Monday, March 31, 2014

A correction in NYT ACA coverage

The New York Times has an excellent front-page story by Abby Goodnough today detailing the "blessings and hurdles" that various people seeking health insurance in Kentucky have encountered under the Affordable Care Act. A key point in one of the marquee narratives did not compute, however.

A certain David Elson, 60, was reported in today's print editions to earn $22k and be eligible for cost-sharing subsidies that would lower his deductible -- but also unable to pay his first monthly premium, reduced via a monthly subsidy of $250 to $350.  In fact, a 60 year-old nonsmoker anywhere in the country earning $22k should be able to access a silver plan for around $100 per month, with Cost Sharing Reduction (CSR) reducing the deductible to under $1000 per month.

Sunday, March 30, 2014

A love lyric for Sunday

Apropos of nothing, I was running Me and Bobby McGee through my head the other day when it occurred to me that it's the best love lyric -- or lovelorn lyric -- I can think of. It has everything. The sharp in-the-moment snapshot:

With them windshield wipers slapping time
and Bobby clapping hands,
we finally sang near every song that driver knew.
The big-picture zoom-out:
From the coal mines of Kentucky
to the California sun,
Bobby shared the secrets of my soul,
standing right beside me Lord through
everything I've done,
Bobby's body kept me from the cold.
 And, above all, the keenest lament in songdom:
And I'd trade all of my tomorrows
for a single yesterday,
feeling Bobby's body close to mine.
That's not abject, it's not maudlin -- it's just the sum of human despair.

Friday, March 28, 2014

Who took your Medicaid away?

In the long, long runup to full implementation of the Affordable Care Act, Jonathan Bernstein was fond of predicting that many people who gained coverage through the new law would not be aware that the ACA -- or "Obamacare" -- was responsible. Over time, the ACA would "disappear." The state exchanges make no reference to the Affordable Care Act -- and neither, for that matter, does Healthcare.gov. As for the Medicaid expansion, Medicaid is Medicaid.

That forecast will probably come true over time -- though perversely, the exchanges' malfunctioning in the early months probably made more people aware of them in the first signup season.  Meanwhile, the political insight underlying the forecast -- that most people pay very little attention to government initiatives and political battles -- makes me wonder about a shorter-term political question.

Thursday, March 27, 2014

The Obamaiad


Early this month, Obama favored Jeffrey Goldberg for a second time with a deep dive into his thinking about the Middle East. This time (for once) I'm going to keep my precis short.* And dear reader, please help me out of a metrical jam by internally pronouncing "neocon" really fast:

Obama, to clear neocon fog,
unburdens himself to Gold blog.
"Though our power's not puny.
we'd have to be loony
to get between Gog and Magog."

And then we were whipsawed off to another quarter:

Wednesday, March 26, 2014

ACA enrollment: driving uphill in a snowstorm.

As George W. Bush's second-term HHS Secretary, Michael Leavitt knows something about rocky rollouts of new government health programs, having overseen the launch of the Medicare Part D prescription drug coverage program, now broadly regarded as a success (e.g., by Leavitt).  As chair of health consultancy Leavitt Partners, he's also contracted with several state governments to help set up their ACA exchanges -- a role that subjected him to fierce conservative fire when he was named head of  Mitt Romney's transition team.  In 2011, he urged Republican governors to be practical and take control of their own state exchanges rather than cede the effort to the federal government. Notwithstanding his many qualms about the Affordable Care Act (e.g., its funding mechanisms), he is a believer both in state exchanges and in extending coverage to uninsured Americans.

It is not surprising, then, that in a January interview with Julie Appleby of Kaiser Health News, Leavitt signaled considerable empathy for the besieged team trying to get the ACA launched. Asked about one of the administration's many adjustments to rules and deadlines -- the extension of catastrophic plan eligibility to those whose 2013 plans were canceled -- he offered a striking metaphor that captures the administration's mindset and m.o.:

They’re trying to find ways to keep enough momentum moving forward.  Think about it like a big snowstorm, and you’re trying to drive a car uphill. The most important thing is to keep momentum and keep it out of the ditch. You might swerve from side to side, or might even do a circle or two. But if you can keep the momentum going up the hill, then you can ultimately succeed. They’re driving on a slick road up a stormy hill. They will do some things they hadn’t anticipated. But forward momentum is their game. At the end of the day, we’ll find out. They may get there; they may end up in a ditch. They may have a collision. Who knows? 

