Two comparisons of Price plan vs. ACA marketplace are roughly congruent

Late last year, I put forward a simple measure of the value (to the beneficiary) of a government subsidy for health insurance in various programs: multiply the percentage of premium covered by subsidy by the actuarial value of the insurance obtained. (A somewhat more streamlined version of the comparison is here at HIO).

For the ACA marketplace, I multiplied the average premium subsidy as reported by HHS (73% of premium) by the weighted average actuarial value obtained by subsidized marketplace enrollees (81%, my calculation) to come up with 59% total subsidized costs.

I then calculated that Tom Price's replacement plan, which has subsidies based on age not income, would on average cover about 40% of ACA benchmark silver plan premiums. I estimated that those flat subsidies would cover about 60% of premium for the cheaper plans to be offered in Price's deregulated market, to which I charitably ascribed an average AV of 60% -- coming up with a total average subsidized cost of 35% or 36%.  Of course, that's for all buyers, whereas only about half of current individual market enrollees are subsidized. Thus Price's plan radically redistributes subsidies from low-income toward higher income prospective enrollees.

Yesterday David Cutler, a Harvard health economist, John Bertko, chief actuary for Covered California, and Topher Spiro, veep for health policy at CAP, published in Vox a more nuanced and sophisticated comparison of the ACA-governed individual market and Tom Price's plan that ended up in pretty much the same place.

Triage, Sister Simone, triage

In a q-and-a session at Health Action 2017 last week, I suggested that Democrats might be savvy to engage with the Cassidy-Collins ACE "replacement" bill, which merely breaks the ACA's fingers rather than disemboweling it. When incoming Families USA exec director Frederick Isasi implied that this could potentially make sense, Sister Simone Campbell, a heroine of ACA passage and defense, rebuked him (and so, by proxy, me):

I have to confess, Frederick, after that great presentation I wanted to … say don’t you dare engage Collins-Cassidy because it’s based on Health Savings Accounts, and only 30 percent of our nation’s families have any savings. So let’s be real.

I don't like HSAs any more than Sister Simone does, but... I have a response up on healthinsurance.org

Health Action 2017: Times that try our souls

I attended Families USA's annual Health Action conference last week and found it deeply moving. My overview is up on healthinsurance.org.  Here's an upshot of sorts:

The conference, to my mind, fulfilled the deepest purpose of such events. It was not so much a matter of convincing the troops that the goal of preventing the repeal of the ACA and further evisceration of Medicaid through block-granting is attainable. Some marquee speakers argued forcefully that those goals are achievable, others implied that the odds are long.

Strength lay more in the collective demonstration of expertise and commitment, evident as much in breakout workshops as in plenary sessions...

Then, zooming out to the plenaries, a highlight was outgoing (outgone?) acting CMS head Andy Slavitt's call to the assembled healthcareniks to respond to

More than half of ACA marketplace enrollees are in states that refused to expand Medicaid

I have noted on multiple occasions that in states that refused the ACA Medicaid expansion, marketplace enrollment has been bolstered by a large contingent of people who "should have" been enrolled in Medicaid. That is, over 2 million marketplace enrollees in those 19 states have incomes between 100% and 138% of the Federal Poverty Level (FPL) -- incomes that would have qualified all of them except for certain legally present noncitizens for Medicaid had their states accepted the expansion.

To review a few facts about these low income enrollees:

• In nonexpansion states, 36% of enrollees had incomes in the 100-138% FPL range. In mid-2016 that came to about 2.1 million enrollees.


• Close to 90% (or more*) of those low-income enrollees selected silver plans and so accessed Cost Sharing Reduction (CSR) subsidies that raised the actuarial value of their plans to 94%. That generally translates to a deductible of $0-250.


• Customer satisfaction in the ACA marketplace is much higher among enrollees who are not in high deductible plans (defined by survey conductor Kaiser as under $1500 for an individual). In Kaiser's 2016 tracking survey, 74% of enrollees in lower deductible plans rated their plans good or excellent, vs. 59% of those in higher deductible plans. And again, the vast majority of enrollees in the 100-138% FPL range are in low deductible plans.

All that said, a fact hiding in plain sight (to me, anyway) is the extent to which nonexpansion states are over-represented in the ACA marketplace. This is not surprising, since a third of enrollees in those states should have been eligible for Medicaid. Nonetheless, I find it rather startling, based on state-by-state data released by HHS in December, that as of the end of the first quarter of 2016, the 19 nonexpansion states contained:

Love knows no repeal: HealthPolicyValentines 2017

Update 2/15: below is this year's complete harvest, as it grew from Feb. 10-14. Last year's trove is here. Love, 2015, here. First love, 2014, here.

----

I felt this afternoon I was getting quick-pitched on HealthPolicyValentines. But matron saint of the tradition, Emma Sandoe, tells me it's always kicked off on the Thursday before V-Day. So, like a loved one rushing to the scene of elopement, here am I (and see bottom for past years):

With this ring I thee wed;
with this kiss doth thou grace me.
Now promise you'll never
repeal and replace me.

     *      *      *

I can't call you true
on this true lovers' day.
You swapped my CSR
for this crummy HSA.

     *      *      *

Affordability and access!
We could eat our cake and have it
if we put our healthcare system
in the hands of Andy Slavitt.

Absent: A Novel speaks to our American present

Since the election, I've stopped reading the print newspaper in the morning. I can't take it in the early morning quiet. I inch into the news by degrees, via Twitter, at intervals throughout the day. I also miss a lot. 

I haven't read much fiction in recent years, so, in the void left by the paper, I resolved to take a tour of the world through fiction.  I thought I'd start with Najuib Mahfouz. But somehow along the way Amazon caught me with Absent by Betool Khedairi, a novel set in Baghdad during the sanctions period in the wake of the first Gulf War.  It's exactly what I wanted -- a day-by-day of life elsewhere. It's grown on me by degrees. It's magnificent.

It's one of those quiet and apparently plotless novels, built encounter by encounter, vignette by vignette, though it's plainly trending somewhere. The "quiet" is quiet desperation. People are slowly starving, or decaying for want of medicine or sanitation or employment (though everyone finds some way to scrape some kind of living). The backdrop is adults' memories of the Days of Plenty, the period before the blockade, and the first Gulf War, and the Iraq-Iran war -- when children going to school had pencils and uniforms, and crosswalks were repainted at intervals, and refrigerators had food in them and stayed on all day.

ACA doctors (of the law): What would you do with $3-5 billion per year?

Republicans in power certainly don't want the ACA marketplace to thrive. But for the most part they don't want it to precipitously collapse, either -- though it's not hard to imagine the Trump administration pushing it off a cliff and then trying to blame Democrats ("it was collapsing already...").

While Republicans have no real wish to make adequate health insurance affordable for lower income people, they may prove somewhat receptive to the wishes insistences of insurers, out of long habit and because, again, they don't want the market to collapse. The Trump administration is reportedly considering a package of short-term stabilizers that includes enabling by administrative fiat a minor increase to age banding (the multiple by which older enrollees can be charged more than younger ones); allowing insurers to cut off coverage for late payers after just 30 days instead of the current 90; and tightening the standards and verification for those seeking "Special Enrollment Periods" (SEPS) outside of open enrollment.

Repair, not replace -- rebranding, or real change? Watch the Medicaid expansion

The battle over ACA repeal-or-whatever is going to go through a lot of twists and turns and bold assertions that will fade like morning dew. Still, the latest Republican messaging and positioning seems at least potentially significant. From The Hill's Peter Sullivan:

Key Republican lawmakers are shifting their goal on ObamaCare from repealing and replacing the law to the more modest goal of repairing it...

“I'm trying to be accurate on this that there are some of these provisions in the law that probably will stay, or we may modify them, but we're going to fix things, we're going to repair things,” House Energy and Commerce Committee Chairman Greg Walden (R-Ore.), a key player on healthcare, told reporters Tuesday.