Michael Bennet misrepresented his Medicare-X bill on CNN

Colorado Senator Michael Bennet, who entered the presidential race on May 2, made headlines yesterday for taking on Bernie Sanders' Medicare for All plan in a CNN Town Hall yesterday. Bennet claimed that it's impracticable to take employer-sponsored insurance away from "180 million people" currently insured through their employers ( a high estimate), especially from millions whose unions have negotiated good benefits.

It's a familiar line of attack. More noteworthy was the fact that Bennet misrepresented his own ACA reform bill, the Medicare-X Choice Act, which introduces a national public option into the ACA exchanges. Here's what Bennet said (my transcript and emphasis):

What we would be much better off doing to get to universal healthcare quickly is to finish the job we started with the Affordable Care Act and have a true public option...The one that I have designed would be administered by Medicare and it would give all of you the chance to choose what's right for you and your family. If you want a public option then you can have it. Basically it's Medicare for all if you want it. But if you to keep the insurance you have, which many people do, you'd be able to do that as well.

This is not literally untrue. As of the fifth year after enactment, anyone could buy into Medicare-X, which would be offered in all counties nationwide alongside private plans in the ACA marketplace. But only a limited number of people could buy in on a subsidized basis. Most people whose employers offer insurance would not be subsidy-eligible.

Medicare for all who want it: Potential and pitfalls

I have suspected for some time that the longest-lasting Democratic presidential candidates may converge on health care reform plans that enable any American to buy into a strong public option (probably deemed "Medicare") at an affordable price. That would include people whose employers offer coverage -- they would be subsidy-eligible if they opt into the public plan.

The existing bill that fits this description is the Medicare for America Act -- a bill that takes such an open-to-all public plan to its logical conclusion by phasing out Medicaid and revamping the Medicare currently available to seniors and the disabled -- and, crucially, adding long-term care insurance. The bill is rich in promise and not free from pitfalls, which I've been more or less live-blogging over the past couple of weeks. I thought I'd take some space here to index those posts, a step toward making something of a coherent whole of them (including some earlier posts). Here goes, then.

The plan that lets anyone buy into Medicare (3/21/19)
This overview at healthinsurance.org starts with my core question: Can Democrats bite off as much healthcare reform as Medicare for America encompasses? Might they pare it back to its core -- a public option buy-in for anyone who wants/needs it?

Medicare for America might let private insurance thrive (3/22/19)
The key condition is that healthcare providers would have to accept "Medicare" payment rates from commercial insurers.

"Medicare for all who want it" raises the kludge question

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Given the "triple veto" imposed on legislators by the U.S. Constitution, U.S. policy is doomed to kludge. Policy design that's logical and internally coherent often can't survive the legislative process.

On the healthcare front, it's been evident since the early aughts that the logical, feasible, appropriately incremental way to improve access and control costs without throwing multiple healthcare industries into chaos and swiftly transitioning 150 million people out of employer-sponsored insurance is to offer a public plan on affordable terms to both employers and employees -- leaving employer insurance to either compete effectively or die on the vine.

Early iterations of such a "public option" included Helen Halpin's CHOICE program (2003), Rep Peter Stark's Americare bill (2006),and Jacob Hacker's Health Care for America plan (2007). All of these enabled any individual to buy in on an income-adjusted basis regardless of whether her employer offered insurance, and gave employers the option of paying into the public plan (e.g., via a payroll tax) rather than offering their own plans.  Instead we got the ACA -- with subsidy eligibility limited to those without access to employer insurance deemed "affordable" (by dubious standards), inadequate subsidies, and dependence on the whims, pricing, negotiated provider payment rates and plan designs of private insurers.

Now we're back to the future with the Medicare for America Act, introduced in late 2018 by Reps Rosa DeLauro and Jan Schakowsky and reintroduced last month. Medicare for America offers a revamped "Medicare" on affordable terms to any citizen or legally present noncitizen who opts in.

The kludge question: Does offering a truly comprehensive and affordable plan on affordable terms to anyone who wants it necessarily entail ending our existing mammoth and Byzantine public health insurance programs, Medicaid and as-currently-structured Medicare? Medicare for America's creators answered "yes."

Folding Medicaid into Medicare for America: Will states pay their share?

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One of the many sweeping transformations of U.S. healthcare mandated by the Medicare for America Act is the absorption of all Medicaid programs -- currently serving some 72 million Americans -- into a revamped Medicare serving all ages. That would occur six years after enactment.

