A Medicare buy-in? Harold Pollack discusses Clinton's trial balloon

Hillary Clinton recently made headlines by expressing openness to allowing not-quite-elderly Americans to buy into Medicare:

“I'm also in favor of what's called the public option, so that people can buy into Medicare at a certain age,” the Democratic presidential front-runner said during a roundtable with local residents at the Mug'N Muffin coffee shop. “Which will take a lot of pressure off the costs.”

That's...confusing, since the public option, as originally conceived and as debated when the Affordable Care Act was being drafted, was a publicly financed health plan that would be offered in the ACA marketplace to prospective enrollees of all ages, competing directly with private plans. It was connected to Medicare only insofar as "strong" versions mandated that the plan would pay healthcare providers at Medicare rates, which are generally lower than those paid by private insurers.

98% of Americans with health insurance are subsidized. How bout the other 2%?

While the ACA has reduced the ranks of the U.S. uninsured by some 17 million, and currently subsidizes private health insurance plans for about 9.4 million* people, it has also raised the price of health insurance for most of those who have to buy their own insurance and don't qualify for ACA premium subsidies.

The latest Kaiser Family Foundation latest survey of enrollees in the individual market suggests that 64% of those enrollees obtained their plans in the ACA marketplace, which means that 53% of current individual market enrollees are subsidized. Borrowing Charles Gaba's estimate of 11.3 million current marketplace enrollees indicates a total individual market enrollment of 17.7 million, about 8.3 million of whom do not get premium subsidies. Some of those full-freight enrollees may be caught in the ACA's family glitch -- that is, an employer offers insurance that's deemed affordable for the employee and so disqualifies her from subsidies, even though family coverage may be far from affordable. Most, though, presumably earn too much to qualify for subsidies.

Those who buy their insurance in the individual market and get no subsidy at all are the only insured Americans whose insurance is unsubsidized, and they are a tiny minority of the insured population. 147 million people who get their insurance through an employer are subsidized via the tax exclusion for employer-sponsored health insurance. 72.4 million Medicaid enrollees and 55.5 million Medicare enrollees are subsidized, as are about 9 million VA-enrolled veterans and, again, 9.4 million ACA marketplace enrollees.

Religious freedom, but...

Two deeply reported stories about religion and the state seem to be ironically paired in today's New York Times.

In China, Ian Johnson reports, authorities have cut off the crosses topping 1700 churches in a heavily Christian district, Zhejiang. That's the bleeding edge of a general tightening of the screws on religious organizations. In a recent speech, President Xi Jinping

Health insurance in the U.S. is deteriorating, Kaiser survey indicates (to me)

[UPDATED, 5:15 p.m.: part of the drop in enrollees' ratings of their plans in 2016 may be due to who's buying the plans rather than what's on offer. See note at bottom.]

The Kaiser Family Foundation released its latest survey of enrollees in the individual market for health insurance today, which also includes some data on enrollees in employer-sponsored insurance (ESI). While majorities still report themselves satisfied with their health plans, the results suggest that health insurance is deteriorating, in ESI as well as in the individual market.

The comparisons provided with results from 2015 and 2014 tell a simple story. Deductibles and cost-sharing are on the rise, so people have more trouble paying their bills, are more often surprised by what their plans don't cover, more often go without needed care, and are therefore less satisfied with their plans. This is all true in employer-sponsored insurance as well as in the individual market, though satisfaction in ESI starts from a higher baseline.*

Data on deductibles brings the overall picture into focus. In the individual market as a whole, more enrollees in low deductible plans report themselves satisfied than those with high deductibles (74% vs. 59% ). The percentage of enrollees in high deductible plans is rising (49%, compared to 36% in 2015 ), and the percentage of those dissatisfied with their plans is also rising (31%, up from 20% in 2015 and 2016). The rise in high deductible plans is proportionate to the drop in reported satisfaction: 66% of all enrollees in ACA-compliant plans report themselves satisfied this year, compared to 74% in 2015.

How many Americans who buy their own insurance are unsubsidized?

One further footnote on the McKinsey & Co. report on the state of the post-ACA individual market for health insurance, discussed in my prior post.

McKinsey opines that the market is unlikely to enter a death spiral because ACA premium subsidies insulate most participants from premium hikes. The report estimates that 69% of current enrollees are subsidized. That strikes me as at least slightly exaggerated.

Kaiser, in its 2015 survey of non-group enrollees on- and of-exchange, found that just under half were subsidized -- or about 59% if you exclude those in grandfathered and grandmothered pre-ACA plans, which are a different risk pool (McKinsey's "methods" note indicates that they include enrollees in non-compliant plans in their estimate of off-exchange enrollees, though they may also assume that some of those in noncompliant plans are in subsidy range)*. UPDATE 5/20: Kaiser's 2016 individual market survey results, reported today, find that 64% of individual market enrollees are now in marketplace plans. 83% of marketplace enrollees are subsidized, suggesting that 53% of the individual market is subsidized.

