Yin on Policy Changes to Reduce Medical Debt

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Associate Professor of Public Policy Wesley Yin was cited in a Health Care Journalism article about the burden of medical debt in the United States. Yin said that medical debt, totaling at least $140 billion, is the single largest source of consumer debt in the United States. To address this issue, the White House announced four steps to ease the burden of medical debt on health care consumers, including holding medical providers and debt collectors accountable for harmful practices and forgiving debt for low-income veterans. “Just shining a light on that type of behavior might lead to reducing the most egregious practices from providers,” Yin said. He expressed hope that the “White House’s actions to shine a light on charity care practices will have a positive effect for low-income individuals.” The policy changes may also “nudge providers to be stronger advocates for increased subsidies for health insurance and Medicaid expansion,” he said.

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Yin on Burden on U.S. Medical Debt

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Associate Professor of Public Policy Wesley Yin’s research into the soaring cost of medical debt in the United States was featured in the UCLA Anderson Review. A study co-authored by Yin and published in the Journal of the American Medical Association found that medical bills sent to collection agencies totaled an estimated $140 billion as of June 2020. That sum, which is bigger than all other sources of debt in collection combined, was tallied even before the pandemic saddled COVID-19 sufferers with unpaid doctor and hospital bills. Medical debt is concentrated in low-income neighborhoods, in the South and in states that refused to expand Medicaid coverage under the Affordable Care Act. “Communities that had been most burdened by medical debt have become even worse off, in absolute and relative terms, due to their leaders choosing not to expand Medicaid,” Yin said. “The results are important because they indicate that these problems are within the control of public policy.”

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Yin on National Burden of Medical Debt

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Associate Professor of Public Policy Wesley Yin spoke to Verywell Health about the results of his research on the burden of medical debt in the United States. “Medical debt has become the largest source of debt and collections than all other sources combined,” Yin said, referring to recent research he co-authored that found 17.8% of individuals in the U.S. had medical debt in collections as of June 2020. “It just speaks to how important the expansion of Medicaid has been towards financial security, financial well-being, as well as reducing disparities in these communities,” he said. When medical bills are left unpaid, it can negatively impact an individual’s credit score and make it more difficult to qualify for loans. In order to curb medical debt, Yin recommended extending subsidies that would allow patients to purchase more affordable insurance plans with a smaller deductible. He also suggested expanding Medicaid, an approach that has been shown to reduce state spending.

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Study Measures Americans’ Growing Medical Debt

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Over the last decade, medical bills have become the largest source of debt that Americans owe collection agencies, according to new research co-authored by Associate Professor of Public Policy Wesley Yin. The $140 billion in unpaid health care bills, held by about 18% of Americans, now exceeds all other debt in collections combined, according to the paper just published in the Journal of the American Medical Association (JAMA). Only debts referred to collection agencies were measured; other unpaid bills owed to health-care providers would push the total amount of debt even higher. Yin and co-authors Raymond Kluender of Harvard Business School, Neale Mahoney of Stanford University and Francis Wong of the National Bureau of Economic Research examined records from the credit rating agency TransUnion from January 2009 to June 2020, reflecting medical care delivered prior to the COVID-19 pandemic. Their comprehensive look at the evolution of medical debt reveals that, while Americans’ household finances largely recovered after the Great Recession, medical debt continued to grow. Yin said the debt was most concentrated in low-income communities and in the South. He added that, in 12 states that chose not to expand Medicaid coverage, significant disparities grew even worse during the period studied. “Addressing the problem of medical debt in the U.S. health care system must be a high priority,” said the authors of a JAMA editorial accompanying the study. “In addition to the potential consequences for health and health care use, the economic and social ramifications of medical debt are likely equally consequential, if not more so.”

 

A Spotlight on Yin’s Research on Health Insurance Literacy

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The podcast Tradeoffs featured Public Policy Associate Professor Wesley Yin’s research into low enrollment rates in public health insurance plans, even when government subsidies are available. The study, which will be published in American Economics Review, noted that 60% of people who are uninsured and eligible for either Medicaid or Affordable Care Act premium tax subsidies choose to remain uninsured. In a randomized field experiment, researchers sent five types of letters to a group of uninsured, subsidy-eligible people in California. The letters contained escalating amounts of information, from merely announcing the start of open enrollment to specifying how much subsidy an individual could receive. Enrollment rates in this group increased about 16%, suggesting that this low-cost intervention increased their health insurance literacy and comfort level in navigating the system. In addition, the new enrollees were healthier, on average, than those already in the system, creating a more stable risk pool. Yin’s study is discussed in the second half of the podcast.

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Super Tuesday, Luskin-Style

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As Super Tuesday drew to a close after 72 hours of campaign twists and turns, Public Policy students and faculty flocked to a watch party at the Luskin School for pizza and political talk. The contest for the Democratic presidential nomination as a two-man race came into focus as returns came in from across the country. In addition to weighing the merits of Sen. Bernie Sanders and former Vice President Joe Biden, students talked about state and local races and the new voting centers rolled out by Los Angeles County for the March 3 primary. Many in the room wore “I Voted” stickers after casting their ballots at Ackerman Union. The crowd also included half a dozen international students who were fascinated by the political process unfolding before them. Professors Martin Gilens and Mark Peterson provided context and commentary as hosts of the event. They were joined by Associate Professor Wesley Yin and Visiting Professor Michael Dukakis, the former Massachusetts governor and 1988 Democratic nominee. Dukakis and his wife, Kitty, shared their own unique perspectives with students at the watch party.

View more photos on Flickr.

 

Super Tuesday Watch Party

Improving India’s Mom-and-Pop Pharmacies

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UCLA Report Provides Strategies for Making Covered California More Affordable Public Policy's Wes Yin helps develop policy options to keep insurance costs down

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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.”

Immersed in the Real World The yearlong Applied Policy Project puts MPP candidates on the front lines to grapple with issues close to home and far afield

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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?”

This APP team earned highest honors for research on resolving employment discrimination complaints more efficiently. Photo by Les Dunseith

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

Applied Policy Project presentations 2018

Wes Yin Coauthors Report on How Graham-Cassidy Plan Could Have Impacted Health Care in California

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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.