Niskanen Notes
Many Americans Live in Terror of Surprise Medical Bills. Could Bipartisan Help Be On The Way?
A recent Kaiser Family Foundation poll finds that surprise medical bills top the list of financial fears for American families:
Surprise medical bills can be astonishingly large, as when Drew Calver, who thought he was fully insured, received a bill for $109,000 for emergency treatment of a heart attack – more than twice his annual salary as a high school teacher.
Surprise medical bills for insured patients most often occur in two situations. One (as in Calver’s case) is emergency treatment at a hospital that is not in the insurer’s network. The other is complex treatment, as for a joint replacement or transplant, which is undertaken at an in-network hospital but with the assistance of some out-of-network participants, such as a radiologist or anesthesiologist. Patients typically do not get to choose these practitioners, and often are unaware of their participation until bills arrive.
An increasing number of states have laws protecting patients from surprise medical bills, but even in those states, there are loopholes. One big loophole concerns certain employer-sponsored insurance plans that are regulated at the federal level. Federal law currently offers no protection against surprise bills.
In September, a bipartisan group of six Senators – Michael Bennet (D-CO), Tom Carper (D-DE), Bill Cassidy (R-LA), Chuck Grassley (R-IA), Claire McCaskill (D-MO), and Todd Young (R-IN) – introduced draft legislation that would offer the needed protection. An analysis by the Brookings Institution summarizes the main provisions of the draft legislation, and offers some suggestions for resolving potential problems.
If enacted, the bill would limit patient cost-sharing to the amount they would owe to an in-network provider; set a payment standard regarding what insurers owe providers in these situations; and, prohibit providers from balance billing patients.
The Brookings analysis provides numerous links to further discussion of the issue of surprise medial bills.
Another Reason To Be Skeptical of Work Requirements for Medicaid
In previous posts, I have been skeptical of work requirements for non-cash welfare programs in general, and for Medicaid in particular. One reason for my skepticism is that the majority of able-bodied recipients of Medicaid already work. Another is that past experience with work requirements, such as the exhaustively studied results of the welfare reforms of the 1990s, show that work requirements fail to move more than a tiny fraction of beneficiaries to self-supporting employment.
Now the results of the latest round of work requirements are starting to come in. New rules for Medicaid recipients in Arkansas are one of these. Writing in the New York Times, Margot Sanger-Katz emphasizes still another reason why work requirements don’t work: Those subject to the requirements are often not aware that they even exist.
Sanger-Katz reports that Medicaid authorities in Arkansas have been realistic in recognizing that many Medicaid recipients cannot be expected to work because of disability, family responsibilities, student status, and so on. Taking those factors into account, they exempted two-thirds of all beneficiaries, leaving just 20,000 people subject to work requirements. But of those, just 1,200 reported to the state that they had completed enough work related activities (which can include job search or training in addition to actual employment) to continue their Medicaid eligibility.
Conservative supporters of work requirements might fantasize that is because the rest just sighed, gave up their benefits, and got jobs. But that is not what Sanger-Katz found.
Instead, she found that huge numbers of beneficiaries were not even aware that they were subject to work requirements.
State officials said they worked hard to get the word out — mailing letters, sending emails, placing phone calls, briefing medical providers, putting posts on social media sites and distributing fliers where Medicaid patients might find them. . . .
But it seems that not everyone opened or read their mail. Ray Hanley, the president of the Arkansas Foundation for Medical Care, which ran a call center for the state, told my colleague Robert Pear that many people never answered their phones. The state said the open rate on emails was between 20 and 30 percent.
And that is not the end of it. Even if Medicaid beneficiaries learn of the work requirements, they may find it difficult to make monthly on-line reports of their work activities, as the system requires. Arkansas has one of the lowest levels of internet penetration in the country, and the website where reports must be made can be confusing even for those with solid computer skills.
The bottom line: If success is to be measured by reducing Medicaid roles, without worrying what happens to those who are dropped, the Arkansas approach looks like it is working. If success means getting beneficiaries into self-supporting employment, it is a dismal failure.
Are Renewables Driving Up Electricity Prices?
The United States’ power mix has evolved substantially over the past 20 years. Regions and states across the country have steadily increased their renewable energy capacity. Nearly half of new, utility-scale, electric generating capacity added to the power grid in 2017 came from renewable energy technologies and aggressive state commitments, such as California’s recent pledge to achieve carbon-free energy by 2045, will ensure that the trend toward a low-carbon (mostly renewable) energy system continues.
Opponents of the transition to renewable energy technologies claim that this technology will burden American families with higher electricity bills, and that policies that support renewable energy amount to an attack on the economy. However, analyzing the relationship between electricity rates and renewable energy growth demonstrates that there is no cause for alarm.
A 2015 study conducted by DBL Investors compares state-level trends in average retail electricity prices to generation from renewable sources, in order to shed light on whether states with more generation from renewables have also experienced higher prices. The paper looks at the top 10 and bottom 10 renewable states, as determined by the share of total electricity generated from all renewable sources. The conclusion is that states with greater reliance on renewables have not experienced dramatically higher retail electricity prices.
The authors found that states with the greatest share of generation coming from renewables has an average retail electricity price of 9.79 cents/kWh in 2013, while the states with the lowest share of generation from renewables averaged 10.28 cents/kWh. The national average price of retail electricity was 10.14 cents/kWh.
Using time series data, between 2001-2013 the average retail electricity price in states that led in renewables improved compared to other states. The figure below demonstrates the price path for the leading renewable states, the national average, and the lagging renewable states.
Prices from the last ten years demonstrate that average retail electricity prices in leading renewable states have increased less than the lagging states and the national average. In 2001, states with the greatest share of renewable energy generation were experiencing average prices that were .15 cents/kWh more than the bottom 10 renewable states. By 2013 the average electricity price in top renewables states was .49 cents/kWh cheaper than the average price in lagging regions.
In order to get a more comprehensive understanding of whether these trends reflect policy choices or the market simply acting on the falling costs of renewables, it is worth comparing the relative prices in states that have adopted Renewable Portfolio Standards (RPS) with non-RPS states. 38 states have adopted RPS policies, In 2007, RPS states had an average retail electricity price that was 2.2 cents/kWh higher than in non-RPS states (when renewable energy technology was far more expensive then it is today),. In 2013, that price discrepancy dropped to .09 cents/kWh, even as more states established RPS programs and ramped up their existing programs.
End to end, the figure above demonstrates that RPS states experienced price increases of 3.02%, while non-RPS states experienced a 3.52% of price increases.
The economies of scale and drastic cost reductions being realized in the renewable energy industry are at the core of the trends described above, and these costs likely to continue dropping in the future. Renewable energy technologies are taking off, and concerns that they will kill American competitiveness and over-burden the pockets of American families have been blown out of proportion. Considering the costs of inaction towards climate change, I would argue that it is much more likely that the energy transition towards a renewable energy-based system will do more to save the American economy than destroy it.
The Cost of America’s Post-9/11 Wars
Tuesday marked the seventeenth anniversary of the terrorist attacks of September 11, 2001. As it should be, the day was marked by remembrances and tributes to the victims. However, it is also incumbent upon us as a country to think of the costs of the policies put in place after the attacks. Some of those costs are not quantifiable. They involve social disruption and personal and national trauma. Others are about the economic effects of the wars and military buildup that the country embarked on over more than a decade and a half after the attacks. However, one cost that should be quantifiable is the financial toll of those wars. Yet, an accurate tally remains elusive.
As Laicie Heeley of the Stimson Center wrote Tuesday at her site Inkstick,
Since the twin towers fell, spending for the “Global War on Terror,” has spread to almost every federal agency on the books, with increases not just at the Departments of Defense, State, and Homeland Security, but also at the Departments of Agriculture and Commerce. By the count of anonpartisan group of budget and counterterrorism experts, which I led, this spending comes to a grand total of $2.8 trillion.
But, we don’t really know much beyond that total, which is clouded, first and foremost, by the fact that the US does not have one consistent definition for what constitutes counterterrorism. While a broad definition is handed down to agencies by the Office of Management and Budget (OMB), those agencies are free to interpret the definition on their own. Over the years, our study group found that this method left a lot of room for inconsistencies, including internal overlap of issues, and even innate bias in the way programs are prioritized government-wide.
