Wednesday, February 14, 2024

Unkind unwinding: Health Policy Valentines 2024

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In a year of existential threats, and an era in which the corporate practice of medicine knows few curbs, there is still a stream of health policy wins worth serenading in the time-honored (since 2012!) tradition of #HealthPolicyValentines. This year’s mash notes below.

In a year of existential threats, and an era in which the corporate practice of medicine knows few curbs, there is still a stream of health policy wins worth serenading in the time-honored (since 2012!) tradition of #HealthPolicyValentines. This year’s mash notes are below.

The Medicaid unwinding
is often blind and cruel.
But spare some V-day love
For ex parte renewal.

* * *

A valentine from Democrats,
enacted, but hardly trending:
An annual Part D cap
on out-of-pocket spending.

* * *

What’s sweeter for seniors
than sugar and spices?
Medicare negotiating
selected drug prices.

* * *

Send flowers, chocolate and smiles
for keeping insurers squirmin’
over AI-driven denials
to Casey Ross and Bob Herman.

* * *


O ACA, flawed child,
I’ll no longer carp
so long as your subsidies
remain enhanced by the ARP.

* * *

For low-income tar heels,
nothing can be finer
than Medicaid expansion
in North Carolina.

* * *

Let’s honor legislation
little known, in point of fact,
preventing harm, unnoticed:
The No Surprises Act.

* * *

As oligarch-funded theocrats
harm the women of this nation,
my love goes to the National
Abortion Federation.

* * *

And one for my wife as I join her on the far side of the age-65 threshold:

After 40 years of love
we’ll take no crap
from MA insurers —
thanks to Medigap.

* * *

While dredging up healthcare doggerel like this, I always end up with some bitter snippets, then remind myself they’re not um, valentines. Since they now exist, however, and at the risk of spoiling the mood, I’ll share a little rage rhyming:

The Supreme Court’s out of control,
but had better not go postal
by voiding the FDA rule
for Mifepristone and Misoprostol.

* * *

Nothing’s more dangerous
for those with colon polyps,
financially speaking,
than private equity rollups.

Take a trip down ACA memory lane with a visit to the Health Policy Valentines archives: Surprise! No Surprises (2023), Flowers in the graveyard (2022), Institutional edition (2021), But love grows old and waxes cold (2020), The Water is Wide: Health Policy Valentines (2019),  HPV (2018), Love Knows No Repeal (2017),  Love in the Time of Obamacare (2016), love, 2015, and Romance of the Rose, Health Policy Edition (2014).

Photo by Aykut Aktemur 

Sunday, January 21, 2024

How has the Medicaid unwinding affected various states' ACA marketplace enrollment?

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My last post stressed that ACA enrollment growth in the Open Enrollment Period for 2024 remains heavily concentrated in states that have refused to enact the ACA Medicaid expansion.

I might have pointed out, though, that the main divide in growth rates is between the 32 HealthCare.gov states and the 19 state-based marketplaces (SBMs). The difference in year-over-year enrollment growth as of Dec. 23 between expansion and nonexpansion states within the HealthCare.gov universe is not large -- 42.1% vs. 35.6%, according to Charles Gaba. Last year, the gap was bigger: enrollment in the nonexpansion states on HealthCare.gov increased by 22.7% in OEP 2023, vs. 9.9% in expansion states on the platform (Gaba). There was a similarly wide spread in growth rates in OEP 2022.

The Medicaid “unwinding” — the resumption in April 2023 of Medicaid redeterminations and disenrollments after a three-year pandemic-induced moratorium — is a major factor in this year’s enrollment gains. As of September, CMS reported that about 1.2 million Medicaid disenrollees (about 13% of the disenrolled) had enrolled in the marketplace (or in the Basic Health Programs available to low-income enrollees in New York and Minnesota) from April through September. As Medicaid disenrollments have now passed 15 million (!), close to 2 million by now may have landed in marketplace plans or the BHPs, accounting for perhaps 40% of enrollment growth.

That boost to enrollment is apparently at work in expansion and nonexpansion states alike. Of the 16 HealthCare.gov states with growth rates above the median, eight are expansion and eight are nonexpansion states. Again, expansion states are sharing more in this year’s strong enrollment growth than in prior post-pandemic years. The Medicaid unwinding may partly explain that. While growth rates remain lower in the SBM states (all of which have expanded Medicaid) than in HealthCare.gov states, strong enrollment growth (13.8%) has resumed in the SBM group in 2024 after remaining basically flat last year.

In my last post, with respect to the Medicaid unwinding, I wrote:

…state Medicaid disenrollment rates don’t clearly correlate with expansion/nonexpansion status or marketplace enrollment rates (at least not obviously; perhaps researchers will tease out significant relationships in years to come).

