Posts Tagged ‘rationing’

means tests are taxes – ACA edition

Monday, September 2nd, 2013

US workers are finally getting near-universal healthcare, but it comes at a price. Chicago economist Casey Mulligan runs the numbers.

Healthcare is valuable but expensive. As a result, many people believe that poor and middle-income households should pay less than full price for their healthcare, and the United States now has its Affordable Care Act (hereafter, ACA) that will soon implement such a policy.

Economics tells us that redistribution typically comes at the cost of reduced incentives to work and earn, yet some economic analyses of the ACA’s labor market effects do not even mention explicit or implicit taxes.  Others note the ACA’s employer penalties, without acknowledging that the Act also includes various implicit taxes on the employee side.  The purpose of this paper is to quantify the contributions of various ACA provisions to time series for the marginal tax rate on labor income. ….

The results are startling. [All ACA] … provisions combined raise marginal tax rates in 2015 by 10 percentage points of total compensation, on average, for about half of the nonelderly adult population and zero percentage points for the rest. ….

The ACA has not been introduced into a tax-free economy, so its marginal tax rate hikes add to marginal tax rates already in effect. I estimate that, by 2015, the average marginal after-tax share among household heads and spouses with near-median weekly earnings will have fallen to 0.50 from 0.60 in 2007, largely from the ACA but also from other expansions in safety net programs. That is a massive 17 percent reduction in the reward to working ….

Casey Mulligan, “Average Marginal Labor Income Tax Rates under the Affordable Care Act“, Supply and Demand (in that order), 29 August 2013.

The full paper, with the same title, was issued as NBER Working Paper No. 19365 (August 2013).

Healthcare is expensive everywhere, but it is abnormally expensive in the USA. ACA will not change this fact.

Professor Mulligan’s calculations include all payroll (“social security”) taxes in addition to income taxes. It is debatable whether mandated contributions to a government pension plan should be counted as taxes. If they are taxes, they are very odd, for the more one pays, the greater the retirement benefits. To me, this looks like forced saving (delayed consumption, purchase of bonds) rather than pure taxation. Also, a US household with two “near-median weekly earnings” is well-to-do, unlike the the median household, which has very small secondary spousal earnings, or none at all.

As this blog has repeatedly emphasized, means tests are equivalent to taxes. There are two ways to avoid this implicit taxation: (1) provide the benefit universally, without a means test, or (2) deny benefits – in this case healthcare – to those who cannot afford to purchase them. Mulligan – like Tea Party Republicans – prefers the second option to the first. I prefer universality, but, instead of providing all healthcare free (or with subsidies and tax breaks), I would restrict government provision to basic healthcare.

Casey B. Mulligan is author of The Redistribution Recession: How Labor Market Distortions Contracted the Economy (Oxford University Press, 2012).

Update. I have now read the full NBER paper, though probably not with enough care. Mulligan, in his conclusions (p. 23) clarifies that “the ACA’s implicit taxes will be experienced primarily by persons above the poverty line”, which is a relief to me. Even half the household heads and spouses empl0yed with weekly earnings near the median will experience no hike in implicit taxes. This is why the average hike is 10 percentage points for those near-median heads and spouses who experience higher implicit taxes, but only 5 percentage points for all near median household heads and spouses. Incidentally, a “median earner” is someone who earns $790 (2014 dollars) per week plus fringe benefits, “which is what the median nonelderly household head or spouse earned in 2007 during a week that they were working” (p. 4). It is not clear whether Mulligan is referring to median household earnings or to a median individual earnings, but his writing suggests the latter.

Now, the effect of means tests on the value of benefits received – i.e., the implicit tax – depends on the nature of the work decision taken. Mulligan looks at the results of three types of work decision: (1) moving from unemployment to employment; (2) entering the labour force; and (3) increasing weekly hours of work. Decision #3 is important because full-time employees (those working 30 hours or more a week) receive no ACA assistance for insurance premiums and out-of-pocket health expenses. Mulligan combines the three implicit taxes “into an overall statutory work incentive index” by taking a simple average (see pp. 2-3). I don’t understand why he does this, nor what such an “average effect” might mean.





the risks of health screening

Sunday, December 20th, 2009

A federal advisory panel [in the USA] recently set off a controversy by recommending that most women without special risk factors delay breast cancer screening until they turn 50, not 40 — and that mammograms then take place only every other year.

These guidelines, which differ from those of some other professional or advocacy organizations, have been called a rash misjudgment and an example of ostrich-like thinking. But this criticism is unfair, both to the scientists who prepared the report and to ostriches (who don’t actually bury their heads in the sand in an attempt to hide).

