Friday, December 30, 2022

Healthcare access in the U.S.: 2022 in review

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It's been a year of crosscurrents in the healthcare industry -- and of reporters exposing those crosscurrents, often with a ten- or twenty-year look-back. We have seen fantastic investigative reporting on hospitals unleashing hellhounds on indebted patients; hospital systems disinvesting in low income neighborhoods and shifting resources to wealthy ones; private equity degrading and pillaging selected healthcare industry segments (1, 2); hospitals prioritizing VIPs in the emergency room; and insurers finding synergies in what used to be conflicts. Provider consolidation continues apace; Medicare Advantage threatens to swallow fee-for-service Medicare, while its profit-maximizing methods are introduced into fee-for-service Medicare; and MA gaming of risk adjustment goes as yet unchecked, or rather inadequately checked. As for our response to Covid (oy), it’s not really my bailiwick, but see the note at bottom.

On the upside, the federal government got its first toehold in negotiating prescription drug prices; a national prohibition on most medical balance-billing went into effect; the FTC under Lina Khan challenged four hospital mergers; with federal prompting, the number of states providing or soon to provide a year of post-partum Medicaid enrollment rose to 34; CMS proposed a rule designed to smooth Medicaid enrollment on multiple fronts, including limiting renewals (and so, disenrollments) to once every twelve months; the ARPA boosts to ACA premium subsidies were extended through 2025, and marketplace enrollment is on track for a second consecutive year of double-digit growth; and the uninsured rate is at an all-time low (though threatened by the pending end of the moratorium on Medicaid disenrollments).

As in past years, xpostfactoid (and my writings elsewhere) focused mainly on the ACA marketplace, with some forays into Medicaid and Medicare, particularly on the causes and impact of Medicare Advantage’s accelerating gains in market share. As always, I closely examined ACA enrollment patterns, with special attention to the complexities that lead enrollees to suboptimal outcomes.

Below, a few posts from 2022 that went over biggest with…me. I’ve limited selections to the period before I ported xpostfactoid to Substack in late September, as the posts on that site are readily skimmed.

At The American Prospect
How the Texas Legislature Learned to Stop Worrying and Love the ACA Marketplace - 4/21/22
Ground zero for rooted reflexive hostility to the Affordable Care Act is Texas. Or was. While the state still wriggles, writhes and resists expanding Medicaid — which would cut its uninsured rate in half — this year the state legislature unanimously passed legislation that massively boosts subsidies in the ACA marketplace — with the cost borne entirely by the federal government. An amazing tale of bipartisan comity in…Texas.

Silver, Bronze, or Gold? Choosing a Metal Level in the ACA Marketplace - 4/25/22
The ACA marketplace purports to associate metal level with value. But Cost Sharing Reduction subsidies, which attach only to silver plans, make a hash of purported metal value. So, a guide to marketplace shopping in different income brackets. Relatedly…
Applying for ACA coverage? Know the ropes (between income levels) - 11/28/22
Understanding how small differences in projected income can have a large impact on your health plan costs can be key to obtaining affordable coverage.

At xpostfactoid 

In New Mexico, a Midas Touch has a double edge - 2/9/22
A look at the downside as well as the much bigger upside of a market in which gold plans are cheaper than silver.

In ACA marketplace in 2022, too much underinsurance (bronze plan selection) at low incomes - 3/23/22
In March 2022, the American Rescue Plan made silver plans with strong CSR free-to-low-cost at incomes up to 200% of the Federal Poverty Level. In 2022, too many low income enrollees bought bronze plans.

11 states where high-income marketplace enrollees went for cheap gold plans - 3/28/22
A look at markets where gold plans cost less than benchmark silver

The high-income surge in ACA marketplace enrollment - 4/7/22
ARPA’s removal of the income cap on ACA premium subsidies had its effect.

Is avoiding overpayment of Medicare Advantage plans beyond U.S. government capacity? - 6/3/22
A dive mainly into MedPAC complaints and proposals. See also “To whose advantage is Medicare Advantage? Parts 1 and 2 (here on Substack).

Average weighted actuarial value in the ACA marketplace - 7/20/22
It’s considerably lower than the average in employer-sponsored insurance, and down somewhat from 2016, thanks mainly to silver loading.

U.S. uninsured rate hits an all-time low - 8/3/22
I’d been expecting such a finding for about a year.

Democrats have twelve years of healthcare accomplishment to run on - 8/31/22
They do, really.

* Note: On the pandemic front, I am no expert, but I credit those who accuse the U.S. of having failed miserably to institute policies and messaging that would reduce Covid infections and fatalities, make resumption of normal activities safer, protect workers, and ease the stress on healthcare systems. Accordingly the U.S. has the highest Covid deaths per 100,000 ratio among peer nations. I lament failures to mandate paid sick leave and workplace safety measures; facilitate, incentivize, and in some cases mandate vaccine boosters; make rapid tests and N-95 masks widely available and free or close to free; institute widespread indoor air quality control; mandate indoor masking when cases spike; provide effective, unified, up-to-date public health messaging; and facilitate equitable global vaccine distribution. Above all, to my mind, the failure to appropriate fresh funds to fight Covid and prepare for future pandemics is unfathomable. You can blame Republicans for blocking requested funding, but neither Democrats in Congress nor the Biden administration fought hard enough to overcome resistance when they might.

On the plus side, legislation providing economic relief led to a near-miraculous economic recovery from the pandemic’s initial shock and prevented a surge in the uninsured rate. And the swift development of effective vaccines was miraculous. 

Wednesday, December 28, 2022

ACA marketplace enrollment may be up 45% in the pandemic era

Dear xpostfactoid readers: All subscriptions are now through Substack alone (still free). I will continue to cross-post on this site, but I've cancelled the feed (it is an excellent free service, but Substack pulls in new subscribers). If you're not subscribed, please visit xpostfactoid on Substack and sign up!

CMS announced yesterday that enrollment through December 15 in ACA marketplace plans on, the federal exchange serving 33 states, is up 18% year-over year. That’s on top of a 27% year-over-year increase in states last year.

Enrollment growth in the pandemic era has been slower in the 18 states (including D.C.) that run their own state-based exchanges (SBEs). Last year, SBE enrollment growth was about 8%, and the all-state total increase ( + SBEs) was 21%. If the 18% growth rate for states holds through the end of the Open Enrollment Period, and the ratio of SBE growth to growth matches last year’s, then total enrollment growth as of the end of OEP 2023 will come in at about 13.7%.

That would peg total enrollment as of the end of OEP at about 16.5 million. Charles Gaba, who’s been tracking SBE enrollment tallies as they come in (they lag’s), projects a range of 16.4-16.9 million (plus 1.1 million in New York and Minnesota’s Basic Health Programs).

A few notes about this continued strong enrollment growth:

Friday, December 23, 2022

No Surprises Act at the (nearly) one-year mark: How are we doing?

Note to subscribers: My apologies for double-subscribing you for some weeks while I tested the Substack platform. Substack is working well -- it does seem to be pulling in new (free) subscribers -- and I think it's time to cut the cord here. I will continue to cross-post on this site but will end the subscription (though I do appreciate its quality free service, which stepped in the breach when Google discontinued RSS).  I hope you will subscribe on Substack (the subscription will remain free) if you're not already subscribed. If you like visiting this site on your own, posts here will continue. Thanks for continuing to read, wherever.

For several years, I was fond of affirming that “surprise” bills — bills sent to insured patients by out-of-network providers working at in-network facilities — were the one systemic healthcare abuse so egregious that even Americans would not tolerate it forever.

This time two years ago, after several false starts, Congress stepped up and managed to include the No Surprises Act (NSA) in a spending omnibus. The bill did ban most surprise billing for emergency care and for scheduled procedures at in-network facilities. The law went into effect on January 1, 2022.

The one major loophole was ground ambulances. 911 ambulance dispatch is still pot-luck: an out-of-network (OON) service may arrive, and may bill you for more than your insurer is willing to pay. But emergency care — and essential “post-stabilization care” — is covered, whether the hospital is in-network or not, or whether the providers who treat the patient are in-network or not. In scheduled procedures at an in-network facility, ancillary providers in a scheduled procedure — the anesthesiologist, the pathologist, the assistant surgeon — cannot surprise-bill the patient. Air ambulances — among the most frequent and expensive balance billers — are covered by the law.

Pre-NSA, surprise billing in the U.S. was prevalent enough to potentially undermine virtually any commercial insurance. According to Kaiser Family Foundation estimates, for people in large employer plans, 18% of all emergency visits and 16% of in-network hospital stays had at least one out-of-network charge associated with the care in 2017. In some facilities and regions, percentages were far higher; in some emergency departments, virtually every provider was OON. Whole business models, including in national private equity-owned ER practices, were based in large part on billing patients at up to 11 times Medicare rates. The major private equity players blocked passage of national balance billing protection at least once.

As the NSA approaches its first birthday, I wondered how the new protections are working. Short answer: there’s not yet much data. CMS has established a national hotline and online form to handle patient complaints but has not yet published any analysis of data collected through the complaint line. 

There is some evidence, though, of “surprises” that didn’t happen. A joint survey* of insurers by America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association released this past November found that more than 9 million claims from providers were subject to the protections of the law — that is, could have triggered balance bills to patients, though presumably not all OON providers in all cases would have sent such bills. The AHIP release notes that each service or procedure was counted as a separate claim, and that a single visit might result in multiple claims (but also in multiple balance bills).

Early impressions

Karen Pollitz, director of the Kaiser Family Foundation’s Program on Patient and Consumer Protections, pointed out to me that oversight of the NSA is largely reliant on complaints. Pollitz said she had heard second-hand that initially, a lot of the complaints that CMS fielded through the national hotline were about billing problems not covered by the law (and lord knows there are many, such as hospitals relentlessly suing patients, garnishing wages and putting liens on houses in pursuit of unpaid bills). That is, callers knew that there was a new law that provided some protection against onerous medical bills, but were unclear as to what those protections entailed. In more recent months, Pollitz has heard, calls have been more on point.

She added, “I gather that most complaints have been referred to other agencies in cases where CMS doesn’t have direct enforcement authority. Complaints are referred to the Department of Labor if the problem is with an employer-sponsored health plan, or to states if the problem is with a provider and the state has stepped up and said it will handle enforcement of providers.” (States can undertake provider enforcement, share it with CMS, or cede it entirely to CMS. On the insurer side, DOL has oversight over self-funded health plans, which insure the majority of people with employer-sponsored insurance.)

Patricia Kelmar, senior director of health care campaigns for the Public Interest Research Group, noted that in just the first nine months of the law, 9 million surprise bills have been prevented. “That's great news to millions of families that don't have to pay a balance bill that they couldn't avoid. That's a lot of money that stays in patients pockets - at their most vulnerable time dealing with a health issue.” More broadly, “It’s always hard to measure something that didn’t happen” (as Pollitz also pointed out). Kelmar said, however, that TV reporters who used to regularly spotlight surprise bills are a good informal source, and one such reporter told her that “calls have totally dropped off.”

Kelmar said that there’s a long way to go in generating public awareness of the new protections. “Do people know they have these protections? If they do get an illegal bill, will they know where to get help? It’s a huge challenge, as medical bills are very complex. Consumers don’t want to open them because, first, they’re usually bad news, and second, they’re hard to understand. We need a clearer billing system in which consumers aren’t afraid to open their medical bills. And we need to be very clear that certain entities shouldn’t be sending bills.”

She added that “CMS is only just beginning its public education campaign. We all have a long way to go to really help consumers.” On that front, Pollitz said that a KFF survey conducted last spring found that three quarters of the public hadn’t heard of the No Surprises Act or knew very little about it.

Kelmar looks to insurers to help increase awareness. She suggests that the insurer’s Explanation of Benefits (EOB) should spell out: “We’ve received these claims from the hospital, applied your insurance, and this is what you owe. Don’t pay more than this.”

I asked why insurers would want to do this. Kelmar said the incentive is strong: “If insurers help patients to identify a surprise bill, they can say ‘Don’t blame us.’ People generally don’t like their insurers, but they can turn that around by helping them avoid surprise bills.” She added that the law helps create a system in which more providers will come in-network.

Most states have Consumer Assistance Programs (CAPs), initially funded with federal grants established by the Affordable Care Act, that field consumer complaints about medical billing. In New York, the CAP hotline is run by nonprofit Community Service Society. Elisabeth Benjamin, VP of health initiatives at CSS, told me that because of awareness generated by the No Surprises Act, “We’ve seen an increase in the number of surprise billing calls. There’s more general awareness around medical debt and billing practices. Also, higher and higher levels of cost-sharing.” Anecdotally, Benjamin said she’d heard that the insurance division of New York’s Department of Financial Services was also getting more calls than pre-NSA about medical billing.

The NSA in action

Health Law Advocates, a nonprofit, provides legal assistance to Massachusetts residents who have problems accessing healthcare or health insurance, or problems with medical bills. While Massachusetts has a balance-billing protection law that predates the ACA, Wells Wilkinson, a senior staff attorney at HLA, says that the NSA has helped in some circumstances where Massachusetts law doesn’t reach.

Wilkinson described one case in which a Massachusetts resident was injured while out of state and treated in a hospital emergency room. He was confronted with two kinds of bills: “One set where the health plan completely denied coverage and he was billed for 100% of charges, and another in which the plan made a payment, and the provider balance-billed for the entire remaining billed cost.”

The layered bills — the patient received four EOBs from his insurer — arose from layered treatment. Initially, the patient went to the ER and was given some scans, but sent home (to a vacation condo) because this was during the pandemic and the hospital did not have an orthopedist on staff. The hospital said they would call after the orthopedist looked at the scans. Next morning, they called and —importantly for insurance purposes — told the patient “you’re not safe to travel” and that he should come in for treatment. The patient then underwent surgery in that hospital. The ‘not safe to travel’ determination was important because under the NSA, OON protections apply as long as ER treatment is necessary to stabilize the patient. If the patient can safely be transported to an in-network facility after stabilization, the protections no longer apply from that point on.

While the reason for the insurer’s 100% denial of what was clearly an emergency service remains inscrutable, Wilkinson says, “We were able to work with the health plan and get all costs eliminated except for small amounts of cost sharing. We also worked with the providers to notify them that they’re not allowed to balance bill for these types of emergency services.” Armed with legal assistance, this patient achieved an independent resolution without recourse to a filed complaint.

That choice underscores a dilemma, however, according to Wilkinson: “Get help from a regulator or try an appeal to the insurer first? One danger in reaching out for assistance: you might miss the insurer’s appeal deadline.”

Gaps and complications

Everyone I spoke to highlighted gaps** in the NSA’s protections — though with an implicit understanding that U.S. healthcare law and billing practices are byzantine and that the law takes a major bite out of patient exposures.

Benjamin at CSS noted that one common complaint that escapes the law’s protections is spurred by a doctor’s office erroneously telling the patient they’re in-network. Often this is a matter of imprecision — “The patient is told ‘we take Blue Cross,' but in fact the office doesn’t take the patient’s particular plan.”

More generally, imprecision with regard to network inclusion is a perpetual and multi-front problem. The PIRG consumer guide to NSA protections warns:

Ask: “Are you part of my plan’s network?”

Do not ask: “Do you take my insurance?”

Sometimes a provider says it will “take” your insurance but it is not in your insurance plan’s network. What the provider means is that it will send the bill to your insurance plan for you but will still charge you an out-of-network rate.

Pollitz at KFF worries about the allowances for OON billing for scheduled procedures, noting that those procedures may be diagnosed while a patient is in the hospital, under circumstances in which it’s difficult to refuse care or seek to ensure that care comes from in-network providers.

“The law says that you can be asked by an OON provider to waive your rights up to 72 hours in advance of scheduling a service. Or, if a service is scheduled less than 72 hours in advance, you have to be given notice — a paper to sign away your rights — no less than three hours in advance.”

“So let’s say you’re in the hospital and the attending doctor decides that morning that you should have an endoscopy — and by the way, the doctor performing the endoscopy is out-of-network.” Should you sign off? How many people will ask for an in-network endoscopist?

Financial pathologies with pathologists

Aside from failure to cover ground ambulances, perhaps the NSA’s largest gap is between the doctor’s office and the lab. While a patient is protected from surprise bills if a healthcare facility —e.g., a hospital, satellite emergency department, or ambulatory care facility — sends blood samples or other test data to an OON provider, there is no such protection if a doctor’s office does so.

I spoke to a cancer patient whose oncologist recently sent her blood sample out for genomic testing without her knowledge. She received an EOB stating that the genomic testing lab was OON and that she would be responsible for the full $5,800 charge. She has not yet been billed. The lab has since asked her permission to file an appeal to her insurer.

Prior to NSA passage, the patient underwent a bone marrow biopsy that was also processed by an OON provider. Her doctor said that the lab in question was the only one he knew of that performed that kind of test at all.

* * *

The NSA should cut the heart out of balance billing practices that not that long ago were endemic in the United States. Most of those who benefit from the law may never know it, as is often the case with good legislation. In early days at least, those who might benefit from it when its provisions are violated may not know to avail themselves of its protections. Over time, the steep fines that attach to violations — $10,000 per episode — should make compliance a norm. We might hope too that in coming years, gaps in the NSA’s protections will be filled.

Americans remain exposed to out-of-pocket healthcare costs that are almost inconceivable in other wealthy countries. But via the NSA, one major and sometimes all-but-unlimited source of financial exposure should be reduced to a shadow of its former self.

- - - - -

* The AHIP/BCBS survey also found that OON bills have submitted for arbitration are far in excess of the level predicted by federal agencies: 90,000 disputes were initiated bay September 30, whereas 17,000 had been predicted for the full year. Given the political clout of hospitals and physician groups, the bill was surprisingly tough on providers in its ground rules for arbitration that OON providers can initiate when they consider the payment offered by the patient’s insurer inadequate. The law emphasizes the “median contracted rate” — the average paid by insurers for the procedure in question in the region in question — as a factor for arbitrators to consider. Lawmakers apparently took to heart studies showing that arbitration rules established by states such as New York and New Jersey that gave more weight to the rates OON providers billed defenseless patients — their “usual and customary charges” led to arbitration awards of payment average about ten times Medicare payment rates. Federal rulemaking centered the median contracted rate more more aggressively, making it a benchmark to be set aside only when other factors offer a compelling case to set it aside. Providers have waged multiple court challenges, and in February 2022, in Texas Medical Association v. U.S. Department of Health and Human Services, et al., a Texas court struck down the rule’s presumptive reliance on the median contracted rate. An amended final rule issued this summer does not privilege the median contracted rate to the same extent as the prior iteration, but retains it as a default standard unless the physician submits factors the median contracted rate does not account for. More court challenges from providers’ groups are in the offing. While the outcomes may have a major effect on healthcare pricing, in this post I wanted to focus on the law’s effect on consumers.

** Last year, I flagged another potential problem with the NSA’s OON protections: In a tiered network, at what level is an OON facility covered?

Photo by A Koolshooter 

Sunday, December 18, 2022

In Washington State, a public option may get some traction

Cascade Care flowing more freely

When considering how states might improve their ACA marketplaces, it’s often struck me that Massachusetts’ ConnectorCare program, which predates the ACA, would be difficult for another state to replicate. That’s too bad, because ConnectorCare offers simpler and better coverage to enrollees with incomes up to 300% of the Federal Poverty Level than does a conventional ACA marketplace. (At incomes above 300% FPL, the Massachusetts marketplace conforms to ACA design.)

Washington state, however, is tacking toward a marketplace that shares some features with ConnectorCare: partial plan standardization, wraparound subsidies offered at low incomes, and a measure of state-imposed cost control. For 2023, those features may be starting to jell.

Wednesday, December 14, 2022

CMS moves to ease choice overload in the ACA marketplace

Meaningful difference?

In its proposed annual set of rule adjustments* for the ACA marketplace for 2024 released yesterday, CMS proposes strong action against one of the marketplace’s most counterproductive current features — the proliferation of plan offerings insurer with all-but-invisible differences between plans.

In many ACA markets, several insurers “spam” the marketplace, as Duke health insurance scholar David Anderson puts it, in this way. In such markets, picking a plan that will minimize your medical expenditures is like trying to pick the most cost-effective choice in your supermarket’s toilet paper aisle.

Here, for example, are the five cheapest Ambetter silver plans available in Chicago. (Quoted premiums** are for a single 40 year-old with an annual income of $40,000.)

Subscribe now

Here are the next five.

I will spare you the next five. That’s right — Ambetter has put up 15 silver plans in the Chicago marketplace.

As a rule, the cheapest insurers offering the narrowest networks are major offenders on this front. (Almost no major hospitals are in-network in Ambetter’s Chicago plans.) In many markets, their near-clone offerings render competitors’ products nearly invisible at the lowest price points. (That’s not quite the case here, as Oscar’s 12 silver plans and BCBS’s seven are interspersed with Ambetter’s at low price points.)

In the 33 states that use the federal exchange,, as well as in eleven of the 18 state-based marketplaces, plans with a standardized benefit structure — the same deductibles, copays, annual maximum out-of-pocket limits (MOOP) and services not subject to the deductible — are available at each metal level. Squint at the offerings displayed above and you’ll see that the second one is marked “standard.” But standard plans swim in a sea of non-standard competitors. While their benefit design may be optimal for average (not all!) applicants, they have nothing obvious to recommend them — not the lowest premiums, nor deductibles, nor MOOPs, nor standard copays.

With 137 plans on offer, Chicago is not the most chaotic marketplace in the country. In fact, it’s not too far off average. The average number of plans available to marketplace applicants in 2023 is 114, up from 26 in 2019, as CMS notes in its proposal to reduce this riot of unmeaningful choice. In Miami, the nation’s largest ACA marketplace, 224 plans are on offer.

How was this mass spamming of the marketplace allowed to metastasize? In 2015, CMS established a standard to ensure that that plans offered by the same insurer be “meaningfully” different. But the standard was toothless, as Anderson points out, and in advance of the plan year for 2019 the Trump administration’s CMS administrator, Seema Verma, did away with it entirely. The primary rationale, according to CMS’s account in this year’s proposed rule (pg. 230 here), was that the number of insurers participating in the exchange had shrunk in the Trump years (there was real anxiety about the possibility of “bare” rating areas where no insurers would participate). But it also reflected Verma’s was ideological commitment to proliferating choice in every health insurance market (including the choice of medically underwritten, lightly regulated, ACA-noncompliant plans).

While markets had indeed contracted after major premium spikes in 2017 and 2018 (the latter triggered by Republicans’ threatened repeal and the Trump administrtion’s regulatory assault on the marketplace), from 2019 forward ACA markets first stabilized and then expanded, with insurers returning to the marketplace and entering new states. The Biden administration has not reinstated (let alone strengthened) meaningful difference regulations — until now.

For 2024, CMS proposes to take a path forged by some state marketplaces and limit the number of nonstandard plans an insurer can offer in a given market. Specifically, the proposal (as summarized on this fact sheet) is

to limit the number of non-standardized plan options that issuers of QHPs can offer through Marketplaces on the Federal platform (including SBM-FPs) to two non-standardized plan options per product network type and metal level (excluding catastrophic plans), in any service area, for PY2024 and beyond, as a condition of QHP certification.

Theoretically, if an insurer offered three network types (HMO, EPO, PPO) at four metal levels, it could still offer 36 plans in one market. But that will not happen. PPO plans are rare in the marketplace, as are platinum plans. Note in the display above that Ambetter (a Centene brand), probably the most prolific spammer in the country, offers only HMO plans. In fact this regulation, if implemented as proposed, may increase meaningful difference among plans, as insurers seeking to differentiate themselves may be moved to vary their network types.

At present this rule is only “proposed.,” and so subject to a comment period, response, and possible revision or withdrawal. As an alternative, CMS floats a “meaningful difference” standard stronger than the previous one but less restrictive than the main proposal: Requiring that the deductibles offered by one insurer in a given metal level and network type vary by at least $1,000. That’s presumably harder to do than, say, offer a $20 copay for a primary care visit and $10 charge for generic drugs in one plan versus a $25 PCP visit and $5 generic drug charge in an alternative.

The primary proposal would require a major change in business model for some of the largest marketplace insurers — and, I think, a much improved choice architecture for prospective applicants. Here’s hoping that CMS follows through.

Update, 12/14/22: Over on Mastodon, David Anderson warns that considerably more than three network variations per insurer per metal level are conceivably allowable (and in the same exchange, Louise Norris points out that POS (Point of Service) networks are another network type). Putting up multiple networks, however, is much harder (and more substantive) than fine-slicing the odd co-pay to field a new plan. I would speculate, too, that incentivizing insurers to offer more PPOs might in fact be beneficial. Meanwhile, Charles Gaba, also surveying this proposed rule change, deploys the cultural reference that inevitably comes to mind when surveying the proliferation of plans: Robin Williams freaking out in the coffee aisle in Moscow on the Hudson. That’s more fun than my Honey Crisp-to-Mackintosh contrast. Charles also provides useful backstory on meaningful difference regulation, or the lack thereof.

- - -

* The annual rule updates are known as the Notice of Benefit and Payment Parameters. The full proposed rule for 2024 is available here.

** The display is from HealthSherpa, a commercial Direct Enrollment broker that displays all plans in all markets that use 

Saturday, December 10, 2022

Do we want hospitals and doctors to take on risk?

See also on Substack

Getting incentives right is always hard

Merrill Goozner, the former editor of Modern Healthcare, has posted a three-part series surveying twelve years of healthcare payment reform projects seeded by the Affordable Care Act and overseen by the federal Center for Medicare and Medicaid Innovation (CMMI). Part 2 focuses on the one notable success among those projects: The welding in 2014 of Maryland’s state-wide all-payer system to a global budget for each hospital that rises slightly below the inflation rate annually. In 2019 the state further expanded the global budget sphere with a Total Cost of Care Model, which sets a per capita limit on Medicare total cost of care in Maryland and provides incentives for hospitals and doctors to coordinate care, reduce hospitalization rates and meet other quality measures.

Goozner notes that according to CMS analysis, “In the eight years since Maryland began global budgeting, the program has saved the federal government well over $1 billion compared to Medicare spending in other states.”

In Part 3, Goozner leans into the premise that not only uniform payment rates and global budgets are essential to effective healthcare cost control, but also “convincing providers to take on risk is key.” That is, providers must be on the hook if per-patient costs exceed targets.

I have a question about that.

Wednesday, December 07, 2022

Nonexpansion states continue to power ACA enrollment growth

Open enrollment

Ever since ACA marketplace enrollment began rising during the Open Enrollment Period for 2021, enrollment growth has been concentrated in states that have refused to enact the ACA Medicaid expansion.  In nonexpansion states, eligibility for marketplace subsidies begins at an income of 100% of the Federal Poverty Level (FPL), compared to 138% FPL in expansion states, where Medicaid is available below that threshold.  

In OEP for 2021, enrollment increased by 10% in 14 nonexpansion states and marginally decreased, by 0.5%, in expansion states. In OEP for 2022, enrollment was up by 30.5% in 12 nonexpansion states, and up 11.5% in expansion states (Oklahoma and Missouri enacted the expansion in 2021).  Over two years, enrollment in the 12 states that still had not expanded as of OEP for 2022 was up 45.1%, compared to 27.0% for all states. Almost three quarters of all enrollment growth over those two years (73.3%) was in states that had not expanded Medicaid as of OEP for 2022. Nonexpansion states include the behemoths Florida and Texas, which together account for 31% of all marketplace enrollment (in 2022, 4.6 million out of 14.5 million total enrollees).

Now Charles Gaba reports that the pattern appears to be repeating during OEP for 2023, though there's a lot of unevenness and uncertainty in weekly reporting (e.g., the 18 state-based marketplaces, which all serve expansion states, have only reported through Nov. 27, versus Dec. 4 in states). With that caveat, enrollment appears to be up 26.7% in nonexpansion states and just 2.7% in expansion states.

Saturday, December 03, 2022

Income up, premium down? Shopping the ACA marketplace in New Jersey


Garden State, from certain angles

New Jersey is one of 8 states* that supplement federal premium subsidies in the ACA marketplace with state-funded "wraparound" subsidies that further reduce enrollees' costs. New Jersey's supplementary subsidies are funded by a state tax on health insurers implemented in July 2020 after Congress repealed a similar tax assessed nationally.

New Jersey's state subsidies rise with income. That works well in the era of the enhanced federal subsidies created by the American Rescue Plan ACA in March 2020 and extended through 2025 by the Inflation Reduction Act, enacted this past summer.  ARPA rendered benchmark silver coverage free at incomes up to 150% FPL and rising to just 2% of income at 200% FPL (for a single person, about $45/month at an income of $27,180). New Jersey's wraparound subsidies all but zero out premiums for benchmark silver up to 200% FPL, as they add $40 per month for an individual and twice that for a family with income in the 150-200% FPL range. (You can explore plans and prices at different incomes and ages with the plan preview tool at GetCoveredNJ, the state exchange.)

The break points between the state subsidy levels do create some odd effects, however. They run as follows for an individual, with twice as much allocated for a family of two or more.

Thursday, December 01, 2022

Two pending health coverage expansions in New Jersey

A Jersey City view of Manhattan

In coming months, two health insurance coverage initiatives will come to fruition in New Jersey.

First, On January 1, 2023, Phase 2 of a Cover All Kids initiative enacted in 2021 will extend Medicaid eligibility to undocumented children under age 19.

Second, on November 23, the state Department of Banking and Insurance (DOBI) announced its intent to propose a regulation requiring health plans regulated by the state to provide comprehensive coverage for abortion, albeit with an opt-out for religious employers. As with almost all state insurance regulations, this does not apply to self-insured employer plans, which are regulated by the federal government through ERISA.

Both bring to fruition initiatives that were delayed by late changes to legislation. When Cover All Kids legislation passed in  June 2021, the legislature, facing state elections in November, balked at funding coverage for undocumented children in FY 2022 (beginning days after budget passage) and broke the initiative into two phases, outlined below. 

Similarly, in January of this year, the legislature codified the right to abortion in New Jersey but held off from requiring that all health plans subject to state regulation cover the procedure .  Instead, the bill directed DOBI to conduct a study to determine whether such a requirement was warranted. Yesterday (Nov. 30), DOBI released the study, which found that "for a variety of reasons, the availability of insurance coverage for such services is inconsistent." 

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Cover All Kids follows Cover Your Ass

Legislation to make health coverage available to all children in New Jersey has been a longstanding goal of state advocacy groups including New Jersey Policy Perspective (which crunched the numbers in a series of reports, first in 2018 and most recently this past June); New Jersey Citizen Action; and the New Jersey for Health Care Coalition, an umbrella group. 

According to NJPP's most recent estimate, of about 88,000 uninsured children in the state, about 53,000 were eligible for coverage, while another 36,000 were ineligible, either because they exceeded income limits (18,000), were undocumented (16,000), or both (2,000). 

The legislation passed in late June 2021 broke the program into two phases. Phase 1, with $20 million in funding for FY 2022, has aimed to enroll uncovered-but-eligible children by eliminating CHIP premiums (already eliminated on an emergency basis in response to the pandemic in March 2020), eliminating the 90-day waiting period for new CHIP enrollees, and conducting outreach to enroll eligible children. 

Phase 2, beginning in January, will offer eligibility to undocumented children* and a buy-in to children in families with income above the state's current 355% FPL CHIP eligibility threshold. Funding allocated for Phase 2 in the state's FY 2023 budget is about $11 million.

As NJ Spotlight's Lilo Stainton noted at passage

the [bill] passed almost unanimously by the Senate and Assembly and signed by Murphy does not mention undocumented or immigrant children. According to several people involved with the process, the language was changed so that lawmakers — who are all up for reelection this year, along with the governor — did not have to be on record voting for a measure that uses public dollars to fund health insurance for undocumented individuals. 

The bill does, however, establish presumptive eligibility for any child whose family income qualifies her for coverage, without reference to immigration status, and mandates school-based outreach to make the availability of coverage known. And as Stainton pointed out, last spring a DHS Q&A affirmed that "DHS, in collaboration with DOBI, will also engage in intensive planning to develop coverage options for uninsured children who are currently ineligible for NJ FamilyCare, either because of family income or immigration status." That's Phase 2.

According to a presentation to the state Medical Assistance Advisory Council (MAAC) on Oct. 27, the "systems build" -- the infrastructure required to enroll undocumented children in Medicaid and CHIP -- is on track to go live in January. A Nov. 30 presentation to the state Dept. of Human Services' Cover All Kids workgroup (unpublished as yet) reiterates that the system is ready to "go green" in January. A communication campaign should go live this month. Children do not need to have social security numbers to be enrolled.

The stated goal in Phase 1 of Cover All Kids was to cover the 53,000 uninsured children in the state who were eligible for subsidized coverage. The Nov. 30 work group presentation notes that since June 2021, the month prior to  Phase 1 enactment, NJ FamilyCare enrollment for those under age 21 increased by 48,928 as of September 2022. 

Those numbers include adults aged 19-21. Among non-ABD children, from July 2021 through October 2022, enrollment increased by 39,917. During this period, however, a moratorium on disenrollments implemented in response to the pandemic in March 2020 remained (and still remains) in place, and that moratorium has driven enrollment growth throughout the pandemic -- accounting for 84% of Medicaid enrollment growth since February 2020 nationwide, according to the Kaiser Family Foundation. 

In New Jersey, that enrollment growth has steadily diminished as the economy has recovered. Among non-ABD children in New Jersey, enrollment grew 5.6% from January to July 2020, 4.1% from July 2020 to January 2021,  3.0%  from Jan-July 2021, 2.2% from July 2021 to Jan. 2022, and 1.7% from Jan.-July 2022. It's not clear that outreach and enrollment streamlining in Cover All Kids in Phase 1 materially affected total enrollment.

Here's hoping that Phase 2 will insure significant numbers of children who are currently shut out of NJ FamilyCare.  While NJPP estimates that 18,000 undocumented children in the state are uninsured, Stainton reported that other advocates think the numbers could be much higher, and no one knows.

Inevitably, the eventual end of the Public Health Emergency will trigger the disenrollment of far more NJ FamilyCare enrollees, a bit fewer than half of whom are children, than the Cover All Kids program will enroll. About 140,000 thousand more children are enrolled in NJ FamilyCare now than in January 2020; tens of thousands may be determined ineligible when redeterminations restart. 

That's not a knock on Cover All Kids: the moratorium was a good thing, its end is unavoidable, and the state is making a good-faith effort to make the resumption of "redeterminations" as undisruptive as it can. What matters in both efforts -- the PHE unwinding and Cover All Kids --  is effective outreach and enrollment assistance -- to transition some who no longer qualify for Medicaid to subsidized marketplace coverage in the first case, and to keep enrollment of undocumented kids as simple as possible in the second.

To step back, it is a major advance to offer health coverage to any child in the state rendered eligible by family income. Premium-free coverage is currently available to all children in the state in families with income up to 355% of the Federal Poverty Level -- $65,000 for a family of two, 98,512 for a family of four.

Abortion coverage guaranteed, but it may cost you

DOBI's announcement of intent to mandate abortion coverage without restrictions notes:  "Currently, policies are available with either abortion coverage for all abortions or only for cases of rape, incest and the life of the mother." While most plans do not impose such restrictions, the report suggests that the rule is needed as much for communication purposes as to expand access: "While information regarding this coverage is included in the Summary of Benefits and Coverage (SBC) it may not always be clear to consumers what coverage is included in each health benefits plan." A potentially confusing description in one plan is cited by way of example. The report also notes that requiring all plans to offer full abortion coverage may make it easier for facilities that perform abortions to accept all insurance plans.

While the report acknowledges that significant numbers of women may have difficulty paying for an abortion (citing median costs of $560 for medicated abortion and $575 for first-trimester medical abortions), and that for insured patients, deductibles may be a barrier, it is silent as to eliminating or restricting those costs. New Jersey FamilyCare, the state Medicaid program, does cover abortion -- usually at the state's expense, as the federal Hyde Amendment bars federal funding for abortion except when the mother's life is in danger or in cases of rape or incest.  

Leaving out-of-pocket costs untouched probably forestalled any resistance on the part of insurers in the state. DOBI canvassed insurers as to cost impact, and "Carriers estimated a range of zero impact to .1% of premium."

The target date for the as-yet-unpublished Proposed Rule to be implemented is Jan. 1, 2024. But DOBI is asking state insurers and health plans "to make coverage for abortion services, without exceptions, effective for the start of the 2023 plan year on January 1, 2023."

That too is better done than left undone.

Update:, 12/2: Via NJPP, One more measure to reduce the “churn” that plagues Medicaid enrollment: Yesterday, NJ Governor Phil Murphy signed 12-month continuous eligibility for Medicaid into law.


* In the vanguard of of opening Medicaid to the undocumented on the state's own dime is California, which offered Medicaid to undocumented residents first under age 19, then under age 26, then over age 50, and soon, on Jan. 1,  2024, to all undocumented residents eligible by income.

Monday, November 28, 2022

At Don't play ACA tennis on an unmarked court

I have a post up at that's a focused subset of my strategic guide to applying for coverage in the ACA marketplace. It's focused on the importance of knowing key "break points" in the income scale that determines ACA benefits:

Robert Frost said that writing poetry without rhyming was like playing tennis without a net. Applying for ACA coverage without knowing the income levels at which benefits change is like playing tennis without any lines. And when you don’t see the lines, it’s easy to hit the ball out.

This piece is largely though not exclusively concerned with the plight of working people in nonexpansion states at risk of being denied subsidized coverage because they forecast a next-year income below the Federal Poverty Level.  The logical and moral travesty of denying people affordable coverage because they earn too little is exacerbated by the fact that many in this situation could avoid being stiffed if they knew the income threshold they must reach. 

Of all the ACA's various gaps and friction points, none burn me as much as the coverage gap -- and the fact that many fall into through sheer ignorance of its existence. I have a more detailed guide to avoiding it here.

Thursday, November 24, 2022

Against gratitude

Repost from 2011

Okay, not really. But I am personally uncomfortable with overt expressions of gratitude, and while I think this is mainly an emotional limitation on my part, there may be at least the ghost of a reasonable caveat in it.

As a teenager, I took a slightly unsavory pleasure in the science fiction of Robert Heinlein.  He not only entertained but also influenced and repelled me. He once wrote (through a character) that there was something sick at the heart of German civilization, and whether that's true or not, I think that the sickness he condemned clings to him, in a kind of gleeful authoritarianism. At the same time, some fragments of his cracker barrel wisdom stayed with me. One of his quirks, voiced by various favored characters, is an aversion to gratitude. As I recall at this distance, he cast it as a power play of the weak, a form of toadying, or guilt masquerading as love.  I think he's wrong to reduce gratitude to those impulses, though gratitude is certainly alloyed with them.  In a similar vein, though, he ridiculed worship, asking why an omniscient, omnibenevolent  God would require the saccharine praise of human beings. That was the question that really stuck with me. It gets at the heart of gratitude, since worship is mainly an expression of gratitude to God.

Such gratitude is -- should be -- a spontaneous expression of love. That's how those who voice it understand it.  But why does it express itself in "saccharine" praise?  In a Thanksgiving post, Andrew Sullivan's Dish suggested an answer:

Sunday, November 20, 2022

The case for Medicaid-like coverage at high-middle incomes: Alex Sheff of Health Care For All Massachusetts

Line up those ducks for ConnectorCare expansion

My last post focused on a plan in Massachusetts to extend eligibility for ConnectorCare, the state's unique low-cost health insurance program for marketplace enrollees with income up to 300% of the Federal Poverty Level, to residents with income up to 500% FPL. This past July, the state legislature passed a budget provision funding the eligibility extension for a two-year pilot period, but  Republican Governor Charlie Baker vetoed it.

Yesterday I spoke to Alex Sheff, policy director at nonprofit Health Care Access for All Massachusetts, a prime mover of the proposal, about the rationale for focusing new state spending on a relatively affluent income segment -- those with household income ranging from $40,770 to $67,950 for an individual and from $83,5250 to $138,750 for a family of four. HCFA commissioned an actuarial study, conducted by Gorman Actuarial Associates, that sketched out the proposal's parameters. HCFA provides phone help to Massachusetts resident who need help enrolling in health coverage and stresses that its policy proposals derive from trends gleaned from the call line.

To keep background as short as possible here (see the last post for more): ConnectorCare features a standardized benefit design (varying somewhat by income bracket) with zero deductibles, low copays, and annual maximum out-of-pocket (MOOP) cost limits lower than those generally available in a conventional state ACA marketplace. Those costs are modestly lower than in the ACA marketplace at the lowest incomes, but much lower at the 200-300% FPL level.* ConnectorCare premiums range from $0 at incomes up to 150% FPL** to $130 per month for a solo enrollee with income in the 250-300% FPL range.

Friday, November 18, 2022

A valediction: The Twitter School of Public Health

As Twitter may well be on the brink of imploding, I want to preserve for the record -- for my own benefit, if no one else's -- my on-site eulogy thread for its central role in my education about healthcare. The like list for each of the four tweets below is a repository of public health and healthcare policy professionals and journalists willing to engage, with much to give. Look for them on Mastodon, or whatever new Twitterish site gains traction. Or of course on Twitter, if it somehow emerges intact. I'm at and now posting at as well as here.

As I inevitably missed a number of tweeps, I'll add a tweet or two today to make the list as complete as possible. 

I love Twitter. My feed is a thing of beauty. I was never bombarded by trolls and missed the hate. Whatever I know about healthcare was basically via Twitter University & the people and documents it led me to. To exaggerate just a little, my social life is one long DM thread.
Co-Founder Get America Covered, Former CMO, and Amateur Sumo
Sr VP, Kaiser Family Foundation (), Director, Program on Medicare Policy and Sr Advisor to the President
Health care business reporter for  and its Health Care Inc. newsletter. Contact: or DM.
HSR PhD candidate . Doggy dad. Former health policy at Harvard SPH. Former think tanker. Wannabe economist. Opinions my own.
Goal-driven fighter for health and social justice. VP . Former . DC πŸ‘, Michigan πŸ’™πŸ‡±πŸ‡Ή-American, stands with πŸ‡ΊπŸ‡¦
United We Stand M4All For-Profit Health Care is morally abhorrent
Data, Analytics, & Strategy - currently  - alum  - proud kentuckian - πŸ³️‍🌈 (he/him) -
Dad; Haverford, LBJ School, UT Law alum; active health care lobbyist
Husband, dad, wonk with  & runner, preferably on trails. Trying to bring Shalom to the commonwealth. The plural of anecdote is not data.