Friday, May 27, 2016

A Medicare buy-in? Harold Pollack discusses Clinton's trial balloon

Hillary Clinton recently made headlines by expressing openness to allowing not-quite-elderly Americans to buy into Medicare:
“I'm also in favor of what's called the public option, so that people can buy into Medicare at a certain age,” the Democratic presidential front-runner said during a roundtable with local residents at the Mug'N Muffin coffee shop. “Which will take a lot of pressure off the costs.”
That's...confusing, since the public option, as originally conceived and as debated when the Affordable Care Act was being drafted, was a publicly financed health plan that would be offered in the ACA marketplace to prospective enrollees of all ages, competing directly with private plans. It was connected to Medicare only insofar as "strong" versions mandated that the plan would pay healthcare providers at Medicare rates, which are generally lower than those paid by private insurers.

Wednesday, May 25, 2016

98% of Americans with health insurance are subsidized. How bout the other 2%?

While the ACA has reduced the ranks of the U.S. uninsured by some 17 million, and currently subsidizes private health insurance plans for about 9.4 million* people, it has also raised the price of health insurance for most of those who have to buy their own insurance and don't qualify for ACA premium subsidies.

The latest Kaiser Family Foundation latest survey of enrollees in the individual market suggests that 64% of those enrollees obtained their plans in the ACA marketplace, which means that 53% of current individual market enrollees are subsidized. Borrowing Charles Gaba's estimate of 11.3 million current marketplace enrollees indicates a total individual market enrollment of 17.7 million, about 8.3 million of whom do not get premium subsidies. Some of those full-freight enrollees may be caught in the ACA's family glitch -- that is, an employer offers insurance that's deemed affordable for the employee and so disqualifies her from subsidies, even though family coverage may be far from affordable. Most, though, presumably earn too much to qualify for subsidies.

Those who buy their insurance in the individual market and get no subsidy at all are the only insured Americans whose insurance is unsubsidized, and they are a tiny minority of the insured population. 147 million people who get their insurance through an employer are subsidized via the tax exclusion for employer-sponsored health insurance. 72.4 million Medicaid enrollees and 55.5 million Medicare enrollees are subsidized, as are about 9 million VA-enrolled veterans and, again, 9.4 million ACA marketplace enrollees.

Sunday, May 22, 2016

Religious freedom, but...

Two deeply reported stories about religion and the state seem to be ironically paired in today's New York Times.

In China, Ian Johnson reports, authorities have cut off the crosses topping 1700 churches in a heavily Christian district, Zhejiang. That's the bleeding edge of a general tightening of the screws on religious organizations. In a recent speech, President Xi Jinping

Friday, May 20, 2016

Health insurance in the U.S. is deteriorating, Kaiser survey indicates (to me)

[UPDATED, 5:15 p.m.: part of the drop in enrollees' ratings of their plans in 2016 may be due to who's buying the plans rather than what's on offer. See note at bottom.]

The Kaiser Family Foundation released its latest survey of enrollees in the individual market for health insurance today, which also includes some data on enrollees in employer-sponsored insurance (ESI). While majorities still report themselves satisfied with their health plans, the results suggest that health insurance is deteriorating, in ESI as well as in the individual market.

The comparisons provided with results from 2015 and 2014 tell a simple story. Deductibles and cost-sharing are on the rise, so people have more trouble paying their bills, are more often surprised by what their plans don't cover, more often go without needed care, and are therefore less satisfied with their plans. This is all true in employer-sponsored insurance as well as in the individual market, though satisfaction in ESI starts from a higher baseline.*

Data on deductibles brings the overall picture into focus. In the individual market as a whole, more enrollees in low deductible plans report themselves satisfied than those with high deductibles (74% vs. 59% ). The percentage of enrollees in high deductible plans is rising (49%, compared to 36% in 2015 ), and the percentage of those dissatisfied with their plans is also rising (31%, up from 20% in 2015 and 2016). The rise in high deductible plans is proportionate to the drop in reported satisfaction: 66% of all enrollees in ACA-compliant plans report themselves satisfied this year, compared to 74% in 2015.

Wednesday, May 18, 2016

How many Americans who buy their own insurance are unsubsidized?

One further footnote on the McKinsey & Co. report on the state of the post-ACA individual market for health insurance, discussed in my prior post.

McKinsey opines that the market is unlikely to enter a death spiral because ACA premium subsidies insulate most participants from premium hikes. The report estimates that 69% of current enrollees are subsidized. That strikes me as at least slightly exaggerated.

Kaiser, in its 2015 survey of non-group enrollees on- and of-exchange, found that just under half were subsidized -- or about 59% if you exclude those in grandfathered and grandmothered pre-ACA plans, which are a different risk pool (McKinsey's "methods" note indicates that they include enrollees in non-compliant plans in their estimate of off-exchange enrollees, though they may also assume that some of those in noncompliant plans are in subsidy range)*. UPDATE 5/20: Kaiser's 2016 individual market survey results, reported today, find that 64% of individual market enrollees are now in marketplace plans. 83% of marketplace enrollees are subsidized, suggesting that 53% of the individual market is subsidized.

The off-exchange market is something of a black box, so it's not surprising that estimates would differ. Also, Kaiser's estimate is from 2015, and the ACA marketplace grew modestly this year. Still, on McKinsey's own terms, I think their estimate is a bit inflated.  Here's its basis:

Monday, May 16, 2016

If you're giving people a Medicaid-like provider network, do it at Medicaid-like prices

McKinsey & Co. has a report on the state of the ACA marketplace (and the whole individual market) that reinforces one dominant point that was already clear: The marketplace is relentlessly pushing insurers toward a narrow network/managed care model.
At the individual carrier level, results varied as well. While most carriers had negative margins after accounting for the 3Rs, approximately 30% of carriers achieved a positive margin in 2014. At the plan level, patterns emerge around performance differences. In the aggregate, plans based on health maintenance organizations (HMOs) had lower losses than plans based on preferred provider organizations (PPOs), consistent with their ability to enable more tightly managed benefits and care. In both 2015 and 2016, the premium increases for HMO plans were roughly half those of PPO plans, which suggests the initial results carriers experienced in the individual market were more favorable for the HMO plans.

Sunday, May 15, 2016

Elisabeth Rosenthal on narrow networks in ACA marketplace: A few "yes buts"

On the front page of today's New York Times Sunday Review, Elisabeth Rosenthal, author of the incomparable Paying Till it Hurts series on the dysfunctions of our price-gouging healthcare system, spotlights the limitations of ACA marketplace plans, starting with narrow networks. It's accurate and fair, acknowledging the good that the law has done. Nonetheless I have some caveats:

1. Rosenthal compares marketplace plans' narrow networks unfavorably with the more robust networks typically offered by employer-sponsored insurance:

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