Tuesday, March 25, 2014

Between Scylla and Charybdis in a hospital bed

The Commonwealth Fund is out with a report*suggesting that the ACA has the potential to reduce the substantial ranks of the nation's underinsured -- those who currently either spend a percentage of their incomes on premiums deemed unaffordable by ACA formulas or who are exposed to out-of-pocket medical expenses high enough to deter them from getting needed care. Jonathan Cohn overviews the core conclusions here.

While affirming that ACA benefits are well-targeted at those likeliest to be underinsured, the report also highlights ways in which the ACA's Qualified Health Plans  (QHPs) may also underinsure -- chiefly via the high deductibles and out-of-pocket cost limits prevalent in bronze plans, selected thus far by 19% of QHP buyers. That much was not news to me. But then the report flagged another underinsurance hazard that brought me up short -- and brought a memory flash. My emphasis below:

Monday, March 24, 2014

Why go through Healthcare.gov or state exchanges if you're subsidy-ineligible? Good reasons for a few

One sub-theme in my article about people who are buying health insurance in the individual market but do not qualify for ACA subsidies was that most of them saw no reason to buy insurance through Healthcare.gov or the state exchanges. Doing so would only add a layer of bureaucracy -- and, given the still-shaky technology, uncertainty.  One person interviewed however ("Jonathan"), did buy on-exchange, because he felt there was some possibility that his income would drop enough during the year to make him and his wife subsidy-eligible. In that case, he could collect the subsidy at tax time. That would be impossible if he had bought off-exchange.

Another interviewee in the piece, Karen in Colorado, referred me to her broker -- call her Amy -- who works mainly with clients who are subsidy-eligible.  Amy cites three reasons why some customers who are not subsidy-eligible might choose to buy on-exchange. First, if the monthly deadline for getting insured as of the first of the next month falls on the weekend, last-minute buyers can apply through the exchange. Second, one insurer, Colorado HealthOP, the state's nonprofit co-op, is only available through the exchange. Finally, in a variation of Jonathan's reasoning, Amy suggests that those who are near the subsidy line should consider signing up through the exchange and taking any subsidy for which they prove eligible as a year-end tax refund rather than as a monthly contribution to their subsidy, so they don't end up owing money if they underestimate their income.

Saturday, March 22, 2014

ACA signup: it ain't over when it's over

[Update, 3/26: Yesterday's announcement that a "special enrollment period" will be granted to anyone who claims s/he tried to enroll before 3/31 underscores the year-round fluidity of enrollment outlined below.]

Anyone who's paying attention knows that March 31 is the open enrollment deadline. After that date, you can't "get covered" for 2014.

Unless, that is, you qualify for Medicaid -- or experience a "qualifying life event" such as a job loss or divorce or childbirth. That's a lot of people.

Roll on, Medicaid, roll on

Medicaid enrollment is continuous. State agencies and private-sector partners work year-round to get kids enrolled in CHIP.  Adults newly eligible in states that have enacted the ACA's Medicaid expansion can enroll year-round too. Enrollment won't be possible through Healthcare.gov, but individuals can apply through conventional channels, and nonprofits working to enroll the uninsured will continue their outreach after 3/31.

Friday, March 21, 2014

Yes, Mitt, it's good to be able to fire "people"

One more outtake from my article about the satisfied unsubsidized -- those who were already buying health insurance in the pre-ACA individual market, earn too much tot qualify for subsidies, but still benefit because they or a family member have a pre-existing condition.

One person featured was Karen, a self-employed artist whose preexisting condition did not lock her out of the market but did lock her into one plan for ten years. The condition stemmed from a rare, benign tumor that required complicated treatment. Initially, that condition did not shut Karen and her husband out from affordable coverage.  But the full tale of how she was locked in by one insurer, what it meant to be locked in, and how the ACA provided relief is worth some elaboration.

