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).

Late Days of Empire Edition: Health Wonk Review

We're addled on many fronts here in Trumpville, and this week's Health Wonk Review reflects that. We have snapshots of a country that continues to trail its peers in population health measures; an opioid vendor looking to short-circuit potential tobacco industry-level liability; an individual market for health insurance offering unaffordable plans to many of the unsubsidized, and freakish bargains to some of the subsidized; and, for a little futuristic relief, a human resources tech vendor that may chain healthcare data to a block, where it shall remain unaltered forever and ever.

At Workers' Comp Insider, Tom Lynch  looks at what the U.S. gets for spending 41% more on health care than our wealthy nation peers in the OECD and 81% more than the entire 35-nation OECD average. Spoiler: not much. We're "sort of like a big-market baseball team spending gazillions more for players than any other team, only to finish out of the running."

At Managed Care Matters, Joe Paduda notes that Purdue Pharma is trying to strike a deal to resolve all state claims relating to opioids. He warns:

The marketplace isn't all roses for the subsidized, either

Sam Baker has an insightful take on the bifurcation of the individual market between the subsidized and the unsubsidized, exacerbated by Trump. I want to offer a caveat, though.

Of the fallout from Trump's cutoff of Cost Sharing Reduction (CSR) reimbursement -- premium spikes for the unsubsidized, bronze and gold bargains for some subsidized -- Baker writes:

All of this has compressed the ACA's benefits. The law was initially designed to move a lot of people into the same system, in which even the people who didn't get a subsidy would benefit from a competitive marketplace to shop for coverage.

Instead, we're ending up in a place where the poorest consumers can get even cheaper coverage than the ACA intended, especially if they choose less comprehensive care, while wealthier consumers increasingly don't have much incentive to get covered at all. Those trends will only grow more pronounced if Republicans successfully repeal the individual mandate in their tax bill, leaving the law with only its carrot, and no stick.

There's nothing inaccurate here. But in general discourse if not here, the perceived bonanza for the subsidized stemming from inflated subsidies may be somewhat overstated.

A Medigap for the Marketplace?

It's well known by now that Trump's cutoff of federal funding for Cost Sharing Reduction (CSR) subsidies in the ACA marketplace has had the paradoxical effect of making free bronze plans widely available to subsidy-eligible marketplace enrollees.

The blessing is something of a mixed one for many buyers with incomes up to 200% of the Federal Poverty Level (FPL), however. Silver plans up to the 200% FPL level come with strong CSR that reduces average deductibles to under $300 (for enrollees up to 150% FPL) or under $1000 (for those in the 151-200% FPL range). That's in contrast to bronze plan deductibles that average over $6,000.  Other out-of-pocket cost differences are commensurate. More than half of current marketplace enrollees have incomes under 200% FPL, and most can probably now find free bronze plans.

CSR was designed to make actual healthcare affordable to low income enrollees -- who, again, constitute more than half of all marketplace enrollees (and more than half of the uninsured; as of 2013, 55% of the uninsured had incomes under 200% FPL). $6,000 deductibles are not generally appropriate for low income people (or arguably, for almost anyone).

On the other hand, a benchmark silver plan for a solo buyer with an income of $24,000 just under 200% FPL costs $126 per month -- versus $0, in many cases now, for bronze.

Since CSR costs the enrollee nothing, CSR-enhanced silver plans used to be worth considerably more in absolute terms than bronze, providing more actuarial value for the buck. That's not necessarily true any more. And a fair number of bronze plans do not subject services such as doctor visits and generic drugs to the deductible. The yearly out-of-pocket maximum for a bronze plan, on the other hand, is $7,350 for an individual -- versus $2,450 for a CSR-enhanced silver plan for enrollees with incomes up to 200% FPL. The out-of-pocket maximum represents an enormous amount of risk for a low income person.

There is an existing market resource, however, that could give some enrollees in free or very cheap bronze plans significant relief from high out-of-pocket costs. That's so-called gap insurance, which offers first-dollar coverage for a range of expenses up to a limit of, say, $5,000 or $10,000. It's not available everywhere, coverage for preexisting conditions is excluded, and coverage is not comprehensive -- it's for named perils such as accidents and critical illness, as commenter Bob Herz cautions below [I have updated here to make those limitations clearer].  But for a healthy enrollee, plans of this sort may provide coverage up to the bronze out-of-pocket maximum and beyond. [Update, 11/23: Comment by Bob Hertz below is on point -- the policy featured below is for named perils only, e.g., accident, heart attack/stroke/"invasive"cancer, plus limited hospital indemnity.]

The tax bill from hell

Let it not be said that I take forecasts as gospel. But three forecasts about the Senate tax bill from our appointed Congressional arbiters, the Joint Committee on Taxation and the Congressional Budget Office, do form a remarkable trifecta. Over ten years, the bill is forecast to

• Increase the deficit by $1.4 trillion
• Raise taxes on every income band up to $50-75,000
• Uninsure 13 million people.

If they teach legislating in hell, this is what you'd learn to come up with.

Halfway back to the future in the individual market for health insurance

The ACA-compliant individual market for health insurance is at a mid-point between Trump sabotage that's been executed and Trump sabotage that's threatened. At present, the market remains viable for most subsidized prospective enrollees -- and even accidentally improved for a good number of them via discounts for bronze and gold plans. It's largely dysfunctional for the unsubsidized, however, after two years of average premium hikes in excess of 20%.

The main (though by no means only) act of sabotage in 2017 was Trump's long-running threat -- executed in October -- to cut off federal reimbursement that the federal government is legally obligated to pay insurers for providing Cost Sharing Reduction (CSR) payments to qualifying enrollees. Stiffed by Trump, insurers had to boost premiums to cover the cost of CSR. That in itself accounted for nearly half of this year's 29% average premium hike, according to Charles Gaba.

The next sabotage threat is individual mandate repeal, coupled with pending administrative action to empower a non-ACA-compliant market of medically underwritten, loosely regulated plans. -- which currently do not satisfy the mandate. Those measures in combination will trigger a fresh wave of premium hikes in the ACA-compliant market by draining its risk pool. Many if not most of the 6-7 million current unsubsidized enrollees in ACA-compliant plans will probably be driven perforce into the unregulated market if this next round of sabotage is fully implemented.

We are already halfway there, I suspect.  Recently I spotlighted the choice facing a 58 year-old in Pottsville, PA who's ineligible for subsidies -- that is, with an income over $47,520 for an individual or $64,080 for a couple. For this person

Replacing the individual mandate with auto-enrollment, part II

A week ago, I suggested that the wide availability of free bronze plans in 2018 for subsidy-eligible potential ACA marketplace enrollees opens a window for replacing the individual mandate with auto-enrollment of the uninsured, a measure that's popped up in various Republican bills and conservative repeal-and-replace proposals.

That was tongue-in-cheek, since the House and Senate tax cut bills make it obvious that Republicans are not interested in using current federally budgeted dollars to insure more people. They'd rather give the subsidy money to the wealthy via tax cuts.

That said, a fact brought to my attention by Politico's Dan Diamond does boost the case for auto-enrollment. 80% of the 6.7 million households that paid the mandate penalty in 2016 (for tax year 2015) had incomes below $50,000 -- that is, near the subsidy eligibility threshold for a single person, $48,240. Many of those households with incomes over $50,000 are also doubtless subsidy eligible. (On the other hand, a good number of those with incomes in subsidy range may have been disqualified for subsidies by an offer of insurance from an employer. Kaiser estimates that 3.7 million are rendered subsidy-ineligible for this reason.)

IRS tables show that payers of the mandate penalty in tax year 2015 were pretty heavily concentrated at income levels where free bronze plans are common this year:

Who'll go to the mat for the individual mandate?

I fear that the trio of Republican senators who killed "skinny repeal" in late July (Collins, Murkowski, McCain) are going to have a hard time rejecting the tax cut bill in the name of the individual mandate.

Skinny repeal was linked to a (somewhat uncertain) presumption that the bill would be merged in conference with the House bill, which included repeal of enhanced federal funding for the Medicaid expansion and imposition of per-capita caps on federal Medicaid spending. Defense of Medicaid was the heart and soul of the Resistance, as it should have been.

Now, we may well get a partial birth abortion of the ACA - - mandate now, massive cuts to Medicaid (including expansion repeal) later. As Andy Slavitt has warned, that splits the "23 million uninsured" baby.

The individual mandate has always been unpopular -- and frankly, after years of both self-inflicted wounds and sabotage of the ACA marketplace, it has cause to be.  Health economists say that the mandate penalty was too small and too lightly enforced to be fully effective. The counterpoint is that a stricter mandate requires stronger subsidies - e.g., a cap on insurance premiums as a percent of income for all buyers, perhaps one that that matches the "affordability" threshold (currently 9.56% of income for employer-sponsored insurance and 8.05% of income for an ACA-compliant bronze plan).

For many who don't qualify for marketplace subsidies but must look to the individual market for coverage, the mandate is already effectively dead - -and so is the market.  To cite just a couple of cases I've had cause to look up lately:

Tax math for dummies like me

The math is plain as day, and Senate Republicans have seized on it: According to the Joint Committee on Taxation, the nonpartisan tax policy counterpart of the Congressional Budget Office, the Senate tax bill cuts taxes on low and middle incomes more sharply than on higher incomes. Right?

Wrong, explains David Kamin, Obama's former Special Assistant to the President for Economic Policy.  The percent cut in your tax rate is very different from the percent increase in your after-tax income. Here is his chart  (with an adjustment at the top end for repeal of the estate tax, which JCT leaves out):

Trump thinks Putin's mind works like his

Trump's walk-back of his avowals that he believes Putin's denials with respect to interfering in US elections is a window into Trump epistemology.

Here's the walk-back:

I believe that he feels that he and Russia did not meddle in the election...I believe very much in our intelligence agencies...what he believes is what he believes.

That, incidentally, does comport with what he said about the Putin:

He said he didn't meddle. He said he didn't meddle. I asked him again. You can only ask so many times...Every time he sees me, he says, 'I didn't do that".. And I believe, I really believe, that when he tells me that, he means it.

Trump actually did not say that Putin didn't meddle. He said Putin "means it" when he say he didn't meddle.

In other words, Trump thinks, or purports to think, that Putin thinks like he does: Whatever he wants to believe is true is true. Or, whatever he finds convenient to affirm is true.

Hey, Republicans: Auto-enrollment is within reach

Put it in Chapter 1 of the Annals of Unintended (though not un-forecast) Consequences: Trump's cutoff of federal funds to reimburse health insurers for Cost Sharing Reduction (CSR) subsidies has made free bronze plans widely available to subsidized buyers in the ACA marketplace*.

So available, in fact, that the Kaiser Family Foundation has calculated that more than half of the 10.7 million people who are uninsured and eligible for marketplace coverage can find free bronze plans in the ACA marketplace, and 70% can access bronze plans for less than the cost of paying the penalty for going without coverage.

That paradoxical effect of cutting off funding for a subsidy suggests a political deal -- a second paradoxical effect.  Recall that ever since Democrats included the individual mandate in the various bills that became the ACA, Republicans have cast the mandate as a mortal threat to freedom -- and seek to this day to repeal (and maybe replace) it.

As a substitute for the mandate, several Republican bills and plan outlines included auto-enrollment of the uninsured in a catastrophic plan that would cost the enrollee nothing, since its premium would equal whatever subsidy the enrollee was eligible for.

For Whom the Bronze Bell Tolls in the ACA Marketplace

My last post looked at the likely impact of the availability of free or very cheap bronze plans for ACA marketplace customers who are eligible for strong Cost Sharing Reduction (CSR), available only with silver plans, in the five largest markets in the country.

In this post, we'll look at current CSR takeup in the five counties in question and consider how it's likely to change. Here are the counties, with their 2017 initial marketplace enrollment totals:

Miami-Dade, FL              387,848
Los Angeles, CA             380,520
Broward, FL                    240,984
Harris, TX (Houston)      240,064
Cook, IL (Chicago)         144,418

While bronze plans generally have deductibles above $6,000, CSR-enhanced silver plans, for enrollees with incomes up to twice the Federal Poverty Level, generally have deductibles in the $0-1,000 range. Silver plan premiums can be hard for CSR-eligible buyers to afford, though. The wider the spread between cheapest bronze and cheapest silver premiums, the more people will choose bronze.

Free bronze or CSR-boosted silver? The choice in 5 top marketplace counties

Trump's cutoff of federal reimbursement to insurers for Cost Sharing Reduction (CSR) subsidies has led to two pricing anomalies in the ACA marketplace that have rightly gotten a lot of attention: gold plans that are cheaper than silver plans (or close to it) in some regions, and bronze plans that are free for large swaths of the subsidy-eligible population.

The gold and bronze discounts* available in many regions of the country are an unmixed blessing for subsidized buyers with incomes above 200% of the Federal Poverty Level (FPL), who are eligible either for no CSR or very weak CSR. The blessing is more ambiguous for buyers with incomes below 200% FPL, however, because for them CSR, which is available only with silver plans, remains a major secondary subsidy. For these buyers, silver plans are priced as if they have an actuarial value of 70% (that is, are designed to cover 70% of the average user's medical costs) but, enhanced by CSR, have AVs of 94% (for buyers up to 150% FPL)  or 87% (for those in the 150-200% FPL range). That translates to an average deductible of $255 (for 94% AV) or $809 (for 87% AV), compared to over $6,000 for bronze plans.

That bargain remains in place. But silver plans can be quite expensive for low income enrollees. The premium for a benchmark silver plan ranges from 2% of income for those in the 100-138% FPL income bracket to 6.3% for enrollees at 200% FPL. The benchmark premium at 200% FPL comes to $127 per month in 2018.

Will the outsized bronze plan discounts available in many places this year tempt a lot CSR-eligible buyers into bronze plans?**  In 2017, over 85% of enrollees with incomes up to 200% FPL selected silver plans and accessed CSR in the 38 states that use the HealthCare.gov federal exchange.

To gauge whether discount bronze is likely to take a big bite out of CSR takeup this year, let's look at the choices facing CSR-eligible enrollees in counties with the most marketplace enrollees. In 2017, these were

Miami-Dade, FL              387,848
Los Angeles, CA             380,520
Broward, FL                    240,984
Harris, TX (Houston)      240,064
Cook, IL (Chicago)         144,418

CSR windfall: Will it have bronze or gold cast?

Those of us who have been anticipating the paradoxical effects for subsidized ACA marketplace shoppers of Trump's cutoff of CSR reimbursement have to split our gaze more between shiny objects.

Designed as an add-on benefit, CSR (Cost Sharing Reduction) radically reduces out-of-pocket costs for silver plan enrollees with incomes under 200% of the Federal Poverty Level (and much more modestly for enrollees in the 200-250% FPL range). Until this month, the federal government reimbursed insurers for the extra benefit. In 2018, insurers will price it in.

What excited folks like David Anderson, Charles Gaba and I* (though we're also appalled by the premium hikes for the unsubsidized) was the prospect that in many states and regions, gold plans would be cheaper than silver. That's because 38 states (according to Charles Gaba's tracking) instructed insurers to load the cost of CSR onto silver plans only, since CSR is only available in silver plans.

This has, um, panned out -- as we now know, since prices have been posted for almost all states. The cheapest gold plan is cheaper than the cheapest silver plan in Pennsylvania, Kansas, New Mexico, Wyoming, most of Texas and Wisconsin, much of Michigan and Florida (including Miami, which has the heaviest concentration of marketplace enrollees in the country), much of California, and parts of several other states. In other regions, the price of gold plans is closer to the price of silver plans than it used to be.

Alert: HealthCare.gov "plan preview" tool is malfunctioning [FIXED as 10/28]

UPDATE, 10/28/17: The main glitch identified in this post -- the HealthCare.gov "preview plans" tool's failure to calculate the subsidy accurately for households in which not all members are seeking marketplace insurance - was fixed in the late hours of 10/27.  The second glitch identified below, pertaining to CSR, is unlikely to be fixed.
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People concerned with the functioning of the ACA marketplace were pleasantly surprised yesterday when HealthCare.gov's "Preview 2018 Plans & Prices" tool went live a week in advance of the launch of Open Enrollment. And as I noted a couple of weeks ago, the information flow on the site is streamlined and well-designed, routing visitors as appropriate to check their eligibility for a special enrollment period for 2017, preview 2017 plans and prices, prep for 2018 enrollment, or apply for Medicaid if their income and state of residence indicates it. It has seemed so far that Trump administration sabotage of the marketplace has not so far extended to the federal exchange.

There are, however, important glitches in the functioning of the preview tool that are likely to seriously mislead some visitors.

The most important glitch was pointed out to me on Twitter (when I pointed out a somewhat more understandable one described below):

Try a married couple with spouse on Medicare. Subsidy estimate is way too big and every plan is free, even if more expensive than benchmark.

— Brian Setzler (@BrianSetzler) October 26, 2017

Like the Alka Seltzer guy, I tried it, and Mr. Setzler is right. If you enter info for a married couple,  and one has access to other insurance, the estimated subsidy is the same. In Essex County, NJ, for a married couple ages 40 and 38 with an income of $33,000 --- slightly over 200% of the Federal Poverty Level -- the estimated subsidy is $633, whether or not one has outside coverage.

We already have the high deductibles...so would adding HSAs hurt?

In my last post I suggested that among the destructive White House demands to alter the Alexander-Murray ACA stabilization bill, one concept -- encouraging takeup of High Deductible Health Plans linked to HSAs -- might be a reasonable concession for Democrats to consider.

My reasoning boiled down to this: Once you have a deductible higher than the HDHP threshold of $1350 individual/$2700 family  -- as well over half of individual market enrollees do -- it doesn't hurt to add the tax-free HSA to help people cope with the expense.

Today I asked Yevgeniy Feyman, a Manhattan Institute adjunct fellow and senior research assistant at the Harvard School of Public Health, for ways to encourage HDHP/HSA takeup in the ACA marketplace. His suggestions:

• Create a seamless process for establishing an HSA -- so that once you sign up for an HSA eligible HDHP, you would be redirected into a pipeline for creating an HSA.


• Simplify the rules by which a high deductible plan can be eligible for linkage to an HSA. At present, no services except the ACA-mandated free preventive services can be covered until the medical deductible is reached. In a family plan, the full family deductible has to be reached before coverage kicks in. These rules could be loosened. At the far end of easing, "you might end up permitting anyone to have an HSA, and just cap contributions at their deductible or max OOP."

Mulvaney's ACA demands: Give him one out of three?

As David Anderson argued in The New York Times on Saturday, at this point Republicans need an ACA stabilization deal more than Democrats do, so Democrats have no real imperative to accede to Trump's ridiculous demands,

In brief: the damage from CSR uncertainty in 2018 is already done; CSR is priced into premiums; most states have adopted a "silver load" strategy to mitigate the damage (concentrating the premium increases in silver plans, the plans with which CSR is available); and pricing in CSR over the longer term actually produces a fiscally wasteful but genuine boost to subsidies for the more affluent among the subsidy-eligible, who really need extra help (making gold plans available for roughly the cost of silver).

The chief motive for Democrats to push for a deal is to win a measure of Republican buy-in and ownership, and therefore stability. That should keep more insurers in. And an appropriation for federal CSR reimbursement in 2019 should drive premiums down, dramatically, i.e. by almost as much as CSR uncertainty (and then stiffing) drove them up this ear. That's potentially a political win for Republicans. But Democrats are inhibited in their political calculations by a desire to, you know, make good insurance affordable for more people.

Given that desire, Democrats would be crazy to yield on repeal of the individual mandate, which would trigger another premium surge and more adverse selection, or on enabling a parallel market in non-comprehensive and medically underwritten insurance, which would also damage the risk pool for comprehensive plans.

There is, however, one White House ask that Democrats might consider addressing in some form. As reported by Axios' Sam Baker, OMB Director Mulvaney made these demands on Fox News Sunday:

Bronze and gold plan discounts in California, 2018

As I noted recently, Covered California has acted on its plan to shield marketplace enrollees from the effects of Republicans' CSR sabotage.  For 2018, a surcharge averaging 12.4% has been loaded onto silver on-exchange plans only (the only plans with which CSR is available) to cover the cost that until now has been reimbursed by the federal government.

We can now examine the effects of the surcharge, which I've done below.  The effects should theoretically be as follows (more detail here):

1. Off-exchange plan pricing should be unaffected by CSR; price differences between metal levels should remain proportionate to actuarial value at each level.
2. Enrollees with incomes under 200% of the Federal Poverty Level (FPL), for whom strong CSR is available, should be unaffected. Subsidies will rise to cover the additional premium, and silver plans will continue to offer outsized value, covering 94% (at incomes up to 150% FPL) or 87% (for incomes from 150-200% FPL) of the average user's costs.
3. Subsidized enrollees in the 200-400% FPL income range will see discounts in bronze and gold plans, since premium subsidies, which are keyed to silver plans, will rise to cover the inflated silver premium.

Let's look at how the expected bronze and gold discounts play out in some of California's 19 rating regions. Because California has standardized plan benefits at each metal level, relatively clean comparisons are possible -- though I would note that last year, relatively expensive PPOs (plans with broader provider networks) were popular in many areas.

Does the Alexander-Murray bill adequately protect vulnerable groups?

The changes to the ACA's Section 1332 state innovation waivers in the Alexander-Murray marketplace stabilization bill  have broad support, having been proposed by multiple HELP Committee hearing participants and endorsed by bipartisan outside advocates including  former acting CMS director Andy Slavitt, one of the ACA's most vocal defenders. These include providing for an expedited waiver process, an emergency waiver process, and the creation of "cookie cutter" waiver templates that multiple states may opt to adopt. (There are dissenters, however, as discussed below.)

Also a matter of broad consensus: easing the terms by which states meet the requirement that a waiver proposal be budget-neutral by 1) allowing states to combine Section 1332 waivers with Medicaid and CHIP waivers and using savings from one to offset extra spending on another, and 2) considering budget impact over the 6-year term of the waiver and a ten-year budget plan.

There is one alteration, though, that gets to the crux of the debate over state flexibility, and was probably a matter of intense negotiation. That is a change to the so-called "guardrails" pertaining to quality and affordability of coverage.

Wrong, wrong, wrong, wrong, wrong

Quick, ACA marketwatchers: what's wrong with the headlines below?

Trump didn't end the Cost Sharing Reduction benefit,  of course, He didn't end government funding for CSR, either -- he just redirected it into a less efficient channel that will cost the Treasury hundreds of billions, hurt unsubsidized enrollees in states that don't make insurers price in CSR in the most efficient way, and provide a windfall for many more affluent subsidized enrollees in states that do concentrate the premium hike where it belongs, in on-exchange silver plans.

Those headlines did a real disservice. A lot of people in this country must be under the impression that a major ACA benefit has been stripped away.  The ledes in many cases did not repair the damage.

60% of ACA marketplace enrollees with CSR are in nonexpansion states

In February of this year I noted that the 19 states that refused to implement the ACA Medicaid expansion comprised 38% of the U.S. population but 53% of ACA marketplace enrollment and 60% of enrollees who accessed Cost Sharing Reduction (CSR) subsidies.

That seems relevant now that Trump has abruptly cut off federal funding for CSR, stiffing insurers for the remainder of this year and leaving them to price the benefit into their 2018 premiums. I've pasted the whole of the post below. Enrollment stats are as of March 31, 2016. There's a state-by-state breakout at bottom of population, CSR enrollment and APTC (premium tax credit) enrollment. This year's enrollment breakout would be roughly proportionate: nationwide, the same 57% of enrollees access CSR. As of the end of the first quarter 2017, CMS reported 10.3 million total enrollees (which, per Charles Gaba, may well have been an undercount, leaving out up to a half million late enrollees), compared to 11.1 million at the same point in 2016.

Before getting to the repost below, a few notes:

1. Many observers are drawing a somewhat misleading conclusion from the high concentration of CSR enrollees in red states. They will be hurt by the CSR funding cutoff only insofar as insurers pull out of the market -- and, longer term, by the thinning of the risk pool caused by unsubsidized enrollment dropping off, which will reduce competition and so plan choice. Unsubsidized enrollees bear the brunt of the premium increases driven by the cutoff of federal funding for CSR. And most of the damage on that front is already done, as most insurers in most states filed rates assuming that CSR would not be reimbursed in 2018 (and/or accounting for more general politically induced uncertainty).

Trump is stiffing health insurers for three months in 2017. States can make Treasury eat the cost.

Oregon's last-minute adjustment to enable insurers to cover the cost of Cost Sharing Reduction (CSR) subsidies for ACA marketplace enrollees in 2018 after Trump abruptly cut off federal reimbursement for those subsidies gave me an idea for how states could also make insurers whole for the last quarter of this year.

Trump is cutting off federal reimbursement for the subsidies, which insurers are obliged to provide but until now have not been able to price into their premiums, later this month.  In most states, insurers have been able to or will be able to adjust premiums to cover CSR in 2018. But they have  to eat the cost for the rest of the year. Unless....

Here's how Oregon will make insurers whole in 2018:

In order to ensure carriers can continue to offer coverage in Oregon, DCBS is ordering health insurance companies offering plans on HealthCare.gov to increase their already approved silver metal tier 2018 plan rates by 7.1 percent.

Can blue states protect their health insurance markets from Trump's executive order?

Can a state that wants to preserve ACA consumer protections protect itself from the executive order Trump signed today, which opens paths to segmenting the risk pools in the individual and small group markets? Consider the case of New Jersey, which had guaranteed issue (and, with no individual mandate, sky-high premiums) pre-ACA.

The Trump EO instructs Treasury, DOL and HHS to expand availability of short-term insurance, allowing it "to cover longer periods and be renewed by the consumer."  That's understood to mean allowing coverage for up to a year -- and so, via renewal, indefinitely, though subject to medical underwriting at renewal as well as at first purchase.  Short-term plans are not subject to ACA coverage rules.

At present, plan duration is limited to three months. Since  that rule only went into effect this April, extending the term to up to a year is not a radical shift from the ACA status quo.  But combined with weak enforcement of the individual mandate, and more exemptions from the mandate stemming from rising premiums, temporary plans available continuously are likely to weaken the ACA risk pool.

Temporary plans are subject to state regulation, however, and health law scholar Nicholas Bagley expects that to continue:

13/ The states should still retain authority to regulate short-term plans -- and to require them to adhere to ACA rules.

— Nicholas Bagley (@nicholas_bagley) October 12, 2017

States vary in their responses to CSR uncertainty

By David Anderson, Charles Gaba, Louise Norris, Andrew Sprung

Note: this post is a joint effort with colleagues who have closely tracked the CSR chaos induced by Trump and Republicans in Congress. Dave Anderson is a former health insurance analyst, now a healthcare scholar at Duke, and a blogger at Balloon Juice; Charles Gaba is the fabled chronicler and analyst of ACA enrollment, marketplace pricing, and healthcare policy; Louise Norris is co-owner with her husband Jay of a health insurance brokerage for individual market customers, and a top source of marketplace information and analysis at her own blog (link in byline) as well as at healthinsurance.org and elsewhere.

Note 2 Today, the Maryland and California exchanges opened their plan preview tools for 2018, with premiums listed. California has implemented its planned CSR surcharge, adding 12.4% to the premium of silver on-exchange plans only. In some regions, the cheapest gold plan is cheaper than the cheapest silver.

Update, 10/14: David Anderson has mapped out the choices states have made to cope with CSR uncertainty (and now, CSR cutoff) here, and Charles Gaba is charting them here.

The open enrollment period for the 2018 ACA Marketplace that begins on November 1, 2017 is likely to confront enrollees with more challenges than any open enrollment since the troubled launch of the ACA Marketplace in October 2013. The time period is shorter, the outreach will be far less robust, and the pricing of plans will behave in ways that people do not expect.  Much of the pricing variance will be a result of choices that states and insurers have made in response to the uncertainty over whether the federal government will continue to reimburse insurers for the Cost Sharing Reduction (CSR) subsidies that insurers are legally obligated to provide to qualified exchange enrollees.  

"X" is for ten: An anniversary for xpostfactoid

Over the weekend, it dawned on me that xpostfactoid's tenth anniversary was coming up. I checked, and indeed, I started blogging continuously on October 10, 2007, after a couple of false starts.

The thought made me rather sad, in that the blog started as Obama came into full focus and is tied up with my hopes of political and national renewal that gained steam throughout 2008  -- as first the seeming miracle of Obama's nomination drive came to fulfillment and then the wonder of the United States electing an African American whose rhetoric and thought was imprinted with Lincoln's took hold. And look where we are now -- in danger of turning that legacy, if not the whole world, to ashes after electing a lifelong fraudster and vicious demagogue, someone an emotionally grounded six-year-old would run from screaming.

But the blog's first posts from fall 2007 feel strangely contemporary. Back then, in the Later Bush Era, I wondered whether American democracy had lost its ability to self-correct -- precisely the capability that Obama spent the next nine years spotlighting as the nation's defining virtue. If you'll indulge a pair of early snippets:

Covered California to middle-class enrollees: There (may be) gold in them thar hills

Update (!) Oct. 11, 2017: CoveredCA has gone live with  its 2018 plan preview tool and has implemented the CSR surcharge discussed below -- 12.4% added to silver on-exchange plans only. That makes gold cheaper than silver in some areas, and CoveredCA is indeed in some cases highlighting gold plan offerings ahead of silver.

Back on August 1 Covered California, the California ACA exchange, announced a proactive approach to enable health insurers to cope with the uncertainty over whether the Trump administration (or Congress) would guarantee them continued reimbursement for Cost Sharing Reduction subsidies.

Insurers would file rate requests under the assumption that CSR will continue to be reimbursed. If reimbursement was not guaranteed by a certain date, however, a surcharge (later pegged at 12.4%) would be added to silver plans sold on-exchange. CSR is available to enrollees with qualifying incomes only if they select silver plans, and only if they buy on-exchange. ACA-compliant silver plans sold off-exchange would not include the surcharge. That surcharge is likely to be triggered on or around October 11, CoveredCA tells me (postponed from an original target of Sept. 30).

The likely results have been widely noted (e.g., here). Off-exchange, plan pricing would remain proportionate to the actuarial value offered at each metal level. On-exchange, the only buyers of silver plans should be those with incomes up to 200% of the Federal Poverty Level, for whom CSR raises the value of silver plans roughly to that of platinum.

How well will healthcare.gov function for 2018?

Everyone who follows the fate of the ACA is by now familiar with the Trump administration's multi-pronged sabotage of the individual market: the constant threat to stop CSR reimbursements to insurers, which in itself has likely driven up 2018 premiums by upwards of 20%; the threats not to enforce the individual mandate, which will likely depress enrollment; the radical cutbacks in enrollment outreach and assistance; the propaganda denigrating marketplace offerings; the shortened enrollment period and gratuitous Sunday shutdown; and now, Trump's looming threat to undermine the risk pool, state authority and ACA consumer protections by giving carte blanche to association health plans.

This multi-pronged assault led me to wonder whether healthcare.gov, the federal exchange, will function adequately. I took a look at the website yesterday, and again today. And I must say, what's there is somewhat reassuring. In fact, today new prompts went up to start preparing people for open enrollment. The array of options on the home page is clear and well designed:

It is easy to get to the initial tasks that people in different situations will want to undertake:

The ACA is London after the Blitz

Trump administration sabotage of the ACA has done serious damage and will likely do more. Uncertainty over CSR reimbursement and enforcement of the individual mandate have themselves driven premiums up by over 20% in 2018 (Gaba's estimate) and driven many insurers out of the individual market.

Those premium hikes will probably knock several million unsubsidized buyers out of the individual market.  Weakened mandate enforcement, real or perceived, will probably reduce the numbers of people enrolled not only in the individual market but also in employer-sponsored insurance and Medicaid. An increased percentage of unsubsidized enrollees in the individual market who do stay in will probably be underinsured, pushed into bronze plans and/or overburdened by the combination of rising premiums and out-of-pocket costs. Poor-to-nonexistent outreach from HHS may result in many current marketplace enrollees failing to shop anew and so re-enrolling in a suboptimal plan. Trump's threat to issue an executive order that reportedly would empower association health plans to evade state regulation via ERISA could bleed health enrollees out of the individual market.

Red states, meanwhile, are lining up to accept HHS's invitation to propose work requirements, time limits and more frequent enrollment redeterminations on Medicaid enrollees, which will likely reduce Medicaid takeup.

It's worth keeping in mind, though, that as long as Republicans fail to pass a repeal bill or cap federal Medicaid spending, the damage thus far can be contained, and reversed if and when Democrats regain power -- or, under divided government, Republicans tire of sabotage. Maintaining the ACA's taxes (to fund benefits), the enhanced federal match rate for the Medicaid expansion (and pre-ACA match rates for the rest of Medicaid), the marketplace infrastructure and subsidy structure -- all of that would have been a January dream come true for any ACA advocate.

CSR takeup: Good enough for me* and Emily Gee

Long before the Cost Sharing Reduction (CSR) subsidies accessed by more than half of enrollees in the ACA marketplace became a political battleground zero, I was preoccupied with CSR as the marketplace's primary (and too limited) defense against underinsurance. In dozens of posts, I explored what leads people to accept or reject CSR, i.e. to buy or forego silver plans if they qualify for the benefit (as CSR is available only with silver plans). Among the most basic conclusions:

1. Although a large body of research suggests that health insurance shoppers often make the wrong choice when faced with relatively small tradeoffs between premium and out-of-pocket costs, a large majority of CSR-eligible marketplace enrollees make the right choice That is, they choose not to leave a large subsidy on the table, despite the fact that silver premiums can be a strain on income and bronze plans temptingly cheap. Over 80% of enrollees eligible for strong CSR -- i.e., enrollees with incomes below 201% of the Federal Poverty Level (FPL) -- choose silver plans.

2. CSR takeup declines in step with the weakening of the benefit at higher income levels, with a sharp drop at 201% FPL, where the benefit weakens almost to insignificance.  Based on data released by CMS in July 2016, the chart below shows the takeup rates in the 38 states that used healthcare.gov in 2016. The rates are inflated by probably about 2 percentage points, for reasons explained in this post. The numbers attached to "Silver" under coverage level are the CSR-enhanced actuarial value of silver at each level.

CSR Takeup: HealthCare.gov states, 2016

Income range	CSR coverage level	Enrollees in income range	Enrollees With CSR	Takeup Percent- age
0-150% FPL	Silver94	3.64m	3.18m	87%
151-200% FPL	Silver87	2.21m	1.83m	83%
201-250% FPL	Silver 73	1.33m	866k	65%

What might moderate Republicans do to the ACA?

From the release of the AHCA on March 4 to Sunday night's amendments to Graham-Cassidy, Republican repeal bills have got ten worse and worse -- more conducive to individual market chaos, more draconian in Medicaid expansion rollback and per capita capping of federal medicaid payments. All of the bills would reduce the ranks of the insured by more than 20 million. Which suggests a question: what would a "good" partial repeal bill look like?

To some extent that's a nonsense question. The ACA embodies a Democratic concession to a core conservative concept: That there's inherent virtue in establishing a competitive insurance market, that doing so will drive down costs and improve healthcare quality (i.e., that insurers can make providers deliver better care more cheaply). The ACA's flaws are in any case all in a conservative direction. Real fixes would include bigger subsidies, including via reinsurance; some means of capping the rates insurers pay providers, as in Medicare Advantage or Medicaid managed care; rules more or less compelling providers to accept the insurance (i.e., if they accept Medicare); and strong incentives for insurers to participate in the market (tied to their eligibility to participate in managed Medicaid or Medicare Advantage markets).

A genuinely moderate Republican would not accept such changes but would seek to amend rather than repeal/replace the ACA -- not just in the short term, as Lamar Alexander has called for, but for the long term, as Susan Collins would probably like to do  There's no shortage of proposed conservative tweaks that might do minimal harm and in some cases perhaps even some good. Yevgeniy Feyman and Paul Howard could write such a bill. Here's my sense of what concessions might be won from Democrats in exchange for CSR and reinsurance funding.

A healthcare homepage chorus screaming STOP at Senate Republicans

Last night I went to the American Medical Association website to retrieve the remarkable joint statement of the AMA, American Academy of Family Physicians, American Hospital
Association, Federation of American Hospitals, America’s Health Insurance Plans, and the
BlueCross BlueShield Association unequivocally calling on the Senate to reject Graham-Cassidy.  .

Though I had already absorbed the statement's stark assertions that the bill would "drastically weaken" individual insurance market, undermine safeguards for those with preexisting conditions, uninsure millions by kicking them off Medicaid, and force on states the "impossible task" of completely transforming their individual markets and Medicaid program in little more than a year, I was nonetheless a bit taken aback by the banner dominating the AMA home page

If bipartisan ACA legislation comes back to the House, remember the Problem Solvers

As hope goes stronger that the Senate will reject the ruinous Graham-Cassidy ACA repeal bill, the back-burnered Senate HELP Committee hearings in pursuit of bipartisan legislation to stabilize the individual insurance market may become relevant again. On Sept. 20, HELP chair Lamar Alexander pulled out of the talks to get on team Scorched Earth.  After John McCain came out against Graham-Cassidy yesterday, Patty Murray, ranking Democrat on the HELP Committee, put out this statement:

I  agree with Senator McCain that the right way to get things done in the Senate—especially on an issue as important to families as their health care—is through regular order and working together to find common ground. I’m still at the table ready to keep working, and I remain confident that we can reach a bipartisan agreement as soon as this latest partisan approach by Republican leaders is finally set aside.

That raises the possibility too that at some point the Problem Solvers, the House caucus formed to seek bipartisan solutions on multiple fronts, could also become relevant. On July 31, the Problem Solvers released a five-point outline for bipartisan market stabilization legislation. As in the HELP Committee, "state flexibility" -- i.e. some easing of the process for states seeking ACA Section 1332 innovation waivers -- was a plank.

On September 5, the day before the first HELP Committee hearing, I participated in a call between BlueWaveNJ and Rep. Josh Gottheimer, Democratic co-chair of the Problem Solvers. It seems another lifetime, as the Graham-Cassidy cancer was still in watchful waiting phase, but we were concerned as to what Democratic Problems Solvers might be prepared to yield on the waiver front. Here's what we learned, as reported on the BlueWaveNJ blog:

My letter to Chris Christie on Graham-Cassidy

Graham-Cassidy's sponsors are relying in large part on support from Republican governors to win senators' votes for the bill. Today, Arizona Governor Doug Ducey came out in favor, notwithstanding that CBPP estimates that Arizona stands to lose $1.6 billion in federal funding in 2026 alone under the bill's redistribution formula.

At BlueWave New Jersey, we are calling on NJ Governor Chris Christie this week to defend the state's Medicaid expansion and coverage gains and come out against Graham-Cassidy. I have a letter in today's print Star-Ledger, but it's not online. Here is the text:

Behold the last and worst of the ACA repeal bills, introduced this week by four Republican U.S. senators.The bill ends the ACA Medicaid expansion, ultimately ends all ACA funding to help people gain health insurance, and guts federal spending on all Medicaid programs, which serve 75 million Americans. 

How could Patty Murray "thread the needle" with Lamar Alexander?

Ever since the Cassidy-Collins bill was introduced in January, I've thought that Democrats should engage with Republicans in Congress who were willing to leave the ACA's taxes and core benefits intact. Cassidy-Collins didn't do that, but I thought it came close enough to be a basis for talks.

Triage was the byword. If a handful of the dozen-odd Republican senators who were then expressing qualms about repeal of the Medicaid expansion in particular could be engaged in compromise negotiations, I thought, that would lessen the chances of passage for a bill that would uninsure tens of millions -- as would the AHCA, the BCRA, and now Cassidy-Graham.

Events have almost proved me wrong. The prevailing Democratic strategy -- we'll talk about fixes when they give up on repeal -- has almost worked. Three repeal bills failed in the Senate. Lamar Alexander, HELP Committee chaired, has held hearings on a bipartisan bill to stabilize the individual market.  And on the other end of the equation, Cassidy -- who seemed like a possible partner since he wanted to preserve ACA taxes and so something like its scale of benefits -- is now a driving force behind a bill that would zero out ACA benefits and lay waste to Medicaid.

Still, ironically, we're at a point again where I'm tempted by similar logic: if Patty Murray and other Democrats engage with Alexander and come up with a compromise stabilization bill, that could blunt the drive toward Cassidy-Collins passage. Would co-sponsors of a stabilization bill, led by Alexander, turn around and vote for Graham-Cassidy?

Synthetic single payer

Here's a healthcare reform bill that fits on a postcard:

The Medicare-for-all Biosimilar Act of 2017

Title 1: Uniform Payment Rate
     Sect. 101. All payers for healthcare services shall pay providers at a rate equal to 120% of current Medicare payment rates. Price schedule will be maintained and updated by CMS, with existing alternative payment programs maintained at the 120% payment ratio. Medicare Advantage benchmarks will be adjusted accordingly.

Title II: Healthcare Budget
     Sect. 201. The Medicare tax will be increased to a level sufficient to fund the government's increased payments in Medicare and Medicaid.

Census: ACA cut uninsured rate in half in Medicaid expansion states by 2016

The Census Bureau released its report on health insurance coverage in the U.S. for 2016 today. One striking trend was flagged by Matt Broaddus at the Center for Budget and Policy Priorities: the gap between states that expanded Medicaid and those that refused continues to widen:



To this let me add a sidelight: in expansion states, the uninsured rate has been cut in half since the main ACA programs were implemented in 2014 -- from 12.9% in 2013 to 6.5% in 2016.

Elizabeth Warren is for single payer, sort of. And against healthcare profiteering...sort of.

Elizabeth Warren sent a letter to supporters last week announcing that she's co-sponsoring Bernie Sanders' Medicare for All bill and asking recipients to sign on as "citizen-co-sponsors."

That's interesting, as Warren herself does not sound exactly all-in.   My emphasis below:

I believe it’s time to take a step back and ask: what is the best way to deliver high quality, low cost health care to all Americans? Everything should be on the table – and that’s why I’m co-sponsoring Bernie Sanders’ Medicare for All bill that will be introduced later this month 

Warren is for putting Bernie's bill on the table -- not necessarily for passing it. There's more hedging near the bottom of the letter:

ACA innovation waivers: a need for speed? Not so fast, says Emma Sandoe

For all the relative comity of the Senate HELP Committee hearings on legislation to strengthen the individual market for health insurance (Sept. 6, Sept. 7), a potential battle line of sort was drawn on Tuesday in statements by the chair, Lamar Alexander, and ranking member, Patty Murray. As the Times' Robert Pear reported:

“To get a result,” Mr. Alexander said, “Democrats will have to agree to something — more flexibility for states — that some may be reluctant to support. And Republicans will have to agree to something, additional funding through the Affordable Care Act, that some may be reluctant to support. That is called a compromise.”

The senior Democrat on the panel, Senator Patty Murray of Washington, said: “Threading this needle won’t be easy. But I do believe an agreement that protects patients and families from higher costs and uncertainty, and maintains the guardrails in our current health care system, is possible.”

How to hand the keys to an unfit successor

How do you hand the keys to the Oval Office to a man you've declared in no uncertain terms to be unfit for the presidency?

Obama's handwritten note to Trump, placed before Inauguration Day in the top drawer of the president's desk, is a carefully calibrated document -- a muted "don't be evil" plea on behalf of the nation, with goals distilled to the most basic: justice, security, democracy. Stark in its simplicity, it's generous without warmth, avoiding the hypocrisy of any hint of confidence in the recipient.

It begins with a depersonalized wish:

"Just a little procedural easing"....watch those ACA innovation waiver guardrails!

The Senate HELP Committee's efforts to pass an ACA stabilization bill are likely to hinge on the ACA's Section 1332 innovation waivers, according to Axios' David Nather:

How they'll give states more flexibility: They want to beef up the ACA's "Section 1332" waivers, but Democrats don't want to do anything that undermines the "guardrails" in those waivers — They can't reduce the number of people with health coverage, make insurance less comprehensive or affordable, or increase the deficit.

• Instead, they'll just try to ease the procedural rules, according to a Senate Democratic aide. The question is whether that will be enough for Republicans.

Just a little procedural easing, ladies and gentlemen! Recall, though, that the BCRA nominally left the ACA guardrails in place -- but effectively gave states carte blanche to knock them down "procedurally." Tim Jost explained back in June (my emphasis):