Sunday, December 08, 2019

Ross Douthat and the "expert-fashioned architecture" of the ACA

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Credit where due: Ross Douthat is a creative thinker, capable of carving new conceptual boundaries across familiar landscapes.  Today, claiming that Democratic voters have tired of Clinton- and Obama-style technocracy, he identifies the competing approaches to policy as moral (Bernie Sanders) and transactional (Joe Biden).

On the healthcare front, citing ""widespread left-wing disappointment with what the Obama-era politics of expertise produced," Douthat asserts:
This disappointment has been strongest on health care, where Obamacare’s most popular provision was the simple socialism of the Medicaid expansion rather than the complicated, expert-fashioned architecture of the exchanges.
He's right on the merits.  The Medicaid expansion accounts for probably 75% or more of the net coverage gains achieved by the ACA.  Enrollee satisfaction is far higher in Medicaid, which covers all of enrollees' costs, than in the marketplace, where satisfaction is inversely proportionate to out-of-pocket cost exposure, and at least half of enrollees are subject to high deductibles and out-of-pocket costs.*

Friday, December 06, 2019

Should Snoopy be your editor?

There is a Peanuts comic series in which Snoopy is working on a novel, and Lucy volunteers to draw a cover for it. Snoopy makes very specific demands, and Lucy returns with the finished product:
Lucy (handing the work product up to Snoopy on dog house): I've finished the drawing for the  cover of your new novel.

Lucy (as Snoopy examines): See? It shows a bunch of pirates and Foreign Legionnaires fighting some tigers and elephants leaping through the air toward a girl who is tied to a submarine.

 Linus (addressing Lucy as she walks away staring at her drawing): Did he like your drawing?

 Lucy: It needs more tigers. 
It needs more tigers. This often comes to mind when I am on the receiving or giving end of editorial input.

Wednesday, December 04, 2019

GetCoveredNJ hits cable TV with its first ad

This time last year, an email correspondent who closely watches the New Jersey ACA marketplace was tearing his hair out for the lack of TV advertising by state agencies working to boost enrollment. New York was flooding the airwaves with ads; NJ was invisible.*

The then-young Murphy administration entered Open Enrollment season flying high on a newly enacted reinsurance program and state-based individual mandate that together had reduced individual market premiums 9% below 2018 levels. While the Trump administration had gutted federal spending on enrollment assistance, from $1.9 million in 2016 to $300,000, the state was kicking in $800,000 for assistance and outreach.

Yet on-exchange enrollment lagged 2018 totals, finishing 7% down, compared to a 4% average drop in 39 states using the federal exchange, By this point (week 5), it was down 14% year-over-year (in all 9 states, a calendar discrepancy between 2017 and 2018 led to a sharp closing of the apparent gap in the final week).

Monday, December 02, 2019

Fewer Americans qualify for ACA marketplace subsidies

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Regardless of whether ACA marketplace enrollment for 2020 is lagging 2019 totals, one persistent marketplace headwind that should get more attention is the long economic recovery. In an article by Bloomberg's Sara Hansard, Andrew Strohman of the American Action Forum puts one finger to this wind:
Unemployment is now about 3.6%, compared with 4% in January. “You could see some more people taking up employer-sponsored insurance rather than enrolling in the individual market,” Strohman said.
Regardless of whether more people are in jobs that offer affordable insurance, the population with incomes in ACA subsidy range (100-400% of the Federal Poverty Level in states that have refused the Medicaid expansion, 138-400% FPL in states that have implemented it) has shrunk since the ACA marketplace launched in 2014. At the same time, the population with incomes above 400% FPL (and so ineligible for ACA subsidies) has swelled.

Friday, November 29, 2019

Just how poor is ACA marketplace takeup?

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If you hadn't looked at the Kaiser Family Foundation's Marketplace Enrollment as a Share of the Potential Population for a while, or the variant for subsidy-eligible enrollment, you would get the impression that the takeup of marketplace offerings has fallen sharply.

That's true, among the unsubsidized, who accounted for 42% of marketplace enrollment in 2016 vs. just 27% this year (see Figure 3 here).  And the picture has never been pretty. But marketplace failure is not as dire as these charts might lead you to believe. And the apparent falloff in enrollment takeup among the subsidy-eligible is an illusion, born of changing methodology and snapshots of different points in the yearly enrollment cycle.

The Kaiser charts that were live through 2017 (and maybe later) reflected enrollment as of March 31, 2016, i.e. after CMS's first-quarter effectuated enrollment snapshot for that year, at which point 87% of those who had selected plans as of the end of Open Enrollment had effectuated (and maintained) coverage. Reported takeup among the population estimated to be eligible for subsidies was 64%. Takeup among all who were eligible for marketplace coverage (i.e., lacking access to employer coverage or public programs like Medicaid and Medicare) was estimated at 40%.  In the current charts, based on enrollment in December 2018, takeup among the subsidy-eligible is estimated at 46%, and among all who might buy marketplace plans at 34%.

Yow. But...

Monday, November 25, 2019

The Kaiser Family Foundation is shaping (or showing the shape of) our healthcare debate

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There is a subtext to Abby Goodnough's excellent overview of voters' preference for a public option or Medicare buy-in over Medicare for All:  the extent to which the Kaiser Family Foundation and its tracking poll of voters' healthcare concerns and perceptions are shaping the debate.

Voters cited in Goodnough's piece reflect the concerns about M4A flagged in Kaiser polls:
About two-thirds of voters like the idea of a public option or Medicare buy-in, according to several recent national polls. This month, the Kaiser Family Foundation tracking poll, which has asked voters about the plan four times since July, found that 65 percent of the public favors the idea, compared with 53 percent who support “Medicare for all.” Large majorities of Democrats and independents favored a public option in Kaiser’s November poll, as did 41 percent of Republicans — roughly the same level as earlier Kaiser polls found but down from an unusual spike of 58 percent in October....

Friday, November 22, 2019

In Health Affairs: Silver loading goes into reverse, cont.

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A Health Affairs blog post by David Anderson, me, and Coleman Drake probes the likely impact of reduced silver loading effects in the ACA marketplace this year. In brief, there are fewer counties nationwide where plans below the benchmark are free to many enrollees, and fewer counties where gold plans cost less than benchmark silver. 

One profound impact may be where potential spreads are narrowest: between benchmark silver and the cheapest silver plan in each region.
The reduced silver spread, while small in dollars, may have a profound impact. At incomes up to 200 percent of poverty, the value of CSR—a free added benefit—exceeds the value of most bronze and gold plan discounts generated by silver loading. Accordingly, enrollees with incomes in the 100–200 percent of poverty range—56 percent of all enrollees in states in 2019—have mostly stuck to silver plans: According to Aron-Dine, 84 percent of enrollees in this income bracket selected silver in 2019, down slightly from 87 percent in 2017. In that same period, enrollees with incomes in the 200–400 percent of poverty range, for whom CSR is unavailable or negligible, took broad advantage of discounts in bronze and gold plans, reducing their silver selection from 60 percent in 2017 to 35 percent in 2019.

Wednesday, November 20, 2019

Another Hanukkah miracle due in Week 7 of ACA Open Enrollment for 2020?

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Last year, enrollment in the ACA marketplace in the 39 states using trailed the prior-year enrollment pretty dramatically in each of CMS's "weekly enrollment snapshots."  By the end of Week 6, enrollment was at 88.3% of the total at the same point in December 2017.  Then lo, at the end of Week 7 the gap had shrunk from 12% to 4%.  What caused the late surge?

The surge was illusory. Week 1 was a day short last year. That was no mystery, and trackers accounted for it, noting that first-week enrollments stood at about 125,000 per day. What was not fully accounted for in advance was that the extra day made up in Week 7, which had seven enrollment days last year vs. just six in 2017, carried a lot more weight than the shorted November day, as enrollment is much heavier at the end of the season. As I noted at the time:

Tuesday, November 19, 2019

Hey blue states: How about offering a public option off-exchange only?

Louise Norris, clearest of expositors, has some mildly ambiguous wording here that set off a lightbulb:
Colorado enacted legislation in 2019 that directed the state to explore ways to create a public option health insurance program that could offer a lower-cost alternative for people who buy their own health insurance.
Eureka: Why doesn't a state offer a public option off-exchange only? That would solve the dilemma caused by the ACA's underfunded subsidies: measures that reduce ACA marketplace premiums for unsubsidized  buyers tend to raise them for subsidized buyers.  (Colorado is not moving toward this option.) N.B. in most states, ACA-compliant plans are offered off-exchange as well as on-exchange. This public option would be ACA compliant.

Friday, November 15, 2019

I almost got snared in the short-term health insurance market

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Sarah Gantz, a Philadelphia Inquirer reporter, has done some great work spotlighting people who were snared by sales pitches for short-term health plans that left them with huge bills when they got seriously ill or injured. Her latest concerns a woman who got stuck with a $36,000 bill when her fixed indemnity plan covered only a small fraction of the tab for surgery after she broke her wrist and back (!) -- (the latter doesn't seem to have caused lasting damage):
Martin thought she’d bought a comprehensive health insurance plan through the government-regulated Affordable Care Act marketplace, But she really visited a website cunningly crafted to look like an ACA portal, which put her in contact by phone with a salesman. He sold her plan that turned out to offer only minimal coverage, and when Martin needed help, his number was disconnected.
The larger point is that since the Trump administration changed the rules to enable so called short-term, limited duration (STLD) plans to extend plan terms to up to a year, and touted them as a cheap alternative to ACA-compliant plans, deceptive marketing for such plans has exploded. Robocalls, websites meant to snare people seeking (with help from Google ads), and hard-sell-quick-sell phone techniques are well chronicled by Gantz.

Louise Norris, a broker of individual market insurance who puts her clients' interests first (and has compiled a virtual encyclopedia on the subject at, acknowledges that there is a role for STLD plans, and that not all of them are terrible. But the market is honeycombed with coverage traps.  In fact, Louise helped me, and someone I was helping, avoid perhaps the subtlest of snares in the STLD market.

Thursday, November 07, 2019

Elizabeth Warren crosses a rhetorical Rubicon

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For almost two years, I have complained at intervals that Elizabeth Warren is faking it on healthcare --- that is, blaming U.S. healthcare dysfunction entirely on the rapine of health insurers and pharma, while giving healthcare providers a pass.

In presenting her plan to finance Bernie-brand Medicare for All, Warren leads with this rhetorical reflex but then, finally, departs from it. She has to, as the plan's viability depends on cutting off providers' most lucrative revenue sources.

Warren's first rhetorical strike in this manifesto is against the usual suspects:

Wednesday, November 06, 2019

Elizabeth Warren's healthcare two-step

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I owe a debt of gratitude to a Jacobin writer, Tim Higginbotham, who lambastes Elizabeth Warren for a) going into what he regards as unproductive detail about the financing of Medicare for All and b) signaling that she doesn't intend to enact M4A any time soon.

It's the latter that interests me. It solves something of a riddle. And unlike Higginbotham, I approve of this message. I think there may be a kind of deep realism in it, not severable from real commitment to major structural change.

Higginbotham notes that Warren's pay-fors depend in part on enacting other major legislation, and that her language accordingly projects Medicare for All into an..eventuality:
Warren’s remaining financing methods bring us to the biggest problem with her plan: its clear lack of urgency. Warren argues that her plan for comprehensive immigration reform could free up $400 billion toward Medicare for All over ten years, while cutting the dangerous military slush fund will free up another $798 billion.

On their own these are important goals, but using major political fights like these to cobble together funding for Medicare for All is a fairly good tell that Warren’s plan is not designed to be implemented anytime soon. This is further evidenced by the language in Warren’s Medium post about her plan: she describes Medicare for All as a “long-term” goal seven times, while couching the rest of the post in similar language (such as saying she wants to move to a Medicare for All system “eventually”).
That's absolutely right. And in fact, near the end of her Medium piece introducing her M4A funding plan, Warren makes it explicit that she won't be fighting to enact BernieCare from day 1, 2021:
Of course, moving to this kind of system will not be easy and will not happen overnight. This is why every serious proposal for Medicare for All contemplates a significant transition period.

Friday, November 01, 2019

How would a 20% drop in base ACA marketplace premiums affect enrollment?

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My last post delved into the paradox of reinsurance in the ACA marketplace: lower base premiums tend to produce higher premiums for subsidized buyers who select plans that cost less than the benchmark (second cheapest silver) plan. Lower premiums also tend to reduce bronze plan discounts generated by silver loading* -- though potentially increasing gold plan discounts.

Just how much do premiums reductions reduce discounts in below-benchmark plans? The effects can be sampled with reference to the average premium nationwide for the lowest cost plan (LCP) at each metal level in 2020, courtesy of the Kaiser Family Foundation.

