Wednesday, May 04, 2016

Could a Clinton HHS entice more Medicaid expansions?

When I was 19, I spent a summer on an archaeological dig in New Mexico. Work groups were mainly led by grad students in archaeology, and I recall someone telling the tale of a Ph.D thesis (not hers) that devoted 600 pages to demonstrating that an artifact dating technique did not work. She said,
somewhat ruefully, something to the effect of, "that's supposed to be useful too."

Below, I want to devote 600 words to an ACA-strengthening proposal that probably won't work. Writing 500 words before realizing this probably has something to do with the decision. But maybe floating it is useful. Maybe it suggests some variation that might work.

The context: I was combing Hillary Clinton's raft of healthcare reform proposals for measures that might be enacted without legislation.  In a prior post, I looked at her proposal to help states form public options in their ACA marketplaces. Next up:

Entice states that have refused the Medicaid expansion to embrace it. Clinton's healthcare page reiterates an Obama administration proposal to "to allow any state that signs up for the Medicaid expansion to receive a 100 percent match for the first three years." That was the original plan, with the federal share dropping in stages to 90% thereafter. But that was beginning in 2014. By statute, at present, states that opt in late don't get the full three years of full reimbursement.Beginning in 2017, the federal contribution to the cost of the expansion starts phasing down to a mere 90%, regardless of when the state implemented (or will implement) the expansion. Altering that would require legislation.

Monday, May 02, 2016

The NIHCM Awards

I was flabbergasted to learn a couple of weeks ago that I'd won the National Institute of Health Care Management (NIHCM) award for digital healthcare journalism, announced today, along with winners in print, trade, broadcast and research.  For me, being named a finalist in the company of top healthcare journalists -- and scholar-journalists -- was win enough.

In the digital category, finalists included two scholars doubling as bloggers and journalists, Austin Frakt and Nicholas Bagley, who have helped to educate me and whom I rely on as sources; Margot Sanger-Katz, who is breaking new ground in data journalism at the New York Times' Upshot; and a lineup of equally impressive reporters. Their entries, with links, are here. Here are the winners in each category:
John Carreyrou & Mike Siconolfi, "Testing Theranos," The Wall Street Journal

Emily Anthes, “Save Blood, Save Lives” & “The Trouble with Checklists,” Nature

Daniel Zwerdling, Robert Little, Nicole Beemsterboer, Barbara Van Woerkon, Robert Benincasa, Samantha Sunne & Lydia Emmanouilidou, “Injured Nurses,” NPR

Andrew Sprung, “When Silver Is Worth More Than Gold or Platinum” (posts 2, 3, 4), xpostfactoid

Martin Hackmann, Jonathan Kolstad & Amanda Kowalski, “Adverse Selection and the Individual Mandate: When Theory Meets Practice,” American Economic Review
My own entry was a cluster of posts focusing on what's been a central preoccupation of mine in my tracking of ACA implementation: the factors that lead low income marketplace enrollees to access or forgo the Cost Sharing Reduction (CSR) subsidies that are available only with silver plans. I've focused on CSR, as I noted in this compendium of posts on the subject, because these secondary, semi-hidden subsidies constitute the ACA marketplace's best defense against underinsurance. Most who are eligible access CSR, but too many don't, and the price is too high for too many.

Thursday, April 28, 2016

For UHC, what's the matter with Iowa?

This week, health insurance Centene announced that it is meeting its profit targets in the ACA marketplace. That's in marked contrast to United Healthcare, which expects to have lost a billion dollars in the marketplace by year's end -- and is withdrawing most of its offerings there in 2017.

I've previously noted that Centene is primarily a managed Medicaid company and has acted like one in the marketplace, fielding plans with low premiums, high deductibles and narrow networks. UHC, the nation's largest provider of employer-sponsored plans, put up more robust networks at higher prices in large markets.

While the contrast seems clean, there's more to the story. UHC is also a major managed Medicaid provider, and in many smaller markets its plans are price competitive.  That's the case in most of Iowa, from whence it is nonetheless withdrawing. In a post on, I examine why that might be -- and wonder why, more broadly, UHC is withdrawing most of its marketplace offerings, instead of replicating the low-cost narrow network model.

Monday, April 25, 2016

Can Hillary Clinton strengthen the ACA without legislation?

Jonathan Cohn has a post urging Bernie Sanders to use his enhanced visibility in the Senate to push for incremental moves toward his long-term goal of a single-payer healthcare system. Shorter term goals within the realm of imagination include letting CMS negotiate drug prices (and, I would add, leave some drugs off the formulary); gradually opening Medicare to people under 65 (perhaps starting with a buy-in option at age 60); and pushing for the widely popular "public option" that didn't make it into the ACA.

So much for Bernie in the Senate. What about Hillary in the White House? Let's be optimistic for a few minutes and assume she gets there. What can she really do to improve healthcare access and affordability?

We don't have to speculate wildly. In typical Hillary Clinton fashion, she has posted a raft of proposals to supplement and strengthen the Affordable Care Act and rein healthcare cost growth. They're lightly sketched in, though, and it's hard to know where Clinton would place her emphasis

One obvious starting point is with those that can be effected by executive action and administrative focus rather than by legislation. Steps requiring legislation are for the most part unlikely to happen, except in the unlikely event that a Democratic blowout takes back the House as well as the Senate -- and legislative possibilities would probably be quite limited even with a narrow Democratic majority.

