Our emerging public option: Medicaid

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Axios's Bob Herman notes that "Medicaid will be a lifeline for droves of Americans affected by the coronavirus pandemic."

The program will pick up many people who lost their income and their health insurance together, as well as people who lost jobs that didn't provide health insurance, and potentially some people who are still working and need medical care but aren't insured.

Indeed it will. As of early this year, about 72 million Americans were enrolled in Medicaid's various programs. Based on an old rule of thumb from Georgetown's Edwin Park that I've cited before, enrollment (including CHIP)  could reach 85 million or more by the time the pandemic subsides:

CARES Act may reduce ACA "coverage gap" in states that refused Medicaid expansion

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The enhanced unemployment benefits provided by the CARES Act, the emergency COVID-19 relief bill signed into law on March 27, count as income for those seeking subsidized health insurance in the ACA marketplace (the income does not count in consideration of Medicaid/CHIP eligibility).

As I noted last week, that's going to vastly reduce premium subsidies and likely wipe out Cost Sharing Reduction subsidies for many newly unemployed people who seek coverage.  On the plus side, however, the rush of temporary income should also narrow the "coverage gap" in states that have refused to enact the ACA Medicaid expansion, including Florida and Texas.

Enhanced unemployment benefit will skew ACA marketplace/Medicaid enrollment

The enhanced unemployment benefits provided in the CARES Act, the massive COVID-19 response bill that passed the Senate 96-0 last night, looks likely to create some strange incentives for the newly uninsured seeking health insurance.

For anyone who qualifies for unemployment insurance, the bill adds an extra $600 week to the normal benefit for four months. That's $10,400 for anyone who stays unemployed for that long (as millions likely will: a staggering 3.3 million new jobless claims were entered this week).  For the first time, UI benefits are available to the "self-employed, independent contractors, those with limited work history, and others who are unable to work as a direct result of the coronavirus public health emergency."

As noted last night by the Brookings Institute's Loren Adler, the extra $600 per week will not be counted for the purposes of determining eligibility for Medicaid and CHIP, but will be counted for determining subsidy eligibility for private plans in the ACA marketplace. If that holds, some fairly high earners will likely end up eligible for Medicaid but not for subsidized marketplace coverage.  That's all the more likely because while Medicaid eligibility is determined on a monthly basis, marketplace subsidies are determined on the basis of annual income -- so income earned up to the time of layoff counts along with the enhanced UI benefit.*

Other may be eligible both for Medicaid and for weak marketplace subsidies. In that case, Medicaid should be the clear choice for most. Let's look at the math.

Unemployed alert: When NOT to seek health insurance through the ACA marketplace

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Update, 3/25: If I understand a brief description of unemployment benefits in the stimulus bill right, many or most of those who qualify for unemployment will receive too much to qualify for Medicaid, unless -- per comment from Stan Dorn below -- the bill text exempts this income from consideration [further update: (unconfirmed) word is that it does!]. More below.

The expected economic fallout from the coronavirus pandemic is shocking. Morgan Stanley forecasts that the unemployment rate will approach 13% next quarter. We're talking Depression.

That onrush will put enormous strain on the enrollment infrastructure established by the ACA for the private plan marketplace and Medicaid, at a time when our healthcare infrastructure will also be under tremendous strain and flux. Thank God the core ACA programs, Medicaid expansion and the subsidized marketplace, are intact and funded. But the enrollment machinery is balky.

I am particularly concerned about one glitch that could flummox a lot of newly uninsured people: the mismatch between marketplace and Medicaid income assessments. In applications processed through the marketplace -- HealthCare.gov and the 13 state exchanges -- subsidy eligibility or Medicaid eligibility (in expansion states) is determined on the basis of annual income. In state Medicaid offices, Medicaid eligibility is determined on the basis of monthly income going forward.

The ACA marketplace in year 7: The navigators' view

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The Affordable Care Act's health insurance marketplace, born on January 1, 2014, isn't a baby any more. In fact you might say it's reached maturity.

Like many children, it's disappointed its parents somewhat, insuring about half as many people as the Congressional Budget Office forecast when the ACA was passed. It's withstood multiple legislative and administrative assaults from Republicans and survived a half dozen near-death experiences via  repeal bills and court challenges to its constitutionality, one of which still looms. The marketplace's lower-profile twin, the ACA Medicaid expansion, has been more successful -- insuring more people more thoroughly for less money.

But the individual market for health insurance reshaped by the ACA is beginning its seventh year of offering comprehensive health insurance to anyone who lacks access to other insurance without regard to their medical history or current health. The ACA-compliant market serves about 13 million people, about three quarters of them subsidized, with the federal government paying about 86% of subsidized enrollees' monthly premium on average.

As the nation is faced with a major pandemic-induced recession, the marketplace and ACA Medicaid expansion stand poised to insure millions who lose employer-based insurance.

Call the midwife

There is a set of marketplace midwives who were in at the birth and have continued their intimate engagement: enrollment assisters, including nonprofit navigators established by the ACA; nonprofit and often volunteer Certified Application Counselors (CACs); and for-profit brokers who work in the individual market.

Emergency Special Enrollment Periods in 12 state ACA marketplaces: How easy?

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Twelve of the thirteen states (including D.C.) that run their own ACA marketplaces have announced emergency Special Enrollment Periods to help the uninsured get covered while the Coronavirus rages. Washington state was first to announce a SEP,  on March 10. CMS is "evaluating" following suit for the 38 states using the federal platform, HealthCare.gov. Idaho is the only holdout (and only red state) among the SBEs.

Kudos to the states that have taken the plunge. May it go smoothly operationally. Some began with some messaging confusion, e.g., info about the emergency SEP that seemed contradicted by older messaging about conventional SEPs, granted only to individuals for life changes such as job loss instead of to anyone seeking insurance. Most of those have been straightened out, but some mixed messaging lingers.  Below, a sampling of clear and not-so-clear home page messaging.

The ACA as recession insurance, revisited

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Almost a year ago, I noted that the ACA marketplace has never operated in a shrinking employment market -- job growth has been steady since the marketplace launched in January 2014.  That's created a (fortunate) headwind for enrollment, and

Conversely, the marketplace -- along with the ACA Medicaid expansion -- stands in reserve as a shock absorber when the next recession or financial crisis hits.

That's now. Goldman Sachs projects that after a 30% spike in jobless claims last week, to 281,000, new claims will hit 2.25 million this week -- an unprecedented surge. Mnuchin, Trump's Treasury Secretary, warned Republican senators this week that unemployment could go to 20%, a level not seen since the Great Depression. In the Great Recession of 2008-9, 9 million people lost their jobs; losses this time around could far exceed that total.

Millions of people are going to lose access to employer-sponsored insurance. The ACA machinery to get them insured is knobbly, but functional and funded. I have a post at healthinsurance.org to help the newly uninsured navigate their options. The basics:

The ACA wars through a pandemic lens: Nicholas Bagley looks back

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I spoke to Nicholas Bagley, health law professor at the University of Michigan, about measures to limit Americans' out-of-pocket exposure for coronavirus treatment -- assuming that in the U.S., simply covering all OOP for everyone treated for the disease at government-set payment rates to providers is not going to happen.

My thought was that Bagley could speak to avoiding legal pitfalls in any such measures. But his sense is that in the current crisis, legal concerns pertain mainly to potential administrative actions  (for example,  Can the CDC Pay for Everyone's Coronavirus Testing?).

Given normal U.S. legislative sclerosis, seeking regulatory authority to do what needs to be done is often fertile ground for legal analysis. Right now, though, the cards may line up for decisive legislative action, as they do in this country when (and only when) Republican political survival depends on it. And while there are multiple constraints to regulatory action, "there are fairly few constraints on Congress's legislative power," Bagley said. "Congress doesn't quite have carte blanche, but close to it. The question is not what does the Constitution allow Congress to do. We should be asking, 'what do we think ought to happen?' And then we should do it."

Limit Americans' out-of-pocket exposure for Coronavirus treatment

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The bill passed by the House yesterday to ease the economic impact of the coronavirus pandemic, H.R. 6201, purports to make coronavirus testing available at no cost to all Americans. That includes office visits, urgent care center visits, and emergency room visits that lead to an order for testing.* It does not, however, include treatment for those who become seriously ill.

David Anderson and Nicholas Bagley are calling for Congress to rise to the crisis by protecting Americans against balance billing -- either by passing comprehensive consumer protection that's been stalled since last fall or, at a minimum, passing a bill to limit out-of-network billing for Coronavirus treatment.

That's vital. I've worried since late February that fear of balance billing would inhibit some Americans from seeking treatment. I've also noted a closely related problem: Americans' huge exposure to out-of-pocket costs for in-network care:

How about a national reporter hotline for Coronavirus balance billing?

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It's been a running joke on healthcare Twitter for some time that Americans' best defense against egregious surprise billing and relentless hospital debt collection is to call a reporter.

With Sarah Kliff (now at the NYT) crowd-sourcing outrageous emergency room bills at Vox and Kaiser Health News maintaining a Bill of the Month series, there's been saturation coverage of these practices that render health insurance effectively illusory for tens for millions of Americans.

With almost comic frequency, ERs caught out billing patients thousands for minimal work and hospital systems exposed for suing thousands of low income patients have forgiven bills or announced that they are changing their dunning practices after being exposed in the national press. For example....

Zuckerberg San Francisco General rolls back a $20,000 ER bill sent to an insured patient after a bicycle accident -- then reviews its practice of balance-billing every privately insured patient brought to its doors. A behemoth dialysis provider cancels a half-million dollar bill. A week after KHN's Jay Hancock reports that University of Virginia has sued 36,000 patients, garnished thousands of paychecks and put liens on homes, the hospital admits it was too aggressive and revamps its financial aid guidelines. Just today we learn that another predatory debt collector in Virginia, VCU Health, will stop garnishing wages and putting liens on people's houses.

Coronavirus alert: How about an emergency Special Enrollment Period for the ACA marketplace?

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Update, 3/12: As noted in the updates at bottom, as of now five state-based marketplaces are running Special Enrollment Periods open to all, two of them triggered by the coronavirus emergency. CMS should do it for the healthcare.gov states. 3/14: Rhode Island makes six. 3/16: New York comes on board. 3/17: Nevada is in. 3/18: Connecticut announces SEP. And Colorado will announce imminently. 3/20: Covered California, already open via a tax-season SEP, available to anyone who affirms they were not aware of the state's new individual mandate, today makes it unconditional with an emergency SEP open to all. And it's open through June 30, by far the longest emergency SEP. 3/20 II: MNSure announces a SEP running March 23 - April 1. 3/20 III: Vermont comes on board, sort of.

Every SBE except Idaho now has enrollment open to the uninsured.

If the coronavirus causes major economic disruption, as now seems likely, the ACA marketplace (including Medicaid enrollment) is likely to get a major stress test.

As I've noted previously, the marketplace has never experienced a recession; the unemployment rate has dropped steadily since it launched in 2014, and enrollment has been basically flat since 2016. It stands ready as a shock absorber when people are laid off.  Those who lose insurance through their jobs are eligible for a Special Enrollment Period.  The machinery for processing SEP requests had better be smooth.

Since subsidy eligibility depends on annual income, the earlier in the year layoffs begin, the more people will qualify for marketplace subsidies (annual income up to $49,960 for an individual) or Medicaid ($17,236). In Medicaid expansion states, even those who have crossed those earnings thresholds should be eligible for Medicaid one month forward if their income is below the monthly Medicaid threshold.* Under various emergency authorities, governors and the president can extend Medicaid eligibility and expedite enrollment, as was done in the wake of 9/11, Hurricane Katrina, and the Flint water crisis.

The marketplace also might be put to more immediate use.  CMS should declare a national Special Enrollment Period for the marketplace (Medicaid enrollment is year-round).

Employer-sponsored insurance is deteriorating. What about fixing it rather than replacing it?

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Medicare for All's main political liability, as the presidential campaign has made clear, is loss aversion: most Americans are insured,  most are reasonably satisfied with their coverage, and a significant minority consider their top-drawer coverage a major asset. Americans also have ample cause to doubt their government's capacity to completely remake the country's healthcare system and serve as the sole source of major medical insurance to everybody.

At the same time, Medicare for All speaks to a current reality: employer-sponsored insurance (ESI), which covers the majority of Americans under age 65, is deteriorating, and Americans know it.  Kaiser Family Foundation tracking poll results released last week neatly capture the core household worries related to healthcare:

About two-thirds of Americans say they are either “very worried” (35%) or “somewhat worried” (30%) about being able to afford unexpected medical bills. This is larger than the share that say they are worried about affording a variety of expenses, including other types of health care costs as well as other household expenses. About half of insured adults say they worry about being able to afford their health insurance deductible (49%) and four in ten (40%) worry about being able to afford their premiums. More than four in ten adults overall worry about affording prescription drug costs (45%).

The ACA at 10: The navigators' tale (preview)

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As the tenth anniversary of the ACA's passage approaches, Health Affairs is out with a landmark series of articles examining the law's history and impact.

To mark the occasion myself, I have interviewed five "navigators" -- nonprofit enrollment assisters chartered by the ACA -- who were in at the birth of the marketplace and have been helping people enroll since fall 2013.

These veterans have assisted thousands of mostly low income people in need of affordable health insurance and have been integral to the enrollment assistance infrastructure of their states -- Florida, South Carolina, West Virginia and Texas, which together account for 28% of all marketplace enrollment. All of these states use the federal HealthCare.gov platform and so have been subject to the Trump administration's 84% cut to navigation funding.

I have completed my writeup of the debriefing of these resilient, tough, devoted professionals and am currently shopping the article draft, which may yet end up here on xpostfactoid. It's a slow process. To ease my impatience, I'm here offering a snippet view of key points.

The ACA at 10: Resilient, yes, but...

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To mark the ACA's tenth anniversary, Sabrina Corlette, Linda Blumberg and Kevin Lucia - three of the nation's leading scholars and architects of healthcare policy -- have written a detailed and entertaining account of the tumultuous history of the ACA marketplace and its impact to date.

Strap in and relive the rough ride through grandmothered pre-ACA plans, the risk corridor massacre, the market correction of 2017, the repeal drive of 2018, the individual mandate repeal and promotion of the medically underwritten short-term market...and relative enrollment stability through it all.

The authors' conclusions are fair but, perhaps necessarily, oversimplify a bit. Let's take the catalog of successes one at a time.

Will Americans' fear of high medical bills hinder Coronavirus containment?

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On Wednesday, I noted that the high out-out of pocket costs that most insured Americans under age 65 are exposed to might deter people who contract the Coronavirus (or suspect they may have contracted it) from seeking treatment.

In employer-sponsored insurance, the average single-person deductible in 2019 was $1,655, according to the Kaiser Family Foundation. 28% of covered workers had a single -person deductible over $2,000.  The median annual maximum out-of-pocket (MOOP) limit (after which the plan pays 100% of covered expenses) was $4,000 (the maximum allowable is $8,100). About two thirds of employer plans require coinsurance for inpatient hospital stays, averaging 20%.

Today, Sarah Kliff reports that an American father and daughter who were subject to mandatory quarantine when they returned from Wuhan province in China were also subject to two mandatory stays in an isolation unit at a nearby children's hospital after the child was heard coughing. After release, "they found a pile of medical bills waiting: $3,918 in charges from hospital doctors, radiologists and an ambulance company."  The father's employer provided health coverage in China, where he had been working, but does not provide it in the U.S.

The card spells MOOP: Will Covid-19 expose Americans to financial risk?

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The Miami Herald reports that a man who developed flu-like symptoms after a business trip to China did what he felt was the right thing and went to the hospital to get tested for the Coronavirus. Hospital officials wanted to give him a CT-scan, but since he knew his insurance was limited, he asked for a flu test first.  Smart move. He tested positive for flu, and that was that -- except for the $3,270 bill that came later, with more to come.

The hospital told him that his share of the bill was $1,400. The story then focused on the fact that this man was in a short-term, limited duration plan that demanded he supply three years of medical records to prove that he didn't have a "pre-existing condition," i.e., a recent prior bout of flu.

That's outrageous, but it misses a broader point about Americans' financial exposure when the Coronavirus spreads. If this individual's medically underwritten policy does pay out, he's not necessarily in a worse financial position than the average insured American who walks into a hospital with suspected Covid-19.

The one executable healthcare reform plan put forward by a presidential candidate

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If I may cannibalize my Twitter thread, a reaction to last night's debate in four tweets:

Healthcare in last night's debate: More blah blah blah about public option vs. M4A and nary a word about Republican intentions to void the ACA, gut Medicaid, bring back medical underwriting, uninsure tens of millions and cut at least $1 trillion in HC spending in first decade.

You have to have goals, yes. But they remind me of old-time communists arguing about who'll clean the toilets when the state withers away.

"Everyone must have access to Medicare-plus, but you can keep your wonderful employer plan if you prefer!" "No, everyone must have free access to everything!" Meanwhile...

It'll be a minor miracle if we're not living in authoritarian austerity state and if a Dem president can wring Medicare drug negotiation, balance billing ban and improvements to ACA subsidies/access through a 51-49 senate.

Six years later: Some stuff we've learned (or think we've learned) about the ACA marketplace

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The ACA marketplace is in its seventh year -- not a baby any more. I was just musing about some things we've learned, or think we've learned. Some are well understood, some are little recognized, some are tentative hypotheses. In no particular order:

• The marketplace came of age during a period of steadily rising employment. That's good news for the country, but has constituted a steady headwind for enrollment. ACA subsidies are on standby as a shock absorber for the next recession (if the courts don't kill the law).


• Since 2018, silver loading* has partly offset factors depressing enrollment, including massive cuts to outreach and advertising, rising incomes and employment, and rising premiums (in 2017-18) and out-of-pocket costs. As of 2019 silver loading had probably boosted enrollment by about 500,000.


• Those out-of-pocket costs have risen relentlessly. That's inevitable in a system where a fixed percentage of income buys a fixed actuarial value, since healthcare costs continue to rise far faster than inflation.  In 2014, the top allowable out-of-pocket maximum for a single enrollee was $6,350.  In 2021, it will be $8,550. The average silver plan deductible (for those who don't qualify for CSR) was $2,425 in 2014 and $4,544 in 2020.

Bronze plans are terrible. Bronze plans are often the best choice.

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In discussion of the ACA marketplace (and health insurance generally), deductibles are often used as a stand-in for out-of-pocket costs. Now here cometh David Anderson to remind us that a plan's maximum out-of-pocket cost (MOOP) can be just as important -- and that the MOOP often does not particularly correspond to metal level.

The highest allowable MOOP at all metal levels is $8,150 (a travesty by international rich country standards).  Here is David's mapping of the range of MOOP for gold plans in HealthCare.gov states.  Dark green is $2,500 MOOP; dark red is $8,150.

As David points out, bronze plans will be a better deal for anyone who knows they'll hit the out-of-pocket max. As he's pointed out elsewhere (and in passing here), it takes a lot more spending to hit the high max in a gold plan -- say, $30,000 -- than in a bronze plan. That's because once you meet your deductible (likely to be relatively low in a gold plan with high MOOP), a high percentage of ensuing costs will be covered in a gold plan until the MOOP is reached, at which point coverage goes to 100% for ensuing costs (if you stay in network).

But love grows old and waxes cold: #HealthPolicyValentines 2020

A healthy Valentine's Day to all! As the rule of law in the U.S. erodes, and the Trump administration comes up with ever new ways to reduce enrollment, services, and affordability in public insurance programs, I can't forbear but to add some, shall we say, antivalentines to this year's mix. They follow the sweeter kind.

Cold wax, not to be confused with waxing cold

Health wonks are sweet,
their rhyming is cute.
Poetic meter
is not their strong suit.

          *     *     *

On hold with the hospital
in some endless billing tiff?
Put down the receiver
and dial @sarahkliff.

States seeking to reduce their uninsured populations must beware a Catch-22

By David M. Anderson, Charles Gaba, Louise Norris and Andrew Sprung

Note: this post is the third joint effort by David, Charles, Louise and me. Others here and here.

State policymakers have been prolific and creative in putting forward measures to strengthen their ACA marketplaces. Measures enacted since 2017 or in progress now include reinsurance programs, which reduced base premiums by an average of 20% in their first year in the first seven states to implement such programs; new or renewed state-based exchanges, which capture insurance user fees that can be used for advertising and outreach; state premium subsidies to supplement federal subsidies; and state-based individual mandates, which can provide funding for all of the above.

Policymakers must recognize, however, that these choices entail tradeoffs — and not just in budgetary constraints. Specifically, built into ACA marketplace architecture is a pricing dynamic that bedevils state attempts to improve ACA marketplace performance: reductions in premiums for unsubsidized enrollees tend to raise premiums for subsidized enrollees. Because premium subsidies are designed so that enrollees pay a fixed percentage of income for the benchmark (second cheapest silver) plan, premium increases also increase subsidies — and tend to increase the difference, or "spread," between the benchmark plan and cheaper plans.

The year after: Does reinsurance boost marketplace enrollment?

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I have written on various occasions about a Catch-22 that bedevils state governments trying to improve affordability and boost enrollment in their ACA marketplaces: reductions in premiums for unsubsidized enrollees tend to raise premiums for subsidized enrollees. Because premium subsidies are designed so that enrollees pay a fixed percentage of income for the benchmark  plan, premium increases also increase subsidies — and tend to increase the  "spread" between the benchmark plan and cheaper plans, creating discounts. Premium reductions reduce those spreads and discounts.

States face this Catch-22 when considering reinsurance programs, for which federal funding is available. By reimbursing insurers for costs incurred by their most expensive enrollees, reinsurance reduces premiums by predictable amounts, averaging 20% in the first year of implementation as of 2019, according to Avalere Health. That helps unsubsidized enrollees but sometimes hurts the subsidized.

By 2018, states faced intense pressure to help the unsubsidized. A federal reinsurance program helped control premiums nationally in the marketplace's first three years of operation, 2014-2016. When the program sunset in 2017, premiums skyrocketed, as they did in 2018 (other factors included insurers' initial underpricing in a new market, which was manifest by 2017, and political turmoil in advance of the 2018 enrollment season). From 2016 to 2018, average benchmark premiums increased by an average of 61%.  By 2019, unsubsidized enrollment in ACA-compliant plans was down about 50% from 2016.

Let's take a look at how enrollment fared in ten of the twelve states that have stood up reinsurance programs (as CMS has encouraged states to do) since 2018 (Rhode Island has not yet reported 2020 totals, and Maine's 2019 enrollment was affected by late implementation of the ACA Medicaid expansion).

Everything changes: Demographics inside and outside the ACA marketplace

Every year at this time I bind sheaves of four blog posts for two submissions to the National Institute of Health Care Management's Digital Health Care Media Awards. Here I'd like to post an outtake: a series of posts probing some under-the-radar facts about the the ACA marketplace and its prospective enrollees.  That is:

• The ACA marketplace and Medicaid expansion have never been tested by recession but stand ready as an economic shock absorber.
• U.S. income gains since 2014 have affected marketplace participation.
• Yearly apparent declines in on-exchange enrollment since 2016 are largely illusory.
• Nonetheless, persistent low takeup bespeaks inadequate subsidies.
• A recent increase in the uninsured population is concentrated at higher incomes.

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Eye of the hurricane? The ACA marketplace in 2020

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While open enrollment in the ACA marketplace has 1-7 days to run in a handful of state-based exchanges (SBEs), and other SBEs haven't reported their data, the overall picture is clear: enrollment in 2020 was essentially flat. Enrollment in the 38 states using HealthCare.gov was down 1.4%, while enrollment in the 13 SBEs will be up 2.6%, leaving total enrollment down 0.3%, according to Charles Gaba's projection.