Here I want to take a look at another measure of the potential impact of the Medicaid unwinding on marketplace enrollment in OEP 2024: The extent to which the migration of Medicaid disenrollees into the marketplace during the off-season boosted each given state’s marketplace enrollment. CMS has tracked those enrollments, from April through September 2023, in the Medicaid Marketplace Unwinding Report. I’ve confined my focus to the 32 states using HealthCare.gov, as state-based marketplaces are quite a various lot, both in market conditions and reporting.

Thursday, January 18, 2024

ACA marketplace enrollment up 135%-plus since 2020 in nonexpansion states; may approach 100% in all states

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Marketplace enrollment in nonexpansion states is up 135% since 2020. Drink!

Politico’s Ben Leonard and Chelsea Cirruzzo, noting that ACA marketplace enrollment during the Open Enrollment Period (OEP) for 2024 was already up 25% over the final OEP 2023 tally as of December 23 (with OEP still running), locate the surge geographically:

So far, states in the South and the Rust Belt have had among the highest rates of enrollment growth between 2023 and 2024 plan years, according to a POLITICO analysis of HHS data.

Louisiana and West Virginia have the highest growth rates — about 63 percent each…Alabama, Arkansas, Georgia, Indiana, Mississippi, Ohio, South Carolina, Tennessee and Texas all had growth rates between 36 and 52 percent.

That is no surprise as to the southern states — for which, read primarily “states that have refused to enact the ACA Medicaid expansion.” While Louisiana is an expansion state, as are the three “rust belt states” cited above, the “nonexpansion” states have driven the marketplace’s surging enrollment growth throughout the pandemic years, as I’ve noted previously with respect to OEP 2021, OEP 2022, and OEP 2023. Every state marketplace is different, and enrollment in a given state may rise or fall in a given year or cluster of years for myriad reasons, but since OEP 2021, the shrinking pool of nonexpansion states (there were 14 in OEP 2021, 10 at present) have accounted for the vast majority of net new enrollments (75% of net new enrollments this year). That’s largely because of sustained growth in behemoths Florida and Texas, which together account for about a third of all marketplace enrollment.

The table below shows enrollment growth from 2020-2024 in the ten states that had not expanded Medicaid as of November 1, 2023, the beginning of OEP 2024. North Carolina enacted its Medicaid expansion beginning December 1, but the migration of low-income marketplace enrollees to Medicaid does not yet show up in the enrollment tallies, so I’ve included North Carolina in the nonexpansion state group. Note also that the totals for OEP 2024 run only through December 23, 2023, while OEP ended on January 16, 2024 in the 32 states using HealthCare.gov and is still running in several state-based marketplaces. Charles Gaba estimates that the final tally for OEP 2024 will rise by another 1-2 million, or 5-11%.

Sunday, January 14, 2024

New York's ACA alchemy: marketplace silver to Essential Plan platinum

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Greener pastures for New Yorkers of a certain income


New York has a pending ACA Section 1332 updated waiver proposal to CMS that would extend eligibility for the Essential Plan, the state’s zero-premium, low-out-of-pocket cost health insurance program, to applicants with incomes up to 250% of the Federal Poverty Level ($36,450 for an individual, $75,000 for a family of four) in April 2024.

The economics of the program appear to defy gravity, and perhaps suggest lessons as to the public funding of health benefits in the United States.

Shedding “Medicaid-ish” payment rates

As currently structured, New York's Essential Plan is a Basic Health Program, an option for states established by Section 1331 the Affordable Care Act. A BHP is a health coverage program for state residents with incomes up to 200% FPL offered in place of standard ACA marketplace coverage. The implicit premise of Section 1331 is that BHPs will pay lower rates to providers and plow those savings into reducing premiums and out-of-pocket costs for enrollees — rather like Medicaid.

The Essential Plan currently provides coverage with an actuarial value of 98% to enrollees with income up to 150% FPL, compared to 94% for benchmark silver coverage in conventional marketplaces, and an AV of 92% to enrollees in the 150-200% FPL income bracket, compared to 87% in the marketplace. The plan has no deductibles at any income level and includes dental and vision coverage. Plan benefits are standardized.

Monday, January 01, 2024

2023: Understanding a maturing ACA marketplace

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Not exactly New Year's fireworks, but the closest equivalent in my photos

Another blogging year goes to the archives. As the years go by it seems I write fewer and fewer posts and spend more and more time on each of them. I’d like to think that means the posts are getting better, but I wouldn’t swear to it.

Perhaps it’s fair to say my understanding of the ACA marketplace is maturing as the marketplace matures. A few themes in this year’s posting flesh that idea out:

  • I have long been concerned with CSR takeup — that is, how many low-income enrollees (that is, a majority of marketplace enrollees) obtain coverage that makes actual care affordable. Since ARPA rendered at least two CSR-enhanced silver plans free for enrollees with income up to 150% FPL and available for no more than 2% of income for those in the 150-200% FPL income range, I have been disappointed to note that silver plan selection at low incomes has not improved as I anticipated, and this March I noted that CSR takeup went backwards in 2023. I then added a spotlight on CSR takeup in states that have not expanded Medicaid, where the vast bulk of enrollees eligible for free CSR silver live. Perhaps more interestingly, following hints from brokers and those who work with them, I examined markets in which some enrollees might have cause to forgo the CSR benefit with eyes wide open, sacrificing low out-of-pocket costs to obtain a more robust provider network or other benefits.

Tuesday, December 26, 2023

The commercial para-universe to the ACA exchanges keeps expanding

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Georgia looking peachy to web-brokers


More or less simultaneously with CMS’s announcement that 15.3 million people had enrolled in health plans via HealthCare.gov through December 15, HealthSherpa announced that 6.1 million of those enrollments were effected through its platform.

I’d like to revisit what that market share tells us about how people are getting coverage through the ACA marketplace today. For background, a couple of points from a recent post:

  • According to a CMS presentation to brokers, in HealthCare.gov states in 2023, 71% of active enrollees (new enrollees and active renewers) were assisted by brokers. 74% of new enrollees — 2.2 million out of 3.0 million — were broker-assisted. HealthCare.gov states accounted for 75% of total enrollment. In total, brokers enrolled 6.8 million of the 9.6 million who actively enrolled. (Of the 2.5 million who were passively re-enrolled, I don’t know how many were broker-assisted, initially, or in plan year 2023.)

  • In HealthCare.gov states, brokers rely heavily on commercial Direct Enrollment (DE) or Enhanced Direct Enrollment (EDE) platforms, which can process enrollments with subsidies (EDE directly; DE via a redirect to hc.gov for the application processing and then a return to the DE platform for plan selection). 81% of active broker-assistance enrollments are via DE or EDE, according to the CMS presentation. In 2023, more than half of enrollments on HealthCare.gov, excluding auto re-enrollments, were via DE/EDE (5.5 million). By my count of 62 EDE entities, thirteen are web brokers, the rest are insurers. The dominant EDE is HealthSherpa, which just announced that it has already processed 2 million enrollments for 2024. In 2023, HealthSherpa claimed to have accounted for 35% of HealthCare.gov state enrollments; the company seems on track to exceed that share this year.

HealthSherpa’s preferred metric for its market share in states using HealthCare.gov (the federal platform, used by 32 states) is its percentage of active enrollments -- that is, new enrollees and re-enrollees who update their accounts and make a deliberate choice of plan. Those who are passively auto re-enrolled are not credited to the platform that initially enrolled them. If OEP 2024’s auto re-enrollment percentage matches that of 2023, (21%), the 15.3 million enrollment total includes 3.2 million auto re-enrollees. That leaves HealthSherpa with just about a 50% share of active enrollment in HealthCare.gov states through December 15.

Sunday, December 17, 2023

A "premium alignment" bill advances in NJ legislature

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Will NJ's ACA marketplace glow as goldenly as its rest areas?

In June, I flagged a bill introduced in the New Jersey legislature this past spring, S3896/A5626, that would require silver plans in the state’s ACA marketplace to be priced roughly on par with gold plans in year 1 and on par with platinum plans in year two — reshaping a market in which gold plans have been priced out of reach for more than 98% of enrollees.

The bill’s logic is simple (though it has a complicated back story): On average, silver plans have a higher actuarial value than gold plans, since most silver plan enrollees qualify for the Cost Sharing Reduction (CSR) that attaches only to silver plans.

The bill was abruptly posted early this month for a December 11 hearing in the Assembly Financial Institutions and Insurance Committee, a committee chaired by one of the bill’s lead sponsors, John McKeon. The bill passed out of committee with no amendments on an 11-0 vote with one abstention. That’s first step in a gauntlet of three Assembly and two Senate committees’ consideration.

I testified in favor on behalf of BlueWave New Jersey, a progressive state advocacy group, along with Laura Waddell of New Jersey Citizen Action. My testimony is below.

- - -

TESTIMONY BEFORE SENATE BUDGET AND APPROPRIATIONS COMMITTEE
December 11, 2023

A5626/S3896 would correct a severe pricing imbalance in New Jersey’s ACA marketplace that weakens coverage for middle-income enrollees in health plans offered on GetCoveredNJ.

New Jersey is unique among U.S. state marketplaces in that in New Jersey gold-level plans – the metal choice that offers a coverage level closest to the average employer-sponsored plans – are priced out of reach for almost all enrollees.  In New Jersey in 2023, just 1.5% of on-exchange enrollees selected gold plans, versus a national average of 11.9% (see CMS Public Use Files, Note 3).  Nationally, according to tables published by the Kaiser Family Foundation, the lowest-cost gold plan premium in each state market is 4% higher than the lowest-cost silver premium in 2024. In New Jersey, the lowest-cost gold premium is priced 37% above the lowest-cost silver plan.

Friday, December 08, 2023

Still growing: OEP 2024 in the ACA marketplace

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CMS’s Week 5 snapshot for the 2024 Open Enrollment Period (OEP) in the ACA marketplace shows 7.3 million active enrollments (new enrollments and active re-enrollments) — a stunning 39% year-over-year increase, according to Charles Gaba’s swift compilation. The snapshot is through December 2 for 32 states using HealthCare.gov and through November 25 for 19 state-based marketplaces (SBMs). New enrollment is up 44%, and active re-enrollment is up 37%, per Gaba. (Passive auto re-enrollment is reported at different times by different exchanges, and some SBM auto re-enrollment tallies are included separately in the snapshot.)

For the year-over year comparison, Gaba has helpfully adjusted for an extra day included in the 2023 Week 5 snapshot. His breakdowns for different state groupings — HealthCare.gov states vs. SBMs, and states that have enacted the ACA Medicaid expansion — are below, in simplified format, and followed by a few observations.

    OEP Week 5: 2023 vs. 2024


Tuesday, November 21, 2023

Update: Ending presumed Medicare eligibility for New Jersey's elder ACA marketplace enrollees

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I’d like to provide a couple of updates regarding an abuse in New Jersey’s individual market that I wrote about in September (here and here). the issue in brief: in 2023, the state’s standard individual health plan contract stipulated that insurers could presume that enrollees over age 65 were eligible for Medicare unless they provide written proof otherwise. Failing that proof, the insurer would assume Medicare eligibility and act as a secondary payer to Medicare — paying only a small fraction of the enrollee’s bills while collecting a full premium. In 2023, about 9,000 enrollees via GetCoveredNJ, the state’s ACA exchange, were over age 65.


As I reported, in May 2023 CMS issued guidance that unambiguously stated that this practice — presuming Medicare eligibility for senior enrollees and acting as a secondary payer — violated ACA requirements. While New Jersey’s Department of Banking and Insurance did not respond to my queries about the New Jersey policy and the CMS guidance, they did respond to the same queries from an nj.com reporter, Karin Price Mueller, whom I approached about the issue. As they told Mueller, on September 27 DOBI issued a directive (described in Mueller’s paywalled article and in my followup post) to insurers in New Jersey’s individual market instructing them to comply with DOBI’s guidance — that is, cease presuming Medicare eligibility and acting as a secondary to Medicare simply because an enrollee was over age 65.

Friday, November 17, 2023

Where and how do people find plans in the ACA marketplace?

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On October 1, 2013, the day the ACA exchanges first opened for business, President Obama promised that the exchanges would enable shopping for health insurance “the same way you shop for a plane ticket on Kayak or a TV on Amazon.”

The wretched dysfunction at launch of the federal exchange, HealthCare.gov (and to varying degrees the state exchanges as well), evident that day, immediately made that promise a laugh line. While two months of technical and political hell ensued before HealthCare.gov was marginally functional, ultimately 7 million people did enroll for 2014 coverage — in line with CMS’s projections — and the image of the insurance shopper sorting through the options on the exchanges took hold. The functioning and messaging on the exchanges improved over time — though the proliferation in recent years of barely-differentiated plans complicated the task of plan selection.

In the ten years since then, I’ve written many posts about the weaknesses and strengths of the exchanges’ functionality and messaging. Do they make it easy to enter a few data points and preview plans and prices (net of subsidy) for the individual viewer? Do they adequately steer those eligible for strong Cost Sharing Reduction to silver plans? In the first cataclysm of the pandemic, did they make Medicaid availability clear? Do their decision support tools (highlighting plans likely to yield the lowest net costs) work well?

All of which might be said to obscure the fact that the unassisted enrollee navigating options via the government-hosted exchanges has become an increasingly rare bird. As insurers have reinvested in the marketplace, brokers selling ACA-compliant plans have proliferated (more than 74,000 were registered in 2023, up from 48,000 in 2019). Since 2021, the Biden administration has replenished the federally funded Navigator enrollment assistance program that the Trump administration had reduced to skeletal form (Navigator funding was cut from $63 million in 2016 to $10 million by 2018, then restored to about $100 million in 2022).