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

Navigator and broker enrollments Maryland 2017
Navigator and broker enrollments in Maryland, 2017

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, 28%* 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 13% since 2016

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 7.5% 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%.

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.

Sunday, June 24, 2018

Actuarial Value in the ACA Marketplace: Down a bit

In 2018, CMS has for the first time ever published data making it possible to calculated the average weighted actuarial value of health plans sold in the 39 states that use the federal marketplace,

The actuarial value is the percentage of the average enrollee's costs a health plan is designed to pay, calculated according to a fixed formula mandated by CMS. Take that with a grain of salt, sprinkled on in a couple of caveats at bottom. Still, AV is a standardized measure that makes comparisons possible. Average AV for both employer plans and Medicare has been calculated to be a bit over 80%.

The ACA mandated specific AV for each of four metal levels (with some wiggle room, per below): 60% for bronze plans, 70% for silver, 80% for gold, 90% for platinum. But secondary Cost Sharing Reduction (CSR) subsidies, available to enrollees with incomes up to 250% of the Federal Poverty Level, complicate the formula. CSR, available only with silver plans, raises AV: to 94% for those with incomes up to 150% FPL; to 87% for those in the 151-200% FPL range; and to 73% at 201-250% FPL.

This year, for the first time, CMS reported exactly how many people were enrolled at each CSR level, albeit only in states, which account for just about three quarters of marketplace enrollees.* So who obtained what in the ACA marketplace this year? Here's the data.

Actuarial value obtained by enrollees on, 2018 

Metal level
Actuarial value
Total enrolled
% enrolled
Weighted AV
Silver - CSR1
Silver - CSR2
Silver - CSR3
Silver - no CSR


* There were just 16,731 platinum (90% AV) enrollees on, and 58,176 catastrophic plan (57% AV) enrollments. Combined, that comes to a weighted AV of 64%, used above to avoid splitting percentages.

Friday, June 22, 2018

Steep enrollment drops in New Jersey's individual market

ACA marketplace enrollment was down 7% in New Jersey as of the end of open enrollment, according to CMS. That's a somewhat steeper drop than the 4% national average and the 5% average among states using, but in range.

This week the state Department of Banking and Insurance (DOBI) released first-quarter enrollment results for the entire individual market, off-exchange as well as on-. It shows more severe drops on both fronts -- particularly off-exchange:

NJ Total Covered Lives Comparison, individual market 2017-2018
New Jersey suffered an average weighted premium increase of 22% in 2018, with steeper increases for market hegemon Horizon Blue Cross. As I noted recently, unsubsidized enrollees didn't get any benefit from silver loading, as there were no discounted silver plans available off-exchange. Unsubsidized enrollees basically had four choices: eat huge premium increases, downshift to bronze, switch to narrow network AmeriHealth, or drop out.

It appears that a significant number of unsubsidized enrollees made that last choice. Off-exchange enrollment was down not only compared to the first quarter of 2017, but compared to the last quarter, when enrollment is at low ebb (overall enrollment is up 6% since Q4 2017, but down 11% since Q1).

Off-exchange enrollment stats are hard to come by, but steep enrollment drops are to be expected.  Matt Fiedler of the Brookings Institute estimated last fall that premium hikes averaging 20.5% nationally in 2017 were likely to reduce overall unsubsidized enrollment by 12.3%. New Jersey's numbers would seem in line with that estimate.

A few notes and question marks regarding both off- and on-exchange enrollment:

Thursday, June 21, 2018

ACA heresy at noon

Once upon a midnight* dreary,
While I pondered weak and weary...

over one more quaint and curious wrinkle in ACA enrollment patterns (New Hampshire enrollment was down 6% in 2018, but subsidized enrollment was up 5%!--why?), I saw something that drew me up short.

I was looking at whether silver loading had created off-exchange discounts in silver plans available in New Hampshire. It had, a little. The plans listed below are the two cheapest silver plans on offer in 2018 to an unsubsidized 50 year-old in Manchester. The top plan is available off-exchange only, the second one both off- and on-exchange. But that's by the way.

discount in off-exchange silver plans in New Hampshire

Saturday, June 16, 2018

Virginia's CSR load should be cut more than in half in 2019

David Anderson makes a valuable point about an after-effect of latter day Medicaid expansions like Virginia's -- that is, expansion following Trump's cutoff of federal reimbursement to insurers for the Cost Sharing Reduction (CSR) subsidies they are obligated to provide to qualifying ACA marketplace enrollees.  

It's this: now that insurers have to price CSR into premiums, Medicaid expansion will reduce premiums for unsubsidized enrollees by removing much of the CSR load.
Virginia — like many other states — had its insurers load the cost of providing CSR into the premiums for silver plans, which are the plans that set the local benchmark from which all premium subsidies are calculated. This led to a significant spike in silver benchmark premiums. Other plans saw significant but far lower premium increases. On average, CSR workarounds led to an extra $960 to $1,040 in premiums for silver plans.

The data shows us that people who were previously eligible for an ACA health plan and will now be eligible for Medicaid under the expansion were the highest per-capita recipients of the cost-sharing reduction subsidies. As these individuals move to Medicaid expansion, the cost of funding CSR through silver premiums will decline.
As it turns out, we know just about how many current Virginia enrollees with CSR will be eligible for Medicaid if their income doesn't change. CMS data shows that, of Virginia's 400,015 enrollees as of the end of Open Enrollment last December, 222,305 obtained CSR. Of those, 120,898 obtained the highest level of CSR, which raises the actuarial value of a silver plan from a baseline of 70% (which is what silver plans without the CSR load would price for) to 94%.

Friday, June 15, 2018

New Jersey's individual market needs some off-exchange discounts in 2019

Trump's cutoff of federal reimbursement to insurers for Cost Sharing Reduction (CSR) subsidies last fall turbo-charged premium hikes in the individual market in 2018.  Those hikes hit unsubsidized enrollees directly. Yet states that allowed insurers to load the cost of CSR onto on-exchange silver plans only, allowing cheaper silver plans to be sold off-exchange, provided a measure of effective relief to the unsubsidized.

In Philadelphia, an unsubsidized 50 year-old could get the cheapest off-exchange silver plan for $153 per month less ($498/month) than the cheapest on-exchange silver plan (for more closely comparable plans, the spread was $94).  In Baltimore, the cheapest silver plan offered on-exchange for a 50 year-old was $88/month more than the same plan off-exchange ($610 vs. $522).

Not so in New Jersey, where individual market premiums rose a weighted average of 22% in 2018, and still more steeply on market hegemon Horizon Blue Cross's most popular silver plans.* New Jersey did allow "silver loading" -- that is, concentrating the cost of CSR in silver plans only, since CSR is only available in silver plans. But none of the three insurers participating in the state's ACA marketplace offered cheaper silver plans off-exchange, as insurers did in many other states.

In fact, none of the three (Horizon, AmeriHealth, Oscar) sold off-exchange plans that differed in any way from their on-exchange offerings.**

Wednesday, June 13, 2018

Medicare expansion: An elastic idea for Democrats

Politico's Jennifer Haberkorn reports that Democratic candidates are avoiding the term "single payer" when staking out their healthcare positions. That's not only because Republicans use the term as a bogey signaling socialized medicine and socialism generally (they did the same with the much more conservative ACA).  More substantively:
Early last year, the DCCC shared verbal guidance with candidates and political consultants about the liabilities of supporting single payer, including polls that showed support for the idea declined once voters heard that it would likely come with significant tax increases and the potential loss of private health coverage many Americans have today, according to sources who saw the guidance.
Instead, Democrats are being urged to embrace the term "Medicare for All" -- which, taken literally, is single payer. Some candidates speak more cautiously of "a path to Medicare for all," however -- a term that's justifiably ambiguous. Any path to universal coverage in the U.S. is likely to be long, and include several stages and potential branchings -- including toward a system in which a public program is available to all, but some choose other options. A number of Democratic bills and proposals reflect this reality. In recent years, many forms of Medicare expansion have been proposed. They include the following, ranked from the most limited to the most expansive.

Friday, June 08, 2018

When ACA marketplace coverage is cheaper than Medicaid

In my last post, I noted that thanks to Virginia's decision to expand Medicaid, a bit over 100,000 current enrollees in the state's ACA marketplace (or people similarly situated next year) will be switching over to Medicaid in 2019.  Also, since the Republican-tinged expansion terms include premiums ranging from $1/month to 2% of income for people in the 100-138% FPL, some of these people will actually pay more for Medicaid coverage than they do now for marketplace plans.

David Anderson covered this ground in more detail:
A single 40 year old making 138% FPL who buys the benchmark Silver plan pays 2% of their income in premiums which translates to $28 per month. People who expect to be relatively healthy will often elect to buy the least expensive Silver. The APTC subsidy is fixed so the choice to buy a lower cost Silver plan means the a dollar for dollar reduction in out of pocket premiums. Significant portions of Virginia including greater Richmond, exurban NoVA and central Virginia between I-81 and I-95 have a Silver plan that is at least $28 less than the Benchmark Silver. This means that there is a $0 premium plan available for folks who will now be moving to Medicaid with a 2% premium.
A couple of points of elaboration: first, not everyone in the 100-138% FPL income band (the group that has been eligible for marketplace subsidies pre-expansion) will pay 2% of income. Second, a lot of people in this income range currently pay less than 2% of income but more than $0.  Some have $0 deductibles; some have small ones ($150). Yearly out-of-pocket maximums range from $900 to $2000 -- I imagine maximum OOP at least will be lower in Medicaid.

Thursday, June 07, 2018

Virginia Medicaid expansion will cut ACA marketplace enrollment by 100,000-plus

Virginia will enact the ACA Medicaid expansion in 2019 -- it's now law. Hurrah! 400,000 people are expected to gain Medicaid coverage. And that includes about 108,000 people who enrolled in ACA marketplace coverage in 2018 (or rather, those similarly situated next year) -- a bit over a quarter of current enrollment. Judging from enrollment attrition recorded in past years, about 90,000 of the potentially Medicaid eligible are probably enrolled in marketplace plans as of now.

Under the expansion, Virginians with income up to 138% of the Federal Poverty Level (FPL) will be eligible for Medicaid. Pre-expansion (i.e., now), eligibility for marketplace subsidies begins at 100% FPL.  According to CMS public use files, 123,245 enrollees as of the end of Open Enrollment had incomes in the 100-150% FPL range. Most of them -- those with incomes from 100-138% FPL -- will be Medicaid-eligible. 

We know more or less how many. In 2016, the one year in which CMS broke out the 100-138% range separately, 82% of of Virginia enrollees in the 100-150% FPL band proved to be in the narrower "shoulda-been-in-Medicaid" range -- 100-138% FPL. Assuming the same proportions this year suggests 108,000 people who might have enrolled in marketplace coverage in 2019, all other things being equal, who will instead enroll in Medicaid.

Wednesday, June 06, 2018

About that victory lap, PA Insurance Department....

Yesterday, the Pennsylvania Insurance Department proudly announced that insurers in the state's ACA-compliant individual market requested premium increases averaging 4.9% -- compared to 30.6% last year.

Insurance Commissioner Jessica Altman took a victory lap:
Altman attributes the minimal increases to Pennsylvania’s competitive market and the department’s efforts to maintain enrollment in the individual market despite the federal government’s efforts to shorten the ACA’s open enrollment period and curtail enrollment outreach, while working to achieve affordability for consumers. The Insurance Department launched an outreach campaign to make up for a lack of marketing from the federal government during the 2018 open enrollment season.

The department also worked to make coverage more affordable for more consumers by mitigating the number of individuals subject to premium increases when the federal government eliminated cost-sharing reduction reimbursements. As a result, 396,725 Pennsylvanians selected health plans on the exchange in 2018, only a small decline from the previous year.
It may well be true that state action helped minimize enrollment losses and so stabilize the market to a degree. But on the top line at least, that "small decline" was not so small. CMS enrollment figures show a 9% drop in marketplace enrollment in Pennsylvania in 2018 -- compared to 4% nationwide and 5% in the 39 states (including PA) that use the federal exchange,

Monday, June 04, 2018

ACA sabotage boomerang, type 3

Recently, I tallied the various ways that Republican sabotage of ACA programs has either backfired entirely or created means of mitigating the intended damage.

Very briefly, sabotage jacks up individual market premiums, which creates inflated federal subsidies, which can be leveraged both by individuals (via discounted bronze and gold plans) and states (via federally funded reinsurance or other innovation waiver programs). Two states, New Jersey and Vermont, have also turned effective repeal of the federal individual mandate to their advantage by creating state mandates, capturing a revenue stream while holding premiums down.

Late last week, the Washington Post's James Hohmann highlighted another form of sabotage that may also at least partially boomerang: Work requirements attached to Medicaid for "able-bodied" adults. It would be hard to find a policy more universally denounced by anyone with any professional experience or scholarly purview of Medicaid. The programs are cruel,wasteful and counterproductive; they will likely  reduce both coverage and employment. And yet...
As President Trump steps up efforts to undermine the law, from repealing the individual mandate to watering down requirements for what needs to be covered in "association health plans," the administration’s willingness to let states impose work requirements on Medicaid recipients has paradoxically given a rationale for Republicans to flip-flop on an issue where they had dug in their heels.

Friday, June 01, 2018

The old machine hums on

The way we're rigged emotionally, death and disease are inherently tragic. Yet at some level I am amazed by the durability and self-regulation of the human body. It seems very strange that I'm still in the same machine I was in when my consciousness emerged. On the whole, despite all the niggling pains and promptings that go on all day, I'd say the body interferes very little in that consciousness. Every waking moment you're thinking about something, and in most of that nonstop churning you forget you have a body. That's true even if bodily awareness breaks in every ten minutes for, say, five seconds.

Thursday, May 31, 2018

New Jersey takes strong action against ACA sabotage: A look-back

As Republican repeal of the ACA's individual mandate loomed last fall, potential remedies for states became self-evident, notwithstanding many political roadblocks. No one had ever challenged a state's authority to impose an individual mandate. And state reinsurance programs had already proved their worth and obtained federal funding.

New Jersey, with strong Democratic majorities in both houses of the legislature and a newly elected progressive governor, was one likely proving ground -- notwithstanding the mandate's unpopularity and the state's fiscal woes. Progressives committed to a working individual market and resumed progress expanding healthcare access were eager to see these remedies tried -- under the tight schedule imposed by insurers' June 20 deadline to file rate requests. The legislature came through, passing mandate and reinsurance bills on April 12. After a long and rather conspicuous silence, Governor Murphy signed them yesterday.

Below is a compendium of my posts and articles on this front, as well as outside efforts with BlueWaveNJ and the NJ for Health Care Coalition that I've been involved in. They address the fiscal challenges as well as the case for the bills.

Sabotage judo: States can turn individual mandate repeal to their advantage (12/14/18)
Impose a mandate and use the revenue to help fund reinsurance

How Gov. Murphy can protect NJ from Obamacare sabotage (NJ Spotlight, 1/17/18)
Specifics for New Jersey -- e.g. death spirals past

Wednesday, May 30, 2018

NJ for Health Care Coalition urges Gov. Murphy: Protect our care. Sign these bills

Update: Murphy signed both bills today!  The Star-Ledger' Susan Livio cites the Coalition letter linked to below.
New Jersey Governor Phil Murphy has been notably quiet about two ACA-defense bills awaiting his signature -- one creating a state individual mandate, the other directing the Dept. of Banking and Insurance to seek federal funding for a reinsurance program for the individual market.

The bills passed both houses of the legislature on April 12; the Governor has until June 7 to act. His hesitation, if there's more to it than due diligence, may stem from fiscal worries about the reinsurance program, as I've noted before.

Today the NJ Coalition for Health Care, an umbrella group of advocacy groups, trade groups, and unions led by New Jersey Citizen Action, sent a letter to Governor Murphy urging him to sign the bills. 17 organizations signed, including BlueWaveNJ, a group I volunteer for. The text is available here.

Tuesday, May 29, 2018

How Democratic candidates should talk about healthcare

The moderate/establishment candidate for the Democratic nomination in New Jersey's 7th Congressional District (a seat very much in play), Tom Malinowski, takes what in my view is an admirably substantive, focused, big-picture healthcare position:
On healthcare, Malinowski said he “does not support Medicare for all, but the idea of a Medicare option for all is worth exploring.” He said he’s spoken to many people who appreciate having healthcare options and he “would not force anyone to give up private health insurance which many Americans are happy with,” though he added that expanding a Medicare option could eventually lead to a single-payer type of system if people chose it voluntarily.
This more or less describes the Center for American Progress's Medicare Extra proposal and the Merkley-Murphy Choose Medicare Act. Those proposals in turn hark back to early versions of the public option, in which a Medicare-ish program was an 800-pound gorilla that private insurance was privileged to compete against if insurers or employers so chose. Some versions envisioned permanent competition between commercial/employer insurance and a public plan, while others expected a phase-out of private insurance (I discussed some of the variations here.)

Either way, my own view is that a public plan that employers and individuals can buy into provides a viable path either to a de facto all-payer system, in which commercial insurers pretty much have to pay similar rates to the public plan to survive, or to single payer.  And merits aside, I think Malinowski does a nice job in short space capturing both the conservative and the transformative appeal of a strong public option set alongside employer-based insurance. It's too bad that Democrats backed away from this model.

Sunday, May 27, 2018

Trump's CSR cutoff boosted ACA enrollment in the 300-400% FPL income bracket

This is to follow up, x-post, on a factoid I noted early this month: while enrollment in states was down 5% overall in 2018, and down 7.5% among those with incomes up to 200% of the Federal Poverty Level (FPL), it was up among wealthier subsidized enrollees. All of the absolute gain came in the 300-400% FPL range.

Enrollment at 200-400% FPL in States

200-250% FPL
250-300% FPL
300-400% FPL
Total 200-400% FPL

That's actually quite striking. In the prior post, I noted
If enrollment in the 200-400% FPL range had been down 7.5% in 2018, as it was in the 100-200% FPL bracket, there would be 254,000 fewer enrollee in states than there are now. If the impact in the states that run their own marketplaces was proportionate, that suggests 342,000 fewer enrollees had the federal government continued to reimburse insurers for CSR.
Most of that gain attributable to silver loading occurred in the 300-400% FPL income bracket. If enrollment in this bracket were down 7.5%, there would be 140,000 fewer enrollees in states (and probably about 188,00 fewer nationwide).

The difference is almost certainly due to the silver loading of CSR costs (see note below), which created discounts in bronze and gold plans that chiefly benefit those with incomes above 200% FPL (below that level the free CSR benefit outweighs the gold/bronze discounts).  So let's look at metal level selection in the 300-400% FPL bracket in 2017 and 2018.

Note: CMS broke out gold selection in 2018 but not in 2017. So the 2017 "gold" line  is derived by subtracting bronze, silver and 1% of enrollment at this level (approx 7900) for catastrophic and platinum,  which together totaled 1 % of enrollment across all income levels [updated 8/9/18].

Enrollment by metal level at 300-400% FPL in States

Total bronze
% bronze
Total silver
% silver
Total gold
% gold

Enrollment totals at the metal levels are derived from whole-number percentages provided by CMS.
Source: CMS State Level Public Use Files, 2017 and  2018.

Bronze enrollment in this income bracket was up by about 150,000 (47%) in 2018, and gold was up by about 64,000 - well more than double.  Silver was down 125,000.

Takeup of subsidized marketplace plans has always been poor in the upper ranges of income eligibility. The bronze/gold discounts made available by Trump's cutoff of federal funding for CSR plainly improved takeup in the upper income range.

There is another factor in the enrollment spike at 300-400% FPL. A higher percentage of enrollees in this income bracket was probably subsidized in 2018 than in 2017. That's because of the huge spike in premiums in 2018. In previous years, younger enrollees in particular with incomes as low as 250% FPL did not qualify for subsidies, because unsubsidized premiums required of them an "affordable" share of income (almost 10% in the 300-400% bracket).

This year, the impact of slipping just below the subsidy line was magnified by the bronze/gold discounts. An older buyer in particular who might have had just a $10/month subsidy for a benchmark silver plan might find a much more dramatic discount in bronze or gold.

Note on Effects of CSR funding cut-off 

When Trump cut off federal reimbursement of insurers for the Cost Sharing Reduction subsidies they're legally required to provide to lower income ACA marketplace enrollees who select silver plans (57% of marketplace enrollees in 2017), most states allowed or required insurers to concentrate the cost of CSR in premiums for silver plans only. States in which 70% of individual market enrollees live concentrated the cost of CSR in on-exchange silver plans only, allowing for cheaper silver plans to be sold off exchange.

Since ACA premium subsidies are keyed to the price of the benchmark (second cheapest) silver plan in each rating area, subsidies rose to cover inflated silver premiums, generating often dramatic discounts in non-silver plans, i.e. gold and bronze (platinum availability and purchase is negligible). In many states, steep increases in silver plan premiums resulted in zero-premium bronze plans becoming available to many buyers (or nominal $1-3/month premiums), and gold plans that were either cheaper than silver or close in price.

Cheap gold plans were a particular boon to enrollees with incomes between 200% and 400% of the Federal Poverty Level (FPL). These buyers are not eligible for strong CSR, which makes silver plans roughly equivalent to platinum plans for buyers up to the 200% FPL threshold. Normally,  enrollees in the 200-400% FPL range would pay between 6% and 10% of their income (percentage rising with income) for a benchmark silver plan with an actuarial value of 70%, i.e. with an average deductible of around $3600). With CSR priced into silver plans in 2018, gold plans  (80% AV, with an average deductible of around $1100) came