Thursday, September 03, 2015

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

Updated 10/9/15, 4/6/16

Cost Sharing Reduction (CSR) subsidies are the ACA marketplace's 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. The top two post focused on California highlight price sensitivity; the Connecticut, New York, Maryland, Rhode Island Washington posts show how website design can shape the choice; and the posts on southern states mostly illustrate that lower income buyers, for whom the CSR benefit is strongest and the cost of silver lowest, are likeliest to access CSR.

Overall, according to the most recent enrollment figures for 2015, 56% of marketplace private plan buyers in all states accessed CSR.  About 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 7% of all buyers bought gold (AV 80%) and 3% bought 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)

Two major divides in the post-ACA individual market (4/1/16)

Supporting the biggest decision for ACA marketplace shoppers (11/3/15)

How bronze plans offer fool's gold to the Treasury (11/1/15)

Surprise! When silver plans are cheaper, more people buy them (10/24/15)

Addled by the metal level (10/5/15)

"Are marketplace plans affordable?" - on Commonwealth Fund survey (9/28/15)

The feds are taking CSR and premium subsidies away from many enrollees (9/8/15)

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 healthinsurance.org (8/12/15)

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

When silver is worth more than gold or platinum (on healthinsurance.org) 6/12/15
     addendum: On ACA exchanges, silver is usually not silver (6/12/15)

New data on cost-sharing reduction in ACA marketplaces (6/3/15)

Scrap the ACA's dual subsidy system? (Re CSR proposal from Richard Mayhew) 4/24/15

Affordable insurance vs. affordable healthcare (4/1/15)

A reduced ACA spending projection that no one should celebrate (3/12/15)

Add CSR to bronze plans 12/6/14

Rational choice in the ACA marketplace (12/2/14)


State Marketplace CSR profiles

Alabama (2015)

California - CSR takeup as influenced by bronze-silver price spreads (2015)

California - Santa Cruz vs. Monterey case study (2015)

California - CSR takeup (2015)

California  - rate increases and CSR (2015)

Connecticut (2015)

Connecticut (2014 - includes first half of open season for 2015)

Florida (2015)

Maryland 2015

Maryland (2014 - includes first half of open season for 2015)

Mississippi (2014)

Mississippi (2015)

New York (2015)

New York (2014)

Rhode Island (2014 - includes first half of open season for 2015)

Washington (2015)

2 comments:

  1. Thanks as always for your excellent detail work.
    I just cannot get my eyes off that figure of 200% of poverty as the cutoff for CSR benefits. If I remember correctly, that corresponds to an annual income of about $22,000 for a single person.
    If Obama had stood up in 2009 and said, "We have a health insurance reform that will give comprehensive insurance to persons under $22,000, either through Medicaid expansion or the back-door subsidies of tax credits and the CSR," there would have been polite response from the left and probably not much more.
    Instead, the millions of workers who make over $22,000 and do not have a generous employer had some hope that the ACA would help them too.
    But they lost out when the deficit hawks in both parties held the ACA to a relatively low budget target.
    Obama figured that half a loaf was better than none at all, and history may in fact prove him right.
    I wish that Sanders and Clinton would state far more directly that they want to expand the CSR's.

    ReplyDelete
  2. There is not much writing about the CSR on the net (many of the best articles and interviews are from you)...........

    So I have a few questions:

    a. Who thought up the CSR idea?

    b. What were the cost estimates (I have seen estimates of $17 billion a year, which seems very high)

    c. Why were CSR's cut back at about $18,000 of income for a single person?

    It feels like CSR's were a backdoor federal expansion of Medicaid. If numerous darn states are holding Medicaid at 100% of poverty (or less), then let's smuggle something close to Medicaid into a federal program that states need not improve.

    As a result, CSR's have the virtue of Medicaid -- helping those in need -- but also the terrible vice of Medicaid, which is the harsh 'cliffs' where the benefit disappears, and the pulling back of benefits if one's income goes up very slightly.

    The obsessive need to tie benefits to exact income is what caused the ACA to have terrible website performance in the first place. Now we have the obsessive pullback of benefits if a tax return does not equal projected income.

    Universal programs are far more desirable than need-based programs. The ACA is just one more reminder of this, not that we needed another reminder.

    Incidentally, a few of the Republican alternatives to the ACA have flat universal tax credits that might be based on age, or are just plain flat.
    Even a broken clock is right twice a day, and these reforms make initial sense to me!

    ReplyDelete

Share