Subsidy-eligible, but unsubsidized

Updated 1/22 with California discussion corrected - please see note 2 at bottom.

Reading about Gallup's latest finding that 3.2 million more Americans were uninsured in 2017 than in 2016, I wondered about a particular (small) group of ACA marketplace enrollees: those with incomes in subsidy range who are nevertheless unsubsidized. Such people might be expected to have a particularly hard time with the steep premium increases of 2017 (not to say 2018 and 2019), as premiums take a huge share of their income.

I wanted to look at this group because Gallup's findings raised some riddles. Gallup found the sharpest increases in the uninsured among people with incomes under $36,000 -- but also found no change in the percentage of people insured by Medicaid. Among types of insurance obtained, the sharpest drop was among those who say they bought their own insurance (although Gallup's numbers for this population are weirdly inflated).  In the ACA marketplace the large majority (84%) who obtained premium subsidies were largely insulated from the year's steep premium hikes -- though reduced competition may have made choices less viable for some. Overall,  marketplace enrollment was down about 5%, or 500,000 in 2017.

The drop in off-marketplace individual market enrollment was doubtless steeper.  But most of those who buy off-exchange are presumably more affluent. It doesn't all seem to quite add up -- hence my interest in the almost invisible low-income unsubsidized individual market enrollees.

Notes on Gallup's latest health insurance status polling

Gallup announced today that the U.S  uninsurance rate, as reflected in its daily surveying, fell to its lowest rate yet recorded in the first quarter of 2016, 11.0% for all adults. Gallup has been conducting this survey in partnership with Healthways since 2008.

Just for the hell of it, I'm going to try a few I'm notes from my phone [updated 4/8/16]:

1. While Gallup headlines a drop from Q1 2015 (11.9%) to Q1 2016 (11.0%), a better contrast is probably with Q2 2015 (11.4%). In 2015, open enrollment did not end until the third week in February; this year it was over on Jan. 31. By Q4 of last year Gallup found that the uninsurance rate had ticked up to 11.9%. There will probably be some attrition this year as well -- though perhaps a bit less, as the ACA marketplace this year for the first time recorded no-pays and terminations more or less as they happened during open enrollment.

Gallup misreads its state ACA data: state-run marketplaces no better at reaching uninsured

Gallup does a great service in tracking the decline in the uninsured rate state-by-state since ACA implementation. But they draw a misleading conclusion from their latest data set:

Collectively, the uninsured rate in states that have chosen to expand Medicaid and set up their own state exchanges or partnerships in the health insurance marketplace declined significantly more last year than the rate in states that did not take these steps. The uninsured rate declined 4.8 points in the 21 states that implemented both of these measures, compared with a 2.7-point drop across the 29 states that have implemented only one or neither of these actions.

In fact, the superior overall performance of these states in reducing un-insurance is due entirely to the Medicaid expansion. Collectively, their exchanges did not perform particularly well with regard to enrolling subsidy-eligible residents in private health plans.

Compare Gallup's chart highlighting state leaders in reaching the uninsured population by both means (Medicaid and private plans) with the Kaiser Family Foundation's snapshot of states that reached the highest percentage of subsidy-eligible private plan buyers. [Update: The initial comparison is of uninsured rates from poll data taken by Gallup throughout 2014 with Kaiser's up-to-date ranking of performance in the QHP market (through 2/15/15). Kaiser's 2014 ranking appears at bottom.]

The ACA: Good policy, tough politics

Three charts may explain in part why the ACA is working as designed, improving life in America, and hurting Democrats politically.

First, Gallup's latest on the uninsured rate:



Next, an assessment of the redistributive effects of the ACA by Henry Aaron and Gary Burtless (via Bill Gardner) :

Can the ACA exchanges steer customers away from bad choices?

An important feature on Healthcare.gov -- improved for the new open season, I believe -- could steer significant numbers of users toward plans best suited to their needs -- and perhaps point a way towards solving the "auto-renewal" problem, whereby existing plan holders may face steep price hikes if they fail to comparison -shop.

The feature in question is addressed to those buyers who are eligible for Cost Sharing Reduction subsidies, which lower plan deductibles and out-of-pockets costs for lower-income buyers -- but only if they buy silver-level plans, which will cost them significantly more per month in premiums than bronze-level plans.

Lower income buyers who choose bronze plans, which have lower premiums, can forfeit thousands of dollars' worth of CSR benefits. Fortunately, the vast majority of CSR-eligible buyers do seem to have found their way to silver, notwithstanding premiums that can be tens of dollars per month higher for individuals and over $100 per month more for families.

