Tuesday, June 30, 2020

Washington's ACA exchange gets its priorities straight

I have criticized state-based ACA exchanges for submerging information about Medicaid, which is likely to insure about twice as many of the newly uninsured as the ACA marketplace.

Scratch that complaint for Washington' state's HealthPlanFinder!  The home page has its priorities right, if the messaging is still a little fuzzy:


Apple Health is the state's Medicaid program, as you'll learn if you click on it. That click will bring you to a page that links to the eligibility requirements. For individual adults, they're clear and clean, paired with a prompt to apply:

Monday, June 29, 2020

"Anyone without health insurance can apply now" -- way to keep it simple, NYSOH

I have criticized messaging on ACA exchanges that's likely to confuse the majority of people newly uninsured after being laid off in the current crisis.  The main problem is that the exchanges submerge information about Medicaid, which is likely to insure more than twice as many newly uninsured people as is the ACA marketplace for private plans. Many who are eligible for Medicaid are likely never to find that out on the exchange websites.

Having obsessed about this a bit (123), I was pleased to encounter a Twitter ad from the New York ACA exchange, New York State of Health, that IMO gets the messaging right:

Friday, June 26, 2020

Loss of health insurance looks modest so far, but it's early days

The Covid-19 pandemic has delivered an unprecedented shock to the U.S. economy, though its duration remains to be seen. Of the 21 million unemployed as of the end of May, 15.3 million were on temporary layoff, according to the Bureau of Labor Statistics. As of the end of May, the BLS reported an unemployment rate of 13.3%, while acknowledging that the rate would be 3 points higher if those classified as employed but absent from work were counted as unemployed, as they should have been (see pg. 6 here).

How many of the newly unemployed will lose access to health insurance? The Urban Institute and the Kaiser Family Foundation both put out estimates in May. At 15% unemployment, Urban forecast that between 17.7 million and 30.1 million would lose access to employer-sponsored insurance, and that about 29% of these people would become uninsured, the rest (71%) enrolling in Medicaid or the ACA marketplace.  Kaiser estimated that the number of people losing access to employer-sponsored insurance (ESI) would be about 87% of total job losses*, and that 79% of those who lost ESI would be eligible for Medicaid or subsidized marketplace insurance. Urban pegged the rise in the uninsured population at 5.2-8.5 million; Kaiser, at about 5.5 million.

What do we know about the impact of job losses on the uninsured rate so far? We do have data. The CDC is reporting results weekly from a Census Bureau "demonstration project," the Household Pulse Survey, a quick-and-dirty web survey introduced with a host of caveats.  The Commonwealth Fund, meanwhile, interviewed 2,271 adults about their health insurance status between May 13 and June 2.

Tuesday, June 23, 2020

In a crisis, Democrats bench the ACA marketplace

young soccer players on bench

As tens of millions of American file for unemployment insurance, about half of those who lose job-based health insurance will be eligible for Medicaid and another 25-30% for ACA marketplace subsidies, according to estimates by the Urban Institute and Kaiser Family Foundation.

The lower percentage potentially picked up by the marketplace is not in itself a knock on that program.  In the U.S., regular unemployment insurance income is very low, and normally accessed only by a minority of the unemployed. In the 35 states that have enacted the ACA Medicaid expansion, those with incomes up to 138% of the Federal Poverty Level (FPL) are eligible for Medicaid. People whose current monthly income is below that threshold are expected to make up a large percentage of those losing job-based coverage.  The $600-per-week extra unemployment insurance (UI) benefit provided for up to four months by the CARES Act does not count toward Medicaid eligibility.

That said, the marketplace has always been a leaky vessel for those who need insurance and qualify for its subsidies (let alone those who need insurance and don't qualify for subsidies, a group that abandoned marketplace coverage in droves in response to the premium runups of 2017-18). A bit less than half of those who qualify for subsidies enroll, according to the Kaiser Family Foundation's 2019 estimate (which I suspect is a tad low). Takeup of Medicaid is much higher. The Kaiser Family Foundation's 2018 estimate of the uninsured who are eligible for Medicaid (6.7 million) is less than 10% of total Medicaid enrollment (73 million in 2018).

Monday, June 22, 2020

Going Japanese with Medicaid for the duration of the pandemic


As pandemic-triggered weekly job losses climbed into the millions and then tens of millions this spring, a cry went up among the healthcare-concerned on Twitter: now the catastrophic weakness of an employer-based health insurance system will hit home.

To which, a reasonable counter: what about Japan? The country has truly universal healthcare, and about 60% of the population is insured through employers. Almost all the rest are insured through residence-based plans run by local governments, including citizens' plans for the nonelderly, covering 27% of the population, and specialized plans for the elderly, covering 13%, according to the Commonwealth Fund. Those proportions are broadly similar to those of the U.S., leaving aside 10% of the U.S. population that was uninsured just prior to the pandemic.  In the U.S., about 54% of the insured population is covered by employer-sponsored plans, 22% by Medicaid, and 15% by Medicare.

Jon Walker has suggested that adapting Japanese model might provide the least disruptive route to universal coverage for the United States:
All adopting a Japanese type of system would require is for the U.S. to take what it is currently doing and heavily standardize it. The biggest change would be scrapping the individual non-employer-based market to put everyone on a government plan, but the individual market is the least popular part of our system anyway.
Americans, like the Japanese, have regionally-based government-run and financed health plans for the (mostly) non-elderly. They're known as Medicaid.*

Thursday, June 18, 2020

Misinformation about Medicaid on state and federal websites

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In one of the many charming technical wrinkles that grace our healthcare system, the income threshold for Medicaid eligibility in states that have enacted the ACA Medicaid expansion (yes, long sentence, that's the point...) is 133% of the Federal Poverty Level (FPL)... except it's actually 138% FPL, thanks to a 5% deduction from an applicant's Modified Adjusted Gross Income (MAGI) mandated by the ACA.

Got that? Good. And who cares? What matters is the monthly income threshold in dollars for households of different sizes, against which people who think they may be eligible can check their income prior to deciding whether to apply.

Some government websites quote 133% FPL as the eligibility threshold for those rendered eligible by the ACA Medicaid expansion. That might not matter -- who knows what 133% FPL is? -- except that some state and federal sites take the trouble to convert that threshold to a monthly income. The wrong monthly income.

Saturday, June 13, 2020

The elephant not in the room on ACA exchanges

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Here's the home page on the Maryland Health Connection, the state's ACA exchange. What's missing from this picture?


Friday, June 12, 2020

Covering the newly uninsured in New York: The BHP advantage

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My last post noted that Medicaid enrollment in New York spiked 2.6% in May and is up 4.2% since March. That's about mid-range among states for Medicaid enrollment growth since Covid-19 triggered mass layoffs.   Total enrollment in New York's mainstream managed Medicaid programs (about two thirds of total Medicaid enrollment in the state) increased by 177,858 from March to May, to 4,363,873.

New York's unemployment rate hit 14.5% in April. At 15% unemployment, the Urban Institute calculates that Medicaid enrollment in New York should eventually increase by between 641,000 and 1.1 million from pre-crisis levels, an increase of about 11-20%.  If a 4% increase as of May seems like a slow start, a new report by the United Hospital Fund analyzing Medicaid enrollment in New York during the Great Recession provides important context. 

From December 2007 to November 2009, as unemployment in New York more or less doubled from 4.8% to 8.9%, Medicaid enrollment increased by 10%, or 400,000. But Medicaid enrollment growth lagged behind job loss: "the fastest average increases in enrollment occurred approximately seven months after the fastest average increases in unemployment."*  

While Medicaid enrollment growth in New York so far seem modest compared to growth in Kentucky and Minnesota, the UHC report, citing growth in March and April, notes, "as the pandemic accelerated, Medicaid’s average monthly growth rate was four times as large as the average monthly growth rate during the Great Recession’s first twelve months."

Medicaid, moreover, is not the whole story. The Urban Institute estimates that approximately half as many of those who lose job-based insurance will find coverage in the ACA marketplace as in Medicaid. New York may do better than that, thanks to its Basic Health Program, the Essential Plan.

Friday, June 05, 2020

Where is Medicaid enrollment surging? Notes from a few states

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Last month, the Urban Institute forecast that at 15% unemployment, between 8.2 million and 14.3 million people would enroll in Medicaid, an increase of 11-20%.* While the job rate officially now stands at 13.3%, it would be 3 points higher if those classified as employed but absent from work were counted as unemployed, as BLS says they should be (see pg. 6 here).

I have been tracking Medicaid enrollment in states that have accepted the ACA Medicaid expansion and that report timely monthly data. As of early May, enrollment in Kentucky and Minnesota was the highest I was able to track, having increased about 8% since February.  Nationally, the increase at that point was probably about half that. In both states, enrollment increased by another 2% from May to June.

Below, a few bulletins from states (including MN and KY) showing significant enrollment growth. A 2% jump in a given month seems like a frequent marker that enrollment is getting in gear.

Thursday, June 04, 2020

Wasting asset for insuring the newly uninsured: State unemployment insurance agencies

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I want to use my small megaphone to help call attention to a vital unused resource in the drive to connect millions of newly unemployed Americans to available subsidized health insurance: state unemployment insurance agencies.

The Brookings Institution put out an admirably clear briefing identifying the size of the target population and the steps state unemployment insurance (UI) agencies should take to inform those seeking unemployment benefits of their insurance options -- and ideally, to help them enroll. That report builds on a Families USA call to action spotlighting the almost total abdication of UI agencies on this front.

Just prior to the pandemic,  a pathetically small proportion of the unemployed (under 30%) accessed unemployment insurance. Historically, a similarly inadequate percentage of the newly unemployed found their way to health insurance within a few months. The ACA appreciably boosted the latter percentage, from 30% to 44%, according to Brookings. Transition from employer-sponsored insurance to Medicaid or marketplace is still missed by the majority.

In the current crisis, the Kaiser Family Foundation estimates that 79% of tens of millions of newly uninsured people will be eligible for either Medicaid (47%) or subsidized marketplace coverage (31%).  We have to do better than we've done historically to connect people to benefits for which they're eligible.

Tuesday, June 02, 2020

"In the mourning we find hope": Biden's somber recast of Obama's story of America

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In his remarks on this week's civil unrest and Trump's authoritarian response today, Biden hit some vitally right notes.  He committed himself as president to obtaining equal justice for all. He spotlighted the depravity of Trump's words and actions in response to this week's demonstrations, accurately recalling their echoes of the vicious police chiefs who assaulted the civil rights demonstrators of the 60s. He spoke of his own crushing personal losses and, with humility and obvious sincerity, modeled the empathy that Trump lacks for suffering triggered by economic inequality and racism. 

Most strikingly to me, he recast Obama's heroic narrative of American history in somber tones even as he echoed Obama's signature tropes -- the pursuit of a more perfect union, the arc of history that bends toward justice.

Monday, June 01, 2020

Medicaid For All Who Want It, Pandemic Edition

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The Kaiser Family Foundation has published an illuminating comparison of one possible and two existing means of subsidizing coverage for those who lose job-based health insurance in the Covid-19 pandemic. The two existing options are Medicaid, for which 47% of the newly uninsured are eligible by Kaiser's estimate, and subsidized marketplace coverage, for which 31% may be eligible. The third option, federal subsidization of 100% of COBRA* premiums, is provided in the HEROES Act passed by the House - and could conceivably win some Republican backing, as it would be a windfall for employers, healthcare providers and insurers as well as the individual recipients.

