Getting insured after job loss: Just how complicated?

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About 27 million of the newly unemployed and their family members have likely lost health insurance, according to a new Kaiser Family Foundation estimate.

The ACA offers a leaky but not entirely unseaworthy lifeboat. According to Kaiser estimates, 79% of the newly uninsured are at present likely eligible for ACA-subsidized coverage -- 12.7 million for Medicaid and CHIP and 8.4 million for subsidized private plans in the ACA marketplace.

The basic buckets that those seeking insurance should find themselves sorted into shouldn't in principle be that complicated. Here's the breakdown:

Uninsurance goes upscale: The Census's Health Insurance Coverage Update for 2018

Yesterday the Census Bureau* released its health insurance estimates for 2018. The top line showed a rise in the uninsured population of 1.9 million, or 0.5% -- the first increase since the ACA's main programs launched.

Disturbingly, the number of uninsured children increased by 425,000, or 0.6%, raising children's uninsured rate to 5.5%. That spike would appear to be due mainly to a drop in Medicaid coverage, given that  Medicaid and CHIP coverage for children was down 1.2%; and the overall percentage of children with public health insurance dropped 0.8%, while the percentage of children with private health insurance ticked up 0.2%. There was also, however, a sharp spike in the uninsured rate among children in households with incomes over 400% of the Federal Poverty Level (FPL), from 1.9% in 2017 to 2.6% in 2018 -- accounting for almost half of the increase in uninsured children.

Folks at Georgetown University and the Center for Budget and Policy Priorities will probably dive  into the spike in uninsured children, as they have been doing for at least a year. Here I just want to throw some sidelights on the Census numbers generally.

1. Affluent uninsured population spikes. Notwithstanding a drop of 2 million  (0.7%) in Medicaid enrollment, the sharpest increases in the uninsured were at high incomes. At 300-399% FPL, the insured rate dropped a full percentage point, from 92.9% to 91.9%, and at over 400% FPL, the rate dropped 0.8%, from 97.3% to 96.6%. Together, these two income groups account for 55% of the population. Particularly striking, the number of uninsured at incomes over 300% FPL increased 23.8% (from 6.631 million in 2017 to 8.215 million in 2018).  The spike in uninsured children at high income levels seems congruent with this drop.

In which Hillary Clinton is confronted by a likely ACA loser (UPDATED)

[Please see 3/16 and 3/17 updates at bottom]

In last night's Democratic town hall forum, an audience member, Teresa O'Donnell of Powell, Ohio, told Hillary Clinton that she voted for Obama, "but then my health insurance skyrocketed, from $490 a month to $1,081 a month, for a family of 4." Charles Gaba has the clip, his own transcription, and an analysis here.

The question's a toughie, because Clinton couldn't very interrogate Ms. O'Donnell to determine all the factors behind her claim.  She did ascertain that the family had previously bought their insurance in the individual market. She then faintly intimated that perhaps O'Donnell hadn't fully checked out her options; credited the ACA with getting costs down generally (though not for all); stressed that she wanted to work to better contain costs; and implicitly blamed the absence in many markets of nonprofit insurers for much of continued cost hikes.

Why does the Census show such small gains among the poor in government-provided health insurance?

If I may reiterate: it seems quite strange to me that the Census health insurance surveys show a net gain for 2014 of just 1.3 million people with incomes under 138% of the Federal Poverty Level enrolled in government insurance plans -- whereas according to HHS, Medicaid enrollment increased by over 9 million in 2014, thanks to the ACA expansion. 138% FPL is the eligibility threshold for Medicaid under the ACA expansion.

The second half of this post provides more detail. According to the Census surveys, those with incomes under 138% FPL showed much stronger gains in private insurance than in public, while those in higher income brackets showed stronger gains in public insurance than in private. That's odd.

The difference may in large part be due to differences in how households are defined: the ACA marketplaces determine eligibility according to who is included in a household tax filing, while the Census surveys (CPS and ACS) consider who lives under one roof. Many other factors are in play, including a modest acceleration in Medicare eligibility and higher income thresholds for children in CHIP than for adults in Medicaid. But none appear on the face of things (as far as I can see) to explain the very low recorded gains in government insurance among adults under 138% FPL (and even more strikingly, under 100% FPL).

Again, there's more detail below the second subhead here (along with some updates added over the weekend). This post is simply to unbury the lead a bit, as I look into the state data.

Underinsured and deep in debt: which cracks did this family fall through?

USA Today has a story today, by Jayne O'Donnell, highlighting the plight of (under)insured Americans who face crippling out-of-pocket healthcare costs. The lead example raises a couple of question marks about exactly how this family fell through various cracks:

Christian and Jaycee Garcia of Silver Spring, Md., have been hard hit by medical bills, even with their out-of-pocket maximum of $6,350 a year for each family member. Their 20-month-old son, CJ, was born with the rare genetic disorder Eagle Barrett Syndrome and severe scoliosis. He will have his 13th surgery in August, with two more to follow in September, all to rebuild his digestive system and urinary tract and to insert metal rods next to his spine so he can sit up without a brace.

