Sunday, December 31, 2017

2017: A year of healthcare combat

2017 was the fourth year in which xpostfactoid focused mostly on healthcare access -- and more specifically, on ACA implementation (and, this year, on de-implementation, threatened and actual).

It was a year of intense combat (to be continued...) and high drama, and I participated not only via writing, but as an advocate in New Jersey working to help ward off ACA repeal, and as a Certified Application Counselor during Open Enrollment.

Below is a look back at a few posts, roughly one per month, that I hope might have contributed something to our understanding of where we've been and where we're headed in the struggle toward (or away from) universal healthcare access. These include:
  • Statistical measures of the extent to which Republican repeal-and-replace bills (AHCA, BCRA) would reduce subsidies to low income Americans (and relatedly, at the contrasting structure and aims of Democratic and Republican healthcare spending cuts).
  • Snapshots of who's benefited most (1, 2) and who's been left out (1,2,3) by ACA offerings.
  • A couple of passes (1, 2) at my vision of how U.S. healthcare might most plausibly and profitably evolve.
Here they are in chronological order, earliest first:

Medicaid envy in the rust belt (1/6/17)

  • A look at the effects of the ACA "deductible cliff" that looms at 200% FPL, the cutoff for strong Cost Sharing Reduction.
  • Confirming that CSR takeup is quite high at the lowest income levels, where the benefit is strongest.

  • Thanks to their refusal to expand Medicaid, states with 38% of the U.S. population account for 53% of marketplace enrollment -- and 60% of CSR enrollment. Some 2 million marketplace enrollees should be in Medicaid.
Psst, Democrats: Help Republicans out of the repeal box via Cassidy Collins (3/7/17)

  • A precursor to my NYT op-ed advancing the same proposal.
AHCA vs. ACA: Total subsidized shares of costs at different income levels and ages (3/19/17)

  • ACA "replacement" comes down to subsidizing much smaller shares of low income people's health insurance costs.
If Republicans had created the ACA marketplace (4/7/17)
  • They would have bullet-proofed it -- that is, showered love on the insurers, as they did when establishing Medicare Part D and boosting Medicare Advantage in 2003.
A Sparer means to universal health insurance (5/18/17)
  • From an expert source, a proposal for expanding Medicaid out.
An American road to single payer (6/17/17)
  • A Medicaid-ish replacement for the ACA marketplace with phased buy-ins for the unsubsidized, small biz, then all employers would move us toward uniform payment rates, with the government paying MCOs.
The real cost of benchmark silver for BCRA enrollees (7/1/17)
  • The senate ACA repeal-and-replace bill offered low income enrollees subsidized private plans with an actuarial value of 58%. This posts compares what enrollees with incomes under 200% FPL would have to pay to get coverage equivalent to CSR-enhanced silver (average AV 90%)
Healthcare spending cuts, Democrat style. Healthcare spending cuts, Republican style. (7/2/17)

Cutting payments to Medicare providers and Medicare Advantage plans is fundamentally different from capping federal Medicaid payments to states.

Go ahead, Trump, cut off CSR payments -- starting in 2018 (8/20/17)

A look at the paradoxical effects of CSR cutoff -- cheap gold and free bronze for the subsidized -- that did pan out in 2018. O Trump, if only thou hadst read xpostfactoid....

States vary in response to CSR uncertainty (with David Anderson, Charles Gaba and Louise Norris - 10/11/17)

More states than you'd think were able to offset the impact of Trump's cutoff of CSR reimbursement, producing anomalous deals for subsidized marketplace enrollees and at least reducing the damage for the unsubsidized.

The ACA is London after the blitz (10/2/17)
  • Republican sabotage has inflicted severe damage on the ACA marketplace and, to a lesser extent, on Medicaid. But as long as the law's funding sources and core programs remain intact, the damage is reparable.
Free bronze or CSR-boosted silver? The choice in 5 top ACA marketplaces (11/4/17)
  • A close look at how the CSR funding cutoff, and consequent loading of the cost of CSR onto silver plans only (in most states), has changed the choices facing the subsidized in the ACA's highest-volume markets.
Steering clear of the subsidy cliff in the ACA marketplace  (12/6/17)
  • After two years of steep premium hikes, individual market coverage is unaffordable for the unsubsidized in many markets.  A look at various ways the self-employed in particular can massage MAGI to stay on the right side of the subsidy cliff.

Lastly, a few interviews with top scholars and CMS vets:

What comes after 'catastrophic success'? Larry Jacobs on Democrats' healthcare options (3/29/17)

Not drowning but waiving: Timothy Jost on how Democrats might compromise responsibly on the ACA (7/12/17)

Compromise maybe a little? Urban's Blumberg and Holahan on what's next for the ACA (8/10/17)

ACA innovation waivers: A need for speed? Not so fast, says Emma Sandoe (9/8/17)

Joshua Peck looks back at's evolution (12/23/17)

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