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| Does Vance have a Hillbilly ACA Elegy for us? |
10/2/24: See post-debate update at bottom.
My last post focused on JD Vance’s sketch of a “concept of a plan” for “building on” the ACA in a second Trump administration. Vance’s remarks on Meet the Press last Sunday seem to promise a more sweeping version of the alternative market of medically underwritten, ACA-noncompliant health plans established by the first Trump administration.
Here I want to focus on a bit of purported family history that Vance injected into his paean to Trump’s alleged improvements to the ACA. This is to encourage political journalists to ask Vance exactly what he’s referring to in the highlighted section below.
Trump governed for four years, and he actually protected the 20 million Americans for four years from losing their health coverage [n.b. ACA marketplace enrollment topped out at 12 million in Trump’s term, and as for the 15 million then insured via the ACA Medicaid expansion, Trump did not “protect” their coverage; Republicans tried to strip it]. He actually protected a lot more additional Americans from losing their health coverage, and he actually insured that a lot of people were able to access coverage for the first time. Members of my own family, for example, got healthcare for the first time under Donald Trump’s administration, so we actually have a real record to run on. He of course has a plan for how to fix American healthcare, but a lot of it goes down to deregulating the insurance markets so that people can choose a plan that actually makes sense for them.
Vance has family in east Kentucky, in Ohio, and maybe elsewhere. Assuming, charitably, that some family members “got healthcare for the first time” in the Trump years, through ACA programs and/or through Trump administration initiatives, how might that have happened? Let’s consider the possibilities.
ACA Medicaid expansion. This is the likeliest vehicle, especially in east Kentucky. Thanks to Kentucky’s Democratic Governor Steve Beshear, and Ohio’s Republican Governor John Kasich, Kentucky and Ohio were among the 24 states that enacted the ACA expansion as of January 2014, extending Medicaid eligibility to most adults with income up to 138% of the Federal Poverty Level (FPL). (In 2012, the Supreme Court made the expansion optional for states.) In Kentucky, Medicaid enrollment rose from 607,000 in September 2013 to 1.33 million in September 2018 — cutting the uninsured rate by more than half, from 14.5% in 2013 to 5.6% in 2018. In Ohio, Medicaid enrollment rose from 2.1 million in Sept. 2013 to 2.7 million in Sept. 2018, and the uninsured rate dropped from 11.0% in 2013 to 6.5% in 2018.
Why might Vance clan members have not accessed health insurance until some time after 2017 — if that is true? We can’t know individual circumstances, of course. But the pandemic did drive a lot of people to seek health insurance for the first time. And Kentucky’s Governor in 2020, Andy Beshear — Steve Beshear’s son — actively encouraged Medicaid enrollment in nightly broadcasts at the height of the pandemic in spring 2020, while the state took various measures to facilitate and stimulate Medicaid enrollment in 2020 (e.g., phone calls to those who filed unemployment claims), leading to a 20% enrollment spike from March to August of that year. Fortunately, a pre-pandemic effort by Republican Governor Matt Bevin, who served between the terms of Steve and Andy Beshear, to impose work requirements on Medicaid enrollees was blocked by the courts.
ACA marketplace, before and during Trump administration. The marketplace was comparatively unlikely to have been the vehicle by which Americans would become newly insured in the Trump years. At the end of the Open Enrollment Period for 2017, marketplace enrollment* in Kentucky stood at 81,155, whereas Medicaid enrollment of those rendered eligible by the ACA (“Group VIII” in CMS parlance) was 472,000. In Ohio, ACA marketplace enrollment in OEP 2017 was 238,843, while 717,000 Medicaid enrollees were in Group VIII. During the Trump years, marketplace enrollment shrank in both states — as in the nation as a whole — to 77,821 in OEP 2021 in Kentucky, and to 201,069 in Ohio.
Enrollment losses in Trump years were curtailed, however, by one measure that did bring some new enrollees into the ACA marketplace.
