Friday, July 31, 2015

Rejoice, Uticans! A shower of silver shall rain upon you in 2016.

Today New York posted 2016 rates for health insurance plans offered on NY State of Health, the state's ACA exchange. I was planning to write about the factors that affect what subsidized ACA private plan buyers will actually pay, when the rates posted for Utica, NY brought me up short. They are a stark illustration how the spread between certain plans offered in one market matters more to subsidized buyers than the sticker price of a given plan -- if they're willing to buy the cheapest plan at a given actuarial value.

On ACA exchanges, premium subsidies are set as a fixed percentage of a buyer's income, benchmarked to the second cheapest silver-level plan in the buyer's market. In 2016, solo buyers who earn exactly 200% of the Federal Poverty Level (FPL) will all pay $124 for the second cheapest silver plan available to them, regardless of where they live. Buyers earning 150% FPL will pay $59 for the benchmark plan.

Wednesday, July 29, 2015

New York's ACA exchange publishes takeup rates for Cost Sharing Reduction

NY State of Health, the state's ACA health insurance marketplace, released detailed enrollment data today (hat tip to who else but Charles Gaba?). With regard to my own little preoccupation -- the degree to which those private plan buyers eligible for Cost Sharing Reduction (CSR) subsidies access the benefit by buying silver plans -- New York is (as far as I know) the first state to do the basic math for me:
The majority of QHP consumers who completed the enrollment process and were eligible for APTC with cost-sharing reductions chose Silver plans in which they can use costsharing reductions. Among those eligible for cost-sharing reductions, enrollment in Silver plans was higher for those eligible for greater levels of subsidy. Ninety-seven percent of those eligible for costsharing reductions at the 94 percent actuarial value level enrolled in a Silver plan, compared with 83 percent at the 87 percent actuarial value level, and 62 percent at the 73 percent actuarial value level. Overall, 78 percent of those who are eligible for cost-sharing reductions, enroll in a Silver plan with that benefit. The remaining 22 percent enroll in different metal levels. These trends are consistent with the
2014 open enrollment period, when overall, only a slightly higher share of cost-sharing reduction eligible enrollees—80 percent—enrolled in these products. 
Last year, I had to tweeze these numbers out of the NY enrollment report myself.  Since they redounded to the state's credit, and a NYSOH spox confirmed them for me, I'd like to think I gave them a nudge toward highlighting the takeup themselves this time around.

Tuesday, July 28, 2015

Pennsylvania Medicaid expansion enrollment jumps; have newly Medicaid-eligible 2014 private plan enrollees jumped with it?

Pennsylvania's somewhat rocky Medicaid expansion, for which enrollment began on December 1 and coverage on January 1, seems now to be firing on all burners. The state's Department of Human Services reported last week that enrollment is up to 439,000, more than two thirds of the state's target of 605,000.

The expansion began slowly. After Pennsylvania declined to expand in 2014, then-Governor Tom Corbett negotiated with HHS to create the kind of "private option" expansion popular with Republican governors. The "Healthy Pennsylvania" plans that were hastily constructed in fall 2014 had different terms for Medicaid-eligibles at different income levels, and eligibility criteria different from the state's existing programs. Adding to the confusion, existing state Medicaid programs required applicants to list their assets as well as their income; the ACA excludes such information from the Medicaid application process. Systems snarled and applications backlogged, though not as radically as in many states.

A transition back to traditional Medicaid initiated by the state's new Democratic Governor, Tom Wolf, kicked off on April 27. That transition will be complete by the end of this month, though some "private option" enrollees will be double-enrolled until September 1. By late April most applications were being processed in a timely manner, meeting the state's 30-day standard, enrollment counselors told me at the time.  Kait Gillis, a DHS spokeswoman, tells me that 150,000 have been enrolled since the transition to traditional Medicaid kicked off.

Monday, July 27, 2015

Some sidelights on Covered California's modest rate increases for 2016

Covered California, the state's ACA health insurance exchange, is boasting today with some justice that the state held 2016 rates down to an average weighted increase of 4%. Other talking points: the average (unweighted) increase of the cheapest silver plan in each region went up just 1.5%, and the average consumer can save 4.5% if she switches to the cheapest plan in the same metal tier.

That last point is somewhat...selective: the apples-to-apples question is what will happen to current holders of the cheapest plan in each metal tier if they switch to 2016's cheapest plan.  On the other hand...there are two other hands.

First, the talking point about switching to the cheapest plan in one's metal level has some extra validity in California, where benefits for all plans in each metal tier are standardized. In other words, the only substantial variable other than price is network quality. Hence, price shopping -- balancing premium versus benefits -- is likely to be less fraught and easier to get right in California than in most states.