Richard H. Thaler, “Economic View: Gauging the Odds (and the Costs) in Health Screening”, New York Times, 20 December 2009.

Behavioural economist Richard Thayler continues with a concise “discussion of the underlying numbers and a bit of probability theory”. He complains “anyone who even suggests that some test be done less often is accused of condoning ‘rationing’, an all-purpose slur against any change that might reduce costs”.

Thaler teaches economics in the University of Chicago Graduate School of Business. He is co-author, with legal scholar Cass Sunstein, of Nudge: Improving Decisions About Health, Wealth, and Happiness (Yale University Press, 2008; updated edition, Penguin, 2009).

kidney transplants and dialysis

Tuesday, December 15th, 2009

Outrageous news from the USA.

Although Medicare is primarily an insurance program for older Americans and the disabled, it has since 1973 covered those with end-stage renal disease, regardless of their age or condition.

The federal program now pays for most costs associated with dialysis and transplantation. But for patients younger than 65, coverage of the anti-rejection dugs — which can run from $1,000 to $3,000 a month — ends after three years. If patients cannot afford the medications, they may lose their donated kidneys and have to return to dialysis while awaiting another transplant.

The policy is widely regarded as pound-foolish. Medicare spends an average of $17,000 a year on kidney transplant recipients, most of it for the anti-rejection drugs, compared with $71,000 a year on dialysis patients and $106,000 for a transplant.

Kevin Sack, “Plan for Kidney Drugs Spurs Division”, New York Times, 15 December 2009.

House Democrats have tabled a proposal to extend Medicare coverage of transplant patients beyond the current limit of 36 months. To pay for the extra coverage, the proposal requires Medicare to “set a flat fee for dialysis treatments and related medications that some providers say would not cover costs”. Those in the business of providing dialysis are lobbying against the proposal. This “supporters of the measure fear … may make it easy for Congress to kill the provision altogether”.

The news story raises a number of questions. Isn’t it possible for a country as wealthy as the USA to provide proper medical care for those who suffer from kidney disease? Why does provision of anti-rejection drugs to transplant recipients have to come at the expense of caring for those who lack a functioning kidney? Can’t US taxpayers afford to support both groups?

rationing health care in the USA

Saturday, November 28th, 2009

MR. GREGORY:  Senator Hutchison, you said this [task force recommendation against routine mammography for women aged 40 to 49] is the beginning of rationing.

SEN. HUTCHISON:  I think it is.

MR. GREGORY:  Why did you say that?

SEN. HUTCHISON:  It’s because it’s whether the insurance and the public option [in the health reform bill] are going to pay for a woman who decides that she wants to have the mammogram before the age of 50 or more than every other year after 50. If the public option doesn’t pay for that–and the task force recommendations are what the public option is going to rely on. So this task force says all of a sudden we’re going to change the guidelines that we have had for all these years.  And now the public option may not pay for those, and that means the insurance companies are going to follow. The key is that these are covered by insurance so women will not have to decide if they’re going to spend $250 to get a mammogram because they and their doctors believe it is right to do so.

That is TV journalist David Gregory interviewing Senator Kay Bailey Hutchison, a Texas Republican, on “Meet the Press” last Sunday (22 November 2009).  Ms Hutchison is a vocal opponent of the Democrats’ health reform bill. Yet she also believes that public or private insurance should cover the full cost of a mammogram. If a woman of any age, on advice of her doctor, wants a mammogram, she should not be forced to pay $250 out-of-pocket in order to obtain it.

Princeton economist Uwe Reinhardt was listening and, only partly tongue-in-cheek, writes

I cannot recall a clearer statement of unreserved support for universal and comprehensive health insurance for America and a more straightforward definition of rationing health care.

Uwe E. Reinhardt, “Health Care Rationing, American-Style”, Economix, 27 November 2009.

Professor Reinhardt is absolutely correct. Senator Hutchinson has been active in promotion of screening for breast cancer, but her logic would apply equally to screening for other cancers, indeed to medical attention for the prevention and treatment of other illnesses, such as hypertension and diabetes. In sum, though she may not be aware of it, Senator Hutchinson’s reasoning supports universal health insurance.

happiness is access to medical care

Tuesday, November 24th, 2009

Dartmouth economist David Blanchflower finds lack of access to a doctor (because of inability to pay) to be an important source of unhappiness in the United States, even for people with high incomes.

The inability to see a doctor is [a] highly significant [determinant of happiness], … even when a full set of controls are included for income, labor status, smoking, exercise and BMI etc.. ….

