Thursday, February 27, 2014

HealthSherpa claims to shorten ACA signup process, subsidy application included

HealthSherpa, one of the first ACA comparison shopping sites to spring up while was dysfunctional, has now gone live as an online broker selling the Qualified Health Plans (QHPs) offered on Several hundred applications have already been initiated on HealthSherpa, according to co-founder Michael Wasser, who handles the site's day-to-day operations.

For those seeking only to comparison-shop for QHPs available given the shopper's location, household membership and income level, HealthSherpa offers a process slightly more streamlined than's "see plans before I apply" feature, which has been working quite well since late December.

More importantly, HealthSherpa now enables a shopper to initiate the buying process on its site.  And the company claims to have streamlined that process as well, even for customers who are applying for federal subsidies. The average customer, Wasser claims, "will save 20 minutes on an hour if they use Health Sherpa over"*

The Washington Post's Brian Fung reported the new functionality on 2/26. It was unclear to me, however, how HealthSherpa could streamline the subsidy application, since all ACA subsidy applications must still be processed through Wasser explained that HealthSherpa has worked with HHS to develop its own dedicated interface on, to which a buyer starting at HealthSherpa is jumped. According to Wasser, 20-30 companies have arranged with HHS to establish such interfaces, called web-based entities, but HealthSherpa believes that theirs is the only one live at present.

Just how will Health Sherpa simplify ACA signup?

UPDATE: Health Sherpa is now live taking QHP applications, routing the subsidy application through but claiming to streamline the process. The next post explains how an application initiated on Sherpa differs from one executed entirely on 
I am  glad to read that HHS is partnering with Health Sherpa, one of the first ACA comparison-shopping sites to turn up while was dysfunctional, to provide an alternate channel enabling people to sign up for Qualified Health Plans offered on the ACA exchanges. But the Washington Post story reporting the arrangement includes some misinformation and leaves the advantages unclear.

According to the Post's Brian Fung:
In November, the Department of Health and Human Services met with [Health Sherpa co-founders George Kalogeropoulous and Ning Liang]  to explore how to turn sites like theirs into a "modular" system -- where third parties could sit on top of the federal data hub and act as another online storefront for Obamacare.

Now, the integration is complete — making it possible to sign up for Obamacare using the Health Sherpa's Web site. Unlike, which was criticized for making visitors enter much of their personal information before verifying their subsidy eligibility and then showing them available plans, Health Sherpa  allows people to window-shop without entering much more than their Zip code, age and income.

It's not true that you have to enter intrusive personal information on to comparison-shop. The shop-only feature is excellent and has been fully functional at least since late December. -- just about as easy as on Health Sherpa. You answer seven questions, and you're in -- able to view all available plans, fully priced with subsidy calculated according to your income estimate, and with access to plan details. No personal information is required (i.e., there's no personal identification attached to your income estimate).

If Health Sherpa is not needed in most states* for easy comparison shopping, what other advantage does it offer?  The Post story implies that Sherpa and other third party sites will be able to streamline the application process, particularly the subsidy application process, but it's not clear how it can do so. Here's the Post account:

Tuesday, February 25, 2014 comes through in a complicated situation

Yesterday's post examined the factors to be weighed by people who face a choice between continuing on an employer-sponsored insurance plan via COBRA and switching to a Qualified Health Plan under the ACA. In brief: an ACA plan is likely to have a lower premium -- especially but not exclusively for those eligible for subsidies -- while a COBRA'd employer-sponsored plan is likely to offer better choice of doctors and hospitals and/or lower out-of-pocket costs.

One sidelight that emerged is that for many in the individual market, income is likely to be variable, and thus subsidy calculation can be delicate. That raises the question of how flexible and fact-specific a new federal bureaucracy is likely to be.  We looked at the case of Marcia, who is in the midst of a divorce just as a her husband is retiring.  Because she is in her mid-fifties, the base price of a silver ACA plan is quite high -- over $600 per month for the cheapest silver plan. Her post-divorce income will qualify her for a monthly subsidy of over $350 per month.  But the interim is uncharted territory. Her husband has just gone off salary and will soon go on Social Security, and their income is pooled for subsidy calculation purposes until the divorce is finalized.

Monday, February 24, 2014

Switching from COBRA to the ACA exchanges

I know a couple of people who will likely save a good deal of money by switching from COBRA to health plans available on ACA exchanges. It strikes me that people making this transition are an important subset of those who may stand to benefit from the ACA.  I'd like to invite people who have made this switch or are considering it to contact me via the "about me" tab on the right margin of this blog.

COBRA, the Consolidated Omnibus Budget Reconciliation Act, first passed in 1986, is best known for allowing people who lose or quit a job to continue on the former employer's group health plan for a fixed period (usually 18 months; 36 months in case of divorce) without the benefit of the employer's contribution.  It can also be tapped by people recently divorced or widowed or whose spouses become eligible for Medicare. An FAQ about eligibility and rules is provided by the Dept. of Labor, here.

Employer-sponsored insurance (ESI) usually provides more expansive coverage than the silver plans that are the benchmark in ACA exchanges -- though that may not be the case for people who qualify for additional subsidies reducing out-of-pocket expenses. But ESI is expensive. People whose income qualifies them for relatively modest ACA subsidies, or no subsidy at all, may have to balance tradeoffs when deciding between COBRA and an ACA plan. Below, in brief, with first-name pseudonyms, are outlines of the two situations I'm familiar with.

Saturday, February 22, 2014

Children, CHIP, Medicaid and the ACA

Means-tested government benefits are inevitably a somewhat blunt instrument. One inflexibility in the Affordable Care Act is its propensity to put children into CHIP and young adults into Medicaid.

Every state has its own threshold for CHIP eligibility, which the ACA incorporates into its calculations. If the state threshold is 300% of the Federal Poverty Level (FPL), then any ACA applicant in that state with children and an income under that benchmark will find their children enrolled in CHIP, while the adults select a subsidized plan from the exchange. A family with CHIP-eligible kids can enroll the whole family in an exchange plan, but the kids will be unsubsidized, according to the Kaiser Family Foundation.

Likewise, a lot of young adults, including most college students, will have an income that qualifies them for Medicaid -- that is, below $15,521 in 2014 --  and so will not be able to get a subsidy for a private plan if it better suits their needs.

Friday, February 21, 2014

Program note

Blogging is slow this week because I'm working on a longer piece reporting on the experiences of people who do not qualify for ACA subsidies and have bought insurance for 2014 off-exchange. A preview is here, ICYMI.

Tuesday, February 18, 2014

Are most buyers on ACA exchanges previously uninsured?

ACA signups tracker Charles Gaba, extrapolating from recent New York state data, postulates that 85-plus percent of February signups for Qualified Health Plans (QHPs) on ACA exchanges are people who were previously uninsured.

If this inference is on target, it shouldn't be too surprising -- though it either contradicts or suggest a rapid reversal of trends asserted in prior reports from insurers and McKinsey & Co. We know that over 80% of QHP signups qualify for subsidies. That suggests almost by definition that a substantial percentage of signups would previously have found insurance on the individual market unaffordable. Moreover, we also know that less than 20% of those who complete the application process on the exchanges but do not qualify for subsidies actually sign up for a plan on the exchanges.

Monday, February 17, 2014

A modest proposal for improving chronic care

Yevgeniy Feyman, as prelude to a proposal* for controlling medical costs for those requiring chronic care (forthcoming in a sequel post), notes:

A 2012 AHRQ study found that in 2009, 1 percent of the population accounted for 21.8 percent of total health care spending.
That imbalance brings another one to mind: the highest-earning 1% of Americans took home about 22 percent of the nation's income in 2012, according to a study by economists Emmanuel Saez and Thomas Piketty.

With apologies to Feyman, I feel compelled to cut in with my own modest proposal for bending the chronic care cost curve -- one  in keeping with our nation's growing reliance on the bounty of billionaires.

Sunday, February 16, 2014

What the Saudis want from the U.S.

The next time you read about the Saudis bitching about the U.S. showing insufficient zeal for military adventure in the Middle East, recall this encounter between Robert Gates and the Saudi King in the summer of 2007, as recounted by Gates in his new memoir. I offer it without comment, just as a benchmark and reminder to be returned to when appropriate.