Although Christian Garcia earns $60,000 a year as a restaurant manager, the more than $700 monthly insurance premiums for his work plan and another privately purchased plan for his wife and kids plus other monthly bills make paying the family's share of the hospital bills impossible. The couple have $11,000 in medical bills they are paying $270 a month on, and bills from two other hospitals have gone to collections. Monthly expenses, including the payment on his medical bills, are about equal to his take-home pay of about $3,000 a month.

Housekeeping note: Pennsylvania story in progress

A note re slow blogging: I've been engaged in my Pennsylvania project -- that is, exploring the implications of some odd enrollment figures in the state.. Specifically, though there's apparently over 140,000 Pennsylvania 2014 QHP enrollees who are now eligible for Medicaid, less than 40,000 2014 QHP enrollees had disenrolled as of March (or at least, to HHS's knowledge as of March). I've had the chance to interview one person newly eligible for Medicaid in 2015 who discovered that fact in February but only applied this month, in the interim paying over $300 per month for an unsubsidized private plan. The resulting story is written but not yet placed (or edited; I've got to cut it by 60%). I've learned a ton in the process.

One useful sidelight: an enrollment counselor at the Pennsylvania Health Access Network tells me that more than half of the people they enrolled in QHPs in 2014 did in fact have household incomes under 138% FPL and so are now eligible for Medicaid. While you might expect that a social service agency's client base might tilt toward lower income buyers, PHAN works all over the state, and that percentage is consistent with CMS's estimate of 141,000 households with QHP enrollees likely to be eligible for Medicaid in 2015.

No, Clinton and Frist, ACA marketplace coverage will not render CHIP unnecessary

In an otherwise eloquent plea by Hillary Clinton and former GOP Senate majority leader Bill Frist for Congress to renew funding for the Children's Health Insurance Program (CHIP), one paragraph brought me up short. It's not strictly speaking inaccurate, but it resorts to a shorthand that, in the way of 750-word op-eds, leaves a misleading impression:

Of course, the American health care landscape has changed significantly since CHIP started. Under the Affordable Care Act, many families with children are now receiving financial help to enroll in private health coverage through the new health insurance marketplace. But while it is possible that private, family-wide policies offered by employers and marketplaces may one day render CHIP unnecessary, for now substantial gaps still exist — and too many children can still fall through them.

In fact, the ACA puts the kids in CHIP in most families in which the adults qualify for private-plan premium subsidies. CHIP eligibility operates independently from adult eligibility for subsidized private plans or Medicaid under the ACA.  Every state sets its own eligibility for CHIP, ranging from 170% of the Federal Poverty Level (FPL) in North Dakota to 405% FPL in New York. The median eligibility is 255% FPL (see this Kaiser Family Foundation chart).

A surprise (to me) regarding Medicaid eligibility under the ACA

I learned an interesting fact about the ACA from Kaiser's Larry Levitt on Twitter today.

It's well-known to ACA watchers that a low-income worker whose employer offers insurance deemed "affordable" according to ACA formula cannot buy subsidized private coverage on the exchanges. What I suspect is less well-known, and what Larry spelled out, is that the availability of employer-sponsored insurance does not negate Medicaid eligibility for someone whose household income is low enough to qualify for Medicaid.

Michael Leavitt on State-level healthcare reform

Beneath the furious passions aroused by the Affordable Care Act lurk broad areas of bipartisan consensus regarding healthcare reform in the United States. Lawmakers in both parties want to move payment for healthcare away from fee-for-service and toward managed care, "bundled" payment by the patient or treatment episode, and risk-based payment, in which providers are rewarded for keeping costs under target and penalized for exceeding it. Both parties also accept the premise that high deductibles and co-pays help control costs -- with lip service at least usually paid to giving patients viable choices by providing information about providers' pricing and quality.

The bipartisan zone is mapped out in a report produced under the auspices of the University of Virginia's Miller Center by a commission co-chaired by Michael Leavitt, former Republican Governor of Utah and Secretary of Health and Human Services under George W. Bush, and Bill Ritter, former Democratic governor of Colorado. Cracking the Code on Healthcare Costs, released in January 2014, focuses on the role of state governments in containing healthcare costs while improving delivery, emphasizing that states have powerful levers on both fronts.  Those levers include administration of Medicaid, state employee health programs, and the state health exchanges established by the ACA, as well as the state regulation of insurance mandated by US law and "state laws affecting market competition and consumer choice, such as antitrust enforcement and requirements for providers to report price and quality information."

The report's working assumption is that, Republican cries of "federal takeover of healthcare" notwithstanding, both the ACA and existing Medicaid rules afford governors and state legislators and administrators ample scope to shape the healthcare markets in their states. Key recommendations include setting annual overall state spending benchmarks, as Massachusetts has done; promoting "coordinated, risk-based care to the disabled and dual-eligible population" -- the most expensive Medicaid beneficiaries; and also promoting coordinated, risk-based plans in the ACA exchanges -- as well as pricing transparency and quality ratings for participating plans.

