is some historical experience of this with the Children’s Health Insurance Program; she asked why one would move away from it at this point to a different or higher income cutoff.

On the asset issue, Collins was struck by Jessica Banthin’s zero asset level for working-age people who are poor, and not much higher than that in some of the upper income categories in that group. There just isn’t much for people to draw on at lower income levels if they do have high out-of-pocket spending.

She also emphasized the importance of being able to disentangle the premiums from the out-of-pocket medical costs. She agreed with Short’s point about premiums being a required price to pay with the individual mandate and the question of whether they buy a sufficient amount of coverage. In the law, the affordability of the premiums is clear; they are on sliding income-related scales for that purpose. Separate from the affordability of the out-of-pocket costs, exposure is a gray issue as a share of income, on an actuarial value level and translating into what it means for families. The measures do different things, premium as a price of health care, and exposure to out-of-pocket costs, in terms of tracking health reform, not only as an economic burden but also as a way to enable people to get the health care that they need.

Collins remarked that Schoen’s work on the underinsured over the past several years shows that people who are underinsured exhibit somewhat similar behaviors to people who are completely without coverage, not getting the health care that they need because of costs and having lots of medical bills. This access issue is very striking in those data.

She echoed Short’s point about needing to examine differences across states. The ACA is implemented at the state level, with a lot of federal guidance. But once it goes to the states, they are in a position not only to implement their exchanges but also to enforce their new market rules. So a state-by-state measure on out-of-pocket exposure is going to be extremely important. The point about vastly different rates of health care cost growth across states also speaks to the need to track by state.

Finally, taking off on what Michael O’Grady said about policy makers, that these measures should be simple for both federal and state policy makers to understand, Collins emphasized that the simplicity of the measure should also include being able to see and understand things that are going in different ways: out-of-pocket costs going in one way and income going in the other way, and being able to disentangle those effects.

James Ziliak observed that, going back to the Wolfe and Meier presentation, he was very sympathetic to the notion that risk is a prospective concept.

At least part of the motivation he detected from the sponsor in developing a measure of MCER is to figure out how to improve well-being. So

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