Below, I compare net-of-subsidy premiums for those averages to net-of-subsidy premiums when those base premiums are cut by 20%. That's the average reduction effected by the seven state reinsurance programs already in operation, according to Avalere. The 20% reduction is compared to what premiums would have been absent the reinsurance, not what they were in the previous year.  In New Jersey, for example, reinsurance cut premiums by 15% in 2019, and a state individual mandate by an additional 7% -- but premiums were 9% below 2018 levels.) Still, let's stick with 20% to make the effect easily visible.

Thursday, October 31, 2019

Should states pursue reinsurance for their ACA marketplaces?

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While sabotaging the ACA marketplace on multiple fronts, the Trump administration has from the beginning supported one means of keeping premiums down: encouraging states to submit waiver proposals seeking federal funding for reinsurance programs.

These programs partially reimburse insurers for costs incurred by individual enrollees that cross a certain threshold. In New Jersey for example, the program pays 60% of an enrollee's costs exceeding $40,000 per year, up to a threshold of $250,000. To date, CMS has approved 12 state reinsurance waiver proposals, 7 of them implemented by 2019.

The ACA marketplace began life with a national federally funded reinsurance program, but it sunset after three years (2014-2016). Not coincidentally, premiums nationwide rose by about 25% in that year -- a year of correction, in which insurers also recognized that they had significantly underpriced coverage in the ACA's first three years. They recovered profitability in 2017.

By reducing premiums, reinsurance also reduces premium subsidies. Trump's HHS has proved willing to pass much of the savings through to the states, providing tens-to-hundreds of millions of dollars annually to the approved programs.

The case against reinsurance

Some progressives, however, have concluded that reinsurance is a poor use of state resources. The ACA benefit structure subjects these programs to a Catch-22: Reducing base premiums tends to raise premiums for subsidized enrollees.

Tuesday, October 29, 2019

Looks like New Jersey's reinsurance trade-off paid off

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New Jersey's Department of Banking and Insurance has published second quarter enrollment numbers for the state's individual market for health insurance. Some upside surprises:

New Jersey Individual Market Enrollment, Second Quarter 2018 to Second Quarter 2019
Q2 2019
Q2 2018
# change
% change

  • Off-exchange enrollment is up from the first quarter -- unusual, because anyone enrolling after December 15, 2018 would have to qualify for a Special Enrollment Period. In Q1, off-exchange enrollment was up 2.98% year-over-year. In Q2, it's up 8.7% over Q2  2018, to 92,798. 

  • On-exchange enrollment, which was down a disappointing 7.1% as of the end of Open Enrollment, has had much lighter attrition than in previous years. It's down just 1.6% since Q1, compared to an average Q1-to-Q2 drop of  6.8% in the three previous years. Accordingly, it's down just 1.1% from Q2 2018.

  • Total individual market enrollment is up 1.6% compared to Q2 2018.  That's all in ACA-compliant plans, as New Jersey bans the lightly regulated, medically underwritten short-term plans promoted by the Trump administration.
New Jersey's 2019 experience is something of a case study for what you might call the reinsurance tradeoff.

Sunday, October 27, 2019

Silver loading 2020 update: The sky isn't falling

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Last week I noted that the discounts for subsidized ACA marketplace enrollees generated by silver loading (see explanation at bottom)* are likely to be somewhat reduced in 2020, given that a) average unsubsidized premiums are down 3-4%, b) and average premiums for the benchmark silver plan are down more sharply (-4%) than average premiums for the cheapest plan at each metal level (-3%).

Let's see how price spreads and discounts at each metal level have changed in the counties with the highest marketplace enrollment nationwide. Together, these 9 counties hold 16% of all on-exchange ACA marketplace enrollment.

Friday, October 25, 2019

Oscar throws a wild card into the 2020 ACA marketplace

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Re the premise of my prior post -- that discounts in bronze and gold plans will be weaker in the 2020 ACA marketplace:  I've stumbled on a wild card, and it's pretty wild. Let's start where we did yesterday:
CMS has published ACA marketplace premiums for 2020.  The top-line news is that premiums have dropped 3-4%.  The key point for subsidized enrollees (69% of the ACA-compliant market) is that silver loading has gone into reverse -- and consequently there will be fewer discounted plans available. That's because benchmark silver plan premiums -- the second-cheapest silver plan in each market, which determines subsidy size -- have dropped more sharply (-4%)  than average premiums for the cheapest plan at each metal level (-3%).
Okay, so discounts stemming from silver loading* may be reduced on average, and in particular, discounts in cheapest silver may be the most impaired. Now for the wild card: Oscar is offering a $0 deductible bronze plan in Florida and Texas (and maybe elsewhere, but those two states account for a quarter of all ACA marketplace enrollment). In Miami, for a 40 year-old at an income of $17,300 -- about 140% FPL -- it's zero premium too; at $24,900 income (just below 200% FPL) it's $79/month.

Thursday, October 24, 2019

Silver loading goes into reverse in 2020

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CMS has published ACA marketplace premiums for 2020.  The top-line news is that premiums have dropped 3-4%.  The key point for subsidized enrollees (69% of the ACA-compliant market) is that silver loading has gone into reverse -- and consequently there will be fewer discounted plans available. That's because benchmark silver plan premiums -- the second-cheapest silver plan in each market, which determines subsidy size -- have dropped more sharply (-4%)  than average premiums for the cheapest plan at each metal level (-3%).

Silver loading, recall, is the byproduct of Trump's October 2017 cutoff of direct federal reimbursement to insurers for the Cost Sharing Reduction (CSR) subsidies they are required to provide to low income marketplace enrollees who select silver plans. Faced with the cutoff at the brink of open enrollment for 2018, most state insurance departments allowed or encouraged insurers to price CSR into silver premiums only. Since premium subsidies, designed so that the enrollee pays a fixed percentage of income, are set to a silver plan benchmark (the second cheapest silver plan), inflated silver premiums create discounts for subsidized buyers in bronze and gold plans.

Tuesday, October 22, 2019

What is Elizabeth Warren cooking up?

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Quick, what's the difference in the way the Des Moines Register and the New York Times quoted Elizabeth Warren's recent I'll-have-a-plan promise?

Des Moines:
"Right now, the cost estimates on Medicare for All vary by trillions and trillions of dollars. And the different revenue streams for how to fund it — there are a lot of them," she said to a crowd of about 475 at Simpson College. "So this is something I’ve been working on for months and months and it’s got just a little more work until it's finished."
New York:
“I plan over the next few weeks to put out a plan that talks about, specifically, the cost of Medicare for all and, specifically, how we pay for it,” she told the crowd at the event, held at Simpson College.

