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:

"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 (1, 2, 3), 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:

Anyone without health insurance can apply now thru #NYSOH. Enrollment is open for all NY State of Health Programs: Medicaid, Essential Plan, Child Health Plus and Qualified Health Plans. Find out what you qualify for by calling 1-855-355-5777 or visiting: https://t.co/v3Ojbz5NCV pic.twitter.com/97t8pPIDSU

— NY State of Health (@NYStateofHealth) 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.

In a crisis, Democrats bench the ACA marketplace

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).

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.*

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.

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?

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.

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.

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.

"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.

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.