The Appian road to autocracy

For Christmas, my wife bought me an excellent new history of ancient Rome, SPQR by Mary Beard, which has proved the best kind of present -- something I never would have bought myself that I'm enjoying immensely. It has the twin virtues of constantly acknowledging uncertainty and ambiguity while articulating a few memorable interpretive themes.

One of these should bring any American living in this moment up short. Previewing her treatment of a century of civil war leading to the end of the Republic, Beard writes:

Looking back over the period, Roman historians regretted the gradual destruction of peaceful politics. Violence was increasingly taken for granted as a political tool. Traditional restraints and conventions broke down, one by one, until swords, clubs and rioting more or less replaced the ballot box. At the same time, to follow Sallust, a very few individuals of enormous power, wealth and military backing came to dominate the state -- until Julies Caesar was officially made 'dictator for life' and then within weeks was assassinated in the name of liberty. When the story is stripped down to its barest and brutal essentials, it consists of a series of key moments and conflicts that led to the dissolution of the free state, a sequence of tipping points that marked the stages in the progressive degeneration of the political process, and a succession of atrocities that lingered in the Roman imagination for centuries (p. 216).

Universal health insurance: A civilized society's single checkout line

This from Richard Mayhew triggered a flash image connected to a pet peeve:

Insurance (of any sort) has two major economic value propositions.  First, it pools risk so that unpayable costs become payable.  This encourages productive risk taking in the face of tail risk. Secondly, because of the pooling function, it reduces the variance faced by any individual in the pool.   Lower variance means more predictability which means less uncertainty.

The image is the single checkout line* in a New York Whole Foods, complete with lights signaling which of about 20 registers are free. That is, there's one line for all registers -- as at the post office, Barnes & Noble and elsewhere.

The pet peeve is large retail stores with lines at each register. There's a little anxiety cost for me in having to choose a line by eyeballing. It feels like defeat if someone in the line I've chosen asks to have the price of an item checked or uses a credit card that doesn't work.

The thought is that true universal health insurance is the unified checkout line of civilized life. What the single line does with customers' time, universal insurance does with money: spread the losses. More checkout counters equals a deeper risk pool. When there's twenty registers, the effect of one person's fifteen minute delay gets spread widely among the customers on the one line.  Ditto with one person's long-term kidney dialysis or diabetes management or multiple chemo rounds in a deep enough risk pool.

#NoRepealWithoutReplace: Tweet to save the ACA

A quick review of the cliff's edge the ACA is up against -- and (perhaps) how to back off it:

1. Republicans are vowing to use budget reconciliation to repeal the core elements of the ACA by February, delaying the defunding of some or all benefits for 2-3 years while they allegedly craft and enact a replacement..

2. As Republicans will have a 52-48 majority in the 115th Congress, insta-repeal can be stopped if three or more Republican senators balk at repeal-and-delay, calling instead for simultaneous repeal-and-replace (none of them will take a stand outright for preserving and amending the ACA).

3. Eighteen Republican senators represent states that have enacted the ACA's Medicaid expansion, which has by itself cut the ranks of the uninsured by about 20% nationwide -- and by more than that in many expansion states.

The ACA's fate may be determined this week

While Republicans have made amply clear their intention to swiftly pass an ACA repeal-and-delay bill in early 2017, it seems to me that a few facts about this looming prospect have not fully sunk in.

The first is that success is not a foregone conclusion. If three Republican senators balk at ripping up the ACA without a replacement in hand -- or at least, without a clear blueprint of how to get to replacement without throwing the individual market for health insurance into turmoil -- then the process slows, and the damage may be mitigated or avoided entirely.

Second, Republicans will never pass "repeal" and "replace" together -- unless perhaps they win 60 senate seats in 2018. Repeal-and-delay is their only option for delivering on their promises.

Third,  the time to stop the train is now -- in the coming week, between Christmas and New Year's, when senators and members of Congress will be home. The ACA had its long hot summer of rabid town halls, demonstration and counter-demonstration. ACA repeal gets a cold short week. And a lot of action is in planning.

These rather basic points were confirmed to me by Christopher Condeluci, a healthcare consultant who was tax and benefits counsel to Republicans on the Senate Finance Committee in 2009, when the ACA was being drafted.

The other subsidy for those who buy their own health insurance

Troubled by the high price of unsubsidized health insurance in the individual market, I have wondered for some time what percentage of those who buy their own insurance without benefit of subsidy are self employed and so claim the self-employed health insurance tax deduction.

I needn't have speculated. Back in October, a google search quickly brought me to detailed estimates provided by the IRS. I've written up the upshot over at healthinsurance.org:

In 2014, 4.2 million tax filers took the self-employed health insurance deduction, deducting a total of $28.1 billion from taxable income, according to a yearly estimate published by the IRS. That comes out to about $6,700 per filer, which indicates that a significant number are deducting premiums for more than one person. $6700 is a bit less than what a pair of 40 year-olds would pay for the average silver-level plan offered in the ACA marketplace 2014.

Hmmmm...Team Trump queasy about ACA insta-repeal?

I credit nothing said by Team Trump...but this does not sound like ACA repeal:

“The enrollment numbers announced today show just how important health care coverage is to millions of Americans,” said Phillip J. Blando, a spokesman for the Trump transition team. “The Trump administration will work closely with Congress, governors, patients, doctors and other stakeholders to fix the Affordable Care Act’s well-documented flaws and provide consumers with stable and predictable health plan choices.”

ACA afflicted by a deductible cliff

The Atlantic's Olga Khazan recently went to Trump country in central Pennsylvania, near Harrisburg, and asked people what they thought of the Affordable Care Act.  A lot of the not-poor were resentful about the Medicaid expansion. Here's the owner of a hair salon who earns too much to qualify for a marketplace subsidy and is old enough to pay near-peak premiums:

Things got even worse for her this year, when several insurers pulled out of Pennsylvania’s Obamacare exchange, leaving her with just a few options, she said. Now, she pays $655 a month, and her deductible is $10,000. “Welcome to my shoes,” she said...

The wealth and health of states, cont.

In my most recent post at healthinsurance.org, I noted that the five states highlighted by the Kaiser Family Foundation as those with the highest percentages of residents with "declinable pre-existing conditions" under pre-ACA rules were also the five poorest states in the nation as measured by median household income. That is, by these broad measures, the sickest states are the poorest states. (Those with "declinable pre-existing conditions" are those who, according to Kaiser, would likely have been unable to obtain health insurance in the individual market prior to ACA enactment. Kaiser conservatively estimates that 27% of U.S. adults under age 65 have DPCs.)

The correlation between state wealth and health carries pretty well through the fifty states. The chart below plots the percentage of residents in each state with declinable pre-existing conditions (DPC, y-axis) against 2015 median household income, according to the Census Bureau.

Obama, dis-illusioner in chief

Obama's year-end press conference on Friday was preceded by breathless expectations, half-voiced, that he would, I don't know, call the election results illegitimate, suspend transition, call on electors not to cast their votes for Trump...the hopes were inchoate.  And the despair when Obama launched into his characteristic slow-talking, methodical, low-drama point-by-points was the Twitter equivalent of Lamentations.

Listening while watching Twitter (twistening?), at first I shared the disillusionment. But gradually I began to feel that Obama's performance was literally that -- dis-illusionment. Obama was telling us some hard truths about the degradation of our institutions. His meta-message was: Russia didn't do this to us - we did it to ourselves.

In fact he was explicit on that point. Here is where my own (wavering) reaction tipped from "he's explaining away his soft-touch response to Russian meddling" to "he's telling us the truth":

Where #the27percent are the 33 percent (with "declinable pre-existing conditions")

The Kaiser Family Foundation has released a report finding that at least 27% of American adults under age 65 have pre-existing conditions that likely would have made it impossible for them to obtain health insurance in the pre-ACA individual market. That's generated a hashtag mainly devoted to testimonials by those with pre-existing conditions (or loved ones who have them ) -- #the27percent.

At healthinsurance.org, I explore a corollary:  the states with the highest concentrations of "declinable pre-existing conditions are also the poorest states in the nation:

Of the six states with the highest “declinable pre-existing conditions”...as of 2015, Mississippi ranks last among the 50 states in median household income, Kentucky 49th, Arkansas 48th, West Virginia 47th, Alabama 46th and Tennessee 40th, according to the Census Bureau.

...and of course, the poorest states are the ones in most dire need of the benefits provided by the ACA. Of the six above, three have accepted the ACA Medicaid expansion -- and cut their uninsurance rates in half. In the other three, over 40% of marketplace enrollees have incomes under 139%, the cutoff for Medicaid eligibility in states that accepted the expansion.

Hope you'll take a look at the related points.

A mantra for Democrats in ACA 'replace' negotiation: "Save Medicaid First"

There's a lot of speculation just now over whether Democrats in the Senate will work with Republicans to pass an ACA replacement after swift repeal. While repeal can substantively be done with just 51 votes via reconciliation, a replacement bill would require 60 votes, and hence eight Democrats. Per Politico:

Twenty-five Democrats are on the ballot in 2018, including 10 in states that Donald Trump just won. The GOP is betting that many or most in the latter group will be under irresistible pressure to back an Obamacare replacement, if the alternative is leaving millions of people in the lurch without insurance.

Greg Sargent responds that if Republicans put forward a plan that covers far fewer people that the ACA (as expected), Democrats can counter that  "they will only support a more generous replacement plan that covers a lot more people than the GOP replacement would.

It seems to me that the major barrier to bipartisan cooperation is the Medicaid expansion. The Medicaid rolls have increased by 16 million since 2013. By Charles Gaba's estimate (updating Kaiser's), 12.3 million new enrollees were rendered eligible by the ACA, which makes Medicaid available to adults with incomes up to 138% of the Federal Poverty Level in states that opt to implement the expansion (as 31 plus DC have done to date).

Up and coming

I have a post up at healthinsurance.org that's frankly a more streamlined version of a prior post here -- comparing the average total value of government subsidies for health insurance in Medicare, the ACA and Tom Price's ACA replacement bill. I'm sure Price would be tickled pink by my conclusion:

In fact, the Price subsidy could be a welcome addition to the ACA if it were grafted onto the current subsidy structure as a kind of alternative minimum subsidy, available perhaps to shoppers with incomes up to, say, 600 percent FPL

 And coming soon (from me)  at healthinsurance.org: a sidelight on Kaiser's finding that thanks to pre-existing conditions, 27% of Americans would likely be denied coverage in the individual market under pre-ACA rules. Hint: the states with the highest percentages of residents with  "declinable pre-existing conditions" are also the states with the lowest median family income -- and so with the most heavily subsidized ACA beneficiaries.  

Give PriceCare to the not-poor

As I noted last week, Tom Price's 2015 ACA repeal-and-replace bill, dubbed the Empower Patients First Act, is a grossly inadequate offering for the 20-plus million mostly poor and near-poor people who have so far gained health insurance through the Affordable Care Act.  Its limited premium subsidies for shoppers in the individual market, adjusted for age but not income, would leave coverage unaffordable for most of the 9 million subsidized enrollees in the ACA marketplace. Worse, by repealing the ACA's Medicaid expansion, it would un-insure virtually all of the roughly 12 million who have gained coverage through the ACA's expansion of eligibility.

Price's EPFA does, however, provide significant aid to those who earn too much to qualify for ACA marketplace credits -- which includes some younger buyers with incomes as low as 250% FPL and a considerable number in the 300-400% FPL range. Insurance seekers who are subsidy-ineligible (or close to it) but not wealthy fare worst under the ACA, as the Urban Institute's Linda Blumberg and John Holahan have highlighted:

Price's subsidies would cover, on average, about 40% of the premium for the average benchmark silver plan offered in the ACA marketplace, and a higher percentage of the premium for the skimpier plans that would be on offer in the deregulated individual market his replacement bill would create. Coupled with an HSA, and possibly with full tax deductibility for any plan purchased in the individual market (as Trump's campaign website proposed), and with continuous coverage protection, it's a program that could work for the modestly affluent (at least, with some compromise preserving essential health benefits as a broad outline while giving states more autonomy to flesh them out).

Cutting off CSR subsidies will hit red state enrollees especially hard

As Republicans gear up to repeal the ACA,  the Kaiser Family Foundation has helpfully broken out how many of the 9.4 million subsidized enrollees in the ACA marketplace (as of March 31) live in each state, and what share of an estimated $32.8 billion to be paid out in premium tax credits this year will be paid out for enrollees in each state.

Greg Sargent, assessing the potential political fallout of cutting off those subsidies, notes:

Some of the states with the highest populations of people getting subsidies are represented by GOP Senators. This includes Florida (more than 1.4 million); Texas (more than 913,000); North Carolina (more than 499,000); Georgia (more than 427,000); and Pennsylvania (more than 321,000). Many other states with GOP senators also have sizable populations getting subsidies.

Today also happens to be the day when a federal appeals court delayed further proceedings in House Republicans' suit to stop the executive branch from funding the Cost Sharing Reduction (CSR) subsidies that reduce out-of-pocket costs for 57% of marketplace enrollees. Since a lower court upheld the suit in May, but stayed any action to cut off the payments, the delay effectively leaves it up to the Trump administration whether to drop the Obama administration's appeal and thus cut off those subsidies, effectively crippling the marketplace instantly* (and disrupting Congressional Republicans' alleged "repeal-and-delay" plans, which would keep the marketplace functioning until a replacement plan is enacted).

It therefore seems appropriate to note that CSR subsidies are particularly prevalent in the 19 states that have refused to enact the ACA's Medicaid expansion -- most of which are Trump country. That's because in those states, a subset of those whom the ACA intended to make eligible for Medicaid, people with incomes between 100% and 138% of the Federal Poverty Level (FPL), are instead eligible for subsidized marketplace coverage.   And since they are in the lowest income bracket eligible for subsidized marketplace coverage, they get the highest level of CSR support for the lowest price.

Tom Price will probably cut your health insurance subsidy in half

Last week, I noted that the federal government pays a bit more than two thirds of total medical costs for the average traditional Medicare enrollee. That is, the government pays about 85% of the premium(s) for insurance that covers a bit more than 80% of the average user's annual medical costs (that latter percentage is known as a health plan's actuarial value). Subsidies for those who chose Medicare Advantage plans are comparable.

In a followup post, applying the same calculation to subsidized enrollees in the ACA marketplace and prospective enrollees in HHS Secretary nominee Tom Price's ACA repeal-and-replace plan, I came up with the following total subsidy values:

Traditional Medicare:  85% of premium paid for AV 81% coverage = 69% of costs

Subsidized ACA marketplace: 73% of premium paid for AV 81% = 59% of costs (highly variable)

Tom Price ACA replacement: 59% of premium paid for AV 60% coverage = 35% of costs

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.

Fly-specking a myth-busting from HHS on the ACA marketplace

As the ACA's fourth open enrollment kicks off in the face of steep rate hikes and reduced competition, HHS Secretary Burwell feels compelled to engage in some "myth busting."

Fair enough, but I in turn feel compelled to, shall we say, qualify the clarifications. My two cents are in italics, below each myth-bust.

Myth #1: Health coverage on the Marketplace is unaffordable.

On the surface, headline rate changes can look spooky – but they don’t actually reflect what the vast majority of people will pay.

If you dig deeper, most consumers shopping on the Marketplace will be able to find a plan between $50 and $100 per month, thanks to financial assistance.

Well...it depends what your definition of "vast majority" is. At present there are 10.5 million marketplace enrollees, and about 1.5 million of them are unsubsidized. There are also 6.9 million enrollees in the off-marketplace individual market, however, by HHS's tallying. Off-marketplace enrollment estimates vary; Mark Farrah Associates pegged the total individual market at 20.2 million in August, which would suggest about 9 million off-marketplace.  

HHS estimates that 2.5 million current off-marketplace enrollees are "potentially" eligible for subsidies, but "potential" does not mean "actual," and the actual number is probably considerably smaller, as I explained here. 

If 2.5 million off-marketplace enrollees were indeed subsidy-eligible, and if the 6.9 million off-marketplace count is accurate, then about 2/3 of current individual marketplace enrollees would be eligible for subsidies. The actual percentage is probably somewhat smaller. At present, by HHS's count, barely more than half of individual market enrollees are subsidized. 

It may be literally true that "the vast majority" of people shopping on the Marketplace will be subsidy eligible, but that's because most individual market customers who are subsidy ineligible are aware of that fact and don't bother with the marketplace.

The unsubsidized individual market is where the wild things are -- and will indeed be spooky for many who are not eligible for subsidies but not truly wealthy.

25% premium hikes "just a flesh wound," say some Democrats

As the steep premium hikes in the individual market for health insurance have become official and specific, some progressives are comforting themselves with the thought that the market's 8-9 million unsubsidized enrollees constitute just 3% of the U.S. population. That's a silly frame.

If the ACA marketplace and larger individual market were firing on all burners, according to Kaiser Family Foundation estimates*, it would serve 27.4 million people, slightly more than half of them subsidized. That's about 60% of the population the ACA was designed to serve most directly b two means:  the Medicaid expansion (envisioned to newly insure about 17 million) and reform/subsidization of the individual market. A core purpose of the law was make the individual market accessible and affordable to all who needed it. That was always going to include 8-10 million people who don't qualify for subsidies -- not all of whom earn over 400% FPL (some have an employer's offer of insurance that they find unaffordable, though the law doesn't deem it so).

About a fifth of the law's current direct "beneficiaries" are unprotected from premium hikes averaging 25% overall and 22% in benchmark silver plans, the best measure of what those seeking decent insurance will be forced to pay. In some states, average increases are far worse -- 45% in Illinois, 57% in Arizona and Minnesota, 76% in Oklahoma. Note that two of those states are blue states, committed to making the law work. If hikes at this year's levels are more than a one-year correction, they're unsustainable.

The two-track individual market for health insurance

[Update/correction - This post originally included an important error: the RWJF breakout of off-marketplace metal levels referred to plans offered, not plans selected. While leaving that data in place, I've added survey data from the Commonwealth Fund regarding off-marketplace enrollees' metal level selections that also is not based on actual selection data but does also look rather similar to metal level selection among unsubsidized on-marketplace enrollees, as reported by HHS.]
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There are basically two individual markets for health insurance in the United States: one for subsidy-eligible people earning under 201% of the Federal Poverty Level (FPL), and one for everyone else.

Subsidy-eligible marketplace shoppers with incomes up to 200% FPL are eligible for Cost Sharing Reduction (CSR) subsidies that radically reduce deductibles, copays and maximum out-of-pocket costs. CSR subsidies are available only to those who buy silver plans, as something over 80% of enrollees with incomes up to 200% FPL do.  CSR weakens sharply at 201% FPL and phases out at 251% FPL.

Some time ago I calculated that the weighted average actuarial value for plans sold on the marketplace in 2016 was just about 80%, (The actuarial value is the percentage of the average enrollee's yearly medical costs that the plan is designed to pay.)   80% AV is close to the average for employer-sponsored health plans, and it sounds good, but it masks a sharp division. For those with incomes up to 200% FPL, the average AV was 86%. For the unsubsidized, it was 69%. For those who obtained premium subsidies but had incomes over 200% FPL, it was also 69%.

While average AV was similar for the unsubsidized and the over-200% FPL-subsidized, their choices were somewhat different. About 60% of the over-200%-FPL subsidized group chose silver plans -- in part because weak CSR attaches to silver plans for those in the 200-250% FPL bracket. Among the unsubsidized, only 39% chose silver, but AV was boosted by 18.5% of this more affluent group choosing gold plans, and 3.3% choosing platinum.

This week, the Robert Wood Johnson Foundation published a study, reported by Modern Healthcare's Harris Meyer, that details plan choices offerings (and prices) in the off-marketplace ACA-compliant individual market. [Update: per note above, see Commonwealth Fund data below.] And it turns out, unsurprisingly, that the choices made by those who bought their plans off-marketplace -- by definition, unsubsidized -- look much like the choices of unsubsidized marketplace enrollees: a lot of bronze, but also a lot of gold and platinum.  Below is the breakout of metal level selections offerings off-marketplace for 2016 according to RWJF.*

Actuarial Value	Percent of Off-marketplace enrollees plan offerings
90 (platinum)	7.0**
80  (gold)	21.6
70 (silver)	33.7
60 (bronze)	33.1
57 (catastrophic)	4.6**
69.6 (Weighed AVG)

Their choice pattern [insofar as it reflects plan offerings]  is pretty close to that of unsubsidized enrollees on HealthCare.gov:

Actuarial Value	Percent of unsubsidized hc.gov enrollees
90 (platinum)	3.3
80  (gold)	18.5
70 (silver)	39.0
60 (bronze)	33.0
57 (catastrophic)	6.8
68.9 (Weighed AVG)

See plans and prices -- and get buttonholed for Cost Sharing Reduction -- on HealthCare.gov

Healthcare.gov has launched its "shop-around" feature for 2017 -- that is, the screen where you can enter a few basic facts about yourself and then preview plans and prices, with your subsidy built into the price estimate.

As in past years, the shoparound has been redesigned. The new design has plusses and minuses in my view. As always, my primary focus is on how well the app communicates about Cost Sharing Reduction (CSR) subsidies, which are available only with silver plans, and only to people with a household income up to 250% of the Federal Poverty Level (FPL).

CSR radically lowers deductibles and copays for buyers with incomes up to 200% FPL and offers a more marginal benefit to those in the 200-250% FPL range. Because the benefit comes only with silver plans, the silver level provides the best value in absolute terms to CSR eligibles.

Because it makes silver plans more valuable than gold plans for anyone with an income up to 200% FPL, CSR is inherently counterintuitive. And because silver plans cost more than bronze, they are easy to miss when plans are ranked by premium, lowest first.

Some state-run ACA marketplaces "default to silver" for CSR-eligible shoppers -- that is, they automatically show silver plans first in the display of available plans. HealthCare.gov appears to have thought long and hard about doing this. Current CEO Kevin Counihan ran Connecticut's ACA marketplace, which has "defaulted to silver" since its launch in 2014. Connecticut has had an unusually high CSR takeup rate.

What Hc.gov decided for 2017 was a kind of optional default to silver. If you're CSR-eligible, the screen below appears before you move on to view available plans (apologies for the cut off phrase at top: it should read "only if you pick a silver plan"):

Since this screen is meant to highlight the benefits of CSR, there's a disconnect in fronting the "estimated total yearly costs." That estimate derives from a prior screen, in which you forecast whether you'll need a low, medium or high level of medical care. The estimate above is for a "low" user.

There may be an appropriate place for that information, but this is not it. What's not highlighted is the radical difference in bronze vs. silver deductibles and copays -- a disproportionate difference, thanks to the CSR subsidy added to silver alone. The light-text explanation at bottom appears to fly in the face of the cost estimate -- which of course presumes that the buyer will be a light user as expected. Risk is left out of the equation implied by the bolded text, as is the extra value added by CSR.

A second flaw is in the contrast of the average premium at each metal level. That average can be skewed by some very expensive options. Most marketplace enrollees consider only the cheapest plans available at each metal level.  In this zip (07079) and income level $23k), the cheapest-plan contrast for a 40 year-old would be between a bronze plan at $69 per month with a $3,000 deductible and a silver plan at $104 with a $300 deductible. That would make a more compelling and coherent contrast:

The good news is, I got that comparison from the shop-around's excellent "compare plans" feature. But I had to first pick through the bronze selections to find the first silver (which, to make matters more confusing, was cheaper than several bronze plans in this zip code). The contrast of CSR-enhanced silver with bronze should be clearer in the intro screen.

A third flaw is that if you go back and edit your information, for example to change the income estimate, you don't get the CSR filter screen the second time around.  You just get plans ranked by premium, and the only alternative filter available at first blush is to rank them by deductible, which can yield off-putting results if there are gold plans at premiums that quintuple lower-cost bronze or silver.

There is in fact an additional "refine results" filter that enables screening for a host of options, but it's in a different color and took me several passes to notice it (I can be a very thick user, but I'm sure I'm not alone in that).

As in previous years, once you've input your basic information and before the screen discussed above appears there's an overview screen that also provides an explanation of CSR. But it's  in light type at the bottom of the page, very subordinate to the centerpiece focused on the tax credit:

The broader shoparound tradeoff is between keeping it short and simple, so that users get a quick view of what they're likely to pay, or slowing the process by adding more information, such as plans that cover the shopper's drugs and have her doctors and hospitals in-network.  This year's shoparound takes  a bit longer to get through  than last year's, which was slower than 2015's. Added this year is a filter to indicate whether one is eligible for subsidies at all, e.g., whether the user has an offer of affordable insurance from an employer, which renders him subsidy-ineligible.

In my view that is a worthy feature, as are the drug and doctor filters, and, if properly contextualized, the total cost estimator, which varies according to whether the user anticipates low, medium or high use of medical services. But I wonder whether a two-tier process mightn't be appropriate. In 2015, you could view plans and prices, with your subsidy priced in, within 30 seconds of visiting the home page.Perhaps the shoparound should start with the most basic info -- zip code, household members with their ages, and family income -- give the price quotes, and then prompt for the additional info in a second stage.  In particular, I'm wary of total cost estimators, which tend to push the cost of unexpected accident or illness out of view. I think the results should be carefully hedged, perhaps with views of what you'll pay under alternative scenarios.

Still, the current shoparound gets you results reasonably fast, and I can't say it ignores CSR, the workings of which are notoriously difficult to communicate. We'll see how it works out for users.

See also:
The ACA's uncertain shield against underinsurance: A CSR compendium

HHS projects no growth in individual market for health insurance in 2017

The salient point about HHS's enrollment projection for the ACA marketplace in 2017 is that it does not project any growth in the individual market as a whole.

The ASPE brief laying out the forecast projects 13.8 million enrollments in the ACA marketplace by the end of open enrollment 2017, an increase of 1.1 million over the end of the 2016 enrollment period. That estimate includes 1.1 million people expected to move from off-marketplace coverage into the marketplace -- a projection based on HHS's recent estimate that 2.5 million off-marketplace enrollees are potentially eligible for marketplace subsidies.

Since insurers' ACA-compliant off-marketplace plans share a risk pool with their on-marketplace plans, a total market that stays flat will not improve insurers' risk pools, except to the extent that those who come on-marketplace switch from pre-ACA grandfathered and grandmothered plans (as far as I can tell, the ASPE brief does not clarify whether some of the anticipated transfers will come from such plans, which are phasing out). Thus the individual market as a whole may not be any more attractive to insurers next year than this year, except to the extent that this year's price hikes cover last year's losses, or the pent-up demand for medical care on the part of previously uninsured marketplace enrollees starts to level off, or regulatory and risk adjustment changes have a positive effect.

On the other hand, as Kaiser's Cynthia Cox pointed out on Twitter, a transfer from off-marketplace to on-marketplace may reduce insurers' temptation to end their marketplace participation and sell off-marketplace only in some regions.

Chipping away at the uninsured: What about those who can't afford employer-sponsored insurance?

Last week, I explored  why HHS's estimate that 9 million of the uninsured may be eligible for ACA marketplace tax credits is so much larger than the Kaiser Family Foundation's estimate of 5.4 million. In brief, the chief differences seem to be a) Kaiser takes into account those among the uninsured who have an offer of insurance from an employer, most of whom are probably ineligible for tax credits, and b) Kaiser also estimates and excludes those with incomes in the 250-400% FPL range who are "potentially" tax credit eligible but in fact ineligible because the unsubsidized premium for the benchmark silver plan in their area is deemed affordable by ACA criteria (i.e., costs under 8-10% of income).

Today, Kaiser updated its 2015 estimates, published in January 2016, of various categories of uninsured. The first thing to note is that the pool has shrunk: Kaiser now estimates 27.2 million nonelderly uninsured in 2016, down from 32.3 million in 2015. Next, the estimated percentage of uninsured who are eligible for financial assistance -- either Medicaid or marketplace subsidies -- is down from 49% to 43%.

That's due in large part to Medicaid enrollment: The estimate of uninsured people eligible for Medicaid is down from 8.9 million in 2015 to 6.4 million at present. But the estimate of the uninsured who are eligible from marketplace tax credits is also down, from 7.0 million in 2015 to 5.3 million now (an estimate Kaiser had already published, with minimal difference, earlier this year, and which I cited in the prior post).

As the ACA marketplace and the larger individual market with which it shares a risk pool wobble this fall, a key question is how close to capacity those linked markets are. Kaiser's new estimates suggest that not only has the pool of uninsured and potentially subsidizable marketplace candidates shrunk, but so has the pool of those who earn too much to qualify for subsidies yet remain uninsured -- from 3.7 million in 2015 to 3.0 million this year. (One thing to watch this year is whether premium spikes reverse that progress among the unsubsidized.)

Put the two together, and the pool of uninsured who might buy health insurance in the individual market has shrunk from 10.7 million to 8.7 million.

Michelle Obama opens the doors of perception

For the second time* in this election season, Michelle Obama riveted the country and the world with moral clarity, in a speech delivered yesterday in New Hampshire. She named Donald Trump before the world. She detailed the effects of his sexual predation -- on herself, voice shaking a little, and on a series of concentric audiences -- the one before her, the nation's children, the world. As she did at the convention, she set Trump's manifest depravity against an idealized portrait of American values as she (or her husband) strives to embody them.

The denunciation was as carefully structured as it was deeply personal. She began, by way of contrast, with a norm as she experiences it, American values that she strives to advance, as expressed in an International Day of the Girl event at the White House  (part of her Let Girls Learn program). There she "had the pleasure of spending hours talking to some of the most amazing young women you will ever meet, young girls here in the U.S. and all around the world." That opened a window on the ravages of male dominance throughout human society - and the route out:

Are 2.5 million off-exchange health plan enrollees subsidy-eligible?

A recent HHS ASPE* analysis of the ACA marketplace and the uninsured found that an estimated 2.5 million people currently enrolled in health plans bought in the off-exchange individual market are potentially eligible for premium subsidies in the ACA marketplace. That is, 2.5 million people may have foregone subsidies by buying off-exchange or may be eligible for them in 2017. That's a pretty eye-popping number -- indicating that 70% of those currently enrolled in the individual market (on- and off-exchange) are subsidy-eligible.

HHS further estimated that 9 million of the uninsured are potentially eligible for subsidies in the ACA marketplace, and that a total of 20.9 million people are subsidy-eligible -- more than double the 9.4 million enrolled in subsidized marketplace plans as of March 31 of this year. Those estimates are markedly different from those of the Kaiser Family Foundation, which estimates that 5.4 million of the uninsured are potentially subsidy-eligible, and pegs the total subsidy-eligible population at 14.9 million.

The HHS analysis is based on different survey data than the Kaiser estimate: HHS uses the National Health Interview Survey (NHIS) while Kaiser relies on the Current Population Survey (CPS). But HHS's higher estimates may stem in large part from two more fundamental differences.

Bill Clinton's other "craziest thing in the world"

I have a post up at healthinsurance.org that looks at an apparent slip from Bill Clinton's political id regarding Obamacare. No, not that "craziest thing in the world" slip -- the one about allowing those who earn too much to qualify for subsidies in the ACA marketplace to buy into Medicaid.

To buy into what? Who suggested that? Certainly not Hillary. But it -- or something very like it  -- might not be such a bad idea. Please take a look.

My last several posts at healthinsurance.org explore outside-the-box ideas for strengthening and/or amending the ACA. They include a Medicare buy-in that Republicans might like and a way to get public option pricing into the ACA marketplace without the 'public' part. Also pointing possible alternate paths: a close look at the Basic Health Programs and proposals to expand them in Minnesota and New York.

Hillary, speak to service workers

In this aphorism by Binyamin Appelbaum lies latent, I think, the organizing principle, articulated or not (okay, not), of Hillary Clinton's economic agenda:

Soon, we will be living in the United States of Home Health Aides, yet the candidates keep talking about steelworkers. 

Let's back up for some context. While U.S. manufacturing output is at an all-time high,  80% of Americans work in the service sector, Appelbaum reports, Yet politicians of both parties keep romanticizing and prioritizing manufacturing jobs:

In which Obama feels the pain of the price tag he imposed on the ACA

In an interview with Jonathan Chait, President Obama rather casually ticked off his first priority for shoring up the ACA:

In my mind the [Affordable Care Act] has been a huge success, but it’s got real problems. They’re eminently fixable problems in terms of strengthening the marketplace, improving the subsidies so more folks can get it, making sure everybody has Medicaid who was qualified under the original legislation, doing more on the cost containment. But you hit a point where if Congress just is not willing to make any constructive modifications and it’s all political football, then you’re getting a suboptimal solution. 

By now, the imperative to enrich the marketplace subsidies is a matter of consensus among progressive healthcare scholars and officials. Out-of-pocket costs are just too high for prospective enrollees with incomes over 200% of the Federal Poverty Level (FPL)*, the cutoff for strong Cost Sharing Reduction (CSR) subsidies, and premium subsidies leave buyers paying too high a percentage of their income -- between 6.4% and 9.7% of income for those in the 200-400% FPL range. In August 2015, Urban Institute scholars Linda Blumberg and John Holahan put out a detailed proposal for subsidy enrichment that included raising the actuarial value of the benchmark plan to 80% from the current 70% , with richer CSR extending further up the income ladder, as well as capping premiums at 8.5% of income for all income levels. Hillary Clinton's rather vague proposal for subsidy enrichment is apparently based on Blumberg and Holahan's. ACA improvement proposals by Timothy Jost and Harold Pollack and Sabrina Corlette and Jack Hoadley also prominently feature subsidy boosts.

The inadequacy of marketplace subsidies was evident to progressives from the beginning. Complaints began when Max Baucus's Senate Finance Committee released its bill in fall 2009, with a subsidy schedule that was far skimpier than that of the House bill.** In his 2011 book about the battle to pass the ACA, Richard Kirsch, national campaign manager from 2008-12 for Health Care for America Now (HCAN), an  umbrella group formed by unions and progressive nonprofits to advocate for universal health care, pins responsibility for the skimpy subsidies primarily on Obama:

Blumberg and Holahan on belling the healthcare cost cat

This week, Urban Institute healthcare scholars Linda Blumberg and John Holahan published a report, Designing a Medicare Buy-In and a Public Plan Marketplace Option: Policy Options and Considerations.

The report demonstrates that while designing a Medicare buy-in would be dazzlingly complex (cf. my modest proposal for simplifying it), designing a "strong" public option would be relatively simple. For both programs, the rationale is also simple: moving part (or potentially all) of the individual market population into plans that pay Medicare rates to healthcare providers.  That, the authors note in conclusion, is is basically a sine qua non of healthcare cost control:

Regardless of the approach taken, providers are likely to resist new insurance options that may move more patients into plans paying lower rates. While this is to be expected, it highlights the perpetual quandary of health care cost containment. Health care spending and its growth cannot be reduced without either paying less, on average, per unit of service rendered or reducing the quantity of services provided. No matter the strategy for containing costs, achieving that goal will take money out of the pockets of providers. To protect providers financially means abdicating cost-containment efforts of any type.

Healthcare scholars who propose means of cutting payments to providers know that they're in the position of mice who propose putting a bell on the cat that stalks them. No one in elected office is willing to bell the cat.

The other side of John Sides' debate skepticism

Those of us who've enjoyed the blogging and tweeting of political scientists in recent years often tease them as the "nothing matters" crowd. As measured by polling, in the normal course of things, gaffes don't matter, campaign ads don't matter...usually even gender doesn't matter.

As for debates...the ur-text for data-driven skepticism about their impact is John Sides'  Do Presidential Debates Really Matter?, published in September 2012.  The subtitle gives you the rhetorical thrust: Remember all the famous moments in past debates that changed the outcome of those elections? Well, they didn’t.

As a preview for tonight's debate, Sides offers an update/recap.  On the skeptical side of the ledger, here are the takeaways:

Mean vs.Median in post-ACA health insurance

This from Princeton's Paul Starr, speaking about the rise in deductibles in employer-sponsored health plans, rang a bell:

Since the ACA, there has been no overall increase in cost sharing. There are higher deductibles, but the ACA has also eliminated most annual and lifetime limits. It has provided for more complete coverage of preventive care.
So, people actually have benefited from the ACA in some ways. But I do not think they understand that...

I think many policy analysts, looking at this objectively, would say this is actually a very good shift. That it makes sense to cover those preventive costs. It makes sense to protect against catastrophic risks. The offset to that is that people have more exposure to routine medical costs up to their deductible. 

Actually, it rang two bells. I noticed this apparent paradox myself in a 2015 Commonwealth Fund survey of underinsurance: deductibles had risen, but the percentages of enrollees going without needed care or having difficulty paying medical bills hadn't. 

More to the point, though, it reminded me of the core claim in a study by Brookings' Loren Adler and Paul Ginsburg of the post-ACA individual market: that premiums are lower than they would have been absent the ACA (and lower than forecast by CBO, even accounting for this year's spike).

"The political magic of C.S. Lewis" went just so far

In a NYT op-ed, Christian conservative Peter Wehner, whose principled opposition to Trump is worthy of respect, holds up C. S. Lewis as a repository of conservative political wisdom:

Professors Dyer and Watson write that Lewis had “a very limited view of government’s role and warrant,” was skeptical of its capacity to inculcate virtue and worried about its paternalistic tendencies. The duty of government was to restrain wrongdoing. Because he believed in the fallen nature of humanity, Lewis was concerned by the concentration of political power. “It is easy to think the State has a lot of different objects — military, political, economic, and what not,” Lewis wrote. “But in a way things are much simpler than that. The State exists simply to promote and to protect the ordinary happiness of human beings in this life.”

Lewis was wary of “morals legislation.” For example, during a period when the criminalization of homosexuality was considered by many to be justified, Lewis asked, “What business is it of the State’s?” Nor did he believe it was the duty of government to promote the Christian ideal of marriage. “A great many people seem to think that if you are a Christian yourself you should try to make divorce difficult for everyone,” he wrote in “Mere Christianity.” “I do not think that. At least I know I should be very angry if the Mohammedans tried to prevent the rest of us from drinking wine. My own view is that the Churches should frankly recognize that the majority of the British people are not Christians and, therefore, cannot be expected to live Christian lives.”

Wehner's portrayal of what Andrew Sullivan would call Lewis' "conservatism of doubt" is accurate as far it goes. That doubt was tonic in some ways. Lewis recognized that theocracy is the worst form of government; that God could be dragooned into support almost any political agenda; and that democracy was necessary to check the corrupting influence of power.

These points reflect Lewis' fundamental sanity and humility. They leave out, however, the limitations of his political perspective.

Medicare buy-in, Republican style

At healthinsurance.org, I explore a possible future political deal to amend the ACA, with help from Jack Hoadley of Georgetown and Harold Pollack of the University of Chicago:

One might assume that Republicans would never go for a Medicare buy-in, as it would expand the ranks of those who get "government-run" insurance.  But what if the buy-in were limited to Medicare Advantage plans, the GOP's beloved Medicare stepchild?

Republicans might view a buy-in limited to Medicare Advantage as a gateway drug. At present, only 2% of Medicare Advantage enrollees switch to traditional Medicare, so those who came in via a buy-in would probably stay in. Increasing MA's already-growing market share from the current 30% toward or beyond parity with traditional Medicare might be tempting to GOP lawmakers.

A few statistical anomalies in healthcareville

Struggling with a difficult post, I just made a little list in my mind of some statistical oddities I've stumbled across in the past year or so in the wonderful world of U.S.  health insurance. Some are mysteries, some are apparent errors, and some involve frames that may give the wrong impression. In no particular order:

1)  In 2016, CBO changed the way it counts Medicaid enrollees under age 65. No, there was not a surge of 16 million unanticipated enrollments, as reported more than once. Rather, CBO started counting "dual eligibles" under age 65 in the Medicaid total, along with enrollees in various limited benefit programs.  More here.

2. Oft-quoted stat: In 2017, the ACA marketplace may have only one insurer in almost one third of U.S. counties. Less quoted: 19% of the population lives in those counties. 72% of the population lives in counties with 3-8 insurers (Kaiser). This is not to sugar-coat bad news, but the effect of recent pullbacks on people should take priority over its effect on acreage.

Hastening to be slaves and tyrants

Here is C.S. Lewis' charming Screwtape, senior devil, who spends his time teaching"junior devils" how to tempt humans to hell. Last line is a blueprint for Trump and his minions:

The use of Fashions in thought is to distract the attention of men from their real dangers. We direct the fashionable outcry of each generation against those vices of which it is least in danger and fix its approval on the virtue nearest to that vice which we are trying to make endemic. The game is to have them running about with fire extinguishers whenever there is a flood, and all crowding to that side of the boat which is already nearly gunwale under. Thus we make it fashionable to expose the dangers of enthusiasm at the very moment when they are all really becoming worldly and lukewarm; a century later, when we are really making them all Byronic and drunk with emotion, the fashionable outcry is directed against the dangers of the mere “understanding”. Cruel ages are put on their guard against Sentimentality, feckless and idle ones against Respectability, lecherous ones against Puritansm; and whenever all men are really hastening to be slaves or tyrants we make Liberalism the prime bogey.