Friday, October 19, 2018

Republicans have already undercut ACA protections for people with pre-existing conditions

As Republicans who voted for last year's ACA repeal bills in the House and Senate profess now that they are committed to protecting insurance access for people with preexisting conditions, it's important to keep in mind a current fact of life that both complicates and clarifies what they tried to do in those bills and the harm those bills would have wrought.

It's this: Republicans have already adulterated the ACA's individual market protections for people with preexisting conditions by means comparable to those stipulated in the House bill, the American Health Care Act (AHCA), and in the Senate bill, the Better Care Reconciliation Act (BCRA).

The AHCA nominally retained the ACA's core protections -- guaranteed issue, modified community rating, and the Essential Health Benefits that each plan must provide. But once adorned with the MacArthur Amendment that made passage possible, the bill enabled states to obtain waivers that allowed insurers to medically underwrite policies offered to people who had experienced a gap in coverage. States could also write their own EHBs. Critics pointed out that once a medically underwritten market was established, healthy people would opt in, leaving the ACA-compliant market to the sick and so driving up premiums. Rewritten EHBs could make mincemeat of caps on yearly out-of-pocket spending, as those caps apply only to services covered by EHBs.

Thursday, October 18, 2018

In which Larry Levitt highlights the missing link in our fevered debate over preexisting conditions

This nineteen month old tweet, posted as House Republicans were poised to release the first iteration of their ACA repeal bill, made a lasting impression on me:

As the repeal attempts are re-litigated this election season (and threatened for next year if Republicans retain control of Congress),  I've noted again and again that the fight over who would protect access to insurance for people with pre-existing conditions is obscuring the more fundamental fight over government funding  for public healthcare programs -- primarily for Medicaid, but also for affordable access in the individual market.

Wednesday, October 17, 2018

Just two Pinocchios for House Republicans who claim they've protected people with preexisting conditions

I'm going to go contrarian here and suggest that House Republicans who claim that they voted to "protect people with preexisting conditions" when they voted for the House ACA repeal bill, the American Health Care Act, are not flat-out lying. They get, say,  two Pinocchios. By current Republican standards, they've got the gaslight turned low. And the furiously passionate battle over whether they're lying obscures the core damage they attempted to wreak on healthcare access in the U.S. -- and will wreak if they maintain control of Congress.

As originally drafted, the AHCA maintained the ACA's essential health benefits, guaranteed issue and modified community rating (base premiums varying only according to age and geographic location). The AHCA would also have
  • Rolled back federal funding for the ACA Medicaid expansion, reducing Medicaid enrollment nationally by 14 million according to CBO estimate.

  • Imposed "per capita caps" on federal Medicaid spending, likely generating perpetual reductions in federal Medicaid spending that would reach the trillions by the second decade, eroding programs that currently serve 75 million people.

Tuesday, October 16, 2018

A glance at silver loading in Covered California 2019

Covered California is up and running for 2019; its 3-month enrollment period has begun. This time last year, with silver loading a brand new thing, I charted the cheapest bronze, silver and gold plans in a sampling of the 19 California rating areas, specifically Los Angeles Regions 15 and 16 (CA's most populous); San Francisco/Region 4; Santa Cruz in Region 16; and the always-anomalously priced, lightly populated Imperial County in Region 13.

In all the sample cases for 2018, the spread between the cheapest bronze and the cheapest silver plan widened in comparison to 2017, and the spread between cheapest silver and cheapest gold narrowed. That's the result of silver loading. For the enrollment population as a whole, accordingly, bronze plan selection upticked from 27% to 29% and gold doubled, from 5% to 10%.

Tuesday, October 09, 2018

The pre-existing condition that matters most is poverty or near-poverty

I've made this point before, but here it is again in USA Today: our distorted political combat, "pre-existing conditions" is standing in for "access to affordable health insurance." The real crux of the Republican assault on the ACA last year was shrinking support for the poor and near-poor. The ACA repeal bill that passed the House in May 2017 would have rolled back the Medicaid expansion, reducing Medicaid enrollment by 14 million, according to the Congressional Budget Office. It would have slow-strangled federal funding for all Medicaid programs, which cover 75 million Americans. It would have eliminated the Cost Sharing Reduction subsidies that make coverage affordable for more than 5 million enrollees in the ACA marketplaces, raising their deductibles by thousands of dollars.
I hope you'll read the whole thing. It's got a compressed snapshot of the impact of Medicaid expansion in four poor southern states.

P.S. The USAT headline foregrounded what I regarded as a kind of grudging subtext: "Republicans hand Democrats an election-year gift on health care and it's a winner." My main point is the one made above.  But maybe that's okay. The piece does end with a "so be it."

Monday, October 08, 2018

Four healthcare questions for Bob Hugin

Bob Hugin, the former Celgene CEO seeking to take Democrat Bob Menendez's New Jersey Senate seat, talks a moderate game on healthcare. He promises to protect access to insurance for people with pre-existing conditions, doesn't trash-talk the Affordable Care Act, and talks up value-based payment and focusing more on prevention than treatment -- pious goals to which politicians in both parties pay tribute.

Hugin is, however, a Republican - a prominent supporter of President Trump, big donor to Paul Ryan's SuperPACs, and aspiring member of Senate Team McConnell. Many of his rather vague pronouncements about existing programs demand greater scrutiny.

Hugin focused on healthcare in a September 26 roundtable in Glen Ridge, covered by Advance Media here. Here are some followup questions reporters -- and voters - -should ask Hugin when he delivers moderate-sounding pronouncements about existing programs. Quotations are from the AM story or the short video embedded in it.

1. "I cannot envision any changes to our health system today that would not protect people with pre-existing conditions." 

Friday, October 05, 2018

For high out-of-pocket costs in employer plans, 3 shock absorbers

The Kaiser Family Foundation's annual Employer Health Benefits Survey was released this week. There are no big surprises. Premium growth remains relatively modest compared to the immediate pre-ACA era - 3% for single coverage and 5% for family -- though still outstripping wage growth. The percentage of workers covered by employer insurance is stable, as is total ESI enrollment, at 152 million. 79% of workers are offered coverage, and 76% take it up -- similar to last year.

Kaiser does emphasize continued rapid growth in deductibles: the average annual deductible has increased 53% in five years. That's a proxy for out-of-pocket costs continuing to rise. Here I want to quickly point out three partially mitigating factors.

1. Increase in HSAs and HRAs (Section 8) - the percentage of workers who hold these accounts dedicated to paying medical expenses, which are linked to high deductible health plans (HDHPs), spiked from 20% in 2014 to 29% in 2016 and has stayed at that higher level. Since employers generally fund these accounts, they partly offset high deductibles while also shrinking the employee's premium. In 2018, the average employer contribution to an HRA for a single person plan, $1149, outstripped the average employee share of the premium, $1142, and covered about half the average deductible, $2245. The average contribution to an HSA, $603, covered more than half the employee's average premium share, $1024, and about a quarter of the deductible. For family coverage, the average HRA employer contribution was $2288, and the average HSA contribution was $1073. HRA contributions are bigger because these accounts are "use it or lose it" for the employee -- whereas an employee owns an HSA, and contributions are tax-sheltered.

