Three signs the ACA private plan marketplace is working

Over at healthinsurance.org, I've noted them: 1) more "active renewals" than expected; 2) relatively low churn; and 3) a high level of takeup for Cost Sharing Reduction (CSR) subsidies -- that is, silver plan selection by buyers with incomes under 200% of the Federal Poverty Level. My takeaway:

Many healthcare professionals and scholars worry that a market providing choice from a large selection of private health plans with a complex array of features and coverage rules offers too much complexity for typical buyers, most of whom are on the lower end of the income scale.

King v. Burwell and Congress v. P5 + 1

Reading friend-of-the-hawks reporter Josh Rogin's account of the difficulties Obama may have getting Iran to agree to a deal that bypasses the U.S. Congress, and so could be overturned by a future (GOP) president, I was reminded of GOP demands that the administration float "contingency" plans in case  the Supreme Court destroys the Affordable Care Act by ruling for the plaintiffs in King v. Burwell.

In both cases, bad-faith opposition to vital and viable policy, the product of immense collective effort and years in the making, may well succeed. In both cases, the saboteurs are demanding a collaboration they've rendered impossible.

Gallup misreads its state ACA data: state-run marketplaces no better at reaching uninsured

Gallup does a great service in tracking the decline in the uninsured rate state-by-state since ACA implementation. But they draw a misleading conclusion from their latest data set:

Collectively, the uninsured rate in states that have chosen to expand Medicaid and set up their own state exchanges or partnerships in the health insurance marketplace declined significantly more last year than the rate in states that did not take these steps. The uninsured rate declined 4.8 points in the 21 states that implemented both of these measures, compared with a 2.7-point drop across the 29 states that have implemented only one or neither of these actions.

In fact, the superior overall performance of these states in reducing un-insurance is due entirely to the Medicaid expansion. Collectively, their exchanges did not perform particularly well with regard to enrolling subsidy-eligible residents in private health plans.

Compare Gallup's chart highlighting state leaders in reaching the uninsured population by both means (Medicaid and private plans) with the Kaiser Family Foundation's snapshot of states that reached the highest percentage of subsidy-eligible private plan buyers. [Update: The initial comparison is of uninsured rates from poll data taken by Gallup throughout 2014 with Kaiser's up-to-date ranking of performance in the QHP market (through 2/15/15). Kaiser's 2014 ranking appears at bottom.]

Michael Leavitt envisions a post-King negotiation to amend the ACA

If the Supreme Court upholds the plaintiffs in King v. Burwell and thus cripples the ACA exchanges in three quarters of the states, what then? Neither side is talking about how they might compromise to avoid de-insuring 7 million Americans and crippling the insurance market. But Michael Leavitt -- former HHS Secretary under George W. Bush, former 3-term governor of Utah, current CEO of an eponymous healthcare consultancy -- goes there, in an interview with me, now up on healthinsurance.org. Here's the core of what he envisions:

[A] possibility would be to take the current subsidy structure, but allow people who qualify for a subsidy to get it not just in a state exchange but in a private exchange that may be authorized by the state. Multiple private exchanges might begin to pop up. You’d end up with  a competitive marketplace with many more exchanges and lots more innovation.

I hope you'll read the whole thing.  And then, perhaps, a prior interview I conducted with Leavitt last June about the scope for state innovation in healthcare that the ACA does provide. And while you're at it, a  January 2014 Leavitt interview with Julie Appleby of KHN in which he expressed considerable empathy for the HHS officials trying to get the ACA implemented.

P.S. My own take on conservative demands for less regulation and more "innovation" in health insurance, probably inspired in part by this interview (though more immediately by Ross Douthat's column on conservative policy proposals), is in the prior post.

Conservative reform of the ACA: cutting strings at different ends

When those few conservatives who would genuinely like to see affordable health insurance available to all Americans -- and the many Republican office holders who pretend to -- float alternatives to the Affordable Care Act, they talk about making insurance more affordable, about offering more choice and flexibility to insurers and hence to customers.

Giving insurers more flexibility generally means three things. First, reducing or eliminating the ACA's federally mandated Essential Health Benefits (EHBs) -- which include mental health, drug treatment, childbirth and children's dental coverages that many people might plausibly protest they don't need. Second, allowing sale of plans with lower actuarial values -- the percentage of the average user's annual medical costs paid by the plan -- than the ACA allows. The law sets a floor of 60% AV in both the employer and individual markets and, in the exchanges, establishes silver-level 70% AV plans as the benchmark to which subsidies and Cost Sharing Reduction subsidies (boosting AV for lower income buyers) are tied. Third, widening the allowable price variation according to the plan holder's age and allowing price variation according to sex.

There's much less here than meets the eye.

Obama's seductive love for America

The irony in this "Obama doesn't love America" crap is that Obama got himself elected by holding up  to Americans a flattering mirror that was suited to the moment.

The national narrative that Obama put forward in 2007/8 had two salient points (okay, may it had three or four or five, but two come to mind here). It was, first, a bid to move the political center to the left -- to cast American history as a progression in which Americans at various crux points demanded and obtained new common investments in shared shared prosperity and new extensions of equal opportunity to an ever-widening and more inclusive circle -- African Americans, women, gays. In Obama's telling, the nation had veered off-course for eight or thirty years, but democratic self-correction was also part of the long historical pattern and would come with him.

That's a kind of "whig history" for America, and it resonated in the wake of a disastrous conservative presidency.  It was also a message essentially common to all Democrats and would have worked for almost any Democrat.

The real contest in 2008 was in the Democratic primary, and perhaps Obama beat Hillary by making this whig history sing, tapping a deep American mysticism previously tapped by Lincoln and -- somewhat more caustically -- by Martin Luther King. This second element was captured by Obama's "more perfect union" trope.  That is: America's founding documents expressed principles for the best ordering of human society, and while the nation has never lived up to these ideals, its democratic engine draws it ever closer -- ever more perfect, never perfected. Those ever-widening circles of inclusive opportunity are bending the arc of history toward justice. Martin Luther's famous "check" of equal opportunity, returned for insufficient funds, is being paid on a very long mortgage schedule.

The disappearing shoparound on Healthcare.gov

While enrollment figures in the ACA's first open season ultimately exceeded expectations, a disturbing number of those who remained uninsured remained ignorant of federal aid that would make insurance affordable for most of them. A McKinsey & Co survey conducted in April 2014 found that two thirds of subsidy-eligible respondents who'd tried to use Healthcare.gov and cited unaffordability as the reason they remained uninsured were unaware that they were eligible for subsidies. In a more recent Kaiser Family Foundation survey, almost half of still-uninsured respondents who said they were "told" they were ineligible for aid appeared to be aid-eligible at the time of the survey (a few months later).

While there are many ways that an applicant in Healthcare.gov or the state exchanges could get that false impression, it would appear that a well-designed, prominently placed "shoparound" feature could go a long way toward remedying the problem. Healthcare.gov has such a feature, and it's pretty easy to use. Punch in your zip code, the number of members of your household with their ages, and your annual income, and within a minute of starting you get a complete list of available plans with subsidy-inclusive prices. That is, you very quickly know the least amount you can pay as a monthly premium (or if you're likely to be eligible for Medicaid) -- that is, if you accurately estimate your income. There's a lot still to figure out -- but you're not likely to be slapped with the full sticker price and think that you're on the hook for all of it, as may have happened to many people who started an application and somehow disqualified themselves for a subsidy while applying (e.g., by saying that they did not plan to file a tax return).

Healthcare.gov did put up a shoparound in the first open season, but it wasn't fully functional until December, and even then it was easy to miss if you weren't looking for it. Therefore I rejoiced when, in the runup to the second open season this November, the new and improved shoparound was one of just two buttons on the home page, labeled "see plans and prices."

That was then. In the course of open season, the shoparound faded from view. By February it was three pages deep.  Its use declined accordingly. In its weekly enrollment summaries, HHS tracked "window shopping Healthcare.gov users" as well as overall site visitors.   Here's three snapshots:

The case against King, by Scalia, Kennedy et al

The plaintiffs in King v. Burwell claim that the ACA's creators intended to coerce states into setting up their own exchanges by authorizing state-established exchanges alone to credit subsidies to buyers -- denying that power to the backup federal exchange.

In response to this manifestly absurd assertion of intent, the law's supporters have pointed out that no one involved in the law's design, passage or implementation understood such coercion to exist; that laws that make federal grants to the states conditional on specific state action invariably spell out the consequences of non-participation; that the ACA's clear intent is to provide near-universal coverage; and that the ACA's core provisions were designed to be interdependent, so that denying subsidies to residents of some states would render the law inoperable.

On  all of these points, no participant has been so eloquent as the four dissenting Supreme Court justices in NFIB v. Sebelius, the suit challenging the law's constitutionality, who asserted that the entire law should be struck down.

In their dissent, Justices Scalia, Kennedy, Thomas and Alito argued repeatedly that to strike down any core provision -- e.g., the individual mandate or the Medicaid expansion -- was to thwart the intent of the law's creators and render the remaining parts of the law unworkable -- hence the imperative to strike down the whole law.

Abbe Gluck has highlighted the dissenters' most direct assertions of interdependence of parts, laying particular stress on their observation that the law's "system of incentives collapses if the federal subsidies are invalidated" because without the subsidies, "the exchanges would not operate as Congress intended and may not operate at all" (dissent, p. 60).

Equally striking is the dissenters' argument that making the Medicaid expansion fully voluntary, as the Court majority did, would also thwart Congress's manifest intent to provide universal coverage and would thus render the entire scheme unworkable.

No, Clinton and Frist, ACA marketplace coverage will not render CHIP unnecessary

In an otherwise eloquent plea by Hillary Clinton and former GOP Senate majority leader Bill Frist for Congress to renew funding for the Children's Health Insurance Program (CHIP), one paragraph brought me up short. It's not strictly speaking inaccurate, but it resorts to a shorthand that, in the way of 750-word op-eds, leaves a misleading impression:

Of course, the American health care landscape has changed significantly since CHIP started. Under the Affordable Care Act, many families with children are now receiving financial help to enroll in private health coverage through the new health insurance marketplace. But while it is possible that private, family-wide policies offered by employers and marketplaces may one day render CHIP unnecessary, for now substantial gaps still exist — and too many children can still fall through them.

In fact, the ACA puts the kids in CHIP in most families in which the adults qualify for private-plan premium subsidies. CHIP eligibility operates independently from adult eligibility for subsidized private plans or Medicaid under the ACA.  Every state sets its own eligibility for CHIP, ranging from 170% of the Federal Poverty Level (FPL) in North Dakota to 405% FPL in New York. The median eligibility is 255% FPL (see this Kaiser Family Foundation chart).

Love in the time of Obamacare

Ah, mid-February, when love and ACA open enrollment both come to climax. Tis the (second annual) season for #Healthpolicyvalentines:

Affordable insurance?
I don't have any.
You are my only
Essential Health Bennie.

        *     *     *

I've turned 26
But what does my Mama care?
She knows I'll stay covered
Thanks to Obamacare.

      *     *     *

Bronze plans are skimpy,
Golds rake your bucks in.
Silver is sweet
with Cost-Sharing Reduction.

     *     *     *

Obama soft-focuses our domestic ills

I usually find Obama interviews, especially long ones, reassuring. His understanding of issues is nuanced and multi-tiered. But his responses to Ezra Klein's questions about domestic issues and trends struck me as disappointingly unfocused, or off-focus, on several fronts. For example:

1. Asked about the causes of growing inequality, he back-loaded labor law:

Now, there are a whole bunch of reasons for that [stagnant middle class wages]. Some of it has to do with technology and entire job sectors being eliminated — travel agents, bank tellers, a lot of middle management — because of efficiencies with the internet and a paperless office. A lot of it has to do with globalization and the rest of the world catching up. Post-World War II, we just had some enormous structural advantages because our competitors had been devastated by war, and we had also made investments that put us ahead of the curve, whether in education or infrastructure or research and development.

Hey, HHS, you're boasting about the wrong metric

If you read the inimitable Elisabeth Rosenthal's account of unhappy ACA plan holders this weekend, you know that high deductibles and out-of-pocket costs are one serious weakness of the coverage offered to many buyers on ACA exchanges.*

One mitigating factor is that most buyers with incomes under 200% of the Federal Poverty Level get Cost Sharing Reduction (CSR) subsidies that strongly reduce deductibles and maximum out-of-pocket costs, to levels superior to those offered by most employer-sponsored plans.  CSR is only available with silver plans, but as I've labored to deduce, best evidence suggests that over 80%** of buyers with incomes under 200% FPL do buy silver, resisting the temptation of lower-premium bronze plans that would leave them on the hook for huge out-of-pocket (OOP) costs.

Given this partial success, I find it baffling that all of HHS' reports of enrollment data are written as if nothing matters but premium -- the lower the better. The report released today boasts:

Narrow networks: a painful of tourniquet on a bleeding healthcare system

Stories of bad buyer experiences with ACA exchange plans often induce me to push back a bit. I can't do that with Elisabeth Rosenthal's laser strike on patients' troubles with ACA plans' narrow networks and mazes of separate copays and coninsurance for different procedures.  Rosenthal is too nuanced, too thorough with context, and too precise in her accounts of buyers' experiences to quibble with. A sampling:

Alison Chavez, 36, who is self-employed, signed up for a marketplace plan in October 2013 that she hoped would be an improvement on her previous plan. She had recently been given a diagnosis of breast cancer and was just beginning therapy, so she was careful to choose a policy on the Covered California marketplace that included her physicians.

But in March, while in the middle of treatment, she was notified that several of her doctors and the hospital were leaving the plan’s network. She was forced to postpone a surgery as she scrambled to buy a new commercial policy that included her doctors. “I’ve been through hell and back, but I came out alive and kicking (just broke),” she wrote in an email

Sail on, Sullydish

I have had a hard time getting my thoughts and feelings together since Andrew Sullivan announced the shuttering of the Dish, happening tomorrow. Like many, I imprinted what political blogging was in large part from Andrew; my own blog grew in part out of interior response -- often opposition -- to  the Dish. As many have noted, one of Sullivan's cardinal virtues is that he will engage with anyone who engages him in good faith -- and will link to anyone he thinks worth reading. Because of that openness, I've been privileged to keep up a running dialogue with him -- here, on the Dish, and via email.  Because the two-way dialogue is real, it always continues for me solo when I read the Dish, and that's what I'll really miss.

Obviously I'm not alone. The Dish crew has had fun with a flood of farewell reader mail this last week. One curated outpouring brought this raucous parting to mind:

“But the wild things cried, “Oh please don’t go - we’ll eat you up - we love you so!”
And Max said, “No!”
The wild things roared their terrible roars and gnashed their terrible teeth and rolled their terrible eyes and showed their terrible claws but Max stepped into his private boat and waved goodbye.”

Image here.


So sail on, Sullydish. I trust we''l hear from Chris, Patrick et al soon, and elsewhere. As for Andrew, after a longish or shortish hibernation I trust he'll yawn awake when the skies clear and grow lank with longing to re-engage the world..  

Yes, Ta-Nehisi Coates, it's good to be right

The Twittersphere -- at least, my Twittersphere -- is widely commending Ta-Nehisi Coates' tribute to Andrew Sullivan.  I can sort of see why -- it captures what Andrew himself has often presented as his core virtue -- but it also seems to me to be based on a perverse premise.

Back when I started blogging, there was an annoying premium on "public smartness" and "being right" among pundits, journalists, and writers. Likely, there is still one today. The need to be publicly smart and constantly right originates both in the writer's ego and in the expectation of incurious readers. The writer gets the psychic reward of praise—"Such and such is really smart" or "Such and such was 'right' on Libya." And the incurious reader gets to believe that there is some order in the world, that there is a stable of learned (mostly) men who will decipher the words of God for them. The incurious readers is not so much looking for writers, as prophets.

Too many aid-eligible ACA applicants say they were "told" otherwise

A Kaiser Family Foundation survey of 10,000 low- and moderate-income Americans conducted last fall finds, disturbingly, that half of those who say they were "told" that they did not qualify for government help obtaining coverage do appear to have in fact been eligible.

It's not entirely clear what respondents meant when they said they were "told" they did not qualify for aid. Many apparently sought outside help.  But it's all too easy to get a "false negative" from the exchanges themselves -- and ACA master navigator Kate Kozeniewski detailed for me several ways this could happen. My writeup is at healthinsurance.org;  a sampling of Kate's list is below. Note that the weak points extend in part to the phone hotline: in Kate's experience, you have to get a supervisor to deal with issues of any complexity.

1. No tax return/no subsidy: At the very outset, Healthcare.gov asks whether the applicant plans to file a tax return – which many people who earn too little to owe income tax habitually do not do. If you click “no,” however it’s “no subsidy for you,” Kozeniewski notes ruefully. There is no warning about this – if you say that you’re not going to file a tax return, you simply move on through the application, and learn at the end that you are ineligible for help paying for coverage.
2. Married? Then file jointly: If you’re married and file separately, you’re not eligible for subsidies. Here too, the website does not warn you that you’re forfeiting subsidies if you put down that you file singly. Kozeniewski has seen a surprising number of single filers. “It seems there’s a decent number of people estranged from their partners who have not gone through the steps of getting a legal divorce. We also see immigrants whose spouses are living in another country. There’s even a fair amount who are married and living in the same household, but who file separately for whatever reason.”

Read the rest here.

The real world case against King: Should the Supreme Court impose "risks and uncertainties" on U.S. economy?

Leave aside for a moment the frankly ridiculous question of whether the text of the ACA authorizes premium subsidies to flow through the federal exchange. .Timothy Jost, surveying 30 amicus briefs filed to support the IRS' reading of the law to that effect, first covers those primarily engaging with the text of the law then turns to those from stakeholders that detail the real-world effects of gutting the ACA.

A note before looking at Jost's powerful survey of these pleadings. Some would argue that these real world effects are immaterial: either the law authorizes subsidies to be credited through Healthcare.gov or it doesn't. As I noted once before, though, the conservative justices who dissented against  the 2012 decision that upheld the constitutionality of the ACA  demonstrated their sensitivity to the real world effects of Supreme Court decisions in that very dissent.

Justices Scalia, Kennedy,Thomas and Alito argued that since the individual mandate was unconstitutional the whole law must be struck down because all its key provisions were interdependent and many of them would wreak economic havoc if left to operate with a core provision removed.  They were quite specific about the potential consequences of disfguring the law without killing it: