Silver loading 2019: What's on offer in the nation's highest-enrollment counties

The ACA marketplace is, as David Anderson says, a county-by-county story. Markets vary widely, or wildly, by location, sometimes down to the zip code. The variation grew positively freakish after Trump cut off CSR reimbursement and insurers responded by silver-loading -- that is, concentrating the cost of CSR in silver plans only (see below for an explanation).

There are counties (like Alfalfa in OK) where anyone with an income under 400% FPL can get a gold plan (deductible $200) for free, but where a 40 year old with an income just over the line will pay $433 per month for the cheapest bronze plan (deductible $5,000). There are counties where no one with an income over 200% FPL can get a silver plan with a deductible lower than $4,000 (Penobscot, Maine). There are counties where premiums for the unsubsidized are relatively low but silver loading has yielded no significant discounts in bronze or gold (Essex, NJ). There are counties where a large gap between the cheapest and benchmark (second cheapest) silver plan render CSR-enhanced free or close to it to most with CSR-eligible incomes, but with no affordable gold plans for those eligible for weak CSR or no CSR (Atkinson, Georgia).

This is all testament to the flawed design and inadequate funding of the ACA marketplace, as well as to the sabotage inflicted on it in the Trump era and prior. Compare Medicare/Medicare Advantage, where a monster public option, heavier and more uniform subsidies, tight constraints on provider payment rates in the private plans, and better benefit standardization create a market that's confusing enough and has large coverage gaps for many but still provides more uniform, adequate and affordable coverage than does the marketplace. (Though the marketplace actually offers more comprehensive coverage to those with incomes under 200% FPL who access CSR.)

All that said, there's a sort of broad middle of silver loading effect, in which bronze and gold plans are cheaper relative to silver than they were pre-2018. For a solo 40 year-old with an income of $24,000, or a bit under 200% FPL, a mid-range silver load effect might create a spread of over $100 per month between the cheapest bronze plan and benchmark silver ($129 per month at this income) and of less than $30 per month between the benchmark and the cheapest gold plan, i.e. up to around $160/month.

Bob Hugin, healthcare moderate?

I doubt it. The Republican candidate for Bob Menendez's New Jersey Senate seat, the past finance chair for Trump's New Jersey campaign, makes moderate noises about healthcare under cover of technocratic blather like paying for value and providing "health care, not sick care.". Someone needs to look beneath the hood and get him on the record as to what extent he'd support Republican healthcare priorities. In the North Jersey Record, I've posed some healthcare questions for him.

Hope you'll take a look: 3 healthcare questions for Bob Hugin

P.S. A more detailed look, with more background and a question about VA care, is here on the blog.

CMS guidance on ACA innovation waivers requires an ACA-compliant benchmark

The Trump administration has opened a new front in its assault on the ACA marketplace's protections for people with pre-existing conditions. This time the vehicle is the ACA's Section 1332 innovation waivers, which enable states to propose alternatives to the ACA's basic marketplace architecture to get their residents covered with affordable, comprehensive insurance.

In guidance issued this week, CMS relaxed strict standards that states have until now had to meet to get waiver proposals approved. Most radically, the new guidelines are designed to enable states to offer subsidies for ACA non-compliant plans, including short-term plans that are medically underwritten and don't have to cover the ACA's Essential Health Benefits.

Subsidizing noncompliant, medically underwritten health plans would seem to be a route to undermine the ACA-compliant market completely -- and potentially render comprehensive coverage unaffordable for subsidized as well as unsubsidized enrollees, especially those with pre-existing conditions.  But I suspect the guidance doesn't go quite as far as it seems to in this regard.  Some constraints on rendering comprehensive insurance unaffordable remain, I'll suggest below -- at least for subsidized enrollees.

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.

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:

When #ACA replacement bill is out, don't get distracted by exchanges.

The big issue is dramatic cuts in Medicaid to pay for huge tax cuts.

— Andy Slavitt (@ASlavitt) March 6, 2017

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.

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.

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%.

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:

...in 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."

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." 

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.

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.