ACA Marketplace snapshot: Bronze plan enrollees drop plans at higher rate than silver plan holders

CMS just released its "attrition report" for the ACA marketplace -- that is, its first snapshot of "effectuated enrollment" as of March 31 after tallying total plan selections at the end of open enrollment on Feb. 1.

The drop is comparable to last year's as of March 31: enrollment is down from 12.7 million to 11.1 million. That is, it's down 13%. As CMS points out, enrollments took place earlier on average this year, so enrollees had somewhat longer to drop out by 3/31.

As I always keep an eye on takeup of Cost Sharing Reduction (CSR) subsidies, available only with silver plans, I was interested to note that as the smoke cleared, the overall rate of silver plan enrollment for the whole marketplace rose markedly, from 67.1% on Feb. 1 to 69.7% as of March 31. The percentage of enrollees in bronze plans went down, from 22.6% to 21.9%.

While bronze enrollment dropped 15.5%, from 2,873,422 to 2,427,337. Silver dropped just 9.3%, from 8,520,787 to 7,721,983.  It makes sense that more people would drop bronze plans, with their deductibles typically north of $6,000 per person. Similarly, by March 31 of last year, bronze enrollment had dropped 15.9% since the end of open enrollment, compared to 11.5% for silver. By June 30, 2015,  bronze was down 18.6%,, and silver 13.3%.

This year, then, silver attrition is 60% of bronze attrition, versus 70% last year. Last year, government audits of enrollees' income claims led to hundreds of thousands having their CSR (and premium) subsidies eliminated or reduced, though that drop was not reported until the enrollment snapshot for June 31, released last September. This year, better data matching has reduced such subsidy reductions by more than two thirds.  Perhaps the higher volume of data audits in 2015 induced a slightly higher proportion of silver plan enrollees to drop their plans, since a good proportion lost some or all of their CSR.

Updated 7/1.

Uh oh: Trump has a coherent narrative

Donald Trump is a kind of idiot savant of demagoguery. Too lazy, ego-driven and solipsistic to analyze the facts of any business deal, let alone policy question, he does have an acute radar for the kinds of scapegoating that large numbers of people will respond to.

So far, though, with the American public as a whole, his credibility has been undercut by his boasting, his schoolyard insults, his lack of impulse control, his whining. Policy aside, a disinterested six-year old should be able to see through him. as 70 percent of Americans have to some degree.

Now, however, in the wake of Britain's primal scream, someone has put together for him a more coherent narrative that I fear could be very powerful, delivered today in a speech in a steel and aluminum shredding plant outside Pittsburgh. Never mind that the narrative fundamentally false -- it has enough elements of truth in it to seem plausible.

Like Obama's speeches, this speech has a historical sweep from the country's founding through Obama's presidency (and Hillary Clinton's tenure as Secretary of State).  While it projects a duce-like can-doism, it eschews direct boasting, as well as racial or religious scapegoating. The enemies are American elites and foreign nations, with the Clintons as the chief avatars of the domestic despoiling class. Trump is always all about blame, but here the domestic betrayers overshadow the overseas cheaters and predatory migrants.

The speech begins with a stab-in-the-back narrative:

A close look at one more ACA glitch

Georgetown University's Sabrina Corlette highlights a glitch in the ACA's provisions aimed at helping young adults obtain health insurance:

Consumer assisters receive frequent questions from parents who want their son or daughter to enroll in their family plan. The Affordable Care Act includes a requirement that health plans permit children under age 26 to stay on their parents’ health plan, regardless of whether or not the child is a tax dependent. However, the FFM currently requires adults under age 26 who are not tax dependents to be assessed separately for subsidy eligibility. The FFM platform does not allow them to enroll together under a family plan if they want to receive subsidies.*

This can have significant financial implications. For example, a young adult whose eligibility for subsidies is screened separately from his or her parents may not have sufficient income to meet the income threshold for premium tax credits (100 percent of the federal poverty line). In a state that hasn’t expanded Medicaid, this may mean that the young person falls into the coverage gap. In addition, a young adult child enrolling separately into a QHP must pay a separate premium and meet a separate deductible and out-of-pocket maximum from the rest of his or her family

Point taken about the Medicaid coverage gap: allowing young adults to be considered part of their parents' household would shield some from it. To put that in perspective, according to Kaiser Family Foundation estimates, there are probably just under a million adults under age 26 in the coverage gap (income 100% FPL in nonexpansion states). Relatively few of them would have parents in subsidized marketplace plans, but perhaps that few is in the tens of thousands.

What about young adults who live in states that have accepted the Medicaid expansion, or those who earn too much to qualify for Medicaid? In expansion states, those earning under 139% of the Federal Poverty Level (FPL), $15,800 this year, are eligible for Medicaid, and so would be better off financially -- if not necessarily with regard to the quality of care available -- on their own.

Subtitle to the Federalist Papers: We are not throwing away our shot

In the grand (or not so grand) tradition of blogging the Bible, another lay impression as I work my way through the Federalist Papers:

Hamilton and Madison are both deeply frustrated and alarmed by what they paint as the ever-more complete enfeeblement of the federal government under the Articles of Confederation. Both, too, present themselves as cold realists with respect to human motives and response to incentives. At the same time, they are breathless with the sense of the U.S.'s potential -- geographically, as a contiguous, fertile, navigable and highly defensible land mass; culturally, as speaking one language and being bred to liberty by English heritage; and politically, as having won the opportunity for a fresh start informed by human experience to date.

Both are at pains to argue that the perceived and often cited failures of democracies past do not apply to representative democracy. Madison, making the distinction in No. 9, touts representative democracy as a kind of emerging technology that the Constitution will bring to scale. Acknowledging that the republics of antiquity present a cautionary tale of constant warfare and corruption, he argues:

Obama, Florida, Hanauer

In an extended interview with Bloomberg editors about America's economic future and role in the global economy, Obama hewed to a simple principle: embrace global trade, but adjust current rules to increase labor's bargaining power while investing in education and skill development. He struck a couple of  notes that recalled things I've read that have resonated with me, about why, where and how wages have to rise. 

First, with respect to manufacturing vs. service jobs:

I think that as we move toward an economy where, because of automation, you need fewer and fewer people to make more and more stuff, more and more of us are going to have to move into the service sector. The service sector historically has been a low-wage sector. And in order for us to make sure that we don’t see this growing divide between haves and have-nots, with a middle class that’s shrinking, we’re going to have to make sure the service sector pays better.

Yes, the U.S. can create some good new advanced manufacturing jobs, in ways that James Fallows has illustrated in his travels around the country for the American Futures project, but the share of those jobs in U.S. employment won't match the totals of yesteryear.  The notion that service jobs are not inherently inferior to manufacturing jobs is one that Richard Florida has been advancing for some time, e.g., in this 2010 essay:

Average income and reported satisfaction in the ACA marketplace: Kaiser survey revisited

A month ago, the Kaiser Family Foundation's annual survey of enrollees in the individual market for health insurance recorded a marked decline in enrollees' satisfaction, closely correlated with a sharp rise in the percentage of enrollees in high-deductible plans.

As I noted at the time, part of the decline in satisfaction and rise in reported high deductibles was attributable to a change in respondents' income distribution. In 2016, a smaller percentage of respondents had incomes below 250% of the Federal Poverty Level (FPL), which is the eligibility cutoff for Cost Sharing Reduction (CSR) subsidies in the ACA marketplace. Most of that drop was concentrated among those with incomes below 138% FPL, as we'll see below.

Recently, Brian Blase of the Mercatus Center framed the deterioration in coverage and satisfaction reflected in the Kaiser survey in stark visual terms. That sent me back to look more closely at the shift in the income distribution of Kaiser respondents, with the help of some details about the income distribution kindly provided by the Kaiser researchers.  Here, first, is the Mercatus graphic:

Trump, backwards and in denial

Some time ago, I noted that headlines beginning "Trump Blames" were not a rare occurrence. Deja vu of the same sort just struck as I read the words "Trump Walks Back." Yup...

Trump walks back comments on guns | MSNBC

www.msnbc.com/thomas.../trump-walks-back-comments-on-guns-708928579568

3 hours ago - Trump walks back comments on guns. Larry Pratt from Gun Owners of America criticizes the laws that were in place in Florida and claims that ...

D'Oh!: Trump Walks Back Positions on N. Korea and U.K.'s Cameron ...

www.usnews.com/.../doh-trump-walks-back-positions-on-...

U.S. News & World Report

May 20, 2016 - But the presumptive GOP nominee gives a thumb's up to the Brexit, another sticky foreign-policy wicket.

Donald Trump Walks Back His Only Detailed Economic Proposal ...

thinkprogress.org/economy/2016/05/05/.../trump-tax-plan-reversal/

ThinkProgress

Donald Trump Walks Back His Only Detailed Economic Proposal. by Bryce Covert May 5, 2016 2:24 pm. CREDIT: AP Photo/Charles Rex Arbogast. Republican ...

Hamilton's ghost in the Gettysburg Address

Nearing the end of Ron Chernow's Hamilton led me to dip into the Federalist Papers last night. No sooner did I crack the volume and start in on No. 1, written by Hamilton, when lo, deja vu ensued. Not because I'd read the words before, though I probably have, but because I felt I was reading the Gettsyburg Address. Here's Hamilton:

After an unequivocal experience of the inefficiency of the subsisting federal government, you are called upon to deliberate on a new Constitution for the United States of America. The subject speaks its own importance; comprehending in its consequences nothing less than the existence of the UNION, the safety and welfare of the parts of which it is composed, the fate of an empire in many respects the most interesting in the world. It has been frequently remarked that it seems to have been reserved to the people of this country, by their conduct and example, to decide the important question, whether societies of men are really capable or not of establishing good government from reflection and choice, or whether they are forever destined to depend for their political constitutions on accident and force. If there be any truth in the remark, the crisis at which we are arrived may with propriety be regarded as the era in which that decision is to be made; and a wrong election of the part we shall act may, in this view, deserve to be considered as the general misfortune of mankind.

And Lincoln:

Forecast: Prices paid for health plans in the ACA marketplace to rise 12-15% in 2017

According to Charles Gaba's tracking of health insurers' rate requests for 2017 in the individual market, health insurers have thus far requested a weighted average rate increase of 22%. That's based on reporting from insurers serving 73% of current enrollees.

Rates requested are different from rates approved, however. And approved rates, weighted according to insurers' market share in the previous year, are different from the average rates that people (and the federal government, via subsidies) actually pay.  That's because enrollees gravitate toward the cheapest plans at each metal level, which pay the same percentage of costs as more expensive plans in the same metal level.

According to Gaba and HHS, here's how rates shook out in 2015, 2016 and thus far for 2017:

No one can say the people are deceived

I don't know what I can add to all the well-informed denunciations and warnings about Trump's demagoguery published in response to his post-Orlando speech.  See, e.g., Francis Wilkinson and Steve Benen. But the manifest depravity of this speech, which raised demonization of Muslims to something approaching Nazi levels, does highlight something basic about the choice before us that's perhaps hiding in plain sight.

The speech rendered all the more obvious truths about Trump that have long been obvious: 1. He is promising to abrogate the Constitution in fundamental ways. 2. He will say anything that he senses will inflame his followers and throw the media into a frenzy. 3. His solipsism is so extreme that there is no boundary line in his mind between what works for him and what is true. 4. He's such an transparently self-aggrandizing fraud that anyone, regardless of education or political engagement, should be able to see through him in two minutes. "Anyone" includes grade school children.

Silver plans to be available for less in ACA marketplace in 2017

Certainly not for everyone. And certainly not for the federal government, which foots the bulk of the premium bill for most marketplace enrollees. But for many and perhaps most subsidized buyers, a silver plan will available for less than they paid in 2016 (or would have paid, had they enrolled).

That's my takeaway from an Avalere Health analysis of rate request data in eight states plus Washington D.C., released last week.

"Most people can find plans for under $100 per month with a deductible under $1000 per month"

I have long been irritated by an apparent mindset at HHS expressed in factoids such as this, from the final enrollment report for 2016:

Nearly 7 in 10 of the consumers who selected, or were automatically enrolled into, a plan in the HealthCare.gov states had the option of selecting a 2016 Marketplace plan with a net premium of $75 or less per month after the advance premium tax credit.

You'd think that all that mattered was premium price -- never mind if that $75 plan is bronze level with a $6,600 deductible. HHS marketing reflects this bias. Here's an email from last December:

Get covered and save: 8 out of 10 people who enrolled in a health insurance plan qualified for financial help. In fact, most people can find plans for $75 or less per month. 

I could go on about this, but as I already have, twice, let's move on. Perhaps a better if not so simple marketing point might be crafted after determining: What's the median price that marketplace enrollees pay for a silver plan? Given the low income skew of the marketplace customer base, that median plan will come with Cost Sharing Reduction that reduces the deductible to perhaps a tenth of the typical bronze plan's and raises the plan's actuarial value to 87%, compared to 60% for the bronze .

Nicholas Kristof, meet Nicholas Kristof

Nicholas Kristof, urging Bernie Sanders not to pull a Nader and help elect Trump, invokes the sum of all Democratic fears:

Presidential campaigns are driven in part by surprises: What if there is a new wave of Central American refugees, or a terror attack by a Muslim recently admitted to the U.S.? Either would bolster Trump’s chances.

Quite so.  But that second horror scenario flashes on a blind spot in Kristof's last column -- a truly remarkable one, relating the saga of a 20 year-old Afghan woman who, denied a formal education and shut up in purdah at home, has used online courses to learn advanced mathematics and other subjects, including English, and now, having gained admission to a junior college in Iowa, seeks a visa to study in the U.S. That's a problem:

Unfortunately, the United States isn’t helping. Last month, the U.S. Embassy in Kabul rejected her application for a student visa. That happens all the time: Brilliant young men and women are accepted by American universities and then denied visas because, under U.S. law, they are seen as immigration risks...

We were young, we bought bronze, we churned....

I've stumbled on what seems like it may be a significant pattern in ACA marketplace enrollment data, but I don't know what it signifies.

It started with a look at detailed data that Covered California has published that focuses on new 2016 enrollees only -- as opposed to all enrollees, including the two thirds of current enrollees who re-enrolled. Earlier this week, I noted with some alarm that bronze plan selection was markedly higher and silver selection lower among the new enrollees than among all enrollees in 2015. Among the new enrollees, 58% selected silver plans and 32% bronze, compared to 65% silver and 25% bronze last year.

Only in passing did I note that according to HHS's national enrollment report, bronze and silver selection in California among all enrollees had only shifted a point this year, to 64% silver/26% bronze. That belatedly set the brain wheel spinning: Re-enrollees must be enrolled in silver at much higher rates than new enrollees.

True. If HHS totals are fully aligned with CoveredCA's tabulation, among California's re-enrollees this year the silver-bronze split is 67-23 -- 18 points wider than among new enrollees.

Takeup of Cost Sharing Reduction increased on HealthCare.gov in 2016

When I looked over HHS's enrollment report for the 2016 ACA marketplace back in March, I seem to have neglected a key point: takeup of Cost Sharing Reduction (CSR) subsidies rose this yearin the 38 states using HealthCare.gov.

That is, the percentage of those enrollees whose incomes qualified them for CSR bought silver plans rose by two percentage points. CSR is available only with silver plans, so those who buy bronze (or, far more rarely, gold or platinum or catastrophic) plans forgo the benefit.  CSR reduces an enrollee's out-of-pocket payments for medical care -- radically for those with incomes up to 200% of the Federal Poverty Level, weakly for those in the 200-250% FPL range. Eligibility ends at 251% FPL.

The uptick in CSR takeup should have been obvious, since silver plan selection among all HealthCare.gov enrollees regardless of income level rose from 69% in 2015 to 71% in 2016. But the overall percentage of enrollees who obtained CSR dropped from 60% at the end of open season 2015* to 59% this year, so I missed the takeup rate increase in those actually eligible for the benefit.

Silver plan selection dropped among new enrollees in California in 2016

Something went wrong in Covered California's 2016 open enrollment [or maybe not- see update, 6/7].

Among the 439,400 new enrollees (31% of total enrollees), bronze plan selection spiked to 31.9%, compared to 24.9% of those enrolled as of June 2015. Silver plan selection among new enrollees was 58.2%, compared to 64.6% as of June 2015 (the data is available here).

Among enrollees in income ranges that are eligible for Cost Sharing Reduction (CSR) subsidies, which are available only with silver plans, silver selection dropped from 75.8% as of June 2015 to 68.1% among new enrollees in 2016.

The CSR benefit weakens sharply at 201% FPL. Among those in the income range for "strong" CSR, that is, those with incomes up to 200% FPL, silver selection dropped from 82.2% as of June 2015 to 75.0% for those who enrolled for the first time in 2016.

About that swift Medicaid expansion enrollment in Louisiana

[Updated 6/3, at bottom]

Yesterday, as Louisiana opened enrollment for those newly eligible for its Medicaid expansion, effective July 1, I noted that probably about 65,000 of the state's enrollees in subsidized private health plans via HealthCare.gov will be newly eligible. Also noted, via Charles Gaba: Governor John Bel Edwards claimed that 175,000 people were already enrolled as of yesterday.

Via contact with Louisiana's Dept. of Health & Hospitals, a few clarifying points:

1. Virtually all of those enrolled as of yesterday, a total of 189,000 by day's end, were transfers from existing limited-benefit public plans. These include 132,000 enrollees in Take Charge Plus, a program focused mainly on family planning, along with a few free office visits; and 56,000 from the Greater New Orleans Health Connection (GNOHC), a no-cost primary care program for low income people in the greater New Orleans area. GNOHC does not provide drug or hospital coverage.

Among 375,000 Louisianans newly eligible for Medicaid: 75,000+ Marketplace enrollees

[see updates at bottom and followup re immediate Medicaid enrollments]

Congratulations to Louisiana for kicking off enrollment in Medicaid under its newly enacted ACA Medicaid expansion today. Enrollment begins today and is effective July 1.

The state estimates that 375,000 residents are newly eligible for Medicaid under the program. According to HHS, the state will be the first in the nation to use food stamp (SNAP) data to determine eligibility and enroll people in Medicaid. The Medicaid program has a dedicated website, Healthy Louisiana, that makes online enrollment at least look easy. On the phone, though, I got stuck in impenetrable feedback.loops calling the number there and on the state Dept. of Health & Hospitals website trying to get a live person (there is no media information number listed on either site). I suspect that outgoing GOP governor Bobby Jindal's massive cuts to government agencies has something to do with that.

One subset of newly eligible potential Medicaid enrollees that causes some inevitable disruption in states that belatedly accept the ACA Medicaid expansion is people currently enrolled in ACA marketplace plans whose income now qualifies them for Medicaid.