Medicaid enrollment in a pandemic: The case of Kentucky

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Update (6/9/20) at bottom, with June enrollment numbers and more information re enrollment outreach in KY.

Of the tens of millions of Americans likely to lose access to health insurance as a result of job losses triggered by the Covid-19 pandemic, the Urban Institute estimates that about half -- 8.2 million in the most conservative of several scenarios -- will enroll in Medicaid. Kentucky appears to have gotten off to a comparatively fast start, though state healthcare advocates see a need for more intense outreach.

Medicaid enrollment in the state has increased by more than 100,000 (8%) since February, from 1.32 million to 1.42 million, according to the state's monthly membership tally.  In 2019, enrollment from March to May was flat, down less than 1%. At 20% unemployment, which we're likely to reach in the next jobs report, between 336,000 and 397,000 Kentuckians are likely to have lost access to job-based insurance, according to the Urban Institute estimate. Urban foresees Medicaid enrollment in Kentucky increasing by between 208,000 and 228,000 thousand if that unemployment rate holds for some months.

Dustin Pugel, a senior policy analyst at the Kentucky Center for Economic Policy, credits Governor Andy Beshear, elected just last November, with stimulating and facilitating crisis Medicaid enrollment.  During his daily televised, widely watched Covid-19 briefings, Beshear regularly starts with ten steps for fighting the virus, and, Pugel says, "One of them is signing up for benefits. Medicaid is mentioned every single time."

The chief fallout from killing Kynect

Articles about the plans of Kentucky's new Republican governor, Matt Bevin, to junk Kynect, the state's home-grown ACA exchange, and switch to Healthcare.gov don't always make it entirely clearly where the loss or risk lies.

There's the waste of some $290 million in federal grant money used to build Kynect, and  $23 million in one-time expenses that the outgoing Beshear administration estimated it would cost to move to the federal exchange. But since the choice of website does not in itself threaten the Medicaid expansion or change private plan offerings (though it may bump up prices, since HealthCare.gov charges insurers a higher assessment than Kynect has), wherein lies the operational damage?

Tapped out in Kentucky, cont.

Yesterday, I took a look at what induced David Elson, a 60 year-old advanced diabetic in Louisville, Kentucky earning $28,000 "in a good year,", to sign up for an ACA health plan with a $350 monthly premium. At that income level (which was almost surely overstated), a benchmark silver plan would have cost him about $180 per month. His tale has been recounted in depth twice by Abby Goodnough in The New York Times.

Why sign up for a plan that cost twice as much as the benchmark? The short answer was that Mr. Elson was trying to keep his doctors -- most importantly, his kidney specialist. That locked him into just one provider, Anthem Blue Cross, and the high premium plan he chose was an alternative to cheaper Anthem plans with higher deductibles and copay-coinsurance combinations that may have cost him more. The problem was that it was always obvious that he could not afford that premium -- one of his providers said as much in Goodnough's March 2014 article -- and he never paid it. His kidneys failed this fall, and he ended up first in charity care and then -- as of today, Jan. 1 -- on Medicare.

As I pointed out yesterday, not only an alternative silver plan offered by another insurer but even a handful of gold and platinum plans with lower premiums and deductibles than the one he selected were available to Mr. Elson in 2014. Trying to keep his doctors came at a price he could not pay.

Today I want to look at one more factor that framed the choices faced by Mr. Elson -- prompted once again by commenter Bob Hertz. That's age-rating.

Tapped out in Kentucky: Back story to an ACA hardship case

It's not quite an iron rule, but it's a fair bet: When a newspaper reports an Obamacare hardship tale, involving someone who's bought a private plan that leaves coverage unaffordable, that person bought the wrong plan.

In two front-page stories separated by nine months, one running today, The New York Times' Abby Goodnough has reported the saga of a very sick 60 year-old gentleman, David Elson, who struggles to continue his work installing security systems while suffering from advanced diabetes. In February 2014 Mr. Elson, who says he earns $28,000 "in a good year," somehow ended up enrolling in a health plan with a monthly premium of $350 (after subsidy) and a deductible of $2,600.

There is nothing wrong with the reporting here (in fact it's excellent reporting, nuanced and empathetic). Mr. Elson made the choices described, for the reasons described below. Newspaper space is not infinite. Nonetheless, anyone familiar with the ACA subsidy scale could tell at a glance that he was paying more than he should -- and, as one of his caregivers noted back in March, more than he could afford.

A correction in NYT ACA coverage

The New York Times has an excellent front-page story by Abby Goodnough today detailing the "blessings and hurdles" that various people seeking health insurance in Kentucky have encountered under the Affordable Care Act. A key point in one of the marquee narratives did not compute, however.

A certain David Elson, 60, was reported in today's print editions to earn $22k and be eligible for cost-sharing subsidies that would lower his deductible -- but also unable to pay his first monthly premium, reduced via a monthly subsidy of $250 to $350.  In fact, a 60 year-old nonsmoker anywhere in the country earning $22k should be able to access a silver plan for around $100 per month, with Cost Sharing Reduction (CSR) reducing the deductible to under $1000 per month.

The Romance of the Rose, health policy edition

#Healthpolicyvalentines are a thing on Twitter. So, to aggregate my morning fun:

Roses are red,
Violets are blue.
I logged on Kynect,
And covered you.

        *     *     *

Violets are blue,
Roses are rouge.
Your income is low,
Your subsidy's huge. 

        *     *     *

Red is the rose,
And violet the heather.
We all have to jump
In the risk pool together. 

        *     *     *

Yellow's the daisy,
And white the azalea
I want the health coverage
They get in Westphalia.

        *     *     *

Azaleas are monochrome,
Daylilies, variegated.
My love for y'all
Is community-rated.

        *     *     *