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Health Care Reform: The source documents behind the news

The Primary Source Crusader (my own mashup of images)

Proponents and opponents alike have been waiting to hear what the plan will be for health care once the Affordable Care Act is repealed. There have also been a lot of statistics thrown around in the course of the public discussion on this topic, and a few people have asked me where some of the numbers they’re hearing are coming from.

First, the World’s Best Healthcare Act of 2017 is indeed a real bill, but it is not the same bill that people have been anticipating and debating for the last couple months. It’s the 2017 version of a 2016 bill that never made it out of committee. When the bill we’ve been expecting gets an actual number, I’ll add it here. Update 3/25/2017: The “real” bill under discussion was H.R.1638, and as of 3/24/2017 the bill has been pulled from consideration. The bill was pulled “pursuant to clause 1(c) of Rule 19,” which states that “when the previous question is operating to adoption or passage of a measure pursuant to a special order of business, the Chair may postpone further consideration of such measure in the House to such time as may be designated by the Speaker” (see the House rules, page 34). I wonder where this leaves the previous Executive Order (predicated on the idea of prompt repeal of the ACA) and its encouragement for states and companies to play fast and lose with ACA rules.

The “real” health care plan, called the American Health Care Act, was originally available to us in the form of two committee prints:

For comparison, here’s the Patient Protection and Affordable Care Act from 2010 (also known as Obamacare). And here are all the health-related bills introduced by the current congress.

What will things cost under the new plan? (section added 3/14/2017)

Update 3/14/2017: The Congressional Budget Office has released its official assessment of the American Health Care Act. This includes estimates of future costs, future numbers of insured Americans, and future market stability. A couple of questions I have about this report are:

  • Because it was deemed “impracticable” the requirement to investigate the macroeconomic impact of the bill is no longer required (see page 4 of the report, which refers to section 402 of the Congressional Budget Act of 1974 – page 40). So that means that a couple of the major questions I had (effects on jobs, effects on uncompensated care ripples) aren’t covered in this report.
  • The “Basis of Estimate” section includes:
    • Effects of Repealing Mandate Penalties (page 8)
    • Major Changes to Medicaid (pages 8-10)
    • Changes to Subsidies and Market Rules for Nongroup Health Insurance Before 2020 (pages 10-13) — employer-based insurance is a group insurance, so this is about individual insurance
    • Changes to Subsidies and Market Rules for Nongroup Health Insurance Beginning in 2020 (pages 13-18)
    • Market Stability (pages 18-19)
    • Other Budgetary Effects of Health Insurance Coverage Provisions (pages 19)
  • The “Net Effects on Health Insurance Coverage” (pages 19-21) section starts “CBO and JCT expect that under the legislation, the number of people without health insurance coverage would increase but that the increase would be limited initially, because insurers have already set their premiums for the current year and many people have already made their enrollment decisions for the year.”
  • The “Net Effects on Health Insurance Premiums” (pages 21-22) section starts: “The legislation would tend to increase average premiums in the nongroup market prior to 2020 and lower average premiums thereafter, relative to the outcomes under current law.” Prior to 2020 premiums could go up by 15-20%, and after 2020 premiums could go down for the younger population, but go up by an additional 20-25% for people over 65.
  • Page 22 includes the “Revenue Effects of Other Provisions,”
  • “Direct Spending Effects of Other Provisions” includes
    • “Prevention and Public Health Fun,” and Community Health Center Programs” sections (page 22)
    • The “Provisions Affecting Planned Parenthood” section (page 23)
    • “Repeal of Medicaid Provisions,” “Repeal of Reductions to Allotments for Disproportionate Share Hospitals,” “Safety Net Funding for States That Did Not Expand Medicaid,” and “Reductions to States’ Medicaid Costs.” (pages 23-24)
  • “CBO has not completed an estimate of the potential impact of the legislation on discretionary spending, which would be subject to future appropriation action.” (page 25)
  • Pages 25-26 lay out “Uncertainty surrounding the estimates”
  • The “Increase in Long-Term Direct Spending and Deficits” section is one sentence long: “CBO estimates that enacting the legislation would not increase net direct spending or on-budget deficits by more than $5 billion in any of the four consecutive 10-year periods beginning in 2027” (page 26).
  • The final page of content (page 27) analyzes “Mandates on State, Local, and Tribal Governments” and “Mandates on the Private Sector,” which measures new legislation against the Unfunded Mandates Reform Act of 1995.
  • All the charts and tables are at the end of the document, pages 29-37. Most of these provide costs over time.

The CBO has written about its methodology on this topic in some detail.

What about the statistics and numbers that have been tossed around lately? Well…

I wrote previously about data that the federal government released about historical and projected health care spending, including both the price tags for the government and for individuals.

Many state senators and representatives have been talking about numbers from their own states, though, so what about the more local numbers? The people who have asked me about these numbers have been interested in Minnesota information, so that’s what I’ll present here, but each state will have something similar. If these numbers look useful to you and you want to know about a state other than Minnesota, the strategies I use for most of this kind of work should work for you. Look especially for state departments of commerce and of health.

Two collections of data and statistics that might be useful to you regardless of state are:

  • SHADAC – State Health Access Data Assistance Center
    In addition to their useful reports, their data center lets you build your own charts based on various official sources, and each chart will tell you which group or agency first published the data so that you can track that group or agency down to see more detail.
  • If you have access to something like ProQuest Statistical Insight, you can find federal and local government information there as well as industry reports that are hard or impossible to find other places.

And for Minnesota, here are some of the reports that answer the major questions I’ve heard:

  • MN Department of Commerce: 2016 Rate Summary
    This includes such things as:

    • Includes percentages of people in the individual market (the marketplaces for ACA plans) vs other types of plans.
    • Which companies participate in the health care market in the state (and you can also see their rate filings individually here) and how many options are available in each county of the state.
    • What the essential health benefits are that are required of every company
    • And some basic statistics on health care rates (this one does not include annual out-of-pocket numbers, but the next link link does)
  • Minnesota Department of Health: Minnesota Health Care Markets Chartbook
    This is a collection of several reports, and they include such things as:

    • Total health care spending by source and by uses of funds.
    • Comparisons of state to national trends.
    • Trends in health care premiums, deductibles, and out-of-pocket expenses, overall and by type of insurance
    • Variations in coverage and costs for three groups: employment-based insurance, small group insurance, and individual insurance.
    • Amount of competition in the health care market by region.
    • Characteristics of those who have no insurance and what the safety net for those people looks like (including a spreadsheet of uncompensated care.
    • Service availability in the different regions of the state.
    • And state-wide service quality reports.
  • Minnesota Department of Health: Health Economics Program
    Does research on and produces reports about health care markets in MN.
  • Minnesota Department of Human Services: Health care programs – initiatives, reports, and advisory committees.

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