xpostfactoid: 2023

Tuesday, December 26, 2023

The commercial para-universe to the ACA exchanges keeps expanding

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Georgia looking peachy to web-brokers

More or less simultaneously with CMS’s announcement that 15.3 million people had enrolled in health plans via HealthCare.gov through December 15, HealthSherpa announced that 6.1 million of those enrollments were effected through its platform.

I’d like to revisit what that market share tells us about how people are getting coverage through the ACA marketplace today. For background, a couple of points from a recent post:

According to a CMS presentation to brokers, in HealthCare.gov states in 2023, 71% of active enrollees (new enrollees and active renewers) were assisted by brokers. 74% of new enrollees — 2.2 million out of 3.0 million — were broker-assisted. HealthCare.gov states accounted for 75% of total enrollment. In total, brokers enrolled 6.8 million of the 9.6 million who actively enrolled. (Of the 2.5 million who were passively re-enrolled, I don’t know how many were broker-assisted, initially, or in plan year 2023.)
In HealthCare.gov states, brokers rely heavily on commercial Direct Enrollment (DE) or Enhanced Direct Enrollment (EDE) platforms, which can process enrollments with subsidies (EDE directly; DE via a redirect to hc.gov for the application processing and then a return to the DE platform for plan selection). 81% of active broker-assistance enrollments are via DE or EDE, according to the CMS presentation. In 2023, more than half of enrollments on HealthCare.gov, excluding auto re-enrollments, were via DE/EDE (5.5 million). By my count of 62 EDE entities, thirteen are web brokers, the rest are insurers. The dominant EDE is HealthSherpa, which just announced that it has already processed 2 million enrollments for 2024. In 2023, HealthSherpa claimed to have accounted for 35% of HealthCare.gov state enrollments; the company seems on track to exceed that share this year.

HealthSherpa’s preferred metric for its market share in states using HealthCare.gov (the federal platform, used by 32 states) is its percentage of active enrollments -- that is, new enrollees and re-enrollees who update their accounts and make a deliberate choice of plan. Those who are passively auto re-enrolled are not credited to the platform that initially enrolled them. If OEP 2024’s auto re-enrollment percentage matches that of 2023, (21%), the 15.3 million enrollment total includes 3.2 million auto re-enrollees. That leaves HealthSherpa with just about a 50% share of active enrollment in HealthCare.gov states through December 15.

A "premium alignment" bill advances in NJ legislature

Will NJ's ACA marketplace glow as goldenly as its rest areas?

In June, I flagged a bill introduced in the New Jersey legislature this past spring, S3896/A5626, that would require silver plans in the state’s ACA marketplace to be priced roughly on par with gold plans in year 1 and on par with platinum plans in year two — reshaping a market in which gold plans have been priced out of reach for more than 98% of enrollees.

The bill’s logic is simple (though it has a complicated back story): On average, silver plans have a higher actuarial value than gold plans, since most silver plan enrollees qualify for the Cost Sharing Reduction (CSR) that attaches only to silver plans.

The bill was abruptly posted early this month for a December 11 hearing in the Assembly Financial Institutions and Insurance Committee, a committee chaired by one of the bill’s lead sponsors, John McKeon. The bill passed out of committee with no amendments on an 11-0 vote with one abstention. That’s first step in a gauntlet of three Assembly and two Senate committees’ consideration.

I testified in favor on behalf of BlueWave New Jersey, a progressive state advocacy group, along with Laura Waddell of New Jersey Citizen Action. My testimony is below.

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TESTIMONY BEFORE SENATE BUDGET AND APPROPRIATIONS COMMITTEE
December 11, 2023

A5626/S3896 would correct a severe pricing imbalance in New Jersey’s ACA marketplace that weakens coverage for middle-income enrollees in health plans offered on GetCoveredNJ.

New Jersey is unique among U.S. state marketplaces in that in New Jersey gold-level plans – the metal choice that offers a coverage level closest to the average employer-sponsored plans – are priced out of reach for almost all enrollees. In New Jersey in 2023, just 1.5% of on-exchange enrollees selected gold plans, versus a national average of 11.9% (see CMS Public Use Files, Note 3). Nationally, according to tables published by the Kaiser Family Foundation, the lowest-cost gold plan premium in each state market is 4% higher than the lowest-cost silver premium in 2024. In New Jersey, the lowest-cost gold premium is priced 37% above the lowest-cost silver plan.

Still growing: OEP 2024 in the ACA marketplace

CMS’s Week 5 snapshot for the 2024 Open Enrollment Period (OEP) in the ACA marketplace shows 7.3 million active enrollments (new enrollments and active re-enrollments) — a stunning 39% year-over-year increase, according to Charles Gaba’s swift compilation. The snapshot is through December 2 for 32 states using HealthCare.gov and through November 25 for 19 state-based marketplaces (SBMs). New enrollment is up 44%, and active re-enrollment is up 37%, per Gaba. (Passive auto re-enrollment is reported at different times by different exchanges, and some SBM auto re-enrollment tallies are included separately in the snapshot.)

For the year-over year comparison, Gaba has helpfully adjusted for an extra day included in the 2023 Week 5 snapshot. His breakdowns for different state groupings — HealthCare.gov states vs. SBMs, and states that have enacted the ACA Medicaid expansion — are below, in simplified format, and followed by a few observations.

OEP Week 5: 2023 vs. 2024

Update: Ending presumed Medicare eligibility for New Jersey's elder ACA marketplace enrollees

I’d like to provide a couple of updates regarding an abuse in New Jersey’s individual market that I wrote about in September (here and here). the issue in brief: in 2023, the state’s standard individual health plan contract stipulated that insurers could presume that enrollees over age 65 were eligible for Medicare unless they provide written proof otherwise. Failing that proof, the insurer would assume Medicare eligibility and act as a secondary payer to Medicare — paying only a small fraction of the enrollee’s bills while collecting a full premium. In 2023, about 9,000 enrollees via GetCoveredNJ, the state’s ACA exchange, were over age 65.

As I reported, in May 2023 CMS issued guidance that unambiguously stated that this practice — presuming Medicare eligibility for senior enrollees and acting as a secondary payer — violated ACA requirements. While New Jersey’s Department of Banking and Insurance did not respond to my queries about the New Jersey policy and the CMS guidance, they did respond to the same queries from an nj.com reporter, Karin Price Mueller, whom I approached about the issue. As they told Mueller, on September 27 DOBI issued a directive (described in Mueller’s paywalled article and in my followup post) to insurers in New Jersey’s individual market instructing them to comply with DOBI’s guidance — that is, cease presuming Medicare eligibility and acting as a secondary to Medicare simply because an enrollee was over age 65.

Where and how do people find plans in the ACA marketplace?

On October 1, 2013, the day the ACA exchanges first opened for business, President Obama promised that the exchanges would enable shopping for health insurance “the same way you shop for a plane ticket on Kayak or a TV on Amazon.”

The wretched dysfunction at launch of the federal exchange, HealthCare.gov (and to varying degrees the state exchanges as well), evident that day, immediately made that promise a laugh line. While two months of technical and political hell ensued before HealthCare.gov was marginally functional, ultimately 7 million people did enroll for 2014 coverage — in line with CMS’s projections — and the image of the insurance shopper sorting through the options on the exchanges took hold. The functioning and messaging on the exchanges improved over time — though the proliferation in recent years of barely-differentiated plans complicated the task of plan selection.

In the ten years since then, I’ve written many posts about the weaknesses and strengths of the exchanges’ functionality and messaging. Do they make it easy to enter a few data points and preview plans and prices (net of subsidy) for the individual viewer? Do they adequately steer those eligible for strong Cost Sharing Reduction to silver plans? In the first cataclysm of the pandemic, did they make Medicaid availability clear? Do their decision support tools (highlighting plans likely to yield the lowest net costs) work well?

All of which might be said to obscure the fact that the unassisted enrollee navigating options via the government-hosted exchanges has become an increasingly rare bird. As insurers have reinvested in the marketplace, brokers selling ACA-compliant plans have proliferated (more than 74,000 were registered in 2023, up from 48,000 in 2019). Since 2021, the Biden administration has replenished the federally funded Navigator enrollment assistance program that the Trump administration had reduced to skeletal form (Navigator funding was cut from $63 million in 2016 to $10 million by 2018, then restored to about $100 million in 2022).

Unwinding to the marketplace in Maryland

In October, CMS reported that of the roughly 5.5 million people disenrolled from Medicaid from the start of the “unwinding” (the end of the pandemic-induced 3-year moratorium on Medicaid disenrollments) through July 31, about 600,000 (592,291) had enrolled in ACA marketplace coverage. Another 95,000 enrolled in the Basic Health Programs that in New York and Minnesota serve lower income enrollees who would otherwise be eligible for subsidized marketplace coverage.

As Charles Gaba notes, these tallies suggest that about 12% of those disenrolled from Medicaid from April to July have enrolled in marketplace or BHP coverage. If that ratio held into November, about 1.1 million of the 10.1 million disenrolled from Medicaid according to KFF’s estimate may have ended up in the ACA marketplace. According to tracking by Georgetown’s Center for Children and Families, as of October, based on the most recent state reports ranging from July to September, net Medicaid enrollment was down by 5.8 million. Assuming that net disenrollment might top 7 million by now, the marketplace may have insured about 15% of the net coverage loss, perhaps a bit higher for adults (as most children who are not insured through employment-sponsored plans end up in Medicaid or CHIP). Here’s hoping a larger percentage of the newly disenrolled find coverage from employers — or already have done so, and have been double-insured since some point after Medicaid redeterminations were paused in March 2020.

While the marketplace is taking up only a modest sliver of those disenrolled from Medicaid, the influx represents a substantial boost to marketplace enrollment. David Stewart, Health Insurance Program Director at the Maryland Area Health Education Center West, which serves primarily rural counties, tells me that since May, appointment traffic for enrollment assistance in his program was more than double normal volume prior to the Open Enrollment Period that began on November 1. To get a sense of how that increase in interest might translate in enrollment I went to the Maryland Health Connection in search of data, and to my surprise, found detailed monthly reports. And indeed, new enrollments from May through September in Maryland in 2023 were more than triple the 2022 total. While enrollment in Maryland as of April 2023 was down 2.7% from April 2022, enrollment as of September 2023 was 13.2% higher than in September 2022.

Walking the crosswalk: CMS seeks to boost CSR takeup

Let us lead you

When full enrollment data for the ACA marketplace in 2023 came out last spring, I expressed concern that the percentage of low-income enrollees forgoing strong Cost Sharing Reduction (CSR) subsidies, which are available only with silver plans, had risen to an all-time high. This in spite of the fact that since March 2021, the two cheapest silver plans in a given marketplace have been available for zero premium for enrollees with income up to 150% of the Federal Poverty Level, and for no more than 2% of income for enrollees with income in the 150-200% FPL range.

The table below shows metal level selection at the two income levels at which “strong” CSR is available in every year since 2017, the peak year for silver plan selection. (A weak version of CSR is available in the 200-250% FPL.)

CSR raises the actuarial value of a silver plan from a baseline of 70% (with no CSR) to 94% at incomes up to 150% FPL and to 87% at incomes in the 150-200% FPL range. Most low-income enrollees who forgo silver plans choose bronze plans, with an AV of 60%; a small but rising number choose gold, with AV of 80% (in about 10 states, gold plans can be cheaper than silver plans).

Virtually the only reason to pass up CSR at incomes up to 150% FPL is if the enrollee wants a more expensive insurer’s silver plan — i.e., in most cases, one with a more robust provider network — and finds it unaffordable. In June, I posited that the percentage of low-income enrollees choosing metal levels other than silver may be rising because of increasing prevalence in the ACA marketplace of ultra-narrow networks. That is, more enrollees may be forgoing CSR with eyes wide open.

Another possible cause of lower CSR takeup may be sheer confusion, as the number of plans on offer in most markets has proliferated to a ridiculous extent, only slightly trimmed back in 2024, thanks to a modest new curb on the number of plans an insurer may offer at each metal level.

In the Open Enrollment Period for 2024, officially kicking off next Wednesday (Nov. 1), we may get some clues as to the extent to which bronze selection at low incomes is due to inadvertence. For 2024, in the 32 states using the federal exchange, HealthCare.gov, CMS has undertaken* to push some low-income bronze plan enrollees into CSR silver:

New for PY 2024, the Marketplace has updated the automatic re-enrollment process to help more consumers take advantage of cost savings. Specifically, the Marketplace will automatically re-enroll certain income-based cost-sharing reduction (CSR)-eligible enrollees who would otherwise be automatically re-enrolled in a Bronze plan into a Silver plan. This automatic re-enrollment will apply only for consumers who do not make an active plan selection on or before the deadline for January 1 coverage, and only if a Silver plan is available in the same product type, with the same provider network, and with a monthly premium after premium tax credits that is no greater than that of the Bronze plan into which they would otherwise be automatically re-enrolled.

Those in “dominated” bronze plans who log on and re-enroll actively “will see the Silver plan highlighted in the online shopping experience if they return to HealthCare.gov on or before December 15 to review their options.” So there are two layers to this effort: a cross-walk (with opt-out) for those who remain passive, and a strong nudge for those who log on and newly assess available plans.

State exchanges may implement the CSR crosswalk if they so choose. Covered California did so beginning in plan year 2022, and Massachusetts auto-enrolled some enrollees in ConnectorCare (silver plans further enhanced by supplemental state subsidies) in 2023.

How many enrollees may be affected by the CSR cross-walk?

For a silver plan premium to be “no greater than” that of the bronze plan from which the enrollee will be switched out, the silver plan must be available for zero premium, as is the case for the two cheapest silver plans in every marketplace for enrollees with income up to 150% FPL. In a few cases, the cheapest plan in a given market may be zero premium at incomes above 150% FPL, and enrollees in a bronze plan from the same insurer with the same network may be auto-switched. For the most part, however, the new policy affects enrollees with income below 150% FPL.

In 2023, of the 5.6 million OEP enrollees in HealthCare.gov states with income in the 100-150% FPL range,** 1.1 million selected bronze or gold plans. Among re-enrollees (as opposed to new enrollees) in that income range, 3.0 million enrolled actively and 1.0 million were auto re-enrolled. For the three quarters of re-enrollees who actively re-enroll, a sharp prompt will push them toward silver if a silver plan from the same insurer with the same network is available at zero premium.

In 2023, the total number of re-enrollees in HealthCare.gov states (9.2 million) was about 90% of the enrollment total for 2022 (10.3 million). We might therefore expect some million non-silver current enrollees with income under 150% FPL to re-enroll (many of them will have enrolled after OEP for 2023, as marketplace turnover is constant, and enrollment is available year-round for those with incomes up to 150% FPL). The wild card is how many of those bronze or gold plan enrollees are in plans from insurers that offered the cheapest and second-cheapest silver plans in their area — and with the same network as the bronze plan the enrollee chose.

We’ve been here before

Covered California, the largest of the state exchanges, enacted the crosswalk to CSR silver in 2022, estimating*** that 32,000 bronze plan enrollees could get a $1/month silver plan from the same insurer (no plans in CA were $0 premium at that time). I looked at the results in April 2022. Silver plan takeup at incomes below 150% FPL ticked up modestly, by about 3 percentage points from 2021 — and that in the year when silver plans became free at incomes up to 150% FPL. In California in February 2022, 16,990 subsidized enrollees out of a total of 258160 with income in the 138-150% FPL range (6.6%) selected bronze plans. In June 2021, the nearest date for which I can find a comparison, 20,270 subsidized enrollees out of 215,490 with income up from 150-200% FPL (9.4%) were enrolled in bronze. In 2023, bronze selection among the subsidized crept back up to 7.9% (19,080 out of 241,350).

At the time of that estimate, in June 2021, only about 28,000 bronze plan enrollees enrolled via Covered California (including those with income under 138% FPL) had incomes under 150% FPL. I presume the analysis found that a considerable number of the 85,550 subsidized bronze plan enrollees in the 150-200% FPL income bracket could also get a free silver plan — possible, as there has been a wide price spread between cheapest and second-cheapest silver in some California rating areas in some years. From 2021 to 2022, the percentage of subsidized enrollees in the 150-200% FPL income bracket in California who selected bronze plans dropped from 19.1% to 15.2%, and held steady in 2023 at 15.1%. Again, though, subsidized silver plan premiums dropped dramatically from 2021 to 2022, thanks to the subsidy enhancements in the American Rescue Plan Act.

Effects may be stronger in HealthCare.gov states, as a much higher percentage of enrollees have income below 150% FPL, thanks to the nonexpansion states. Also, I don’t believe that Covered California implemented the heightened prompt to choose CSR silver for those who actively re-enroll. On the other hand, Covered California’s shopping tool does “default to silver” — that is, show silver plans at the top of the list of available plans — when silver plans are available for zero premium.

Do brokers need a prompt?

When assessing the possible impact of the CSR crosswalk (and strong nudge for active enrollees), it’s important to keep in mind that most ACA marketplace enrollees do not act alone, and many enrolled in the HealthCare.gov system never look at a HealthCare.gov screen. 71% of active re-enrollees in HealthCare.gov states were assisted by brokers ~~or nonprofit enrollment assisters~~ in 2023, as well as 58% in California and 76% in New York. A large majority of brokers use commercial e-broker platforms (enabled for “Direct Enrollment” or “Enhanced Direct Enrollment”), not the HealthCare.gov interface. HealthSherpa, the largest e-broker, alone accounted for 35% of enrollments in the HealthCare.gov system in 2023. The e-brokers are required, however, to follow form with HealthCare.gov in the CSR crosswalk, and to provide the enhanced “nudge'“ toward silver for active re-enrollees.*** Whether a significant number of brokers need such prompts to avoid placing their clients in dominated plans is an interesting question.

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* A crosswalk to silver from dominated plans was proposed in a 2021 article by David M. Anderson, Petra W. Rasmussen and Coleman Drake.

** In the ten states that have not yet enacted the ACA Medicaid expansion (soon to be nine, as NC is expanding on Dec. 1), all of which use HealthCare.gov, eligibility for ACA marketplace subsidies begins at 100% FPL. In states that have enacted the expansion, eligibility begins at 138% FPL; below that threshold, enrollees are eligible for Medicaid. A large majority of enrollees with income below 150% FPL are in the nonexpansion states, most of them in Florida and Texas.

138,000 enrollees in HealthCare.gov states in 2023 had incomes below 100% FPL. Legally present noncitizens subject to the 5-year federal bar on Medicaid eligibility are eligible for marketplace subsidies even if their income is below 100% FPL. I have left enrollees with income below 100% FPL out of the HealthCare.gov calculations above because a fairly large percentage are subsidy-ineligible.

*** HealthSherpa, which like many platforms will foreground silver plans for user eligible for strong CSR, provides this screen for such enrollees if they opt for another metal level:

Thursday, October 05, 2023

Enrollment at ages 65 and up in the ACA marketplace has nearly tripled since 2017

Medicare, no -- coverage, yes?

My last two posts (1, 2) investigated a practice, first countenanced and then codified by New Jersey insurance regulators, allowing ACA marketplace insurers to denude enrollees over age 65 of most of their coverage by presuming them eligible for Medicare unless they proved otherwise, e.g., by applying for Medicare while knowing they were ineligible. (Seniors who have not paid U.S. payroll taxes for at least 10 years or not been married to someone who has, e.g., many older immigrants, are not eligible for free Part A Medicare and are eligible for ACA marketplace subsidies if their income qualifies them.) Prompted by resulting mainstream news coverage, NJ’s Department of Banking and Insurance (DOBI) has ordered individual market insurers to cease this theft of coverage.

As DOBI disclosed that individual market insurers in the state have been presuming Medicare eligibility in senior enrollees at least since 2016, I took a look at how many enrollees might have been affected. Along the way, I noted a statistical oddity: by 2023, enrollment in the over-65 age group had more than doubled since 2017, from 3,943 to 8,929 (a precise age breakout is not provided for 2016). Total enrollment in all age groups in the state increased just 16% from 2017 to 2023, from 295,067 to 341,901.

That prompted me to look at national enrollment in the 65+ age group over the same span. Enrollment in this (small) age group has almost tripled since 2017, while overall enrollment is up 34%, from 12.2 million in 2017 to 16.4 million in 2023. The data source in the table below is CMS’s State-level Public Use Files.

NJ DOBI responds: No more elder abuse in the ACA marketplace

My last post spotlighted a form of elder abuse in New Jersey’s ACA marketplace. The state’s Individual Health Program (IHC) allows or requires insurers in the individual market to presume that enrollees who are over age 65 are eligible for Medicare — unless the enrollee provides proof positive otherwise.

If such proof is not furnished (at least one insurer, AmeriHealth, requires a letter from the Social Security Administration, which in turn requires applying for Medicare)— the insurer pays the enrollee’s claims only as a secondary payer, presuming that Medicare will pay the bulk of each claim. That leaves the enrollee on the hook for the bulk of every medical bill she incurs, rendering the insurance policy’s statutory out-of-pocket limit essentially void. NJ DOBI has been allowing insurers to do this since 2016, and in 2023 ratified the practice, stipulating in the standard policy policy form that the insurer “will assume the Covered Person is Eligible for Medicare and pay secondary benefits as set forth in this section unless the Covered Person provides written documentation that proves the Covered Person is not Eligible for Medicare” (p. 126)

CMS guidance issued on May 24, 2023 flatly forbids this practice, as CMS told me in response to a query, adding “CMS has been in contact with the New Jersey Department of Banking and Insurance (NJDOBI) regarding this issue. We recommend contacting NJDOBI for further information.” The May 24 guidance states that an ACA-compliant individual market insurer “may not limit or exclude coverage based on the theoretical possibility of an individual’s enrollment in other coverage… regardless of whether an individual is (or is presumed) eligible for Medicare.”

NJ DOBI did not respond to my repeated requests for comment on the state insurers’ apparent continuing violation of the CMS guidance — under color of state regulation. But an investigative reporter at NJ.com and the Star-Ledger, Karin Price Mueller, got on the case. And DOBI did respond to Mueller. Thus pushed, they are apparently ending the practice — effective yesterday:

“In light of the possible confusion in the market, the department (Wednesday) issued its own directive to carriers in the individual market — both on and off the marketplace — to ensure they are following the (Medicare guidance), which falls under the `Conformity with Law’ provision of the standard individual health benefits plans,” spokeswoman Dawn Thomas said.
The agency has told all insurance carriers to review the benefits of individuals who are 65 and older and enrolled in plans through GetCoveredNJ “to ensure that the policyholders are receiving the appropriate coverage, and that all coverage is consistent with the applicable Federal Guidance,” she said.
Thomas also said DOBI is reviewing how consumers may have been affected.
“Specifically, it is requiring that all carriers provide information on how the rule was implemented, including any requirements placed on consumers 65+ years of age, and what specific documentation may have been required for both on and off marketplace consumers,” Thomas said.
And, she said, the agency will make sure the language is clear when the 2024 plans roll around.
“If GetCoveredNJ determines a consumer eligible for a marketplace plan, the consumer should remain eligible and get the full benefits of the policy selected,” she said.

If those promises look a little soft to jaded eyes, other language in DOBI’s statement to Mueller, which she shared with me, was less equivocal:

On May 24, 2023, the Centers for Medicare and Medicaid Services (CMS) released guidance to insurers that demonstrated to the department that the IHC board’s rule change was not in compliance with CMS rules. Therefore, in June, the department informed carriers that the CMS guidance will govern the individual market and made clear the department accepted CMS’ position.

Apparently, that June bulletin changed nothing. Now, pending enforcement, this longstanding abuse of the fundamental ACA promise (quality affordable comprehensive coverage) appears to be ended going forward. But “going forward” points to a problem, which Mueller gave me a chance to articulate:

“I’m delighted to learn that DOBI is now acting swiftly to end this abusive practice — allowing Obamacare insurers to strip older plan members of most of the coverage to which they’re entitled,” Sprung said. “Now DOBI needs to dig in and find out whether there are people who have been subject to this practice for years who may have been saddled with provider bills that their insurer should have paid — and if so, to make sure those wrongs are righted.”

DOBI clarified to Mueller that NJ individual market insurers have been allowed to presume over-65 enrollees eligible for Medicare and act as a secondary payer at least since 2016. I have viewed bills from 2022 that reflect that practice. So there is compensatory work to be done. In 2023, almost 9000 enrollees through GetCoveredNJ were over 65. How many have been enrolled, and shorted coverage, in seven or more years?

Why 2016? In that year’s annual Notice of Benefit and Payment Parameters (NBPP) for the ACA marketplace, clarified that a marketplace enrollee who turns 65 during the plan year and enrolls in Medicare can maintain her marketplace plan, though she would lose eligibility for subsidies. A Medicare enrollee can even renew a marketplace plan if that plan does not change, i.e. if a new “contract of insurance” is not required. Why anyone would want to pay full freight for a marketplace plan (at least $800+/month in New Jersey in 2023 for an over-65 enrollee) when they are enrolled in Medicare is hard to fathom, but it can be done.

While finalizing this rule, CMS noted, “Several commenters expressed concerns that individuals enrolled in Medicare and those who are eligible for but not yet covered by Medicare present a significant burden to the single risk pool” (p. 94068). That is very likely the concern that New Jersey’s individual market insurers brought to regulators to get permission to presume elder enrollees eligible for Medicare. Ever since (if not before), in at least some if not virtually all cases, they have been getting full premiums for enrollees over age 65 while paying only what Medicare is presumed not to pay on claims.

Hats off to Karin Mueller, who was able to get what I could not from DOBI.

New Jersey's Department of Banking and Insurance lays a trap for elderly enrollees in the state's ACA marketplace

Filling out an application for subsidized health insurance in the ACA marketplace can be straightforward — or not so straightforward. If the exchange’s “trusted sources” of information do not readily identify you, uploading proof of identity nd getting it accepted can be a…process (especially in a family with mixed immigration status). If you are self-employed and your income is not obviously reflected in regular monthly payments, documenting your claimed income and having the documentation accepted can also be a multi-stage process.

That said, once your documentation is accepted and your monthly subsidy is assessed, you are good to go, right?

Not always. Not in New Jersey, anyway, where the insurer can come after you for additional documentation — and potentially reduce your coverage to a shadow.

Meeting the minds of Chinese students in Xi'an

If you’ll excuse an off-topic post, a graduate school friend of mine (circa 1990…), Wendy Bashant, has published a truly memorable account of her year teaching at a “Chinese MIT” - interrupted but not derailed by the pandemic. The book opens a real window into the minds of Chinese students — elite but not necessarily privileged. Their writings, liberally excerpted, reflect a huge variety of childhood experiences in a country that contains multitudes. The book is The Same Bright Moon: Teaching China’s New Generation During Covid. My Amazon review is below.

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After decades serving as a dean at various U.S. colleges and universities, Wendy Bashant was burned out and ready to return to her teaching roots and meet the minds of students in a distant land. With her equally willing physician husband, she landed in mid-2019 at Jiaotong University in Xi'an, a megacity in central China, tasked with teaching American literature and writing at a school she describes as MIT-equivalent. In the course of a teaching year, she also experienced a pandemic, Chinese-style: emergency travel through a ghosted airport; swift, strict lockdown; partially successful experiments with remote teaching; and gradual return to something like normalcy under a regime of strict, unquestioned rules.

A passionate and empathic teacher, Bashant managed to form deep connections and spur original thought from a significant number of her students. She shares their reflections on their childhoods, their aspirations, and how they think the world works through conversation (in-class and one-on-one) and through the students' essays and poems. The writings and conversations offer a series of truly illuminating windows into young Chinese adults' varied experiences and mindsets. One reality that comes through very clearly is that China contains multitudes: the students' home environments range from rural villages to megacities (and often to both, as one recurring pattern is parents working in the city while their children live with grandparents in the home village), their parents from professionals or government officials to laborers with minimal education. The students have lived through decades of rapid change; often their parents' experience is radically different from their that of their grandparents, and the students’ essays describe these discrepancies.

Bashant develops a rather lovely framework to encompass this diversity, adapting the (fading) Chinese tradition of the "hundred family jacket," in which local families donate embroidered cloth patches to a newborn's family, to be sewn onto a jacket that's worn at festivals. Bashant's "jacket" is a map of China in which she places various students, chapter by chapter (initially, as a device to remember their names), as their narratives reflect the diverse regions and cultures in which they grew up, from open plains near Mongolia to small dark grandparents' apartments in megacities. This works, because the students' essays do take us to these places.

While these students have been studying English since they were 5 (Bashant tells us), English is a second and very foreign language. The essays reflect this -- along with, to my ear, a sometimes reflexive reliance on authority -- governmental, parental, commercial -- to frame the writer's thoughts. The book's drama comes in large part from students' efforts -- sometimes stunningly successful -- to break out of conventional wisdom and think for themselves.

Bashant gives a vivid account of the physical privations and social pleasures of living in a 60s-era Chinese apartment block that houses the university community, ranging from professors to custodians. The Bashants are showered with food, invited to residents' family homes outside of town, helped through logistical difficulties. You have to credit their resilience and willingness to embrace new experience. I would have liked to hear a bit more about the experience and perspective of husband David, who worked as a tutor and translator of scientific texts at the university.

While antagonism between China and the U.S. was not as intense in 2019 as now, it was rising quickly, and turbo-charged during the pandemic as Trump unleashed his incontinent verbal fury at China. The Bashants are asked constantly about Trump and about American attitudes toward China. Bashant's students voice some negative perceptions about Americans and America, but these do not seem to impede their relationship with her -- at least not for the students whose experience she chronicles and records. Bashant does not really engage politically (there would be severe constraints on doing so in China, I imagine). There are no discussions of Trump either as appalling anomaly or true expression of the worst American traditions. Nor does Bashant engage with escalating authoritarianism in China. Indeed, she seems receptive to positive aspects of Chinese governance -- that is, the tight restrictions and preventive procedures (many of which proved to be mistaken epidemiologically) in the first months of the pandemic.

That said, The Same Bright Moon fulfills the premise of its title: that minds can meet across cultures, that we can process the common elements of human experience very differently, while communicating and gaining some understanding of these differences; that on an individual level at least, empathy can bridge continents.

In Massachusetts, ACA Marketplace enrollees with income up to 500% FPL get affordable platinum coverage

A rickety but serviceable connector

In a two-year pilot program beginning in 2024, Massachusetts has extended eligibility for ConnectorCare, the state’s alternative to a standard ACA marketplace that features standardized plans with low out-of-pocket costs, to applicants with incomes up to 500% of the Federal Poverty Level (FPL), or $72,900 for an individual in 2024. Since the ACA marketplace’s 2014 inception, ConnectorCare has been the (only) option for applicants with income ranging from 138% FPL, the Medicaid eligibility threshold, to 300% FPL. The extension means that almost all subsidy-eligible marketplace enrollees will get a standardized ConnectorCare plan, at least through 2025.

All insurers who offer plans in Massachusetts’ regular ACA exchange (available through this year to enrollees with income over 300% FPL) will be required for the first time to offer ConnectorCare plans in 2024. Importantly, since ConnectorCare plans are in a single risk pool with the insurer’s offerings in the higher income marketplace, extending eligibility to 500% FPL should not cannibalize the Health Connector market plans offered to enrollees with income above that threshold. That is, the extension should not drive up premiums for those who get no subsidy or minimal subsidy.

The Massachusetts legislature included such an extension in its budget passed in August 2022, but Republican Governor Charlie Baker vetoed it. Last month, Democratic Governor Maura Healy, inaugurated this past January, signed the eligibility extension into law.

Could the FTC's proposed ban on noncompete clauses curb private equity incursions in healthcare?

“Then,” I cried, half desperate, “grant me at least a new servitude!”

The corruption of U.S. healthcare by the profit motive reaches a kind of apotheosis in the incursions of private equity into industry subsectors (hospice, nursing homes) and targeted physician practice specialties — e.g., the PEAR specialties (pathology, emergency, anesthesiology, radiology), dermatology, ophthalmology gastroenterology, orthopedics, and others. It’s common PE practice to load an acquisition with debt and then laser-focus on cutting costs and maximizing revenue.

In Private Equity and the Corporatization of Health Care, a paper posted in March 2023 (with a 2024 publication date in the Stanford Law Review), Erin C. Fuse Brown and Mark A. Hall acknowledge that “it remains unclear whether private equity investment is fundamentally more threatening to health policy than other forms of acquisition and financial investment,” but at the same time assert:

Even if PE investment in health care poses risks that are not unique to PE, it appears to heighten those risks by being more adept or ruthless at identifying profit opportunities and economies of scale among previously fragmented providers, consolidating physician specialty markets and raising costs as they go.’

Retention in ACA marketplace continues to improve

CMS just dropped its Effectuated Enrollment Early 2023 Snapshot and Full Year 2022 Average — a document I’ve been eagerly awaiting.

To my eye, the main takeaway is that in the second full year of enrollment after the American Rescue Plan Act (ARPA) boosted ACA marketplace subsidies, retention and off-season enrollment remain impressive. That’s reflected in average monthly enrollment for 2022 as well as early effectuated enrollment for 2023.

Year-over-year, from 2022 to 2023, early effectuated enrollment (enrollment as of the first month when premiums were due for all who selected plans during the Open Enrollment Period, or OEP) increased by 13.4% — more than the 12.7% year-over-year increase in plan selections during OEP, as the percentage of OEP plan selectors who effectuated enrollment reached an all-time high. That increase in retention of OEP signups continues a long-term trend.

The table below shows the ratios of early effectuated enrollment and average monthly enrollment to OEP signups since 2016.

ACA Marketplace Retention, 2016-2023

Sources: CMS Public Use Files and Effectuated Enrollment Snapshots

Limit short-term health plans to a...short term? Buyers and sellers speak out

My last post considered a rule proposed by the Departments of Health and Human Services, Treasury and Labor to restore a three-month term limit on so-called Short Term, Limited Duration (STLD) health plans. Those plans are currently available for year-long terms in some states, renewable for up to three years.

My main point was that if the removal of the ACA’s original income cap on subsidies by the American Rescue Plan Act (ARPA), extended through 2025 by the Inflation Reduction Act, is not further extended, STLD plans will once again be the only viable option as of 2026 for some modestly affluent non-elderly people who lack access to employer-sponsored or other insurance. For that reason, I suggested that the proposed rule automatically sunset if the income cap on subsidies returns.

To review briefly: STLD plans are not regulated as insurance and not compliant with ACA rules for individual health plans. They are medically underwritten, do not have to cover the ACA’s Essential Health Benefits (drug and mental health benefits are often excluded or very limited), are not subject to the balance billing protection provided by the No Surprises Act, and generally cap benefits at $1 million or $2 million. Some but not all STLD plans have provider networks (and so some balance billing protection) and annual out-of-pocket caps for covered benefits.

For further perspective I turned to the comments submitted so far in response to the proposed rule. There are just 43, from a mix of consumers and brokers (as opposed to more than 25,000 for the FDA’s proposed ban on most noncompete agreements). All, perhaps not surprisingly, ask that the allowable STLD term not be shortened as proposed.

A caveat about curtailing short-term limited duration health plans

It’s generally a good thing when the Biden administration repeals a Trump-era administrative rule. Under current ACA marketplace conditions, a rule proposed by HHS, Treasury and the Department of Labor to restore a three-month term limit on so-called Short Term, Limited Duration (STLD) health plans is a good thing. In a rule finalized in August 2018, the Trump administration extended the allowable duration of such plans to a year, renewable for up to three years, creating an alternative market to the ACA-compliant individual market.

STLD plans by legal definition are not insurance and not subject to regulation by the ACA, HIPAA, the No Surprises Act, or the law mandating parity between physical and mental health coverage (MHPAEA). STLD plans 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. These plans do not have to cover the ACA’s Essential Health Benefits and often exclude drug coverage and mental health care. They often have no provider network - -instead, they set their own rates in payment to medical providers and thus leave enrollees subject to extensive balance billing — which is still possible, as these plans are not subject to the No Surprises Act, which began protecting people in ACA-compliant plans in 2022. (In many markets, however, United HealthCare does offer STLD plans that have a provider network.)

For the Trump administration, which inherited Republicans’ dead-end opposition to and demonization of everything ACA, STLD plans represented a kind of ideal, harking back to the Shangri-la of the pre-ACA individual market, in which plans without restrictive provider networks (and with coverage limitations similar to those of STLD plans) cost lucky, healthy enrollees considerably less than unsubsidized ACA-compliant plans would later cost. Seema Verma, Trump’s CMS director, lionized “choice” — a market teeming with lightly regulated options offering very partial coverage — and that is what the Trump administration created. Verma even floated ACA “waiver concepts” inviting the states to seek approval for providing federal subsidies for ACA-noncompliant plans.

Part D party! The Biden administration boosts a boast

"The IRA saved me $103 in Part D OOP!"

The Biden administration is rightly broadcasting the out-of-pocket savings that the Inflation Reduction Act will yield to enrollees in Medicare Part D prescription drug plans. That said, the headline claim in the White House fact sheet turned my head:

New data shows nearly 19 million seniors and other Medicare beneficiaries will save an estimated $400 per year in prescription drug costs because of President Biden’s out-of-pocket spending cap

Thanks to President Biden’s Inflation Reduction Act, out-of-pocket spending on prescription drugs at the pharmacy will be capped at $2,000 per year for Medicare Part D enrollees starting in 2025. Today, the Department of Health and Human Services (HHS) released data showing that 18.7 million (or 1 in 3) seniors and people with disabilities who are enrolled in Part D plans will save, on average, $400 per year when the $2,000 cap and other Inflation Reduction Act provisions go into effect in 2025. And some enrollees will save even more: 1.9 million enrollees with the highest drug costs will save an average of $2,500 per year starting in 2025. Overall, the law’s Part D benefits provisions will reduce enrollee out-of-pocket spending by about $7.4 billion annually.

Is there a pithy way to say that averages smooth out a lot of variation? Savings from the IRA’s changes to Part D are (appropriately) weighted toward a few million enrollees with really heavy out-of-pocket exposure.

Trading out-of-pocket cost protection for network adequacy in the ACA marketplace

Bronze sometimes works

In a prior post, I raised concern that the percentage of ACA marketplace enrollees eligible for strong Cost Sharing Reduction (CSR) subsidies who access that valuable benefit by selecting silver plans has not increased significantly since the American Rescue Plan Act of March 2021 made benchmark silver plans much more affordable. (CSR is available only with silver plans.)

This despite the fact that ARPA rendered the benchmark (second cheapest) silver plan free for enrollees with income up to 150% of the Federal Poverty Level and costing no more than about $45/month for a single enrollee with income up to 200% FPL. While CSR takeup did improve modestly in 2022, it slipped in 2023 — to its lowest level ever for enrollees with income up to 150% FPL (80.2%) and to its second-lowest for enrollees in the 150-200% FPL range.

In New Jersey's ACA marketplace, a "premium alignment" bill would turn gold plan pricing on its head

Gold skies, but almost no gold Obamacare, in New Jersey

On May 22, New Jersey state Senator Joseph Vitale, chair of the Health, Human Services, and Seniors Committee, introduced a bill (S3896) that mandates “premium alignment” — a.k.a. strict silver loading — in the state’s individual and small group health insurance markets. That is, insurers would be required to comply with the letter of the ACA statute that requires them to price plans at different metal levels in strict proportion to the actuarial value of each metal level. (Actuarial value refers to the percentage of the average enrollee’s costs the plan is designed to pay for, according to a formula promulgated by CMS.)

In effect, mandating that strict proportionality means pricing gold plans below silver plans with the same network (or, in New Jersey in the first year after enactment, roughly at par with silver plans, as explained below). That’s been the case since 2018, the first plan year after Trump cut off direct reimbursement of insurers for the value of Cost Sharing Reduction (CSR) subsidies, which attach to silver plans only. The cutoff induced most states to direct insurers to price CSR into silver plan premiums only, a practice that came to be known as silver loading. CSR raises the actuarial value of a silver plan to a roughly platinum level** for enrollees with income up to 200% of the Federal Poverty Level — — that is, for about 80% of on-exchange silver plan enrollees nationally (though far less in New Jersey, as discussed below). In 2023, the average actuarial value among silver plan enrollees on all ACA exchanges was about 87%, compared to 80% for gold plans.*

The other side of compressed premium spreads

Wide spreads have benefits and risks

As the ACA marketplace suffered steep premium increases and Republican political assault in 2017, one of the hardest-learned lessons for policymakers was that action to reduce baseline premiums (full retail cost before subsidy) would hurt more enrollees than it helped and reduce total enrollment.

That is, reducing retail premiums also reduces premium subsidies, and in particular, reduces price spreads between the benchmark (second cheapest) silver plan, which determines the size of subsidies, and plans cheaper than the benchmark, making those plans more expensive net of subsidy.

Can the risk adjustment gravy train for Medicare Advantage be slowed or stopped? A conversation with Richard Kronick

This past March, as in many Marches previous, MedPAC’s annual report to Congress found that a) the federal government is paying Medicare Advantage plans more than it would pay to cover the same enrollees in traditional, fee-for-service Medicare; b) that excess payment is widening (from 104% in 2022 to 106% this year); c) almost all the excess payment (almost 5 percentage points) stems from a risk adjustment system that enables MA plans inflating their enrollees’ risk scores, and d) the risk score gap between MA enrollees and FFS enrollees is also widening.

Sum it all up, and risk adjustment stands out as the engine by which MA is swallowing FFS Medicare. 2023 is the first year in which more Medicare enrollees are enrolled in MA than in FFS. MedPAC raises the possibility that in some counties at least FFS may no longer serve as a reliable benchmark for CMS’s capitated payment rates to MA plans. Those benchmarks - -which, according to MedPAC, also require adjustment — are the tether that hold MA provider payment rates close to those set by FFS Medicare. That tether is basically the only effective control on provider payment rates.

A modest proposal: Revenue-neutral risk adjustment in MA

MA insurers’ inflation of their enrollees’ risk scores is so obvious and pervasive that CMS is statutorily required to shave a minimum of 5.9% off of MA risk scores. It’s not enough. MedPAC estimates that in 2022 MA risk scores exceeded the scores that MA enrollees would be ascribed in FFS Medicare by 10.8%. In November 2021, Richard Kronick, a former CMS official and current professor at UCSD, and F. Michael Chua, also of UCSD, pegged the MA coding excess at 20% — almost double the MedPAC estimate — and estimated that the resulting overpayments would total $600 billion from 2023 to 2031 if not adjusted.

High auto re-enrollment rates in the SBMs, revisited

Sometimes, you can do worse

My last post flagged dramatically different rates of “active” health plan renewal and autorenewal in the 33 states using the federal ACA marketplace, Healthcare.gov, compared to the 18 states (including D.C.) that run their own marketplaces. This post take a second run at whether the high autorenewal rates in the state-based marketplaces (SBMs) are problematic.

In HealthCare.gov (the “FFM,” or federally facilitated marketplace), 72% of renewals in the Open Enrollment Period 2023 were active, meaning the enrollee logged into the marketplace, updated their personal information, and affirmatively chose either to remain in last year’s plan or choose a new one. In the SBMs, just 28% of renewals were active; 72% of returning consumers were auto re-enrolled.

Auto re-enrollment can be dangerous, because 1) enrollees’ personal circumstances that affect subsidies — their income and the family members seeking coverage in the exchange — may change; 2) an enrollee’s current plan’s premium may rise in the coming year; and 3) most unpredictably, the benchmark (second cheapest silver) plan against which subsidies are set can change. If the coming year’s benchmark plan has a lower premium than the current’ year’s, subsidies shrink, since enrollees pay a fixed percentage of income for the benchmark plan. If the enrollee’s premium rises and the benchmark falls, it’s a double whammy.

I therefore presented high auto re-enrollment rates as a troubling feature of the SBMs, and maybe in some cases they are. But there are also differences in SBM and FFM practice that may make auto re-enrollment more viable for more enrollees in the SBMs.

Enrollees get better information earlier in at least some SBMs

Most strikingly, independent health insurance broker Sheron Sidbury, who serves clients both in Maryland, which runs an SBM, and Virginia, which uses HealthCare.gov, explained in a lengthy Twitter exchange that in Maryland, plans and prices are posted on October 1, well in advance of the Nov. 1 kickoff of Open Enrollment. In Maryland, Sidbury explains:

Do the ACA's state-based marketplaces have an auto re-enrollment problem?

Enrollment should be active

It has been clear since plan offerings were posted for the ACA marketplace’s second Open Enrollment Period (OEP) in fall 2014 that “auto re-enrollment” can be dangerous for enrollees.

If marketplace enrollees take no action during OEP — declining to log on and update their income and other information relevant to subsidy eligibility and subsidy size, and review available plans — HealthCare.gov or the relevant state-based marketplace will auto-enroll them in their prior year plans, tapping the IRS and other data sources to update income and other personal information. If that plan is no longer offered, the marketplace will “crosswalk” the enrollee into the nearest equivalent, e.g., a plan by the same insurer in the same metal level. If the marketplace determines that the enrollee is no longer subsidy eligible, it will enroll her with no subsidy, exposing her to hundreds of dollars per month in premiums (one month, if she fails to pay any premium in the new plan year). Disenrollment occurs only if the person logs on and initiates it — or fails to pay the monthly premium when the new plan year begins.

Even when the enrollee’s income and family composition are essentially unchanged, remaining in last year’s plan (or a substitute into which one is crosswalked) without examining this year’s options can lead to major new expense. The plan’s premium may rise significantly. Worse, if another insurer (often a new entrant into the local market) undersells last year’s benchmark plan — the second cheapest plan, against which subsides are set — subsidies may shrink, hitting an enrollee who stays in a plan with a rising premium with a double whammy. The media was full of such stories in the fall of 2014. I told one myself, about a family of 3 in Philadelphia whose premium for a silver plan would have gone from $0 to $196 per month if a navigator hadn’t provided guidance.

The problem is not new, and it hasn’t gotten any better. In fact it’s gotten worse, as narrow-network HMO plans have become prevalent at the lowest price points, and cut-rate new entrants sometime render plans with more robust networks more expensive.. Another aspect of the problem is also not new, but when when it was brought to my attention this week it rather shocked me, and it may have major policy implications.

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