Dave Chandra, a Senior Policy Analyst at the Center on Budget and Policy Priorities and a Certified Application Counselor, tells me that this year, if an applicant who qualifies for CSR takes steps toward buying a bronze plan (or, less probably, gold or platinum), a prominent pop-up message will warn her that she is eligible for CSR and will forfeit it if she proceeds. Here it is:

Let them all in? Laying a thought experiment on top of a thought experiment

Jeff Spross of ThinkProgress thinks we should give all kids who arrive on our borders immediate legal status. Josiah Neeley of the Texas Public Policy Foundation responds (on Twitter) by dangling a bit of bait: "why not let in anyone who wants come? Spross suggests that the U.S. could handle the influx if it had to or wanted to. Neeley then asks, "How many do you think would come if we accepted anyone who wanted to come?"

This recalled me to a thought experiment that seems apropos, though I'm not sure why -- maybe because it suggests, indirectly, how much running room we have. Courtesy of James Fallows:

I mentioned yesterday that Thomas Barnett had given a realistic brief appraisal of China's strengths and weaknesses in an NPR interview. A point I particularly liked was this tip for comparing American and Chinese scale:

If Americans wanted to imagine what it would take to be "strong" in the way China currently is, he said, all we'd have to do is think of moving the entire population of the Western Hemisphere into our existing borders. Every single Mexican. (Rather than enforcing the southern border, we'd require everyone to cross it, headed north.) Every Haitian, Cuban, and Jamaican. Everyone from Central America. All 190 million from Brazil. And so on. Even the Canadians. China, by the way, is just about the same size as the United States, though a larger share of its land area is desert, mountain, or otherwise nonarable.

Gallup: A shift away from employer-sponsored health insurance?

The top line in Gallup's latest polling on Americans insurance status is that the percentage of uninsured Americans continued to drop throughout the first quarter of 2014 -- after reaching an all-time high in the third quarter of 2013. Greg Sargent digests the apparent good news with the appropriate dose of caution here. But I want to call attention to another possible significant trend in the Gallup data, though it too could be mere statistical noise.

Th survey results seem to reflect a shift away from employer-sponsored insurance (ESI) towards privately-purchased plans, Medicaid, and Medicare (the last is inevitable as America ages):

"In Mitt Romney's America..." -- Scare us, Obama

As I've said before, these recent Gallup numbers frighten me: voters give Romney the edge in handling deficit and debt, 54-39, and economic growth, 52-42. Together they suggest that people are buying Romney's core pitch: an able businessman is well equipped to run the economy.  The perception could well be decisive.

On the campaign trail, Obama is contrasting his core economic vision with Romney's, and that's good. He's tying Romney's Bain tenure to his trickle-down economics, and that's fair and potentially helpful -- though I think he desperately needs a bulked-up Super Pac to keep his hands clean while the team offsets all the scurrilous shit that Crossroads & co. will heap on his own head.

But what seems to my amateur political sensibility the most effective way to tear down the perception of Romney's economic competence is also the most truthful way: hammer home in detail the ruinous spending cuts and tax cuts that Romney has proposed for the country.  Scare people. Because these proposals are scary -- and most Americans oppose them when they're spelled out in ways that Romney dare not do.

I think Obama was on the right track when he hammered the Ryan budget in detail, extrapolating the specific cuts that would be called for if the broad category cuts were distributed evenly, filling in the details that Ryan decorously left blank.  He needs to do the same with Romney's proposals, which are in sync with Ryan's. I want to see the economic equivalent of Ted Kennedy's vision of Robert Bork's America. Romney's America would suffer

Gallup's scary polling on economic issues

As the economy goes, so goes the electorate's assessment of the President's ability to run the economy. That's the way it's always been, in all electorates. It's no good railing or making excuses. It's an electoral law of nature.

Nonetheless, two numbers in Gallup's current polling of American's economic assessment of the two candidates frighten and anger me. Voters give Romney the edge in handling deficit and debt, 54-39, and economic growth, 52-42. They give Obama the edge on other economic issue rated of high importance, including healthcare and college costs, and the candidates are virtually tied on jobs.   But the two on which Romney leads are the broadest economic fundamentals.

Is Obama still paying for the debt ceiling debacle?

On  Marketplace this evening, Gallup's Frank Newport delivered  bad news for Obama: by a nine point margin, Americans think that the economy will be in better shape for years from now if Romney is elected than if he is. The question is, why do they think that?  They prefer Obama's tax policies and "balanced" approach to deficit reduction. They would hate the massive cuts to domestic spending necessitated by Romney skeleton of a budget if they could be made aware of them. They support the separate elements of the job creation package Obama put forward last fall.

I would have thought that the answer is, first, that an incumbent president inevitably gets blamed for a weak economy, and second, that they have so far bought the Romney pitch that a highly successful businessman is well equipped to turn the economy around.  But Newport said something that turned my head around and brought me back to August 1, 2011:  "Romney does better than Obama in terms of being able to manage the government."

Teach your constituents well

Ezra Klein spotlights a potential problem for the GOP in 2012: in 2010, candidates incited the party's base and the nation's seniors to fear and loathe the Medicare spending reductions with which Democrats largely funded the Affordable Care Act -- and now, just a few months later, the party has backed Ryan's plan to privatize and radically devalue Medicare.  Klein further  notes a polling anomaly: Republicans are far more averse than Democrats to any attempts to reform Medicare:

A Gallup poll released Wednesday underscored the tension in the Republican coalition. It asked Americans whether they “think the government should completely overhaul Medicare to control the cost of the program, make major changes to Medicare but not completely overhaul it, make minor changes to Medicare, or should the government not try to control the costs of Medicare?” Among Democrats, “minor changes” was most popular, followed by “major changes.”

You might assume that Republicans would be a lot friendlier to remaking the program. Not so. Among Republicans, “not try to control costs” was the most popular position, followed by “minor changes.” And to call Ryan’s plan anything less than a complete overhaul would be to insult it.

Patronizing pundit watch

Jonathan Chait, defending Obama's inalienable right to blame Bush for the ecnomic mess we're still digging out from:

The financial crisis of 2008 made it inevitable that unemployment would rise sharply through 2009. It also caused the budget deficit to skyrocket...

Most voters, of course, don't follow these issues closely enough to gain a detailed understanding of cause and effect. They just tend to notice that unemployment and the budget deficit have risen while President Obama has held office.

Gallup, April 21, 2010:

More than a year into Barack Obama's presidency, Americans are more likely to say George W. Bush is responsible for today's economic problems than they are to say Obama is responsible. Gallup shows a significant uptick since last July in the percentage of Americans blaming Obama at least a moderate amount (from 32% to 50%), but little decrease (from 80% to 75%) in the percentage blaming Bush.

Happiness Indices: Post-industrial and Pre-Modern

Richard Florida, diving into Gallup research on people's self-reported levels of happiness in different countries, brought to the surface of my mind two contradictory -- or seemingly contradictory -- ideas I have long harbored (sometimes musing fitfully on their apparent contradictoriness) regarding the relative happiness of different societies. 

Here, first (via Sullivan), is Florida's idea, which tracks with one general assumption of mine:

It is not just the level of economic development that matters, but its nature and type. The past several decades have seen a shift from older industrial-style economies and societies to newer post-industrial ones characterized by higher levels of knowledge-based, professional, and creative jobs, more highly educated populations, and a shift toward what Ronald Inglehart has dubbed "post-materialist values" -- a diminished commitment to traditional authority and institutions and a shift toward self-expression, openness, and tolerance. My recent research with Charlotta Mellander and Jason Rentfrow finds evidence that post-industrial socioeconomic structures and post-materialist values matter to the happiness of nations, especially of the most advanced nations...

Obama endorses Hillary!

More verbal judo from Obama yesterday. At a news conference in a high school gym in Johnstown, PA, he was invited to pile on to the rising calls for Hillary to drop out because intraparty warfare is undermining his chances to beat McCain.

Obama's response:

My attitude is that Senator Clinton can run as long as she wants.Her name is on the ballot. She is a fierce and formidable opponent, and she obviously believes she would make the best nominee and the best president.

As to a Gallup poll showing that 28% of Clinton supporters and 19% of Obama supports say they'll vote for McCain if the their candidate does not get the nomination:

You know, there’s no doubt that among some of my supporters or some of her supporters, there’s probably been some irritation created,” he said. “You can’t tell me that some of my supporters are going to say, well, we’d rather have the guy who may want to stay in Iraq for a hundred years because we’re mad that Senator Clinton ran a negative ad against Senator Obama. And I think the converse is true as well.

Once again, Obama's graciousness in the heat of combat makes the Clintons look small. As Bill Clinton continues to mouth fulsome praise of John McCain (the same McCain who repeatedly lambasted Bill as unfit to be commander-in-chief), Obama expresses incredulity that his own supporters would choose McCain over Hillary. By crediting Hillary's belief that she is the best candidate, he throws her belittling of him into sharp relief while coolly projecting his own confidence that her 'belief' is mistaken. Instead of piling on, he displays again the character and leadership style that's making voters and superdelegates choose him.

Try to imagine Hillary saying, in effect, that a Democrat would have to be crazy to choose McCain over Obama. Or imagine her in his situation, with a near-insurmountable delegate lead and supporters calling publicly for Obama to withdraw. Remember her mind's tailkick when asked to affirm that Obama was not a Muslim: "...as far as I know." And ask yourself: which candidate projects strength, detachment, ability to see the contest and the players as they are, to digest the brouhaha du jour and deliver a measured response?

Prevailing in day-to-day combat with Hillary Clinton is an admittedly poor proxy for dealing with international crises. But no one crosses "the commander-in-chief threshold" until they're commander in chief. And Obama has shown over the course of many months that he's better able to keep his head in a fight than Hillary is.

Related posts:
Changing 'the rules' on Clinton
Debunked! Obama spanks the Clinton Kids again
Truth and Transformation
Obama Praises Clinton, and Buries Him
Obama: Man, those Clinton Kids are Something