Medicare for America would be available to Americans of all ages and incomes -- and free to everyone in a household with an income below 200% of the Federal Poverty Level (FPL). That's far above the eligibility threshold for Medicaid programs -- with the exception CHIP in some states, for which children in families with incomes as high as 400% FPL may be eligible. Families with incomes between 200% and 400% FPL would have to pay a percentage of income -- probably not higher than 4% -- to insure the whole family. The new program would include comprehensive disability services and 100% coverage for the medically frail and for chronic disease treatment, as well as dental, vision and hearing services.

State governments -- many of them sure to be deeply hostile -- would be subject to two major requirements: 1)  cede control of service for their Medicaid populations, and 2) reimburse the federal government with "maintenance of effort" payments equivalent to their current Medicaid responsibilities, adjusted annually for inflation. Those requirements are certain to be challenged in court, as was the ACA Medicaid expansion.

Seniors' costs under Medicare for America, continued

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In my last post I noted that while the revamped and expanded Medicare available to all under the Medicare for America Act of 2019 would serve most Americans very well, some people who turn 65 after full enactment would pay more in premium than they would today for traditional Medicare Parts B and D, or comparably priced Medicare Advantage.

They would get far more for the money -- most notably, long-term care insurance, dental, visual and hearing coverage, and 100% coverage for a host of vital services like chronic disease management, addiction and mental health treatment, and care for the medically frail. Still, higher premiums for seniors with incomes above about $50,000 for an individual or $80,000 for a couple is a political problem that needs to be thought out.  Here, I have a bit more data to sketch in.

If Medicare for America passes, some seniors would pay more (and get more) than at present

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Medicare for America,  the bill that would allow anyone at any age to buy into a revamped Medicare at an income-adjusted price (e.g., $0 for the bottom 30% of the income distribution), would be a clear benefit to anyone under 65. Even for those who continue to get insured through their employers, it would offer the true freedom from job-lock that the ACA promised and largely failed to deliver.

Most seniors who turn 65 after the new program would come into full effect (2023 were it to pass this year) would be gainers too (those enrolled in current Medicare before the new program launches would have the option of continuing to pay their then-current premiums). A fair number of new enrollees, however, would pay far more in premium than they would for existing fee-for-service Medicare or a Medicare Advantage plan. They would get more for their money. But the expectation that when you turn 65 you can get reliable insurance for under $200 per month is pretty hard-wired into Americans, I suspect. Violating that expectation for a substantial subset of the 3-4 million people who age into Medicare in year one (and every year following) is a political problem to be reckoned with.

Would Medicare for America phase out employer-sponsored insurance?

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It's often regarded as an open question whether the Medicare for America Act, were it to become law, would lead to a phase-out of private insurance. The bill makes a revamped Medicare available to anyone of any age who wants or needs it, with premiums adjusted by income even if the enrollee has access to employer-sponsored insurance.

The revamped "Medicare" is free to anyone whose household income is below 200% of the Federal Poverty Level (FPL) -- about 30% of the population. For those with incomes over 600% FPL, the premium is 8% of income. Those in the 200-600% FPL range will pay a sliding scale, topping out at 8%. Newborns are auto-enrolled, as are the uninsured. Employers can either pay an 8% payroll tax and direct their employees to the public program, or continue to offer their own health plans. Medicare Advantage continues alongside the public program.

I do not think the bill would kill of employer-sponsored insurance, though it would likely shrink the market to a kind of blue-chip perk for well compensated employees. ESI is likely to persist for several reasons:

• The bill stipulates that medical providers have to accept "Medicare" payment rates (not identical to current rates, but based on them) from private insurers.


• The employer tax exemption for health benefits persists. In fact, the ACA's "Cadillac Tax" on especially generous plan (long postponed) is repealed.


• Most importantly, the 8% of income that affluent people would pay for the revamped "Medicare" is considerably more than many pay out-of-pocket for employer-sponsored insurance.

The average premium for family coverage in ESI was $19,616 in 2018, according the Kaiser Family Foundation's Employer Health Benefits Survey, with the employee footing $5,547, or 28%.  For a couple with one child earning $125,000 -- a shade over 600% FPL -- that's 4% of income.

A major fix in Medicare for America 2.0

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Medicare for America, the sweeping healthcare reform bill that allows anyone to buy into a revamped Medicare at an income-adjusted premium, has the potential to transform U.S. healthcare into either an all-payer or a single-payer system.

The bill, first introduced by Reps Rosa DeLauro and Jean Schakowsky in December 2018 and reintroduced on May 1 this year, allows both Medicare Advantage and employer-sponsored insurance to continue, and stipulates that healthcare providers must accept (revised) Medicare payment rates from those private programs.  But because employees can opt into "Medicare" on an income-adjusted basis even if their employers offer compliant private insurance, private insurance will have to establish a real competitive advantage if it's to survive alongside the generous public program.

The headline change in the reintroduced bill is elimination of deductibles, which were modest enough in the original bill (topping out at $350 individual/$500 family). But a more significant change improves the bill's financing and provides ballast for the competition between public and private sectors.

Benefit cliffs in the ACA marketplace

Dave Anderson highlights an important weakness in the subsidy structure for the ACA marketplace. As income rises, the enrollee's share of the premium for a benchmark silver plan is subject to sudden and irregular bump-ups, which Anderson compares to jolts in marginal tax rates.  Take the case of a couple looking to buy a benchmark silver plan:

From $17,000 to$20,000 this couple pays an extra $2 per month for every thousand dollars more they earn a year.  Annually this is about a 2% marginal tax rate on the additional income.  And then there is a huge bump from $20,000 to $21,000.  The benchmark premium suddenly becomes $256 more expensive.  This is a 25% marginal rate...

And then the marginal rate drops again when the family increases their earnings from $21,000 to $22,000.  The marginal rate for this slice is now about 11%.  The marginal rate for couples earning under 300% FPL is in the mid-teens, and then there is a drop in the marginal rate to just under 10% for 300% to 400% FPL and then a potential massive spike as soon as someone earns over 400% FPL.

The spikes in out-of-pocket (OOP) costs this couple is exposed to as income rises are even more sudden -- and, I think, potentially damaging to family finances -- than the premium spikes. The main benefit cliff is formed by the sudden fadeaway of Cost Sharing Reduction (CSR) subsidies at 201% FPL, where the actuarial value of a silver plan drops from 87% to 73%.  CSR disappears entirely at 251% FPL, and the coverage offered by a benchmark silver plan with no CSR, which has an AV of 70%, is clearly underinsurance for those without significant financial resources.

Take a hike, xpost

I neglected to mention that I'm on vacation this week. I'll be back early next. I've been reluctant to spoil my frame of mind with news of our latest spasms toward oligarchy, authoritarianism and/or war, so I'm pretty out of it.  I gather Trump has taken a stand against balance billing. Does he know what it is?  I have long suspected that balance billing is the one healthcare abuse so egregious that even Americans won't tolerate it indefinitely. But watch our pols bipartisanly give away the store to providers.

What if a candidate took voters' stated healthcare priorities literally?

In its low-key way, the Kaiser Family Foundation has been warning Democrats for some time that the electorate is not strongly demanding Medicare for All, or sweeping healthcare system change generally.

With about 90% of the population insured (and perhaps a third underinsured), Drew Altman noted a month ago that voters' main overall healthcare priority is lowering their own out-of-pocket costs. The latest Kaiser tracking poll, conducted this month, fleshes this out:

Drug costs. Surprise bills. Access to affordable insurance if you get sick (e.g., if you lose your job). Underlying these concerns, Altman pointed out, is the poll finding that half of people who are sick have trouble paying their medical bills. With deductibles soaring, 43% said it was hard to pay their medical bills before the deductible kicks in.

Secondarily, there is broad support for expanding financial help to more people who need to buy health insurance in the individual market. There's majority support, in theory, for Medicare for All, but Kaiser's January tracking poll found that that support collapses collapses from 56% to 37% when people are asked if they would support a program that raises most people's taxes or eliminates private health insurance companies.

Meeting voters where they are on healthcare

These responses raise the question: what would a healthcare platform that aims to give voters what they say they want look like?  Addressing voters' stated wishes piecemeal may not be optimal policy: systemic change might be needed to address core concerns. Most fundamentally, reducing individuals' out-of-pocket costs requires bringing down the underlying cost of care, if the cost is not simply to be shifted to the tax burden.

At the same time, a candidate who floats a plan that would leave the current core elements of our health insurance sources intact -- preserving employer-sponsored insurance, existing Medicare, Medicaid and the ACA marketplace -- might have some running room to impose reforms that pinch healthcare industry revenues.

Providers would fight a strong balance billing ban and a strong public option in the ACA marketplace -- but they might ultimately  settle for these reforms that don't radically shrink the employer insurance cash cow. Ditto for insurers. They will fight a public option in the ACA marketplace -- but it's less of a threat than Medicare for All, or a public option that's affordably open to pretty much anyone. As for pharma...let's assume for the sake of argument here that it's possible to take on one healthcare industry head-on if you're not taking on all at once.

