Medicaid expansion states on HealthCare.gov account for nearly all enrollment losses in 2019

In yesterday's post, I  missed the most startling point in the ACA enrollment data I'd been staring at.

It's this: In 2019, virtually all of the enrollment decline in the ACA marketplace was concentrated in states on the HealthCare.gov platform that have expanded Medicaid. That's excluding Virginia and Maine, which are expanding Medicaid in 2019.*

Charles Gaba projects virtually flat enrollment in the states that run their own exchanges, in many of which enrollment for 2019 is still open. In the 16 remaining non-expansion states using HealthCare.gov, enrollment in 2019 is down less than 1% from enrollment in 2018 (excluding late adjustments, which should roughly cancel out similar adjustments made last year). Enrollment in the 21 HealthCare.gov states that have expanded Medicaid (excluding VA and ME) is down 7% in 2019. It was also down 7% in 2018, compared to 4% the in non-expansion states.

As I noted yesterday, outsized enrollment losses in 2018 were concentrated at lower income levels, where enrollment assistance is probably most vital, and where the value of Cost Sharing Reduction (CSR) mostly outstrips the value of  bronze and gold discounts generated by silver loading** (an income breakout is not yet available for 2019). In HealthCare.gov expansion states, enrollment in the 100-150% FPL income band, where CSR is strongest, cratered in 2018, dropping 14%. At 150-200% FPL, enrollment in these states dropped 11%.

At higher income levels, as was the case generally in 2018, silver loading discounts in these states seem to have partially offset the forces driving enrollment down at lower income levels. At 300-400% FPL, enrollment in these states was up 8% in 2018 (it was up 12% in non-expansion states).

Two key factors in state-by-state ACA enrollment performance

Last week, I noted that in the 39 states using the HealthCare.gov platform, enrollment declines from 2018 to 2019 were generally steeper in states that had accepted the ACA Medicaid expansion than in states that have so far refused to expand.

Excluding Virginia and Maine, which are expanding Medicaid as of Jan. 1 2019, 13 of the 18 states with enrollment performance above the hc.gov median are nonexpansion states, while 15 of 18 below the median are expansion states (as is Kentucky, at the median).

My working assumption is that a measure of enrollment stability in non-expansion states is grounded in the one third-plus of enrollees in those states who have incomes that would qualify them for Medicaid in expansion states (100-138% of the Federal Poverty Level). This is the income level at which ACA marketplace offerings are most affordable and comprehensive.  At 100-138% FPL, the premium for a benchmark silver plan with an actuarial value of 94% (average deductible $355) costs just 2% of income.

Apparently cutting against this hypothesis is the fact that in HealthCare.gov states in 2018, enrollment dropped 7% at 100-150% FPL while remaining essentially flat at 200-400% FPL, as at the higher income levels, silver loading discounts (see note at bottom) largely offset the effects of cuts to advertising and enrollment outreach. But the drop at 100-150% FPL was much steeper in the expansion states on the platform, where subsidy eligibility begins at 138% FPL (so that the income band is effectively 138-150% FPL). In expansion states on HealthCare.gov, enrollment in this income band cratered 14% in 2018, compared to 6% in the nonexpansion states.* At 138-150% FPL, a benchmark silver plan -- still at 94% AV -- costs 3-4% of income, compared to 2% of income for those below 138% FPL.  And while silver loading reduced enrollment losses at 200-400% FPL in 2018, the resulting discounts in many cases evaporated in 2019 (though new discounts also emerged).**

The chart below sets 2019 enrollment performance beside the percentage of enrollees in a state who obtain silver plans with the highest level of CSR, which raises the actuarial value of a silver plan to 94%.  That percentage is generally much higher in nonexpansion states, where over three quarters of the enrollees in 94% AV silver would be in Medicaid if their state had accepted the expansion. The relationship is significant, I think,  but can be trumped by silver loading effects, as they are in some (not all) of the highlighted states below, as well as by other factors noted below. In states marked in red, the relationship between the percentage of enrollees at 94% AV silver and enrollment performance is most sharply out of whack; in those marked in tan, more moderately so. The apparent effects (or lack thereof) of premium changes from 2018 to 2019 in highlighted states are discussed below.

The median percentage of enrollees with 94% AV silver plans in these 37 states is 19%. The median enrollment change is Kentucky's -5.38%.  I have excluded Virginia and Maine, as they are in the midst of Medicaid expansion.

