With the ACA in its fifth year of full expansion, we now have an established track record in the expanding states to help estimate what the actual costs of expansion will be to the states and how those costs have compared to states’ projections. This Issue Brief reviews that evidence, and evaluates continuing claims by Medicaid opponents that expansion is a “proven disaster” for state budgets. The strong balance of objective evidence indicates that actual costs to states so far from expanding Medicaid are negligible or minor, and that states across the political spectrum do not regret their decisions to expand Medicaid.
Our analysis of the CEX shows that the number of Americans living on less than $4 per day is effectively zero. Since 1980, the CEX has reported on the annual consumption expenditures of 222,170 households. Of these 222,170 cases, 175 reported spending less than $4 per person per day. That’s one household in 1,270.
Deaton’s claims of Third World poverty in the U.S. can also be rebutted by examining the actual living conditions of families with ostensible incomes below the deep-poverty level.
Rather than 1.7 percent of the population living in deep poverty, expenditure surveys show the figure is only 0.08 percent.
The only consistent characteristic of the Affordable Care Act (ACA) is its ability to generate litigation. The gift that keeps on giving for Obamacare opponents seems to defy common law doctrines curbing the practices of champerty and maintenance (frivolous lawsuits).
Administrative Costs Associated With Physician Billing and Insurance-Related Activities at an Academic Health Care SystemFebruary 26, 2018
Importance Administrative costs in the US health care system are an important component of total health care spending, and a substantial proportion of these costs are attributable to billing and insurance-related activities.
Objective To examine and estimate the administrative costs associated with physician billing activities in a large academic health care system with a certified electronic health record system.
Design, Setting, and Participants This study used time-driven activity-based costing. Interviews were conducted with 27 health system administrators and 34 physicians in 2016 and 2017 to construct a process map charting the path of an insurance claim through the revenue cycle management process. These data were used to calculate the cost for each major billing and insurance-related activity and were aggregated to estimate the health system’s total cost of processing an insurance claim.
Exposures Estimated time required to perform billing and insurance-related activities, based on interviews with management personnel and physicians.
Main Outcomes and Measures Estimated billing and insurance-related costs for 5 types of patient encounters: primary care visits, discharged emergency department visits, general medicine inpatient stays, ambulatory surgical procedures, and inpatient surgical procedures.
Results Estimated processing time and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of these totals, time and costs for activities carried out by physicians were estimated at a median of 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure. Of professional revenue, professional billing costs were estimated to represent 14.5% for primary care visits, 25.2% for emergency department visits, 8.0% for general medicine inpatient stays, 13.4% for ambulatory surgical procedures, and 3.1% for inpatient surgical procedures.
Conclusions and Relevance In a time-driven activity-based costing study in a large academic health care system with a certified electronic health record system, the estimated costs of billing and insurance-related activities ranged from $20 for a primary care visit to $215 for an inpatient surgical procedure. Knowledge of how specific billing and insurance-related activities contribute to administrative costs may help inform policy solutions to reduce these expenses.
Resetting the Scoreboard: Why CBO Should Abandon Its Flawed Analysis of the Center for Medicare and Medicaid InnovationFebruary 15, 2018
Congress created the Center for Medicare and Medicaid Innovation (CMMI) in the Affordable Care Act and vested it with extraordinary powers. CMMI can conduct demonstration projects in the Medicare, Medicaid and Children’s Health Insurance Program and expand those projects nationwide without congressional approval.
The Congressional Budget Office (CBO) believes that CMMI will achieve substantial federal savings. It bases this conclusion not on analyses of projects that CMMI has undertaken, but on faith in the CMMI process. CBO assumes that process will produce money-saving ideas and that the center will scrap failed projects and expand
“The savings that CBO expects to result from the center’s activities,” a senior CBO official said in congressional testimony, “stem largely from the judgment that successful demonstrations will be expanded and achieve savings.”
The statement’s circularity – CBO “expects” CMMI to achieve savings because CMMI will “achieve savings” – is but one way which the agency’s analysis of CMMI departs from its long-established methods of preparing estimates. In addition to assuming that CMMI will sometime in the future conceive, launch and nationalize successful projects, CBO conjured a numerical factor to convert its assumptions into dollar estimates. It then embedded these numbers in its Medicare baseline, the yardstick against which it measures legislation.
CBO’s unique approach to CMMI thus colors its analysis of legislation designed to achieve Medicare savings. CBO believes that any bill that would overlap with any ongoing or possible future CMMI demonstration would increase Medicare spending above baseline levels. Even if Congress offers up a proposal that would reduce spending relative to the statute, CBO will score it as a spending hike if it believes that CMMI might someday test a similar policy.
CBO thus ascribes unobserved and unobservable savings to projects that CMMI has not yet undertaken (and may never undertake), quantifies these savings through the application of an arbitrary numerical factor, incorporates the savings into its Medicare baseline, and measures the budgetary effects of legislation against this revised baseline.
This paper traces the history of Medicare demonstration projects and shows how CMMI’s authorities differ from its predecessors. It then examines CBO’s assumptions about CMMI, carefully tracing the reasoning that has led to its conclusions. It then shows how recent events, including the Trump Administration’s cancellation of CMMI projects that CBO believed would save money, expose flaws in CBO’s assumptions and reasoning. It concludes with recommendations for CBO, Congress and the executive branch with respect to CMMI.
This paper develops the first evidence on how individuals’ union membership status affects their net fiscal impact, the difference between taxes they pay and cost of public benefits they receive, enriching our understanding of how labor relations interacts with public economics. Current Population Survey data between 1994 and 2015 in pooled cross-sections and individual first-difference models yield evidence that union membership has a positive net fiscal impact through the worker-level channels studied.
The growth of novel flexible work formats raises a number of questions about their effects upon health and the potential required changes in public policy. However, answering these questions is hampered by lack of suitable data. This is the first paper that draws on comprehensive longitudinal administrative data to examine the impact of self-employment in terms of health. It also considers an objective measure of health – hospital admissions – that is not subject to recall or other biases that may affect previous studies. Our findings, based on a representative sample of over 100,000 individuals followed monthly from 2005 to 2011 in Portugal, indicate that the likelihood of hospital admission of self-employed individuals is about half that of wage workers. This finding holds even when accounting for a potential self-selection of the healthy into self-employment. Similar results are found for mortality rates.