In Schoen’s underinsured study, she said, the drivers are not the high, out-of-pocket catastrophic costs, but increasing rates of people with high deductibles and high out-of-pocket spending because of their low first-dollar coverage on their policies.

Short remarked that at some point it might be important to look at routine recommended medical expenditures. It is not so much a matter of risk, as to see whether the allowance in the SPM for a little bit more would adequately cover routine kinds of care for people at lower income levels. She questioned if the little bit more is actually enough; there might be an argument for increasing it.

Barbara Wolfe made the point that everyone, if they have value, could buy health insurance. The problem is that one cannot buy a decent policy in the individual market; the policies are not available or are very limited. In addition to being all there is, they are quite expensive relative to policies in the group market, even the small-group market.

Her second point is that, before the ACA, many individuals with preexisting conditions could not buy coverage. They certainly could not buy coverage for their existing condition, at least for a fixed period of time. She gave as an example one of her students with a preexisting condition that could not be covered even though she was part of very large group, the state government sector, at the time.

If part of the purpose is to evaluate the ACA, then a good starting point is probably 2009 or earlier. To have a benchmark of some of the gains, then some of the work should use an earlier starting point, before any of those preexisting conditions, including ones for children, which were among the first to go into effect.

In talking about these matrixes and groups, the closer one gets to a narrowly defined group, the further one moves away from risk, because eventually, there is a cell of one. She said she thought that the study panel will have to think about how narrowly defined those cells should be. When people buy insurance for their home or their auto, they are getting a rate that depends on some kind of group; they are not getting their own individual rate.

People do face a risk. Some of that risk is just based on age, and it should not depend on an individual’s already-diagnosed preexisting condition. Some people, particularly individuals with limited access, won’t know that they have a condition because they have not received the medical care that would put them into the risk index. So it is important to think through how narrowly defined those matrixes should be.

Many other aspects of medical care, such as oral health, have not traditionally been included in most health care policies. These are components that have important potential for poverty in the future, so they are important in thinking about how to define this benefit plan.

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