2019: Medicare at Will, Warren in the whirlpool, silver loading Year 2....

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Below, a look back at some xpost focal points in 2019. Short version: the posts below index multiple posts on recurring themes:

Elizabeth Warren's healthcare toggle switch
Two years of rather quavery support for Medicare for All

Medicare for all who want it: Potential and pitfalls 
Scrutinizing the Medicare for America bill

Silver loading and 2019 enrollment
What impact has silver loading had so far? What can be done to increase its impact -- that is, to further boost ACA subsidies?

*          *          *

Early this year, I assumed that as the Democratic presidential candidate field was winnowed, the surviving candidates would converge on a "Medicare for all who want it" model for next-gen healthcare reform.

Whither humanity? Three NYT snapshots

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

*         *         *

The front page of today's print New York Times greeted Sunday breakfasters with what feels like a typical trio of world-going-to-hell headlines above the fold:

• Nearly 80 Die As Blast Strikes Somali Capital
• As It Detains parents, China Weans Children From Islam
• Trump Eroding Role Of Science In Government

As antidote, in the op-ed pages Nicholas Kristof offered up his annual reminder that by quantitative material measures the human condition continues to improve; extreme poverty, debilitating disease and child mortality are declining, literacy is growing, hundreds of thousands climb out of extreme poverty daily. 

In the same op-ed section, Ross Douthat leads with a truly arresting take on the last decade:

Assessing 2020 ACA marketplace enrollment? Don't forget Virginia's 2-year Medicaid expansion shakeout

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

In assessing total ACA marketplace enrollment for 2020, it's important to keep in mind that the fallout from Medicaid expansion expansion in Virginia continued into a second year.

As I've noted before, that's generally been the case in states that have enacted belated Medicaid expansions after the ACA's core programs launched in 2014.

Marketplace enrollment drops when a state implements the Medicaid expansion (rendered voluntary to states by the Supreme Court in 2012) because the lowest-income marketplace enrollees become eligible for Medicaid -- and therefore no longer eligible for marketplace plans, at least theoretically.

In expansion states, people with incomes up to 138% of the Federal Poverty Level (FPL) are eligible for Medicaid -- and so, not for marketplace subsidies. In states that have refused the expansion (e.g., Virginia until Jan. 2019), eligibility for marketplace coverage begins at 100% FPL.

Michael Bloomberg's healthcare plan eats its own tail

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Michael Bloomberg's just-released health coverage plan would do some good if enacted. It's introduced, however, with a false premise.

Deeming "a Medicare-like public option" the "first step," the plan outline pronounces:

A public insurance option would improve consumer choice and increase competition in the private insurance market, pushing down everyone’s premiums. People of modest means who buy the public option would be eligible for the same subsidies that would apply on the health insurance exchanges.

As students of the ACA marketplace know, however, within the marketplace structure, when base (pre-subsidy) premiums shrink, the premiums paid by subsidized enrollees tend to go up. That's because the subsidies are designed so that the enrollee pays a fixed percentage of income (rising with income) for the benchmark (second cheapest silver) plan. If you buy a plan that's cheaper than the benchmark, your subsidy goes further (and these days, thanks to silver loading*, may cover the whole premium). When premiums go down, price spreads between the benchmark and cheaper plans tend to shrink, reducing discounts for the cheapest silver plan and for bronze plans. If a public option reduces premiums, as Bloomberg promises, it will increase them more often than otherwise for subsidized buyers. Ditto for reinsurance, proposed to reduce premiums another 10%.

The Cadillac Tax: An idea whose time never came

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

To the surprise of no one, it looks like the ACA's long-postponed Cadillac ax, an excise tax on employer-sponsored health plans that exceed a certain cost threshold,  is slated for legislative execution, along with the medical device tax.

Against the vociferous opposition of unions and employers, Obama fought to preserve the Cadillac Tax, a linchpin of the ACA's efforts to control healthcare costs. CBO estimates that repeal will cost the treasury $200 billion over ten years.

On one level, it's sad that Congress can't make taxes with powerful opponents stick. Medical device tax repeal is a dead giveaway.  But the Cadillac Tax was based on two false premises.

Uninsurance goes (slightly) upscale, Kaiser edition

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

In September, the annual Census Bureau update on health insurance coverage in the U.S. reported a 0.5% rise  in the uninsured population in 2018 -- an increase of 1.9 million uninsured. I noted at the time:

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.

These losses were concentrated in private insurance, down 1.3% percentage points at both income levels. The private insurance losses stem in part from the individual market, where unsubsidized enrollment dropped by 1.8 million in 2018, according to the Kaiser Family Foundation's estimate.  That drop is part of a longer term free-fall, from 9.1 million unsubsidized in the individual market in in the first quarter of  2016  to 4.7 million in Q1 2019, according to Kaiser.

Yesterday, the Kaiser Family Foundation released an updated analysis of the uninsured population. Kaiser finds a smaller increase in the uninsured in 2018 than did the Census, 500,000.  In contrast to the Census, Kaiser finds equal increases in the uninsured at 100-199% of the Federal Poverty Level and at over 200% FPL, with a statistically insignificant decrease at incomes below 100% FPL.  Regarding the increase at not-poor incomes, a couple of points from the analysis stand out:

Forget free bronze plans: millions of uninsured are eligible for CSR silver

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

The Kaiser Family Foundation is out with an analysis estimating that 4.7 million uninsured Americans are eligible for free bronze plans in the ACA marketplace. That's a bit less than half of the uninsured who are eligible for marketplace subsidies, according to a 2017 Kaiser estimate.

These estimates have emerged as a Kaiser tradition in the Trump era , which in ACA terms is the silver loading era. "Silver loading" 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. One result is $0-premium bronze plans available to millions.

Arguably, "free bronze" is useful chiefly as a marker of the extent of bronze plan discounts, which are more popular at the upper income end of ACA subsidy eligibility, 200-400% of the Federal Poverty Level (FPL) than at the lower end, 100-200% FPL, which still accounts for the majority of on-exchange enrollees. At upper income levels, bronze plans are likelier to be cheap than free.

In 2019, 89% of enrollees with incomes in the 100-150% FPL range in the 39 states using HealthCare.gov  selected silver plans. At 300-400% FPL, just 24% selected silver, vs. 58% for bronze and 17% for gold. Cheap bronze is more of a lure than free bronze. At low incomes, the value of CSR outstrips the value of bronze discounts generated by silver loading.

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

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

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.*

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.

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, HealthCare.gov. By this point (week 5), it was down 14% year-over-year (in all 9 HealthCare.gov states, a calendar discrepancy between 2017 and 2018 led to a sharp closing of the apparent gap in the final week).

Fewer Americans qualify for ACA marketplace subsidies

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

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.