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Press Briefing on the President's State of the Union Health Care Initiative

White House Conference Center In Focus: Health Care

State of the Union 2007

PARTICIPANTS

Julie Goon, Special Assistant to the President for Economic Policy

Katherine Baicker, Council of Economic Advisors 3:59 P.M. ESTMR. FRATTO: Good afternoon. Thanks for coming on relatively shortnotice. We wanted to give you all an opportunity to dig in a little bitto the health proposals that President Bush alluded to in his radioaddress this weekend, and make sure that you have an opportunity to talkto some of our policy experts and to get a little bit deeper into it sothat we're all on the same page.We're excited about the proposals the President put forth and will putforth tomorrow night in his State of the Union address. We've askedJulie Goon, who is with the National Economic Council and a health carepolicy expert, and Kate Baicker is a member of the Council of EconomicAdvisors, to give a fuller briefing on both -- we're going to talk aboutboth proposals. I'm going to ask Julie to come up first to frame up theissue in the context of President Bush's -- the way he views health careand health care reform. And then we'll ask Kate to get in a little bitmore deeply on the tax proposal and how that will affect health care andhealth care reform.So, Julie, do you want to come up and lead us off?MS. GOON: Thanks, Tony, and thanks to all of you who are here today.I think I just want to start out by saying the President has had a wholeseries of health policies that continue to remain the foundation of thethings that we are doing in the health care area, including the workthat is going on with respect to transparency and getting moreinformation available to consumers; the work with respect to healthinformation technology and health savings accounts, trying to makeinsurance more portable across state lines, et cetera.But in looking at the coming year and recognizing that this is the yearthat the state Children's Health Insurance Program is up forreauthorization, that this is a good year to really refocus andre-target on a lot of the ideas that people have had about how toprovide for more insurance coverage for people who don't have access tothat coverage right now.The President felt that it was important that we ensure that affordablecoverage is available in the states, that is why an important piece ofwhat he's going to be talking about tomorrow has to do with theAffordable Choices Initiative that will help states who make basicprivate affordable health insurance available in their states, provideadditional help to those states to help subsidize insurance coverage forpeople who are poor and who are uninsurable at this point.And I think Secretary Leavitt has been very instrumental in pulling thisinitiative together. He's been talking to a lot of governors who havecome forward with their own ideas. We'll be doing more of that over thenext several weeks, and the President will be talking about that, aswell, in the State of the Union. And it's part of the fact sheet onhealth care that came out today.Complementary to that is the need to address some of the biases in thetax system and reform the tax code to realign those incentives toprovide for more of a reason for people to purchase health insurancecoverage. As many of you know, right now you have a tax benefit for thepurchase of health insurance coverage if you purchase it within theemployment setting. If you have to buy health insurance in thenon-group setting you do not get that same kind of tax advantage.And so the tax reform proposal that the President will put forward inthe State of the Union levels the playing field between insurancecoverage purchased inside the employer market and outside the employermarket, and does it in a fairly innovative and creative way, in a way Ithink that we haven't seen before, and Kate will be able to talk in morespecific detail about that. But, essentially, it puts in place astandard uniform deduction for the purchase of health insurancecoverage. So if you purchase coverage, you get this deduction, and it'sthe same for everybody.This is an immediate benefit to people who don't have insurance now whohave wanted to purchase it but haven't been able to do so because of thecost of health insurance coverage and because they don't get this taxbenefit. It's an immediate benefit to people who have purchasedcoverage in the non-group market already, and it helps a majority --millions of Americans who currently have insurance coverage throughtheir employer -- will get additional tax benefit as a result of thischange in policy.There have been a lot of people who have been concerned that doingsomething like this doesn't necessarily improve the market for healthinsurance, and I would just like to point to our experience over thelast couple of years in the Medicare Part D program. As many of youremember, when that debate started, folks didn't think there would bepeople who would be interested in offering prescription drug coverage inthe Medicare program. A number of companies came forward to do so.Initially the actuaries estimated that the cost of that coverage wouldbe fairly high, and would grow. And as all of you know, when seniorsand other beneficiaries got a look at the choices that were available tothem, what was in those benefit packages and what the costs were, as aresult of their choices, we have a very competitive market in MedicarePart D, and the average premium is down 40 percent from what it wasanticipated to be when that program first started.So getting back to the specifics on the tax piece, why don't I turn itover to Kate, and then we're both available to answer more questions onthis. Thank you.MS. BAICKER: Thanks. So Julie did a great job laying out the biglandscape of what we'd like to do, and then I'm going to be the geek andtry to explain how it actually works. So any clarifying questions wouldbe most welcome.As you know, right now when you get insurance through your employer,that insurance isn't subject to taxation, so it's part of yourcompensation that you're getting income and payroll tax-free. And thatmeans that people have a really strong incentive to get more generousemployer policies to cover all the health care they might want toconsume because if you go out into the health care marketplace to buy adoctor's office visit, you're usually paying for that with after-taxdollars. But if you get that covered by your employer-provided plan,it's covered with pre-tax dollars, and that's a big discount. Andthat's a lot of the reason why we see such generous first-dollarcoverage in the employer market as the norm, unlike other industries,like auto insurance or home owner's insurance.So what this proposal would do is change the system to level the playingfield in two ways. It will level the playing field for people who arebuying insurance on their own, relative to those who are getting it inthe employer market, or through their jobs. And it will level theplaying field for people who want to get basic policies with lowerpremiums, and then pay for routine care out of pocket relative to peoplewho want to get more generous, deluxe, gold-plated plans. Right now themost generous tax benefits are reserved for people with the mostgenerous employer-provided health insurance.What this plan would do is give a flat, standard deduction for anybodywho purchases any kind of health insurance, no matter how much thehealth insurance costs and no matter where they get it. It would be$15,000 for people purchasing family policy, $7,500 for peoplepurchasing single policies. So if your employer is giving you insurancethrough your job, you get the standard deduction. If you go buy healthinsurance on your own, you get the standard deduction.If your policycosts $5,000, you still get $15,000 of compensation tax-free. If yourpolicy costs $20,000, you still get $15,000 of compensation tax-free,using the family example.So who does this help, who does this hurt, what's the total cost? It'srevenue-neutral over the whole health care system and over the 10-yearbudget window.Anybody who doesn't have insurance right now has areally strong incentive to go get insurance. Right now an insurancepolicy on the individual market or the non-group market, if you're justgoing to get your own family policy, the average cost of one of thosepolicies right now is about $5,200.Take a family earning $60,000 in the 15-percent income tax bracket,15-percent payroll tax bracket, if they are currently uninsured and theygo buy insurance, under the current system it costs them $5,200 today.Under this system in 2009, once it phases in, they get $15,000 ofcompensation tax-free.They're paying 30 percent marginal tax rate onthat, so that's $4,500. That's a huge chunk of the cost of an insurancepolicy out there. So it makes insurance much more affordable for thosepeople.So anybody who is uninsured right now is a big winner under theproposal. So are people who are buying insurance on their own. Ifyou're out there and you've already purchased your own non-groupinsurance or your own insurance not through your job, for the most partyou're getting no tax benefit.So this is a pure win for you.Your taxbill goes down.Now, what about people getting insurance through their jobs right now?Anybody getting a policy under the standard deduction, a family policyof less than $15,000, or an individual policy of less than $7,500 wouldimmediately see a lower tax bill. That's because they would get astandard $15,000 deduction for a family, but then they would have tocount as taxable income their insurance policy, but it would be lowerthan the $15,000, so their tax bill would go down.That's 80 percent of the policies offered in the employer market. So asof January 1, 2009, when this policy gets implemented, we hope, if youlook at all the policies offered in the employer market, 80 percent ofthem would be under that standard deduction. So those policies would besubject to lower taxes.Twenty percent of the policies, the ones that are left, are actuallyhigher than the standard deduction. And that means that if peopledidn't change their behavior at all, their tax bills would go up becausethey would be taxed on the extra amount above the standard deduction.So if your policy for your family costs $20,000, you get the standard$15,000 deduction -- that leaves $5,000 extra taxable income that you'dhave to pay income and payroll taxes on that you don't now. So those 20percent of people might see their tax bills go up. On the other hand,they have some time between now and then to change their compensationpackages.One of the things that we think is inefficient about the way our taxsystem treats health care is the strong subsidy for more generousemployer-provided policies relative to everybody else -- people buyinginsurance on their own or people getting less-generous policies. Thiswould give people a chance as they're