Tuesday, March 20, 2018

Health Insurers' risk corridor suits could seek a lot more than $12.3 billion

Stephanie Armour reports in the Wall Street Journal that a decision should come down soon from the U.S. Court of Appeals for the Federal Circuit in two of the risk corridor lawsuits against the federal government filed by health insurers seeking reimbursement for losses in the ACA marketplace. Those suits seek a total of about $12.3 billion in risk corridor payments the government failed to make in 2014, 2015 and 2016.  In fact, the bill could be considerably higher if insurers prevail. That's what I'd like to spotlight, below.

The risk corridors, to review briefly, were one of three risk management programs the ACA established to cushion health insurers' plunge into an unprecedented market structure. Insurers with losses above a fixed threshold would get a large chunk of them reimbursed by the federal government, while those with profits above a mirror-image threshold would pay a chunk of those gains in. The ACA statute states that insurer losses will be paid according to this formula, and HHS guidance through 2013 affirmed this. In early 2014, though, with the program under attack from Marco Rubio and other Republicans, HHS and CMS indicated that reimbursements would be revenue neutral, and reduced if the contributions from profitable insurers did not cover unprofitable insurers' losses. Republicans then, in omnibus funding bills for FY 2015 and 2016, banned the agency from using its funding streams to pay any shortfall beyond insurers' contributions. In October 2015, CMS announced that it would pay just 12.6% of $2.87 billion in insurers' compensable 2014 losses. A cascade of failures among the nonprofit insurance co-ops established (and underfunded) by the ACA followed. How many of those co-ops would have survived had the risk corridor promises been kept is debatable.  By 2016, the last year of the program, unpaid risk corridor losses totaled $12.3 billion.

The insurers have a clear case on the merits, regardless of what the courts decide about the paradox of funds promised by statute by unappropriated by Congress (one of several such paradoxes generated by serial Republican sabotage of the ACA, all of them eroding the full faith and credit of the U.S. government). One aspect of the complaint highlighting the extent of the moral debt, and possibly the financial one, caught my eye in the class action complaint joined by some 150 insurers, Health Republic Insurance Company v. The United States of America.

Saturday, March 17, 2018

Who'd be hurt by restored federal CSR funding? A snapshot from Maryland

Update: snapshot from Rhode Island added at bottom, 3/19.

Based on 2017 ACA marketplace enrollment data, Aviva Aron-Dine of the Center on Budget and Policy Priorities estimates that as many as 36% of marketplace enrollees might be harmed if federal funding for Cost Sharing Reduction (CSR) payments is restored by Congress. That's an upper bound, if all who could potentially benefit in 2018 by switching from silver plans to other metal levels did so. It comes to about 22% of all individual market enrollees, since about 40% of those in ACA-compliant plans bought their plans off-exchange -- and so are ineligible for subsidies.

One sample of data already available for 2018 -- Maryland's -- indicates that Aron-Dine's estimates are on target. I have something of a quibble with how the potentially harmed population is defined, however.

Wednesday, March 14, 2018

Inflation that tracks your march to death

As the ACA-compliant individual market shuddered under a second consecutive round of premium hikes averaging well north of 20% in 2018, I took in an earful of stories from people in their fifties and sixties who were paying full freight, partly recounted here.

One thing that struck me somewhere along the way is the impact of the personal inflation hit induced simply by aging. In the best of markets, late-middle-agers will pay 4-5% more in many years simply for getting a year older. that's  a turbo-charge to double-digit hikes for everyone (particularly for couples).

David Anderson, who may do a more analytical post about this, was kind enough to pull an ACA age rating chart for me. I begin at age 45,  just before price increases accelerate. This is for one bronze plan in Arizona:

Monday, March 12, 2018

We're not in ACA Repeal-and-Replaceville. We're in Cassidy-Collinstown

Peter Suderman argues that The GOP Accidentally Replaced Obamacare:
Republicans, having failed to repeal Obamacare, have stumbled, almost accidentally, into replacing it. For better and for worse, and with little coherent vision at work, they are making Obamacare their own. And over time, they are likely to embrace it.
There's a good degree of truth in this. Suderman runs through the panoply of Republican legislative and administrative whacks at the ACA's structure and benefits on the federal and state level: individual mandate repeal; creation of a parallel market of non-ACA-compliant plans; regulatory hurdles to Medicaid enrollment aimed particularly at the ACA Medicaid expansion population; repeal of the Independent Payment Advisory Board for Medicare. And Suderman adds a creative future-cast twist: If Democrats take power and pursue a fully or quasi-single payer system, Republicans may end up defending the relatively moderate -- and Republican-moderated (or adulterated) -- status quo, i.e. the ACA.

