tag:blogger.com,1999:blog-85123622024-03-16T18:07:45.965-04:00xpostfactoidMostly about the ACA: Obamacare to Trumpcare to Bidencare.Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.comBlogger3363125tag:blogger.com,1999:blog-8512362.post-34669371727620973052024-03-15T12:10:00.002-04:002024-03-15T12:11:22.383-04:00Biden administration to ACA enrollment assistors: Please credit yourselves<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up.</i></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgIuOV3mZDDQK9x64Q1fbjYmo77RcTyD3Hp5Dv7_UXNuofU12v18L-J6TKwcI_sFcQPHVpGAwMstPoJ9AgfwgYdhvvTjgN1ouSRNzBSVrd2IranEjFzc2FLfe_pd2T_AKXhyphenhyphen_fcvd1_m1Vkom_ZGxjRUC1yHEJ9Hch3PbCm2Ubje6vkUbEX3MtLg/s5760/pexels-christina-morillo-1181722.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="3840" data-original-width="5760" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgIuOV3mZDDQK9x64Q1fbjYmo77RcTyD3Hp5Dv7_UXNuofU12v18L-J6TKwcI_sFcQPHVpGAwMstPoJ9AgfwgYdhvvTjgN1ouSRNzBSVrd2IranEjFzc2FLfe_pd2T_AKXhyphenhyphen_fcvd1_m1Vkom_ZGxjRUC1yHEJ9Hch3PbCm2Ubje6vkUbEX3MtLg/w400-h266/pexels-christina-morillo-1181722.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Please add my 13-digit ID<br /><br /><br /></td></tr></tbody></table><p data-pm-slice="1 1 []">CMS is apparently working to redress the Trump administration’s attack on the effectiveness of the nonprofit enrollment assistors chartered by the ACA and partly funded by the federal government.</p><p>Earlier this week CMS sent this memo to enrollment assistors:</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLg5QOfNl_HwmwnBqCh_ZpCoveJ5JZUL0oEyFbb2uVbLgxgZryNmvS-WhvUiQgj0KT2pWYXUek7juVMfY7Ml9B8HGayDlo02sPvtBZuIjq73B4t6sfdFGCEuQ6W1dDQviejb-EqN9Qgmff_lNKlOHEV0Z2v1mCTVqwEGL8aCHmxovIaUckZ9R2KQ/s921/ensure.webp" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="362" data-original-width="921" height="252" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLg5QOfNl_HwmwnBqCh_ZpCoveJ5JZUL0oEyFbb2uVbLgxgZryNmvS-WhvUiQgj0KT2pWYXUek7juVMfY7Ml9B8HGayDlo02sPvtBZuIjq73B4t6sfdFGCEuQ6W1dDQviejb-EqN9Qgmff_lNKlOHEV0Z2v1mCTVqwEGL8aCHmxovIaUckZ9R2KQ/w640-h252/ensure.webp" width="640" /></a></div><p data-pm-slice="1 1 []">The memo spells out the rationale for ensuring that navigators, CACs and EAP, who have no direct financial incentive to credit themselves on marketplace enrollments they facilitate, do so anyway:</p><blockquote><p>Including your assister ID will help the Centers for Medicare & Medicaid Services (CMS) to better understand the support that the assister community provides and continue to improve the consumer experience….</p><p>Understanding your reach as an assister is important to enhancing the support CMS provides you and the consumers you assist.</p></blockquote><p>There is a long history behind this exhortation.<br /><br /></p><span><a name='more'></a></span><p data-pm-slice="1 1 []"><strong>2014-2016: An enrollment assistance ecosystem evolves</strong></p><p>The ACA statute <a href="https://www.law.cornell.edu/cfr/text/45/155.210" rel="noopener noreferrer nofollow" target="_blank">established</a> the Navigator program to provide enrollment assistance, outreach and education to consumers eligible for marketplace and Medicaid coverage. The law stipulated that the ACA exchanges -- which turned out, not by design, to be dominated by the federal exchange -- fund navigator programs. During the Obama administration, funding for the Navigator program topped out at $63 million for the 38 states using HealthCare.gov in 2016.</p><p>The Navigator program was always a relatively small part — numerically, at least — of the ecosystem of nonprofit enrollment assistance that developed during the Obama administration in advance of and through Plan Years 2014-2016. The Kaiser Family Foundation (KFF) mapped out that ecosystem in a 2016 <a href="https://www.kff.org/report-section/2016-survey-of-health-insurance-marketplace-assister-programs-and-brokers-section-1-assister-programs-characteristics-and-people-helped/" rel="noopener noreferrer nofollow" target="_blank">survey report</a>, and I provided some back history (with input from KFF’s Jennifer Tolbert) <a href="https://xpostfactoid.blogspot.com/2018/07/true-imagepictured-lies-cms-attack-on.html" rel="noopener noreferrer nofollow" target="_blank">here</a>. A separate dedicated funding steam for enrollment assistance within Federally Qualified Health Centers reached about $150 million in 2016. The 13 state-based exchanges invested about $85 million in that year, according to KFF. A broad array of nonprofit groups deploying Certified Application Counselors (CACs), mostly privately funded, accounted for 55% of people helped by nonprofit assisters, according to KFF. Navigator programs, which have a unique mandate to provide outreach and education as well as enrollment assistance, accounted for 10% of all assistance programs and 17% of assisted clients in 2016, per KFF. </p><p>In all, KFF estimated that some 5,000 assistance programs deploying 30,000 assistors served about 5.3 million clients in 2016. Most programs reported to KFF that they enrolled most of the people they worked with, either in Medicaid or in marketplace coverage -- and far more in the former than the latter.</p><p><strong>2017-2020: The Trump administration’s War on Navigators</strong></p><p>The Trump administration famously <a href="https://chirblog.org/massive-navigator-funding-cuts-risks/" rel="noopener noreferrer nofollow" target="_blank">gutted funding</a> for the Navigator program in HealthCare.gov states, <a href="https://www.kff.org/affordable-care-act/issue-brief/data-note-changes-in-2017-federal-navigator-funding/" rel="noopener noreferrer nofollow" target="_blank">abruptly reducing it</a> from $63 million in 2016 to $36 million in 2017 (in advance of the Open Enrollment Period for 2018) and $10 million in 2018 (for OEP 2019). CMS, led by Seema Verma, justified the cuts by deeming the program ineffective, <a href="https://www.cms.gov/newsroom/press-releases/cms-announces-new-funding-opportunity-announcement-federally-facilitated-exchange-navigator-program" rel="noopener noreferrer nofollow" target="_blank">claiming</a> that navigators enrolled fewer than 1% of HealthCare.gov enrollees for Plan Years 2017 and 2018, while brokers were credited with 42% of enrollments at far less cost to the federal government. At the same time, Verma’s CMS boosted logistical and outreach support for for-profit health insurance brokers and agents, which probably did have long-term positive effects on enrollment, as discussed in <a href="https://xpostfactoid.substack.com/p/the-trump-administration-and-the" rel="noopener noreferrer nofollow" target="_blank">this post</a>. )</p><p>The data point at the heart of this ideological assault is the one addressed in the CMS memo above: the low number of HealthCare.gov enrollments that record the input of a navigator in the “Application Help” segment of the enrollment application. That basis for attacking the program’s effectiveness was highly misleading, as many defenders pointed out. </p><p>Most fundamentally, Navigator programs, commissioned to find and help low-income, low-information, immigrant, rural, and other vulnerable populations, enroll far more people in Medicaid than in the ACA private plan marketplace, as they reported to KFF, and as I documented through several state-based marketplace reports in the <a href="https://xpostfactoid.blogspot.com/2018/07/true-imagepictured-lies-cms-attack-on.html" rel="noopener noreferrer nofollow" target="_blank">post</a> cited above.</p><p>Secondly, unlike brokers and agents, nonprofit assistors have no financial incentive to get themselves credited on the HealthCare.gov application. The Obama administration never particularly pressured them to do so, and neither did supervisors in many programs. Government-certified nonprofit assistors are also charged not to positively recommend any given plan, but rather to provide neutral information to inform the enrollee’s choice. In many cases it is ultimately the client who pulls the trigger. Indeed, if I remember correctly from my own CAC training, assistors are technically not supposed to operate the keyboard during the application. In any case, pushing clients to enter a “13-digit alphanumeric ID” as part of a long and challenging application is not in many service-oriented nonprofit workers’ DNA. All in all, KFF noted, the number of one-on-one encounters navigators reported was 15 times higher than the number of QHP selections recorded electronically. And again, most assistance groups reported to KFF that most clients did find coverage — mostly in Medicaid, sometimes in the marketplace.</p><p><strong>The Biden Restoration: 2021—</strong></p><p>When the Biden administration took office at the height of the COVID-19 pandemic, it swiftly a) opened an emergency Special Enrollment Period extending from February-August 2021; b) provided a huge boost to marketplace subsidies and subsidy eligibility, effective in March 2021; and c) threw some quick cash at the Navigator programs, which had been operating on a shoestring in the Trump years. Then, for OEP 2022, the administration <a href="https://www.cms.gov/newsroom/press-releases/biden-harris-administration-quadruples-number-health-care-navigators-ahead-healthcaregov-open" rel="noopener noreferrer nofollow" target="_blank">boosted Navigator funding</a> eightfold, to $80 million, quadrupling the number of navigators in the field. For OEP 2024, federal funding for Navigators in 33 HealthCare.gov states rose to <a href="https://www.aha.org/news/headline/2023-09-05-cms-awards-navigator-grants-plan-year-2024" rel="noopener noreferrer nofollow" target="_blank">$98.6 million</a>. The Biden administration wants navigators to document that that money is well spent.</p><p>Since OEP 2021 (administered by the Trump administration in late 2020), ACA marketplace enrollment has <a href="https://xpostfactoid.substack.com/p/southern-comfort-aca-marketplace" rel="noopener noreferrer nofollow" target="_blank">increased by 87%</a> — almost certainly fueled above all by the massive subsidy boosts included in the American Rescue Plan Act of March 2021 (and extended through 2025 by the Inflation Reduction Act of August 2022). When <a href="https://www.whitehouse.gov/cea/written-materials/2024/01/24/record-marketplace-coverage-in-2024-a-banner-year-for-coverage/#:~:text=Enrollment%20reached%20over%2021%20million,ACA%20Marketplaces%20a%20decade%20earlier." rel="noopener noreferrer nofollow" target="_blank">touting the results</a> — 21% enrollment growth in OEP 2022, 13% growth in OEP 2023, 30% growth in OEP 2024 — the administration always cites the increased Navigator funding, along with other factors. Analysts and <a href="https://www.politico.com/newsletters/politico-pulse/2024/01/17/obamacare-enrollment-is-surging-heres-where-00135882" rel="noopener noreferrer nofollow" target="_blank">news outlets</a>, including <a href="https://www.kff.org/policy-watch/another-year-of-record-aca-marketplace-signups-driven-in-part-by-medicaid-unwinding-and-enhanced-subsidies/" rel="noopener noreferrer nofollow" target="_blank">KFF</a>, also name-check the program when accounting for the enrollment gains. The Biden administration appears to be seeking supporting data. As far as I know, no individual or group has surveyed or assessed the nonprofit enrollment assistance universe since KFF’s 2016 survey. (I took a qualitative dive into <a href="https://xpostfactoid.blogspot.com/2020/03/the-aca-marketplace-in-year-7.html" rel="noopener noreferrer nofollow" target="_blank">navigators’ experience</a> in 2020, but that’s not the same thing.)</p><p>Registered navigator-assisted enrollments are not likely to provide much support, except relatively (perhaps rising from 1% to say 3% of enrollments on HealthCare.gov?) — for all the reasons noted above. I don’t know whether Navigator-assisted Medicaid enrollments through the HealthCare.gov portal will be tallied, but even if they are, a) three quarters of HealthCare.gov enrollments are in states that have refused to enact the ACA Medicaid expansion, and b) in many states, navigators use separate Medicaid enrollment portals for Medicaid-eligible enrollees, as going through HealthCare.gov can add administrative friction.</p><p>It’s also important to keep in mind that the Biden administration has continued the Trump administration’s support of for-profit brokerage, continuing to encourage development of Enhanced Direct Enrollment (EDE) on commercial online platforms (mostly <a href="https://xpostfactoid.blogspot.com/2021/06/the-second-biggest-health-insurance.html" rel="noopener noreferrer nofollow" target="_blank">HealthSherpa</a>), where brokers enroll and track the majority of their clients in HealthCare.gov states. As I’ve <a href="https://xpostfactoid.substack.com/p/where-and-how-do-aca-marketplace" rel="noopener noreferrer nofollow" target="_blank">noted recently</a>, brokers execute the majority of enrollments on HealthCare.gov, and half or more of active enrollments (excluding passive auto-re-enrollment) are executed through EDE platforms. While the army of nonprofit enrollment assistors has doubtless grown from the 30,000 tracked by KFF in 2016, the ranks of brokers registered with HealthCare.gov has increased from 49,000 in 2018 to 83,000 at present.</p><p>Navigators and other nonprofit assistors play a vital role in getting vulnerable, low-income, immigrant, and hard-to-reach populations into health coverage. A comprehensive assessment of their impact is long overdue. Credited marketplace enrollments may provide a significant if minor data point in that assessment.</p><p>Caveat: The CMS memo cited above may not be unique to this year. I have searched my own mail from CMS and don’t see a prior-year version. If you know of precedents, please let me know.</p><p><a href="https://www.pexels.com/photo/woman-wearing-red-top-holding-silver-macbook-1181722/" rel="noopener noreferrer nofollow" target="_blank">Photo</a> by Christina Morillo </p><p><br /><br /></p><p><br /></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-60507655268728988402024-02-26T09:43:00.002-05:002024-02-26T09:43:11.076-05:00How the Trump administration handled the ACA marketplace, Part 3: Regulation<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up.</i></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNJTK7oRamyTuiqEW_WUNbWBaKLyF5-BNBrE1bjnes3T-flSlFy767o0x5UO8bxcFIcys5ZqfpVjojg4MC1UTfAP_7yDoEZ3g0JwlYjapXjVxPy_Ci1nrYYtiVqNbW9p3phWbYZ-zr6kAfG7tlqXFbuW9VrfPX4QzGk_bXASRhwqfvU1_1D6nfrA/s3278/pexels-cottonbro-studio-9818817.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3278" data-original-width="2185" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNJTK7oRamyTuiqEW_WUNbWBaKLyF5-BNBrE1bjnes3T-flSlFy767o0x5UO8bxcFIcys5ZqfpVjojg4MC1UTfAP_7yDoEZ3g0JwlYjapXjVxPy_Ci1nrYYtiVqNbW9p3phWbYZ-zr6kAfG7tlqXFbuW9VrfPX4QzGk_bXASRhwqfvU1_1D6nfrA/w266-h400/pexels-cottonbro-studio-9818817.jpg" width="266" /></a></div><br /><p data-pm-slice="1 1 []">This post is Part 3 of an assessment of Trump administration policy with respect to the ACA, most specifically the ACA marketplace. <a href="https://xpostfactoid.substack.com/p/the-trump-administration-and-the" rel="" target="_blank">Part 1</a> overviewed the administration’s early encouragement of state reinsurance programs, Trump’s cutoff of direct reimbursement of insurers for Cost Sharing Reduction subsidies, and the defunding of the Navigator enrollment assister program, paired with considerable support for health insurance brokers.</p><p><a href="https://xpostfactoid.substack.com/p/the-trump-administration-and-the-c45" rel="noopener noreferrer nofollow" target="_blank">Part 2</a> reviewed the effective repeal of the individual mandate penalty, paired with regulations designed to boost an alternative market of ACA-noncompliant plans. Here, we’ll look at how Seema Verma’s CMS loosened rules for insurers and tightened them for marketplace applicants.<span></span></p><a name='more'></a><p></p><p data-pm-slice="1 1 []"><strong>Marketplace regulation.</strong></p><p>In comments accompanying their various regulatory actions in the ACA marketplace, Trump officials expressed contempt and hostility for the marketplace as they inherited it — as well as solicitous intent to keep insurers aboard.</p><p>When finalizing a “market stabilization” <a href="https://www.federalregister.gov/documents/2017/04/18/2017-07712/patient-protection-and-affordable-care-act-market-stabilization" rel="noopener noreferrer nofollow" target="_blank">rule</a> in April 2017, CMS stated, reasonably enough:</p><blockquote data-pm-slice="2 1 []"><p>Robust issuer participation in the individual and small group markets is critical for ensuring consumers have access to affordable, quality coverage, and have real choice in coverage. Continued uncertainty around the future of the markets and concerns regarding the risk pools are two of the primary reasons issuer participation in some areas around the country has been limited. The changes in this rule are intended to promote issuer participation in these markets and to address concerns raised by issuers, States, and consumers. We believe these changes will result in broader choices and more affordable coverage.</p></blockquote><p>Ironically, the imperative to mollify insurers at this point was largely triggered by the Republican Congress’s effort to “repeal and replace” the ACA’s core programs, including the marketplace, and by the looming threat that Trump would stiff insurers by cutting off direct CSR reimbursement in mid plan year (the market correction and enrollment contraction of 2017 also played a role). The rule stabilization rule effected an industry wish list of tweaks, including</p><ul><li><p>A shortened Open Enrollment Period (aimed at “reducing opportunities for adverse selection by those who learn they will need medical services in late December and January”);</p></li><li><p>increased verification of off-season enrollees’ claims to merit a Special Enrollment Period, requiring verification for 100% rather than 50% of applicants (to deter people from finding their way into the marketplace only when they needed care);</p></li><li><p>a much-increased range of allowable “de minimis” variation from the statutory target for actuarial value at silver, gold and platinum metal levels (allowing plans to vary four points below and two points above the nominal AV, for example from 66% to 72% for silver plans without CSR), and -4/+5 points for bronze; and</p></li><li><p>increased latitude for states to loosen network adequacy requirements.</p></li></ul><p>A year later, in April 2018, the administration’s final Notice of Benefit and Payment Parameters for the 2019 marketplace (<a href="https://www.cms.gov/newsroom/press-releases/cms-issues-final-2019-payment-notice-rule-increase-access-affordable-health-plans-americans" rel="noopener noreferrer nofollow" target="_blank">NBPP</a>) did not hold back administrators’ feelings about the program they were bound to administer:</p><blockquote><p>The final rule will mitigate the harmful impacts of Obamacare and empower states to regulate their insurance market. The rule will do this by advancing the Administration’s goals to increase state flexibility, improve affordability, strengthen program integrity, empower consumers, promote stability, and reduce unnecessary regulatory burdens imposed by the Patient Protection and Affordable Care Act.</p></blockquote><p>The 2019 NBPP granted states more “flexibility” in selecting their EHB benchmark plan (the plan that defines in detail the scope of EHBs in that state) by allowing regulators in each state to select a benchmark plan from any other state, i.e., to race to the bottom if they so chose. The rule also eliminated already-weak “meaningful difference” standards that purported to prevent insurers from offering multiple plans with only minor (and often near-invisible) differences.</p><p>ACA state marketplaces did stabilize from 2018 forward before expanding in the pandemic (especially once propelled by the subsidy boosts enacted in the American Rescue Plan Act). Average premiums, after spiking 21% in 2017 (a year of correction) and 26% in 2018 (a year of political tumult), changed within a range of +1.3% to -3.0% in the years 2019-2022. Off-exchange (unsubsidized) enrollment, while difficult to track, probably stopped shrinking by 2019, after being cut in half by the premium spikes of 2017-18. While on-exchange plan selection as of the end of each Open Enrollment Period dropped in each plan year from 2017 through 2019, average monthly enrollment barely budged — and in fact reached a new high in 2020, fueled by pandemic-driven off-season enrollment.</p><div class="captioned-image-container"><figure><a class="image-link image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":211,"width":564,"resizeWidth":null,"bytes":null,"alt":"","title":null,"type":null,"href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="211" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6dbb51ee-9dc9-4f5d-985b-21701a7799d3_564x211.png 1456w" title="" width="564" /></picture><div></div></div></a></figure></div><h6><strong>Sources: CMS </strong><a href="https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files" rel="" target="_blank"><strong>Public Use Files</strong></a><strong> and </strong><a href="https://www.cms.gov/files/document/early-2023-and-full-year-2022-effectuated-enrollment-report.pdf" rel="" target="_blank"><strong>Effectuated Enrollment Snapshots</strong></a><strong>; </strong><a href="https://xpostfactoid.substack.com/p/aca-effectuated-enrollment-in-2023" rel="noopener noreferrer nofollow" target="_blank"><strong>this post</strong></a></h6><p>Whether or not Trump-era regulatory changes helped stabilize premiums and markets, some at least degraded product offerings. Networks grew ever narrower — a change driven mainly by competition and the success of insurers known chiefly for their managed Medicaid plans, but perhaps encouraged by loosened network adequacy standards. In the absence of a “meaningful difference” standard, markets became plagued by a plethora of meaningless choice, to the point where the average ACA shopper had to sort through <a href="https://xpostfactoid.substack.com/p/cms-proposes-cleaning-out-an-augean" rel="noopener noreferrer nofollow" target="_blank">114 plans in 2023</a> (in Miami-Dade County in Florida, the nation’s highest-enrollment county, 224 plans were available). The Trump administration also increased regulatory burdens for prospective enrollees, increasing the chances of being disenrolled or deprived of subsidy for failing to meet various verification requirements.</p><p>I asked David Anderson, a former UPMC analyst now finishing a Ph.D. at Duke, about the effects of these insurer-friendly regulations. As to motive, Anderson suggested that HHS and CMS leadership were primarily interested in helping “modestly affluent and healthy families” — those with income somewhat above the 400% FPL cap on subsidy eligibility, the constituency slammed by the sharp rate hikes of 2017 and 2018. He suspects that Tom Price and Seema Verma did not understand (or care about?) the dynamic by which reducing unsubsidized premiums tends to make coverage less affordable for subsidized enrollees (the majority) by reducing premium spreads, and so making plans that cost less than the benchmark more expensive, net of subsidy. In the Trump years, CMS would take measures that might “lose two or three covered unsubsidized lives [enrollments'] to get one unsubsidized life.”</p><p>As to the effects on enrollment of these regulatory tweaks, in 2018, Anderson suggested, “silver loading swamped it all.” That is, Trump’s cutoff of CSR reimbursement, and the resulting pricing of CSR into silver plans in most states (see the previous post), made zero-premium plans available to millions more applicants than previously. Then came the pandemic, stimulating an unprecedented surge of off-season enrollments in 2020 (helped by <a href="https://xpostfactoid.blogspot.com/2020/04/healthcaregov-will-not-require-proof-of.html" rel="noopener noreferrer nofollow" target="_blank">streamlined SEP procedures</a> and, in the state-based marketplaces, <a href="https://xpostfactoid.blogspot.com/2020/03/emergency-special-enrollment-periods-in.html" rel="noopener noreferrer nofollow" target="_blank">emergency SEPs for all</a>). In March 2021 the ARPA subsidy boosts made coverage radically more affordable at all income levels, and a subsequent nationwide emergency SEP — in effect an extended extra Open Enrollment Period — stimulated an <a href="https://www.hhs.gov/sites/default/files/2021-sep-final-enrollment-report.pdf" rel="noopener noreferrer nofollow" target="_blank">enrollment surge</a> that has not yet abated. </p><p>The Biden administration has rolled back several regulations designed to boost predictability and profitability for insurers — <a href="https://xpostfactoid.blogspot.com/2022/02/why-healthcaregov-is-offering-year.html" rel="noopener noreferrer nofollow" target="_blank">expanding SEP opportunities</a>, <a href="https://xpostfactoid.blogspot.com/2021/06/in-may-cms-quietly-shrank-acas-coverage.html" rel="noopener noreferrer nofollow" target="_blank">eliminating income verification</a> for those whose incomes might be <em>below</em> the eligibility threshold (mainly in states that had not expanded Medicaid), <a href="https://xpostfactoid.substack.com/p/cms-proposes-cleaning-out-an-augean" rel="noopener noreferrer nofollow" target="_blank">reducing</a> the number of allowable non-standard plans at each metal level, and tightening network adequacy requirements. Increased affordability enabled by the ARPA subsidies, drawing in more healthy enrollees who might have forgone less affordable offerings, has probably overwhelmed any negative effects these measures may have had on insurer profitability. Increased insurer participation and<a href="https://www.kff.org/health-costs/state-indicator/health-insurance-broker-compensation/?currentTimeframe=7&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D" rel="noopener noreferrer nofollow" target="_blank"> increased broker commissions</a> suggest as much. </p><p>To the extent that the Trump administration harmed actual, prospective and potential marketplace enrollees, it was by nibbling around the regulatory edges. Some of the administration’s insurer-friendly moves may have helped stabilize markets at the margins. Ironically, given Trump’s stated intent, the CSR cutoff gave the markets their biggest boost until the pandemic, the ARPA subsidy boosts, and the Biden administration’s regulatory initiatives made coverage significantly more affordable and somewhat easier to obtain — bringing the Affordable Care Act within credible range of living up to its name.</p><p><a href="https://www.pexels.com/photo/photo-of-a-woman-wearing-an-orange-suit-9818817/" rel="noopener noreferrer nofollow" target="_blank">Photo</a> by cottonbro studio </p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-59454396526536004472024-02-23T10:16:00.001-05:002024-02-23T10:16:10.884-05:00How the Trump administration handled the ACA marketplace, Part 2<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up.</i></p><p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSyzgLwqAGtVQtcbTAAl2W02pGGnkyPrp76WZIOfTURbqMNtd1iBYBlJJ1pNL9Zn2zFCBF8CW7SmcKgmpnCXCZvvv-8Lhl4jqJZGyo1DK5xyS1H-1uixfdBXO8tndOng7LBJoDI8tlE3RId4tWG-5xvAk3LUEC1ZnseNdYSo6aLY6cxJnHIkEqEw/s934/Dali.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="675" data-original-width="934" height="462" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSyzgLwqAGtVQtcbTAAl2W02pGGnkyPrp76WZIOfTURbqMNtd1iBYBlJJ1pNL9Zn2zFCBF8CW7SmcKgmpnCXCZvvv-8Lhl4jqJZGyo1DK5xyS1H-1uixfdBXO8tndOng7LBJoDI8tlE3RId4tWG-5xvAk3LUEC1ZnseNdYSo6aLY6cxJnHIkEqEw/w640-h462/Dali.png" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">The Trump administration stretched the clock for short-term, limited duration health plans</td></tr></tbody></table><br /></p><p data-pm-slice="1 1 []">This post is Part 2 of an assessment of Trump administration policy with respect to the ACA, most specifically the ACA marketplace. <a href="https://xpostfactoid.substack.com/p/the-trump-administration-and-the" rel="noopener noreferrer nofollow" target="_blank">Part 1</a> overviewed the administration’s early encouragement of state reinsurance programs, Trump’s cutoff of direct reimbursement of insurers for Cost Sharing Reduction subsidies, and the defunding of the Navigator enrollment assister program, paired with considerable support for health insurance brokers.</p><p>Below, we’ll look at the effective repeal of the individual mandate penalty (the one legislative initiative considered), and regulations designed to boost an alternative market of ACA-noncompliant plans.</p><p data-pm-slice="1 1 []">As each part keeps ballooning as I write it, we’ll leave other administrative changes, loosening requirements on insurers and tightening them on prospective enrollees, to a Part 3. </p><p><strong>Zeroing out the individual mandate penalty</strong>. After the Republican Senate in the summer of 2017 declined to take up the ACA “repeal and replace” bill passed by the House and then failed to pass its own repeal/replace alternative, John McCain famously scotched a final attempt to pass a “skinny” repeal bill that would have simply repealed the individual mandate and brought the Senate into conference with the House, perhaps to make one more run at a more comprehensive repeal/replace alternative. Following those failures, Republicans reduced the mandate penalty to zero in their massive tax cut bill passed in December 2017. </p><p>As an expression of intent to dismantle the ACA, the zero-penalty mandate’s chief function was to enable Republicans’ final attempt to void the ACA through the courts. In February 2018, a group of 20 states, led by Texas, sued to have the mandate declared unconstitutional, and the entire ACA statute voided. The suit sought ACA nullification on the ridiculous grounds that a) the 2012 Supreme Court decision upholding the constitutionality of the mandate did so only on the basis that the mandate is a tax, and within Congress’s taxing power; b) a zeroed-out mandate is no longer a tax; and c) since the Democratic Congress passed a <a href="https://www.law.cornell.edu/uscode/text/42/18091" rel="noopener noreferrer nofollow" target="_blank">resolution</a> in 2010 declaring that the mandate was an “essential part” of the ACA’s overall “regulation of economic activity,” the whole law (including myriad parts unconnected with the ACA marketplace) had to be vacated. In June 2021 a 7-2 Supreme Court majority <a href="https://www.supremecourt.gov/opinions/20pdf/19-840_6jfm.pdf" rel="noopener noreferrer nofollow" target="_blank">dismissed</a> the suit, finding that the plaintiffs did not have standing because no one was harmed by a $0 penalty. The litigation did enable the Trump administration, 20 Republican attorneys general, and <a href="https://www.cnn.com/2020/12/10/politics/read-house-republicans-texas-supreme-court/index.html" rel="noopener noreferrer nofollow" target="_blank">126 House Republicans </a>who signed an amicus brief in support of the plaintiffs to display root-and-branch opposition to the ACA for another three years after the legislative repeal drive failed.</p><p>Negation of the mandate was expected to drive healthier enrollees out of the market, raising premiums and thus further reducing enrollment. In 2019, CBO <a href="https://www.cbo.gov/system/files/2019-05/55085-HealthCoverageSubsidies_0.pdf" rel="noopener noreferrer nofollow" target="_blank">forecast</a> (p. 11) that the $0 mandate penalty would increase the uninsured population by 7 million, or a bit more than 2%, and reduce marketplace enrollment by 4 million.</p><p><span></span></p><a name='more'></a><p></p><p data-pm-slice="1 1 []">The eliminated penalty did doubtless induce some people to forego health coverage. But after the first zero-penalty year, the zeroed-out penalty collided first with the pandemic and ensuing massive (short-term) job losses, which stimulated off-season enrollment in Medicaid and the marketplace in 2020, and then the moratorium on Medicaid disenrollments (via the Families First and Coronavirus Response Act) and the enhanced marketplace premium subsidies enacted as part of the American Rescue Plan Act (ARPA) in March 2020 — as well as a sharply rebounding economy that swiftly erased the job losses of spring 2020. As a result, Medicaid enrollment increased by more than 20 million from March 2020 to March 2023 (an effect now unwinding swiftly if not quite completely) and marketplace enrollment <a href="https://xpostfactoid.substack.com/p/southern-comfort-aca-marketplace" rel="noopener noreferrer nofollow" target="_blank">almost doubled</a> from 2020 to 2024, increasing by 10 million. The national uninsured rate reached an <a href="https://aspe.hhs.gov/sites/default/files/documents/e06a66dfc6f62afc8bb809038dfaebe4/Uninsured-Record-Low-Q12023.pdf" rel="noopener noreferrer nofollow" target="_blank">all-time low</a> of 7.7% in early 2023.</p><p>To some extent, market response to the ARPA subsidy boosts bears out Obama’s anti-mandate stance during the 2008 presidential campaign: “the problem,” he said in one debate, “is not that folks are trying to avoid getting health care. The problem is they can't afford it. And that's why my plan emphasizes lowering costs."</p><p>Whatever its effect on the uninsured rate and marketplace enrollment and premiums, the mandate’s negation drained much of the poison from Republicans’ dead-end opposition to the ACA (the doomed lawsuit notwithstanding). Trump effectively made that argument in his 2018 State of the Union Address, <a href="https://www.cnbc.com/2018/01/30/trump-touts-repeal-of-obamacare-individual-mandate.html#:~:text=President%20Donald%20Trump%20boasted%20about,be%20suspended%20effective%20in%202019." rel="noopener noreferrer nofollow" target="_blank">asserting</a>, “We repealed the core of disastrous Obamacare — the individual mandate is now gone.” </p><p>Declare victory and get out. On the political front, however — regardless of the policy fallout — mandate negation was a major boost to acceptance of the ACA by the public. Obama himself ran against forcing people to buy private insurance in 2007/8 before embracing a mandate in 2009; it had been a major Republican attack point since it first appeared in the legislation that became the ACA; and it was consistently the least approved feature of the law. Results in a <a href="https://www.kff.org/affordable-care-act/issue-brief/explaining-california-v-texas-a-guide-to-the-case-challenging-the-aca/" rel="noopener noreferrer nofollow" target="_blank">2012 KFF</a> survey are typical:</p><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":296,"width":607,"resizeWidth":null,"bytes":66105,"alt":"","title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="296" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F0647f9c1-9570-4f92-a84f-5c8ee2240a9f_607x296.png 1456w" title="" width="607" /></picture><div></div></div></a></figure></div><p>As evidence of the extent to which Republican hostility to the ACA marketplace has moderated in at least some quarters, see my <a href="https://prospect.org/health/texas-legislature-learned-to-stop-worrying-and-love-aca-marketplace/" rel="noopener noreferrer nofollow" target="_blank">account</a> of how a bill mandating strict “premium alignment” (pricing gold plans well below silver) won support — and a unanimous vote in favor — in the Texas legislature in 2022. The bill was co-sponsored by arch-conservative rep. Tom Oliverson, a physician and chair of the Texas House Insurance Committee. Oliverson acknowledged that it was a worthy goal to “make the marketplace work as well as it can” and told me, “I think we’re all strongly opposed to single-payer, see it as a dead-end street. We need a competitive, robust marketplace and want those options to be as attractive and competitive as it can be.”</p><p><strong>Setting up a parallel market</strong>. The Trump administration also strove to undermine the ACA’s establishment of a nationwide individual market for comprehensive health insurance providing guaranteed issue (premiums varying only by age and location, not by individual medical history) and standardized Essential Health Benefits, with annual out-of-pocket maximums and no annual or lifetime caps on coverage. By <a href="https://www.cms.gov/newsroom/press-releases/hhs-news-release-trump-administration-delivers-promise-more-affordable-health-insurance-options" rel="noopener noreferrer nofollow" target="_blank">administrative rule</a> in 2018, HHS, DOL and Treasury stood up a parallel market of lightly-regulated, medically underwritten plans that did not offer a full suite of EHBs (with drug and substance abuse coverage generally lacking, and pregnancy never covered) and that often exposed (and still expose) enrollees to extensive balance billing. They did this by extending the allowable term of existing, lightly regulated Short Term, Limited Duration (STLD) plans to a full year, renewable up to three years. </p><p>This parallel market <a href="https://www.cbpp.org/research/direct-enrollment-in-marketplace-coverage-lacks-protections-for-consumers-exposes-them-to" rel="noopener noreferrer nofollow" target="_blank">stimulated</a> a rash of unscrupulous brokers and online “lead generators” to steer insurance seekers away from the ACA-compliant market. As Dylan Scott of Vox <a href="https://www.vox.com/2020/6/30/21275498/trump-obamacare-repeal-short-term-health-care-insurance-scam" rel="noopener noreferrer nofollow" target="_blank">pointed out</a> in 2020 (citing RWJF research), almost any online search for health insurance would lead the seeker primarily to the lead generators. (This does not seem to be the case at present, at least on my browser; CMS, state regulators, and Google and other search engines have <a href="https://xpostfactoid.blogspot.com/2022/03/good-news-alert-web-search-for-health.html" rel="noopener noreferrer nofollow" target="_blank">played whack-a-mole with the lead generators </a>for years.) As insurers pulled away from the ACA marketplace in 2017-18, broker commissions for ACA-compliant plans, never generous, shrank, and commissions for STLD plans are far more lucrative. (That’s because STLD plans are more lucrative for insurers, as they are not constrained by the ACA’s <a href="https://crsreports.congress.gov/product/pdf/R/R42735#:~:text=The%20ACA%20requires%20an%20annual,MLR%20for%20large%20group%20plans." rel="noopener noreferrer nofollow" target="_blank">minimum MLR requirements</a> and sometimes spend little more than half of premiums on claims.) </p><p>The administration also <a href="https://www.commonwealthfund.org/blog/2019/past-future-association-health-plans#:~:text=Trump%20Administration's%20AHP%20Rule&text=Under%20DOL's%20new%20regulations%2C%20an,purpose%20was%20offering%20health%20coverage" rel="noopener noreferrer nofollow" target="_blank">loosened the rules</a> under which various entities could form association health plans that qualified as large group plans (i.e. less tightly regulated, and exempt from most state oversight and regulation). AHPs had proved a rich breeding ground for fraud in past decades. In March 2019 a federal district court in D.C. struck down the Trump administration rule. The administration appealed; the Biden administration requested a stay while it revealed the rule; and in December 2023 the Dept. of Labor <a href="https://public-inspection.federalregister.gov/2023-27510.pdf" rel="noopener noreferrer nofollow" target="_blank">proposed to rescind</a> the Trump-era rule.</p><p>Negation of the individual mandate was a lynchpin of this parallel market, as choosing an ACA-noncompliant plan would no longer result in a tax penalty for failing to maintain “minimum essential coverage.”</p><p>To further stimulate the parallel market, CMS administrator Seema Verma proposed loosening the requirements for state “innovation waiver” proposals authorized under ACA Section 1332 and issued a set of “<a href="https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Downloads/Waiver-Concepts-Fact-Sheet.pdf" rel="noopener noreferrer nofollow" target="_blank">waiver concepts</a>” inviting states to propose schemes that would enable ACA-noncompliant plans to access federal premium subsidies. Georgia was the only state to partially accept the invitation, filing a <a href="https://www.kff.org/wp-content/uploads/2020/11/Georgia-1332-Waiver-Application-Final-07312020_vF1_0.pdf" rel="noopener noreferrer nofollow" target="_blank">waiver proposal</a> in late 2020 that, along with establishing a reinsurance program, would eliminate a centralized state-sponsored exchange, establish a “copper” plan level with an actuarial value below the minimum required by the ACA statute, and, in one <a href="https://www.cbpp.org/research/health/georgias-1332-waiver-proposal-puts-coverage-at-risk-for-tens-of-thousands" rel="noopener noreferrer nofollow" target="_blank">early iteration</a>, allow plans that did not include all EHBs (that provision was cut from the submitted waiver). While the Trump administration approved the waiver in November 2020, the Biden administration suspended approval of all but the reinsurance program, pending redesign. Georgia is now seeking to open a convention state-base marketplace, albeit the first to enable <a href="https://www.cms.gov/marketplace/agents-brokers/direct-enrollment-partners" rel="noopener noreferrer nofollow" target="_blank">Enhanced Direct Enrollment</a> on commercial sites (see the <a href="https://xpostfactoid.substack.com/p/the-trump-administration-and-the" rel="noopener noreferrer nofollow" target="_blank">previous post</a> for a discussion of EDE).</p><p>Taking the short term and limited duration out of Short Term Limited Duration insurance was a bad solution to a real problem. The Affordable Care Act promised to make adequate, affordable insurance available to all, via public program or private insurance, but under-subsidization meant that the program fell far short of that promise. Most acutely, the income cap on subsidy eligibility ensured that minimum essential coverage was unaffordable to several million people (as the ACA’s guaranteed issue and EHB requirements had raised the price of coverage). In the most extreme case, a pair of 64 year-olds in Nebraska with an income of $67,000 — just over the 400% FPL threshold n 2018— would have to pay an average of $2,667 per month for the lowest-cost bronze plan available. That year, the <a href="https://www.kff.org/private-insurance/issue-brief/deductibles-in-aca-marketplace-plans/" rel="noopener noreferrer nofollow" target="_blank">average</a> bronze plan single-person deductible was $6,002. More broadly, in August 2015 Urban Institute scholars Linda Blumberg and John Holahan <a href="https://www.urban.org/sites/default/files/publication/65196/2000328-After-King-v.-Burwell-Next-Steps-for-the-Affordable-Care-Act.pdf" rel="noopener noreferrer nofollow" target="_blank">calculated</a>, in a proposal for ACA reform, that marketplace enrollees in the 400-500% FPL range would pay 18% of income for marketplace premiums and out-of-pocket costs at the median and 25% of income at the 90th percentile.* </p><p>Takeup of STLD plans appears to have been far more limited than some market watchers <a href="https://www.urban.org/sites/default/files/publication/96781/2001727_updated_finalized.pdf" rel="noopener noreferrer nofollow" target="_blank">feared</a> or CBO predicted in the wake of the Trump rule. That’s in part because <a href="https://www.healthinsurance.org/blog/short-term-health-insurance-limits/" rel="noopener noreferrer nofollow" target="_blank">more than half of states</a> either limit STLD terms on their own (as the Trump administration rule permitted) or ban them altogether. A recent Commonwealth Fund <a href="https://www.commonwealthfund.org/blog/2023/tightening-rules-around-short-term-health-insurance-plans-wont-lead-more-people-going" rel="noopener noreferrer nofollow" target="_blank">analysis</a> concluded:</p><blockquote><p>A modest number of people — no more than one-fifth of the 1.5 million the CBO projected — are likely to have enrolled in STLDI plans that became available after the Trump administration’s regulatory change. This enrollment mainly appears to have displaced marketplace coverage. There is no evidence that the broader availability of STLDI plans had any meaningful effect on nongroup coverage in general or on uninsurance.</p></blockquote><p>The expanded STLD plan market at least potentially degraded ACA marketplace risk pools and left some people with illusory insurance that failed them when they needed it, as several news accounts <a href="https://www.propublica.org/article/junk-insurance" rel="noopener noreferrer nofollow" target="_blank">related</a>. </p><p>That said, the extended-term STLD market provided at least some protection to some subsidy-ineligible people who were priced out of the ACA marketplace. (In late 2019, my son plugged a coverage hole of several months with an STLD plan from UHC that had a maximum out-of-pocket cap and a decent provider network.)</p><p>Stay tuned next week for an overview of Trump administration regulations affecting marketplace plan design and enrollment procedures.</p><p> - - -<br /> *Blumberg and Holahan accordingly proposed subsidy enhancements that seemed like a progressive impossible dream at the time, but in 2021 the American Rescue Plan Act, under cover of pandemic emergency, boosted premium subsidies even further, albeit on a temporary basis, extended by the Inflation Reduction Act through 2025. ARPA did not boost the benchmark to gold as Blumberg and Holahan proposed, however — perhaps because Trump’s CSR cutoff and the ensuing silver loading at least potentially sets gold premiums below benchmark, as outlined in Part 1.)</p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-69210565593323136002024-02-21T12:23:00.006-05:002024-02-23T10:23:27.443-05:00How the Trump administration handled the ACA marketplace, Part 1<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up.</i></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEji0nGwhb8LniIy1GfS9C_BqXoDAI9sGNKnTevex6k3pGf1KzUt6LsZKmDBKHc9BBgoWtuypVl-Ikssjhqqf4JMQMGVvRc6Q0TAFq5Kmdj3MzE6UpS7IqmmQZelesMAbCfQCpE1YaizXmSE7aiJxCEkWS4IYO9IEe96PuBtSBxzJnJ5IBE1tTGchA/s2048/20170227_122924.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1152" data-original-width="2048" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEji0nGwhb8LniIy1GfS9C_BqXoDAI9sGNKnTevex6k3pGf1KzUt6LsZKmDBKHc9BBgoWtuypVl-Ikssjhqqf4JMQMGVvRc6Q0TAFq5Kmdj3MzE6UpS7IqmmQZelesMAbCfQCpE1YaizXmSE7aiJxCEkWS4IYO9IEe96PuBtSBxzJnJ5IBE1tTGchA/w400-h225/20170227_122924.jpg" width="400" /></a></div><br /><p></p><p data-pm-slice="1 1 []">In the wake of Trump’s vow to repeal the ACA if elected, Larry Levitt, Kaiser Family Foundation, <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2815369" rel="noopener noreferrer nofollow" target="_blank">outline</a>s the former president’s past and purported future healthcare agenda. </p><blockquote><p>One of Trump’s biggest political failures as president was his inability to persuade Congress to repeal the Affordable Care Act (ACA). However, the Trump administration did make significant changes to the ACA, including repealing the individual mandate penalty, reducing federal <a href="https://www.kff.org/report-section/president-trumps-record-on-health-care-issue-brief/#ACA" rel="noopener noreferrer nofollow" target="_blank">funding</a> for consumer assistance (navigators) by 84% and outreach by 90%, and expanding short-term insurance plans that can exclude coverage of preexisting conditions. And, the Trump administration supported an ultimately unsuccessful <a href="https://www.bbc.com/news/world-us-canada-57516488" rel="noopener noreferrer nofollow" target="_blank">lawsuit</a> to overturn the ACA.</p><p>In one of the stranger policy twists, the Trump administration ended payments to ACA insurers to compensate them for a requirement to provide reduced cost sharing for low-income patients. At the time, Trump said this would cause Obamacare to be <a href="https://www.reuters.com/article/us-usa-healthcare-trump/trump-declares-obamacare-dead-urges-democratic-help-for-short-term-fix-idUSKBN1CL2EZ/" rel="noopener noreferrer nofollow" target="_blank">“dead” and “gone</a>.” But, insurers responded by increasing premiums, which in turn increased federal premium subsidies and costs to the federal government, likely <a href="https://www.healthaffairs.org/content/forefront/data-silver-loading-boosting-insurance-coverage" rel="noopener noreferrer nofollow" target="_blank">strengthening</a> the ACA.</p><p>In the current campaign, Trump has <a href="https://thehill.com/policy/healthcare/4376743-trump-vows-to-replace-obamacare-with-his-own-alternative/" rel="noopener noreferrer nofollow" target="_blank">vowed</a> several times to try again to repeal and replace the ACA, saying he would create a plan with “much better health care.”</p></blockquote><p>Trump certainly meant harm to the ACA. His comments in the wake of abruptly cutting off direct reimbursement of insurers for the value of Cost Sharing Reduction, cited by Levitt above, show his intent, as does his pressure on Republicans in Congress to pass legislation gutting its core programs. Should Trump regain the presidency, there is no question that he will pursue the agenda that Levitt outlines in his conclusion, including the ACA-related parts:</p><blockquote><p>Trump’s record as president from 2017 to 2021, combined with recent comments on the campaign trail, suggest he would pursue policies to weaken the ACA, reduce federal spending on Medicaid, restrict access to abortion and family planning, and scale back benefits for immigrants if reelected as president in 2024.</p></blockquote><p>Moreover, should Trump regain the presidency, he would lead a Republican party even more subservient to his will than in his first term. A Republican Congress would almost surely roll back the ACA Medicaid expansion and impose sharp spending caps on surviving Medicaid programs, as well as deregulating and largely defunding the ACA marketplace, as failed Republican legislation aimed to do in 2017. Should Democrats control one or both houses of Congress, an HHS Department filled with MAGA partisans, in line with plans currently being laid by well-funded right-wing organizations like the Heritage Foundation to <a href="https://apnews.com/article/election-2024-conservatives-trump-heritage-857eb794e505f1c6710eb03fd5b58981" rel="noopener noreferrer nofollow" target="_blank">root out technocratic expertise and install Trump loyalists </a>at every level in all federal departments, would doubtless pull out all stops to undermine the marketplace and reduce Medicaid enrollments.</p><p>In Trump’s first administration, his appointments to HHS and CMS also were hostile to the structure of the ACA marketplace and the Medicaid expansion. Most notably, CMS administrator Seema Verma <a href="https://www.hhs.gov/sites/default/files/sec-price-admin-verma-ltr.pdf" rel="noopener noreferrer nofollow" target="_blank">encouraged states</a> to impose work requirements on “non-disabled, working age Medicaid enrollees — with some success, although the measures were largely checked by the courts. She also pushed states to conduct <a href="https://www.kff.org/medicaid/issue-brief/medicaid-program-integrity-and-current-issues/" rel="noopener noreferrer nofollow" target="_blank">more frequent income and eligibility checks</a> on Medicaid enrollees, encouraging the kind of procedural disenrollments (often of people who never received demands for information) now plaguing the post-pandemic Medicaid unwinding. '</p><p>But Verma and HHS Secretaries Tom Price and Alex Azar were also more constrained by conventional political incentives and the needs of corporate, state and individual constituents than their successors in a second Trump administration would likely be. The administration’s record with respect to ACA marketplace administration was mixed. Some measures harmed product quality and enrollment; some measures boosted enrollment and retention.<span></span></p><a name='more'></a> Here I want to review the effects of several Trump administration initiatives (and one legislative act):<p></p><ul><li><p>Reinsurance</p></li><li><p>Cutoff of direct reimbursement of insurers for Cost Sharing Reduction</p></li><li><p>Defunding the Navigator enrollment assistance program; boosting brokerage participation</p></li><li><p>Zeroing out the individual mandate penalty for going uninsured</p></li><li><p>Standing up a medically underwritten alternative market</p></li></ul><p>I’ll need two posts to get through this agenda. This post will cover reinsurance, the CSR cutoff, and treatment of navigators and brokers.</p><p class="button-wrapper" data-attrs="{"url":"%%checkout_url%%","text":"Subscribe now","action":null,"class":null}" data-component-name="ButtonCreateButton"><a class="button primary" href="%%checkout_url%%">Subscribe now</a></p><p><strong>Reinsurance</strong>. When the ACA marketplace launched in November 2013 (selling plans effective in 2014), premiums came in lower than expected, as insurers jockeyed for position in a new market. Premium growth was modest through 2016. In 2017, however, a three-year federally funded reinsurance program established by the ACA expired, and concurrently, insurers had enough data to recognize that they had underpriced initial offerings, as the risk pools were smaller, older and sicker than anticipated. A sharp correction ensued, with <a href="https://www.kff.org/affordable-care-act/state-indicator/marketplace-average-benchmark-premiums/?currentTimeframe=7&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D" rel="noopener noreferrer nofollow" target="_blank">benchmark silver premiums</a> increasing by an average of 20% from 2016 to 2017. In March 2017, then-HHS Secretary Tom Price <a href="https://public3.pagefreezer.com/browse/HHS.gov/31-12-2020T08:51/https://www.hhs.gov/about/news/2017/03/13/offering-states-flexibility-increase-market-stability-and-affordable-choices.html" rel="noopener noreferrer nofollow" target="_blank">invited states</a> to submit innovation waiver proposals to establish state reinsurance programs, partially funded by the “pass-through” of federal savings resulting from lower premium and therefore lower premium subsidies. By 2020, HHS had approved <a href="https://www.kff.org/affordable-care-act/fact-sheet/tracking-section-1332-state-innovation-waivers/" rel="noopener noreferrer nofollow" target="_blank">15 such state waivers</a>. In most of these programs, the state pays a percentage of claims for enrollees whose costs pass a certain threshold, up to a cap — e.g., in Colorado, the state pays 60% of individual claims between $30,000 and $400,000. </p><p>Many progressives have soured on reinsurance programs, as they tend to weaken options for subsidized enrollees (the vast majority of enrollees). By reducing premiums, reinsurance reduces “spreads” between the benchmark second cheapest silver plan — the plan that determines subsidy size — and plans that cost less than benchmark (that is, one silver plan, most bronze plans, and in some states and regions, some or all gold plans). In the era of subsidies enhanced by the American Rescue Plan (March 2021 through at least 2025), when almost 90% of enrollees are subsidized, reducing unsubsidized premiums can be viewed as a poor use of state funds. In the wake of the large premium spikes of 2017 and 2018, however, the ACA-compliant market bled unsubsidized enrollees. According to KFF estimates, unsubsidized enrollment in ACA-compliant plans <a href="https://www.kff.org/private-insurance/issue-brief/data-note-changes-in-enrollment-in-the-individual-health-insurance-market-through-early-2019/" rel="noopener noreferrer nofollow" target="_blank">dropped by essentially half</a> from Q1 2016 to Q1 2019, from 6.7 million to 3.4 million. Reinsurance programs probably <a href="https://xpostfactoid.blogspot.com/2019/10/looks-like-new-jerseys-reinsurance.html" rel="noopener noreferrer nofollow" target="_blank">helped staunch</a> that bleeding. At a time when about 40% of enrollees were unsubsidized, the tradeoff (to the extent that the effect on subsidized premiums was understood) seemed worth it.</p><p><strong>CSR cutoff.</strong> This really is the strangest chapter in the Trump administration’s handling of the ACA. The ACA statute stipulates that the federal government reimburse insurers separately for the value of Cost Sharing Reduction, a secondary benefit that attaches only to silver plans in the ACA marketplace and only for enrollees with income up to 250% of the Federal Poverty Level (FPL). But the drafters neglected to make funding for CSR mandatory, and the Republican Congress refused to fund it. Through 2016, the Obama administration found the necessary funds in couch cushions, and the Republican House sued in 2014 to stop the payments. A judge upheld the suit but stayed the ruling pending appeal. When Trump was elected, it was widely anticipated that he would cut off the payments. In October 2017, following the final death knell for legislative ACA repeal, he did so — abruptly, not only ending reimbursement for the upcoming 2018 plan year, but stiffing insurers for the last three months of 2017. As Levitt notes, he then crowed that he’d killed the marketplace.</p><p>The thing was, though, the likely effects of cutting off CSR reimbursement were by that point long understood, and insurers and state regulators were prepared (though time was short to adjust for the 2018 coverage year, with open enrollment for 2018 just two weeks away). Regulators in almost all states <a href="https://xpostfactoid.blogspot.com/2017/10/states-vary-in-their-responses-to-csr.html" rel="noopener noreferrer nofollow" target="_blank">allowed or encouraged insurers</a> to price CSR into silver plans only, inflating silver premiums and therefore premium subsidies, which are set so that enrollees pay a fixed percentage of income (on a sliding scale) for the benchmark second cheapest silver plan. Inflated benchmark premiums widened spreads between the benchmark and cheaper plans, rendering bronze plans free for millions of enrollees. Moreover, the CSR now loaded into silver premiums makes silver plans roughly equivalent to platinum for enrollees with income up to 200% FPL — the vast majority of silver plan enrollees. When fully implemented, “silver loading” — pricing silver plans in accord with the average actuarial value obtained by silver plan enrollees — makes silver plans more expensive than gold plans.</p><p>This dynamic was first laid out in an <a href="https://aspe.hhs.gov/sites/default/files/private/pdf/156571/ASPE_IB_CSRs.pdf" rel="noopener noreferrer nofollow" target="_blank">HHS ASPE brief</a> in December 2015, followed by an Urban Institute <a href="http://www.urban.org/sites/default/files/publication/77111/2000590-The-Implications-of-a-Finding-for-the-Plaintiffs-in-House-v-Burwell.pdf" rel="noopener noreferrer nofollow" target="_blank">analysis</a> in January 2016. In August 2017, the Congressional Budget Office forecast that cutting off direct CSR reimbursement would increase federal spending on premiums by <a href="https://www.cbo.gov/publication/53009" rel="noopener noreferrer nofollow" target="_blank">$194 billion</a> over ten years. That is, Trump might have anticipated (and HHS officials surely knew) that his purported death blow to the ACA would inject almost $200 billion into a marketplace that had been hobbled from the start by inadequate subsidization.</p><p>The only question was whether abrupt cutoff — without reimbursement for CSR already provided in Plan Year 2017 — would drive out a critical mass of insurers at a time when insurer participation in the marketplace had shrunk to dangerous levels (policymakers feared that the marketplace might be plagued with “bare counties,” where no insurer offered plans). David Anderson <a href="https://balloon-juice.com/2017/05/19/csr-and-the-limited-time-fuse-on-it/" rel="noopener noreferrer nofollow" target="_blank">scoped out this danger</a> in May 2017, responding to a Politico <a href="https://www.politico.com/story/2017/05/19/donald-trump-end-payments-obamacare-subsidies-238616" rel="noopener noreferrer nofollow" target="_blank">story</a> warning that abrupt CSR cutoff “could send the health law’s insurance markets into a tailspin.” While concluding that being stiffed for the bulk of 2017 could drive many insurers out of the market by thinning out their reserves, Anderson concluded, in his terse way, “The CSR threat loses its ability to blow up the market by sometime in the fall.” Trump dropped his hammer too late. (In a <a href="https://balloon-juice.com/2017/05/10/csr-assumptions-and-impacts/" rel="noopener noreferrer nofollow" target="_blank">followup post</a>, Anderson detailed the financial risk that an early cutoff of CSR payments would impose on insurers.) And the courts ultimately ordered the federal government to make insurers whole for the three months that Trump stiffed them (as Anderson also implicitly predicted).</p><p>As it turned out, “silver loading” —pricing the full value of CSR into silver plans — never really took full effect in most states, as insurers continue to underprice silver plans. That’s apparently because a) they compete to offer lowest-cost and benchmark silver, still the dominant metal level; b) low-income enrollees in plans with strong CSR utilize medical care less than anticipated, inhibited by relatively low but still substantial out-of-pocket costs; and c) the ACA’s risk adjustment formula doesn’t reflect this low utilization and thus <a href="https://www.healthaffairs.org/content/forefront/aca-metal-tier-mispricing-improving-affordability-solving-actuarial-mystery" rel="noopener noreferrer nofollow" target="_blank">tends to penalize insurers</a> who sell a lot of bronze or gold plans. In about fifteen states, however, <a href="https://www.kff.org/affordable-care-act/state-indicator/average-marketplace-premiums-by-metal-tier/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D" rel="noopener noreferrer nofollow" target="_blank">average gold premiums are lower than average benchmark silver premiums</a>, some by regulatory or legislative requirements, and some by insurers choices. And in all states, silver loading has generated significantly lower-cost bronze plans and at least somewhat lower-cost gold plans, net of subsidy, than would be the case were CSR still reimbursed separately. In 2018, KFF <a href="https://www.healthcaredive.com/news/42m-americans-eligible-for-free-aca-coverage-kff-says/544220/" rel="noopener noreferrer nofollow" target="_blank">estimated</a> that 4.2 million uninsured people were eligible for a free bronze plan. As a result, according to an <a href="https://www.healthaffairs.org/content/forefront/data-silver-loading-boosting-insurance-coverage" rel="noopener noreferrer nofollow" target="_blank">estimate</a> by Aviva Aron-Dine (linked to by Levitt above), the CSR cutoff had boosted enrollment by about 5% by 2019.</p><p>About eight states now effectively require marketplace insurers to price silver plans either in strict accord with the average actuarial value obtained by silver plan enrollees (thanks to CSR, the majority in most states are in plans with 94% or 87% AV) or, more radically, under the assumption that <em>all</em> silver plan enrollees have income under 200% FPL and therefore obtain AV of 94% or 87%. The latter (<a href="https://www.healthaffairs.org/content/forefront/new-mexico-dramatically-reduced-marketplace-deductibles-zero-cost-state" rel="noopener noreferrer nofollow" target="_blank">pioneered by New Mexico</a>) is meant to be a self-fulfilling prophecy, since this assumption prices gold plans (80% AV) well below silver, so no one ineligible for the two highest levels of CSR has any reason to choose silver. </p><p>These policy initiatives have largely been spurred by progressive policy advocate Stan Dorn and a pair of conservative actuaries, Greg Fann and Daniel Cruz — who, unlike most conservative policymakers in healthcare, are committed to making the ACA marketplace work as well as possible. While strict “premium alignment” has been implemented mainly in blue states, Fann and Cruz help the idea to take root, incredibly, in Texas, where the average lowest-cost gold premium in 2024 is 14% below the average benchmark silver premium. This premium alignment policy, first implemented in Plan Year 2023, probably is a factor in the 89% enrollment growth the Texas marketplace experienced from 2022 to 2024, an increase of more than 1.6 million. I told the rather remarkable story of how strict premium alignment took hold in the Texas legislature - -which passed the measure unanimously — <a href="https://prospect.org/health/texas-legislature-learned-to-stop-worrying-and-love-aca-marketplace/" rel="noopener noreferrer nofollow" target="_blank">here</a>. </p><p><strong>Defunding navigators/supporting brokers</strong>. The Trump administration had a rooted hostility to the Navigator nonprofit enrollment assistance program, established by ACA statute and funded by insurer user fees paid to the federal marketplace in states that use HealthCare.gov. (State-based marketplaces collect their own fees and fund their own enrollment assistance programs.) Seema Verma’s CMS gutted navigator funding, cutting it in two stages from $63 million in 2016 to $10 million in 2018 and years following. For justification, CMS released a report (the link appears to be dead) asserting that the program was ineffectual, as few enrollments on HealthCare.gov were credited to navigators. The report ignored key facts: a) unlike brokers, navigators were not oriented toward nor incentivized to be credited as assisters in HealthCare.gov enrollments, and not authorized to positively recommend a particular plan, and b) navigators, who primarily serve a low-income population, by their own report helped far more people enroll in Medicaid than in the marketplace (state exchange reports also <a href="https://xpostfactoid.blogspot.com/2018/07/true-imagepictured-lies-cms-attack-on.html" rel="noopener noreferrer nofollow" target="_blank">bear this out</a>). (On the first point, a Kaiser Family Foundation <a href="https://www.kff.org/affordable-care-act/issue-brief/data-note-changes-in-2017-federal-navigator-funding/" rel="noopener noreferrer nofollow" target="_blank">reported</a>, “The healthcare.gov online application includes a field where Navigator staff can enter their identification number for each consumer whom they assist. Navigators report that program staff have not been trained on this data entry and did not consistently enter it.) Verma’s CMS also <a href="https://www.vox.com/2017/8/31/16236280/trump-obamacare-outreach-ads" rel="noopener noreferrer nofollow" target="_blank">cut advertising</a> for the marketplace from $100 million to $10 million.</p><p>CMS’s assault on the navigator program may have reduced enrollment to some degree, and it deprived many low-income enrollees of guidance to enrollment in a program, the ACA marketplace, that remains poorly understood by vast swaths of the U.S. population to this day. It may also have reduced Medicaid enrollment. But the harm should be put in perspective on two fronts.</p><p>First, while federally funded Navigator organizations play a sort of quarterbacking role among nonprofit enrollment assistance programs in some states, numerically they represent a relatively small part of the enrollment assistance ecosystem. In 2016, according to another <a href="https://www.kff.org/report-section/2016-survey-of-health-insurance-marketplace-assister-programs-and-brokers-section-1-assister-programs-characteristics-and-people-helped/" rel="noopener noreferrer nofollow" target="_blank">KFF survey</a>, Navigator organizations constituted only 10% of some 5,000 assister programs, accounting for 17% of the 5.3 million people served by such programs. (As the Biden administration has boosted Navigator funding to about $100 million per year, they may now account for a somewhat larger percentage.) Dedicated funding for enrollment assistance at Federally Qualified Health Centers, hard-wired into FQHC funding to the tune of $150 million in 2016, dwarfed Navigator funding and doubtless still does. Independently funded programs fielding Certified Application Counselors (CACs), who undergo a federal training program somewhat more limited than the program for Navigators, accounted for 65% of assister programs in 2016. In the Trump years, navigator programs survived on a shoestring (program leaders and veteran navigators described their cutbacks and adaptations to me in <a href="https://xpostfactoid.blogspot.com/2020/03/the-aca-marketplace-in-year-7.html" rel="noopener noreferrer nofollow" target="_blank">this post</a>), cutting staff, relying more on remote assistance (spurred by the pandemic), and cutting back on the outreach/education programs that are part of their mandate.</p><p>Second, while the Trump administration starved the navigators, it fed the brokers — who, even in 2016, accounted for more marketplace enrollments than did nonprofit assisters. In the Obama years, HealthCare.gov’s “find help” feature separated nonprofit assisters and brokers (and, if I remember right, defaulted to nonprofit help). The Trump administration mingled the two, and stood up a “help on demand” program — continued by the Biden administration — in which a site visitor could enter her zip code and phone number or email address and be contacted promptly by a certified broker. </p><p>Perhaps more importantly, Trump’s CMS actively <a href="https://www.youtube.com/watch?v=-EIKSKIeIoA" rel="noopener noreferrer nofollow" target="_blank">encouraged</a> and facilitated development of the commercial Direct Enrollment and subsequent <a href="https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/Impact-EDE-OEP-2021-Coverage.pdf" rel="noopener noreferrer nofollow" target="_blank">Enhanced Direct Enrollment</a> (EDE) program, through which commercial online brokers can be certified by CMS to take applications and process subsidies without appearing to shift applicants to the federal exchange. EDE-enabled e-brokers, led by the market-dominating HealthSherpa, provide brokers with a range of tools enabling them to track and serve clients. EDE has also streamlined the enrollment process itself: An application can be completed more quickly on HealthSherpa than on HealthCare.gov. </p><p>EDE, which so far is enabled only in the 32 states using HealthCare.gov, may at least partly explained why enrollment growth in HealthCare.gov states in the pandemic years has <a href="https://xpostfactoid.substack.com/p/whats-up-with-the-state-based-marketplaces" rel="noopener noreferrer nofollow" target="_blank">far outstripped </a>enrollment in states running their own exchanges. As I’ve <a href="https://xpostfactoid.substack.com/p/on-bypassing-healthcaregov-and-in" rel="noopener noreferrer nofollow" target="_blank">noted recently</a>, in HealthCare.gov states in 2023, brokers assisted more than 70% of active enrollments on HealthCare.gov (excluding passive auto-re-enrollment), and 81% of active broker-assistance enrollments were via DE or EDE. HealthSherpa processes more new enrollments and active re-enrollments than HealthCare.gov does directly. 83,000 brokers are now registered with the federal exchange, up from 49,000 in 2018.</p><p>Some brokers are unscrupulous. But the extensive industry infrastructure that pre-dates the ACA ensured that they would play an essential role in marketplace enrollment, and that role has grown. There are far more brokers selling ACA plans than there are nonprofit enrollment assisters, and the latter help more people eligible for Medicaid than for the marketplace. The Biden administration has continued to support EDE development — and brokers.</p><p>The Trump administration’s fondness for DE and EDE probably has roots in a conservative goal, as old as the ACA, to decentralize the marketplace. Effecting enrollments through commercial sites — a goal reflected in a Georgia waiver proposal, to be discussed in Part II, to do away with any centralized state-sponsored exchange — was ideologically affiliated with breaking the ACA-compliant plan mold, founded on guaranteed issue and mandatory Essential Health Benefits. EDE platforms are anchored to HealthCare.gov, however, and subject to strict regulation — regulation that CMS has <a href="https://xpostfactoid.substack.com/p/on-bypassing-healthcaregov-and-in" rel="noopener noreferrer nofollow" target="_blank">proposed to tighten</a> in preparation for enabling state-based marketplaces to embrace EDE. </p><p>It should also be noted that CMS’s gutting of navigator funding was paired with sharp reductions in marketing and advertising and complemented by rhetorical and ideological hostility to the marketplace as currently constituted. HealthCare.gov messaging in the Trump years — e.g., in email marketing to people with HealthCare.gov logins — never had anything good to say about the coverage on offer; the enrollment reminders were bare-bones and grudging. The Trump administration also cut the Open Enrollment Period in HealthCare.gov states to six weeks. That measure probably reduced OEP enrollment, while it also apparently reduced enrollment attrition, as only those who knew they needed coverage found their way to enrollment. Retention improved steadily through the Trump years, also spurred by the widespread availability of zero-premium plans boosted by silver loading. In fact, when improved retention is taken into account, the reduced end-of-OEP enrollment in the Trump years looks like <a href="https://xpostfactoid.substack.com/p/aca-effectuated-enrollment-in-2023" rel="noopener noreferrer nofollow" target="_blank">something of an illusion</a>.</p><p>Next up (later this week or early next): mandate penalty repeal and the ACA-noncompliant market.</p><p><i><br /></i></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-22897437400314698392024-02-14T08:23:00.000-05:002024-02-14T08:23:55.128-05:00Unkind unwinding: Health Policy Valentines 2024<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEii1AWtyI77z52ymUsHlYUizJ76gb4CWJz_E-2SMFsl1F3rXR6jEFmjCqP5yK-t65Q2mVv3i2vPSvDpJfz6Q87pVPZj3dMc5b2YF3R42mi9WgPTKsMrb9rFT8jRzQ5isTCUOq8rP9zl1ozjtDQ-9G9_PgaQBI6-Ka3VwNQnX6mXuohoF7Zl1j_2Yw/s1555/pexels-aykut-aktemur-19212469%20smaller.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1555" data-original-width="1166" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEii1AWtyI77z52ymUsHlYUizJ76gb4CWJz_E-2SMFsl1F3rXR6jEFmjCqP5yK-t65Q2mVv3i2vPSvDpJfz6Q87pVPZj3dMc5b2YF3R42mi9WgPTKsMrb9rFT8jRzQ5isTCUOq8rP9zl1ozjtDQ-9G9_PgaQBI6-Ka3VwNQnX6mXuohoF7Zl1j_2Yw/w300-h400/pexels-aykut-aktemur-19212469%20smaller.jpg" width="300" /></a></div><br /><p data-pm-slice="1 1 []">In a year of existential threats, and an era in which the corporate practice of medicine knows few curbs, there is still a stream of health policy wins worth serenading in the time-honored (since <a href="https://www.advisory.com/daily-briefing/2022/02/14/health-policy-valentines" rel="noopener noreferrer nofollow" target="_blank">2012!</a>) tradition of #HealthPolicyValentines. This year’s mash notes below.</p><p data-pm-slice="1 1 []">In a year of existential threats, and an era in which the corporate practice of medicine knows few curbs, there is still a stream of health policy wins worth serenading in the time-honored (since <a href="https://www.advisory.com/daily-briefing/2022/02/14/health-policy-valentines" rel="noopener noreferrer nofollow" target="_blank">2012!</a>) tradition of #HealthPolicyValentines. This year’s mash notes are below.</p><p>The Medicaid unwinding<br />is often blind and cruel.<br />But spare some V-day love<br />For ex parte renewal.</p><p> * * *</p><p>A valentine from Democrats,<br />enacted, but hardly trending:<br />An annual Part D cap<br />on out-of-pocket spending.</p><p> * * *</p><p>What’s sweeter for seniors<br />than sugar and spices?<br />Medicare negotiating<br />selected drug prices.</p><p> * * *</p><p>Send flowers, chocolate and smiles<br />for keeping insurers squirmin’<br />over <a href="https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/" rel="noopener noreferrer nofollow" target="_blank">AI-driven denials</a><br />to Casey Ross and Bob Herman.</p><p> * * *</p><hr /><p data-pm-slice="1 1 []">O ACA, flawed child,<br />I’ll no longer carp<br />so long as your subsidies<br />remain enhanced by the ARP.</p><p> * * *</p><p>For low-income tar heels,<br />nothing can be finer<br />than Medicaid expansion<br />in North Carolina.</p><p> * * *</p><p>Let’s honor legislation<br />little known, in point of fact,<br />preventing harm, unnoticed:<br />The No Surprises Act.</p><p> * * *</p><p>As oligarch-funded theocrats<br />harm the women of this nation,<br />my love goes to the National<br />Abortion Federation.</p><p> * * *</p><p>And one for my wife as I join her on the far side of the age-65 threshold:</p><p>After 40 years of love<br />we’ll take no crap<br />from MA insurers — <br />thanks to Medigap.</p><p> * * *</p><p>While dredging up healthcare doggerel like this, I always end up with some bitter snippets, then remind myself they’re not um, valentines. Since they now exist, however, and at the risk of spoiling the mood, I’ll share a little rage rhyming:</p><p>The Supreme Court’s out of control,<br />but had better not go postal<br />by voiding the FDA rule<br />for Mifepristone and Misoprostol. </p><p> * * *</p><p></p><p></p><p></p><p>Nothing’s more dangerous<br />for those with colon polyps,<br />financially speaking,<br />than <a href="https://kffhealthnews.org/news/article/bill-of-the-month-free-colonoscopies-random-supplies-charge/" rel="noopener noreferrer nofollow" target="_blank">private equity rollups</a>. </p><p></p><p>Take a trip down ACA memory lane with a visit to the Health Policy Valentines archives: <a href="https://xpostfactoid.substack.com/p/surprise-no-surprises-health-policy" rel="noopener noreferrer nofollow" target="_blank">Surprise! No Surprises</a> (2023), <a href="https://xpostfactoid.blogspot.com/2022/02/flowers-in-graveyard-health-policy.html" rel="noopener noreferrer nofollow" target="_blank">Flowers in the graveyard</a> (2022), <a href="https://xpostfactoid.blogspot.com/2021/02/health-policy-valentines-2021.html" rel="noopener noreferrer nofollow" target="_blank">Institutional edition</a> (2021), <a href="https://xpostfactoid.blogspot.com/2020/02/but-love-grows-old-and-waxes-cold.html" rel="noopener noreferrer nofollow" target="_blank">But love grows old and waxes cold</a> (2020), <a href="https://xpostfactoid.blogspot.com/2019/02/the-water-is-wide-health-policy.html" rel="noopener noreferrer nofollow" target="_blank">The Water is Wide: Health Policy Valentines</a> (2019), <a href="https://xpostfactoid.blogspot.com/2018/02/health-policy-valentines-2018.html" rel="noopener noreferrer nofollow" target="_blank"> HPV</a> (2018), <a href="http://xpostfactoid.blogspot.com/2017/02/love-knows-no-repeal.html" rel="noopener noreferrer nofollow" target="_blank">Love Knows No Repeal</a> (2017), <a href="https://xpostfactoid.blogspot.com/2016/02/love-in-time-of-obamacare-2016.html" rel="noopener noreferrer nofollow" target="_blank">Love in the Time of Obamacare</a> (2016), love, <a href="http://xpostfactoid.blogspot.com/2015/02/love-in-time-of-obamcare.html" rel="noopener noreferrer nofollow" target="_blank">2015,</a> and <a href="https://xpostfactoid.blogspot.com/2014/02/the-romance-of-rose-health-policy.html" rel="noopener noreferrer nofollow" target="_blank">Romance of the Rose, Health Policy Edition</a> (2014).</p><p data-pm-slice="1 1 []"><a href="https://www.pexels.com/photo/spools-of-thread-19212469/" rel="noopener noreferrer nofollow" target="_blank">Photo</a> by Aykut Aktemur </p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-59685456888945136312024-01-21T14:48:00.003-05:002024-01-21T14:48:24.711-05:00How has the Medicaid unwinding affected various states' ACA marketplace enrollment?<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p data-pm-slice="1 1 []">My <a href="https://xpostfactoid.substack.com/p/southern-comfort-aca-marketplace" rel="noopener noreferrer nofollow" target="_blank">last post</a> stressed that ACA enrollment growth in the Open Enrollment Period for 2024 remains heavily concentrated in states that have refused to enact the ACA Medicaid expansion.</p><p>I might have pointed out, though, that the main divide in growth rates is between the 32 HealthCare.gov states and the 19 state-based marketplaces (SBMs). The difference in year-over-year enrollment growth as of Dec. 23 between expansion and nonexpansion states within the HealthCare.gov universe is not large -- 42.1% vs. 35.6%, according to <a href="https://acasignups.net/24/01/10/state-state-breakout-florida-breaks-40m-texas-adds-10m-wv-79-much-more" rel="noopener noreferrer nofollow" target="_blank">Charles Gaba</a>. Last year, the gap was bigger: enrollment in the nonexpansion states on HealthCare.gov increased by 22.7% in OEP 2023, vs. 9.9% in expansion states on the platform (<a href="https://acasignups.net/graph-oep-2023-edition" rel="noopener noreferrer nofollow" target="_blank">Gaba</a>). There was a similarly wide spread in growth rates in OEP 2022.</p><p>The Medicaid “unwinding” — the resumption in April 2023 of Medicaid redeterminations and disenrollments after a three-year pandemic-induced moratorium — is a major factor in this year’s enrollment gains. As of September, CMS reported that about 1.2 million Medicaid disenrollees (about 13% of the disenrolled) had enrolled in the marketplace (or in the Basic Health Programs available to low-income enrollees in New York and Minnesota) from April through September. As Medicaid disenrollments have now passed <a href="https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-unwinding-tracker/" rel="noopener noreferrer nofollow" target="_blank">15 million</a> (!), close to 2 million by now may have landed in marketplace plans or the BHPs, accounting for perhaps 40% of enrollment growth. </p><p>That boost to enrollment is apparently at work in expansion and nonexpansion states alike. Of the 16 HealthCare.gov states with growth rates above the median, eight are expansion and eight are nonexpansion states. Again, expansion states are sharing more in this year’s strong enrollment growth than in prior post-pandemic years. The Medicaid unwinding may partly explain that. While growth rates remain lower in the SBM states (all of which have expanded Medicaid) than in HealthCare.gov states, strong enrollment growth (13.8%) has resumed in the SBM group in 2024 after remaining <a href="https://xpostfactoid.substack.com/p/whats-up-with-the-acas-state-based" rel="noopener noreferrer nofollow" target="_blank">basically flat</a> last year.</p><p>In my last post, with respect to the Medicaid unwinding, I wrote:</p><blockquote><p>…state Medicaid <a href="https://www.kff.org/report-section/medicaid-enrollment-and-unwinding-tracker-overview/" rel="" target="_blank">disenrollment rates</a> don’t clearly correlate with expansion/nonexpansion status or marketplace enrollment rates (at least not obviously; perhaps researchers will tease out significant relationships in years to come).</p></blockquote><p>Here I want to take a look at another measure of the potential impact of the Medicaid unwinding on marketplace enrollment in OEP 2024: The extent to which the migration of Medicaid disenrollees into the marketplace during the off-season boosted each given state’s marketplace enrollment. CMS has tracked those enrollments, from April through September 2023, in the <a href="https://data.medicaid.gov/dataset/9a83ba5e-05f5-47f5-82de-f3a59233a912" rel="noopener noreferrer nofollow" target="_blank">Medicaid Marketplace Unwinding Report</a>. I’ve confined my focus to the 32 states using HealthCare.gov, as state-based marketplaces are quite a various lot, both in market conditions and reporting.</p><span><a name='more'></a></span><p data-pm-slice="1 1 []">In the table below, I calculated each state’s total of “unwinding” marketplace enrollees — those disenrolled from Medicaid who enrolled in marketplace plans — as a percentage of the state’s OEP 2023 enrollment total. Then I compared those percentages with the state’s marketplace enrollment change from OEP 2023 to OEP 2024 (as of December 23, when 90-95% of end-of-OEP enrollment was likely tallied). </p><p>There does appear to be a relationship between the intensity of the off-season influx of Medicaid disenrollees into a given state marketplace and enrollment growth in that state as reflected in OEP 2024. (Perhaps by May or June, we’ll learn how many Medicaid disenrollees in each state enrolled in the marketplace throughout OEP). The ten states with the lowest enrollment growth in OEP 2024 all had below-average “unwinding” enrollment from April through September, measured as a percentage of total enrollment in OEP 2023. Nine of the ten states with the highest enrollment growth in OEP 2024 had above-average unwinding enrollment percentages. </p><p>States below are sorted by their OEP 2024 enrollment increase, highest to lowest.</p><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":690,"width":610,"resizeWidth":null,"bytes":74736,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="690" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F684fcf01-d4e8-4f25-916e-1c687880a5f1_610x690.png 1456w" width="610" /></picture><div></div></div></a></figure></div><p>Is there a relationship between unwinding enrollment and OEP enrollment growth? Perhaps.</p><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd4d8fadd-902d-4734-9947-ab5768123b41_995x742.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd4d8fadd-902d-4734-9947-ab5768123b41_995x742.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd4d8fadd-902d-4734-9947-ab5768123b41_995x742.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd4d8fadd-902d-4734-9947-ab5768123b41_995x742.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd4d8fadd-902d-4734-9947-ab5768123b41_995x742.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/d4d8fadd-902d-4734-9947-ab5768123b41_995x742.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":742,"width":995,"resizeWidth":null,"bytes":129828,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="477" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd4d8fadd-902d-4734-9947-ab5768123b41_995x742.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd4d8fadd-902d-4734-9947-ab5768123b41_995x742.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd4d8fadd-902d-4734-9947-ab5768123b41_995x742.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd4d8fadd-902d-4734-9947-ab5768123b41_995x742.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd4d8fadd-902d-4734-9947-ab5768123b41_995x742.png 1456w" width="640" /></picture><div></div></div></a></figure></div><p>One of my sons asked ChatGPT to assess the extent of the correlation and the significance. The Chatbot came up with a Pearson correlation coefficient of 0.713, p-value 1.07×10^-6 [0.00000107]. My other son ran his own test and got substantially the same result (and improved on my charting, above). Score one for ChatGPT (and my sons).</p><p>There’s a sense in which the data reported here may be somewhat tautological. As noted above, close to 2 million Medicaid disenrollees have likely entered the marketplace since April. It’s not surprising that states that had a lot of transfers (relative to their prior marketplace enrollment population) would tend to show higher enrollment growth.</p><p><em>Why</em> a given state would have more than average transfers from Medicaid to the marketplace (relative to prior marketplace enrollment) is a different question. Is it because the state disenrolled more Medicaid enrollees than average, or disenrolled them more quickly? (States’ pace of redetermination varies widely; CMS encouraged states to spread redeterminations out evenly over 12 months, but some have rushed to purge the rolls.) Is it because the state did a particularly good job referring Medicaid disenrollees to the marketplace and helping them find access to enrollment assistance?* Is it because disenrollees in the state had lower average incomes than disenrollees in other states (as is likely in nonexpansion states) and were therefore likelier to find free or very low-cost coverage in the marketplace?</p><p>In the spring, via CMS’s Marketplace Open Enrollment Period <a href="https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files" rel="noopener noreferrer nofollow" target="_blank">Public Use Files</a>, we’ll get income, age, and ethnicity breakouts of marketplace enrollees. Perhaps late next summer, we’ll have complete information as to Medicaid disenrollments and Medicaid-to-marketplace transitions. It’s early to try to read the tea leaves. But what’s a blog for?</p><p>Data sources for the table above, in addition to the Medicaid Marketplace Unwinding Report and Charles Gaba posts cited above, are the Jan. 10 <a href="https://www.cms.gov/newsroom/fact-sheets/marketplace-2024-open-enrollment-period-report-national-snapshot-0" rel="noopener noreferrer nofollow" target="_blank">enrollment snapshot</a> for OEP 2024 and CMS’s state-level marketplace public use files for prior years.</p><p> —-</p><p> * In separate <a href="https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/data-reporting/monthly-data-reports/index.html" rel="noopener noreferrer nofollow" target="_blank">data sets</a>, CMS has reported the number of Medicaid disenrollees per state as well as the number of disenrollees who enrolled in the marketplace, cited above, both updated to September. Putting the two together, Charles Gaba has <a href="https://acasignups.net/24/01/04/cms-report-12-million-those-kicked-medicaid-enrolled-aca-exchange-plans-or-bhps-thru" rel="noopener noreferrer nofollow" target="_blank">reported</a> the percentage of Medicaid/CHIP disenrollees enrolled in QHPs (or BHPs) for each state. Those percentages do not correlate with OEP 2024 enrollment growth.</p><p>Four SBM states — California, Maryland, Massachusetts and Rhode Island — are <a href="https://www.commonwealthfund.org/blog/2023/what-states-are-doing-keep-people-covered-medicaid-continuous-enrollment-unwinds#:~:text=Lowering%20Administrative%20Hurdles%3A%20Auto%2DEnrollment,lost%20Medicaid%20or%20CHIP%20coverage." rel="noopener noreferrer nofollow" target="_blank">auto-enrolling</a> Medicaid disenrollees who qualify for marketplace subsidies into marketplace plans. While Massachusetts and Maryland show high Medicaid disenrollment-to-marketplace percentages in Gaba’s charting — above 20% — California and Rhode Island transition just 4-5%. The conversion data for the SBMs seems anomalous in various ways - -enrollment rates among those eligible for subsidies are weirdly low — which is why I confined my attention here to the FFM.</p><p><br /><span></span></p><!--more--><p></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-81466748082004960162024-01-18T08:21:00.001-05:002024-01-18T08:21:24.476-05:00ACA marketplace enrollment up 135%-plus since 2020 in nonexpansion states; may approach 100% in all states<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnSW6yWyrcVdyMrM92Ao8CPZXJwaDBnj6JRMrChe-LdccIraa7zkqlpvFGiaEJVRHqpsE93Q6wEkJxnUGFXw7T0w3TEhwDzUutD_0RWBtbI9rQSuockWFKhqzX8aaz7OeE-6lsZK6XnuFp9uVUpckek4cQdUmlFdwpBEKpvzkBtosNFZ4_wKPV3Q/s2016/smaller.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="2016" data-original-width="1512" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnSW6yWyrcVdyMrM92Ao8CPZXJwaDBnj6JRMrChe-LdccIraa7zkqlpvFGiaEJVRHqpsE93Q6wEkJxnUGFXw7T0w3TEhwDzUutD_0RWBtbI9rQSuockWFKhqzX8aaz7OeE-6lsZK6XnuFp9uVUpckek4cQdUmlFdwpBEKpvzkBtosNFZ4_wKPV3Q/s320/smaller.jpg" width="240" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: x-small;">Marketplace enrollment in nonexpansion states is up 135% since 2020. Drink!</span></td></tr></tbody></table><br /></p><p data-pm-slice="1 1 []">Politico’s Ben Leonard and Chelsea Cirruzzo, <a href="https://www.politico.com/newsletters/politico-pulse/2024/01/17/obamacare-enrollment-is-surging-heres-where-00135882" rel="noopener noreferrer nofollow" target="_blank">noting</a> that ACA marketplace enrollment during the Open Enrollment Period (OEP) for 2024 was already up 25% over the final OEP 2023 tally as of December 23 (with OEP still running), locate the surge geographically:</p><blockquote><p>So far, states in the South and the Rust Belt have had among the highest rates of enrollment growth between 2023 and 2024 plan years, according to a POLITICO analysis of HHS data.</p><p>Louisiana and West Virginia have the highest growth rates — about 63 percent each…Alabama, Arkansas, Georgia, Indiana, Mississippi, Ohio, South Carolina, Tennessee and Texas all had growth rates between 36 and 52 percent.</p></blockquote><p>That is no surprise as to the southern states — for which, read primarily “states that have refused to enact the ACA Medicaid expansion.” While Louisiana is an expansion state, as are the three “rust belt states” cited above, the “nonexpansion” states have driven the marketplace’s surging enrollment growth throughout the pandemic years, as I’ve noted previously with respect to OEP <a href="https://xpostfactoid.blogspot.com/2020/12/aca-marketplace-enrollment-up-10-in.html" rel="noopener noreferrer nofollow" target="_blank">2021</a>, OEP <a href="https://xpostfactoid.blogspot.com/2022/01/aca-marketplace-enrollment-up-45-in-two.html" rel="noopener noreferrer nofollow" target="_blank">2022</a>, and OEP <a href="https://xpostfactoid.substack.com/p/aca-marketplace-enrollment-in-states" rel="noopener noreferrer nofollow" target="_blank">2023</a>. Every state marketplace is different, and enrollment in a given state may rise or fall in a given year or cluster of years for myriad reasons, but since OEP 2021, the shrinking pool of nonexpansion states (there were 14 in OEP 2021, 10 at present) have accounted for the vast majority of net new enrollments (75% of net new enrollments this year). That’s largely because of sustained growth in behemoths Florida and Texas, which together account for about a third of all marketplace enrollment.</p><p>The table below shows enrollment growth from 2020-2024 in the ten states that had not expanded Medicaid as of November 1, 2023, the beginning of OEP 2024. North Carolina enacted its Medicaid expansion beginning December 1, but the migration of low-income marketplace enrollees to Medicaid does not yet show up in the enrollment tallies, so I’ve included North Carolina in the nonexpansion state group. Note also that the totals for OEP 2024 run only through December 23, 2023, while OEP ended on January 16, 2024 in the 32 states using HealthCare.gov and is still running in several state-based marketplaces. Charles Gaba <a href="https://acasignups.net/24/01/17/final-2024-aca-open-enrollment-period-projection-213m-225m-qhps-227m-238m-qhps-bhps" rel="noopener noreferrer nofollow" target="_blank">estimates</a> that the final tally for OEP 2024 will rise by another 1-2 million, or 5-11%.<span></span></p><a name='more'></a><p></p><h3 data-pm-slice="1 1 []"><strong>Total Plan Selections in Nonexpansion States, HealthCare.gov States, and All States, OEP 2020-2024</strong></h3><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/cf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":501,"width":892,"resizeWidth":null,"bytes":56571,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="359" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fcf13f70e-47e4-4b14-ae7c-ad20834a1fee_892x501.png 1456w" width="640" /></picture><div></div></div></a></figure></div><h6>Sources: CMS Marketplace Open Enrollment Period <a href="https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files" rel="noopener noreferrer nofollow" target="_blank">Public Use Files</a>; Marketplace 2024 OEP <a href="https://www.cms.gov/newsroom/fact-sheets/marketplace-2024-open-enrollment-period-report-national-snapshot-0" rel="noopener noreferrer nofollow" target="_blank">National Snapshot</a>, Jan. 10, 2024.</h6><p>Why is the enrollment surge since 2020 so concentrated in nonexpansion states? Start with the premise that the pandemic motivated a lot of people to get health insurance — and in its early months, triggered loss of employment-based insurance for millions who were laid off. Next, in nonexpansion states, eligibility for marketplace subsidies begins at 100% of the Federal Poverty Level (FPL), as opposed to 138% FPL in expansion states, where Medicaid is available to adults with income below that threshold. The generous supplemental unemployment insurance provided by the pandemic-relief CARES Act in March 2020 pushed may have pushed a lot of low-income households in nonexpansion states over the 100% FPL threshold — below which lurks the “coverage gap,” with neither Medicaid nor subsidized marketplace coverage available to most adults in those states. Rapid economic recovery, near-full employment, and rising wages probably further shrunk the population in the coverage gap. </p><p>Finally, turbo-charging the surge, in March 2021 the American Rescue Plan Act increased marketplace subsidies across the board — and rendered benchmark silver coverage with strong Cost Sharing Reduction free to enrollees with income in the 100-150% FPL range (the enhanced subsidies are funded through 2025). In 2023, <a href="https://xpostfactoid.substack.com/p/aca-marketplace-enrollment-in-the" rel="noopener noreferrer nofollow" target="_blank">nearly half</a> of all enrollees in nonexpansion states (4.8 million out of 8.9 million) had income in the 100-150% FPL range.</p><p>As for the four expansion states flagged by Politico with 2024 enrollment increases ranging from 36-63%, I don’t see any clear pattern. The Medicaid unwinding — the resumption of Medicaid enrollment redeterminations and disenrollments after a 3-year pandemic moratorium — has boosted ACA enrollment since it began in April, but state Medicaid <a href="https://www.kff.org/report-section/medicaid-enrollment-and-unwinding-tracker-overview/" rel="noopener noreferrer nofollow" target="_blank">disenrollment rates</a> don’t clearly correlate with expansion/nonexpansion status or marketplace enrollment rates (at least not obviously; perhaps researchers will tease out significant relationships in years to come). </p><p>It may be worth noting that enrollment from OEP 2020 to 2021 dropped in three of these four states (Louisiana, West Virginia and Indiana) and rose only modestly in the fourth (up 2.2% in Ohio). West Virginia’s marketplace is very small — the ACA cut the uninsured rate in half that very poor state entirely via the Medicaid expansion — and had long been unattractive to prospective enrollees before the ARPA subsidy boosts, as veteran navigators in the state <a href="https://xpostfactoid.blogspot.com/2020/03/the-aca-marketplace-in-year-7.html" rel="noopener noreferrer nofollow" target="_blank">explained to me in 2020</a>. In Louisiana, enrollment dropped for years following a Medicaid expansion enacted in July 2016, from 214,148 in 2016 to 109,855 in 2018 and 83,159 in 2021, before jumping to 99,626 in the wake of the ARPA subsidy boosts in OEP 2022 and snapping back to 196,600 with this year’s surge. </p><p>For what it’s worth, below I’ve added the enrollment history of these four states from 2020-2023 to my previous charting of enrollment growth in nonexpansion states, HealthCare.gov states, and all states in those years. Growth since 2020 in this state group was near the national average in the 2020-2023 period.</p><div class="captioned-image-container"><figure><h3 data-pm-slice="1 1 []"><strong>Total Plan Selections in Nonexpansion States, HealthCare.gov States, and All States, OEP 2020-2024</strong></h3></figure></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgL0In9bu1F8IIn2nR5Fi6_meIMpu6IEup9WxFTbuaItkG_TFTh67353HV3AgVttPPF7bodq9vVtKbVDTzN3QaSTjGC3tdnZKqP-xZc0zfc_Lfy1l0MeMAMMzACb0KPmMP8led_U1n0k5WZHS_6c2ZJ4dsxt9VrJf-e7SqetmAv39MO3AecE7Z9kA/s892/nonex%202020-24.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="505" data-original-width="892" height="362" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgL0In9bu1F8IIn2nR5Fi6_meIMpu6IEup9WxFTbuaItkG_TFTh67353HV3AgVttPPF7bodq9vVtKbVDTzN3QaSTjGC3tdnZKqP-xZc0zfc_Lfy1l0MeMAMMzACb0KPmMP8led_U1n0k5WZHS_6c2ZJ4dsxt9VrJf-e7SqetmAv39MO3AecE7Z9kA/w640-h362/nonex%202020-24.png" width="640" /></a></div><h6 data-pm-slice="1 1 []">Sources: CMS Marketplace Open Enrollment Period <a href="https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files" rel="noopener noreferrer nofollow" target="_blank">Public Use Files</a>; Marketplace 2024 OEP <a href="https://www.cms.gov/newsroom/fact-sheets/marketplace-2024-open-enrollment-period-report-national-snapshot-0" rel="noopener noreferrer nofollow" target="_blank">National Snapshot</a>, Jan. 10, 2024.</h6><p data-pm-slice="1 1 []">Why is the enrollment surge since 2020 so concentrated in nonexpansion states? Start with the premise that the pandemic motivated a lot of people to get health insurance — and in its early months, triggered loss of employment-based insurance for millions who were laid off. Next, in nonexpansion states, eligibility for marketplace subsidies begins at 100% of the Federal Poverty Level (FPL), as opposed to 138% FPL in expansion states, where Medicaid is available to adults with income below that threshold. The generous supplemental unemployment insurance provided by the pandemic-relief CARES Act in March 2020 pushed may have pushed a lot of low-income households in nonexpansion states over the 100% FPL threshold — below which lurks the “coverage gap,” with neither Medicaid nor subsidized marketplace coverage available to most adults in those states. Rapid economic recovery, near-full employment, and rising wages probably further shrunk the population in the coverage gap. </p><p>Finally, turbo-charging the surge, in March 2021 the American Rescue Plan Act increased marketplace subsidies across the board — and rendered benchmark silver coverage with strong Cost Sharing Reduction free to enrollees with income in the 100-150% FPL range (the enhanced subsidies are funded through 2025). In 2023, <a href="https://xpostfactoid.substack.com/p/aca-marketplace-enrollment-in-the" rel="noopener noreferrer nofollow" target="_blank">nearly half</a> of all enrollees in nonexpansion states (4.8 million out of 8.9 million) had income in the 100-150% FPL range.</p><p>As for the four expansion states flagged by Politico with 2024 enrollment increases ranging from 36-63%, I don’t see any clear pattern. The Medicaid unwinding — the resumption of Medicaid enrollment redeterminations and disenrollments after a 3-year pandemic moratorium — has boosted ACA enrollment since it began in April, but state Medicaid <a href="https://www.kff.org/report-section/medicaid-enrollment-and-unwinding-tracker-overview/" rel="noopener noreferrer nofollow" target="_blank">disenrollment rates</a> don’t clearly correlate with expansion/nonexpansion status or marketplace enrollment rates (at least not obviously; perhaps researchers will tease out significant relationships in years to come). </p><p>It may be worth noting that enrollment from OEP 2020 to 2021 dropped in three of these four states (Louisiana, West Virginia and Indiana) and rose only modestly in the fourth (up 2.2% in Ohio). West Virginia’s marketplace is very small — the ACA cut the uninsured rate in half that very poor state entirely via the Medicaid expansion — and had long been unattractive to prospective enrollees before the ARPA subsidy boosts, as veteran navigators in the state <a href="https://xpostfactoid.blogspot.com/2020/03/the-aca-marketplace-in-year-7.html" rel="noopener noreferrer nofollow" target="_blank">explained to me in 2020</a>. In Louisiana, enrollment dropped for years following a Medicaid expansion enacted in July 2016, from 214,148 in 2016 to 109,855 in 2018 and 83,159 in 2021, before jumping to 99,626 in the wake of the ARPA subsidy boosts in OEP 2022 and snapping back to 196,600 with this year’s surge. </p><p>For what it’s worth, below I’ve added the enrollment history of these four states from 2020-2023 to my previous charting of enrollment growth in nonexpansion states, HealthCare.gov states, and all states in those years. Growth since 2020 in this state group was near the national average in the 2020-2023 period.</p><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":581,"width":824,"resizeWidth":null,"bytes":65984,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="451" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5dbdeff5-947c-4f02-b00a-0f33e75d0ec5_824x581.png 1456w" width="640" /></picture><div></div></div></a></figure></div><h6>Source: CMS Marketplace Open Enrollment Period <a href="https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files" rel="noopener noreferrer nofollow" target="_blank">Public Use Files</a>.</h6><p>Underscoring the state-specific nature of many enrollment surges, Charles Gaba’s <a href="https://acasignups.net/24/01/10/state-state-breakout-florida-breaks-40m-texas-adds-10m-wv-79-much-more" rel="noopener noreferrer nofollow" target="_blank">tabulation</a> as of the Jan. 10 snapshot, which makes a year-over-year comparison with same-time-last year reporting and includes updates from reports in states that run their own marketplaces, shows increases above 36% in Arizona, Kansas, Missouri, New Mexico (which boosted state-based supplemental subsidies) and Oklahoma in 2024. It’s worth noting, too, that while enrollment growth in state-based marketplaces continues to lag national averages, as it has throughout the pandemic years, growth in the SBMs taken together is a strong 14%, per Gaba. Indeed, the “growth gap” between nonexpansion states and expansion states has narrowed significantly this year. That may be due in part to the Medicaid unwinding.</p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-13102759926291724442024-01-14T08:39:00.006-05:002024-01-14T14:42:31.187-05:00New York's ACA alchemy: marketplace silver to Essential Plan platinum<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyv-af5aWj40XdYoR83OOqtPCF1Qeg7ft3uMWE0sy6uG-pP-SRKY1efthwtF6Zv753UFhgPX5XC7EHgdoKWeZD7OasPll4u8Cpn26E8mmgF2CGFF4GeP1cviNHJjXM7IzX5037e76dKTxqFW2taqHXokwoveEzKCb6BQL0HiG2cmD7TpUj8nFqqA/s1214/3some.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="911" data-original-width="1214" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyv-af5aWj40XdYoR83OOqtPCF1Qeg7ft3uMWE0sy6uG-pP-SRKY1efthwtF6Zv753UFhgPX5XC7EHgdoKWeZD7OasPll4u8Cpn26E8mmgF2CGFF4GeP1cviNHJjXM7IzX5037e76dKTxqFW2taqHXokwoveEzKCb6BQL0HiG2cmD7TpUj8nFqqA/w400-h300/3some.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Greener pastures for New Yorkers of a certain income<br /><br /><div style="text-align: left;"><br /></div></td></tr></tbody></table><p></p><p data-pm-slice="1 1 []">New York has a pending ACA Section 1332 <a href="https://info.nystateofhealth.ny.gov/sites/default/files/NY%201332%20Waiver%20Updated%20Application%2011-13-2023.pdf" rel="noopener noreferrer nofollow" target="_blank">updated waiver proposal</a> to CMS that would extend eligibility for the Essential Plan, the state’s zero-premium, low-out-of-pocket cost health insurance program, to applicants with incomes up to 250% of the Federal Poverty Level ($36,450 for an individual, $75,000 for a family of four) in April 2024.</p><p>The economics of the program appear to defy gravity, and perhaps suggest lessons as to the public funding of health benefits in the United States.</p><p><strong>Shedding “Medicaid-ish” payment rates</strong></p><p>As currently structured, New York's Essential Plan is a <a href="https://www.blogger.com/blog/post/edit/8512362/8903972311026241929#" rel="noopener noreferrer nofollow" target="_blank">Basic Health Program</a>, an option for states established by Section 1331 the Affordable Care Act. A BHP is a health coverage program for state residents with incomes up to 200% FPL offered in place of standard ACA marketplace coverage. The implicit premise of Section 1331 is that BHPs will pay lower rates to providers and plow those savings into reducing premiums and out-of-pocket costs for enrollees — rather like Medicaid. </p><p>The Essential Plan currently provides coverage with an actuarial value of 98% to enrollees with income up to 150% FPL, compared to 94% for benchmark silver coverage in conventional marketplaces, and an AV of 92% to enrollees in the 150-200% FPL income bracket, compared to 87% in the marketplace. The plan has no deductibles at any income level and includes dental and vision coverage. Plan benefits are <a href="https://info.nystateofhealth.ny.gov/sites/default/files/Essential%20Plan%20At%20a%20Glance%20Card%20-%20English%202023.pdf" rel="noopener noreferrer nofollow" target="_blank">standardized</a>.<span></span></p><a name='more'></a><p></p><p data-pm-slice="1 1 []">Originally, the Essential Plan directed participating insurers — a group all but identical to those providing ACA marketplace coverage to New Yorkers at higher incomes — to pay providers <a href="https://www.health.ny.gov/health_care/managed_care/essential/docs/guidance.pdf" rel="noopener noreferrer nofollow" target="_blank">Medicaid rates plus 20%</a> for enrollees in the 139-200% FPL income range — i.e., those who would be in the marketplace if not for the EP. For enrollees with income below 139% FPL, the EP paid Medicaid rates. This enrollment group is comprised of legally present noncitizens subject to the federal “5-year bar” to federal Medicaid funding for legally present non-citizens. Prior to the BHP launch in April 2015, New York had been fully funding Medicaid enrollment for these immigrants without federal contribution since 2001, in accordance with a state court order. The ACA’s funding of marketplace or BHP coverage for those subject to the 5-year bar was a huge windfall and a major impetus for creating a BHP; upon launch of the EP, 225,000 state-funded Medicaid enrollees were immediately transferred to the program. </p><p>Those original payment rates were what one might expect of a BHP. In June 2021, however, New York <a href="https://www.health.ny.gov/health_care/managed_care/essential/docs/guidance_2.0.pdf" rel="noopener noreferrer nofollow" target="_blank">increased reimbursement rates</a> in the EP plan versions offered at the two higher income levels (139-150% FPL and 150-200% FPL) to 225% of Medicare for hospital inpatient and outpatient services, budgeting $420 million in FY 2022 for the increased payments, while eliminating the prior $20/month premium for enrollees with income above 139% FPL. In June 2023, the state <a href="https://www.health.ny.gov/health_care/managed_care/essential/docs/guidance_3.0.pdf" rel="noopener noreferrer nofollow" target="_blank">extended</a> the 225% of Medicare payment rate to versions of the EP offered at lower incomes (0-100% FPL and 101-138% FPL) and included physician services in the increased rate, budgeting an additional $800 million annually.</p><p>The proposed waiver would extend BP eligibility with the enhanced payment rates and zero premium to enrollees with income up to 250% FPL. Since a Basic Health Program by statute can only be offered to enrollees with income up to 200% FPL, the proposed extension is via an ACA Section 1332 “innovation waiver,” by which a state can propose alternative structures to the standard ACA marketplace. These proposals must offer equally comprehensive coverage equally affordably to at least as many people as the standard marketplace — and they must not increase the federal deficit, i.e., they must cost the federal government an amount equivalent to what the standard marketplace would cost. Under the waiver, the Essential Plan would lose — or rather “suspend” — BHP status for the 5-year duration of the waiver — which means that federal funding would rise from 95% of the estimated cost of a conventional marketplace to 100%. </p><p><strong>Giving enrollees more for less</strong></p><p>In a standard (and New York’s current) ACA marketplace, a benchmark silver plan for for enrollees in the 200-250% FPL income bracket has an actuarial value of 73%. The benchmark plan (the second cheapest silver plan) determines the federal premium subsidy, as enrollees pay a fixed percentage of income on a sliding income scale for the benchmark. Enrollees pay premiums that vary according to their income and plan choice; at an income of $36,000, just under 250% FPL, a single enrollee would pay $116 per month for the benchmark, with the federal government kicking in $688/month. The proposed EP extension would instead provide enrollees in this income bracket with 92% AV coverage for zero premium — at avowedly no additional cost to the federal government. In the 200-250% FPL income bracket, a marketplace silver plan can have an out-of-pocket maximum as high as $7,550 per adult in 2024. The EP OOP max at this income level is just $2,000.</p><p>The state estimates that transition to the EP will save the average enrollee in the 200-250% FPL income bracket $4,600* annually, split nearly evenly between premiums and out-of-pocket costs (updated waiver proposal, p. 48). The proposal forecasts a slight net enrollment increase, with a reduction in 2024 of about 71,000 enrollees in the marketplace and an increase of about 89,000 in the EP — which, with its zero premium, has higher takeup rates. By 2028, the net enrollment increase is forecast to rise to about 28,000, or 2%.</p><p>Despite all these reductions in cost for enrollees in the 200-250% FPL income bracket who move from marketplace to EP, the waiver proposal shows a lower premium per month per person (PMPM) for the EP than for qualified health plans (QHPs) in the marketplace. For 2024, the November update to the proposal estimates a $761 PMPM average premium for subsidized QHP enrollees, versus $629 PMPM for the EP. The <a href="https://info.nystateofhealth.ny.gov/sites/default/files/NY%201332%20Waiver%20Application_5.12.2023.pdf" rel="noopener noreferrer nofollow" target="_blank">original proposal</a>, from May 2023, broke out the provider payment boosts as a separate line item, $800 million per year (the boost is capped at that amount and would be reduced if that ceiling is reached), and so showed an even sharper premium difference: $740 PMPM for subsidized marketplace coverage compared to $569 PMPM for the EP. The provider payment increase is estimated to add about 10% to the EP premium. Also broken out separately is a proposed $100 million to reduce enrollee cost sharing at higher income levels in 2024, trended forward every year. In the November update, both costs are incorporated in the EP premium. </p><p>It seems natural to wonder: how can New York eliminate premiums paid by enrollees in a given income bracket (200-250% FPL), provide 92% AV coverage in that bracket, mandate provider payment rates that match or exceed national average commercial rates by most estimates**, and provide dental and visual coverage — all at a cost to the federal government below the cost of subsidizing 73% AV marketplace coverage in this income bracket?</p><p>I posed this question to Elisabeth Benjamin. VP of Health Benefits at New York’s Community Service Society and a primary architect of the Essential Plan (and co-author of a <a href="https://www.healthinsurance.org/blog/a-more-affordable-affordable-care-act/" rel="noopener noreferrer nofollow" target="_blank">pre-ACA blueprint</a> for a state universal coverage plan that presages many EP features). For starters, Benjamin told me, the increased provider payment rates are still lower than those paid in New York’s individual market (by the same insurers). Further, enrollees in the Essential Plan are both healthier and use less healthcare services (utilization is generally lower at lower incomes, even adjusting for health status). While the 200-250% FPL population might be expected to have higher utilization than the current income groups, the much higher takeup of the EP than of marketplace coverage (97% vs. 72% among those qualified for coverage in the two programs, according to a 2023 <a href="https://info.nystateofhealth.ny.gov/sites/default/files/Health%20Insurance%20Coverage%20Update%20-%20April%202023.pdf" rel="noopener noreferrer nofollow" target="_blank">enrollment update</a>) should reduce per-person utilization in this income group when it moves to the EP. Finally, the EP requires a medical loss ratio no lower than 86% — that is, insurers must spend 86% of premium revenue on enrollees’ medical claims. In 2022, the average MLR for QHPs in the New York marketplace in the 200-250% FPL bracket was 79.2% (just below the ACA’s 80% statutory minimum), according to the original waiver proposal.</p><p>That low MLR in the 200-250% FPL bracket is in marked contrast to an average MLR of 94.6% for New York enrollees at incomes above 250% FPL — underscoring the extent to which utilization rises with income (partly because higher income enrollees tend to be older). The waiver proposal could, theoretically, have bid to reduce marketplace premiums by combining the EP and marketplace risk pools, as Massachusetts does with the BHP-like ConnectorCare and the “regular” marketplace available at higher incomes. The single risk pool has paved the way for Massachusetts to extend ConnectorCare eligibility to 500% FPL this year without cannibalizing the marketplace for higher-income residents. By statute, a BHP must maintain a separate risk pool, but the waiver proposal would suspend the EP’s BHP status. But unification cuts two ways: it would raise premiums in the EP and reduce federal funding by reducing premiums for the benchmark silver plan, which determines subsidies. The same is true for a state reinsurance program, which would also reduce benchmark premiums and so subsidies. Instead, New York proposes to compensate insurers separately for removal of the lower-cost enrollees in the 200-250% FPL bracket from the QHP risk pool.</p><p><strong>Converting high QHP premiums to (federal) gold</strong></p><p>Benjamin also told me that the $800 million allocated annually to boosting provider payment will come out of the surplus in the EP’s trust fund, which, as Bill Hammond of the Empire Center has <a href="https://www.empirecenter.org/publications/the-essential-plans-accumulated-surplus/" rel="noopener noreferrer nofollow" target="_blank">pointed out</a>, has grown to enormous proportions, topping $10 billion in 2023. That surplus is the result of the difference between premiums for the EP and benchmark silver plans in the state’s ACA marketplace — which, as Hammond notes in a <a href="https://www.empirecenter.org/publications/the-absurd-math-of-new-yorks-essential-plan/" rel="noopener noreferrer nofollow" target="_blank">subsequent post</a>, exceed national average benchmark premiums by 54%. The enhanced marketplace subsidies provided in March 2021 by the American Rescue Plan Act have further fueled the annual surplus, as Hammond’s table below shows (my emphasis):</p><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Facdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Facdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Facdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Facdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Facdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/acdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":335,"width":742,"resizeWidth":null,"bytes":35996,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="181" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Facdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Facdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Facdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Facdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Facdc4f8a-1e9d-47d8-bf59-cf7666687ab2_742x335.png 1456w" width="400" /></picture><div></div></div></a></figure></div><p>According to the 2023 enrollment report cited above, ARPA increased federal payments to the Essential Plan by $800-900 million per year.</p><p>In effect, New York is leveraging high costs in the individual market to extend eligibility and improve coverage in the EP — zeroing out premiums, reducing out-of-pocket costs, adding dental and vision care, and boosting provider payment and so, presumably, provider network adequacy. That probably explains why the waiver proposal does not seek to combine the EP and marketplace risk pools (and according to Benjamin, CMS would frown at a request to combine them, as it would spirit of Section 1331). As long as the ARPA-enhanced marketplace subsidy schedule is in effect (which it may not be after 2025), no one who lacks access to other affordable insurance pays more than 8.5% of income for a benchmark silver plan in the marketplace. Thus an increase in unsubsidized premiums hurts no one except federal taxpayers (and, potentially, enrollees who choose plans that cost more than the benchmark, as spreads rise with premiums).</p><p>The waiver proposal does take full account of the possibility — perhaps likelihood — that the ARPA subsidy boosts won’t be extended beyond 2025, providing enrollment and spending projections with and without ARPA subsidy extension. It also proposes to suspend rather than absolutely end the Essential Plan’s BHP status, so that the program could revert to BHP status if the 5-year waiver is not renewed. Combining risk pools would complicate a reversion to BHP status, as the risk pools would have to be re-separated.</p><p><strong>A better model than the marketplace?</strong></p><p>Like Massachusetts’ BHP-like ConnectorCare, for which the state has extended eligibility up to 500% FPL, the Essential Plan suggests a more efficient model for subsidized health coverage than the ACA marketplace, which is essentially a reformed individual market, providing insurers with broad latitude to vary enrollee cost structures within the constraints of a fixed actuarial value. With their standardized benefits, low out-of-pocket costs, and (relatively) low provider payment rates, the Essential Plan, Minnesota’s BHP (MinnesotaCare), and ConnectorCare*** more closely resemble Medicaid managed care programs than the pre-ACA individual market. I have <a href="https://www.healthinsurance.org/blog/replacing-the-aca-with-something-terrific/" rel="noopener noreferrer nofollow" target="_blank">speculated before</a> that if Medicaid eligibility were expanded further up the income chain (Medicaid for All Who Need It?), Medicaid payment rates and provider networks would have to improve. That’s essentially what’s happened with the Essential Plan, albeit with payment rates that would be considered extravagant in most states. Were New York not able to leverage the high provider payment rates prevalent in the state (reflected in the individual market premiums that determine marketplace funding), the payment rates would doubtless be more moderate, as they were in the Essential Plan’s early years.</p><p>Postscript: Thanks to <a href="https://www.healthinsurance.org/authors/louise-norris/" rel="noopener noreferrer nofollow" target="_blank">Louise Norris</a> for alerting me to a December 18 <a href="https://www.cms.gov/files/document/ny-1332-waiver_updated-application12182023.pdf" rel="noopener noreferrer nofollow" target="_blank">further update</a> to the waiver proposal, seeking approval to extend eligibility to the state’s Deferred Action for Childhood Arrivals (DACA) population up to 250% FPL. The prior proposal anticipated extending eligibility to DACA recipients when CMS finalizes a rule affirming DACA eligibility for marketplace coverage. Now — prompted by comments submitted in response to the waiver proposal — the state asserts its authority to cover DACA recipients and asks CMS to ratify that in advance of the anticipated April 1 start date for the EP expansion. The state anticipates slightly more than 3,000 DACA enrollees.</p><p> —</p><p> * I am a bit surprised by the estimate that the average enrollee in the 200-250% FPL bracket will save $2,200 in premiums. In 2024, as noted above, a benchmark silver plan would cost an enrollee with an income just below 250% FPL $116 per month, or $1,392 per year. While premiums will rise over ten years, and FPL brackets will adjust for inflation, the percentage of income required for benchmark silver will not change, at least as projected in the with and without ARPA extension (legislation could also pare back as well as end or maintain the current subsidy schedule as is). In 2023 in New York, 56% of enrollees in the 200-250% FPL bracket selected silver plans, 31% selected bronze, 8% selected gold, probably a bit shy of 4% platinum, and 1% catastrophic (the latter two are not specified by income in the Public Use Files; estimates are based on metal level share in all income brackets). That averages out to an AV of just about 70%. Perhaps silver plans that cost more than the benchmark (second cheapest silver plan) are bought frequently.</p><p> ** A 2022 <a href="https://www.cbo.gov/system/files/2022-01/57422-medical-prices.pdf" rel="noopener noreferrer nofollow" target="_blank">CBO report</a> overviewing various studies of commercial payment rates found an average estimate of 240% of Medicare for outpatient services and 182% for inpatient services. Physician rates are usually estimated as closer to Medicare. A 2021 Urban Institute <a href="https://www.urban.org/sites/default/files/publication/104945/commercial-health-insurance-markups-over-medicare-prices-for-physician-services-vary-widely-by-specialty.pdf" rel="noopener noreferrer nofollow" target="_blank">study</a> of various specialties found a weighted average commercial payment rate of 160% of Medicare for seventeen specialties, noting that previous studies generally pegged average rates at 120-140% of Medicare.</p><p> ***ConnectorCare, unlike the BHPs, does not set capitation rates for participating insurers. Technically the standardized ConnectorCare plans are silver QHPs with supplemental state subsidies that raise AV. The program controls costs by setting enrollee premium levels for the lowest-cost participating plan only, inducing insurers to compete for that quasi-benchmark position. </p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-71779692011739879922024-01-01T10:21:00.004-05:002024-01-01T10:21:39.744-05:002023: Understanding a maturing ACA marketplace<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm1KfoAAmoz9m-DA-RLfS1e34678ow86a8xr2sp_O8uUeEBW8zB8DX_vhlLMHN14gpCcc1_LvkPCncTOYZHyfdCvRBNYYo0DOLD3A2z_TdJTqL_jBP0Cwpwy4JtQ7e48TGYPi2V0Qrh2hQF8p_KYlYlypv1Deo4oBaU9BI3LKYtdZAWDhfI9gpvQ/s5312/20180719_210444.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="2988" data-original-width="5312" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm1KfoAAmoz9m-DA-RLfS1e34678ow86a8xr2sp_O8uUeEBW8zB8DX_vhlLMHN14gpCcc1_LvkPCncTOYZHyfdCvRBNYYo0DOLD3A2z_TdJTqL_jBP0Cwpwy4JtQ7e48TGYPi2V0Qrh2hQF8p_KYlYlypv1Deo4oBaU9BI3LKYtdZAWDhfI9gpvQ/s320/20180719_210444.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: x-small;">Not exactly New Year's fireworks, but the closest equivalent in my photos</span></td></tr></tbody></table><br />Another blogging year goes to the archives. As the years go by it seems I write fewer and fewer posts and spend more and more time on each of them. I’d like to think that means the posts are getting better, but I wouldn’t swear to it.</p><p>Perhaps it’s fair to say my understanding of the ACA marketplace is maturing as the marketplace matures. A few themes in this year’s posting flesh that idea out:</p><ul><li><p>I have long been concerned with CSR takeup — that is, how many low-income enrollees (that is, a majority of marketplace enrollees) obtain coverage that makes actual care affordable. Since ARPA rendered at least two CSR-enhanced silver plans free for enrollees with income up to 150% FPL and available for no more than 2% of income for those in the 150-200% FPL income range, I have been disappointed to note that silver plan selection at low incomes has not improved as I anticipated, and this March I noted that CSR takeup <a href="https://xpostfactoid.substack.com/p/underinsurance-spikes-among-low-income" rel="noopener noreferrer nofollow" target="_blank">went backwards in 2023</a>. I then added a <a href="https://xpostfactoid.substack.com/p/csr-a-bridge-too-far-spotlight-on" rel="noopener noreferrer nofollow" target="_blank">spotlight on CSR takeup in states that have not expanded Medicaid</a>, where the vast bulk of enrollees eligible for free CSR silver live. Perhaps more interestingly, following hints from brokers and those who work with them, I examined markets in which some enrollees might have cause to <a href="https://xpostfactoid.substack.com/p/forgoing-high-csr-silver-coverage" rel="noopener noreferrer nofollow" target="_blank">forgo the CSR benefit with eyes wide open</a>, sacrificing low out-of-pocket costs to obtain a more robust provider network or other benefits.<span></span></p><a name='more'></a><p></p></li></ul><ul data-pm-slice="3 1 []"><li>Since late 2013, I have followed the development of Direct Enrollment and Enhanced Direct Enrollment (DE and EDE) provided by commercial platforms selling ACA marketplace plans. This year, I gave full attention to the fact that most ACA marketplace enrollments are broker-assisted, and that most broker-assisted enrollments are executed via DE or EDE (probably mostly the latter by now). While I have paid much attention over the years to the usability and presentation of vital information on HealthCare.gov and the state exchanges, this year I looked at <a href="https://xpostfactoid.substack.com/p/where-and-how-do-aca-marketplace" rel="noopener noreferrer nofollow" target="_blank">where and how ACA marketplace enrollments actually happen</a>, spotlighting the fact that many and probably most marketplace enrollees never visit a government-operated exchange.<p></p></li><li><p>DE and EDE are only possible in states that use the federal exchange, HealthCare.gov, though <a href="https://xpostfactoid.substack.com/p/on-bypassing-healthcaregov-and-in" rel="noopener noreferrer nofollow" target="_blank">that is poised to change in coming years</a>. Given the centrality of brokers to marketplace enrollment, and brokers’ heavy reliance on EDE platforms where available, the lack of DE/EDE in state marketplaces may be a contributing factor in <a href="https://xpostfactoid.substack.com/p/whats-up-with-the-acas-state-based" rel="noopener noreferrer nofollow" target="_blank">lagging enrollment growth in SBM states</a> in the pandemic years. On the other hand, slow growth in the SBM states since 2020 may be chiefly due to <a href="https://xpostfactoid.substack.com/p/whats-up-with-the-state-based-marketplaces" rel="noopener noreferrer nofollow" target="_blank">better penetration and lower uninsured rates in prior years</a>, along with other demographic factors.</p></li></ul><p>This year I also spotlighted a marketplace abuse apparently unique to New Jersey: insurers in the state were <a href="https://xpostfactoid.substack.com/p/new-jerseys-dobi-lays-a-trap-for" rel="noopener noreferrer nofollow" target="_blank">presuming marketplace enrollees over age 65 eligible for Medicare unless they proved otherwise</a>, and acting as a secondary payer (while collecting full premium) in the absence of such proof. In response to my query, CMS pointed me to guidance issued in May 2023 stating unequivocally that this presumption of Medicare eligibility was impermissible. Stonewalled on this obvious violation of the ACA statute by New Jersey’s Department of Banking and Insurance, I enlisted the help of nj.com reporter Karen Price Mueller, whose inquiry prompted DOBI to issue a directive to insurers telling them to cease and desist from this practice (which had been codified in the state’s standard individual market contracts in 2023 and permitted since at least 2016). DOBI had previously acknowledged that the CMS guidance must be followed but apparently had not acted to end the practice in 2023. Mueller’s article, spotlighting the plight of a friend of mine subjected to this abuse of the spirit and letter of the ACA, is <a href="https://www.nj.com/news/2023/09/a-mistake-may-have-cost-seniors-thousands-in-healthcare-costs-nj-is-fixing-it.html" rel="noopener noreferrer nofollow" target="_blank">paywalled</a>, but quoted at some length in my <a href="https://xpostfactoid.substack.com/p/dobi-responds-but-not-to-me-no-more" rel="noopener noreferrer nofollow" target="_blank">followup post</a>. DOBI has also <a href="https://xpostfactoid.substack.com/p/ending-abuse-of-elder-enrollees-in" rel="noopener noreferrer nofollow" target="_blank">removed the presumption of Medicare eligibility for over-65 enrollees</a> from the 2024 standard contracts.</p><p>Also this year, I took a look at the <a href="https://xpostfactoid.substack.com/p/could-the-ftcs-proposed-ban-on-noncompete" rel="noopener noreferrer nofollow" target="_blank">possible effect of the FTC’s proposed ban on noncompete clauses in employment contracts on the growth of private equity ownership of physician practices</a> and other medical services and facilities, which has been galloping apace. I also delved into a battleground in Medicare Advantage payment, the industry’s apparent exploitation of risk adjustment to inflate payment. On this score I <a href="https://xpostfactoid.substack.com/p/adjusting-risk-adjustment-in-medicare" rel="noopener noreferrer nofollow" target="_blank">interviewed Richard Kronick</a>, a leading critic of current risk adjustment practice. </p><p>Coming soon are what look to be blockbuster enrollment totals for the ACA marketplace in 2024. Marketplace growth in the last three years is poignant for those of us worried about the prospects for extending the improved subsidies temporarily implemented by the American Rescue Plan Act beyond 2025. Flawed as the ACA marketplace is, under the ARPA subsidy schedule (extended through 2025 by the Inflation Reduction Act) has staked a fair claim to fulfilling its creators’ intent and CBO’s initial predictions. That progress is at risk in 2025. Then again, so is American democracy and almost everything we hold dear.</p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-39270354821566583122023-12-26T14:24:00.004-05:002023-12-26T14:24:40.878-05:00The commercial para-universe to the ACA exchanges keeps expanding<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5duAyU9Wcy_SLHWYxxuUdceN8y7IXUwvH9nbffhqAfwSu6AaiTuufWccNimDcR89tEpwqkZsbicaqwvTsz9xiZzwqji8952cAX0hWKoIK0fW1aSIBmRh982jqLlvL6BcayUOlvWOyHZSIgR_nTUjQdREL6SfkKl28HLd1nr8RAnlBLDoBrn1Txw/s441/peaches.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="331" data-original-width="441" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5duAyU9Wcy_SLHWYxxuUdceN8y7IXUwvH9nbffhqAfwSu6AaiTuufWccNimDcR89tEpwqkZsbicaqwvTsz9xiZzwqji8952cAX0hWKoIK0fW1aSIBmRh982jqLlvL6BcayUOlvWOyHZSIgR_nTUjQdREL6SfkKl28HLd1nr8RAnlBLDoBrn1Txw/s320/peaches.png" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Georgia looking peachy to web-brokers<br /><br /><div style="text-align: left;"><br /></div></td></tr></tbody></table></p><p data-pm-slice="1 1 []">More or less simultaneously with CMS’s <a href="https://www.cms.gov/newsroom/press-releases/healthcaregov-enrollment-exceeds-15-million-surpassing-previous-years-milestones" rel="noopener noreferrer nofollow" target="_blank">announcement</a> that 15.3 million people had enrolled in health plans via HealthCare.gov through December 15, HealthSherpa <a href="https://blog.healthsherpa.com/over-6-million-people-secure-healthcare-coverage-through-healthsherpa/" rel="noopener noreferrer nofollow" target="_blank">announced</a> that 6.1 million of those enrollments were effected through its platform. </p><p>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:</p><ul><li><p>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.)</p></li><li><p>In HealthCare.gov states, brokers rely heavily on commercial <a href="https://www.cms.gov/marketplace/agents-brokers/direct-enrollment-partners" rel="noopener noreferrer nofollow" target="_blank">Direct Enrollment (DE) or Enhanced Direct Enrollment (EDE) platforms</a>, 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 <a href="https://www.cms.gov/files/document/ede-approved-partner.pdf" rel="noopener noreferrer nofollow" target="_blank">62 EDE entities</a>, thirteen are web brokers, the rest are insurers. The dominant EDE is HealthSherpa, which just <a href="https://x.com/GeorgeK_HS/status/1725204101561188483?s=20" rel="noopener noreferrer nofollow" target="_blank">announced</a> that it has already processed 2 million enrollments for 2024. In 2023, HealthSherpa <a href="https://blog.healthsherpa.com/healthsherpa-continues-to-be-the-largest-private-channel-for-aca-enrollments-in-the-us-insuring-over-5-million-people-for-2023-and-growing-more-than-50-year-over-year/" rel="noopener noreferrer nofollow" target="_blank">claimed</a> to have accounted for 35% of HealthCare.gov state enrollments; the company seems on track to exceed that share this year. </p></li></ul><p>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.<span></span></p><a name='more'></a><p></p><p data-pm-slice="1 1 []">Next question: what is HealthSherpa’s share of enrollment on all DE/EDE platforms? EDE has been rapidly replacing the older DE, which visibly re-directs enrollees to HealthCare.gov to process the application, but DE still exists. HealthSherpa was the first EDE platform approved by CMS, and <a href="https://www.healthsherpa.com/ede" rel="noopener noreferrer nofollow" target="_blank">claimed</a> a 90% share of EDE enrollments in 2021, but there are currently more than a dozen web-brokers on CMS’s <a href="https://www.cms.gov/files/document/ede-approved-partner.pdf" rel="noopener noreferrer nofollow" target="_blank">list of approved EDE providers</a> (along with about 50 insurers, most of which license HealthSherpa’s platform).</p><p>In February 2023, HealthSherpa <a href="https://blog.healthsherpa.com/healthsherpa-continues-to-be-the-largest-private-channel-for-aca-enrollments-in-the-us-insuring-over-5-million-people-for-2023-and-growing-more-than-50-year-over-year/" rel="noopener noreferrer nofollow" target="_blank">claimed</a> 35% of HealthCare.gov enrollment during OEP 2023, which comes to about 4.3 million (the 5.1 million in the topline of the post includes enrollments outside of OEP). The same post claims “about half” of active enrollment, which would suggest 4.8 million or a bit less. Very roughly, to the extent these (not quite congruent) claims are accurate, HealthSherpa is claiming about 80% of DE/EDE enrollment (5.5 million, per above) in 2023. If the company’s share held in 2024, that suggests about 7.5 million enrollments via DE/EDE through December 15, or 49% of total HealthCare.gov enrollment, and about 62% of active enrollment on the platform.</p><p><strong>Prepping EDE in state-based exchanges</strong></p><p>Through OEP 2024, DE/EDE has not been enabled in any of the state exchanges, which in 2023 accounted for 25% of enrollment nationally. That is about to change, and much of CMS’s 2025 Notice of Benefit and Payment Parameters (<a href="http://Payment" rel="noopener noreferrer nofollow" target="_blank">NBPP</a>) is devoted to establishing rules for state authorization and supervision of DE/EDE entities — in expectation that “current and future State Exchanges may seek to implement DE programs similar to the FFEs and SBE-FPs” (p. 157). (The NBPP also includes constant references to “an increasing number of consumers utilizing the DE pathways to enroll in coverage through the Exchanges” (p. 156)). The 2025 NBPP estimates that five states will opt to operate a web-broker program — i.e., enable DE/EDE platforms (p. 317). </p><p>In particular, Georgia, which has been granted <a href="https://www.messerfinancial.com/resources/news-blog/georgia-state-based-exchange-update" rel="noopener noreferrer nofollow" target="_blank">conditional approval</a> to launch a state exchange in 2025, after being denied approval to quick-start one in 2024, has <a href="http://file:///C:/Users/Andrew%20Sprung/Downloads/Georgia%20SBE%20Blueprint%20Letter%20for%20CMS_02.14.2023.pdf" rel="noopener noreferrer nofollow" target="_blank">expressed intent</a> to allow certified web brokers “to offer consumer shopping, plan selection and enrollment” (Sect. 2.10). </p><p>As Georgia had submitted a waiver proposal in the Trump years (rejected by the Biden administration) to do away with government-run exchanges altogether, Georgia’s stated readiness on this front may have something to do with CMS elaborating requirements that state-based exchanges essentially mirror CMS’s regulation and oversight of EDE — e.g., requirements that e-brokers provide complete and accurate information comparable to what is provided on the state exchange, update displays to include new information added by the exchanges, establish and prove operational integrity, and adhere to codes of conduct established for EDEs authorized to process HealthCare.gov applications. In sum:</p><blockquote><p>The NBPP proposes requiring state exchanges that authorize DE/EDE to “meet the same or, at a minimum, similar standards as are required in the FFEs and SBE-FPs to protect consumers. These safeguards focus on mitigating the potential for confusion between QHPs and non-QHPs (including the eligibility for APTC and/or CSR as it relates to QHPs versus non-QHPs) and as to which products are available through the Exchange and what products are not, ensuring proper eligibility determinations, protecting against security breaches or incidents through implementation of operational readiness reviews (as websites that have not been tested to see if they are operationally ready may provide improper eligibility determinations or may have security flaws that could make a breach involving consumer PII more likely) and through the other minimum Federal standards in § 155.221 that we propose to extend to State Exchanges and their DE entities” (p. 158).</p></blockquote><p>The NBPP devotes a good deal of attention to ensuring that DE/EDE platforms are not used for deceptive marketing than to ensuring operational integrity:</p><blockquote><p>As proposed to be applied in State Exchanges, web-brokers would be required to provide consumers with correct information, without omission of material fact, regarding the applicable State Exchange, QHPs offered through the applicable State Exchange, and insurance affordability programs. In addition, web-brokers who assist with or facilitate enrollment of qualified individuals, qualified employers, or qualified employees, in coverage in a manner that constitutes enrollment through a State Exchange, or assist individuals in applying for APTCs and CSRs for QHPs sold through a State Exchange, would also be required to refrain from marketing or conduct that is misleading (including by having a website that the State Exchange determines could mislead a consumer into believing they are visiting the State Exchange’s website), coercive, or discriminates based on race, color, national origin, disability, age, or sex (pp. 144-145).</p></blockquote><p>CMS supported the development of commercial ACA enrollment platforms from the get-go. In fact, the web-brokers-to-be provided something of a lifeline, <a href="https://xpostfactoid.blogspot.com/2013/11/who-needs-healthcaregov.html" rel="noopener noreferrer nofollow" target="_blank">at least informationally</a>, while HealthCare.gov and the state exchange were malfunctioning in the first months of the marketplace’s existence in late 2013. During the Trump years CMS encouraged DE/EDE development enthusiastically, along with promotion of flesh-and-blood brokers, and the Biden administration has provided continuity in this regard. </p><p>The market, in the form of participating insurers, also has supported brokerage in years following the nadir of insurer participation in 2018. Broker commissions, which according to a KFF <a href="https://www.kff.org/health-costs/state-indicator/health-insurance-broker-compensation/?currentTimeframe=7&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D" rel="noopener noreferrer nofollow" target="_blank">tracker</a> averaged $12.79 per member per month for new accounts in 2014, bottomed out at $9.73 per month in 2018. inched up a few cents PMPM in 2019, then jumped to $12.93 PMPM in 2020 and $15.16 in 2021, the last year tracked by KFF. Current <a href="https://www.enrollinsurance.com/aca-commissions" rel="noopener noreferrer nofollow" target="_blank">tracking</a> by Agility Insurance Services for 2024 shows rates in the $20-30 PMPM range (based on eyeballing, not any posted average).</p><p>In sum, CMS recognizes that ACA marketplace enrollment is predominantly broker-assisted and that EDE is an important tool for brokers. In fact the unavailability of EDE in state-based exchanges to date may be a factor in their <a href="https://xpostfactoid.substack.com/p/whats-up-with-the-state-based-marketplaces" rel="noopener noreferrer nofollow" target="_blank">lagging enrollment growth</a> during the pandemic years, though that is speculative. As more states launch their own exchanges — we’ve gone from 12 SBEs in 2018 to 19 this year — EDE enablement may prove to be a core functionality.</p><p><a href="https://www.pexels.com/photo/fresh-ripe-fruits-in-bowl-on-table-4397786/" rel="noopener noreferrer nofollow" target="_blank">Photo</a> by Karolina Grabowska </p><p><i><br /></i></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-50232241481537823652023-12-17T09:12:00.003-05:002023-12-17T11:15:14.351-05:00A "premium alignment" bill advances in NJ legislature<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9OoAUwPgb8KnEVdlG1z_Dqsdda653vUG2hx_OxkwwKOqyZgWM9YU6dmnYYhTJo2WmF89mXz-ly5wWy72GNocTHHbH6sZbs7rVk2FeWR-ZKJZU88BZRvCrNiul7Is9taq4aOXsLbWsXcbp7SySzZ4MAFfVN5xkomW7BOThpI74bIUt2xn034Unog/s980/WW.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="409" data-original-width="980" height="168" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9OoAUwPgb8KnEVdlG1z_Dqsdda653vUG2hx_OxkwwKOqyZgWM9YU6dmnYYhTJo2WmF89mXz-ly5wWy72GNocTHHbH6sZbs7rVk2FeWR-ZKJZU88BZRvCrNiul7Is9taq4aOXsLbWsXcbp7SySzZ4MAFfVN5xkomW7BOThpI74bIUt2xn034Unog/w400-h168/WW.png" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Will NJ's ACA marketplace glow as goldenly as its rest areas?</td></tr></tbody></table><br />In June, I <a href="https://pub.njleg.state.nj.us/Bills/2022/S4000/3896_I1.PDF" rel="noopener noreferrer nofollow" target="_blank">flagged a bill</a> introduced in the New Jersey legislature this past spring, <a href="https://pub.njleg.state.nj.us/Bills/2022/S4000/3896_I1.PDF" rel="noopener noreferrer nofollow" target="_blank">S3896/A5626</a>, 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.</p><p>The bill’s logic is simple (though it has a <a href="https://xpostfactoid.blogspot.com/2017/07/go-ahead-trump-cut-off-csr-payments.html" rel="noopener noreferrer nofollow" target="_blank">complicated back story</a>): 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.</p><p>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.</p><p>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.</p><p> - - -</p><p>TESTIMONY BEFORE SENATE BUDGET AND APPROPRIATIONS COMMITTEE<br />December 11, 2023<br /><br />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.</p><p>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 <em>37%</em> above the lowest-cost silver plan.<span></span></p><a name='more'></a> In Pennsylvania and Texas, two states that have taken measures similar to A5266, lowest-cost gold plans are priced well below lowest-cost silver plans, as shown below, and bronze plans are also a relative bargain. A5266 would correct a severe imbalance – and would follow several state governments (e.g., Pennsylvania, Maryland, Virginia, New Mexico, Colorado, and believe it or not, Texas) in making gold plans more affordable than the national average.<p></p><p><strong>Average Marketplace Premiums by Metal Tier, 2024 - </strong><a href="https://www.kff.org/health-reform/state-indicator/average-marketplace-premiums-by-metal-tier/?currentTimeframe=0&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D,%22states%22:%7B%22new-jersey%22:%7B%7D,%22texas%22:%7B%7D,%22pennsylvania%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D" rel="noopener noreferrer nofollow" target="_blank"><strong>KFF</strong></a><a href="#_edn1" rel="noopener noreferrer nofollow" target="_blank"><strong>[1]</strong></a><strong><br /></strong>Unsubsidized premiums for a 40 year-old</p><div class="captioned-image-container"><figure><a class="image-link image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":208,"width":486,"resizeWidth":null,"bytes":11935,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="208" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F73557464-56f9-499c-ab9a-9c218ffa5b4f_486x208.png 1456w" width="486" /></picture><div></div></div></a></figure></div><p>Gold plans (and bronze plans) matter most for middle-income enrollees – those with income above 200% of the Federal Poverty Level (in 2024, that’s $29,160 for an individual, $60,000 for a family of four). Below the 200% FPL threshold, silver plans (and only silver plans) come with Cost Sharing Reduction (CSR), which raises them to an effectively platinum coverage level (an actuarial value of 94% at incomes up to 150% FPL, and 87% at incomes in the 150-200% FPL range). New Jersey’s supplementary premium subsidies make the benchmark silver plan effectively free at incomes all the way up to 200% FPL, and silver plans are usually the best choice up to that income threshold. </p><p>Above the 200% FPL level, however, there is a benefit cliff. Silver plans with weak CSR (at incomes in the 200-250% FPL range) or no CSR (at incomes over 250% FPL) expose enrollees to much higher out-of-pocket costs than the average employer-sponsored plan.</p><p>In states that have taken measures similar to A5626, requiring insurers to price gold plans on a par with or below silver plans with the same provider network, enrollees with income above the 200% FPL threshold have the opportunity to reduce their out-of-pocket costs by choosing affordable gold plans. Those states include Pennsylvania and Texas. Compare the premium for the lowest-cost gold plan available in 2023 in three mid-size cities: Newark, Pittsburgh, PA, and Corpus Christi, TX:</p><p><strong>Lowest-Cost Gold Plan in three Mid-Sized Cities, 2024<br /></strong>Premium (after subsidy) for single 43 year-old, income $37,000/year</p><div class="captioned-image-container"><figure><a class="image-link image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":87,"width":640,"resizeWidth":null,"bytes":5739,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="87" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F6b03b2c8-e9a9-4a98-bf58-4b1a3267fc2d_640x87.png 1456w" width="640" /></picture><div></div></div></a></figure></div><p>Sources: GetCoveredNJ, Pennie, HealthCare.gov<a href="#_edn1" rel="noopener noreferrer nofollow" target="_blank">[2]</a></p><hr /><p>Next, consider the effect on metal level choice in these three states:</p><p><strong>Effects of Strictly Aligning Premiums with Actuarial Value – Or Not<br />ACA Marketplace, 2023</strong></p><p><strong>Gold Plan Selection at Incomes Above 200% of Federal Poverty Level, 2023</strong></p><div class="captioned-image-container"><figure><a class="image-link image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":104,"width":635,"resizeWidth":null,"bytes":9124,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="104" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F04b5ba90-cab3-4a83-a5dc-a4340d04fa57_635x104.png 1456w" width="635" /></picture><div></div></div></a></figure></div><p>Source: CMS <a href="https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files" rel="noopener noreferrer nofollow" target="_blank">Public Use Files</a><a href="#_edn1" rel="noopener noreferrer nofollow" target="_blank">[3]</a> for the ACA marketplace. Excluded: enrollees with income unknown. </p><p>A5626 would pull off a trifecta: It would align plan pricing more strictly with the value each plan offers to enrollees; it would make gold and bronze plans much cheaper for New Jersey enrollees; and it would effectively charge this benefit boost to the federal government. It would do this by ensuring that the full value of Cost Sharing Reduction, which most silver plan enrollees receive, is reflected in silver plan premiums.</p><p>In the first year of enactment, A5626 would require that silver plans be priced at the average actuarial value obtained by all silver plan enrollees in the state, including those for whom CSR boosts the AV from the baseline 70% to 73%, 87%, or 94% (the three CSR levels). In New Jersey, that means pricing silver plans roughly on par with gold plans, which have an AV of 80% (close to the average for employer-sponsored plans<a href="#_edn1" rel="noopener noreferrer nofollow" target="_blank">[4]</a>). In the second year, insurers would be required to price silver plans as if all enrollees obtained strong CSR – that is, to price silver as if the average AV were 90%, or platinum level -- well above gold’s 80% AV. That’s meant to be a self-fulfilling prophecy: If gold plans are cheaper than silver, then no one with an income above 200% FPL should buy silver plans, because gold AV is higher than silver AV at incomes above 200% FPL.</p><p>ACA premium subsidies are structured so that enrollees pay a fixed percentage of income for the benchmark (second cheapest) silver plan. When silver plan premiums rise, so do premium subsidies, rendering gold and bronze plans cheaper for enrollees. Those subsidies are funded entirely by the federal government. For those who are ineligible for subsidies, New Jersey offers silver plans off-exchange that do <em>not</em> price in the value of CSR. Thus the premium alignment mandated by A5626 is win-win-win for New Jersey enrollees, insurers, and the state budget.</p><p>Thank you for the opportunity to testify today. BlueWaveNJ is a grassroots group committed to helping secure economic justice and equal opportunity for all Americans and all New Jerseyans. We look forward to working with you to make health coverage more affordable for hundreds of thousands of New Jerseyans by passing A5626/S3896 into law. It is imperative to act now, while an administration is in place that will support this legislation.</p><hr /><p>Notes</p><p><a href="#_ednref1" rel="noopener noreferrer nofollow" target="_blank">[1]</a> KFF, Average Marketplace Premiums by Metal Tier, 2018-2024, <a href="https://www.kff.org/health-reform/state-indicator/average-marketplace-premiums-by-metal-tier/?currentTimeframe=0&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D,%22states%22:%7B%22new-jersey%22:%7B%7D,%22texas%22:%7B%7D,%22pennsylvania%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D" rel="noopener noreferrer nofollow" target="_blank">https://www.kff.org/health-reform/state-indicator/average-marketplace-premiums-by-metal-tier/?currentTimeframe=0&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D,%22states%22:%7B%22new-jersey%22:%7B%7D,%22texas%22:%7B%7D,%22pennsylvania%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D</a></p><p><a href="#_ednref1" rel="noopener noreferrer nofollow" target="_blank">[</a>2] See the plan-shopping tools offered by each exchange:</p><p><a href="https://www.nj.gov/getcoverednj/getstarted/compare/" rel="noopener noreferrer nofollow" target="_blank">https://www.nj.gov/getcoverednj/getstarted/compare/</a> <a href="https://enroll.pennie.com/hix/preeligibility#/" rel="noopener noreferrer nofollow" target="_blank">https://enroll.pennie.com/hix/preeligibility#/</a> <br /><a href="https://www.healthcare.gov/see-plans/#/" rel="noopener noreferrer nofollow" target="_blank">https://www.healthcare.gov/see-plans/#/</a></p><p><a href="#_ednref1" rel="noopener noreferrer nofollow" target="_blank">[3]</a> <a href="https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files" rel="noopener noreferrer nofollow" target="_blank">https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files</a></p><p>[<a href="#_ednref1" rel="noopener noreferrer nofollow" target="_blank">4]</a> See KFF, “What the Actuarial Values in the Affordable Care Act Mean” - 2011, <a href="https://www.kff.org/wp-content/uploads/2013/01/8177.pdf" rel="noopener noreferrer nofollow" target="_blank">https://www.kff.org/wp-content/uploads/2013/01/8177.pdf</a></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-18703554379642762402023-12-08T08:39:00.004-05:002023-12-10T16:55:19.560-05:00Still growing: OEP 2024 in the ACA marketplace<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRM6-A4Ay9kjhpKukjE2HB42fXqpXDkux5cyY2_N0LqEcU_N-Jyyv0qPhzr3hNVG5KeQWf70dbn3EuUivDpLzacrSdxOU7nAzPANbKZFGfXB98pEbKTwgy5lx5v2URpGPrSa4zxtizcNOoi3WpcE51JXOVZPd1PgLp_QWM1NDZStmfMXXronXMCg/s786/Ferdinand.webp" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="589" data-original-width="786" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRM6-A4Ay9kjhpKukjE2HB42fXqpXDkux5cyY2_N0LqEcU_N-Jyyv0qPhzr3hNVG5KeQWf70dbn3EuUivDpLzacrSdxOU7nAzPANbKZFGfXB98pEbKTwgy5lx5v2URpGPrSa4zxtizcNOoi3WpcE51JXOVZPd1PgLp_QWM1NDZStmfMXXronXMCg/s320/Ferdinand.webp" width="320" /></a></div><br /><p></p><p data-pm-slice="1 1 []">CMS’s Week 5 <a href="https://www.cms.gov/newsroom/fact-sheets/marketplace-2024-open-enrollment-period-report-national-snapshot-2" rel="noopener noreferrer nofollow" target="_blank">snapshot</a> 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 <a href="https://acasignups.net/23/12/06/2024-oep-state-state-actual-confirmed-qhps-108m-yy-changes-101-much-more" rel="noopener noreferrer nofollow" target="_blank">compilation</a>. 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.)</p><p>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.</p><p><strong> <span style="font-size: large;">OEP Week 5: 2023 vs. 2024</span></strong></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgx4yEzULB0CQr0lJxLXLY-jyfaext-QPwEr5KS9FAT8gBsNpCZktuqNm2uCbpkL7H69g9aBNhqeqBKTB8eY6k3rmCenvf-qmXLI6jrcIWd40VweQFmFxUVeOIsnHEPUsjsKCfXAYatYIFuF1B3Cr3eJDifetp8sxXe-JL1oGeZGt1KTSB4HGfyIg/s539/OEP%20week%205.webp" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="184" data-original-width="539" height="218" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgx4yEzULB0CQr0lJxLXLY-jyfaext-QPwEr5KS9FAT8gBsNpCZktuqNm2uCbpkL7H69g9aBNhqeqBKTB8eY6k3rmCenvf-qmXLI6jrcIWd40VweQFmFxUVeOIsnHEPUsjsKCfXAYatYIFuF1B3Cr3eJDifetp8sxXe-JL1oGeZGt1KTSB4HGfyIg/w640-h218/OEP%20week%205.webp" width="640" /></a></div><br /><span><a name='more'></a></span>Observations and speculations:<p></p><ol data-pm-slice="3 3 []"><li><p>While this is the third consecutive year of strong enrollment growth, still probably driven in part by the subsidy enhancements enacted in the American Rescue Plan Act (ARPA) in March 2021, this year’s growth needs to be viewed in the context of the Medicaid “unwinding” — that is the resumption in April 2023 of Medicaid “redeterminations” and disenrollments after a three-year pandemic-induced moratorium. As of August, about 800,000 of those disenrolled from Medicare had enrolled in QHPs. More broadly, CMS reported in the <a href="https://www.cms.gov/newsroom/press-releases/more-45-million-select-affordable-health-coverage-aca-marketplace-coverage-start-open-enrollment" rel="noopener noreferrer nofollow" target="_blank">Week 3 snapshot</a>, “Prior to the start of the 2024 OEP, approximately 1.5 million more people enrolled in Marketplace coverage nationwide from March to September 2023, compared to the same period in 2022.” Those new off-season enrollments have presumably swelled the pool of re-enrollees, while ongoing Medicaid disenrollments may be boosting new marketplace enrollments.</p></li><li><p>The stark apparent difference in growth rates between HealthCare.gov states and SBM states, while continuing a <a href="https://xpostfactoid.substack.com/p/whats-up-with-the-state-based-marketplaces" rel="noopener noreferrer nofollow" target="_blank">post-pandemic trend</a>, is somewhat skewed by a rocky debut for Virginia’s marketplace, which to this point is showing a 63% year-over-year decrease in active enrollment (from 88,405 to 32,951), though the state has also booked more than 300,000 auto re-enrollments. Discounting Virginia, the other SBMs are up 36.4% year-over-year — not wildly different from the HealthCare.gov average.</p></li><li><p>One might think that the pool of Medicaid disenrollees eligible for marketplace enrollment would be larger in expansion states, since eligibility depends simply on an income threshold that many may have crossed after the rapid economic recovery from the initial pandemic shock. On the other hand, the SBM states are mostly Democrat-run and probably tend on balance to exercise more due diligence in Medicaid redeterminations than the nonexpansion states and many expansion states on Healthcare.gov. The expansion states that use HealthCare.gov are more of a mixed bag politically, and their enrollment increase is closer to that of the nonexpansion states (39.7% vs. 42.8%).</p></li><li><p><br /></p></li><li><p><br /></p></li><li><p><br /></p></li><li><p>The SBM states are wealthier on balance. According to CMS’s <a href="https://data.medicaid.gov/dataset/9a83ba5e-05f5-47f5-82de-f3a59233a912" rel="noopener noreferrer nofollow" target="_blank">Marketplace Medicaid Unwinding Report</a> and <a href="https://data.medicaid.gov/dataset/5670e72c-e44e-4282-ab67-4ebebaba3cbd" rel="noopener noreferrer nofollow" target="_blank">SBM Medicaid Unwinding Report</a>, a much lower percentage of Medicaid disenrollees who seek marketplace coverage in the SBM states end up enrolling. Only about a third of SBM applicants deemed subsidy-eligible enrolled in QHPs, for some reason, and only about 20% of those determined eligible for QHPs with or without subsidy. In HealthCare.gov states, in contrast, 71% of those deemed QHP-eligible did enroll. That is frankly a pretty baffling discrepancy. In nonexpansion states, which make up the majority of HealthCare.gov enrollment (and the majority of enrollment growth nationwide), a large percentage of marketplace applicants are eligible for free or very low-cost, high-CSR silver coverage.* On the other hand, nine SBM states offer supplemental subsidies on top of federal ACA marketplace subsidies.<br /><br />5. During the pandemic years, the nonexpansion states (a shrinking pool) have accounted for <a href="https://xpostfactoid.substack.com/p/aca-marketplace-enrollment-in-states" rel="noopener noreferrer nofollow" target="_blank">the vast bulk</a> of marketplace enrollment growth. That’s true so far in this OEP, even though Florida and Texas, the behemoths driving enrollment growth in the post-ARPA era, are either below or right at the national average growth so far this OEP. Totals for the nonexpansion states (excluding North Carolina, which has expanded as of Dec. 1**) are below.<br /><br /> <b>OEP Week 5: 2023 vs. 2024 - Nonexpansion states</b></p><ol data-pm-slice="3 1 []"><li><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/d2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":297,"width":538,"resizeWidth":null,"bytes":22509,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="297" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fd2f1f686-2d68-4ffc-8d30-1cdda0fdbf2b_538x297.png 1456w" width="538" /></picture><div></div></div></a></figure></div><p>Four of the nine nonexpansion states are among the 12 states where, as Gaba notes, enrollment is more than 50% higher than the same point last year (with Alabama just below the threshold). Ten are on the federal exchange (TN, OH, WV, LA, IN, SC, AR, OK, GA, MO) and two are SBMs (DC and Rhode Island). See <a href="https://acasignups.net/23/12/07/2024-oep-state-state-actual-confirmed-qhps-108m-yy-changes-101-much-more" rel="noopener noreferrer nofollow" target="_blank">Gaba</a> for a complete listing of state enrollment tallies.</p><p></p><p>6. As I <a href="https://xpostfactoid.substack.com/p/where-and-how-do-aca-marketplace" rel="noopener noreferrer nofollow" target="_blank">noted recently</a>, the increased engagement of brokers in the marketplace, and brokers’ increased use of commercial Enhanced Direct Enrollment (EDE) platforms, may be facilitating enrollment growth. In 2023, more than 70% of active enrollments in HealthCare.gov states were broker-assisted. The dominant EDE, HealthSherpa, serving thousands of brokers and running a number of insurers’ direct enrollment platforms, <a href="https://x.com/GeorgeK_HS/status/1731796151194529792?s=20" rel="noopener noreferrer nofollow" target="_blank">claims</a> as of December 4 to have executed 4 million enrollments in HealthCare.gov states, or well more than half of the 6.5 million in HealthCare.gov states tallied through December 4 (up from <a href="https://blog.healthsherpa.com/healthsherpa-continues-to-be-the-largest-private-channel-for-aca-enrollments-in-the-us-insuring-over-5-million-people-for-2023-and-growing-more-than-50-year-over-year/" rel="noopener noreferrer nofollow" target="_blank">about 35% </a>in 2023). It appears that more enrollments are processed through HealthSherpa than directly on HealthCare.gov — or any other exchange. To date, no SBMs enable EDE or its predecessor DE (Direct Enrollment, which required a trip through HealthCare.gov for subsidy processing), while more than 80% of broker-assisted enrollments on HealthCare.gov are via DE or EDE.</p><p></p><p>7. Boosted by ARPA, the marketplace is approaching its intended purpose: covering most of those who lack access to other affordable insurance. It would be a real shame if the ARPA boosts were allowed to expire in 2026, as scheduled. It’s hard to see how they can be extended if Republicans retain the House or Senate, let alone the presidency. </p></li></ol><p>Postscript: Just for fun: if the ratio between the year-over-year increase in Week 5 and the YoY increase at the end of OEP this year is the same as last year (no real reason it should be - there are a lot of vagaries in the reporting), enrollment at the end of OEP for 2024 would be 20.9 million. Last year, Gaba <a href="https://acasignups.net/22/12/07/easiest-way-republicans-hurt-aca-exchange-enrollment-expand-medicaid" rel="noopener noreferrer nofollow" target="_blank">reported</a> the Week 5 YoY increase as 17.9%, but if he had adjusted for an extra day in OEP 2022 it would have been 21.6%, by my calculation. End-of-OEP enrollment was up 12.7%. If that ratio between Week 5 and end-of-OEP were to hold, enrollment this year would be up about 22.8% from 16,357,030 for OEP 2023.<br /><br />---</p><p>* In New York and Minnesota, low-income enrollees go to the states’ Basic Health Programs rather than to marketplace, and some 120,000 “unwinding” applicants have enrolled in the BHPs (vs. 181,000 in QHPs). The BHP enrollments don’t affect the reported percentages of QHP-eligibles who enroll. </p><p>** North Carolina will transfer marketplace enrollees with income below the 138% FPL Medicaid eligibility threshold to Medicaid.—-</p></li></ol>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-86878297990813251022023-11-21T16:51:00.003-05:002023-11-21T16:51:51.463-05:00Update: Ending presumed Medicare eligibility for New Jersey's elder ACA marketplace enrollees<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOZkFzzrxxZs-6PTqKcSG255lO9jqpRTG4852G9xK36zVcU6UcOBbUxezuPaqOEVriUpDLaG8lmh-LmwnWlcVv0xaOmQzHp9dL2LvZqYxW-N45bCSHSCRDMSuh-t71_5dOE4SEeqxOfWoCRastiuPH1iIbxIkHebneUUuvQJobwruQNhvf2mCSnw/s331/Catch%2022.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="331" data-original-width="236" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOZkFzzrxxZs-6PTqKcSG255lO9jqpRTG4852G9xK36zVcU6UcOBbUxezuPaqOEVriUpDLaG8lmh-LmwnWlcVv0xaOmQzHp9dL2LvZqYxW-N45bCSHSCRDMSuh-t71_5dOE4SEeqxOfWoCRastiuPH1iIbxIkHebneUUuvQJobwruQNhvf2mCSnw/s320/Catch%2022.png" width="228" /></a></div><br /><p></p><p data-pm-slice="1 1 []">I’d like to provide a couple of updates regarding an abuse in New Jersey’s individual market that I wrote about in September (<a href="https://xpostfactoid.substack.com/p/new-jerseys-dobi-lays-a-trap-for" rel="noopener noreferrer nofollow" target="_blank">here</a> and <a href="https://xpostfactoid.substack.com/p/dobi-responds-but-not-to-me-no-more" rel="noopener noreferrer nofollow" target="_blank">here</a>). 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.</p><p data-pm-slice="1 1 []"><span><br /></span>As I <a href="https://xpostfactoid.substack.com/p/new-jerseys-dobi-lays-a-trap-for" rel="noopener noreferrer nofollow" target="_blank">reported</a>, in May 2023 CMS issued <a href="https://www.cms.gov/files/document/benefit-coordination-and-medicare-eligibility.pdf" rel="noopener noreferrer nofollow" target="_blank">guidance</a> 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 <a href="https://www.nj.com/news/2023/09/a-mistake-may-have-cost-seniors-thousands-in-healthcare-costs-nj-is-fixing-it.html" rel="noopener noreferrer nofollow" target="_blank">article</a> and in my <a href="https://xpostfactoid.substack.com/p/dobi-responds-but-not-to-me-no-more" rel="noopener noreferrer nofollow" target="_blank">followup post</a>) 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.</p><span><a name='more'></a></span><p data-pm-slice="1 1 []">DOBI told Mueller it had instructed all carriers to review the benefits of any individual who is enrolled in a 2023 individual marketplace plan and is age 65 or older to ensure that the policyholders are receiving the appropriate coverage, and that all coverage is consistent with the applicable Federal Guidance. DOBI said it was “working to determine how each carrier implemented the board’s rule change both on and off the marketplace and any possible consumer impact.” Finally, DOBI stated that it would ask the Independent Health Coverage Program (IHC) board (an independent entity) to rescind the provision in the 2024 standard individual market plans.</p><p>Now, as to updates:</p><p> 1. In the case a New Jersey marketplace enrollee over age 65 with which I’m personally familiar, AmeriHealth has in fact been adjusting 2023 provider bills one by one, paying providers as primary rather than secondary insurer, erasing thousands of dollars in the “my cost” column in the claims summary provided to the enrollee. </p><p>2. In October, several advocacy groups that are part of the New Jersey for Health Care Coalition sent a letter to DOBI inquiring about followup and enforcement of DOBI’s September 27 directive. The letter expressed concern that while DOBI’s directive went out in September, the standard contract enabling presumption of Medicare eligibility had been in effect throughout 2023 — and the practice of presuming Medicare eligibility in 65 enrollees, as DOBI informed Mueller, has been going on since at least 2016. In response, DOBI specified that the September directive was for the entirety of plan year 2023, retroactive to Jan 1, 2023. That does leave open the question of harm to enrollees for whom New Jersey IHC insurers acted as secondary to Medicare in prior years. DOBI’s letter also clarified what should have been obvious: an eligibility determination by the state ACA exchange, GetCoveredNJ, entitles an enrollee to the full benefits of the policy selected. Insurers never had any business assuming otherwise — but the IHC board allowed them to.</p><p> 3. Some time in the last few days, the IHC Board published <a href="https://nj.gov/dobi/division_insurance/ihcseh/rules/ihc231116/AR11_20_2023proposal.pdf" rel="noopener noreferrer nofollow" target="_blank">proposed amendments</a> to the standard IHC contracts for 2024. The document does propose rescinding insurers’ ability to act as a secondary payer to Medicare upon presumption of Medicare eligibility:</p><blockquote><p>In accordance with guidance released by the United States Centers for Medicare & Medicaid Services (CMS) in May 2023, the Board proposes amendments which state that in the absence of enrollment in other primary coverage, such as Medicare, a standard plan will not take that other coverage into account when paying for covered services or supplies.* In addition, the Board proposes language mandating that a standard plan will not limit or exclude coverage based on eligibility for other coverage and that coordination of benefits occurs only when the Covered Person is enrolled in other coverage (p. 3).</p></blockquote><p>The <a href="https://nj.gov/dobi/division_insurance/ihcseh/rules/ihc231116/AR11_20_2023AppendixA.pdf" rel="noopener noreferrer nofollow" target="_blank">standard contract</a> for 2024 states that eligibility for Medicare, let alone presumed eligibility for Medicare, will not preclude the IHC insurer acting as the primary payer:</p><blockquote><p>In the absence of enrollment in other primary coverage, such as Medicare, We will not take that other coverage into account when paying for covered services or supplies. We will not limit or exclude coverage based on eligibility for other coverage. Coordination of benefits occurs only when the Covered Person is enrolled in other coverage (p. 121).</p></blockquote><p>Eligibility for Medicare without enrollment could come into play for people who use the full 6-month window for enrollment in Medicare at age 65, as that window extends three months beyond the month in which one turns 65 (and many people pay much less for coverage in the ACA marketplace than they will for Medicare). The more harmful effect of the now-rescinded secondary payer practice was the <em>presumption</em> of Medicare eligibility at age 65, as a significant number of seniors lack the ten years of taxpaying work history (or marriage to someone with that work history) required for premium-free Medicare Part A coverage. Citizens and legally present noncitizens who are not entitled to free Part A coverage are eligible for ACA marketplace subsidies — and so for full coverage in the marketplace. I suspect, though I lack data, that most U.S. residents over age 65 who are not eligible for free Part A coverage are immigrants.</p><p> - - - </p><p>* The language here — can’t take the coverage a person doesn’t have into account — recalls the “logic” that runs through <a href="https://www.goodreads.com/quotes/418411-just-what-the-hell-did-you-mean-you-bastard-when" rel="noopener noreferrer nofollow" target="_blank"><em>Catch 22</em></a>:</p><blockquote><p>"I didn't say you couldn't punish me, sir."</p><p>"When," asked the colonel.</p><p>"When what, sir?"…</p><p>"When didn't you say we couldn't punish you?…</p><p>Clevinger took a deep breath. "I always didn't say you couldn't punish me, sir.”</p></blockquote><p></p><p data-pm-slice="1 1 []"><span></span></p><!--more--><p></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-75516102362699777512023-11-17T12:40:00.001-05:002023-11-17T12:40:59.739-05:00Where and how do people find plans in the ACA marketplace?<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgWtRcWFxDeMLsxGqEagfoEw2WsSNIXdQ2AmYDBCl7GwHZXNCU9thoc0oLBZUs83BH8KraXdY22zFMDS1fYF9VBqXMUIdxErb4NgKZXoKwuLlZeS0IFiyWi0nOqP-RxnaJCm3c7U5SUu6kUtOE_F1ZUcNOBat1-RHLis5Qy0CvfmZIa7MRGbV6IlQ/s521/Other%20door.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="521" data-original-width="409" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgWtRcWFxDeMLsxGqEagfoEw2WsSNIXdQ2AmYDBCl7GwHZXNCU9thoc0oLBZUs83BH8KraXdY22zFMDS1fYF9VBqXMUIdxErb4NgKZXoKwuLlZeS0IFiyWi0nOqP-RxnaJCm3c7U5SUu6kUtOE_F1ZUcNOBat1-RHLis5Qy0CvfmZIa7MRGbV6IlQ/s320/Other%20door.png" width="251" /></a></div><br /><p></p><p data-pm-slice="1 1 []">On October 1, 2013, the day the ACA exchanges first opened for business, President Obama <a href="https://www.nbcnews.com/politics/politics-news/obama-hails-opening-health-insurance-marketplace-admits-some-glitches-flna8c11310916" rel="noopener noreferrer nofollow" target="_blank">promised</a> 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.” </p><p>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.</p><p>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?</p><p>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 <a href="https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/Agents-and-Brokers-in-the-Marketplace.pdf" rel="noopener noreferrer nofollow" target="_blank">2019</a>). 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 <a href="https://www.kff.org/private-insurance/issue-brief/data-note-further-reductions-in-navigator-funding-for-federal-marketplace-states/" rel="noopener noreferrer nofollow" target="_blank">was cut </a>from $63 million in 2016 to $10 million by 2018, then restored to about $100 million in 2022).<br /><span></span></p><span><a name='more'></a></span><p data-pm-slice="1 1 []">To get a sense of how marketplace enrollees find coverage, it’s worth keeping these points in mind:</p><ul><li><p>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.)</p></li><li><p>In HealthCare.gov states, brokers rely heavily on commercial <a href="https://www.cms.gov/marketplace/agents-brokers/direct-enrollment-partners" rel="noopener noreferrer nofollow" target="_blank">Direct Enrollment (DE) or Enhanced Direct Enrollment (EDE) platforms</a>, which can process enrollments with subsidies (EDE directly; DE via a redirect to hc.gov for the subsidy calculation). 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 <a href="https://www.cms.gov/files/document/ede-approved-partner.pdf" rel="noopener noreferrer nofollow" target="_blank">62 EDE entities</a>, thirteen are web brokers, the rest are insurers. The dominant EDE is HealthSherpa, which just <a href="https://x.com/GeorgeK_HS/status/1725204101561188483?s=20" rel="noopener noreferrer nofollow" target="_blank">announced</a> that it has already processed 2 million enrollments for 2024. In 2023, HealthSherpa <a href="https://blog.healthsherpa.com/healthsherpa-continues-to-be-the-largest-private-channel-for-aca-enrollments-in-the-us-insuring-over-5-million-people-for-2023-and-growing-more-than-50-year-over-year/" rel="noopener noreferrer nofollow" target="_blank">claimed</a> to have accounted for 35% of HealthCare.gov state enrollments; the company seems on track to exceed that share this year. It’s possible that HeathSherpa processes more marketplace enrollments than any government-run exchange (assuming that other EDEs also have a substantial share of HealthCare.gov enrollment). To my eye, HealthSherpa is by far the easiest exchange to navigate and the clearest in presenting essential information.</p></li><li><p>In the California exchange, which accounted for 10% of national on-exchange enrollment in 2023, 58% of enrollees were broker-assisted, and another 7% were assisted by nonprofit Certified Enrollment Counselors, Service Center Representatives at the exchange, or other assisters. (See the 2023 Open Enrollment and Renewal Gross Plan Selection Profile, <a href="https://hbex.coveredca.com/data-research/" rel="noopener noreferrer nofollow" target="_blank">here</a>.)</p></li><li><p>In New York in 2023, according to a presentation by New York State of Health, the state exchange, 76% of enrollees were helped either by brokers or by nonprofit assisters. In Maryland, as of <a href="https://www.marylandhbe.com/wp-content/uploads/2023/11/Executive-Report-as-of-10.31.23.pdf" rel="noopener noreferrer nofollow" target="_blank">October 2023</a>, 36% of active enrollees (new or plan-changing renewals) self-served; the rest were assisted by brokers, navigators or the state exchange call center. In <a href="https://c4-media.s3.amazonaws.com/wp-content/uploads/2023/03/31121205/By-the-Numbers-final-OE10.pdf" rel="noopener noreferrer nofollow" target="_blank">Colorado</a> in OEP 2023, 62% of enrollments were broker-assisted. In <a href="https://agency.pennie.com/wp-content/uploads/2023/10/Pennie-Annual-Report-2022-Final.pdf" rel="noopener noreferrer nofollow" target="_blank">Pennsylvania</a> in OEP 2023, just 44% of enrollments were through brokers [CO and PA added 11/17/23].</p></li><li><p>Back in 2016, a <a href="https://www.kff.org/report-section/2016-survey-of-health-insurance-marketplace-assister-programs-and-brokers-section-2-in-person-assistance-during-open-enrollment/" rel="noopener noreferrer nofollow" target="_blank">KFF analysis</a> tracked an ecosystem of certified nonprofit enrollment assistance that nationally deployed 34,000 assisters who said they helped 5.3 million people (many of whom likely ended up in Medicaid) in OEP 2016. These included members of the Navigator program, funded by CMS in Healthcare.gov states (with $63 million in 2016); assisters in Federally Qualified Health Centers, funded with a portion of each FQHC’s federal funding (about $150 million that year); and Certified Application Counselor programs, funded privately or in some cases by states. While Navigator funding was cut to $10 million by the Trump administration by 2018 and refunded by the Biden administration to <a href="https://www.aha.org/news/headline/2023-09-05-cms-awards-navigator-grants-plan-year-2024" rel="noopener noreferrer nofollow" target="_blank">$98.6 million</a> for OEP 2024, navigators account for only a fraction — albeit an important, often coordinating fraction — of nonprofit, government-certified enrollment assistance (funding for enrollment assistance in FQHCs has always been larger). As far as I know, no one has tracked the development or metamorphosis of this system since KFF in 2016.</p></li><li><p>About 1-2 million unsubsidized enrollees in ACA-compliant plans still enroll off-exchange, which also means off-EDE.</p></li></ul><p>None of this is to suggest that the public faces of HealthCare.gov and the state exchanges are irrelevant. A substantial minority of enrollees do enroll unassisted. A significant percentage of broker- and navigator- or CAC-assisted enrollees find their broker or assister on the government sites. (A <a href="https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/Help-On-Demand-Marketplace-Updates.pdf" rel="noopener noreferrer nofollow" target="_blank">2019 CMS report</a> boasted that 15% of brokers serving the marketplace participated in the <a href="https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/Help-On-Demand-Overview.pdf" rel="noopener noreferrer nofollow" target="_blank">Help on Demand</a> program that the Trump administration, which boosted brokers while all but defunding and <a href="https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-07-10-2.html" rel="noopener noreferrer nofollow" target="_blank">denigrating</a> navigators, initiated on HealthCare.gov. The Biden administration has <a href="https://xpostfactoid.blogspot.com/2021/11/under-biden-healthcaregov-maintains-its.html" rel="noopener noreferrer nofollow" target="_blank">maintained this program</a>, and participation has doubtless expanded considerably.) Brokers and enrollment assisters share screens with clients, in various ways and to varying degrees (though brokers, I imagine, are likelier to share information from EDE platforms). About 10 of the states running their own exchanges offer supplemental state-based subsidies or other state initiatives that can only be accessed via the state exchange, and none of them to date enable processing via EDE. Finally, the exchanges are the final, ultimate authority for complete and accurate listings of all offerings in all markets.</p><p>Nonetheless, it’s important to keep in mind that most enrollees in ACA-compliant plans do not navigate the plan selection and enrollment process soup-to-nuts via HealthCare.gov or the state exchanges. As <a href="https://www.kff.org/health-reform/report/2022-survey-of-aca-marketplace-assister-programs-and-brokers/" rel="noopener noreferrer nofollow" target="_blank">survey data</a> indicates that most consumers’ understanding of insurance terms and plan features is quite incomplete, it’s good that most enrollees access assistance. As to the quality of that assistance in brokerages large and small — that’s a different inquiry.</p><p></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-52194233877997620422023-11-09T14:38:00.001-05:002023-11-09T14:38:25.474-05:00Unwinding to the marketplace in Maryland<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0Mxf3RAE6-cx6r75EK4PiCfqnPSAJTtI0O8I4M8u6swVhyphenhyphenHfj091NtJpuhlATKtWL-cP62Tq38uZDlIXWTppwhoVdWGkc93lrNxIuWq-i-zfBse-gWChZX5eW-jFs138Xu5knCwsHnRvrV2fonncKJk1KfOL8Jb-vbdm7BojGhoIbIuEPC5ylKQ/s1125/on%20laptop.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="750" data-original-width="1125" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0Mxf3RAE6-cx6r75EK4PiCfqnPSAJTtI0O8I4M8u6swVhyphenhyphenHfj091NtJpuhlATKtWL-cP62Tq38uZDlIXWTppwhoVdWGkc93lrNxIuWq-i-zfBse-gWChZX5eW-jFs138Xu5knCwsHnRvrV2fonncKJk1KfOL8Jb-vbdm7BojGhoIbIuEPC5ylKQ/s320/on%20laptop.jpeg" width="320" /></a></div><br /><p></p><p data-pm-slice="1 1 []">In October, CMS <a href="https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/data-reporting/monthly-data-reports/index.html" rel="noopener noreferrer nofollow" target="_blank">reported</a> that of the roughly <a href="https://www.medicaid.gov/sites/default/files/2023-10/july-2023-national-summary-renewal-outcomes.pdf" rel="noopener noreferrer nofollow" target="_blank">5.5 million</a> 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. </p><p>As Charles Gaba <a href="https://acasignups.net/23/11/08/cms-report-680k-those-kicked-medicaid-enrolled-aca-exchange-plans-or-bhps-thru-july-updated" rel="noopener noreferrer nofollow" target="_blank">notes</a>, 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 <a href="https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-unwinding-tracker/" rel="noopener noreferrer nofollow" target="_blank">KFF’s estimate</a> may have ended up in the ACA marketplace. According to <a href="https://ccf.georgetown.edu/unwinding-enrollment-data/" rel="noopener noreferrer nofollow" target="_blank">tracking</a> by Georgetown’s Center for Children and Families, as of October, based on the most recent state reports ranging from July to September, <em>net</em> 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.</p><p>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 <a href="https://www.marylandhbe.com/news-resources/reports-data/" rel="noopener noreferrer nofollow" target="_blank">monthly reports</a>. 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.<span><br /></span></p><a name='more'></a><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEig0m9p-CPd15ddb9v7IfGMmyp9JUIoRRe-0K_s-XGo1yV1N615dRB17-qGIUzmsCwDWLUgFkb2kFLfxpO8qEEk8Sq1I9EGS-yEx_LOgXmKql2CyqxdiRQkyuJlDWV8p6WKIwGHLM5CsvdvhJ2V0sErNyXsj_63w0pw9lx9h94n9WUrE2QNSLc1sw/s654/Maryland%20marketplace%20unwinding.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="216" data-original-width="654" height="212" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEig0m9p-CPd15ddb9v7IfGMmyp9JUIoRRe-0K_s-XGo1yV1N615dRB17-qGIUzmsCwDWLUgFkb2kFLfxpO8qEEk8Sq1I9EGS-yEx_LOgXmKql2CyqxdiRQkyuJlDWV8p6WKIwGHLM5CsvdvhJ2V0sErNyXsj_63w0pw9lx9h94n9WUrE2QNSLc1sw/w640-h212/Maryland%20marketplace%20unwinding.png" width="640" /></a></div><p></p><p data-pm-slice="1 1 []">According to the Georgetown <a href="https://ccf.georgetown.edu/unwinding-enrollment-data/" rel="noopener noreferrer nofollow" target="_blank">disenrollment tracker</a>, net Medicaid enrollment in Maryland dropped by 60,529 from May through September 2023. The state marketplace tallies above show that marketplace enrollment increased by a net 19,334 from May through September. The ratio of net marketplace increase to net Medicaid decrease in Maryland appears to be considerably higher than in the country as a whole. That’s not surprising: Maryland state agencies, according to Stewart, are oriented toward maximizing coverage.</p><p>In a conversation last week, Stewart told me that his organization works closely with local officials in the Maryland Department of Health; enrollment officials can contact Medicaid supervisors and caseworkers directly and troubleshoot problems in real time. Unlike in most states, Maryland Health Connection, the state ACA exchange, not only processes Medicaid enrollments directly — it is also the primary vehicle for Medicaid applications. An integrated platform for enrollment in a wide array of government benefits, <a href="https://mymdthink.maryland.gov/home/#/" rel="noopener noreferrer nofollow" target="_blank">MDThink</a>, is scheduled for full implementation in early 2025.</p><p>The fact that marketplace and Medicaid enrollment are in the same system, Stewart said via email, </p><blockquote><p>helps us with things like procedural drops (when the system incorrectly takes someone out of MA [Medical Assistance, the Maryland term for Medicaid]. Health Department, Social Services case workers and my navigators all have access to the same information. It helps tremendously when resolving problems for a particular person. Case workers can take an application all the way to plan selection and hand off to us. We do the same for MA cases and hand off to them when it is a more complicated case…</p><p>Because Medicaid and QHPs are in the same system, collaboration between navigators and case workers is easy. We can read each other’s case notes for example. We can see who last worked with a consumer. And while case workers do not assist with QHP plan selection, it is incredibly helpful for my navigators to receive an application which is ready for plan selection. We know we can trust the work of the HD. This year with the “unwinding” everybody in the system is experiencing much higher appointment volumes. It saves us precious time. The advantages of being in the same system are born out every day.</p></blockquote><p>That Medicaid case workers will “take an application all the way to plan selection” indicates a level of administrative support and system integration that I believe is quite rare in this country. According to the CMS’s <a href="https://data.medicaid.gov/dataset/5670e72c-e44e-4282-ab67-4ebebaba3cbd" rel="noopener noreferrer nofollow" target="_blank">State-based Marketplace Unwinding Report</a>, Maryland is one of four states (with CA, MA and RI) enabling “automatic QHP selection” in the unwinding — though according to Stewart, the state Health Department completes the application but does not select/enroll the applicant in a particular plan. Through July, according to CMS data, more than 8,000 enrollments in Maryland were automatic.</p><p>This is not to imply that the unwinding in Maryland is smooth sailing, or that state systems are glitch free. The state has had its share of “procedural drops” — for example, dropping a whole family when one member is found ineligible. But at least in the rural counties Stewart works in, the Health Department will respond promptly when such a drop is brought to their attention and swiftly restore coverage, which in such cases is retroactive. “The environment is pretty pro health insurance,” Stewart says. </p><p>One mystery in CMS’s tracking of Medicaid-to-marketplace conversions is the extremely low percentage of subsidy eligibility in some state-based marketplaces among those who are disenrolled from Medicaid and seek marketplace coverage. Maryland is among them: only 41% of Medicaid “unwinding” disenrollees determined eligible for marketplace coverage are eligible for subsidies (see Gaba’s chart <a href="https://acasignups.net/23/11/08/cms-report-680k-those-kicked-medicaid-enrolled-aca-exchange-plans-or-bhps-thru-july-updated" rel="noopener noreferrer nofollow" target="_blank">here</a>). Other states with a low subsidy-eligible ration are Kentucky (25%), Vermont (43%), California (45%) and Minnesota (47%). Nationally, the percentage of “unwinding” applicants deemed marketplace eligible who are also subsidy eligible is 74%. During the Open Enrollment Period (OEP) for 2024 coverage, the percentage was 86% for all states, and 73% in SBM states. As Gaba points out, the subsidy-eligible percentage is much higher in the states that have refused to enact the ACA Medicaid expansion, all of which use the federal exchange, HealthCare.gov. In Florida, 91% of Medicaid disenrollees deemed eligible for marketplace coverage are subsidy-eligible, as are 86% in Texas. Those two states together account for 32% of “unwinding” enrollees.</p><p>Marketplace applicants can be ineligible for subsidies mainly for two reasons: unsubsidized benchmark coverage (the second-cheapest silver plan) costs less than 8.5% of their household income, or they have access to other coverage deemed affordable, usually employer-sponsored coverage. In the unwinding, a higher percentage of enrollees are subsidy-ineligible than in OEP for 2023; ; in Maryland, the gap is particularly wide — 59% ineligible for subsidies in the unwinding vs. 39% in OEP. It may be that a substantial number of people with considerable earning power who lost jobs early in the pandemic were “frozen” in Medicaid and now earn too much to qualify for marketplace subsidies. Maryland does have the third-lowest average benchmark premiums in the nation ($346/month for a 40 year-old, vs. $477/month nationally). In Baltimore, a 26 year-old earning $40,000, or a 30 year-old earning $44,000 annually, would be ineligible for subsidies. Many may also report that they are eligible for employer-sponsored coverage, though it’s unclear why that percentage would be higher than in OEP.</p><p>If anyone has other ideas as to why so many Medicaid disenrollees who apply for marketplace coverage are not subsidy eligible, please let me know.</p><p data-pm-slice="1 1 []">Photo by <a class="Link_link__mTUkz clickable_clickable__Klxi1 spacing_noMargin__Q_PsJ" href="https://www.pexels.com/@ketut-subiyanto/" rel="nofollow" target="_blank"><strong>Ketut Subiyanto</strong></a></p><p><br /></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-44414600199927036342023-10-28T08:08:00.001-04:002023-10-28T08:08:24.542-04:00Walking the crosswalk: CMS seeks to boost CSR takeup<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOLrFAuTm7jMeifkKZ-kFfv3_qQmrVvoq65iQFiR7rMzIL5Dqv4J_AOYDlCauTlVn_CHjMK6zaSYzgs0gfYAJf7kRwESSYo57k7vph3T_1aIY7TcUSkZ1t50E25xymupkxZFT_z4oaXxljyomKM6ZEi4c96BD3uW-OT9tEBhH51iiJ7VjTUap8WA/s1941/Egyptians.webp" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1941" data-original-width="1456" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOLrFAuTm7jMeifkKZ-kFfv3_qQmrVvoq65iQFiR7rMzIL5Dqv4J_AOYDlCauTlVn_CHjMK6zaSYzgs0gfYAJf7kRwESSYo57k7vph3T_1aIY7TcUSkZ1t50E25xymupkxZFT_z4oaXxljyomKM6ZEi4c96BD3uW-OT9tEBhH51iiJ7VjTUap8WA/s320/Egyptians.webp" width="240" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Let us lead you</td></tr></tbody></table><p data-pm-slice="1 1 []">When full enrollment data for the ACA marketplace in 2023 came out last spring, I <a href="https://xpostfactoid.substack.com/p/underinsurance-spikes-among-low-income" rel="noopener noreferrer nofollow" target="_blank">expressed concern</a> 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.</p><p>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.)</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiGU_U_mPmBAY15n15dXh-cqpY74SuqVwYfHDisaIheQAyprCA1053UvKGylTFQxTsoRhMN514eiSUHhJDqwDcKNrnadEcjWNVx75_ClfE0Ll2eEBXz-1wZsZGeHHK8b5Do1Xt3lLt0KYsOl2UZSjVXd29agGctpAEAiNNfIHfZ7nsIhP8xkIyNQ/s629/CSR%20takeup.webp" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="453" data-original-width="629" height="460" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiGU_U_mPmBAY15n15dXh-cqpY74SuqVwYfHDisaIheQAyprCA1053UvKGylTFQxTsoRhMN514eiSUHhJDqwDcKNrnadEcjWNVx75_ClfE0Ll2eEBXz-1wZsZGeHHK8b5Do1Xt3lLt0KYsOl2UZSjVXd29agGctpAEAiNNfIHfZ7nsIhP8xkIyNQ/w640-h460/CSR%20takeup.webp" width="640" /></a></div><p data-pm-slice="1 1 []">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). </p><p>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 <a href="https://xpostfactoid.substack.com/p/forgoing-high-csr-silver-coverage" rel="noopener noreferrer nofollow" target="_blank">eyes wide open</a>. </p><p>Another possible cause of lower CSR takeup may be sheer confusion, as the number of plans on offer in most markets has <a href="https://xpostfactoid.substack.com/p/cms-proposes-cleaning-out-an-augean" rel="noopener noreferrer nofollow" target="_blank">proliferated to a ridiculous extent</a>, 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.</p><p>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 <a href="https://www.cms.gov/newsroom/fact-sheets/marketplace-plan-year-2024-open-enrollment-fact-sheet" rel="noopener noreferrer nofollow" target="_blank">undertaken</a>* to push some low-income bronze plan enrollees into CSR silver:</p><hr /><blockquote><p>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.</p></blockquote><p>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.</p><p>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.</p><p><strong>How many enrollees may be affected by the CSR cross-walk?</strong></p><p>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. </p><p>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. </p><p>In 2023, the total number of <em>re</em>-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.</p><p><strong>We’ve been here before</strong></p><p>Covered California, the largest of the state exchanges, enacted the crosswalk to CSR silver in 2022, <a href="https://board.coveredca.com/meetings/2021/June/Policy.and.Action-June.2021-Final.pdf" rel="noopener noreferrer nofollow" target="_blank">estimating</a>*** 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 <a href="https://xpostfactoid.blogspot.com/2022/04/auto-upgrading-in-covered-california.html" rel="noopener noreferrer nofollow" target="_blank">looked at the results</a> 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).</p><p>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.</p><p>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.</p><p><strong>Do brokers need a prompt?</strong></p><p>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 <s>or nonprofit enrollment assisters</s> 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 “<a href="https://www.cms.gov/marketplace/agents-brokers/direct-enrollment-partners" rel="noopener noreferrer nofollow" target="_blank">Direct Enrollment” or “Enhanced Direct Enrollment”</a>), not the HealthCare.gov interface. HealthSherpa, the largest e-broker, alone accounted for <a href="https://blog.healthsherpa.com/healthsherpa-continues-to-be-the-largest-private-channel-for-aca-enrollments-in-the-us-insuring-over-5-million-people-for-2023-and-growing-more-than-50-year-over-year/" rel="noopener noreferrer nofollow" target="_blank">35% of enrollments</a> 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.</p><p> - - -</p><p>* A crosswalk to silver from dominated plans was proposed in a 2021 <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2782057" rel="noopener noreferrer nofollow" target="_blank">article</a> by David M. Anderson, Petra W. Rasmussen and Coleman Drake.</p><p>** 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. </p><p>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.</p><p>*** 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:</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIqQ-1zhXh0fag_Ao1XDJytJRXUS5UbiMF4wTtKU5GbAuzZNVXcbsVa1l-5Cqp9_0zb29tjC7KPSIl0ngUQQdIFk-Kq8AyAqNrheULlt159MKorhA94sqmAFmFQC7-G5ZY9uZojYUVgUUJfpVD_o_ZRfompmGzz6SZBWL7-WWvNZFhoeJf7Ys8Hg/s447/HS%20prompt.webp" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="447" data-original-width="404" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIqQ-1zhXh0fag_Ao1XDJytJRXUS5UbiMF4wTtKU5GbAuzZNVXcbsVa1l-5Cqp9_0zb29tjC7KPSIl0ngUQQdIFk-Kq8AyAqNrheULlt159MKorhA94sqmAFmFQC7-G5ZY9uZojYUVgUUJfpVD_o_ZRfompmGzz6SZBWL7-WWvNZFhoeJf7Ys8Hg/s320/HS%20prompt.webp" width="289" /></a></div><br /><p><br /></p><p><br /></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-24923058357064217752023-10-05T13:04:00.004-04:002023-10-28T08:00:20.402-04:00Enrollment at ages 65 and up in the ACA marketplace has nearly tripled since 2017<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJYYhYi2fCMLl99e6_gnwrCxlzlX6Ix1I4Eqd3LY9bTYf6_EAUeULbE6l0PbIQhEeqoi3YDrqcx9N-k7p-MEchn0xV_7qY3No3rOtUuooCRQ_JbAqudiEPHtWhna5ZIcsAyoSSPDFuXA_fYE6WB7gdvI9UWkiRC3uNxRzSAazi0kvvGo_st1olRg/s5760/pexels-kampus-production-7983579.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="3840" data-original-width="5760" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJYYhYi2fCMLl99e6_gnwrCxlzlX6Ix1I4Eqd3LY9bTYf6_EAUeULbE6l0PbIQhEeqoi3YDrqcx9N-k7p-MEchn0xV_7qY3No3rOtUuooCRQ_JbAqudiEPHtWhna5ZIcsAyoSSPDFuXA_fYE6WB7gdvI9UWkiRC3uNxRzSAazi0kvvGo_st1olRg/w400-h266/pexels-kampus-production-7983579.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Medicare, no -- coverage, yes?<br /><br /><br /></td></tr></tbody></table><p></p><p data-pm-slice="1 1 []">My last two posts (<a href="https://xpostfactoid.substack.com/p/new-jerseys-dobi-lays-a-trap-for" rel="noopener noreferrer nofollow" target="_blank">1</a>, <a href="https://xpostfactoid.substack.com/p/dobi-responds-but-not-to-me-no-more" rel="noopener noreferrer nofollow" target="_blank">2</a>) 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 <a href="https://www.nj.com/news/2023/09/a-mistake-may-have-cost-seniors-thousands-in-healthcare-costs-nj-is-fixing-it.html" rel="noopener noreferrer nofollow" target="_blank">mainstream news coverage</a>, NJ’s Department of Banking and Insurance (DOBI) has ordered individual market insurers to cease this theft of coverage.</p><p>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.</p><p>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 <a href="https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files" rel="noopener noreferrer nofollow" target="_blank">State-level Public Use Files</a>.<span></span></p><a name='more'></a><p></p><p class="MsoNormal"><b><span style="font-size: 14pt; line-height: 107%;">ACA
Marketplace Enrollment at Ages 65 and Up, 2017-2023<o:p></o:p></span></b></p><table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody><tr>
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<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b>Year<o:p></o:p></b></p>
</td>
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<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b>Total
Enrollment (all ages)<o:p></o:p></b></p>
</td>
<td style="border-left: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b>Enrollment
Age 65+<o:p></o:p></b></p>
</td>
<td style="border-left: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b>% of Total
Enrollment Age 65+<o:p></o:p></b></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2017<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">12,216,007<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">107,661<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">0.88<o:p></o:p></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2018<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">11,780,175<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">131,611*<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">1.12<o:p></o:p></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2019<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">11,444,141<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">145,307<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">1.27<o:p></o:p></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2020<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">11,409,447<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">150,725<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">1.32<o:p></o:p></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2021<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">12,004,365<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">187,333<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">1.56<o:p></o:p></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2022<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">14,511,077<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">235,603<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">1.62<o:p></o:p></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">2023<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.85pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">16,357,030<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">287,715<o:p></o:p></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 116.9pt;" valign="top" width="156">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">1.76<o:p></o:p></p>
</td>
</tr>
</tbody></table><p>
</p><p class="MsoNormal">* The 2018 PUF provides Age 65+ enrollment totals for all
states, but marks the national total NR.</p><p class="MsoNormal">What might explain this disproportionate increase in enrollment in the highest age bracket? I don’t know. It does seem likely, however, that two changes in subsidy structure in the ACA marketplace since 2017 may have played a role.</p><p data-pm-slice="1 1 []">1. <strong>Silver loading</strong>. In October 2017, Trump abruptly cut off direct reimbursement of insurers for the value of the Cost Sharing Reduction subsidies that attach to silver plans (and only silver plans) for enrollees with income up to 250% of the Federal Poverty Level (FPL). The move was not unexpected, and most states allowed or required insurers to price the value of CSR directly into silver plans in 2018. Since premium subsidies, designed so that the enrollee pays a fixed percentage of income, are set to a silver plan benchmark (the second cheapest silver plan), inflated silver premiums effectively create discounts for subsidized buyers in bronze and gold plans. Since unsubsidized premiums rise with age (premiums for a 64 year-old are triple those for a 21 year-old), the effect is more intense for older enrollees, as “spreads” between the benchmark and cheaper plans rise with the premium.</p><p>As a result of silver loading, the number of enrollees who could obtain a bronze plan for zero premium expanded dramatically, beginning in 2018. The higher the enrollee’s age, the higher the income at which free plans were (and are) available.* In advance of the 2018 enrollment year, the first in which silver loading was practiced, the consultancy Oliver Wyman <a href="https://www.oliverwyman.com/our-expertise/perspectives/health/2017/oct/changes_to_bronzehe.html" rel="noopener noreferrer nofollow" target="_blank">charted</a> the wide availability of free bronze plans at high incomes and advanced age.</p><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Febe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Febe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Febe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Febe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Febe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/ebe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":390,"width":580,"resizeWidth":null,"bytes":null,"alt":null,"title":null,"type":null,"href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="390" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Febe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Febe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Febe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Febe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Febe589cf-967f-4b1b-9106-da70bcb35d11_580x390.jpeg 1456w" width="580" /></picture><div></div></div></a></figure></div><p>2. <strong>ARPA subsidy enhancements.</strong> The American Rescue Plan Act, enacted in March 2021, increased marketplace subsidies at every income level and removed the notorious income cap on subsidy eligibility, previously set at 400% FPL (in 2021, $51,040 for a single person and $68,960 for a couple). In August 2022, the Inflation Reduction Act extended the ARPA subsidy boosts through 2025. Here too, subsidy enhancements have a more intense effect as age rises, at least for plans that cost less than the benchmark. Free bronze plans are doubtless now available to most legally present U.S. residents over age 65 who lack access to Medicare. Silver plans with strong CSR are available free to all enrollees with income up to 150% FPL, and for no more than $45/month per enrollee for those in the 150-200% FPL range (the cheapest silver plan may offer a small or not-so-small discount on CSR relative to the benchmark plan).</p><p class="MsoNormal">Via <a href="https://www.healthsherpa.com/marketplace/zip_code" rel="noopener noreferrer nofollow" target="_blank">HealthSherpa</a>, here are the highest income levels at which free plans are available to 64 year-olds in a selection of major U.S. cities. Premiums at age 65+ are the same as at 64. <o:p></o:p></p><p class="MsoNormal"><span class="MsoHyperlink"><b><span color="windowtext" style="font-size: 14pt; line-height: 107%;">Free
Plan Availability in Major U.S. Cities for single enrollee, age 64 and up, 2023<o:p></o:p></span></b></span></p><table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody><tr>
<td style="border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.8pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">City<o:p></o:p></span></span></p>
</td>
<td style="border-left: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">Highest income for free bronze<o:p></o:p></span></span></p>
</td>
<td style="border-left: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">Highest FPL % for free bronze<o:p></o:p></span></span></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.8pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">Los Angeles, CA (90011)<o:p></o:p></span></span></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">$38,300<o:p></o:p></span></span></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">281% FPL<o:p></o:p></span></span></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.8pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">Phoenix, AZ (85011)<o:p></o:p></span></span></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">$38,600<o:p></o:p></span></span></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">284% FPL<o:p></o:p></span></span></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.8pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">Atlanta, GA (30310)<o:p></o:p></span></span></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">$42,100<o:p></o:p></span></span></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">310% FPL<o:p></o:p></span></span></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.8pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">Chicago, IL (60606)<o:p></o:p></span></span></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">$43,800<o:p></o:p></span></span></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">322% FPL<o:p></o:p></span></span></p>
</td>
</tr>
<tr>
<td style="border-top: none; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.8pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">Miami, FL (33129)<o:p></o:p></span></span></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">$48,200<o:p></o:p></span></span></p>
</td>
<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">355% FPL<o:p></o:p></span></span></p>
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<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">Dallas, TX (75088)<o:p></o:p></span></span></p>
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<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">$48,800<o:p></o:p></span></span></p>
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<td style="border-bottom: 1pt solid windowtext; border-left: none; border-right: 1pt solid windowtext; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 155.85pt;" valign="top" width="208">
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span class="MsoHyperlink"><span color="windowtext">359% FPL<o:p></o:p></span></span></p>
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</p><p class="MsoNormal"><span class="MsoHyperlink"><span color="windowtext"> </span></span>Silver loading and the ARPA subsidy boosts stimulated enrollment at all income levels. The effects of both intensify as age rises. While other factors (accumulating word of mouth?) may have stimulated senior enrollment in the marketplace, enhanced subsidies seem likely to have been a factor.</p><p> - - - -</p><p>*In some states and regions, silver loading made gold plans cheaper than silver (as CSR-enhanced silver at incomes up to 200% FPL has a higher actuarial value than gold), dramatically boosting gold plan discounts and enrollment. In fact, since most enrollees in silver plans do obtain the higher levels of CSR (raising actuarial value to 94% or 87%, compared to 80% for gold), gold plans <em>should</em> be priced below silver. As insurers tend to underprice silver — still the dominant metal level (since most enrollees are CSR-eligible) and the benchmark-setter — some states have more strictly required insurers, by legislation and/or regulation, to price silver plans higher than gold plans. <a href="https://xpostfactoid.blogspot.com/2022/07/a-midas-touch-on-new-mexicos-aca.html" rel="noopener noreferrer nofollow" target="_blank">New Mexico</a> and <a href="https://prospect.org/health/texas-legislature-learned-to-stop-worrying-and-love-aca-marketplace/" rel="noopener noreferrer nofollow" target="_blank">Texas</a> have the strictest requirements in this regard.</p><p><a href="https://www.pexels.com/photo/elderly-man-in-pink-polo-shirt-sitting-on-table-using-laptop-7983579/" rel="noopener noreferrer nofollow" target="_blank">Photo</a> by Kampus Production </p><p><br /></p><p><br /></p><p><br /></p><p> </p><p><i><br /></i></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-15399811851582975082023-09-28T18:00:00.003-04:002023-10-05T12:57:12.723-04:00NJ DOBI responds: No more elder abuse in the ACA marketplace<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up.</i></p><p data-pm-slice="1 1 []">My <a href="https://xpostfactoid.substack.com/p/new-jerseys-dobi-lays-a-trap-for" rel="noopener noreferrer nofollow" target="_blank">last post</a> 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. </p><p>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 <a href="https://www.nj.gov/dobi/division_insurance/ihcseh/rules/ihc221229/A50_D.pdf" rel="noopener noreferrer nofollow" target="_blank">standard policy policy form</a> 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)</p><p>CMS <a href="https://www.cms.gov/files/document/benefit-coordination-and-medicare-eligibility.pdf" rel="noopener noreferrer nofollow" target="_blank">guidance</a> 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.”</p><p>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, <a href="https://www.nj.com/news/2023/09/a-mistake-may-have-cost-seniors-thousands-in-healthcare-costs-nj-is-fixing-it.html" rel="noopener noreferrer nofollow" target="_blank">got on the case</a>. And DOBI did respond to Mueller. Thus pushed, they are apparently ending the practice — effective yesterday:<span><br /><br /></span></p><blockquote data-pm-slice="2 1 []"><p>“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.</p><p>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.</p><p>Thomas also said DOBI is reviewing how consumers may have been affected.</p><p>“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.</p><p>And, she said, the agency will make sure the language is clear when the 2024 plans roll around.</p><p>“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.</p></blockquote><p>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:</p><blockquote><p>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.</p></blockquote><p>Apparently, that June bulletin changed nothing. Now, pending enforcement, this longstanding abuse of the fundamental ACA promise (quality affordable <em>comprehensive</em> coverage) appears to be ended going forward. But “going forward” points to a problem, which Mueller gave me a chance to articulate:</p><blockquote><p>“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.”</p></blockquote><p>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?</p><p>Why 2016? In that year’s annual <a href="https://www.govinfo.gov/content/pkg/FR-2016-12-22/pdf/2016-30433.pdf" rel="noopener noreferrer nofollow" target="_blank">Notice of Benefit and Payment Parameters</a> (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. </p><p>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 <em>presume</em> 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.</p><p>Hats off to Karin Mueller, who was able to get what I could not from DOBI.</p><p><span></span></p><a name='more'></a><p></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-28109271950967159742023-09-15T12:37:00.000-04:002023-09-15T12:37:47.135-04:00New Jersey's Department of Banking and Insurance lays a trap for elderly enrollees in the state's ACA marketplace<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i></p><p data-pm-slice="1 1 []">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. </p><p>That said, once your documentation is accepted and your monthly subsidy is assessed, you are good to go, right?</p><p>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.<span></span></p><a name='more'></a><p></p><p>Specifically, New Jersey’s Department of Banking and Insurance (NJ DOBI) allows or indeed requires insurers in its Individual Health Coverage (IHC) program to presume that enrollees who are over age 65 are eligible for Medicare — unless the enrollee provides proof positive otherwise. AmeriHealth, the insurer with the largest market share in enrollments via GetCoveredNJ, the state ACA exchange, requires such enrollees to obtain a letter from the Social Security Administration stating that they are ineligible, and why. Otherwise, the insurer pays their claims only as a secondary payer, presuming that Medicare will pay the bulk of each claim. </p><p>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.</p><p>As of the end of the New Jersey ACA marketplace’s Open Enrollment Period for 2023, 8,929 enrollees in health plans obtained through GetCoveredNJ were over age 65 (as were 287,715 ACA marketplace enrollees nationally). Most of them are probably legally present immigrants who lack the <a href="https://www.medicareinteractive.org/get-answers/medicare-health-coverage-options/original-medicare-costs/eligibility-for-premium-free-part-a-if-you-are-over-65-and-medicare-eligible" rel="noopener noreferrer nofollow" target="_blank">40 quarters</a> (10 years) of tax-paying work required to obtain free Part A Medicare (those who are ineligible for free Part A coverage are eligible for subsidized plans in the ACA marketplace if their income qualifies them). The onus is now on all New Jersey marketplace enrollees over age 65 to prove that they are ineligible for Medicare. That entails applying to the Social Security Administration and getting a rejection letter, which can take up to 60 days, according to the SSA help line. Obtaining proof of ineligibility is also…a process.</p><p>The rule allowing this presumption of Medicare eligibility and placing the burden of proof of ineligibility on the enrollee was apparently added to New Jersey’s regulations for the individual market this year.* The <a href="https://www.state.nj.us/dobi/division_insurance/ihcseh/rules/ihc221129/proposalsummary.pdf" rel="noopener noreferrer nofollow" target="_blank">Proposed Amendments</a> to the NJ's Standard Health Benefit Plans in the individual market, published last fall, state: </p><blockquote><p>The Board proposes to remove Medicare from the scope of the Coordination of Benefits Provision and add a provision addressing the effect of Medicare on individual coverage. This new provision clarifies the secondary status of individual benefits when a person is entitled to Medicare as well as addresses the obligation of the consumer to provide information regarding Medicare eligibility. The Benefits from Other Plans provision cross references the newly added provision (p. 6). </p></blockquote><p>The provision appears in the <a href="https://www.nj.gov/dobi/division_insurance/ihcseh/rules/ihc221229/A50_D.pdf" rel="noopener noreferrer nofollow" target="_blank">standard individual policy</a> for NJ's individual market for 2023, published by NJ DOBI:</p><blockquote><p>The Covered Person must respond to Our [the insurer’s] inquiries regarding whether they are Eligible for Medicare or Entitled to Medicare. When a Covered Person turns 65 We 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. If Our records show that the Covered Person is Entitled to Medicare due to disability or ESRD We pay secondary benefits as set forth in this section unless the Covered Person provides written documentation that proves they are not Entitled** to Medicare and thus Our records are incorrect ( (p. 126). </p></blockquote><p>As to the secondary benefits:</p><blockquote><p>The benefit payable under this Policy will equal the applicable cost sharing under Medicare Parts A and B for the services and supplies received. For example, if Medicare Part B would have paid 80% of the Medicare allowed charge, the benefit payable under this Policy would be the cost sharing of 20% of the Medicare allowed charge. This Policy will not pay benefits that would have been payable by Medicare Parts A or B if the person had enrolled for Medicare Parts A and B (pp. 125-126).</p></blockquote><p>These provisions appear to be illegal. I queried the federal Center for Medicare and Medicaid Services (CMS), because it seemed to me that if an ACA exchange finds an applicant eligible for premium subsidies, that person must have been determined ineligible for Medicare — e.g., by an immigration document showing that the person could not have obtained the required work history for full Medicare eligibility. A spokesperson for CMS pretty much confirmed that, via email (my emphasis below):</p><blockquote><p>In May 2023, CMS issued an FAQ clarifying the benefit coordination between individual health insurance coverage and Medicare. The FAQ clarifies that pursuant to the essential health benefits and actuarial value requirements under the Affordable Care Act, <strong>a health insurance issuer offering non-grandfathered [ACA compliant] individual health insurance coverage may not change the plan payment level or refuse to pay for otherwise covered services on the basis that an individual is eligible for Medicare but not actually enrolled in Medicare.</strong> The FAQ is available at <a href="https://www.cms.gov/files/document/benefit-coordination-and-medicare-eligibility.pdf" rel="noopener noreferrer nofollow" target="_blank">https://www.cms.gov/files/document/benefit-coordination-and-medicare-eligibility.pdf</a>.</p><p>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.</p></blockquote><p>Here is the relevant CMS guidance at the link provided above, dated May 24, 2023: </p><blockquote><p><strong>Q: An individual is enrolled in non-grandfathered individual health insurance coverage and is eligible for Medicare but isn’t enrolled in Medicare. May the issuer change the payment level for or refuse to pay for covered services for which Medicare would have paid had the person been enrolled in Medicare? </strong></p><p>No. In the absence of enrollment in other primary coverage (such as Medicare), an issuer offering non-grandfathered (non-grandmothered) individual health insurance coverage cannot take that other coverage into account when paying for covered services. Pursuant to the EHB and AV requirements under the Affordable Care Act,[3] an issuer offering non-grandfathered individual health insurance coverage may not limit or exclude coverage based on the theoretical possibility of an individual’s enrollment in other coverage. [4] Additionally, modifying a benefit design based on an individual’s eligibility for Medicare could be considered as violating federal non-discrimination prohibitions.[5]</p></blockquote><p>A footnote adds a germane qualifier (my emphasis):</p><blockquote><p>4 This is true regardless of whether an individual is (<strong>or is presumed</strong>) eligible for Medicare on the basis of age, disability, or end-stage renal disease but not actually enrolled in Medicare.</p></blockquote><p>NJ DOBI has authorized insurers in its individual market to do what is explicitly prohibited here. In fact they are compelled by contract to do it.</p><p>For an enrollee over age 65, the lowest-cost silver plan sold on GetCoveredNJ commands a premium in excess of $900 per month, paid by some combination of the federal government, New Jersey (which provides supplemental state subsidies to most enrollees), and the enrollee. Yet if that enrollee does not provide a letter from the SSA proving ineligibility for Medicare, the standard contract stipulates that the insurer will pay only 20% of the Medicare-allowed charge for each bill, leaving providers to pursue the individual receiving care for the balance, if they are so inclined. I have viewed current AmeriHealth bills, sent to a person over age 65 who is not eligible for Medicare, in which every charge, each for hundreds of dollars, is ascribed a code that signifies, according to the Explanation of Remark Codes:</p><blockquote><p>You are eligible for Medicare as the Primary payer, but have not enrolled. The amounts payable under Medicare, as the primary payer, are excluded and IBC [Independent Blue Cross, AmeriHealth’s parent] will pay as the secondary payer. <em>The provider may bill you for the excluded amounts</em> (my emphasis). </p></blockquote><p>Those provider bills can easily run into the thousands or tens of thousands of dollars, unlimited by the insurance policy’s putative annual out-of-pocket maximum.</p><p>I have contacted NJ DOBI four times about the provision enabling this billing behavior and have received no response. My questions:</p><ul><li><p>Is DOBI aware of an apparent contradiction between the presumption of Medicare eligibility provided in the standard IHC contract and CMS guidance? In DOBI's view, is there in fact a contradiction?</p></li><li><p>Is the language cited above a policy change initiated in the 2023 plan year?</p></li><li><p>What is the rationale for allowing or requiring the presumption of Medicare eligibility for over-65 IHC enrollees?</p></li><li><p>Is it possible for any enrollee who enrolled via GetCoveredNJ who is receiving APTC and/or NJ Plan Savings to be eligible for Medicare? Does the GetCoveredNJ application not preclude that?</p></li><li><p>Does DOBI have any data as to how many over-65 ACA marketplace enrollees in the state have proved eligible for Medicare, in 2023 or any other time period?</p></li><li><p>What percentage of over-65 marketplace enrollees in the state (there were 8,929 as of the end of the 2023 Open Enrollment Period, per CMS’s state-level <a href="https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files" rel="noopener noreferrer nofollow" target="_blank">Public Use Files</a>) are legally present noncitizens?</p></li><li><p>How many current NJ marketplace enrollees are currently presumed by insurers to be eligible for Medicare? That is, for how many current enrollees is Medicare the presumed primary insurer as of now?</p></li><li><p>If an insurer is receiving the full marketplace premium for an enrollee (via various payers) can it in fact legally serve as a secondary insurer? </p></li><li><p>Is DOBI concerned about the administrative burden for legally present noncitizens, determined eligible for APTC by GetCoveredNJ, having provided required immigration status documentation, being required post-enrollment to obtain proof of Medicare ineligibility from SSA?</p></li></ul><p>If DOBI will not answer me, perhaps they’ll answer CMS.</p><p>—-</p><p>* An AmeriHealth employee told me that the requirement for enrollees to prove their ineligibility for Medicare to the insurer is a new regulation, effective in April 2023. While NJ DOBI has not confirmed this to me — or responded to any of my repeated inquiries about the requirement — the proposed rule cited above indicates that the AmeriHealth employee’s account is accurate. The requirement is not part of the most recent <a href="https://www.nj.gov/dobi/division_insurance/ihcseh/rules/ihc210317/a50_d.pdf">prior standard contract</a> published by DOBI, effective 1/1/2020.</p><p>** In government nomenclature, “entitled” to Medicare means enrolled. A person rendered eligible for Medicare by end-stage renal disease can in fact opt not to enroll and still be eligible for subsidized marketplace coverage. The policy terms here are thus requiring the ESRD-eligible marketplace enrollee to document that he is not <em>enrolled</em> in Medicare.</p><p><i><br /></i></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-10641085935689661842023-09-12T08:48:00.003-04:002023-09-12T08:48:19.077-04:00Meeting the minds of Chinese students in Xi'an<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i> </p><p data-pm-slice="1 1 []">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 <a href="https://www.left-bank.com/book/9798885280525" rel="noopener noreferrer nofollow" target="_blank">The Same Bright Moon: Teaching China’s New Generation During Covid.</a> My <a href="https://www.amazon.com/Same-Bright-Moon-Teaching-Generation/product-reviews/B0CDNM82VZ/ref=cm_cr_dp_d_show_all_btm?ie=UTF8&reviewerType=all_reviews" rel="noopener noreferrer nofollow" target="_blank">Amazon review</a> is below.</p><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg" target="_blank"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":346,"width":225,"resizeWidth":null,"bytes":19071,"alt":null,"title":null,"type":"image/jpeg","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="320" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg 1456w" style="margin-left: auto; margin-right: auto;" width="208" /></td></tr><tr><td class="tr-caption" style="text-align: center;">The Same Bright Moon</td></tr></tbody></table><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F33ce1b57-63e3-4f76-9d08-5adc75f8b006_225x346.jpeg 1456w" type="image/webp"></source></picture><div></div></div></a></figure></div><p> * * *</p><p>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. <br /><br />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.<span><br /><br /></span></p><p data-pm-slice="1 1 []">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.</p><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":381,"width":494,"resizeWidth":null,"bytes":293103,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="381" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F795a4838-ea32-45a4-855b-77d83d9dd05b_494x381.png 1456w" width="494" /></picture><div></div></div></a></figure></div><p>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. <br /><br />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.<br /><br />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. <br /><br />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.</p><p><span></span></p><a name='more'></a><p></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-85925254753651790152023-09-09T08:00:00.002-04:002023-09-09T10:43:09.710-04:00In Massachusetts, ACA Marketplace enrollees with income up to 500% FPL get affordable platinum coverage<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i> </p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvqQmy0r2Dky-F_UJJcafuwdk2IL2JH-3flN0pbNKbcJJMGpllQTyX1Qp9jRY-jYrkDCjXDceUpngPO-nurFF2OgZn-Xhr1bbEW4uBsyZF2x-tTLYn2KJ7KQHHXxdZzHuzoWJflRJCpQ_lypNFPIA1BneWq0MsfEgzG-GyTUs3Cnz6DEu15QHwEw/s1300/Atherton%20Bridge.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1020" data-original-width="1300" height="251" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvqQmy0r2Dky-F_UJJcafuwdk2IL2JH-3flN0pbNKbcJJMGpllQTyX1Qp9jRY-jYrkDCjXDceUpngPO-nurFF2OgZn-Xhr1bbEW4uBsyZF2x-tTLYn2KJ7KQHHXxdZzHuzoWJflRJCpQ_lypNFPIA1BneWq0MsfEgzG-GyTUs3Cnz6DEu15QHwEw/s320/Atherton%20Bridge.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">A rickety but serviceable connector</td></tr></tbody></table><br /><p data-pm-slice="1 1 []">In a two-year pilot program beginning in 2024, Massachusetts has <a href="https://www.mahealthconnector.org/pilot-expansion-of-connectorcare-release" rel="noopener noreferrer nofollow" target="_blank">extended eligibility </a>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. </p><p>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.</p><p>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. </p><a name='more'></a><p></p><p data-pm-slice="1 1 []">In a pair of posts published last November, I described the c<a href="https://xpostfactoid.substack.com/p/massachusetts-poised-to-extend-connectorcares" rel="noopener noreferrer nofollow" target="_blank">urrent ConnectorCare program</a>, its history and financing, and the proposed extension, and <a href="https://xpostfactoid.substack.com/p/the-case-for-medicaid-like-coverage" rel="noopener noreferrer nofollow" target="_blank">the case for extending eligibility to 500% FPL</a> as made by Alex Sheff, policy director at nonprofit Health Care For All Massachusetts, a prime mover of the proposal. In brief: Massachusetts is a relatively wealthy state; nearly half of marketplace enrollees have incomes over 300% FPL; research shows that middle-income insured state residents have trouble paying healthcare costs; underinsurance is a bigger problem than lack of insurance, as 97.5% of state residents are insured; and the 300% FPL ConnectorCare eligibility threshold created a sharp “benefit cliff,” as out-of-pocket costs are radically lower in ConnectorCare than in regular marketplace plans. In ConnectorCare, the actuarial value of the standardized plans ranges from 99.6% to 92% (descending as income rises), whereas most enrollees in the upper-income marketplace obtain silver or bronze plans with AV of 60-70%. </p><p><strong>ConnectorCare: Low out-of-pocket costs and standard plans to 500% FPL</strong></p><p>Below is the <a href="https://www.mahealthconnector.org/wp-content/uploads/ConnectorCare-Overview-2023.pdf" rel="noopener noreferrer nofollow" target="_blank">benefit structure</a> for ConnectorCare plans at different income levels in 2023. It will be unchanged in 2024, according to Jason Lefferts, chief of communications for the Massachusetts Health Connector, and the type 3 benefits listed in the far right column will be offered to enrollees in the 300-500% FPL range. According to Marissa Woltmann, chief of policy for the Connector, the lowest-cost plan will cost $219 per month for a single enrollee with an income in the 300-400% FPL range, and $255 per month for those with income in the 400-500% range. </p><div class="captioned-image-container"><figure><a class="image-link is-viewable-img image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":571,"width":674,"resizeWidth":null,"bytes":145775,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="542" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F5bab9e57-c182-4678-97a9-4b13bc272c8c_674x571.png 1456w" width="640" /></picture><div></div></div></a></figure></div><div class="captioned-image-container"><figure><a class="image-link image2" data-component-name="Image2ToDOM" href="https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png" target="_blank"><div class="image2-inset"><picture><source sizes="100vw" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_webp,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png 1456w" type="image/webp"></source><img alt="" class="sizing-normal" data-attrs="{"src":"https://substack-post-media.s3.amazonaws.com/public/images/a2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png","srcNoWatermark":null,"fullscreen":null,"imageSize":null,"height":136,"width":266,"resizeWidth":null,"bytes":11278,"alt":null,"title":null,"type":"image/png","href":null,"belowTheFold":false,"topImage":false,"internalRedirect":null}" height="136" sizes="100vw" src="https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png" srcset="https://substackcdn.com/image/fetch/w_424,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png 424w, https://substackcdn.com/image/fetch/w_848,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png 848w, https://substackcdn.com/image/fetch/w_1272,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png 1272w, https://substackcdn.com/image/fetch/w_1456,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa2fa2964-5dbd-49e5-845c-bc962408e1ce_266x136.png 1456w" width="266" /></picture><div></div></div></a></figure></div><p data-pm-slice="1 1 []">For an enrollee with an income just over 300% FPL, the chief advantage of the ConnectorCare expansion is relief in out-of-pocket costs. In 2023, in Jamaica Plain, a Boston neighborhood, the lowest-cost silver plan for a 43 year-old single enrollee (roughly median age for the ACA marketplace) with an income just over 300% FPL in 2023 ($40,800) would cost $197 per month, and the lowest-cost bronze plan would be available for $131/month. Using the FPL scale that will be in place for 2024, raising the just-over-300% FPL income to $42,750, the enrollee would pay $220 for lowest-cost silver (virtually identical to what she’ll pay for the lowest-cost ConnectorCare plan) or $154/month for bronze. The silver plan would have a deductible of $2,000 and the bronze plan, $2,850 — compared to <em>zero</em> deductible in ConnectorCare. (The current lowest-cost silver and bronze plans quoted above are standardized models, as are most but not all plans offered in the Health Connector.)</p><p>Even more dramatic is the difference in maximum out-of-cost exposure. In Massachusetts’ standardized “high bronze” and silver plans alike in 2023, the single-person out-of-pocket maximum is $9,100. In ConnectorCare, the combined medical/drug OOP max for the 300-500% FPL bracket will be $2,225 in 2024. An emergency room visit will cost $100 in ConnectorCare, compared to $350 <em>after</em> <em>the deductible</em> in the current lowest-cost silver plan ($2000 deductible) and $400 after the deductible in the lowest-cost non-HSA bronze plan ($2,850 deductible). </p><p><strong>Tradeoffs</strong></p><p>It is conceivable that some enrollees with income just over the 300% FPL threshold would prefer paying about $65/month less for a bronze plan. “There are some tradeoffs with regard to premium versus cost-sharing — if you think about bronze deductibles and how many services are subject to that deductible,” Woltmann told me. “We’re still in process of determining eligibilities for 2024 and looking at where people are today to understand what those member impacts might be - -some people will see premiums come down, some people might see something slightly higher.”</p><p>At the upper end of the expanded eligibility scale, premiums are likely to be considerably lower in ConnectorCare than they would have been in the Health Connector (the conventional ACA marketplace). A 43 year old in Jamaica Plain earning $72,800 this year — just under 500% FPL in the 2024 marketplace — would pay $417/month this year for lowest-cost silver and $351/month for lowest-cost bronze, compared to $255/month in 2024 for the lowest-cost ConnectorCare plan. (Historically, premiums for ConnectorCare plans other than the lowest-cost plan have varied only minimally, with the exception of one broad-network carrier. With all state marketplace insurers required to offer ConnectorCare plans in 2024, perhaps that will change.) In fact, a person earning just under 500% FPL will pay a smaller percentage of income for the lowest-cost ConnectorCare plan, 4.2%, than a person earning just over 300% FPL, who will pay 6%. At just over 400% FPL, the required percentage is 5.2%.</p><p><strong>Easing the Medicaid Unwinding</strong></p><p>Since implementing its health reform plan — the ACA’s precursor — in 2006, Massachusetts has had the lowest uninsured rate in the nation — <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D" rel="noopener noreferrer nofollow" target="_blank">2.5% uninsured</a> in 2021, compared to 8.6% for the country as a whole. Thanks to Medicaid expansion and ConnectorCare, zero-cost high-AV coverage is available for free at incomes up to 200% FPL, while zero-deductible low-cost coverage has been available to 300% FPL. In the pandemic, however, total marketplace enrollment in Massachusetts has declined — mainly, according to Woltmann, because the 3-year pause in Medicaid disenrollments implemented as a pandemic emergency measure in March 2020 froze the usual churn between MassHealth, the state Medicaid program, and ConnectorCare. </p><p>ConnectorCare enrollment <a href="https://www.mahealthconnector.org/wp-content/uploads/Health-Connector-OE22-Brief-060122.pdf" rel="noopener noreferrer nofollow" target="_blank">declined</a> from 207,000 in January 2020 to 148,000 in January 2022 and 122,000 in <a href="https://www.mahealthconnector.org/wp-content/uploads/Health-Connector-MassHealth-Renewals-Dashboard-08-04-23.pdf" rel="noopener noreferrer nofollow" target="_blank">January 2023</a>. Since the Medicaid “unwinding” — the resumption of eligibility redeterminations — kicked off in May of this year, however, Woltmann pointed out, ConnectorCare enrollment has rebounded 143,000, with net new enrollment accelerating in July and August. The ConnectorCare expansion may help broaden and deepen that rebound in 2024 as Medicaid redeterminations continue. Alex Sheff of HCFA told me <a href="https://xpostfactoid.substack.com/p/the-case-for-medicaid-like-coverage" rel="noopener noreferrer nofollow" target="_blank">last Novembe</a>r that HCFA’s experience with phone enrollment assistance indicates that many people who were “frozen” in Medicaid enrollment during the pandemic likely have income in the 300-500% FPL range in high-income Massachusetts.</p><p><strong>Freedom from “choice”</strong></p><p>One of the less tangible benefits of offering all but the most affluent enrollees in a state individual market the standardized ConnectorCare plans is freeing enrollees from the proliferation of <a href="https://xpostfactoid.substack.com/p/cms-proposes-cleaning-out-an-augean" rel="noopener noreferrer nofollow" target="_blank">meaningless and bewildering choice</a> that plagues most state ACA marketplaces. ACA marketplace enrollees in 2023 are confronted with an average of 114 plans to choose from, with some insurers flooding the zone with more than a dozen plans in one metal level, many with only minimal differences in benefits. ConnectorCare plans have uniform benefits — and the out-of-pockets costs are uniformly low. The country would be better off if the entire market nationally were remade in ConnectorCare’s image.</p><div class="subscription-widget-wrap" data-attrs="{"url":"%%checkout_url%%","text":"Subscribe","language":"en"}" data-component-name="SubscribeWidgetToDOM"><div class="subscription-widget show-subscribe"><div class="preamble"><p data-pm-slice="1 1 []">Related:</p><p><a href="https://xpostfactoid.substack.com/p/massachusetts-poised-to-extend-connectorcares" rel="noopener noreferrer nofollow" target="_blank">Massachusetts poised to extend ConnectorCare's low out-of-pocket costs to 500% FPL</a> (11/17/22)<br /><br /></p><p><a href="https://xpostfactoid.substack.com/p/massachusetts-poised-to-extend-connectorcares" rel="noopener noreferrer nofollow" target="_blank">The case for affordable "platinum" health coverage at middle- to high-middle incomes</a><br />(11/21/22)</p></div><form class="subscription-widget-subscribe"><div class="fake-input-wrapper"><div class="fake-input"></div><div class="fake-button"></div></div></form></div></div><p> </p><p><br /></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-27803557822321844642023-08-15T15:09:00.003-04:002023-08-15T15:22:58.911-04:00Could the FTC's proposed ban on noncompete clauses curb private equity incursions in healthcare?<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i> </p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8vsJpblQ1VbENb8jmhhjmyNt-m4FNDIoj7oxZyY-ejdhgBR-yrm6k0HgGOwfvTqZLDUtqtFIZrIU5nJSHEQn53DmvW1EWpFIeFd2PgD8DT1Xze73q54RvgKiUoxTlEfHNOVkKGXT4LqzN1UEezbteyfdyP6Fd2HuXXtPDTAnDN6KCenaZ_X_rbw/s600/Charlotte_Bront%C3%AB.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="600" data-original-width="424" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8vsJpblQ1VbENb8jmhhjmyNt-m4FNDIoj7oxZyY-ejdhgBR-yrm6k0HgGOwfvTqZLDUtqtFIZrIU5nJSHEQn53DmvW1EWpFIeFd2PgD8DT1Xze73q54RvgKiUoxTlEfHNOVkKGXT4LqzN1UEezbteyfdyP6Fd2HuXXtPDTAnDN6KCenaZ_X_rbw/s320/Charlotte_Bront%C3%AB.jpg" width="226" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="background-color: white; color: #565656; font-family: "Atkinson Hyperlegible", "Helvetica Neue", Arial, sans-serif; text-align: start;"><span style="font-size: x-small;">“Then,” I cried, half desperate, “grant me at least a new servitude!”</span></span></td></tr></tbody></table><p data-pm-slice="1 1 []">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.</p><p>In <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4373557" rel="noopener noreferrer nofollow" target="_blank">Private Equity and the Corporatization of Health Care</a>, 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:</p><blockquote><p>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.’<span></span></p><a name='more'></a><p></p></blockquote><p>Fuse Brown and Hall offer a detailed assessment of several legal and regulatory tools available to curb a “corporatization” of healthcare that is not limited to but epitomized by private equity-owned practices and healthcare institutions. They summarize exploitive business strategies that raise “a core set of public policy concerns” including</p><blockquote><p>consolidation and attendant price increases; overutilization, overbilling, and aggressive coding practices; shirking unprofitable services or patients; threats to physicians’ clinical decisions and independence; and compromising the quality of patient care. In human terms, these threats manifest as unmanageable medical bills and harsh collection practices, clinicians experiencing moral distress and burnout under pressure to put profits over patients, and, in extreme cases, alarming declines in the quality of patient care.</p></blockquote><p>PE incursions into targeted practice specialties in targeted locales is galloping apace. According to a recent <a href="https://www.antitrustinstitute.org/wp-content/uploads/2023/07/AAI-UCB-EG_Private-Equity-I-Physician-Practice-Report_FINAL.pdf" rel="noopener noreferrer nofollow" target="_blank">analysis</a> by scholars (Richard M. Scheffler et al.) at the University of California’s Petris Center and the Washington Center for Equitable Growth, published by the American Antitrust Institute, PE deals for physician practices have increased from 75 in 2012 to 484 in 2021. In more than a quarter of metropolitan statistical areas (MSAs), a PE firm has at least 30% market share in a targeted practice area. In several of the specialties studied, the study found statistically significant price increases in MSAs where a PE firm had achieved at least 30% market share.</p><p data-pm-slice="1 1 []"><strong>Does a rusting regulatory arsenal include a sleeper nuke?</strong></p><p>To curb these trends, Fuse Brown and Hall call on federal and state regulators to “dust off,” update, and aggressively deploy legal tools including antitrust enforcement, fraud and abuse enforcement, and state laws restricting the corporate practice of medicine and physician employment. Key recommendations include to lower the dollar threshold at which health industry acquisitions must be reported to regulators; increase antitrust scrutiny of serial small acquisitions (roll-ups) that enable practice area dominance in a given region; apply the False Claims Act more aggressively, e.g. by holding PE firms liable for their acquisitions’ billing practices; enforce and update little-used and often somewhat archaic state laws purporting to ban the “corporate practice of medicine,” for example by going after widely-used Management Service Organizations (MSOs) if they are effectively controlling how the physicians practices they serve actually practice medicine; and enforce state “fee-splitting” laws that purportedly prevent unlicensed corporations (e.g., MSOs) from profiting from physicians’ professional income.</p><p>While Fuse Brown and Hall gamely detail how these legal tools might be deployed and strengthened — by vigorous use, new administrative rule-making, and new legislation — they also imply that regulators are generally outgunned and engaged in whack-a-mole against corporate juggernauts focused on maximizing revenue. Given that pessimistic undertone, I was intrigued by their rather brief treatment of one more regulatory tool: limitation of noncompete clauses for physicians. Noting the FTC’s <a href="https://www.govinfo.gov/content/pkg/FR-2023-01-19/pdf/2023-00414.pdf" rel="noopener noreferrer nofollow" target="_blank">proposed rule</a> banning almost all noncompete clauses across all industries (issued on January 5 this year), the authors rather laconically report: </p><blockquote><p>analysts predict that the FTC’s ban on noncompetes could cause a dramatic collapse of investment in physician practices if investors could not prevent the core value of the investment (the physicians) from walking away. [256]</p></blockquote><p>Wait, what? Antitrust and fraud enforcement are glacial and under-resourced; CPOM laws are archaic and loophole-ridden — but pulling the thread that binds physicians to their employers could unravel the whole vast profit-mining enterprise? </p><p>The sources that Fuse Brown and Hall cite for the potential “dramatic collapse” claim include <a href="https://www.healthcaredive.com/news/physicians-no-longer-bound-by-noncompetes-FTC-ban/639920/#:~:text=Doctors%20no%20longer%20bound%20by%20noncompetes%20under%20FTC's%20proposed%20ban,-Published%20Jan.&text=The%20Federal%20Trade%20Commission's%20proposed,and%20the%20patients%20they%20treat" rel="noopener noreferrer nofollow" target="_blank">corporate attorneys</a> and — most directly — Blade Madden, author of the Hospitalogy blog at WorkWeek. Madden notes (scroll to the third story <a href="https://t.co/fKWvTAB001" rel="noopener noreferrer nofollow" target="_blank">here</a>) that if the rule is finalized as written, nonprofit hospital systems would get a major leg up because they are not subject to FTC regulation (though some commenters on the proposed rule have suggested that the FTC could team with other agencies to reach nonprofits). That limitation is also stressed by many physician trade groups and individual physicians who submitted comments in response to the proposed rule to the FTC. As to private equity, however, Madden speculates that under a noncompete ban:</p><blockquote><p>Physician practice M&A would fall apart. Would PE-backed groups crumble? Physicians would have no obligation to stay and constantly tell their financial backers, “we can leave whenever we want” = this creates an incredibly risky asset on the investment side. Why provide capital for a business whose core asset could leave the next day? That dynamic leads me to believe that in a future with no non-competes, more organizations might become physician-led, or investment would change drastically…</p><p>In all likelihood, given the level of uncertainty and the need for some level of retention and stickiness in the relationship between employers and employees, the non-compete will narrow in scope but stay in the picture.</p></blockquote><p><strong>Corporate medicine in a post-noncompete world</strong></p><p>Would a near-full ban on noncompetes lead to a collapse in physician practice M&A? Katherine Gudiksen, executive editor for The Source on Healthcare Price and Competition at UC San Francisco, points out that California has long had a full ban on noncompete clauses, as well as a strong law banning the Corporate Practice of Medicine. But the state is not an outlier with respect to the level of private equity investment in physician practices — in part because many major private equity firms are located in the state. </p><p>As to the larger question of corporate owners creating intolerable working conditions for healthcare workers generally, Gudiksen says that while noncompetes are an important factor, “consolidation is the bigger issue.” If you work in a region where one hospital group is dominant (e.g., as a hospital nurse or physician in a practice area that works only in hospitals), “it doesn’t matter if you can leave.” (I would add, though, that freedom from noncompetes is salient in concentrated markets with two or three major hospital groups.) Big picture: constraint of noncompetes is “necessary but not sufficient” to curb corporate degradation of working conditions in healthcare.</p><p>Gudiksen stresses that physicians are only one type of healthcare employee (albeit the most powerful) constrained by noncompetes. Nurses, nurses’ aides, and other workers in hospitals, nursing homes, physician practices are also bound by noncompetes, and equally if not more stressed, by working conditions imposed by corporate owners.</p><p>Loren Adler, associate director at the Brookings Schaeffer Initiative on Health Policy, says that if the proposed rule does in fact go through in a form that bans most noncompete clauses for physicians, private equity-owned practices would likely find other contractual means to retain physicians — for example, by offering a wage increase if the physicians stays in place for a certain amount of time. Adler suggests that while such positive incentives might be effective for retention, they might disincentivize imposing policies that make working conditions deteriorate.</p><p>As Scheffler et al. note, while making a case for requiring physician groups to report on key quality measures, “PE firms often respond better to financial incentives than other owners, so better aligning these incentives has the potential to make PE ownership a driver of increased healthcare quality.” Similarly, if the restrictive noncompete clauses that are the current norm were replaced by positive incentives to stay with a current employer — making departure somewhat expensive but not ruinous — PE firms might have a stake in creating attractive working conditions for their employees.</p><p><strong>A major question about the FTC proposed rule</strong></p><p>Scholars who have studied the extent and effects of private equity’s incursions into healthcare markets don’t seem particularly focused on the FTC’s proposed noncompete rule. The apparent lack of interest may stem from skepticism about the rule being finalized and withstanding court scrutiny, given the current conservative cast of the Supreme Court and the federal judiciary generally. </p><p>The FTC has historically pursued its mandate (in <a href="https://www.law.cornell.edu/uscode/text/15/45" rel="noopener noreferrer nofollow" target="_blank">Section 5</a> of the FTC Act) to prevent “unfair methods of competition” through adjudication of abuses rather than through rulemaking. <a href="https://www.law.cornell.edu/uscode/text/15/46" rel="noopener noreferrer nofollow" target="_blank">Section 6 (g)</a> of the FTC Act does empower the FTC to “make rules and regulations” with respect to “unfair methods of competition in or affecting commerce.” But that terse authorization could fall afoul, as a Congressional Research Service <a href="https://crsreports.congress.gov/product/pdf/LSB/LSB10635#:~:text=Because%20Section%205%20of%20the,that%20fall%20within%20that%20category" rel="noopener noreferrer nofollow" target="_blank">report</a> rather delicately suggests, of either the <a href="https://ballotpedia.org/Nondelegation_doctrine#:~:text=The%20nondelegation%20doctrine%2C%20one%20of,allow%20others%20to%20make%20laws." rel="noopener noreferrer nofollow" target="_blank">nondelegation doctrine</a>, holding that legislators can’t essentially outsource legislation to government agencies with vague directives, or the <a href="https://crsreports.congress.gov/product/pdf/IF/IF12077" rel="noopener noreferrer nofollow" target="_blank">major questions doctrine</a> recently promulgated by the Supreme Court’s conservative majority, which cautions agencies against issuing rules of “vast economic and political significance” not clearly authorized by statute. </p><p>Less delicately, in a <a href="https://www.ftc.gov/system/files/ftc_gov/pdf/p201000noncompetewilsondissent.pdf" rel="noopener noreferrer nofollow" target="_blank">dissent </a>issued in tandem with the proposed rule on January 5, then-FTC Commissioner Christine Wilson laid out the legal case against the rule’s constitutionality, including evidence of alleged Congressional intent not to empower the FTC to issues rules governing competition. Wilson <a href="https://www.ftc.gov/system/files/ftc_gov/pdf/p180200wilsonresignationletter.pdf" rel="noopener noreferrer nofollow" target="_blank">resigned</a> from the FTC in March 2023.</p><p>In short, the FTC’s proposed noncompete ban could be a ripe sacrifice for the many federal judges (including six Supreme Court justices) who don’t look kindly on federal agencies asserting sweeping new regulatory authority based on new interpretations of terse provisions in decades-old statutes. </p><p>Conversely, a trio of law professors, Bill Araiza, Jeffrey Lubbers and Peter Shane, argue in a <a href="https://www.regulations.gov/comment/FTC-2023-0007-21024" rel="noopener noreferrer nofollow" target="_blank">comment</a> on the proposed rule that regulating unfair methods of competition (UMC) is squarely within the FTC's writ; that the FTC has ruled on many occasions that noncompete clauses constitute UMC; and that "canonical Supreme Court precedent" holds that "agencies may freely choose between rulemaking and adjudication" for matters within their purview. Araiza, Lubbers and Shane argue that the proposed rule does not run afoul of the nondelegation doctrine because the FTC Act's mandate to regulate UMC meets the "<a href="https://constitution.congress.gov/browse/essay/artI-S1-5-3/ALDE_00001317/#:~:text=United%20States%2C%20517%20U.S.%20748,that%20implement%20its%20statutes.%20)." rel="noopener noreferrer nofollow" target="_blank">intelligible principle</a>" test, setting boundaries to the authority delegated. They assert that the "major questions" doctrine does not apply, because that doctrine has been applied only when an agency brings new matters under its purview ( (e.g., classifying greenhouse gasses as "pollutants") , not when it undertakes "a new approach to a problem long within its substantive purview." It seems that most observers, however, expect that the right-tilting lower federal courts where plaintiffs will doubtless file their suits, and ultimately the conservative Supreme Court majority, will assert their characteristic hostility to a federal agency launching a highly consequential “new approach” to a problem it has long dealt with by other means.</p><p><strong>Doctors flood the comment line</strong></p><p>On the other hand, the wealthy “dear friends” with whom the oligarchic wing of the Supreme Court apparently spends its extensive leisure time may include the odd physician. Leaving the justices’ personal relationships aside, physicians collectively have wielded considerable clout in U.S. policymaking (see: national health insurance: lack thereof in the United States). And physicians — although they constitute the <a href="https://www.medicaleconomics.com/view/americas-doctors-the-unhappy-richest-1" rel="noopener noreferrer nofollow" target="_blank">largest occupational group</a> in the nation’s top 1% of earners — are not happy with current work conditions. To judge from the more than <a href="https://www.regulations.gov/document/FTC-2023-0007-0001/comment?filter=physicians" rel="noopener noreferrer nofollow" target="_blank">5,660 comments</a> with which physicians and physician practice trade groups have flooded the FTC (more than a quarter of the 21,200 comments submitted in response to the proposed noncompete ban), doctors broadly consider themselves indentured servants — mostly to hospital systems, but also to private equity-owned and other corporate practice groups. In a chorus of thousands, their submitted comments all but unanimously (excepting a few corporate-own practices) urge the FTC to follow through with an end to noncompete agreements in doctors’ employment contracts. </p><p>The proposed rule specifically addresses the impact of noncompete agreements on physicians, one of four sample employment markets the rule spotlights (see pp. 3523-24 <a href="https://www.govinfo.gov/content/pkg/FR-2023-01-19/pdf/2023-00414.pdf" rel="noopener noreferrer nofollow" target="_blank">here</a>). While the proposed rule’s analysis of the effects of noncompetes on physicians focuses on estimates of suppressed wages, physicians’ comments focus more on the frequent impossibility of leaving a job with intolerable work conditions without moving out of state or ceasing practice for 1-3 years. The dominant claims are that noncompete clauses contribute to physician burnout, restrict supply of a given practice within a given area, degrade the quality of care in various ways, and cause moral harm by forcing physicians to compromise their commitment to patients’ welfare . (In February, Luke Goldstein at The American Prospect <a href="https://prospect.org/health/02-15-2023-doctors-pandemic-noncompete-hospitals/" rel="noopener noreferrer nofollow" target="_blank">relayed </a> accounts of physicians who were prevented by noncompetes from working at overburdened hospitals other than their employer or ex-employer at the height of the pandemic.)</p><p>Noncompetes, writes <a href="https://www.regulations.gov/comment/FTC-2023-0007-9096" rel="noopener noreferrer nofollow" target="_blank">one physician</a> anonymously, “force physicians to stay in toxic work environments for the sake of family or their community, and this leads to burnout and ultimately leaving the workforce. Physicians should have the freedom to leave an unsustainable work environment. Noncompete clauses “give the freedom for employers to focus less on employee retention and more on profits, driving increased burnout and unfair labor environments.” Another physician<a href="https://www.regulations.gov/comment/FTC-2023-0007-10964" rel="noopener noreferrer nofollow" target="_blank"> writes</a> that noncompetes “lock young physicians into practices/hospitals whether or not these institutions continue to align with a physician's goals. They give institutions free rein to abuse physicians.” “I do not have a non-compete now,” a third doctor <a href="https://www.regulations.gov/comment/FTC-2023-0007-6786" rel="noopener noreferrer nofollow" target="_blank">writes</a>, “but I have signed contracts with a non-compete before as a physician and had to move when administration abruptly changed the terms of compensation and the way the practice was run. I was rapidly burning out after the changes were implemented, and it was hurting my health. I knew that if I kept going, I was going to hurt my patients by not delivering the best possible care that I knew I could provide. I know what it feels like to have my autonomy suddenly challenged and have nowhere to go without having to move from the area entirely. But that was exactly what I had to do for my sanity - I moved.” </p><p>A pediatric eye surgeon who reports that a noncompete banned her from practicing in half of her state of residence should she leave her job, <a href="https://www.regulations.gov/comment/FTC-2023-0007-8210" rel="noopener noreferrer nofollow" target="_blank">avers</a>, “The physician non-compete causes BURNOUT TO OUR PHYSICIANS by forcing them to remain in jobs that leave them otherwise unfulfilled and unwell. The physician non-complete is likely leading to a higher physician intent to leave the field of medicine all together, in a country in which is already seeing an ever-increasing physician shortage.”</p><p><strong>Focus on moral harm</strong></p><p>The American Academy of Emergency Physicians <a href="https://www.regulations.gov/comment/FTC-2023-0007-14443" rel="noopener noreferrer nofollow" target="_blank">broadens</a> the allegations of social harm — and moral harm for doctors:</p><blockquote><p>the combination of noncompete clauses with a lack of due process, is a powerful malignant force serving to intimidate physicians against speaking out for patient rights. The recent COVID pandemic has provided multiple examples of physicians being fired, removed from the schedule, or otherwise relegated for speaking out about patient safety issues. The goal of noncompete clauses is to intimidate the emergency physician into unquestioning servitude to business interests. Given physicians’ ethical obligation to patients, many continue to speak out for patient safety; however, knowing that they can be fired at will and then forced to relocate their family to another city or state can have a chilling effect on physicians advocacy for patients. </p></blockquote><p>The American College of Cardiology also charges that noncompete agreements enable the degradation of medical practice, claiming, “It is much easier to enforce clinically unattractive utilization policies and fail to fund or develop clinical programs when physicians have strong non-compete clauses.”</p><p>As many doctors testify, they are subject to noncompetes even when the employer terminates them, e.g., <a href="https://www.regulations.gov/comment/FTC-2023-0007-3697" rel="noopener noreferrer nofollow" target="_blank">for lack of work during the pandemic</a>.</p><p><strong>Who pays physicians, and who can regulate which employers?</strong></p><p>While the FTC cites <a href="https://jhr.uwpress.org/content/55/3/1025" rel="noopener noreferrer nofollow" target="_blank">research</a> from circa 2018 finding that 45% of physicians are subject to noncompete agreements, many physician groups suggest that those numbers are out of date, as the percentage of physicians who own their own practices wholly or partly continues to shrink. A Michigan branch of the American Academy of Family physicians reports, “The proportion of family physicians who are employed continues to grow each year, with 73% of all AAFP members and 91% of new physicians…working as employees” — up from 59% in 2011. The American College of Cardiology <a href="https://www.regulations.gov/comment/FTC-2023-0007-18079" rel="noopener noreferrer nofollow" target="_blank">claims</a> that while 90% of cardiologists were in private practice in 2008, by 2018 84% were employees; 68% were subject to restrictive covenants; and only 10% reported the ability to negotiate any change in those covenants. Overall, according to <a href="https://www.beckershospitalreview.com/hospital-physician-relationships/74-of-physicians-are-hospital-or-corporate-employees-with-pandemic-fueling-increase.html" rel="noopener noreferrer nofollow" target="_blank">Avalere Health</a>, 74% of physicians were employed by hospitals, health systems or corporate entities in January 2022, up from 62% just three years prior.</p><p>Since hospitals and hospital systems are the largest employers of doctors, many commenters criticize the proposed rule’s apparent inability to reach “nonprofit” employers - i.e., the majority of hospitals. Many worry that large, powerful nonprofit systems will gain a competitive advantage. The American Osteopathic Association <a href="https://www.regulations.gov/comment/FTC-2023-0007-20289" rel="noopener noreferrer nofollow" target="_blank">asks</a> the FTC to find a regulatory path to avoid this large hole in the proposed rule: “We strongly urge the FTC to identify a pathway, including through potential collaboration with other federal agencies, to ensure that nonprofit entities are also prohibited from misusing non-compete clauses.”</p><p>At least one other federal government entity has recently concerned itself with noncompete agreements. This past May, National Labor Relations Board (NLRB) General Counsel Jennifer Abruzzo declared in <a class="text__text__1FZLe text__inherit-color__3208F text__inherit-font__1Y8w3 text__inherit-size__1DZJi link__underline_default__2prE_" href="https://apps.nlrb.gov/link/document.aspx/09031d4583a87168" rel="noopener noreferrer nofollow" target="_blank">a memo</a> to agency lawyers that most noncompete agreements infringe on employees’ right to organize, interfering with Section 7 of the National Labor Relations Act. Abruzzo cites the threat of being cut off from finding new employment if efforts at collective action cost employees their jobs. Physician efforts to unionize are in fact <a href="https://www.wired.com/story/health-doctor-unions/#:~:text=In%20the%20past%20two%20years,New%20York%20leading%20the%20way." rel="noopener noreferrer nofollow" target="_blank">increasing</a>, albeit mainly among interns, for whom union membership has <a href="https://prospect.org/health/2023-08-04-when-mds-go-union/" rel="noopener noreferrer nofollow" target="_blank">surged</a> in the past two years. The Prospect’s Harold Meyerson, <a href="https://prospect.org/health/2023-08-04-when-mds-go-union/" rel="noopener noreferrer nofollow" target="_blank">delving</a> into recent unionization efforts, cites a February 2023 <a href="https://opmed.doximity.com/articles/nearly-two-thirds-of-clinicians-are-willing-to-join-a-union-poll-finds" rel="noopener noreferrer nofollow" target="_blank">poll</a> in which almost two thirds of 1600 responding practicing physicians said they were willing to join a union. A finding that noncompete clauses violate the NLRA is germane to physicians’ working conditions — and more germane to more heavily unionized healthcare workers, including <a href="https://www.nytimes.com/2021/01/28/health/covid-health-workers-unions.html" rel="noopener noreferrer nofollow" target="_blank">nurses and nurses’ aides</a>.</p><p><strong>Knock-on effects of a long legal battle</strong></p><p>Whether or not some version of the FTC’s proposed rule is finalized and upheld by the courts, the spotlight the proposed rule turns on the effects of noncompetes, in healthcare as elsewhere, is likely to shine for several years and could lead to significant changes. By way of analogy, while the Supreme Court in 1972 rejected baseball player Curt Flood’s challenge to Major League Baseball’s notorious reserve clause, enabled by MLB’s antitrust exemption, the case highlighted the effective indentured servitude of professional athletes and helped pave the way for a negotiated modification of the reserve clause in 1976, allowing players to become free agents after six years with the team with which their major league career started. Over time, that negotiated adjustment utterly transformed the player-owner relationship.</p><p>The FTC’s proposed rule may stimulate states to increase restrictions on noncompetes, generally or for physicians and/or other healthcare workers specifically. Four states — California, Minnesota, North Dakota and Oklahoma — ban all or nearly all noncompetes. Minnesota just <a href="https://www.lw.com/admin/upload/SiteAttachments/New-Minnesota-Law-Bans-Most-Post-Employment-Non-Competes-6-Key-Takeaways.pdf" rel="noopener noreferrer nofollow" target="_blank">passed its ban</a> this year, effective July 1. In New York, a <a href="https://www.crowell.com/en/insights/client-alerts/new-york-legislature-passes-ban-on-non-compete-agreements#:~:text=On%20June%2020%2C%202023%2C%20the,prohibition%20on%20non%2Dcompete%20agreements." rel="noopener noreferrer nofollow" target="_blank">near-total ban</a> is on Governor Kathy Hochul’s desk. Another <a href="https://beckreedriden.com/wp-content/uploads/2022/08/Noncompetes-50-State-Survey-Chart-20220817.pdf" rel="noopener noreferrer nofollow" target="_blank">20 states</a> ban or restrict noncompetes for physicians, though some restrictions are quite limited — e.g., in Florida, to physicians in rural areas. In Texas, the physician employee must be given a buyout option, though the buyout price may be in six figures. A <a href="https://capitol.texas.gov/tlodocs/88R/analysis/html/SB01534I.htm" rel="noopener noreferrer nofollow" target="_blank">bill</a> passed by the Texas Senate this spring would limit the buyout to a year’s salary and the noncompete to a year’s duration. Gudiksen notes that “states are looking at passing laws in this area.”</p><p>If the FTC finalizes some version of the noncompete ban in <a href="https://news.bloomberglaw.com/antitrust/ftc-expected-to-vote-in-2024-on-rule-to-ban-noncompete-clauses" rel="noopener noreferrer nofollow" target="_blank">April 2024</a> as anticipated, years of litigation are likely to follow. Long-running legal battles involving high-stakes national policy raise awareness and legislative metabolism. If the FTC rule is struck down, or if states perceive the rule as eventually finalized as being weak, she says, noncompetes “will definitely come up” in legislative session. </p><p>While noncompetes may not be on the brink of extinction in the U.S., physician groups, nurses’ unions and service unions may be primed to reduce their hold in the healthcare industry. Given current staffing shortages, Gudiksen points out, “hospital staff has more negotiating leverage than before Covid.” And while individual physicians may often not be in a position to avoid or negotiate noncompete provisions with regionally dominant hospital systems (particularly in practice areas that can function only in hospitals), heightened awareness may render onerous noncompetes a poison pill of sorts for private equity buy-out offers when the target practice is physician-owned. Short of seismic change, an extended battle over noncompetes could conceivably slow the pace of practice acquisitions and improve corporate owners’ behavior.</p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-1683160493292241692023-08-11T16:53:00.005-04:002023-11-21T13:18:14.587-05:00Retention in ACA marketplace continues to improve<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i> </p><p data-pm-slice="1 1 []">CMS just dropped its <a href="https://www.cms.gov/files/document/early-2023-and-full-year-2022-effectuated-enrollment-report.pdf" rel="noopener noreferrer nofollow" target="_blank">Effectuated Enrollment Early 2023 Snapshot and Full Year 2022 Average</a> — a document I’ve been eagerly awaiting. </p><p data-pm-slice="1 1 []">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.</p><p>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.</p><p>The table below shows the ratios of early effectuated enrollment and average monthly enrollment to OEP signups since 2016.</p><p style="text-align: center;"><strong> ACA Marketplace Retention, 2016-2023 </strong></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtwQoMMIMQTl19Wy6rgsTO75Mj54Ik0yUGOKTUsYD2ug9Ocph6j4MwbLGScX7vZ8JLA_t0iSQX_5vRx1PrWv01BfG2wZXnBeoq8ZPg5x8_cGkVZ6uDIisV_qYTr3Jnv3guCERpn8TVimmSAEU9JwiRMnRIp9U-_gaWWAc0ZCYinEsOzCeU709E9w/s564/avg%20monthly.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="211" data-original-width="564" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtwQoMMIMQTl19Wy6rgsTO75Mj54Ik0yUGOKTUsYD2ug9Ocph6j4MwbLGScX7vZ8JLA_t0iSQX_5vRx1PrWv01BfG2wZXnBeoq8ZPg5x8_cGkVZ6uDIisV_qYTr3Jnv3guCERpn8TVimmSAEU9JwiRMnRIp9U-_gaWWAc0ZCYinEsOzCeU709E9w/w640-h240/avg%20monthly.png" width="640" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><strong style="--tw-border-spacing-x: 0; --tw-border-spacing-y: 0; --tw-ring-color: rgb(59 130 246 / 0.5); --tw-ring-offset-color: #fff; --tw-ring-offset-shadow: 0 0 #0000; --tw-ring-offset-width: 0px; --tw-ring-shadow: 0 0 #0000; --tw-rotate: 0; --tw-scale-x: 1; --tw-scale-y: 1; --tw-scroll-snap-strictness: proximity; --tw-shadow-colored: 0 0 #0000; --tw-shadow: 0 0 #0000; --tw-skew-x: 0; --tw-skew-y: 0; --tw-translate-x: 0; --tw-translate-y: 0; background-color: white; color: #404040; font-family: "SF Compact Display", -apple-system, BlinkMacSystemFont, "Segoe UI", Roboto, Helvetica, Arial, sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol"; font-size: 12.73px; text-align: start;"><span style="--tw-border-spacing-x: 0; --tw-border-spacing-y: 0; --tw-ring-color: rgb(59 130 246 / 0.5); --tw-ring-offset-color: #fff; --tw-ring-offset-shadow: 0 0 #0000; --tw-ring-offset-width: 0px; --tw-ring-shadow: 0 0 #0000; --tw-rotate: 0; --tw-scale-x: 1; --tw-scale-y: 1; --tw-scroll-snap-strictness: proximity; --tw-shadow-colored: 0 0 #0000; --tw-shadow: 0 0 #0000; --tw-skew-x: 0; --tw-skew-y: 0; --tw-translate-x: 0; --tw-translate-y: 0;">Sources: CMS </span><a href="https://www.cms.gov/data-research/statistics-trends-and-reports/marketplace-products/2023-marketplace-open-enrollment-period-public-use-files" rel="" style="--tw-border-spacing-x: 0; --tw-border-spacing-y: 0; --tw-ring-color: rgb(59 130 246 / 0.5); --tw-ring-offset-color: #fff; --tw-ring-offset-shadow: 0 0 #0000; --tw-ring-offset-width: 0px; --tw-ring-shadow: 0 0 #0000; --tw-rotate: 0; --tw-scale-x: 1; --tw-scale-y: 1; --tw-scroll-snap-strictness: proximity; --tw-shadow-colored: 0 0 #0000; --tw-shadow: 0 0 #0000; --tw-skew-x: 0; --tw-skew-y: 0; --tw-translate-x: 0; --tw-translate-y: 0;">Public Use Files</a><span style="--tw-border-spacing-x: 0; --tw-border-spacing-y: 0; --tw-ring-color: rgb(59 130 246 / 0.5); --tw-ring-offset-color: #fff; --tw-ring-offset-shadow: 0 0 #0000; --tw-ring-offset-width: 0px; --tw-ring-shadow: 0 0 #0000; --tw-rotate: 0; --tw-scale-x: 1; --tw-scale-y: 1; --tw-scroll-snap-strictness: proximity; --tw-shadow-colored: 0 0 #0000; --tw-shadow: 0 0 #0000; --tw-skew-x: 0; --tw-skew-y: 0; --tw-translate-x: 0; --tw-translate-y: 0;"> and </span><a href="https://www.cms.gov/files/document/early-2023-and-full-year-2022-effectuated-enrollment-report.pdf" rel="" style="--tw-border-spacing-x: 0; --tw-border-spacing-y: 0; --tw-ring-color: rgb(59 130 246 / 0.5); --tw-ring-offset-color: #fff; --tw-ring-offset-shadow: 0 0 #0000; --tw-ring-offset-width: 0px; --tw-ring-shadow: 0 0 #0000; --tw-rotate: 0; --tw-scale-x: 1; --tw-scale-y: 1; --tw-scroll-snap-strictness: proximity; --tw-shadow-colored: 0 0 #0000; --tw-shadow: 0 0 #0000; --tw-skew-x: 0; --tw-skew-y: 0; --tw-translate-x: 0; --tw-translate-y: 0;">Effectuated Enrollment Snapshots</a></strong></div><span><a name='more'></a></span><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;"><p data-pm-slice="1 1 []">Back in 2016 — the marketplace’s peak enrollment year before ARPA (and Covid) changed the calculus — the snapshot of early effectuated (paid-up) enrollment was just 85% of the total for plan selections as of the end of OEP, compared to 96% in 2023. The improved effectuation rate puts adds new perspective to enrollment growth in the post-ARPA era. While plan selections in OEP are 29% higher in 2023 than in 2016, early effectuated enrollment is 45% higher (almost 5 million higher). Average monthly enrollment will likely follow suit. </p><p>On-exchange enrollment gains since ARPA enactment need to be considered in light of a collapse in off-exchange ACA enrollment that occurred in the wake of steep premium increases in 2017 and 2018. Off-exchange enrollment dropped from 5.1 million in Q1 2016 to 2.0 million in Q1 2019, according to Kaiser Family Foundation <a href="https://www.kff.org/private-insurance/issue-brief/data-note-changes-in-enrollment-in-the-individual-health-insurance-market-through-early-2019/" rel="noopener noreferrer nofollow" target="_blank">estimates</a>. 2023 is the first year since 2016 in which it can be stated with confidence that enrollment in ACA-compliant individual market plans is at an all-time high.</p><p>Retention improved steadily through the Trump years — probably because reduced advertising and outreach, coupled with a shortened OEP, filtered out more marginal enrollees — as did, perhaps, the zeroing out of the individual mandate penalty in 2019. </p><p>Also contributing: <a href="https://www.healthaffairs.org/do/10.1377/forefront.20190913.296052/" rel="noopener noreferrer nofollow" target="_blank">Silver loading</a> — the pricing of the value of Cost Sharing Reduction (CSR) subsidies directly into silver plans, which began in 2018 after Trump cut off separate reimbursement of insurers for CSR (see note below). Silver loading sharply increased the number of enrollees paying zero premium. To drop a zero-premium plan, you have to take positive action.</p><p>In March 2021, ARPA put free or near-free enrollment on steroids, making benchmark silver plans free at incomes up to 150% FPL and reducing their cost at every higher income level. As of the end of OEP for 2023, 4.5 million enrollees with income up to 150% FPL, for whom the two lowest-cost silver plans are free, had accessed silver plans (though some are paying premiums for more expensive silver plans). Many millions more accessed free bronze plans. <a href="https://www.cms.gov/files/document/health-insurance-exchanges-2023-open-enrollment-report-final.pdf" rel="noopener noreferrer nofollow" target="_blank">35% of all enrollees</a> as of the end of OEP 2023 selected plans with premiums of $10/month or less. Among those who effectuated enrollment, that would come to about 5.5 million.</p><p data-pm-slice="1 1 []">One possible contributor to the continued high ratio in 2022 of average monthly enrollment to end-of-OEP enrollment is the rule, <a href="https://xpostfactoid.blogspot.com/2022/02/why-healthcaregov-is-offering-year.html" rel="noopener noreferrer nofollow" target="_blank">enacted in early 2022</a>, allowing enrollees with income up to 150% FPL to enroll year-round. The ratio of average monthly enrollment to end-of-OEP enrollment was <a href="https://xpostfactoid.blogspot.com/2022/10/total-individual-market-enrollment-in.html" rel="noopener noreferrer nofollow" target="_blank">extraordinarily high in 2021</a> because of an emergency Special Enrollment Period, overlapping with enactment in March 2021 of the ARPA subsidy boosts, that effectively created a second OEP from February through August (with some variation in state-based marketplaces). The SEP attracted <a href="https://www.hhs.gov/sites/default/files/2021-sep-final-enrollment-report.pdf" rel="noopener noreferrer nofollow" target="_blank">2.1 million</a> enrollments in that time frame, an extraordinary one-time surge. It’s worth noting that the ratio of average monthly to end-of-OEP enrollment in 2022 dipped only modestly below the 2021 unicorn.</p><p data-pm-slice="1 1 []">The ratio of average monthly enrollment to initial OEP plan selections may also prove to be very high, as a result to the end of the 3-year pause in Medicaid disenrollments. The Medicaid “unwinding,” which some states began in April, is setting off <a href="https://ccf.georgetown.edu/2023/08/09/limited-child-medicaid-unwinding-data-begins-to-paint-bleak-picture-highlights-need-for-more-transparency/" rel="noopener noreferrer nofollow" target="_blank">multiple</a> <a href="https://www.latimes.com/business/story/2023-07-27/column-millions-of-americans-are-about-to-lose-their-healthcare-coverage-many-have-no-idea" rel="noopener noreferrer nofollow" target="_blank">alarm</a> <a href="https://www.star-telegram.com/news/local/article277511743.html" rel="noopener noreferrer nofollow" target="_blank">bells</a>, as some states are gleefully kicking people off Medicaid as fast as they can process them. Medicaid disenrollment does trigger a SEP for marketplace enrollment, and some states at least are working hard to effect a warm handoff from Medicaid to marketplace. </p><p data-pm-slice="1 1 []">One other point worth noting: Enrollment in plans with Cost Sharing Reduction (CSR) increased at a lower rate year-over-year, 11%, than overall enrollment, which increased by 13%, and enrollment with premium subsidies, which increased by 15%. That is, the percentage of enrollees who accessed CSR, available to low-income enrollees who selected silver plans, diminished, while bronze plan enrollment has increased. <a href="https://xpostfactoid.substack.com/p/underinsurance-spikes-among-low-income" rel="noopener noreferrer nofollow" target="_blank">This post</a> and <a href="https://xpostfactoid.substack.com/p/forgoing-high-csr-silver-coverage" rel="noopener noreferrer nofollow" target="_blank">this post</a> explore potential explanations for this drop in takeup of the valuable CRS benefit.</p><p>—</p><p><a href="https://www.healthaffairs.org/do/10.1377/forefront.20210222.921409/" rel="noopener noreferrer nofollow" target="_blank">Silver loading</a> is an ACA marketplace pricing practice that began in 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. Since ACA premium subsidies are set to a silver plan benchmark, premium subsidies rose along with silver plan premiums, creating relative bargains in bronze and gold plans. Silver loading made zero-premium bronze plans widely available at incomes up to (and beyond) 200% FPL.</p><p>Postscript. Back in 2014, as marketplace signups surged toward the end of an extended OEP, recovering from the initial disastrous launch of HealthCare.gov, ACA antagonists (and Republican House members) pointedly noted that signing up for coverage during OEP did not entail effectuating enrollment: “But how many have paid?” was a major trolling theme. Charles Gaba, who engaged heavily in that 2014 infowar, <a href="https://acasignups.net/23/08/11/new-cms-confirms-effectuated-aca-enrollment-and-how-many-have-paid-are-all-time-highs" rel="noopener noreferrer nofollow" target="_blank">recounts it today</a> while processing the effectuated enrollment snapshot. Charles also digs into the nuances of what early effectuated enrollment signifies (it may include a bit of post-OEP SEP enrollment) and differences among states.</p></div><p></p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-89806215511647356992023-07-26T12:46:00.002-04:002023-07-26T12:46:30.560-04:00Limit short-term health plans to a...short term? Buyers and sellers speak out<p><i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i> </p><p>My last post considered a <a href="https://public-inspection.federalregister.gov/2023-14238.pdf" rel="noopener noreferrer nofollow" target="_blank">rule</a> 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.</p><p>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.</p><p>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.</p><p>For further perspective I turned to the <a href="https://www.regulations.gov/document/CMS-2023-0116-0001/comment?pageNumber=1" rel="noopener noreferrer nofollow" target="_blank">comments</a> 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.<span></span></p><a name='more'></a><p></p><p><strong>No insurance seeker left behind? Not quite</strong></p><p>A fair number of consumer commenters and some brokers as well seem to be unaware of key features of the ACA marketplace, including the current absence of an income cap on subsidy eligibility, the generosity of subsidies and extent of subsidy eligibility created by ARPA, and the availability of Special Enrollment Periods for people who lose other coverage (e.g., an employer’s). Some comments are ideologically driven and express hostility to the ACA’s reshaping of the individual market.</p><p>A few brokers, however, detail remaining groups of people who have no viable option outside the STLD market who would be harmed if forced to find a new plan after four months (three months plus an allowed one-month extension). Some consumer commenters indicate that they are in one of these categories (derived largely from this <a href="https://www.regulations.gov/comment/CMS-2023-0116-0033" rel="noopener noreferrer nofollow" target="_blank">broker comment</a>), which include:</p><ul><li><p>People in the coverage gap in states that have refused to enact the ACA Medicaid expansion — that is, adults with household income below 100% of the Federal Poverty Level, who don’t qualify for marketplace subsidies and in most cases also don’t qualify for Medicaid.</p></li><li><p>People who for whatever reason missed or skipped Open Enrollment or had their plans canceled — say, for failure to provide required documentation of income or immigration status.</p></li><li><p>The undocumented, or people visiting the U.S. for more than a few months.</p></li><li><p>Young adults, for whom 8.5% of income for high-deductible coverage (the max paid for a benchmark silver plan) may be a substantial bite (say, $262/month for a single person with an income of $37,000), and who can sometimes find adequate, much cheaper substitutes in the short-term market.</p></li><li><p>People who live in two states (you can keep switching marketplace coverage via SEP, but that’s tricky).</p></li><li><p>People who cannot find an affordable marketplace plan that provides access to needed providers. Provider networks in many ACA marketplaces are horrific, particularly for the lower-priced plans in each metal level.</p></li><li><p>Itinerant workers. Two brokers cited travel nurses, one <a href="https://www.regulations.gov/comment/CMS-2023-0116-0023" rel="noopener noreferrer nofollow" target="_blank">claiming</a> that there are 1.7 million of them.</p></li></ul><p>Regarding those who realize they need coverage outside of the annual Open Enrollment Period: while some might regard that as a personal failure, it’s a “failure” to which almost anyone might find themselves susceptible — not least because of frequent administrative incompetence and error at the agencies that handle enrollment. (I knew of one Medicaid applicant who received a rejection notice, then, seven months later, an insurance card indicating coverage beginning at the time of rejection.) Blame who you will, ignorance of what’s available to nonelderly adults who lack access to employer-sponsored insurance is endemic. According to KFF’s most recent <a href="https://www.kff.org/uninsured/issue-brief/a-closer-look-at-the-remaining-uninsured-population-eligible-for-medicaid-and-chip/" rel="noopener noreferrer nofollow" target="_blank">estimate</a>, 64% of the 27.5 million uninsured are eligible either for Medicaid or for marketplace subsidies. Millions of people don’t know what’s available, don’t know how to access it, are tripped up by application complexities when they do try to enroll, or don’t recognize or act soon enough when they lose coverage — for example, if their income rises enough to disqualify them from Medicaid.</p><p>A fixed open enrollment period in the ACA marketplace is essential to keep people from enrolling only when they get sick. But given the hard realities created by our patchwork of health insurance programs, I thought one agent’s <a href="https://www.regulations.gov/comment/CMS-2023-0116-0031" rel="noopener noreferrer nofollow" target="_blank">proposal</a> was reasonable: “I would suggest that you change the maximum duration of the short term plan to be "to the end of the year (Dec 31)" in order to coordinate with the open enrollment effective date of ACA plan eligibility (Jan 1) and assure continued coverage.”</p><p><strong>Those who prefer not to obtain ACA-compliant coverage</strong></p><p>With respect to the limitations of STLD plans and protections offered by ACA-compliant plans, a Texas consumer’s comment is worth considering, notwithstanding a palpable hostility to the ACA:</p><blockquote><p>I have been truly flummoxed by the people who say my short-term plan (that I have 24 month contract for) is "junk" insurance. I have spent hours and hours researching plans after obamacare upended the market, and the only "junk" insurance plans I've found were on healthcare.gov. Those are accepted by virtually no private doctor or facility, only by one publicly funded hospital and doctors tied to that hospital (in one of the largest counties in Texas). When I broke my arm, I was taken to a private hospital, and my "junk" insurance paid fully, quickly, and without complication. On obamacare plans, I would have been out of network at virtually every hospital and doctor I saw during that illness.</p></blockquote><p>It’s true that provider networks in Texas are often extremely limited, as Dallas-area broker Jennifer Chumbley, president and CEO of KG Health Insurance, has <a href="https://xpostfactoid.substack.com/p/whos-buying-into-the-aca-marketplace" rel="noopener noreferrer nofollow" target="_blank">described to me in detail</a>. In response to this comment, Chumbley also pointed out, however, that while certain STLD plans might work well for a broken arm, coverage is likelier to be more problematic for severe illness, such as cancer. </p><p>First, Chumbley noted, drug coverage is generally extremely limited. I checked out drug coverage in short-term plans available via eHealth in Dallas. Three out of four carriers offer no drug coverage. A third, United Health, caps drug coverage at $2,500 for 12-month plans with a $7,500 deductible, or $5,000 for plans with a $15,000 deductible; some longer term plans cover only physician-administered drugs. Coverage for non-generic drugs generally only kicks in after the deductible. Cancer drugs can run to hundreds of thousands of dollars.</p><p>Second, Chumbley suggested that when cancer treatment is sought, a short-term plan will look closely for evidence that the disease pre-existed coverage. Even if the insurer does ultimately grant coverage, they may hold up payment — and so, treatment — while they investigate.</p><p>As to the complaints about ACA-compliant coverage, Chumbley acknowledged again that networks can be very narrow but noted that for emergency care at least, the No Surprises Act has mitigated the harm, as emergency treatment (through stabilization) is no longer subject to balance billing. (Prior to the ACA, much of Texas was ground zero for rampant balance billing in emergency care.) But there’s no denying that major hospital systems are out of network in many, many ACA-compliant plans.</p><p><strong>Regulating a grayish market</strong></p><p>Regulating short-term plans more tightly — say, by subjecting them to the ACA’s MLR rule requiring that 80% of premium revenue be spent on medical care — is something of a Catch-22. Make the plans too good, and they will suck healthy people out of the ACA-compliant risk pool. Leave them barely regulated — free to spend, say, 45% of premium dollars on medical care — and people will get burned, deceived in many cases by predatory brokers.</p><p>More than one commenting broker who opposed restoring the three-month term limit expressed support for the bulked-up disclosure the proposed rule would mandate. The disclosure as currently drafted details the limitations of STLD plans and the availability of marketplace coverage:</p><blockquote><p>IMPORTANT: This is short-term, limited-duration insurance. This is temporary insurance. It isn’t comprehensive health insurance. Review your policy carefully to make sure you understand what is covered and any limitations on coverage.</p><p>This insurance might not cover or might limit coverage for:</p><ul><li><p>preexisting conditions; or</p></li><li><p>essential health benefits (such as pediatric, hospital, emergency, maternity, mental health, and substance use services, prescription drugs, or preventive care).</p></li><li><p>You won’t qualify for Federal financial help to pay for premiums or out-of-pocket costs.</p></li><li><p>You aren’t protected from surprise medical bills.</p></li><li><p>When this policy ends, you might have to wait until an open enrollment period to get comprehensive health insurance.</p></li><li><p>Visit HealthCare.gov online or call 1-800-318-2596 (TTY: 1-855-889-4325) to review your options for comprehensive health insurance. If you’re eligible for coverage through your employer or a family member’s employer, contact the employer for more information. Contact your State department of insurance if you have questions or complaints about this policy.</p></li></ul></blockquote><p>As noted by Georgetown’s Sabrina Corlette in <a href="https://www.healthaffairs.org/content/forefront/administration-takes-action-limit-junk-health-insurance" rel="noopener noreferrer nofollow" target="_blank">Health Affairs</a>, “The tri-agencies [issuing the proposed rule] seek public feedback on ways to prevent or mitigate the potential that consumers will mistakenly purchase STLDI instead of comprehensive coverage during the annual open enrollment period.”</p><p> * * *</p><p>The alternative market would not be necessary in a healthcare system where good-enough insurance is not only available, but positively hard to avoid — for all. The ARPA boosts to ACA premium subsidies got us closer to that point, but by no means all the way there. And given the very possible sunsetting of the ARPA subsidy schedule in 2026 — with restoration of the income cap on subsidies at 400% FPL — the STLD market’s dysfunctional place in a dysfunctional system may swell again.</p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0tag:blogger.com,1999:blog-8512362.post-75377221819296162222023-07-18T19:38:00.002-04:002023-07-21T15:14:01.436-04:00A caveat about curtailing short-term limited duration health plans<p> <i>Note: All xpostfactoid subscriptions are now through <a href="https://xpostfactoid.substack.com/" target="_blank">Substack</a> alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit <a href="https://xpostfactoid.substack.com/" target="_blank">xpostfactoid on Substack</a> and sign up!</i> </p><p data-pm-slice="1 1 []">It’s generally a good thing when the Biden administration repeals a Trump-era administrative rule. Under current ACA marketplace conditions, a <a href="https://public-inspection.federalregister.gov/2023-14238.pdf" rel="noopener noreferrer nofollow" target="_blank">rule</a> 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.</p><p>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 (<a href="https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet" rel="noopener noreferrer nofollow" target="_blank">MHPAEA</a>). 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.)</p><p>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 “<a href="https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Downloads/Waiver-Concepts-Fact-Sheet.pdf" rel="noopener noreferrer nofollow" target="_blank">waiver concepts</a>” inviting the states to seek approval for providing federal subsidies for ACA-noncompliant plans.<span></span></p><a name='more'></a>STLD plans spend as little as 45% of premium dollars on enrollee’s medical care, as opposed to the the 80% minimum required of ACA plans. Insurers pay <a href="https://xpostfactoid.blogspot.com/2021/11/the-brokers-tale-louise-norris-on.html" rel="noopener noreferrer nofollow" target="_blank">much higher commissions </a>for STLD plans than for ACA-compliant plans, and deceptive marketing for STLDs exploded online after the Trump administration extended the allowable term (the STLD market was further stimulated by the zeroing out of the individual mandate penalty for not carrying ACA-compliant insurance, effective in 2019).<p></p><p>While the Trump administration promoted bad solutions (see also <a href="https://www.commonwealthfund.org/blog/2019/past-future-association-health-plans#:~:text=The%20Trump%20administration%20has%20made,found%20the%20new%20rules%20violate" rel="noopener noreferrer nofollow" target="_blank">association health plans</a>) to the ACA’s shortcomings, it was responding to very real shortcomings — most notably, the unaffordability of ACA-compliant plans for a significant number of Americans who lacked access to other affordable insurance (e.g., through an employer or via Medicaid or Medicare). At inception, the ACA marketplace was seriously undersubsidized. Perhaps the most acute affordability problem (excepting those with incomes below the poverty line in states that refused to enact the ACA Medicaid expansion) was suffered by those with incomes modestly above the cap for subsidy eligibility — 400% of the Federal Poverty Level, which in the 2018 marketplace was $48,240 for an individual and $98,400 for a family of four (for Open Enrollment 2024, 400% FPL will be $58,320 for an individual and $120,000 for a family of four).</p><p>For those ineligible for subsidies, STLD plans were sometimes the only option that provided any level of coverage at anything approaching an affordable premium. Back in 2017, anticipating the Trump STLD term expansion, I <a href="https://xpostfactoid.blogspot.com/2017/11/halfway-back-to-future-in-individual.html" rel="noopener noreferrer nofollow" target="_blank">spotlighted</a> such a plight for a subsidy-ineligible 58 year-old in Pottsville, PA:</p><blockquote><p>…the cheapest bronze plan available is from Geisinger at $898 per month. The deductible is $6,100, though doctor visits are not subject to it.. The cheapest silver plan is $1069 per month, offered off-exchange only, with a $5000 deductible...</p><p>…The cheapest [short-term] plan available in the Pottsville market [listed by online broker <a href="https://www.ehealthinsurance.com/" rel="noopener noreferrer nofollow" target="_blank">eHealth</a>] is $88 per month. It has a $750,000 coverage cap for the three month duration, a $5,000 deductible, a $10,000 out-of-pocket maximum (including the deductible) and 50% coinsurance for various services. Subject to that coverage limit, it does offer catastrophic coverage of sorts.</p></blockquote><p>The American Rescue Plan Act (ARPA), enacted in March 2021, largely eliminated plights like this — except, again, for people with income below 100% FPL in the ten states that still have not expanded Medicaid eligibility. With that cruel exception, no one — or rather, no citizen or legally present noncitizen — who lacks access to other affordable insurance pays more than 8.5% of income for the benchmark (second cheapest) silver plan in their area — and usually far less for bronze coverage. While paying 8.5% of income for a silver plan with, say, a $5,000 deductible (usually with many services not subject to that deductible) may not feel like the pinnacle of government largess, the days of facing premiums at 15-20% of income or more are, for the most part, gone for the present.</p><p>The key words here, though, are “for the present.” The subsidy cliff looms again, as the Inflation Reduction Act extended the ARPA subsidy increases (originally a pandemic “rescue” measure in effect through 2022) only through 2025. The odds that Democrats will control the House, Senate and presidency in 2025 are low. And while much of the venom has finally drained out of Republican hostility to the ACA marketplace, the odds that Republicans will accede to an extension of the ARPA subsidy schedule also seem low. Maybe a full or partial ARPA subsidy extension can be bargained for in an omnibus bill. Maybe Republicans won’t want to force — and be blamed for — a return of the subsidy cliff at 400% FPL. But a snap-back to the pre-ARPA ACA subsidy schedule, with its infamous subsidy cliff, seems far from unlikely. </p><p>If we do go back to the undersubsidized ACA future, the STLD market will once again be the only marginally viable option for a substantial number of people — perhaps 3-5 million. Absent the ARPA subsidy boosts, a pair of 64 year-olds in Charleston, West Virginia with an income just over 400% FPL ($78,880) would as of now pay $3,048 per month for the cheapest bronze plan — with a per-person deductible of $9,100. (West Virginia has the second-highest premiums in the country, and 64 year-olds pay three times as much as 20somethings. Premiums in West Virginia are so high that under ARPA, if the two 64 year-olds earn $500,000/year, they qualify for a $450/month subsidy.) In the current short-term market, according to eHealth, a 12-month UHC plan with a $7,500 per-person deductible, a $17,500 out-of-pocket max and a $1 million coverage cap is available (without taking account of pre-existing conditions) for $481 per month. </p><p>In Phoenix, Arizona (a state with premiums near the national average), absent ARPA, two 52 year-olds with income at 401% FPL would pay $885/month for the cheapest bronze plan — again, with deductibles of $9,100 each. With ARPA in place, the cheapest silver plan is available for $552/month. At present, a UHC 12-month short-term plan with the same $7,500 per-person deductible, a $17,500 out-of-pocket max and a $1 million coverage cap as in Charleston, WV is available to this Phoenix couple for $346/month — if they have no pre-existing conditions. </p><p>These UHC STLD plans do have some drug coverage, capped at $2,500. They do have a decent provider network, and they do have an annual out-of-pocket maximum for in-network care.</p><p>Absent ARPA, if I were half of the Phoenix couple I’d probably go for the ACA-compliant coverage. If I were part of the West Virginia couple, however (that much older, and in a high-premium state), I suspect I’d go for the STLD plan — and hold my breath till Medicare (where a different Hobson’s choice awaits, between Medicare Advantage at $328 month for two vs. traditional Medicare + Part D + Medigap, at more than double that). </p><p>My point, again, is that if the subsidy cliff returns, we will be back in a world where STLD is the only game in town for some. And we may very well be staring at a subsidy cliff again in 2026. For that reason, I would make the current proposed rule shortening STLD terms contingent on the continued absence of an income cap on subsidies. There is recent precedent for such contingency. In September 2021, CMS finalized a rule providing <a href="https://www.healthinsurance.org/special-enrollment-guide/an-sep-if-your-income-doesnt-exceed-150-of-the-federal-poverty-level/" rel="noopener noreferrer nofollow" target="_blank">year-round marketplace enrollment</a> for applicants with income up to 150% FPL, but made the rule contingent on the continued availability of free benchmark silver plans (provided by ARPA) up to that income threshold. At the same time, the stiff warnings as to the limitations of STLD plans that the proposed rule mandates — warning that the plans might not cover or might limit coverage for pre-existing conditions; needn’t cover EHBs’ don’t protect from surprise billing; and are not subsidy-eligible — should be permanent.</p><p>Some postscripts: 1. Sabrina Corlett of Georgetown University provides a very <a href="https://chirblog.org/administration-takes-action-to-limit-junk-health-insurance/" rel="noopener noreferrer nofollow" target="_blank">complete account</a> of the regulatory history of STLD plans, the provisions of the proposed rule, the rule’s forecast effects on coverage, and its provisions for other sub-insurance products known as “excepted benefits” (e.g., fixed indemnity plans, plans covering specific conditions like cancer, and others). 2. With characteristic thoroughness and accuracy, Louise Norris covers <a href="https://www.healthinsurance.org/short-term-health-insurance/" rel="noopener noreferrer nofollow" target="_blank">every aspect</a> of short-term plan coverage and who might need it under what circumstances. 3. In November 2021 I <a href="https://xpostfactoid.blogspot.com/2021/11/the-brokers-tale-louise-norris-on.html" rel="noopener noreferrer nofollow" target="_blank">interviewed Louise</a> about the skewed incentives that lead some brokers to sell as many STLD plans as they can.</p>Andrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.com0