negotiating contracts with theiremployers to take more of their compensation in the form of wages andless in the form of health benefits. So that 20 percent has somerecourse between now and then.The other way that helps keep the whole package revenue neutral is thatthe $15,000 or $7,500 would be indexed to CPI, not general health carecosts, and one of the goals of this policy is really to rationalize ourhealth care spending so that we're getting higher-value, more efficientcare, and we hope in the long run that that substantially brings downthe trajectory of growth in national health spending overall, becausepeople will be purchasing higher-value plans, they'll be allocatingtheir health care dollars more efficiently. We think that will bringdown national health spending both immediately, as people change thequantity of health insurance versus wages that they take in theircompensation packages, and even more in the long run, as there's anincentive to develop a more rational, efficient health care system, morecost-effective technology, more provider competition.So that's the bare bones, but I bet that there are questions.Q When you talk about the cost of your insurance policy being $15,000or $7,500, are you just counting the employer side or is it the employeeand employer side?MS. BAICKER: So the deduction, the standard deduction has nothing to dowith how much your health insurance costs under this proposal.That'sthe part that's hard to get your mind around because it's so differentfrom how it works right now.So if you -- no matter how much your health insurance costs, no matterhow much is spent on your health insurance by you and your employer, youget a $15,000 deduction for your family. Now is that a win or a lossfor you? It depends on how much you were spending before, and really itdepends on how much you were spending with pre-tax dollars before. Now,for everybody the employer portion is pre-tax.For most people in bigfirms, the employee contribution is pre-tax, too, because you're doingit through a cafeteria plan or an FFA.For some people, their employeeshare towards their employer premium was already being taxed.So when we think about the tax benefit that you get because of thestandard deduction, that doesn't depend at all on how much your healthinsurance policy costs. But when you think about how much that isrelative to what you're paying now, you want to think about how much ofyour premium now is getting paid with pre-tax dollars.For most people,that's the employer plus the employee share. For some people, it's justthe employer share.Q If I want to know if I'm over the threshold and I'm going to betaxed, I add what I'm throwing in, plus what my employer is throwing in?MS. BAICKER: So let me put it another way, your taxable income, if thispolicy is implemented, will be your wages and anything your employer ispaying for health insurance. You're already paying your share out ofyour wages, so your total taxable income is the check that you get, pluswhatever your employer has paid directly to the health insurancecompany. You may have to give back some of your check for the healthinsurance. And then you get to take off of that $15,000. And so for 80percent of policies that $15,000 is more than what was getting pitchedin. But for some people, it might be less.Q The figure I saw was that in '05, most employer-provided healthpolicies were running $11,000-plus.MS. BAICKER: I believe today in '07, the average employer policy is$11,500 --MS. GOON: For a family.MS. BAICKER: For a family, or I think the average family policyoverall, so it incorporates the mix of the number of people in thefamily. Then the policy gets implemented -- this proposal will beimplemented in 2009 -- the $11,500 average today, if you were to inflatethat up to 2009 so that you could compare it to the $15,000 would bemore like $13,600. And that's the number that we used to figure out the80 percent-20 percent breakdown.Q But you're saying -- since we're dealing here with marginal taxrates based on a $15,000 deduction.MS. BAICKER: All the calculations were done in 2009 dollars.Q The assumption then is that a family of four is going to be able tofind a $5,000 health plan and not the $13,600 --MS. BAICKER: No, there's no assumption like that -- no, no, no.Q I'm sorry, I misunderstood then. I thought you said that --MS. BAICKER: I gave some examples, and I hope that those weren't takenas the general rule, so let me --Q A $15,000 tax deduction, assuming a 30-percent tax bracket, givesyou $4,500 to pay for your health plan.MS. BAICKER: Exactly.Right, and so then I gave as a benchmark for youa comparison for what the average individual market policy costs. Butthat doesn't mean everybody would find it for that. I was just tryingto give you a sense of how far that would go for a family that's ontheir own. So one of the groups that we're concerned about, theuninsured; we're concerned about families who are going out on their ownto buy health insurance; and then we're concerned about people gettinginsurance from their employer, and I tried to give you some statisticsfor each group.Q Let me ask one other question if I can. It seems like there aresome people at the bottom end of the scale who make too much to qualifyfor Medicaid and not enough to benefit from the tax deduction.Howlarge a group is that?MS. BAICKER: That's why the two proposals that Julie talked aboutdovetail so nicely, and I'll turn back to her in a second. But I'llremind you that it's income and