Thursday, September 03, 2015

The ACA's uncertain shield against underinsurance: A CSR compendium

As I've asserted more than once, Cost Sharing Reduction (CSR) subsidies are the ACA marketplaces' best defense against underinsurance for private plan buyers. That's why I've been so interested in who accesses or fails to access CSR and why -- and why takeup varies widely from state to state.

Below is an index of my posts examining the factors affecting CSR takeup, along with some posts questioning whether the benefit ought to be restructured.  I've done a fair number of single-state snapshots, and they're listed separately at bottom.  [UPDATE, 2:45: I was just able to update my little quibble with Avalere (second post below) about total CSR takeup; the differing assumptions were as I expected. I do think they lowballed it a little.]

Overall, according to the most recent enrollment figures for 2015, 57.4% of marketplace private plan buyers in all states accessed CSR. Somewhere north of 80% of them reported a household income under 201% of the Federal Poverty Level (FPL) and so received a strong version of the benefit, raising the actuarial value of their silver plans to 94% (up to 150% FPL) or 87% (151-250% FPL). Another 10% of all buyers bought gold (AV 80%) or platinum (AV 90%) plans. 21% bought bronze plans (AV 60%) with their sky-high deductibles, usually ranging from $5,000-6,600 per person.

Here's a sampling of my posts on the subject.

National CSR takeup (and implications)

Five factors shaping CSR takeup on ACA exchanges (9/1/15)

A quibble with Avalere over CSR takeup (8/20/15; updated, 9/3/15)

Is Obamcare's bronze trap widening? (on (8/12/15)

Income levels and CSR takeup in states that refused Medicaid expansion (8/23/15)

Tuesday, September 01, 2015

No man is an island -- but the GOP is

Yesterday, in a speech in Anchorage starkly laying out the current and future effects of climate change, Obama rhetorically placed his opposition on an island unto themselves, as besieged intellectually as Alaskan islanders now are physically. That reminded me of something. Here's the passage:
But if those trend lines continue the way they are, there’s not going to be a nation on this Earth that’s not impacted negatively.  People will suffer.  Economies will suffer.  Entire nations will find themselves under severe, severe problems.  More drought; more floods; rising sea levels; greater migration; more refugees; more scarcity; more conflict.

That’s one path we can take.  The other path is to embrace the human ingenuity that can do something about it.  This is within our power.  This is a solvable problem if we start now.

And we’re starting to see that enough consensus is being built internationally and within each of our own body politics that we may have the political will -- finally -- to get moving.

So the time to heed the critics and the cynics and the deniers is past.  The time to plead ignorance is surely past.  Those who want to ignore the science, they are increasingly alone.  They’re on their own shrinking island. 
Here's the association. Defending the Iran deal in early August, Obama similarly quarantined the opposition: 

Five factors driving (or inhibiting) CSR takeup in ACA private plan markets

I want to lay out some notes here for a regression analysis of what drives takeup (or the lack of takeup) of Cost Sharing Reduction (CSR) subsidies among buyers of private health plans on ACA exchanges. CSR reduces out-of-pocket costs for buyers with incomes under 251% of the Federal Poverty Level (FPL).  The benefit is quite strong up to 200% FPL, but almost negligible in the 201-250% FPL range.

CSR is best understood not as some obscure secondary benefit but as the ACA's best defense against underinsurance -- that is, against leaving plan holders on the hook for more medical expenses than they can afford. Thanks to CSR, about 60% of buyers on ACA exchanges buy insurance with an actuarial value of 80% or higher - - coverage comparable to or more comprehensive than that offered by most employers. Without CSR, only 10% of exchange customers would access that AV level. CSR provides insurance with AV 87% or 94% to about half of ACA exchange customers.

CSR is a leaky vessel, however, Only about three quarters of those who are eligible access the benefit, including probably a bit over 80% of those eligible for "strong" CSR (AV 87% or 94%). Silver plan premiums can be a hard swallow for low income buyers. In 2015, somewhere between 15% and 20% of buyers under 201% FPL probably opted for cheaper bronze plans with their sky-high deductibles (usually over $5,000 per individual).

CSR takeup among all eligible buyers varies quite a bit from state to state, most commonly between 70% and 80%, more broadly between about 68% and 85% -- discounting a few states that have layered their own benefit structures on the national ACA template (e.g., Minnesota and Massachusetts).  In various posts, I've spotlighted factors that have an impact (or may have an impact) on CSR takeup levels, though none form a basis for consistent predictions. Below, I've listed those factors in what I would guess to be descending order of likely impact.

Monday, August 31, 2015

Name Ohio "McKinley" -- and don't stop there!

Republicans, particularly Ohio Republicans, are of course up in arms about the Obama administration's announcement that it would use its executive authority to restore Mount McKinley (named in 1896 by a gold prospector who heard of the president-to-be's nomination) to its historic name, Denali, "the high one," as it had been known for centuries. Alaskans have requested the change for decades (and changed the name themselves via the state Board on Geographic Names in 1975), and (Republican) Senator Lisa Murkowski recorded a video thanking Obama for the change, but never mind.*  John Boehner, whose district is in Ohio, is "deeply disappointed" that McKinley's "great legacy" is losing a monument. Senator Rob Portman bemoans the diss of a "proud Ohioan" (while erroneously deeming the McKinley naming a post-assassination honor).

These complaints are disappointingly circumspect. It's time for presidential candidates to up the ante against the pandering president. Why focus on mere isolated slags of stone? Scratch a bit, and it seems a bunch of squish multiculturalists got hold of state naming boards when this country was young. Why not name all these states that ignore our European heritage and great legacy after (GOP) presidents?**

Alabama (Muskagean)
Alaska (Aleut)
Arkansas (Sioux)
Connecticut (Algonquian)
Hawaii (Polynesian)
Idaho (Comanche)

Sunday, August 30, 2015

Why Trump wants a wall

There's a prototype for Trump's wall along the Mexican border:

If you're going to build an 1800-mile wall, why not stuff it with apartments?  And of course, Mexicans can come through the "beautiful door" and build it..and have their remittances taxed to pay for it.  It will have not only gorgeous views of the Rio Grande. but the best lawns.

As president, Trump can set up a public-private partnership with himself. The U.S. can be renamed Trump Place. What's not to like?

Thursday, August 27, 2015

Which insured Americans get no subsidy whatsoever?

Who are the Americans who get no help from the federal government paying for their health insurance?

The uninsured, of course. Also, those who buy their insurance in the nongroup market (on- or off-exchange) and a) earn too much to qualify for subsidies, and b) are not self-employed.

It's important to recognize that the self-employed do get a subsidy: the self-employment health insurance deduction. If your health insurance costs less than your total self-employed earnings, you can deduct the whole cost from your earnings. A recent study indicates that this deduction takes an average of 22% off the average self-employed tax filer's health insurance bill.

My question: what percentage of buyers in the nongroup market are not subsidy eligible and not self-employed? They are the only insured Americans who get no government aid paying for insurance. Most of them, that is: there is also a medical expense deduction available to any household that spends more than 10% of its Adjusted Gross Income on medical expenses, including insurance. Only expenses over 10% of AGI can be deducted.

Sunday, August 23, 2015

Biden in Pilgrimage to Democrats' Matron Saint

In honor of James Fallows' found art department: The NYT 'weekend briefing' on my phone had the image below directly beneath the headline below

Biden, Considering White House Bid, Meets with Elizabeth Warren

Let us hope he found what he was seeking.

Article here. The image was actually attached to this one.

Friday, August 21, 2015

How many of the uninsured know what's on offer? Not many, Urban finds

With ACA private plan market enrollment lagging initial CBO projections, one key question is whether those who qualify for aid but remain uninsured are doing so because they can't afford what's on offer or because they still don't know what's on offer.

The Urban Institute's latest Health Reform Monitoring Survey (HRMS), conducted in March 2015, indicates that both factors are at work, but comes down more on the side of ignorance of what's on offer. That's "good news" in the sense that ignorance can be rectified for less money than too-skimpy offerings -- though an Urban analysis released earlier this week warns that outreach and marketplace operations are underfunded, as are the subsidies intended to make coverage affordable.

The HRMS found that 43.1% of still-uninsured have household incomes that may be* in the range that qualify them for subsidized private plans on ACA exchanges. Another 27.7% have incomes that would qualify them for Medicaid under the ACA expansion and live in states that have accepted the expansion (including an unmeasured percentage of both undocumented and legally present immigrants** who do not qualify). 22.6% are in the "coverage gap," earning under 100% of the Federal Poverty Level in states that have refused to expand Medicaid. Just 6.6% of the uninsured earn too much to qualify for any aid.

Fully 60% of those likely to qualify for aid say they remain uninsured because costs are too high or they can't afford coverage. But... here is the key point, in my view: