Washington's ACA exchange gets its priorities straight

I have criticized state-based ACA exchanges for submerging information about Medicaid, which is likely to insure about twice as many of the newly uninsured as the ACA marketplace.

Scratch that complaint for Washington' state's HealthPlanFinder!  The home page has its priorities right, if the messaging is still a little fuzzy:

Apple Health is the state's Medicaid program, as you'll learn if you click on it. That click will bring you to a page that links to the eligibility requirements. For individual adults, they're clear and clean, paired with a prompt to apply:

In Washington State, too many low-income bronze plan buyers

Washington HealthPlanFinder, the state's ACA exchange, has set the standard for enrollment data reporting, providing a more detailed and complete account of private plan buyers' demographics and behavior than any other state to date. Washington is a wealthy state, with a median household income (2013) of $60,106, compared to a national median of $51,939.   Its buyers of private plans on the exchange (known as Quality Health Plans, or QHPs) are accordingly a much wealthier group than the average among the 37 states that used the federal exchange, healthcare.gov.

Only 12.5% of Washington's QHP buyers have incomes under 150% of the Federal Poverty Level (FPL), compared to 24% in those healthcare.gov states that accepted the Medicaid expansion -- and 50% in healthcare.gov states that refused the expansion. (In non-expansion states, eligibility for QHP subsidies began at 100% FPL, versus 138% FPL in expansion states, and those between 100 and 138% FPL swelled the QHP enrollments, accounting for about a third of all enrollments in non-expansion states.) Low takeup in this low-income band perhaps explains in part why Washington has reached just 32% of its target QHP market as calculated by the Kaiser Family Foundation, versus 42% for the nation as a whole. Conversely, Washington has been very successful in expanding its Medicaid rolls. The enrollment report tallies 533,628 "Medicaid expansion adults," far exceeding a 2012 Urban Institute forecast of 330,000.

Too many poor buyers of bronze plans

While Washington's relatively small number of enrollees in the 100-150% FPL income band may be in large part a matter of demographics, there is one way in which the state exchange has seemingly failed lower-income buyers. Takeup of Cost Sharing Reduction subsidies, available only with silver plans and only to buyers with incomes below 250% FPL, is lower in Washington than on healthcare.gov, and much lower than in states like New York and Connecticut that take special measures to highlight CSR for those who are eligible for it.

Bette in Spokane has some genuine pain (probably. Or maybe not...see updates)

[multiple updates, through 2/3/14]

Yes, the brief "ACA victim" story that Rep. Kathy McMorris Rodgers (R-Wa) inserted in her response to the State of the Union address was cherry-picked and misleading. The pain that the ACA inflicted on the couple in question was exaggerated. But it was probably real. They are in the relatively small subset of Americans who may fare worse under the ACA than under the pre-ACA status quo.

Here is the tale that Rodgers told:

Not long ago I got a letter from Bette in Spokane, who hoped the President’s health care law would save her money – but found out instead that her premiums were going up nearly $700 a month.

Reporter David Wasson of the Spokesman-Review tracked Bette down and learned that she is hostile to the ACA ("I wouldn't go on that Obama website at all") and did not check out her options on the exchange. The $700 difference was between the plan she and her husband carried in 2013 and the plan their insurance company offered in replacement. Here are the basics: