Wednesday, April 01, 2015

Affordable health insurance vs. affordable health care

One of the flaws of the Affordable Care Act is that it partially (not entirely!) confuses affordable insurance with affordable health care.

On the plus side, for insurance purchase purposes, the ACA benchmarks affordability to silver-level plans and calibrates the out-of-pocket costs these plans impose on buyers to income, via Cost Sharing Reduction (CSR) subsidies, which raise the plans' actuarial value to 94% for buyers with incomes under 150% of the Federal Poverty Level and to 87% for buyers under 200% FPL.

On the minus side, CSR fades to near-insignificance at 201% FPL; silver plan premiums slope toward unaffordability for a lot of buyers somewhere over 150% FPL; and the ACA dangles cheaper bronze plans with deductibles north of $5,000 in front of low-income buyers, for many of whom many of those plans will do very little good.

Also on the downside, for the purposes of determining whether a person or family has access to "affordable" insurance (and so whether they are subject to the mandate to purchase it), the ACA benchmarks affordability to the cheapest available bronze plan -- which, again, is likely to have a per-person deductible and out-of-pocket maximum in the $5000-6,600 range. Some bronze plans offer some services, such as low-copay doctor visits or generic drugs, before the deductible is reached, but many (my spot-checks make me suspect most) do not. They do offer mandated free preventive services, but those a patchwork.

Tuesday, March 31, 2015

1.9 million private plan enrollees on would have been eligible for Medicaid if their states had accepted the expansion

In a post on, I report that almost 2 million of the private plan enrollees on would have qualified for Medicaid if their states had embraced the ACA Medicaid expansion.

That is, about a third of the six million-plus private plan enrollees in non-expansion states and about 22% of all ACA private plan signups would have been in Medicaid if the Supreme Court had not made the expansion optional or if every state had embraced it voluntarily. In that case, there would probably be fewer than 10 million signups in the "Qualified Health Plans" (QHPs) offered on the exchanges today.

In their furious rejection of everything associated with the ACA, and cruel denial of insurance to millions of their constituents, red state governors and legislatures gave the QHP markets in their states a vital boost.

In the post, I explore the weakness in exchange offerings that these statistics imply. In brief, because exchange offerings are so much cheaper and offer such dramatically better coverage at the lower end of the subsidy-eligible income range, takeup is dramatically better among the lowest-income eligible uninsured than among the uninsured in higher subsidy-eligible income bands, as Avalere recently concluded.

Here I just want to add some support to my calculation that about 1.9 QHP enrollees in non-expansion states had incomes in the 100-138% FPL range, which would have put them in the Medicaid pool in expansion states.

Sunday, March 29, 2015

In Washington State, too many low-income bronze plan buyers

Washington HealthPlanFinder, the state's ACA exchange, has set the standard for enrollment data reporting, providing a more detailed and complete account of private plan buyers' demographics and behavior than any other state to date. Washington is a wealthy state, with a median household income (2013) of $60,106, compared to a national median of $51,939.   Its buyers of private plans on the exchange (known as Quality Health Plans, or QHPs) are accordingly a much wealthier group than the average among the 37 states that used the federal exchange,

Only 12.5% of Washington's QHP buyers have incomes under 150% of the Federal Poverty Level (FPL), compared to 24% in those states that accepted the Medicaid expansion -- and 50% in states that refused the expansion. (In non-expansion states, eligibility for QHP subsidies began at 100% FPL, versus 138% FPL in expansion states, and those between 100 and 138% FPL swelled the QHP enrollments, accounting for about a third of all enrollments in non-expansion states.) Low takeup in this low-income band perhaps explains in part why Washington has reached just 32% of its target QHP market as calculated by the Kaiser Family Foundation, versus 42% for the nation as a whole. Conversely, Washington has been very successful in expanding its Medicaid rolls. The enrollment report tallies 533,628 "Medicaid expansion adults," far exceeding a 2012 Urban Institute forecast of 330,000.

Too many poor buyers of bronze plans

While Washington's relatively small number of enrollees in the 100-150% FPL income band may be in large part a matter of demographics, there is one way in which the state exchange has seemingly failed lower-income buyers. Takeup of Cost Sharing Reduction subsidies, available only with silver plans and only to buyers with incomes below 250% FPL, is lower in Washington than on, and much lower than in states like New York and Connecticut that take special measures to highlight CSR for those who are eligible for it.

