Buying a health plan: Don't try this at home?

In a recent post, I cheered a bit while noting that most ACA marketplace users who should have bought silver-level health plans did in fact buy silver plans.

That is, most people whose income qualified them for subsidies reducing their plan deductibles and out-of-pocket costs -- subsidies available only with silver plans -- did buy silver. Somewhat less than 20% of those eligible for Cost Sharing Reduction (CSR) bought bronze plans, which have higher deductibles and copays and disqualify a buyer from CSR..

Perhaps a 15-20% "bad choice" rate is too high. After speaking with ACA navigator Kate Kozeniewski of Resources for Human Development (RHD), however, I had to wonder why the numbers weren't worse.

Premiums reign supreme

I asked  Kozeniewski, a program coordinator who helped oversee assistance provided to 45,000 people in Pennsylvania while directly assisting hundreds herself, whether clients generally understood the importance of CSR.

"We found across the board that people were not aware that cost sharing was not available to them unless they chose a silver plan," Kozeniewski said. Almost invariably, she said, people would look at the lowest monthly premium available (as reduced according to their income) and say,"This seems like it's within my budget, so I'll start here, and if this works, this is fine."

Having some health insurance is better than having none. But American insurance...

Those of us engaged in the long struggle to pass and implement the ACA have (not wrongly) fixated on how vital it is to have health insurance, and we've been cheered by the roughly 25% reduction in the nation's uninsured in the ACA's first year. We've also celebrated the ACA's ending of arbitrary policy rescissions, yearly and lifetime coverage caps, medical underwriting, and plans lacking essential benefits like childbirth and drug treatment.

Some coverage is better than none. But recent good reporting is also highlighting the extent to which much if not most health insurance in America remains inadequate, exposing plan holders to sometimes substantial, sometimes damaging and sometimes ruinous costs. The incidence of such exposure may be rising rather than falling, as employers continue to offload the cost of care onto employees.

Did too many low income ACA shoppers buy bronze plans?

Modern Healthcare's Virgil Dickson reports on a weak link in ACA coverage:

Obamacare enrollees are straining the finances of community health centers around the country, some health center leaders say.

The issue is that many lower-income patients with insurance coverage through the federal and state exchanges bought bronze-tier plans with lower premiums but high deductibles, coinsurance and copayments and no federal cost-sharing subsidies. When these patients face high out-of-pocket costs for care that falls below the deductible, they can't afford it. 

Deductibles on bronze plans average $5000 per person nationwide. In some regions, those high-deductible plans provide office visits and generic drugs at moderate co-pays before the deductible kicks in; in others, they don't. Lots of bronze plans really just provide catastrophic coverage with the ACA's mandatory free preventive care services -- substantial but not matching everyone's top needs by any means -- tossed in.

Silver (only) bullet: the lesser-known ACA subsidies

Low income people who qualify for private-plan subsidies under the ACA-- that is, those who earn too much to qualify for Medicaid but less than 250% of the Federal Poverty Level (FPL)-- should not, for the most part, be in bronze plans.  Recognizing that deductibles in the thousands are not viable for people at these income levels (138%--250% FPL), the ACA provides Cost Sharing Reduction (CSR) subsidies -- but only with silver plans (which have lower deductibles and copays than bronze to begin with). If you don't buy silver, no CSR fo you.

The CSR subsidies are particularly generous under 200% FPL, covering 94% of an average user's costs for those earning up to 150% of the Federal Poverty Level (FPL), 87% for those earning 151-200% FPL, and a more modestly boosted 73% for those between 200% and 250% FPL.

Most who should have bought silver bought -- silver

The good news is that overall, the marketplace worked more or less as intended, in that 76% of subsidy-eligible buyers on healthcare.gov bought silver plans, according to an HHS May 1 report. Of those who didn't, perhaps a higher percentage had incomes between 250%--400% FPL, which would at least mean that they weren't leaving CSR on the table.  Just 20% of users in all marketplaces (state-run as well as healthcare.gov) bought bronze plans, and since 33% of buyers who earned too much to qualify for subsidies bought bronze, somewhat less than 20% of the subsidy-eligible must have done so. I would hope, again, that the percentage of CSR-eligible buyers who bought bronze is lower still.

Repetition again*

I share in the general admiration for the tour de force in gotcha editing pasted below the jump -- so much so that I've added its author to my blogroll.  But of course I want to add my two cents.

Elisabeth Rosenthal exposes hospitals as free-billing zones

I stand back in awe from the healthcare reporting of The New York Times' Elisabeth Rosenthal, who since June 2013 has been exposing in front-page blockbuster after blockbuster the rampant greed and depraved price-gouging endemic to the US healthcare system. Her nine-part "paying till it hurts" series, indexed here, is worthy of a Pulitzer. It should galvanize the country as Silent Spring or The Other America did.

Rosenthal's latest exposes many hospital ORs as free-billing zones in which an array of doctors, physical therapists and other service providers can insinuate themselves in a procedure without the patient's prior knowledge or consent, whether they're in the patient's insurance network or not -- and then relentlessly pursue either the insurer or the patient or both for their exorbitant billings.

The most egregious example Rosenthal spotlights is when neurosurgeons or orthopedists call in out-of-network surgeons to assist -- who bill at out-of-network rates, to the tune of $117,000 in the headline case.  Then there's the smaller-scale gouging:

Unexpected fees are routinely generated outside the operating room as well. On the wards, a dermatologist may be called in to examine a rash and perform an expensive biopsy. The person in scrubs who walks a patient to a bathroom for the first time after hip surgery may turn out to be a physical therapist billing $400.

Rosenthal's fully-documented examples will make you afraid ever to set foot in a hospital -- unless perhaps you're on Medicare with full-bore Medigap insurance. A few policy takeaways from this tale of systemic depravity:

If you answer the first question wrong on healthcare.gov, no soup(sidy) for you

Back in April, when the ACA's extended open season was finally over, surveys conducted by McKinsey & Co. and PerryUndem (for EnrollAmerica) indicated that most of the still-uninsured were eligible for ACA subsidies (or Medicaid, in expansion states) but didn't know it. In fact, McKinsey found that two thirds of subsidy-eligible respondents who visited healthcare.gov but did not enroll were not aware of their eligibility -- and so had no idea how much health insurance would actually cost them.

I have an article up at The New Republic (my first there) examining why so many of the uninsured remain unaware of what the ACA has to offer them. In all fairness, the first answer must be that knowledge penetration takes time -- the CBO always projected a 3 to 4-year path to full takeup.

Two questions about Obama's thinking about ISIS

Peter Baker has a purported insider's view of Obama's thinking about the ISIS crisis™, based on interviews with 10 people present at two recent dinners the president held with foreign policy experts and journalists. Like most such exercises, it's not particularly revealing (with one exception noted at bottom), as the president is putting best foot forward with his guests and the guests assess him through a partisan prism (Richard Haas is respectfully negative, Jane Harman equivocally positive).  

I was struck, though, by two questions Obama's not-so-private exegesis left unanswered. I don't doubt that he has considered these questions in depth, but he has not seen fit to address them directly.

The first concerns his decision to ramp up aid to "moderate" Syrian rebels and support them with air strikes as appropriate.

Obama phones it in

In press conferences on Aug. 28, Sept. 3 and Sept. 5, and in a Meet the Press interview on Sept. 7, Obama provided considerable detail about the way he plans to "degrade and ultimately destroy" ISIS. Key themes, cumulatively elaborated over the four sessions, were that 1) The U.S. would not act precipitously in Syria; 2) Obama would not "Americanize" struggle -- U.S. military support would be calibrated to Sunni political action; and 3) the effort would build methodically and take considerable time.

Earlier today I traced these themes through all four of these quite recent Q&As because I assumed that they would serve as prelude to tonight's speech, which would distill them and continue to bring them into sharper focus. But the speech didn't do that. It was the comic book version -- the barest outline. It did not grapple with how the U.S. can build capacity to fight ISIS and foster the beginnings of viable government in Syria, an effort that Obama previously more or less rejected as futile -- and which he did address at least partially on 9/5 and 9/7, suggesting that the difference is greater motive and pressure on nearby Sunni nations to act in concert. He didn't provide any detail as to what degree of Congressional buy-in he considers necessary or unnecessary.  He held up U.S. efforts against al Qaeda affiliates in Yemen and Somalia as models, rather than his fight against core al Qaeda, seemingly to minimize the threat, though ISIS arguably has more capacity now than bin Laden's group ever did.

No, Obama is not plunging neck-deep in the Big Muddy

"We don't have a strategy yet." Those words of Obama's in an Aug. 28 press conference so flipped out the foreign policy establishment and media that no one heard heard what Obama was saying.

A translation: The conditions are not yet in place for significant U.S. military action against ISIS in Syria. Our efforts now are concentrated on beginning to create such conditions.

Those who fear that Obama is poised to plunge neck-deep in the Syrian muddy (here's to you, Mr. Sullivan) might look again at how he has elaborated this point repeatedly  -- in press conferences on Sept. 3 and Sept. 5, and in his Meet the Press interview with Chuck Todd that aired Sept. 7.

Here's how he put it on Aug. 28:

The Republicans' ACA shell game

The most credible rap against the Affordable Care Act is that it raises the cost of insurance bought in the individual market for people who have no preexisting conditions and earn too much to qualify for subsidies.

That is true. Hence all the "rate shock" stories bruited by the GOP last fall.  Most of those stories did not survive scrutiny, because the GOP went for dramatic hardship cases, and most true hardship cases qualify for subsidized coverage.  Those truly dinged by the law were more like a couple with two children profiled by the New York Times earning about $100,000 per year and a single 50-something man earning just under $50,000 profiled in the same article -- folks on the wrong side of the subsidy cliff.*

Somewhere between one and five million people suffered at least short-term financial harm of this sort. Their numbers are now dwarfed by the 6-7 million people getting subsidized private plan coverage, the 7 million-odd added to the Medicaid rolls, and the 2-3 million under age 26 who gained coverage on their parents' plans.

The law as a whole remains unpopular -- because Republicans have been relentlessly smearing it for five years, because the individual mandate has always been an unpopular concept, because healthcare.gov dysfunction imprinted "train wreck" perceptions before the problems were patched and signups surged, and because astounding numbers of the still-uninsured still don't know that they qualify for subsidized coverage.

Nevertheless, reality has seeped in enough to sap the strength of the Republican attack.  And as the intensity of that attack has diminished, its policy core has shrunk to a simple line that masks a core evasion. Here's one iteration, as expressed to Talking Points Memo's Sahil Kapur:

"Ensuring that people with preexisting conditions have access to coverage has long been a popular policy, and one where there is bipartisan agreement. It's the the entirety of ObamaCare that remains EXTREMELY unpopular," Brad Dayspring, a spokesman for the Senate GOP's campaign arm, told TPM in an email.

Question for Obama: Why is arming a "moderate" Syrian opposition no longer a "fantasy"?

Back in January Obama suggested to David Remnick that trying to arm and shape a "moderate" opposition to Assad was futile:

... I asked Obama if he was haunted by Syria, and, though the mask of his equipoise rarely slips, an indignant expression crossed his face. “I am haunted by what’s happened,” he said. “I am not haunted by my decision not to engage in another Middle Eastern war. It is very difficult to imagine a scenario in which our involvement in Syria would have led to a better outcome, short of us being willing to undertake an effort in size and scope similar to what we did in Iraq. And when I hear people suggesting that somehow if we had just financed and armed the opposition earlier, that somehow Assad would be gone by now and we’d have a peaceful transition, it’s magical thinking.

“It’s not as if we didn’t discuss this extensively down in the Situation Room. It’s not as if we did not solicit—and continue to solicit—opinions from a wide range of folks. Very early in this process, I actually asked the C.I.A. to analyze examples of America financing and supplying arms to an insurgency in a country that actually worked out well. And they couldn’t come up with much. We have looked at this from every angle. 

More recently, he told members of Congress that the notion that the U.S. could have conjured an effective moderate opposition was "a fantasy."  Now, though, as he told Chuck Todd in an interview airing today, his nascent strategy in Syria depends on building such an opposition. When Todd challenged him as to how ISIS could be defeated in Syria without U.S. troops, here was his response:

Contain, degrade, destroy ISIS? It's a timeline

[Update 9/5, 12:15 p.m. ET: in a press conference in Wales that just ended, Obama added "ultimately" at least thrice to the phrase "degrade and ultimately destroy" and variants, reinforcing the 'timeline' theme below.]

I'm not qualified to assess the efficacy of Obama's past or current conduct of policy with respect to Syria and Iraq. But I am well attuned to Obama's rhetoric and the thinking it reflects. On that basis, I can tell you that the media angst over whether he's signaled intent to contain, degrade or destroy ISIS is a lot of hooey.

Current U.S. policy, as Obama has described it and to the extent it can be disclosed, is pretty straightforward. U.S. air power will contain ISIS, and begin to degrade its warmaking capacity, while regional actors get their act together, with the help of U.S. prodding and incentives. To the extent that they do so, efforts will escalate to destroy ISIS.

Contain, degrade and destroy are stages in a process, timeline uncertain and dependent on strategic goals such as winning Sunni Iraqi buy-in to the new government and getting Gulf states to act in concert in finding viable Syrian opposition to back (while also, I would guess, working to leverage and to some extent covertly coordinate with warfare against ISIS conducted by Iran and Syria).

It's true that Obama's rhetoric has served to temper more overheated pronouncements by Biden, Kerry and others. And there was a real division between Powers' denunciation of the Russian invasion of Ukraine and Obama's refusal to call it that. But his own rhetoric with respect to Iraq, Syria and ISIS can be cast as  inconsistent or conflicted only if you break apart the implicit and contingent timeline he's outlined with the help of various verbs.

No, Virginia, ACA administrators do not need to "retain" the prior 8 million signups in 2015

Tis the season for preview articles spotlighting the challenges of signing up more uninsured and retaining the newly insured in Year 2 of the Affordable Care Act. The New York Times' Reed Abelson, in an otherwise excellent overview, repeats a common fallacy:

the Obama administration is expected to try to persuade about five million more people to sign up while also trying to ensure that eight million people who now have coverage renew for another year.

No one can or will try to ensure eight million renewals, because a very large proportion of 2014's enrollees -- perhaps half or more -- will not need to renew their coverage. They will be covered by new employers, or new spouses, or newly employed old spouses, or they will lose income and become eligible for Medicaid, or they will go on disability, or die, or, or, or...