The Times wrestles with ACA re-enrollment; I call some fouls

To a point, New York Times healthcare writers (see byline below) did a good job explaining the complexities of the renewal decision facing many buyers of health plans on the ACA exchanges for 2014. But I have three beefs with the front-page presentation.

The first is in the headline (not the reporters' responsibility). The lead that follows clarifies the problem -- but for many, of course, the headline shapes perception:

Cost of Coverage Under Affordable Care Act to Increase in 2015
By ROBERT PEAR, REED ABELSON and AGUSTIN ARMENDARIZ NOV. 14, 2014

WASHINGTON — The Obama administration on Friday unveiled data showing that many Americans with health insurance bought under the Affordable Care Act could face substantial price increases next year — in some cases as much as 20 percent — unless they switch plans.

Unless they switch plans is the key. For the 85% of buyers who qualify for federal subsidies, their costs will not go up at all if they buy the benchmark second-cheapest Silver-level plan, or a cheaper plan -- except insofar as their income rises. Their share of the premium is a fixed percentage of their income. In fact, if their income is flat they may qualify for higher Cost Sharing Reduction (CSR) benefits, since the formula for determining those benefits is adjusted yearly for inflation.

Getting the word to the uninsured: Can Healthcare.gov show the subsidy, pronto?

More than half of the uninsured don't know that the government will help fund their insurance, according to the Kaiser Family Foundation. More than half of the subsidy-eligible who shopped but didn't buy on healthcare.gov didn't recognize that they were eligible for subsidies, according to McKinsey and Company.

A functioning shop-around feature, in which a user punches in location, household members and income and gets price quotes with subsidies included, could be a major weapon against that widespread ignorance. When Healthcare.gov launched, or failed to launch, last fall, it didn't have one. In December a shoparound was up and functioning -- but many folks never saw it; the home page didn't particularly steer you to it.

This year is different. The shoparound showing quotes for 2015 was up before Open Season launched, and you couldn't miss it (good news: now that Open Season has kicked off, that's still true). How effective is it?

I have an article up on Healthinsurance.org that explores its strengths and weaknesses, with expert health. In brief, the good news: you can't miss the shoparound when you visit hc.gov, and if you try it, you can get price quotes in under a minute.  And the bad: the guidance toward silver plans for those eligible for Cost Sharing Reduction subsidies, which are available only with silver, is still weak, and the information about CSR subsidies is incomplete. More generally, the level of decision support is not up to that of select states, like Idaho, the only state to exit Healthcare.gov and launch its own exchange this year.

Is the tax code the best route to attacking wage stagnation?

David Leonhardt identifies stagnant wages as the political issue of our time and the prime mover of Democrats' current woes, as they've been left holding the bag during a period in which median income has fallen. He runs through a list of measures that in part address the problem, of which some (infrastructure) have been blocked by Republicans, others (investment in education) work slowly (if at all), and still others (health reform) have made some headway -- but without much direct or immediate impact on most middle class voters. He then segues to a short-term solution that he suggests might provide at least political relief:

Truly new ideas don’t come along very often in any field, including economics.

So it goes with lifting middle-class incomes. The best hope for doing so, in the immediate future, is probably the oldest and most obvious play in the book: a tax cut.

A few years ago, a middle-class tax cut would have seemed a silly idea. Both Mr. Bush and Mr. Obama had already cut taxes, and the federal budget deficit was enormous. But the deficit has since fallen sharply, thanks in part to lower health costs. Meanwhile, middle- and lower-income families are reaping a disproportionately small share of economic growth. Having the government try to rectify the situation doesn’t sound so silly now — and probably won’t in the 2016 presidential campaign.

Leonhardt admits that the country as a whole is under-taxed, short of revenue for other economy-building action. Hence he suggests pairing a middle class tax cut with a further hike on the wealthy, which of course Republicans will never allow. It's not entirely clear whether he's touting the tax cut because it helps plug the income gap a bit, or because it may stimulate the economy and thus tighten the labor market enough to generate upward pressure on wages. Most likely both.

Healthcare.gov 2.0 is live. A couple of problems...

Healthcare.gov's shop-around feature for 2015 went live last night. While there are some notable improvements, I see a couple of problems that I want to highlight right away.

In the quest to design a website that helps people find the health insurance that's right for them, there's a tension between making the process easy and providing essential information. The new shop-around has come down on the side of "more info" than the prior one. But the info is not always more accessible.

First problem: sometime in the off-season, on the shop-around feature, hc.gov added pop-up definitions of "deductible" and "out-of-pocket maximum" and "co-payments/co-insurance" on all price quotes. Inexplicably, they're gone in the 2015 shop-around.  Maybe they'll be coming online shortly? (Shop-around for the remainder of 2014 is still live if you want to compare.)

Healthcare.gov is already better than it was when Open Season ended

On the eve when Healthcare.gov is scheduled to go live with the shop-around feature for plans available in 2015, here's a spot of good news about how that feature's already been upgraded. This is a pull-out from something I noticed mid-post, and so buried a bit, late last week.

[Update: 2015 shop-around is live now. As HealthSherpa did during the last open season, its starts with a single prompt for a zip code to draw a user in. While it asks for the same info as last season, it breaks the presentation into several screens, probably help people avoid missing key questions. BUT...the mouseovers are gone! Update post here.]

One complaint often voiced about healthcare.gov last year was that important information was not provided in context. For example, when University of Pennsylvania researchers studies the experiences of young,  well-educated users of the site, their first recommendation for improvement was to provide instantly accessible glossary definitions of key insurance terms -- i.e., popup definitions that appear when you mouse over the terms, on the plan price quotes or elsewhere.

The shop-around feature on hc.gov has remained live (though somewhat difficult to find) during the off-season, for the benefit of people eligible for "special enrollment periods" because they've undergone life-changing events such as job loss or divorce or marriage.  And I'm happy to report that at some point in recent months (or weeks), pop-up definitions have appeared. They work on the screen grab below:

Evidence from Kaiser: Most ACA shoppers made informed choices

How well-equipped are America's uninsured to shop for private health insurance in the ACA's marketplace?

The scary news going in was that most of the target population had a poor grasp of fundamental insurance concepts such as "deductible" and "copay." The good news is that most buyers seem to have picked up a working knowledge of the basic tradeoff between monthly premiums and likely out-of-pocket costs by the time they pulled the trigger.

I have noted in multiple posts, summarized here, that the vast majority of lower-income ACA shoppers avoided high deductible bronze plans and availed themselves of the Cost Sharing Reduction  (CSR) subsidies available only with silver plans -- even when, as in Mississippi, the silver plans cost them significantly more per month.  Now, Kaiser Family Foundation survey data, reported this week, suggest that private plan buyers considered deductibles and co-pays almost as important as monthly premiums.

Master saboteurs

You've got to hand it to Mitch McConnell and the Republicans generally: Basically every aspect of their strategy and execution since Obama was first elected has been effective. Poison public perception of effective legislation like the stimulus and the ACA? Check.  Block all constructive legislation since winning the House, and blame Obama for inaction?  Check. Inhibit economic growth with savage austerity during a demand slump?  Check. Outmaneuver the president on budget issues by proving willing, or seeming willing, to shut down the government, default on the national debt, and pull the trigger on spending cuts beyond what anyone would have dreamed a few years ago? Check.  Depopulate the executive branch by slow-walking all appointments (until the filibuster rule change this year)? Check. Disenfranchise hundreds of thousands of black and Hispanic voters with voter suppression measures? Check. Flood the airwaves with dark money supplied by their corporate and ideological masters? Check.

It's all worked. Some say the victories are Pyrrhic and will be short-lived. But if they can keep Obama's approval numbers in the low 40s or worse, and keep economic growth at a steady sputter, they may win control of the only branch and level of government they don't dominate.

Two ways to reform the ACA's free preventive services

The Wharton School's Mark Pauly has co-authored an article (with Duke's Frank A. Sloane and Sean D. Sullivan at U. Washington) arguing that the free preventive care services mandated by the ACA to be covered by all insurance plans should be subject to cost-benefit analysis. Currently they are not; the decisions of the two entities that determine which preventive services must be provided for free  "are based on a comparison of health benefits and risks alone," as Rebecka Rosenquist summarizes on the blog of the Leonard Davis Institute at Penn. She further notes:

Pauly and colleagues note that the groups “have no responsibility for a total expenditures budget for medical services that would constrain their recommendations.” They cite an analysis that shows a 1.5 percent increase in private insurance premiums due to the cost of the US Preventive Services Task Force recommendations. “When they do recommend a new costly vaccine or service, that recommendation usually increases both public and private spending (including insurance premiums).”

Indeed. Outcomes research funded by the ACA should also shape Medicare reimbursements, but demagogic screams about health care "rationing" made that impossible. Recall, too, the outcry in November 2009 when the US Preventive Services Task Force -- one of the two agencies* charged with setting the ACA's free preventive services mandates -- downgraded its mammography recommendation for women under 40, deeming that the decision whether to undergo the test should be based on individual circumstance.  The ACA drafters rushed to mandate free mammograms at any age.

Rational choice in the ACA marketplace

Here's another piece of the puzzle in my quest to figure out why ACA private plan buyers bought low-premium, high-deductible bronze plans in much higher proportions in some states than in others (8% of Mississippi plan buyers selected bronze; 41% of Hawaiian shoppers did). A good predictor is each state's public health profile. (Thanks to Brad G. for putting me on the trail.)

Bronze plans, in which deductibles average over $5,000 per person, are bad deals for people who are likely to make heavy use of medical services. They're also bad deals for low-income buyers, who can access generous Cost Sharing Reduction subsidies that reduce deductibles and co-pays (radically for those with incomes under 200% of the Federal Poverty Level) -- but only if the buyer chooses a silver plan. Low income buyers are often in poor health, and know it. Most ACA buyers have been uninsured and so may have pent-up healthcare needs.

I have previously noted that a very high percentage of buyers eligible for CSR did in fact choose silver plans, and that lower income states did have lower percentages of bronze buyers -- though there are notable exceptions up and down the scale. The same is true for measures of public health in each state. Wealthier states tend to have healthier residents -- though wealth disparities within states can complicate the picture.

In the chart below, I have tabulated three public health measures drawn from the Kaiser Family Foundation's State Health Facts: life expectancy, incidence of  Diabetes, and obesity -- for the ten states with the lowest and highest takeup of bronze plans. The average bronze takeup states in the former group is 14.25% of all plan buyers, and in the latter group, 31.1%.  In all three health measures, the low-bronze-takeup states as a group significantly underperform the high-bronze-takeup group. The income disparity between the two groups is also stark.*

Maybe we should call blue states bronze states

In several posts, I have tried to track how successful the ACA exchanges were in steering lower-income buyers of private plans toward silver plans, the only metal level at which subsidies that reduce deductibles and out-of-pocket costs are available. Low-income buyers of bronze plans, which offer low premiums but sky-high deductibles, forfeit access to these Cost Sharing Reduction (CSR) subsidies, which radically reduce costs for those with household incomes under 200% of the Federal Poverty Level and phase out at 250% FPL.

On the whole, the news is good, though information that correlates metal level selection with buyers' income is sketchy. In New York, the only state that breaks out metal level selection by income bracket, 89% of buyers under 200% FPL chose silver plans and so took advantage of CSR. In the federal exchange, only 15% of buyers who qualified for any kind of subsidy bought bronze plans.

Bronze plan selection varies quite a bit by state, however, for reasons that are hard to tease out.  For starters, more people on average bought bronze in the 14 states (plus D.C.) that built their own exchanges -- most of which are also among the wealthier states.

State per capita income seems to affect metal level selection. interacting with other factors such as premium prices, the quality of outreach to the uninsured, whether the state expanded Medicaid (which takes out potential buyers between 100 and 138% FPL), and the age composition of the buying pool.*

My thanks to a friendly stranger on Twitter who put together a scatterplot correlating state median income and bronze plan selection. That led me to the latest census data on median household income by state. Below, I've matched it up with HHS state-by-state data on ACA buyers' metal level selections.

For ACA buyers at all income levels, here are the bronze takeup rates for the thirteen highest- and thirteen lowest-earning states:

In Mississippi ACA rollout, one big disaster, one small success

Politico's Sarah Varney has a beautifully reported, infuriating account of how Tea Party government in Mississippi sabotaged the state's ACA rollout, leaving Mississippi "the only state in the union where the percentage of uninsured residents has gone up, not down."

The tale has three parts: 1) the state's Tea Party governor elected in 2012, Phil Bryant, undercut and induced the closure of the state's home-built insurance exchange, a project in which the state insurance commissioner (and Haley Barbour crony) Mike Chaney was deeply invested, and which was briefly operative before full ACA implementation. 2) The state refused to participate in outreach to the uninsured and, by closing its exchange, forfeited substantial federal aid for outreach. 3) The state rejected the ACA's Medicaid expansion, which would have extended Medicaid eligibility to an estimated 333,000 uninsured residents. Mississippi was also among the poorest performers in attracting competition to the exchange: most counties had only insurer, Humana, offering plans.

I would add a footnote. Of those three factors, the refusal to expand Medicaid in the nation's poorest state was by far the most consequential.  As part of Healthcare.gov, Mississippi's state exchange did not ultimately perform so badly.  The state exchange enrolled 61,494 people in private plans, 20.6% of the estimated 298,000 uninsured residents eligible to buy insurance on the exchange. That's not great, but it's a higher percentage than that achieved in several states that built their own troubled exchanges, and better than 17 states overall.

Had Mississippi achieved the national average percentage of eligible signups, 28%, another 22,000 residents would be insured. An estimated 138,000 Mississippians, by contrast, fell into the so-called Medicaid gap -- that is, they would have been eligible for the blocked expansion but earn too little to qualify for subsidized coverage on the exchange. Again, 333,000 state residents were estimated to be newly eligible for Medicaid under the expansion. And many states that expanded Medicaid actually exceeded their target enrollments.

What the ACA can't cure

I recently referred to Investor's Business Daily reporter Jed Graham's coverage of the ACA as "adversarial." He objected. I responded, "I don't ignore or minimize ACA flaws but would not object to a characterization of my writing on it as "sympathetic."

That set me thinking about everything that troubles me about the ACA -- or, more accurately, things that trouble me about the US healthcare system that the ACA is unlikely to fix -- though it may help catalyze reform on several of these fronts. Here's the list:

1. All private health insurance in the U.S. is inadequate -- thanks to the shameful out-of-network billing, balance billing, and creative billing by hospitals, physicians and other providers documented in sickening detail by Elisabeth Rosenthal in her Paying Till it Hurts series. We are in the grip of a depraved system in which hospitals often operate as free billing zones and payers' attempts to control costs just generate new loopholes.

2. For the unsubsidized and lightly subsidized, private insurance on the ACA exchanges is too expensive. Or rather, medical care obtained under the insurance is too expensive.  One of the law's strengths is the Cost Sharing Reduction (CSR) that reduces deductibles and out-of-pocket costs for buyers with incomes below 200% of the Federal Poverty Level to levels comparable to those offered in top-grade employer-sponsored insurance (much more modest CSR is offered to those between 200% and 250% FPL).  Those cost control come into play if low income buyers choose silver plans (fortunately, most do) and if  they are not hit by the kind of out-of-network and balance billing that Rosenthal documents. Those above 200% FPL, however, have to choose between high monthly premiums and often sky-high deductibles, average over $5,000 for bronze plans (which may be tempting to many at the upper range of subsidy eligibility).

Ebola's Information Paradox, Part II: Do we hear?

Looking back to a devastating Cholera outbreak in a poor neighborhood of London in 1854, Steven Johnson notes that "it took two entire weeks before the press began treating the outbreak as a major news event for the city."  A hundred and sixty years later, we're safer (although more fearful) because news travels faster:

Compare this pattern of information flow to the way news spreads now. On Thursday, Craig Spencer, a New York doctor, was given a diagnosis of Ebola after presenting a high fever, and the entire world learned of the test result within hours of the patient himself learning it. News spread with similar velocity several weeks ago with the Dallas Ebola victim, Thomas Duncan. In a sense, it took news of the cholera outbreak a week to travel the 20 blocks from Soho to Fleet Street in 1854; today, the news travels at nearly the speed of light, as data traverses fiber-optic cables. Thanks to that technology, the news channels have been on permanent Ebola watch for weeks now, despite the fact that, as the joke went on Twitter, more Americans have been married to Kim Kardashian than have died in the United States from Ebola.

Well yes, wonderful. But how long did it take for news of a deadly, fast-developing epidemic in West Africa to bubble up into full public consciousness in the United States? The psychological quarantining of a poor region in the grip of a terrible affliction persists.

A surprise (to me) regarding Medicaid eligibility under the ACA

I learned an interesting fact about the ACA from Kaiser's Larry Levitt on Twitter today.

It's well-known to ACA watchers that a low-income worker whose employer offers insurance deemed "affordable" according to ACA formula cannot buy subsidized private coverage on the exchanges. What I suspect is less well-known, and what Larry spelled out, is that the availability of employer-sponsored insurance does not negate Medicaid eligibility for someone whose household income is low enough to qualify for Medicaid.

I agree

with this Dish reader:

I choose to believe that Obama will not adopt Bush administration interpretation of torture treaty obligations, will not adopt a West African travel ban, and will not go deep into Syrian quagmire.

Maybe “hope” is a better word.

Re Sully's closer: "I’m hoping too. And doing what little I can to help make it so": When I read the Times article claiming that Obama is "considering reaffirming the Bush administration’s position that the treaty [UN Convention Against Torture] imposes no legal obligation on the United States to bar cruelty outside its borders," I knew exactly what Sullivan's response would look like.  And that the White House would know too. And that Sullivan speaks for Obama's base on this front, or at least a large part of it. For whatever that's worth.

NYT spotlights plight of ACA bronze plan buyers, leaves out vital context

[first posted 10/18]

The Times has a front-page story today, by Abby Goodnough and Robert Pear, that highlights the plight of ACA private plan buyers who bought plans with such high deductibles that they are foregoing needed treatment.  This is a real problem -- bronze plans in particular have terribly high deductibles, averaging $5,000 per individual -- but vital context is missing. Here's the framing:

About 7.3 million Americans are enrolled in private coverage through the Affordable Care Act marketplaces, and more than 80 percent qualified for federal subsidies to help with the cost of their monthly premiums. But many are still on the hook for deductibles that can top $5,000 for individuals and $10,000 for families — the trade-off, insurers say, for keeping premiums for the marketplace plans relatively low. The result is that some people — no firm data exists on how many — say they hesitate to use their new insurance because of the high out-of-pocket costs.

The first thing to note is that low-income ACA shoppers were generally not subject to these high deductibles. Low-income marketplace shoppers should generally not be buying bronze plans  -- not only because the deductibles are higher than those of silver-level plans, but because the silver plans alone come with Cost Sharing Reduction (CSR) subsidies. These reduce deductibles and maximum out-of-pocket costs for buyers with household income below 250% of the Federal Poverty Level (FPL). CSR subsidies are really large for buyers under 200% FPL, giving silver plans actuarial values comparable to those of the most generous employer-sponsored plans for those in that income range. The Goodnough-Pear story does explain CSR, but deep in the story, following four hard-case individual narratives.

Bronze plans had relatively low takeup in the ACA's first open season. According to HHS statistics, just 20% of users in all marketplaces (state-run as well as healthcare.gov) bought bronze plans. Since 33% of buyers who earned too much to qualify for subsidies bought bronze, less than 20% of the subsidy-eligible must have done so.

The ACA marketplace and the toilet paper aisle

My last post was in protest to a New York Times front-page article that highlighted the very real plight of ACA private plan buyers who were forgoing needed medical care because they'd bought high-deductible, mostly bronze-level plans. My beef was that the article omitted important context, e.g., that only 20% of ACA shoppers selected bronze and that the vast majority of low-income buyers who were eligible for Cost Sharing Reduction (CSR) bought silver plans that allowed them to access those important secondary subsidies.

I also suggested that the four individual narratives in the piece should not be taken at face value -- in particular, the plight of one woman who had selected a bronze plan with a $6,000 deductible but was plainly eligible for CSR that would have brought the deductible down to $500 at worst and as low as $25, depending on what plan she chose. This woman plainly made the wrong plan choice -- in itself a significant problem, but not one that the Times article addressed.

I want to focus here on a second brief narrative in the Times story, in which the woman in question was somewhat higher-income and so faced a tougher choice, with less obviously attractive options. Here's the tale:

CMS warns current ACA enrollees to shop anew.

I am glad to note that CMS, in its outreach to current enrollees in ACA plans, is shifting its emphasis away from auto-enroll and toward encouragement to shop for the best deal.

When current enrollees log onto healthcare.gov  after the 2015 marketplace opens on November 15, their new applications  will be pre-filled with their latest information from 2014. That's good. CMS also provides a good deal of information in fairly simple terms in this 5-step instruction sheet. Also good. It begins with a useful warning:

REVIEW - PLANS CHANGE, PEOPLE CHANGE. Every year, insurance companies can make changes to premiums, cost-sharing, or the benefits and services they provide. Review your plan’s 2015 coverage to make sure it still meets your needs and you’re getting the best plan for you. 

What the outreach does not do is explain that a person's current plan may lose "benchmark" status if new (or revamped) entries undersell it -- and if so, the subsidized enrollee will be on the hook for the whole difference between the cost of the benchmark plan and her current plan. That's because subsidy levels are tied to the  price of the benchmark -- the second cheapest silver plan in a given area. If you buy that plan, your share of the premium will be a fixed percentage of your income. If your plan costs more than the benchmark, you pay the difference. That difference may be especially large for older buyers, for whom the unsubsidized premium can be up to three times as large as the premium for a younger buyer.

I can see why CMS might calculate that a "benchmark gap" is too complex a concept to explain in written materials. Encourage people to compare, and they should see the difference between the cost of their current plan and cheaper options.  I'll leave it to online "product scientists" or market psychologists or others with data and experience to judge whether that's the right call. 

Grazing in the gaffeteria

Kevin Drum meditates on "the usual preoccupation that political reporters have with process over substance":

For example, Steve Benen notes today that Kentucky Democrat Alison Lundergan Grimes recently dodged "a straightforward question about whom she voted for in the 2012 presidential election" and got hammered for it. But in Iowa, when Ernst refused to say if she wants to shut down the Environmental Protection Agency or what she'd do for those who’d lose health care coverage if Obamacare is repealed, the reaction was mostly crickets.

News from New York: Most low-income ACA private plan buyers chose wisely

Recent readers know that I've been trying to get a bead on how many lower-income buyers of private health insurance plans on ACA exchanges bought bronze plans and so forfeited Cost Sharing Reduction (CSR) subsidies that reduce deductibles and out-of-pocket costs. CSR, on offer to those with household incomes below 250% of the Federal Poverty Level (FPL), is available only with silver plans.

In the federal exchange, covering 36 states, 76% of ACA private plan enrollees who qualified for premium subsidies bought silver plans. Not all of them also qualified for CSR, and so it seems likely that a higher percentage of those who did so qualify bought silver. In the federal exchange, which accounted for about two thirds of all plans sold, just 15% of subsidy-eligible buyers chose bronze plans, which carry the highest deductibles and out-of-pocket (OOP) costs.

Three states that I know of, Washington, Colorado and New York, have published data breaking out buyers' metal-level selections according to specific income levels. New York and Colorado are the only states I know of that report specifically, albeit indirectly, on the choices of buyers with household incomes under 200% of the Federal Poverty Level (FPL), the cutoff for really substantial CSR. Colorado is an outlier with a very high bronze takeup, to be dealt with in a future post. The news out of New York, in contrast, is quite good on this front, though a bit tricky to tease out.*

Tax code progressivity isn't everything. But the top line matters

"Don't soak the rich," Edward D. Kleinbard admonishes U.S. policymakers in today's Times. Countries with less progressive tax systems than the U.S., which tax everyone more and spend more on social services and other public goods, do a better job of reducing inequality (and fostering citizens' welfare) than the U.S. does. Lower income citizens get disproportionately more value from government spending, and an adequate tax base must be broad-based.

I take the point -- made with equal force two days ago by Vox's Cathie Jo Martin and Alexander Hertel-Fernandez [update: Mike Konczal and Matt Bruenig both demonstrate the alleged US progressivity is an illusion -- see below]. But there's a counterpoint. The U.S. may have a more progressive tax system and skimpier social welfare than the wealthy countries of Europe -- that's a longstanding reality. But all these countries have moved in the same direction over the past thirty years, and all have suffered widening income inequality. Here's Thomas Piketty's explanation:

Footnote to a Kliff note

Walmart announced earlier this week that it would stop offering health insurance to 30,000 employees who work less than 30 hours per week. Sarah Kliff points out that many of them will be better off on ACA plans:

Think of the 36-year-old Walmart employee here in Washington, D.C. who works 29 hours per week at the company's average wage of $12.73 per hour. She earns just about $19,000 annually if she works every week of the year.

If Walmart doesn't offer her insurance, the Kaiser Family Foundation's subsidy calculator shows that she qualifies for a $1,751 subsidy from the federal government to help buy coverage on the exchange. With that financial help, she can buy insurance for as little as an $7 per month. As a low-wage worker, she gets some of the most generous financial help.

But if Walmart does offer her coverage, it becomes her only option. She doesn't qualify for federal help and the $7 plan disappears. Walmart's plan, meanwhile, is way more expensive. The average premium there works out to $111 per month.

For many Walmart part-timers, the ACA offers an even better deal than this snapshot shows.  In addition to a premium subsidy that covers three quarters of the monthly premium, this person (if single) is eligible for generous Cost Sharing Reduction (CSR) that dramatically reduces her deductible and maximum out-of-pocket (OOP) costs. DC is not on healthcare.gov, so I checked what would be on offer if she lived in Fairfax, Virginia. There, she could choose a silver plan that costs $64 a month, with a $600 deductible and a $2250 OOP max -- or a plan that costs $74 per month but has no deductible and a $2250 OOP max.

Paul Krugman agrees with me

Back when  Paul "the stimulus was too small!" Krugman was in full Cassandra mode, just after the November 2010 shellacking, I took issue with one of his numerous whacks at Obama:

...take this sideswipe at the stimulus in Krugman's latest crie de coeur about the Fed's refusal to raise its inflation target:

...fearing opposition in Congress, the Obama administration offered an inadequate plan, only to see the plan weakened further in the Senate. In the end, the small rise in federal spending was effectively offset by cuts at the state and local level, so that there was no real stimulus to the economy.

Wasn't one of the core purposes of the stimulus to offset spending cuts by state and local governments? That's what stimulus does -- offset drops in demand. Of course, Krugman believes that there was too little state aid, along with too little of everything, in the Recovery Act, and naturally a stimulus should do more than offset other government spending cuts. But still, offsetting those cuts is a "real stimulus to the economy." The Recovery Act unquestionably preserved hundreds of thousands of state and local government jobs, and GDP would have been lower if this hadn't been done.

This may seem a semantic quibble. But it's a symptom, I think, of an oversimplified narrative. Krugman has implied elsewhere that the right-sized stimulus would have set the economy roaring back to life (as has Martin Wolf). To what degree is that credible? If Obama had asked for $1.2 trillion and got $950 billion, what's the math on the counterfactual? Unemployment at 8.3%?  And the effect of such a drop on the electorate? I confess it could be substantial. But there's an awful lot of what-ifs there, beginning with the premise that a substantially larger stimulus could have got through the Senate. And the narrative leaves out some externalities, such as the Euro sovereign debt crisis, which seemed to stop a decent-looking recovery in its tracks. Not to mention the credible possibility, forecast now by a growing number of economists and business leaders (e.g., here and here), that a substantial recovery may be on the horizon now. 

Some time in 2012, Krugman had a change of heart about Obama, and now he is out with a defense of Obama's record just as a host of ex-cabinet members and in-office Democrats is piling on (he himself notes the irony in this). Now behold his retrospective view of the (still too-small) stimulus:

ACA signups: Why is bronze more popular in blue states?

It's good news that more than three quarters of those who bought private health insurance plans on the ACA exchanges selected silver-level plans.  Most of those who qualified for help with premiums also qualified for subsidies reducing deductibles and other out-of-pocket costs.Those subsidies, dubbed Cost Sharing Reduction (CSR) were only available with silver plans.

According to a May 1 HHS issue brief, in the federal marketplace (healthcare.gov), only 15% of buyers eligible for any kind of subsidy bought bronze plans, which have lower monthly premiums but higher deductibles and cost-sharing and render a buyer ineligible for CSR.  Presumably an even lower percentage of those eligible for CSR bought bronze -- again, good news.

The percentage of bronze buyers varies considerably by state, however. Just 5% of subsidy-eligible Pennsylvania buyers selected bronze, while in Washington state, 36% did (Washington breaks out buyers' choices by income level).*  Overall, 25% of buyers in the state marketplaces selected bronze, versus 20% in the federal marketplace.  The outliers in the high-bronze column are all states that ran their own marketplaces.**

Those states are blue-to-purple;they're the ones where state government tried to make the ACA work. How did they end up with higher concentrations of bronze buyers?

ACA Signups: "Over 9.5 million served"?*

Charles Gaba has been tracking ACA enrollments during the off-season, as he did during open season. He estimates that approximately 9,000 people per day are signing up for private plans via "special enrollment" periods, with net attrition of about 2% per month as people drop plans for a variety of reasons.

Tonight Gaba estimates that there have been about 9.5 total private plan (QHP, for Qualified Health Plan) signups to date That's a number that most people will mentally offset, as HHS recently announced that about 7.3 million are currently enrolled in QHPs. Perhaps a bit less than half of that 2.2 million difference is comprised of people who never paid, the rest dropping plans at various points.

It's natural and to a degree fitting to focus on the number of current enrollees. That number is important in that a) the ACA has a long way to go to full takeup -- CBO forecasts 25 million exchange users by in 2018 --  and b) the states' risk pools need to maintain critical mass to establish a viable market. Still, the total number served since the outset -- discounting, perhaps, most of those who never paid -- is also significant.

Buying a health plan: Don't try this at home?

In a recent post, I cheered a bit while noting that most ACA marketplace users who should have bought silver-level health plans did in fact buy silver plans.

That is, most people whose income qualified them for subsidies reducing their plan deductibles and out-of-pocket costs -- subsidies available only with silver plans -- did buy silver. Somewhat less than 20% of those eligible for Cost Sharing Reduction (CSR) bought bronze plans, which have higher deductibles and copays and disqualify a buyer from CSR..

Perhaps a 15-20% "bad choice" rate is too high. After speaking with ACA navigator Kate Kozeniewski of Resources for Human Development (RHD), however, I had to wonder why the numbers weren't worse.

Premiums reign supreme

I asked  Kozeniewski, a program coordinator who helped oversee assistance provided to 45,000 people in Pennsylvania while directly assisting hundreds herself, whether clients generally understood the importance of CSR.

"We found across the board that people were not aware that cost sharing was not available to them unless they chose a silver plan," Kozeniewski said. Almost invariably, she said, people would look at the lowest monthly premium available (as reduced according to their income) and say,"This seems like it's within my budget, so I'll start here, and if this works, this is fine."

Having some health insurance is better than having none. But American insurance...

Those of us engaged in the long struggle to pass and implement the ACA have (not wrongly) fixated on how vital it is to have health insurance, and we've been cheered by the roughly 25% reduction in the nation's uninsured in the ACA's first year. We've also celebrated the ACA's ending of arbitrary policy rescissions, yearly and lifetime coverage caps, medical underwriting, and plans lacking essential benefits like childbirth and drug treatment.

Some coverage is better than none. But recent good reporting is also highlighting the extent to which much if not most health insurance in America remains inadequate, exposing plan holders to sometimes substantial, sometimes damaging and sometimes ruinous costs. The incidence of such exposure may be rising rather than falling, as employers continue to offload the cost of care onto employees.

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.

Repetition again*

I share in the general admiration for the tour de force in gotcha editing pasted below the jump -- so much so that I've added its author to my blogroll.  But of course I want to add my two cents.

Elisabeth Rosenthal exposes hospitals as free-billing zones

I stand back in awe from the healthcare reporting of The New York Times' Elisabeth Rosenthal, who since June 2013 has been exposing in front-page blockbuster after blockbuster the rampant greed and depraved price-gouging endemic to the US healthcare system. Her nine-part "paying till it hurts" series, indexed here, is worthy of a Pulitzer. It should galvanize the country as Silent Spring or The Other America did.

Rosenthal's latest exposes many hospital ORs as free-billing zones in which an array of doctors, physical therapists and other service providers can insinuate themselves in a procedure without the patient's prior knowledge or consent, whether they're in the patient's insurance network or not -- and then relentlessly pursue either the insurer or the patient or both for their exorbitant billings.

The most egregious example Rosenthal spotlights is when neurosurgeons or orthopedists call in out-of-network surgeons to assist -- who bill at out-of-network rates, to the tune of $117,000 in the headline case.  Then there's the smaller-scale gouging:

Unexpected fees are routinely generated outside the operating room as well. On the wards, a dermatologist may be called in to examine a rash and perform an expensive biopsy. The person in scrubs who walks a patient to a bathroom for the first time after hip surgery may turn out to be a physical therapist billing $400.

Rosenthal's fully-documented examples will make you afraid ever to set foot in a hospital -- unless perhaps you're on Medicare with full-bore Medigap insurance. A few policy takeaways from this tale of systemic depravity:

If you answer the first question wrong on healthcare.gov, no soup(sidy) for you

Back in April, when the ACA's extended open season was finally over, surveys conducted by McKinsey & Co. and PerryUndem (for EnrollAmerica) indicated that most of the still-uninsured were eligible for ACA subsidies (or Medicaid, in expansion states) but didn't know it. In fact, McKinsey found that two thirds of subsidy-eligible respondents who visited healthcare.gov but did not enroll were not aware of their eligibility -- and so had no idea how much health insurance would actually cost them.

I have an article up at The New Republic (my first there) examining why so many of the uninsured remain unaware of what the ACA has to offer them. In all fairness, the first answer must be that knowledge penetration takes time -- the CBO always projected a 3 to 4-year path to full takeup.

Two questions about Obama's thinking about ISIS

Peter Baker has a purported insider's view of Obama's thinking about the ISIS crisis™, based on interviews with 10 people present at two recent dinners the president held with foreign policy experts and journalists. Like most such exercises, it's not particularly revealing (with one exception noted at bottom), as the president is putting best foot forward with his guests and the guests assess him through a partisan prism (Richard Haas is respectfully negative, Jane Harman equivocally positive).  

I was struck, though, by two questions Obama's not-so-private exegesis left unanswered. I don't doubt that he has considered these questions in depth, but he has not seen fit to address them directly.

The first concerns his decision to ramp up aid to "moderate" Syrian rebels and support them with air strikes as appropriate.

Obama phones it in

In press conferences on Aug. 28, Sept. 3 and Sept. 5, and in a Meet the Press interview on Sept. 7, Obama provided considerable detail about the way he plans to "degrade and ultimately destroy" ISIS. Key themes, cumulatively elaborated over the four sessions, were that 1) The U.S. would not act precipitously in Syria; 2) Obama would not "Americanize" struggle -- U.S. military support would be calibrated to Sunni political action; and 3) the effort would build methodically and take considerable time.

Earlier today I traced these themes through all four of these quite recent Q&As because I assumed that they would serve as prelude to tonight's speech, which would distill them and continue to bring them into sharper focus. But the speech didn't do that. It was the comic book version -- the barest outline. It did not grapple with how the U.S. can build capacity to fight ISIS and foster the beginnings of viable government in Syria, an effort that Obama previously more or less rejected as futile -- and which he did address at least partially on 9/5 and 9/7, suggesting that the difference is greater motive and pressure on nearby Sunni nations to act in concert. He didn't provide any detail as to what degree of Congressional buy-in he considers necessary or unnecessary.  He held up U.S. efforts against al Qaeda affiliates in Yemen and Somalia as models, rather than his fight against core al Qaeda, seemingly to minimize the threat, though ISIS arguably has more capacity now than bin Laden's group ever did.

No, Obama is not plunging neck-deep in the Big Muddy

"We don't have a strategy yet." Those words of Obama's in an Aug. 28 press conference so flipped out the foreign policy establishment and media that no one heard heard what Obama was saying.

A translation: The conditions are not yet in place for significant U.S. military action against ISIS in Syria. Our efforts now are concentrated on beginning to create such conditions.

Those who fear that Obama is poised to plunge neck-deep in the Syrian muddy (here's to you, Mr. Sullivan) might look again at how he has elaborated this point repeatedly  -- in press conferences on Sept. 3 and Sept. 5, and in his Meet the Press interview with Chuck Todd that aired Sept. 7.

Here's how he put it on Aug. 28:

The Republicans' ACA shell game

The most credible rap against the Affordable Care Act is that it raises the cost of insurance bought in the individual market for people who have no preexisting conditions and earn too much to qualify for subsidies.

That is true. Hence all the "rate shock" stories bruited by the GOP last fall.  Most of those stories did not survive scrutiny, because the GOP went for dramatic hardship cases, and most true hardship cases qualify for subsidized coverage.  Those truly dinged by the law were more like a couple with two children profiled by the New York Times earning about $100,000 per year and a single 50-something man earning just under $50,000 profiled in the same article -- folks on the wrong side of the subsidy cliff.*

Somewhere between one and five million people suffered at least short-term financial harm of this sort. Their numbers are now dwarfed by the 6-7 million people getting subsidized private plan coverage, the 7 million-odd added to the Medicaid rolls, and the 2-3 million under age 26 who gained coverage on their parents' plans.

The law as a whole remains unpopular -- because Republicans have been relentlessly smearing it for five years, because the individual mandate has always been an unpopular concept, because healthcare.gov dysfunction imprinted "train wreck" perceptions before the problems were patched and signups surged, and because astounding numbers of the still-uninsured still don't know that they qualify for subsidized coverage.

Nevertheless, reality has seeped in enough to sap the strength of the Republican attack.  And as the intensity of that attack has diminished, its policy core has shrunk to a simple line that masks a core evasion. Here's one iteration, as expressed to Talking Points Memo's Sahil Kapur:

"Ensuring that people with preexisting conditions have access to coverage has long been a popular policy, and one where there is bipartisan agreement. It's the the entirety of ObamaCare that remains EXTREMELY unpopular," Brad Dayspring, a spokesman for the Senate GOP's campaign arm, told TPM in an email.

Question for Obama: Why is arming a "moderate" Syrian opposition no longer a "fantasy"?

Back in January Obama suggested to David Remnick that trying to arm and shape a "moderate" opposition to Assad was futile:

... I asked Obama if he was haunted by Syria, and, though the mask of his equipoise rarely slips, an indignant expression crossed his face. “I am haunted by what’s happened,” he said. “I am not haunted by my decision not to engage in another Middle Eastern war. It is very difficult to imagine a scenario in which our involvement in Syria would have led to a better outcome, short of us being willing to undertake an effort in size and scope similar to what we did in Iraq. And when I hear people suggesting that somehow if we had just financed and armed the opposition earlier, that somehow Assad would be gone by now and we’d have a peaceful transition, it’s magical thinking.

“It’s not as if we didn’t discuss this extensively down in the Situation Room. It’s not as if we did not solicit—and continue to solicit—opinions from a wide range of folks. Very early in this process, I actually asked the C.I.A. to analyze examples of America financing and supplying arms to an insurgency in a country that actually worked out well. And they couldn’t come up with much. We have looked at this from every angle. 

More recently, he told members of Congress that the notion that the U.S. could have conjured an effective moderate opposition was "a fantasy."  Now, though, as he told Chuck Todd in an interview airing today, his nascent strategy in Syria depends on building such an opposition. When Todd challenged him as to how ISIS could be defeated in Syria without U.S. troops, here was his response:

Contain, degrade, destroy ISIS? It's a timeline

[Update 9/5, 12:15 p.m. ET: in a press conference in Wales that just ended, Obama added "ultimately" at least thrice to the phrase "degrade and ultimately destroy" and variants, reinforcing the 'timeline' theme below.]

I'm not qualified to assess the efficacy of Obama's past or current conduct of policy with respect to Syria and Iraq. But I am well attuned to Obama's rhetoric and the thinking it reflects. On that basis, I can tell you that the media angst over whether he's signaled intent to contain, degrade or destroy ISIS is a lot of hooey.

Current U.S. policy, as Obama has described it and to the extent it can be disclosed, is pretty straightforward. U.S. air power will contain ISIS, and begin to degrade its warmaking capacity, while regional actors get their act together, with the help of U.S. prodding and incentives. To the extent that they do so, efforts will escalate to destroy ISIS.

Contain, degrade and destroy are stages in a process, timeline uncertain and dependent on strategic goals such as winning Sunni Iraqi buy-in to the new government and getting Gulf states to act in concert in finding viable Syrian opposition to back (while also, I would guess, working to leverage and to some extent covertly coordinate with warfare against ISIS conducted by Iran and Syria).

It's true that Obama's rhetoric has served to temper more overheated pronouncements by Biden, Kerry and others. And there was a real division between Powers' denunciation of the Russian invasion of Ukraine and Obama's refusal to call it that. But his own rhetoric with respect to Iraq, Syria and ISIS can be cast as  inconsistent or conflicted only if you break apart the implicit and contingent timeline he's outlined with the help of various verbs.

No, Virginia, ACA administrators do not need to "retain" the prior 8 million signups in 2015

Tis the season for preview articles spotlighting the challenges of signing up more uninsured and retaining the newly insured in Year 2 of the Affordable Care Act. The New York Times' Reed Abelson, in an otherwise excellent overview, repeats a common fallacy:

the Obama administration is expected to try to persuade about five million more people to sign up while also trying to ensure that eight million people who now have coverage renew for another year.

No one can or will try to ensure eight million renewals, because a very large proportion of 2014's enrollees -- perhaps half or more -- will not need to renew their coverage. They will be covered by new employers, or new spouses, or newly employed old spouses, or they will lose income and become eligible for Medicaid, or they will go on disability, or die, or, or, or...

"We don't have a strategy yet" is a strategy

Regardless of whether Obama's assertion that "we don't have a strategy yet" for confronting ISIS in Syria and potentially beyond (as opposed to in Iraq) was well advised, it was not a gaffe in the sense of an inconvenient truth that slipped out.

It couldn't have just slipped out, because Obama reiterated the point and elaborated it at length. His reasons for describing the strategy as in progress and TBA were multiple: 1) to reassure that he was not beginning a large-scale military operation without consulting Congress; 2) to pressure prospective coalition partners to play their parts and emphasize that US action depends in large part on their cooperation; and 3) to differentiate between immediate, limited military action and a more sustained, multilateral, slower-building and Congressionally authorized effort.  That's all in his second iteration of the strategy-to-be:

Gideon Levy, Jeremiah

I want to stay near silent in paying tribute, via this 2010 profile by Johann Hari, to Gideon Levy, Israel's most hated Jewish Israeli reporter and one of its bravest. Just a couple of excerpts below (okay, four)..

Levy’s father never saw any parallels between the fact he was turned into a refugee, and the 800,000 Palestinians who were turned into refugees by the creation of the state of Israel. “Never! People didn’t think like that. We never discussed it, ever.” Yet in the territories, Levy began to see flickers of his father everywhere – in the broken men and women never able to settle, dreaming forever of going home.

and

Inching toward immortality

Kaiser Health News reports on medical research -- funded, albeit minisculey, by the ACA -- that taps into longstanding dreams:

Imagine if scientists could recreate you---or at least part of you---on a chip.

That might help doctors identify drugs that would help you heal faster, bypassing the sometimes painful trial-and-error process and hefty health care costs that accompany arriving at the right treatment.

Right now, at the University of California, Berkeley, researchers in bioengineer Kevin Healy's lab are working to make that happen. Funded under a provision of the health law, they're trying to grow human organ tissue, like heart and liver, on tiny chips.

Science fiction writers  have long envisioned variations on this theme-- e.g.. organ banks, rejuvenation via replacement of body parts. transfer of a individual consciousness into a spare body.  Back in the disk drive era, I put a less physical imagining into a children's poem:

A Good Dream

I dreamed I saved my sister on disk--
brother, was I relieved.
If any harm should come to her
she could be retrieved.

Will the ACA reduce the disability rolls?

Two years ago, I was riveted by TNR reporter Alec MacGillis' chat with a woman on line for a free REM medical clinic in rural Tennessee. Notwithstanding that she knew nothing about the ACA, she offered a stunning instant analysis, once the basics were described to her, of one likely economic effect:

..it it was hard to find visitors to the clinic who would not benefit directly from the law. Barbara Hickey, 54, is a diabetic who lost her insurance five years ago when her husband was injured at his job making fiberglass pipes. She gets discounted diabetic medication from a charity, but came to the clinic to ask a doctor about blood in her urine.

Under the law, she would qualify for Medicaid. Her eyebrows shot up as the law was described to her. "If they put that law into effect, a lot of people won't need disability," she said. "A lot of people go onto disability because they can't afford health insurance."

Lo, Ms. Hickey was a prophet (perhaps). In Arkansas, which has sliced its uninsured rate almost in half since ACA enactment, mainly by enrolling nearly 200,000 Arkansans in the state's "private option" Medicaid alternative, disability claims seem to be dropping.* Modern Healthcare's Paul Demko reports:**

In which Clinton slams Obama by articulating his "organizing principle"

A typical account of Hillary Clinton's assessment of Obama's foreign policy in the Goldberg interview ran like this one in the New York Times:

Her blunt public criticism of the president’s foreign policy in The Atlantic this week touched off frustration among Mr. Obama’s advisers and supporters, especially her suggestion that under Mr. Obama, the United States lacked an “organizing principle” in its approach to international relations. “ ‘Don’t do stupid stuff’ is not an organizing principle,” Mrs. Clinton said.

Three things to note about this takeaway:

1. Clinton didn't say that "don't do stupid stuff" is Obama's organizing principle, or that he lacks one. In fact she said the opposite.

2.  The "organizing principle" that Clinton articulated, when pressed, is indistinguishable from Obama's, and, just like Obama's, incorporates "don't do stupid shit" but doesn't end there  (though the particulars of her favored policies on specific issues may quite different, in disturbing ways -- more on this at bottom).

3. Obama has articulated that principle continually since his first year in office.

A stealth modernist's divine lamppost

Lev Grossman, a fantasy writer whose works I have not yet been privileged to read, has a wonderful, wonderful, wonderful tribute to C. S. Lewis, who brought him into the worlds of reading and of fantasy. He focuses first on a passage that I used to xerox for students, also trying to capture its magic:

Even more than that, it’s the way he uses language—which is nothing like the way fantasists used language before him. There’s no sense of nostalgia. There’s no medieval floridness. There’s no fairy tale condescension to the child reader. It’s very straight, and very clean—there’s no Vaseline on the lens. You see everything clearly, not with sparkles or a flowery sense of wonderment, but with very specific physical details. Look at the attention to detail as you watch Lucy going through the wardrobe:

This must be a simply enormous wardrobe!" thought Lucy, going still further in and pushing the soft folds of the coats aside to make room for her. Then she noticed that there was something crunching under her feet. "I wonder is that more mothballs?" she thought, stooping down to feel it with her hand. But instead of feeling the hard, smooth wood of the floor of the wardrobe, she felt something soft and powdery and extremely cold. "This is very queer," she said, and went on a step or two further.

"What's a subsidy?" -- It's hard to reach the uninsured

Back in May, I noted a remarkable finding in a McKinsey survey of those who bought or sought health insurance in the individual market during the ACA's first open season:  Most of those who failed to obtain coverage were eligible for subsidies but did not know they were eligible. Two thirds of subsidy-eligible respondents who visited healthcare.gov but did not enroll were not aware of their eligibility -- and so had no idea how much health insurance would actually cost them.

Those findings are corroborated in a survey conducted at about the same time (April 10-28), commissioned by EnrollAmerica and conducted by PerryUndem Research/Communication. I just happened on this because HuffPost's Jeffrey Young cited the results in a story about the challenges of meeting signup targets in ACA year 2. Ignorance among the uninsured remains perhaps the greatest barrier (excepting the refusal of about half the states to accept the law's Medicaid expansion).

The EnrollAmerica survey drew responses from 671 new enrollees and 853 people who remained uninsured. 60% of those who remained uninsured said they wanted insurance. Only 21% of those who did not try to enroll knew that financial help was available to low-to-moderate income buyers -- and only 38% of those tried but failed to enroll were aware of this basic fact.

Perhaps even more remarkably, only 56% of those who did enroll in coverage knew that the law gives financial help to low- and moderate-income buyers. At the same time, 75% of enrollees, including 69% of those who enrolled online, said that the signup process was easy. Perhaps in this one regard it was a bit too easy, i.e., it was not hammered home that your friendly federal government was subsidizing your purchase.

Hillary Clinton was not so hawkish on Iraq

Jonathan Ladd sensibly questions the premise that  Hillary Clinton would act like a hawk as president, as opposed to talking a little like one now. As evidence that she would not, he cites the foreign policy continuity between the (Bill) Clinton and Obama administrations (of which she is of course a lynchpin), and the fact that the only hawkish action she's ever taken was her vote in October 2002 to authorize the use of force in Iraq.

I would complicate somewhat Ladd's contention that in her tenure as Obama's Secretary of State Clinton's "actions supported President Obama's less confrontational, less militaristic policies rather than the neoconservative policies advanced by the Bush administration." She supported the generals' plans for a surge in Afghanistan (the modifications were all Obama's own), urged the Libyan intervention, supported early intervention in support of "moderate" rebels in Syria, and claims that she always worked either to deny or reduce to a token Iran's "right to enrichment."  That doesn't mean that she wasn't a loyal administration member, but it does indicate that her relative hawkishness is more than talk. I find her stance with regard to Iran particularly disturbing, in that it bespeaks not just "hawkishness" per se but also near-complete deference to Netanyahu and AIPAC -- a deference to which her Goldberg interview pays really stunning and disturbing tribute.

To switch gears, though, I'd like to offer collateral support to Ladd's contention that Clinton's Senate vote to authorize the use of military force in Iraq does not necessarily indicate a predisposition to use military force generally.  Ladd concentrates on the strong political incentives to support the resolution. I'd add that Clinton cast her vote as a vote for diplomacy and a chance to avoid war. On several occasions following, she urged Bush not to rush to war. She was hardly a profile in courage in this regard: those urgings devolved into meek peeps as war approached in March 2003. But they do indicate that if she held the reins, she may have been content to force invasive inspections -- arguably a tool of the kind of "smart power" she claims to advocate.

If you're dropping ACA coverage for any reason, I'd like to hear from you

[moving this forward per request for input at bottom...]

Charles Gaba, ACA signups tracker extraordinaire, dives into a scary-sounding claim about attrition among people who signed up for private health plans on ACA exchanges -- Aetna enrollments to drop 30%! -- and provides some clarity: attrition for private insurers generally is likely coming in at about 2.5% per month, as expected.

That attrition -- offset, to an unclear degree*, by off-season "special enrollment period signups -- is expected and normal. A Kaiser study found that only 62% of people who had individual market coverage in January 2010 still had in July 2010.  According to an older study by Mathematica Policy Research,  while, 5.3 percent of the non-elderly population had non-group [individual market] coverage  in any given month, only 2.1 percent held non-group coverage for the entire year, and 9.7 percent had non-group coverage at some point during the year.

Of the four people I know personally who obtained insurance on ACA exchanges, none will stay pat for more than fourteen months, and two will be off their plans within six months of signup. One is a woman recently divorced who found a job in July and was covered by her employer as of August 1; another is entering a graduate program that provides free (or at least premium-free) health insurance, effective Sept. 1. A third is switching from a high-deductible ACA plan to insurance provided by his wife's employer. Another qualified for Medicaid, then found a job (without insurance) in June, notified the authorities and was allowed to remain on Medicaid for a year, dated from the point when he reported change of status. If his income doesn't change, he'll qualify for a subsidized private plan with Cost Sharing Reduction when his Medicaid eligibility ends.