Working through a broker many years ago, Karen and her found a plan from Blue Shield for a few hundred dollars per month. "But the rates went up 20 to 30 percent every year," Karen recalls. "I kept renewing -- I was terrified to change anything -- I thought even changing to a different policy with the same company might result in rescission." By 2013, the couple was paying $1,200 a month.

Larry Levitt, a senior vice president at the Kaiser Family Foundation, shed some light on the probable cause of those rate hikes.  Before the ACA took full effect, "It was uncommon (and arguably illegal) for insurers to raise an individual’s premium because of their health status. What was more common was for insurers to close certain product lines to new sales. People in those products who were healthy could get other coverage, often with the same carrier. People who were sick were stuck there and faced big premium increases, which applied uniformly to everyone in the product. The big premium increases you used to see in the individual market were often in these closed blocks of business."

Thursday, March 20, 2014

When a 30 year-old's health insurance decision was a matter of life or death

Yesterday the Atlantic ran an article of mine about the ACA's satisfied unsubsidized -- those who earn too much to qualify for ACA subsidies but were happy with the insurance they found for 2014 under ACA rules because they or a family member have a pre-existing condition.

The original draft was cut down quite a bit, necessarily and appropriately for a general interest publication. Personally, though, I find the full stories of how these "health insurance veterans" navigated the individual market over the course of a decade or two fascinating. One outtake is below; I'll put up another tomorrow.

An individual market vet prefers PPOs

Frank, 40, a film producer, and his wife Sharon, also 40, a film editor, live and work in Los Angeles, among the legions of independent contractors in the film industry. The couple has a 5 year-old son. Sharon has a preexisting condition -- she was diagnosed with thyroid cancer in 2003, which was fortunately caught early and treated successfully.  Intuition and prudence probably saved Sharon's life, as well as the couple's finances. Frank's recollection of the way two young professionals navigated a world in which health insurance was not a given provides a window into the problems the ACA is designed to address.

"At that time, we usually didn't get health insurance," Frank recalls, "but Sharon was working on a program that did provide insurance.  The job ended, and she was going to move on to another thing, and was like, you know, 'I am going to pay for the COBRA and continue my health insurance.' She felt there was something wrong with her neck.  I remember thinking, you don't really have to do that. I didn't have health insurance. I had left where I was and was trying to do some writing, and my attitude was, 'we don't have the money.' She said, 'I really think it's important.'  And she was dead on the money, because she had thyroid cancer.  She was lucky, it wasn't terribly severe, she caught it pretty early, but it took some time -- she had to have three separate surgeries."

Wednesday, March 19, 2014

The ACA's satisfied unsubsidized

Over at the Atlantic, in my off-xpostfactoid reporting debut, I have a story recounting the experiences of several people
whose family income disqualifies them for subsidies and who bought insurance on the individual market for 2014. All had family members with preexisting conditions, which means they benefited from the ACA's prohibition on basing price or eligibility on medical history. All had been paying above-market rates or faced limited choices because of a family member's medical history.
As the article points out, this is a very large subset of the U.S. population  - somewhere between 19 to 50 percent of individuals, according to an HHS report overviewing various studies -- and a larger proportion of households. Conversely, a large number of subsidy-ineligible buyers who were in the individual market for insurance in 2013 and do not have preexisting conditions have seen their premiums rise, as the article acknowledges at various points. I have recounted the experiences of two of them here.

I have been trying my hand at reporting -- getting information from people and writing it down in context -- since early February.  The resulting posts to date are listed below.

What if the (Republican) dog catches the Obamacar(e)?
Children, CHIP, Medicaid and the ACA
Switching from COBRA to the ACA exchanges
Healthcare.gov comes through in a complicated situation
HealthSherpa claims to shorten ACA signup process
COBRA or the ACA?

Tuesday, March 18, 2014

Sorry, gay marrieds: health insurers have to recognize your marriage

Equal protection under the law is a precious concept. For some gay married couples, however, recognition of their marriage by health insurers, newly required by HHS, may result in equal rejection under the law -- for Affordable Care Act subsidies.

Until March 14, insurers in states that do not recognize gay marriage could refuse to insure same-sex couples under the same policy.  This cost the victims nothing but disrespect, as there is no marriage discount in the nongroup insurance market.  Nonetheless, HHS has now clarified, an insurer is deemed to illegally discriminate if:

The issuer chooses not to offer, on the same terms and conditions as those offered to an opposite-sex spouse, coverage of a same-sex spouse based on a marriage that was validly entered into in a jurisdiction where the laws authorize the marriage of two individuals of the same sex, regardless of the jurisdiction in which the insurance policy is offered, sold, issued, renewed, in effect, or operated, or where the policyholder resides.

Sunday, March 16, 2014

Obamacare to be repealed and replaced in 2017...

In at least one state, that is.

Almost everything that Republicans who profess to want to reduce the ranks of the uninsured on the ACA's scale say they want to do can be done via state waivers effective 2017.

Here is a summary of ACA Sec. 1332, Waiver for State innovation, from an ACA outline posted on the Democratic Policy and Communication Center website:
Beginning in 2017, allows States to apply for a waiver for up to 5 years of requirements relating to qualified health plans, Exchanges, cost-sharing reductions, tax credits, the individual responsibility requirement, and shared responsibility for employers. Requires States to enact a law and to comply with regulations that ensure transparency. Requires the Secretary to provide to a State the aggregate amount of tax credits and cost-sharing reductions that would have been paid to residents of the State in the absence of a waiver. Requires the Secretary to determine that the State plan for a waiver will provide coverage that is at least as comprehensive and affordable, to at least a comparable number of residents, as this title would provide; and that it will not increase the Federal deficit.

Friday, March 14, 2014

How Obama might ditch the individual mandate and save the ACA

The "doc fix" legislation that would replace the current unsustainable physician payment formula for Medicare while transitioning payments away from fee-for-service is a rather remarkable instance of substantive bipartisan cooperation. Republicans and Democrats have agreed on methods of bundling payments and paying for quality that, whatever their merits, would require intensive government monitoring.  Had these methods been incorporated in the Affordable Care Act, Republicans would doubtless be demonizing them as relentlessly as they have the thus-far-dormant Independent Payment Advisory Board for Medicare, notwithstanding that Paul Ryan included a similar board in his 2009 Patients' Choice Act.

The doc fix must be "paid for," however, since the un-implementable cuts to doctors' payments mandated by the law they would replace are incorporated into the federal budget baseline. And in the pay-for, Republicans in both houses of Congress have introduced a poison pill: delay or repeal the Affordable Care Act's individual mandate. That would save money by ensuring that far fewer people enroll in Medicaid or enroll in the ACA's Qualified Health Plans (mostly with federal subsidies). CBO estimates that  the 5-year delay proposed by the House GOP would result 13 million fewer insured Americans by 2018: seven million fewer buying private health plans, five million fewer in Medicaid, and a million eschewing employer-provided insurance.

As written, such a bill would probably destroy the ACA, draining the risk pool and thus inducing insurers to jack up prices. That's assuming no viable replacement for the mandate, however.  In fact the outline of a viable replacement exists, in the ACA "repeal and replace" proposal introduced in the Senate this past February by Senators Coburn, Burr and Hatch.

Thursday, March 13, 2014

Healthy, relatively wealthy, and hit by ACA rate hikes

Past and forthcoming posts of mine have looked (and will look) at the situations of several people who do not qualify for ACA subsidies but were still satisfied with the coverage they obtained for 2014.  That is because they all either had pre-existing conditions or were in a household where someone else had one -- as do a very large percentage of Americans, particularly those over forty in households larger than one person. As for the young, the overwhelming majority of them are subsidy-eligible.

At the same time, of the 12-18 million people who bought insurance in the individual market in 2013, nearly half were not eligible for subsidies, according to the Urban Institute. Of the substantial percentage of them who were not punished for a pre-existing condition in the pre-ACA market, many will pay more for coverage in 2014 than they did last year (click here for more statistical detail on these fronts).  Some will get better coverage for the extra money, but some won't, and some will get coverage they would not buy if they did not have to.

