ECONOMIC REPORT OF THE PRESIDENT

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Box 4-2: Dynamics in the Individual Health Insurance Market After two years of moderate premium growth for plans offered through the Health Insurance Marketplace, premiums are increasing at a faster pace for 2017, though experience will vary widely across states (ASPE 2016b). This box discusses the factors that are driving changes in Marketplace premiums in 2017, as well as their implications for the future of the individual market. Contrary to some recent claims, a range of evidence demonstrates that this year’s premium changes are part of the ordinary process of adjustment in a new market, not a harbinger of future market instability. Factors Driving 2017 Premium Changes Insurers faced significant challenges in setting premiums in the years immediately following implementation of the ACA’s reforms to the individual market. The ACA brought many new people into the individual market, including people with pre-existing health conditions who had previously been locked out of the market and people who could newly afford coverage because of the law’s financial assistance. These major changes made predicting average medical costs in the reformed market difficult. This in turn created a significant risk that insurers would underestimate or overestimate the level of premiums required to finance those claims. In addition, some insurers may have intentionally underpriced when setting premiums in an attempt to attract the many new consumers who have entered the individual health insurance market during its first few years, accepting losses in the short run in exchange for higher market shares in the long run. It is now clear that, on average, insurers underpriced in the early years of the new market. Insurers are estimated to have incurred losses of around 5 percent of premium revenue on ACA-compliant health insurance policies in 2014, the market’s first year (McKinsey 2016). To achieve sustainable pricing in subsequent years, insurers needed to make up for these initial losses while also accommodating two additional factors. The first was the ordinary upward trend in medical costs, which averaged around 4 percent a year, though, as discussed below, this has likely been partially offset by ongoing improvements in the ACA-compliant risk pool relative to 2014. The second was the scheduled phasedown of the ACA’s transitional reinsurance program, which defrayed a portion of insurers’ claims spending on high-cost enrollees in 2014 through 2016. The decline in payments from this program added around 7 percent to premium growth in each of 2015, 2016, and 2017. The net effect of these various factors is that returning premiums to a sustainable level by 2017 likely required premium increases averaging a bit more than 10 percent per year in 2015, 2016, and 2017. But the premium for the second-lowest Reforming the Health Care System | 215
silver (or “benchmark”) plan increased by just 2 percent in 2015 and 7 percent in 2016 in the states using the HealthCare.gov enrollment platform, necessitating much more significant adjustments in 2017. The pattern of premium changes across areas strongly supports the view that Marketplace premium changes are being driven in substantial part by insurers’ efforts to bring premiums in line with costs after having initially underpriced. Figure 4-ii illustrates how the annual percentage increase in the premium for the benchmark plan from 2014 to 2017 varies based on the level of the benchmark premium in 2014. In the four-fifths of the country with higher benchmark premiums in 2014, the median person has seen average annual increases in the benchmark of below 10 percent, less than what would have been needed to cover normal increases in medical costs and the gradual phasedown of the ACA’s transitional reinsurance program. By contrast, the fifth of the country that had the lowest premiums in 2014 has seen much larger increases since then. This pattern is what would have been expected if insurers in some areas significantly underpriced in 2014 and have been working to bring premiums back in line with costs since then, while insurers in other areas priced appropriately or overpriced. It is also important to note that, even after the increases seen for 2017, Marketplace premiums remain roughly in line with CBO’s initial projections (ASPE 2016b). The average benchmark premium for 2014 was about 15 percent below what the Congressional Budget Office had Figure 4-ii Average Annual Change in Benchmark Premium, by Quintile of 2014 Benchmark Premium, 2014–2017 Average Annual Percent Change in Benchmark Premium, 2014–2017 40 35 75th Percentile Median 30 25th Percentile 25 20 15 10 5 0 -5 -10 1 (Lowest) 2 3 4 5 (Highest) Quintile of 2014 Benchmark Premium Note: Premiums analyzed at the county level. Quintiles defined to have equal non-elderly populations. Data limited to states using HealthCare.gov in all years. Source: Department of Health and Human Services; American Community Survey; CEA calculations. 216 | Chapter 4
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ECONOMIC REPORT OF THE PRESIDENT To
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C O N T E N T S ECONOMIC REPORT OF
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economic report of the president To
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eforms in history. Banks have sharp
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the annual report of the council of
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C O N T E N T S CHAPTER 1: EIGHT YE
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. THE ECONOMIC RATIONALE FOR FEDERA
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2.4. Government Purchases as Share
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4.iii. Premium for the Benchmark Pl
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6.18. Systemic Risk (SRISK) 2005-20
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C H A P T E R 1 EIGHT YEARS OF RECO
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Figure 1-1 Actual and Consensus For
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Figure 1-3 Real Hourly Wage Growth
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Figure 1-4 Real GDP per Capita: Eur
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Figure 1-6 Household Net Worth in t
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Figure 1-8 Global Trade Flows in th