So, here's the hypothetical platform:

Strong balance billing protection. Balance billing is the one form of abuse in the U.S. healthcare system that's so egregious, even Americans may not stand for it much longer -- hence the bipartisan draft legislation introduced in the Senate to provide relief. Vox and Kaiser Health News have been doing God's work exposing shocking-but-routine instances of price-gouging. As cited in a Brookings analysis, some 20% of emergency room episodes, 9% of scheduled procedures and 50% of ambulance services result in out-of-network bills for patients

A strong solution would ban balance billing for a) people brought to an out-of-network ED in an emergency, b) people who get emergency care at an in-network facility, and c) people who schedule a procedure with an in-network primary provider at an in-network facility. A viable solution should also not drive up the cost of care by requiring insurers to pay billed costs at huge multiples of Medicare rates, as do some proposals and state bills that mandate arbitration, or use billed costs as a benchmark..

A strong solution put forward in the Brookings analysis would a) cap all out-of-network billing at 125% Medicare and b)  ban independent billing for targeted specialties, e.g.,  emergency, ancillary clinician, hospitalist, and neonatology services delivered at an in-network facility.  That puts the onus on hospitals to negotiate rates acceptable to those specialists.

Prescription drug relief. Medicare should negotiate rates not only for Medicare Part D but for the whole nation -- joining virtually every other wealthy country in having the national government negotiate uniform rates for prescription drugs for all payers. Medicare should also be empowered to create a formulary, i.e. not cover every drug, i.e. have the power to walk away when there's a viable alternative.  This is not going to happen. But in the proposal phase, go big here to balance the moderation of the overall package. Fallbacks might include a) empowering Medicare to negotiate for Part D plans only; b) creation of a drug oversight board empowered to flag and punish or roll back price-gouging as defined by statute; and c) various current bipartisan initiatives to encourage generic production and competition.

Augmented ACA.  Improvements to the ACA should a) make individual market coverage affordable, including via affordable out-of-pocket costs, for anyone at any income level who lacks affordable access to other insurance (e.g., affordable employer insurance or Medicaid); and b) control underlying costs, so that the improved subsidies required by a) are affordable to the Treasury.

A bill that might fit the, um, bill would

a) Raise the benchmark plan in the ACA marketplace, for which enrollees pay a fixed/sliding percentage of income, from 70% actuarial value to 80% AV, i.e. from silver level to gold in the current marketplace scheme. 80% AV is near the average for employer-sponsored insurance.

b) Erase the current subsidy cliff, which renders coverage extremely expensive for many who are just beyond the income threshold for subsidies (400% of the Federal Poverty Level, or roughly $49,000 for an individual/$100,000 for a family of four). Cap premiums for the benchmark plan at 8.5% of income for anyone otherwise eligible with an income over 400% FPL.

c) Improve premium and cost sharing subsidies at incomes below 400% FPL, requiring a lower percentage of income to pay the benchmark premium and providing higher AV for benchmark plans.

d) Create a strong public option, paying Medicare rates to providers (with some adjustments for rural hospitals and primary care) and requiring providers who accept Medicare to accept the public plan. This would also push down the rates that commercial marketplace insurers pay providers, and remove providers' incentive to refuse to accept the commercial marketplace plans, most of which would probably pay more than the public option.

e) Enable people whose employers offer insurance to access subsidies for marketplace coverage if the employer plan a) costs more than 8.5% of income, including for family coverage if the employee has a family, and/or b) offers less than 80% AV coverage.

Point e) does not open the sluice gates to the public plan as wide as does the Medicare for America bill, soon to be reintroduced by Reps Rosa De Lauro and Jan Schakowsky, which allows anyone to buy into the public plan at no more than 10% of income (and much less at lower incomes, including $0 for people with incomes up to 200% FPL).  Because the public option in Medicare for America is free to people with incomes up  200% FPL (with zero out-of-pocket costs as well), it also entails folding Medicaid into the new public plan -- and existing Medicare, with long-term-care added. It also auto-enrolls newborns as of 2022 (or probably 2023 in the upcoming update).

Medicare for America opens a plausible path either to Medicare for All (albeit with out-of-pocket costs for most enrollees) or to a de facto all-payer system, since the bill stipulates that providers must accept the public plan's payment rates from commercial insurers (in employer insurance and Medicare Advantage). It's a coherent set of measures for major system transformation.

The plan above is much more limited. It's also a much lighter lift. But it does cram an awful lot of systemic reform into the Overton Window  opened by Medicare for All and Medicare for America -- while leaving a candidate like Elizabeth Warren free to propose spending trillions on education, childcare and other priorities .

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:

Medicare-X 2.0 deserves a second look

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As originally introduced by Senators Bennet and Kaine in October 2017, the Medicare-X Choice Act (summary here) placed a big fish --  a strong public option -- in a small pond, the ACA marketplace.

The "Medicare-X" public option would first be introduced into low-competition areas in the ACA marketplace, and then into all rating areas. The public plan would pay Medicare rates to providers, and providers who accept Medicare would be required to accept it. But in the first iteration, eligibility for subsidies adhered to ACA criteria, and the subsidies themselves were not improved. While it might improve affordability for the unsubsidized, its appeal to subsidized enrollees might be more limited, though the full Medicare provider network might be a powerful draw. As to premium, however,  I noted recently

By conforming to current ACA subsidy structure, Medicare-X runs afoul of the ACA paradox: measures that reduce unsubsidized premiums do not improve affordability for the two thirds of current individual market enrollees who receive subsidies. In fact, premium reductions often reduce discounts by compressing price spread between benchmark plans, against which subsidies are set, and cheaper plans, to which the subsidy can be applied.

The bill did phase in a small business buy-in, and that might be attractive, as the unsubsidized price might be a relative bargain for small businesses, and the provider network would be unbeatable. It might thus expand the small group market,  which enrolled an estimated 13.6 million people in 2016.

The update introduced this month (bill here, summary here) widens the pool of potential beneficiaries, combining measures that expand subsidy eligibility and reduce unsubsidized premiums -- potentially offsetting the cost of subsidizing more enrollees. It's a limited and cost-conscious expansion of benefits that might make the ACA work more as designed.

Toward universal coverage: A bestiary of Democratic healthcare bills

I have a post up at BlueWaveNJ that offers a framework for assessing more than a half dozen Democratic bills that would build on or replace the ACA to move the U.S. closer to universal healthcare. Here's the premise:

The extent to which these various bills address the demand for affordability can be viewed in two dimensions.

First is the degree to which they make coverage more affordable and reduce out-of-pocket costs for the ACA's original intended beneficiaries: those who lack access to other affordable insurance, mainly employer-sponsored insurance. Second is the degree to which they impact affordability for the 150-plus million current enrollees in employer plans.

A third question is the degree to which each bill reduces healthcare costs on a per person basis, including costs paid by government. Most (not all) Medicare expansion/public option bills increase the population enrolled in plans paying Medicare rates to healthcare providers, as opposed to much higher commercial rates. Most also establish some kind of drug pricing commission enabling Medicare to negotiate or regulate prescription drug prices.

The post, an updated and somewhat streamlined version of this one, overviews seven bills.  Hope you'll take a look.

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Medicare at Will

I have posited repeatedly (here, here, here) that the gateway to real healthcare system transformation (and cost control) is a buy-in to a strong public option that's open to employees as well as employers. A strong public option is one that pays providers at Medicare rates or some adjusted variation, and that all providers who accept Medicare are required to accept.

The public plan must set premiums and out-of-pocket costs at affordable levels for all comers and must be truly available to all, including those whose employers offer private insurance. It should be the baseline against which private coverage must compete, setting a de facto all-payer rate (unless those offering and buying top-drawer coverage want to pay above that baseline).

The Medicare for America bill does all this and also a great deal more -- transforming existing Medicare, including long-term care, folding in Medicaid, auto-enrolling all newborns four years after enactment. I'm not sure the U.S. political system can handle all that mandated transformation at once: in my view the buy-in for employers and employees is the essential core.

This kind of public option, which dates back to the early 2000s in basic concept, has a branding problem. "Medicare for All" has been a dominant watchword and battlecry since 2016, courtesy of Bernie Sanders. "Medicare for America" does not differentiate itself conceptually.  "Medicare for All Who Want or Need It" is...ugh.  Articles such as this one put the buy-in concept under the rubric of Medicare for All, where it doesn't fit.

So I'm here today just to float a name and creed: Medicare at Will. The public plan should  be an affordable option that anyone can choose, with premiums and OOP adjusted to income even if other insurance is available.  Medicare at will is in syllabic balance with Medicare for All. It incorporates the "if you like your plan you can keep it" meme without making any unsustainable promises. In fact it's all about a promise kept: Medicare is always there if you want it or need it.

#MedicareAtWill, friends.

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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).

Cold comfort for low income workers insured through their employers

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The Kaiser Family Foundation and the Peterson Center on Health Care released a report yesterday showing that low income families enrolled in employer-sponsored health insurance (ESI) pay a much higher percentage of their income on premiums and out-of-pocket expenses than do higher income employees. That isn't surprising, though the percentage of income eaten up by healthcare is disturbing. Families in ESI earning up to 199% of the Federal Poverty Level (FPL) spend an average of 14% of income on healthcare, according to Kaiser's analysis of Census data. Families with at least one member in poor or fair health spend an average of 18.5% of income on healthcare.

What is somewhat surprising -- to me, anyway -- is that lower income families with ESI do not spend more in absolute terms than better-paid employees. I was under the impression that low income workers are often offered much skimpier insurance than higher income workers. That impression was at least partly derived from Kaiser's annual Employee Health Benefits Survey. Here's the contrast between employers with mainly low- vs. high-income employees from the 2018 survey:

Latinx enrollment continues to *rise* in HealthCare.gov states

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In 2019, an anomaly in ACA marketplace enrollment continues: for the third straight year, Latinx enrollment has risen in HealthCare.gov states, while overall enrollment has fallen.

Caveats abound. Ethnic data is self-reported, and about a quarter of enrollees don't report ethnicity -- which CMS has broken out separately from race since 2017*. But still, the steady rise in the percentage of enrollees who self-report as "Hispanic/Latino" is striking.

Latinx enrollment, 2016-2019, HealthCare.gov states

Self-reported ethnicity 

Enrollee group	2016*	2017	2018	2019
Latinx	918,626	956,516	1,033,699	1,037,306
All enrollees	9,719,648	9,201,805	8,743,642	8,411,614
Percent Latinx	9.5%	10.4%	11.8%	13.3%

* Because Kentucky switched to the HealthCare.gov platform in 2017, I have added the state's totals to the 2016 totals for HealthCare.gov states. Because there is no 2016 breakout of Hispanic enrollment in KY in  2016 (as it was an state-based-exchange), I have estimated the total (1656) by adding 14.8% to the 2017 total (1442), as that's the degree to which 2016 enrollment exceeds 2017 in the state.

BlueWaveNJ on the cost of ACA nullification

Here's what BlueWaveNJ thinks of Donald Trump's now-total support for the ridiculous suit seeking to nullify the entire ACA:

The Trump administration's recent shift to full support of a lawsuit filed by 20 Republican attorneys general and governors seeking to have the entire Affordable Care Act declared unconstitutional is a legal absurdity and a wantonly cruel and reckless policy decision. The plaintiffs argue, and the Trump administration now agrees, that the entire ACA became unconstitutional when Congress reduced the individual mandate penalty to zero in late 2017, because the Supreme Court in 2012 held that the mandate was Constitutional only as an exercise of Congress's taxing power. That is rank sophistry rejected by attorneys and legal scholars across the political spectrum -- suggesting in effect that the Republican Congress repealed the ACA by accident when it zeroed out the mandate penalty as part of the tax package passed in December 2017 after failing in multiple attempts to repeal the law's core programs earlier that year.

There's more...  

CSR takeup bends slightly under silver load at incomes up to 200% FPL

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For ACA marketplace enrollees with incomes up to 200% of the Federal Poverty Level (FPL), silver-level plans are almost always the wisest choice. Through 2017, silver plans were priced as if they had an actuarial value of 70%, compared to 60% for bronze plans and 80% for gold. The Cost Sharing Reduction (CSR) subsidy, however, raises the AV of a silver plan to 94% for those with incomes up to 150% FPL, and to 87% for those with incomes in the 151-200% FPL range. Insurers were reimbursed separately for CSR, and it wasn't priced into premiums.

That changed when Trump cut off direct CSR reimbursement in October 2017. In 2018, CSR was priced into premiums -- in most states, into silver premiums alone. By 2019, almost all states allowed this "silver loading." Since ACA premium subsidies are designed so that the enrollee pays a fixed percentage of income for a silver benchmark plan, inflated silver premiums boost subsidies and so create discounts for subsidized buyers in bronze and gold plans. But these discounts are not enough to offset the value of the CSR that's available up to 200% FPL.

The story is quite different at 201-250% FPL, where CSR is weak, raising the AV for silver plans to just 73%. In that income range, gold and bronze plan discounts often do outstrip the value of CSR -- almost as strongly as they do at incomes above 250% FPL, where the silver AV is 70%.