In October 2017, Trump cut off direct reimbursement of insurers for the value of the Cost Sharing Reduction (CSR) subsidies that attach to silver-level plans in the ACA marketplace for low-income enrollees. (The ACA statute mandates those reimbursements but left funding to Congress; a Republican Congress refused the funding and sued to stop it; and when Trump took office a court ruling, stayed pending appeal, had upheld the suit.) While Trump boasted that this long-anticipated move left the ACA private-plan marketplace “virtually dead,” the already-predicted result was to make bronze and gold plans more affordable for subsidized enrollees. That’s because state regulators allowed, encouraged or required insurers to price the value of CSR into silver plans only, since CSR is available only with silver plans. Since the ACA’s income-adjusted premium subsidies are set to a silver benchmark, subsidies rose with silver premiums. This “silver loading” made zero-premium bronze plans newly available to millions of enrollees, and low-cost gold plans to hundreds of thousands more. According to a 2020 KFF estimate, approximately 4.7 million uninsured Americans had access to a free bronze plan, including 31% of the uninsured in Kentucky and 18% in Ohio. While overall enrollment dropped from OEP 2017 to OEP 2021, bronze enrollment rose by 20,000 in Kentucky and 40,000 in Ohio in that period. Who knows, perhaps some Vance family members were among them. (See this post for an overview of the CSR wars that led to silver loading, and how silver loading has played out.)
Short-term, limited duration (STLD) plans. As discussed in some detail in my last post, the Trump administration’s chief initiative on the health insurance front (and the likeliest basis for Trump’s claim to have “built on” the ACA) was to stand up a parallel market of ACA-noncompliant plans by extending the allowable term for so-called short-term, limited duration plans. These plans are not required to provide all of the ACA’s Essential Health Benefits; they are medically underwritten; and they are not subject to the ACA requirement that at least 80% of premiums be spent on enrollees’ claims (with a couple of other allowed expenses included). Full-year STLD plans were presumably attractive chiefly to healthy people who either had income too high to qualify for ACA premium subsidies (i.e., above 400% FPL, the eligibility cap temporarily removed by the American Rescue Plan Act in 2021), or who found ACA coverage too expensive even with premium subsidies (rendered more generous by ARPA in 2021), or who were ideologically opposed to the ACA. According to various news reports and studies, the STLD market also snared a number of people who would have been eligible for marketplace subsidies, in some cases misled by unscrupulous brokers, as broker commissions were (and remain) more generous than marketplace commissions. If Vance family members found coverage they found affordable and satisfactory in STLD market, I imagine he’d be singing that fact from the rooftops.
What is the point of this exercise in speculation? First, it’s unlikely but not entirely impossible that Vance family members were helped to first-time insurance by Trump administration initiatives or via ACA programs during the Trump years — and if the claim is wholly false or partly false or misleading, we should know that. Second, tracing the hypothetical path to new coverage during the Trump years is a decent way to get a sense of how the insurance options for those who lacked access to employer-sponsored plans evolved in that period — as well as the chief means by which the ACA cut the uninsured rate in the pre-ARPA era.
Postscript, 9/19/24: I have been mulling takeaways from the hypothetical above:
1) Until the ARPA subsidy enhancements (which made benchmark silver coverage free at incomes up to 150% FPL) spurred an immediate enrollment surge in spring/summer 2021, coverage gains through the ACA were almost entirely due to the Medicaid expansion.
2) The rapid post-ARPA enrollment growth in the marketplace is overwhelmingly concentrated at low incomes in the ten states (including Florida and Texas) that still have refused to enact the ACA Medicaid expansion. If those states were to expand Medicaid eligibility, more than half of post-pandemic marketplace enrollment growth would evaporate**, and improvement in the uninsured rate attributable to the ACA would once again be mainly a Medicaid story. Individual market enrollment would probably drop to about 15 million, meaning the individual market would insure perhaps 1% more of the U.S. population than it did pre-ACA. The ACA improved coverage in the individual market (at least with ARPA-level subsidies wiping out the cost increase for most enrollees), and the availability of insurance regardless of health status for those who lose access to other insurance is an important reform. Still, were Medicaid expansion nationwide (as the ACA’s creators intended), the ACA-reformed individual market, for all the political heat it has generated, would revert to something of a sideshow.
3) For low-income people, Medicaid is usually preferable to marketplace coverage, as a) benefits are standardized, and so it doesn’t confront enrollees with a host of substandard choices, which increasingly may be pushed by the kind of high-volume call-center brokerage that the ARPA subsidy boosts seem to have spawned, and b) there are virtually no out-of-pocket costs. Which raises the question: why not replace the individual market with an improved Medicaid, or with a Medicaid-like program along the lines of the Basic Health Programs operating in New York and Minnesota or Massachusetts’ ConnectorCare? In late 2016, I “suggested” that Trump propose further Medicaid expansion as his “terrific” health reform plan, knowing full well he wouldn’t. If Vance were a real populist and not a fascist fraud, he might well propose something along these lines. But of course, gutting Medicaid is one of Republicans’ core goals.
Update, 9/30: Via Greg Sargent, I’ve learned that in 2017 Vance criticized repeal of the ACA Medicaid expansion in the House and Senate repeal/replace bills. That’s not really evidence that his family members were insured via the expansion, but it’s consonant with that hypothesis. In a July 2017 op-ed in the New York Times, Vance wrote:
The “full repeal” bill is nothing of the sort — it preserves the regulatory structure of Obamacare, but withdraws its supports for the poor. The House version of replacement would transfer many from Medicaid to the private market, but it doesn’t ensure that those transferred can meaningfully purchase care in that market. The Senate bill offers a bit more to the needy, but still leaves many unable to pay for basic services. In the rosiest projections of each version, millions will be unable to pay for basic health care. This wasn’t acceptable to Reagan in 1961, and it shouldn’t be acceptable to his political heirs.
UPDATE, 10/2/24: In the debate last night, Vance updated his statement re his family members obtaining insurance in the Trump years:
Well, of course, we're going to cover Americans with pre-existing conditions. In fact, a lot of my family members have gotten health care, I believe, you know, members of my family actually got private health insurance, at least, for the first time, switched off of Medicaid onto private insurance for the first time, under Donald Trump's leadership.
There is virtually no way Donald Trump’s “leadership,” i.e., changes to the ACA on his watch, could have induced someone to switch from Medicaid to private insurance. Possibilities: 1) he’s lying — as he did throughout the debate (and throughout the campaign); or 2) Vance’s family members earned out of Medicaid — earned too much to qualify — and transitioned either to an employer-sponsored plan or to marketplace coverage (probably subsidized). Such a transition would have had nothing to do with Trump administration initiatives with respect to health insurance. Theoretically, Vance family members might have bought coverage in the STLD market or from an association health plan, but it’s highly unlikely anyone would voluntarily leave Medicaid, which is free and comprehensive though often offers a very limited provider network, and switched to ACA-noncompliant insurance, which costs money and is far from comprehensive.
Voluntarily switching from Medicaid to marketplace insurance is also unlikely, and if the Medicaid eligibility is income-based — e.g., if the enrollee is rendered eligible by the ACA Medicaid expansion — such a switch requires either a real change in income or income massaging in the application. I’m aware of one specialized circumstance in which this can happen: in 20-plus states, all Medicaid enrollees over age 55 are subject to Medicaid estate recovery, which means the state in which they were enrolled can recover the cost of their Medicaid enrollment from their estate after their death. According to an elder law attorney I know, older insurance seekers with low income but substantial assets are sometimes at pains to earn out of Medicaid into the marketplace. But the change of administrations would have had nothing to do with any such niche needs or solutions.
Going further afield: It’s possible but unlikely that Trump’s cutoff of direct reimbursement of insurers for the value of Cost Sharing Reduction (CSR), which created discounts in bronze and gold plans when insurers reacted by pricing the value of CSR into silver plan premiums (as CSR is available only with silver plans), rendered marketplace coverage more affordable for family Vance. It’s also just barely possible that one of the state-based reinsurance programs that the Trump administration did encourage made unsubsidized ACA-compliant more affordable for family Vance (15 states implemented such programs by 2020). But a transition from Medicaid to unsubsidized ACA-compliant coverage is highly unlikely and would suggest a large jump in income. Reinsurance programs did not make coverage more affordable for subsidized enrollees, i.e., more than 80% of on-exchange enrollees in the Trump years.
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* All marketplace enrollment totals are taken from CMS’s Marketplace Open Enrollment Public Use Files. Group VIII (ACA eligibility) Medicaid enrollment totals can be found in Medicaid Enrollment Data Collected Through MBES.
**As I noted in this post, “Almost three quarters of all enrollment growth since 2020 — 7.3 million out of a total increase of 9.9 million — is in the ten states that had refused to enact the ACA Medicaid expansion as of the beginning of OEP 2024… In the ten nonexpansion states, 5.8 million enrollees in OEP 2024 reported incomes (100-138% FPL) that would put almost all of them in Medicaid in expansion states. That’s about 28% of all marketplace enrollees.”
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