Susan Pendergrass is joined by Elias Tsapelas, director of state budget and fiscal policy at the Show-Me Institute, to explain what was actually at stake in the recent federal government shutdown. They break down the debate over extended Affordable Care Act subsidies, why health insurance costs keep rising, how COVID-era provisions distorted the marketplace, and what Congress may do next.

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Timestamps

00:00 Understanding the Government Shutdown
06:31 The Debate Over ACA Subsidies
09:10 Impact of the Affordable Care Act
13:24 Proposals for Health Care Reform
17:53 The Future of Health Care Costs

Transcript

Susan Pendergrass (00:00)
Well, this is going to be a very timely and interesting conversation with the Show-Me Institute’s own Elias Tsapelas. You are the Director of State Budget and Fiscal Policy, two things that are front and center right now, but I really wanted to just have you on to talk about a little bit of stuff around the recent government shutdown.

And I just want to say upfront, if I understand this correctly, the federal government can’t pay its bills unless it’s got an approved budget to pay the bills, right? And the fiscal year runs October 1st to September 30th. And if you don’t have a new budget for the next year, you can’t pay your bills. So it’s up to the Senate, the House, and the President to agree on a budget. And this past September, as has happened before, they could not agree, and Democrats were holding out, and that caused the government to shut down. What were Democrats saying they were holding out for?

Elias Tsapelas (00:52)
Well, I guess I should start with just a little caveat that some of what the Democrats were saying they were holding out for was not precisely what was on the table. So no matter what happens, health care premiums are going to be going up, that’s just a fact, because health care costs are up. Health care costs are going up everywhere. Hospitals, Medicaid, we see it everywhere.

Susan Pendergrass (00:56)
You know, fix it up for me. Why?

Elias Tsapelas (01:20)
What they were holding out for were these extended or expanded ACA subsidies, Affordable Care Act subsidies. We’re talking about the marketplace here. This is typically for people making between 100 percent and 400 percent of the federal poverty limit. For example, a couple of two: 100 percent of the federal poverty limit is about $21,000 per year, 400 percent is about $85,000 per year. That’s roughly the range you’re looking at.

Now, some small employers do purchase plans through the marketplace, but the big piece here is that the ACA provides subsidies for people. And the way it works, essentially, is that people pay a proportion of their income. If your income is 100 percent of the federal poverty limit, you’re going to pay roughly 2 percent of your income. Now, there are extended subsidies that change that calculation. But the point being, the law set out that if you make this amount of money, you’re only going to pay this much on health insurance, and the government is going to subsidize the rest. You are not sensitive to costs at all, because your costs are tied to your income.

Susan Pendergrass (02:54)
So, for example, if you earn $4,000 a month, theoretically, and I don’t know the numbers, the government would say you won’t pay any more than $300 in insurance premiums?

Elias Tsapelas (03:05)
Yep. And so that is a percentage that you pay scaled off how much income you have from that 100 to 400 percent. That is a core piece of how the Affordable Care Act worked, and everyone paid a portion based on the base subsidies.

Now, what the debate was about, or what Democrats were holding out for, was expanded subsidies, which came about during COVID as part of the American Rescue Plan, ARPA. And it did a couple things, but they were subsidies on top of regular subsidies. So this was not, “If this doesn’t happen, everyone is going to be paying unsubsidized plans.” This was an additional type of subsidy. These additional subsidies were set to expire at the end of the year, at the end of December. ARPA gave four years of subsidies.

Susan Pendergrass (04:04)
Because it was COVID related, temporary, and they said, “We’ll cover more of your premium through December 31, 2025.”

Elias Tsapelas (04:14)
Yes, I think part of the calculation was that people were going to like it so much that it would be hard to get rid of. And it’s certainly the case: if these subsidies go away, people will be paying more.

Susan Pendergrass (04:15)
Ahem.

Elias Tsapelas (04:27)
But that is not to say there would be no subsidies at all. These extended subsidies did a couple things. For people between 100 and 150 percent of the federal poverty limit, quick caveat: in Missouri, if you make under 138 percent, you’re on Medicaid, so you don’t pay anything, but in many states without Medicaid expansion, people go on the marketplace. What these expanded subsidies did is: if you made between 100 and 150 percent of the federal poverty limit, you paid zero percent of your income. You got a plan for free.

You would still have some cost sharing, and the sliding scale up to 400 percent that the normal subsidies used was lowered, so people under regular subsidies who made 400 percent of the federal poverty limit were paying about 10 percent of their income. With the expanded subsidies, you’d only pay 8.5 percent, and the subsidies no longer stopped at 400 percent. They would go all the way up. You would never pay more than 8.5 percent of your income.

Susan Pendergrass (05:30)
Okay.

Elias Tsapelas (05:42)
But typically, people above 400 percent of the federal poverty limit don’t want to buy ACA plans because 8.5 percent of income is expensive. Still, a decent number of people were impacted. It costs a decent amount of money. The Congressional Budget Office says extending these expanded subsidies costs about $350 billion over 10 years. Very expensive. But there are a lot of issues here, which Republicans are pushing back on as they negotiate whether to extend these by the end of the year.

Susan Pendergrass (06:31)
So now we’re in this argument of whether we extend COVID subsidies or not. And like you said, Republicans seemed willing to say maybe a year, or maybe we’ll vote on it in December. Essentially the Democrats didn’t get any of what they asked for, right?

Elias Tsapelas (06:48)
Yeah. A key piece is that when Democrats passed this in ARPA, no Republicans voted for it. There’s a variety of reasons, but a big one is that it exacerbates problems with the Affordable Care Act. People buying health insurance are seeing higher prices, high deductibles, high copays, so people don’t want to buy it. These additional subsidies got more people into the market, but at a very expensive cost. And because people are not cost sensitive, their share is tied to their income, the subsidies scale regardless of what insurance companies charge. That creates unintended effects. There were allegations of fraud. And a larger discussion: if we’re going to spend $350 billion per 10 years, is there not a better way to get healthier people to buy health insurance? Is there a better way to help people?

And the people most impacted are those around 400 percent of the federal poverty limit, not very low income people. Higher income people. And often near retirement folks who aren’t working anymore but aren’t yet on Medicare. They need health insurance, they have health needs, and insurance gets very expensive. That was something the Affordable Care Act tried to deal with. But doubling down on continuously funding this subsidy system is something Republicans didn’t want to do.

Susan Pendergrass (09:10)
Yeah. So we had Brian Blase of Paragon on the podcast, and he absolutely did not want those COVID related subsidies extended. He claimed that the Affordable Care Act caused health related expenses to go up. Do you know how that works?

Elias Tsapelas (09:45)
There are a couple things going on. One big thing Brian talks about is likely enormous fraud from the expanded subsidies. Bloomberg had a good article about what happened in Florida. As soon as the federal government offered zero premium plans for people between 100 and 150 percent of the federal poverty limit, background: Florida hasn’t expanded Medicaid, so people enroll on the marketplace. What happened is that it became a business for insurance brokers to get people enrolled. Brokers make money off enrollments, and people don’t care if they aren’t paying premiums.

So you had an enormous increase in people supposedly making between 100 and 150 percent of the federal poverty limit. Census data suggests far fewer people actually make that income. Tons were getting health insurance for free, and many weren’t using it. You’d expect higher usage. There are reasons to think there was widespread fraud.

More broadly, ACA plans must cover many things people don’t need, which drives up costs. And the marketplace risk pool is heavily made up of sick people, fewer healthy people, which makes insurance expensive.

So the bigger discussion is: how do you get healthier people into the market? How do you offer plans people want? Republicans are taking a stand that doubling down on the ACA model, with subsidies disconnected from costs, won’t work long term.

Susan Pendergrass (13:24)
Correct me if I’m wrong on this, but didn’t Senator Thune or somebody suggest just sending people $5,000?

Elias Tsapelas (13:30)
I don’t know if it was exactly that amount, but yes, there have been proposals essentially saying: maybe there will need to be a one year extension of subsidies because new plans start soon and it would be hard to roll out big changes in a month. But some ideas, from Senator Cassidy, Senator Thune, and others, propose approving the same amount of money but sending it directly to people instead of insurance companies. For many people, subsidies are worth over $30,000 a year. If people got $30,000, they might not spend it all on an ACA plan costing that much. They might buy a cheaper plan, use out of pocket spending, or seek non ACA compliant plans. There are ideas: HSAs, short term plans, specialized plans. A key piece is giving the money to people, not insurance companies, so someone has an incentive to reduce costs.

Susan Pendergrass (15:47)
Yeah. Well, the shutdown ended. Nothing really changed, right?

Elias Tsapelas (15:52)
Yeah. Congress will have to work a lot in the last month of the year. I’m a little disappointed. There were almost some very interesting budget related court cases that could have come from the shutdown. One argument was whether the government must fund food stamps, or SNAP, during a shutdown, whether they must give out money not appropriated. Some judges said yes. That raises major questions: can courts tell the executive branch to spend money Congress didn’t appropriate?

Susan Pendergrass (16:54)
I think they were told that they don’t, right, in the end?

Elias Tsapelas (16:59)
The Supreme Court basically said courts needed to wrestle with the issue. It got resolved before a final answer. We don’t know for now. Judges were on different sides. Democrats pushed back noting that in previous budgets, they fought to fund things, but the executive branch simply didn’t spend the money. There’s a lot of interesting stuff: can courts force funding, can the executive disregard congressional appropriations? I’m upset that didn’t get resolved. But the ACA issue is big enough that Congress has its hands full.

Susan Pendergrass (17:53)
Some folks said that because of the SNAP benefit question, we were just getting to the point where Americans were paying attention to the shutdown and then it ended. And what’s interesting is the amount of misinformation and hard to follow information. I saw headlines about someone’s insurance premiums going from $300 to $2,600. I don’t know if any of that was right, but it got a lot of play.

Elias Tsapelas (18:28)
I don’t think it was covered especially well in terms of what was being argued, because the government shut down far before these subsidies expired. There was a lot of muddying of the waters. Some people thought if subsidies weren’t extended, no one would have subsidies, even though the people most impacted would just go from paying 8.5 percent of income to 10 percent. Not nothing, but not catastrophic.

Health care costs are going up broadly. Medicare enrollees are getting renewal notices. Everything is going up. ARPA was designed to be temporary. If it were supposed to be permanent, Congress could have made it permanent. Whether Democrats thought it would be continued forever or just help temporarily is unclear. But if Congress comes up with something that makes health insurance better, I’m all for it. There are tough decisions. Congress has struggled with ACA reform for a decade.

Susan Pendergrass (20:20)
I think we know the answer to that. At the federal level, when they want to do big splashy things, ARPA, the ACA, the Tax Cuts and Jobs Act, they make expenses short term to reduce the fiscal note, assuming someone will renew them later. Same thing with the Tax Cuts and Jobs Act. They assume future lawmakers will extend them. So it’s not unreasonable that ARPA had temporary provisions assuming they’d get extended. I guess not this time.

Elias Tsapelas (21:12)
People’s health care costs going up is a big issue. People won’t be happy regardless. But returning to issues that should have been addressed when the ACA passed is important. The marketplace is dysfunctional and too expensive. Hopefully Congress finds something better. And I don’t want to minimize issues for people close to retirement. That’s a big issue: people between 55 and 65, not on Medicare yet, often have significant health needs. If you tell a 60 year old who isn’t working that coverage is $40,000 a year, that won’t work.

Susan Pendergrass (21:53)
Yeah. That’s right.

Elias Tsapelas (22:23)
More options will be good. That is an important group that needs to be addressed.

Susan Pendergrass (23:07)
Well, thanks for explaining it so clearly and helping our listeners understand what was actually on the table. It’s a complicated topic, but we’ll watch it unfold over the next year, and hopefully you’ll come back and explain what’s happening as it unfolds.

Elias Tsapelas (23:23)
Hopefully something does happen, so there is something to explain. That would be the best case scenario.

Susan Pendergrass (23:25)
That’s right. All right, well, thanks so much, Elias. Really appreciate it.

Elias Tsapelas (23:31)
Thank you.

Produced by Show-Me Opportunity

The post What the Government Shutdown Was Really About with Elias Tsapelas appeared first on Show-Me Institute.

The first proposal, brought forth in the Senate, would request a “global waiver” from the federal government for Missouri’s Medicaid funds. A global waiver would deliver federal funding to the state’s Medicaid program without all the strings attached. Such a dramatic change in policy would allow for enormous flexibility for state legislators to craft a Medicaid program that can best help our state’s most vulnerable citizens without the similarly enormous burden of federal regulations that currently bedevil the program.

This is how Fox 2 describes the idea:

A Senate committee heard testimony Wednesday on a bill that would direct the state Department of Social Services to seek a “global waiver” from federal Medicaid requirements to remake the state’s program.

Sponsoring Sen. David Sater says the intent is to ask the federal government to provide Missouri’s Medicaid money as a block grant, giving the state greater flexibility over how to spend it. Federal Medicaid dollars currently are provided on a matching basis for each state dollar that’s spent on health care services.

Translation: Missouri would decide how best to serve Missouri Medicaid patients. Crazy, right?

Now if the waiver sounds to our longtime readers a lot like the block grant idea we’ve written about in the past, that’s because functionally, it is. Our full proposal would take the grant money and split it into HSAs for low-income beneficiaries, empowering them to make decisions about their health while simultaneously providing incentive for participants to save money and shop for care. These ideas are largely captured in the second bill I referenced in the introduction. That HSA idea is, of course, just one of many potential reforms to the Medicaid program that could happen under a waiver or block grant, so Missouri’s plan could be different from plans agreed to in Florida, Illinois, or any other state. That’s a feature of the block grant, and given that a block grant proposal is currently being floated by the President, we may soon have the opportunity to see the laboratories of democracy at work in an effort to provide and better-tailor care in the Medicaid program.

But to get there? The doors to those labs need to be thrown open, and that’s where the waiver and block grants come in. I hope these ideas continue to work their way through the legislative process, as they are likely to be front and center during this legislative session—especially, as seems reasonably likely, if the federal government green-lights block granting of Medicaid from its end.

The post Medicaid Waiver Request A Great Idea appeared first on Show-Me Institute.

Opportunity beckons.  This is your chance to do something big. In breaking into your midnight slumbers, I hope only to point the way forward – with a few thoughts on how to accelerate growth and quicken prosperity in Missouri come the New Year.

One is to tell you plainly: Stop trying to pick winners and losers with taxpayer money. Let’s say (to use a real example) a group of businessmen tell you that they need $120 million in public support ($40 million from the state and another $80 million from the city) to build a new soccer stadium and bring a Major League Soccer franchise to downtown Saint Louis. While predicting that the project will create jobs and ancillary development, backers are asking for taxpayer money to pay for about two-thirds of the cost of building the stadium.

You must say “No” to all such proposals. If professional investors demand major subsidies for a profit-seeking venture, then you know (or should know) it’s a bad deal for taxpayers. Governor-elect Eric Greitens has already signaled his opposition to the $40 million in state tax credits for the proposed stadium. You can go further – much further – by reducing annual spending on state tax credits for targeted economic development from more than $350 million per year down to zero. That would free up money for better purposes (see next point).

Two is to leave more after-tax money in the pockets of wage earners and business owners alike. People and businesses vote with their feet. They move out of states where the “tax price” of living, working, or running a business is too high and into states where it is lower. If you include the 1 percent earnings tax in our two biggest cities, Missouri has a top income tax rate of 7 percent, which is more than all but 11 states. You should slash state income taxes 50 percent over the next three years.

Three is to end compulsory unionism as a condition of employment. Six out of eight neighboring states have already passed right-to-work legislation. Missouri should join them in embracing greater freedom and competition in the workplace.

Four is to promote public sector union democracy and transparency. Public sector employees should have the right to say “yea” or “nay” to continued union representation at intervals of every two or three years. At the same time, Missouri should close the loophole that allows public officials and government unions to conduct collective bargaining in closed sessions.

Five is to allow charter schools – now limited to the Kansas City and Saint Louis areas – to expand statewide without limitation. Missouri should adopt innovative programs, such as education savings accounts and tax credit-funded scholarships, enabling public school students trapped in underperforming school districts to attend private schools.

Six is encourage greater competition and choice in another area ripe for reform – health care. You can begin by converting much of Missouri’s Medicaid program into health savings accounts (HSAs).   After purchasing catastrophic health care plans, beneficiaries would be free to tailor their spending to their needs and roll over unspent money from one year to the next.

Seven is to eliminate a major disincentive that keeps many poor people from looking for jobs – the loss of public welfare benefits that too often results from finding gainful employment. Earned income tax credits (EITCs) are one practical solution to this problem.

Arise and shine, Missouri legislators.  This is a once-in-a-lifetime opportunity to make exceptional progress across a broad range of important public policy issues.

The post Listen Up, Missouri Lawmakers: Here Are Seven Resolutions for 2017 appeared first on Show-Me Institute.

As first appearing in the Columbia Missourian:

“Beware the Greeks bearing gifts” is one of the better-known sayings in classical literature, a reference to the Trojan Horse of antiquity. Its meaning: When someone offers a gift that looks too good to be true, be careful. It may be filled with hidden menace. This is the case today with Senate Bill 419 (SB 419), a bill before the Missouri General Assembly that would expand—and supposedly “reform”—Medicaid.

The text of the proposal pays lip service to a cadre of good market reforms: health savings accounts, private option insurance plans, and setting new standards for maximizing cost-sharing obligations, to name a few. But all of that is just eye candy. Nothing in the language of the bill guarantees that any reforms will actually occur. SB 419 supporters (incorrectly) portray the plan as a “block grant” that would provide the state with maximum flexibility to craft a “Missouri solution” to Medicaid’s cost and quality problems. The bill, however, actually calls for Missouri to request a waiver from the federal government—so that it actually can be allowed to receive funds as a block grant. The difference between a waiver and a block grant is not simply an issue of semantics. Block grants are financial aid packages the federal government awards to states. These grants can be applied to general areas of social welfare instead of specific programs. Block grants sound good, and they generally are good because they maximize state flexibility. SB 419, however, isn’t a block grant. Missouri does not have the power to block grant Medicaid funds from the federal government, hence the need for the waiver.

Even if the federal government approved a waiver today that included all of the market reforms we could dream up, the federal government could simply deny the waiver’s renewal in the future—leaving the state with the Medicaid expansion of SB 419 but none of the reform. Take Florida for example. It’s being coerced into Obamacare’s Medicaid expansion after the federal government revoked their waiver agreement, which actually predated the Affordable Care Act. SB 419’s suggested reforms may not last even if approved, but the costly expansion it puts into motion might very well remain, tucked neatly inside Troy’s—that is, Missouri’s—doors.

Moreover, there is no reason for “reform legislation” to concentrate power for future eligibility determinations for the Medicaid program in a 10-person committee—as SB 419 inexplicably does—rather than with the general assembly, as is the case today. Is it really a ”reform” to make future Medicaid expansions achievable through a small cadre, rather than through all of the elected members of the general assembly? Is that who we want making multibillion-dollar state commitments with the metaphorical credit cards of our kids and grandkids?

In fact, the bill’s subtle legislative craftsmanship not only cloaks the cost of the plan in the garb of conditional and ultimately temporary reform, but it also shifts decision-making power so that legislation won’t even have to be passed to make expansions in the future. That should worry us all.

Medicaid really does need to be reformed, both for beneficiaries and taxpayers, and to be clear, many of the ideas articulated, but not guaranteed, by SB 419 are quite good. But Missourians need to be very cautious before embracing a plan that purports to “fix” Medicaid’s problems when it is simply more likely to exacerbate them. Better to leave a wooden horse outside the door.

Michael Rathbone is a policy researcher at the Show-Me Institute.

The post Beware Medicaid Expansion, Even If It Is Billed as Reform appeared first on Show-Me Institute.

In his 2006 book The Audacity of Hope, then-U.S. Sen. Barack Obama was correct when he called America’s Medicaid system “broken.” Unfortunately, the program remains broken almost a decade later; from busting state budgets to delivering substandard care and access to our most needy, Medicaid serves as an important reminder that spending is no substitute for reform.

More spending, however, is exactly what some in Jefferson City want. Repackaged as a “Medicaid Transformation,” the Medicaid expansion element of the president’s health care law is being rebranded because “the Obamacare Medicaid expansion” — which is what it is — would never fly with the public.

Missourians recognize that, rather than expansion, Medicaid needs reform. Free-market ideas can take us in a better direction to deliver improved care to the less fortunate while also better serving the taxpayers who fund the program.

Free-market Medicaid reform principles aim to empower individuals, improve access and services for the needy, address problems of bureaucratic waste and leverage market forces to improve care for all. Indeed, markets have helped to make all sorts of goods and services less expensive and more available in many areas of our lives. They can do the same for health care.

Here are some ideas the state should be considering to make Medicaid better.

First, empower Medicaid’s patients. An important Oregon study suggests one of the few health benefits of Medicaid enrollment is the knowledge that an enrollee will not become bankrupt if the worst happens. With that in mind, Missouri should convert much of its Medicaid program into government-held health savings accounts (HSAs), splitting current Medicaid spending levels among the beneficiaries. After purchasing at least a catastrophic health care plan, beneficiaries could roll over any remaining money from year to year. This would provide the safety net Medicaid was supposed to be while still allowing patients to tailor their spending to their needs. One size does not fit all when it comes to health care. The state should stop acting like it does.

Second, give Medicaid enrollees an incentive to leave the program. Another Oregon study found that rather than decrease unnecessary emergency room use, Medicaid enrollment actually increased it. As a reform, then, if an enrollee abides by the program’s rules and avoids wasteful ER use, the enrollee could take some percentage of the remaining money with him or her when leaving the program, either as a private HSA or as a reduced amount in cash. This would help both the patient and the taxpayers: It would reward the Medicaid enrollee for healthy and fiscally prudent behaviors and reduce taxpayers’ costs.

Third, with so many newly minted, price-conscious Medicaid consumers, implement price transparency measures for common medical procedures. The federal government has started the process of forcing greater hospital price transparency, but states have done a poor job of empowering customers with the information to shop for health care like they can for cars, homes and even Lasik eye procedures. This also would reduce Medicaid access problems; rather than enrollees having to find providers who accept Medicaid patients, Medicaid beneficiaries could go practically anywhere with their HSA accounts.

Finally, pursue regulatory reforms of “certificate of need” and “scope of practice” laws, areas of regulation that often act as needless barriers to patient care. Along with ensuring prices are as transparent as possible, the state should make sure care is as accessible as possible through as many places and people as possible. Well-researched regulatory reforms that remove unnecessary obstacles to care would help both the poor and middle class.

To be clear, these ideas are meant to contribute to the Medicaid reform conversation, not end it. But that is what the conversation in Jefferson City should be about — reform, not expansion. It is time for the state deliver on its promise of a better Medicaid program.

Patrick Ishmael is a policy analyst at the Show-Me Institute, which promotes market solutions for Missouri public policy.

The post Expansion Is Wrong Move For Medicaid appeared first on Show-Me Institute.

What would be a better way to deliver this care? Here are some ideas:

• The state currently spends (roughly) between $3,000 and $5,000 on each child and adult enrolled in the Medicaid program. Split the current level of Medicaid spending into the equivalent of state-held health savings accounts (HSA) that the beneficiary controls. After the purchase of at least a catastrophic insurance plan, the enrollee could decide what additional health services he or she needs to spend money on, if any. Leftover money could be rolled over year to year, meaning beneficiaries wouldn’t feel compelled to use or lose those health dollars unnecessarily.
• Give enrollees a reason to leave the Medicaid program on their own. If a Medicaid patient complies with the regulations of the program — high among them, to not use emergency room services unnecessarily — then the patient could take the bulk of the leftover money when he or she exits the program, either as an HSA or as a reduced amount in cash. Indeed, beneficiaries would have something to gain by leaving Medicaid.
• Health insurance is insurance first, not a health plan. One of the few benefits found in an Oregon study on Medicaid was that enrollees felt financially secure after they joined the program. Not only can Medicaid reform of the nature described above provide that security, it can do it at a lower cost and with greater flexibility for the patient.
• Sow the seeds of even wider, positive health care reforms. A market-based reform of the kind articulated here would inject thousands of cost-conscious consumers into the health care marketplace who are not only empowered to negotiate for the services they need, but have the incentive to negotiate.

That’s where I would start Medicaid’s reformation. You can call these ideas a free-market solution or a transformation, but most importantly, I think you could call it a vast improvement over what we have now. Medicaid needs to be reformed first and foremost, and failure to do so will hurt all of its stakeholders. Patients and taxpayers deserve better than the status quo; I think these proposals would help to move the reform discussion and the Medicaid program in the right direction.

The post What Would A Free-Market Medicaid Reform Look Like? appeared first on Show-Me Institute.

Never mind that our prior coverage met the standards for our family just fine. Never mind that we were fully covering our family and other taxpayers were not subsidizing us. Never mind that our insurance now provides us with additional coverage that we neither want nor need. The old plan suited our needs just fine.

Is it possible that we should be blaming our insurer instead of the government? Maybe, but because Obamacare made changes that eliminated the options for our prior plan, I think my anger is appropriately directed at the government and the people who voted PPACA in.  We were told that we could keep our health plan if we wanted to under Obamacare. They lied.

The post My Obamacare Story appeared first on Show-Me Institute.

To cite a question that occupied a whole day of testimony: If the federal government can compel you to buy health insurance, can it also compel you to buy broccoli – or anything else that it deems to be in your best interests?

Should the Supreme Court uphold the law, it will signify that the act has met the minimal standard of constitutionality. Nothing more. The debate over constitutionality, however it is resolved, should not obscure the fact the PPACA is a really bad law. Let us count the ways that it violates basic principles of sound policy.

1. It exemplifies a legislate-in-haste-repent-at-leisure mentality. Few Senators and Congressmen had time to read the 2,700-page bill before it was brought to a vote. Then House Speaker Nancy Pelosi famously stated, “We have to pass the bill so that you can find out what’s in it.”

2. It violates the principle of impartiality. The same rules should apply to everyone. Already the administration has granted a long list of exemptions to various companies and unions.

3. It grants extraordinary powers to unelected bureaucrats to micro-manage health care and health insurance down to the smallest details of what is covered and what is not. Recently, the Department of Health and Human Services dictated that employers, including religious organizations, must cover contraception and abortion-causing drugs in their health plans. Apart from any moral objections to such provisions, why should the federal government tell employers and employees what their health insurance has to cover?

4. Good public policy would encourage health care consumers to shop around and purchase insurance policies that are best suited to their own needs and spending priorities. The PPACA does the opposite. Decision-making power is turned over to bureaucrats, who pay no price for decisions that are costly or wrong-headed.

5, 6, and 7. Good public policy does not raise false expectations. Backers of the health reform bill violated this principle three times over. They promised a) anyone can “keep their plan if they like it;” b) the plan would mandate many new benefits and still reduce the average family premium by $2,500; and c) that it would not add “a single dime” to the federal deficit.

According to a McKinsey & Co study, a third to a half of employers plan to stop offering health insurance beginning in 2014. Another study concludes that a typical family health insurance plan costing $12,300 today will cost more than twice that by 2019. And finally, the administration has grudgingly acknowledged spiraling costs under its plan.

8. Good public policy avoids ticking time bombs. The health-care law is filled with them.

The legislation will increase Medicaid enrollment by an estimated 24 million new beneficiaries by 2015. Missouri and other states struggling to balance their budgets will pick up a significant share of the cost.

The law includes a massive new health entitlement/income redistribution program for families earning more than three times the poverty level. In 2014, it will channel up to $3,000 in taxpayer funds to families making up to $95,000.

PPACA discriminates against young people, forcing them to purchase health insurance at inflated prices in order to subsidize older beneficiaries. Simultaneously, the law imposes severe penalties on young people who use Health Savings Accounts to secure benefits for themselves in later years.

9. The PPACA is fiscally irresponsible. It includes a raft of new taxes. But these appear to be wholly inadequate to the task of paying the bill for over-promising and extending new entitlements to tens of millions of people. That leaves rationing as a last resort, and the government’s own reports contemplate major cutbacks in Medicare spending down the road.

10. The Affordable Care Act is truly unaffordable . . . and unsustainable. Perhaps the Supreme Court will strike it down. But whatever the Court decides, that does not excuse our elected representatives from their responsibilities. Our government should not erode our freedoms, degrade our quality of life, or bankrupt our future. The PPACA does all of those things. If not struck down, it should be repealed.

Andrew B. Wilson is a resident fellow and senior writer at the Show-Me Institute, which promotes market solutions for Missouri public policy.

The post Health Care Law Violates Sound Public Policy In 10 Ways appeared first on Show-Me Institute.

PPACA’s negative economic effects only compound the problems of a slow recovery in which young people in particular are hurting financially. The official unemployment rate in the United States is 8.3 percent, but for people ages 16-25, it is almost double that, at 16.5 percent. The Wall Street Journal describes the situation as “Generation Jobless,” and while college graduates have better opportunities than non-college graduates, they are still making less and saving less than if they had graduated in better economic times. There is no doubt that people of all ages are suffering, but unemployment during some of the most important wealth-building years could be disastrous when today’s young adults are ready to retire — both personally and for the country.

Unfortunately, PPACA only worsens the situation because it raises taxes. Yesterday, Americans for Tax Reform highlighted the (at least) four tax hikes contained in PPACA which hurt young people. The first two are especially troubling to me: the “excise tax,” for not buying a government-approved insurance plan; and the “medicine cabinet tax,” which prevents people from using flex accounts and Health Savings Accounts to pay for non-prescription, over-the-counter medicine. The former penalizes people for not purchasing a government-approved health insurance plan; the latter reduces choice and flexibility with one’s personal health dollars.

Young people are less likely to draw deeply on prescription medication benefits or other health care services than older and less healthy policyholders. The result? The government forces young people to pay for insurance plans that they do not need and will not use, and prevents them from taking full advantage of HSAs — health care dollars they would control and manage as part of their own personal budgets. Essentially, the government is forcing young people to subsidize the health care of others during some of their most economically fragile years.

That is bad policy and bad news for young people. PPACA may be marketed as “reform,” but it harms young people, who already are hurting economically, by raising costs and reducing choice.

The post Reminder: Health Care ‘Reform’ Law Raises Costs On Young People appeared first on Show-Me Institute.

When Missourians passed Proposition C last August with more than 71 percent of the vote, they signaled opposition to the individual health insurance mandate that is central to the federal health care reform law adopted by Congress earlier this year. Policymakers in Missouri should take steps to represent their constituency’s resounding opposition to the measure. Missouri’s attorney general, Chris Koster, has the opportunity to do just that by joining 20 other states in a Florida lawsuit against Obamacare. Governors and attorneys general who decide to participate have until January 10 to join the suit.

There are many reasons why Missouri should join the health care reform lawsuit. The individual mandate requiring Americans to carry insurance overreaches the federal government’s authority under the Constitution’s commerce clause. Health care is just one among the many goods and services that individuals in Missouri consume, and courts have never interpreted the commerce clause as giving lawmakers the authority to require individuals to purchase a product.

The case that’s being heard in Florida is one of the few among the two dozen pending challenges to the new health care reform law that also contests the law’s expansion of eligibility requirements for Medicaid, the joint federal-state health insurance program for the poor. Expanding Medicaid would burden the state budget, and may exacerbate the existing deficit. Lawmakers in Missouri have already made cuts to education and public safety, and other cuts to essential services — or increased taxes — could be necessary if the Medicaid program were expanded.

Medicaid is already one of the largest expenses in Missouri’s budget, and the new health care law depends on an expansion of Medicaid for its projected increase in insurance coverage. In fiscal year 2008, Medicaid spending in Missouri totaled more than $7.09 billion. The federal government pays for the majority of the expenditures, but Missouri taxpayers covered $2.66 billion, or more than 12.5 percent, of the state’s total $21.2 billion budget. Although the law initially requires the federal government to absorb the full cost of the expansion, states could eventually pay 10 percent.

The states that are party to the health care reform lawsuit argue that the law impinges on state sovereignty by requiring the use of state funds to cover a much larger share of low-income people through Medicaid. Not only does it undermine state autonomy, it is also unnecessary.

There are alternative ways to provide health care to uninsured and low-income populations without restricting individual liberties and freedom of choice. When the government allows more competition and choice in insurance markets, people can better choose how to balance cost with their own relative tolerance for risk. One successful strategy would be to eliminate the way in which insurance is tied to employment, and instead encourage health savings accounts (HSAs), which would allow individuals to purchase portable, cost-effective policies, save for foreseeable health-related expenses, and hedging against unknown future risk.

Top-down, centralized plans can’t take into account the many varied needs and preferences of the hundreds of millions of people such plans will inevitably affect. By signing on to this Florida lawsuit, Attorney General Koster can help signal that Missourians are capable of making their own health insurance decisions without an intrusive federal mandate.

Christine Harbin is a policy analyst for the Show-Me Institute, an independent think tank promoting free-market solutions for Missouri public policy.

The post Missouri’s Attorney General Should Join Health Care Reform Lawsuit appeared first on Show-Me Institute.

I hope the SNL editors research and footnote the types of benefits offered to the Show-Me Institute’s employees, if any, and that Harbin discloses her participation, if any, in them. My guess is that she would refuse to disclose which benefits she receives, much like the GOP Congress refused to do this week.

The commenter guessed incorrectly. Even though I don’t consider it to be relevant to my argument, nor do I consider it to be the responsibility of the Springfield News-Leader to investigate it before running an editorial, I’m happy to clarify the health care benefits that I enjoy. This is no secret — it’s something that I mentioned yesterday when I was talking about health care policy on the Mike Ferguson show on the Eagle 93.9 FM in Columbia. It’s a characteristic of my generation — we tend to be very willing to disclose details of our finances.

I have a health savings account (HSA) and a health insurance policy with a $5,000 deductible. My monthly premium, which I pay out of pocket, is around $100, which is manageable. I work at the Show-Me Institute because I am committed to the ideas of liberty and individual responsibility — certainly not because I receive a lucrative benefits package, because I don’t. If I simply wanted a fat paycheck, I would get a job in the private sector or become a school superintendent.

Insurance policies are not one-size-fits-all, particularly in health care. Although high deductible insurance plans and HSAs work very well for healthy 20-somethings like John Payne and me, I’ll readily admit that it is not something that works best for everybody. However, a plan that works best for everybody doesn’t exist. A so-called Cadillac insurance plan with a low deductible, for instance, would be a poor fit for me at this time in my life. This is precisely why health care should remain in the free market — it preserves consumer choice and ensures that individuals can select the policies that fit their needs. We can see that when the government increases the number of mandates, the cost of coverage rises.

Show-Me Institute staff and scholars have highlighted the advantages of HSAs previously. As one particular benefit, my policy is portable (i.e., it’s not tied to my employer). Therefore, if I were to leave the Show-Me Institute, my health care coverage would be unaffected. From my perspective as a young person, an additional benefit of an HSA is that it serves as a tax-sheltered savings account. Unlike flexible savings accounts, which expire every Dec. 31, the money that I put into my HSA rolls over each year. Furthermore, if I don’t spend the money in my account by age 65, I can withdraw it without penalty like I would with a traditional IRA.

The bottom line is that it is important to preserve choice in health care. Overall welfare would decrease if families and individuals weren’t free to choose the policies that best fit their particular lifestyles and budget constraints.

The post Hello, My Name Is Christine and I Have a Health Savings Account appeared first on Show-Me Institute.

“The clinic will provide affordable access to top-quality dental and vision care to its members without the limitations and costs associated with traditional insurance,” Dickerson said.

People who join the cooperative become part owners and pay dues to get basic services such as checkups, cleanings and comprehensive exams.

For many reasons, health cooperatives are a great free-market health care solution. There are many positive consequences to increasing the number of health cooperatives in the market, such as improving patient access, lowering costs, and reducing bureaucracy. Because individuals will be spending their own money (not the money of a third-party insurance provider), they will consume health care more deliberately, as they would with a health savings account (HSA). Increasing the number of health care cooperatives in the market would place downward pressure on the cost of routine medical care. Patients would be better off, not only because their health care would cost less, but also because specialty providers could focus their resources on the patients that need more critical care.

To my grave disappointment, however, the project is subsidized by state targeted tax credits. Again from the article:

Gov. Jay Nixon joined Watch Me Smile dental and vision cooperative developer W. Weaver Dickerson at the former First Federal Bank building to announce the project and $2.05 million in state economic development incentives. […]

His company is receiving $1.3 million in Missouri Quality Jobs funding and a $750,000 community development block grant, Nixon said.

If past performance of the Quality Jobs program is predictive of its future, this particular project might not deliver on its projected fiscal impact. According to an April 2010 report on tax credit cost controls from the state auditor’s office, the actual redemptions of the Quality Jobs program exceeded the projected long-term fiscal impact. For fiscal years 2005 to 2009, the fiscal notes projected $124,000,000 in economic impact, but only $10,724,353 was measured — $113,275,647 below the projection. Failing to deliver on promises, in terms of job creation and economic activity, is a problem that’s pervasive in tax credit programs in Missouri and other states.

Because the consumer demand for routine primary health care services is high and constant, I suspect that this project would be successful independent of subsidy. The general welfare in Missouri would benefit from the proliferation of health care cooperatives, but subsidizing their development negates at least some of their benefit.

The post A Pyrrhic Victory for the Free Market appeared first on Show-Me Institute.

Right now we’re estimating the cost of the minimum benefit package that everyone will be required to have at $4,750 for individuals and $12,250 for families — understanding that the proclivity in this Congress and in this Department of Health and Human Services is to add benefits, not reduce them, making the package even more expensive. That translates into a minimum health benefit of $2.28 an hour for full time workers (individual coverage) and $5.89 an hour (family coverage) for fulltime employees.

Granted, the law does not specify how much of the premium must be paid by the employer versus the employee — other than a government requirement that the employee’s share cannot exceed 9.5% of family income for low- and moderate-income workers and an industry rule of thumb that employers must pick up at least 50% of the tab. But the economic effects are the same, regardless of who writes the checks.

In four years’ time, the minimum cost of labor will be a $7.25 cash minimum wage and a $5.89 health minimum wage (family), for a total of $13.14 an hour or about $27,331 a year. (I think you can see already that no one is going to want to hire low-wage workers with families.)

Employers could also dump workers onto government exchanges, but that costs them $2,000 in penalties per instance. Either way, the costs of employing low-productivity employees will rise dramatically, which means that not only will the health care reform bill fail to increase access to health care for many low-income people — it may also cost them their jobs.

The post Neither Health Nor Wealth appeared first on Show-Me Institute.

Unfortunately, the new health care reform law placed new restrictions on consumer-driven health care plans. Beginning in 2011, patients will no longer be able to pay for over-the-counter medications out of their HSAs unless a doctor prescribes them. Furthermore, tax-free contributions to the accounts will be capped at $2,500. These aren’t major changes to the law, but at the margin they make these plans less useful, so fewer people will purchase the policies. Speaking as a happy customer of a consumer-driven plan, most of the money I have spent from my HSA so far has been on minor health care products, like over-the-counter drugs. The new regulation substantially limits the usefulness of the account to me. Before the year ends, I will probably buy up massive quantities of all over-the-counter drugs I might need for the next few years, so I do not have to pay out of pocket for them.

I do not fear that my plan will be regulated out of existence this year or next, but as it slowly becomes indistinguishable from all other health care plans, its proven advantages will slowly vanish, as well.

The post Death by a Thousand Cuts appeared first on Show-Me Institute.

As of 2009, Missouri had 41 mandates for health insurance. Considered singly, no individual mandate had a large impact on premium costs, but they each had a marginal impact. Every incremental increase in the cost of health insurance premiums leads to the possibility that some unknown number of individuals and businesses are no longer able to afford their previous coverage.

Here is a look at mandates in Missouri (data compiled from the Council for Affordable Health Insurance):

As we’ve discussed before here at Show-Me Daily, injecting competition into the insurance market is really the only long-term solution that will both increase coverage and lower health care costs. Sarah Brodsky has also suggested tuition tax credits for autistic children as another alternative to insurance mandates.

Regardless of how one looks at the issue, mandates do not serve as a solution. The list provided by CAHI contained 130 different mandates throughout all of the states and Washington, D.C. Health insurance would be prohibitively expensive for far more people if every policy had to cover all 130 items, and there will still be many other conditions or diseases that are not covered. Does every 20-year-old want insurance against Alzheimer’s disease? Does every 60-year-old want insurance against autism?

With more choice in the insurance market, people can better choose for which illnesses or conditions they wish to be insured. Eliminating the way in which insurance is tied to employment and encouraging health savings accounts would allow individuals to purchase portable, cost-effective policies, saving for foreseeable health-related expenses while hedging against unknown future risk.

The post Missouri’s Many Health Insurance Mandates appeared first on Show-Me Institute.

There has been a lot of charged rhetoric on the topic of autism mandates, and I’m positive that its proponents have had the best of intentions. (In fact, I played softball last weekend with one of the sponsors of the bill, Sen. Eric Schmitt, and he seemed like a great guy.)

It’s important, though, to understand the economic mechanisms behind mandates. Insurance becomes prohibitively expensive if the government attempts to mandate coverage of everything that could happen to anyone. As I’ve mentioned before, high-deductible health savings accounts are one of the best ways to handle these sorts of issues; once the policy owner exceeds a certain deductible, their insurance can cover the cost of treatment. The high deductible helps to minimize costs by reducing the health care wedge between patient and doctor, as well as reserving insurance for its intended purpose: large, catastrophic costs. Market competition is a more effective way to bring health coverage to all children with autism and other conditions, and not just a select few.

(Also, a quick thanks to John Combest for linking to my op-ed in the Springfield News-Leader! My op-ed will also be available in the Sunday edition of the Joplin Globe.)

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These plans have been celebrated as a market solution that helps contain health care costs, a mechanism that the new federal health care legislation lacks. Unfortunately — and, perhaps, ironically — HSAs may no longer be an option under the new legislation. Katherine Nix of the Heritage Foundation’s blog The Foundry writes:

Unfortunately, Obamacare threatens to render HSA/HDHP plans a thing of the past. It’s a regulatory thing. It all depends on how the Department of Health and Human Services decides to calculate the actuarial value of HDHPs. According to Roy Ramthun of HSA Consulting, if HHS opts not to “count” contributions to HSAs as part of the actuarial value, then “HDHPs, many of which have actuarial values below 60 percent (or whatever the final standard becomes) based on the insurance coverage alone, could no longer be sold.”

HSAs bring market forces to the health care industry; they minimize the health care wedge between health care consumers and the costs of their care by removing the veil between consumer and price. It would be unfortunate for the nation — and for Missourians, who have enjoyed the opportunity to purchase HSAs since 2007 — if they become no longer a viable insurance option.

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Like all things, health care is a finite resource. As such, it is always rationed in some way. The important issue to determine is who — or what — is doing the rationing, and what criteria is used. After all, people ration in their daily lives when they choose how much of their paychecks to spend on groceries, clothes, or movie tickets. When individuals ration, they decide between individual trade-offs. The difference is not the mechanism, but the actor.

The price system is arguably the most efficient method to allocate resources. As Nobel laureate economist F.A. Hayek articulated in “The Use of Knowledge in Society,” the price system contains information for both the seller and buyer. With health care, however, true costs are largely veiled by what can be termed a “health care wedge” — a separation of consumers from knowledge of costs. A patient may face a decision of whether to seek treatment in the form of high-cost, high-intensity care or low-cost, low-intensity care (or no care, as the case may be) but lacks real price information to make an informed decision about whether the expected outcome will be worth the cost. This lack of information makes the high-cost, high-intensity care more appealing in situations where it might not otherwise be chosen. Because of the skewed incentive structure that this creates in the current health insurance market, costs will continue to rise. This leads some to believe that it is necessary for the government to establish new ways of rationing care, which ignores the real problem: the separation of consumer and cost of treatment. By finding a way to mitigate that health care wedge, the decisions about when and why to ration can be returned to individuals and their physicians.

How can this be done? Nearly two decades ago, Show-Me Institute scholar Susan Feigenbaum suggested a different mechanism for health insurance: indemnity insurance. She likened the process to automobile insurance. When an illness is diagnosed, the insurance company would follow a process that is similar to when an automobile claim is made. The company would assess the medical issue and write a check for the probable cost. The customer would then be able to choose how to spend that money.

This system would create an incentive to shop around. Less intensive — and less costly — treatments become would more appealing, because thriftiness is rewarded. Some people would choose to use the entire amount for intensive health care. Others, especially those with terminal illnesses, might opt for minimal hospice or palliative care and set aside the remainder in a trust fund for a child or grandchild. Depending on how this type of plan were implemented, certain caveats could be included, like specifying a minimum level of required care, or precluding autonomy in making medical choices for those deemed too sick to make a sound decision. Those issues aside, indemnity insurance would place the decision in the hands of the individual.

The important thing is that this mechanism would introduce competition into one of the more expensive areas of health care, end-of-life care. Competition is necessary to bring down health care costs in the long term. Indemnity care is not the only possible solution, but it is one that must be considered, alongside other market-based solutions like health savings accounts. Missourians would benefit with an opportunity to choose from a variety of market-based health care options.

The post Death Panels and the Market appeared first on Show-Me Institute.

Interestingly, exemptions will be granted for some very specific cases. The most common ones are financial hardship, religious objections, and those without coverage for less than three months. The exact level of financial hardship is spelled out in the law quite succinctly; the only people who qualify are those with incomes below the tax filing threshold (in 2009, the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples).

The other side of the situation is that if you have employer-sponsored health care insurance, or pay for your own insurance, you can keep your current policy. However, the new law requires a higher minimal standard of benefits for all participants. As a result, it is expected that by 2016 all policies will cost 10 to 13 percent more than the expected future cost of a current policy extended to that year. Countering that expense will be a potential tax credit by which a family of four that has an income of less than $88,000 will receive tax credits to help pay insurance premiums and deductibles. At the same time, people at the other end of the economic spectrum will be given a new burden. Those families that report an income of more than $250,000 per year will have to pay more in the form of a Medicare payroll tax; their unearned income will be subject to an additional 3.8-percent tax.

As you know, in the past some of my colleagues advised individuals and small businesses to purchase health savings accounts (HSAs). The new law will have an immediate effect on people that took that advice. It will exclude a currently accepted practice, in which the costs of over-the-counter drugs not prescribed by a doctor were reimbursed on a tax-free basis. The law will increase the penalties for inappropriate distributions from HSAs, also; that is, for withdrawals that are not used for qualified medical expenses. But, to the best of my knowledge, none of my friends were using their HSAs for unqualified expenses.

So, what does this mean to the people of Missouri today? At this specific point in time, very little seems to be happening that has a direct immediate impact on most readers of this blog. The fines and penalties that might become associated with an independent attitude won’t kick in for another few years. But a lot more will happen in other aspects of the health care arena by that time. They say that the true art and science of economics involves an understanding of the changes that occur at the margin, and we need to look at all the little bitty changes, one at a time, to see how they fit. So far, and from this single perspective, these marginal changes are quite minimal. But this is just the beginning. Going through the health care bill section by section during the next few weeks will give us a better idea of what it is really all about.

The post What Does the Patient Protection Act Do to the Average Missourian Today? appeared first on Show-Me Institute.

S.B. 618 would require insurance plans to cover up to $55,000 annually for autism diagnosis and treatment for children up to the age of 21. A mandate of any amount increases health insurance costs, and the bill’s substantial commitment would assuredly have a noticeable effect. Its proponents argue that it would increase the price of health care premiums by less than 1 percent, while insurers believe it could raise premiums up to 3 or 4 percent. Although the bill would exclude small businesses if it raised their premiums by more than 5 percent, any increase would necessarily price some marginal number of people and companies out of the insurance market, forcing them to cut coverage or reduce hiring.

Autism is a problem in Missouri, and it is not difficult to be swept up by the heart-wrenching stories of families with autistic children. But there are many disorders and diseases that afflict people — children and adults alike — and mandated coverage of all or even most of these problems would make insurance prohibitively expensive. These kinds of mandated coverage makes insurance more expensive especially for those with diseases that are not given state protection.

It’s important to note that some forms of autism aid already exist. Although not as comprehensive as an insurance mandate, there are publicly and privately funded resources for Missouri children with autism spectrum disorders, including Medicaid waivers for families who would not otherwise qualify for assistance, and a nonprofit private school for children with severe autism.

A large part of the argument in favor of the mandate lies in the unpredictability of health insurance when it is attached to employment — a problem only exacerbated by the current economic climate — and the difficulties involved in obtaining a plan that covers autism. Instead of government-imposed mandates about coverage, families should be free to choose an insurance plan that best fits their needs. Politicians cannot know the optimal equilibrium point between price, risk, and security for any type of insurance coverage, let alone for autism, because that equilibrium will differ for everyone.

The bill in question adds a much-needed amendment allowing Missourians to purchase out-of-state insurance that does not mandate autism coverage, although Missouri already has a mechanism that would help all families find affordable health insurance. Health savings accounts (HSAs) allow policyholders to become consumers, giving them the power to choose an appropriate coverage level. HSAs are portable, and therefore less dependent on job stability that may not always be available in an uncertain economic climate. Both employers and employees can contribute pretax funds to HSAs, which can then be used toward paying most basic health expenses. With an HSA and an accompanying high-deductible plan, consumers can budget their health care expenditures more effectively than bureaucratic cost-cutting is able to do.

State mandates raise health insurance costs across the board, and decrease people’s access to affordable coverage. In the long run, the most effective solution for families with autistic children — or any other disorder — is to open the insurance market to further competition, giving them a practical economic incentive to cater to such niche markets. Small businesses — at any point, but especially during a recession — are extremely cost-sensitive to changes in premiums like the one that would assuredly occur following a large mandate on autism treatment and diagnosis. Although this insurance mandate aims to help families with autistic children, it would simultaneously hurt another group of Missourians who would face significant cost increases, or even the potential loss of their own health insurance coverage.

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