Rapid marketplace enrollment growth in nonexpansion states, revisited

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I don't know whether ACA marketplace observers have fully fathomed the extent to which the nonexpansion states drove the enrollment surge during the emergency Special Enrollment Period that ran from Feb. 15 to August 15 on HealthCare.gov -- and indeed, over the past two years.

Also not fully fathomed: the extent of total enrollment growth in all states during the pandemic.

Even with balance-billing protection, a tiered network may cause tears

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My last post involved a close look at the severely tiered provider network in the silver plans sold in the ACA marketplace by Independence Blue Cross, the dominant insurer in Philadelphia and southeastern Pennsylvania.  On a second look, a thought occurred to me: tiered networks that place go-to hospitals in higher tiers put an asterisk of sorts on balance-billing protections for emergency care, including those due to come online nationally when the No Surprises Act takes effect on January 1.

Under the No Surprises Act, emergency care is billed at in-network rates whether or not the hospital or facility is within the provider network of the patient's health plan. But what exactly is an "in-network rate" in a tiered network? Depends on the tier.

Independence's HMO plans sold in the ACA marketplace have three tiers. Its second-cheapest silver offering on Pennie, Pennsylvania's ACA exchange, the Keystone HMO Silver Proactive plan, posts a deductible of $0. But that's in Tier 1 only. For enrollees with incomes too high to qualify for Cost Sharing Reduction (CSR),* Tiers 2 and 3 have a deductible of $6,000 for an individual and $12,000 for a family. 

Independence Blue Cross sells only 24-carat gold plans in Philadelphia and surrounding counties

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What is wrong with this picture?

These health plan quotes, taken from the health plan comparison tool provided on Pennie, Pennsylvania's online ACA marketplace, show the lowest-cost silver and gold plans offered in Philadelphia by southeastern Pennsylvania's dominant insurer to a 40 year-old with an income of $38,000.  (Premiums are net of a federal subsidy of $262 per month.) 

In the pricing of its lowest-cost gold plan, Independence Blue Cross, issuer of the Keystone health plans listed above, is an outlier, in that its lowest cost gold plan is priced well above its lowest cost silver plans. That's not how it's supposed to work in Pennsylvania.

Notes from the SEP: On record marketplace enrollment in August 2021

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CMS today released a final enrollment report for the emergency Special Enrollment Period that ran in HealthCare.gov states from Feb. 15--Aug. 15 this year, and for mostly comparable lengths in the 15 state-based marketplaces. 

The top line: 2.8 million new enrollments nationally in that period. A few quick notes:

1. Effectuated enrollment in August 2021, 12,199,393, is up 14.6% over 2020, the previous high (10,642,088*), and 22% over enrollment in August 2016, the peak prior to 2020.  Caveat: off-exchange enrollment in ACA-compliant plans dropped by about 3 million from 2016 to 2019, according to KFF estimates. On-exchange enrollment is about 2.2 million above the August 2016 total.
   
   
2. While 2.8 million people newly enrolled in marketplace coverage during the SEP, total enrollment has risen by only 900,000 since February, when effectuated enrollment stood at 11.3 million.  That's steeper attrition than I anticipated when I estimated total enrollment at 12.7 million through July.
   
   

Dropping the Medicare age to 60 also requires...

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130 House Democrats have co-sponsored a bill introduced on September 3 by Pramila Jayapal, the Improving Medicare Coverage Act, that would drop the Medicare eligibility age to 60 -- simply and cleanly, with Medicare offered on the same terms at age 60 as it now is at age 65, within six months of enactment. That's the headline. But the bill does something else that's arguably more consequential. 

Without other changes to Medicare, dropping the eligibility age to 60 would be a mixed blessing at best. That's because for 60-64 year-olds with income below 200% of the Federal Poverty Level ($25,520 for an individual, $34,480 for a couple in 2021), Medicare in its current form would be considerably more expensive than ACA marketplace coverage (as enhanced through 2022 by the American Rescue Plan Act in enacted in March) -- excepting for those who are dually eligible for Medicaid and Medicare. While just over a quarter of the U.S. population is in households with incomes below 200% FPL, about half of the uninsured have incomes below that threshold.  

Jayapal's bill changes the equation by making all Medicare enrollees with income below 200% FPL eligible for a new Medicare Cost Assistance Program that would zero out premiums, coinsurance and deductibles for Medicare Parts A (hospital)  and B (physician and outpatient), and also subsidize Part D prescription drug coverage (covering the entire Part D premium and reducing prescription copays to single-digit dollar amounts).  The bill would also move administration of these benefits from state Medicaid programs to Medicare, with the federal government assuming 100% of costs now shared with states.

Viewing the uninsured rate through foggy lenses

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Snapshots of the health insurance status of the U.S. population are blurry.

When you look at the CMS tally of Medicaid enrollment increase since the pandemic struck, it seems, simply, that the increase swamps most estimates of the number of people that lost employer-sponsored insurance. Other factors are at work, of course. But the one large number is considerably larger than the other large number.

But official Medicaid enrollment totals may not be an entirely reliable measure of how many people are actually covered by Medicaid, and know themselves as such -- particularly during this pandemic, when disenrollments have been paused since March 2020. State Medicaid agencies are, to varying extents, blind beasts.

I know a young man who, during a year of transition, lived in two states and worked at three jobs, with a period of unemployment. At different points in the year he applied for Medicaid in two (blue) states and received rejection notices. From both of those states, months later (and months apart), while insured through a new employer, he was sent managed Medicaid membership cards and informed that he'd be enrolled since shortly after his application was completed.  In both states, it took some doing and some time to get himself disenrolled.

How will Medicare enhancement change the current public-private Medicare ecosystem?

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Democrats' aspirations to add dental, hearing and vision benefits to Medicare raises questions about the interactions between tradition, fee-for service (FFS) Medicare, Medicare Advantage (MA), and Medigap. These center on MA's growing market share, its funding mechanism, the gaps in FFS Medicare coverage that MA plans partially fill, and the value of Medigap for those who can afford it (or whose employers fund it).

Below, a brief outline (distilled mainly from KFF briefs) of how the three programs (FFS, MA and Medigap) interact/compete at present, followed by questions about how pending legislation may alter the ecosystem.