Robert Laszewski's ACA blind spot

Robert Laszewski, health insurance consultant and blogger, is among the critics of the Affordable Care Act whom supporters of the law respect the most. He knows the market, he knows the law, he wants to see everyone insured, he's not averse to calling out Republican idiocy and mendacity, and he wants to fix the law, not repeal it. Ezra Klein's Wonkblog named him "Pundit of the Year" for 2013.

Yet Laszewski has a bias, which progressive healthcare reporters, including Klein, are slow to call out.  His ur-insurance buyer is a veteran of the pre-ACA individual market, healthy, ineligible for ACA subsidies or for only limited subsidy, and so hit by rate shock.  His chief complaint seems to be that ACA-compliant plans are weighed down by unnecessary Essential Health Benefits, which drive up the base premiums and so increase the hit to the unsubsidzed.

The plight of this cohort is real, and the law could be amended to ease it. Yet Laszewski generally fails to acknowledge that such victims are far outnumbered by ACA beneficiaries, that negative responses to the law have been shaped in large part by five years of Republican disinformation, that guaranteed issue is a much larger driver of unsubsidized rate increases than the benefit mandates, and that the law is on target so far to meet long-term CBO projections.

Laszewski's bias in on display in his latest post -- which pleased progressives by acknowledging that Democrats pledging to modify the law are more in line with public opinion than Republicans vowing to repeal it. Here's the nub of his case that the law is in trouble because people do not like the core offering:

Tell me your ACA-shopping story

Always fair-minded, Jonathan Cohn pauses in his celebration of lower-than-forecast ACA premiums (as highlighted by the latest CBO update) to acknowledge:

In the transition from the old system, in which insurers could charge higher prices to the sick or avoid them altogether, to a new system, in which everybody pays the same price regardless of pre-existing condition, some young and healthy people must now pay more for their individual policies

The "and" in "young and healthy" is interesting, because, as the conjunction suggests if you look twice, it's not just the young who are paying more under ACA rules. Some if not most healthy older buyers who were in the individual market in 2013 are now paying more -- that is, if no one sharing the insurance has a preexisting condition.*

If you're in the individual market and you're paying more for your insurance in 2014 than you did in 2013, I'd like to speak to you (or, for that matter, if you're unsubsidized and paying less or about the same).  I'd like some detail about what your prior policy covered vs. what your current one does -- what were the tradeoffs. (I wrote up two such stories last month, and I'd like to do more.)

States on Healthcare.gov have closed the signup gap a bit with states running their own exchanges

A week ago (Jan. 6), Theda Skocpol  crunched state-by-state ACA signup numbers tracked by Charles Gaba and concluded, not surprisingly, that takeup was far higher in states trying to make the law work than in states ignoring or actively impeding the exchanges (not to mention the Medicaid expansion).

That conclusion was not surprising, but the statistics were badly skewed by wide discrepancies in the timeliness of the states' reporting.  HealthCare.gov was barely functional until early December, but the majority of states reliant on HealthCare.gov had posted signup figures only through 11/30 at the time of Skocpol's report.  Almost none had yet tallied the rush of signups immediately preceding and following the 12/23 deadline (later extended) for buyers seeking to obtain coverage effective January 1.  A much-reproduced chart accompanying Skocpol's report showed states relying on HealthCare.gov with anemic exchange takeup rates -- ranging, in various breakouts, from 3% to 6.3% of first-year CBO projections for each state. In contrast, Skocpol showed the 14 states running their own exchanges (and accepting the Medicaid expansion) with a collective exchange takeup rate of 37.2% of CBO projections. (Skocpol gave a rather unsatisfactory account of how the reporting gap should be handled on Charles Gaba's blog, here.)

In the intervening week, seven states relying on HealthCare.gov have updated their signup numbers at least through December 23: Delaware Idaho, Iowa, Nebraska, New Mexico, South Dakota, Wyoming.* Collectively, according to my tote-up, they have reached 16.9% of CBO projections -- 41,186 out of 244,000.

In contrast, the 14 states and District of Columbia running their own exchanges have by my count reached 32.9% of CBO projections -- 1,036,131 out of 3,143,000 projected. (I don't know where the discrepancy with Skocpol's 37.2% comes from; D.C., which she may have omitted, has a 36% takeup rate). Moreover, the Healthcare.gov states' reporting still chronologically lags that of the self-operating states: most of the latter have numbers updated into the first week of January, while most of the HealthCare.gov numbers I've cited date from the last week of December.