The big picture is perhaps relatively simple. Premiums were down slightly on average; insurers did not register major impact from the zeroing out of the individual mandate in 2019; the market in aggregate was stable.  But the ACA marketplace is really 50 marketplaces -- or thousands, if you count each rating area -- and a lot of change is bubbling under the surface, from Medicaid expansions in red states to new state-based subsidies in blue states.  Nationally, too, the initial tally sparks several questions:

Frederick Isasi: Three healthcare trends, three power struggles

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At Families USA's Health Action conference last week, FUSA executive director Frederick Isasi, in a presentation for attending media, identified three healthcare trends for 2020.  It struck me that at the heart of each enumerated "trend" is a looming political battle, each of them central to the U.S.'s current existential struggle between oligarchy and renewed democracy. Let's look at each in turn.

1. Value. Describing Americans' demand for "value" in healthcare, Isasi was not speaking primarily about "value-based care," i.e. outcomes-based alternatives to fee-for-service payment. He focused rather on out-of-control prices paid to providers that are rendering care unaffordable to tens of millions. He pointed out that healthcare costs have climbed 600% in the last 40 years and nearly tripled as a percentage of GDP, rendering care unaffordable for tens of millions.  "Almost half of Americans say they have trouble affording healthcare," he said. "People are more scared of paying for getting sick than they are of getting sick."

As to the cause of runaway costs, Isasi blamed the market power of the various healthcare industries: "it's a highly subsidized sector with almost no government oversight." The struggle to hold down costs is less technocratic than political: forcing powerful industries to accept curbs on their pricing power.  Potentially enabling that struggle is a sea change in public attitudes: While coverage has eroded in recent years, Isasi noted, the ACA has wrought a sea change in Americans' expectations: "acceptance of the right to access is a new societal norm."

At Health Action 2020: Once more unto the breach, dear friends

I've had my yearly fix from Health Action 2020, Families USA's annual conference for healthcare advocates, policy people, scholars, and, most importantly I think, front-line ACA enrollment counselors.

I attended my first Health Action conference in January 2017, days after Trump was "sworn," aka perjured, into office. Republicans were promising swift ACA repeal -- "repeal and delay" was their watchword of the moment, meaning they would sunset the marketplace and Medicaid expansion swiftly and fill in the details later. The conference was composed of several hundred people devoted to preventing that. "Our action should lead to their inaction," declared incoming FUSA president Frederick Isasi. And mirabilis, that's exactly what happened.

In 2017 I felt keenly that the conference was run and attended by people who had devoted years or decades to expanding healthcare access in the U.S. -- all now faced with the prospect that their work would be unraveled. I wrote about an emanation of collective strength, institutional and individual, from the participants.  And this year I kept flashing back.

Since the impeachment process got into gear this year, I have often felt that American democracy is going down. It's terrifying to watch the entire Republican party fall in behind Trump to neuter Congress's power to hold a corrupt would-be autocrat accountable for on-the-record abuse of power.  Once again, the people on the stage and in the room reminded me that despite the grave threat to democracy posed by a party in power that's given up on democracy, the country has huge reserves for resistance: people who know how to be free; institutions that know how to wield political influence in service of the common good; courts that at least sometimes uphold the rule of law.

No mandate penalty, no problem? The jury's still out

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The Kaiser Family Foundation is peerless as a source of data and analysis of the ACA marketplace, and indeed of all U.S. healthcare markets. So it's probably foolish of me to question a simple, unequivocal and important conclusion by KFF president and CEO Drew Altman. Still...

Altman, who has a regular column conforming to Axios' radically short format, begins his latest with this declarative:

The Affordable Care Act’s insurance market has not been materially affected by the elimination of the individual mandate penalty.

Evidence: premiums are down in 2020, marketplace insurers are profitable, the risk pool has not apparently worsened, enrollment is more or less stable, and the Medicaid expansion appears to have been "largely unaffected."

That's a lot of evidence in short space. The marketplace, and the Medicaid expansion are clearly functioning without the mandate. But still, I think it's too soon to declare the effect of zeroing out the mandate negligible.  Caveats:

Juice it, Jersey: What silver loading anemia looks like

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I have noted before that New Jersey's implementation of an individual mandate and a reinsurance program in its ACA marketplace in 2019 illustrates the tradeoffs involved in reducing premiums in the ACA marketplace. In brief: unsubsidized premiums down, subsidized premiums up.

I have also noted that in New Jersey, silver loading is underpowered -- that is, it has produced weaker-than-average discounts in bronze plans and no discounts in gold plans, which accounted for an anemic 2% of enrollment in 2019.

Last week, David Anderson and Coleman Drake published a study indicating that the widespread availability of free bronze plans, a major byproduct of silver loading*, has had a particularly strong impact on enrollment.  The authors noted that this effect is conspicuously lacking in Jersey, and suggested a reason:

New Jersey restricts cost-sharing variation within metal levels. In 2019 New Jersey bronze plans were required to have an actuarial value of 64 percent—higher than the 58.5 percent minimum allowed by federal law. This regulation limited the financial exposure of existing enrollees by preventing them from selecting plans with higher cost sharing. However, it also limited the premium spread between the benchmark silver plan and bronze plans, which reduced the availability of zero-dollar premium plans in the state and thereby reduced enrollment. A trade-off thus exists between reducing enrollees’ financial exposure by increasing minimum actuarial value levels and increasing insurance coverage via the zero-price effect.

Has silver loading reduced mortality?

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In early 2017, the IRS sent letters to 3.9 million taxpayers who had paid the ACA's individual mandate penalty in 2015, encouraging the recipients to obtain health insurance and avoid the penalty.  A study of the results* published last month found that 1) those who received the letter were 1.3 percentage points likelier to enroll in coverage in the year following than penalty payers who did not receive it, and 2) that receiving the letter reduced mortality  over the next two years among 45-64 year-olds -- by about six deaths per ten thousand, a significant result.

Drilling into the data-set of millions, the authors infer that in this heart attack and cancer-prone age group, "each month of coverage (on average) reduces baseline mortality among those who enroll in coverage by approximately 2.4%." As to how insurance might have this effect among 45-64 year-olds who lacked coverage in the previous year, the authors posit:

For coverage to reduce mortality over this time horizon, it must affect conditions that: (1) can cause death quickly if left untreated or unmanaged, and (2) for which treatment or management can prevent or delay mortality. For example, individuals lacking health insurance may delay seeking care when experiencing symptoms of acute conditions (e.g., heart attack or stroke), and such delays increase the likelihood of short-term mortality (Smolderen et al., 2010; Medford-Davis et al., 2016)... Separately, obtaining coverage may reduce mortality by causing the diagnosis of certain chronic conditions for which treatment has rapid protective effects. For example, cardiovascular drugs have been observed to reduce mortality from heart disease within months of beginning treatment.

While attracting young adults into the ACA marketplace would improve the risk pool and so put downward pressure on premiums, attracting older adults saves lives. It is likely that silver loading, the pricing practice that's generated windfall discounts in bronze and gold plans in the ACA marketplace since 2018, has boosted enrollment more among older enrollees than among younger ones.

Is "free" a magic word in the ACA marketplace?

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Healthcare scholars David M. Anderson and Coleman Drake have published a study that analyzes the impact of free bronze plans, which became available to millions of prospective ACA marketplace plans in 2018, on enrollment.

Ubiquitous free bronze is one result of "silver loading," 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. As a result of silver loading, $0-premium bronze plans available to millions.

Perhaps the most striking finding in Anderson and Drake's paper is the sheer ubiquity of free bronze plans, particularly for enrollees over age 45 (since premiums rise with age, and the benchmark plan costs subsidized enrollees a fixed percentage of income regardless of age, older enrollees have larger subsidies to cover plans that cost less than the benchmark). The authors divined the availability of free bronze by matching enrollment data, which CMS breaks out by county, income, age and metal level in the 38 states that use HealthCare.gov, with pricing data, which CMS also provides. 

Free bronze, they found,was available in 2019 to almost every marketplace enrollee with an income below 150% of the Federal Poverty Level (FPL) -- that is, to about 3 million enrollees in HealthCare.gov states, more than a third of all enrollees. It was available to most enrollees at 150-200% FPL, and to a large majority of enrollees over age 45 in the 200-250% FPL income bracket.