Rejoice, Uticans! A shower of silver shall rain upon you in 2016.

UPDATE: I'm afraid I have to retract the gist of this post, which comes mainly near the end: we don't actually know the spread between the benchmark and cheapest silver plans in each New York region for 2016.  Looking at the spread between the silver-plan prices posted by the different insurers, it escaped me that a given insurer could put up the cheapest and second cheapest silver plan in a given area -- so the difference between insurers' average silver prices, as reported by the state, is not the spread between benchmark and cheapest silver. The posted averages do not reveal the benchmark. I apologize to anyone who absorbed the misinformation.

P.S. I discovered the error when I went to check 2015 prices and how a "cheapest silver" windfall would affect them. Of course I might have known, as I've done a lot of "shopping" on healthcare.gov and have rarely seen a really significant gap between cheapest- and second-cheapest silver. I think I was thrown off by California's just-published 2016 rate chart, which explicitly highlights some very large spreads between benchmark and cheapest silver, with one plan price quoted for each insurer. That's presumably because benefits in CA are standardized for each metal level.

P.P.S. I also seem to have forgotten for the moment that NY is launching a Basic Health Plan in 2016, thereby wiping out the under-200% FPL market and rendering the issue of CSR takeup all but moot, as CSR is negligible at 200-250% FPL. That'll teach me to post in haste before rushing out on a Friday evening reverse commute to hang over the balconies at the new Whitney Museum:

New Whitney

So, never mind, except for the general principle:
--------------

Today New York posted 2016 rates for health insurance plans offered on NY State of Health, the state's ACA exchange. I was planning to write about the factors that affect what subsidized ACA private plan buyers will actually pay, when the rates posted for Utica, NY brought me up short. They are a stark illustration how the spread between certain plans offered in one market matters more to subsidized buyers than the sticker price of a given plan -- if they're willing to buy the cheapest plan at a given actuarial value.

On ACA exchanges, premium subsidies are set as a fixed percentage of a buyer's income, benchmarked to the second cheapest silver-level plan in the buyer's market. In 2016, solo buyers who earn exactly 200% of the Federal Poverty Level (FPL) will all pay $124 for the second cheapest silver plan available to them, regardless of where they live. Buyers earning 150% FPL will pay $59 for the benchmark plan.

New York's ACA exchange publishes takeup rates for Cost Sharing Reduction

NY State of Health, the state's ACA health insurance marketplace, released detailed enrollment data today (hat tip to who else but Charles Gaba?). With regard to my own little preoccupation -- the degree to which those private plan buyers eligible for Cost Sharing Reduction (CSR) subsidies access the benefit by buying silver plans -- New York is (as far as I know) the first state to do the basic math for me:

The majority of QHP consumers who completed the enrollment process and were eligible for APTC with cost-sharing reductions chose Silver plans in which they can use costsharing reductions. Among those eligible for cost-sharing reductions, enrollment in Silver plans was higher for those eligible for greater levels of subsidy. Ninety-seven percent of those eligible for costsharing reductions at the 94 percent actuarial value level enrolled in a Silver plan, compared with 83 percent at the 87 percent actuarial value level, and 62 percent at the 73 percent actuarial value level. Overall, 78 percent of those who are eligible for cost-sharing reductions, enroll in a Silver plan with that benefit. The remaining 22 percent enroll in different metal levels. These trends are consistent with the
2014 open enrollment period, when overall, only a slightly higher share of cost-sharing reduction eligible enrollees—80 percent—enrolled in these products. 

Last year, I had to tweeze these numbers out of the NY enrollment report myself.  Since they redounded to the state's credit, and a NYSOH spox confirmed them for me, I'd like to think I gave them a nudge toward highlighting the takeup themselves this time around.

Pennsylvania Medicaid expansion enrollment jumps; have newly Medicaid-eligible 2014 private plan enrollees jumped with it?

Pennsylvania's somewhat rocky Medicaid expansion, for which enrollment began on December 1 and coverage on January 1, seems now to be firing on all burners. The state's Department of Human Services reported last week that enrollment is up to 439,000, more than two thirds of the state's target of 605,000.

The expansion began slowly. After Pennsylvania declined to expand in 2014, then-Governor Tom Corbett negotiated with HHS to create the kind of "private option" expansion popular with Republican governors. The "Healthy Pennsylvania" plans that were hastily constructed in fall 2014 had different terms for Medicaid-eligibles at different income levels, and eligibility criteria different from the state's existing programs. Adding to the confusion, existing state Medicaid programs required applicants to list their assets as well as their income; the ACA excludes such information from the Medicaid application process. Systems snarled and applications backlogged, though not as radically as in many states.

A transition back to traditional Medicaid initiated by the state's new Democratic Governor, Tom Wolf, kicked off on April 27. That transition will be complete by the end of this month, though some "private option" enrollees will be double-enrolled until September 1. By late April most applications were being processed in a timely manner, meeting the state's 30-day standard, enrollment counselors told me at the time.  Kait Gillis, a DHS spokeswoman, tells me that 150,000 have been enrolled since the transition to traditional Medicaid kicked off.

Some sidelights on Covered California's modest rate increases for 2016

Covered California, the state's ACA health insurance exchange, is boasting today with some justice that the state held 2016 rates down to an average weighted increase of 4%. Other talking points: the average (unweighted) increase of the cheapest silver plan in each region went up just 1.5%, and the average consumer can save 4.5% if she switches to the cheapest plan in the same metal tier.

That last point is somewhat...selective: the apples-to-apples question is what will happen to current holders of the cheapest plan in each metal tier if they switch to 2016's cheapest plan.  On the other hand...there are two other hands.

First, the talking point about switching to the cheapest plan in one's metal level has some extra validity in California, where benefits for all plans in each metal tier are standardized. In other words, the only substantial variable other than price is network quality. Hence, price shopping -- balancing premium versus benefits -- is likely to be less fraught and easier to get right in California than in most states.

Second, it's good news that the cheapest silver plan in each region went up an average of just 1.5%-- but the import of that factoid depends in part on a second data point. That would be the average increase for the second cheapest silver plan in each region, which is the benchmark according to which premium subsidies are set. That is, a buyer's premium is calculated to leave him paying a fixed percentage of his income for the second cheapest silver plan available to him. If the benchmark silver plan goes up more than the cheapest silver plan, that's good for the buyer: it increases the affordability of silver-level coverage.  Covered California's full rate report shows that the benchmark plans went up an average of 1.8%, very modestly (on average) increasing the spread and so the affordability of the cheapest silver plan. It also shows that the cheapest bronze plan went up an average of 3.3% -- making the cheapest silver relatively (albeit slightly) more attractive.

The source of Huckabee's Holocaust porn

President Obama quite rightly read Mike Huckabee's disgusting, inflammatory assertion that the nuclear deal with Iran "will take the Israelis and march them to the door of the oven” as "an effort to push Mr. Trump out of the headlines. "  Most observers see it in that context: Trump is leading GOP contenders on a dive to a new bottom.

But where did the hysteria compressed in Huckabee's sound byte come from? Who writes the GOP's tune on dealings with Iran and middle east policy generally?

Netanyahu, natch.

To mark Holocaust Memorial Day back in April, "in a speech," The Washington Examiner's Paul Bedard noted, "already winning attention in Washington," Netanyahu "compared Washington's deal with Iran to Europe's appeasement of Adolf Hitler which led to the Holocaust and world war."

New light on QHP enrollees' income levels in states that refused to expand Medicaid

Below are some state-by-state numbers for private health plan enrollment in the 21 Healthcare.gov states that refused to expand Medicaid.  The state enrollment totals at different income levels are extracted from the county-by-county data released by HHS in early July. I've sandwiched those tallies between the states' median household incomes as of 2013 and Kaiser's estimates of the percentage of potential private plan enrollees that each state has enrolled as of March 31, 2015.*

What I'm after is possible causes of state variations in the percentage of enrollees eligible for Cost Sharing Reduction (CSR) subsidies who accessed that benefit by buying silver plans, the only metal level at which CSR is offered. CSR is available to buyers of Qualified Health Plans (QHPs) whose household incomes are below 251% of the Federal Poverty Level (FPL). In nonexpansion states, that's fully 80% of QHP buyers.**

In the chart below, states are listed in ascending order of median household income. I track the percentage of buyers in each states whose household incomes are between 100% and 150% FPL, for reasons explained below, as well as those who are CSR-eligible (0-250% FPL***). The next-to-last column tracks the percentage of CSR-eligible buyers who selected silver plans and so obtained the benefit.****

Utah and Alaska are on course to expand Medicaid. Are their eligibility estimates inflated? (Updated)

Both Alaska and Utah seem to be on course to implement the ACA Medicaid expansion. In Alaska, Governor Bill Walker is asserting his authority to do so without the approval of the legislature. In Utah, Governor Gary Herbert has struck a deal with legislative leaders -- still perhaps facing a rocky course toward legislative approval -- to seek a waiver for a "private option" form of the expansion.

In both states, as in any state, pro and con arguments over expansion are based on cost estimates which are in turn based on estimates of how many state residents will gain eligibility for Medicaid. It's noteworthy that in both states, in 2015, the Kaiser Family Foundation radically cut its 2014 estimate of those in the "coverage gap" -- that is, those whose incomes would have qualified them for Medicaid had their states accepted the expansion but are too low to qualify them for subsidized private plan coverage on ACA exchanges.*

In Alaska, Kaiser's estimate of the Medicaid gap population shrank from 17,290 as of March 31, 2014 to 10,500 as of  April 17 of this year. In Utah, the drop was from 57,850 in 2014 to 30,000 in 2015. These estimate cuts are mainly due to a redesign of insurance questions in the Census Bureau's Current Population Survey, intended to address previous under-reporting of respondents' insurance coverage.** While Kaiser cut its estimates for every state, the reductions in Utah and Alaska were far and away the largest. In both states, though, state officials' estimates of the "gap" population are closer to Kaiser's earlier estimates than to the newly reduced ones. In both states, in fact, working estimates are higher than Kaiser's 2014 figures.

For ACA plan buyers, it's not the price, it's the price spread

There's good news and bad news in this forecast by Avalere Health of average premium increases in 2016 for health plans sold on ACA exchanges:

...premiums for the lowest and second lowest cost silver plans in the eight states analyzed will increase on average 4.5 percent and 1.0 percent respectively, compared to a 5.8 percent across all silver exchange plans. 

There was similar good news/bad news in HHS's report on actual premium increases from 2014 to 2015:

Premiums for the benchmark (second-lowest cost) silver plan will increase modestly, by 2 percent on average this year before tax credits, while premiums for the lowest-cost silver plan will increase on average by 5 percent. The plans offering the lowest prices have sometimes changed from 2014 to 2015, so consumers should shop around to find
the plan that best meets their needs and budget.

Call me naive, but...

the assurance in the last sentence of the first paragraph of the Joint Comprehensive Plan of Action between Iran and the E3/EU+3, while obviously not sufficient in itself, is not insignificant either:

Iran reaffirms that under no circumstances will Iran ever seek, develop or acquire any
nuclear weapons.

That's reaffirmed,  by the way, because Iran has asserted repeatedly that Khamenei declared as much in a fatwa, though that fatwa was allegedly never written down. Now, there it is, and again, standing alone as the third numbered provision in the document's preamble:

iii. Iran reaffirms that under no circumstances will Iran ever seek, develop or
acquire any nuclear weapons.

Where are Pennsylvania's low-income 2014 private plan enrollees?

As I've noted before,  I've been been trying to determine what happened to Pennsylvania's apparently large number of  low-income 2014 private plan enrollees who became eligible for Medicaid when the state belatedly enacted the ACA Medicaid expansion, effective Jan. 1 2015. My working hypothesis has been that large numbers of them stayed auto-enrolled in QHPs -- or re-enrolled prior to the expansion kickoff in December. Detailed enrollment data released by HHS early this month calls that notion into question however.

