Last week, after the House health care bill was unveiled, the CBO released their analysis of the bill. In it was a few paragraphs on the public health insurance option that seemed noteworthy and puzzling:

Roughly one-fifth of the people purchasing coverage through the exchanges would enroll in the public plan, meaning that total enrollment in that plan would be about 6 million.

That estimate of enrollment reflects CBO’s assessment that a public plan paying negotiated rates would attract a broad network of providers but would typically have premiums that are somewhat higher than the average premiums for the private plans in the exchanges. The rates the public plan pays to providers would, on average, probably be comparable to the rates paid by private insurers participating in the exchanges. The public plan would have lower administrative costs than those private plans but would probably engage in less management of utilization by its enrollees and attract a less healthy pool of enrollees. (The effects of that “adverse selection” on the public plan’s premiums would be only partially offset by the “risk adjustment” procedures that would apply to all plans operating in the exchanges.)

This analysis confirms a lot of what I’ve been saying about the insurance industry. Even with regulation, they will continue to seek out younger, healthier people they can make money on, while dumping older, sicker people they lose money on. Risk adjustment mechanisms (such as those built into the House bill) can help mitigate some of this, and surely, stronger risk adjustment mechanisms may be necessary. But as usual, the CBO is obscuring the real story.

Jonathan Gruber, MIT health care economist, has put together a fuller picture of the CBO’s analysis of the public health insurance option:

In a letter released today, the Congressional Budget Office (the official government scoring agency) reported that they estimated the cost of an individual low-cost plan in the exchange to be $5300 in 2016. This is a plan with an "actuarial value" (roughly, the share of expenses for a given population covered by insurance) of 70%. In their September 22nd letter to the Senate Finance Committee, the CBO projected that, absent reform, the cost of an individual policy in the non-group market would be $6000 for a plan with an actuarial value of 60%. This implies that the same plan that cost $6000 without reform would cost $4540 with reform, or almost 25% less.

In other words, Gruber says the CBO has confirmed that even though the public option premiums themselves may be slightly higher than private premiums within the Exchange, the public health insurance option will act to keep overall premium levels down.

The CBO’s analysis of the House health care bill seems to confirm this, saying [pdf]:

"[The House bill] would also include a public plan that CBO estimates would place some downward pressure on the premiums of private plans operating in the exchanges.

While it’s hard to accurately predict what’s going to happen eight or ten years from now, the overall picture is clear. Put together, the conclusion by the CBO is that the public option works. Not only does it save money – $25 billion, less than a public option with negotiated rates, but still a chunk of change – but it holds down private premiums as well.

(also posted at the NOW! blog)

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