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 healthinsurance.org.

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 healthinsurance.org, 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.

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.

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

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

"I said they have to cover all pre-existing conditions. I didn't say they couldn't charge tens of thousands of dollars per policy to cover some." https://t.co/YLGVeUuWdC

— xpostfactoid (@xpostfactoid) September 24, 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.

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.

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.

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.

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 healthinsurance.org, 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	State rank: median income	Uninsured 2013	Uninsured 2016	Growth in Medicaid enrollment 2013-2018	Marketplace enrollment March 2018	Total indiv market enrollment
Arkansas	46	17.8%	9.1%	328,302	61,702	unknown
Kentucky	47	16.3%	7.2%	637,486	81,023	115,595
Louisiana	49	22.7%*	11.4%*	430,604	93,178	unknown
W Virginia	48	14.2%	8.8%	189,025	25,205	39,371

*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.

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 hc.gov who are unsubsidized masks a 10% drop in enrollment among the unsubsidized -- exacerbated by heavy attrition in February.

GAO highlights the silver load offset to HHS sabotage - 8/24/18
The GAO report on HHS actions that depressed marketplace enrollment also shows a key effect of silver loading: average premiums at each metal level. This post matches that with shifts in metal level choice at different income levels, e.g. a massive shift out of silver at 200-400% FPL.

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 healthcare.gov 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 healthcare.gov were subsidized, but 90% have incomes in the 100-400% FPL range. Why the gap?

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:

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:

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.