In recent days I've heard from two of them, neither unsympathetic to the ACA (yes, my readership is skewed that way).  Sam, living in New Hampshire, was hit hard by a premium increase this year.  If the timing of certain life events had been somewhat different, however, he might have benefited directly from the law's enactment. His initial note indicates somewhat unusual circumstances:

Tuesday, March 11, 2014

Near ACA subsidy cliff? Covered California spox suggests calling an accountant

I have noted on several occasions that health insurance shoppers near the edge of the ACA subsidy cliff should see an accountant:
The premium subsidy cliff for older exchange buyers is more serious, especially if there are two of them in a household.   To return to an example I cited previously, take a pair of 55 year-olds with a 23 year-old son or daughter. For them, the cheapest silver plan in Essex County New Jersey is $1,357 per month.  If the family income is $63,000, the monthly subsidy is $876, their monthly payment to $481.  At $79,119 (299% FPL), the subsidy has dropped modestly, to $756. At $79,121, it's -- zero.

In this case, some serious money is at stake at the cliff. But it seems to me that the likeliest reaction is not to reduce hours or income but to manipulate MAGI -- especially since the stakes are higher as you go up the income scale, and so those at the steeper cliff's edge are likely to be more sophisticated. In fact, they're likely to be self-employed -- i.e., earning a relatively decent income while lacking access to employer-sponsored insurance. And as I've noted before, the taxable income of the self-employed is notoriously malleable at the margins. Sticking another thousand or two in an individual 401k or buying yourself a new computer at Christmas may put you a few inches back from the subsidy cliff.

Monday, March 10, 2014

Gallup: A shift away from employer-sponsored health insurance?

The top line in Gallup's latest polling on Americans insurance status is that the percentage of uninsured Americans continued to drop throughout the first quarter of 2014 -- after reaching an all-time high in the third quarter of 2013. Greg Sargent digests the apparent good news with the appropriate dose of caution here. But I want to call attention to another possible significant trend in the Gallup data, though it too could be mere statistical noise.

Th survey results seem to reflect a shift away from employer-sponsored insurance (ESI) towards privately-purchased plans, Medicaid, and Medicare (the last is inevitable as America ages):

Sunday, March 09, 2014

COBRA or the ACA? cont.

A while back, I put up a pair of posts examining the factors to be weighed by people faced with a choice between continuing an employer-sponsored health plan via COBRA or buying a health plan on an ACA exchange.

Once case involved a couple, ages 62 and 57, navigating a simultaneous retirement and divorce. As both are subsidy-eligible, an ACA plan yields big savings. The other involved a single New York-based 31 year-old who's been continuing good coverage via COBRA and is at the edge of subsidy eligibility. An ACA plan would slash his monthly fee considerably, even without subsidy, while offering more restrictive coverage.

COBRA is likely to be the better choice, however, for older insurance-seekers who are not eligible for subsidies.  Employer-sponsored insurance is usually not age-rated -- that is, it doesn't cost more for older plan members -- and the coverage it offers generally has a higher actuarial value than the ACA's benchmark silver plans. ACA plans are more modestly age-rated than plans in the pre-ACA individual market -- the ratio of oldest to youngest is capped at 3-to-1, versus the 5-to-1 cap that most states allowed pre-ACA. Still, many older buyers can leverage the lack of age rating in their ESI to get better coverage for the same price than on the exchanges.

Saturday, March 08, 2014

Stat shots of the unsubsidized uninsured

Barring any slip between cup and lip, I should have an article coming out soon that recounts the experiences of several people who do not qualify for ACA subsidies but who have bought insurance plans for 2014 in the new ACA-enacted universe.  A preview is here. In the process, I've tried to get a grip on just how many such people there may be and how they're likely to fare under the ACA.

A Health Affairs post by Urban Institute researchers Lisa Clemans-Cope and Nathaniel Anderson has helped me bring the statistical picture into focus. I should say into relative focus, because there's a good deal of uncertainty in every stat shot. With that caveat, here goes:
  • Estimates based on 2009 surveys conducted by different federal agencies as to how many Americans were buying insurance in the individual market vary widely, from 9.1 million in the Medical Expenditure Panels Survey to 25.3 million in the American Community Survey. A mid-range estimate from the National Health Interview Survey (NHIS) conducted by the CDC is 14.0 million.

