what the historical prices would have been when adjusted for general inflation to the prices of June 2022 (based on the overall CPI).  The June prices are not the highest gas prices have been – they hit $5.51 a gallon in July 2008 – but they are close.  Although declining in recent weeks as I am writing this, it remains to be seen whether gas prices might resume their upward trend sometime soon.  The markets continue to be volatile, and prices could soon set a new record.

Whether that will happen will depend in part on what the policy response now is.  There are measures that can be taken that will reduce prices, but also measures that are being discussed that would likely have little effect, or might even raise prices. In this section, I will first discuss why, given the underlying causes of the price increases this year discussed above, some of the measures being discussed will likely do little and might indeed be counterproductive.  I will then discuss measures that could help lead to a reduction in prices.

1)  What Not To Do

First, some policies that will not lead to lower prices, or might even lead to higher prices:

a)  Perhaps the most widespread assumption is that if OPEC produced more crude oil, gasoline prices would then fall.  But that should not be expected given the current situation.  As seen in the chart at the top of this post, the crack spread widened sharply starting in late February, as a certain share of global refining capacity became not usable.  In the already tight markets refinery capacity became the effective binding constraint, not the price of crude oil.

More crude oil production by OPEC (or indeed by anyone) could well lead to lower crude oil prices – and indeed likely would.  But unless more of that crude oil can be refined into final fuel products such as gasoline, the available supply of gas in the market would not be affected.  Retail prices would remain the same.  What would change is that if crude oil prices decline by some amount with the increased supply of crude, the crack spread would widen.  That is, refiners would gain by this.  Consumers would not.

b)  For the same reason, sale of crude oil out of the Strategic Petroleum Reserve should not be expected to lead to lower retail prices for gas either.  President Biden announced on March 31 that the US would start to sell one million barrels of crude oil per day (an unprecedented amount) out of the US Strategic Petroleum Reserve for at least six months.  This announcement may well have had some effect on crude oil prices:  Crude oil prices had been rising through late March and then fell a bit (before returning to March levels in late May, and then continuing to rise until mid-June).  But this did not affect retail prices for fuels, which continued to rise until the last few weeks.  Rather, the crack spread rose (as seen in the chart at the top of this post) as refiners were able to obtain a larger margin between what they could sell their products for and what they had to pay for their crude oil.

c)  Also popular has been the proposal to reduce or eliminate taxes on the sale of gas and other fuels.  The federal tax is 18.4 cents per gallon on gasoline and 24.4 cents on diesel, while state taxes are of varying amounts.

President Biden on June 24 called on Congress to approve a temporary suspension of federal taxes on gas and diesel for three months.  As of my writing this, Congress had not approved such a suspension (it would complicate infrastructure funding, as such funding is linked to fuel tax revenues), and it does not look likely that it will.  But one never knows.  And as of July 6, six states had suspended their state fuel taxes for varying periods, with many more considering it.

What effect would such a tax cut have?  First, consider the federal tax, as it applies across the entire country.  As discussed above, the supply of fuels such as gas and diesel is constrained by available refinery capacity.  Economists refer to this as operating where the supply curve is “vertical”, in that a higher price for the fuel cannot elicit a significant increase in the supply of the fuel in the near-term, due to the capacity constraint.  A lower tax will not then lead to a lower price, as a lower price (if one saw it) would lead to greater demands for the fuels and refiners cannot supply more.  In such a situation, refiners are earning a rent, and a lower tax to be paid on the fuels will just mean that the refiners will be able to earn an even larger profit than they are already.  The crack spread will go up by the amount the tax on fuels is reduced.

The situation would be different if refiners could supply a higher amount.  Retail prices would fall by some amount due to the reduction in the tax, supplies would rise by some amount, and in the end consumers and refiners would share in the near-term gains from the lower tax.  What those relative shares will be will depend on how responsive the supply of fuels would be from the refiners (the elasticity of supply).  In the extremes, if refiners are able and willing to supply the increase in demand at an unchanged price (the supply curve is flat), then retail prices will fall by the entire amount of the tax cut and consumers will enjoy all of the benefit.  But if refiners are unable to supply more due to capacity constraints, then retail prices will be unchanged by the tax cut and refiners will pocket the full amount of the tax cut.  Currently, we are far closer to the latter set of circumstances than to the former.

The situation is a bit different at the state level.  If one state cuts its taxes while the taxes remain the same elsewhere, refiners will be able to move product to meet the higher sales of fuels in the state where taxes were cut.  This would, however, be at the expense of lower supply in the states that did not cut their taxes.  Fuel prices in the state cutting its taxes (and not matched by others) will fall by some amount due to the now higher availability of fuels in that state.  But with the overall supply constrained by what the refineries can produce, the lower amounts supplied to the rest of the country will lead to higher prices in the rest of the country.

Overall there will be no benefit, and indeed on average prices (net of taxes) will rise.  But there will be some redistribution across the states.  The amount will depend on what share of the states decide to cut their taxes.  At one extreme, if only one state does it and that state does not account for a large share of the overall US market, then the retail price (inclusive of taxes) will fall in that state.  If that state is small, prices elsewhere in the country would only rise by a small amount, but they still would rise.  But if more and more states decide to cut their fuel taxes, then one will approach the situation discussed above with the cut in federal taxes on fuels.  The full benefits of the lower taxes will accrue to the oil refiners, not to any consumers.

Finally, one needs to recognize that there is no free lunch.  The states cutting their fuel taxes will need to make up for the revenues they consequently lose.  To fund the expenditures paid for by the fuel taxes (often investments in road and other infrastructure), those states would need to raise their taxes on something else.

2)  What To Do

So what would lead to lower fuel prices given the current conditions?  The simple fact is that for prices to go down, one will need either to increase the supply of the refined products, or reduce the demand for them.  Taking up each:

a)  As was discussed above, refineries normally operate at close to their maximum capacity, and there is not much margin to respond to unforeseen demands.  Refineries are expensive, hence are not designed with much excess capacity to spare, and when operating are operated on a continuous, 24-hour a day, basis.  They also need to be shut down periodically for scheduled maintenance, as well as when unscheduled maintenance is required or when a strong storm threatens.

Still, there might be some measures that can be taken to push refinery throughput at least a bit higher.  Refiners certainly have an incentive to do so, given how high the crack spread is now (three to four times higher in recent months than what it was on average between 2014 and 2021).  But the crack spread does not need to be anywhere close to that high to provide a strong incentive.  A spread that is double what it would be in more normal times should more than suffice to elicit refiners to do whatever they can to maximize refinery throughputs.

There will also be an element of luck, given the increasingly volatile weather conditions that climate change has brought.  One can see this in a simple snapshot of a chart available on the EIA website, showing idle US refinery capacity (which is more properly measured by and referred to as distillation capacity) by month going back to 1985:

Volatility rose significantly starting in 2005 (the year of Hurricanes Katrina and Rita) and has been high since.  The sharp peaks seen in the chart are all in September or October – the peak months of hurricane season for the US.  Especially prominent peaks in the capacity that had to be idled were in September 2008 (Hurricanes Gustav and Ike), September 2017 (Hurricane Harvey), and September 2021 (Hurricane Ida).  With hurricanes threatening, refineries must be shut down for safety.  How fast they can then reopen depends on how much damage was done, but will require some time even if there was only limited damage.

It is impossible to say what will happen in the upcoming hurricane season.  But with the market so tight, any closures could have a large impact on prices.

b)  The other side to focus on is demand.  This could also be more productive in the near term given that little more may be possible on the supply side (as well as subject to chance, given the uncertainty in what will happen in the upcoming hurricane season).  But progress on demand-side measures will depend on political will, and Americans have been historically averse to measures that would reduce the near-term demand for fuels.

But it is important to recognize that not much would be needed in terms of reduced demand in order to reduce fuel prices by a substantial amount.  This is precisely because the demand for fuels is so price inelastic, as discussed before.  That is, a substantially higher price for gas does not lead to all that much of a reduction in the quantity of it purchased.  What economists call the “demand curve” (the amount purchased at any given price) is close to vertical.  When this is coupled with an also close to vertical supply curve for refined products (as refineries are operating close to their capacity, and cannot produce more no matter what price they can get), small shifts in the amount demanded at any given price will have a major effect.

[An annex at the end of this post uses simple supply and demand curves to examine this graphically.]

Given this lack of sensitivity to price under current conditions for both supply and demand, it would not take all that much to get prices to fall by a substantial amount.  Supply of refined products is constrained by refineries operating at close to their maximum, while on the demand side, purchases of fuels do not adjust by much when prices change.  As was noted above, the EIA in 2014 published an estimate of the price elasticity of demand for gasoline of just -0.02 to -0.04.  That implies that a 10% rise in the price of gas would reduce demand by only 0.2 to 0.4%.  Others have estimated higher elasticities, but all still relatively low.

Suppose, for the sake of illustration, that the price elasticity of demand was -0.10, so that a 10% rise in the price would lead to a reduction in demand of 1%.  This relationship also tells us a good deal about the shape of the demand curve – specifically its slope (locally).  If facing a completely vertical supply curve, then it implies that a 1% reduction in the demand for gasoline at any given price (meaning a shift in that demand curve to the left by 1%) would lead to a new price that is 10% lower than before.  And a 2% shift would lead to a price that is 20% lower.  While extrapolating in this way from what might be true for small changes to something substantially larger is dangerous, a 20% fall in the price of gas that is at $5.00 per gallon would lead to a new price of $4.00 per gallon – all resulting from just a 2% shift in the demand.  This is substantial but depends, as noted above, on how responsive demand is to the price.  If truly not very responsive, as is commonly held by many, then it will not take much of a reduction in demand (at any given price) to lead to a very substantial reduction in the price.

How, then, might one reduce the demand for fuels?  One possibility would be to encourage more work from home.  One saw the effect of this on fuel demands (and hence prices) in 2020, when working from home was required for health reasons at the start of the Covid crisis.  Workers are now returning to the office, but perhaps our political leaders should encourage a delay in this, or at least a slower pace on the return.  But it probably could not be mandated, and indeed probably should not be simply for the sake of cutting the price of gasoline.  And while opinions differ on this, some would say that extending work-from-home even further will reduce worker productivity.

A better way to reduce fuel demands would be to provide a greater incentive to take public transit rather than drive a car for a higher share of the trips one undertakes.  One could do the following:  First, raise tax revenues that could be used for these measures by raising federal taxes on fuels by, say, $0.25 per gallon.  As was noted above, when one is operating with a vertical supply curve, as we are now, increasing taxes on fuels will not lead to higher prices for the consumer.  The crack spread would fall, but with that spread that has varied between $1.00 and $1.50 per gallon in recent months, a higher fuel tax of $0.25 per gallon would still leave that crack spread at two to three times the $0.36 it averaged before.

According to EIA data, the total supply of motor gasoline in the US averaged 9.3 million barrels per day between 2016 and 2019 (taking a four-year average, and excluding 2020 due to Covid), while diesel supply averaged 4.0 million barrels per day.  Mutliplying this sum of 13.3 million barrels per day by 42 gallons per barrel and 365 days per year, the annual supply of these fuels averaged 204 billion gallons.  Rounding this to 200 billion gallons, a tax of $0.25 per gallon would raise $50 billion on an annualized basis.

This could be used to support public transit.  Something that could be done instantly (starting literally the next day) would be simply to stop charging fares on public transit systems – including buses, rail (subways), commuter trains, and whatever.  According to the National Transit Database, in 2019 all these public transit systems generated a total of $16.1 billion in revenues, mostly from fares but including also other locally-generated revenues such as from the sale of advertising.  (Again, 2020 was an unrepresentative year due to Covid so it is better to use 2019 figures.)  The database does not separate out fares from other revenues, but even if one treated it all as fares, the $16 billion needed would be far below the $50 billion that would be generated (on an annualized basis) by increasing the federal tax on gasoline and diesel by $0.25.

Filling empty seats on buses and subways also does not cost anything.  Indeed, operating costs would in fact go down by not having to collect fares.  There are significant direct costs in collecting fares (and to ensure too much is not stolen), but one would also gain operational efficiencies.  Buses now take a relatively long time to cover some route in part because at each stop people have to line up and go one-by-one through the front door to pay their fares in some way.  Not having to take so long at each stop would allow the buses to cover their routes at a faster pace.  This would increase effective capacity or, if capacity were to be kept the same as before, one could provide that capacity with fewer buses and their drivers.

The aim is to shift people from driving their cars to taking public transit for a higher share of the trips they take.  To the extent this simply fills up some of the empty seats, there is then no additional cost.  But if ridership increases by a substantial amount (something to hope for), capacity would need to grow.  This could most easily be accommodated by additional buses.  This would cost something, but according to the National Transit Database figures, the total spent in 2019 from all sources (federal, state, and local), for all modes of public transit, for both operating and capital costs, was $79 billion.  With the $34 billion left after using $16 billion to cover fares (out of the $50 billion that the $0.25 per gallon would collect), one could cover an increase in spending on public transit of more than 40%.  This would be far more than what would be needed even with a huge increase in ridership.  But we are now going beyond the very short-term measures that could be taken to reduce fuel demand.  However, with the long-term need to reduce the burning of fossil fuels, it is good to see that even a relatively modest fee of just $0.25 per gallon of fuel could support such an expansion in public transit.

Such an approach would lead to a reduction in the demand for those fuels.  How much I cannot say with the information I have, but it should be substantial.  And as discussed before, even a small reduction in the demand for these fuels should lead to a substantial fall in their price.  That fall in price would also be of benefit to all those who purchase these fuels, including those in rural areas who are far from any public transit option.  It would be a mistake to presume that stopping the collection of fares on public transit systems would only be of benefit to the users of public transit.

D.  Concluding Remarks

The price of gas is certainly high.  Although not quite a record (when general inflation is accounted for) it is close.  This has led to a number of proposals aimed at reducing those prices.  Particularly popular politically has been to cut fuel taxes for at least some period, with this championed both by President Biden (for federal fuel taxes) and in a number of states (where several have done this already for the state-level fuel taxes).  Many also blame OPEC for managing supplies in order to drive crude oil prices higher.  To address this, there have both been major sales out of the Strategic Petroleum Reserve (of one million barrels of crude a day), as well as diplomacy to try to get others to boost their supply of oil.

Under current market conditions, however, these initiatives should not be expected to reduce prices.  The issue right now is that refineries are the binding constraint.  They are producing as much of the refined products (fuels, etc.) as they can, but limits on their capacity keep them from producing more.  One sees this in the crack spread, which jumped up in late February immediately following the Russian invasion of Ukraine.  A substantial share of Russian refinery capacity became unusable, and this served as a tipping point in an already tight market.

Under such conditions, a lower price for crude oil will not lead to lower retail prices for fuels.  While it would benefit refiners (the crack spread would widen), the prices at the pump would not be affected unless refiners were somehow then able to raise their production.  Similarly, a cut in fuel taxes should not be expected to lead to lower fuel prices at the pump.  Rather, refiners would receive a windfall as they would receive a higher share of the retail price.  Refiners are already doing extremely well, with a crack spread in recent months that has been three to four times what it averaged between 2014 and 2021.  There is no need to make this even more generous.

To reduce retail prices, one should instead reduce demand.  One measure that would do this would be simply to stop charging fares on public transit.  Inducing only some of those now driving to use transit more often could have a significant impact on prices.  This is because the demand for fuels is not terribly responsive to price (consumers in the US do not cut back on their car use all that much when prices are higher), at the same time as the supply of fuels is limited by refinery capacity (so the supply of fuels cannot go up by much despite higher prices).  With both the demand and supply curves close to vertical, a small shift left or right in the curves can have a big impact on prices.

It would not cost all that much to end the collection of transit fares either.  Not only can it be done instantly (simply stop collecting), but the total public transit systems received in 2019 in fares paid (as well as in other revenues, such as from advertising) was only $16 billion.  One could easily cover this by increasing the federal taxes on fuels.  As noted above, a cut in fuel taxes would not lead to lower fuel prices.  For the same reason, an increase in fuel taxes (within limits) would not lead to higher fuel prices.  And just a $0.25 per gallon increase in federal fuel taxes would raise roughly $50 billion on an annualized basis.

It should be kept in mind that all this is based on current market conditions.  Those conditions can change, and change suddenly – as we saw in late February with the launch of the Russian invasion.  Thus, for example, while the crack spread is currently very high, this is in part a function of where crude oil prices are.  As of the week ending July 8, the price of West Texas intermediate was $103 per barrel.  With gas and diesel prices where they were then, the crack spread was $1.02 per gallon – far above the $0.36 per gallon it had averaged between 2014 and 2021.  But at a higher price for crude oil, the crack spread would fall.  At $131 per barrel (and with gas and diesel prices where they were as of the week ending July 8), the crack spread would be back at $0.36 per gallon.  And at $146 per barrel, the crack spread would be zero.  Presumably, if crude prices approached such a level refiners would cut back on production, leading to higher gas and diesel prices.  Crude oil prices would then be the binding factor, and efforts to lower those prices (e.g. by sales out of the Strategic Petroleum Reserve, or more OPEC production) could then matter.

The point of this blog post is that that is not where we are now.  Current conditions call for a different policy response.

 

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Annex:  Supply and Demand Curves to Show the Impacts of the Options

For those of you familiar with simple supply and demand curves, it is easy to see the impacts of the policy options discussed verbally in the text above.

The supply curve of fuels from refineries slopes upward from a curve that is relatively shallow to something increasingly steep and ultimately to vertical.  At relatively low levels of production, where there is a good deal of excess capacity in the refineries, a small rise in prices for the fuels will elicit a strong supply response.  But as production approaches the maximum capacity of what the refineries can produce (in the near term, given existing plant), there can only be little and ultimately no more production no matter how high the price goes.

The demand curve is steep.  That is, if prices rise by some amount, the quantity of fuels demanded does not fall by all that much.  The price elasticity of demand is low.

Retail taxes per gallon of fuel add to the supply cost.  That is, in the figure above, the red curve (marked S2) is what the supplies would be at some lower (possibly zero) retail fuel tax per gallon sold, while the blue curve (marked S1) is what the supply would be at some higher tax rate.  The supply curve will shift upwards.  That is, for any given quantity of supply, a higher price will be needed for that amount to be supplied.

When the supply curve is relatively shallow and upward sloping, as in the lower left of the diagram, then a cut in the tax (from the blue curve to the red), with a demand curve such as D3, will lead to some increase in supply and a significantly lower price.  The price, in the diagram, would fall from P3 to P4.  This is the logic behind the proposals, such as have been made by President Biden, for a temporary cut in federal fuel taxes.

However, this is not where current market conditions are.  Rather, refineries are operating at close to their maximum capacity, and one is in an area where the supply curve is close to vertical.  When the supply curve is vertical, a reduction in fuel taxes will simply shift that vertical curve downwards, but with one vertical curve simply sitting on top of the other vertical curve.  While a reduction in the tax per gallon will increase how much the refiner receives, after taxes, it will not lead to a higher amount being supplied (refiners cannot produce any more) nor will it lead to a lower price for consumers.  The lower taxes will simply be reflected in higher profits for the refiners.

In terms of the supply and demand curves depicted above, one would be in an area such as that depicted with the demand curve D1 with a price of P1.  If the supply curve is shifted downwards due to the tax cut (from the blue curve S1 to the red curve S2), with nothing done to affect the demand curve, then the price remains at P1.

In contrast, if the market conditions are such that the demand curve is at D1 and the supply curve is close to vertical, yielding a price of P1, a relatively modest shift in the demand curve to the left, i.e. from D1 to D2, leads to a sizeable fall in the price – from P1 to P2.  The fall in the price is large because both the demand curve and the supply curve are steep, and indeed close to vertical for the supply curve.  In such conditions, modest changes in demand can have a big impact on the price.

A shift of the demand curve shows how much demand would change (at the given price) due to a change in some underlying factor other than price.  Inducing drivers to shift to public transit by ending the charging of fares on transit systems is one such example.  There are others, such as encouraging more work from home (so no commute at all is needed).  And should the economy fall into a recession (which I see as increasingly likely in 2023), there will also be a reduction in fuel demands.  But the latter is not a cause of lower prices that one should hope for.

 

A Carbon Tax with Redistribution Would Be a Significant Help to the Poor

A.  Introduction

Economists have long recommended taxing pollution as an effective as well as efficient way to achieve societal aims to counter that pollution.  What is commonly called a “carbon tax”, but which in fact would apply to all emissions of greenhouse gases (where carbon dioxide, CO2, is the largest contributor), would do this.  “Cap and trade” schemes, where polluters are required to acquire and pay for a limited number of permits, act similarly.  The prime example in the US of such a cap and trade scheme was the program to sharply reduce the sulfur dioxide (SO2) pollution from the burning of coal in power plants.  That program was launched in 1995 and was a major success.  Not only did the benefits exceed the costs by a factor of 14 to 1 (with some estimates even higher – as much as 100 to 1), but the cost of achieving that SO2 reduction was only one-half to one-quarter of what officials expected it would have cost had they followed the traditional regulatory approach.

Cost savings of half or three-quarters are not something to sneer at.  Reducing greenhouse gas emissions, which is quite possibly the greatest challenge of our times, will be expensive.  The benefits will be far greater, so it is certainly worthwhile to incur those expenses (and it is just silly to argue that “we cannot afford it” – the benefits far exceed the costs).  One should, however, still want to minimize those costs.

But while such cost savings are hugely important, one should also not ignore the distributional consequences of any such plan.  These are a concern of many, and rightly so.  The poor should not be harmed, both because they are poor and because their modest consumption is not the primary cause of the pollution problem we are facing.  But this is where there has been a good deal of confusion and misunderstanding.  A tax on all greenhouse gas emissions, with the revenue thus generated then distributed back to all on an equal per capita basis, would be significantly beneficial to the poor in purely financial terms.  Indeed it would be beneficial to most of the population since it is a minority of the population (mostly those who are far better off financially than most) who account for a disproportionate share of emissions.

A specific carbon tax plan that would work in this way was discussed in an earlier post on this blog.  I would refer the reader to that earlier post for the details on that plan.  But briefly, under this proposal all emissions of greenhouse gases (not simply from power plants, but from all sources) would pay a tax of $49 per metric ton of CO2 (or per ton of CO2 equivalent for other greenhouse gases, such as methane).  A fee of $49 per metric ton would be equivalent to about $44.50 per common ton (2,000 pounds, as commonly used in the US but nowhere else in the world).  The revenues thus generated would then be distributed back, in full, to the entire population in equal per capita terms, on a monthly or quarterly basis.  There would also be a border-tax adjustment on goods imported, which would create the incentive for other countries to join in such a scheme (as the US would charge the same carbon tax on such goods when the source country hadn’t, but with those revenues then distributed to Americans).

The US Treasury published a study of this scheme in January 2017, and estimated that such a tax would generate $194 billion of revenues in its initial year (which was assumed to be 2019).  This would allow for a distribution of $583 to every American (man, woman, and child – not just adults).  Furthermore, the authors estimated what the impact would be by family income decile, and concluded that the bottom 7 deciles of families (the bottom 70%, as ranked by income) would enjoy a net benefit, while only the richest 30% would pay a net cost.

That distributional impact will be the focus of this blog post.  It has not received sufficient attention in the discussion on how to address climate change.  While the Treasury study did provide estimates on what the impacts by income decile would be (although not always in an easy to understand form), views on a carbon tax often appear to assume, incorrectly, that the poor will pay the most as a share of their income, while the rich will be able to get away with avoiding the tax.  The impact would in fact be the opposite.  Indeed, while the primary aim of the program is, and should be, the reduction of greenhouse gas emissions, its redistributive benefits are such that on that basis alone the program would have much to commend it.  It would also be just.  As noted above, the poor do not account for a disproportionate share of greenhouse gas emissions – the rich do – yet the poor suffer similarly, if not greater, from the consequences.

This blog post will first review those estimated net cash benefits by family income decile, both in dollar amounts and as a share of income.  To give a sense of how important this is in magnitude, it will then examine how these net benefits compare to the most important current cash transfer program in the US – food stamp benefits.  Finally, it will briefly review the politics of such a program.  Perceptions have, unfortunately, been adverse, and many pundits believe a carbon tax program would never be approved.  Perhaps this might change if news sources paid greater attention to the distribution and economic justice benefits.

B.  Net Benefits or Costs by Family Income Decile from a Carbon Tax with Redistribution

The chart at the top of this post shows what the average net impact would be in dollars per person, by family cash income decile, if a carbon tax of $49 per metric ton were charged with the revenues then distributed on an equal per capita basis.  While prices of energy and other goods whose production or use leads to greenhouse gas emissions would rise, the revenues from the tax thus generated would go back in full to the population.  Those groups who account for a less than proportionate share of greenhouse gas emissions (the poor and much of the middle class) would come out ahead, while those with the income and lifestyle that lead to a greater than average share of greenhouse gas emissions (the rich) will end up paying in more.

The figures are derived from estimates made by the staff of the US Treasury – staff that regularly undertake assessments of the incidence across income groups of various tax proposals.  The study was published in January 2017, and the estimates are of what the impacts would have been had the tax been in place for 2019.  The results were presented in tables following a standard format for such tax incidence studies, with the dollars per person impact of the chart above derived from those tables.

To arrive at these estimates, the Treasury staff first calculated what the impact of such a $49 per metric ton carbon tax would be on the prices of goods.  Such a tax would, for example, raise the price of gasoline by $0.44 per gallon based on the CO2 emitted in its production and when it is burned.  Using standard input-output tables they could then estimate what the price changes would be on a comprehensive set of goods, and based on historic consumption patterns work out what the impacts would be on households by income decile.  The net impact would then follow from distributing back on an equal per capita basis the revenues collected by the tax.  For 2019, the Treasury staff estimated $194 billion would be collected (a bit less than 1% of GDP), which would allow for a transfer back of $583 per person.

Those in the poorest 10% of households would receive an estimated $535 net benefit per person from such a scheme.  The cost of the goods they consume would go up by $48 per person over the course of a year, but they would receive back $583.  They do not account for a major share of greenhouse gas emissions because they cannot afford to consume much.  They are poor, and a family earning, say, $20,000 a year consumes far less of everything than a family earning $200,000 a year.  In terms of greenhouse gas emissions implicit in the Treasury numbers, the poorest 10% of Americans account only for a bit less than 1.0 metric tons of CO2 emissions per person per year (including the CO2 equivalent in other greenhouse gases).  The richest 10% account for close to 36 tons CO2 equivalent per person per year.

As one goes from the lower income deciles to the higher, consumption rises and CO2 emissions from the goods consumed rises.  But it is not a linear trend by decile.  Rather, higher-income households account for a more than proportionate share of greenhouse gas emissions.  As a consequence, the break-even point is not at the 50th percentile of households (as it would be if the trend were linear), but rather something higher.  In the Treasury estimates, households up through the 70th percentile (the 7th decile) would on average still come out ahead.  Only the top three deciles (the richest 30%) would end up paying more for the carbon tax than what they would receive back.  But this is simply because they account for a disproportionately high share of greenhouse gas emissions.  It is fully warranted and just that they should pay more for the pollution they cause.

But it is also worth noting that while the richer household would pay more in dollar terms than they receive back, those higher dollar amounts are modest when taken as a share of their high incomes:

In dollar terms the richest 10% would pay in a net $1,166 per person in this scheme, as per the chart at the top of this post.  But this would be just 1.0% of their per-person incomes.  The 9th decile (families in the 80 to 90th percentile) would pay in a net of 0.7% of their incomes, and the 8th decile would pay in a net of 0.3%. At the other end of the distribution, the poorest 10% (the 1st decile) would receive a net benefit equal to 8.9% of their incomes.  This is not minor.  The relatively modest (as a share of incomes) net transfers from the higher-income households permit a quite substantial rise (in percentage terms) in the incomes of poorer households.

C.  A Comparison to Transfers in the Food Stamps Program

The food stamps program (formally now called SNAP, for Supplemental Nutrition Assistance Program) is the largest cash income transfer program in the US designed specifically to assist the poor.  (While the cost of Medicaid is higher, those payments are made directly to health care providers for their medical services to the poor.)  How would the net transfers under a carbon tax with redistribution compare to SNAP?  Are they in the same ballpark?

I had expected they would not be close.  However, it turns out that they are not that far apart.  While food stamps would still provide a greater transfer for the very poorest households, the supplement to income that those households would receive by such a carbon tax scheme would be significant.  Furthermore, the carbon tax scheme would be of greater benefit than food stamps are, on average, for lower middle-class households (those in the 3rd decile and above).

The Congressional Budget Office (CBO) has estimated how food stamp (SNAP) benefits are distributed by household income decile.  While the forecast year is different (2016 for SNAP vs. 2019 for the carbon tax), for the purposes here the comparison is close enough.  From the CBO figures one can work out the annual net benefits per person under SNAP for households in the 1st to 4th deciles (with the 5th through the 10th deciles then aggregated by the CBO, as they were all small):

The average annual benefits from SNAP were estimated to be about $1,500 per person for households in the poorest decile and $690 per person in the 2nd decile.  These are larger than the estimated net benefits of these two groups under a carbon tax program (of $535 and $464 per person, respectively), but it was surprising, at least to me, that they are as close as they are.  The food stamp program is specifically targeted to assist the poor to purchase the food that they need.  A carbon tax with redistribution program is aimed at cutting back greenhouse gas emissions, with the funds generated then distributed back to households on an equal per capita basis.  They have very different aims, but the redistribution under each is significant.

D.  But the Current Politics of Such a Program Are Not Favorable

A carbon tax with redistribution program would therefore not only reduce greenhouse gas emissions at a lower cost than traditional approaches, but would also provide for an equitable redistribution from those who account for a disproportionate share of greenhouse gas emissions (the rich) to those who do not (the poor).  But news reporters and political pundits, including those who are personally in favor of such a program, consider it politically impossible.  And in what was supposed to be a personal email, but which was part of those obtained by Russian government hackers and then released via WikiLeaks in order to assist the Trump presidential campaign, John Podesta, the senior campaign manager for Hillary Clinton, wrote:  “We have done extensive polling on a carbon tax.  It all sucks.”

Published polls indicate that the degree of support or not for a carbon tax program depends critically on how the question is worded.  If the question is stated as something such as “Would you be in favor of taxing corporations based on their carbon emissions”, polls have found two-thirds or more of Americans in support.  But if the question is worded as something such as “Would you be in favor of paying a carbon tax on the goods you purchase”, the support is less (often still more than a majority, depending on the specific poll, but less than two-thirds).  But they really amount to the same thing.

There are various reasons for this, starting with that the issue is a complex one, is not well understood, and hence opinions can be easily influenced based on how the issue is framed.  This opens the field to well-funded vested interests (such as the fossil fuel companies) being able to influence votes by sophisticated advertising.  Opponents were able to outspend proponents by 2 to 1 in Washington State in 2018, when a referendum on a proposed carbon tax was defeated (as it had been also in 2016).  Political scientists who have studied the two Washington State referenda believe they would be similarly defeated elsewhere.

There appear to be two main concerns:  The first is that “a carbon tax will hurt the poor”.  But as examined above, the opposite would be the case.  The poor would very much benefit, as their low consumption only accounts for a small share of carbon emissions (they are poor, and do not consume much of anything), but they would receive an equal per capita share of the revenues raised.

In distinct contrast, but often not recognized, a program to reduce greenhouse gas emissions based on traditional regulation would still see an increase in costs (and indeed likely by much more, as noted above), but with no compensation for the poor.  The poor would then definitely lose.  There may then be calls to add on a layer of special subsidies to compensate the poor, but these rarely work well.

The second concern often heard is that “a carbon tax is just a nudge” and in the end will not get greenhouse gas emissions down.  There may also be the view (internally inconsistent, but still held) that the rich are so rich that they will not cut back on their consumption of high carbon-emission goods despite the tax, while at the same time the rich can switch their consumption (by buying an electric car, for example, to replace their gasoline one) while the poor cannot.

But the prices do matter.  As noted at the start of this post, the experience with the cap and trade program for SO2 from the burning of coal (where a price is put on the SO2 emissions) found it to be highly effective in bringing SO2 emissions down quickly.  Or as was discussed in an earlier post on this blog, charging polluters for their emissions would be key to getting utilities to switch use to clean energy sources.  The cost of both solar and wind new generation power capacity has come down sharply over the past decade, to the point where, for new capacity, they are the cheapest sources available.  But this is for new generation.  When there is no charge for the greenhouse gases emitted, it is still cheaper to keep burning gas and often coal in existing plants, as the up-front capital costs have already been incurred and do not affect the decision of what to use for current generation.  But as estimated in that earlier post, if those plants were charged $40 per ton for their CO2 emissions, it would be cheaper for the power utilities to build new solar or wind plants and use these to replace existing fossil fuel plants.

There are many other substitution possibilities as well, but many may not be well known when the focus is on a particular sector.  For example, livestock account for about 30% of methane emissions resulting from human activity.  This is roughly the same share as methane emissions from the production and distribution of fossil fuels.  And methane is a particularly potent greenhouse gas, with 86 times the global warming potential over a 20-year horizon of an equal weight of CO2.  Yet a simple modification of the diets of cows will reduce their methane emissions (due to their digestive system – methane comes out as burps and farts) by 33%.  One simply needs to add to their feed just 100 grams of lemongrass per day and the digestive chemistry changes to produce far less methane.  Burger King will now start to purchase its beef from such sources.

This is a simple and inexpensive change, yet one that is being done only by Burger King and a few others in order to gain favorable publicity.  But a tax on such greenhouse gas emissions would induce such an adjustment to the diets of livestock more broadly (as well as research on other dietary changes, that might lead to an even greater reduction in methane emissions).  A regulatory focus on emissions from power plants alone would not see this.  One might argue that a broader regulatory system would cover emissions from such agricultural practices, and in principle it should.  But there has been little discussion of extending the regulation of greenhouse gas emissions to the agricultural sector.

More fundamentally, regulations are set and then kept fixed over time in order to permit those who are regulated to work out and then implement plans to comply.  Such systems are not good, by their nature, at handling innovations, as by definition innovations are not foreseen.  Yet innovations are precisely what one should want to encourage, and indeed the ex-post assessment of the SO2 emissions trading program found that it was innovations that led to costs being far lower than had been anticipated.  A carbon tax program would similarly encourage innovations, while regulatory schemes can not handle them well.

There may well be other concerns, including ones left unstated.  Individuals may feel, for example, that while climate change is indeed a major issue and needs to be addressed, and that redistribution under a carbon tax program might well be equitable overall, that they will nonetheless lose.  And some will.  Those who account for a disproportionately high share of greenhouse gas emissions through the goods they purchase will end up paying more.  But costs will also rise under the alternative of a regulatory approach (and indeed rise by a good deal more), which will affect them as well.  If they do indeed account for a disproportionately high share of greenhouse gas emissions, they should be especially in favor of an approach that would bring these emissions down at the lowest possible cost.  A scheme that puts a price on carbon emissions, such as in a carbon tax scheme, would do this at a lower cost than traditional approaches.

So while many have concerns with a carbon tax with redistribution scheme, much of this is due to a misunderstanding of what the impacts would be, as well as of what the impacts would be of alternatives.  One sees this in the range of responses to polling questions on such schemes, where the degree of support depends very much on how the questions are worded or framed.  There is a need to explain better how a carbon tax with redistribution program would work, and we have collectively (analysts, media, and politicians) failed to do this.

There are also some simple steps one can take which would likely increase the attractiveness of such a program.  For example, perceptions would likely be far better if the initial rebate checks were sent up-front, before the carbon taxes were first to go into effect, rather than later, at the end of whatever period is chosen.  Instead of households being asked to finance the higher costs over the period until they received their first rebate checks, one would have the government do this.  This would not only make sense financially (government can fund itself more cheaply than households can), but more important, politically.  Households would see up-front that they are, indeed, receiving a rebate check before the prices go up to reflect the carbon tax.

And one should not be too pessimistic.  While polling responses depend on the precise wording used, as noted above, the polling results still usually show a majority in support.  But the issue needs to be explained better.  There are problems, clearly, when issues such as the impact on the poor from such a scheme are so fundamentally misunderstood.

E.  Conclusion 

Charging for greenhouse gases emitted (a carbon tax), with the revenues collected then distributed back to the population on an equal per capita basis, would be both efficient (lower cost) and equitable.  Indeed, the transfers from those who account for an especially high share of greenhouse gas emissions (the rich) to those who account for very little of them (the poor), would provide a significant supplement to the incomes of the poor.  While the redistributive effect is not the primary aim of the program (reducing greenhouse gases is), that redistributive effect would be both beneficial and significant.  It should not be ignored.

The conventional wisdom, however, is that such a scheme could not command a majority in a referendum.  The issue is complex, and well-funded vested interests (the fossil fuel companies) have been able to use that complexity to propagate a sufficient level of concern to defeat such referenda.  The impact on the poor has in particular been misportrayed.

But climate change really does need to be addressed.  One should want to do this at the lowest possible cost while also in an equitable manner.  Hopefully, as more learn what carbon tax schemes can achieve, politicians will obtain the support they need to move forward with such a program.

The Plans for Medicare-for-All and Medicare-for-All-Who-Want-It: A Comparison and a Path Forward

A.  Introduction

The US health care funding system is a mess.  One consequence is that despite spending far more than any other country in the world for its health care system (about 18% of GDP currently, where the next highest country spends only about 12%), US health care outcomes are mediocre at best.  Among OECD member countries, only a few countries, with incomes well below that of the US (some countries of Central or Eastern Europe or in Latin America), have worse outcomes than the US in such standard measures as life expectancy or infant mortality rates.

Bringing this to the level of individual families, the Kaiser Family Foundation found (based on a survey of firms) that the average cost of an employer-sponsored health plan in the US in 2019 came to $20,576 for family coverage.  Of this, the share covered directly by the employer (as part of its overall worker compensation package) came to $14,561 (71%) while the worker paid via premia an additional $6,015 (29%).  For 2018, the figures were a total cost of $19,616, with $14,069 for the employer share and $5,547 for the employee share.  Median family income in 2018 (the most recent year available) in the US was $80,663 (Census Bureau estimate).  Adding in the employer share of the cost of the health plan to cash family income, the total cost of an employer-sponsored health care plan came to 21% of this expanded family income.

On top of this, a family will have to pay out-of-pocket the costs of deductibles, co-pays, co-insurance, and health care costs not covered under their insurance plan.  Milliman, a health care advisory firm, estimated that in 2018 such out-of-pocket costs were an average of an additional $4,704 for a family of four.  This would bring the total cost of health care for a family of four to $24,320, or 26% of expanded family income.  This is huge.  And the burden is of course proportionally larger for the 50% of the population with an income below the median.

Such a high cost for health care is in and of itself a giant problem.  But beyond this, not having effective access to the health care system, at whatever the cost, is even worse.  It can literally be a matter of life and death.

It should not therefore be a surprise that what to do about health care has become a prominent issue in the race for the Democratic nomination for the presidency in 2020.  While each candidate has his or her own specific proposals, most are grouped around one of two alternatives:  A single-payer Medicare-for-All plan, where Elizabeth Warren has released the most detailed proposal on what she would seek to do; and plans which would add a public option to the Obamacare exchanges, which has been dubbed Medicare-for-All-Who-Want-It by Pete Buttigieg, its most prominent proponent.

This blog post will review these two alternative proposals, focusing on the implications of each.  In addition, Elizabeth Warren has also released a detailed plan for what would be, under her proposals, a transition to a Medicare-for-All system during which she would add a public option to the Obamacare exchanges.  On the surface this would appear similar to the Medicare-for-All-Who-Want-It proposals of Buttigieg and others, but there are in fact important differences in the specifics.  After discussing the Warren Medicare-for-All proposal and then the Buttigieg Medicare-for-All-Who-Want-It proposal, this post will then review the Warren transition proposal and its differences with the Buttigieg plan.

To summarize very briefly, the implications of these different plans include:

a)  The Warren Medicare-for-All plan, while providing comprehensive and generous health care coverage for all in the US, would also imply massive shifts in how health care is funded.  Total costs would not rise (an increase due to the broader coverage would be offset, she argues, by efficiency gains of similar magnitude).  But the shifts in how health care would be funded are staggeringly large, potentially disruptive, and unrealistic in the view of many analysts.

b)  The Medicare-for-All-Who-Want-It plan, in contrast, need not in principle cost much.  A public-managed option added to the Obamacare health insurance exchanges could be priced to cover its costs, just as private insurers on the exchanges do now (along with their profits).  And indeed, a careful analysis by the Congressional Budget Office (which will be discussed further below) concluded that the overall impact of allowing a public option would reduce the fiscal deficit significantly, due to indirect effects that would reduce public expenditures while increasing public revenues.  However, the specific Buttiegieg plan goes further than just adding a public option, by increasing the health care plan subsidies significantly and providing them to a broader range of families and individuals than receive them now.  With this as well as other measures, Buttiegieg estimates his proposals would lead to increased federal spending, but of only $1.5 trillion over ten years.  This would be well below the $26.5 trillion shifted to federal spending in the Warren Medicare-for-All plan.

However, while a Medicare-for-All approach (such as proposed by Warren) would lead to everyone enrolled in a similar (and comprehensive) health insurance plan with funding through federal government sources, the addition of a public option to the Obamacare exchanges would lead to what would still be a highly diverse and variable set of health insurance plans, with very different levels of coverage and very different costs.  Some enrollees would pay relatively little (if they are young and healthy, or of low income) while others would pay much more (if they are older, or of moderate or higher income).  The health care funding system would remain fragmented, extremely complex, and with widely varying costs for different families and individuals.  And from such a starting point it would then be difficult to transition to a Medicare-for-All system, even if the overwhelming majority choose to enroll in the public option.

c)  Finally, while the Warren transition plan would add a public option at the start of the process, her public option would be of a health plan that is very different from the public option of Buttiegieg, Biden, and others.  Her proposed public option would be for an insurance plan that is similarly comprehensive to what she has proposed for her Medicare-for-All plan.  It would also then receive, from the start, a high level of subsidy, benefiting those who choose to enroll in that public option.  These subsidies would be funded centrally by the government.  The overall expense would depend on how many would choose to enroll in the plans, but with the comprehensive coverage proposed by Warren coupled with high subsidies, it would be foolish for most not to enroll.  While this would then provide a path to a compulsory Medicare-for-All system, the funding that would need to be provided would be large.

B.  The Elizabeth Warren Medicare-for-All Plan

Elizabeth Warren has presented the most detailed proposal for how her Medicare-for-All plan would be set up, and importantly also how it would be paid for.  Medical costs covered would be expansive in her plan, and include not only that 100% of the cost of the medical services that Medicare currently provides for would be covered (i.e. no deductibles, no co-pays, no co-insurance), but so would medical expenses such as for dental and visual services, and for prescription drugs.  This would be much broader than what Medicare as it currently exists covers, as Medicare has a deductible, limits on the number of hospital days covered, and generally covers only 80% of doctor services.  Furthermore, Medicare does not cover expenses for dental, visual, and certain other areas of care, and while Medicare Part D now covers certain prescription drug costs, there are limits on how much it pays.

This expansive coverage is similar (indeed probably identical) to what Senator Bernie Sanders has proposed.  But while Elizabeth Warren has presented a detailed plan on how the costs of the expansive health funding program would be covered, Bernie Sanders has not.  Rather (at least as of this writing) Sanders has made available a six-page note titled “Options to Finance Medicare for All”.  But while the alternative funding sources outlined in that note are presented as options from which to choose, if one adds up the estimated amounts that would be raised by summing up all of the options presented the total of $16.2 trillion over ten years would not suffice to cover the costs of his Medicare-for-All program.  As we will see below, the shift in health care spending to the federal government, even after an assumed $7.5 trillion in savings through various measures, would come to $26.5 trillion over ten years.

We will therefore focus on the Warren plan, although on the cost side the figures would be similar to what Sanders has proposed.  And there will be a lot of numbers.  The key issue for the Warren (and Sanders) plans is that the dollar amounts involved are massive.  It is important to stress that this does not mean health care costs will be higher (other than certain costs from the increased access, to be offset by savings from several reforms), but rather that there will be shifts (and massive shifts) from how these costs are covered now to how they would be covered under the Medicare-for-All plan.

To see these shifts, it is best to start from estimates of what national health care expenditures would be should the US keep the current system.  A ten-year period is being covered (as is standard in most budget analyses), and for the purpose of this exercise the Warren team has come up with estimates of how those costs would then change if their plan were fully in place for the years 2020-29.  This is of course notional, as the full Medicare-for-All plan was not in place on January 1, 2020.  But use of the 2020-29 period is reasonable to demonstrate what would happen under such a plan, as reasonable estimates can be made for such a period.

For what health expenditures are expected to be under current law, most US analysts use the detailed forecasts provided each year by the professional staff at the Centers for Medicare and Medicaid Services (CMS).  The most recent National Health Expenditure (NHE) projections, covering the period 2018-27, were released in February 2019, and the figures presented below are based on Table 16 of that set of forecast tables.  The NHE projections stop at 2027 and hence do not include 2028 and 2029, but for those final two years I extrapolated from the 2027 estimates based on the growth rates in the forecast numbers of the last few years before 2027 (specifically, 2025 to 2027).  Other analysts would use similar methods, and for the final two years of a ten-year series the totals will be close.

As we will see below, the Warren figures are mostly, although not entirely, consistent with these NHE forecasts.  The causes of the limited inconsistencies are not fully clear, as the Warren figures are mostly presented in terms of what the shifts would be from some base.  Despite this, it is still useful to review first the NHE numbers, as they will give one a sense of the magnitudes involved in the funding of our health care system as it currently exists.  And they are huge.

The NHE forecasts (extrapolated for the final years, as noted above) for health expenditures between 2020 and 2029 under current law will be:

in $ trillion

GDP share

Total National Health Expenditures under Current Law:  2020-29

$52.5

18.9%

A.  Federal Government

$15.8

5.7%

  Private insurance for government employees

$0.5

0.2%

  Medicare taxes for government employees

$0.1

0.0%

  Medicare from budget

$6.0

2.1%

  Medicaid

$5.5

2.0%

  Other health programs (CHIP, DOD, VA, more)

$3.8

1.4%

B.  State and Local Government

$8.7

3.1%

  Private insurance for government employees

$2.8

1.0%

  Medicare taxes for government employees

$0.2

0.1%

  Medicaid

$3.4

1.2%

  Other health programs

$2.3

0.8%

C.  Private Business

$10.1

3.6%

  Private insurance for employees

$7.7

2.8%

  Other (Medicare, disability, worker comp, more)

$2.4

0.8%

D.  Households

$14.3

5.2%

  Private insurance premia and employee share

$5.1

1.8%

  Medicare taxes

$4.0

1.4%

  Out-of-Pocket

$5.2

1.9%

E.  Other Private Revenue (philanthropy, more)

$3.5

1.3%

Total national health expenditures under current law are forecast to be $52.5 trillion dollars over the period 2020 to 2029.  This is huge.  It comes to an average of 18.9% of GDP over the period as a whole, rising from 17.9% in 2020 to 19.9% in 2029.  By way of comparison, the Congressional Budget Office forecast of total federal government tax and other revenues (including all income taxes, Social Security taxes, and everything else) will be less than this, summing “only” to $45.6 trillion over this period.  Addressing how health care spending is funded will unavoidably deal with huge dollar amounts.

The $52.5 trillion in total health care costs are then funded through a combination of the amounts spent by the federal government ($15.8 trillion), state and local governments ($8.7 trillion), private businesses for their employees ($10.1 trillion), households ($14.3 trillion), and other sources, including philanthropy ($3.5 trillion).  Taking the federal government expenditures as an example, the NHE forecasts are that the federal government will spend $0.5 trillion over the ten years for its payments to private insurers to cover health insurance for federal workers, and $0.1 trillion in Medicare taxes for those federal employees.  These are relatively minor amounts but are included for completeness.  The really major expenditures are then what the federal government will provide directly to Medicare from the budget ($6.0 trillion), will spend on Medicaid ($5.5 trillion), and will spend on other health programs such as for CHIP (the Children’s Health Insurance Program), for the Department of Defense, for the VA, and so on ($3.8 trillion).

The breakdowns in the other components of health care spending are similar, and will not be repeated here.  But it is useful to note that even under current law, the total being spent on health care by government (the federal $15.8 trillion as well as the state and local $8.7 trillion) would be expected to come to $22.5 trillion over the ten years, or 43% of the $52.5 trillion forecast to be spent.  Government is already heavily involved in health care funding in the US, even though the system is often described as “employer-based”.

This mix of health care funding sources would then differ dramatically under any Medicare-for-All proposal, even with total health care expenditures unchanged.  Elizabeth Warren provides specifics on what this would be under her plan (available at both her campaign website and identically also at this commercial website in case her website is eventually closed).  Additional detail is provided in two more technical notes, prepared by advisors to her campaign, first on the overall costs of her Medicare-for-All plan, and second on the taxes and other measures that would be implemented to fund the federal government expenditures in such a program.

The specifics on the costs are presented in the following table:

Warren Medicare-for-All Plan:  2020-29

in $ trillion

GDP share

A.  Base National Health Expenditures

$52.0

18.7%

  Increase in cost from expanded cover

$7.0

2.5%

B.  Total Health Expenditures if nothing else done

$59.0

21.2%

1) National health spending not affected by plan

$8.0

2.9%

2) Base level of Federal Govt Spending before plan

$17.0

6.1%

C.  Increase in Federal Govt Spending Before Savings

$34.0

12.2%

D.  Savings from Reforms

$7.5

2.7%

1) Lower Admin Costs (beyond Urban Inst estimate)

$1.8

0.6%

2) Lower Costs of Prescription Drugs

$1.7

0.6%

3) Lower Costs and Payments to Health Providers

$2.9

1.0%

4) Slower Growth of Medical Costs

$1.1

0.4%

E.  Net Increase in Federal Govt Spending

$26.5

9.5%

As a base from which to start, the Warren team used estimates made by analysts at the Urban Institute of what total national health expenditures would be under current law and then under a Medicare-for-All system (with the expansive cover proposed by Warren as well as by Sanders).  The Urban Institute forecasts that under current law, total national health expenditures would be $52.0 trillion for the period 2020-29.  This is a bit below the $52.5 trillion figure arrived at using the NHE forecasts of the staff at the Centers for Medicare and Medicaid Services (CMS), but close (99%).  The Urban Institute has its own model for forecasting health expenditures, but say that they use the CMS figures for certain components they do not directly model.

The $52 trillion in health expenditures would be under current law.  The more expansive cover under the Warren (and Sanders) plans would then make health care more widely available, and the Urban Institute estimated (in a separate, but linked, publication) that this would lead to a net increase in health care costs of $7 trillion over the 2020-29 period.  This is a net increase as the Urban Institute includes in the $7 trillion certain savings from a Medicare-for-All system, in particular savings from the far lower administrative costs of Medicare compared to the costs at private insurers in the US (savings I discussed in an earlier post on this blog).

Total national health spending would then be $59 trillion over the ten years.  To arrive at what the federal government would be funding out of this, the Urban Institute analysts first subtracted $8 trillion of health care costs that they estimate would not be affected under a switch to a Medicare-for-All funding system.  These include a variety of expenditures, such as medical care for the military and their families when deployed overseas, acute care for people living in institutions (such as prisons as well as nursing homes), certain state and local government direct expenditures, public health programs, and so on.

The Urban Institute then estimates that other federal government health expenditures (under current law) would total $17 trillion over the ten years.  This is higher than the $15.8 trillion forecast in the CMS NHE numbers discussed above, and it is not clear why (particularly as certain of the federal government expenditures, such as for military personnel, are included in the $8 trillion figure of costs that will not be affected).  The Urban Institute reports made publicly available are not technical documents, so many of the details are not explained and documented.  But based on the $17 trillion figure for federal health spending, the increase in federal health expenditures (due to shifts from others under a Medicare-for-All plan), would be $59t – $8t – $17t = $34 trillion.

The Warren advisors started from this $34 trillion figure.  From this, they estimated that savings from several measures that would accompany their plan would lead to $7.5 trillion in lower national health care costs over the period.  One would be further savings from the lower administrative costs of the far more efficient Medicare system.  The Urban Institute estimated that such administrative costs (as a share of total costs of the insurance plan) could, conservatively, be reduced to 6% under Medicare, down from the 12.2% that it costs private insurers to administer their insurance plans (in their high-cost business model, with its negotiated networks and other such costs).  The Warren team argued, reasonably, that this could be reduced further to just 2.3%, which is what it now in fact costs Medicare to administer its system.

The Warren advisors then estimated that other cost savings could be achieved through reforms of the prescription drug system in the US ($1.7 trillion), through lower costs incurred by health care providers when they need only to deal with one insurance provider (Medicare) rather than the complex system of private insurers they must now contend with (and then lower payments to reflect this – an estimated $2.9 trillion in savings), and an overall slower growth of health care costs ($1.1 trillion).

With the estimated $7.5 trillion in savings from such measures, the net increase in federal spending for health care over the ten year period would be $26.5 trillion ( = $34.0t – $7.5t).

This is still a giant number.  Recall that the CBO estimate of all federal government tax and other revenue over this period totals just $45.6 trillion, and $26.5 trillion is 58% of this.  So how would Warren cover this cost?:

Warren Plan:  Paying for the Shift to Federal Govt Spending

in $ trillion

GDP share

Net Increase In Federal Spending

$26.5

9.5%

A.  Taxes / Transfers from Current Health Care Spending:

$14.9

5.4%

1) Transfer from State/Local Govt health insurance savings

$6.1

2.2%

2) Tax Private Businesses amount of insurance savings

$8.8

3.2%

B.  Other New Taxes / Federal Govt Spending Reductions:

$11.7

4.2%

1) Taxes on worker income now spent on health insurance

$1.4

0.5%

2) Financial transactions tax of 0.1%

$0.8

0.3%

3) Systemic risk fee on large financial institutions

$0.1

0.0%

4) End accelerated depreciation for large businesses

$1.25

0.5%

5) Minimum tax on foreign earnings of 35% + tax on foreign firms in US

$1.65

0.6%

6) Additional tax of 3% on wealth over $1 billion

$1.0

0.4%

7) Capital gains (as accrued) taxed at regular rates for richest 1%

$2.0

0.7%

8) Better tax law enforcement

$2.3

0.8%

9) Tax revenues from normalization of immigrants

$0.4

0.1%

10) Reduction in military spending

$0.8

0.3%

C.  Reductions in Health Care Funding

$12.2 4.4%

1) Household savings on health costs (insurance + out-of-pocket)

$12.0

4.3%

2) Net private business savings on health costs

$0.2

0.1%

First, Warren would require that state and local governments transfer to the federal level what those governments are now spending out of their own budgets for private insurance for state employees ($2.8 trillion in the table above of the CMS NHE forecasts) plus what those governments spend out of their budgets for Medicaid ($3.4 trillion in the CMS NHE figures).  The total in the CMS NHE figures of $6.2 trillion is within roundoff of the $6.1 trillion in the Warren estimates.  Whether such a transfer is politically realistic is a separate question.  I can imagine that a number of the state governments (particularly those in Republican hands) would tell the federal authorities that it is great that they are now covering those health care costs directly (under a Medicare-for-All system), but that they will keep the savings in their budgets for themselves.  In any case, it would certainly be litigated in the courts.

Warren would then also set what would in essence (or in actuality) be a tax on private businesses, equal to 98% of what those businesses now spend for the employer share of the health care premia for the private insurance for their workers.  Warren’s team estimates that businesses would spend under current law a total of $9.0 trillion over the ten year period on their share of their employer-based health insurance plans, and 98% of this is $8.8 trillion.  The $9.0 trillion figure appears to be broadly consistent with the CMS NHE figures discussed above, which estimates that private businesses will spend $7.7 trillion over the period on private health insurance for its employees, and also some portion of a further $2.4 trillion in other health expenses the employers will incur.

But the main issue with the new $8.8 trillion tax on private businesses is that it would be set, business by business, to reflect what that business is currently spending for its share (or, more precisely, 98% of its share) of the private health insurance plans for its workers.  Thus firms with health insurance plans that are generous in what they cover and in what share of health care costs they pay (and hence are more expensive), will pay more.  Workers at such firms might be accepting lower wages than they could earn elsewhere, knowing that the generous health insurance plans cover more, including more of what they would otherwise need to pay out-of-pocket.  At the other end, there are firms with stingy plans that are cheap, or even with no health insurance plans at all (which is legal if the firm has fewer than 50 employees, although health insurance plans are still common among such firms).  These firms would pay much less, or even nothing at all, under the Warren proposal, even though their workers, like everyone, would be covered by Medicare-for-All.

Many would view this as inequitable:  Firms with strong health care plans would be penalized, as they would then pay more into the Medicare-for-All funding, while firms with stingy or no health care plans would pay less or even nothing at all.  While there would be some undefined phasing in period in the Warren proposal to more equal shares being charged across firms, this would only be implemented over several years.

Furthermore, knowing that at least for some initial period the firms with the more generous plans would pay more and the firms with the more stingy plans would pay less, would create a perverse set of incentives.  In the mid-November update on her plans (which will be discussed in more detail later in this post), Senator Warren said that she would not introduce legislation for her Medicare-for-All plan until her third year in office.  That would mean that the new Medicare-for-All system would not enter into effect until at least her fourth year in office, and more likely no earlier than two or three years after that (as any such major reform takes time to implement).  If firms expect this to take place at some point in the next several years, they would have a strong incentive to revise the health insurance plans they sponsor for their employees in the direction of making them more stingy, or dropping them altogether if they legally can.

It is therefore likely that at least this aspect of the Warren plan will be revised should it go forward.  An addition to the payroll tax we now pay for Social Security and for Medicare is one likely alternative, and will also give a sense of the magnitudes involved.  Currently workers pay on their wages (half directly and half by their employers on their behalf as part of their overall compensation package) a tax of 12.4% on wages up to $137,700 in 2020 ($132,900 in 2019).  In addition, they pay 2.9% to fund Medicare (with no ceiling), for a total payroll tax of 15.3% on wages up to the ceiling.

The Congressional Budget Office, in their August 2019 forecasts, estimated that the Social Security tax (of 12.4%) will raise $11,269 billion in revenues over 2020-29.  To raise $8.8 trillion on this same wage base, would therefore require a rate of 9.7% (based on the proportions).  The overall payroll tax would then increase from the current 15.3% to a new 25.0%.  Many might view this as too much to pay, but one should recognize that it reflects what is now, on average, being paid on wages once one adds together Social Security, Medicare, and what the average employer pays for its share (or more precisely, 98% of its share) of the private health insurance plans for its employees.  One should also note that while 25% might seem high, it is substantially less than the approximately 40% rate found for payroll taxes (employer and employee combined) in a number of European countries (including Germany, the Netherlands, Belgium, Sweden, and Italy, and with France at over 50%).

Transferring to the federal government what is now being paid out by state and local governments for health insurance ($6.1 trillion, including the state portion for Medicaid), and by 98% of what private businesses are paying ($8.8 trillion), would then leave $11.7 trillion to be raised from other sources (where $11.7t = $26.5t – $6.1t – $8.8t, with rounding).  The Warren plan lists ten specific measures to do this:  six would be new taxes (or increases in existing or proposed taxes); one would be tax revenues from personal incomes that would become taxable with the move to Medicare-for-All; one would be increased revenues from better tax law enforcement; one would be taxes on incomes of immigrants who have had their status normalized; and one would be savings from reduced military spending.  A total of $10.9 trillion would come from higher taxes and $0.8 trillion from military spending reductions.

This is a wide, and diverse, set of funding sources.  I will not comment on each, but note that some analysts consider at least some of the revenue forecasts to be highly optimistic.  And one should always be skeptical when “better tax law enforcement” is assumed to raise a substantial share of the increased revenues needed ($2.3 trillion over ten years in the Warren plan, or 0.8% of GDP, which is huge).

Nevertheless, the Warren plan at least sets out proposals on how revenues might be raised (or expenditures reduced).  She should be commended for this, and it is in sharp contrast to, for example, the Republican / Trump tax cuts approved in December 2017.  Those tax cuts were forecast to lead to a loss in government revenues of $1.5 trillion over ten years (and it now appears that the losses will be even higher).  No effort was made by Trump or by the Republicans in Congress on how those revenue losses would be covered – the revenue losses would instead simply be added to overall government debt.  Warren, in contrast, has laid out specific proposals on how shifting health care expenditures to the federal level would be covered.  While one can be skeptical of certain of the figures, there is at least the recognition that something should be done to cover the shift in health costs.

It is also telling that the measures listed seek to avoid what might be obviously taxes on middle-class incomes.  Presumably this was done for political purposes, but one should recognize that at least some of the measures will impact middle-class incomes.  Specifically, it should be recognized that what employers pay for what is termed “the employer share” of health insurance premia for their employees is, in reality, a portion of the overall compensation package being paid to workers.  Over time, workers’ wages adjust to reflect this.  And while under the Warren plan this employer share (or 98% of it) would be transferred to the government, such a transfer would eventually become a uniform tax on employers (and as discussed above, this should probably be done immediately to avoid the perverse incentives of a gradual shift). The payroll tax would need to increase by 9.7% points to cover this, bringing the total payroll tax (for Social Security, current Medicare, and part of the cost of the new Medicare-for-All program) to 25.0%.  This is a tax on middle-class incomes.  There is nothing necessarily wrong with that, but it should be recognized.

Similarly, the Warren plan recognizes that since what workers now pay as their direct share of the cost of the employer-sponsored health insurance plans will go away under a Medicare-for-All system, the increase in income taxes on such incomes (as they are now largely income tax-exempt) would be substantial ($1.4 trillion over ten years in their estimate).  While fully reasonable, this is still a tax on middle-class incomes.

With total health care spending about the same ($7.0 trillion more for the increased access, offset by $7.5 trillion in cost reductions, for a net reduction of $0.5 trillion), but with $11.7 trillion in funding from new taxes and other measures, which groups will be spending less?  Under this plan, households would no longer pay health insurance premia nor out-of-pocket for most health care expenses.  The Warren campaign put this figure at $11 trillion over the ten-year period, which would then go to zero.  In addition, private businesses would gain the 2% from the requirement that they transfer 98% (not 100%) of what they now pay in health insurance premia, which would be an additional $0.2 trillion.  The total gain then by these two groups would be $11.2 trillion (ignoring, for this calculation, that some portion of the additional taxes would be paid by them).

But this does not add up properly.  After struggling with this for some time, I believe a mistake was made by the Warren advisors (which may have arisen as they were in a rush to get the plan out).  Assuming all the underlying numbers are correct, the $11.7 trillion raised by additional taxes (mainly) plus the $0.5 trillion net reduction in national health care spending under the plan ($7.0 trillion in more comprehensive coverage, minus $7.5 trillion in cost savings), would imply that the total gain by households and private businesses would be $12.2 trillion.  With the private businesses gaining $0.2 trillion (the 2%), this would imply a $12 trillion gain by households, not $11 trillion.  My guess is that instead of adding the net $0.5 trillion reduction in overall health care expenditures to the $11.7 trillion in increased funding (a total of $12.2 trillion), they subtracted it (a total of $11.2 trillion).

This is not fully clear as all the underlying numbers from the Urban Institute used by the Warren advisors have not been made publicly available (at least not from what I have been able to find).  Of relevance here is how they arrived at their figure that health care costs totaling $34 trillion would shift to the federal government under a Medicare-for-All plan such as that of Senator Warren (and Senator Sanders).  Nor did the Warren advisors present all the numbers on what each of the groups (state and local governments, private businesses, and households) would spend under current law and under their Medicare-for-All proposal.  Rather, they only provided how each of these would change.

[Side note:  There is possibly also another issue.  The CMS NHE figures discussed above forecast that total household expenditures over the period for private health insurance premia and for out-of-pocket expenses would total just $10.3 trillion.  On top of this, households would also spend $4.0 trillion in existing Medicare taxes (for old age cover).  While the Warren plan does not address this explicitly, implicit in her numbers is that the taxes gathered for old-age Medicare would remain as they are now (even though Medicare benefits would switch to the more generous cover of the Warren Medicare-for-All plan, such as no deductibles or co-pays).  But if households will be spending $10.3 trillion over the period for health care premia and other expenses, then their savings under the Warren plan cannot be $11 trillion, much less $12 trillion.  What is going on?  It is not fully clear, as the full set of underlying numbers have not been presented, but it is possible that the Warren advisors are working from a forecast that household spending on health care will total $11 trillion, rather than the $10.3 trillion forecast in the CMS NHE figures.  We would need to see the underlying numbers to sort this out.]

With the exception of this possible “glitch”, the Warren plan does, however, provide us with a good sense of the magnitudes of what the shifts in costs would be under a comprehensive Medicare-for-All plan.

In summary, with the US spending so much on health care ($52.0 or $52.5 trillion expected over the ten-year period under current law, or close to 19% of GDP), shifting how those costs are paid from private to public insurance will inevitably imply massive dollar amounts.  This does not mean higher amounts would be spent on health care.  Indeed, with Medicare far more cost-efficient than private insurers, total costs for a given level of coverage will go down.  But the shifts will still be massive.

The Warren plan covers these costs by three steps:  First, while an enhanced level of coverage would be provided (which by itself would increase overall costs by an estimated $7.0 trillion), these would be more than fully offset by measures which would save on costs (by an estimated $7.5 trillion).  Second, what state and local governments are now spending for health care coverage ($6.1 trillion), and 98% of what private businesses are spending as part of the wage packages for their employees ($8.8 trillion), would be transferred to the federal government, as the federal government would now cover these health care costs under the Medicare-for-All plan.  And third, the remaining $11.7 trillion needed to cover the additional federal level expenditures (of $26.5 trillion under the plan) would come from a wide range of measures, mostly of new or increased taxes, but also from a cut in military spending.

The net result would then be that households would no longer pay for health insurance directly, nor for current out-of-pocket costs.  These would be paid for through indirect means, as outlined above.  One can debate the extent to which these new taxes (in particular the transfer from private firms of what they are now paying for their employee health insurance) will impact households, but in the end there will be impacts.  Some households will end up spending less than they are now, and some will spend more.  And given the magnitudes of the underlying health care costs involved, those impacts will be huge.

C.  The Buttigieg Medicare-for-All-Who-Want-It Plan

Pete Buttigieg, as well as several other of the Democratic candidates for president (notably former Vice President Joe Biden and Senator Amy Klobuchar), have proposed instead adding a public option to the Obamacare market exchanges.  Buttigieg calls this Medicare-for-All-Who-Want-It, and has said that if private insurers then do not respond with something dramatically better “this public plan will create a natural glide-path to Medicare for All”.  This option would be a publicly managed (perhaps by Medicare) insurance plan, with similar coverage to what is now offered by private insurers and made available through the Obamacare marketplace exchanges along with the private insurance plans.  Buttigieg’s basic proposal is available at his campaign web site, with more detail provided at this additional post.

To see how this would work, we will first review how prices and other features for the health insurance plans are currently set by private insurers on the Obamacare exchanges, and then how the public option as proposed by Buttigieg would fit into this system.  One can then draw the implications for the system that one would end up with – a system that would be quite different from a Medicare-for-All system such as that proposed by Senator Warren.  And an important question is whether a system with a public option such as that proposed by Buttigieg would in fact create a “natural glide-path” to Medicare-for-All.

The Obamacare marketplace exchanges allow individuals to choose, from among the private plans offered in their particular jurisdiction, a health insurance plan for themselves as an individual or for their family.  The plans offered on the exchanges are not (other than for a few exceptions for small businesses) for the health insurance offered through employers.  Thus they are priced by the insurance companies to reflect what the risk (health expenses) would be, on average, for the individual.  There are some restrictions on how the prices for the individual plans can be set, most notably by not charging different rates for males and females, nor excluding (or charging different rates) those with pre-existing health conditions.  But other than these restrictions, the premia that are charged to individuals vary, and vary widely, based on a number of factors.

Specifically, they can vary by:

a)  The age of the individual (or of the family members in a family plan):  Health care costs are generally higher for older individuals.  While private insurers had lobbied to be able to charge prices for the oldest individuals that would be covered (age 64, as Medicare starts at age 65) of as much as five times the prices for the youngest, the final legislation set the limit at three times.  Still, this is a broad range.

b)  Location:  The price of the insurance plan varies by where the individual lives – not just by state but down to the county level within a state.  Health care costs can differ greatly across the country.  And while this is often attributed to general living costs being higher in some parts of the country than in others, a more important factor is the extent to which effective competition drives down (or not) the costs charged by doctors and hospitals on the one hand, and by the private insurers themselves on the other hand.  As discussed in an earlier post on this blog, much of the health care system in the US is characterized as a bilateral oligopoly in any given locality, where there might be only one or a few hospitals (where those few hospitals may themselves be part of a chain with common ownership), only a few doctors in particular medical specialties, and where there are also may only be a small number (including possibly just one) of health care insurers.

Health care prices charged will be high where such competition is limited, and low relative to elsewhere where such competition is more extensive.  Thus, for example, the premium rate for a 40-year old individual enrolled in the benchmark Obamacare insurance plan in 2020 in Minnesota is an average (across the state) of $309 per month (the lowest in the nation), while the benchmark rate in next-door Iowa is $742 per month (the second-highest in the nation) and $881 in not-so-far-away Wyoming (the highest).  The cost of living does not differ that much across these states.  The extent of competition does.

c)  Tobacco use:  While states can opt out of this (or limit it further), the Affordable Care Act allowed that health insurance plans offered on the marketplace exchanges could charge up to 50% more for those individuals who smoke.  This would partially compensate for the much higher health care costs of smokers.

d)  The extent of health care costs covered:  Finally, the Obamacare exchanges allowed for up to four bands or categories of insurance plans, designated by the labels Bronze, Silver, Gold, and Platinum.  They differed in terms of the share of health care costs that would, on average, be covered under the insurance plan, and the share that would then be covered by the individual (in terms of the premium to be paid for the plan, and through the deductibles, co-pays, co-insurance, and other costs, up to some out-of-pocket maximum).  A Bronze level plan would be expected, on average over all the individuals enrolled in the plan, to cover 60% of medical care costs, a Silver plan would cover 70%, a Gold plan 80%, and a Platinum plan 90%.

But the plans offered within a band (Bronze, Silver, Gold, Platinum) can differ widely in what the mix would be between the deductible, the specific co-pay and co-insurance rates, the out-of-pocket maximum, and then in the premium to be paid.  The plans could also differ in exactly what medical costs they cover (e.g. some cover dental costs, some cover prescription drugs, etc.), which doctors and hospitals were in the network for that plan, and what (if any) costs would be covered if one obtained medical services from an out of network doctor or hospital.

The resulting prices for the plans will therefore differ markedly across individuals in the nation.  To illustrate how wide this variation can be, even within just one state, I looked at the cost of the insurance plans offered in two regions of Florida.  Florida was chosen because its average benchmark plan premium rate ($468 in 2020) is close to the US average ($462), and it is a largish state where up to six insurers compete in offering plans in some parts of the state, while in other parts of the state only one insurer offers plans.  Choosing each just at random, I looked at the plans offered in Wakulla County, in the northern part of the state, which has just one insurer offering plans, and in Hillsborough County, around Tampa in the central part of the state, where five insurers offer plans.  One can find the plans offered, with all the details on their prices and coverage, at the Affordable Care Act web site, HealthCare.gov.

The costs differ dramatically between the two regions, and are systematically higher in Wakulla County.  I priced what a family plan would cost, with a household of four:  a man of 35, a woman of 35, a boy of 12, and a girl of 10 (although sex will not matter).  The cost of the second-lowest cost Silver plan (the benchmark plan, which I will discuss further below) would be $2,451.12 per month ($29,413 per year) in Wakulla, or 80% higher than the benchmark plan rate of $1,358.94 per month ($16,307 per year) in Hillsborough.  But the effective price difference was even greater, as the deductible in the Wakulla benchmark plan is $11,900, versus a deductible of $8,000 in Hillsborough.  And the plans differed in various other ways as well.

At the low end of the price range, the least expensive plan offered in Wakulla (a Bronze level plan) would still cost $1,538.22 per month ($18,459 per year), which is 52% more than the least expensive plan offered in Hillsborough of $1,011.00 per month ($12,132 per year).  Both of these plans had a deductible of $16,300 for the family, and also an out of pocket maximum of $16,300.  That is, these were essentially catastrophic health care plans that would not cover any health care expenses unless very high health care costs ($16,300) were incurred in the year.  Furthermore, one would have to pay $34,759 in Wakulla ($28,432 in Hillsborough) for the monthly premia plus the out of pocket expenses in any year when one’s health care costs exceeded the out of pocket maximum.

These costs are huge but reflect the fact that, as discussed at the top of this post, health care costs are simply very high in the US.  The amounts paid in premia each year (of $29,413 in Wakulla and $16,307 in Hillsborough) span the average paid (in 2019) of $20,576 for a family plan in employer-sponsored coverage discussed at the top of this post.  The main difference is that a large share (71% on average in 2019) of the cost of the employer-sponsored plans is hidden as it is paid by the employer from the overall compensation package for the employees, but before what is then (residually) paid in wages to the workers.  But the cost is still there.

Competition (or lack of it) between insurers also matter.  The far higher costs in Wakulla relative to Hillsborough are not due to a much higher cost of living in that part of the state (indeed, the cost of living there is probably lower), but rather because only one insurer is offering plans in Wakulla versus five in Hillsborough.  But even with the benefit of competition between insurers, it would be difficult for most families to be able to afford, on their own, such health insurance costs.  Hence a key aspect of the Affordable Care Act are federally funded subsidies provided to individuals and households to be able to purchase such health care coverage.  But this also adds an additional layer of complexity.

There are two forms of these subsidies provided for under the Affordable Care Act.  One is a subsidy on the insurance premia paid.  This is set according to the cost of the second-lowest cost Silver level plan in the area where the individual lives (termed the “benchmark plan”), and sets the subsidy to be equal to the difference between the cost of that benchmark plan and some percentage of family income.  That percentage varies by family income, and starts low (2.08% of family income in 2019, for example, for family incomes of up to 133% of the federal poverty line), and rises up to 9.86% (in 2019) for a family income between 300 and 400% of the federal poverty line.  There is no subsidy for those with incomes above 400% of the federal poverty line.  The percentages are adjusted year to year according to a formula that reflects certain relative price changes.  The ceiling rate of 9.86% in 2019, for example, began at 9.5% in 2014, and in fact fell in 2020 to 9.78%.

[Technical Note:  Why the second-lowest price to determine the benchmark plan?  It follows from a basic finding of those who analyze how markets function best.  If you are selling a product, then one wants those who are bidding to buy the product to bid the highest price that they are willing to pay.  But if the price that they will pay in the end depends on the price they specifically offer, they will bias their bid price downwards in the hope that they will get the product at a somewhat lower price.  And since all the bidders follow the same logic, the price will be biased low.  By providing the product to the one who bids the highest, but at the price of the second-highest bidder, one will remove that systematic bias.  In the case here, where one is offering a product for sale (the insurance plan), the same logic holds, but it will be the second-lowest priced plan chosen to serve as the benchmark.  And while the issue here is a price to be used for setting the subsidy that will be provided to those participating in these markets, the same principle holds.]

The second subsidy, provided for those with incomes up to 250% of the federal poverty line, covers a share of the out-of-pocket costs for deductibles, co-pays, and co-insurance.  The insurance companies would initially provide these (i.e. not charge the individual for these when health costs are incurred), and under the Affordable Care Act would then be compensated by the federal government for these costs.  However, the Trump administration working with the then Republican-controlled Congress ended these payments to the insurance companies, by zeroing out the funds for these in the budget.

The insurance companies were, however, still obliged by law to provide these cost-sharing subsidies to the eligible (low income) enrollees in their plans.  The result was that the insurance companies were forced to raise their premium rates on the plans to everyone to cover those costs.

Here it is important to note a feature of how the Obamacare premium subsidies are structured.  Since the amount a person eligible for a premium subsidy (i.e. with income up to 400% of the federal poverty line) will pay is fixed at some percentage of their income, any increase in the cost of the benchmark insurance plan for that individual will be matched dollar for dollar by an increase in the premium subsidy.  Hence the decision by Trump and the Republicans in Congress to end the cost-sharing subsidies led directly to a similar amount of higher premium subsidies being paid, with little or no savings to the budget.

But it gets worse. While those receiving the premium subsidies (those with incomes up to 400% of the federal poverty line) would not be affected by the now higher plan prices, middle-income households with incomes above that 400% line would have to pay the higher prices.  As a result, some of those households dropped their coverage due to the higher cost.  This in turn led the insurance companies to raise the costs of their plans by even more (due to the more limited, and likely higher risk, mix of enrollees in their plans).  This in turn then led to even higher premium subsidies being paid to those eligible (those with incomes below 400% of the poverty line).  The end result of this effort by Trump and the Republicans in Congress to undermine the Obamacare exchanges was to increase the amount spent in the federal budget over what would have been the case had they continued to fund the cost-sharing subsidies.

The Buttigieg plan (and similarly that of others, such as Joe Biden) would then be to keep this basic structure, but add to it a publicly-managed health insurance option.  It would be sold on the Obamacare marketplace exchanges, in parallel with the private plans, and those seeking health care insurance in those markets would be able to choose whichever they preferred.

What would be the impact?  The Congressional Budget Office provided estimates in an analysis undertaken in 2013.  They concluded that a public option would be able to provide health plans similar to the private plans offered on the Obamacare exchanges, but at premium rates that would be 7 to 8% less.  That is, for similar coverage the greater efficiency that could be achieved by a publicly managed option (due to greater scale, the ability to piggy-back on the extremely efficient Medicare system, and by not paying the profit margins that the private health insurers demand), could provide insurance cover at a significantly lower cost.  Note this 7 to 8% lower cost would be an average across the country – it would be more in some areas and less in others.  And with the public option priced at this level, covering its costs, the CBO estimates (conservatively, it would appear) that 35% of those participating in the Obamacare exchanges would choose this public option.

And it gets better.  While there would be no direct effect on the net government budget by offering a public option priced to cover its costs (no more and no less), there would be significant positive indirect effects.  First, government outlays would be reduced, as the new competition brought on to the Obamacare exchanges by the public option would drive down overall prices on the exchanges, and in particular the price of the benchmark insurance plan (the second-lowest cost Silver plan).  At these lower costs, the amount the government would need to spend on premium subsidies for existing enrollees with incomes up to 400% of the federal poverty line would go down.  This would be partially (and only partially) offset, however, by a larger number of those currently with no insurance choosing now to enroll through the exchanges to obtain health care insurance.  A number of these individuals and their families would be eligible for premium subsidies.  However, while this would be a cost to the budget, increased enrollment is a good thing and was, after all, the primary objective of the Affordable Care Act.

Second, with some workers (and their employers) now finding the insurance options on the exchanges more attractive, a switch of some share of workers to the exchanges will lead to an increase in the taxable share of worker incomes.  Hence government revenues would go up.

The impact of these two sets of indirect effects would be significant savings to the government budget.  The CBO estimates were for the period 2014 to 2023, but assumed the program would be in effect only from 2016 to 2023 and with a ramping up period in 2016.  Hence this was not a true ten-year impact estimate.  But if one extrapolates the CBO figures for a full ten years, and for the period 2020 to 2029 (the same period as was used above for the Warren plan), the net savings to the budget would be about $320 billion.  This is not small.

Adding a public option to the Obamacare exchanges would therefore appear to be an obvious thing to do, and it is.  And indeed, a public option was included in the Affordable Care Act legislation as it was originally passed in the House of Representatives in 2009.  But it was then taken out by the Senate.  The Democrats had a majority in the Senate at that time, but still abided by the legislative rules that required a 60 vote majority to pass major pieces of legislation.  (This was later effectively changed by Senate Majority Leader Mitch McConnell when Republicans took control of the Senate so that, for example, the major re-writing of the tax code in December 2017 was deemed to require only 51 votes to pass.)  But to get to 60 votes, the Democrats needed the vote of Senator Joe Lieberman of Connecticut.  Lieberman would only agree if the public option was taken out.  Lieberman represented Connecticut and insurers are especially influential in that state, providing significant campaign contributions and with several headquartered there.  And it is only the private insurers who will lose out by allowing competition from a public option.  As a consequence, the Affordable Care Act as ultimately passed did not include a public option.