Thursday, March 26, 2015

"Obamacare, Obamacare! stay a little. Ha!*

As Greg Sargent never tires of reminding us, Republicans have been promising an ACA replacement plan for 50 months now and haven't been able to deliver. Ergo, Sargent asserts, claims by Republican legislators that they are developing a plan to replace the ACA and keep premium subsidies flowing should the Supreme Court rule for the plaintiffs in King are a ruse, designed to convince swing justices that chaos won't erupt if the court invalidates subsidies credited through the federal exchange.

That is probably at least partially true, as Republicans have long proven themselves unable to unite behind a plan that would replace a large portion of ACA benefits while creating different winners and losers. But there are plans and plans (and motives and motives), and elected officials don't yank away existing benefits lightly. While Republicans may well be paralyzed by a Supreme Court decision that gives them what they say they want, there are elements in the plans they're floating that could find their way, sooner or later, into a post-King settlement.  Republicans' lack of unity could lead them to punt, perhaps declaring victory with relatively modest gains while restoring most of the status quo.

Most interesting in this regard are Republican proposals to freeze or patch the the current system while they devise a fix. Here's how one very sympathetically worded account describes such a measure:

Wednesday, March 25, 2015

Israelis read Obama right. Well, half right.

I have been arguing that the Obama administration's promise to reassess its approach to the Israeli-Palestinian conflict in light of Netanyahu's late-election disavowal of a two-state solution is not an expression of pique but the seizing of an opportunity. A report from the New York Times' Jodi Rudoren suggests that a lot of Israelis agree with me:
Several Israeli analysts said the administration’s criticism of Mr. Netanyahu seemed like a pretext for a longstanding plan to change the United States’ policy of protecting Israel in international forums, which the administration has said it will reassess. Others suspect a ploy to undermine Israel’s lobbying efforts against the American negotiations for a nuclear accord with Iran.
I don't know that there was a longstanding plan; policymaking is usually more reactive than people assume. But any rational U.S. actor (see Baker, James) would look for an opportunity to alter the U.S.'s one-sided relationship with Israel -- the U.S.'s near-total absence of leverage, the political imperative to provide unconditional support no matter how thoroughly Israel undercuts U.S. policy, the impossibility of imposing consequences such as limiting aid or joining the rest of the world in condemning Israeli settlement activity.

I see Giora Eiland, a former Israeli national security adviser (cited by Rudoren), as half right here:

Tuesday, March 24, 2015

Chastising Netanyahu: Fury or cold calculation?

Characterizing the Obama administration's reaction to Netanyahu's late-election comments denigrating Arab voters and promising to prevent formation of a Palestinian state, the New York Times' Jodi Rudoren and Julie Davis echo a comment them in asserting
the White House issued a new signal that it remained furious with Mr. Netanyahu for campaign comments that also appeared to close the door on a two-state solution to the Palestinian conflict.
there was no sign of any softening from the administration over its anger with Mr. Netanyahu over his comments about the Palestinian question.
Perhaps Obama, Kerry et al really were personally incensed by Netanyahu's comments. I've read at least one account quoting anonymous sources who claimed they were. Perhaps they find it useful to project "fury."  But I see the reaction more as seizing an opportunity than as an expression of pique.

Sunday, March 22, 2015

On U.S. support for Israel, Obama is turning the battleship a few degrees

As Obama discussed U.S. policy with respect to Israel in his recent sit-down with Huffington Post's Sam Stein, there were a couple of surprise turns -- at least, surprising to me as a transcript reader.

First, this:
OBAMA: Well, I had a chance to speak to Prime Minister Netanyahu yesterday, congratulated his party on his victory
'Congratulated...his party.' Not Netanyahu himself, not for the campaign he ran. Every word that Obama has said in response to Netanyahu's late-stage campaign comments and the election results has been calibrated to pressure the prime minister to prove by deeds, not words, that he is walking back his campaign promise to forestall a Palestinian state on his watch. Congratulation of the party, rather than the man, arguably advances that aim: "So we’re evaluating what’s taking place. I think Prime Minister Netanyahu still has to form a government; we’ll be in close consultation with them."  On the plus side, Netanyahu's surprise success came at the expense of parties on his right, so should he reverse tone and course he has some room to maneuver.

No one expects him to, though. Which leads to the second surprise turn of a sentence: