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FiveThirtyEight

Politics

Pick your subheadline:

a) It’s time to stop being polite and start getting real.
b) Here’s hoping a picture is worth 1,000 words.

Any questions?

OK, I imagine that there will be a few. Here’s how I came up with these numbers.

Senate Bill. These estimates are straightforward — they’re taken directly from the CBO’s report on premiums for people at different income levels. A family of four earning an income of $54,000 would pay $4,000 in premiums, and could expect to incur another $5,000 in out-of-pocket costs. The $4,000 premium represents a substantial discount, because the government is covering 72 percent of the premium — meaning that the gross cost of the premium is $14,286, some $10,286 of which the government pays.

One caution: this reflects the situation before the public option was removed from the bill. But, provided that the subsidy schedule isn’t changed as well, that shouldn’t change these numbers much.

Status Quo. In 2009, the average premium for a family in the individual market was $6,328, according to the insurance lobbying group AHIP. However, this figure paints an optimistic picture for two reasons. Firstly, the average family size in the AHIP dataset is 3.03 people; for a family of four, that number would scale upward to $7,925, by my calculations. Secondly, the CBO’s estimates are based on 2016 figures, not 2009, so to make an apples-to-apples comparison, we have to account for inflation. According to Kaiser, the average cost of health coverage has increased by about 8.7 percent annually over the past decade, and by 8.8 percent for family coverage. Let’s scale that down slightly, assuming 7.5 annual inflation in premiums from 2009 through 2016 inclusive. That would bring the cost of the family’s premium up by a nominal 66 percent, to $13,149. And remember: these are based on estimates of premiums provided by the insurance lobby. I have no particular reason to think that they’re biased, but if they are, it’s probably on the low side.

Not only, however, would this family paying a lot more under the status quo, but they’d be doing so for inferior insurance. According to the CBO, the amount of coverage in the individual market would improve by between 27 and 30 percent under the Senate’s bill. Taking the midpoint of those numbers (28.5 percent), we can infer that there would be about $1,427 in additional cost sharing to this family in the status quo as compared with the Senate bill; this would bring their cost sharing to $6,427 total.

Add the $6,247 to the $13,149 and you get an annual cost of $19,576 — for a family earning $54,000! Obviously, very few such families are going to be able to afford that unless they have a lot of money in the bank. So, some of these families will go without insurance, or they’ll by really crappy insurance, or they’ll pay the premiums but skimp on out-of-pocket costs, which will negatively impact their fiscal and physical health. But if this family were to want to obtain equivalent coverage to that which would be available to them for $9,000 in the Senate bill, it would cost them between $19,000 and $20,000, according to my estimates.

Status Quo with SCHIP. Fortunately, some families in this predicament do receive some relief via the SCHIP program. SCHIP eligibility varies from state to state; a family earning income at 225 percent of the poverty line, as this family does, is eligible for SCHIP in about half of the country.

Premiums are fairly cheap under SCHIP — for a family at 225 percent of poverty, generally on the order of about $60 per month to cover two children. We’ll assume that this will inflate slightly to $75 per month, or $900 per year, by 2016.

The two adults in the household will still have to buy insurance in the individual market, which will cost $7,684 by 2016. That makes the family’s total premium $8,584.

For the adults, we assume that the cost sharing component runs proportional to premiums, and totals $3,756. For the children, this calculation is a little bit more ambiguous. Out-of-pocket costs under SCHIP are capped at 5 percent of family income, which would be $2,700 for this family. But that’s a cap and not an average — we’ll assume that the average is half of the cap, or $1,350. Total cost-sharing, therefore, is $5,106 between the adults and the children.

This means that premiums plus out of pocket costs will equal $13,690 for this family. I estimate the subsidy by subtracting this figure from the cost of unsubsidized insurance in the individual market; the difference is $5,885.

Caveat/Disclaimer. There are, obviously, some simplifying assumptions here, especially with regard to SCHIP. The only thing I can promise you is that I’m “showing my work”. I would actively encourage people to pick apart these numbers and come up with their own, more robust estimates. One thing that should probably be accounted for is that the families in both the status quo and the status quo + SCHIP cases will frequently be able to deduct their health care expenses from their taxable income, especially if they’ve incurred substantial out-of-pocket costs. That means that the difference in net costs is slightly exaggerated by my figures.

* * *

Nevertheless, it’s clear that this family would be receiving a very substantial subsidy, on the order of $10,000 in pretax income, under the Senate’s bill. The reason I picked this particular family is because it provides a reality check against the example selected by the great Darcy Burner, who argued in an article at Open Left:

Affordable coverage for everyone: FAIL.

The latest CBO estimates for the Senate bill say that a family of four with a household income of $54,000/year should expect to pay 17% of their gross income on healthcare – about $9,000/year. (And that was when there was a public option to hold down costs!) That’s more than they’ll spend on federal taxes. That’s more than they’ll spend on food. I’m guessing if you took a poll, very few Americans would consider that affordable. And because of the way they’ve approached this, there’s no effective cost cap on premiums and nothing providing downward pressure, so this is a problem that would get worse rather than better over time.

We can debate whether $9,000 for a family earning $54,000 is “affordable”; what we know is that it’s a hell of a lot more affordable than the status quo, under which the family might have to pay more than twice as much to receive equivalent coverage.

In fact, Burner’s example is unfortunately chosen; she picked one of the groups — a low-income family in the individual market — that would benefit the most under the Senate package. Other groups would not be so beneficially impacted. Premiums are projected to rise slightly, for instance, for high-income earners in the individual market, although this is a small fraction of people and they’d get better health coverage as a result. And people in the employer market would not be much affected, except those with generous benefits packages subject to the excise tax; these folks would have to pay more out of pocket, although probably in exchange for more cash income. On the other hand, there are those who have a pre-existing condition and who are not able to buy health coverage at all, and for whom the benefit is almost incalculably large.

I understand that most of the liberal skepticism over the Senate bill is well intentioned. But it has become way, way off the mark. Where do you think the $800 billion goes? It goes to low-income families just like these. Where do you think it comes from? We won’t know for sure until the Senate and House produce their conference bill, but it comes substantially from corporations and high-income earners, plus some efficiency gains.

Because this is primarily a political analysis blog, I think people tend to assume that I’m lost in the political forest and not seeing the policy trees. In fact, the opposite is true. For any “progressive” who is concerned about the inequality of wealth, income and opportunity in America, this bill would be an absolutely monumental achievement. The more compelling critique, rather, is that the bill would fail to significantly “bend the cost curve”. I don’t dismiss that criticism at all, and certainly the insertion of a public option would have helped at the margins. But fundamentally, that is a critique that would traditionally be associated with the conservative side of the debate, as it ultimately goes to mounting deficits in the wake of expanded government entitlements.

And please do pick apart my numbers: I’m sure that you will find some questionable assumptions and possibly some outright errors. But if you found a persuasive, progressive policy rationale against the bill, I’d be stunned.

EDIT — Another important point or two: To the extent there are critiques about this post, they are liable to revolve around the fact that $9,000 is not so affordable for our not-so-imaginary family. Two things to note on this:

Firstly, in most years, the family will not be paying $9,000. They’ll be paying closer to $4,000 — the base cost of the premium — or maybe $5,000 for a few meds and doctors’ visits and so forth. The costs will be much higher in those years when a member of the family gets sick. But the alternative in those years would be not having health insurance at all — and in that case, either the the family member might die from the condition or the family will go bankrupt trying to prevent that.

Also, frankly, the individual mandate penalty is not very harsh, especially for lower-income people, so there’s some potential for gaming the system in a way that isn’t economically optimal but would give this particular family a better deal than suggested above.

Secondly, the critiques over the level of subsidies are rather tangential to where the locus of progressive energy has been — on the public option. The presence of a watered-down public option would make very little difference in terms of this family’s cost structure — and yet, this same bill with a public option is one that most liberals would be head-over-heels for.

I happen to agree that the cost subsidies need to be improved somewhat for this type of family and indeed I wish that this is where more of the left’s energy had been directed. Fortunately, I think this is something that really can (still) be improved in conference committee or on the floor. For instance, if you adopted the House bill’s subsidies for families at under 250% of poverty, and the Senate’s (which actually become more generous) for people at greater than 250% of poverty — perhaps in exchange for a harsher (not weaker!) individual mandate penalty — you’d have a pretty reasonable compromise.

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