Suderman's neat conceit leaves a core factor out of the equation, though: funding.

Thursday, March 08, 2018

Can Medicare Advantage plans lower enrollees' out-of-pocket costs? A talk with Kaiser's Juliette Cubanski

A month ago, I took a look at the resources available -- or unavailable -- to Medicaid enrollees who face a "Medicare cliff" when they turn 65 -- that is, a transition from having basically all their medical expenses covered to a program that carries a monthly premium for most of $134, requires 20% copays for most medical services and potentially huge outlays for inpatient hospital care, and has no cap on out-of-pocket costs.

Some 10.7 million Medicare enrollees are "dual eligibles" of one kind or another -- enrolled either in ABD (Aged/Blind/Disabled) Medicaid, which provides comprehensive coverage,  or in Medicare Savings Programs (MSPs), which offer more partial coverage, or in some cases both.  But the income thresholds for all of these programs are lower than for Medicaid in states that accepted the ACA expansion, and the asset tests for the MSPs are quite low -- $7560 for an individual, excluding home and car.  The application process is complex, and help and outreach are underfunded.  (For a useful overview, see Josh Schultz.)

For the many seniors of quite limited means who don't qualify for MSPs, I wondered to what extent Medicare Advantage (MA) plans might function as a de facto discount plan. About one third of current Medicare enrollees are in MA plans. MA plans usually incorporate a Part D drug plan, and often the premium is lower than the combined premium for Medicare Parts B and D (e.g., in zero-premium plans, in which enrollees pay only their Medicare Part B premium).  MA plans may offer extra benefits, such as dental, vision or hearing coverage (often quite limited). Perhaps most importantly, they cap out-of-pocket costs at a maximum of $6,700 per year. The main tradeoff is acceptance of a limited provider network -- often quite limited.

I spoke to Juliette Cubanski, Associate Director of the Program on Medicare Policy at the Kaiser Family Foundation and lead author of a recent Kaiser report on healthcare spending in Medicare households, about the appeal, real or perceived, of Medicare Advantage plans for lower income Medicare enrollees.  An edited q-and-a is below.

xpostfactoid: Does Medicare Advantage often offer effective de facto discounts over traditional Medicare?

Tuesday, March 06, 2018

Getting creamed in New Jersey: Testimony of the unsubsidized

As noted in my last post  (and called for in my January op-ed), a bill introduced in the New Jersey Senate  (S-1877) last month would implement a state individual mandate and earmark the penalty revenue for a state reinsurance program. A companion bill (S-1878) would authorize pursuit of an ACA innovation waiver to seek federal funding for the reinsurance, as Alaska, Oregon and Minnesota* have successfully done.

BlueWaveNJ, a grassroots group for which I volunteer, supports these paired bills. We have lots of members who insure themselves through the individual market -- many subsidized, and many unsubsidized. In support of the bills, we collected testimony from the latter group -- who were slammed by this year's premium increases. Yesterday, I submitted their testimony at a hearing of the state Senate's Budget and Appropriations Committee, which approved amended versions of both bills.

The testimony is posted here, on the BlueWaveNJ website. As the personal narratives indicate:
These are individuals in their fifties and sixties now facing premiums in the $600-1000/month range and family premiums north of $2000.  They describe tough choices between narrow network coverage and still-higher premiums, or between narrow networks and down-sizing to bronze plans that offer basically catastrophic coverage. Subsidized members are faced with a similar choice between ultra-narrow networks and steep premium increases or reduced coverage.

Saturday, March 03, 2018

New Jersey bill aims to block Trump admin's proposed rule for Association Health Plans

New Jersey is relatively well defended against the Trump administration efforts to fragment the individual and small group health insurance markets by allowing short-term plans to be sold for year-long terms and easing the path for association health plans (AHPs) to be deemed employers in their own right and so gain large group status.

New Jersey bans short-term plans outright, and tightly regulates association plans (the main species of  multiple employer welfare arrangements, or MEWAs, that is, plans that cover the employees of two or more unrelated employers). In Jersey, MEWAs are regulated as small group plans,even if they're self-funded. (While self-funded plans generally are subject to federal oversight under ERISA, which preempts state law, there has long been an exception enabling states to exert all but full  regulatory control over MEWAs.)

As small group plans, MEWAs in New Jersey are subject to the full suite of ACA coverage rules, including Essential Health Benefits. Small group plans are not available to self-employed individuals, or to small businesses that have no employees other than owner and spouse.. Under the Department of Labor's proposed rule for AHPs, these self-employed individuals and small business owners would be eligible to enroll in AHPs that gain large group status.

Does the proposed rule threaten New Jersey's current regulation of AHPs? That's not clear. On the one hand, "The proposed rules also would not modify the States’ authority to regulate health insurance issuers or the insurance policies they sell to AHPs" (p. 42). At the same time, Kevin Lucia, a professor in Georgetown University's Health Policy Institute, cites concern among experts "that this is potentially going to have to be litigated. If you're an association and you set up in Oklahoma, if you read these regulations, you think, well I can sell everywhere -- and yet, California tells me I can't come in?"

Bottom line for Lucia: "It's a big question whether states will be able to maintain their authority to regulate MEWAs."

That uncertainty likely drives a provision addressing MEWAs in a bill introduced in the New Jersey legislature, S-1877, that would establish a state individual mandate to replace the federal mandate effectively repealed by the Republican Congress.

Tuesday, February 27, 2018

Hey Senator Warren, Medicare Extra fills your prescription

Last month, at the Health Access 2018 conference, Elizabeth Warren decried rising out-of-pocket costs required in employer-sponsored health plans and demanded that a new round of healthcare reform "require private insurers to be just as affordable as public insurers like Medicare and Medicaid.”  (I discussed the speech at some length here.)

That formulation struck me as problematic in several ways: 1) Medicaid and Medicare offer very different levels of affordability (except where they're merged for dual eligibles); 2) employer-sponsored insurance, on average, is "just as affordable" as Medicare and in fact provides better protection against crushing out-of-pocket costs than traditional Medicare; and 3) Warren bashed insurers alone for price-gouging without mentioning provider payment rates, which would have to be squashed down if commercial insurance were subject to stricter affordability mandates.

Perhaps, though, Warren had some inkling of the Medicare-for-all-who-need-or-want-it plan that was brewing at the Center for American Progress, released yesterday.

Saturday, February 24, 2018

Medicare Extra creates an all-payer system -- via a bank shot for employers

Like many "Medicare for All" or "Medicare for Most" plans that preceded it, the Center for American Progress's Medicare Extra plan, released on Feb. 22, preserves employer-sponsored insurance. Employers can opt to continue to offer their own plans, with a minimum actuarial value of 80% (near the current employer average). They can sponsor their employees' entry into Medicare Extra. Or they can leave their employees to enter the system on their own and reimburse the government.

The plan spells out two reasons for maintaining employer-sponsored insurance: keep employer dollars in the system, and minimize disruption (if you and your employer like your plan, you can keep it):
U.S. employers currently provide coverage to 152 million Americans and contribute $485 billion toward premiums each year. Surveys indicate that the majority of employees are satisfied with their employer coverage. Medicare Extra would account for this satisfaction and preserve employer financing so that the federal government does not unnecessarily absorb this enormous cost.

Friday, February 23, 2018

Timothy Jost and Harold Pollack weigh in on Medicare Extra

Yesterday, the Center for American Progress released a sweeping but incremental proposal to vastly expand Medicare and transition the U.S. to a more or less "all-payer" system, in which whatever private insurance remains (in employer plans, and Medicare Advantage-like plans) pays more or less the same rates and offers more or less the same benefits as a revamped Medicare, dubbed Medicare Extra. Medicaid and CHIP would also be folded in. Everyone would be covered.

It's a well designed proposal that's hard for a progressive not to like on the merits. But could Democrats ever pass anything like this? I asked Timothy Jost and Harold Pollack and got surprisingly different answers (I'll say that Pollack surprised me more than Jost). The article, with extensive input from both, is up at healthinsurance.org

POSTSCRIPT, 2/24: One thing is nagging me a bit as reaction to the article unfolds. Harold Pollack suggests that  "Democrats will be much more ruthless the next time around" -- they're done trying to placate not only Republicans but, to a certain extent, healthcare industry interests; they're virtually forced to go for broke if they get the chance. That strikes a deep chord with progressives; it breaks something loose in a progressive heart. Timothy Jost, on the other hand, throws cold water, ticking off the forces that will be aligned against a strong drive toward universal coverage and cost control. What fun is that? But Jost and Pollack's reactions are not as far apart as they appear. Jost does point out that if Democrats gain power any time soon they'll be under strong pressure from the activists a party depends on to go big. And Pollack, in comments that did not make it into the text (my bad?), said that he thinks there's a good chance Trump will be re-elected -- and also acknowledged that industry would hack some parts off before anything like this would ever get enacted.