ACA is here to stay

Does the ACA significantly constrain state innovation, or encourage it? I spoke about current and potential state efforts to transform healthcare delivery with Michael Leavitt and with Professor Raymond Sheppach, project director for Cracking the Code, whose comments I'll relay in a followup post.

Children, CHIP, Medicaid and the ACA

Means-tested government benefits are inevitably a somewhat blunt instrument. One inflexibility in the Affordable Care Act is its propensity to put children into CHIP and young adults into Medicaid.

Every state has its own threshold for CHIP eligibility, which the ACA incorporates into its calculations. If the state threshold is 300% of the Federal Poverty Level (FPL), then any ACA applicant in that state with children and an income under that benchmark will find their children enrolled in CHIP, while the adults select a subsidized plan from the exchange. A family with CHIP-eligible kids can enroll the whole family in an exchange plan, but the kids will be unsubsidized, according to the Kaiser Family Foundation.

Likewise, a lot of young adults, including most college students, will have an income that qualifies them for Medicaid -- that is, below $15,521 in 2014 --  and so will not be able to get a subsidy for a private plan if it better suits their needs.

Just what has a single mother of three lost in Wisconsin's Medicaid "expansion"?

Today's New York Times has an illuminating contrast of how one-party rule is changing life in the "twinned cities" of Duluth, MN (Democratic) and Superior, WI (Republican). The article's finale focuses on how the Affordable Care Act affects people in Minnesota, which runs its own exchange and is implementing "an expansion of the state’s already far-reaching Medicaid system," and Wisconsin, which declined to run its own exchange and has just won federal approval for a conditional Medicaid expansion, which will offer Medicaid to childless adults earning less than 100% of the Federal Poverty Level (FPL) while at the same time ending existing Medicaid coverage for adults who earn more than 100% FPL*, pushing them onto the exchanges**.

Times reporter Monica Davey found a single mother of three in Superior, WI in the latter category, newly booted off Medicaid because she earns over 100% FPL. Her situation is doubly ironic, in that she works for a nonprofit that serving homeless people -- including helping them sign up for Medicaid -- but is herself a Republican and supporter of Scott Brown Walker. That is perhaps why she has not fully checked out her own options -- which have indeed been worsened by Walker's some win/some lose Medicaid shift, but not as badly as she may think.  The Times article did not delve very deeply into her options  -- so we'll fill in the gap below. Here's the situation:

A CHIP off the old block in the ACA

Test-driving HealthCare.gov  in various locales, I was a bit surprised to learn that in New Jersey, the kids (under age 19) in a family of four with an income of  $75,000 would be eligible for the Children's Health Insurance Program (CHIP).

Probing for the break point, I found that if the same family earned $82,424, the kids would still be in CHIP. At $82,425 they would not.  The exchange would offer a subsidized plan for the whole family.

The cost difference for the family is negligible. Because families are subsidized so that premiums equal a fixed percentage of the family income, the subsidy for the family just over the CHIP line grows to cover the difference. The subsidy for the $82,235 family in Essex County is $616 per month, while for the CHIP-eligible family earning a dollar less, it's $297. Net result: their premiums for identical silver plans are within a couple of dollars of each other (in Essex County, $654--$655 for the benchmark second cheapest plan). 

CHIP eligibility is not tied to the ACA Medicaid expansion, and every state has its own eligibility break point. In New York, it's 400% of the Federal Poverty Level (FPL). In Texas, it's 200%. In New Jersey, oddly left blank on this otherwise useful map, it's 350% (the FPL for a family of four was $23,550 in 2013). Exchange shoppers in states that have opted out of the Medicaid expansion may nonetheless swell the CHIP rolls a bit -- though only if those shoppers had previously failed to take advantage of their kids' CHIP eligibility.

How did we get to a $39 billion headline?

Taking up a question from one of yesterday's posts:

P.S. Watching Democrats apparently give ground yard by yard -- from accepting a reported $32-33 billion in cuts earlier this week to  $37-38 billion today, not to say even getting in this range in the first place  --  is so baffling that I wonder, by defensive reflex if nothing else, if there isn't more to this than meets the eye. Are some of those billions illusory, i.e. offloaded into areas Democrats don't care about or want to cut?  Has the weighting changed in some way that offsets the sticker amount?  

 And how, given the final sticker amount, can Obama find the "audacity" to claim this?

But beginning to live within our means is the only way to protect those investments that will help America compete for new jobs -- investments in our kids’ education and student loans; in clean energy and life-saving medical research. We protected the investments we need to win the future.

Here is a Dem answer -- or spin:

“1) $17 BILLION IN ‘CHIMPS’ -- WE SPREAD OUT THE CUTS ACROSS OTHER PARTS OF THE BUDGET. We insisted that meeting in the middle on cuts would require looking beyond domestic discretionary spending—and we prevailed. More than half—or $17 billion—of the final round of spending cuts came from changes in mandatory programs, or CHIMPs. The emphasis on this part of the budget staved off severe cuts to key domestic programs like education, clean energy, and medical research. 

"The CHIMPS," cried Mr. Rochester. "Deuce take me if I did not forget the CHIMPS!"*   Or make that Mr. Rogers (David), who explained back on April 3: