Let's call it 160% Medicare...Washington state public option

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[Updates at bottom: bill is on the Governor's desk]

A few days back, I noted that the state public option bill working its way through the Washington legislature provides an object lesson in how hard it is to expand the pool of people in health plans paying Medicare rates.  An early iteration of the bill had the public plan paying Medicare rates, but a version that passed the House on April 10 had upped the maximum aggregate payment rate to 150% Medicare. The Senate declined to pass this bill, and it went to conference.

Now a new version (ESSB 5526) has emerged from Senate-House conference (kindly flagged for me by Amy Lotven of Inside Health Policy, who will have a story up about it later today). And guess what -- the maximum aggregate payment rate* is up to 160% Medicare.  For reference, commercial payment rates to hospitals average 188% Medicare nationally, according to a 2017 CBO report, and about 128% Medicare for physicians, according to MEDPAC.

Further, the director of the state Health Care Authority can waive the rate cap if she "determines that selective contracting will result in actuarially sound premium rates that are no greater than the qualified health plan's previous plan year rates adjusted for inflation." The director can also waive the rate cap if a carrier contracted to provide the public option can't form a provider network that meets the stipulated network adequacy standards, or if the carrier can offer premiums 10% lower than those of the previous plan year without conforming to the rate cap.

100% Medicare, 150%, 160%.... I am reminded* of the accounting approach of Rabbit, Winnie the Pooh's friend:

Expanding the footprint of Medicare payment rates is hard: Washington State edition

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It's ironic that the path for healthcare reform preferred by allied U.S. healthcare industries is embodied in a bill introduced by Elizabeth Warren.

The Partnership For America's Health Care Future, a coalition of major hospital, health insurance, physician and pharma trade groups formed to preemptively nuke any expansion of pubic insurance, would like government to spend more to insure more people and lower their out-of-pocket costs. But they want government to do this while paying commercial rates to providers. Robert Pear summarizes:

The coalition, like President Trump, attacks any proposals that smack of socialized medicine. But it also has a positive agenda. It wants to expand Medicaid under the Affordable Care Act in Texas, Florida and other states that have yet to do so. It wants to expand federal subsidies under the health law so insurance will be affordable to more people. And it wants to stabilize premiums by persuading states to set up reinsurance programs, using a combination of federal and state funds to help pay the largest claims.

While preserving the core ACA structure, Warren's bill removes the ACA's income cap on eligibility for premium subsidies and gives a major boost to ACA premium and cost sharing subsidies at all income levels. While it would tighten insurers' margins a bit, and impose stricter standards on their provider networks, it would boost enrollment and the federal government's share of premiums paid. Insurers should be happy with it,  notwithstanding the rhetorical broadside against insurers with which Warren introduced the bill. It should also be attractive to providers, since it does not impose caps on provider payment rates. .

Should Democrats gain control of the presidency and both houses of Congress, boosting ACA marketplace subsidies -- and, to a certain extent -- eligibility -- should be relatively easy. What won't be easy: expanding the footprint of public insurance that pays Medicare rates (or less) to providers (an exception is Medicaid expansion, for which the target population generally lacks access to commercial insurance).

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.

Did too many low income ACA shoppers buy bronze plans?

Modern Healthcare's Virgil Dickson reports on a weak link in ACA coverage:

Obamacare enrollees are straining the finances of community health centers around the country, some health center leaders say.

The issue is that many lower-income patients with insurance coverage through the federal and state exchanges bought bronze-tier plans with lower premiums but high deductibles, coinsurance and copayments and no federal cost-sharing subsidies. When these patients face high out-of-pocket costs for care that falls below the deductible, they can't afford it. 

Deductibles on bronze plans average $5000 per person nationwide. In some regions, those high-deductible plans provide office visits and generic drugs at moderate co-pays before the deductible kicks in; in others, they don't. Lots of bronze plans really just provide catastrophic coverage with the ACA's mandatory free preventive care services -- substantial but not matching everyone's top needs by any means -- tossed in.

Silver (only) bullet: the lesser-known ACA subsidies

Low income people who qualify for private-plan subsidies under the ACA-- that is, those who earn too much to qualify for Medicaid but less than 250% of the Federal Poverty Level (FPL)-- should not, for the most part, be in bronze plans.  Recognizing that deductibles in the thousands are not viable for people at these income levels (138%--250% FPL), the ACA provides Cost Sharing Reduction (CSR) subsidies -- but only with silver plans (which have lower deductibles and copays than bronze to begin with). If you don't buy silver, no CSR fo you.

The CSR subsidies are particularly generous under 200% FPL, covering 94% of an average user's costs for those earning up to 150% of the Federal Poverty Level (FPL), 87% for those earning 151-200% FPL, and a more modestly boosted 73% for those between 200% and 250% FPL.

Most who should have bought silver bought -- silver

The good news is that overall, the marketplace worked more or less as intended, in that 76% of subsidy-eligible buyers on healthcare.gov bought silver plans, according to an HHS May 1 report. Of those who didn't, perhaps a higher percentage had incomes between 250%--400% FPL, which would at least mean that they weren't leaving CSR on the table.  Just 20% of users in all marketplaces (state-run as well as healthcare.gov) bought bronze plans, and since 33% of buyers who earned too much to qualify for subsidies bought bronze, somewhat less than 20% of the subsidy-eligible must have done so. I would hope, again, that the percentage of CSR-eligible buyers who bought bronze is lower still.

Stat shots of the unsubsidized uninsured

Barring any slip between cup and lip, I should have an article coming out soon that recounts the experiences of several people who do not qualify for ACA subsidies but who have bought insurance plans for 2014 in the new ACA-enacted universe.  A preview is here. In the process, I've tried to get a grip on just how many such people there may be and how they're likely to fare under the ACA.

A Health Affairs post by Urban Institute researchers Lisa Clemans-Cope and Nathaniel Anderson has helped me bring the statistical picture into focus. I should say into relative focus, because there's a good deal of uncertainty in every stat shot. With that caveat, here goes:

• Estimates based on 2009 surveys conducted by different federal agencies as to how many Americans were buying insurance in the individual market vary widely, from 9.1 million in the Medical Expenditure Panels Survey to 25.3 million in the American Community Survey. A mid-range estimate from the National Health Interview Survey (NHIS) conducted by the CDC is 14.0 million.


• In December 2013, the Health Reform Monitoring Survey found that 18.6% of those insured in the individual market received cancellation notices attributing cancellation to the ACA, and  another 6% had their policies cancelled for other stated reasons.  Using that data, and the NHIS estimate of 14 million in in the individual market, Clemans-Cope and Anderson  estimate that 2.6 million people received policy cancellations that their insurers blamed on the ACA (and one might infer another 840,000 cancelled for other stated reasons).


• According to a March 2013 Urban Institute study, 48.6% of those currently in the individual market are ineligible for subsidies. If that ratio is right, and the estimate of 2.6 million cancellations attributed to the ACA is on target, about 1.2 million people who received cancellation notices blamed on the ACA would be ineligible for subsidies.  Of those, some probably had pre-existing conditions and will do better under the ACA.
  


• The Urban Institute study estimates the current individual market at 12.8 million, 6.2 million of whom would be subsidy-ineligible.