Friday, May 20, 2022

ACA on the rocks

Subscribe to xpostfactoid 

Today Politico sounded an alarm that's been rising in Democratic policy circles: Democrats are walking right into an Obamacare fiasco of their own making. That is, if their lawmaking capacity is so paralyzed that they fail to extend the major boosts to ACA marketplace subsidies provided by the American Rescue Plan Act through 2022.

Politico's Adam Cancryn and Megan Messerly warn concisely:

The scenario has alarmed vulnerable lawmakers and White House allies, who have privately warned senior Democrats in recent weeks that the issue could cost Democrats control of the Senate and decimate their hard-earned reputation as the party of health care.

Politico does report some talks between Manchin and Democratic leadership. At this point, whether ARPA subsidies get extended appears to boil down to whether Manchin and/or Sinema simply want to destroy Democrats' electoral prospects -- now, and given the Republican drive to suppress votes and doctor vote counts, maybe forever. At the Washington Post's Plum Line, Greg Sargent is doubtful that Manchin will let any meaningful legislation pass.

As the clock ticks, I feel compelled to add my popgun to the salvo of increasingly desperate progressive healthcare groups and individuals begging Democrats to find a way to break the Manchin-Sinema blockade and extend the marketplace subsidy boosts provided by the American Rescue Plan. 

Monday, May 16, 2022

Hi diddley dee, it's HDHP for me

Subscribe to xpostfactoid 

Welp, after 25 years of employer-sponsored health coverage provided by a hospital, my wife and I are enrolled in ACA marketplace coverage, effective June 1.

I have a post pending  up at outlining how, as an older couple with enough savings to cover the annual out-of-pocket maximum, we were pushed relentlessly by the marketplace benefit structure (and the U.S. tax code) to enroll in a high deductible bronze plan linked to an HSA. 

Monday, May 09, 2022

John Roberts, James Joyce, the individual mandate, Medicaid Estate Recovery, and "affordable" care

Subscribe to xpostfactoid 

A good book about Ireland's history since 1958, Fintan O'Toole's We Don't Know Ourselves: A Personal History of Modern Ireland led me to a second attempt at James Joyce's Ulysses, which I stalled out on decades ago, somewhere after Leopold Bloom emerges from an outhouse. Further I plod. One thing I will say for Joyce's internal babble is it does make you somewhat more mindful -- inclined to track your own perceptions and fleeting thoughts. 

So it was that I caught one lightning round of associations at lunchtime today:

--  John Roberts -- trying to moderate Roe strike-down?

-- Roberts -- headed off one radical conservative decision by saving the ACA's individual mandate "as a tax." 

Thursday, May 05, 2022

If HHS cuts back short-term plans, they'd best be sure that the ARP subsidy boosts are extended

Subscribe to xpostfactoid 

 Alice Ollstein of Politico relays:

[HHS Secretary] Becerra says he's "in the midst of rulemaking" to crack down on skimpy health insurance plans that Democratic lawmakers and activists call "junk plans." No word on when that rule could come out, but it would undo the Trump admin's rule opening the door to more of those plans.

The "skimpy health plans" are so-called short-term limited duration (STLD) plans promoted and facilitated by the Trump administration. STLD plans are not ACA-compliant: they don't have to cover the ACA-mandated Essential Health Benefits (and usually don't provide coverage of most prescription drugs), and they are medically underwritten, meaning that applicants with pre-existing conditions can be charged more, denied coverage altogether, or offered coverage with the pre-existing condition excluded.

Wednesday, April 27, 2022

How not to explain ACA metal levels (and, I hope, how to)

Subscribe to xpostfactoid 

I have a post up at that aims to guide ACA marketplace shoppers in selecting the metal level (bronze, silver, gold, very occasionally platform) that works best for them. My opener was the product of a lot of trial and error:

When shopping for a health plan in the ACA marketplace, it’s important to recognize that while Bronze, Gold and Platinum plans have the same value no matter who is shopping, the value of Silver plans varies with income. Accordingly, the metal level that will best suit your needs is also likely to vary with income.

That basic fact is a given to anyone who's studied the marketplace and so may seem obvious. But it's counterintuitive, and it's the single most salient fact about metal level selection.'s guide to the metal levels all but completely obscures it (and many other guides follow suit):

Monday, April 25, 2022

The "upper coverage gap" in nonexpansion states has likely shrunk dramatically since 2019

Subscribe to xpostfactoid 

In early 2021, the Kaiser Family Foundation published an updated analysis of the ACA coverage gap -- that is, the plight of low-income adults shut out of Medicaid in the twelve states that have refused to enact the ACA Medicaid expansion. While focused mainly on adults with income below 100% of the Federal Poverty Level -- those who qualify for no government help obtaining health insurance in nonexpansion states -- the analysis also included an estimate of the number of uninsured in the 100-138% FPL income range in each of these states. 

That population, which would be eligible for Medicaid had these states enacted the expansion, is eligible for premium subsidies in the ACA marketplace. In this income range, silver plans are enhanced by Cost Sharing Reduction that raises the actuarial value of a silver plan to 94%. Until March 2021, a benchmark silver plan cost 2% of income for enrollees with income up to 138% FPL. Nonetheless, KFF estimates indicated that almost half of adults in this income range in nonexpansion states were uninsured as of the end of the 2020 Open Enrollment Period.

Enrollment in this income bracket in nonexpansion states has surged since OEP 2020, however. It* increased by 17% during OEP 2021, doubtless spurred by the pandemic and its disruptions to employment and income (including supplemental unemployment income that may have pushed many people over the 100% FPL eligibility threshold).  It surged by another 24% in 2022, this time spurred in part by subsidy increases provided through 2022 by the American Rescue Plan, which made benchmark silver coverage free at this income level.

Thursday, April 21, 2022

How Republican lawmakers in Texas made their peace with (don't call it) Obamacare

Subscribe to xpostfactoid 

 ...not entirely, as they still refuse to enact the ACA Medicaid expansion, which would have the largest impact.  But still, remarkably, the Texas legislature unanimously passed a bipartisan bill designed to improve the state's ACA marketplace. I have told the political tale in The American Prospect.

Specifically, the enacted bill directs the Texas Department of Insurance to undertake 'focused rate review' of plans offered in the marketplace -- a decade after ceding that function to CMS. It directs the Department to “focus its rate review in a manner that uniformly maximizes the benefits of silver loading, making coverage more affordable.” That is, to make gold plans cheaper than silver, and increase discounts in bronze plans.

The rub-your-eyes aspect of this, to my mind, is that the bill's Republican sponsor in the Texas House, Tom Oliverson, now talks about the ACA marketplace in terms that Max Baucus might have envisioned certain Republican senators using in 2009, when he and other Democratic old bulls of the Senate dreamed of a bipartisan bill: 

Monday, April 18, 2022

Auto-upgrading in Covered California

Subscribe to xpostfactoid 

Player piano
Music auto-enrolled

Back in early March, looking at Covered California's enrollment breakouts before CMS released detailed marketplace enrollment data for all states, I expressed some disappointment that the enhanced subsidies provided by the American Rescue Plan  Act did not have a stronger impact on silver plan selection at low incomes. 

Under ARPA, the two cheapest silver plans in any rating area are free at incomes up to 150% FPL. At incomes up to 150% FPL, Cost Sharing Reduction (CSR), available only with silver plans, reduces the silver plan single-person medical deductible to $75 in California's standardized plans, compared to $6,300 for ordinary bronze plans (with a $500 drug deductible) and $7,000 for HDHP bronze. The out-of-pocket maximum for silver plans at this income level is $800, versus $8,200 for bronze and $7,000 for HDHP bronze. Silver benefits at this income level. are also superior to gold plans (OOP max $8,200) and platinum plans (OOP max $4,500).

In Open Enrollment 2022, 10% of California enrollees* in the 138-150% FPL category chose metal levels other than silver.  While that may seem like a modest percentage, it's not when you consider the extent to which CSR at this income level increases silver plan value beyond that of plans offered at any other metal level, including platinum. In California in 2022, silver selection at this income level was three percentage points higher than in 2021 and just one percentage point higher than in 2020.

The lack of a strong increase in silver plan selection when silver plans were available free is all the more surprising in light of a fact I didn't know when I wrote the prior post. In advance of Open Enrollment for 2022, Covered California, the state exchange, implemented a new policy, enabled by the ARPA subsidy boosts, whereby

Bronze enrollees eligible for the highest level of cost-sharing subsidies are autorenewed in a silver plan — allowing them to access cost-sharing assistance — with the same insurer and provider network for a $0 premium, if available.

Sunday, April 17, 2022

Placeholder: silver loading in Texas

Subscribe to xpostfactoid 

I've had a pretty long blogging hiatus, and that's in part because I've been working on a longer piece about Texas -- Texas! -- passing a law directing the state department of insurance to take on active rate review in the ACA marketplace and in fact "focus its rate review in a manner that uniformly maximizes the benefits of silver loading."  

Mirabilis! The law has been fleshed out in a proposed rule, and in 2023 gold plans in Texas will be priced well below silver plans. 

Thursday, April 07, 2022

The high-income surge in ACA marketplace enrollment: nonexpansion state edition

Subscribe to xpostfactoid 

Enrollment in the ACA marketplace increased by 21% in the Open Enrollment Period for 2022, compared to OEP 2021. The main cause was almost surely the boost to premium subsidies provided through 2022 by the American Rescue Plan Act, which reduced the percentage of income required to buy a benchmark silver plan in every income category and removed the income cap on subsidy eligibility, formerly 400% of the Federal Poverty Level (FPL).

My last post focused on the income distribution of the enrollment increases. In percentage terms, increases were concentrated at high incomes, though the raw number of new enrollees in the 100-150% FPL, by far the largest income bracket, was far higher than in higher brackets. In this post, we'll add the distribution in the twelve states that still have not enacted the ACA Medicaid expansion, where half of enrollees have incomes in the 100-150% FPL range. Those twelve states account for slightly more than half of ACA marketplace enrollment, as some 40% of their marketplace enrollees would be in Medicaid had these states enacted the expansion.

Tuesday, April 05, 2022

ACA marketplace enrollment surged at high incomes in 2022

Subscribe to xpostfactoid 

Enrollment in the ACA marketplace has historically -- and appropriately -- been weighted toward people in low-income households. Lower income workers are less likely to have access to affordable employer insurance. While just 17% of the U.S. population is in households with income between 100 and 200% of the Federal Poverty Level (FPL), 52% of marketplace enrollees nationally had income in that range as of the end of the Open Enrollment Period (OEP) for 2021. In the twelve states that have still refused to enact the ACA Medicaid expansion, where most adults with income below 100% FPL have no access to subsidized insurance, more than half of enrollees have incomes below 150% FPL.

The American Rescue Plan Act, passed in March 2021, boosted premium subsidies in the ACA marketplace at every income level, removed the former income cap on subsidy eligibility (400% FPL), and made silver plans with strong Cost Sharing Reduction free at incomes up to 150% FPL, as well as much cheaper than previously in the 150-200% FPL income bracket (0-2% of income instead of roughly 4-6% for a benchmark silver plan).  During the emergency Special Enrollment Period that ran through half of 2021, fully 45% of enrollment in the 36 states then using the federal exchange, (where enrollment is dominated by the nonexpansion states) had income below 150% FPL. About 62% were below 200% FPL. Enrollment growth in OEP for 2021 (before the ARPA subsidy boosts were enacted) was also concentrated in nonexpansion states and heavily weighted toward low incomes in those states.

Given this history, as enrollment surged during the Open Enrollment Period for 2022, I was blithely confident that growth was concentrated at low incomes. I was wrong.  Texas health insurance broker Jenny Hogue was onto something:

In my little corner of Texas, its not the 100%'ers that moved back, its the people who were getting killed with the subsidy cap pre-ARPA. A lot of conversations started with "is it true I can get a subsidy if my wife and I make more than $70K?".

Friday, April 01, 2022

CMS's invitation to low-income bronze enrollees to switch to silver

Subscribe to xpostfactoid 

About 620,000 ACA marketplace enrollees with income in the 100-150% FPL range have enrolled in bronze plans. Having just implemented continuous year-round enrollment for people with income up to 150% FPL, CMS is openly -- in fact expressly -- inviting these bronze plan enrollees to switch to silver. I have a post at amplifying this invitation:

At incomes up to 250% FPL, Silver plans are enhanced by cost-sharing reduction, which reduces out-of-pocket costs. CSR is particularly strong at incomes up to 150% FPL, where it reduces the average deductible to $146 and the average annual out-of-pocket maximum – the most an enrollee will pay for in-network care – to $1,208. Bronze plans – in prior years usually the only free option – have deductibles averaging $7,051 and OOP maxes usually in the $7,000-8,700 range.

The post further notes that CMS rulemaking is explicitly tailored to steer low-income enrollees into silver plans, quoting the finalization of the rule establishing the year-round enrollment at income up to 150% FPL:

Monday, March 28, 2022

11 states where higher-income ACA marketplace enrollees went for cheap gold plans

Subscribe to xpostfactoid 

(Program note: the second part of this post looks at 11 states where gold plan selection was highest in 2022. If you've no use for my musings on what ACA markets should look like, skip down to the subhead "Top gold plan markets in 2022" below.)

Having spent much of Saturday looking into gold plan selection in the ACA marketplace in 2022 (it's at a record level), I found myself musing on Sunday morning that an ideal metal level distribution, in very broad outline, would be silver for low income, gold for the middle class, and bronze for the wealthy.

Silver at low incomes, because Cost Sharing Reduction (CSR), available only with silver plans, is such a huge value-add for enrollees with incomes up to 200% FPL, rendering silver plans roughly platinum-equivalent at no additional cost to the enrollee. Silver plans are now free for enrollees with incomes up to 150% FPL and available for no more than 2% of income up to 200% FPL. They should be the near-universal choice up to that threshold (alas, they're not).

Friday, March 25, 2022 should tell 600,000 low-income bronze plan enrollees: switch to silver

Subscribe to xpostfactoid 

The message above, provided to shoppers on who estimate low incomes, isn't enough to keep a significant number of low-income enrollees out of bronze plans.

My last post focused on the stubborn persistence of significant bronze plan selection among low-income enrollees in the ACA marketplace in 2022, despite the fact that premium subsidy increases provided by the American Rescue Plan Act made the benchmark silver plan with strong Cost Sharing Reduction free to enrollees with incomes up to 150% FPL, and much cheaper than in previous years for those with incomes in the 150-200% FPL range.

Among enrollees with income between 100% and 150% FPL, 14% -- more than 600,000 -- selected bronze plans for 2022. While bronze plan selection at incomes in the 100-150% range did tick down a bit from the prior year, it remained higher than in any year prior to 2021.

President Biden's January 28, 2021 Executive Order 14009, “Strengthening Medicaid and the Affordable Care Act," declares, "it is the policy of my Administration to protect and strengthen Medicaid and the ACA and to make high-quality healthcare accessible and affordable for every American." Bronze plans obtained by people with income below 150% FPL do not advance that policy.

Bronze plan single-person deductibles average over $7,000, compared to under $150 for silver plans as enhanced by the CSR provided to enrollees with incomes up to 150% FPL. Annual out-of-pocket maximums in bronze plans generally exceed $8,000,* compared to an average of $1,208 in silver plans. 

600,000 bronze plan enrollees below the 150% FPL threshold is almost 600,000 too many.

CMS has given itself a tool to reduce this underinsured population. Last July it finalized, and this month it implemented, a rule creating "monthly special enrollment period" for enrollees with incomes up to 150% FPL -- effectively establishing continuous year-round enrollment for the lowest-income marketplace applicants. The rule not only allows the uninsured to enroll outside the annual Open Enrollment Period; it also allows current enrollees with income up to 150% FPL to switch to a silver plan. 

Wednesday, March 23, 2022

In ACA marketplace in 2022, too much underinsurance (bronze plan selection) at low incomes

Subscribe to xpostfactoid 

We have had plenty of time to celebrate the 21% surge in ACA marketplace enrollment, most likely triggered primarily by the major boosts to premium subsidies provided last March by the American Rescue Plan Act (ARPA). Now, with CMS's Public Use Files tracking marketplace enrollment for 2022 released on the ACA's 12th anniversary, it's time for some disappointment.  

In the 33 states, for which CMS provides detailed plan selection breakouts, the ARPA subsidy boosts did not reduce underinsurance as much as might have been expected during the Open Enrollment Period (OEP) for 2022.  That is, silver plan selection at low incomes (up to 200% FPL), where Cost Sharing Reduction (CSR) makes silver plans far and away the best value for almost all enrollees, modestly reversed a four-year slide, but not nearly as much as might have been expected. 

In states this year, 60% of enrollees had incomes below 200% FPL, and 80% of them selected silver plans. 

Enrollment by metal level at low incomes states

100-150% FPL


% bronze

% silver
















SEP 2021(0-150%)


93.0% (estimate)




Tuesday, March 22, 2022

Good news alert: Web search for health insurance has been cleaned up

Subscribe (free) to xpostfactoid

ACA marketplace enrollment surged by 21% in 2022, from 12.0 million as of the end of the Open Enrollment Period for 2021 to 14.5 million in OEP 2022.  The primary cause was plainly the massive boosts to premium subsidies provided by the American Rescue Plan in March 2021 (witness the enrollment surge in the emergency Special Enrollment Period in effect when the boosted subsidies came into effect). Ramped-up federally funded enrollment assistance and advertising may also have helped.

A less visible marketing measure may also have been a factor: the online search environment has been cleaned up.  Search today on Google for "health insurance" or "Obamacare" and, the federal exchange that serves 33 states, will top the search results. Search for "health insurance Nevada" and Nevada Health Link, the state-run ACA exchange, will be on top. The same is true for all of the 17 states (and D.C.) that run their own exchanges. There are some slight variations on Yahoo and Bing, but results there are also generally reliable. 

Saturday, March 12, 2022

Not your older sister's marketplace: Web awards for the ACA exchanges

Subscribe (free) to xpostfactoid

Whatever you think of the ACA marketplace as a means of providing health insurance to those who lack access to other sources, the exchanges themselves, viewed as online enrollment and information portals, have come a long way in recent years, with a few exceptions.*

Since 2020, six states  -- Pennsylvania, New Jersey, Nevada, Maine, New Mexico and Kentucky -- have left, the federal exchange now used by 33 states, and launched new state-based exchanges -- or, in the case of Kentucky, revived an SBE that had been killed by a Republican governor. All work pretty well with the exception of Kentucky's KyNect, which has some bugs to work out as it attempts to serve as a portal for multiple government benefits. 

Three of the new exchanges-- in PA, NJ and NV -- were designed by the tech vendor GetInsured, and are similar in many respects, notably a pretty user-friendly shop and compare tool that manages to display the handful of questions you need to answer to get price estimates on one page. GetInsured also designed exchanges for California and Idaho and revamped the shopping tool for Minnesota and Washington. In the pre-application plan preview stage, these exchanges all have a similar look and feel, both in the shop-and-compare question phase and in the display of available plans -- with the exception of Washington, which retains an archaic and confusing design in the latter. 

Saturday, March 05, 2022

Did ARPA increase CSR takeup and so reduce underinsurance? A view from Covered California

Ever since the American Rescue Plan Act's boosts to premium subsidies in the ACA marketplace came online last March (and even before), a chief interest of mine has been whether the enhanced subsidies will reduce underinsurance as well as boosting enrollment (and so reducing uninsurance). 

The chief source of reductions in underinsurance would be improved takeup of silver plans with Cost Sharing Reduction (CSR) at incomes up to 200% FPL* ($25,760 for a solo enrollee). CSR is available only with silver plans. As boosted by ARPA,  a benchmark (second cheapest) silver plan is now free at incomes up to 150% FPL and costs 0-2% of income at 150-200% FPL. At 200% FPL, benchmark silver used to cost about $135 per month for a single person; it now tops out at $43/month. More than half of ACA marketplace enrollees have income below 200% FPL.

As noted in this post, silver plan selection among low-income enrollees had been sliding since 2017, but  ARPA did apparently reverse the trend during the emergency Special Enrollment Period that ran from Feb. 15 to Aug. 15 last year in states, and for varying periods in the 18 state-based exchanges.  Below, we'll get a point of comparison from California.

Wednesday, March 02, 2022

A clarification re year-round marketplace enrollment at incomes below 150% FPL

Subscribe (free) to xpostfactoid

This is an update concerning the new "monthly Special Enrollment Period" -- effectively, year-round enrollment - -that CMS has implemented on for applicants with incomes below 150% FPL (currently $19,140 for an individual, $32,580 for a family of four).* 

In a prior post about the monthly SEP, I emphasized that the vast majority  (88%) of enrollees with incomes below the 150% FPL threshold are in states that have refused to enact the ACA Medicaid expansion, and that one effect may be to reduce the "coverage gap" in those states -- that is, the lack of subsidized coverage available to adults with incomes below 100% FPL, the minimum threshold for marketplace subsidy eligibility. During the pandemic, marketplace enrollment has increased by leaps and bounds in nonexpansion states -- it's up 45% in two years -- and half the enrolment in those states is at incomes below 150% FPL. Noting that subsidy eligibility is based on an applicant's estimate of future income, and that income is notoriously difficult to predict for low earners, I outlined a regulatory question posed by the rule establishing the monthly SEP:

Monday, February 28, 2022

Whither the off-exchange individual market? Tea leaves in New Jersey

Subscribe (free) to xpostfactoid

Jersey City skyline

One open question created by the American Rescue Plan Act's boost to ACA marketplace subsidies is the extent to which off-exchange enrollment in ACA-compliant plans has migrated to the exchanges. A related question is how many people who would have been ineligible for subsidies and uninsured pre-ARPA (or insured in noncompliant plans) were drawn into the exchanges.

New Jersey, one of the few states that tracks off-exchange enrollment on a quarterly basis and has a large off-exchange enrollment cohort, will eventually provide an interesting sampling. Unfortunately, the off-exchange tally is at present only complete through Q4 2020. But the state's on-exchange enrollment reports provide some hints, explored below. 

Wednesday, February 23, 2022

New Jersey launches year-round marketplace enrollment at incomes below 200% FPL

Subscribe (free) to xpostfactoid

My last post delved into CMS's motives and goals in establishing continuous year-round enrollment for ACA marketplace enrollees with income up to 150% FPL, as long as benchmark silver coverage remains free to that income level.

New Jersey has gone the feds one better, today announcing year-round enrollment on GetCoveredNJ, the state exchange, for enrollees with income up to 200% FPL ($25,760 annually for an individual; $53,000 for a family of four). 

Various state-specific conditions suggest motives for going that high:

1. Supplemental state subsidies provided in New Jersey make silver coverage free all the way to the 200% FPL threshold. In finalizing its rule establishing continuous enrollment to 150% FPL, CMS suggested (pp. 91-92 here) that limiting the open enrollment to those for whom benchmark coverage is free limits the risk of adverse selection. For that reason, CMS conditions extending the continuous SEP beyond this year on extension of the enhanced subsidies provided through 2022 by the American Rescue Plan.

2. New Jersey is one of a handful of states that imposed a state-level individual mandate after the Republican Congress zeroed out the penalty for the federal mandate. There has been a degree of buyer's remorse about the mandate among progressive groups. It was enacted in 2018 to partly fund a state reinsurance program (about two thirds-funded by the federal government), which reduced premiums for unsubsidized (i.e., mostly affluent) enrollees. Most people who pay the mandate penalty are low income. Continuous enrollment, along with the targeting of uninsured taxpayers described below, would reduce low-income exposure to the mandate.

Sunday, February 20, 2022

Why is offering year-round enrollment at low incomes

CMS has soft-launched a new "monthly special enrollment period" (SEP) for health insurance seekers with incomes below 150% of the Federal Poverty Level in states that use the federal exchange, This new rule, finalized last fall, effectively creates continuous enrollment for the lowest-income enrollees. At present, the SEP can be accessed by calling the help center (1-800-318-2596); it will be available online on by late March. State-based exchanges can implement this continuous enrollment at their option. 

Louise Norris covers every nuance of the rule's operation here. I will focus on CMS's stated motives and goals, and the likely impact.

The rule stipulates that the monthly SEP will only be operative as long as benchmark silver coverage remains free to enrollees with income up to the 150% FPL threshold. Boosts to ACA marketplace subsidies provided by the American Rescue Plan Act (ARPA) created that free coverage through 2022. While Democrats clearly intended and have been expected to extend the ARPA subsidies beyond this year, that is no longer certain now that the Build Back Better legislation has stalled.

Continuous enrollment in coverage available free at low incomes is of a piece with Medicaid enrollment practices, as well as with enrollment in the Basic Health Programs established under the ACA by Minnesota and New York. BHPs offer free or low-premium coverage with low-out-of-pocket costs -- rather like Medicaid -- to residents with incomes up to 200% FPL. 

In its September 27, 2021 update to ACA rules, CMS spelled out the rationale for the new monthly low-income SEP. The broad context, cited in the executive summary, is President Biden's January 28, 2021 Executive Order 14009, “Strengthening Medicaid and the Affordable Care Act," which declares:

millions of people who are potentially eligible for coverage under the ACA or other laws remain uninsured, and obtaining insurance benefits is more difficult than necessary. For these reasons, it is the policy of my Administration to protect and strengthen Medicaid and the ACA and to make high-quality healthcare accessible and affordable for every American. 

Monday, February 14, 2022

Flowers in the graveyard: Health Policy Valentines 2022

Subscribe to xpostfactoid

U.S. healthcare policy is no rose garden, but this year's HealthPolicyValentines salute a few sweet blossoms. That's notwithstanding the staggering failures of policy -- in many cases malevolent and corrupt -- that have swelled the pandemic death toll to an unfathomable 900,000.

         *     *     *

I'm in love with a cold hard fact:
We've enacted the No Surprises Act.

         *     *     *

Affordable Care?
Yes, we can!
Thanks to the American
Rescue Plan.

A massive boost to subsidies meant
enrollment up twenty-one percent.

Wednesday, February 09, 2022

In New Mexico, a Midas touch has a double edge

Subscribe to (free) xpostfactoid

Let's take one more look at enrollment results in New Mexico's ACA marketplace, where extreme silver loading rendered average lowest-cost gold plan premiums 14% lower than those of lowest-cost silver plans, and gold plans were available well below the cost of a benchmark silver plan statewide (excepting those for whom silver plans also were free, or had single-digit premiums).

The unadulterated good news was for enrollees with incomes above 200% of the Federal Poverty Level, more than two thirds of whom chose gold plans, while only about 13% choose bronze. That's a real advance.

The good news at incomes below 200% FPL was that just 4% chose bronze plans, which carry deductibles usually in the $7,000 range for an individual.  Most of those who selected bronze at low income levels may have been subsidy-ineligible, usually because of an employer's offer of insurance. That's generally the case for a small percentage of enrollees with incomes in subsidy range.

The not-so-good news is that 31% of enrollees with incomes in the 138-200% FPL range chose gold plans, although silver plans have a higher actuarial value than gold plans at incomes below 200% FPL, reflected most dramatically in annual maximum out-of-pocket cost (MOOP) caps that can't go higher than $2,900, vs. a maximum allowable MOOP of $8,700 for gold plans. 

Friday, February 04, 2022

In 2022, New Mexicans grabbed the gold in the ACA marketplace

Back in mid-October, I devoted a handful of posts (1, 2, 3) to New Mexico's great ACA marketplace experiment: instructing insurers to price silver plans as platinum-value in 2022 -- that is, as if no one with an income over 200% FPL would buy a silver plan. Below that income threshold, silver plans, enhanced by strong Cost Sharing Reduction (CSR), actually are platinum-equivalent, having an actuarial value of 94% (at incomes up to 150% FPL) or 87% at 150-200% FPL). The instructions were adhered to: throughout the state gold plans offered for 2022 were priced well below the benchmark silver plan.

The results were largely as planned, and can fairly be deemed a success. At incomes over 200% FPL, two thirds of enrollees chose gold plans, compared to 35% last year. At incomes in the 138-200% FPL range, comprising most enrollees eligible for strong CSR,  65% of enrollees chose silver plans -- and just 4% chose bronze, generally a bad choice for low income people, with single-person deductibles averaging about $7,000.  Among all enrollees, 57% chose gold plans.

Enrollment was up modestly, from 42,984 in Open Enrollment 2021 to 45,973 this year, a 7% increase. That's below the 11.5% average increase this year for states that have expanded Medicaid, as New Mexico has. But New Mexico launched a new state-based exchange, bewellnm, in the Open Enrollment Period for 2022, and that transition has often triggered enrollment losses for other states.

Here are the metal level choices broken out by income (courtesy of bewellnm, at the first link above):

Thursday, January 27, 2022

ACA marketplace enrollment up 45% in two years in nonexpansion states

The final snapshot for the Open Enrollment Period on and ten state-based exchanges is in. We're almost done, though eight SBEs are still open. Already, enrollment in marketplace plans is up 21% over OEP 2021, to a record-breaking 14.5 million nationally, well above the previous high of 12.7 million in 2016.

Two caveats. First, when the Trump administration cut OEP in to six weeks (Nov. 1 - Dec. 15) and gutted advertising and enrollment assistance in states, while plan selection in OEP dropped, attrition also dropped -- that is, the percentage of people who never paid their first premium went way down. Early effectuated enrollment went from 85% of OEP plan selections in 2016 to 94% in  2021. A longer OEP and heavier outreach apparently attracts more marginal enrollees -- though with benchmark silver plans now free up at incomes up to 150% FPL and cheaper at all incomes, attrition may not drop to pre-2017 levels. 

Second, the steep premium hikes of 2017 and 2018 decimated off-exchange enrollment in ACA-compliant plans, which dropped from 5.0 million in Q1 2016 to 2.1 million in Q1 2019, by KFF's estimate. All told, individual individual market enrollment may be about where it was at the 2016 peak.

Sunday, January 23, 2022

On climbing out of the ACA coverage gap

The latest quarterly estimates of health insurance coverage from the National Health Interview Survey (NHIS) show a drop in the uninsured rate for all ages from 9.7% in Q2 2021 to 8.9% in Q3. That's probably not statistically significant. The confidence intervals largely overlap;  quarterly rates bounce around quite a bit; they are "published prior to final data editing and final weighting"; and response rates have been affected by the pandemic.

That said, the changes among adults aged 18-64 in the lowest income segment -- those with incomes below the Federal Poverty Level -- may be worth pausing over:

Wednesday, January 19, 2022

Fixing the ACA’s Medicare Glitch

By Louise Norris and Andrew Sprung
It's my pleasure to team up in this post with Louise Norris, a health insurance broker and ACA chronicler extraordinaire at and At those two sites, Louise has effectively created a constantly updated encyclopedia of the ACA, covering a host of enrollment situations, regulations, marketplace features, and histories of each state marketplace. She has done similar work about Medicare at

*          *          *

For most Americans, enrollment in Medicare is cause for celebration. At last: affordable, reliable insurance you can’t lose. Medicare enrollment can entail some complex determinations (do I qualify for any Medicare Savings Programs?) and decisions (Medigap or Medicare Advantage?) For many seniors, too, the burden of premiums and out-of-pocket expenses is heavy. Still, by American standards, Medicare is reliable and affordable.

For “near-elderly” couples (under age 65)  who are insured through the Health Insurance Marketplace established by the Affordable Care Act, however, the transition of the elder spouse into Medicare can bring sticker shock and extra expense. That’s because ACA premium subsidies are designed so that enrollees pay a fixed percentage of household income for the benchmark (second cheapest) silver plan in their area – and they pay the same percentage (reduced through 2022 by the American Rescue Plan enacted in March 2021) regardless of how many people need insurance. 

A couple that was paying 8% in premiums for a benchmark silver plan to cover both of them will still pay 8% of income when only one of them is covered in the marketplace. When one of them transitions to Medicare, they will pay the marketplace premium plus the Medicare premium. In the illustration below, they will pay somewhere between 11% and 14% of income in premiums to cover them both, depending on whether the Medicare enrollee opts to buy a Medigap policy.

Thursday, January 13, 2022

When an average deductible goes up, and a median deductible goes down, what shakes?

Subscribe (free) to xpostfactoid

An ASPE brief released by HHS today, highlighting the relatively low out-of-pocket costs available to low-income ACA marketplace enrollees who enroll in silver plans with Cost Sharing Reduction (CSR) subsidies, centers on a rather strange claim: 

Median and average deductibles, after CSRs, differ substantially among enrollees. The median deductible decreased from $1,000 to $750 between 2017 and 2021 (prior to implementation of the American Rescue Plan (ARP), while the average deductible increased from $2,405 to $2,825. The difference between median and average deductibles is primarily driven by the fact that the majority of enrollees are eligible for and select CSR-silver plans; the average deductible is driven up by the smaller share of enrollees enrolled in plans without CSRs.

Why is there now a "smaller share of enrollees enrolled in plans without CSRs"? It's not because low income enrollees selected silver plans at a higher rate in 2021 than in 2017 - - the opposite is true. Let's dig in.  

It's important to keep in mind the different levels of CSR. At incomes up to 150% FPL($19,140 for an individual in 2022), CSR raises the actuarial value of a silver plan to 94%; at incomes from 150% to 200% FPL ($25,520), to 87%, and from 200% to 250% FPL ($31,900), to 73%, only negligibly above baseline silver AV of 70%, which attaches to silver plans for enrollees with incomes above 250% FPL. 

1. Why did the median deductible go down while the average deductible went up? The average deductibles for CSR plans with an AV of 94% (CSR94) and 87% (CSR87) did go down a bit, while average silver plan deductibles at other income levels rose, as did gold and platinum deductibles. For CSR87, the average went down from $661 in 2017 to $530 in 2021, according to the ASPE brief.  But total enrollment in CSR94 and CSR87 plans does not quite reach the median in any year.

Friday, January 07, 2022

Breaking the BHP ring fence: New York's Hochul proposes Essential Plan eligibility to 250% FPL

Subscribe (free) to xpostfactoid

This significant tidbit, gleaned from New York Governor Kathy Hochul's State of the State Address, was reported in yesterday's Politico Pulse newsletter:

...Hochul proposed raising income eligibility for New York’s Essential Plan — which provides health insurance to New Yorkers who don’t qualify for Medicaid — from 200 percent of the federal poverty level to at least 250 percent, pending federal approval. The policy is estimated to reduce the number of uninsured New Yorkers by at least 14,000 and make health care more affordable for at least 92,000 people.

This initiative is not mentioned in the published text of Hochul's speech. I can't find any further written trace of it.  To extend eligibility beyond the current 200% FPL income threshold would appear to require the filing of a state ACA innovation waiver requesting federal approval.  [Update: this language is in the State of the State Book, page 34. The NY Dept. of Health confirms that the state will have to submit an innovation waiver proposal, and adds that there will be more detail in the executive budget proposal.]

If the proposal pans out, it could pave a state route to essentially replacing -- at least in large part -- the ACA marketplace with a program more cost-effective for enrollees and governments alike.

Wednesday, January 05, 2022

Surprise billing protection is here! The promise (and a few limitations) of the No Surprises Act

The No Surprises Act -- federal legislation protecting most enrollees in most health plans from most surprise billing -- went into effect on January 1. Good news!

To review briefly, enrollees in employer-sponsored plans -- including self-funded plans -- and ACA-compliant individual market plans (as well as grandfathered pre-ACA plans)  cannot be billed more than their in-network share of costs for:

  • Emergency care, including post-emergency stabilization care, at out-of-network facilities or from out-of-network providers at in-network facilities.
  • Non-emergency care provided by out-of-network providers at in-network facilities or in support of an in-network lead provider. For example, anesthesiologists, radiologists, assistance surgeons etc. cannot balance-bill for their services provided by an in-network surgeon.
  • Air ambulances -- among the most notorious balance-billers for tens of thousands of dollars. Ground ambulance charges are not protected.
The U.S. being the U.S., there are some definite and potential holes in the new protections (ground ambulance charges being the most obvious and salient). Enforcement falls to a tangle of federal and state agencies, depending in part on whether the health plan is self-funded and whether the state in which a violation occurs proves to "substantially enforce" the law (if not, HHS is a fallback). The Kaiser Family Foundation maps out that potential maze. On the plus side, CMS has stood up an online consumer complaint form on its info page about the new protections.