2017: A year of healthcare combat

2017 was the fourth year in which xpostfactoid focused mostly on healthcare access -- and more specifically, on ACA implementation (and, this year, on de-implementation, threatened and actual).

It was a year of intense combat (to be continued...) and high drama, and I participated not only via writing, but as an advocate in New Jersey working to help ward off ACA repeal, and as a Certified Application Counselor during Open Enrollment.

Below is a look back at a few posts, roughly one per month, that I hope might have contributed something to our understanding of where we've been and where we're headed in the struggle toward (or away from) universal healthcare access. These include:

• Statistical measures of the extent to which Republican repeal-and-replace bills (AHCA, BCRA) would reduce subsidies to low income Americans (and relatedly, at the contrasting structure and aims of Democratic and Republican healthcare spending cuts).

• Previewing the paradoxical effects of Trump's cutoff of federal reimbursements for Cost Sharing Reduction subsidies, then spotlighting the actual effects in counties where marketplace enrollment is heaviest.

• Snapshots of who's benefited most (1, 2) and who's been left out (1,2,3) by ACA offerings.

• A couple of passes (1, 2) at my vision of how U.S. healthcare might most plausibly and profitably evolve.

Here they are in chronological order, earliest first:

Joshua Peck looks back at HealthCare.gov's evolution

Part of the credit for surprisingly strong enrollment in the ACA marketplace this season probably should go to the smooth functioning of HealthCare.gov, the federal online marketplace that serves 39 states.

In the runup to open enrollment, market watchers wondered whether hostility to the ACA at the top of HHS and CMS would extend to the website's functioning. Three weeks prior to kickoff, though, I noted that the information flow from the HealthCare.gov home page was effective, steering people both to the plan preview tool and to a quick determination whether they'd likely be eligible for Medicaid or subsidies.

On November 1 (launch day) the "see plans and prices" option disappeared from the home page. The "see plans" tool  enables a user to anonymously enter a handful of data points (zip code, ages of household members, income) and see a complete menu of available health plans, with prices that include the user's estimated subsidy. Its near invisibility led (some weeks later) to  Twitter chatter about possible sabotage. I noted that the preview tool had also been submerged in previous open enrollments -- which had baffled and frustrated me from early 2015 on. At which point Joshua Peck, HealthCare.gov's Chief Marketing Officer before the Trump administration took office, weighed in:

Joshua Peck‏ @JoshuaFAPeck Dec 9MoreWhile counterintuitive, more consumers are more likely to ultimately find a plan and enroll if they go through the app vs. See Plans. It's not an evil plot, though when I look for it myself it can feel that way.  Direct messageThat

That led to a phone conversation. The "see plans and prices" feature is a terrific tool.  It takes less than a minute to get a sense of what you need to pay for coverage. Since multiple surveys show that large percentages of the uninsured do not know what kind or degree of financial help is available to them, the plan preview tool has always struck me as particularly valuable.

Christmas for ACA advocates

Healthcare Twitter was on edge today, as final open enrollment figures for HealthCare.gov were running a day late:

Maybe no one will notice how good the numbers are if they’re dumped on the Friday before Christmas...

— Lori Lodes (@loril) December 21, 2017

That triggered a bout of galloping Twitter procrastination on my part:

Twas the Friday before Christmas
and atop CMS
a late enrollment surge
was causing distress.

MEWAs were hung
on the chimney with care,
and Santa'd made the mandate
vanish in thin air.

And Seema in her kerchief,
and Price in his cap,
had worked to bend enrollment
until it would snap.

When all of a sudden I heard such a clatter
I sprang to my screen to see what was the matter.

In which I fire a popgun against balance billing

When I went to the doctor last week, I tried a little experiment while filling out the paperwork:

That's a little hard to read. I crossed out the services for which I was asked to agree to be financially responsible should my insurer fail to pay in full. I should have also crossed out the preceding - "I agree that I am financially responsible for any unpaid balance." But this was just testing whether anyone in the office would notice/object. They didn't.

Sabotage judo: States can turn individual mandate repeal to their advantage

With repeal of the ACA's individual mandate apparently imminent, health law scholar Nicholas Bagley urges states to mitigate the damage by...getting their own damn mandate:

Adopting mandates at the state level would help stabilize insurance markets, thereby keeping premiums in check and forestalling coverage losses. It would also provide a welcome source of revenue: Some people will still prefer to pay a penalty than buy insurance. Plus, the states don’t need to stick with the precise terms of the federal mandate, which has been reviled (from different quarters) both for heavy-handedness and its ineffectuality. Stiffer state-level penalties would still be unpopular, but at least they’d work better.

I'd like to suggest that states take this a step further. Why not use the revenue collected from the state mandate to partially fund a reinsurance program?  Reinsurance has repeatedly proven  to sharply reduce premiums  (leading Susan Collins to propose an underfunded federal program to offset the effects of mandate repeal).

CBO projects that mandate repeal will cost the federal government $5 billion per year in forgone penalty payments by 2020 and $6 billion per year by 2025 (while saving the government more than 10 times as much in premium subsidies). States can capture that revenue for themselves by implementing their own mandates. California, with 12% of the nation's population, might collect $600 million per year in 2020 (to the extent that mandate revenue is proportionate to population). New York, with 6% of the population, might pull in $300 million. Jersey might manage $135 million; Minnesota, $85 million. These are crude calculations, but they give some idea of scope.

On tax bill, Josh Gottheimer's Problem Solving is a problem

Josh Gottheimer, the member of Congress from New Jersey's 5th District (rural west and suburban north Jersey), beat a Tea Party incumbent in 2016 and so has to be cut some centrist slack. He has made bipartisanship his brand and co-leads the self-named Problem Solvers, a caucus of about 40 reps, half Republican and half Democrat. In the summer, after ACA repeal bills failed in the Senate, the Problem Solvers put forth an ACA marketplace stabilization proposal that looked rather like the Alexander-Murray bill that later took shape in the Senate (discussed in this post). It got no traction but did no harm.

In tax bill season, though, Gottheimer's bipartisan shtick is turning dangerous, IMO.  He has said he wants to "get to yes" on a tax cut bill; he's put out a proposal, in concert with NJ Republican Leonard Lance, that avoids the most direct harm to New Jersey (restoring SALT and mortgage deductions) while ignoring the bill's overall devastation of the federal budget and disfiguration of the tax code. This too will probably do no harm...but if the bill that comes out of House-Senate conference does mostly restore the SALT and mortgage deductions, a few Democratic votes in support would be a very bad thing.

That's my working assumption, anyway - and I have a letter in NorthJersey.com arguing as much. Gottheimer's claims that his plan provides "deficit reduction" particularly stick in the craw:

What I've learned as an ACA assister

This Open Enrollment period I've been volunteering a few hours per week as a Certified Application Counselor (CAC) for the ACA marketplace, at an office in Newark, NJ. I haven't had as much experience as I would have liked, but here, very generally, are a few things I've learned.

• The government could save a lot of money by opening Medicare and Medicaid to all legally present immigrants*.  Marketplace premiums for Medicare-age immigrants are sky-high -- and often paid entirely by the federal government. Oddly, marketplace plans may actually be better than traditional Medicare for elderly immigrants -- if they stay in network, e.g., if their middle-aged children can find them in-network providers. That's because marketplace plans, unlike traditional Medicare, have an out-of-pocket maximum. Then again, dual eligibles would be better of Medicare/Medicaid.


• Similarly, legally present immigrants with Medicaid-eligible income but subject to the 5-year bar for Medicaid eligibility cost the government more in marketplace plans than they would in Medicaid (as does anyone; see Private Option, Arkansas). They would also be better off in Medicaid -- the out-of-pocket costs attached to silver plans, even with strong Cost Sharing Reduction attached, are a high bar for people with Medicaid-eligible incomes.

Planning a two-step retirement, because health insurance

My last post looked at the various ways that self-employed people in particular can limit their taxable income to stay on the right side of the ACA subsidy cliff, which has reached untenable heights for people in their late 50s and early 60s. We're at the point where getting on the wrong side of the subsidy-eligible line can mean $10,000-plus in extra health insurance costs for older shoppers in the individual market for health insurance.

The situation reflects broader societal dysfunction. We have a gaping hole in the safety net patched by an insanely diverse panoply of tax-sheltered accounts -- which some lucky and nimble affluent-but-not-rich people may hopscotch across to safety.

Take the case of a couple of 58 year-olds in a northeast city where the cost of living is high -- their modest dwelling is worth over $600k and taxed accordingly. The wife, Samara, is a hospital nurse, and the husband, Aman, is a solo consultant of some kind. Both have earnings in the $75k range. Thanks to assiduous feeding of their 401k retirement accounts (they've saved a bit over $1 million between them), their Adjusted Gross Income (AGI) is about $110,000 -- far below their gross, but far above the ACA's subsidy eligibility threshold of $64,960. That's not an issue for now, because they get good insurance through Samara's hospital job.

But what if Samara is hoping by age 62 or so to...not retire, but work per diem, or try an encore career? An unsubsidized ACA-compliant two-person bronze plan with per person deductibles in the $6-7000 range  might cost them $1500 or $2000 a month by age 62.  Can the couple get below the subsidy line without a radical cut in income? Can Samara escape health insurance-induced job lock?

Steering clear of the subsidy cliff in the ACA marketplace

It's plain this year that the individual market for health insurance is unaffordable for many of the unsubsidized, particularly those in their late fifties or early sixties. The subsidy cliff has reached a fatal height for many.

This week Kaiser Health News reporter Rachel Bluth spotlighted a stark example: A 62 year-old woman in Chattanooga, Tennessee who earned $80,000 working for a consultancy deliberately cut her hours, reducing her income by a third to get herself and her husband below the subsidy line ($64,080 for a two-person household in 2017). The total household income was $92,000.  The woman, Anne Cornwell, cut her income by $24,000 -- and her insurance bill by $27,000.

This drastic solution set me thinking about ways to keep on the right side of the subsidy cliff, i.e., 400% of the Federal Poverty Level. In 2018, that's a  Modified Adjusted Gross Income (MAGI)  of $48,240 for an individual, $64,960 for a couple, and $98,400 for a family of four.

Many but not all resources for reducing MAGI are available only to the self-employed. They include the following.

Where we're at now

Just a brief and not particularly original thought as I try to process Senate passage of this travesty of a tax bill.

While Trump's election has the feel of a perfect storm catastrophe, perfect storms are usually the result of a a long sequence of dysfunctions, and the total corruption of the Republican party was bound to lead to catastrophe at some point. I recall Jonathan Chait saying as much as an episode of debt ceiling legislative terrorism loomed in (IIRC) 2013. His point was not that that particular crisis would lead to default, but that a party always willing to go to the brink in defense of an ideology cooked up to serve the narrow interests of the superrich would lead us over the cliff at some point. Put another way, if it had not been completely evident before, it was evident after Obama's reelection that the fever would not break.

In some ways it's a consolation to view our plight not as an accident that a breath of wind could blown off course but as a reckoning with pathologies we've been collectively grappling with at least since the Reagan era (and far earlier, as every origin has multiple origins behind it).