Wednesday, October 29, 2014

In Mississippi ACA rollout, one big disaster, one small success

Politico's Sarah Varney has a beautifully reported, infuriating account of how Tea Party government in Mississippi sabotaged the state's ACA rollout, leaving Mississippi "the only state in the union where the percentage of uninsured residents has gone up, not down."

The tale has three parts: 1) the state's Tea Party governor elected in 2012, Phil Bryant, undercut and induced the closure of the state's home-built insurance exchange, a project in which the state insurance commissioner (and Haley Barbour crony) Mike Chaney was deeply invested, and which was briefly operative before full ACA implementation. 2) The state refused to participate in outreach to the uninsured and, by closing its exchange, forfeited substantial federal aid for outreach. 3) The state rejected the ACA's Medicaid expansion, which would have extended Medicaid eligibility to an estimated 333,000 uninsured residents. Mississippi was also among the poorest performers in attracting competition to the exchange: most counties had only insurer, Humana, offering plans.

I would add a footnote. Of those three factors, the refusal to expand Medicaid in the nation's poorest state was by far the most consequential.  As part of, Mississippi's state exchange did not ultimately perform so badly.  The state exchange enrolled 61,494 people in private plans, 20.6% of the estimated 298,000 uninsured residents eligible to buy insurance on the exchange. That's not great, but it's a higher percentage than that achieved in several states that built their own troubled exchanges, and better than 17 states overall.

Had Mississippi achieved the national average percentage of eligible signups, 28%, another 22,000 residents would be insured. An estimated 138,000 Mississippians, by contrast, fell into the so-called Medicaid gap -- that is, they would have been eligible for the blocked expansion but earn too little to qualify for subsidized coverage on the exchange. Again, 333,000 state residents were estimated to be newly eligible for Medicaid under the expansion. And many states that expanded Medicaid actually exceeded their target enrollments.

Sunday, October 26, 2014

What the ACA can't cure

I recently referred to Investor's Business Daily reporter Jed Graham's coverage of the ACA as "adversarial." He objected. I responded, "I don't ignore or minimize ACA flaws but would not object to a characterization of my writing on it as "sympathetic."

That set me thinking about everything that troubles me about the ACA -- or, more accurately, things that trouble me about the US healthcare system that the ACA is unlikely to fix -- though it may help catalyze reform on several of these fronts. Here's the list:

1. All private health insurance in the U.S. is inadequate -- thanks to the shameful out-of-network billing, balance billing, and creative billing by hospitals, physicians and other providers documented in sickening detail by Elisabeth Rosenthal in her Paying Till it Hurts series. We are in the grip of a depraved system in which hospitals often operate as free billing zones and payers' attempts to control costs just generate new loopholes.

2. For the unsubsidized and lightly subsidized, private insurance on the ACA exchanges is too expensive. Or rather, medical care obtained under the insurance is too expensive.  One of the law's strengths is the Cost Sharing Reduction (CSR) that reduces deductibles and out-of-pocket costs for buyers with incomes below 200% of the Federal Poverty Level to levels comparable to those offered in top-grade employer-sponsored insurance (much more modest CSR is offered to those between 200% and 250% FPL).  Those cost control come into play if low income buyers choose silver plans (fortunately, most do) and if  they are not hit by the kind of out-of-network and balance billing that Rosenthal documents. Those above 200% FPL, however, have to choose between high monthly premiums and often sky-high deductibles, average over $5,000 for bronze plans (which may be tempting to many at the upper range of subsidy eligibility).

Saturday, October 25, 2014

Ebola's Information Paradox, Part II: Do we hear?

Looking back to a devastating Cholera outbreak in a poor neighborhood of London in 1854, Steven Johnson notes that "it took two entire weeks before the press began treating the outbreak as a major news event for the city."  A hundred and sixty years later, we're safer (although more fearful) because news travels faster:
Compare this pattern of information flow to the way news spreads now. On Thursday, Craig Spencer, a New York doctor, was given a diagnosis of Ebola after presenting a high fever, and the entire world learned of the test result within hours of the patient himself learning it. News spread with similar velocity several weeks ago with the Dallas Ebola victim, Thomas Duncan. In a sense, it took news of the cholera outbreak a week to travel the 20 blocks from Soho to Fleet Street in 1854; today, the news travels at nearly the speed of light, as data traverses fiber-optic cables. Thanks to that technology, the news channels have been on permanent Ebola watch for weeks now, despite the fact that, as the joke went on Twitter, more Americans have been married to Kim Kardashian than have died in the United States from Ebola.
Well yes, wonderful. But how long did it take for news of a deadly, fast-developing epidemic in West Africa to bubble up into full public consciousness in the United States? The psychological quarantining of a poor region in the grip of a terrible affliction persists.

Wednesday, October 22, 2014

A surprise (to me) regarding Medicaid eligibility under the ACA

I learned an interesting fact about the ACA from Kaiser's Larry Levitt on Twitter today.

It's well-known to ACA watchers that a low-income worker whose employer offers insurance deemed "affordable" according to ACA formula cannot buy subsidized private coverage on the exchanges. What I suspect is less well-known, and what Larry spelled out, is that the availability of employer-sponsored insurance does not negate Medicaid eligibility for someone whose household income is low enough to qualify for Medicaid.

Monday, October 20, 2014

I agree

with this Dish reader:
I choose to believe that Obama will not adopt Bush administration interpretation of torture treaty obligations, will not adopt a West African travel ban, and will not go deep into Syrian quagmire.

Maybe “hope” is a better word.
Re Sully's closer: "I’m hoping too. And doing what little I can to help make it so": When I read the Times article claiming that Obama is "considering reaffirming the Bush administration’s position that the treaty [UN Convention Against Torture] imposes no legal obligation on the United States to bar cruelty outside its borders," I knew exactly what Sullivan's response would look like.  And that the White House would know too. And that Sullivan speaks for Obama's base on this front, or at least a large part of it. For whatever that's worth.

NYT spotlights plight of ACA bronze plan buyers, leaves out vital context

[first posted 10/18]

The Times has a front-page story today, by Abby Goodnough and Robert Pear, that highlights the plight of ACA private plan buyers who bought plans with such high deductibles that they are foregoing needed treatment.  This is a real problem -- bronze plans in particular have terribly high deductibles, averaging $5,000 per individual -- but vital context is missing. Here's the framing:
About 7.3 million Americans are enrolled in private coverage through the Affordable Care Act marketplaces, and more than 80 percent qualified for federal subsidies to help with the cost of their monthly premiums. But many are still on the hook for deductibles that can top $5,000 for individuals and $10,000 for families — the trade-off, insurers say, for keeping premiums for the marketplace plans relatively low. The result is that some people — no firm data exists on how many — say they hesitate to use their new insurance because of the high out-of-pocket costs.
The first thing to note is that low-income ACA shoppers were generally not subject to these high deductibles. Low-income marketplace shoppers should generally not be buying bronze plans  -- not only because the deductibles are higher than those of silver-level plans, but because the silver plans alone come with Cost Sharing Reduction (CSR) subsidies. These reduce deductibles and maximum out-of-pocket costs for buyers with household income below 250% of the Federal Poverty Level (FPL). CSR subsidies are really large for buyers under 200% FPL, giving silver plans actuarial values comparable to those of the most generous employer-sponsored plans for those in that income range. The Goodnough-Pear story does explain CSR, but deep in the story, following four hard-case individual narratives.

Bronze plans had relatively low takeup in the ACA's first open season. According to HHS statistics, just 20% of users in all marketplaces (state-run as well as bought bronze plans. Since 33% of buyers who earned too much to qualify for subsidies bought bronze, less than 20% of the subsidy-eligible must have done so.

Sunday, October 19, 2014

The ACA marketplace and the toilet paper aisle

My last post was in protest to a New York Times front-page article that highlighted the very real plight of ACA private plan buyers who were forgoing needed medical care because they'd bought high-deductible, mostly bronze-level plans. My beef was that the article omitted important context, e.g., that only 20% of ACA shoppers selected bronze and that the vast majority of low-income buyers who were eligible for Cost Sharing Reduction (CSR) bought silver plans that allowed them to access those important secondary subsidies.

I also suggested that the four individual narratives in the piece should not be taken at face value -- in particular, the plight of one woman who had selected a bronze plan with a $6,000 deductible but was plainly eligible for CSR that would have brought the deductible down to $500 at worst and as low as $25, depending on what plan she chose. This woman plainly made the wrong plan choice -- in itself a significant problem, but not one that the Times article addressed.

I want to focus here on a second brief narrative in the Times story, in which the woman in question was somewhat higher-income and so faced a tougher choice, with less obviously attractive options. Here's the tale:

Thursday, October 16, 2014

CMS warns current ACA enrollees to shop anew.

I am glad to note that CMS, in its outreach to current enrollees in ACA plans, is shifting its emphasis away from auto-enroll and toward encouragement to shop for the best deal.

When current enrollees log onto  after the 2015 marketplace opens on November 15, their new applications  will be pre-filled with their latest information from 2014. That's good. CMS also provides a good deal of information in fairly simple terms in this 5-step instruction sheet. Also good. It begins with a useful warning:
REVIEW - PLANS CHANGE, PEOPLE CHANGE. Every year, insurance companies can make changes to premiums, cost-sharing, or the benefits and services they provide. Review your plan’s 2015 coverage to make sure it still meets your needs and you’re getting the best plan for you. 
What the outreach does not do is explain that a person's current plan may lose "benchmark" status if new (or revamped) entries undersell it -- and if so, the subsidized enrollee will be on the hook for the whole difference between the cost of the benchmark plan and her current plan. That's because subsidy levels are tied to the  price of the benchmark -- the second cheapest silver plan in a given area. If you buy that plan, your share of the premium will be a fixed percentage of your income. If your plan costs more than the benchmark, you pay the difference. That difference may be especially large for older buyers, for whom the unsubsidized premium can be up to three times as large as the premium for a younger buyer.

I can see why CMS might calculate that a "benchmark gap" is too complex a concept to explain in written materials. Encourage people to compare, and they should see the difference between the cost of their current plan and cheaper options.  I'll leave it to online "product scientists" or market psychologists or others with data and experience to judge whether that's the right call.