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Subsequent revisions to fourth-quar
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Percent 6 Figure 1-9 Fiscal Expansi
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substantial costs to the Federal Go
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worked to promote innovation and in
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expansion, a period of low producti
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The 2017 Economic Report of the Pre
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Chapter 4: Reforming the Health Car
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to the ACA and other factors. The A
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than 98 percent of Americans should
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Figure 1-13 Borrowers in Income Dri
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success of the financial rescue and
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einforced U.S. leadership in the ru
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Partnership (OGP), a global partner
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Figure 1-16 Labor Productivity Grow
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Labor Force Participation Household
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number of steps to ensure that econ
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C H A P T E R 2 THE YEAR IN REVIEW
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Percent 11 Figure 2-1 Unemployment
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allowing for additional investments
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Percentage Point 0.6 0.4 Figure 2-3
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public, largely highway constructio
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The size of the Federal Reserve’s
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Figure 2-5 Private-Sector Payroll E
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fell 80 percent from September 2014
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Figure 2-8 Rates of Part-Time Work,
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Figure 2-v Prime-Age Male Labor For
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Output Real GDP grew 1.6 percent ov
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Figure 2-11 Compensation and Consum
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Table 2-i Optimal Weighting for Hou
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esults suggest that, to a first app
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Figure 2-viii Real GDP, Average and
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Figure 2-13 Consumer Sentiment and
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Figure 2-xi Household Debt Service,
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Ratio to Annual DPI 1.10 1.05 Figur
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Figure 2-17 National House Price In
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Index 220 Figure 2-19 Housing Affor
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Figure 2-21 Composition of Growth i
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Figure 2-23 Capital Services per Un
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Box 2-7: Explanations for the Recen
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Figure 2-xv Business Fixed Investme
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Figure 2-26 Foreign Real GDP and U.
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somewhat generalizable (Box 2-8), b
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prices weakened and the global econ
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inadequate demand has contributed t
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Figure 2-31 Nominal Wage Inflation
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Figure 2-33 Real Hourly Wage Growth
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Index 6 Figure 2-36 Financial Condi
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Percent 4.0 Figure 2-38 Nominal Lon
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Dollars per Barrel 80 Figure 2-40 B
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Figure 2-41 IMF World Real GDP Grow
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against the Mexican peso, the Chine
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United Kingdom It has been a turbul
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for example, Japan has grown almost
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Figure 2-45 Credit to Nonfinancial
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Meanwhile, core inflation (excludin
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kept rates low across a wide range
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Investments in surface transportati
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Table 2-2 Supply-Side Components of
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Conclusion The economy continued to
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not increased from 1973 to 2013, in
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developments; individual behavior;
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action affecting income inequality
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have occurred. In doing so, these p
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Percent 24 21 18 15 12 9 6 African
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without the policy response.5 These
Page 169 and 170: Box 3-2: Income Inequality and the
Page 171 and 172: unable to obtain insurance at any p
Page 173 and 174: Figure 3-7B Percent 50 Uninsured Ra
Page 175 and 176: and have not expanded Medicaid foun
Page 177 and 178: Box 3-3: Safety Net Policies as Ins
Page 179 and 180: Millions of People 18 Figure 3-8 Im
Page 181 and 182: Figure 3-9 Effective Tax Rates for
Page 183 and 184: Box 3-4: Additional Actions to Make
Page 185 and 186: $294 million in newly appropriated
Page 187 and 188: 15 10 5 0 -5 -10 -15 Figure 3-12 Pe
Page 189 and 190: Administration with those of previo
Page 191 and 192: as a share of potential GDP by Pres
Page 193 and 194: Figure 3-17 Changes in the Distribu
Page 195 and 196: 30 25 20 15 10 5 0 Single Source: C
Page 197 and 198: ate on capital gains and dividends
Page 200 and 201: C H A P T E R 4 REFORMING THE HEALT
Page 202 and 203: eneficiaries have received cumulati
Page 204 and 205: form of lower premium costs and ind
Page 206 and 207: Percent 25 20 Creation of Medicare
Page 208 and 209: Figure 4-3 Health Insurance Coverag
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Page 212 and 213: Percent Uninsured 25 CHIP Created 2
Page 214 and 215: Legislative actions subsequent to C
Page 216 and 217: Percent Uninsured 40 35 Figure 4-7
Page 218 and 219: ecause of the ACA’s provision all
Page 222 and 223: projected during the debate over th
Page 224 and 225: whelming majority of Marketplace en
Page 226 and 227: Figure 4-v Change in Benchmark Prem
Page 228 and 229: 20 Figure 4-10 Share of Workers in
Page 230 and 231: percent during the decade preceding
Page 232 and 233: Panel A: Share with a Personal Doct
Page 234 and 235: Box 4-3: Interpreting Results from
Page 236 and 237: Fortunately, the OHIE is not the on
Page 238 and 239: Figure 4-14 Uncompensated Care as a
Page 240 and 241: Figure 4-15 Uninsured Rate by Popul
Page 242 and 243: Figure 4-17 Monthly Gain in Private
Page 244 and 245: Change in Working-Age Employment to
Page 246 and 247: this cross-sectional relationship b
Page 248 and 249: ecent discussions of macroeconomic
Page 250 and 251: Figure 4-23 Life Expectancy at Birt
Page 252 and 253: Figure 4-24 Mortality Rate vs. Medi
Page 254 and 255: more to cover Medicare patients tha
Page 256 and 257: example, through CMMI, the Administ
Page 258 and 259: orient payment around the entirety
Page 260 and 261: Percent of Payments 60 Figure 4-26
Page 262 and 263: covered under ACO contracts at the
Page 264 and 265: Additional Steps to Reform the Heal
Page 266 and 267: legislation that overrides the reco
Page 268 and 269: Figure 4-28 Health Care Price Infla
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Figure 4-30 Trends in Real Prices f
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average growth rate of real per enr
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Figure 4-34 Growth in Real Costs fo
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made a large, readily quantifiable
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in states experiencing weaker and s
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distribution, holding fixed both sp
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individuals among individuals 65 an
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Figure 4-40 Average Real Deductible
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Figure 4-41 Real Per-Enrollee Presc
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educe the growth rate of Medicare s
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improvements will strengthen ACOs
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-5 0 -2 Figure 4-42 Cumulative Perc
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Woolhandler 2015). These analysts a
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productivity on the job. These bene
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Figure 4-46 Premiums and Cost Shari
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(KFF 2016). Another fifth of tradit
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2030 2028 2026 2024 2022 2020 2018
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C H A P T E R 5 INVESTING IN HIGHER
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Gainful Employment regulations. To
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Thousands of 2015 Dollars 900 800 7
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externalities, credit constraints,
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Figure 5-4 Earnings by Age and Educ
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Figure 5-5 Variation in Earnings by
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Box 5-1: Anti-Poverty Efforts and E
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careers. Some of the effects of the
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eligibility cutoff likewise finds s
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Box 5-2: Federal Investments in K-1
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Evaluations of early local Promise
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America’s College Promise Playboo
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Dollars 45,000 40,000 35,000 30,000
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pre-payment penalty. Second, by tyi
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equirements, pushed efforts associa
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Figure 5-16 Size of Outstanding Loa
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Figure 5-17 Average Monthly Payment
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Figure 5-18 Distribution of Key Out
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Figure 5-20 Earnings by Family Inco
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to student needs and improve test s
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Box 5-5: Making Sure Students Enter
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prior, the early FAFSA reform helps
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Figure 5-ii Number of Institutions
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Figure 5-23 Gainful Employment Earn
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Additionally, Pell Grants can be be
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C H A P T E R 6 STRENGTHENING THE F
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with no easy way to get the funds f
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public has limited information, run
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value added of the sector has gradu
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managers. Thus, after fees, savers
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Too Many Resources in Finance? Beyo
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of the firm after the purchase affe
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Percent 100 Figure 6-2 Mortgage Ori
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Figure 6-4 Case-Shiller Home Price
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Figure 6-7 Global OTC Derivative Ma
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consumer and investor protections.
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Figure 6-iv Top 5 Banks as Share of
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cult to replace with services from
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Are U.S. Banks Too Big? The questio
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The three federal banking agencies
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Risk Taking The Dodd-Frank Act took
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Box 6-3: The Performance of Communi
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Figure 6-ix Return on Assets of Ban
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egulators can take a more holistic
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Figure 6-13 Repo and Reverse Repo,
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Figure 6-15 Private Funds Reporting
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Days 60 Figure 6-16 Weighted-Averag
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Figure 6-18 Systemic Risk (SRISK),
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In the absence of another financial
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lower funding costs in 2007-09, “
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through the Dodd-Frank Act and othe
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Prior to the financial crisis, one
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asis.24 One of the advantages of ce
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findings from the NRSRO examination
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Prior to the crisis, enforcement of
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Box 6-5: Addressing the Problem of
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Table 6-i Sources of Investment Adv
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financial system and the systems of
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Box 6-6: The JOBS Act While it was
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Figure 6-23 S&P 500, 2003-2016 Inde
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Figure 6-27 Mortgage Delinquency an
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It created the FSOC to consider ris
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energy efficient and lower greenhou
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of domestic actions to reduce green
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people and vegetation (U.S. Global
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investment are much higher than the
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Delaying Action on Climate Change I
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uses and land management activities
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Carbon Pollution Standards for Powe
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a projected range of $16 billion to
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these resulted in insignificant cha
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Figure 7-4 Corporate Average Fuel E
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diesel fuel and jet fuel. The Vehic
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Box 7-3: Building Resilience to Cur
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sources in the oil and gas sector,
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emissions and total greenhouse gas
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Figure 7-7 Energy Intensity of Real
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Figure 7-10 U.S. Petroleum Consumpt
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Figure 7-12 Energy Intensity Transp
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Figure 7-14c Energy Intensity Comme
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Figure 7-16 U.S. Energy Consumption
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2008 to 7 percent in 2015. Figure 7
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Index, 2008 =0 0.1 0.0 -0.1 Figure
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Figure 7-23 Decomposition of Emissi
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three determinants of emissions? If
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Percent 100 80 Figure 7-26 Sectoral
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characteristics, and management tre
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oil and gas sector) were subsequent
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while creating new jobs and raising
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such as using similar methodologies
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Box 7-4: Supporting Increased Penet
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sector, the fee would incentivize p
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to be used to decompose emissions i
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Reinvestment Act.” NBER Working P
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D’Amico, Stefania, et al. 2012.
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______. 2016. “Chapter 3: Develop
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Chetty, Raj, et al. 2014. “Where
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NBER Working Paper 22170. Cambridge
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American Hospital Association and H
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Cantor, Joel C., et al. 2012. “Ea
Page 505 and 506:
______. 2012a. “Direct Spending a
Page 507 and 508:
Dranove, David, Craig Garthwaite, a
Page 509 and 510:
Wars: Global Solutions for Developi
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Huang, Jidong, and Frank J. Chaloup
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McWilliams, J. Michael. 2016. “Ch
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Pinkovskiy, Maxim. 2014. “The Imp
Page 517 and 518:
______. 2016. “Certification of M
Page 519 and 520:
Arcidiacono, Peter, V. Joseph Hotz,
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Bulman, George, and Caroline Hoxby.
Page 523 and 524:
______. 2015a. “Economic Costs of
Page 525 and 526:
Dobbie, Will, and Roland G. Fryer J
Page 527 and 528:
Committee on Health, Education, Lab
Page 529 and 530:
Jepsen, Christopher, Kenneth Troske
Page 531 and 532:
Marcotte, Dave E., et al. 2005. “
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Reynolds, Arthur J., et al. 2011.
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Chapter 6 Acharya, Viral. V., Deniz
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Fama, Eugene F., and Kenneth R. Fre
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Wheelock, David C., and Paul W. Wil
Page 541 and 542:
______. 2016a. “The Economics of
Page 543 and 544:
______. 2016c. Short Term Energy Ou
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Interagency Working Group on the So
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Office of Management and Budget (OM
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A P P E N D I X A REPORT TO THE PRE
Page 553 and 554:
Council Members and Their Dates of
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Report to the President on the Acti
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consulting with a wide variety of o
Page 560 and 561:
In October, the Council released a
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Research Economists David Boddy . .
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A P P E N D I X B STATISTICAL TABLE
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GOVERNMENT FINANCE, INTEREST RATES,
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Year or quarter Table B-1. Percent
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Table B-2. Gross domestic product,
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Table B-3. Quantity and price index
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Table B-5. Real exports and imports
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Year Total Table B-7. Real farm inc
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Table B-9. Median money income (in
Page 581 and 582:
Labor Market Indicators Table B-11.
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Year or month Table B-12. Civilian
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Table B-14. Employees on nonagricul
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Year or month Table B-15. Hours and
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Government Finance, Interest Rates,
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Table B-19. Federal receipts and ou
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Table B-21. Federal and State and l
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Table B-23. U.S. Treasury securitie
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Year and month Bills (at auction) 1
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Year and month Table B-26. Money st
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