Thursday, June 30, 2022

In New Jersey, some protections from abortion criminalization and liability

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

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

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

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

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

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


* I earlier summarized a superseded version of this bill.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

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Tuesday, June 28, 2022

Good news rescinded: Online search for health insurance is again a trackless wasteland

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

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

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

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

Saturday, June 25, 2022

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

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

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

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

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

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

Friday, June 17, 2022

Why Manchin may let the ACA subsidy boosts die

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

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

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

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

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

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

Friday, June 03, 2022

Is avoiding overpayment of Medicare Advantage plans beyond U.S. government capacity?

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In the telling of MedPAC (the Medicare Payment Advisory Commission, a Congressional agency), the premise governing the government's creation and support of Medicare Advantage, and predecessor private Medicare programs, has always functioned as a kind of slipknot.

The premise is that by managing care efficiently, private insurers will serve Medicare enrollees more cheaply than does FFS Medicare while improving (or at least not worsening) outcomes -- and also pass a good portion of the savings to enrollees in the form of reduced out-of-pocket costs and additional services.

MA plans do serve enrollees more cheaply, in the sense that they pay out less to providers per enrollee. They also pass about $2,000 in annual savings to members in the form of reduced out-of-pocket costs and added coverage, such as (variously limited) dental, hearing and vision care.

What they don't do -- ever -- is save the government (i.e., taxpayers) money, at least not in an absolute sense. By MedPAC's estimate, covering enrollees through MA currently costs about 104% of the cost of covering the same enrollees through traditional fee-for-service (FFS) Medicare.