Pollack's take on the politics the Medicare Extra plan surprised me. I thought he'd be as dubious about the prospects for success as Jost. The fact that he wasn't gives this article its charge, I think (along with the workable architecture of the Medicare Extra plan itself). But I'm also pretty sure that Pollack would be the first to acknowledge that Jost may well be right -- that our political system will prove incapable of putting through such sweeping and coherent reform.

Wednesday, February 21, 2018

The ACA marketplace is damaged and taking new hits...but it's not a high risk pool and probably won't be

Update, 3/8/18: Various analyses are now predicting steeper premium hikes and coverage losses than I anticipated here, resulting from the combined effects of mandate repeal and greenlighting of short-term and AHP plans. See Urban Institute, 2/26, and Covered California, 3/8.
Since it first hit email boxes a few months (or maybe a year-plus?) ago, Vitals, Axios' healthcare e-newsletter, has beguiled its way into a first read. Editor Sam Baker, and Axios generally, have taken the holy grail (or shibboleth) of contemporary prose, concision, to a new level, sating our short attention spans while salting news aggregation with interpretation.  I find the trademark "be smart" tagline a touch patronizing, but the substance of that signposted takeaway is nearly always on point.

That said, I'm going to quibble with today's lead storylette, with a point behind the quibble that goes beyond Axios, I think.

The news item is HHS's proposed rule to allow loosely regulated short-term health plans to be sold for terms as long as a year rather than three months, the limit that went into effect last April. Since short-term plans are cheap, medically underwritten and not bound to cover Essential Health Benefits, they are poised to attract healthier buyers. With this rule, Trump's HHS punches one more hole in the ACA risk pool

Here's my quibble. According to Sam Baker, The ACA-compliant individual market is "sliding deeper into something a lot more like a makeshift high-risk pool, in which healthy people are absent and the government simply pays to cover sick people." I think that's overstated.

Tuesday, February 20, 2018

The catastrophic option in a degrading market for health insurance

Okay, so short-term health plans are back to not really being short-term -- or likely will be so, as of July. HHS has rolled back the Obama administration rule that limited such plans to three-month terms, a rule that only went into effect last April.  Once again, these plans -- which do not comply with ACA coverage rules and can be medically underwritten and exclude coverage for pre-existing conditions -- can be offered for up to a year.

So big deal, you might say. Short-term plans with year-long terms were available from 2014-2016 (and in the first quarter of 2017) and did not have a huge impact on ACA marketplace enrollment. Yes, but this time it's different, for two reasons. First, the individual mandate is effectively repealed as of 2019, so people need not obtain ACA-compliant coverage. Second, premiums in the ACA-compliant market have skyrocketed in the last two years (thanks largely to Republican sabotage), so more people are priced out. Louise Norris's analysis strongly implies that HHS is lowballing projected enrollment with its estimate of 100-200,000.  See Louise's post for a thorough overview of how short-term plans work and who's likely to buy them.

Short-term plans can be very cheap, and coverage can be very limited (especially if you have a serious pre-existing condition, which will be excluded). ACA-compliant plans, on the other hand, can be astronomically expensive if you're not subsidy-eligible, particularly if you're in your late fifties or early sixties.

As the individual market for health insurance fractures, I want to take a look at one tweener market that may help a few people navigate between the Scylla of unaffordable coverage (say, $1,000 per month for a solo plan with a $7000 deductible) and the Charybdis of unregulated coverage that may exclude, say, drug coverage or pregnancy, cap total coverage, and be medically underwritten.

Thursday, February 15, 2018

On HealthCare.gov, CSR takeup rose steadily from 2015 through 2017

One aspect of ACA marketplace enrollment that's intrigued me ever since HHS started producing enrollment statistics is "CSR takeup" -- the percentage of enrollees who are eligible for Cost Sharing Reduction (CSR) subsidies who access the benefit by selecting silver plans, the only level at which CSR is available.

