In a fraudster's grip

This is just to note that today Paul Krugman caught the essence of the Trump presidency in 80 words:

Our government hasn’t always done the right thing. But it has kept its promises, to nations and individuals alike.

Now all of that is in question. Everyone, from small nations who thought they were protected against Russian aggression, to Mexican entrepreneurs who thought they had guaranteed access to our markets, to Iraqi interpreters who thought their service with the U.S. meant an assurance of sanctuary, now has to wonder whether they’ll be treated like stiffed contractors at a Trump hotel.

Anyone over the age of five, regardless of political propensity or education level, should have been able to see that this is what Trump would deliver. Those who couldn't see it, driven by whatever passion or need, willfully shut their ears and eyes. His depravity was as manifest as Hitler's. Whether his will to evil is as intense, we'll learn.

Help me tell ACA stories

Greetings, dear readers: I would like to tell stories about people's experiences with lesser-known ACA benefits -- or shortcomings. Writeups may appear elsewhere -- healthinsurance.org or other publications -- or here.  These are the categories I have in mind:

1) Donut hole: I'd like to speak to Medicare enrollees who have benefitted (or not so much) from the ACA's gradual closing of the "donut hole" in prescription drug coverage.

2) Lifetime coverage caps: pre ACA, in 2009, 59% of people insured through employers were subject to lifetime caps on coverage -- typically $2 million by 2009, but often $1 million. The ACA banned lifetime and annual caps.  In a recent post, I  dug up a 2007 study finding that 20,000-25,000 people would hit lifetime caps by 2009.and forecasting that 300,000 would max out by 2019 if the caps were not raised. I'd like to speak to anyone who ever hit the caps, or was saved from the caps by the ACA, or is worried about hitting the caps (because of an expensive chronic condition) post-ACA.

If ACA is repealed, how many will max out on restored lifetime coverage caps?

In the waning days of his noble tenure as acting CMS director -- perhaps the last era in which CMS and HHS will function as fact-based agencies dedicated to improving healthcare delivery -- Andy Slavitt became a forceful Twitter advocate for the ACA, the payment reforms initiated under the ACA and MACRA, and other programs that require money, effort and commitment.

Among those tweets was one that listed 19 benefits that would be lost under ACA repeal, most of them little-known, including this:

That set me wondering: how many people would hit the coverage caps? And lo, an estimate exists. In our till-now-at-least-partially-fact-based-society, it sometimes seems that someone (or some interest group) has looked into almost any question that can be posed.

An exit ramp for Republican senators queasy about ACA repeal-and-delay

Yesterday, two Republican senators who have been most vocal about the dangers of repealing the ACA without replacement, Bill Cassidy of Louisiana and Susan Collins of Maine, introduced a "replacement" bill that looks something like the compromise envisioned by many healthcare wonks, giving states the freedom to accept or redesign the core ACA benefit structure. Senators Shelley Moore Capito, R-WV, and Johnny Isakson, R-GA, are co-sponsors. Vitally, it does not repeal the taxes that fund ACA benefits. Full text is here; a one page summary, here

The plan is offspring of a bill Cassidy introduced in 2015*, when the possibility loomed that the Supreme Court would rule for the plaintiffs in King v. Burwell and ban the federal exchange HealthCare.gov, from granting premium subsidies. It allows states to either keep their ACA marketplace as is, or opt for a conservative alternative based on subsidized Health Savings Accounts (HSAs) and catastrophic plans offered in a deregulated market. It also leaves intact the ACA's "innovation waivers" allowing states to cook up their own coverage schemes to deploy comparable dollars to cover comparable numbers of people. A Republican HHS would presumably be disposed to wave through such alternative schemes if they have a conservative cast.

Losers and winners under medical underwriting

This post is a by-product of my prior post de-gaslighting Betsy McCaughey's ridiculous claim that only 500,000 people would be affected by repeal of the ACA's protections for people with pre-existing conditions seeking insurance in the individual market.   I believe I have a sharpened view of who's been helped and who's been hurt in the post-ACA individual market.

Spoiler alert: in the pre-ACA individual market, more than half of those who needed insurance were either denied coverage, discouraged from applying, offered insurance that excluded coverage for their pre-existing condition, or offered coverage at above-market rates.

McCaughey's argument was built on misrepresenting a 2010 report issued by Henry Waxman and Bart Stupak, then-chairs of the House Energy and Commerce Committee, that drew on data elicited from the four large health insurers in the 2009 individual market , The main takeaways in this study were that coverage denials on the basis of applicants' prior medical history rose rapidly from 2007 to 2009, and that the denial rate reached 15.3% in 2009. That latter figure is roughly at the midpoint between the result of a 2009 AHIP survey of member insurers, which found a denial rate of 12.7%, and the Kaiser Family Foundation's 2013 estimate that 18% of applicants were denied (perhaps the denial rate continued to rise after 2009).

The Waxman-Stupak report  also cited an internal document from one of the insurers articulating a common assumption: that in reality about one third of applicants were effectively shut out of the market, as many were discouraged from applying by brokers, or past experience. The report further noted that one of the four insurers provided 15% of its customers with polices that excluded coverage for their pre-existing condition. While it did not provide an overall estimate for such targeted exclusions, the AHIP survey reports that 6% of coverage offers included such exclusions (and some participating insurers did not report on this question).

Betsy McCaughey, mother of the death panel myth, is gaslighting the ACA again

Betsy McCaughey, chief gaslighter of the Clinton health reform plan in 1993, and originator of the groundless charges in 2009 that blossomed into Sarah Palin's viral lie that the ACA was creating death panels, is out with fresh nonsense about the current individual market for health insurance and how Republicans might improve it.

In a Wall Street Journal op-ed, McCaughey claims that high risk pools could easily and effectively protect those with pre-existing conditions and so safely return the individual market to medical underwriting -- that is, basing health insurance pricing and availability on the health of each applicant.

McCaughey's claim that only about 500,000 Americans would be "in jeopardy" if ACA protections for those with pre-existing conditions were repealed is off by a probable factor of 10. Her argument in favor of high risk pools as a panacea is false in every particular.

To get to 500,000, McCaughey cites a 2010 report issued by Henry Waxman and Bart Stupak, then-chairs of the House Energy and Commerce Committee, finding that the four largest health insurers denied some 257,000 people coverage in 2009 on the basis of pre-existing conditions. She suggests that that was the total number of denials in that year, then adds in 70,000 reported by the four insurers to have been denied coverage for specific claims on the basis of "riders" excluding coverage for their pre-existing conditions, and 225,000 covered by pre-ACA high risk pools, to get her estimate.

That estimate is ridiculous on its face. The Waxman-Stupak report spells out explicitly that the four insurers provided data representing only a slice of the market -- somewhere between 10 and 30%, most likely.* The key finding was that 15.3% of applicants were denied coverage by medical underwriting. The report further cites an internal insurance company document to suggest that about one third of applicants were effectively shut out of the market, as many were discouraged from applying by brokers, or past experience.

Fight ACA insta-repeal: Contact strategically placed friends and family

Congressional aides and other political insiders often say that elected officials pretty much discount calls and letters from those outside their own constituency. Taking that received wisdom to heart, I have been pitching friends and family in states with Republican senators to call or email those senators and urge them to reject ACA "repeal-and-delay" -- and encouraging people in my local advocacy group, BlueWaveNJ, to do the same.

Using what comes to hand, I thought I'd share my template letters here -- that is, letters to friends and family in Texas and Pennsylvania. Texas first, because interesting news prompted me to cook it up yesterday.  But the PA letter  is more of a general template, with more resources and context Ohio is next for me. Each one includes contact info and state health facts, courtesy mainly of Families USA's tool to pull same.

So if you've read this far, would you please call or write Unc in Ohio or former college roommate in Louisiana and ask them to call/email their senators? Please use/share/adapt the PA template letter (below the TX one) if it's useful - or maybe just the link library at the end of it.  Thanks...

*          *          *

Dear AUNTIE IN TEXAS:

Texas Senator John Cornyn today said something very interesting about ACA repeal:

A group of Republican governors met with Republican members of the Senate Finance Committee on Thursday, and some expressed concerns about the number of people who could lose insurance once GOP lawmakers repeal the Affordable Care Act.

One of the top concerns is what will happen to individuals who became eligible for Medicaid with its expansion under Obamacare. The Senate's No. 2 Republican, however, promised that no one who got coverage under Medicaid expansion will lose it.

When Cornyn was asked if he was concerned about people who've benefited from Medicaid expansion losing coverage, he said it was a shared concern.

"Were all concerned, but it ain't going to happen," Cornyn said. "Will you write that down... It ain't gonna happen."

A good day for the ACA

While there will doubtless be many shifts and turns in the battle over the ACA, the road to repeal has seemingly got steeper for Republicans in the last couple of days. Some good developments:

1) Trump blew in with his promises to cover everyone, with low deductibles, and to enact his magic replacement at the same time as ACA repeal. That would seem to make it harder for Republicans in Congress to proceed with repeal-and-delay.

2) The Congressional Budget Office, traditionally the arbiter of the fiscal viability of proposed legislation, did the Urban Institute one better and estimated that the repeal-and-delay bill Republicans passed in late 2015 (vetoed by Obama) would un-insure 32 million people in a decade.

3) Media coverage pretty universally noted that the Jan. 15 rallies reflected deep support for the ACA and stiff resistance to repeal from its proponents. The NYT's Robert Pear, generally caustic about the ACA, put it this way:

ACA defenders don't need to "learn from" the Tea Party. They beat them in 2009-10

The fight to save the ACA is on, and all across the land, progressive groups large and small are mobilizing the law's supporters to let their senators and reps know the cost of dis-insuring 20 million people -- more, if Republicans block-grant Medicaid and/or collapse the individual market, less if they pass some poorly funded and designed facsimile of the ACA.

In reaction to the 35 "protect our care" rallies staged across the land on Sunday (Jan. 15), I keep seeing sentiments to the effect of  "progressives are learning from the Tea Party."  That's a half-truth at best, in that supporters of the ACA-in-progress fought protestors at least to a draw in 2009-2010 (proponents won in the sense that they got the ACA passed, but they did (briefly) have a 60-vote Senate majority and a large House majority). The ACA would never have got anywhere near the finish line without the most massive grass-roots advocacy ever achieved.

The Tea Party protests against the ACA-in-progress at Town Hall meetings in the long hot summer of 2009 have become part of American political lore. What’s less well known is that progressive groups supporting health reform fought back on the spot, often with equal or superior manpower and local impact. The media preferred the screamers, of course.

There was a massive coordinated effort led by Health Care for American Now (HCAN), an umbrella organization for groups committed to universal healthcare, formed in the runup to the 2008 election. Member groups’ ability to muster supporters provided vital support that kept many representatives and senators committed to passing the bill that became the ACA.

TrumpCare's coming! What kind of garbage in a gold box awaits us?

The Washington Post's Robert Costa published the gist of an interview with Trump last night in which Trump claimed that his administration is putting the finishing touches on a health reform plan that would provide universal access to affordable, low deductible coverage. This is so apparently out of keeping with existing Republican ACA replacement plans that it's hard to know what to make of it. Here are three possibilities:

1) Trump's plan will depend heavily on "mini-med" plans for low income people -- that is plans with low up-front costs but tight caps on how much the plan will pay (annual caps, lifetime caps or both).  An ACA replacement plan put forward by Senator Bill Cassidy (R-Louisiana) and Rep. Pete Sessions (R-Texas) features such plans for the poor.

2) Trump will offer a plan that proposes something very like Medicaid for people higher up the income chain than the ACA does with something very like Tom Price's plan for people with somewhat higher incomes -- that is, relatively small tax credits, unadjusted for income, to be spent in a deregulated insurance market. I've proposed this myself, and I think it's too good to be Trump.

It's up to you to save the ACA

I have a piece up on healthinsurance.org, arguing that Republicans' ACA insta-repeal train can be derailed, and how-to-ing the basic forms of citizen action by which we can all do our part.

It's mostly the nuts and bolts of how to phone, write, tweet, etc., but here's my closing argument that it's all eminently worth doing:

Any and all Republican senators are worth contacting with a “no repeal without delay” message. Taking away constituents’ existing benefits is not in senators’ job description. Almost none of them want to do it, though they have almost all promised to in some form. Those who have expressed doubts include some of the hardest core conservatives (Cotton, Paul).

Some may stealthily work against a swift repeal even if they’re publicly for it. Some may also work to mitigate the effects if it does pass – for example, by delaying repeal of the taxes along with the benefits. If that happens, the ACA may in effect be “renewed” indefinitely.

Remember – just three Republican senators are needed to kill passage via reconciliation. It’s also possible that the “queasies” will insist that repeal of key features such as taxes that the fund benefits or the individual mandate be delayed along with the premium subsidies and Medicaid expansion – and that the hard-core right wing may then in turn balk, on grounds that the bill is a “repeal” only in name.

By hook or crook, supporters of the law should be able to help Democrats in Congress find a way to preserve the vast improvement the ACA has wrought in millions of Americans’ lives.

Hope you'll take a look.

Careful with that study! A second look at enrollment decisions in Covered California

A study of the buying decisions of enrollees in California's ACA marketplace, Covered California, in 2014, suggests that a lot of people left benefits on the table:

The Affordable Care Act includes financial assistance that reduces both premiums and cost-sharing amounts for lower-income Americans, to increase the affordability of health insurance coverage and care. To receive both types of assistance, enrollees must purchase a qualified health plan through a public insurance exchange, and those eligible for the cost-sharing reduction must purchase a silver-tier plan. We estimate that 31 percent of individual-market enrollees in California who were likely eligible for financial assistance purchased plans that were not silver tier or that were not sold on the state’s exchange and thus missed opportunities to receive premium or cost-sharing assistance or both. Lower-income enrollees who chose plans not eligible for subsidies had two to three times higher odds of reporting difficulty paying premiums and out-of-pocket expenses during the year, compared to those who chose eligible plans. Regardless of how the structure of the individual market evolves in the coming years, efforts are likely needed to steer lower-income enrollees away from financially suboptimal plan choices.

The study, just published in Health Affairs, lead author Vicki Fung of Harvard and Mass General, is based on  survey responses from 2103 enrollees and has some very interesting results regarding the difficulty (or lack thereof) that enrollees experienced paying premiums and out-of-pocket expenses at different income levels and benefit levels. But while the authors are quite thorough in enumerating the study's limitations, some caveats are worth elaborating.* In brief: CSR takeup is higher at income levels where the benefit is strong, and many of those deemed potentially eligible for subsidies are not in fact eligible.

Let's look more closely at the more specific claims.

The Rosetta Stone of Cost Sharing Reduction takeup in the ACA marketplace

I don't know why it's taken me so long to notice, but something I've always wanted to know about ACA enrollment has been hiding in plain sight since July.

The question is what percentage of marketplace enrollees at different income levels who are eligible for Cost Sharing Reduction (CSR) subsidies do in fact access the benefit by selecting silver plans, the only metal level at which CSR is available. This is important, because out-of-pocket expenses for lower income enrollees -- which means most enrollees -- are basically only manageable in CSR-enhanced plans.

CSR raises the actuarial value of a silver plan from a baseline of 70% to 94% for those with incomes up to 150% FPL; to 87% for those in the 150-200% FPL range, and to just 73% for those between 200% and 250% FPL.  Conversely, the percentage of income required to buy a silver plan rises with income -- disproportionately, to judge from takeup, which is higher at lower income levels.  Those who opt for a lower premium by buying bronze plans are leaving a valuable benefit on the table and letting themselves in for deductibles generally north of $6,000.

Every year since the launch of the ACA marketplace for 2014, HHS has published ever-more specific enrollment data (for HealthCare.gov states in particular). But CSR takeup at different levels has had to be extrapolated from various not-quite-complete hints, including data published by states that run their own marketplaces.

That was the case, that is, until this past July, when a CMS data brief  appeared with a CSR Rosetta Stone wrapped in the middle. And I'm going to take a little credit for that, as well as drawing conclusions.

Medicaid envy in the rust belt

Yesterday, Drew Altman, president of the Kaiser Family Foundation, published an op-ed in the New York Times in which he reported results of focus groups that KFF conducted with Trump voters in rust belt states who are enrolled in Medicaid and ACA marketplace plans.  One set of complaints from marketplace enrollees is worth pondering:

They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance — for which they were eligible for subsidies — saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it.

While Medicaid enrollees may have difficulty finding an in-network provider for a given need, they generally not only pay little-to-nothing in premiums and out-of-pocket costs, but also are shielded from balance billing to greater or lesser extent by state law*, Medicaid beneficiaries generally rate their coverage higher than marketplace enrollees -- although, as Altman points out, large majorities of marketplace enrollees also generally rate their coverage at least satisfactory (Trump voters are likely less satisfied than the average). While no one likes a narrow network, it may be the case that what people dislike most is not a narrow choice of providers, but the risk that an out-of-network provider will inflict himself on you, or more exactly, on your checkbook.

Who are the "20 million" insured via the ACA?

In references to the roughly 20 million people the ACA has said to have insured, three things tend to be conflated: 1) the net increase in the insured population since ACA enactment (roughly 20 million), 2) the number insured through the ACA marketplace (10-11 million at present), and 3) the number insured through the individual market (18-20 million, about half of them subsidized).

Below, a few points aiming to clarify who's benefiting and to what degree. Teaser: don't miss my slicing of CPS data in the chart below.

1. The contributing streams to the 20 million increase in insured Americans include  a) an increase of 17 million in Medicaid enrollment since July-Sept. 2013, including nearly 12 million categorized by states as rendered newly eligible by the ACA; b) 8-9 million subsidized enrollees in the ACA marketplace, contributing to an increase in overall individual market enrollment of roughly the same size;c)  2-3 million adults under age 26 added to their parents' health plans; and 4) a possible moderate increase in enrollment in employer-sponsored plans.

How Democrats might lose the ACA insta-repeal battle and win the war

In the interview I posted last week with Chris Condeluci, who was counsel to Republicans on the Senate Finance Committee when the ACA was being drafted,  I foregrounded the most urgent point at present: ACA proponents have a very short window to deter lightning passage of a repeal-and-delay bill, and at least a handful of Republican senators may be responsive to pressure and balk at repeal with no replacement. Three defections would kill insta-repeal, if Democrats hold together.

I think this possibility has been underplayed. 21 Republican senators are in states that have enacted the Medicaid expansion, and many of those states have slashed their uninsurance rates by 40% or more.

Still, odds are probably that Republicans will go through with a repeal-and-delay, in which they preserve the ACA Medicaid expansion and marketplace subsidies for at least 2-3 years while they allegedly craft a replacement plan.

If that's the case, there's still a high-stakes battle to be fought. Its outline can be discerned in the detailed options menu Condeluci laid out for Republicans (or their aides) racing to draft a repeal bill. Since that interesting material was buried rather deep in the prior post, I've reposted it below.

The sticking point (to my mind) is whether repeal of the taxes that largely fund ACA benefits is delayed along with repeal of the benefits. If not, the Medicaid expansion is probably dead, along with marketplace subsidies that make coverage affordable for lower-income buyers. The negotiations with Democrats over a replacement bill that Condeluci envisions are really only possible if substantial tax revenue is still coming in.