Tuesday, June 09, 2015

Connecticut continues to crush it on Cost Sharing Reduction

Connecticut's ACA exchange, Access Health Connecticut, has provided me with a breakout of private plan buyers' metal level selection sorted by income level. The data makes clear that Connecticut continues to lead the way among ACA exchanges in helping low income buyers make choices that will provide them with the strongest financial protection.

There's two things to keep in mind about metal level selection. The first is that bronze plans, the cheapest level with the lowest premiums, usually have deductibles in the $5,000-6,600 range for an individual.  The second is that the Cost Sharing Reduction (CSR) subsidies available to low income buyers are available only with silver plans. CSR reduces deductibles, co-pays and maximum out-of-pocket costs radically for buyers with family incomes below 200% of the Federal Poverty Level (FPL) and much more weakly for buyers in the 200-250% FPL range. Bronze plans are almost always a terrible choice for buyers under 200% FPL -- those buyers are leaving a large extra subsidy on the table and rendering most healthcare unaffordable for themselves.

ACA exchanges vary widely in how effectively they get that information across. The key measure is the percentage of buyers with incomes under 200% FPL who choose silver plans.

In Connecticut, 89% of 2015 private plan buyers with incomes under 200% FPL chose silver.  I had preliminary numbers indicating as much back in December, and the ratio held steady through the end of open season and to June 1. Slightly more than a third of all enrollees, 34,601, have incomes under 200% FPL, and 30,641 of them bought silver and accessed CSR.* Just 6% bought bronze plans. That is a real triumph. 4% bought gold.

For buyers with incomes in the 200-250% range, CSR is a minimal benefit. At that income level it raises the actuarial value of a silver plan from 70% to just 73%, compared to 87% for buyers with incomes from 150-200% FPL and 94% for buyers under 150% FPL. Accordingly, silver plan selection generally drops suddenly at 201% FPL -- to 59% in New York and 50% in Colorado (2014 numbers).  In Connecticut this year, CSR takeup at 200-250% FPL is a relatively high 64% (9,866 out 15,459 buyers at that income level).

Bronze buyers were more affluent

Connecticut's total enrollment figures for plans at each metal level illustrate the wide variation in the income composition of state buying pools. Overall, 59% of the state's private plan buyers selected silver, and 22% bought bronze.Those numbers would seem to compare unfavorably with the March totals for the 37 states using healthcare-gov:  69% silver and 21% bronze. But those aggregate totals are misleading. First, Connecticut is the second wealthiest state in the nation, with a median household income of about $68,000, versus a national median of about 51,000 (as of 2013) and a doubtless lower median for the hc.gov states. Second, Connecticut implemented the ACA's Medicaid expansion, whereas three quarters of the buyers on healthcare.gov were in states that refused it. In Medicaid expansion states, eligibility for subsidized private plans begins at 138% FPL, with those below that level placed in Medicaid. In non-expansion states, eligibility for subsidized private plans begins at 100% FPL -- and about a third of buyers in those states were under 138% FPL

Thus, whereas just 17%% of healthcare.gov customers had incomes over 250% FPL -- the CSR cutoff -- in Connecticut, 51% did. Of those 52,740 ineligible for CSR, 33% (17,561) chose bronze. Another 23% chose gold. Among all buyers in Connecticut, 16% bought gold, compared to 6% on healthcare.gov (platinum takeup, however, was minuscule in Connecticut -- about 1%, vs. 3% on the federal exchange).

Connecticut had superior silver takeup where it counted -- under 200% FPL. Its 89% silver selection at that income level is well above the takeup on hc.gov, which I've estimated at 81-83%.

The high CSR takeup in Connecticut is no mystery. The Connecticut site shows CSR-eligible applicants silver plans first; that is, the menu of plans available to a given user defaults to silver, both in the pre-application "shop-around" feature and in the actual application. Other states that actively steer CSR-eligibles toward silver -- e.g., New York and Rhode Island -- show similar high silver takeup under 200% FPL.

It might have been hoped that when Kevin Counihan, Access Health CT's first CEO, moved to take charge of healthcare.gov for the 2015 open season, he would have ported over Connecticut's approach to CSR. So far that has not happened -- and HHS seems more fixated on touting low plan premiums than on selling plans that will actually provide coverage when people get sick. But here's hoping that best practices like effective CSR-steerage eventually trickle their way through whichever exchanges survive and emerge in coming years.

* Somehow, 158 silver plan buyers with incomes under 250% FPL obtained premium subsidies but not CSR subsidies. I don't know how that's possible. If I find out, I'll update. If you know, please let me know. UPDATE: Larry Levitt tells me that some silver plans on the exchange are offered as is to CSR-eligibles without a CSR adjustment - technically, CSR-enhanced plans are different plans from the same plan offered to an applicant at a higher income level. Next question: why? -- that is, why make silver non-CSR plans available to CSR-eligible buyers? Just another trap.

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