Thursday, September 29, 2022

To Whose advantage is Medicare Advantage? Part 2

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"They have to authorize this"

To whose advantage is Medicare Advantage? Part 1 of this inquiry overviewed the tradeoffs for enrollees and the primary payer -- the federal government. In this post, we'll hear from professionals who deal with MA enrollees and plans.

First, a recap of the issues overviewed in Part 1, based mainly on analysis from MedPAC, the Kaiser Family Foundation, and comments on MA recently solicited by CMS.

Wednesday, September 28, 2022

A note to subscribers

Dear xpostfactoid subscribers: I would like to start publishing on Substack, which I gather has social media-ish characteristics that could be helpful. I've taken the liberty of porting the subscriber list to Substack (and accidentally sent one post already to the whole list -- apologies). If you will bear with me through a brief trial, a handful of posts will come through both subscription services, at which point I'll cut bait with one. I have no intention of charging a subscription fee, as Substack enables.  Thank you for your forbearance. 

Tuesday, September 27, 2022

Glory hallelujah, for a moment

 Last night I had what is for me a very rare thing -- a dream filled with joy. As always, it's hard to distinguish the dream itself from the interpretive memory of it immediately after -- and possibly later, too. But as best as I can manage...

I was lying flat on my back under the sky, possibly in a trench, as I had been reading a few pages about World War I in Brad DeLong's Slouching Toward Bethlehem before bed. I had a strong feeling of relief and release. We -- I and my family, or community, or possibly nation -- were safe and free. We had prevailed in some life-threatening struggle.

The sky was full of stars.  I thought of singing, but for some reason it seemed more appropriate, or feasible, to write across the sky, and I could do this with my finger, as you do on certain credit card touchpads. I was about to write, or maybe did write, Glory, or Gloria -- maybe Glory Hallelujah, or Gloria in excelcis deo (I seem to have been mulling this as I woke). I thought I would get something going among those around me, a kind of chorus of joy. Not sure whether I did get it started.

There may have been some undertone in this of the election -- fending off rising Republican fascism -- or of the Ukraine war. Maybe I injected those associations later. In any case, I relate it in case there was some intuitive hope that might be shared, as I imagined the "gloria' chorus might be.

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Wednesday, September 21, 2022

To whose advantage is Medicare Advantage? Part 1

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Note: Enrollment in Medicare Advantage plans is poised to surpass enrollment in traditional, fee-for-service (FFS) Medicare in 2023. MA's rapid growth raises major questions about the shape of Medicare coverage going forward. This is the first of two posts examining the pros and cons of Medicare Advantage. This post outlines the major issues as framed by MedPAC and select researchers, along with the basic economic tradeoffs for enrollees. Part 2 will report the experience of a hospitalist, brokers, and various stakeholders who responded to a CMS request for feedback about the MA program.

There is a slipknot quality to attempts to compare the value and utility of traditional, fee-for-service (FFS) Medicare and Medicare Advantage.

Medicare Advantage plans generally place bids to CMS far below CMS benchmarks, which are based on an adjusted estimate of what it costs to provide FFS Medicare to enrollees in the plan's geographic area. On average, according to the 2022 MedPAC report, MA plans spend 15% less to provide Part A and B benefits than FFS Medicare would spend.  But CMS pays Medicare Advantage plans an average of 104% of what it would pay for FFS Medicare coverage for the same enrollees. But MA plans use the excess payment to provide an estimated $2,000 per member in surplus benefits or out-of-pocket cost relief. But, according to MedPAC, the value of MA-furnished extra services as actually used by enrollees is elusive, because of inadequate reporting requirements, and the quality ratings that increase payments to MA plans do a poor job measuring quality.

With regard to outcomes, MA plans employ treatment protocols that do minimize some so-called low-value care and, in some cases at least, boost usage of preventive care that, according to some studies, can reduce cardiac events, foot amputations for diabetics, ER trips, hospital admittances, and other conditions and services. But there is also good evidence that MA plans inhibit or impede access to needed or high-value care, introduce expensive and sometimes dangerous bureaucratic hurdles to obtaining needed care, and drive enrollees with intense medical needs back to FFS. 

Most notoriously, by multiple accounts, MA plans often impede, block, limit options and reduce the duration of post-acute care. Comments about MA that CMS recently solicited from stakeholders detail these complaints (from physician and hospital associations, practitioners, acute care personnel, patients, brokers and others) again and again and again. A major strain in these complaints is from state employees forced into MA plans by retirement benefit packages.

This month, the Kaiser Family Foundation published a report, based on a literature review of 62 studies published since 2016, comparing "Beneficiary Experience, Affordability, Utilization, and Quality in Medicare Advantage and Traditional Medicare." The authors' conclusions are...inconclusive:

Saturday, September 17, 2022

Will Medicaid's "great unwinding" when the PHE ends trigger a "great uninsuring"?

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During the pandemic, from February 2020 to May 2022, Medicaid enrollment increased by 18 million, or 29%, according to administrative data that CMS collects from states. That's mainly because of a moratorium on disenrollments that began in March 2020 and has yet to end. The moratorium will end when the federal government declares an end to the  Public Health Emergency, which will happen in mid-January 2023 at the earliest (the PHE has been extended repeatedly in 3-month increments). 

As noted in my last post, the disruption that may be triggered by the resumption of state "redeterminations" of Medicaid enrollees' eligibility, and subsequent disenrollment of some, is a focus of considerable angst -- and preparations, in states where Medicaid personnel are committed to keeping as many people insured as possible, to proceed with due deliberation and compassion. The Urban Institute has estimated that 15 million people may be disenrolled over the course of a year, the time period that CMS has asked states to devote to clearing the "redetermination" backlog. The Kaiser Family Foundation (KFF) estimates somewhat more modest losses, in a range from 5.3 million to 14.2 million.

This week the Census Bureau released its annual report on health insurance coverage in the United States. Based on the annual supplement to the Current Population Survey, the report shows a more modest increase in Medicaid enrollment from 2020 to 2021 -- 0.9% -- than CMS's administrative data would indicate.  According to CMS, Medicaid and CHIP enrollment increased by 6.6 million from December 2020 to December 2021. That's about 2% of the population.

The Census Bureau also released a second report, spotlighting health insurance changes over two years, and based on the American Community Survey. which interviews people throughout the year about their current insurance status (the CPS, conducted early in the year, asks respondents if they were insured at any point in the past year).  The ACS also shows a gap between Medicaid enrollment gains as reflected in administrative data compared to the survey data. According to the report, the percentage of the population insured by Medicaid increased by 1.3% over two years, from 2019 to 2021 (based, again, on surveys conducted throughout each year). The administrative data records an increase of 11.7 million enrollees from June 2019 to June 2021. That's about 3.5% of the population.

An analysis of the ACS data by KFF attempts to explain this gap. The explanation suggests to me that the disenrollments that will begin at the end of the PHE may not be as disruptive as "15 million disenrolled" might indicate -- at least in states that work in good faith and with due diligence to establish contact with all enrollees, accurately determine their status, and help them consider their options.  My emphasis via yellow highlight below (the bolded subhead is in the original):

Saturday, September 10, 2022

Preparing for the great Medicaid unwinding: the case of New Jersey

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NJ FamilyCare end-of-PHE alert

The pending end of the Public Health Emergency declared by the federal government in March 2020 will trigger something of an earthquake among Medicaid enrollees.  

As of May of this year, enrollment in Medicaid and CHIP had increased by 18.3 million -- 26% -- since February 2020, the last month unaffected by the pandemic. Some 90 million Americans, well more than a quarter of the population, are now enrolled in Medicaid or CHIP.  That increase is mostly due to a moratorium on disenrollments enacted in March 2020 as part of the Families First Coronavirus Response act, which conditioned a 6.2% increase in the federal government's share of each state's Medicaid costs on implementing the moratorium (all states complied).  The Kaiser Family Foundation (KFF) estimates that 84% of the enrollment increase during the pandemic is attributable to the moratorium.

Wednesday, August 31, 2022

Democrats have twelve years of healthcare accomplishment to run on

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Chuck Schumer tours Adirondack Medical Center

HuffPost reports that Priorities USA is urging Democrats to tout recent healthcare achievements:

In a memo set to be published Wednesday, Priorities USA says the most popular achievements of President Joe Biden’s tenure are giving Medicare the power to negotiate prescription drug pricescapping the price of insulin and continuing expanded subsidies for the Affordable Care Act.

Priorities USA recommends focusing on these issues while also attacking Republicans for working to restrict abortion rights in the wake of the Supreme Court decision overturning Roe v. Wade.