Sources: Charles Gaba, CMS state-level Public Use Files, 2018.

About that "late enrollment surge"

At the end of Week 6 of Open Enrollment for 2019 in the 39 states that use HealthCare.gov, all-state enrollment, at 4,132,432, was 88.3% of the Week 6 total for 2018.

By the end of Week 7, the final week, the 2019 total (8,454,882) was 95.8% of the 2018 total. Surprise! News stories reference a late enrollment surge. But the surge was a mirage -- generated by a slight difference in the weekly breakdown of an enrollment season that was 45 days in both years. Or rather, the surge was normal and happens every year -- this year the pace did not accelerate more than last.

In CMS's weekly enrollment snapshots, "Week 1" had four days in November 2017 and three days in November 2018. "Week 7," conversely, had six days in December 2017 and seven days this December.

Enrollment season starts slowly and ends fast. This year, enrollments averaged 123,892 per day in Week 1 and 617,493 in Week 7. More than half of all enrollment -- 51% -- happened in the final week (boosted by about 1.7 million auto-enrollments or passive renewals, added in at the end). Last year, 47% of enrollees were booked in the final (6-day) week.

A key factor in state-by-state enrollment performance on HealthCare.gov

Okay, a rather elemental discovery regarding ACA marketplace enrollment for 2019, which was down 4.2% overall in 39 states using HealthCare.gov.

Courtesy of Charles Gaba, here is the enrollment performance by state, 2019 vs. 2018, with a little coloring book intervention of mine in the far-left column. What distinguishes the highlighted states?

The invisible primary for judicial repeal of the ACA

Slapped on a Friday evening with a hyperpartisan judge's palpably ridiculous decision purporting to strike down the entire ACA, I suspect that many progressive minds restarted a two-stroke motor that's been running since Texas v. U.S. first stained the horizon.

Stroke 1: this suit is too ridiculous even for Republican judges.  It claims in effect that Republicans in Congress repealed the entire ACA in a fit of absent-mindedness when they zeroed out the mandate penalty last December.

Stroke 2: we had the same reaction to the two prior anti-ACA suits to reach the Supreme Court, one of which failed by a 5-4 and the other by a 6-3 count. Will the absurd again become Republican orthodoxy?

Will this legal nightmare recur? Jack Balkin offers crucial perspective:

Blue waivers! Synthetic silver loading, anyone?

First the bad news: Seema Verma's CMS has invited states to undermine guaranteed issue and comprehensive coverage in their ACA marketplaces, floating four "waiver concepts" that converge on one idea: subsidizing medically underwritten, lightly regulated insurance.

Now the good news: CMS has invited states to be creative. Blue states might think about taking up the offer to redesign the ACA marketplace subsidy structure. Those states, however, will want to stay within the statutory "guardrails" for ACA Section 1332 innovation waivers that recent Trump administration guidance seeks to, um, wave away: provide coverage as comprehensive and affordable to as many people as does the existing marketplace design, without increasing the federal deficit.

The financial constraint -- deliver better benefits without spending more money -- has rendered Section 1332 something of a Catch-22 for states aiming to maintain a private market in which plans offer comprehensive coverage without regard to applicants' medical history.

But Trump's October 2017 cutoff of direct  reimbursement of insurers for Cost Sharing Reduction (CSR) and the resulting "silver loading" -- pricing CSR into silver plans only, since CSR is available only with silver plans -- has created a windfall that might be leveraged if CMS plays by Section 1332 rules. (See note below if you're unfamiliar with how silver loading works.)

Silver loading has inflated subsidies as well as premiums and created discounts in bronze and gold plans benefiting some two million enrollees, boosting enrollment and partially offsetting other forms of Trump administration sabotage. CBO estimates the cost to the Treasury at $194 billion over ten years. But the benefits have been haphazard and inefficiently distributed. Via waiver, perhaps a state could make better use of its share.

Is New Jersey's unsubsidized marketplace enrollment migrating off-exchange?

Politico and Modern Healthcare have both wondered why ACA marketplace enrollment for 2019 is down in New Jersey, as in most of the 39 states using HealthCare.gov. As MH's Shelby Livingston put it, New Jersey "did everything right" to boost enrollment -- swiftly passed a state individual mandate and implemented a reinsurance program that brought 2019 premiums an average of 9% below 2018 levels. Yet 5 weeks into Open Enrollment for 2019, enrollment is down 13% compared to 2018. In all 39 HealthCare.gov states, it's down 10.4%.

One hope is that lower premiums are driving more enrollees whose incomes are too high to qualify for subsidies into the off-exchange ACA compliant market. There should be at least some movement in that direction, for two reasons.

First, benchmark silver plan premiums dropped a long way -- 15% in much of the state. Consequently, fewer people with incomes at the upper end of subsidy eligibility qualified for subsidies this year, because the unsubsidized premium cost less than the "affordability" threshold, 9.86% of income at 300-400% FPL. In 2018 in New Jersey, 37,991 enrollees as of the end of Open Enrollment had incomes in the 300-400% FPL range.

Second, this year New Jersey's Department of Banking and Insurance actively encouraged insurers to use on-exchange-only "silver loading" (see note below) to offer cheaper silver plans off-exchange only. AmeriHealth and Oscar responded. AmeriHealth's three cheapest silver are offered off-exchange only; the cheapest one, a narrow network HSA, costs a 46 year-old $108 per month less than the cheapest on-exchange silver.  Oscar's cheapest off-exchange silver plan is $39 per month less for a 46-year old than its cheapest on-exchange silver.  And in Jersey, an unusually high percentage of off-exchange enrollees do choose silver -- 65% in 2018.

As of the end of Open Enrollment for 2018, New Jersey had 62,360 unsubsidized enrollees on-exchange. Some of those enrollees, plus a significant share of the 38k in the 300-400% FPL band, may have some incentive to move off-exchange.

A closer look at off-exchange enrollment in New Jersey, however, suggests that such movement may be limited.

Silver loading improves with age

I have noted before that ACA marketplace enrollment in 2018 was stronger at the upper income levels among those eligible for subsidies.

That's because the discounts in bronze and gold plans created by silver loading (see note below) are chiefly relevant to those who earn too much to qualify for strong Cost Sharing Reduction (CSR), which is available only with silver plans. Also, the huge spike in benchmark silver premiums in 2018 rendered more people in the 300-400% FPL subsidy-eligible than in previous years.

I just stumbled on a breakout I never used that shows a corollary: enrollment as a percentage of 2017 enrollment also rose with age This is in HealthCare.gov states:

Waiving the ACA marketplace away (at healthinsurance.org)

It doesn't matter to anyone but me, but work on articles for outside publications sometimes leads to long blogging pauses. Pending [update: now posted] : a look at likely fallout from CMS's "waiver concepts" released Nov. 29 -- very broad templates for how the Trump administration would like to see states implement ACA innovation waivers under the guidance CMS issued on Oct. 24.

That guidance took an ax to the so-called "guardrails" previously constraining the ACA Section 1332 innovation waivers: statutory requirements that alternative schemes developed in waiver proposals provide coverage as comprehensive and affordable to as many people as would the default ACA design, without increasing the deficit. Trump's CMS decoupled the requirement to provide coverage as comprehensive and affordable from the requirement to cover as many people, declaring that equally comprehensive/affordable insurance had to be merely "available," not "provided."

CMS also erased 2015 guidance stipulating that changes could not harm vulnerable groups such as low income, older or high-medical-need enrollees, declaring, in effect, that such populations could be harmed "slightly" in pursuit of covering more people more cheaply.

Three of the four waiver concepts ring variations on one uber-concept: using the federal dollars currently devoted to subsidizing coverage in the ACA marketplace to subsidize ACA-noncompliant products such as short-term plans.

In a pending post [now up] at healthinsurance.org, I try to flesh out how programs conforming to the "concepts" might affect the vulnerable populations named in the superceded 2015 guidance: low income, older, and sicker enrollees. In an outtake, I question whether proposals conforming to the concepts can adhere even to the weakened guidance CMS issued in October, let alone violating the ACA statute:

Further, it's questionable whether the waiver concepts could pass muster even under the new CMS guidance. The new guidance affirms that coverage as comprehensive and affordable as that on offer without the proposed scheme has to be available, even if fewer people choose it.. While the CMS fact sheet laying out the waiver concepts states that proposals must meet the statutory guardrails, it offers no hints as to how the developed concepts might satisfy even the "availability" standard.

That argument is developed in more detail (with respect to subsidizing noncompliant plans, prior to release of the waiver concepts) here. 

UPDATE, 12/8: Joel McElvain, a former Dept. of Justice lawyer who participated in the defense of the ACA in the two cases that reached the Supreme Court, has since argued in detail that the October guidance violates the ACA's statutory language. He also, by the way, affirms the thesis advanced in this post:

There is, at a minimum, substantial doubt as to whether some of the concepts that HHS described in the discussion paper could meet even the agencies’ newly-announced interpretation of Section 1332; it is questionable whether state residents would continue to have access to the same level of comprehensive, affordable health coverage under a waiver that siphons off healthy people from the risk pool, as HHS appears to be contemplating.     

We're in Cassidy-Collinsville, Chapter 2

Last March, Peter Suderman wrote a clever column claiming that Republican changes to the ACA -- repeal of the individual mandate, creation of a parallel ACA-noncompliant individual market -- were achieving the goals of the ACA repeal/replace bills. I noted the missing piece there: defunding the ACA, in particular the Medicaid expansion and Medicaid more generally. That was the "hot-beating heart" of the failed Republican repeal bills. Instead of AHCA- light, I suggested:

In the aftermath of the 2017 assault, the ACA resembles not so much a system established by a mainstream Republican repeal-and-replace bill as it does the kind of compromise that might have emerged from a negotiation over the Cassidy-Collins bill introduced in January 2017, if negotiation over such a plan had been possible (it wasn't, because no more than a handful of Republicans were interested in the bill).

Do CMS's new "waiver concepts" violate even the new waiver guidance?

When HHS and the Treasury first took a meat axe to the so-called "guardrails" to ACA Section 1332 innovation waivers in late October, I argued that the guardrails were not down entirely.

Specifically, even as CMS Administrator Seema Verma actively encouraged proposals that would allow premium subsidies to be applied to short-term or other ACA-noncompliant plans, a state would still have to use an ACA-compliant plan, or something very like it with guaranteed issue, to set the benchmark by which subsidies are calculated.

That's the case (I think) in spite of -- or maybe because of -- the shift in the new guidance from requiring waiver proposals to cover as many people as comprehensively as the ACA to merely making comparably affordable and comprehensive coverage available to as many people. Here's the key language:

The Departments may consider these guardrails met if access to coverage that is as affordable and comprehensive as coverage forecasted to have been available in the absence of the waiver is projected to be available to a comparable number of people under the waiver.

In ACA marketplace, more discount counties -- but which counties count?

Taking the country as a whole, are ACA marketplace offerings more or less attractive to prospective enrollees, subsidized and unsubsidized, in 2019 than in 2018?

The question takes on urgency as a lag in on-exchange enrollment persists into week 4 of Open Enrollment for 2019. In the 39 states using HealthCare.gov, enrollment is down 11% compared to this time last year. If plan offerings are roughly equal in value to last year's, depressed enrollment could easily be accounted for by repeal of the individual mandate penalty, establishment of a parallel lightly regulated, medically underwritten "short-term plan" market, and further drastic cuts to federal spending on enrollment assistance and advertising. Still, in 2018 the windfall bargains generated by silver loading (see note at bottom) partly offset the prior round of Trump administration sabotage, and the question lingers whether something similar may happen this year.

Some top-line facts may suggest that marketplaces are offering better value to more people in 2019 than in 2018. Unsubsidized premiums are down slightly on average. More states are silver loading, creating discounts in bronze and gold plans and/or encouraging insurers to offer off-exchange silver plans with no CSR load. The number of counties where a gold plan is available for less than the benchmark silver plan has increased from 595 in 2018 to 1136 in 2019. And the Kaiser Family Foundation reports that free bronze plans are available to subsidized enrollees at every subsidy-eligible income level in more counties in 2019 than in 2018.

There are counties and counties, however. One county may have 10 million people; another, 95. The Kaiser report includes a map that color-codes counties where free bronze is available to a 40 year-old with an income of $30,000 for the first time in 2019  A mouseover reveals that most of those counties are rural.

Lower benchmark premiums may contribute to reduced on-exchange enrollment in 2019

Three weeks into open enrollment for 2019, ACA marketplace enrollment in the 39 states that use HealthCare.gov is down 11%. compared to this time last year (adjusting for one less open day so far this year).  There's a lot of potential reasons for that: further draconian cuts to advertising and enrollment assistance, repeal of the individual mandate in tandem with allowing medically underwritten short-term plans to provide full-year renewable insurance, election distraction, etc.

One less recognized factor that could have a measurable impact on on-exchange enrollment for 2019 is a likely drop in the subsidy-eligible population at higher income levels, mainly 300-400% FPL.

Though marketplace enrollees are theoretically eligible for subsidies if their incomes are below 401% FPL, subsidies are only credited if the unsubsidized benchmark silver plan premium exceeds the percentage of income deemed affordable. At 300-400% FPL, that's 9.86% of income. Historically, many young enrollees in particular with incomes below 400% FPL did not qualify for subsidies (because unsubsidized premiums are lower for younger adults).

In 2018, benchmark premiums shot up 34%, due in large part to various forms of Republican sabotage. That spike doubtless helped drive a 10% increase in on-exchange enrollment at the 300-400% FPL income level in HealthCare.gov states, while enrollment dropped at every other income level.

Enrollment by income level, 2017 vs. 2018

HealthCare.gov 

Year	Total enrollment	100% to 150% FPL	151% to 200% FPL	201% to 250% FPL	251% to 300%  FPL	301%- 400%  FPL	Other FPL*
2017	9,201,805	3,208,242	2,050,555	1,312,520	752,403	786,678	1,091,407
2018	8,743,642	2,979,236	1,885,778	1,277,488	747,165	867,198	986,777
Change	-5.0%	-7%	-8%	-3%	-1%	+10%	-10%

* "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.

Drop in low income uninsured is partly due to drop in low income population

In 2015, I noted that Democrats had paid in political blood for devising a health reform scheme that primarily benefited people in the lower third of the national income distribution  (those with incomes below 200% of the Federal Poverty level), where more than half of the country's uninsured were concentrated pre-ACA.

Chance led me this morning to take a bird's eye view of how the income distribution of the uninsured changed from 2013 (pre-ACA) to 2017. This snapshot is based on the Census Bureau's annual September report, Health Insurance Coverage in the United States, for 2014 and 2017.

The percentage of the uninsured in the lowest income brackets has shrunk considerably. But that's in part because the percentage of the total population in those brackets has also shrunk.  In 2013, 39% of the population and 59% of the nation's uninsured were in households with incomes below $50k. In 2017, 49% of the uninsured and 34% of the total population were in households with incomes below that threshold.

Here is the breakout by income group.

How the ACA marketplace falls short of Medicare

When Americans turn 65, they're faced with a huge variety in Medicare offerings. In addition to or in place of the three parts of traditional, fee-for-service (FFS) Medicare, two of which require enrollee action to enroll, a typical enrollee may choose from among 10 distinct types of Medigap plan, each with a mandatory benefit structure, or from an average of 24 Medicare Advantage offerings that incorporate, with some tradeoffs, the benefits of  Medicare Parts A, B and D (hospital, medical  and prescription drug coverage). Low income enrollees may need often hard-to-find assistance, and a wheelbarrow full of financial documents, to access supplementary Medicaid or Medicare Savings Program (MSP) benefits that pick up all, most or some of their out-of-pocket costs.

Notwithstanding this Byzantine array of programs and choices, the generous national subsidization and fixed benefit structure of  FFM Medicare provide a stable backbone to the program. The bottom line is that 95% of the over-65 population has access to health insurance with an actuarial value a bit north of  80%  for something under $200 per month, with options that take AV up to 100% for up to about $400 per month. Step-ups for the wealthiest 5% of the eligible population are proportionate and affordable.  Roughly a sixth of some 45 million Medicare enrollees over age 65 are low income "dual eligibles" for whom Medicaid picks up much or all of out-of-pocket costs.

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 HealthCare.gov, 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 hc.gov 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 HealthCare.gov chief marketing officer Joshua Peck is less sanguine:

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: HealthCare.gov, 2017-2018

Year	Number enrolled at 0-200% FPL*	Percent enrolled at 0-200% FPL	No. enrolled at 201-400% FPL	Percent enrolled at 201-400% FPL
2017	5,507,246	59.8%	2,851,601	31.0%
2018	5,092,349	58.2%	2,891,851	33.0%

Source: Public Use Files (2018, 2017) published by CMS

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.

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).

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 healthinsurance.org

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.

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.