To explore this issue further [I estimate effects] … by income group. The effect of not seeing a doctor is significant in each of the equations. Particularly impressive is the fact that this is the case even for those in the highest income category [>=$75,000] … , even if they are in very good or excellent health. The effects are broadly of the same orders of magnitude … [–] approximately the same as the difference between zero income and income of $75,000 or more or between working as an employee and having been unemployed for at least twelve months.

These effects are larger than the effects from the equivalent amount of money that the service would cost, because the person could simply pay for them. But that is to be expected as what is being picked up is not the cost of the coverage itself but the service needed. So health insurance, say costs $10,000 a year but if an individual falls ill, the cost could be half a million dollars. Hence the need for insurance.

They, or a member of their family, have just experienced a negative health shock. The uncertainty around subsequent health care expenses could be causing this big fall in happiness. By falling ill, the person who needs the treatment experienced a major negative income and wealth shock. Not having access to a doctor lowers life satisfaction and worsens mental health. And by a lot, even controlling for income, education and many other controls. This is true even for people with high incomes. Hence, providing health care coverage for all will likely raise the health and happiness of the nation.

David G. Blanchflower, “Happiness and Health Care Coverage”, IZA Discussion Paper 4450 (September 2009).

Professor Blanchflower analyses data for the years 2005 through 2008 from the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS was established in 1984 by the Centers for Disease Control and Prevention (CDC). More than 350,000 adults in all 50 US states are interviewed each year by telephone.

In 2008 15.6% of all BRFSS respondents –up from 13.6% in 2005– answered “yes” to the question “Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?”. Noteworthy is the fact that 8% of respondents with health care coverage were among those answering this question in the affirmative. “Presumably”, suggests Blanchard, “this arose because of large deductibles or because of restrictions on access to doctors of choice through HMOs”. Health care is often rationed, even for those with private insurance.

rationing medical care

Wednesday, August 26th, 2009

Allocation of scarce medical interventions [-including beds in intensive care units, organs, and vaccines during pandemic influenza-] is a perennial challenge. During the 1940s, an expert committee allocated—without public input—then-novel penicillin to American soldiers before civilians, using expected efficacy and speed of return to duty as criteria. During the 1960s, committees in Seattle allocated scarce dialysis machines using prognosis, current health, social worth, and dependants as criteria. How can scarce medical interventions be allocated justly? This paper identifies and evaluates eight simple principles that have been suggested. Although some are better than others, no single principle allocates interventions justly. Rather, morally relevant simple principles must be combined into multiprinciple allocation systems. We evaluate three existing systems and then recommend a new one: the complete lives system.

Eight simple ethical principles for allocation can be classified into four categories, according to their core ethical values: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. We do not regard ability to pay as a plausible option for the scarce life-saving interventions we discuss. ….

The complete lives system [that we recommend] discriminates against older people. …. Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

Govind Persad, Alan Wertheimer, Ezekiel J Emanuel, “Principles for allocation of scarce medical interventions”, Lancet, Vol 373 (31 January 2009), pp. 423-431. (Free download, registration required.)

The authors claim BS, PhD and MD degrees, respectively, and work in the Department of Bioethics of the National Institutes of Health (NIS) in Bethesda, Maryland, USA. Dr Emanuel (1957-), who, as Director of the Department, is the superior of his co-authors, is currently Special Advisor for Health Policy to Peter Orszag, the Director of President Obama’s Office of Management and Budget.

Dr Emanuel has become a figure of controversy in the US healthcare debate. Note that he and his co-authors rule out a market solution – increasing price to the point that demand equals supply – in the case of medical interventions. Most – though not all – Canadians would agree. The same is true, I believe, of Europeans. But in the United States, many favour treating health care like any product or service, to be distributed by ability to pay, perhaps with some minimimal distribution of free services to the poor. This, after all, is the way that food, which is essential for life, is distributed: food stamps for the poor, market prices for everyone else.

Dr Emanuel and his colleagues raise very serious and very difficult ethical issues. As Princeton philosopher Peter Singer recently explained, rationing of health care is inevitable. A public debate over how we ration is necessary. Should the wealthy be allowed to spend their own money to jump to the head of the queue? Countries such as Canada and the United Kingdom, with single-payer systems of health care, explicitly prohibit this. The United Kingdom does allow any citizen who has the desire – and the means – to do so to leave the public system and access private health care. Canada so far has not granted its citizens this freedom, but the US border, and a system where health care is rationed only by price, for most Canadians is only a short drive away.