Friday, April 22, 2016

Medicaid outperforms marketplace in Kaiser probe of low income ACA beneficiaries

The Kaiser Family Foundation conducted focus groups of low income people newly insured by the ACA. Participants qualified either for Medicaid or for subsidized marketplace plans with Cost Sharing Reduction subsidies -- if they chose silver level plans, which some didn't. There were nine focus groups in six cities, convened early this year. Conclusions, in brief:

1. Medicaid enrollees were pleased, grateful and relieved to have the coverage -- though some were disappointed that the coverage did not relieve them of existing medical debt. They found the cost structure (no premium, modest copays) appropriate.

2. Marketplace coverage is better than nothing. Many used it to access medical care that they had long denied themselves; many found it more affordable than their past options. For some it was a Godsend. But...many were confused by the array of choices and complexity of terms; sorely stretched by either the out-of-pocket costs or the premiums or both; and tortured and terrified by balance billing or otherwise uncovered costs.

3. Many are sorely in need of dental and visual coverage that the plans (including Medicaid in many places) don't provide.

The results and testimonials clarified and reinforced several impressions and emerging (if still malleable) convictions of mine about our healthcare system generally and the ACA specifically. Here they are, illustrated by select comments from the Kaiser focus group participants.

Thursday, April 21, 2016

Proposed in Minnesota, an industrial-strength public option

Minnesota progressives and elected officials in the state's Democratic Farmer-Labor party (DFL) are yearning to get back to the future with MinnesotaCare, the state's excellent public insurance program for residents of low-to-moderate income who earn too much to qualify for Medicaid.

Prior to ACA implementation, MinnesotaCare was available to Minnesotans with incomes up to 275% of the Federal Poverty Level. In 2015, the plan was converted under the ACA into a Basic Health Plan, which qualified it for federal funding but cut off eligibility at 200% FPL. Former enrollees above that income level were sent to the ACA marketplace, where both premiums  and out-of-pocket costs are considerably higher.

A task force appointed by the governor recommended in mid-January that the state seek an ACA innovation waiver to restore MinnesotaCare eligibility to 275% FPL, with funding equivalent to the cost of federal marketplace subsidies for enrollees up to that income threshold. I wrote about that plan and its implications on in January. Its impact on the private plan marketplace and larger individual market would be fairly modest -- just 37,000 enrollees in the 200-275% FPL range are forecast -- but it would provide high actuarial value coverage to the majority of those who would otherwise be eligible for subsidies in the ACA marketplace if MinnesotaCare did not exist.

Last month, a more radical proposal was introduced in legislation in the Minnesota State Senate. I have a piece up about this proposal today on It would offer MinnesotaCare at only modestly reduced actuarial value (if reduced at all) to anyone who wanted to buy in. While costs have not yet been closely calculated, the hope is that the premium would be in silver plan range:

Tuesday, April 19, 2016

What kinds of health plans are unsubsidized buyers choosing? A hint from HealthSherpa

Recently, I posted a series of comparisons of the health insurance obtained in the ACA marketplace by enrollees who were a) unsubsidized, b) subsidized, and c) heavily subsidized (i.e. with access to strong Cost Sharing Reduction (CSR) subsidies). In brief, the weighted average actuarial value of plans obtained by subsidized buyers was 81.4%, compared to 68.9% for the unsubsidized.  The perhaps more significant contrast was between those with incomes under 200% of the Federal Poverty Level, where CSR is strong, and everyone else. Average AV for buyers below 200% FPL was 86.3%. Subsidized buyers over 200% FPL obtained coverage only marginally richer than did unsubsidized buyers.

In that post I posited, tentatively, that the 1.4 million unsubsidized buyers who obtained plans on might stand in as a proxy for the estimated 9.6 million out-of-marketplace buyers of ACA-compliant plans.  While every buyer on and in the 12 state-run marketplaces is tabulated, the out-of-marketplace market is something of a black box.

Now I have a sliver of corroboration from HealthSherpa, a commercial online broker with a sleek interface and easy enrollment process. HealthSherpa is one of dozens of e-brokers authorized to process subsidized marketplace applications, which it does via a dedicated interface on (as do other brokers). According to co-founder Ning Liang, HealthSherpa has enrolled some 500,000 people in marketplace plans to date (since 2014). HealthSherpa sells in the 38 states using,and recently added  Liang sent me metal level selection data from the most recent 100,000 enrollees, all for 2016.

One surprise is that the vast majority of the 100,000, 88%, are subsidized enrollees. Finding one's way to HealthSherpa implies a certain degree of web savvy, and probably also relative youth, and most young enrollees are subsidy-eligible. So we are dealing with an unsubsidized sample of just 11,812, and all are buying plans available in the ACA marketplace, as opposed to ACA-compliant plans offered exclusively outside the marketplace.

All that said, the metal level selections of the HealthSherpa sample are pretty close to those of the unsubsidized enrollees. Here are the numbers for unsubsidized buyers from HealthSherpa: