Macro Roundup

This is Heritage’s health care proposal you asked about. It’s not a comprehensive plan but offers a series of potential, in many cases current innovations based on the current system (some of these, like telemedicine, likely have been accelerated by the pandemic)

Steve

1. Provide opportunity for individuals to delink health care from employment. “…In an ideal world, most people would own their own health insurance and take it with them as they traveled from job to job and in and out of the labor market. Some employers may have better insurance than is available on the open market. But others might prefer to make a cash contribution to help employees pay their own premiums rather than provide insurance directly. Some employers were actually doing that before Obamacare. They used an account called aHealth Reimbursement Arrangement (HRA), providing tax-free funds employees could use to buy their own health insurance. But with Obamacare came regulations and threats of steep employer fines that effectively deep-sixed this option. Thankfully, the Trump administration is reversing course. Beginning next January, employers will be able to use HRAs to help employees obtain their own coverage with the administration’s blessing…”
2. Make Medicare more open to “direct primary care.”“….Under the arrangement, Medicare would pay a fixed monthly fee to a physician or physician group instead of the traditional fee-for-service payments. In return, the physicians would provide virtually all primary care. The fees would range from $90 to $120 a month, depending on the patient’s age and medical complexity….”
3. Expanded use of telemedicine“…Medicare doesn’t pay for any of this. And since private insurers and employers tend to pay the way Medicare pays, the entire country is missing out on incredible advances in telemedical technology….Federal law (the Social Security Act) allows Medicare to pay for telemedicine only under strictly limited circumstances… The CMS is acting aggressively to change this. As of January 1 of this year, doctors in Medicare Advantage plans and accountable-care organizations can now bill Medicare if they use phone, email, Skype, and other technologies to consult with patients remotely to determine if they need an in-office visit. Patients can be anywhere, including their own homes. Doctors can also bill Medicare to review and analyze medical images patients send them. And they can bill for telemedical consultations with other doctors. But these are still baby steps. Congress needs to liberate telemedicine once and for all….”
4. Allow specialized healthcare plans“….The most successful Obamacare insurers are Medicaid contractors. The plans that have survived in the exchanges look like Medicaid managed care with a high deductible. The networks include only those doctors who will accept Medicaid fees coupled with all the hassle of managed-care bureaucracy….Before Obamacare, most states had risk pools for the small number of people who entered the individual market with an expensive preexisting condition and were denied access to ordinary insurance coverage. The risk-pool plans looked like garden-variety Blue Cross plans, with access to almost all doctors and hospitals. While some risk pools had problems — such as being over-subscribed and unable to take new customers — those problems were discrete and addressable…..Health Care Choices Proposal, developed by the Health Policy Consensus Group and supported by more than 100 conservative leaders across the country. This proposal would block-grant Obamacare funds to the states and give them wide discretion to reform their individual health-insurance markets. The Center for Health and the Economy estimates that this proposal would lower health-care premiums by as much as a third, would insure about the same number of people as Obamacare, and would better protect people with preexisting conditions and high health costs….”
5. Expand use of Health Savings Accounts, “…To take advantage of the full potential of HSAs, we need three policy changes: (1) People should be able to use completely flexible HSAs, wrapping them around any health-insurance plan and using them to pay for any medical costs the plan does cover; (2) they should be able to use their HSAs to pay premiums as well as out-of-pocket expenses; and (3) health plans should be allowed to have “shared savings programs,” where enrollees who choose better and cheaper care get to keep their share of their savings in their HSA…”
   Marie Fishpaw and John Goodman, "A Health Plan For President Trump," Heritage Foundation, August 2, 2019, https://www.heritage.org/health-care-reform/commentary/health-plan-president-trump

Research from Federal Reserve argues that the r* has been persistently negative since late 2009. Great chart.

They start with the 10-year yield“…We estimate the natural rate of interest (r∗ ) using a semi-structural model of the U.S. economy that jointly characterizes the trend and cyclical factors of key macroeconomic variables such as output, the unemployment rate, inflation, and short- and long-term interest rates. We specify a monetary policy rule and an equation that characterizes the 10-year Treasury yield to exploit the information provided by both interest rates to infer r∗.However, the use of a monetary policy rule with a sample that spans the Great Recession and its aftermath poses a challenge because of the effective lower bound. We devise a Bayesian estimation technique that incorporates a Tobit-like specification to deal with the censoring problem. We compare and validate our model specifications using pseudo out-of-sample forecasting exercises and Bayes factors. Our results show that the smoothed value of r∗declined sharply around the Great Recession, eventually falling below zero, and has remained negative since then. Our results also indicate that obviating the censoring would imply higher estimates of r∗than otherwise….”

They find, “…We estimate our model with a sample that covers 1962:Q1 to 2020:Q1. Our estimate of r∗gradually declines starting in the mid-1980s and enters negative territory in mid 2009, although the real-time estimate only does so in mid-2011; r∗is estimated to have hovered around -1% since 2016, in line with simple estimates of the short-term real interest rate, before gradually edging down to -1.7% over the last year of our sample. We find that the shadow federal funds rate would have reached -6.7% at the trough of the Great Recession. Regarding the natural unemployment rate, we find that it has been steadily declining since 2010, when it reached 5.7%, to a level of 4.6% in 2020:Q1. Our measure of the (time-varying) trend output growth rate has declined over time and has been around 1.7% per year since 2012. Finally, our estimate of the output gap is similar to those from the CBO and the staff of the Federal Reserve Board. It peaked at slightly above 2% in 2019 and has declined to about 1% since then…”

Manuel Gonz´alez-Astudillo Jean-Philippe Laforte, “Estimates of r* Consistent with a Supply-Side Structure and a Monetary Policy Rule for the U.S. Economy,“ Federal Reserve Board, October 2020, https://www.federalreserve.gov/econres/feds/files/2020085pap.pdf

James Capretta, "CBO presents options for covering the uninsured," American Enterprise Institute, October 5, 2020, https://www.aei.org/articles/cbo-presents-options-for-covering-the-uninsured/

Allison Percy and Karen Stockley, “Who Went Without Health Insurance In 2019, and Why?” Congressional Budget Office, September 2020, https://www.cbo.gov/system/files/2020-09/56504-Health-Insurance.pdf

Jared Maeda and Karen Stockley, “Policies to Achieve Near-Universal Health Insurance Coverage,” Congressional Budget Office, October 2020, https://www.cbo.gov/system/files/2020-10/56620-near-universal-coverage.pdf

Capretta here makes no sense according to CBO“…0 million people are uninsured because they are residing in the U.S. without proper legal status; as such, they are ineligible for subsidized coverage.6 million people are ineligible for employer coverage but have incomes too high to qualify for subsidized premiums through the ACA exchanges; they could enroll in plans offered in the nongroup market but would be required to pay the full premiums themselves. Finally, there are 3.2 million people who have incomes below the federal poverty line and live in states that did not expand Medicaid as allowed by the ACA.This group falls into a “coverage gap” in current law; their incomes are too low to qualify for subsidized premiums in the ACA exchanges and yet too high to qualify for Medicaid. The first priority of any future effort to cover the uninsured should be to ensure this population can enroll in either Medicaid or another alternative that requires no premium payment….”

And only 1/3 of persons not insured not eligible for subsidized coverage“…In 2019, an estimated 30 million people under the age of 65, or 12 percent of that population, were uninsured. One reason for the lack of insurance coverage was a lack of subsidized options. About one-third of uninsured people under the age of 65 did not have access to coverage that was subsidized by the government or an employer: 13 percent were noncitizens who were not lawfully present in this country; 11 percent had income that was less than 100 percent of the FPL and lived in a state that did not expand Medicaid; and 9 percent had income that was too high to qualify for marketplace subsidies(see Figure 1)…”

“…About two-thirds of the 30 million uninsured people under the age of 65 had access to some form of subsidized coverage but were not enrolled, although those options were subsidized to different degrees: 17 percent were eligible for Medicaid or CHIP; 19 percent were eligible for subsidized coverage through the marketplaces established under the ACA; and 31 percent had access to coverage through an employer. Most of those people could have purchased health insurance that cost less than 10 percent of their income, but fewer people had an option that cost less than 5 percent of their income. Those people lacked health insurance coverage because they did not consider it to be worth the cost or because of the complexities of the enrollment process, among other reasons….”

But bottom line according toCBO only 9.8mm people who are currently uninsured are not eligible for subsidized coverage under the current systems, and 4mm are not lawfully present in the country, so only5.8mm peoplearen’t being captured by the current system. The other 20mm people don’t have health insurance because to quote CBO “…Those people lacked health insurance coverage because they did not consider it to be worth the cost or because of the complexities of the enrollment process, among other reasons…”

Peter Orszag, "Maybe Low Interest Rates Won’t Last Forever,"Bloomberg, October 8, 2020, https://www.bloomberg.com/opinion/articles/2020-10-08/maybe-low-interest-rates-won-t-last-forever

Here’s the argument, “….. The authors argue that the era of low rates was fundamentally caused by demographics and the entry of China and Eastern Europe into the global trading system. The result was that, from 1991 to 2018, the effective global labor supply more than doubled, which in turn pushed interest rates down (while also depressing inflation and wages and boosting inequality). As they write, “the rise of China, globalisation and the reincorporation of Eastern Europe into the world trading system, together with … the arrival of the baby boomers into the labour force and the improvement in the dependency ratio, together with greater women’s employment, produced the largest ever, massive positive labour supply shock.” The deflationary pressure caused by this supply produced the era of low nominal and real rates. Goodhart and Pradhan go on to argue that the demographic sweet spot of the past three decades is now reversing, with the ratio of dependents (the elderly and the young) to workers rising in the advanced economies and in China. Indeed, working-age populations are now stagnant or falling across most of the world outside of Africa and India.The underlying tectonic plate of aging, the authors argue, will soon reverse the previous deflationary pressures. The consequences? “The main thesis of this book,” the authors write, “is that the great demographic reversal will shortly raise inflation and interest rates…”

Orszag on inflationary prospects, “…Almost no one predicts a large rebound in either nominal or real interest rates. So what might go wrong? First, and just to get this out of the way, I was wrong more than a decade ago to worry about an increase in rates. History has, to put it gently, not been kind to that view. By 2011, I had seen enough to know my initial fears were misplaced, and the lesson, learned the hard way, is to be more skeptical about the conventional wisdom…”