The recent announcement by Aetna Insurance Company that it will exit the health insurance market in most of the states where it now operates raises a fundamental question about the stability of the Affordable Care Act. As shown by the following map from yesterday’s New York Times, it appears that at least five states with 17% of the American population will have only one health insurer to choose from next year. As the Wall Street Journal’s Greg Ip points out in a recent article, “the problem isn’t technical or temporary, it is intrinsic to how the law was written” Specifically:
Insurance is supposed to price risk but the ACA changed this. Insurers can no longer charge or exclude coverage for pre-existing conditions, charge men and women different rates, or charge older customers more than three times as much as the young.
For example, a 64-year-old consumes six times as much health care as the average 21-year-old. Adhering to the 3-to-1 maximum ratio, the insurer would have to greatly overcharge the 21-year-old than his actual cost and/or greatly undercharge the 64-year-old.
The rational response for unsound pricing is for young and healthy customers to stay away and sick, older customers to flock to the exchanges. ACA mechanisms to prevent this type of behavior aren’t working very well.
One example of this is that the ACA exchanges, which provide income-based subsidies for those without employer provided health insurance, are mainly attracting those people just slightly above the poverty line who get the biggest subsidies (see chart).
I have pointed out many times that the cost of health care, especially for the entitlement programs of Medicare and Medicaid, is the fundamental driver of our exploding national debt and therefore must be curtailed. But now, in addition to the cost problem, we are discovering that the ACA also has a fundamental access problem as well. Big changes are clearly needed in the ACA. More details later!
I know that I occasionally repeat myself, but I can’t help it! In my opinion there are two major problems facing our country:
Slow economic growth which has averaged only an anemic 2.1% since the end of the Great Recession seven years ago.
Exploding national debt, now the highest it has been since the end of WWII. Unless we can quickly shrink our annual deficits down to zero, and therefore stop adding to the debt, interest payments on the debt will eventually rise to horrendous levels.
Two recent newspaper articles address the slow growth problem. Greg Ip, writing in the Wall Street Journal, points out that (worldwide) employment growth is up while productivity growth is down (see chart below). Neil Irwin, writing in the New York Times, explains this dichotomy by pointing out that most job growth in the last decade has been in (low productivity) services rather than (high productivity) manufacturing. In other words, the U.S. economy is now producing lots of new temporary and contract jobs which do not add very much to the overall economic growth which produces higher wages and overall prosperity.
The economist John Cochrane has clearly described why productivity growth, and therefore overall economic growth, has stagnated in recent years. Here is a short summary:
Over-regulation. The Dodd-Frank Act and Affordable Care Act, for example, are hampering growth by strangling the financial and healthcare sectors of the economy.
Inefficient Taxation. Growth oriented taxation would have the lowest possible marginal rates paid for by shrinking deductions. Taxing consumption rather than income and savings would be even better.
Illegal Immigration. Solving our immigration problem would turn millions of illegals into productive citizens. An adequate Guest Worker program and e-Verify enforcement would solve this problem without the need for amnesty.
Conclusion: There are solutions to the severe economic problems facing our country. Does our political system have the flexibility to adopt these workable policies?
I have devoted several recent posts to discussing the desirability of a Balanced Budget Amendment to the U.S. Constitution as well as the specifics of how to set it up in an effective yet flexible manner. The Wall Street Journal’s Greg Ip has a pertinent article along this line in today’s paper, “Don’t Celebrate the End of Austerity” in which he argues that the recent congressional deal for the current 2016 budget year, which I and many others have criticized as being fiscally irresponsible, will finally contribute to economic growth after five years of overly “austere” budgets.
This raises the critical question: is it possible to speed up economic growth without the stimulus of deficit spending? Would a BBA create a stranglehold on spending which would slow down the economy? I feel very strongly that fiscal responsibility and economic growth are compatible and, in fact, contribute to each other in the long run. Here is what we should do:
First of all, either through Congressional action or with a Constitutional Convention, a BBA needs to be proposed, and then ratified, to put our fiscal house in order before our rapidly growing debt rises to ruinous levels. A flexible BBA would include a five year phase in period, after ratification, to give Congress time to prepare for it. There will be some pain in achieving this initial balance but it needs to be done and the sooner the better.
Secondly, a flexible BBA would also allow for a 2/3 majority of each House to override strict balance. This feature could be used not only for a wartime emergency, for example, but also for occasional recessionary periods where stimulus is needed.
Finally, keep in mind that the real goal is not a BBA per se, but rather to put our debt on a downward path over time as a percentage of GDP. This is what a flexible BBA will accomplish.
Once initial balance is achieved, it will be relatively easy to hold new debt down to manageable levels. Our current fiscal problem will then be largely solved and we can continue building a stronger, freer and more prosperous future for our country.