Here was the original premise. Most of Pennsylvania's 2014 enrollees in private plans (so-called Qualified Health Plans, or QHPs) re-enrolled for 2015.  As of May 2014, Pennsylvania had 318,000 enrollees. As of the end of open enrollment in mid-Feburary 2015, 276,732 were re-enrolled, according to the breakout HHS published this month. A large percentage of those re-enrollees might now be Medicaid-eligible -- and so theoretically ineligible for private plan subsidies. I had originally estimated that about one third of QHP enrollees as of late 2014 -- perhaps 90,000 -- had incomes under 138% of the Federal Poverty Level (FPL), which would qualify them for Medicaid. Then I learned that by February, CMS had compiled a a list of 141,000 Pennsylvania households with at least one QHP enrollee determined to be Medicaid-eligible (CMS has confirmed this for me.)  If accurate, that's close to or more than half of PA's QHP enrollees as of late 2014 (Those households had some 175,000 members).

Moreover, for 2015 the state had 160,961 auto-enrollments - enrollees who took no action and so were automatically re-enrolled in their 2014 plan or a substitute provided by their insurer.  That suggests a large potential pool of people who may not have noted or chose to ignore their eligibility for what was originally Pennsylvania's "private option" Medicaid expansion, which was quite rocky at the outset.

Why am I now questioning this premise? The current income distribution of Pennsylvania's QHP enrollees, revealed in the data HHS published in early July, looks more like that of an expansion state than a nonexpansion state. As of of the end of open enrollment in mid-February 2015, 131,470 out of a total of 472,697 Pennsylvania QHP enrollees, or 28%, had incomes in the 100-150% FPL range.

Saved from the Medicaid Gap

Prompted in part by my observation last week that at least a third of Florida's 1.4 million private plan enrollees on healthcare.gov would have been Medicaid-eligible if the state had accepted the ACA Medicaid expansion, Richard Mayhew poses a question (or rather, elaborates on one posed in a comment on my post):

Liberal technocrats have been assuming that the states which refuse to expand are giving up massive amounts of money and thus economic growth by refusing to expand Medicaid will eventually expand.  However, are we accounting for the additional cash flow coming in as premium and cost sharing subsidies for people making between 100% and 138% Federal Poverty Line.

Leaving aside the financial question, we can make some reasonable estimates as to what percentage of those who would have been eligible for Medicaid had their states not refused the expansion are now in subsidized private health plans purchased on healthcare.gov. (All but one of the states that refused the expansion use the federal exchange).

On one side of the equation, we have Kaiser's state-by-state estimates of how many people fall in the Medicaid gap -- that is, have household incomes under 100% of the Federal Poverty Level (FPL) but are shut out of Medicaid in their state. On the other side is the number of subsidized private plan buyers in non-expansion states who have incomes in the 100-138% FPL range -- those who would have been eligible for Medicaid if their states had accepted the expansion.

ACA in Mississippi: Low incomes, high silver selection, high attrition -- and no Medicaid

The first thing to note about Mississippi's ACA private plan marketplace enrollment is that attrition after initial signup was terrible. As of the end of open season in mid-February, the state had 104,523 enrollments through healthcare.gov; as of March 31, the total had dropped to 80,011, just 77% of the February total. On all 37 states using healthcare.gov, 87% of initial enrollees were still aboard by March 31.

The high attrition is particularly distressing in that Mississippi's enrollment population is about as low-income as they come -- and consequently, enrollees' premiums were comparatively low and the actuarial value of their plans quite high. Of those who were enrolled as of mid-February, 89% had incomes under 250% of the Federal Poverty Level* (FPL) and so were eligible for Cost Sharing Reduction (CSR) subsidies if they bought silver plans. Among those eligible, 85% did select silver and so access CSR.

Alabama's Obamacare buyers ride a Silverado

Spotlight here is on Alabama in my continuing close look at how many low income ACA private plan buyers accessed Cost Sharing Reduction (CSR) subsidies by buying silver plans. (Yesterday, HHS released detailed county-level data about buyers of private plans on healthcare.gov, the federal exchange, enabling a close look at state stats.)

CSR is available to buyers with household incomes below 251% of the Federal Poverty Level (FPL), and strongest for buyers under 201% FPL. It is available only with silver plans, the second-cheapest of four metal levels available on ACA exchanges -- a fact that's less than obvious to the average shopper, Buyers under 201% FPL are leaving a really strong benefit on the table if they don't buy silver plans (see the note at bottom for more detail). I consider the percentage of buyers under 201% FPL who select silver an important measure of how well the exchange is functioning in a given state. (Those in the 201-250% FPL range are likelier to have good cause to forego the relatively negligible CSR provided at that level.)

Refusal to expand Medicaid swelled Florida's private plan ACA signups

Today CMS released detailed county-by-county enrollment data for private plans signups in the 37 states using healthcare.gov in 2015, as of February 22, just past the end of open enrollment,*. State-by-state income and metal level selection figures can be toted up from the county data Let's take a quick look at Florida and specifically Miami-Dade county, site of 2015's strongest signup surge.

We already knew that Florida -- which to date has refused to enact the ACA Medicaid expansion -- became the state with the most private plan enrollments, logging just shy of 1.6 million by the end of open season in February. According to the Kaiser Family Foundation, the state had enrolled 57% of its potential marketplace population as of March 31, 2015 (at which point Kaiser shows private plan enrollment at 1.4 million), second best in the country.  Of the 1.6 million state enrollees reported by HHS, 392,000 were in Miami-Dade County. Kaiser's research has previously spotlight Hialeah, a mainly Hispanic region just outside Miami (and in Miami-Dade County), as home to the zip code with the largest number of signups in the U.S.  Enrollment fever took hold there -- "Consumers can sign up for coverage in a mall, at a discount store, at a shoe store, and even at a barber shop," reported the Miami Herald in January.

"You oughtta be in Medicaid..."

Today's data release confirms that as in states that refused the Medicaid expansion generally, Florida's and Miami-Dade's private plan enrollments were swelled by enrollees who would have been eligible for Medicaid if the state had accepted the expansion. In Florida, 856,092 private plan enrollees -- more than half (53.6%) of the total -- had incomes between 100% and 150% of the Federal Poverty Level (FPL).  That compares with 47% in all states using healthcare.gov that refused to expand Medicaid, and just 22% in expansion states.

Those with incomes in 100-138% FPL range would be Medicaid-eligible if the state had expanded. We don't know exactly how many there are, but my prior analysis of national enrollment numbers suggests that at least two thirds of the 856k in the 100-150% FPL range are Medicaid-eligible -- a bit more than a third of all private plan enrollees in the state (and maybe a good deal more).

In Miami-Dade, the proportion of low-income enrollees is even more eye-popping. Fully two thirds of enrollees -- 259,000 out of 392,000 -- had incomes in the 100-150% FPL range.  Some 85% had incomes under 200% FPL, the threshold below which really strong Cost Sharing Reduction (CSR) subsidies are available with silver-level plans.

The president's left hand

In response to those who paint Richard Nixon as a master of liberal domestic policy, Elizabeth Drew cites his approach to formation of the Environmental Protection Agency:

He’s given credit for signing into law several bills to improve the environment, including establishing the Environmental Protection Agency. But in fact, Nixon wasn’t very interested in the subject and he fobbed it off on his aides to handle, saying at one point: “Just keep me out of trouble on environmental issues.” He privately called the then-rising environmental movement “crap” for “clowns.” 

That jogged a memory.  according to Nick Kotz in Judgment Days: Lyndon Baines Johnson, Martin Luther King, Jr. and the Laws that Changed America, shortly after the Kennedy assassination, LBJ met with U.S. ambassador to Vietnam Henry Cabot Lodge and told him, "I am not going to lose Vietnam."  Afterward,

Last laugh for Republicans in the SCOTUS session that was

Democrats were still in their happy dance over Supreme Court decisions preserving ACA subsidies and legalizing gay marriage throughout the U.S. when, in its final orders of the year, the Court agreed to hear cases poised to gut pubic unions and affirmative action.

In Friedrichs v. California Teachers Association, ten California teachers are challenging a requirement that they pay fees to the teachers union for nonpolitical services, chiefly collective bargaining. That's the type of provision that Scott Walker killed in Wisconsin; without it, pubic sector unions wither. As Mark Joseph Stern at Slate points out, "there is virtually no chance" that the Supreme Court will rule against the teachers: