Attention, Paul Krugman: Not everyone votes

Am I crazy or is Paul Krugman making a really elemental mistake here?

As Greg Sargent points out, the choice of Tom Price for HHS probably means the death of Obamacare. Never mind the supposed replacement; it will be a bust. So here’s the question: how many people just shot themselves in the face?

My first pass answer is, between 3.5 and 4 million. But someone who’s better at trawling through Census data can no doubt do better.

Here’s my calculation: we start with the Census-measured decline in uninsurance among non-Hispanic whites, which was 6 million between 2013 and 2015. Essentially all of those gains will be lost if Price gets his way.

How many of those white insurance-losers voted for Trump? Whites in general gave him 57 percent of their votes. Whites without a college degree — much more likely to have been uninsured pre-Obama — gave him 66 percent. Apportioning the insurance-losers using these numbers gives us 3.42 million if we use the overall vote share, or 3.96 million if we use the non-college vote share.

The assumption appears to be that everyone votes. Turnout this year is currently reported at 58.6%. It's probably lower for most of those who gained insurance via the ACA, as their incomes are below median: according to the Current Population Survey, almost three quarters of those who gained insurance in both 2014 and 2015 have incomes below twice the Federal Poverty Level, and nearly all have incomes under 300% FPL. Lower income people have lower turnout rates.  It would appear that Krugman's total needs to be sliced almost in half.

Tom Price's ACA replacement plan opens a sluice gate to privatizing Medicare

Tom Price, Trump's choice for HHS Secretary, is the author of the Empowering Patients First Act,  an ACA replacement plan that provides age-based subsidies for deregulated health insurance, unadjusted by income.

Those subsidies are skimpy, particularly for older buyers, as Price would loosen age banding, and for low income shoppers, as the subsidy level would leave coverage unaffordable.  Jed Graham of IBD runs the numbers for a 64 year-old couple earning 150 of the Federal Poverty Level (FPL) and finds that while an ACA plan might cost them 8-12% of their income (($2-3,000, out-of-pocket costs included) in a bad year, a plan purchased under Price's legislation would take 80% ($18,000).

The Price plan (let's call it EPFA)  is a bare-bones version of "premium support," in which the government gives beneficiaries a fixed sum and sends them to shop in a deregulated marketplace (the ACA sets up a more generous and regulated premium support program).  Since Price also aims to pass legislation this year to convert Medicare to a premium support system, his plan -- which allows people to opt out of Medicare and receive the plan's fixed tax credit --  can be viewed as an ultimate vision for Medicare, Republican style.

Can the electoral college revert to its original function to negate its original intent?

There's a knot in the logic of those urging the presidential electors to deny Trump an electoral college majority. It comes between these two propositions:

1. The founders (wisely?) established the electoral college as a potential veto of the popular choice* in case the people (or state legislatures) voted in a demagogue.

2. The popular choice in this election was not a dangerous demagogue, as Hilary Clinton will end up with about 2.5 million more votes than Trump.

Thus, the electoral college should use its veto function to un-veto the popular choice rather than to countermand it.

The disconnect is between the electoral college as designed versus the electoral college as evolved. It was designed to be a deliberative body (or set of bodies, as each state's electors meet separately). It evolved into an inexact and unreliable mirror and intended rubber stamp of the popular choice. Like a human appendix, it serves no practical function except to rupture occasionally.

Many people don't know what's on offer through the ACA. Or through Medicare.

According to the Kaiser Family Foundation's most recent estimate, as of March 31, 64% of Americans who were eligible for subsidized health plans sold in the ACA marketplace were enrolled. 

One persistent barrier to getting the uninsured covered has been simple ignorance of what's available (though a too-large percentage of the uninsured who do check out their options find marketplace coverage unaffordable). While the numbers have improved year by year, in the Commonwealth Fund's 2016 tracking survey, 43% of the uninsured with incomes under 250% of the Federal Poverty Level were unaware of the existence of the ACA marketplace. Of the uninsured who were aware of the marketplace, 64% said they did not visit it because they did not think they could get affordable coverage there. While that was probably true for a significant number (e.g., the undocumented, those with an employer's offer of insurance, and those who did not qualify for subsidies), , a substantial portion doubtless remain unaware that subsidies are available.

"What have you got to lose?" -- Republicans' latest lie about the ACA

As they gear up to repeal all or part of the ACA, Republicans in Congress are coming out with a new (or recycled) lie about the benefits they'll be taking away, with or without a replacement. The lie has some basis in truth, but it is a gross distortion.

Here's the ur-iteration as voiced by Sen. Johnny Isakson, R-Georgia, to Politico's Jennifer Haberkorn, who asked Isakson what might become of the roughly 20 million people who have gained coverage through the ACA. His response:

Most of those 20 million got bronze policies with a great big deductible and not much insurance, so I don’t know that there’s going to be a big backlash,..There are some minefields out there but we can deal with them.

In a note, Politico points out that "most people on the exchanges choose silver plans, which provide a higher level of benefits." But that only clears one level of the mendacity expressed here.

For starters, more than 60% of those who gained coverage through the ACA did so via the Medicaid expansion (though not in Isakson's Georgia, which has refused to implement it). Medicaid generally has no premium and covers all, or very close to all, out-of-pocket expenses. People who have obtained Medicaid coverage through the ACA express high levels of satisfaction -- 88% of new Medicaid enrollees were satisfied with their coverage, according to the Commonwealth Fund's 2016 tracking survey.

What exactly is the Medicare guarantee?

As Paul Ryan revs up Republican engines for Medicare privatization, Nancy Pelosi vows to Greg Sargent that Democrats will fight it to the death:

Pelosi adamantly stated that Democrats would not give any ground on the core ideological dispute here, which is over whether to maintain a government coverage guarantee. “We are not going to a casino — this is a guarantee,” Pelosi said. “This is a value system for us, and we will fight for it. Is it a guarantee, or not?”

This raises a question: what precisely is the Medicare guarantee?

At present, there's a pretty specific answer: for 95% of seniors, the federal government will pay about 85% of the premiums for insurance that covers a bit more than 80% of the average user's medical costs. That's what traditional Medicare does right now, via Parts A, B and D, for those whose incomes are below $85,000 for a single person or $170,000 for a couple.

Put another way, the federal government pays a bit more than two thirds of the average senior's total medical costs. Low income beneficiaries have all or part of their premiums and out-of-pocket costs paid by Medicaid, though a variety of programs. High income seniors pay higher shares of their premiums, with the percentage stepped up through several income brackets.

What Ryan wants to do to Medicare

Last week, Paul Ryan indicated that he wants to move fast not only to repeal the ACA but to privatize Medicare to a premium support structure, as he's been proposing since 2011.

Of course, Medicare is already almost 1/3 privatized, in that 31% of enrollees have chosen Medicare Advantage plans rather than traditional fee-for-service Medicare. And MA's market share is growing year by year.  So why is Ryan so compelled to accelerate the process?

I have a post up at medicareresources.org, sister publication to healthinsurance.org, that aims to answer that question. Democrats generally assume that Ryan wants to shift the costs of Medicare away from the federal government and onto seniors, and I think that's right, but he has not explicitly called for doing so since 2011. His plan is studiously vague, and therefore hard to pin down. But what it would do, I think, along with de-emphasizing traditional Medicare by making it one choice among many on an exchange, is cut the cord that currently binds the rates that MA plans pay to providers to the rates paid by traditional Medicare.  That would accelerate cost growth in MA, which would in turn probably trigger a shift of costs to seniors.

I hope you'll read the post.

A managed Medicaid bailout for repeal-and-delay Republicans

A week ago I suggested, in a kind of desperate good-Trump fantasy, that if Trump really wanted to fulfill his campaign promise to replace the ACA with "something beautiful," he could replace the ACA marketplace with a managed Medicaid buy-in for anyone who needed it.

Earlier this week, Michael Sparer, Chair of Columbia's Mailman School of Public Health, published in NEJM a somewhat akin proposal that could serve as both a basis for permanent compromise and a stopgap if we end up in "repeal-and-delay" limbo. Rather than creating a "fallback" public option from scratch, as President Obama and others have proposed,

A better idea, I believe, and one that could conceivably lead to a political compromise, is to rely on Medicaid managed-care plans to offer an exchange plan wherever they operate where there would otherwise be only one participating insurer. This strategy could work even if ACA premium subsidies for exchange enrollees were eliminated and replaced by some alternative version of tax credits or rebates.

That too might seem like a pipe dream, in that it requires constructive Republican action to keep people insured, not to mention expanding the Medicaid expansion. But maybe not! Austin Frakt's* reading of the political tea leaves suggests that some kind of stopgap staving off total collapse may become the new normal. Reacting to Senator Lamar Alexander's forecast that Republicans might need six years to forge an alternative that could overcome a filibuster, Frakt writes:

The individual mandate is not the hill for Democrats to die on

A few days ago, Adrianna McIntyre sketched out the likely contours of Republican plans to replace the ACA.  In the main, three core changes have been floated in a variety of plans: deregulate the kinds of insurance plans available in the individual market (e.g., loosening age-banding, allowing lower actuarial values, and reducing EHBs); block-grant Medicaid (without, Adrianna guesses, clawing back the ACA eligibility expansion); and end the individual mandate, replacing it with "continuous coverage" protection from medical underwriting.

If those contours prove to be on target, the question of how many people lose coverage will come down to funding. If Republicans end the federal government's 90-100% funding of Medicaid for those rendered newly eligible by the ACA, as Ryan proposes, the ranks of the uninsured will rise rapidly. If subsidies for enrollees in the individual market are cut significantly, or become much skimpier for lower-income enrollees (the bulk of current enrollees), many enrollees will find themselves unable to pay. If the ACA's high federal matching rate for Medicaid is left in place and funding for tax credits in the individual market is not radically cut, change will be more gradual.

One change that need not be too disruptive, I suspect -- if done right -- is replacing the individual mandate with continuous coverage protection -- that is, protection from medical underwriting for anyone who maintains continuous coverage.  "Done right" means rendering coverage available and affordable to those who lose their jobs and/or income.

"Redemption" threatens the ACA marketplace (and Medicaid and Medicare)

In the post-election nightmare we're now living in, existing Republican blueprints to "repeal and replace" the ACA are newly relevant. Perhaps the most comprehensive plan was published by the American Enterprise Institute in December 2015 and prepared by an all-star cast of conservative healthcare wonks including James Capretta, Yuval Levin, Ramesh Ponnuru  and Avik Roy.

Reading this plan today, I was struck with deja vu stemming from my slow read, nearly complete,  of Eric Foner's Reconstruction: America's Unfinished Revolution, an epic chronicle of the failure of post-Civil War Republicans' efforts to endow the South's freedmen (and pre-war free blacks) with a modicum of political representation and civil rights. Over time, as Republican willingness to enforce those rights militarily waned, the resurgent white oligarchy used terror and violence to disenfranchise African Americans and regain total political control. The toolbox for maintaining that control over decades sounds very contemporary:

Fiscal retrenchment went hand in hand with a retreat from the idea of an activist state meeting broad social responsibilities. “Spend nothing unless absolutely necessary,” Gov. George F. Drew advised the Florida legislature in 1877, and lawmakers took his advice to heart, abolishing the penitentiary, thus saving $ 25,000, and abandoning a nearly completed Agricultural College, leaving the state without any institution of higher learning, public or private. Alabama’s Redeemers closed public hospitals at Montgomery and Talladega and Louisiana’s were “so economical that … state services to the people almost disappeared.” Similar reductions affected provisions for the insane and blind as well as appropriations for Southern paupers, despite the lingering effects of the economic  depression. South Carolina Democrats tightened collections from blacks owing mortgages to the state land commission, producing a “pell-mell rout of Negro settlers.” Public education— described as a “luxury” by one Redeemer governor— was especially hard hit, as some states all but dismantled the education systems established during Reconstruction. Texas began charging fees in its schools, while Mississippi and Alabama abolished statewide school taxes, placing the entire burden of funding on local communities. Louisiana spent so little on education that it became the only state in the Union in which the percentage of native whites unable to read or write actually rose between 1880 and 1900. School enrollment in Arkansas did not regain Reconstruction levels until the 1890s. Blacks suffered the most from educational retrenchment, for the gap between expenditures for black and white pupils steadily widened (Kindle locations 11077-11089).

The Medicaid expansion...expanded?

I have a post up at healthinsurance.org that mulls over this forecast from Reed Abelson's article about ACA replacement:

The Trump administration and Congress “are not going to pull out the rug from people,” said Dr. J. Mario Molina, the chief executive of Molina Healthcare, a for-profit insurer. He predicted that the earliest the law could be repealed was 2018, and that it would be replaced with something like a modified version of Medicaid, the government insurance for poor people. “The debate is not around the what, but around the how,” he said.

It's not surprising that the CEO of a Medicaid managed care company would anticipate Medicaid managed care for all who need it. For Trump, it would have the benefit of simplicity. But it would also require commitment, follow-through, and bucking Republican hatred of Medicaid, so we'd have to put it in the "highly unlikely" box.

But I think it would be worth doing. And a suitable "modified version of Medicaid" already exists - as explained in the post, which I hope you'll read.

TrumpTruth

It should be no secret to anyone, but in a Wall Street Journal interview, Trump just laid bare his theory of truth:

Asked whether he thought his rhetoric had gone too far in the campaign, the president-elect responded: “No. I won.”

Mr. Trump suggested he would now turn more positive, saying that was true of his victory speech early Wednesday morning as well as his comments with Mr. Obama at the White House Thursday. “It’s different now,” he said.

So, in brief: it's okay to say anything that advances your end, and Trump demonized Obama and his policies simply to gain his end. No longer needed, no longer true.

In case you didn't know.

Shock treatment or catastrophe?

During one of the GOP's exercises in debt ceiling terrorism, I think in 2013, Jonathan Chait wrote (in a piece I can't locate) that Republican extremism would lead to catastrophe eventually (here is a variant).

That forecast played in my mind whenever I looked ahead at elections -- not just to 2016, but beyond. My thought was, it's a two-party system, and Republicans have to win the presidency sooner or later. Would we win a breathing space in which Democratic reforms could be cemented and the GOP would finally begin to moderate? Which would happen first, Republican victory or moderation?

Now we have our answer. In 2012, Obama told donors that if he won reelection, 'the fever would break." He won, and it went to 106 degrees, and spread to half the electorate.

Sometimes catastrophe is the route to progress -- as in the Great Depression, which ushered in FDR's huge and long-lasting majorities in Congress and ultimately led to enduring acceptance of the pillars of the welfare state: social security, unemployment insurance, labor protections, bank regulation.

Does competition help ACA marketplace customers? Mayhew's Tennessee test

In 2015, I spent some time tracking the effects of "CSR discounts" in select ACA marketplaces -- that is, discounts on the Cost Sharing Reduction subsidies offered to low income enrollees (i.e., most enrollees to date) when they buy silver plans -- and only silver plans.

Since the ACA's income-based premium subsidies are set according to the price of the benchmark second cheapest silver plan in a given area, a "CSR discount" is available when the cheapest silver plan has a significantly lower premium than the benchmark.  Such a discount lowers income shoppers' temptation to buy bronze plans, which are much cheaper but have sky-high deductibles and no CSR.

Large CSR discounts are not the norm in the ACA marketplace, but they're not rare either. I found some evidence, across California and in two adjacent CA counties, that where the discount is significant, silver plan selection rises.

My interest stemmed from a concern whether most low income buyers in the marketplace were likely to obtain coverage adequate to their needs --   in shorthand, obtaining plans with deductibles in the $0 to $750 range (the range CSR-enhanced silver plans for those with incomes up to twice the poverty level) rather than in the $5000 to $6850 range (typical of bronze plans). Richard Mayhew, a health insurance professional, shares that interest but also homes in on the effects of various price configurations on insurers' health. With two thirds to three quarters of insurers in the ACA marketplace posting losses there, and a quarter of last year's participating insurers exiting the market, that concern must be shared by all who want to see the marketplace function as designed.