Last year, the Department of Defense and Internal Revenue system released an estimate of the cost of America’s post-September 11thwars as a result of provision included in the fiscal year 2017 National Defense Authorization Act by Congressman John Lewis. The total was $1.5 trillion, or $7,700 per taxpayer. In a more detailed estimate from March of this year, the Pentagon again put the cost of the wars at $1.5 trillion. However, the figures only account for the Pentagon’s portion of these wars. As the Cost of War Project at Brown University’s Watson Institute for International and Public Affairs has shown, much of the cost of these wars will come in the form of long term medical care for veterans that is paid for outside of the Pentagon’s budget (see the table below for project’s estimate).
In the introduction to a report last year discussing the fragmented nature of the data on the cost of the wars, Anthony Cordesman of the Center for Strategic and International Studies wrote, “One of the striking aspects of American military power is how little serious attention is spent on examining the key elements of its total cost by war and mission, and the linkage between the use of resources and the presence of an effective strategy.” Cordesman blamed both the executive and legislative branches for this failure. It is not surprise though that neither wants to understand the full costs of these wars, as it might constitute a first step toward accountability for them.
As I’ve written elsewhere, knowledge of the costs of America’s wars is likely insufficient to producing political accountability for them. However, it is necessary. An accurate accounting of the full costs of the country’s post-September 11th conflicts is a first step to putting in place policies that might raise the salience of war for an American public that is largely insulated from them.
Measuring The Ambition of The Market Choice Act: A Quantum Leap for Carbon Pricing
The Market Choice Act (MCA) introduced by Carlos Curbelo ended the decade long hiatus on any Republican-sponsored carbon pricing initiative, and represents an increasing prevalence of this topic in U.S. climate policy discussions. The $24 per ton tax on CO2 emissions indicates that climate change is a serious issue that deserves our attention and requires immediate action.
Although the MCA is a significant effort, from within the ranks of the GOP House Caucus, to address concerns associated with rising CO2 emissions, the bill has received muted praise from environmentalists. David Doniger and Derek Murrow, from the Natural Resources Defense Council, note in their article that Rep. Curbelo’s bill is a notable breakthrough; however, they lament that the bill’s “targets and tax rate escalation clause are not adequate to ensure that we will achieve the near and long-term emission reductions required by science.”
This criticism is understandable and might true, if you want to use science-based emissions targets to judge its ambition. We know that carbon emissions have to fall dramatically to slow global warming. But that the proposed policy may fail to meet that particular decarbonization goal is not a indication that it is unambitious. An alternative evaluation starts with where we are today (with paltry carbon pricing in the United States and internationally) and where we would be if the MCA were to become law. In short, it would be the largest and most ambitious carbon pricing scheme in the world.
In 2020, the implementation year of the MCA, the tax is expected to generate $93 billion dollars and nearly $1 trillion dollars in the first 10 years. This achievement is even more impressive when put into context of the revenue generated by all the current carbon pricing schemes around the globe. The World Bank’s 2018 report on the State and Trend of Carbon Pricing found that $33 billion of revenue was generated by all carbon pricing schemes in 2017, up from $22 billion in 2016. The MCA tax scheme alone generates almost triple the revenues in only the first year of implementation than the sum total of all carbon pricing schemes from the globe, combined.
This comparison sheds light on just how substantial an achievement the MCA would be in terms of placing a meaningful carbon price across a wide base. Murrow and Doniger voice concerns that the bill will not reduce carbon pollution enough to protect Americans from the worse effects of climate change. However, in comparing the emissions pathway of the MCA with the pathway expected under the Clean Power Plan or expanded regulatory measures, it is difficult to understand why Murrow and Doniger stipulate that Curbelo’s bill does not do enough.
Marc Halfstead provides an insightful analysis of the emissions pathway of the MCA and finds that the bill will reduce CO2 emissions in the power sector by 56 percent below 2005 levels in 2030. For comparison, the Clean Power Plan was expected to reduce emissions by 32 percent below 2005 levels. It is clear that the MCA’s estimated emissions reduction achievements are considerable relative to the current state politically feasible policy options for emissions reductions
The MCA is a novel and important proposal and should be critically evaluated. However, critiquing the bill’s tax structure and claiming it lacks ambition completely ignores the reality of climate policy today. Judging by the revenue, the MCA made law would be the most ambitious carbon pricing program in the universe. It would be a quantum leap above the rest.