Silver can be expensive for low income enrollees -- a benchmark silver plan costs an enrollee with an income at 200% of the Federal Poverty Level about $125 per month. At the same time, up to 200% FPL, CSR dramatically reduces out-of-pocket costs. (The benefit is much weaker for those in the 200-250% FPL range, and silver plan selection tapers off accordingly among enrollees over 200% FPL.)

One fact that's escaped me until now: CSR takeup rose steadily from 2015 through 2017, at least in the states using the federal exchange, HealthCare.gov (as 37 states did in 2015 and 39 in 2017). That's been somewhat obscured by the fact that the percentage of all enrollees with CSR has not risen. But enrollees' income mix on the federal platform has shifted upward as states on the platform enacted late Medicaid expansion, and as two states that expanded Medicaid early, Hawaii and Kentucky, came on board the federal platform. In 2015, 78% of enrollees were known to have incomes under 251% FPL. In 2017, 74% were below that threshold.

Monday, February 12, 2018

Health Policy Valentines 2018

Wait, no, this can't be my fifth year of #HealthPolicyValentines.* But yes: here is Love Knows No Repeal (2017),  Love in the Time of Obamacare (2016), love, 2015, and first love, 2014.

And who'd have thought we'd have at least two Trump-era V-days with the ACA unrepealed? But here we are...

Spite is served hot,
Revenge is served cold.
Trump cut off CSR,
We got cheap bronze and gold.

     *      *      *

Replace came up empty,
Repeal served up zeroes.
We love you, Little Lobbyists,
True national heroes.

     *      *      *

Heller was craven,
Capito, afraid.
Collins, McCain, Murkowski
saved our Medicaid.

*      *      *

Thursday, February 08, 2018

Think ACA enrollment is complicated? Try Medicare

One of the early and persistent raps against the ACA is that the benefit structure and application process are too complex. There's a lot of questions to answer. It takes a half hour to an hour -- if you're not called on to provide extra verification for your identity or immigration status or income. There are benefit cliffs -- between Medicaid and the marketplace; between marketplace enrollees who qualify for strong Cost Sharing Reduction and those who don't; and, most precipitous (for older enrollees), between those who qualify for premium subsidies and those who don't. As for plan offerings, in some markets a dominant insurer will throw up a half-dozen minutely differentiated plans, sowing confusion.

All this is true. But I'd like to take a first pass here at a myth that I'd like to explore more fully later: that by comparison, Medicare is a blessed zone of simplicity, equity and benefit adequacy.

Monday, February 05, 2018

We won, now what? My account of Health Action 2018 at Crooked Media

The Affordable Care Act's passage through 2017 was a bit like Odysseus' ship sailing past the six-headed monster Scylla: six men gone, but the ship sails on (only to be destroyed by thunderbolt a few episodes later, but never mind that part). 

Health Action 2018, Families USA's annual confab of healthcare activists, was largely devoted to taking the measure of the political power somewhat miraculously tapped by a wave grassroots passion and action that staved off repeal -- and groping toward a path by which Democrats can build on or move beyond the ACA in years ahead.

I have an article up at Crooked Media that examines what kinds of next steps - or false starts -- the conference conversations point toward:

Friday, February 02, 2018

What I learned at Health Action 2018

Below, a few notes from Health Action 2018, Families USA's annual conference -- things I learned, or learned in more detail, or was forcefully reminded of. [Update: my report about what the conference suggested about where Democrats may be headed on the healthcare front is up at Crooked Media.]

         Re Medicare:
  • Many low income sixtysomethings face a "Medicare cliff" at age 65. They've had all their medical expenses paid by Medicaid;  now, suddenly, they're faced with Medicare's 20% copays, drug costs, etc. (Leslie Fried, National Council on Aging)

  • Medicare Savings Programs (MSPs), a variety of programs through which low-income Medicare enrollees' premiums or out-of--pocket costs are picked up by Medicaid, are all underutilized. Only about half of those eligible are enrolled. Funding for State Health Insurance Assistance Programs (SHIP), which provide enrollment assistance to seniors, is grossly inadequate and at risk. Susan Collins has stood up for SHIP. (Leslie Fried).  I plan to learn more/post more about the Medicaid-->Medicare cliff.