It was also the only encounter with a foreign leader in which I lost my cool. Abdullah, a heavyset man in his eighties with a history of health problems, was very sharp and did not mince words as he smoked one cigarette after another. He wanted a full-scale military attack on Iranian military targets, not just the nuclear sites. He warned that if we did not attack, the Saudis “must go our own way to protect our interests.” As far as I was concerned, he was asking the United States to send its sons and daughters into a war with Iran in order to protect the Saudi position in the Gulf and the region, as if we were mercenaries. He was asking us to shed American blood, but at no time did he suggest that any Saudi blood might be spilled. He went on and

Saturday, February 15, 2014

Buying unsubsidized insurance in the ACA universe: A preview

A few days ago, I noted that less than 20% of those who had completed applications on ACA exchanges and been found ineligible for subsidies had actually enrolled in plans through the exchanges.  I added an invitation to people who were shopping for insurance without a subsidy to share their experience with me.

I have since spoken to several people who have bought insurance off-exchange. I will report on their fascinating experiences in a few days: first, I want also to speak to brokers and perhaps others who can overview the off-exchange individual market (if you can help, please let me know). Here, I'd just like to overview a few patterns and general observations. Some are obvious but perhaps still not widely recognized. Here goes:

1) If you are subsidy-ineligible, there is no reason to complete the transaction through or a state ACA exchange.  Why add an extra layer of bureaucracy and send you application through the shaky "834" tunnel? (An 834 transmission is a reporting tool that brokers, and now the exchanges, sue to send completed applications to insurers.) Also, why not get a sense of how responsive competing insurers are? [Update, 2/17: a reader provides a reason to buy on the exchange: "future income is never guaranteed and if I end up unemployed or with a lower than expected income in 2014, I can get the subsidies later when I file my taxes if I’m eligible. "]

2) Price aside, the individual market is much easier to navigate than it used to be -- first, because the ACA exchanges offer a quick lay of the land and price benchmark, and second, because medical history is no longer relevant.  Two people told me that all you need is a credit card -- the insurers don't even ask for a driver's license.  And if you come to a broker quoting an exchange plan in your price range and asking if they can beat it, you are shopping with the benefit of solid price discovery.

Friday, February 14, 2014

The Romance of the Rose, health policy edition

#Healthpolicyvalentines are a thing on Twitter. So, to aggregate my morning fun:

Roses are red,
Violets are blue.
I logged on Kynect,
And covered you.

        *     *     *

Violets are blue,
Roses are rouge.
Your income is low,
Your subsidy's huge. 

        *     *     *

Red is the rose,
And violet the heather.
We all have to jump
In the risk pool together. 

        *     *     *

Yellow's the daisy,
And white the azalea
I want the health coverage
They get in Westphalia.

        *     *     *

Azaleas are monochrome,
Daylilies, variegated.
My love for y'all
Is community-rated.

        *     *     *

Thursday, February 13, 2014

Democracy in action, kinda

On one level, it's hard to imagine anyone taking issue with Carl Hulse's take on the passage this week of the "clean" debt ceiling hike:
After the shutdown, the filibusters and years of stalled bills, it was the actual passage of legislation this week that revealed the true depth of congressional dysfunction.
Hulse suggests that if only 28 House Republicans vote for a bill that a majority of them probably want to pass, something is deeply amiss:

Wednesday, February 12, 2014

Left behind: the uninsured who don't qualify for ACA subsidies

HHS released ACA signup numbers updated through January today. And while much of the news is good -- January exchange signups exceeded pre-launch projections -- one pattern repeated from the December update troubles me a bit.  While most of those who go through the application process and qualify for subsidies are enrolling in plans, those whose income disqualifies them for subsidies are hanging back.

This pattern was evident when signup numbers through December were released a month ago. A headline number was that 79% of those who had enrolled in exchange plans qualified for premium subsidies. However, as Corey Husak, a staff assistant to Senator McCaskill, pointed out to me on Twitter, only about 65% of those who had "applied for coverage in completed applications," not all of whom had enrolled, were eligible either for subsidies or for Medicaid/CHIP. More to the point, of the 5.14 million who had completed applications and were found eligible for marketplace plan enrollment, nearly half, 2.38 million, were not eligible for subsidies, versus 2.76 million who were subsidy-eligible.

Tuesday, February 11, 2014

Don't call it Medicaid: Don Taylor on expanding health insurance in the South

In yesterday's long look at the likely future of the ACA, one somewhat submerged sub-theme was that much of whatever change comes to the ACA is likely to be state-based.  The Obama administration has proven itself willing to bend far in granting state waivers for privatized Medicaid expansions. Broader waivers enabling states to submit plans to meet ACA coverage goals by alternative means will be available starting in 2017. The law's federalist structure is both a strength and a weakness -- enabling the stonewalling and sabotage we've seen so far, but also, via state waivers, state-specific redesigns more in keeping with a state's political culture.

Don Taylor's fascinating take on the cultural barriers to extending health insurance access in the South came toward the end of a very long piece. Allow me to re-present that section below.

*          *          *          * 
For Taylor, a lifelong southerner, the imperative to expand health insurance access in the South is personal. Taylor has sketched out various visions of long-term progressive-conservative compromise on healthcare reform (here's one) and has submitted detailed proposals to the North Carolina legislature for privatized Medicaid expansion. The chief inducement for Democrats to negotiate, he suggests, is to cover the 25-30 million people that the ACA leaves out.

 "If I were to argue for negotiation from a pro-ACA perspective," Taylor said, "I'd be most worried about the uneven rollout, with the South left out.  I'd look to come up with some way to make the South willing to expand insurance coverage." He adds that there's probably no way to do this between now and the next election in 2014 in states that haven’t already starting moving that direction.

Monday, February 10, 2014

What if the (Republican) dog catches the Obamacar(e)?

Healthcare economists Austin Frakt, Donald Taylor and Yevgeniy Feyman on the future of healthcare reform

If Republicans win both houses of Congress and the presidency by 2017, what will they do to the Affordable Care Act?

The first substantive "repeal and replace" legislative proposal offered by Republicans since the ACA passed, unveiled in outline on January 27 by Republican Sens. Tom Coburn (OK), Richard Burr (NC), and Orrin Hatch (UT), purports to settle that question by making repeal of the ACA its first provision.  The Coburn-Burr-Hatch proposal (CBH*) has led healthcare wonks on the left and right, however, to conclude the opposite: "Repeal ACA, RIP," as Donald Taylor of Duke titled his analysis.

That's because after the "repeal" provision come the come the "replace" provisions, and to greater or lesser degree most are cousins of their counterparts in the ACA. CBH subsidizes insurance for people whose earnings fall between 100% and 300% of the Federal Poverty Level (FPL); provides a functional if more porous equivalent of the individual mandate and guaranteed issue; allows adults up to age 26 to stay on their parents' plans; bars lifetime coverage caps and  policy cancellations for reasons other than fraud; semi-privatizes Medicaid; taxes employer-sponsored insurance more heavily than the ACA does; and leaves the ACA's Medicare payment reforms and cuts untouched.

CBH thus clarifies that we are in a healthcare world remade by the ACA, and any conservative proposal that purports to cover as many people as the ACA, or close to it, must retain its basic infrastructure: subsidized private insurance, with some mechanism for minimizing medical underwriting and luring almost everyone into the risk pool. In short, the first relatively fleshed-out "repeal and replace" proposal demonstrates that "replace" effectively erases "repeal."

If repeal is all but off the table, how would a GOP-controlled federal government alter the ACA? I asked three healthcare economists to consider that question: progressives Donald Taylor of Duke and Austin Frakt of the U.S. Department of Veterans Affairs and Boston University, and conservative Yevgeniy Feyman of the Manhattan Institute. There was substantial consensus among them that repeal is dead -- but also that conservative alterations of the ACA are likely. Feyman is  eager to open the individual market to a greater variety of plans than the ACA allows on its exchanges.  Frakt and Taylor have long urged compromise that could win Republican acceptance and deploy "conservative designs for progressive ends," as Frakt put it (as the ACA itself does). Both Taylor and Frakt find some provisions of CBH palatable and even desirable on the merits. (Frakt, Taylor and Feyman all blog extensively on healthcare reform: Frakt at the healthcare policy blog The Incidental Economist, where he is co-editor in chief; Taylor on his personal blog; and Feyman at Forbes.)

Sunday, February 09, 2014

A tribal battle over health insurance portability

In 1990, linguist Deborah Tannen made a splash with You Just Don't Understand, a study suggesting that men and women speak fundamentally different languages, informed by different values, and so often talk past each other.

Psychologist Jonathan Haidt has demonstrated something similar with liberals and conservatives: they march to different moral drummers and so make very different ethical judgments about what government and community owe to the individual and vice versa. In a 2012 op-ed, Haidt described liberal and conservative value schemes as different tribal affinities defined by different sacred objects -- for liberals, "formerly victimized groups," for conservatives, "God and country." The villains are all symmetric: elite oppression vs. intrusive and redistributive government. More on Haidt's schema below.

I thought of Haidt's contrasting value systems while reading a Washington Post profile of two people who have left jobs because the ACA made health insurance outside the workplace available to them.

Edward Snowden, rhetorician?

Edward Snowden turned the NSA's tools against it -- or, depending on your point of view, ultimately in service to it. He also knows how to turn a phrase inside out to assert a moral contrast -- or else, his ACLU lawyer (Ben Wizner?) does, or the two in concert do.  This little barb in today's NYT front-pager* about how Snowden caught his documents caught my eye:

Saturday, February 08, 2014

Query: will the doc fix bend the healthcare cost curve?

[Program note: the lede is somewhat buried here, in that the post goes from exposition to open query 5 paragraphs down. Also, see update at bottom re doc fix pay-fors]

The doc fix is in, as Sarah Kliff pithily put it. That is, bipartisan legislation unveiled on Feb. 6 would repeal the broken Medicare payment formula that has had to be patched every year -- and transition essentially all Medicare payment to doctors away from fee-for-service and into (alleged) payment-for-performance.

Under the proposed legislation, three existing merit-based incentive payment programs would be consolidated. Payments to doctors will be adjusted based on a composite score of their performance compared to peers comprised of  scores in four categories: 1) quality of care; 2) resource use; 3) "meaningful use" of electronic health records (EHRs); and 4) improvement over their own past performance.* The quality measures, to be updated every year with input from "eligible professional organizations and other relevant stakeholders," are in five categories: clinical care, safety, care coordination, patient and caregiver experience, and population health and prevention.

If it passes and works more or less as designed -- two enormous ifs -- the doc fix, as I have noted before, could eclipse in impact all the toxically politicized budget wrangling of the past five years.  "Healthcare reform is entitlement reform": if Medicare cost growth is slowed significantly, our fiscal future is likely secured  If it works (or, for that matter, if it fails spectacularly), the doc fix could have more impact on the healthcare cost curve than the Affordable Care Act, since its package of consolidated performance incentives, as Sarah Kliff points out, "constitute a more significant move toward pay-for-value than is the Affordable Care Act, where those efforts are either limited to pilot programs (like the Accountable Care Organizations) or, if they are system-wide, tend to limit providers' risk to two percent or three percent of their reimbursements. Going up to nine percent [as the doc fix does by 2021] would step up the incentives in a pretty major way."

It's a supreme irony that this potentially radical long-term budget reform is strongly bipartisan -- put forward by the outgoing chair of the Senate Finance Committee, Max Baucus, and the Republican Chairs of the House Ways and Means and Energy and Commerce Committees, Dave Camp and Fred Upton. I wonder if it can stay that way. Partisanship will be in force on the unresolved matter of how to pay for the fix, which needs to be paid for only because the status quo baked an unsustainable "Sustainable Growth Rate" into long-term budget projections.** The collaboration on new payment mechanisms, however, is evidence that either a) Republicans are capable of rational thought and action when an issue is somehow sequestered from ideological dispute, or b) that both parties are in the grip of untested shibboleths regarding the potential of pay-for-performance and currently prevalent principles of its design. Probably a bit of both.

A program note: as I mentioned in a prior post, I am branching out from amateur blogging to amateur reporting.  On the prior subject on which I mentioned I would seek expert input -- "what will Republicans do to the ACA if they win both houses of Congress and the presidency by 2014?" --I have completed an article based on in-depth discussions with healthcare economists on both sides of the political spectrum that will either appear on this blog or elsewhere early next week. I plan to do the same with respect to the potential impact of the doc fix (that is, the SGR Repeal and Medicare Provider Payment Modernization Act). Let me again go open source here (my prior query drew a blogged response from Duke's Don Taylor) and pose the following questions:

Thursday, February 06, 2014

Will the ACA boost retirement savings?

The CBO's new projection that the Affordable Care Act would lead to a labor force reduction equivalent to 2.3 million jobs by 2021 stems in part from an assumption that some people will be reluctant to boost their income because doing so may reduce or eliminate their ACA subsidies.

Perhaps. The ACA includes some subsidy cliffs -- break points at which reporting an extra dollar of income will sharply increase the cost of insurance.  But besides earning less, there are other ways to reduce one's taxable income that should be available even to many lower-income workers.

Wednesday, February 05, 2014

The health insurance "who pays?" tug-of-war

If you're going to cut a string to a certain length, whichever end you cut, you'll still have the same length.

The first substantive "repeal and replace" legislative proposal offered by Republicans since the ACA passed, unveiled in outline on January 27 by Republican Sens. Tom Coburn (OK), Richard Burr (NC), and Orrin Hatch (UT), illustrates that basic principle on multiple fronts. That's because its core provisions are to greater or lesser degrees cousins of their counterparts in the ACA.

As Don Taylor has been pointing out for a week, the rollout of the Coburn-Burr-Hatch  proposal last Monday highlights the fact that any real attempt to replace the ACA while at least roughly matching its coverage goals will expose the GOP to the same kinds of attacks -- perhaps more from their right wing than from the Democrats -- as they've been leveling at Democrats since the ACA took shape in 2009. 

In some cases, the choices advanced in Coburn et al's so-called Patient CARE Act (following Taylor, I'll call it PCARE) may represent improvements over parallel provisions in the ACA. But all such choices involve tradeoffs -- alternate plans will have, to varying degree different winners and losers  (high taxpayers vs. subsidized insureds; young vs. old; employer-insured vs. individual market-insured; healthy vs. sick).  Many if not most of us will be on different sides of each of these divides at different points.

One feature of PCARE, or rather two interrelating features, throw the nature of these tradeoffs into relief. For years, Republicans have been screaming that the ACA forces young adults in the individual market to subsidize older participants. That's because the ACA limits the allowable extent to which the oldest participants can be charged more than the youngest to a 3-to-1 ratio, whereas pre-ACA, most states allowed ratios of  5-to-1 or more (42 states, according to AHIP). That alleged bilking of the young was at the heart of the case against the ACA's constitutionality argued in the Supreme Court in March 2012 and fueled all the cries of "rate shock" from conservative critics of the ACA in 2013. According to the Kaiser Family Foundation, the impact of the narrower age banding on young adults' premiums is pretty modest, but never mind.

Tuesday, February 04, 2014

Obama's pre-k advocacy: agenda-setting vs. polarization

When President Obama boasted during the State of the Union address that 30 states had started preschool initiatives, I mentally gave him some credit for agenda-setting. But some contiguous corner of the mind added that there's got to be caveats to that.  A Times article today by Richard Perez-Pena and Motoko Rich about the national drive toward state-funded preschool brings the caveats into focus.

First, while momentum in the last year has been impressive,  with new initiatives in Alabama, Michigan, Minnesota, Montana, and San Antonio, the movement has been picking up steam for at least a decade, with the number of children in state-funded preschool more than doubling since 2002.  And as this year's initiatives illustrate, the effort has been bipartisan. Perez-Pena and Rich outline the political imperatives:
Few government programs have broader appeal than preschool. A telephone poll conducted in July for the First Five Years Fund, a nonprofit group that advocates early education programs, found that 60 percent of registered Republicans and 84 percent of Democrats supported a proposal to expand public preschool by raising the federal tobacco tax.

“Preschool is, generally speaking, a crowd pleaser,” said Chester E. Finn Jr., president of the Thomas B. Fordham Institute, a conservative-leaning education policy group.