Buttigieg’s full health care plan includes a number of other proposals as well.  Generally, all the candidates support them (even Trump says he does on some of them), including requirements such as ending surprise out-of-network billing (when care is provided at an in-network hospital by an out-of-network doctor or other provider, and then billed at often shockingly high out-of-network rates); limits on what those out-of-network rates can be (Buttigieg would set a ceiling of two times the Medicare rates); allowing Medicare to negotiate on prescription drug prices used in health care services it covers (Medicare is currently blocked from doing so by law); and more.  But while all the candidates support such reforms, there are powerful vested interests that have so far succeeded in blocking them.

Buttigieg would also lower the share of family income used to determine the premium subsidies they are eligible for.  As discussed above, that share is 9.78% in 2020 for those with incomes between 300 and 400% of the federal poverty line (and lower for those at lower income levels).  Buttigieg would set the ceiling rate at 8.5% (with lower rates for those at lower incomes), and importantly would also remove the limit on family incomes for eligibility.  This would be significant for many.  Take, as an example, the price of the benchmark plan being offered in 2020 in Wakulla County, Florida, of $29,413 for a family of four (at the ages specified, as discussed above).  With the federal poverty line in 2020 of $26,200 for a family of four, and hence $104,800 as 400% of this poverty line, such a family would be required to pay 9.78% of their income ($10,249) for their share of the cost should they choose the benchmark insurance plan, and would receive a subsidy of $19,164 (where $19,164 = $29,413 – $10,249).  If they earned $1 more than 400% of the poverty line, they would receive no subsidy and would have to pay the full $29,413 should they purchase the benchmark plan.

In the Buttigieg proposal, the share of income would be capped at 8.5%, so for someone at 400% of the poverty line their share of the cost would be $8,908 instead of $10,249.  Furthermore, it would not be restricted only to those with an income below 400% of the poverty line.  So if the benchmark plan cost were to remain at $29,413 (the CBO estimates it would go down by 7 to 8% if a public option is introduced, as noted above, but leave that aside for here), families with incomes of up to $346,035 would be eligible in this county of Florida for at least some subsidy, with the subsidy having diminished smoothly to zero at that point.

Another difference is that Buttgieg proposes that the benchmark plan be shifted from the second-lowest cost Silver plan to a Gold-level plan (presumably also second-lowest cost, although he does not say specifically in what is posted).  Gold-level plans have more generous benefits than the Silver plans, but at the cost of higher premia.  Hence the premium subsidies would be higher for any given level of income given the 8.5% cap.  Keep in mind also that the Affordable Care Act premium subsidies, while determined relative to the cost of the benchmark insurance plan, can then be used by the individual for any other plan offered on the exchanges.  The dollar amount provided under the subsidy will be the same.

Buttigieg would also auto-enroll into the public option (which could then later be switched by the individual to one of the private plans) those who would otherwise be eligible for free insurance.  This would be in cases where they would have been eligible for Medicaid had that state accepted the expansion under the Affordable Care Act but then refused to do so, or in cases where the individual or family would have been eligible for a zero-cost plan after the premium and cost-sharing subsidies are taken into account.  Possibly more problematic would be the Buttigieg proposal to enroll retroactively someone without a health insurance plan who would then need some health care treatment.  This could provide an incentive not to enroll in any insurance plan (with its associated monthly premia) unless and until some substantial health care cost is incurred.

How would this be paid for?  Buttigieg estimates that the 10-year cost would be $1.5 trillion, which is modest compared to the Medicare-for-All plans.  There is no way I can check that figure, but it appears plausible.  Part of the reason it is relatively modest is that for those workers enrolled in an employer-based plan but who choose to switch to the public option (as they would now be allowed to do), Buttigieg would require the employer to pay in an amount equal to what they would otherwise have paid for that employee’s health insurance plan.

While one should want to require something of this nature, exactly how it would work is not clear.  There could be an adverse selection problem.  If the employer was required to pay in an amount that is the pro-rated share of the cost of one worker in the company plan, and hence the same for each worker whether old or young or with a pre-existing condition or not, there would be an incentive to encourage (perhaps quietly) the workers with the more expensive expected health insurance expenses to switch to the public program.  How to set the prices of what the companies would pay to avoid such negative outcomes would need to be worked out.  There is also the issue that the system would create an incentive for companies to scrimp on the coverage of the health plans they offer, so that they would then both encourage workers to shift to the public option and pay less into that system when their workers do so.

But such issues should be resolvable, for example by tying what the employer would pay for an employee switching to the public option not to what the employer was spending before on their health plan, but rather to what providing health care coverage would cost in the public option for that worker.

The addition, then, of the public option would be a major improvement over what we have now.  Would it, however, provide as Buttigieg asserts a “natural glide-path to Medicare for All” if private health insurers “are not able to offer something dramatically better” than what they have now?  That is not so clear.

The addition of the public option to the present system would not fundamentally change the system.  One would continue to have a highly complex and fragmented system, with disparate plans where any individual’s cost of health insurance would depend on several factors.  Specifically, even for the same degree of coverage in terms of what medical costs are covered and for the same deductible, co-pays, and so on, the cost of their health plan would vary depending on the expected health care risks of the individual (their age), how much it then costs to address any consequent health care issues that arise (their location), and their income (for those eligible for subsidies).

Setting aside the income (health care subsidies) issue for the moment, we have noted above that health plan costs can vary by up to a factor of three based on age.  And the costs by location vary similarly.  Even using state-wide averages (the variation will be greater if one took into account the different costs at the county level within a state), the average cost of the benchmark insurance plan for a 40-year-old in 2020 is $881 per month in Wyoming but $309 in Minnesota.  This is a ratio (between the most expensive and the least) of close to three.  Putting just these two cost factors together, the range of costs for an individual across the country can vary by a factor of nine.  Taking within state variation in cost also into account would lead to an even higher ratio.

By what path would this then possibly transition to a Medicare-for-All system?  Suppose one is at the point where 90% or more of the population has chosen to enroll in the public option.  While almost all of the population might then be in a publicly managed health care plan, they would be in plans where either they (or other parties on their behalf, i.e. their employers or the government) are paying premia that could vary by a factor of nine or more for the exact same coverage.  Some (the young and healthy, living in areas where health care costs are more modest) would be paying relatively little, while others (the old and those living in areas where health care costs are especially high) would be paying much more.  This is not what most people envision when referring to Medicare-for-All.

Would this then transition to a true Medicare-for-All system?  That could be difficult.  In a Medicare-for-All system as most people view it, the amount paid for health care would vary only based on income.  The current Medicare system (for those aged 65 and older) is funded by a combination of taxes on wages (2.9% of wages of workers of all ages, technically half by the employer and half by the employee), and by monthly premia for those enrolled in Medicare (where these premia start at $144.60 monthly in 2020 per person, and rise to as much as $491.60 per person for those at high-income levels).

If the Medicare-for-All system were then funded, directly or indirectly, by taxes and/or premia that are based solely on income (such as a higher payroll tax, for example), the transition would imply that those who were before paying relatively modest amounts in premia for their health care plans (whether via the public option or in one of the private plans) would end up paying more.  And it could be much more given the factor of nine (or greater) range in the cost of these plans.  One should expect that they will scream loudly, and seek to block such a transition.

This would then not be a “natural glide path” to Medicare-for-All.  Rather, unless something major is done, and forced through despite the likely opposition of those who would end up paying more for their health care insurance, the system would likely remain as now, with a highly fragmented and complex system of multiple health care plans, at widely varying premium rates, with some paying relatively modest amounts and some an order of magnitude more.

[And a point of full disclosure:  I had myself, in an earlier post on this blog, not seen this issue.  I had argued that a system with an efficient public option could lead, through competition, to a Medicare-for-All system.  The proposal I had discussed there included that the publicly-managed option would be allowed also to compete on the market for employer-sponsored plans, and not just in the market for individual cover, but the issue would remain.  One would end up in a system with widely varying premia rates, based on the risk of those being covered, and it would then be difficult to move out of such a system to one where what is paid is linked solely to income.]

D.  The Warren Plan for a Public Option as a Transition to Her Medicare-for-All Plan

Senator Warren announced her Medicare-for-All plan (described in section B above) on November 1, 2019.  Two weeks later, on November 15, she announced that as first step she would seek to add a public option early in her administration, while postponing to the third year of her prospective administration seeking approval in Congress for her Medicare-for-All plan.  See the link here for this proposal at her campaign website, or here for the same proposal at an external website.

While there are a number of health care reforms she presents in this proposal, several of which she says could be implemented by executive order alone and not require congressional legislation, I will focus here on how she envisions her public option.  It is quite different from the public option as discussed by Buttigieg, Biden, and others, and indeed Warren labels it (somewhat confusingly) a “Medicare for All option”.  It would be offered on the Obamacare market exchanges, along with the private insurance plans that are there now, but would differ from them in key ways.

Most importantly, Warren’s public option would provide for a far more generous level of coverage than what is covered under the private health insurance plans, with this paid for in part by substantially more generous government subsidies than what would be provided to those who enroll in any of the private health insurance plans.  That is, this would no longer be a level playing field, with the public option priced to cover its costs and then competing on the basis of being able to operate more efficiently and at a lower cost than the private plans.

This then addresses the key question, discussed above, of how to transition from a system of multiple, competing, health plan options, to a single-payer Medicare-for-All system.  The answer is that the public option that Warren proposes to add in the first year of her administration would be so generous, and at such a low cost to the individual, that it would make little sense for almost anyone not to enroll in it.

Specifically, under her proposals:

a)  The Warren public option health insurance plan would be comprehensive in what it covers, matching what would be covered in Warren’s November 1 Medicare-for-All proposal.  That is, in addition to what the insurance options on the Obamacare exchanges are now required to include, her public option would include coverage for expenses such as for dental care, vision services, auditory, mental care, long term care, and more.  This would be far broader than what the current Medicare system covers for those over age 65 (but as part of her proposal, she would have Medicare expand its coverage to include these additional medical expenses as well).

b)  There would be a zero deductible from the start, and some unspecified (but low) cap on out-of-pocket expenses.

c)  The Warren public option would be free for those below the age of 18, and free as well for households with incomes below 200% of the federal poverty line (i.e. $52,400 for a family of four in 2020).  Note that in effect this makes Medicaid redundant, as all those now eligible for Medicaid (those with incomes up to 130% of the federal poverty line, but less in states that did not accept the expansion of Medicaid provided for in the Affordable Care Act) would be better off with the proposed Warren public option.

d)  The Warren public option plan premiums, co-pays, and co-insurance would then be set so that the plan would initially cover 90% of expected medical costs.  Note that while a Platinum level plan on the Obamacare exchanges also covers 90%, the public option plan proposed by Warren would cover a broader range of medical expenses (dental, etc.), so they are not fully comparable.

e)  Premium subsidies for the Warren public option (and usable only for this option) would be set so that households do not spend more than 5.0% of their incomes for the insurance plans (and less for those at lower incomes).  This would be well below the 9.86% ceiling in effect in 2019 on premium subsidies (9.78% in 2020) under the current Affordable Care Act system for those purchasing coverage on the exchanges.  Importantly, and as Buttigieg also proposes, these subsidies would be available for households of any income, and not capped at a household income of 400% of the federal poverty line.

The new subsidies would be generous compared to what is now provided.  While it is not clear how much it would cost on average for the comprehensive coverage (with zero deductible) as envisioned in the Warren public option (no estimate was provided in what was posted by the Warren campaign) if one assumes a modest plan cost of $25,000 per year for this expansive cover, the subsidies would be:

Family Income

5% of Income

Subsidy

$100,000

$5,000

$20,000

$300,000

$15,000

$10,000

$500,000

$25,000

$0

The subsidy would only fully phase out at an income of $500,000 in this example.  This would mean that even some households with an income in the top 1% in the US (incomes that started at about $475,000 in 2019) would be receiving subsidies to purchase their health insurance plan.

f)  Keep in mind as well that, as was discussed earlier, any increase in the cost of providing the insurance plan will be covered dollar-for-dollar with an increased subsidy (for those receiving any subsidy).  The amount the individual pays is capped at 5% of income.  This is important as Warren would have the 90% share of expected medical costs being covered by the insurance plan rising “in subsequent years” to 100%.  While this more generous cover would, in normal insurance, need to be paid for by higher premia, the 5% of incomes cap on what will be charged in effect means that the more generous cover would be paid for by higher government subsidies, dollar for dollar, for all those eligible to receive such subsidies.

g)  For those who choose to continue to enroll in one of the private insurance plans offered on the Obamacare exchanges, Warren has that the share of income required from the individual would be “lowered” from the 9.86% rate of 2019 (9.78% in 2020).  But she does not specify to what rate it would be lowered to.  Presumably if the intention is to lower it to the 5.0% rate that would apply for Warren’s public option, they would have said so.  And the subsidy would also be made more generous by benchmarking it to the cost of Gold level plans, rather than the second-lowest cost Silver plan.  Finally, the Warren plan says that for those choosing still to enroll in one of the private insurance plans they would also “lift the upper income limit on eligibility” for the premium subsidies from the current 400% of the federal poverty line.  But it is not clear if it would be removed altogether, or simply lifted to some higher level.

These measures would lead to an increased level of subsidies for those choosing to remain with one of the private plans on the Obamacare exchanges.  But while there is much that is not fully clear here, it does appear clear that the subsidies would not rise to what would be provided to those who choose instead to enroll in the Warren public option.  And what would certainly be the case is that the public option as proposed by Warren would provide a more comprehensive level of health cost cover than what is being covered in the private plans, and with a zero deductible, lower co-pay and co-insurance rates, and a lower out-of-pocket ceiling.

h)  Workers in firms that provide company-sponsored health insurance plans could opt to enroll in the Warren public option instead.  For those who do, their companies would be required to “pay an appropriate fee” to the government.  How that “appropriate fee” would be set was not specified.  If linked to what the employer would be otherwise paying for the company-sponsored plan for the worker, one would have the same adverse selection issue that was discussed above for the similar proposal in the Buttigieg plan.  But it should be possible to address this in some way.

How much would this cost, and how would it be paid for?  As noted above, no specific cost estimates (on neither the cost of a typical plan nor the cost of the overall proposal) are provided in what the Warren campaign posted.  All that is clear is that with the more comprehensive list of what is covered, along with the zero deductible, modest co-pays and co-insurance, and a low limit on out-of-pocket expenses, the Warren public option plans will cost more to provide than what the Platinum level plans offered on the exchanges cost.  This is true even though both would be priced to cover 90% of expected medical costs, since the list of medical costs covered would be broader.

But while the cost of providing the Warren public option plan would be higher, the cost to the individuals signing on to it would be lower due to the greater premium and other subsidies that would be made available for it (with the 5.0% limit on family income, with no ceiling on income for eligibility).  With such subsidies being made available, it is difficult to see why anyone would not wish to sign on to such a plan.  While technically voluntary, and with private insurance “allowed” to compete for such business, this would be far from a level playing field.

Thus there would be a significant cost to the overall government budget to cover the cost of the subsidies provided to those signing on to the Warren public option.  But as noted, no estimate was provided in what was posted by the Warren campaign of what this might be.  All that was provided was the statement that the cost would be less than what her full Medicare-for-All plan (as discussed in Section B above) would cost.  She notes that that proposal had listed a number of taxes and other measures to pay for the Medicare-for-All plan, and that the more modest cost of her proposed public option could make use of some subset of these.

But how much less would that cost be?  It would of course depend on how many people enroll, and that is not known.  But with the higher subsidies provided for a far more extensive cover than available in the private plans offered on the Obamacare exchanges, and indeed more extensive than in most employer-sponsored private health insurance plans, there are not many who would not be personally better off by switching to the Warren public option.

There would, however, be at least one key difference in the funding, at least to start.  While Warren has that individuals with incomes over 250% of the federal poverty line would pay premia for the public option she is proposing, with this capped at no more than 5.0% of family income, the full Warren Medicare-for-All plan would have no such premia.  But paying premia of 5% of income would generate significant funding.  While Warren says that the 5% rate would be scaled down over time (at some unspecified pace), a crude back-of-the-envelope calculation indicates that a 5% charge (if applied throughout the 2020-29 period) could provide on the order of about 40%, and possibly more, of the $11.7 trillion in extra funding (for the 2020-29 period) that would be required in Warren’s Medicare-for-All plan

Specifically, the share of family income to be paid for premia (whether 5.0%, or the 9.86% in 2019 on the current Obamacare exchanges) is based on a share of taxable household income.  With some minor adjustments (which can be ignored for the purposes here), that income is the adjusted gross income shown on the family’s income tax return.  Using data for 2016 reported by the IRS, the total adjusted gross income shown on all tax returns filed in the US that year was $10,226 billion.  Of this, $1,960 billion was reported by households with incomes of less than $50,000 (which also accounted for 59.4% of all returns filed).  Since this is roughly what 250% of the poverty line would be (for a family of four), where Warren would not charge any premium rate, those incomes will be excluded.  And while the premium rate would then only be phased up with incomes to the full 5.0% rate, Warren does not say what the pace of that would be.  Taking the extreme case by assuming it would go immediately to the 5.0%, the total adjusted gross income on tax returns filed for 2016 for incomes of $50,000 or more would then be $8,266 billion (= $10,226b – $1,960b).

To make this comparable to the figures discussed in Section B above on the cost of Warren’s full Medicare-for-All plan, one can then take this as a share of GDP and apply it to the forecast value of GDP for the 2020-29 period.  Note first that the figure for overall adjusted gross income as reported on tax returns ($10,226 billion in 2016) is less than GDP (which was $18,715 billion in 2016) for a number of reasons.  Taxable income, as defined under tax law, differs from income as defined in the GDP accounts, and there are other factors as well (such as corporate income).  But the two will generally move together.  Applying then the share of GDP in 2016 accounted for by households with incomes of more than $50,000, to the forecast total GDP for the 2020-29 period ($261,911 billion) and then taking 5.0% of that, households would pay (assuming 100% enroll) about $5.8 trillion if applied to the full ten year period.  This would be a substantial portion of the $11.7 trillion that would need to be raised by new taxes or government spending reductions in the Warren Medicare-for-All plan.  That is, very roughly, half.

This assumes, however, that the premia paid will always be 5.0% of incomes.  But that will not be the case.  The premia will be set at some rate, and households would pay only up to whatever that rate is (but no more than 5.0% of their incomes).  As noted above, even with a premium rate of $25,000 a year (likely low for an average rate, given the generosity of what would be covered), households with incomes of up to $500,000 a year would be receiving subsidies.  And $500,000 a year for household income is approximately the break-point between the 99% and the 1% in terms of income ranking.  If one assumes that the 1% choose not to enroll in the Warren public option, but rather buy their health insurance directly from some private provider, the impact on health care costs incurred in the public plans would be negligible.  They are only 1% of the total (assuming the other 99% do enroll), plus they probably have lower per person health care costs than for those of lower incomes (the rich are generally healthier, with a lower incidence of heart disease, cancer, diabetes, and so on).

But the richest 1% do account for a significant share of overall household income.  Again using the IRS data for 2016, the richest 1% of households accounted for 17.2% of overall adjusted gross income of all households.  Taking this as a share of GDP, applying that share to the forecast 2020-29 GDP, taking 5% of it and subtracting that amount from what would be generated if all households paid the 5%, one arrives at a figure of $4.6 trillion for the funding that could be raised.  This would be close to 40% of the $11.7 trillion required.

These estimates are rough, and would apply only to the initial years of the program Warren is recommending as part of a transition to her Medicare-for-All plan.  But it suggests that 40% or more of the extra government funding required could be raised by charging a 5% premium to those with incomes over 250% of the poverty line.  Note that the $11.7 trillion in net funding needed (over ten years) already has taken into account a transfer from state and local governments of what they would otherwise be spending on Medicaid and other health insurance programs that would become redundant under Warren’s plans.  It is also net of transfers from private companies of what they would otherwise be spending on the employer shares of company-sponsored health insurance plans.  Thus the 5% premium would be a substitute for some share of the additional taxes that Warren has proposed in her Medicare-for-All plan.  But as that 5% premium rate is reduced to zero over time under her proposals, that full set of additional taxes would be needed.  Just not right away.

Still, the amounts involved are huge.  If everyone (other than the extremely rich) choose to enroll in Warren’s public option, as it would make sense for them to do, the 5% premia paid would come to 1.7% of GDP.  The $11.7 trillion required in the full Medicare-for-All plan comes to 4.2% of the ten-year GDP.  Thus there would be a need to raise from some set of sources an additional 2.5% (= 4.2% – 1.7%) of GDP.  GDP in 2020 will total about $22 trillion, and 2.5% of this is $550 billion.  That is a massive amount to be raised.  Keep in mind that this is not additional spending, but rather in effect a transfer from what would otherwise be spent on health care (through the insurance premia we now pay, plus out-of-pocket expenses).  Indeed, there would be a net saving by moving to a more efficient / lower-cost health care funding system.  But that $550 billion would still need to be raised.

E.  Summary, and a Path Forward

The health care funding system in the US certainly needs to change.  The US spends far more than any other country in the world on health care, but despite this health care outcomes are worse than elsewhere.

Fundamental reform is needed, and a number of proposals have been made.  The most far reaching would be to move to a Medicare-for-All system.  Senator Elizabeth Warren has made a detailed proposal on how this would work and what the funding needs would be, and is to be commended for this.  But the funding needs would be massive.  While overall spending on medical care would not go up (indeed it would go down under her plan), there would be massive shifts from how the payments are made now (via premia paid for private health insurance and out-of-pocket) to how they would be made in a single-payer Medicare-for-All scheme.

In Warren’s plan, the shift in spending through government accounts would total an estimated $34.0 trillion over the ten years of 2020-29 (12.2% of GDP), if nothing else is done.  However, Warren’s team estimates that there would be savings of $7.5 trillion from a number of reforms and other efficiency gains leaving $26.5 trillion (9.5% of GDP) to be funded.  To provide a sense of how large this is, it can be compared to the forecast by the CBO that individual income taxes over this period would in total raise less, at only $23.2 trillion.

Part of the $26.5 trillion would be covered by transfers from state and local governments of what they currently spend on health care programs out of their own budgets (primarily Medicaid), and part from transfers of 98% of what private companies spend on the employer share of company-sponsored health care plans for their employees.  But even assuming such transfers will be possible (it is likely they will be strongly resisted), there will still be a need to raise a further $11.7 trillion (4.2% of GDP).  Warren proposes to do this through a series of measures, mostly from new taxes.  In terms of 2020 GDP of about $22 trillion, that 4.2% would come to $920 billion.  This is huge.

Given such amounts to be raised, plus concerns over the possible disruption that any such plan might cause (where one especially never wants to face disruption when health is at stake), many prefer a more gradual and possibly more modest reform.  An obvious alternative would be to include in the Obamacare market exchanges a public option, similar to Medicare and possibly managed by Medicare itself.  Allowing also employees currently on a company-sponsored health insurance plan to opt in to the public option should they wish (with their company still paying a fee tied to what they otherwise would be spending for the worker), one would have that those who want a Medicare-like plan could choose it, and those who don’t don’t.

The Congressional Budget Office has estimated that such a public option could be provided at a cost that is, on average, 7 to 8% less than what private plans charge, as the public option would be more efficient.  On top of this, there would be significant indirect savings to the overall government budget.

But would this then provide “a natural glide-path” to a Medicare-for-All system, as Buttigieg asserts?  That is not so clear.  The reason is that the public option would price plans similar to how the private plans are now priced (just 7 to 8% lower on average).  Their prices would reflect the risks of the individuals being covered and the cost of providing health care where they live.  Thus even if the public option grew to dominate the market, one would still have a wide range of health care premia being paid, which could easily vary by an order of magnitude between the low risk / low cost individuals to the high risk / high cost ones.  And the system would then remain like this, complex and with a wide range of costs linked to factors other than income.  Moving that system to one where the costs depend only on income would lead to higher costs for the low risk / low cost individuals in the system, and they will likely complain loudly.

How was this addressed in the second plan that Warren put out, where (in addition to a long list of other reforms) a public option would be made available immediately, as a transition step to her full Medicare-for-All scheme?  The answer is that the “public option” Warren proposed was quite different from the public option referred to by Buttigieg (as well as by Biden, Klobuchar, and others).  The public option as normally presented has been an option that competes with the private plans on the Obamacare exchanges, priced to cover its costs and receiving no special advantages.

Warren’s public option is different.  It would be comprehensive in terms of what it covered, would not have a deductible, only low co-pay and co-insurance rates, and a low out-of-pocket ceiling.  And while the premium for such a plan would need to be relatively high to cover such benefits and low out-of-pocket costs, Warren would provide government subsidies so that no one would need to pay more than 5% of their incomes to cover those costs.  And at a 5% ceiling, those subsidies could go to some pretty rich people.  Assuming a premium of $25,000 a year would be required to cover the costs of the plans (a conservative estimate, given what it would cover), households with incomes of up to $500,000 a year would be eligible.  That is, all but the richest 1% would be eligible.

In such a system one could choose to continue with a private plan, but for most it would be foolish not to switch.  Thus while this public option as proposed by Warren would be competing with the private plans, it would not be on a level playing field.  Rather, those enrolling in the public option of Warren would receive subsidies substantially greater than what those enrolling in a private plan could.  There is nothing necessarily wrong with this, but it should be recognized.  And those subsidies would have to be funded from somewhere.

The Warren team provided no estimate of what the overall cost of this might be, but simply noted that it would be something less than the full Medicare-for-All plan she had earlier proposed.  And the premium of up to 5% of family income that would be paid to cover a portion of the cost would be a significant source of funds.  But even including this, and assuming most Americans (other than the rich in the top 1%) chose to enroll in Warren’s public option, there would be a need to find $550 billion in additional government funding (if this applied in 2020).

These amounts are all huge.  But given the amount the US is now spending on health care (about $4 trillion expected in 2020, or 18% of GDP), any fundamental shift in how health care is funded will involve massive amounts.  And again it should be emphasized that the amounts needed do not imply a net increase in what will be spent, as the reforms being considered can be expected to reduce overall health care costs.  Nevertheless, the amounts are large, and will lead to major interpersonal shifts (with some paying less than they are now, and some paying more and possibly much more).  Those impacts should not be downplayed.

Still, the Warren plan for a transition to a Medicare-for-All system would be a plan for how to move forward.  It may well not be possible to do this quickly, given the size of the shifts in funding sources.  But one can envision where one might start with a public option such as Warren has proposed (exhaustive in what it covers, and with a zero deductible), but where the ceiling on family income for the premia might start not at 5% but perhaps more like the 8.5% Buttiegieg has proposed.  Then this would be reduced over time, perhaps by 1% point per year while other funding sources are scaled up, with this eventually brought down to zero.  At that point we would be in a full Medicare-for-All system.