Wednesday, January 31, 2018

At Health Action 2018, a focus on racial discrimination in healthcare

Last week I attended Health Action 2018, Families USA's annual gathering of healthcare advocates, ACA navigators, healthcare wonks and politicos.  I have a post in progress probing where the conference suggests Democrats may be headed next on the healthcare front.

One piece of that puzzle is how directly Democrats focus on equity issues -- specifically racial and ethnic inequities.  These present something of a political conundrum in that, as longtime former Senate aide (and healthcare adviser in the Obama administration ) Chris Jennings put it, "equity doesn't sell."  Proposals pitched to help the disadvantaged, Jennings asserted, arouse suspicions among many that others' gain will be their loss. People value programs that seem to treat everyone equally. "Medicare for all" polls well because it's perceived as a system that all pay into and all benefit from.

Notwithstanding that reality -- or perceived reality -- Families USA, to its credit, is training its focus on equity issues, and the conference reflected that in two plenary sessions in particular. Below is an an outtake of sorts from my broader conference overview in progress, focused on those panels -- and on Cory Booker's speech, which also focused on equity.

Friday, January 26, 2018

Elizabeth Warren is faking it on healthcare

Delivering a keynote at Families USA's annual Health Action conference, Elizabeth Warren signaled either that she hasn't studied U.S. healthcare very closely or that she cares to attack only politically convenient targets on this front.

Warren lambasted the travesty that American families are one sickness away from financial ruin -- a major early discovery of hers - and that's great.  She excoriated the country's major private insurers as faithless partners in the Affordable Care Act, and that's fair enough (though the U.S. government has in turn been a faithless partner of the insurers). She suggested that those insurers who want the privilege of participating in the profitable Medicare Advantage and managed Medicaid markets should be required to participate in the ACA marketplace, and that's reasonable, at least in outline.

But she also presented the unaffordability of healthcare in the U.S., and the huge out-of-pocket costs that many insured Americans face, as purely a product of insurance industry rapine. Not a word about pricing-gouging by hospitals and doctors; the fine science of upcoding; the loopholes allowing self-dealing; the privileging of expensive procedures; the outsourcing to hedge fund- and private equity-backed price maximizers; the predatory balance billing. Providers got a total pass. I sentence Senator Warren to read Elisabeth Rosenthal's An American Sickness, which meticulously documents all these cost inflators and their evolution

Saturday, January 20, 2018

Subsidy-eligible, but unsubsidized

Updated 1/22 with California discussion corrected - please see note 2 at bottom.

Reading about Gallup's latest finding that 3.2 million more Americans were uninsured in 2017 than in 2016, I wondered about a particular (small) group of ACA marketplace enrollees: those with incomes in subsidy range who are nevertheless unsubsidized. Such people might be expected to have a particularly hard time with the steep premium increases of 2017 (not to say 2018 and 2019), as premiums take a huge share of their income.

I wanted to look at this group because Gallup's findings raised some riddles. Gallup found the sharpest increases in the uninsured among people with incomes under $36,000 -- but also found no change in the percentage of people insured by Medicaid. Among types of insurance obtained, the sharpest drop was among those who say they bought their own insurance (although Gallup's numbers for this population are weirdly inflated).  In the ACA marketplace the large majority (84%) who obtained premium subsidies were largely insulated from the year's steep premium hikes -- though reduced competition may have made choices less viable for some. Overall,  marketplace enrollment was down about 5%, or 500,000 in 2017.

The drop in off-marketplace individual market enrollment was doubtless steeper.  But most of those who buy off-exchange are presumably more affluent. It doesn't all seem to quite add up -- hence my interest in the almost invisible low-income unsubsidized individual market enrollees.

Wednesday, January 17, 2018

How Phil Murphy can counteract ACA sabotage in New Jersey

I've suggested before that states can protect their individual markets for health insurance by passing their own individual mandates -- and using the revenue to further shore up their individual markets. In NJ Spotlight, I make the case specifically for New Jersey.

Revenue from the mandate
could be dedicated to strengthening the state’s individual health insurance market. One possibility would be direct financial help for people who don’t qualify for ACA premium subsidies — a group hit particularly hard by the premium hikes of the past two years. Another option is to spend the money on enrollment assistance and outreach, which the federal government radically cut in 2017. A third option is to dedicate the funds to a state-based reinsurance program.
Mandate revenue would not fully fund a reinsurance program, and New Jersey is in terrible fiscal shape.
But the state can also seek federal reinsurance funding via an ACA “innovation waiver”, as HHS specifically suggested last spring. Funding may be granted as a “pass-through” of savings derived from lower premiums — since lower premiums mean lower subsidies, which are paid by the federal government.
The rest, once more, is here.

