Tuesday, December 31, 2019

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

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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.

That forecast proved half wrong, as Bernie Sanders' siren song lured first Kamala Harris and then Elizabeth Warren onto the rocks (or toward the Big Rock Candy Mountain) of Medicare for All. Both tacked back toward a transitional buy-in period, and both foundered. Warren, I noted, has signaled ambivalence about BernieCare since she first signed on in September 2017. While she regards private health insurance as parasitic, and in fact one-dimensionally blames all our healthcare woes on insurers, she is also aware that an all-out-push for BernieCare would swallow all her own well-wrought plans on other fronts to restructure the U.S. economy and empower workers to recapture the share of profits they enjoyed in the pre-Reagan era.  As it may have swallowed her campaign.

My personal assumption is that the only viable path for the U.S. to universal coverage and essential cost control is to introduce a strong public option paying something close to Medicare rates -- and expand the pool of Americans who have affordable access to it, immediately or in stages. The sluice gate to true transformation is to make the PO (call it "Medicare" if you like) available  on a subsidized basis to people with access to employer-sponsored insurance. I doubt our political capacity to do even that in one fell swoop, which is why my forecast "path for presidential candidates" (first link above) envisions doing it in stages. These might include lifting the ACA's income cap on subsidy eligibility, and letting small employers and then eventually all employers buy in.

While both Biden and Buttigieg have sketched in "Medicare for all who want it" plans, the most fully developed current blueprint is the Medicare for America bill introduced by Rep. Rosa DeLauro (CT-03) and Rep. Jan Schakowsky (IL-09). I scrutinized that bill in at least eight posts, collected here. Particularly worth noting: 1) the bill would require healthcare providers to accept adjusted Medicare payment rates from private insurers, creating a de facto all-payer system of uniform payment rates, and 2) the bill would require some seniors to pay considerably more for Medicare (albeit with long-term care coverage added) than they do now -- a major political vulnerability, underscoring that every transformative healthcare bill entails painful tradeoffs.

While the presidential candidates spin fantasy plans, the Kaiser Family Foundation has been warning all year that the candidates are not meeting voters where they are on healthcare -- that is, not addressing voters' stated concerns as reflecting in Kaiser tracking surveys.  Those warnings led me to speculate: what if a candidate took voters stated healthcare concerns literally?

Perhaps the likeliest electoral outcome in 2020 is continued divided government, either with a reelected Trump and a still-Democratic House or with a Democratic president and a Republican Senate. In either scenario the ACA would likely limp along, though Trump would doubtless mount fresh regulatory assaults, e.g., enabling states to use premium subsidies on medically underwritten plans (as may happen pre-2021). Under divided government, the ACA Medicaid expansion will continue to do its good work (though in a Trump second term, courts may greenlight Medicaid work requirements), and the subsidized ACA marketplace will continue as a mixed blessing -- undersubsidized, varying widely from state to state and county to county, volatile, unaffordable for many who earn too much to qualify for subsidies -- but still a vital resource for about ten million people who lack access to other insurance.

Given the marketplace's under-subsidization, the windfall created by Trump's cutoff of direct reimbursement of insurers for Cost Sharing Reduction (CSR) subsidies and the subsequent recourse in most states to silver loading -- pricing CSR into silver plans only, creating discounts in bronze and gold plans -- is a big deal, and has partly offset other Republican attempts to sandbag the marketplace. Yet silver loading has not reached its full potential and has in fact stalled in 2020. Stimulated by actuaries Greg Fann and Daniel Cruz, I wrote a series of posts examining the progress of silver loading and the potential for regulators to increase the benefits by requiring insurers to price plans at the different metal levels more proportionately to real actuarial value.

Partly thanks to silver loading, a surprising fact emerged this year: on-exchange enrollment really hasn't fallen since 2016 -- though total individual market insurance has fallen, as unsubsidized enrollment (mostly off-exchange) has cratered. Enrollment has shifted slightly up the income scale, though, partly because fewer Americans are in lower income brackets. In fact, uninsurance has moved up the income scale. Meanwhile, the ACA has never yet been called on to fulfill one key latent function: recession insurance.

To indulge in a bit of year-end navel gazing: I've begun to feel recently that I need to freshen my approach to healthcare writing. In 2014, when I first deliberately transitioned from political vanity blogging to trying to provide some new information on the healthcare front, I got my feet wet in reporting and publishing elsewhere -- interviewing unsubsidized marketplace enrollees, enrollment counselors and web designers, small group brokers, among others, to get a sense of how the ACA's new programs and rules were playing out. In the Trump era, joining fights to fend of ACA repeal,  elect a Democratic House, and strengthen the ACA in my home state led me to focus more on op-ed, e.g. at the New York Times, USA Today, NJ Spotlight, and elsewhere. In the last two years, a longtime informal collaboration with healthcare bloggers David Anderson, Charles Gaba and Louise Norris has led to three coauthored posts analyzing silver loading effects and enrollment in Health Affairs. I've mixed these three types of writing at healthinsurance.org, to which I'm grateful for the consistent outside forum.

Throughout this period -- 2014 to now -- I've applied my middle school math skills to enrollment and census data and freely consulted and interviewed healthcare economists and scholars -- e.g., Timothy Jost, Harold Pollack, Nicholas Bagley, Linda Blumberg, John Holahan, Sabrina Corlette and Jack Hoadley -- and basically been tutored by Kaiser's Larry Levitt and Cynthia Cox. I have learned a ton, but lately I feel that I've both burrowed too narrowly (mostly into ACA marketplace enrollment) and just scratched the surface. In the 'learn new things' department, I've just completed a graduate course in statistics in the humanities at Montclair State, which will hopefully improve my reading of research articles.  But I think I've stalled somewhat in my amateur reporting -- I don't pick up the phone enough. It's comparatively easy (for me) to talk to scholars. It's hard to develop a wider array of sources, especially without an institutional base. I'm not much for New Year's resolutions. But I'll put out a soft one for doing more reporting.

Happy New Year, everyone. Thanks for reading.

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