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.

Moreover, while Woodward and Rugaber report that Medicaid enrollment among those rendered newly eligible by the ACA  "appears to be stable at about 12 million people," overall Medicaid/CHIP enrollment was down by about a million** from June 2017 to June 2018.  Repeal of the individual mandate penalty, though not effective until 2019, may have had an effect, as repeal was in the air for much of the year, and many people were under the impression it had already happened, or would be effective in 2018.  The individual mandate has a significant effect on Medicaid enrollment, as the CBO reports forecasting the effects of the failed  Republican ACA repeal bills noted repeatedly.***
There is good evidence, then, that sabotage has pushed some three million people out of programs established or supported by the ACA. If the NHIS findings are on target, full employment may have taken up the slack. An aging of baby boomers into Medicare could also be a factor.

As for the claim that Obama was also blaming Republicans for problems that manifested sharply when premiums for 2017 were filed, that's true, in a sense. Premiums spiked in 2017, and off-exchange enrollment losses were steep. The proximate causes were the expiration of the marketplace's 3-year startup reinsurance program, and the fact that insurers realized by 2017 that they had initially underpriced.

But Republican sabotage of the marketplace did not begin in January 2017, when the Trump administration, in a first blow, killed final-week advertising during open enrollment and likely reduced enrollment by several hundred thousand. It began, as Louise Norris has documented, as soon as the ACA became law, and encompassed red state refusal to engage in active regulation of marketplace insurers; red state refusal to commit resources to enrollment assistance, and active impediment of federally funded assisters; defunding of the risk corridors, which triggered the collapse of most of the state insurance co-ops and shook insurers' trust in the full faith and credit of the United States government; two court challenges that went to the Supreme Court; refusal to appropriate funding for Cost Sharing Reduction; refusal to allow fixes to any of the law's inevitable flaws, such as the family glitch, etc. etc. These actions collectively worsened the risk pool and at least exacerbated the premium spikes and insurer withdrawals of 2017 -- which were on course to largely self-correct in 2018 and beyond. This eight year track record of maligning and impeding the law probably reduced enrollment by a good deal more than 3 million.

Obama's ACA-related claims were just one of several topics on which Woodward and Rugaber dinged the former president. For many readers, I suspect, the chief reaction will be nostalgia for a president who shades the truth  only to the degree alleged herein.

Update, 6:00 p.m.: The Census Bureau today released health insurance statistics compiled from the 2018 Current Population Survey Annual Social and Economic Supplements (CPS ASEC) and the American Community Survey (ACS). The surveys show no significant change in the insured population from 2016 to 2017. One interesting tidbit: the share of the population insured through Medicare increased by 0.6%, and the percentage insured through the military by 0.2%. If those trends continued through 2018, those gains could largely offset a drop in the individual market and Medicaid equivalent to 1% of the population (i.e., about 3 million).
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* Republican actions that disrupted the market and depressed enrollment include 1) signalling that enforcement of the individual mandate would be weak; 2) spooking insurers by coming within a whisker of repeal of the ACA's core programs, an effort that extended from January through September; 3) gutting federal spending on advertising and enrollment assistance; 4) cutting off direct federal reimbursement of insurers for Cost Sharing Reduction subsidies, which drove a premium spike north of 10%; and 5) repealing the individual mandate penalty, effective in 2019 but affecting public perception throughout the fall.

** The preliminary monthly enrollment report for June 2018 shows a total difference since the second half of 2013 (just prior to ACA implementation) that's 1.25 million lower than the difference in June 2017. The 2018 total is preliminary, however, while the 2017 total was updated, and updates generally increase the total modestly. I cannot get access to updated totals in recent months -- that info requires a login.

***The Medicaid work requirements greenlighted by CMS early this year and sought (via waiver application to CMS) by 11 states have not yet had a statistical impact, though Arkansas has managed to cull its rolls by 4,500 by imposing work reporting requirements designed to be difficult for the enrollment population. The work requirements, if not struck down by the courts, will likely depress Medicaid enrollment significantly going forward.


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