There's a certain symmetry between fully subsidized COBRA and Medicaid. Both options would be zero-premium in almost all cases (a few states have imposed premiums on higher income Medicaid enrollees). The tradeoff: employers' relatively robust provider networks versus Medicaid's zero-to-minimal out-of-pocket costs.

According to Kaiser, the average actuarial value of an employer-sponsored plan is 85%, meaning it's designed to cover 85% of the average enrollee's medical expenses. The average deductible in employer-sponsored insurance is $1,655, and the average out-of-pocket maximum for individuals is about $4,000.   AV for Medicaid is effectively 100% or very close to it.  Medicaid is also a much better deal for taxpayers. As Kaiser points out, private insurers (including self-funded employer plans) pay almost twice Medicare rates, and a still higher multiple of Medicaid rates.

The clear loser in this triple comparison is marketplace coverage, as for most of those who lose job-based coverage it requires higher premiums (which are zero in the other two options), higher out-of-pocket costs, and provider networks often as narrow as Medicaid's.

Wednesday, May 27, 2020

Medicaid enrollment in a pandemic: The case of Kentucky

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Update (6/9/20) at bottom, with June enrollment numbers and more information re enrollment outreach in KY.

Of the tens of millions of Americans likely to lose access to health insurance as a result of job losses triggered by the Covid-19 pandemic, the Urban Institute estimates that about half -- 8.2 million in the most conservative of several scenarios -- will enroll in Medicaid. Kentucky appears to have gotten off to a comparatively fast start, though state healthcare advocates see a need for more intense outreach.

Medicaid enrollment in the state has increased by more than 100,000 (8%) since February, from 1.32 million to 1.42 million, according to the state's monthly membership tally.  In 2019, enrollment from March to May was flat, down less than 1%. At 20% unemployment, which we're likely to reach in the next jobs report, between 336,000 and 397,000 Kentuckians are likely to have lost access to job-based insurance, according to the Urban Institute estimate. Urban foresees Medicaid enrollment in Kentucky increasing by between 208,000 and 228,000 thousand if that unemployment rate holds for some months.

Dustin Pugel, a senior policy analyst at the Kentucky Center for Economic Policy, credits Governor Andy Beshear, elected just last November, with stimulating and facilitating crisis Medicaid enrollment.  During his daily televised, widely watched Covid-19 briefings, Beshear regularly starts with ten steps for fighting the virus, and, Pugel says, "One of them is signing up for benefits. Medicaid is mentioned every single time."

Thursday, May 21, 2020

C'mon, states: take the wraps off Medicaid

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On the eve of the pandemic, about 13 million Americans were enrolled in ACA-compliant individual market health insurance plans. About 71 million were enrolled in Medicaid.

As job losses triggered by the pandemic exceeded 30 million, the Urban Institute forecast that at a 15% unemployment rate, among 17.7-30.0 million people losing access to employer-sponsored insurance, just under half would enroll in Medicaid and just under a quarter in marketplace or other private insurance.* Analyses by the Kaiser Family Foundation and Health Management Associates also show Medicaid to be the main vehicle for insuring those who lose access to employer-sponsored insurance.

Every ACA exchange, every state Medicaid agency, and arguably every state government website should be foregrounding an app that looks (and works) like this:



Wednesday, May 20, 2020

New Jersey's "Get Covered" message submerges Medicaid

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New Jersey, a very blue state with a liberal governor and large Democratic majorities in both houses of the legislature, is committed to helping hundreds of thousands of residents newly uninsured in the Covid-19 pandemic to find subsidized coverage. The state has launched an information campaign to help people get covered.

But New Jersey's ACA marketplace is stuck in limbo during a tough time. The state is in the process of creating its own state-based exchange (SBE), scheduled to launch on November 1. In the meantime, it's technically an SBE, but still using the federal exchange, HealthCare.gov, for enrollment.

That creates a messaging problem. The state has created a website, Get Covered New Jersey, to help people find coverage. But it has to be a complex switching station. Those eligible for subsidized marketplace coverage need to enroll through HealthCare.gov. Those eligible for Medicaid -- probably the majority of the newly uninsured -- can also apply via HealthCare.gov but, for reasons explained below, are probably better off applying directly through the state's Medicaid program, New Jersey Family Care. Finally, those who earn too much to qualify for aid need to be aware of ACA-compliant plans offered off-exchange only, especially since these include the cheapest silver plan available.

Get Covered New Jersey tries, but in my view fails to help people figure out quickly what kind of help they're eligible for, and act accordingly.

The main problem is that the site doesn't foreground Medicaid or, most vitally, a Medicaid eligibility screener. According to an Urban Institute estimate, almost half of New Jersey's  newly uninsured residents (224,000 out of 489,000 by the study's more conservative of two estimates) should end up in Medicaid, while just under a quarter may enroll in marketplace coverage.

Sunday, May 17, 2020

Obama's bid to bend the arc back toward justice

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In 2013, I marveled as pundits expressed surprise when Obama said what he'd always said about the economic case for a fairer distribution of wealth. It seemed that the connection Obama constantly asserted between fairness and prosperity hadn't registered. I wondered, Will we hear Obama in retrospect?

The answer now appears to be yes, evident in the outpouring of love and longing in reaction to his virtual commencement speeches for graduates of historical black colleges and universities and all high school graduates. But not in the way I'd anticipated.

Obama's core pitch, as candidate and president, was for a recommitment to shared prosperity -- public investment, income redistribution -- after decades of steadily encroaching plutocracy. He encased this pitch in a seductive narrative of American history in which this commitment to the common good was renewed and extended at intervals: the nation might err, but its long-term course was to approach ever nearer to fulfilling its founding principles of equal rights and shared opportunity. Democracy, embodied in bottom-up demand for justice, enabled periodic course correction: American history followed the arc that bends toward justice.

Friday, May 15, 2020

Hey America, let's go through the Obamagate

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Trump, displeased by U.S. law enforcement and intelligence agencies' investigations of the criminals and traitors who staffed his 2016 campaign and early administration, is deploying Barr (and his own deranged rhetoric) to smear and criminalize those efforts and tie them to the past administration under the rubric of "Obamagate."

In Trump parlance, "Obamagate" is a mass of trumped-up charges and projections advancing the fiction that Obama, like Trump himself, deployed law enforcement and intelligence to pursue his personal enemies and protect his personal friends. Obamagate is a moral looking glass through which Trump's face is imposed on Obama's.

I'll give Trump this: The term does have a certain resonance. Would that this country could pass through an equally fantastic Obamagate to various norms and benefits we took for granted when Obama was president.

If only we could..
  • Pass through an Obamagate to a time when the president put the national interest above his personal interests, and worked as hard to advance prosperity and opportunity in states run by his political rivals as in states run by his political allies.

Wednesday, May 13, 2020

Getting insured after job loss: Just how complicated?

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About 27 million of the newly unemployed and their family members have likely lost health insurance, according to a new Kaiser Family Foundation estimate.

The ACA offers a leaky but not entirely unseaworthy lifeboat. According to Kaiser estimates, 79% of the newly uninsured are at present likely eligible for ACA-subsidized coverage -- 12.7 million for Medicaid and CHIP and 8.4 million for subsidized private plans in the ACA marketplace.

The basic buckets that those seeking insurance should find themselves sorted into shouldn't in principle be that complicated. Here's the breakdown:

Monday, May 11, 2020

The ACA as it should have been: Massachusetts' ConnectorCare in a crisis

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On March 11, the Massachusetts Health Connector became the first ACA marketplace to respond to the flood of job losses triggered by the Covid-19 pandemic by opening an emergency Special Enrollment Period (SEP) in which any uninsured resident could enroll in private market coverage. Eventually, 12 of the 13 state-based exchanges opened emergency SEPs, whereas HealthCare.gov, the federal exchange serving 38 states, declined to do so, though HealthCare.gov has taken steps to ease the normal SEP-for-cause application process. 

On  May 1, Massachusetts reported that in the SEP's first 40 days, 8,300 state residents had gained coverage specifically through the emergency SEP, while 20,200 in total had enrolled in coverage in March and April -- the bulk of them via ordinary SEPs, in which an applicant reports a life change, usually loss of other insurance, that qualifies her to enroll outside of the annual fall Open Enrollment period.

It's hard to assess the success or impact of the emergency SEPs based on these kinds of data snippets, which several state marketplaces have put out. On the whole, March/April enrollment in Massachusetts represents 6.3% of enrollment as of the end of Open Enrollment in January. That does seem a somewhat elevated off-season pace.* In any case, it's likely that Medicaid will pick up the lion's share of the newly uninsured, and the enrollment report did not include Medicaid numbers.

Thursday, May 07, 2020

Enrollment in Medicaid surges in Minnesota

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An Urban Institute analysis released this week, How the COVID-19 Recession Could Affect Health Insurance Coverage, estimates, in the more conservative of two models deployed, that if the unemployment rate reaches 15%, Medicaid enrollment will increase by 8.2 million  nationally. That would constitute a 16% increase in total Medicaid enrollment for the under-65 population.

Minnesota appears to be halfway there already. The state tracks enrollment in managed* Medicaid and MinnesotaCare, a Basic Health Program that provides Medicaid-like coverage to people in households with income up to 200% of the Federal Poverty Level, on a monthly basis.

From February to May this year, managed Medicaid enrollment in Minnesota for adults age 21-64 is up 10.4%. For pregnant women, it's up 16%. Enrollment of children is up 6%. Enrollment in MinnesotaCare, the BHP, is up 24% -- though enrollment in that particular program was up almost as much in Feb-May 2019.

In total, managed Medicaid/MinnesotaCare enrollment has increased by 77,142 (8%) since February, more than five times last's year's increase in the same period of 14,547 (2%).  Since mid-March, 590,000 Minnesotans have applied for unemployment benefits, according to the state Management and Budget office's May budget projection.

Tuesday, May 05, 2020

ACA enrollment in a pandemic: What we know so far

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Roughly 30 million Americans have filed jobless claims in the last six weeks. Slightly fewer than half that number may have also lost health insurance, according to an analysis by the Economic Policy Institute.*

The Urban Institute estimates that 59% of those in industries most vulnerable to job loss who lose job-based coverage will have access to government-supported insurance -- Medicaid, CHIP, or the ACA marketplace. How many accept the help is a different question.

The SEP imperative

The answer may depend in part on how wide the ACA online exchanges open the door. Normally, the uninsured can seek coverage only during a limited Open Enrollment Period (Nov. 1 - Dec. 15 in the federal exchange, longer in the 13 state-based exchanges), unless a change in life circumstances during the off-season renders them newly eligible. In that case they are granted a Special Enrollment Period (SEP). Applying for a SEP adds steps to the already complicated ACA enrollment process. Under normal circumstances, an applicant has to upload or mail in proof of loss of coverage, or proof of another SEP trigger, such as marriage.

Wednesday, April 29, 2020

Insuring the newly uninsured: COBRA or ACA?

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So what about fully funding COBRA for the millions or tens of millions of Americans who lose job-based coverage? That is, bail out everyone -- insurers, employers large and small, employees, and hospitals and doctors, who depend on the commercial insurance gravy train?

It's the most expensive way to keep the ranks of the uninsured from ballooning. It's also the least disruptive way.  Families USA, hardly a corporate water-carrying outfit, supports it.

Thought bubbles:

Monday, April 27, 2020

Boosting ACA coverage in a time of mass unemployment: State options

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In the past five weeks 26 million Americans have lost their jobs. Could national impoverishment prepare a path to universal health coverage?

When tens of millions of household incomes shrink toward the poverty level, tens of millions will become eligible for Medicaid. If double-digit unemployment persists for many years, the program may be upgraded by popular demand and its eligibility threshold may creep up by degrees.

All bets are off if Trump is reelected, as Republicans are sworn enemies of Medicaid. Their 10 years' war against the ACA has at bottom been a drive to defund Medicaid -- roll back the ACA eligibility expansion, impose block granting or per capita caps on remaining Medicaid programs, and throw up barriers to enrollment like work requirements and frequent "redeterminations" of eligibility.  If Republicans regain control of Congress as well as the presidency any time soon -- or neutralize Congress under authoritarian rule -- they'll doubtless succeed in shrinking and hollowing out the program.

If they don't, Medicaid will remain funded, and it stands ready to catch a hefty proportion of the newly unemployed in the 36 states that have enacted the ACA Medicaid expansion. Total enrollment is likely to increase by 16.5 million to about 87 million according to the mid-range estimate in an analysis by Health Management Associates. With no end to our coronavirus exposure in sight, we are probably looking at double-digit unemployment for the foreseeable future. Elevated Medicaid enrollment may persist.

If Democrats win the presidency in 2020, but lack power or will to enact sweeping new coverage expansions, Medicaid coverage, perhaps under different names, will likely expand further.

Blue states looking to avoid (or roll back) massive increases in their uninsured population should look closely at existing state programs that extend Medicaid-like coverage up the income ladder.  There are two existing models that states might follow.

Wednesday, April 22, 2020

CMS answers a $600 question

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While CMS has declined to open an emergency Special Enrollment Period for all comers on HealthCare.gov, the agency is taking steps to smooth the enrollment path for the newly uninsured. Here's a roundup of some constructive moves, some of which I've noted in recent posts:
  • The $600/week extra unemployment benefit provided in the CARES Act is income that counts toward the level of subsidy eligibility in the ACA marketplace but does not count toward Medicaid and CHIP eligibility. That seems a recipe for potential enrollment confusion on a platform that enrolls people in both programs. In response to a query, however, CMS tells me, "HealthCare.gov will be updated to apply logic to ensure federal pandemic UC is counted correctly and unemployed consumers receive the accurate eligibility determination." That is, applicants should report their full UI income in the application, and HealthCare.gov will be able to discount it for the purposes of determining Medicaid eligibility. That's good news, if the "logic" holds up as intended. [Update, 4/24: just to highlight the verb tense above, CMS says that they will add this capability, which means that it's not yet operative.]

  • CMS also says that if an applicant's year-to-date income or projected full-year income exceeds the Medicaid eligibility threshold, but current monthly income is below the monthly threshold ($1468 for an individual, $3013 for a family of four), HealthCare.gov will recognize Medicaid eligibility and "transfer the consumer’s information to the state Medicaid or CHIP agency as appropriate." As I've noted in prior posts, in this situation navigators generally prefer to apply directly to state agencies for Medicaid. But whether or not it's difficult in practice to report both annual (or projected annual) and current monthly income on hc.gov and get the right result if one is over and the other is under the threshold, it's possible.

  • As noted in my last post, those who apply for a Special Enrollment Period on grounds that they recently lost health coverage (usually after job loss) will not have to document the loss of coverage -- only attest to it. I am not sure whether that is true for other SEP causes, such as marriage.

Tuesday, April 21, 2020

HealthCare.gov will not require proof of loss of coverage from the newly uninsured

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CMS has refused to follow the lead of the thirteen state-based ACA marketplaces and open an emergency Special Enrollment Period (SEP) in the 38 states using HealthCare.gov, the federal ACA enrollment platform.  But the agency is taking smaller steps to smooth the enrollment path for the newly uninsured.

An emergency SEP would allow anyone who's uninsured to seek coverage in the marketplace as they can during the yearly Open Enrollment period, which on HealthCare.gov runs from Nov. 1 - December 15. Instead, only those who have have a qualifying "life change" -- e.g., loss of job-based coverage -- can enroll in marketplace plans. That requires applying for a SEP, which is a process in itself.  (Medicaid enrollment is open year-round, but many of the newly uninsured may not be aware if they're Medicaid-eligible -- all uninsured need a general message that coverage of one kind or another is available.)

Yesterday, Amy Lotven of Inside Health Policy reported (paywalled) that CMS has created a new Covid-19 page (parts of which I reviewed in my previous post) -- and, more significantly
CMS is providing flexibility around submission of certain documents, such as a document confirming loss of coverage from one’s employer, during the pandemic emergency, the agency says.

Saturday, April 18, 2020

Smooth the path to Medicaid enrollment for the newly uninsured

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As tens of millions of Americans lose job-based health insurance, the heavyweight in reducing the ranks of the newly uninsured is going to be Medicaid -- at least, in the 36 states that have enacted the Medicaid expansion  (and if Democrats don't push through a 100% COBRA subsidy). Medicaid will far outweigh the ACA marketplace for several reasons:
  • Medicaid eligibility is based on monthly income, whereas marketplace subsidy eligibility is based on annual income. Mid-year, marketplace subsidies are therefore weakened by income earned year-to-date.
  • The average normal unemployment benefit nationally is $378 per week* -- close to the Medicaid eligibility threshold in expansion states for a single person ($1468/month) and well below the threshold for any larger family. 
  • The extra $600/week UI benefit provided for up to 4 months by the CARES Act does not count as income for Medicaid eligibility purposes, but it does count toward subsidy eligibility in the ACA marketplace. 

Wednesday, April 15, 2020

ACA marketplace 2020: CSR takeup continues to erode

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In the current crisis, as millions lose employer-based insurance, the fine points of ACA marketplace enrollment back in Open Enrollment for 2020 are not going to get anyone's pulse racing.

That's especially true since the 2020 marketplace was quite stable. Enrollment nationwide was essentially flat; unsubsidized premiums were down slightly; and silver loading effects (discounts in bronze and gold plans, explained below) fluctuated within states and rating areas but did not change much on net.

Nonetheless, significant trends that surfaced in 2017 and were intensified by silver loading from 2018 forward continued. Silver plan selection continued to erode, though gold selection remained flat: the marketplace is "bronzing," which means more people are in plans with very high deductibles, averaging over $6,000 for a single person.

Friday, April 10, 2020

With Biden's public option, who needs Biden's Medicare buy-in?

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Joe Biden's healthcare reform plan, released last July, is a light sketch of a familiar reform model: "Medicare" for all who want it, centered on a public option that anyone can buy into on a subsidized basis.

Biden proposes a public option offered within the ACA marketplace, paying Medicare rates or something close them to providers (though the language is vague here) and available on a subsidized basis to people whose employers offer health coverage as well as those who lack access to employer-sponsored insurance (though the language on this front is also ambiguous*). The public option, and private plans within the ACA marketplace at the same benchmark metal level, would cover between 80% and 100% of the average enrollee's costs, diminishing with income, at premiums ranging from zero to 8.5% of income.**

A bill introduced in the House by Reps Jan Schakowsky and Rosa DeLauro, the Medicare for America bill, has this basic structure but integrates the new public option into a more comprehensive healthcare system overhaul, revamping and folding in both existing Medicare and Medicaid, and offering buy-ins to employers of all sizes.  Biden's bill leaves Medicaid and existing Medicare intact and does not offer buy-ins to employers, only employees.

That leaves an opening of sorts for Biden's latest initiative: opening existing Medicare to adults aged 60 and over. Such a step is imaginable as a stopgap that could be effected more quickly than Biden's more sweeping overhaul. But Biden is proposing that the opt-in to existing Medicare co-exist as an option beside "the Biden Medicare-like public option — as well as other subsidized private plans available to individuals through the Affordable Care Act."

Tuesday, April 07, 2020

Squinting at likely new Medicaid and marketplace enrollment as job losses accelerate

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Charles Gaba has used early enrollment data from state-based ACA marketplaces that have opened up emergency Special Enrollment Periods to hazard an estimate: If HealthCare.gov, the federal exchange that handles ACA marketplace enrollment for 38 states, were to open a no-strings attached emergency SEP for sixty days, about a million more people than usual would enroll in marketplace plans in those two months.

That's based on a rough quadrupling of normal off-season enrollment in 3 states (Maryland, Colorado, Minnesota) that have opened emergency SEPs that enable applicants to complete an application online, more or less as they would during the yearly Open Enrollment season. (In 3 states that require emergency SEP applicants to initiate the application with a phone call (Connecticut, Washington, Nevada), enrollment is up just 22-35%.) As of 2015, about 6,000 people per day were enrolling via HealthCare.gov in nine months outside of Open Enrollment season. An extra 18,000/day for 60 days (assuming an easy, wide open SEP) would come to 1,080,000 additional new enrollees.

A few further observations:
  • Process matters: The difference in states that enable online applications vs. those that require a phone call to begin the process appears dramatic, though data is scarce at this point (12 SBEs, including California and New York, have opened emergency SEPs; just six have released any data).  That said, HealthCare.gov, for which CMS refused to open an emergency SEP, requires those who lose job-based coverage to verify the date they lost coverage in writing before they can enroll in a marketplace plan.  With 10 million newly unemployed in a two-week period, that could cause an administrative train wreck.

  • More than two months? While an emergency Special Enrollment Period must maintain the perception that enrollment isn't open year-round, so that people don't wait until they get sick to enroll, a continuing crisis is likely to lead to continuing extensions, as has already happened in many states.

  • Early days yet: Shelli Quenga, Director of Programs at the Palmetto Project in North Charleston, South Carolina, said last week that her agency was so far busiest helping people get food stamps: "people have to eat every day, so they think more about their food benefits than they do about their health benefits." That's a typical sequence of concerns, according to Quenga.

  • Early days, Part B: While enrollment from the 10-odd million newly unemployed as of April 2 hasn't fully gotten going, the tidal wave of job losses probably hasn't peaked yet.

  • Medicaid will matter more: Gaba reports that in Maryland, SEP enrollment from March 16 through April 6 totaled 8,454 in Medicaid (which is open year-round) and 5,735 in the marketplace. [Update, 4/23/20: MNSure, the Minnesota ACA exchange, announced SEP enrollment numbers yesterday that showed a similar percentage of users, 60%, applying for either Medicaid or MinnesotaCare, a Medicaid-like "basic health program' available to applicants in the 139-200% FPL income range.] The CARES Act, signed into law on March 27, will likely further skew enrollment toward Medicaid. As I've noted previously, the $600/week extra unemployment benefit the new law provides for up to four months counts as income for the purpose of calculating ACA marketplace subsidies, but not toward Medicaid eligibility. Up to $10,200 of extra income will disqualify many marketplace applicants for secondary Cost Sharing Reduction subsidies and render others ineligible for premium subsidies, or else will sharply reduce those subsidies. 
One widely circulated projection, from Health Management Associates, foresees up to 35 million Americans losing job-based coverage, with a mid-range estimate of 23 million, which comes to an unemployment rate of 17.5%.  Health Management foresees enrollment in ACA-compliant private plans remaining more or less flat, as some marketplace enrollees switch to Medicaid. In the mid-range estimate, Medicaid enrollment grows by some 17 million as the uninsured population rises from 29 million to 34-35 million.

I had missed the likelihood of people shifting from marketplace to Medicaid. The differing tax treatment should accelerate that too. At the same time, the unemployment income boost should newly qualify some people in states that have refused the ACA Medicaid expansion for marketplace coverage by raising their countable household income over 100 % FPL.

Related:
ACA enrollment train wreck coming
Our emerging public option: Medicaid
CARES Act may reduce coverage gap in states that refused to expand Medicaid
Enhanced unemployment benefit will skew marketplace enrollment
Emergency special enrollment periods in 12 states: How easy?
How about an emergency Special Enrollment Period for the ACA marketplace?

Sunday, April 05, 2020

Reverse reinsurance for COVID-19 treatment

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The case for the federal government picking up the cost of all COVID-19 treatment for everyone, not just the uninsured, is compelling.* Benefits include:
  • Eliminating inhibitions about seeking treatment, thereby helping to contain contagion as well as saving lives. 
  • Avoiding a major channel of financial harm at a time when tens of millions are likely to suffer extensive financial harm.
  • Establishing a unified database of treatment/results.
  • Paying providers swiftly while eliminating price-gouging via balance billing (which enacted COVID-19 legislation has so far enabled at providers' behest).
At the same time, as we pile on trillions in federal debt with abandon, there's no reason that private insurers and self-funded health plans shouldn't pay their fair share.

A mechanism already exists to calibrate what constitutes such a "fair share." It's the statutory Medical Loss Ratio (MLR) that health plans are required to maintain. MLR is the percentage of premiums a plan spends on medical care for enrollees. The ACA-mandated minimum MLR is 80% for individual and small group plans and 85% for large group plans. If a plan spends below those thresholds on claims, it's required to rebate the employer (in group plans) or the enrollees (in individual market plans).

Friday, April 03, 2020

ACA enrollment train wreck coming

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Update, 4/21/20: On a CCIO webinar for enrollment assisters, a moderator said that HealthCare.gov as of now is accepting simple attestation from an applicant that she has lost health coverage -- the marketplace is not requiring documentation of loss of coverage. That's very good news.

On Tuesday, the Trump administration dashed widespread hopes that it would open an emergency Special Enrollment Period in the ACA marketplace for the 38 states using HealthCare.gov, the federal exchange, allowing anyone who was uninsured to apply for coverage. Twelve of the thirteen state-based exchanges have opened such emergency SEPs, and most are extending the deadline.

The White House told reporter Amy Lotven that an emergency SEP is not needed because "there's already special enrollment for job loss." That's wrong, as Charles Gaba and others pointed out: there's a SEP for loss of insurance that usually follows job loss.

Not only does that ordinary SEP exclude those who were uninsured before job loss -- it's also likely to make obtaining insurance a dauntingly difficult and dangerously slow process for the millions who do lose employer-based insurance and seek new coverage through HealthCare.gov.

The normal SEP crawl

Shelli Quenga, Director of Programs at the Palmetto Project in North Charleston, South Carolina, a nonprofit brokerage* serving primarily low income clients, explained to me that obtaining a SEP after loss of job-based (or other) insurance coverage is difficult in the best of times. "The process is deliberately cumbersome, and it's going to cause people to remain without coverage," she worries.

Thursday, April 02, 2020

The newly unemployed also need an emergency Special Enrollment Period

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After a week or two of rumors that the Trump administration would open an emergency Special Enrollment Period (SEP) on HealthCare.gov, the federal ACA exchange used by 38 states, the administration announced on Tuesday that it would not do so. Twelve of the thirteen state-based exchanges have announced emergency SEPs since March 10, with only Republican-ruled Idaho demurring.

As Jeff Young put it, team Trump could not choke down "an admission that the law and its benefits help people." Their spite will likely cost some people their lives and others all their worldly wealth. As the Kaiser Family Foundation's Larry Levitt noted, some 9.2 million of the nation's uninsured were eligible for ACA marketplace subsidies at last count (i.e., as of 2018).

Normally, enrollment in ACA-compliant private plans is only possible during Open Enrollment, which runs Nov. 1 - Dec. 15 in HealthCare.gov states. A SEP is available at other times only to those who undergo a "life change," such as loss of employer coverage, marriage, divorce, death of a family member, etc.

Whether fear of COVID-19 and the huge costs of hospitalization (ranging from about $9,000-90,000 by Kaiser's estimate) would induce many of the uninsured to seek coverage is an open question.*  Poor takeup among the subsidy-eligible has persisted since the ACA marketplace launched. The 9 million subsidy-eligible uninsured estimated by Kaiser roughly match total on-exchange enrollment. Takeup is better among those rendered eligible for Medicaid by the ACA expansion, but Kaiser also estimates that about 7 million uninsured are eligible for Medicaid and CHIP. An emergency SEP, plus a concerted public information campaign, might shrink those ranks.

The main benefit of an emergency SEP opened unconditionally to all may lie elsewhere, however. ACA enrollment can be complicated at the best of times. An ordinary SEP, including one triggered by job loss and attendant insurance loss, adds friction.  An applicant has to attest to and verify the loss of insurance; the marketplace has to confirm it, grant the SEP, and then open the gate. In some states, accepting evidence of loss of coverage is up to the insurance company with which the applicant seeks to enroll.

Wednesday, April 01, 2020

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:

Tuesday, March 31, 2020

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.

Thursday, March 26, 2020

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.*

Others 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.

Tuesday, March 24, 2020

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

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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 complication that could flummox a lot of newly uninsured people: the mismatch between marketplace and Medicaid income assessments. While subsidy eligibility and subsidy size in the marketplace is determined on the basis of annual income, Medicaid eligibility is determined on the basis of monthly income.  While the HealthCare.gov application prompts applicants to report both estimated annual and current monthly income, and should find Medicaid eligibility on the basis of monthly income if it's below the threshold, several experienced enrollment assisters have told me that in this circumstance they prefer to apply directly through a state Medicaid office or website.*


It also suggests that some people may actually have a choice of marketplace or Medicaid, since a newly unemployed person, or a self-employed person whose income drops abruptly, has to estimate income for the year. Let's say you're a single adult whose job pays $4,000 per month,and you're laid off at the beginning of April, when you've earned $12,000 to date. Estimate your income for the full year at $17,000, and you're on Medicaid. Estimate it at $18,000, and you're in the marketplace, and eligible for the highest level of Cost Sharing Reduction, which will put your deductible in the $0-500 range. A benchmark silver plan will cost you $56 per month at that income.  At a $20,000 annual income, the benchmark premium will go to $77/month and the deductible (under the second strongest CSR level level) will probably be in the $500-1000 range.

Because the ACA Medicaid expansion established no asset test for Medicaid eligibility -- anyone in a household with income under 138% of the Federal Poverty Level qualifies -- high earners could become Medicaid-eligible even if their year-to-date income at the time of unemployment exceeds the threshold for subsidy eligibility in the marketplace (400% FPL, or $49,960 for an individual, $103,000 for a family of four). That assumes no unemployment insurance income, or a level below Medicaid eligibility.  High self-employed earners may find themselves in this category if their sources of income dissolve. [Update, 4/26: The CARES Act renders the self-employed and others not ordinarily eligible for unemployment benefits eligible -- and adds a $600/wk extra UI benefit for up to four months. See note at bottom.]

The experience of people I've helped apply for Medicaid suggests that enrollment is often slow and balky. State Medicaid offices and enrollment websites will likely be flooded with new applicants. A lot will depend on the prevailing attitude in a given state government. In a disaster, states can seek Medicaid waivers to streamline eligibility determinations -- essentially to enroll anyone who declares an income that renders them eligible, and suspending eligibility redeterminations for the duration of the crisis.* In recent years states have gone the other way, stepping up their technological ability to detect income increases that disqualify people from Medicaid.

So the question now for state governments is what do you want to do? Minimize your uninsured population during a pandemic, or minimize state expenditure on Medicaid?

In a pandemic, you want low income people on Medicaid.** No premium, no cost sharing, no balance billing, no muss no fuss once you've located providers who accept the insurance. In fact we should always want low income people on Medicaid -- say, to 200% FPL. But that's a tale for a different day, unless the pandemic changes our legislative dynamics beyond recognition.

Related: Uninsured in a pandemic? Seek help -- it's likely available
----
*  Update, 4/26: I had originally written that HealthCare.gov might not recognize Medicaid eligibility based on current monthly income if the actual or estimated annual income exceeded the annual eligibility threshold. That was an error -- though several experienced navigators told me that they prefer applying directly through state Medicaid departments in this circumstance.

One further complication: The CARES Act, the Covid-19 relief bill signed into law on March 27, provides a $600/week boost to ordinary unemployment income for up to four months, which comes to a maximum of $10,200. This income counts in the determination of marketplace subsidy eligibility but does not count toward Medicaid eligibility. While CMS has promised to enable HealthCare.gov to recognize the extra $600/week unemployment benefit as income for marketplace purposes while discounting it when determining Medicaid eligibility, that capability is not yet in place.

** On March 22, the president declared a national emergency under the Stafford Act. That clears the way for states to seek Section 1135 Medicaid waivers, which enables these measures, among others:
- Temporarily suspend prior authorization requirements;
- Extend existing authorizations for services through the end of the public health emergency;
- Modify certain timeline requirements for state fair hearings and appeals;
- Relax provider enrollment requirements to allow states to more quickly enroll out-of-state or other new providers to expand access to care, and
- Relax public notice and submission deadlines for certain COVID-19 focused Medicaid state plan amendments, enabling states to make changes faster and ensure they can be retroactive to the beginning of the emergency. 
 CMS has encouraged Section 1135 waivers, and in fact published blanket waivers available for the asking; 13 states have had such waivers approved.  But a different kind of waiver -- a Section 1115 waiver -- is required to ease eligibility procedures. Under a Section 1115 waiver, New York after 9/11 offered four months of Medicaid coverage to eligible New York City residents through a simplified application. After Hurricane Katrina, via a Section 1115 waiver, evacuees unable to provide documentation were allowed to self-attest to Medicaid eligibility criteria.


Monday, March 23, 2020

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.

Sunday, March 22, 2020

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

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Update, 4/7/20: Early emergency SEP data collected by Charles Gaba indicates that states that require a phone call to begin the SEP application are seeing slower enrollment than states where an emergency SEP application can be completed online.

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.

Friday, March 20, 2020

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:

Wednesday, March 18, 2020

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."

Sunday, March 15, 2020

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:

Wednesday, March 11, 2020

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.

Monday, March 09, 2020

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).

Friday, March 06, 2020

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%).

Wednesday, March 04, 2020

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.

Tuesday, March 03, 2020

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.