  • In December 2013, the Health Reform Monitoring Survey found that 18.6% of those insured in the individual market received cancellation notices attributing cancellation to the ACA, and  another 6% had their policies cancelled for other stated reasons.  Using that data, and the NHIS estimate of 14 million in in the individual market, Clemans-Cope and Anderson  estimate that 2.6 million people received policy cancellations that their insurers blamed on the ACA (and one might infer another 840,000 cancelled for other stated reasons).

  • According to a March 2013 Urban Institute study, 48.6% of those currently in the individual market are ineligible for subsidies. If that ratio is right, and the estimate of 2.6 million cancellations attributed to the ACA is on target, about 1.2 million people who received cancellation notices blamed on the ACA would be ineligible for subsidies.  Of those, some probably had pre-existing conditions and will do better under the ACA.

  • The Urban Institute study estimates the current individual market at 12.8 million, 6.2 million of whom would be subsidy-ineligible.

Thursday, March 06, 2014

OOPS! Don't forget the lower-profile Obamacare subsidies

Robert Laszlewski, one of the better-informed of the Affordable Care Act's relentless critics, doubts the law's sustainability based mainly on one much-reiterated premise:

The biggest flaw is that the product the Obama administration is trying to sell to consumers is not the product people want to buy.

By that he means that there are millions of people (like himself) who are forced to subsidize insurance for the sick (who can no longer be charged more based on their medical condition) or the relatively old (who can now be charged a mere three times more than the youngest plan members, rather than up to five times more, as was common pre-ACA) -- or to buy coverage for services they don't want, such as childbirth or mental health or substance abuse treatment.

It's true that some people in those categories will pay more for insurance on the individual market under the ACA than they did previously, though probably for only a short period (historically, most people buying insurance in the individual market  have not stayed long).  But I don't think they will affect the law's long-term viability by fleeing the market in droves -- because there probably are not droves of them.

Despite prices and deductibles that can look daunting to, say, healthy subsidy-ineligible 27 year-olds, a majority of people who lack access to employer-sponsored insurance are likely to be satisfied with their ACA options.  Two large categories are likely to be satisfied: the subsidized, and those whose household includes someone with a preexisting condition.

Tuesday, March 04, 2014

Is the ACA reducing underinsurance?

About 16 percent of the U.S. population has no health insurance. Reducing that percentage by more than half is a primary purpose of the Affordable Care Act. As subsidized coverage in a reformed individual market has become available for the first time in 2014, news coverage has understandably focused mainly on how many previously uninsured people are gaining coverage.

But the ACA also rewrote the rules governing what kinds of coverage health insurance policies had to offer. The revamp was designed to address a problem nearly as pressing as reducing the ranks of the uninsured: tens of millions of Americans were also underinsured, or unreliably insured.  Coverage was subject to annual or lifetime caps and to arbitrary rescission.  Essential benefits such as hospitalization, mental healthcare, rehabilitative care and childbirth were excluded from many policies.

Many ACA provisions designed to end underinsurance have been in effect for some time  -- the ban on lifetime coverage limits has been in place since September 23, 2010, as has mandatory free coverage for a long list of preventive services, including birth control  I would like to examine the extent to which serious uninderinsurance has already been reduced.  What follows is a kind of scope-of-question outline -- a few questions, a few premises, a few observations.

Monday, March 03, 2014

Are gays Putin's Jews?

Copping to next to no prior knowledge here, a claim about Putin's motives and world view caught my eye once, then twice in my weekend reading about the Ukraine crisis:

First, from Timothy Snyder:

Russian intervention in Ukraine is directed against the EU, which Moscow has now decided is a threat to its interests and indeed a civilizational challenge. President Putin’s global crusade against gays has become, during these last few weeks, a specific foreign policy doctrine directed against the EU. The Kremlin has made clear that control of Ukraine is one step towards the creation of a Eurasian Union, a rival organization to the EU which will reject European “decadence” in favor of a defense of Christian heterosexuality etc. For months press organs close to the Kremlin have referred to Europe as “Gayropa.”

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