The off-exchange market is something of a black box, so it's not surprising that estimates would differ. Also, Kaiser's estimate is from 2015, and the ACA marketplace grew modestly this year. Still, on McKinsey's own terms, I think their estimate is a bit inflated.  Here's its basis:

If you're giving people a Medicaid-like provider network, do it at Medicaid-like prices

McKinsey & Co. has a report on the state of the ACA marketplace (and the whole individual market) that reinforces one dominant point that was already clear: The marketplace is relentlessly pushing insurers toward a narrow network/managed care model.

At the individual carrier level, results varied as well. While most carriers had negative margins after accounting for the 3Rs, approximately 30% of carriers achieved a positive margin in 2014. At the plan level, patterns emerge around performance differences. In the aggregate, plans based on health maintenance organizations (HMOs) had lower losses than plans based on preferred provider organizations (PPOs), consistent with their ability to enable more tightly managed benefits and care. In both 2015 and 2016, the premium increases for HMO plans were roughly half those of PPO plans, which suggests the initial results carriers experienced in the individual market were more favorable for the HMO plans.

Elisabeth Rosenthal on narrow networks in ACA marketplace: A few "yes buts"

On the front page of today's New York Times Sunday Review, Elisabeth Rosenthal, author of the incomparable Paying Till it Hurts series on the dysfunctions of our price-gouging healthcare system, spotlights the limitations of ACA marketplace plans, starting with narrow networks. It's accurate and fair, acknowledging the good that the law has done. Nonetheless I have some caveats:

1. Rosenthal compares marketplace plans' narrow networks unfavorably with the more robust networks typically offered by employer-sponsored insurance:

Do Democrats and Republicans get the same coverage in the ACA marketplace?

UPDATED 5/20: Liz Hamel, Kaiser's director of survey research, was kind enough to send me some cross-tabs addressing the core question here -- whether Democrats and Republicans obtained similar coverage in the individual market.  See below!

Kaiser Family Foundation president Drew Altman, previewing a Kaiser survey of enrollees in private plans sold in the ACA marketplace, highlights the startling fact that partisanship seems to be the dominant factor in whether enrollees report being harmed or helped by the law.

While no one would likely dispute Altman's main conclusion, it does, to my mind, raise a question. Here's the gist:

In the Kaiser survey, which will be published next week, 29% of Republicans in marketplace plans (i.e., Obamacare) say they have benefited from the ACA compared with 75% of Democrats, a 46-point difference. There is no reason to believe that there are demographic differences between these Republican or Democratic marketplace enrollees that would explain this large of a difference in their responses. They are all purchasing coverage in the ACA marketplaces, and most members of each group are receiving premium subsidies under the law. Overall, substantially more marketplace-plan enrollees say that they benefited from the ACA (54%) than say they were negatively affected (35%).

Demographic differences between Democrats and Republicans doubtless don't explain this large of a difference in perception. But it seems possible to me that demographic differences -- specifically income differences -- might explain part of the perception divide.

Clinton's ACA subsidy sweeteners: Something for everyone

Of the roughly 24 million people whose health insurance is currently subsidized as a result of the Affordable Care Act*, over 80% have incomes below 200% the Federal Poverty Level (FPL).

About 14 million more people are enrolled in Medicaid than would have been had there been no ACA. They live in households with incomes below 138% FPL.  Of approximately 9 million subsidized enrollees in private plans sold in the ACA marketplace**, about 60%, or 5.4 million, have incomes under 200% FPL.

If banks are where the money are, the poor and "near-poor," as The CDC's National Health Interview Survey (NHIS) defines people in the 100-200% FPL range, are where the uninsured are most concentrated. A third of the U.S. population lives in households with incomes under 200% FPL. In 2013, just prior to ACA implementation, 55% of the uninsured had incomes below that level, according the most recent update of the Census Bureau's Current Population Survey. As of the first three quarters of 2015, according to the NHIS, the uninsured rate among those under age 65 had been cut by 35% for the poor (under 100% FPL) and by 38% for the near-poor (100-200% FPL).