Amen. And below those top lines -- the healthcare provisions in the Inflation Reduction Act passed this month -- Democrats should also tout a long tail of recent accomplishments that have improved healthcare affordability and access. Their claim to be the party of healthcare bears not only recent but cumulative weight.

Healthcare was a potent issue for Democrats in 2018, with Republicans fresh off their failed attempt to repeal the ACA's core programs in 2017.  Because they failed, the ACA Medicaid expansion and subsidized marketplace survived to catch the newly uninsured when more than 20 million Americans lost their jobs in the first onslaught of the COVID-19 pandemic. 

Wednesday, August 24, 2022

Dem chorus rising: Don't let them take your freedom

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For most of the post-January 6 era, the U.S. has seemed to be sleepwalking toward autocracy. 

Republicans swiftly fell in all but unanimously behind Trump's Big Lie that he won the 2020 election; red states passed a raft of voter suppression laws; Trump acolytes positioned themselves to seize control of election administration and machinery; pardoned Team Trump criminals and the RNC encouraged thousands to sign up as poll workers; and diehard election deniers won Republican primaries for secretary of state, attorney general and governor in key states.

Meanwhile, inflation dominated headlines, Biden's approval rating sank to record lows for a first- and second-year president, courts upheld Republican gerrymanders and struck down Democratic ones, off-year elections swung heavily toward Republicans, and Republicans led in generic Congressional polling.

Then came the riveting January 6 Commission hearings in June and July, with Republican officials laying bare Trump's criminality and pathology -- and smack in the middle of that timeline, the intense shock of the Supreme Court ruling in Dobbs, overturning Roe v. Wade. Democrats woke up -- some Democrats, anyway. Gavin Newsom laid down a keynote in a July 4 ad aimed at Floridians ("inviting "them to move to California): freedom is under attack in your state...don't let them take your freedom.

Thursday, August 18, 2022

Loony interlude


I wish the photo were better...

No healthcare this week, as we are in the Adirondacks, at a collection of Finnish (?!) huts on a small crystalline lake, with no motorboats allowed. On sunny Tuesday morning, in kayaks, we watched a family of loons (father, mother, adolescent) pursue and eat their breakfast. They sail along intermittently in tandem, with adults constantly diving for a minute or so at a time and coming up a few hundred feet away. After some time the female came up with a small silver fish, which she worked around in her beak for a long time, both as she swam back to the other two and as they circled together. At one point the male appeared to make a grab at it. Eventually she put it down the young one's throat. Then it was rinse, repeat: one of the adults (not sure which) caught another fish, worked it for a while, then swallowed it.

Thursday, August 11, 2022

Widespread misconception of Medicare Part D enrollees' out-of-pocket exposure

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I object

Late last year, I took some pains to tease out the out-of-pocket (OOP) exposure of Medicare Part D enrollees up to the point where they reach the so-called "catastrophic threshold" of coverage. Beyond that point, they're responsible for a comparatively low 5% of subsequent costs until the end of the coverage year. 

The answer is no real mystery: it's well understood by involved professionals and scholars. It's just awfully hard to derive from general news coverage and even trade press coverage or scholarly coverage.

The exposure up to the catastrophic threshold in 2022 is $2,937, despite an often-cited cap of $7,050, referred to in the trade as the trOOP cap, or true out of pocket cap. 

Monday, August 08, 2022

Attention, Bernie Sanders: Medicare benefits from Inflation Reduction Act begin in 2023

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Free in 2023

Senate Democrats' passage of the Inflation Reduction Act yesterday evening was an exercise in the art of the possible, the culmination of a year-long immersion in the reality principle. Senate Democrats as a body probed to the last minute what first Manchin and finally Sinema would allow them to pass, and ultimately maxed out on that allowance. 

The result is powerful legislation that gives us a fighting chance to mitigate the worst effects of climate change and sets up a starter home for Medicare to negotiate prescription drug prices. It also boosts the perhaps still-long odds that Democrats can hold the Senate and House and so stave off the Republican threat to democracy itself.

Friday, August 05, 2022

How much drug price control are we getting in the Inflation Reduction Act?

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When media addresses the prescription drug cost control measures in the Inflation Reduction Act, the provisions empowering Medicare to negotiate the price of select high-value drugs tends to suck up all the attention. 

Rightly, perhaps. While the negotiation regime is slow to start (beginning with 10 drugs to be negotiated in 2026), modest in number (rising to 20 drugs negotiated in 2029), and abjuring reference pricing from European countries (instead capping prices at a set discount of average U.S. prices), it establishes a vital principle, and the scope and terms of negotiation may be expanded and strengthened over time. 

That said,  a lower-profile provision that kicks in quickly (in 2023) is projected (by the Congressional Budget Office) to save/raise roughly as much money as drug negotiation: Inflation caps on the prices of drugs currently on the market. If a drug manufacturer raises the average price charged for a given drug by an amount that exceeds the consumer price index for urban consumers (CPI-U) it must rebate the difference to Medicare. That provision not only starts right away, it also applies to employer-sponsored and individual market health plans as well as Medicare (the rebates accrue from all drugs sold but are paid only to the federal government). CBO projects that the inflation caps will generate $62 billion in savings and $38 billion in revenue over ten years.

Wednesday, August 03, 2022

U.S. uninsured rate hits an all-time low; Biden's HHS takes a victory lap; xpostfactoid claims prepostfactoid credit

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Record broken!

Biden's HHS took something of a victory lap yesterday, announcing that the national uninsured rate -- 8.0% for all ages --  was at an all-time low in the first quarter of 2022. Since the fourth quarter of 2020, the uninsured rate has dropped by 2.7 percentage both for ages 18-64 and for children, according to the ASPE* brief.

The brief is based on quarterly updates from the National Health Interview Survey. Those updates are notoriously bouncy, but the change over the time frame selected is clearly statistically significant. 

The brief asserts: "These gains in health insurance coverage are concurrent with [mustn't claim causality, now...] the implementation of the American Rescue Plan’s enhanced Marketplace subsidies, the continuous enrollment provision in Medicaid, several recent state Medicaid expansions, and substantial enrollment outreach by the Biden-Harris Administration in 2021- 2022."

I must note that I've been something of a canary in the coal mine on this front, first speculating that we might be approaching an uninsured low in April 2021; wondering whether the 2021 Special Enrollment Period coupled with the ARPA subsidy boosts might have got us there by late August 2021; and parsing the NHIS quarterly data in light of the 2022 marketplace enrollment surge in January 2022.

Ultimately, I noted in the January post, the enrollment math, if not the survey data, told a fairly simple story:

Monday, July 25, 2022

All Dem (and doc) hands on deck to get Medicare drug negotiation/ACA subsidy boosts across the finish line

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It struck my eye last week  that Doctors for America, a physician advocacy group that supports single-payer healthcare, saw fit to call on member docs (via email) to lobby for what's left of the Democrats' reconciliation bill:

This is a decisive week in Congress with the Senate poised to vote on several crucial pieces of legislation, including allowing the HHS Secretary to negotiate for Medicare drug pricing, out-of-pocket caps in Part D, and rebates for price increases exceeding inflation. There are also new provisions to make vaccines free for Medicare beneficiaries, to stabilize premiums, and expand the Medicare low-income subsidy programs.

We hope the Senate will move forward with a meaningful reconciliation package that includes the drug price provisions before the August recess. But we need to apply pressure to do so.  Remind your senators to choose #PatientsOverPolitics and pass the reconciliation bill this week, including all of the health care provisions promised to the American people. 

Friday, July 22, 2022

A Midas touch on New Mexico's ACA exchange, revisited

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Kudos to health insurance analyst and advocate Stan Dorn and actuary Greg Fann for selling the New Mexico Office of the Superintendent of Insurance on strict silver loading in advance of Open Enrollment for 2022.   

In brief, the Superintendent required marketplace insurers to price silver plans on a par with platinum, since silver plans, thanks to Cost Sharing Reduction (CSR) subsidies, do have platinum-equivalent actuarial value for enrollees with incomes up to 200% FPL. The directive is meant to be a self-fulfilling prophecy: if gold plans are cheaper than silver plans -- and in New Mexico in 2022, gold plans were 10% cheaper on average -- no one with income over 200% FPL should buy silver plans, which have a lower AV than gold plans. In that case, the average AV for silver plan enrollees will indeed be platinum equivalent. 

New Mexico didn't quite get there, but came close. In Health Affairs this week, Stan Dorn analyzed the results, spotlighting a massive decrease in enrollment in bronze plans, which have deductibles averaging more than $7,000:

Dorn argues forcefully that New Mexico's pricing directive should be adopted nationally, explaining in detail the flaws in CMS's risk adjustment formula for marketplace plans that favors silver plans, incentivizing insurers to underprice them, and urging a fix.