Wednesday, October 03, 2018

Framing the battle for the House in New Jersey: Healthcare!

At BlueWaveNJ, I've been part of a team that's produced print handouts to frame the healthcare debate in three battleground congressional districts:
  • NJ-3, where Obama admin alum Andy Kim is challenging Tom MacArthur, the "moderate" who brought the AHCA, Paul Ryan's ACA repeal bill, back from the dead with an amendment allowing states to re-introduce medical underwriting in the individual market.

  • NJ-7, where Tom Malinowski, Obama's former Assistant Secretary of State for Democracy, Human Rights and Labor, is challenging Leonard Lance, a relative moderate who voted against the AHCA after voting to "repeal, defund or dismantle" the ACA (his words) more than forty times.
  • NJ-11, where current House Budget Committee Chair Rodney Frelinghuysen is retiring, and Tea Party darling/state rep Jay Webber, a blood enemy of Planned Parenthood, is running against former Navy helicopter pilot and federal prosecutor Mikie Sherrill.
Of the three, Malinowski has the most detailed and thoughtful healthcare policy positions, including support for a broad Medicare opt-in plan like the Center for American Progress's  Medicare Extra plan. But the focus in each of these pieces is really on the Republican's buy-in  to Team GOP's recent attempts and current plans to dismantle existing healthcare programs -- the ACA, Medicaid, and, ultimately, Medicare -- and the Democrat's commitment to preserving what's already in place.

Below the fold, screenshots of each candidate contrast. At bottom, the front of each of these 5&8 "postcards." Going extra large for MacArthur, who's as responsible as anyone for repeal getting so close.

Thursday, September 27, 2018

At HIO: What if Josh Hawley isn't lying?

In case you haven't heard enough about the mendacity of Missouri attorney general and Senate candidate Josh Hawley...I have a somewhat different take up on

Hawley recently cut an ad promising that he will protect access to health insurance for pre-existing conditions - citing his own young son who has a rare chronic condition. Thing is, as Missouri AG he's party to the suit seeking to strike down the ACA -- either in its entirety, as the plaintiffs have asked, or merely its pre-ex protections, as the Trump administration has asked.  That set off a lot of observers' hypocrisy beepers.

At HIO, I suggest, for the sake of argument, taking Hawley at his word. What if Republicans retain control of Congress and do preserve the ACA's guaranteed issue, modified community rating, and EHBs?  It's possible.... the first version of the House repeal bill, the American Health Care Act, did just that. It also would have un-insured 24 million Americans, per CBO estimate -- mainly by gutting Medicaid and the ACA's income-sensitive subsidy structure.

So that's a spoiler, but please take a look anyway.

Map of Malfunction: Health Wonk Review

This month's Health Wonk Review offers a smorgasbord of smart takes on the morphing ACA marketplace; various dysfunctions (and one or two functions) of U.S. health care; and political wars over Medicare and the ACA.

Whither the ACA?

First up: A trio of bloggers who focus mainly on the ACA each grapple with current political currents and policy and service changes.
Louise Norris takes to VeryWell Health to pose a basic question What is Reinsurance and Why are States Pursuing It? Spoiler: it reduces premiums mainly at federal government expense, offsetting some of the disruption and sabotage of the past two years. And at, Louise covers everything you need to know about short-term plans -- past, present and immediate future -- with her signature thoroughness and clarity. Here she delves into pros and cons for an individual and here into changes in law and variations by state. Worth noting: while Louise fully recognizes the harm that the short-term market may do the ACA-compliant market, she also recognizes that many people are priced out of the current market and for some, short-term offerings may prove emphatically better than nothing.

Wednesday, September 26, 2018

A small refuge from the Trump administration's public charge cruelty

The Trump administration's proposed new rule jeopardizing the immigration status of legally present noncitiizens who tap non-cash benefits like Medicaid or food stamps is a travesty -- of public health, economics and human rights. If finalized, it will kill people by denying them medical care, harm the life prospects of millions of children, and put us one more long step down the road toward discriminatory treatment of a class of people demonized by the federal government. About 27 million people who are noncitizens themselves or live in a family including a noncitizen could be subject to the vastly expanded "public charge" rule.

There is one class of benefits left out of the demerit dragnet: ACA marketplace subsidies.  And ironically, a previous immigrant-bashing provision in federal law insulates a few hundred thousand immigrants from the proposed expansion of the public charge rule.

Tuesday, September 25, 2018

What if Josh Hawley and friends do preserve protections for people with pre-existing conditions?

I have a post pending at elaborating on this Twitter thread, which now does double duty as placeholder:

Friday, September 21, 2018

In New Jersey's 2019 ACA marketplace, fruits of reinsurance, individual mandate, and silver loading

New Jersey's Dept. of Banking and Insurance has posted individual market health plan prices for 2019. Thanks to the state's new reinsurance program, state-based individual mandate, and silver loading (actively encouraged by DOBI), unsubsidized enrollees will see price drops from 2018. According to DOBI, premiums are down 9% on average, and 22% below where they would be if not for the reinsurance program and the state individual mandate enacted this year. For the subsidized, it looks pretty much like status quo ante -- although network changes and plan design changes could alter that picture.

As was the case last year, AmeriHealth has sewn up all the lowest price points. AmeriHealth and Oscar are offering discounted silver plans off-exchange -- presumably because of silver loading (Cost Sharing Reduction, available only with silver plans and only on-exchange, is not priced into off-exchange silver).  Horizon is not offering any off-exchange discounts, but it has dropped prices about 7% from last year. A few salient year-to-year comparisons below. Quoted premiums are for a 46 year-old -- where they're a clean 1.5 times the base rate posted by DOBI.
  • The cheapest silver plan for a 46 year-old was $468 per month in 2018. This year, cheapest silver is $359, offered off-exchange only. They're both AmeriHealth, but they're not the same plan. The off-ex 2019 cheapest is a "Select Silver EPO", a new designation for AmeriHealth, and it's an HSA plan, which means that all services except mandatory free preventive care are subject to the deductible. The cheapest non-HSA silver is an AmeriHealth HMO ("Local Value"), for $381 per month. That plan may have a better network than the "Advantage" network, which in some areas at least is quite limited.

Wednesday, September 19, 2018

Re-litigating the ACA repeal bills of 2017: Pre-existing conditions and beyond

In House and Senate races across the country, Republicans are being held to account for their support of last year's ACA repeal bills, the American Health Care Act (AHCA), which passed the House on May 4, and to a lesser extent, the parallel Better Care Reconciliation Act, which died in the Senate.

The fight often focuses on whether supporters voted to undermine protections for people with pre-existing conditions. The original AHCA, which never came to a vote because it lacked the votes to pass, maintained the ACA's guaranteed issue, modified community rating and Essential Health Benefits (EHBs). It passed only when Rep. Tom MacArthur, R-NJ3, introduced an amendment that won hard-right support by enabling states to open the door to medical underwriting -- and rewrite the EHBs.

MacArthur and allies argue that the door was only cracked a bit, and that those with pre-existing conditions were protected. Only those who had last been insured in the individual market and who failed to maintain continuous coverage could be subject to medical underwriting -- and the state had to establish a high risk pool or reinsurance program for those so exposed, tapping an $8 billion pool established by the bill.

This defense has been widely debunked, most recently by Washington Post fact-checker Glenn Kessler today. I'll get to that argument in a moment, as I have something to add. First, I want to reiterate that the whole argument is something of a diversion --- and, because Republicans have a superficially credible defense here, the argument serves their purposes.  Oddly, though, it arguably serves Democrats' purposes too, because a) they can win it, and b) the repeal bills' even more egregious outrages are difficult for Dems to spotlight.

Monday, September 17, 2018

Congressional races are all about "pre-existing conditions." Gubernatorial races spotlight Medicaid

Last week I wrote about how Democrats running in red states use "protection for people with pre-existing conditions" as a proxy for defending the ACA as a whole. In many states, Democrats still can't call the ACA by its name or discuss its actual programs. For example, in an ad that's gone viral, Joe Manchin never mentions the ACA -- or the ACA Medicaid expansion that has cut West Virginia's uninsured rate in half.  He's not alone.

Today brings two articles on how the healthcare debate is shaping up in races across the country. One qualifies my claim a bit; the other corroborates it.

In Huffington Post, Jonathan Cohn spotlights three gubernatorial races -- in Michigan, Ohio and Nevada --  in which the Democratic candidate is openly attacking the Republican for opposing Medicaid expansion, while the Republican is repudiating that past rejection. These are purple states, at least historically, that have increased their Medicaid enrollment by 1.3 million collectively since mid-2013. They've cut their combined uninsured populations from 2.9 million in 2013 to 1.5 million in 2017. according to Census survey results released this month.  Now, Republican candidates Schuette (Michigan), DeWine (Ohio) and Laxalt (Nevada) have all pledged to preserve the expansion, notwithstanding their prior opposition to it. In the governor's races, the expansion is an open topic of discussion.

Wednesday, September 12, 2018

Obama's ACA sabotage claims: Checking the AP fact-checkers

Today Associated Press fact checkers Calvin Woodward and Christopher Rugaber spank Obama for claiming that Republican sabotage of the ACA "has already cost more than 3 million Americans their health insurance.' Okay, the claim is debatable, but the fact checkers need a fact check. Or at least some qualification.

Woodward and Rugaber allege that "Obama is cherry picking survey results" and blaming Republicans for all the ACA marketplace's problems, which had begun before the Trump administration took over. Both true to a degree. But...

The dueling surveys are Gallup-Sharecare, which found that the uninsured rate among adults had upticked 1.3% by the end of 2017, which translates to 3.2 million fewer insured, and the CDC's Nation Health Interview Survey (NHIS), which found the uninsured population essentially unchanged from Q1 2017 to Q1 2018. Obama was relying on Gallup. For sure, that suited his purposes. But there is some corroborating evidence as to the effects of turmoil in the ACA marketplace -- largely though not entirely as a result Republican sabotage.

AP notes that marketplace enrollment dropped by "only" about 900,000 in 2018, the year that Republican-induced disruptions* took full effect. That's true -- but those disruptions triggered a massive premium spike in 2018 that devastated off-exchange enrollment in ACA-compliant plans -- that is, among those who don't qualify for ACA subsidies and so bore the full brunt of the premium increases.

According to the Kaiser Family Foundation, off-exchange enrollment dropped by 2.3 million, or 38%, from the first quarter of 2017 to the first quarter of 2018. On-exchange enrollment was also down by a couple of hundred thousand (here I take mild issue with Kaiser, which chose not to correct a CMS reporting error in 2017). Enrollment would have been depressed still further -- by several hundred thousand -- if not for the paradoxical effect of Trump's cutoff of direct federal funding for Cost Sharing Reduction (CSR).  When insurers priced CSR mostly into silver plan premiums, that move alone drove premiums up by double digits for unsubsidized enrollees, but also created discounts  in bronze and gold plans for the subsidy-eligible that boosted enrollment among the more affluent subsidized.

Monday, September 10, 2018

The pre-existing conditions proxy war

Protection for people with pre-existing conditions is a red-hot button this election season. The public overwhelmingly supports maintaining the ACA's protections, and worries about losing them; Republicans keep assaulting them while pretending not to.

This is the battleground where both political parties have chosen to fight. That's kind of astonishing in poor red states that have expanded Medicaid -- like, say, West Virginia. Joe Manchin, the Democratic senator up for re-election in WV this year, dares not say the words "Affordable Care Act," "Obamacare," or even "Medicaid." Preserving access to health insurance for people with pre-existing conditions is the ground he'll die on.

But Medicaid, as I explore in a post up at, is most ofwhat's at stake in West Virginia -- and more generally, in poor red states that have accepted the ACA Medicaid expansion. The expansion is the means by which those states have cut their uninsurance rates in half:

Impact of Medicaid Expansion in Low Income states

State rank: median income
Uninsured 2013
Uninsured 2016
Growth in Medicaid enrollment 2013-2018
Marketplace enrollment
March 2018
Total indiv market enrollment
W Virginia

*For Louisiana, the uninsured rate is among adults age 18-64, as opposed to the whole population.

That the Medicaid expansion can't be talked about is a measure of the depravity of our politics, the extent to which Republicans have gaslit this debate. So I argue in the HIO piece. Hope you'll check it out.

P.S. One point I should have emphasized more in the HIO piece is that in West Virginia, where Medicaid is a dirty word, enrollees often say they have a "medical card" (which, per below, says nothing about Medicaid). What if Manchin made  his mantra "Pat Morrisey wants to take away your medical card?" It's true. And 29% of state residents have one. Thanks to Simon Haeder for the screen shot.

P.P.S. Also courtesy of Haeder, a list of what Medicaid is called in each of the 50 states -- though it's missing NJ Family Care, used in my home state, so maybe others.

Friday, September 07, 2018

Everything you always wanted to know about ACA marketplace enrollment 2018

Narrow focus curse: I've sliced 2018 ACA marketplace enrollment  so many ways I've lost track myself and too often go rooting around this blog for some half-remembered breakout. For my own sake, then, here is an index, omitting some redundant or not particularly illuminating posts.

The main takeaway for this year is pretty obvious: huge premium hikes, largely induced by Republican sabotage, sharply reduced unsubsidized enrollment while leaving subsidized enrollment relatively stable.

A second important takeaway that I've spotlighted more than once is less obvious: among the subsidized, enrollment dropped pretty sharply for those with incomes in the 100-200% FPL range; stayed more or less flat at 200-300% FPL, and rose sharply at 300-400% FPL.  A post I co-wrote with David Anderson, running in Health Affairs today, tells that story and draws conclusions about the crosswinds created by various Republican actions.

13* Ways of looking at enrollment 2018

* Okay, a few more than 13. Poetic license and all that.

National enrollment

Small enrollment shifts are not so small - 8/25/18
For example, a 1% shift in the percentage of all enrollees on who are unsubsidized masks a 10% drop in enrollment among the unsubsidized -- exacerbated by heavy attrition in February.

Silver loading vs. sabotage in non-expansion states - 8/14/18
Compares 2018 enrollment gains and losses by income group in states that refused to expand Medicaid with those recorded for as a whole and in California

Unsubsidized on-exchange enrollment is also shrinking fast - 8/8/18
An unsurprising effect of massive premium hikes

Unsubsidized, but in subsidy range, in the ACA marketplace - 8/5/18
85% of enrollees via were subsidized, but 90% have incomes in the 100-400% FPL range. Why the gap?

Thursday, September 06, 2018

New Jersey balance billing protection law is strong on scheduled procedures

Earlier this week I raised a question whether New Jersey's new law protecting insured patients from balance billing requires patients in scheduled procedures to confirm in advance that not only the physician performing the procedure and the facility where it's performed are in network, but that all participating providers, such as anesthesiologists and radiologists, are also in-network. The question was triggered by language like this (Section 5b):
A health care professional who is a physician shall provide the covered person, to the extent the information is available, with the name, practice name, mailing address, and telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology, radiology, or assistant surgeon services in connection with care to be provided in the physician’s office for the covered person or coordinated or referred by the physician for the covered person at the time of referral to, or coordination of, services with that provider. The physician shall provide instructions as to how to determine the health benefits plans in which the health care provider participates and recommend that the covered person should contact the covered person’s carrier for further consultation on costs associated with these services.
Other bill language, I noted, seems to indicate that the patient is not responsible for ascertaining that all personnel are in network. 

Maura Collinsgru, health care program director at New Jersey Citizen Action and a prime mover of the NJ for Health Care Coalition, tells me that the onus is not on the patient to make all those determinations:

Wednesday, September 05, 2018

Bring back the PPACA!

A reader writes: 
It is two years out [from Trump's election] and every major press outlet uses "Obamacare." That just polarizes things.

They should have come up with a better name than Affordable Care Act. That does not even capture modified community ratings – guaranteed issue –essential benefits – private enterprise (the  Republican plan). This is why Medicare for All getting better polling. 
My first thought was, imagine trying to get across "guaranteed issue,"  "modified community ratings" and "essential health benefits" in a bill title. Then a near-forgotten set of syllables popped into my head: the Patient Protection and Affordable Care Act (PPACA). "Patient protection," of course, is all about guaranteeing access to comprehensive coverage to all who want it -- including people with pre-existing conditions, who constitute somewhere between a fifth and half the population.

Nancy Pelosi famously/infamously said "we have to pass the bill so that you can find out what's in it," and people do understand and like the protections for people with pre-existing conditions. A Kaiser Family Foundation poll released today makes that clear:

Monday, September 03, 2018

New Jersey's new balance billing protection law: How complete is the protection?

New Jersey's new law limiting balance billing*, which goes into effect this week, provides patients in fully funded insurance plans -- and in some self-funded plans -- with important protections. The law
  • effectively bans balance billing of  insured patients who get emergency hospital care, regardless of whether those who treat them (or even the facility) are out of network.  
  • Protects patients who arrange for scheduled procedures from in-network providers at in-network facilities from balance billing by undisclosed out-of-network providers (more on that below).  
  • Establishes a "baseball arbitration" dispute resolution system for insurers billed by out-of-network providers. That is, the arbitrator rules in favor of one of the two parties' position rather than splitting the difference. That should put downward pressure on providers' OON billing rates, and so on premiums.
  • Includes -- uniquely among state balance billing laws -- an opt-in for self-funded employer plans, which are governed by ERISA, not by state law. The majority of people who are insured through their employer are in self-funded plans.
  • Enables balance-billed patients insured via a self-funded plan that does not opt in to initiate arbitration with a balance billing OON provider. 
That's a pretty strong set of protections, with creative workarounds the gigantic impediment to state protection on this front: the fact that self-funded plans are not subject to state insurance regulation wth regard to balance billing (and many other things).  The bill was fruit of a ten-year struggle, and I'm grateful (e.g. to its primary and co-sponsors, including Sen. Joseph Vitale) for its passage.

I'm somewhat troubled, however, by its mechanism for preventing balancing billing by out-of-network providers -- e..g, anesthesiologists, radiologists, pathologists, and assistant surgeons-- participating in a scheduled procedure at an in-network facility when the primary physician is also in network. The onus appears to be on the patient to do a lot of checking. Or maybe not. The text seems to be ambiguous on this front.

Thursday, August 30, 2018

NHIS puts individual market angst in perspective

The Kaiser Family Foundation reports that individual market enrollment dropped by about 2 million from the first quarter of 2017 to the first quarter of 2018. Medicaid/CHIP enrollment is down by about 1 million in the same period, to 73.8 million in April of this year (preliminary count*).

Together those reported drops, if accurate, would account for about 1% of the U.S. population under age 65.  Yet according to the preliminary results of the National Health Interview Survey (NHIS) for the first quarter of 2018, released this week, the uninsured population has not changed significantly since 2017.  In fact, the percentage of the total population that is uninsured has downticked from 9.1% to 8.8%, and among the under-65 population from 10.7% to 10.3%, though those changes are not deemed statistically significant.

Saturday, August 25, 2018

Small enrollment shifts are not so small: Zooming in from the GAO's 30,000 foot view of the ACA marketplace

It struck me, looking at the big-picture breakouts of 2017-2018 enrollment in states presented in the GAO report, that shifts that I have puzzled over under a microscope look small in aggregate.

Viewed the other way round, changes that look small in aggregate mask some significant shifts among enrollees in ethnicity, income and age. A few examples below, mostly from the states that the GAO focused on (while exposing HHS's willful management failures). I'm leaving aside a not-so-small shift in metal level selection that I've pretty much beaten to death, e.g., yesterday.

1. Subsidized vs. unsubsidized enrollment 

A one-point drop in the overall share of enrollees who are unsubsidized doesn't sound like much. But viewed in itself, unsubsidized enrollment was down 9.7% on in 2017, compared to 5% for all enrollment. For many of the unsubsidized, moreover, the sticker shock triggered by premium increases in excess of 30% seems to have struck late. Among the unsubsidized, effectuated enrollment in all states as of March 15 was a stunning 29% below the tally as of the end of open enrollment. For the market as a whole, the drop was 9.4%; for the subsidized, it was just 5.5%. Year-over-year, effectuated enrollment  among the unsubsidized for all states as of March was down 17% .

Friday, August 24, 2018

GAO highlights the silver load offset to HHS sabotage

The GAO's report on HHS's performance in managing Open Enrollment for 2018 on hits HHS hard for dereliction of its duty to maximize enrollment in the ACA marketplace. The report lambastes HHS for using bad data to gut navigator funding; for ignoring performance data while constructing a bogus rationale for gutting advertising; and for refusing to set enrollment targets that would enable the agency to target efforts where performance was lagging.

These failures, the report asserts in measured bureaucratese,
could affect HHS's ability to meet its objective, such as its objectives of improving Americans' access to healthcare.
Unspoken is that policies instituted by HHS leadership did advance Trump's goal: to highlight and exacerbate the flaws of a program created by Democrats.

The report also includes stats that highlight the effects of "silver loading" the cost of Cost Sharing Reduction (CSR) after Trump cut off direct reimbursement of insurers for that mandatory benefit, forcing them to price it into premiums. Since CSR is available only with silver plans, most states allowed insurers to price it into silver plans only. Since premium subsidies are keyed to a silver benchmark, silver loading increased subsidies, creating discounts in bronze and gold plans. Here is a graphic representation of the discounts thus created:

Monday, August 20, 2018

Alex Azar's poison pitch to the unsubsidized uninsured

Charles Gaba is out with a magisterial take-down of HHS Secretary Alex Azar's op-ed touting the Trump administration's promotion of  medically underwritten 'short-term" health plans (now with terms of up to 364 days, renewable twice) as a solution for those who have been priced out of the ACA marketplace.

Gaba points out that in decrying the high cost of ACA-compliant plans for the unsubsidized, Azar ignores:
  • The extent to which various forms of Trump administration sabotage have driven the huge premium increases of the past two years.
  • The premium growth trend in the pre-ACA individual market.
  • The average actuarial value of pre-ACA plans compared to ACA-compliant plans.
  • The likely impact of a barely-regulated short-term market on the ACA risk pool.
  • The gross inadequacies of short-term plans now on the market.
I want to focus on two other major sleights of hand Azar indulges in. The first concerns the target market potentially served by short-term plans, and the second, the source of their affordability.

Friday, August 17, 2018

Tom MacArthur gutted ACA protections for people with pre-existing conditions. Can Andy Kim make the charge stick?

Axios offers an interesting first look at a battle that will play out in a lot of Congressional districts defended by Republicans who voted for the ACA repeal bill, the American Health Care Act (AHCA) as amended by Tom MacArthur (NJ-3).

Democrats will say the incumbent voted to gut protections for people with pre-existing conditions -- that is, the ACA rules forbidding insurers in the individual market to base premiums on an applicant's medical condition or history. Incumbents -- e.g. MacArthur, who introduced the amendment that opened the door to medical underwriting -- will say not so:
Sen. Heidi Heitkamp of North Dakota, one of the most vulnerable Democrats up for re-election this year, is out with a new ad that claims her opponent, Rep. Kevin Cramer, voted to gut protections on pre-existing conditions. Axios' Caitlin Owens has the lowdown:
  • Naturally, Cramer doesn't like the ad. The North Dakota GOP accused Heitkamp of telling "repeated lies" about his stance on pre-existing conditions.

Thursday, August 16, 2018

Good News in New Jersey: CMS approves state reinsurance waiver

Some good ACA news out of New Jersey: CMS has approved the state's reinsurance waiver proposal, designed to reduce premiums by 15% in 2019.

The bill mandating pursuit of this waiver was paired with a bill establishing a state individual mandate, which according to the state Dept. of Banking and Insurance reduced requested rate increases by about 7%.  Taken together, the mandate and reinsurance program will push 2019 premiums more than 20% below where they would have been absent these two programs and down an average of about 9% from this year. That in the wake of average increases of 22% for 2018.

It's worth tallying the various ways New Jersey has girded its individual market against Republican sabotage.  The state

Wednesday, August 15, 2018

Surprise! ACA marketplace sabotage hit the most vulnerable hard

I fear I buried the lead somewhat in yesterday's look at how ACA enrollment losses were distributed among income groups in states that refused the ACA Medicaid expansion.

The distribution in the 18 nonexpansion states that use looked a lot like the distribution in all 39 states -- not surprising, since 69% of enrollees are concentrated in those states -- a fact kind of astonishing in itself. But enrollment is inflated in nonexpansion states because, thanks to a lucky ACA drafting error, eligibility for subsidies in those states begins at 100% of the Federal Poverty Level (FPL), whereas in expansion states it begins at 138% FPL. Those below that threshold in expansion states are eligible for Medicaid.

As I did note in the prior post, fully 36%* of enrollees in nonexpansion states, about 2.2 million as of the end of Open Enrollment, have incomes that would qualify them for Medicaid if their states accepted the expansion (as Virginia has for 2019, and as Maine has, though still blocked by Governor LePage's obstruction). Within that population, or rather, within the somewhat wider 100-150% FPL band broken out by CMS, enrollment dropped 6% in those states in 2018. That's a loss mainly among people who should be in Medicaid, and who are likely to be uninsured if they pass up marketplace enrollment, and for whom the marketplace is a relatively affordable deal -- premiums capped at 2% of income for CSR-enhanced plans with a 94% actuarial value. (Ironically, the Medicaid work requirements imposed by some expansion states will likely uninsure more people than the cuts in enrollment assistance and outreach in the marketplace.)

More broadly, the relatively modest top line of ACA on-exchange enrollment loss in 2018 -- about 4% -- shouldn't blind us to the fact that the loss was close to double that among people with incomes in the 100-200% FPL range (7.5% in as a whole). For that population, the core marketplace offering hasn't changed much, although fixed actuarial values mean a bit more out-of-pocket expense every year, and reduced competition may reduce quality of choice in many markets.

Tuesday, August 14, 2018

Silver loading vs. sabotage in non-expansion states

This post continues the story of how, where and to what extent silver loading offset all the factors pushing ACA marketplace enrollment down in 2018: the shortened enrollment period, massive cuts to advertising and enrollment assistance, Trump screaming the ACA is dead, huge premium spikes turbo-charged by CSR cutoff and yearlong uncertainty, etc. etc.

In previous posts I noted that silver loading, which created discounts in bronze and gold plans for subsidized buyers (see note at bottom), seems to have boosted enrollment by about 8 percentage points in the 200-400% FPL income range, both in 39 states and in California.

Enrollment losses were concentrated first and foremost among the unsubsidized, off- and on-exchange, and next among those at the lower income range of subsidy eligibility (100-200% FPL), where the CSR benefit still outweighed the bronze and gold discounts. They were partly offset at 200-400% FPL, where negligible or no CSR is available, and where in many locations, the discounts created by silver loading meant more value for less money was on offer than in previous years.

Here we'll take a look at the 18 states using that had not accepted the ACA Medicaid expansion as of 2018* (one more expansion state, Idaho, has a state-based exchange, and the enrollment breakouts we're looking at here are not available there).

Wednesday, August 08, 2018

Unsubsidized on-exchange enrollment is also shrinking fast

Off-exchange enrollment in ACA-compliant plans is contracting sharply. The Kaiser Family Foundation reports that average monthly enrollment in off-exchange ACA-compliant plans was down 25% from 2016 to 2017. Further, all off-exchange enrollment (including in grandfathered and grandmothered pre-ACA plans) was down 38% from the first quarter of 2017 to the first quarter of 2018. It's not yet possible to break out the drop in ACA-compliant off-exchange plans alone, but it's likely close to that 38% top line.

Wow.  The Kaiser study also shows that the average individual market premium rose from $339 in 2016 to $490 in 2018 -- a 45% increase* over two years. That's driving a lot of unsubsidized people out of the market.

It's known, but has not been much emphasized, that the drop in unsubsidized enrollment through the ACA exchanges, is also sharp. Kaiser shows a drop from 1.6 million to 1.4 million in effectuated enrollment from March 2017 to March 2018. And as I noted recently, Kaiser chose not to estimate an undercount in CMS's report of effectuated enrollment in 2017 (the undercount is acknowledged in an endnote).

Tuesday, August 07, 2018

Did CMS just bless silver loading? Or prepare to end it?

Last week, CMS released a bulletin that openly invited insurers in the ACA-compliant individual market to offer off-exchange plans that are free of the CSR load:
To address increases in premiums of qualified health plans (QHPs) on account of the cessation of federal funding for cost-sharing reduction (CSR) payment to issuers, or “loading,” and its effect on unsubsidized enrollees, the Centers for Medicare & Medicaid Services (CMS) is encouraging states to allow Exchange issuers to offer individual market plans that do not include this load, and that will only be available outside the Exchange. Thus, CMS encourages the offering of unloaded silver plans outside the Exchange in states where the issuer has placed the load on silver QHPs on the Exchange, and encourages the offering of unloaded plans of all AV levels outside the Exchange in states where the issuer has placed the load on all AV level plans.

Monday, August 06, 2018

Psst, red states, want to destroy your ACA-compliant market? Set strict standards for short-term plans

Most discussion of the Trump administration's finalized rule allowing short-term health plans to be sold for a term of up to one year and renewed for up to three years spotlights not only the likely damage to risk pools in the ACA-compliant market, but also the dangers to enrollees posed by far-from-comprehensive insurance.

The Kaiser Family Foundation, for example, analyzed current short-term offerings available in 45 states. The report emphasized the impact of medical underwriting, exclusions for pre-existing conditions, medical loss ratios averaging 67% (and 50% for the two largest carriers) -- and the holes in coverage:
Of the short-term products offered on eHealth and/or Agile Health Insurance across all states, 43% do not cover mental health services, 62% do not cover services for substance abuse treatment (both alcohol and other drugs), 71% do not cover outpatient prescription drugs, and no plans cover maternity care. In seven states, none of these four benefit categories are covered in the short-term policies offered.
The plans on offer on do look pretty bad. I looked at one that does provide "prescription drug coverage" -- with a relatively low deductible of $1000 -- but with this caveat:
Covered after plan deductible when prescribed on an inpatient basis for a covered Injury or Sickness. Outpatient not covered; discount only.
As for the hospital where you have to get that covered drug prescription: benefits are capped at $1000/day.

When reading about such Swiss-cheese coverage, I've wondered: what if the federal government or a state required these medically underwritten plans to meet ACA standards, or something close to them? -- e.g., cover Essential Health Benefits, offer actuarial value of at least 60%, perhaps meet a minimum MLR of, say 75%? Or: what if insurers decided to take advantage of a new market opportunity and offer ACA-comparable plans in the noncompliant market?  Suppose they offered EHBs and a relatively high actuarial value, but with a yearly benefit cap?

I suspect that the public policy impact might be worse than under current rules, which allow plans to exclude pretty much whatever they want.

Sunday, August 05, 2018

Unsubsidized, but in subsidy range, in the ACA marketplace

One useful feature of the ACA enrollment statistics published by Covered California: the state breaks out unsubsidized and subsidized enrollees in every income category.

Within ordinary subsidy range (138-400% FPL), the percentage of unsubsidized enrollees is appropriately small: 1.2% (15,170 out of 1,222,010).

The situation is different at very low incomes, 0-138% FPL, at which level people should be eligible for Medicaid, as California is an expansion state. The exception is legally present noncitizens subject to a federal 5-year bar on Medicaid eligibility -- they are eligible for marketplace subsidies. In California this year, there are 38,580 enrollees with incomes under 138% FPL, and 10,850 of them (28%) are unsubsidized. That substantial unsubsidized low income population has been a constant in California enrollment reporting. But again, in normal subsidy range, the numbers of unsubsidized enrollees are low.

The story is quite different in the 39 states that use There, 85% (7,463,080) received subsidies of some kind,* whereas 90% (7,756,865) have incomes in ordinary subsidy range, 100-400% FPL (the lower threshold is 100% FPL in the 18 states that have not expanded Medicaid eligibility).

Thursday, August 02, 2018

Shifts in the enrollment population in the ACA marketplace in 2018

Recently I've spotlighted the extent to which silver loading boosted ACA marketplace enrollment among those with incomes between 200% and 400% of the Federal Poverty Level (FPL) - -that is, those at the higher end of subsidy eligibility. The boost occurred both in the 39 states and in California.

"Silver loading" refers to discounts in bronze and gold plans for subsidized marketplace enrollees generated by Trump's cutoff last October of direct federal reimbursement for the Cost Sharing Reduction (CSR) subsidies insurers are obligated to provide to low income enrollees who select silver plans. See note at bottom for an explanation.

The discounts proved more attractive to those with incomes over 200% FPL, because for most buyers below that income level, the value of CSR outstripped that of the bronze/gold discounts on offer.  Compared to 2017 enrollment levels, 2018 enrollment in both states and California at 201-400% FPL outperformed enrollment below 200% FPL by about 8 percentage points.

The concentration of that enrollment boost has modestly shifted the income distribution of ACA enrollees. Historically, a majority of enrollees nationally have been eligible for the strong CSR available to those with incomes up to 200% FPL, and that's still the case. But the majority is a bit smaller.

Here is the shift in income distribution among the subsidized in states and California in 2018.

Tuesday, July 31, 2018

A CMS misinformation byte is getting into the woodwork

Axios today reports on the Kaiser Family Foundation's latest data note on individual market enrollment. The main takeaway is that unsubsidized enrollment is down by two million in 2018: brutal premium hikes are driving the unsubsidized out of the individual market.  I was brought up short, however, by this offsetting claim:
Subsidized enrollment grew by about 500,000 people.
Kaiser here is retailing CMS's comparison of effectuated enrollment as of March 2017 and March 2018, tallying those who enrolled on-exchange paid their premiums in February.  These snapshots show total on-exchange enrollment at 10.6 million in March 2018 and 10.3 million in March 2017, and subsidized enrollment at 9.2 million in 2018 vs. 8.7 million in 2017.

As I noted three weeks ago, that comparison is erroneous:

Thursday, July 26, 2018

Covered California's silver loading enrollment boost mirrors's

Recently I noted that 2018 enrollment losses among subsidized buyers on were concentrated at lower income levels, i.e., 100-200% of the Federal Poverty Level(FPL). At the upper range of subsidy-eligible incomes, 200-400% FPL, enrollment actually rose slightly -- or more precisely, dropped very slightly at 200-300% FPL, and rose significantly at 300-400% FPL.

The reason is not hard to find. Discounts in bronze and gold plans generated by Trump's cutoff of direct reimbursement to insurers for Cost Sharing Reduction (CSR) subsidies, available only with silver plans, made marketplace offerings more attractive to those in the 200-400% FPL range than in past years (see note below for an explanation of how this worked). For enrollees in the 100-200% FPL range, in contrast, CSR remained strong enough to outweigh those new discounts in other metal levels, so the marketplace value proposition remained more or less status quo ante. On, the percentage of enrollees in the 100-150% FPL income range who selected silver plans actually rose slightly, to from 89% to 90%, while at 150-200% FPL silver selection shrank fairly modestly, from 83% to 78%.

For enrollees in the 200-400% FPL range, improved affordability in metal levels other than silver seems to have largely offset the effects of a shortened enrollment period, radically reduced federal spending on marketing and enrollment assistance, confusion sewn by Trump's declaration that the ACA is dead, and pending repeal of the individual mandate (not effective until 2019 but very much in the news before and during open enrollment).  The 7.5% enrollment drop at the 100-200% FPL income level shows the more or less full imprint of those factors.

California's ACA marketplace, Covered California, is an alternative universe where different results might have been expected. In California, the marketing commitment remained strong, plan designs are standardized, regulatory oversight and competition are robust, premium increases in the last two years were about half the national average, and a highly structured silver loading strategy was put in place early and publicized.  Consequently, effectuated enrollment on Covered California as of March 2018 is up 4% over March 2017, whereas enrollment in the country as a whole is down 2%.*  Off-exchange enrollment stayed steady in California, whereas it dropped 20% nationally in 2017, according to CMS, and likely further in 2018, as unsubsidized enrollees bore the full brunt of premium hikes that reached about 50% in two years.

Nonetheless, subsidized enrollment in California shows a similar pattern to subsidized enrollment on While the year-over-year change is better for California at every income level, showing improvement in all but one (150-200% FPL), the pronounced enrollment performance gap between those eligible for strong CSR and those who are not (and to whom gold and bronze discounts were therefore more consequential) more or less mirrors the gap in the

Sunday, July 22, 2018

True Image/pictured lies: The CMS attack on ACA navigators

The Kaiser Family Foundation has done in-depth spadework to debunk CMS's Trumpishly false basis for gutting funding for the ACA navigator program, publishing rebuttal reports in 2017, when federal funding was cut from $63 million previously allocated to $36 million in actual grants, and again this month, when the grants for 2019 were slashed to a nominal $10 million.

Not to rehash the Kaiser case in detail, I want to widen the perspective a bit -- to situate navigator programs within the full array of nonprofit ACA assistance programs that evolved out of the original navigator mandate, and to spotlight the scope of Medicaid enrollment assistance left out of CMS's assessment of navigator performance.

Thursday, July 12, 2018

No, CMS, ACA marketplace enrollment isn't up this year, and doesn't justify navigator funding cuts

To justify gutting funding for the navigators who help low income people enroll in health insurance subsidized by the ACA (Medicaid as well as marketplace), CMS is turning a bogus talking point it concocted last year inside out. Here's the current claim, as reported by KHN's Phil Galewitz:
CMS also notes that after last year’s navigator funding was reduced, the overall enrollment in Obamacare plans increased slightly (when counting people who paid their first month’s premiums) to 10.6 million people.
Comparing 2017 and 2018 totals at the end of open enrollment  (before many enrollees have paid their first premium), total ACA marketplace enrollment was down 4% this year. CMS's comparison above uses the totals from the "effectuated enrollment snapshots" from 2017 and 2018, which tracked how many people were enrolled (and had paid their first premiums) as of February in each year. The reported total at that point was 10.3 million in 2017, vs. 10.6 million this year.

As Charles Gaba pointed out last year (and revisits here), however, the 2017 "snapshot" exaggerated early attrition by failing to take into account the fact that those who enrolled between 1/15 and 1/31 (the final day of OE in 2017) did not have payments due until March 1.  There were 539,352* enrollees in that time frame.  None of them could effectuated their coverage for February, which is the population counted in the "snapshot." If those enrollees effectuated coverage at the same rate as enrollees before 1/15 (88.5%), there were 10.8 million who had effectuated or would soon effectuate as of the time of CMS's tally. That total outstrips this year's by 2% .**

Some CMS-y data for the ACA marketplace

Update, 8/12/2018: The data error spotlighted here has been corrected. The state-level PUF (link in text below) published by CMS now lists California CSR enrollment as of the end of Open Enrollment 2018 as 666,053, not 939,688. That's close to my estimate below of 668,557. As noted below, Covered California had confirmed to me that they sent the wrong figure to CMS and were working to update. CC now informs me that they submitted the updated figure on July 31.

The correction changes the national CSR enrollment count to 6,028,558 from  6,302,193. That's 51.3% of all marketplace enrollment (as noted below), not 53.6%. Apparently, though, CSR enrollment as a percentage of all enrollment had upticked back to 53% (or 52.7% to be more exact) as of the March effectuated enrollment snapshot (also linked to below).
The Public Use Files for ACA marketplace enrollment published annually by CMS provide useful detailed breakouts of enrollment in various categories, but they're not error-free.

Having recently compared the rates at which subsidized and unsubsidized enrollees dropped out early in 2018 (mainly by never paying their first premium), I thought I'd look at the attrition rate for those who obtain Cost Sharing Reduction (CSR) subsidies. And I happned on a large error in the reported total of CSR enrollees in California.

According to the 2018 state-level PUF, 939,688 of California's 1,521,524 enrollees as of the end of Open Enrollment obtained CSR. That's a high but not impossible percentage. But...only 853,787 California enrollees are listed as having chosen silver plans. And CSR is available only with silver. I am told by Covered California, the state's ACA exchange, that CoveredCA submitted the incorrect data figure for that cell to CMS and is working to correct it.

Tuesday, July 10, 2018

Sabotage triage: New Jersey's instructions to individual market health insurers

It's hard to keep up with Trump administration sabotage of the ACA marketplace. Credit New Jersey's Dept. of Banking and Insurance (DOBI) with doing what it can to help health insurers cope.

In light of CMS's abrupt and capricious suspension of risk adjustment payments* to marketplace insurers in response to what should have been a minor legal glitch, DOBI has moved the deadline for individual market insurers to file rate requests from tomorrow (July 11) to July 18. DOBI has also instructed insurers to take two contingencies into account: the possibility that risk adjustment payments will remain suspended, and the likelihood that CMS (yes, the same CMS that planted the risk adjustment IED late last week) will approve the state's waiver application for federal funding for a reinsurance program, submitted on July 2.

The guidance issued today instructs insurers to file rate requests that a) assume risk adjustment payments will continue for 2019, and b) do not take the possibility of reinsurance into account. But insurers are also instructed to a)  discuss the potential impact on rates if risk adjustment payments were to be discontinued for 2019, and b) file alternative rates that assume the reinsurance program will be in place in 2019, under the terms proposed in the state's waiver application.

Thursday, July 05, 2018

Unsubsidized ACA marketplace enrollees drop out early

Early this week, CMS reported that unsubsidized enrollment in ACA-compliant plans dropped 20% in 2018, while subsidized enrollment dropped just 3%. I pointed out that on-exchange unsubsidized enrollment dropped much more modestly, just 6%. That bespeaks a still steeper drop in off-exchange enrollment, suggesting that some previous off-exchange enrollees may have moved on-exchange in 2018 -- some obtaining subsidies, others not.

Today Charles Gaba notes that while unsubsidized on-exchange enrollment did not drop precipitously this year, first-month attrition among the unsubsidized who enrolled on-exchange was massive -- in a year in which overall attrition appears lighter than usual (over 80% of on-exchange enrollees are subsidized). While only 5.6% of subsidized enrollees are reported to have dropped coverage as March 15, 29%* of unsubsidized enrollees did.  This may not be surprising in a year in which premiums rose an average of 27%, largely as a result of Republican sabotage (cutoff of direct CSR reimbursement, radical cuts in enrollment assistance and advertising, weak enforcement of the individual mandate).

While the attrition among the unsubsidized this year is startling, it continues a pattern. Far higher percentages of unsubsidized than subsidized enrollees also dropped out in 2017 and 2016, rising each year. At the same time, attrition among subsidized enrollees dropped each year.

Wednesday, July 04, 2018

Six ways New Jersey is fighting off Obamacare sabotage

Statue of Liberty from Liberty State Park

Since Trump's inauguration, the ACA marketplace has undergone multiple waves of sabotage from the administration and the Republican Congress. Leaving aside some short-term hits, such as the cutoff of advertising at the end of Open Enrollment for 2017, these are the structural elements:
  • Radical reduction in federal funding for enrollment assistance and advertising
  • Cutoff of direct federal reimbursement to insurers for the Cost Sharing Reduction (CSR) subsidies they are obligated to provide to low income enrollees (now priced into premiums)
  • Effective repeal of  the individual mandate, which requires those for whom coverage is deemed affordable to obtain it or pay a penalty (Republican Congress zeroed out the penalty)
  • Regulatory promotion of a parallel market in medically underwritten short-term plans and association health plans -- measures designed to worsen the risk pool in the ACA-compliant market.
The ACA was designed to promote state innovation and autonomy, within fairly firm boundaries. While those boundaries have been breached on multiple fronts, states still have leeway to stay within them or actively reconstitute them. Meanwhile, thanks to the failure of Republicans' repeal legislation, federal funding for the core programs remains in place -- and has even been inefficiently enhanced, via the CSR funding cutoff, since reimbursing CSR is more cost-effective for the federal government than paying premium subsidies inflated by CSR.

It strikes me that New Jersey is unique in the degree to which it has acted to fend off the sabotage. Going into 2019 enrollment, the state has:

Tuesday, July 03, 2018

Time for New Jersey's Health Insurers to Do Their Part to Counter ACA Sabotage

Jersey City skyline

New Jersey's legislature, governor and Department of Banking and Insurance (DOBI)) have acted swiftly and decisively to protect the state's individual market for health insurance from several rounds of Republican sabotage.

On May 30, Governor Murphy signed into law two bills designed to hold down individual market premiums. The first created a state "individual mandate" -- a  requirement that those for whom affordable insurance is available obtain it or pay a tax penalty -- to replace the federal mandate that the Republican Congress repealed as part of its tax bill last September. The second measure directed DOBI to seek federal funding for a reinsurance program that would restrain premium increases.  DOBI submitted its proposal on July 2,  designed to reduce premiums by 15% per year compared to what they would have been without the reinsurance.

Both of those measures benefit insurers as well as consumers -- the mandate by keeping healthier enrollees in the risk pool, the reinsurance program by reducing insurers' risk.  Now it's time for health insurers to do their part -- by structuring their offerings to maximize federal subsidies and hold unsubsidized buyers harmless from a prior round of Trump administration sabotage.

Monday, July 02, 2018

Off-exchange ACA enrollment dropped 20% in 2017. Why did unsubsidized on-exchange stay stable?

In October 2017, Matt Fiedler of the Brookings Institute estimated that premium hikes averaging 20.5% nationally in the ACA-compliant individual market in 2017 were likely to reduce unsubsidized enrollment by 12.3%.

Today, CMS is out with a report claiming that unsubsidized enrollment dropped 20% nationally in 2017. Average monthly enrollment among the unsubsidized was down 1.3 million. Subsidized enrollment was down just 3%, despite Republican repeal threats and a late cutoff of advertising (along with active denigration of the offerings) by the Trump administration. The subsidized were insulated from the premium hikes; the unsubsidized of course were not.

One peculiarity: all of the drop in unsubsidized enrollment was apparently off-exchange. In fact, unsubsidized enrollment on and the state exchanges rose slightly in 2017, from 2.1 million to 2.2 million (though the "unknown" subsidy status of 83,516 enrollees all but closes the gap).

Friday, June 29, 2018

Hispanic Enrollment on up 8% in 2018

To return to a point I addled somewhat last week...

Applicants for health insurance on, the federal platform used by 39 states, are prompted to identify their race, and separately, whether they are of Hispanic/Latino "ethnicity." The questions are optional. Race is reported as unknown for 30% of enrollees, and ethnicity as unknown for 25%. The data is self-reported and somewhat volatile. I've been warned it should be taken with a grain of salt -- or considerably more.

That said, in 2018 self-identified Hispanic/Latino enrollment on is up 8% compared to 2017, to 1,033,699, and up 12.7% from 2016. Overall enrollment on is down 9% since 2016, to 8,743,642. Those self-reporting as Hispanic in 2016 accounted for 9.5% of total enrollment on; in 2018, they accounted for 11.8%.

[Update, 8/25/18]: in 2016, ethnicity was not broken out separately from race, and a larger percentage of race was reported as "unknown" than in subsequent years. In 2017, moreover, when ethnicity was broken out separately, there was no "unknown" category -- simply Hispanic/not Hispanic. The comparison with 2016 seems particularly suspect, since race and ethnicity were rolled together. ]

In Florida, the state with the highest ACA marketplace enrollment and the highest takeup among those who are subsidy-eligible, Hispanic enrollment was way up in 2018, from 327,965 to 378,471. That's a 15% increase, and accounts for most of the 39-state increase. Overall Florida enrollment was down 2.5%. In Miami-Dade County, however, which is about two thirds Hispanic, enrollment was up by about 7,000, to 394,677. In Osceola County, 45% Hispanic, enrollment was up about 1,700, to 40,414.

Here is Hispanic and total enrollment, 2018 vs. 2017, in the 10 Florida counties with the highest Hispanic enrollment this year.  In all of them, Hispanic enrollment is up this year -- not surprising given the large overall increase.

Monday, June 25, 2018

ACA marketplace enrollment, 2018: Answers and questions

In 2018, ACA marketplace enrollment dropped 5% in the 39 states using the and 4% nationally. The more detailed data that CMS compiles for the states (accounting for three quarters of all enrollees) show that enrollment dropped most sharply at the lowest income levels -- where, thanks to Cost Sharing Reduction (CSR) subsidies, the most comprehensive coverage is available.*

Here's the breakdown of enrollment by income level in 2018 vs. 2017** on

Enrollment by Income Level on, 2018 vs. 2017

Total enrollment
100% to 150% FPL
150% to 200% FPL
200% to 250% FPL
250% to 300%  FPL
300%- 400%  FPL
Other FPL*

2018 as % 2017
 "Other FPL" is comprised mostly of unsubsidized enrollees. About one quarter are likely enrollees with incomes under 100% FPL, most of whom are likely legally present noncitizens time-barred from Medicaid, who are subsidy-eligible.

Why was enrollment down sharply at 100-200% FPL, down modestly from 201-300% FPL, and up at 300-400% FPL? The higher the income, the more definite the answers.