On Trump's fight to uninsure people

Saturday, October 19, 2019

Rule of law, for now

It is contingently heartening that Trump administration's most egregious and damaging attempts to restrict government-supported access to healthcare for immigrants and low income people have so far been slapped down by the courts.  That is, Medicaid work requirements in Kentucky and Arkansas, and the public charge rule, stayed nationally for now.

The counterpoints are many: these stays were all imposed by Clinton and Obama appointees; the Supreme Court could overturn all; the stayed public charge rule is still having a chilling effect, inducing immigrants to forgo vital services for their children as well as themselves; and an ideologically blinkered 5th Circuit may be on the brink of striking down or impairing the ACA - in which case its fate may depend on aged liberal justices surviving through next June.  Our institutional resilience is the sound of one hand clapping.

I have a post in progress for to this effect -- this one's a placeholder.  [update, 10/22: here it is].

Tuesday, October 15, 2019

Privatizing Medicare: Paul Ryan's soul goes marching on

ICYM the prior post on Trump's executive order aiming to advance the privatization of Medicare on multiple fronts, I've had the chance to refine it twice, on BlueWaveNJ and at (hence the blogging drought here).

The short version (from the post):
Issued on October 3, Trump’s order instructs the Secretary of Health and Human Services (HHS) to take steps aiming to
  • “Voucherize” Medicare in the manner proposed by Paul Ryan – that is, let private Medicare Advantage plans set prices for traditional Medicare, rather than vice versa as at present.
  • Create a private insurance market outside of Medicare for wealthy seniors that would likely lure doctors away from participation in Medicare.
  • Subject Medicare enrollees to the joys of “balance billing” – getting billed by providers for amount in excess of their normal share of the Medicare bill.

Friday, October 04, 2019

Trump's bid to destroy Medicare

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It's clear that Trump is working to destroy U.S. democracy -- selling U.S. aid and favors to countries in exchange for pursuing trumped-up charges against his political opponents.

Now he's following up via executive order with a bid to destroy Medicare.

In the runaway train that is U.S. healthcare costs, Medicare (and Medicaid) is the only substantial brake, in that the government sets prices paid to providers, albeit with outsized provider input. Medicare hospital rates are about half* those paid on average by commercial insurers. Rates paid to physicians average about 78% of commercial rates -- and in high-demand specialties and regions with few providers, commercial insurers often pay four, five and six times Medicare rates.

In countries that successfully offer universal coverage, the government either serves as the sole payer, sets rates for all payers, or oversees all-payer negotiations. The U.S. alone leaves commercial insurers to be divided and conquered by payers. That's the main reason U.S. healthcare costs average about double the OECD average.

In an executive order that begins with a deranged preamble slandering Medicare for All proposals, Trump orders the Department of Health and Human Services to prepare the ground for ending Medicare rate-setting:

Saturday, September 28, 2019

The logic underpinning Medicare for all who want it

Blog as sketchpad: as employer-sponsored insurance continues to slowly, steadily bleed Americans white, I think the case for a strong public option that anyone can buy into on an affordable, income-adjusted basis boils down to a few simple propositions:

1. Employer insurance is deteriorating because employers (through insurance intermediaries) lack pricing power. Every year, premium and OOP increases exceed inflation and wage growth.
2. The competition needed to endow them with that power is a strong public option paying providers Medicare rates or some variant.
3. Once such a public option establishes all-payer rates, either de facto or by fiat**, we will have space to determine whether private insurance adds any value
4. Under those revamped market conditions, we can afford to be agnostic as to whether private insurance survives or dies.

FN - This little credo started life as a postscript to a slightly longer version of the argument.

* The Medicare for America bill, which establishes a strong public option paying modified Medicare rates (110% Medicare, with adjustments for primary care, mental health and underserved areas), stipulates that providers who accept the public plan must accept the same payment rates from commercial insurers. Competition from a strong public option could more slowly have the same effect.

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Friday, September 27, 2019

Just how big a bite does healthcare cost growth take out of earnings?

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The Kaiser Family Foundation's Employer Health Benefits Survey for 2019, released this week, shows a continued upward march in premiums and out-of-pocket costs. While costs have risen more slowly in the past five years than in the previous five, and in the last ten years (2009-2019) than in the previous ten (1999-2009), they continue to outpace inflation and wage growth. 

To get a feel for how much wage growth is eaten by health costs, let's look at some broad averages: the average increase in premiums and deductibles set against the average increase in the mean wage. Jeffrey Young's overview of the survey results at HuffPost provides a useful starting point:
In the past 10 years, the average premium for job-based health insurance that covers a family has risen 54%, to $20,756. Moreover, the amount of that premium workers pay for family coverage has increased 71%, to $6,015.

Thursday, September 26, 2019

Employer-sponsored insurance as we know it is unsustainable. Now what?

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Kaiser's 2019 Employer Health Benefits Survey, released yesterday, highlights a basic I noted a month ago (based on a Kaiser precursor report): employer-sponsored health insurance is deteriorating. Average family plan premiums have topped $20,000; average deductibles have topped $1,600. Family premiums have increased 54% over ten years. That's actually down from the previous ten years, when rates more than doubled. But the climb in excess of inflation has been relentless.

The system most consistently fails low income workers -- many of whom would be better off if the employer offered no insurance, rendering them eligible for ACA marketplace subsidies. KFF president Drew Altman lays out the basics:
  • Roughly 36 million American workers earn $25,000 per year or less — retail workers, personal care attendants, warehouse workers and many more.
  • Just 33% of workers at lower-wage firms offering health benefits are covered by their employer’s health benefits, well below the 63% share at other firms offering coverage.
  • These low-wage workers pay an average of $7,000 per year just toward the premium for a family plan.
  • Workers in low-wage firms also face much higher deductibles: a $2,679 annual single deductible, while at other firms, the average is $1,610.
My takeaways:

Wednesday, September 25, 2019

Unsubsidized? Buy bronze (probably)

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In a post yesterday, David Anderson clarified something I understood only vaguely: once a health plan enrollee meets her deductible, her incurred costs will reach the plan's annual out-of-pocket (OOP) maximum much more slowly in a plan with a high actuarial value (say, a plan covering 80% of costs) than in a low-AV plan (covering 60% of costs).

The ACA requires plans to cap enrollees annual OOP costs at no more than $7,900. Most plans at all metal levels have OOP caps over $5,000, with the exception of silver plans enhanced by strong Cost Sharing Reduction CSR) subsidies available to low income enrollees.  By the standards of the U.S.'s peer countries, that's a grotesque amount of risk for an average person to assume, but that's the world we Americans have made ourselves.

Anderson plots the rate at which an enrollee's total incurred medical costs will hit the maximum allowable OOP max in  bronze, silver, and gold plans with these features:

Monday, September 23, 2019

Elizabeth Warren's healthcare toggle switch: A two-year review

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An hour ago I stumbled on a two year old post teasing out Elizabeth Warren's ambivalence about Bernie Sanders' Medicare for All bill, as expressed on the occasion of her co-sponsoring it. That's led me to reflect on the apparent cross-currents in Warren's mind drawing her alternately toward and away from fast-track hard-core single payer.

Here are some longstanding key points in Warren's healthcare stance, fleshed out in the links provided at bottom.

1. Warren's entire political outlook and diagnosis of the U.S.'s economic and political woes is founded on her understanding of the impact of medical debt and other costs of illness (e.g., lost wages) on ordinary Americans.

2. Warren's outrage against banks and other financial institutions that she views as helping Americans "drown in debt,"  taken up several notches in the wake of the 2008 financial crisis, transfers easily to outrage against health insurers -- which are, after all, financial institutions of a sort.

Friday, September 20, 2019

What's so great about Medicare?

Kaiser Family Foundation polling indicates that when a majority of Americans say they're in favor of Medicare for all, most are thinking of the program as it currently exists, not as Bernie Sanders re-imagines it.*

Which raises the question: Why is Medicare's brand so strong?  I've explored the question over at, companion site to

Personally I would rate Medicare somewhere along the lines of a review advertised by a Cleveland restaurant long ago: Not great, but more than adequate when you consider the alternatives. For all its gaps and flaws, Americans exhale when they hit age 65. Hope you'll click through for a bit more detail.

* Most apparently are also thinking that everyone should be able to opt in, not that everyone should be auto-enrolled with no alternatives.

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Thursday, September 19, 2019

Buttigieg goes first! -- Decries predatory hospital pricing and proposes to do something about it

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I have been part of a chorus of healthcare writers complaining that when Democratic presidential candidates excoriate profiteering by health insurers and pharma, they always give providers a pass. Relatedly, my last post salutes three hard-hitting stories published this year -- two of them in the last week -- that spotlight predatory billing or collections by hospitals and private equity-owned physician staffing companies.

While no candidate participating in the September 12 CNN debate took Kaiser Health News editor-in-chief Elizabeth Rosenthal's pre-debate invitation...
one candidate caught the cue this week. Today, Pete Buttigieg is out with a "Medicare for all who want it" plan (rather like Biden's, FWIW). In a statement, as reported by HuffPost's Jonathan Cohn, Buttigieg rounded up the usual healthcare suspects -- plus one (my emphasis):
“For years, Washington politicians have allowed the pharmaceutical industry, giant insurance companies, and powerful hospital systems to profit off of people when they are at their sickest and most vulnerable,” Buttigieg said in a prepared statement. “My ‘Medicare for All Who Want It’ plan will create a health care system that puts power in the hands of each American.”

Tuesday, September 17, 2019

Healthcare regulation by exposé

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It's been said that shaming by journalists doth not a regulatory regime make. But in 2019, national healthcare reporters are giving it a go.

Back in January, Sarah Kliff, then at Vox (now at the NYT), reported that Zuckerberg San Francisco General Hospital, a go-to destination for trauma victims, did not accept any private insurance plans. Every private who enters the hospital gets balance billed (or did at the time of writing) -- often for tens of thousands of dollars. The stories were vivid and egregious.

The next shoe dropped in April:
Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies, a move that comes three months after a Vox story drew national attention to the hospital’s abnormal and aggressive billing tactics.

Thursday, September 12, 2019

Uninsurance goes upscale: The Census's Health Insurance Coverage Update for 2018

Yesterday the Census Bureau* released its health insurance estimates for 2018. The top line showed a rise in the uninsured population of 1.9 million, or 0.5% -- the first increase since the ACA's main programs launched.

Disturbingly, the number of uninsured children increased by 425,000, or 0.6%, raising children's uninsured rate to 5.5%. That spike would appear to be due mainly to a drop in Medicaid coverage, given that  Medicaid and CHIP coverage for children was down 1.2%; and the overall percentage of children with public health insurance dropped 0.8%, while the percentage of children with private health insurance ticked up 0.2%. There was also, however, a sharp spike in the uninsured rate among children in households with incomes over 400% of the Federal Poverty Level (FPL), from 1.9% in 2017 to 2.6% in 2018 -- accounting for almost half of the increase in uninsured children.

Folks at Georgetown University and the Center for Budget and Policy Priorities will probably dive  into the spike in uninsured children, as they have been doing for at least a year. Here I just want to throw some sidelights on the Census numbers generally.

1. Affluent uninsured population spikes. Notwithstanding a drop of 2 million  (0.7%) in Medicaid enrollment, the sharpest increases in the uninsured were at high incomes. At 300-399% FPL, the insured rate dropped a full percentage point, from 92.9% to 91.9%, and at over 400% FPL, the rate dropped 0.8%, from 97.3% to 96.6%. Together, these two income groups account for 55% of the population. Particularly striking, the number of uninsured at incomes over 300% FPL increased 23.8% (from 6.631 million in 2017 to 8.215 million in 2018).  The spike in uninsured children at high income levels seems congruent with this drop.

Tuesday, September 10, 2019

When silver loading discounts trump strong CSR (the nonexpansion state "advantage," take 5)

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This post picks up where the last one left off, further examining potential partial explanations for why ACA marketplace enrollment declines on in 2019 were much sharper in states that have expanded Medicaid than in states that have refused the expansion. I raised a question in that post, bolded in the excerpt below.

Enrollment changes by income, states
2019 enrollment as a percentage of 2018, as of the end of OE in each year

State group
Total enrollment
100-150% FPL
150-200% FPL
100-200%  FPL
200-400% FPL
* Excluding Virginia and Maine   Source: CMS state-level public use files 

The enrollment performance gaps at 100-200% FPL and 200-400% FPL are comparable. I would be tempted to suggest that the gap at 100-150% FPL is due to the concentration of low income enrollees in the nonexpansion states (those at 100-138% FPL, who pay less for top-level CSR silver plans than do those at 138-150% FPL), and that the gap at 200-400% FPL is due to stronger silver loading in the non-expansion states. But the large performance gap at 150-200% FPL kind of belies that -- unless, perhaps, silver loading at that income level is pulling more prospective enrollees into free or ultra-cheap bronze plans in the nonexpansion states. In the silver loading era, silver plan selection at 150-200% FPL has dropped from 83% in 2017 (pre silver loading) to 76% in 2019 in states. The lure is bronze coverage that is often free at that income level, while benchmark (second cheapest) silver costs about $130/month at 200% FPL. I guess I need to test whether bronze selection in this income band has risen faster in nonexpansion states.

Friday, September 06, 2019

Why 2019 ACA enrollment drops were concentrated in Medicaid expansion states on, Take 4

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In December and January, I took several whacks at explaining why 2019 enrollment losses in the 39 states were concentrated in the states that had expanded Medicaid. In those 21 states, plan selections as of the end of Open Enrollment were down 7% from 2018, compared to a 1% drop in 16 states that have refused to expand Medicaid. (I excluded Virginia and Maine, which expanded Medicaid in 2019, affecting enrollment options and results.)

First hypothesis was that the heavy concentration of enrollees in non-expansion states with incomes that would have qualified them for Medicaid in expansion states is especially "sticky." People in this income group (100-138% of the Federal Poverty Level) pay just 2% of income for a benchmark silver plan that comes with the highest level of Cost Sharing Reduction (CSR), raising the actuarial value of a silver plan to 94%, which usually translates to a deductible in the $0-500 range.  About a third of enrollees in nonexpansion states are in this income category. While about 15% of enrollees in expansion states have incomes in the 138-150% FPL range, which qualifies them for the 94% AV silver, they pay 3-4% of income for the benchmark.

Second hypothesis was that silver loading effects are stronger in nonexpansion states, because all those low income enrollees raise the average actuarial value of silver plans (which varies with income). In Florida, the blended AV of all silver plan enrollees is 91.5% in 2019.  (If you're unfamiliar with silver loading, see the note at bottom.)

Recently a third possible factor occurred to me: expansion states have a higher percentage of enrollees with incomes too high to qualify for subsidies, and enrollment losses among the unsubsidized were much steeper in the market as a whole than among the subsidized. This factor did play a role, but it was partly offset by the fact that in this category losses were steeper in nonexpansion states. The higher concentration of unsubsidized enrollees in expansion states cancelled out that advantage, however, so that losses in unsubsidized enrollment took basically equal bites out of total enrollment in both groups.

Sunday, September 01, 2019

For further study

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I'm going to be a little Labor Day weekend lazy here and jot down a few questions I'd like to look into, rather than provide any actual information about them. If you have any answers, please comment!

1. Credential inflation.  My wife, a certified nurse-midwife, rolls her eyes at the increasing impossibility of getting credentialed in her field without a doctorate. She spoke recently to a young labor & delivery nurse who's planning to become a midwife and is facing four years of study and likely debt. Apparently you can't get certified as a midwife in NJ now without doing the doctorate (not a Ph.D.), and that's a nationwide trend. "We have to do it," was the word for a university program director, because all the other nursing specialty and other non-physician medical professions like OT are doing it.

Tuesday, August 27, 2019

Healthcare reformers can't leave employer-sponsored insurance untouched

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Presidential candidates and other Democrats who want to patch or build on the ACA rather than create a substantially new system generally neglect, to varying degrees, an attendant problem: employer-sponsored insurance (ESI) is also in dire need of reform.

A Kaiser Family Foundation's report on large employer coverage released this month found that health spending by families in large employer plans has grown twice as fast as wages over the past decade. The employer share of costs in family coverage (premium plus out-of-pocket) has downticked only slightly:  it was 68% in 2008 and 66% in 2018.  But families and employers alike are tapped out: total costs increased 67% over those ten years. The total cost of large group coverage for a family of four now averages $22,000 per year. Reducing healthcare costs is among voters' top priorities.

Beyond the steady-but-high yearly increases recorded by Kaiser, yesterday NYT reporters Reed Abelson and Katie Thomas spotlighted a recent development that could be destabilizing: the proliferation of specialty drugs for rare diseases, which can carry price tags in the millions per patient per year. As Abelson and Thomas note, about 10% of the population is afflicted with rare diseases,  and more than half the drugs approved in 2018 targeted such diseases.

Monday, August 26, 2019

Who pays for astronomically expensive orphan drugs? Some questions prompted by the NYT report

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The Times' Reed Abelson and Katie Thomas have a major story exploring a key factor in rising healthcare costs: specialty drugs for rare diseases, which increasingly can carry price tags in the millions per patient per year. The trend and the impact are laid out succinctly:
Rare diseases, however, aren’t all that rare. There are an estimated 7,000 of them, and about 30 million Americans have one — roughly the same number of people in the United States with diabetes. And although there are no treatments for most rare diseases, new therapies are coming on the market nearly every month,  with some reaching beyond $2 million a year for a single treatment. Of 59 new drugs approved in 2018, more than half, or 34, were for rare diseases. 
Leaving aside the broad question of how the U.S. might contain costs for these drugs without choking off their development, the story prompted a few thoughts and questions about how these costs are currently distributed, and how that might change. Some factors to consider:

Thursday, August 22, 2019

Surprise! New Jersey ACA marketplace outperforms the national market

When CMS reported enrollment totals in the ACA marketplace at the end of Open Enrollment last December, the news for New Jersey was disappointing.

Despite (or per below, partly because of) a 9% average reduction in premiums last year, fruit of a new reinsurance program and a state-enacted individual mandate, on-exchange enrollment dropped 7.1% -- a performance that lagged the national marketplace (down 2.7%) and the 39 states that rely on the federal platform (down 3.8%) -- though right at the median for states that have expanded Medicaid (and so get less juice from silver loading)*.

When the state released off-exchange numbers in June, the results provided a measure of consolation. Off-exchange enrollment was up 3%, shrinking the total individual market enrollment loss to 4% from Q1 2018 to Q1 2019.

The main cause of the contrary results is not hard to find. Three quarters of on-exchange enrollment in New Jersey is subsidized.  In David Anderson's pithy formulation, "Reinsurance, all else being equal, helps the unsubsidized and hurts the subsidized." That's true of any measure or market force that reduces average premiums. When the benchmark (second cheapest silver) plan premium goes down, subsidies are reduced accordingly, and price spreads between the benchmark and cheaper plans tend to shrink, reducing discounts.

Wednesday, August 21, 2019

The retentive ACA marketplace, revisited

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In my last post, I noted that enrollment drops in the ACA marketplace recorded in each year of the Trump era at the end of Open Enrollment more or less evaporate in yearly comparisons of average monthly enrollment, or end-of-year enrollment.

That is, it seems that fewer people in the last two years drop out without paying, and perhaps a higher percentage remain enrolled all year (many people in the ACA marketplace do have good reasons not to remain enrolled all year -- one of the marketplace's vital roles is as a stopgap). That's congruent with another change recorded in 2019: new enrollments down (-15.7%), re-enrollments up (2.3%), as of the end of Open Enrollment.

Why have apparent enrollment drops as of the end of OE in each of the last three years either shrunk or eroded entirely over the course of the year? A few possibilities:

Friday, August 16, 2019

CMS subtext: The ACA marketplace is in recovery

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The CMS report on long-term enrollment trends in the ACA marketplace has a stark lede:
During two successive years of declining enrollment, from 2016 to 2018, unsubsidized enrollment declined by 2.5 million people, representing a 40 percent drop nationally. 
That's bad. But the report includes data that leads to a clear conclusion: The ACA-compliant individual market has stabilized. It is rife with problems and there are many enrollees whom it does not serve well, but it's passed through a crisis. Consider the following points (some derived from the report, others not):
  1. Subsidized enrollment was higher in 2018 than in 2016, generally understood to be the enrollment peak. In fact, total on-exchange enrollment was higher in December 2018 than in 2016. (Off-exchange enrollment, where the bulk of unsubsidized enrollment occurs, did drop sharply in those years.)

  2. Subsidized enrollment is higher in 2019 than in 2018, as of February of each year, when all enrollees have had at least one payment due (see CMS's  (2018 and 2019 Effectuated Enrollment Snapshots). 

Thursday, August 15, 2019

Is subsidized enrollment in the ACA marketplace really up since 2016?

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CMS's report on long-term enrollment trends in the ACA marketplace released this week emphasized the 40% drop in unsubsidized enrollment from 2016 to 2018. But the counterpoint came as something of a surprise: subsidized enrollment, according to CMS, is up since 2016.

If you look at the most often cited enrollment numbers for each year -- total plan selections reported by CMS annually at the end of the open enrollment season  -- total subsidized enrollment is down substantially -- 7.1% from 2016 to 2018, and 7.7% from 2016 to 2019. But average monthly enrollment was higher in 2018 than in 2016 -- and probably will be slightly higher this year.

It might appear that retention has improved -- more people stay in their plans for more of the year. But that's not clear, as average monthly enrollment in 2018 is not quite the same measure as in years prior.  Let's look at the numbers:

Wednesday, August 14, 2019

CSR attrition vs. silver loading stimulus, 2017-2019

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In my last post, I noted that in the Trump era, ACA marketplace enrollment has shifted toward the middle of the income distribution. While enrollment has cratered for the unsubsidized, and eroded by 16% since 2016 among low income enrollees (100-200% FPL, in states), it's stayed basically flat at the upper end of the subsidy-eligible income scale, 201-400% FPL.

In brief, the market got much worse for the unsubsidized, as premiums spiked 21% in 2017 and 26% in 2018, and marginally worse for low income enrollees, as out of pocket costs rose yearly in plans with fixed actuarial values. It got better, however, for many enrollees in the 200-400% FPL income range, since a) rising premiums made more people at the upper end of the range subsidy eligible, and b) Trump's cutoff of direct CSR reimbursement for insurers in fall 2017 induced "silver loading" that created discounts in bronze and gold plans (see note below if you're unfamiliar with silver loading).

Tuesday, August 13, 2019

ACA marketplace enrollment is down at low incomes as well as at high ones

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[Update, 8/15: CMS data on average monthly enrollment in each year appears to suggest that apparent year-over-year enrollment drops among the subsidized as of the end of Open Enrollment may have evaporated (in 2018, and perhaps 2019) as the year progressed. See this post.]

CMS is out with a report highlighting, not to say gloating over, a steep decline in unsubsidized enrollment in the ACA-compliant individual market from 2016 to 2018.  Nationally, while subsidized enrollment was up 1.3% in that period, unsubsidized enrollment crashed 40%, from an average monthly enrollment of 6.27 million in 2016 to 3.77 million in 2018.

That's not surprising, given premium increases averaging 21% in 2017 and 26% in 2018, and the obvious fact that the ACA marketplace was under-subsidized from the start and essentially unaffordable for many people with incomes modestly above the 400% FPL subsidy cutoff, as Urban Institute scholars Linda Blumberg and John Holahan pointed out in 2015:

Here I'd like to add a corollary: Enrollment since 2016 has declined not only at the top of the income scale, among those with incomes above 400% FPL, but at the bottom, among those with incomes up 200% FPL. It's shifted toward the upper end of subsidy eligibility, into the 200-400% FPL income range. The percentage of enrollees with incomes in that range has risen from 29.5% in 2016 to 34% in 2019 in states, and from 40.4% to 44.1% in California.

Monday, August 12, 2019

New Jersey individual market premiums set to rise, bucking national trend

Surprise...while individual market premiums for 2020 are up an average of just 0.7% in the 40-odd states tracked so far* by Charles Gaba, requested rates are up a weighted average of 8.6% in New Jersey -- after a 9% drop last year, the product mainly of a new reinsurance program and a state-enacted individual mandate.

AmeriHealth, which gained market share this year and currently enrolls 41% of the total NJ individual market, is requesting increases averaging 11%. Horizon Blue Cross, with 62% market share, is requesting increases averaging 6.2%. Oscar, with 4.4% market share, is requesting a 16.3% average increase.

Here are the rate requests (from Enrollment is negligible in Horizon Health of New Jersey, Horizon's HMO. AmeriHealth HMO accounts for 11.4% of AmeriHealth's Q1 2019 enrollment. Oxford Health enrollment is negligible.

Some context, presented without attempt at causal explanation:

Saturday, August 03, 2019

Triage: A moderate healthcare reform proposal

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Prescript (8/7/19): it occurs to me that this rather kludgy patch to our current system boils down to a simple rule: no one pays more than 8% of income for less than 80% AV insurance.  Paid for in part by expanding the footprint of Medicare payment rates.
*          *          *
I want to float here a path to healthcare system reform that starts a gear shift or two below the Medicare for America bill, which creates a strong public option that anyone can buy into at an income-adjusted price. I am mindful of David Anderson's warning that a Democratic president who goes for sweeping healthcare reform (assuming at best a narrow Senate majority and abolishment of the filibuster) will have bandwidth for little else -- and I think other imperatives, like attacking global warming, should come first.

First, a set of working assumptions (and background on current bills) that undergird where I land (skip to the subhead, where the proposal starts, if you're so inclined).

1. The U.S. healthcare system is outrageously expensive, unjust, and inefficient, distorted by two related structural flaws:

Thursday, August 01, 2019

Should the U.S. ditch private insurance?

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Elizabeth Warren has gotten tight with Ady Barkan, a brave ALS patient and advocate for Medicare for All. In the July 30 debate, she told his tale:
The guy who has ALS, this isn’t this is somebody who has health insurance and dying. Every month he has about $9,000 in medical bills that his insurance company won’t cover. His wife Rachel is on the phone for hours and hours and hours begging the insurance company please cover what the doctors say he needs.
Barkan, in his turn, tweeted during the next night's debate: 
Fair enough. Whether to preserve private insurance, and how to reform it if so, are the questions that divide Democratic candidates' approaches to healthcare reform, at least theoretically (what each of them would truly aim to accomplish via legislation introduced in 2021, and how they would balance their healthcare goals with other priorities, are questions they should be asked). 

In any case, let's look at the rap sheet against insurance companies -- and set it against their claims to add value to our healthcare system.

The raps
  • Divided and conquered: All but uniquely among wealthy countries, the U.S. leaves private insurers to each separately negotiate payment rates with healthcare providers. The fragmented payer universe gives providers outsized bargaining leverage, particularly in areas with dominant hospital systems or provider shortages.  Accordingly, commercial insurers pay hospitals about 189% of Medicare rates, according to a Congressional Budget Office estimate, and 241% Medicare according to a more recent RAND study. Commercial rates for doctors are about 128% Medicare, according to MEDPAC

Wednesday, July 31, 2019

Bernie Sanders is the Pied Piper of Healthcare Hamlin

Political battles can be semantic, but important. Such is the case with Democrats wrestling with the meaning of Medicare for all.

This week Kamala Harris came out with a healthcare reform plan that seems designed to resolve her past flip-flops as to whether private insurance should be phased out entirely. In brief, she proposed a 10-year path to "Medicare for all" that includes Medicare Advantage -- private plans reimbursed by the federal government and conforming to strict coverage rules. Employers could also offer "Medicare Advantage" plans.  Lots of question marks, but the intent to preserve the public/private hybrid of Medicare as we know it is clear.

Bernie's camp lit into the plan, claiming in effect that the his bill's title (Medicare for All) is politically trademarked. “Call it anything you want, but you can’t call this plan Medicare for All," Sanders' campaign manager Faiz Shakir said in a statement. Pramila Jayapal, lead sponsor of the House version, tweeted, "as lead sponsor of #MedicareForAll, I find it misleading when my fellow Democrats use the #M4A name to describe proposals that are NOT #MedicareForAll."

That's a straight trademark play: we own the hashtag, we own the name. The subtext is that the One True Path to Medicare for All is Sanders and Jayapal's Big Rock Candy Mountain in which a single government entity provides 100% coverage of everything for everyone, funded entirely by over $3 trillion per year in new taxes ($1.5 trillion according to Bernie).

Monday, July 29, 2019

New colors in the spectrum of Democratic healthcare reform plans

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For some time, Democratic next-gen healthcare reform proposals have fallen on a spectrum  that I've thought as anchored by three main proposal types. Here they are, in ascending order of cost and degree of system change:
  • ACA 2.0 - Improve the ACA mainly by a) bulking up the subsidies and extending them farther up the income scale, and/or b) introducing a national public option within the ACA marketplace framework. Chief exemplars: Elizabeth Warren's ACA 2.0 bill; Senators Bennet and Kaine's Medicare-X

  • Medicare for all who want it: Introduce a strong public option that anyone can buy into on an income-adjusted basis, even if they have access to other affordable insurance, e.g., insurance offered by an employer. Chief current exemplars: The Center for American Progress's Medicare Extra, which is the basis of Reps. DeLauro and Schakowsky's Medicare for America bill.

  • Medicare for All (that covers everything for everyone at no cost to anyone except via taxes). Private insurance essentially ends. Chief exemplars: - Bernie Sander's Medicare for All bill, and Rep. Jayapal's House variant.

Thursday, July 25, 2019

The Ten Counts of Obstruction (with apologies to Lin-Manuel...)

It's been said no one's read Mueller's 448-page report. Well but, the 8-page summaries of Parts 1 and 2 are pretty direct. Well but, that's still a lot of text.

So let's try it Lin-Manuel Miranda style (soundtrack here):

The Ten Counts of Obstruction

For the nation's instruction,
The ten counts of obstruction:

Number 1: 

Russian hacks electrify the nation.
Call it fake news while you seek more information.

Number 2

Summon Comey to the throne like you're royalty.
Tell him you demand unconditional loyalty.

Wednesday, July 24, 2019

Pelosi and co. on impeachment: Not if, when?

In some ways, the press conference held by Pelosi, Cummings, Nadler and Schiff in the wake of Mueller's testimony today was exquisitely frustrating. Their dual message made no sense on its face: the president manifestly deserves impeachment but we need more evidence. Nadler said the president committed crimes. Pelosi also said that "crimes were committed against our Constitution," albeit in passive voice. Schiff said Trump was disloyal to the country, citing his negotiating the Moscow Trump Tower deal while seeking the presidency without telling the public. So how can they not open an impeachment inquiry?

At the same time, it seemed to me that these committee chairs and Pelosi in particular may have turned a corner. This was the first time I've heard Pelosi speak about impeachment without actively undercutting it. They were stalling, but they were implicitly promising to get there.

This promise -- too strong a word -- was almost explicit at the end. Schiff, all but acknowledging that the Senate would not convict, also declared that that was not the point. My emphasis (and rough transcript) below:

Tuesday, July 23, 2019

New enrollment drop in California: Probably the mandate repeal

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Covered California, the state's ACA exchange, recently released its March Active Member Profile, the year's first detailed breakout of enrollment data for all enrollees (repeated quarterly). It follows a prior breakout for new enrollees. The Active Member numbers show some market stability -- they're broadly similar to last year's. They may also support CoveredCA's previous explanation of a drop in new enrollment.

On January 30, CoveredCA put out an analysis  as of the end of open enrollment, emphasizing that while enrollment was virtually flat overall compared to 2018 (down 0.5%), new enrollments had tumbled 23.7%. CoveredCA attributed this worrisome drop (offset by a 7.5% increase in re-enrollments) to repeal of the individual mandate penalty, noting that the new enrollment drop was "relatively evenly spread across demographics." California has since enacted measures intended to reverse the damage, instituting a state individual mandate and state-funded premium subsidies to supplement the federal subsidies.

I wondered whether part of the drop in new enrollment may have been caused by an overall 8.7% average weighted increase in premiums in 2019 and/or by changes in the discounts in gold and bronze plans generated by silver loading (see note at bottom for an explanation). The answer appears to be no -- it was the mandate repeal. Ready for a null-result report?