Second, it's good news that the cheapest silver plan in each region went up an average of just 1.5%-- but the import of that factoid depends in part on a second data point. That would be the average increase for the second cheapest silver plan in each region, which is the benchmark according to which premium subsidies are set. That is, a buyer's premium is calculated to leave him paying a fixed percentage of his income for the second cheapest silver plan available to him. If the benchmark silver plan goes up more than the cheapest silver plan, that's good for the buyer: it increases the affordability of silver-level coverage.  Covered California's full rate report shows that the benchmark plans went up an average of 1.8%, very modestly (on average) increasing the spread and so the affordability of the cheapest silver plan. It also shows that the cheapest bronze plan went up an average of 3.3% -- making the cheapest silver relatively (albeit slightly) more attractive.

The source of Huckabee's Holocaust porn

President Obama quite rightly read Mike Huckabee's disgusting, inflammatory assertion that the nuclear deal with Iran "will take the Israelis and march them to the door of the oven” as "an effort to push Mr. Trump out of the headlines. "  Most observers see it in that context: Trump is leading GOP contenders on a dive to a new bottom.

But where did the hysteria compressed in Huckabee's sound byte come from? Who writes the GOP's tune on dealings with Iran and middle east policy generally?

Netanyahu, natch.

To mark Holocaust Memorial Day back in April, "in a speech," The Washington Examiner's Paul Bedard noted, "already winning attention in Washington," Netanyahu "compared Washington's deal with Iran to Europe's appeasement of Adolf Hitler which led to the Holocaust and world war."

Thursday, July 23, 2015

New light on QHP enrollees' income levels in states that refused to expand Medicaid

Below are some state-by-state numbers for private health plan enrollment in the 21 states that refused to expand Medicaid.  The state enrollment totals at different income levels are extracted from the county-by-county data released by HHS in early July. I've sandwiched those tallies between the states' median household incomes as of 2013 and Kaiser's estimates of the percentage of potential private plan enrollees that each state has enrolled as of March 31, 2015.*

What I'm after is possible causes of state variations in the percentage of enrollees eligible for Cost Sharing Reduction (CSR) subsidies who accessed that benefit by buying silver plans, the only metal level at which CSR is offered. CSR is available to buyers of Qualified Health Plans (QHPs) whose household incomes are below 251% of the Federal Poverty Level (FPL). In nonexpansion states, that's fully 80% of QHP buyers.**

In the chart below, states are listed in ascending order of median household income. I track the percentage of buyers in each states whose household incomes are between 100% and 150% FPL, for reasons explained below, as well as those who are CSR-eligible (0-250% FPL***). The next-to-last column tracks the percentage of CSR-eligible buyers who selected silver plans and so obtained the benefit.****

Saturday, July 18, 2015

Utah and Alaska are on course to expand Medicaid. Are their eligibility estimates inflated? (Updated)

Both Alaska and Utah seem to be on course to implement the ACA Medicaid expansion. In Alaska, Governor Bill Walker is asserting his authority to do so without the approval of the legislature. In Utah, Governor Gary Herbert has struck a deal with legislative leaders -- still perhaps facing a rocky course toward legislative approval -- to seek a waiver for a "private option" form of the expansion.

In both states, as in any state, pro and con arguments over expansion are based on cost estimates which are in turn based on estimates of how many state residents will gain eligibility for Medicaid. It's noteworthy that in both states, in 2015, the Kaiser Family Foundation radically cut its 2014 estimate of those in the "coverage gap" -- that is, those whose incomes would have qualified them for Medicaid had their states accepted the expansion but are too low to qualify them for subsidized private plan coverage on ACA exchanges.*

In Alaska, Kaiser's estimate of the Medicaid gap population shrank from 17,290 as of March 31, 2014 to 10,500 as of  April 17 of this year. In Utah, the drop was from 57,850 in 2014 to 30,000 in 2015. These estimate cuts are mainly due to a redesign of insurance questions in the Census Bureau's Current Population Survey, intended to address previous under-reporting of respondents' insurance coverage.** While Kaiser cut its estimates for every state, the reductions in Utah and Alaska were far and away the largest. In both states, though, state officials' estimates of the "gap" population are closer to Kaiser's earlier estimates than to the newly reduced ones. In both states, in fact, working estimates are higher than Kaiser's 2014 figures.

Wednesday, July 15, 2015

For ACA plan buyers, it's not the price, it's the price spread

There's good news and bad news in this forecast by Avalere Health of average premium increases in 2016 for health plans sold on ACA exchanges:
...premiums for the lowest and second lowest cost silver plans in the eight states analyzed will increase on average 4.5 percent and 1.0 percent respectively, compared to a 5.8 percent across all silver exchange plans. 
There was similar good news/bad news in HHS's report on actual premium increases from 2014 to 2015:
Premiums for the benchmark (second-lowest cost) silver plan will increase modestly, by 2 percent on average this year before tax credits, while premiums for the lowest-cost silver plan will increase on average by 5 percent. The plans offering the lowest prices have sometimes changed from 2014 to 2015, so consumers should shop around to find
the plan that best meets their needs and budget.