The discussion about having different thresholds was interesting. Should there be different thresholds for the poor, the near poor, and the elderly or for the chronically ill? Will the study panel be comfortable coming to a consensus on that? Is it something the study panel can explain to a broad audience compellingly? The question of income versus assets is also an important issue.

He next addressed the realities and the quality of the data, getting to the question of using data from the Current Population Survey Annual Social and Economic Supplement (CPS ASEC), the Medical Expenditure Panel Survey (MEPS), or both. What are the options in terms of imputation, collecting new information, or some other way?

O’Grady said he found the discussion of TRIM3 interesting, bringing to mind that this measure has to go out to a broad audience. He observed that once the talk moves away from a survey or an imputation of a survey toward modeling, it is viewed much more as a black box.


Pamela Short repeated the question Michael Hurd asked earlier, why a measure of MCER is being developed. From the day’s discussion, she came to realize that the problem of evaluating the effects of the Affordable Care Act (ACA) was probably front and center, at least from the sponsor’s point of view. That’s why the workshop participants spent so much time talking about prospective measures and insurance and not so much about burden.

People are indeed going to be spending more on insurance because it will be required, she said. The fact that the ACA requires everyone to be insured presumes that there are benefits, so there is a need for a good and convincing way of quantifying those benefits. But a lot of people who spend more on insurance will not benefit, because they will not get sick and so will not spend a lot out-of-pocket. To add up the benefits of having insurance, there is a real conceptual problem if one only looks after the fact at out-of-pocket expenses, because that does not attribute any benefit from having insurance to people who do not use it.

The situation is similar to buying life insurance. Why buy life insurance, since one does not want to use it? The benefit of health insurance is that some people who did not have insurance are going to be freed of the risk of major out-of-pocket medical expenses, and some people who have insurance are going to get much better insurance, at an affordable price. Consequently, Short observed, this issue of showing the value of insurance or measuring the value of insurance is central in evaluating the ACA. A closely related issue is defining adequate insurance (or “minimum essential benefits” in the ACA).

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