Monday, January 15, 2018

There's Martin Luther King's dream. Then there's his American reality principle

Martin Luther King's finest hour may have come when he took a stand against the Vietnam War, breaking with the president with whom he'd partnered to pass epochal civil rights legislation.

Returning to the speech in which King took that stand, I find myself taking a weird kind of solace in his clearheaded denunciation of the violence that tore at two societies. It's a reminder, in the Trump era, that American betrayal of American ideals is continual, that backlash is continual, that mass violence inflicted on foreign populations is continual, and systemic injustice inflicted on minorities at home is continuous.

Why does that reminder offer solace?  Because along with the failure, success has also been continual: we have recovered from, and partially redressed, so many past self-inflicted wounds. Somehow, this account of how the triumphs of the civil rights movement turned to ashes reminds also that there was a residue of progress -- and also some lessons learned from Vietnam that held in some measure for 20-30 years.

Here is the core indictment in King's speech against the war delivered at Ebenezer Baptist Church on April 30, 1967:

Friday, January 12, 2018

Choosing a metal level in the CSR-addled Maryland marketplace: Not bad, enrollees!

In Maryland's ACA marketplace, as in much of the country, Trump's cutoff of reimbursement to insurers for Cost Sharing Reduction (CSR) drove huge premium increases for unsubsidized buyers -- but also bizarre bargains for the subsidy-eligible.

Throughout the state, all subsidy-eligible* enrollees with incomes below 200% of the Federal Poverty Level (FPL) could obtain an bronze plan for under $20 per month. Most at this income level -- e.g., everyone over 30 -- could get a bronze plan for under $4 per month. In the state's most populous counties, subsidy-eligible buyers could get a gold plan for just a few dollars more than a silver one.  And in several rural counties, an enormously expensive benchmark (second cheapest) silver plan, which determines subsidy size, rendered silver and gold plans as well as bronze plans free for many enrollees.

The effects of these pricing anomalies on the subsidized were mostly beneficial, as you might expect. Discounted (not to mention free) gold plans are a real boon to enrollees with incomes over 200% FPL, for whom silver plans have high out-of-pocket costs (sharply reduced for those up to 200% FPL by strong CSR). And free bronze plans are better than nothing, even with the $6200 deductible they carry in the most populous counties.

But anomalous pricing also can create problems. Some enrollees eligible for strong CSR might be tempted to choose  bronze plans (deductible $6200) over silver (deductible $0). Some enrollees under 200% FPL might also have been tempted by gold plans that cost slightly more than the cheapest silver -- not recognizing that CSR-enhanced silver plans cover more of their out-of-pocket costs than gold (i.e., are just straight-out more valuable).

So how did enrollees' choices shake out? Courtesy of the Maryland Health Connection, I have a breakout of enrollees metal level choices at different income levels, posted below.  And they look pretty good:

A few observations:

Thursday, January 11, 2018

Subsidized ACA marketplace enrollment ROSE 2% in Maryland in 2018

ACA marketplace enrollment in Maryland for 2018 was down only slightly (2.6%) in 2018 That's a strong performance, as I noted earlier this week, "given the shortened enrollment period, radically cut federal funding for enrollment outreach and advertising, and general confusion generated by administration sabotage."

I also speculated that the drop-off may have been concentrated in unsubsidized prospective enrollees -- the only ones materially hurt by the state's enormous premium spikes (which actually benefited subsidized enrollees by inflating subsidies).  That is in fact the case.

In 2018, 32,171 enrollees in on-exchange private plans in Maryland were unsubsidized, according to numbers sent to me by the Maryland Health Connection (the state's ACA marketplace). That's out of 153,584 total enrollees (21%). In 2017, as of the end of Open Enrollment, 38,903 were unsubsidized out of a total of 157,832 enrolled (25%), according to Public Use Files published by CMS.*

That is, subsidized enrollment for 2018 was up about 2% -- to 121,413, compared to 118,928 in 2017. That jibes with the Maryland exchange's reporting that African American enrollment was up 12%, Hispanic enrollment up 10%, and rural enrollment up about 10%.

Wednesday, January 10, 2018

You may balance-bill me at will: This hospital contract is literally bulletproof

I went to our local community hospital for some routine blood work today. The new wing is open! From the plain former reception desk, you're directed down a long space age-y corridor to the new reception office, a warren of glass cubicles that looks like a customs and immigration area in a shiny new airport. After presenting your insurance card and i.d., you're asked to wait until you're called into one of these cubicles for a one-on-one encounter in which you're compelled to sign your life away.

That is, you are presented with four (4) disclosures and contracts of adhesion to sign (contracts, that is, in which the terms are dictated entirely by one party). You sign under the gaze of the hospital employee across the desk, and you do not sign the paper. The contracts are encased in plexiglass, perhaps because I'm not the only smart-ass on the planet who sometimes alters them. You sign on an electronic pad like those that take your credit card in retail stores. The hard case enclosing the paper contracts makes them literally bulletproof.

And what you agree to, most notably, is to let any of the multitude of "independent contractors" who may breeze by your bed (if you're an inpatient) bill as much as they friggin' please, and send the bill to you. Here's the deal you can't refuse:

Monday, January 08, 2018

Maryland ACA enrollment spotlights effects of Trump's CSR sabotage

Maryland announced late last week that its ACA marketplace enrollment for 2018 totaled 153,571, down 2.6% from 2017 -- a good result, given the shortened enrollment period, radically cut federal funding for enrollment outreach and advertising, and general confusion generated by administration sabotage.

Maryland reports, further, that African-American enrollment was up 12 percent, Hispanic enrollment up 10 percent, and enrollment in rural areas up around 10 percent. Those increases suggest that enrollment drop-off may be concentrated in the unsubsidized population, which has historically been high in wealthy Maryland -- 25% of on-exchange enrollment in 2017, compared to 16% nationwide.

That makes sense, considering that in Maryland a) premiums soared a weighted average 43.8%, according to Charles Gaba's blog, with much of the hike attributable to Trump's cutoff of CSR reimbursement, and b) Maryland insurers concentrated the added cost of CSR on on-marketplace silver plans, with cheaper silver plans available off-exchange.  Thus some unsubsidized 2017 enrollees may have been priced out by huge premium increases, and some may have moved off-exchange to find somewhat cheaper plans.

Steep as the average premium hikes were, the increase in the federal government's subsidy bill was even steeper, and that's worth looking at more closely:

Wednesday, January 03, 2018

In which Idaho offers a quarter loaf to its uninsured poor

Thanks to Dylan Scott for flagging a draft ACA innovation waiver proposal published by the Idaho Department of Insurance this past November. Someone in the ensuing Twitter stream called the proposal "creative" -- and it is, in the sense that repeal of the ACA individual mandate is creative. That is, it "saves" money by insuring fewer people at higher per-person cost than the ACA default structure -- in this case, proposing a private alternative to Medicaid expansion.

More specifically, the proposal would newly insure one fifth as many Idaho residents as would Medicaid expansion at about one third of the added cost. That's notwithstanding the fact that while Medicaid expansion would cost about $300 million more per year in total than the status quo arrangement, the federal government would pay five sixths of the added cost.*

That's genuinely creative when you allow that the more cost-effective alternative -- Medicaid expansion -- has proven to be a political impossibility in the state. It's also an implicit confession that a Republican state government prefers to spend more per person while leaving a larger percentage of its population uninsured -- without any attempt to argue that the more-expensive insurance is better for enrollees or yields other social (as opposed to ideological) benefits.

Monday, January 01, 2018

A Tralfamadorian view of the U.S. economy from James C. Scott

 I have been reading James C. Scott's Seeing Like a State, which argues repeatedly that centrally planned communities and economies cannot subsist without the unsanctioned return of small-scale, below-the-radar activity of people forced to circumvent the master plan.

The quick-fire examples below, offered in a final-chapter overview, brought me up short. The workarounds prompted by a "formal command economy" have been elaborated in depth and reiterated throughout the book. What got my attention is the throwaway final sentence, asserting something that has been not elaborated at all in preceding chapters:
Many modern cities, and not just those in the Third World, function and survive by virtue of slums and squatter settlements whose residents provide essential services. A formal command economy, as we have seen, is contingent on petty trade, bartering, and deals that are typically illegal. A formal economy of pension systems, social security, and medical benefits is underwritten by a mobile, floating population with few of these protections (p. 352, Kindle edition).