Those with incomes over 200% FPL were not that far behind: the uninsurance rate for those above that income level fell by 30% from 2013 to 2015, according to the NHIS (from 9.6% to 6.7%).  But that may be a result more of stick than carrot: the tax penalty for remaining uninsured is quite stiff for higher earners. Among those in the upper range of ACA subsidy eligibility, 200-400% FPL, takeup has been poor. Above 200% FPL, subsidies require enrollees to pay between 6.4% and 9.7% of their incomes for benchmark silver plans. Cost Sharing Reduction subsidies fade to insignificance above 200% FPL and phase out entirely at 251% FPL, leaving silver plan holders with high deductibles and out-of-pocket costs.

Here comes Aunt Hillary's cavalry 

The concentration of ACA benefits on the poor and near-poor probably underlies the law's low approval ratings.  Enter Hillary Clinton's wish list. Her proposed package of supplements and sweeteners to ACA subsidies has something for people at all points in the income distribution, very much including those at the top of it (my emphasis below):

For United Healthcare, What's the matter with Iowa? -- Part II

Last week, over at healthinsurance.org, I looked into something of a paradox in United Healthcare's misadventures in the ACA marketplace, from most of which they are withdrawing.

In brief:  in many large markets, UHC offered high-priced plans with comparatively robust provider networks, as you might think befits the nation's largest provider of employer-sponsored health plans. At the same time, UHC is also a major player nationally in Medicaid managed care, which you might think equips the company to offer low-priced plans with narrow networks. And in many smaller and rural markets, they did just that. In Iowa, for example, they were price competitive in most of the state. Yet their market share was low -- about 19% in the counties in which they participated, in almost all of which they have just two competitors. And they are withdrawing from the Iowa marketplace.

Why did UHC not fare better in Iowa? Today I have some new pieces of the puzzle.

Could a Clinton HHS entice more Medicaid expansions?

When I was 19, I spent a summer on an archaeological dig in New Mexico. Work groups were mainly led by grad students in archaeology, and I recall someone telling the tale of a Ph.D thesis (not hers) that devoted 600 pages to demonstrating that an artifact dating technique did not work. She said,
somewhat ruefully, something to the effect of, "that's supposed to be useful too."

Below, I want to devote 600 words to an ACA-strengthening proposal that probably won't work. Writing 500 words before realizing this probably has something to do with the decision. But maybe floating it is useful. Maybe it suggests some variation that might work.

The context: I was combing Hillary Clinton's raft of healthcare reform proposals for measures that might be enacted without legislation.  In a prior post, I looked at her proposal to help states form public options in their ACA marketplaces. Next up:

Entice states that have refused the Medicaid expansion to embrace it. Clinton's healthcare page reiterates an Obama administration proposal to "to allow any state that signs up for the Medicaid expansion to receive a 100 percent match for the first three years." That was the original plan, with the federal share dropping in stages to 90% thereafter. But that was beginning in 2014. By statute, at present, states that opt in late don't get the full three years of full reimbursement.Beginning in 2017, the federal contribution to the cost of the expansion starts phasing down to a mere 90%, regardless of when the state implemented (or will implement) the expansion. Altering that would require legislation.

The NIHCM Awards

I was flabbergasted to learn a couple of weeks ago that I'd won the National Institute of Health Care Management (NIHCM) award for digital healthcare journalism, announced today, along with winners in print, trade, broadcast and research.  For me, being named a finalist in the company of top healthcare journalists -- and scholar-journalists -- was win enough.

In the digital category, finalists included two scholars doubling as bloggers and journalists, Austin Frakt and Nicholas Bagley, who have helped to educate me and whom I rely on as sources; Margot Sanger-Katz, who is breaking new ground in data journalism at the New York Times' Upshot; and a lineup of equally impressive reporters. Their entries, with links, are here. Here are the winners in each category:

John Carreyrou & Mike Siconolfi, "Testing Theranos," The Wall Street Journal

Emily Anthes, “Save Blood, Save Lives” & “The Trouble with Checklists,” Nature

Daniel Zwerdling, Robert Little, Nicole Beemsterboer, Barbara Van Woerkon, Robert Benincasa, Samantha Sunne & Lydia Emmanouilidou, “Injured Nurses,” NPR

Andrew Sprung, “When Silver Is Worth More Than Gold or Platinum” (posts 2, 3, 4), xpostfactoid

Martin Hackmann, Jonathan Kolstad & Amanda Kowalski, “Adverse Selection and the Individual Mandate: When Theory Meets Practice,” American Economic Review

My own entry was a cluster of posts focusing on what's been a central preoccupation of mine in my tracking of ACA implementation: the factors that lead low income marketplace enrollees to access or forgo the Cost Sharing Reduction (CSR) subsidies that are available only with silver plans. I've focused on CSR, as I noted in this compendium of posts on the subject, because these secondary, semi-hidden subsidies constitute the ACA marketplace's best defense against underinsurance. Most who are eligible access CSR, but too many don't, and the price is too high for too many.