payroll taxes.So some of the -- thinkabout families who are earning too little to pay income taxes, too muchor with the wrong family structure to be on a public program. They'restill getting the payroll tax benefit, which is substantial.Q Social Security and Medicare?MS. BAICKER: Right, and that's 15 percent, so they're still getting 15percent of $15,000 or 15 percent of $7,500 for an individual, even ifthey have no income tax liability. That said, there are going to besome groups for whom that's not enough to get them a health insurancepolicy because somebody is sick, because they're very low income. Andfor those groups, the Affordable Choices Initiative is there to helpfill in the gaps.MS. GOON: And as Kate said, that's why these two policies are socomplementary.A lot of states have been looking at their options totry and use the flexibility that was given to them in the DeficitReduction Act, to do waivers in their Medicaid programs, to look atsubsidizing coverage beyond the Medicaid eligibility groups, et cetera.And the Affordable Choices Initiative is a way that we want to helpstates who want to make insurance affordable for their citizens byensuring that we are providing additional federal help towards that endas long as the state is committed to making basic affordable healthinsurance available in that state.Q I have a question on the phase-in period.What do you have inmind? I presume the deductions would be lower in the earlier year?MS. BAICKER: The deductions would start at $15,000 for a family, $7,500for an individual in '09, when it took effect, and then they would beindexed to CPI, so they would grow gradually over time.Q So you're assuming it starts in 2009, I'm sorry, I misunderstood.And also --MR. FRATTO: That's the phase in. There's no, sort of --MS. BAICKER: There is nothing until 2009, and then it's here.Q And then the other question, is this perhaps an indirect way oftrying to encourage more health savings accounts, since it seems like alot of people's encouragement here is to buy high-deductible standardpolicies, which often can be paired with HSAs?MS. BAICKER: Certainly HSAs are a great step in this direction, andthis is an even bigger step towards leveling the playing field andremoving some of the weird disincentives to getting basic insurance andpaying for routine care out of pocket.What this really does is givepeople the flexibility to structure plans that work best for them.So you can think about -- you could get a lower premium by having ahigher deductible, by having a smaller panel of physicians covered, byhaving more cost sharing throughout the distribution of spending, by allsorts of different ways. And those policies would be on equal footingif you got them in the group market or the non-group market. So itreally frees up a lot of parameters for people. That said, HSAs are agreat thing and remain in the tax code.Q One other question. For those that are uninsured now, it'sarguable that some of them, because they don't have insurance, or havepreexisting conditions that might be rejected, or they might have to payquite a bit more for a standard policy, and how does your plan address--MS. GOON: Well, this gets back, again, to the Affordable ChoicesInitiative with the states, and working with the states to encouragebetter funding of uninsurable risk pools, which many states have, somestates don't; but working with the states to really identify how best totarget additional subsidies to people who need insurance in that state.In many cases, it will be people who have preexisting conditions, inother cases it will be more of the poor.Q How will this affect retirees who have supplemental coverage, A,and when does it become revenue-neutral? Is it revenue neutralimmediately, or does that come with the indexing?MS. BAICKER: So question one, it treats all people with private healthinsurance the same way. So it doesn't matter where you're getting it --if you're buying it on your own, if it's through a former employer or acurrent employer, as long as you have at least catastrophic coverage orbetter, then you get the standard deduction. So retirees are given thesame benefits from the tax code as everybody else. So it really levelsthe playing field for them.As for revenue-neutral, it's revenue-neutral over the 10-year windowtogether. So in the early years, it's a revenue loser, and in the lateryears, it's a revenue winner.Q When does it become a revenue winner?MS. BAICKER: I don't have that in front of me. Roughly in the middle.But I'll check. But there's a -- I think it's roughly in the middle,but I'll have to check that for you.Q Do you know what it's going to cost the first year?MS. BAICKER: Again, I don't have that whole stream in front of me. Wecan get that information for you. And that will be in the budget.Q Is this in any way part of a long-term philosophy to wean peopleoff of employer-provided plans that have become so burdensome foremployers?MS. BAICKER: This is part of a long-run philosophy to level the playingfield, and to really let people pick the mix of compensation that's bestfor them. People like getting their insurance through their employer,and they're going to continue getting their insurance through theiremployer for a lot of people. Some people may go to the non-groupmarket once this playing field is more level for them, and they havethat option. And a lot of people who are not getting any insurance aregoing to have options open to them that weren't open before. But it'sdefinitely part of a long-run philosophy to level the playing field andlet people change their compensation mix accordingly.Q Does this administration believe that employer-provided care hasbecome overly burdensome for business?MR. FRATTO: That's a decision for -- that's not a question for us.What this reform does is remove inequities in the tax code, where youhave a certain part of America that receives a 100 percent benefit, andanother portion of our citizens that receives zero or near zero benefitthrough the tax code. We think about it as tax reform that levels theplaying field and provides a basic, standard benefit to all Americans.How it affects businesses -- there are dynamics there that will work outbetween businesses and their employees. I could tell you businessmenwho -- business owners who are in the administration, people who --people like Secretary Paulson and Al Hubbard and others who have runbusinesses feel that their employees want employer-provided healthcoverage and they want to provide it because it's their way ofattracting the best talent. And so there are incentives here that wecan't predict -- that's going to be decided between businesses and theiremployees.MS. BAICKER: And just one thing to add on. The health care systemoverall, because of the inefficiencies that are built in, is a bigburden on all of us. It's a big burden on employees and employers andtaxpayers and the federal budget. And something needs to be done torein in health care spending because we're not getting value for ourdollars. So this proposal will be a big step in the direction ofgetting more bang for the buck for our health care spending, because Ithink nobody in the country can afford to keep spending more and moreand more money on a health care system that's broken.Q This will be a tax hike for some people?MS. BAICKER: This is revenue-neutral tax reform. There are alwaysgoing to be some winners and some losers, but the people who mightinitially be losers have options.Q Maybe this follows on her question, maybe I didn't quite get theanswer. Can you explain, how does this affect Medicare recipients, andalso people with Medicare but who buy supplemental policies? I justdidn't quite grasp the --MS. GOON: If you buy supplemental policies right now, I don't think youget any tax benefit from that, because you're doing it all in after-taxdollars.MS. BAICKER: This is for purchasers of private health insurance.Q So, in other words, let's say you're a retiree, but you also have,like -- you're buying AARP insurance --MS. GOON: So I'm retiree on Medicare?Q A retiree on Medicare, but you're also buying AARP. Do you get thededuction, or not?MS. GOON: I think we have to get back to you on that, but I don't thinkthis speaks to this supplemental insurance. It's traditional --Q Primary health insurance?MS. GOON: Yes, primary health insurance. And Medicare is taking careof that for those beneficiaries.Q I wonder -- I'm just doing some quick back-of-the-napkin math here-- at what point does the average cost of a family plan cross over that$15,000 barrier and the deduction there no longer is as effective as ifit were under the -- two or three years --MS. BAICKER: At $15,000.Q Yes, but how long does that take?Two or three years --MS. BAICKER: Oh, the average policy get to $15,000? A few years after2009. I can sort of do a back of the envelope, that if it goes from$11,500 to $13,600 between now and 2009, then I'm going to say --MS. GOON: I think we'd want to get back to you on that.MS. BAICKER: Yes.MR. FRATTO: Just to be clear, any projections on that are relativelystatic projections, right?MS. GOON: Right.MS. BAICKER: Absolutely.MS. GOON: They don't take into account changes in the health caremarketplace that we expect to occur as a result of this policy.Q Do you think they'll ever cross that?MS. GOON: I didn't say that.Q How large do you expect that impact to be on the health caremarketplace, though?MS. BAICKER: There are a number of channels through which this willaffect health care consumption. Immediately it will affect quantitiesthat people consume because they'll be changing their mix ofcompensation and their choice of health care plan. It will affectprices through provider competition. And then in the long run, it willaffect the development of more cost-effective health technology. Andthat's your real bang for the buck.Putting all of that together, our best guess is that within themedium-term, you're talking about lowering health expenditures, a shareof GDP, by about half a percentage point, and that's a lot of money.MR. FRATTO: And if there's any question as to whether the health caredelivery system, in terms of selling health policies, acts in any waylike a market today, ask yourselves right now -- and I won't ask for ashow of hands -- but if anyone here knows what the value of your policyis, what you pay for health care. I'd say very few of you have any --and I don't know, either. Very few of us have any idea of what ourhealth policies cost.So that's compensation that we're receiving from our employees that wehave zero transparency on. It doesn't show up in your W2 form; you haveno idea of what that share of your compensation is.And I'll ask a second question -- is when was the last time you weresitting at home eating dinner with your family and received an annoyingphone call from a health insurer trying to market you a health careplan? This just doesn't happen today because there isn't the market forit. Insurance companies are not out th