By Mary Braswell
With California taking steps to revamp its health care system, research by the UCLA Luskin School of Public Affairs is guiding the conversation.
The report, published Feb. 1, details strategies to improve the affordability of Covered California, the state’s health insurance marketplace. It was co-authored by economist Wes Yin, associate professor of public policy at UCLA Luskin.
Affordability is “the top challenge for individuals who are insured as well as those who remain uninsured,” according to the report (PDF), which lays out a wide array of proposals to meet that challenge, including:
- capping out-of-pocket premiums for all eligible Californians;
- offering expanded cost-sharing benefits, which would lower deductibles and the cost of office visits; and
- creating a California-only penalty for those who opt out of coverage, to replace the penalty that was phased out by the federal government.
“This will help push the conversation forward, now with policy options that we know will improve affordability and market stability,” said Yin, who wrote the report with economist Nicholas Tilipman of the University of Illinois, Chicago, and Covered California’s policy and research division.
Commissioned under a state law, the report was presented to the governor’s office and state Legislature. It was developed amid a shifting landscape for health care in California.
On Jan. 30, Covered California reported mixed figures for 2019 enrollment. Although the number of Californians held steady from 2018 to 2019, the number of new enrollees dropped by 23.7 percent. In addition, on the first day of his term, Gov. Gavin Newsom unveiled his own far-reaching health care plan, calling for increased premium subsidies and Medicaid coverage for undocumented youths up to age 26, among other reforms.
“Our analysis gives policymakers a sense for how different approaches benefit Californians and at what cost,” Yin said. “So this report bolsters the governor’s effort to improve health care access.”
The dialogue, he said, will include a debate over the state’s funding priorities.
“From a wider lens, it’s helpful to think about how we can best spend that next public dollar,” Yin said. “It could be health care, it could be pre-K programs, it could be public education or parental leave benefits. These are all important. And there is a strong argument for improving the affordability of health care coverage and reducing cost-sharing burdens. Coverage improves health — especially mental health — it improves chronic disease management and it drastically reduces the risk of catastrophic spending and debt incurred by consumers.”
The report includes proposals to address the divisive issue of penalties for Californians who choose not to buy health insurance. Covered California attributes the decline in new enrollments to removal of the federal individual mandate penalty beginning this year. A statewide penalty would create a fresh incentive to opt in.
“The penalty appears to be quite impactful,” Yin said. “What we’re seeing in Covered California the past year shows that, and our modeling also shows that. Zeroing out the penalty has directly caused premiums to increase and enrollment to drop. Including a penalty while making plans more affordable can be both an effective and fair way of expanding coverage and lowering premiums.”
The report also notes that premium costs can vary widely for consumers based on their age and geographic location. “For consumers nearing retirement age living in high-cost regions, premium costs can exceed 30 percent of income for the most common benefit package,” it said.
To make health insurance more affordable for those consumers, California could use subsidies to cap all premium payments at 15 percent of annual income. Currently, subsidies are offered only to people who earn up to 400 percent of the federal poverty level, or $103,000 for a family of four. Consumers who earn just over the 400 percent threshold would not qualify for federal premium subsidies, Yin said. A 15 percent cap would also eliminate this so-called tax-credit cliff.
The report’s policy options are based on a model developed by Yin and Tilipman that shows the potential effects that various policy proposals would have on health care enrollment, consumer health spending and public spending.
As elected officials and consumers debate competing visions of health care reform — from repealing the federal Affordable Care Act to moving to a state-run single-payer system — Yin said the proposals are aimed at expanding coverage and increasing affordability as much as possible.
“Let’s find ways to build on the successes of the Affordable Care Act and make it work better,” Yin said. “These are models for improvement.”
By Mary Braswell
It’s a year’s worth of exacting work, whittled down to a 20-minute talk.
And for some, it’s over in a flash.
“We were all talking about it afterward. ‘That was 20 minutes? It felt like five minutes!’ ” Ramandeep Kaur said of her team’s Applied Policy Project presentation, a rite of passage for all Luskin School MPP candidates.
Kaur’s team was one of 13 to stand before a packed lecture hall over three evenings in May. Each succinctly presented a policy issue, reviewed their research, made a case for the wisest course of action — then fielded a barrage of questions from their peers and professors. They also produced polished reports laying out their findings in detail.
In short, they were using skills each will need as they leave UCLA Luskin and put their master’s degrees to work.
“These Applied Policy Projects are extremely beneficial to our MPP students as they are an opportunity to put all of their policy analysis skills to work in a real-world setting,” Public Policy Vice Chair Manisha Shah said.
“In their first year, students learn so many of the tools necessary to do policy analysis, and then in their second year, they get to implement these tools in the APP,” Shah said. “The final product is an important piece of policy analysis on topics ranging from health to housing to the environment to social justice issues … and the list goes on.”
This year’s APP teams conducted rigorous research on issues near and far — from the drinkability of Los Angeles tap water to human rights abuses in Europe.
Some of the teams formed a year in advance, as students with similar interests and complementary skill sets banded together. Knowing they would work on the APP during their entire second year, they chose topics close to their hearts.
“I knew I wanted to do a project I was passionate about, a project that had an advocacy lens on it,” Kaur said.
Teammate Annia Yoshizumi had worked with the UCLA Luskin-based Center for Neighborhood Knowledge (CNK) and suggested pursuing a project on housing. Allan Nguyen and Xiaoyue Zheng brought strong data analysis skills to the team, Kaur said.
Their research on the impact of drastic rent increases in unincorporated L.A. County benefited two clients, CNK and the Los Angeles Center for Community Law and Action.
“For me personally, I did grow up in L.A., and my parents did live in a rent-controlled apartment, and they were able to then save a lot of money and purchase a house,” Kaur said. “But that’s not an opportunity that many people have. So how do you tell that story so that people understand?”
Another team focused on preserving undocumented patients’ access to healthcare in a time of anti-immigrant rhetoric. Two of the team’s members are earning concurrent MPP and M.D. degrees through UCLA’s Prime Program, including Joe Torres, who was undocumented himself until he became a U.S. citizen in 2016.
Working with Venice Family Clinic, which has provided medical care to vulnerable populations in West Los Angeles for nearly 50 years, the team paired data analysis with extensive surveys in English and Spanish. Among the findings: In the wake of the 2016 presidential election, 64 percent reported more fear or anxiety about ICE raids specifically at clinics, and 39 percent felt less safe taking their U.S. citizen children to the doctor.
To maintain the trust of its patients, Venice Family Clinic should step up the security of its patient records and forge partnerships with legal advocates in the community, the team recommended.
This year’s APP clients were a diverse lot, including the Partnership for L.A. Schools, the Clean Power Alliance, the European Implementation Network, an administrative judge for the Equal Employment and Opportunity Commission and several local government entities.
One team that shared an interest in international development took on the World Bank as a client. Their focus was assessing financial incentives for hospitals in the Kyrgyz Republic to improve infant and maternal mortality rates.
Key to the project were interviews conducted with agencies on the ground, team member Tanya Honey said.
“That’s the thing I love to do — I love doing outreach,” said Honey, who spent hours on international calls with the World Health Organization, United Nations and USAID. She credits faculty advisor Wes Yin with pushing the team to use these conversations with experts to provide context to their data.
“I think that was extremely valuable to our project,” Honey said, adding, “I’ve never heard so many Russian accents!” With a bachelor’s degree in linguistics, Honey speaks Spanish, French, Italian, Chinese, Hindu and English, but “not Russian — yet.”
To prepare for their APP presentation, Honey’s team recruited students from the Luskin School’s third-floor Commons to serve as a mock audience.
“We were definitely a little bit nervous,” she said, but fortunately her team had substantial experience in public speaking. Teammate Parshan Khosravi is an officer and advocate with the Graduate Students Association, and others have taught classes as teacher’s aides or presented papers at symposiums.
Another APP tradition also helped calm nerves: dressing like you mean business. “I actually feel more confident when I dress up,” Honey said.
Following each APP presentation is a question and answer period that can be daunting. While everyone in the audience is supportive of the presenters, many are also experts in their fields and can readily spot holes in data, assumptions and methodology.
Kaur’s team knew that its main policy recommendation — a rent stabilization ordinance — was controversial.
“A lot of economists do not like RSOs, so we knew we were going to be hit with a lot of questions about that,” she said.
But her team was confident in their analysis and ready for any challenge they might face.
“We did a mock presentation in front of both of our clients, and had them ask us really hard questions that they get in the field when they talk about any sort of tenant protection policy,” she said. “So that really prepped us.”
Also important to Kaur’s team was putting a human face on their policy analysis. They included tenants’ voices because “we really wanted to frame it in a way that people understood who this policy was going to impact.”
Faculty advisors for this year’s APP teams were Shah, Yin, Meredith Phillips and John Villasenor. “What’s great about the experience is that, while it is a real-world experience, it is also a guided experience in that each group is assigned to a Public Policy professor who advises them through the entire process,” Shah said.
This year, three APP projects were singled out for special recognition:
- Highest honors: Reducing Delay to Promote Civil Rights: How Administrative Judges at the EEOC Can Resolve Employment Discrimination Complaints in a Fair Yet Efficient Manner (Delvin Turner, Elizabeth Joun, David Lyons)
- Honors: Social Determinants of Health Literacy: Optimizing Public Health Outreach and Education Strategies in Long Beach, California (Stephanie Berger, Marisa Conner, Alexander Fung, Taylor Wyatt)
- Honors: LA TAP (Tap Water Action Plan): Evaluating the Customer Experience of Tap Water in Los Angeles (Virdiana Auger-Velez, Rachel Lacoe, Caleb Rabinowitz, Bei Zhao)
Find more photos from the 2018 Applied Policy Project presentations on Flickr
An analysis of the potential impact of a proposed amendment to the American Health Care Act of 2017, known as the Graham-Cassidy plan, found that the now-abandoned proposal could have triggered the near-term collapse of California’s individual health insurance market. The analysis, developed by John Bertko, chief actuary for Covered California, and UCLA Luskin’s Wes Yin modeled two scenarios that examined how California leaders might respond to a federal funding cut of nearly $139 billion between 2020 and 2027. In both cases, the consequences of the cuts would start taking effect in 2020 and quickly lead to millions losing their coverage. In one scenario, California’s individual market could experience what is commonly referred to as a death spiral, according to a news release issued Sept. 25, 2017, by Covered California. “The decline in the number of those receiving financial help to buy individual market coverage, while requiring health plans to provide coverage to those with pre-existing conditions, would very likely lead to the collapse of the individual market by 2021 if not before,” said Yin, an economist and coauthor of the analysis who is also an associate professor of public policy and management at UCLA Luskin.
By Stan Paul
By necessity, the Master of Public Policy (MPP) students at the UCLA Luskin School of Public Affairs quickly begin learning skills and tools to complete the program and prepare for problem-solving careers in the public, private and nonprofit sectors.
The students, working in groups, must clear one final hurdle to graduate: the Applied Policy Project presentation. Each group has 20 minutes to impress faculty and peers by showcasing what they have learned during two rigorous years of study.
Each year, a diverse group of clients “hire” the students, usually in teams of two or more, to tackle real-world problems and offer actionable recommendations and feasible solutions.
“I think one of the exciting aspects of the APP is the variety of topics covered,” said Manisha Shah, associate professor of public policy and faculty coordinator of the program. “Because our students have a diverse set of interests and because we encourage them to identify their own clients, the result is an interesting variety of APP projects.”
Among this year’s clients were the Southern California Association of Governments, Covered California, Peterson Institute for International Economics and a member of the California State Assembly. Internal clients included a research center within the Luskin School, a professional program elsewhere on campus and the University of California’s Office of the President.
“The first-year curriculum of the MPP program is tool-driven,” Shah said. “What I mean by that is we try to give students a diverse set of tools — both quantitative and qualitative — that will help guide them through the APP process and ultimately go out into the real world and conduct policy analysis on issues close to their hearts.”
Shah said she was fortunate to advise a diverse set of APP groups this year. One group of students found that behavioral tools such as reciprocity and commitment devices should be implemented in schools to increase consumption of fruits and vegetables in an attempt to combat obesity. Another group helped improve the service delivery model of an organization in L.A. that tries to get at-risk youth into better employment opportunities. And another group proposed interventions and policies aimed at reducing displacement and gentrification in South L.A.
In all, 18 presentations were made. Luskin faculty watched and then asked questions that tested the students’ depth and breadth of knowledge and the thoroughness of their projects.
The range of projects is broad, including:
- Local and regional issues such as investments in electric vehicle charging stations in Los Angeles and a rent stabilization ordinance to prevent displacement of low-income minority communities in South Los Angeles.
- Statewide issues such as bail reform, insuring Californians, health care, access to water and juvenile justice.
- National and global issues like mitigating the negative impacts of trade on employment in the U.S. auto industry and improving local-level governance amid decentralization reforms in the Ukraine.
A closer look at some of this year’s APPs follows.
Gender Issues in Engineering
Applying qualitative and quantitative methods to their study for the UC’s Office of the President, Traci Kawaguchi, Yuhan Sun and Eri Suzuki focused on the need for connections in their analysis of system-wide retention by gender in engineering at the undergraduate level. They initially determined that the retention rate of female engineering students was significantly lower than for male engineering classmates across the UC system.
Their faculty adviser, Professor of Public Policy John Villasenor, also holds an appointment in electrical engineering at UCLA. He helped connect them with UCLA engineering students, which led to interviews with aspiring female engineers.
Women and men had similar levels of academic performance in the first year, but the qualitative interview uncovered that “affinity groups play a key role in affirming engineering identity and belonging in the field,” according to the UCLA Luskin students’ written summary.
“I think the big thing that came up was just the idea of fitting in,” Kawaguchi said. “When you go into a classroom that is 80 percent male … it may make you feel that you don’t necessarily belong.”
Team members analyzed policy options based on anticipated effectiveness, cost feasibility and institutional feasibility, and they recommended support for female students based on a sense of community and belonging. Adoption of residential living communities and formal peer mentoring programs for female undergraduate students in engineering were also recommended.
A Program to Help Plug-In Commuters
Another APP team focused on plug-in vehicles with a limited range on all-electric power that switch to gasoline-based power after batteries are exhausted. Specifically, the group studied how workplace charging stations in Los Angeles could increase the number of miles that vehicles travel without burning gasoline.
MPP students James Di Filippo, Mahito Moriyama, Toru Terai, Kelly Trumbull and Jiahui Zhang completed their project, “Prioritizing Electric Vehicle Charging Station Investments in Los Angeles County,” for the Southern California Association of Governments (SCAG). Their model combined commuting data from SCAG’s transportation demand study with plug-in electric vehicle registration data, information on vehicle all-electric range, and point data on existing charging infrastructure locations.
The students found that nearly 6,000 plug-in hybrid commuters could benefit from workplace charging but currently do not have access. Full support of those commuters’ vehicles would yield about 76,000 additional miles driven on electric power each day.
The potential increase is concentrated in just a few zones. Di Filippo said that the group used a tool from the Environmental Protection Agency to identify zones that fall within disadvantaged communities that might require additional support, which were more than a third of all zones identified as having potential for investment across Los Angeles County. SCAG should direct additional funding toward those disadvantaged communities to ensure that the benefits are distributed equitably, the students said.
Di Filippo said that the APP process was challenging but rewarding. “I credit my teammates for pulling together quickly, conceptualizing and delivering a strong report that offers actionable information for SCAG’s electric vehicle charging infrastructure siting decisions in only eight weeks,” he said. “My team was fortunate to have the support of faculty and peers who were invaluable in shaping our thinking on key aspects of the report.”
Healthy Food for Children
Sarah White and teammates Sydney Ganon, Hiroto Iwaoka and Jonathan McIlroy examined behavioral economics for tools in nutrition education curricula. Their goal was to promote long-term healthy food choices and habits in third and fourth grade students in light of a growing recognition of negative health outcomes of childhood obesity.
“While the field of behavioral economics is still fairly new, we read a lot of the existing literature and had reason to believe that really low-cost interventions could potentially have large impacts on getting people to make better choices for themselves,” White said.
One challenge that behavioral economics has “rarely, if at all, studied within the realm of children’s nutrition.” That made evaluating different policy options more difficult. “We had to evaluate each policy option on our own,” White said.
The group’s recommendations bundled three potential behavioral tools that are cost-effective. Giving attractive names such as “power peas” to fruits and vegetables in the cafeteria would frame foods in a way that is appealing to children. Giving students something as simple as a sticker and thanking them for choosing the healthy option would promote reciprocity. Having students set goals for eating better would make them more likely to stay committed.
Rocking his Comeback
For one student, Ayappa Biddanda, the final APP presentation was a long time in the making. In the early 2000s he left UCLA Luskin to pursue an opportunity that turned into a career in the music industry. He came back this year to do his final presentation — and thus finish his master’s degree.
Biddanda’s project evaluated the impact of an educational enrichment program called Rock the Classroom that paired local musicians with students in the Los Angeles Unified School District. Biddanda’s solo presentation on the final night of the APP program literally rocked the classroom with musical sound bites and his enthusiastic, informative and professionally presented argument that, in education, “art matters.”
A Fond Farewell
Wrapping up two decades of APP presentations, Mark Peterson, chair of the department, thanked the students for their efforts. “I really want you all to applaud yourselves,” he said. “The hard work that went into all of the presentations was obvious to us all, and we really just admire the time you put into all of this and the work that you did to put these presentations on a scale of professionalism that we like to see.”
The 2017 APPs ended on a bittersweet note, with Peterson acknowledging the retirement of a key player. Maciek Kolodziejczak is a longtime UCLA staff member who joined the public policy program when it was founded more than 20 years ago and has long coordinated the APP presentations.
“Sadly, this is the last time that this part of the APP program will be orchestrated, moderated and run by Maciek,” Peterson said.
From the UCLA Luskin Flickr feed:
Wes Yin is an associate professor in the UCLA Luskin Department of Public Policy and the Anderson School of Management at UCLA, and is a Faculty Research Fellow at the National Bureau of Economic Research. Prior to coming to UCLA, Yin served as Acting Assistant Secretary of Economic Policy at the Department of Treasury, and as a Senior Economist in the White House Council of Economic Advisers, in the Obama Administration. He also taught at Boston University and the University of Chicago, and was a Robert Wood Johnson Scholar in Health Policy at Harvard University.
Yin researches health care, economic development, and consumer finance. His current research studies how innovation and policy reforms in health care and social insurance affect consumer health and financial well-being, public finance, and equity.
PUBLISHED AND FORTHCOMING ECONOMICS PAPERS
The Market for High-Quality Medicine: Retail Chain Entry and Drug Quality in India (with Daniel Bennett) Review of Economics and Statistics, March 2019, Volume 101(1) p.76-90 [Appendix]
Insurers’ Negotiating Leverage and the External Effect of Medicare Part D (with Darius Lakdawalla), Review of Economics and Statistics, 97:2 p.314-331 May 2015 (an earlier version appears as NBER working paper no. 16251)
R&D Policy, Agency Costs and Innovation in Personalized Medicine, Journal of Health Economics, September 2009, 28(5), pp. 950-962
Market Incentives and Pharmaceutical Innovation, Journal of Health Economics, July 2008, 27(4), pp. 1060-1077
Female Empowerment: Impact of a Commitment Savings Product in the Philippines (with Nava Ashraf and Dean Karlan) World Development, 2010, 38(3), pages 333-344
Tying Odysseus to the Mast: Evidence from a Commitment Savings Product in the Philippines (with Nava Ashraf and Dean Karlan) Quarterly Journal of Economics, May 2006, 121(2). Winner of TIAA-CREF 2006 Certificate of Excellence
Designing Targeting Schemes with Poverty Maps: Does Disaggregation Help? (with Berk Özler, Chris Elbers, Tomoki Fujii, Peter Lanjouw), Journal of Development Economics, May 2007, 83(1)
Deposit Collectors (with Nava Ashraf and Dean Karlan), Advances in Economic Analysis & Policy, March 2006, 6(2), Article 5
The Role of Behavioral Frictions in Health Insurance Marketplace Enrollment and Risk: Evidence from a Field Experiment (with Richard Domurat and Isaac Menashe) [Online Appendix]
Provider Market Power and Adverse Selection in Health Insurance
Markets (with Richard Domurat and Nicholas Tilipman)
PUBLISHED POLICY and MEDICAL JOURNAL ARTICLES
“Potential Impacts of Graham-Cassidy-Heller-Johnson on Californians and the Individual Health Insurance Market” Covered California Report, September 25, 2017 (w/ John Berko)
“Evaluating the Potential Consequences of Terminating Direct Federal Cost-Sharing Reduction (CSR) Funding” Covered California Report, January 26, 2017 (w/Richard Domurat) [Appendix]
“Trump’s “populist” economic proposals come with massive catches. Here’s what to watch for.” Vox, November 18, 2016
Strengthening Risk Protection through Private Long-Term Care Insurance. Brookings Institution, Hamilton Project Discussion Paper 2015-06, June 2015
Value of Survival Gains in Chronic Myeloid Leukemia (with John Penrod, J. Ross Maclean, Darius Lakdawalla and Tomas Philipson) American Journal of Managed Care 2012 Nov;18(11 Suppl):S257-64
The impact of Medicare Part D on Medicare-Medicaid Dual-eligible Beneficiaries’ Prescription Utilization and Expenditures (with Caleb Alexander and Anirban Basu), Health Services Research, February 2010, 45(1), pp. 133-151
Valuing health technologies at NICE: Recommendations for Improved Incorporation of Treatment Value in HTA (with Dana Goldman, Darius Lakdawalla and Tomas Philipson) Health Economics October 2010, 10(11) pp. 1109-1116
The Effect of the Medicare Part D Prescription Benefit on Drug Utilization and Expenditures (with Anirban Basu, James Zhang, Atonu Rabbani, David Meltzer, Caleb Alexander) Annals of Internal Medicine, Lead article, February 2008, 148:3 pp. 169-177
Solutions and Challenges to Curing Global Health Inequality Innovations 2(4), October 2007, 2(4), pp. 72-80
Impact of the Medicare Part D prescription benefit on use of generic drugs and different therapeutic drug classes (with James Zhang and Caleb Alexander) The Journal of General Internal Medicine, October 2008, 23:10 pp. 1673-1678
Testing Savings Product Innovations Using an Experimental Methodology (with Nava Ashraf and Dean Karlan), Asian Development Bank, Economics and Research Department Technical Paper No. 8. November, 2003
A Review of Commitment Savings Products in Developing Countries (with Nava Ashraf, Nathalie Gons and Dean Karlan), Asian Development Bank, Economics and Research Department Working Paper No. 45 June, 2003
Econometrics (MPP Core) (PP208)
Public Finance (and the Economics of Inequality) (Econ 415)
Health Care Finance and Management (MBA and MPP elective) (MGMT298 & PP290)