Thursday, November 15, 2018

Slow start to Open Enrollment 2019

The Democrats' capture of the House of Representatives has saved the ACA's core programs and funding. Most fundamentally, Republicans have lost their chance to cut the trillion-plus dollars over ten years in federal healthcare spending that they tried to cut last year -- most of it in Medicaid. Instead, the ACA's expanded Medicaid eligibility may be available in seven more states by 2020 than in 2018.  And the ACA marketplace's income-adjusted and relatively generous subsidies (compared to proposed Republican replacements) remain intact.

That said, early reports from Open Enrollment for 2019 suggest that various forms of Republican sabotage -- massive cuts to advertising and enrollment assistance, creation of a medically underwritten market in conjunction with repeal of the individual mandate -- may be taking their toll.  Enrollment on, the federal exchange serving 39 states, was down about 13% in the first week (adjusted for a one day difference in days open) and 8% in week 2.

That could mean nothing, or it could mean a lot. Enrollment could catch up with last year's (which was down 5% in states from 2017 and 9% from 2016), or fall further behind. Charles Gaba chalks the slow start up to election distraction -- in the media if not for the public at large -- although, weighing all factors pro and con, he'd previously predicted a 5% drop this year. Former chief marketing officer Joshua Peck is less sanguine:

Saturday, November 10, 2018

New Medicaid expansion + increased silver loading should improve ACA marketplace risk pools

Over the next couple of years, two forces will be at work to make ACA marketplace risk pools somewhat wealthier and therefore healthier -- even as other factors pull the other way.

The factors working to improve the risk pool are Medicaid expansion, which pulls the lowest income  enrollees out of the marketplace, and silver loading*, which creates discounts in bronze and gold plans that mainly benefit (and draw in) enrollees at the upper income range of subsidy eligibility (201-400% of the Federal Poverty Level).

At incomes below 201% FPL, the bronze/gold discounts for the most part are not valuable enough to offset the free, strong Cost Sharing Reduction subsidy available at that income level, and available only with silver plans. At 200-400% FPL, the discounts were attractive enough to offset factors inhibiting enrollment for 2018, such as the huge advertising and outreach cuts implemented by the Trump administration and confusion about repeal and the individual mandate. As I've noted before, compared to 2017 enrollment levels, 2018 enrollment  at 201-400% FPL outperformed enrollment below 201% FPL by about 8 percentage points. That in turn shifted the income distribution of exchange enrollees upwards a couple of percentage points:

Income distribution of subsidized enrollees:, 2017-2018

Number enrolled at 0-200% FPL*
Percent enrolled at 0-200% FPL
No. enrolled at 201-400% FPL
Percent enrolled at 201-400% FPL

Source: Public Use Files (20182017) published by CMS

Friday, November 09, 2018

Gold in Texas's broad empty spaces

A county is a flexible unit of demarcation, especially in the U.S. Los Angeles County (population 10 million) is 100,000 times larger than Loving County, Texas (pop. 95).

Insurance premiums in the individual market also vary wildly by geography, with county lines often (but not always) marking a rating area boundary. This may make sense from a business standpoint for commercial insurers, but it's a ridiculous principle for social policy. Living on the wrong side of a street can cost a person thousands of dollars.

Assessing the national ACA marketplace by county can create mistaken impressions. In the runup to Open Enrollment 2017, Republicans, ever eager to denigrate the marketplace, were crowing that one third of counties had only one insurer. That was true, but only 19% of enrollees (estimated prior to open enrollment) had a choice of just one insurer. That reflected market deterioration for sure, but 19% is not 31%.

Last year, when Trump cut off direct federal reimbursement for Cost Sharing Reduction (CSR) subsidies, most states and insurers coped  by loading the cost of  CSR into silver plans only, since CSR is available only in silver plans. Since premium subsidies vary by income and are keyed to a silver benchmark, this had the effect in many states and rating areas of creating large discounts for subsidized enrollees in bronze and gold plans. In some cases, gold plans were cheaper than benchmark silver for subsidized buyers. This windfall boosted enrollment at the upper income range of subsidy eligibility, where CSR is weak to nonexistent. Gold plan enrollment quadrupled in some states, and bronze enrollment rose from 23% of total enrollment in 2017 to 29% in 2018.

Plan offerings were finalized last fall shortly after Trump cut off CSR reimbursement in October. David Anderson swiftly and very usefully mapped out the effects of silver loading by county nationally,and he has done so again this year, when more states (almost all) have adopted silver loading.  The map shows broad areas where the gold plans are available for less than benchmark silver. That's the case in 1,136 counties in 2019, compared to 595 this year. On the map, counties with such anomalous gold pricing are marked in green -- the darker the green, the cheaper the gold relative to the benchmark.

There are counties and counties, however. David's map shows a sea of green in Texas, so I've been meaning for a while to check out the offerings.

Wednesday, November 07, 2018

ACA probably saved, along with democracy

Below, the gist of an email I sent to a local advocacy group I'm involved with, the BlueWaveNJ healthcare committee. Links added here.
The election results are something of a Rorschach test for each of us, but the core fact is Dems taking the House and 6-7 governorships. The House win was not a certain thing by any stretch, -- and it means Republicans can't crush democracy, the rule of law....or the ACA. Or Medicaid. Or, next up, Medicare -- which Republicans still want to privatize. The U.S. healthcare system in all its dysfunctional glory has been spared massive despoilment.

While the fate of ACA rules guaranteeing access to individual market insurance for people with preexisting conditions drew all the passion, the battle over ACA repeal has always been fundamentally a funding battle - mainly over funding for Medicaid, which the Republican repeal bills would have cut by some $800 billion dollars. Overall, in 2017 Republicans tried to cut $1 trillion-plus in federal spending to provide access to affordable insurance, eviscerating ACA marketplace subsidies along with Medicaid. That appears to be off the table.  So do Republican plans to cut even more than that going forward (reflected in the 2019 House budget resolution).

Friday, November 02, 2018

Miracle on 45's Watch

On the downside, there's Republicans' multi-front assault on ACA programs and funding. On the upside, there's a health access miracle that we can ratify on Nov. 6 -- if the U.S. doesn't suffer a second straight electoral catastrophe. By way of pre-election encouragement today, I look at the bright side on