| 来源类型 | Report |
| 规范类型 | 报告 |
| A better (but modest) case for high-risk pools | |
| Mark V. Pauly; Thomas P. Miller | |
| 发表日期 | 2017-03-24 |
| 出版年 | 2017 |
| 语种 | 英语 |
| 摘要 | Key Points The relatively modest, but significant, problem of several million Americans at risk of limited or no insurance coverage due to serious preexisting health conditions should and can be addressed more effectively. The Affordable Care Act’s combination of adjusted community rating, guaranteed issue, income-related premium subsidies, and a weak individual mandate made its individual insurance market coverage less attractive to younger and healthier individuals. A well-targeted and adequately funded high-risk-pool approach would provide a fair and efficient way to ensure insurance coverage without preexisting condition exclusions, reduce premiums in the rest of the individual market, and help expand overall coverage. Introduction This year, much of the current debate about repeal-and-replace alternatives to Obamacare centers on this challenge from defenders of the status quo: How can the new Trump administration and a Republican Congress keep their general promise to protect insurance coverage for individuals with high-risk, preexisting health conditions, without compelling other low-risk insureds to pay higher premiums? It assumes the obvious answer is “not possible,” accompanied by the warning that “tens of thousands of people, or more, will die if you try to do anything else.” Then the rest of this closed-loop political argument kicks in with one seemingly simple solution: The individual mandate under the Affordable Care Act (ACA) remains essential to compel low risks to pay more than the likely costs of their medical claims, so that high risks can pay less than they are expected to cost. For example, former Secretary Robert Reich made this formulaic claim last month on CNN,1 and he was slowed only momentarily by an opponent’s comment that the current mandate seems too weak to force enough low risks to enroll in Obamacare’s coverage and sustain the participation of low-risk insureds and insurers in general. On the other hand, the White House and Republican congressional leaders plan to eliminate all penalties under the ACA’s individual mandate, rather than strengthen them, but maintain the law’s prohibition on health-risk rating. On March 13, the Congressional Budget Office estimated that these moves, as proposed in the Republican-sponsored American Health Care Act (AHCA), would substantially increase the number of uninsured Americans, while causing individual insurance market premiums to rise over the next few years.2 Even more recently, Harvard economist David Cutler criticized the AHCA for reducing insurance payments for the healthy and necessarily increasing them for the sick.3 Cutler posits that a large share of medical costs are predictable. He claims that the ACA spreads costs for the less fortunate across everyone through its combination of adjusted community rating, reasonably generous benefits, the individual mandate, and taxes to subsidize their premiums and out-of-pocket expenses. Cutler then faults the AHCA for failing to address the persistently ill.4 Preexisting Condition Coverage Problems Are Really Just About the Individual Market These views of how insurance markets can, and do, operate often manage to be both far too shallow and sweeping (quite a simultaneous combination!). They overlook more than just the limitations of legal mandates to purchase whatever the federal government deems appropriate. As a starting point, this issue needs to be confined to the individual insurance market. Most Americans who receive coverage in the employer group market or through Medicare and Medicaid already operated under other rules and practices established well before Obamacare policies that pool risks quite differently. Individuals who are covered by employer-sponsored insurance cannot be directly singled out to pay higher premiums, face coverage restrictions, or even lose their coverage based on their individual health status or that of their dependents. That was largely the case for many decades as a matter of good business sense by employers (recruiting and retaining good workers is hard enough), but federal legislation (the Health Insurance Portability and Accountability Act of 1996) made those business practices more uniform and mandatory. That law also established rules to protect workers switching jobs to move seamlessly from one employer’s insurance plan to another such plan, as long as the worker had maintained so-called “continuous qualified coverage” for a sufficient period of time. Enrollees in our two largest taxpayer-subsidized entitlement programs are either charged the same premium at a given income level regardless of risk (Medicare) or do not have any premiums at all (Medicaid). Medicare essentially pools everyone over age 65, regardless of their particular age or health status. Medicaid provides coverage for low-income Americans of all ages, although the scope and scale of its benefits differ for various categories of beneficiaries. (For time and space considerations, we are oversimplifying some lesser exceptions and variations to those general rules in the two programs.) The basic point is that the issue of preexisting conditions and restrictions on access to insurance based on one’s health status really applies to only a small fraction of Americans—those formerly uninsured seeking coverage in the individual market or trying to move from one individual market plan to another. Although the size of that market expanded under the ACA’s mix of increased taxpayer subsidies, coverage mandates, and tighter insurance rules, the total market (including mostly average or low risks) is still not much more than about 20 million insured Americans, plus conceivably another 15–20 million currently uninsured potential customers. Even here, policy and practice for the individual market before the ACA was far from the Hobbesian imagery painted by its critics. Individual insurers, first voluntarily and then as required by federal law, promised not to re-underwrite and single out persons who became high risks for high premiums. This guaranteed renewability provision was occasionally ignored or sidestepped by dropping whole blocs of customers or ones who provided incorrect information when applying, but those incidents were rare. Those exceptions faced bad publicity and legal sanctions from regulators or in the courts. The real problem for high-risk customers was limited to those who chose to go without insurance and then sought it only when they really expected high benefits from it. Read the full report. Notes |
| 主题 | Economics ; Health Economics |
| 标签 | Affordable Care Act (Obamacare) ; American Health Care Act (Trumpcare) ; Health care costs ; Health care policy ; health insurance ; What to Do: Policy Recommendations on Health Care |
| URL | https://www.aei.org/research-products/report/a-better-but-modest-case-for-high-risk-pools/ |
| 来源智库 | American Enterprise Institute (United States) |
| 资源类型 | 智库出版物 |
| 条目标识符 | http://119.78.100.153/handle/2XGU8XDN/206371 |
| 推荐引用方式 GB/T 7714 | Mark V. Pauly,Thomas P. Miller. A better (but modest) case for high-risk pools. 2017. |
| 条目包含的文件 | ||||||
| 文件名称/大小 | 资源类型 | 版本类型 | 开放类型 | 使用许可 | ||
| A-better-but-modest-（3191KB） | 智库出版物 | 限制开放 | CC BY-NC-SA | 浏览 | ||
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