All that said, while metal level selection at incomes above 200% FPL in New Mexico is an unbridled triumph, there's a caveat to the drop in bronze plan enrollment at incomes below 200% FPL (the middle row above).  Bronze plan takeup at low incomes would have dropped significantly in any case -- and did drop nationally -- because the Open Enrollment Period for 2022 was the first (and possibly the only) OEP in which the premium subsidy enhancements provided by the American Rescue Plan were in effect. Those subsidy boosts made benchmark silver coverage free at incomes up to 150% FPL and available for 0-2% of income for enrollees in the 150-200% FPL range. In states, bronze plan selection dropped by 2 percentage points in the 100-150% FPL income range and by 8 percentage points at 150-200% FPL from OEP 2021 to OEP 2022. 

The bronze selection decrease at low incomes in New Mexico was much sharper. But far too many enrollees at income below 200% FPL switched into gold plans rather than silver, which have far lower out-of-pocket costs than gold plans at incomes below 200% FPL.  This is no knock on New Mexico pricing practices, but rather on presentation flaws on the newly minted state exchange, BeWellNM.  The New Mexico exchange does not emphasize the availability of CSR at low incomes. The display, uniquely among ACA exchanges, buries the annual out-of-pocket maximum for each plan (you have to go two clicks in from the top-line display for each plan to find the OOP max) -- and OOP max is where the silver advantage is sharpest, topping out at $2,900 for high-CSR silver compared to $8,700 for gold. 

Worst, the site has a malfunctioning total cost estimation tool, which apparently uses the unsubsidized premium to estimate "costs in a bad year," completely obscuring silver plans OOP max advantage.  (I described these flaws and their effects, with screenshots, in this post.)

The result: silver plan selection at incomes below 200% FPL was just 62% in New Mexico in 2022, compared to 81.5% nationally and 80% in the thirteen state-based exchanges that enroll people with incomes under 200% FPL and provide metal level choices broken out by income. (Those totals are based on my calculations from CMS's Public Use Files and omit the 1.6% of enrollees with income below 100% FPL). 

The 5% bronze selection in New Mexico at incomes below 200% FPL is a sterling accomplishment. But most of the 33% of enrollees in that income bracket who selected gold plans should be in silver. For some, getting a cheaper gold plan from a desired insurer might be worth the extra out-of-pocket exposure, which might be in the $5,000-6,000 range (as discussed here). But most would be better off in silver.

ACA metal level structure is confusing, as bronze, gold and platinum actuarial value is fixed at all incomes whereas as silver plans come with no less than four different AVs, depending on income.  The fact that silver plans can be worth more than gold -- as they are for slightly more than half of marketplace enrollees -- is deeply counterintuitive. Display matters. For enrollees with income under 200% FPL, silver plans should be displayed at the top of results. OOP maxes should always be clearly visible, and defined via mouseover. The availability of CSR and its impact should be heavily signposted. 

Gold plans should be consistently cheaper than silver plans nationally, as Dorn argues (and as David Anderson and I have also done). If metal levels are priced as in New Mexico, plans with an AV of at least 80% (gold) should be available at a premium at or below the benchmark against which subsidies are set. To maximize the value available, however, decision support on most exchanges also needs to be improved.

Update from Stan Dorn (click through for essential gif):

Replying to
...In yet another brilliant, creative NM policy innovation, they are labeling all high-AV products as “turquoise,” a favorite NM color that will easily signal the highest value options for each consumer

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Wednesday, July 20, 2022

Average weighted actuarial value in the ACA marketplace: about 77%

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How much exposure to out-of-pocket costs are ACA marketplace enrollees subject to, compared, say, to enrollees in employer-sponsored plans?

Exposure varies widely, according to income and metal level choice. The deductible for a marketplace enrollee with household income below 150% of the Federal Poverty Level ($19,320 for a single person) who selects a silver plan is likely to be zero (the median) or under $150 (the average), with an annual out-of-pocket maximum averaging about $1,200. For a single person with an income just over 250% FPL ($32,201), that silver plan will carry an average deductible over $4,700 (though many services, including doctor visits may not be subject to it) and an out-of-pocket max likely over $8,000. For a bronze plan enrollee at any income level, the deductible will probably top $7,000, with an out-of-pocket max near the highest allowable, $8,700.

What about actuarial value -- the percentage of the average enrollee's costs the plan is designed to cover? In employer-sponsored plans, AV averages 85-86%, according to the Kaiser Family Foundation. In the ACA marketplace, according to my calculations below, the average AV obtained by 2022 enrollees in 2022 was 77.4%. Marketplace AV ranges from 94% for silver plan enrollees in the lowest income category to 60% for bronze plans (and about 57% for the 0.6% of enrollees who select catastrophic plans, for which subsidies are not available).

Tuesday, July 12, 2022

How prevalent is underinsurance among ACA beneficiaries?

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Big rain, small umbrella

In a New York Times op-ed Aaron Carroll, a physician and highly reliable assessor of data (his Bad Food Bible sifts expertly through a lot of bullshit in dietary research) makes two incontrovertible points about U.S. healthcare:

1. Americans are burdened with uniquely high out-of-pocket costs that induce us to forego need as well as unneeded care.

2. The ACA partly replicated this gaping flaw in our healthcare system, inflicting ridiculously high deductibles and out-of-pocket maximums on a significant number of marketplace enrollees.

But the argument includes what I regard as a slight (and common) distortion of emphasis in his overview of marketplace enrollees' high out-of-pocket costs: 

The average deductible on a silver-level plan on the A.C.A. exchanges rose to $4,500 in 2021. If people tried to buy plans with a lower premium, at a bronze level, the average deductible rose to more than $6,000. Granted, some cost-sharing reductions are available for those who make less than 250 percent of the federal poverty line, but even after accounting for those, the average deductible was more than $3,100 for silver plans.

Monday, July 11, 2022

New Jersey enacts an easy enrollment program for the uninsured

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New Jersey Governor Phil Murphy today signed a bill  (A674/S1646) establishing an "easy enrollment" program for health insurance, the New Jersey Department of Banking and Insurance announced this afternoon (a press release just arrived by email; I can't find it online yet). Update! - here it is.

Maryland pioneered "check the box" programs like this, in which the state prompts uninsured residents to indicate an interest in getting insured and provides help (to the extent creaky state bureaucracies can manage it) with getting an application started. Here is the guts of the initiative in New Jersey:

Through this program, uninsured and underinsured residents can indicate their interest in coverage for themselves or a household member on their tax return or through unemployment insurance benefit claims, which will be shared with the New Jersey Department of Banking and Insurance.    

As required by the legislation, the department will create a system to analyze the data collected through tax returns and unemployment benefit claims to determine a resident’s eligibility for health insurance coverage and ability to receive financial help through Get Covered New Jersey and proactively connect with qualifying residents to help them enroll. The law also permits the department to work with the Department of Human Services to determine an individual’s eligibility for NJ FamilyCare and share data with the agency for that assessment.       

Several things to note here. First, the prompt to seek health insurance will appear not only on the tax return but on an unemployment benefit claim. The latter is very important, as it comes at a moment when the applicant's income has dropped dramatically, qualifying many for Medicaid. In states that have enacted the ACA Medicaid expansion (e.g., New Jersey), eligibility is based on monthly income (currently $1563 for an individual, $3,191 for a family of four). During the pandemic, Kentucky had the Dept. of uninsurance pass applicant data to the state Medicaid agency, helping to drive a 14% increase in Medicaid enrollment from February to July 2020.

Second, the department collecting the data will share the data with the Dept. of Banking and Insurance, which runs the state ACA exchange (GetCoveredNJ), and with the Dept. of Human Services, which runs NJ FamilyCare, the state Medicaid program. The departments can determine eligibility for NJ FamilyCare or for subsidized marketplace coverage, if the enrollee gives permission for the various departments to share information. The bill statement emphasizes interagency coordination:

The bill requires the Commissioner of Banking and Insurance, in coordination with the Commissioner of Human Services, the Commissioner of Labor and Workforce Development, and the State Treasurer to develop and implement systems, policies, and practices that encourage, facilitate, and streamline determination of eligibility for insurance affordability assistance and enrollment in minimum essential coverage to achieve the purposes of the program.

Finally, because New Jersey (unlike Maryland) is one of a handful of states that implemented a state individual mandate to obtain insurance after the federal mandate penalty was zeroed out, the uninsured tax filer has a strong incentive to check the box, as obtaining insurance will get the penalty for going uninsured waived. For most respondents, obtaining coverage should be either free or very low-cost. In New Jersey's ACA marketplace, supplemental state subsidies, in concert with the major federal boosts to marketplace subsidies provided by the American Rescue Plan Act (which will expire at the end of this year unless Democrats manage to extend them, benchmark silver coverage with strong Cost Sharing Reduction is effectively free, or very close to it, at incomes up to 200% of the Federal Poverty Level ($25,760 for an individual, $53,000 for a family of four). 

This is a good strong bill that should reduce the uninsured population in New Jersey, currently just shy of 700,000. Its impact will be blunted somewhat if Democrats fail to extend the ARPA marketplace subsidies. But its chief impact will probably be in Medicaid in any case, which is unaffected by the level of marketplace subsidization.

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Thursday, July 07, 2022

A "Manchin trim" for the ARPA subsidy boosts to Obamacare?

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A high-end haircut for the ARPA subsidies?

It's been reported in the last week or two that Manchin may be open to negotiating a bill that would raise about $1 trillion in new revenue over ten years and devote about half of that to new spending. Yesterday, the Washington Post's Greg Sargent reported that $200 billion of that new spending may be allocated to extending the American Rescue Plan Act's increases in ACA marketplace subsidies (which expire at the end of 2022):

If around $300 billion of that [$500 billion in new spending] went to funding the transition to clean energy, through tax incentives and other means — a key part of BBB that Manchin appears open to — that would leave around $200 billion for expanded ACA subsidies.

Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation, says it’s absolutely possible to fund the vast bulk of extended subsidies with that sum. The cost of extending all of them would be an estimated $220 billion, so getting that down to $200 billion, perhaps by shaving those subsidies for the highest-income people eligible, would be doable.

Welp. I have been assuming that with $500 billion over ten years reportedly on the table, a lot of competing priorities would be in the running. If $200 billion really does get allocated to extending the ARPA subsidies, then no problemo, as Larry Levitt suggests. But all these broad outlines (including the broadest, whether any deal gets done) are very uncertain, and I assume a smaller sum (if any) may be allocated to enhancing a version of the ARPA subsidy boosts. 

Thursday, June 30, 2022

In New Jersey, some protections from abortion criminalization and liability

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The New Jersey legislature has passed two bills designed to mitigate the state criminalization of abortion and state-authorized vigilante fascism enabled by the Supreme Court.

A3974 bars extradition from New Jersey for any "crime" as defined in other states that "relates to reproductive health services."

A3975* Bars New Jersey abortion providers and facilitators from disclosing any communication from those seeking reproductive services and any information obtained by examination. In particular, providers are barred from providing information or expending effort "in furtherance of any interstate investigation or proceeding seeking to impose civil or criminal liability upon a person or entity for receiving, providing, or abetting reproductive health services. It also provides that professional licensing boards in the state cannot penalize any provider for providing reproductive health services barred in another state if those services are legal in New Jersey.

The budget that goes to Governor Murphy for signature today includes $5 million for abortion provider training, $5 million for clinic security, $10 million for facility upgrades, etc. and $10 million more than allocated last year to family planning services. 

What did not pass, though some of its provisions and variations of those provisions are reflected in the items above, was a bill  (A4350/S2918) that would have mandated that health plans cover abortion (most in the state do), provided free abortions to the uninsured and undocumented, criminalized intimidation of those seeking or providing abortions, and provided even more robust legal protections to those seeking or providing abortion in the state. 

The language in the two bills described above, protecting out-of-state abortion recipients from extradition or disclosure of information to fuel criminal investigations or civil suits brought by vigilantes or other state governments, throws into sharp relief the patchwork hellscape of sexual fascism unleashed by the Supreme Court. 


* I earlier summarized a superseded version of this bill. Apologies for the error. 

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Tuesday, June 28, 2022

Good news rescinded: Online search for health insurance is again a trackless wasteland

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Earlier this month, Kaiser Health News reporter Bram Sable-Smith told the tales of people who had searched for health insurance online last fall and ended up snared by an unscrupulous health care sharing ministry selling illusory health coverage.  These shoppers had clicked on "lead generator" websites advertising health insurance, which in turn referred them to unscrupulous brokers selling the junk product.

Such stories are not new and all too common, but this one caught my eye because I myself reported back in March that web search for health insurance had been substantially cleaned up in advance of Open Enrollment last fall.  Search for "health insurance" or "health insurance [any state]," I wrote, and either (the federal exchange) or the appropriate state-based exchange will top the results. 

A major driver of the improvement, I wrote, was a change in policy at Google, which unfolded in two states. First, in May 2020, Google a posted a policy update stating that the company would l no longer allow ads for documents and/or services that can be obtained directly from a government or a delegated provider (a company that has been officially entrusted or assigned by a government). Then, in June 2021, Google applied this policy to health insurance, stating in an update that entities advertising health insurance must be a licensed provider (e.g., broker) registered to provide ACA-compliant plans in all locations where they do business. I was told that a parallel policy for web search was implemented shortly afterward, and I noted Yahoo and Bing appear to have followed suit.

While I extensively tested the basic premise (ACA exchanges will top search results for health insurance), I'm sorry to report both that I apparently missed some loopholes and that the search landscape has more recently degenerated. It is no longer the case that an ACA exchange will reliably top search results for "health insurance," alone or with a state name added (e.g., "health insurance Oklahoma"). I am not sure what's changed and why, and will look for answers. But a few notes:

Saturday, June 25, 2022

Triage: A dedicated source of funding to extend the ARPA subsidy boosts (if all else fails)

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The increases to premium subsidies in the ACA marketplace provided through 2022 by the American Rescue Plan Act (ARPA) have been a policy success, helping to boost marketplace enrollment by 21% this year.  During Democrats' long, weary negotiations over the Build Back Better bill in the fall, extension of those subsidies (first permanently, then, foolishly, for just 3 years) was taken as a given.  Even when BBB negotiation collapsed, failure to extend the subsidies seemed unthinkable...until it didn't.  

By May, it began to seem that Joe Manchin might not allow any Democratic priorities to pass via a reconciliation (bypassing the filibuster, and requiring all Senate Democrats to be on board). More recently, there's been a pulse -- apparently serious negotiations for a stripped-down bill possibly including climate investments, repeal of Republican tax cuts, empowering Medicare to negotiate prescription drug costs, and, maybe maybe, extension of the ARPA subsidy boosts for marketplace coverage.

Most recently, Manchin has made vaguely sympathetic but equivocal noises about extending the subsidy boosts, which are not a priority for him (the ACA Medicaid expansion insures about ten times as many West Virginians as the ACA private plan marketplace). And as Politico's Adam Cancryn outlines, his maunderings have left Democrats trying to squeeze them in with a dilemma.

Manchin hath decreed that a) any programs included in the reconciliation package be permanent, rather than sunsetting after a fixed number of years, and b) half the money raised through tax increases go to deficit reduction, leaving about $500 billion over ten years for all spending priorities. CBO estimated the 10-year cost of permanent extension of the ARPA subsidies at $210 billion. Prescription drug pricing reforms are projected to raise somewhere over $100 billion, depending on how they're structured. The three-year cost of ARPA subsidy extension, per CBO, is $74 billion. But, per Manchin temporary programs!

Given this Catch-22, it may be worth thinking about ever-present but studiously ignored (rightly, on the extra-Manchin merits) policy option: Fund the ARPA-level subsidies by funding the marketplace's Cost Sharing Reduction (CSR) subsidies in the original, statutory way, directly reimbursing insurers for their CSR costs.  CSR reduces out-of-pocket costs for low income enrollees (a slight majority of enrollees) who select silver plans.

Friday, June 17, 2022

Why Manchin may let the ACA subsidy boosts die

Alarm bells are gonging for the possibility that even if Joe Manchin deigns to dictate to Democrats the terms of a reconciliation bill he'll vote for that includes some fragment of Democrats' spending priorities, it may not include extension of the boosts to ACA marketplace subsidies provided through 2022 in the American Rescue Plan Act. 

Charles Gaba relays reports from one paywalled site (Inside Health Policy) via another:

When a Punchbowl News reporter asked Thursday... whether a reconciliation deal is expected soon, Pelosi’s response was, “It’s alive.”

“There are certain concerns we have about subsidies in the health care bill and the rest, which may or may not be in the negotiations,” she said.

...President Joe Biden included drug pricing reform in an inflation-fighting proposal released over the weekend -- but his plan did not mention the enhanced ACA credits, raising some eyebrows.

..Democrats had counted on drug price controls to pay for the enhanced ACA subsidies, but Manchin recently said the subsidies did not come up in his talks with the White House.