To promote economic efficiency and the goal of universal health coverage, perhaps members of Congress should not be required to enroll in the new insurance exchanges.
The Affordable Care Act of 2010 seeks to invigorate the nongroup health insurance market – that is, health insurance that people can buy without going through an employer – by creating and subsidizing insurance exchanges similar to the one created by Massachusetts in 2007. In addition, the law seeks to make health insurance affordable for middle-class families by having the federal government pay part of premiums and out-of-pocket costs, but only for people buying nongroup health insurance through the new exchanges.
A provision of the law known as the Grassley amendment requires members of Congress and their staffs to obtain their own health insurance through the exchanges. The amendment gives the authors of the law, and the authors of future tweaks of the law, a personal stake in the success of the plans to be provided through the new exchanges.
Because members of Congress are accustomed to high-quality medical care provided to them through federal employee benefit programs, one might expect that they would push for top quality care to be delivered through the exchanges too. That is one reason why an (ultimately unfounded) report that the Grassley amendment might be reversed prompted so much outrage. (What’s actually at issue is uncertainty over whether the employer contributions in the current health plan for those on Capitol Hill can be applied to coverage through the exchanges.)
But the possibility that middle-class families could obtain care that is both top quality – good enough for your senator – and subsidized creates a number of economic problems. It gives employers a stronger incentive to drop their coverage, because employers and their employees can take comfort in the prospect that the alternative to employer insurance is a health plan that is good enough for your senator.
If the exchange plans were good enough, people who are rushing to find a job, and people considering leaving their job, would no longer have to see employment as their only means of obtaining top quality, subsidized coverage. As a result, some of those would work less (see the Congressional Budget Office on some of health reform’s work incentives, and a 1994 explanation from Alan Krueger and Uwe E. Reinhardt).
The more attractive the subsidized plans are, the more people will join them, and the greater the costs to the federal government. If the Affordable Care Act proves to be too expensive, drastic steps may result, such as closing enrollment in the subsidized exchange plans or repeal of the law all together. Either result would mean that the law’s objectives would go unmet.
There is an alternative approach, pursued in Massachusetts, for those not covered through an employer, a spouse’s employer, or Medicaid or Medicare. They may be eligible to join one of several subsidized plans under the state’s Commonwealth Care program (most are operated by the Medicaid managed care organizations), but those are less desirable than the plans typically offered by employers. With that as the alternative for their middle-class employees, employers would be discouraged from dropping coverage. People would have an incentive to work, because that’s where the best plans would be available.
Massachusetts did not have anything like the Grassley amendment.
For these reasons, economists have long recommended that subsidized goods be of somewhat lower quality than goods available without subsidy. Massachusetts followed that advice, and found that (a) their health reform approach significantly reduced the number of uninsured and that (b) less than 10 percent of the people in Massachusetts whose family income fell in the subsidy-eligible range chose to participate in the subsidized plans.
Although politically incorrect and perhaps unfair, allowing members of Congress to keep their federal employee coverage might be the best thing for universal coverage and reducing the impact of the Affordable Care Act on the federal budget.