Hedges, lies and pablum: Clinton to Goldberg

In a prior post, I may have overemphasized the hedge element in Hillary Clinton's interview with Jeffrey Goldberg, published Sunday. Hedging her criticisms of current policy and her interventionist impulses was definitely a part of the performance. But that performance was equal parts hedges, bald-faced lies and pablum in support of an implied general propensity toward more aggressive action that itself may prove illusory.

For the lies, see Peter Beinart. Everything Clinton said about Netanyahu and his dealings with the Palestinians in his two spells as prime minister was untrue. He didn't "move toward a Palestinian state" in the mid-nineties, he didn't agree to a meaningful settlement freeze in 2009, he didn't engage with Assad in 2009-2010, he didn't offer the Palestinians "Barak-like options"--or any concrete proposals -- in the last round of negotiations that collapsed this spring, and he either never relinquished or has recently reaffirmed a determination never to give up security control of the West Bank. As for the assault on Gaza, Clinton simply parroted IDF talking points.

With regard to the hedging, as I argued in the prior post, Clinton did not suggest that jihadism is a threat on the scale of communism, only that containment was an overall strategy that might be adapted to any toxic ideology that poses a threat to global order. Containment-as-framework was further hedged by allusions to the many mistakes the U.S. made in the Cold War, to be improved by "smart power" and "after-action reviews." Clinton's invocations of "smart power" sound a lot like Obama's oft-stated preferences for deploying nonmilitary tools of U.S. influence, as does her acknowledgement of "the limits of our power to spread freedom and democracy."

Read Goldberg's interview with Hillary Clinton before you read Goldberg's account of that interview

I've seen more than one tweet this morning to the effect that Hillary Clinton "threw Obama under an ISIS-driven Humvee" in a long, probing, interview with Jeffrey Goldberg.  I think that's a wrong impression created by Goldberg's introductory overview, which overstates her actual and implied criticisms of Obama.

It's no secret that Clinton advocated for early U.S. support of allegedly moderate factions in the Syrian opposition. And it's necessary and prudent for Hillary to distance herself from Obama, or position herself to do so, in that a) she genuinely is more interventionist, and b) the world could blow up on Obama and doom her chances if she's seen as a continuation. But it's also in Hillary's DNA to hedge, both from a desire to cover both sides and an ability to see complexity (except with regard to Israel, to which she pandered without inhibition). And in at least three instances, Goldberg emphasized just one side of her equation.

First, with regard to the Syrian intervention. Here's Goldberg:

In an interview with me earlier this week, she used her sharpest language yet to describe the "failure" that resulted from the decision to keep the U.S. on the sidelines during the first phase of the Syrian uprising.

“The failure to help build up a credible fighting force of the people who were the originators of the protests against Assad—there were Islamists, there were secularists, there was everything in the middle—the failure to do that left a big vacuum, which the jihadists have now filled,” Clinton said.

And here's Hillary, in the interview:

Barbarians at the gate

From Robin Wright in the New Yorker, a warning about the Islamic State that concentrates the mind:

There is a broader danger. The direct American presence may galvanize more jihadis to the Islamic State. There was no Al Qaeda presence in Iraq until after the United States deployed troops in 2003, an act that fuelled Al Qaeda’s local appeal, on territorial, political, and religious grounds. In Iraq and Syria, ISIS is now estimated to have between ten thousand and twenty thousand fighters, including a couple of thousand with Western passports and a hundred or so from the United States.

As the United States confronts ISIS, the dangers that Americans will be targeted at home grow. Last month, the F.B.I.’s director, James B. Comey, said that the domestic threat emanating from ISIS “keeps me up at night,” that ISISwas a potential “launching ground” for attacks of the kind that occurred on September 11, 2001. The Attorney General, Eric H. Holder, Jr., told ABC News that ISIS, particularly its American jihadis, “gives us really extreme, extreme concern. . . . In some ways, it’s more frightening than anything I think I’ve seen as Attorney General.”

If you like your ACA plan, you very likely won't be renewing anyway

Sam Baker and  Jonathan Cohn have both spotlighted a Milliman briefing paper warning of an important potential glitch looming as the ACA's second Open Season approaches. It's this: while the government is encouraging current customers to renew their current plans via auto-enrollment, many customers may see significant price spikes if the plan they selected last year loses its status as a "benchmark" plan.

Subsidies are keyed to the second cheapest silver plan in each market, deemed the benchmark; subsidized customers who buy a plan more expensive than the benchmark have to pay the whole difference. Thus, if the ACA affordability formula decrees that you should pay $30 per month for a benchmark plan with a base premium of $300, and that plan's premium spikes to $350 and it cedes its benchmark status, you'll now be on the hook for $80 per month rather than $30 if you stick with it. To stay at roughly the $30 level, you'll have to switch to one of the two cheapest silver plans on offer this year. (Additionally, if the benchmark plan price goes up, customers' advanced premiums may also go up if they re-apply rather than auto-enroll.)

I wouldn't dream of downplaying this very important potential glitch. But I think it's worth noting an often-unnoticed market factor that will mitigate its impact somewhat: there's tremendous churn in the individual market, and it's likely that half or more of those who enrolled in private plans in 2014 will be looking to renew. Many will have found jobs that offer insurance; some will become eligible for Medicaid; some will marry or move and need to select a new plan in any case. In November 2013, healthcare scholars Rick Curtis and John Graves estimated (with some caveats) that just 42 percent of Americans eligible for subsidized exchange coverage at end of 2014 (i.e., the upcoming open enrollment season) were eligible in the prior year. That doesn't quite tell us what percentage of those currently enrolled in subsidized exchange plans will not be seeking coverage for 2015, but it gives an idea of the degree of turnover.

The ACA preserved state regulation of health insurance

Yesterday I noted that the state-vs.-federal exchange debate within the Democratic party in early 2010 was focused primarily on which level of government would regulate insurance -- and not, as Halbig proponents are suggesting, on whether the "backstop" federal exchange created by the Senate bill would be enabled to issue tax credits.

Both before and after the Scott Brown earthquake, the question was how the Senate and House bills would be reconciled. The House bill created a federal exchange, with an opt-out for states that wanted to create their own. The Senate bill stipulated that states would establish their own exchanges, with an opt-out for those that chose to cede the function to the federal government.

As it turned out, the reconciliation bill that tacked House modifications on the Senate bill did not substantially alter the Senate bill's state exchange structure -- though it did, by the way, include a tax reporting provision that referred directly to tax credits allocated by the federal exchange, a provision that should lay to rest the Halbig contention that ACA tax provisions preclude the federal exchange allocating tax credits.  And although the federal government did end up running most of the state exchanges, in the sense of running the website processing citizens' applications, regulation of insurance, within the broad coverage parameters set by the ACA, remained mainly in state hands.*

Evidence of that retained state control can be found in the varying steepness of 2015 health insurance premium increases in different states. Overall, the rate hikes are in line with or slightly below the increases of previous years. A heat map by PriceWaterhouseCooper indicates that states that ran their own exchanges, and so more actively oversaw the offerings approved for sale, were on balance subject to more moderate increases (Vermont is an exception). From the data that's come in so far (only about half of the states have so far reported wholly or partly on 2015 rates), Jonathan Cohn extracts an illustrative tale of two states:

No, Ben Nelson didn't scuttle the ACA's federal exchange

[Update, 1/29/15: As Jonathan Cohn reports, Nelson has just precisely confirmed the reading below of his position re federal and state exchanges.]

The latest bit of sophistry deployed by Halbig supporters to convince the world that the Senate Democrats who drafted the ACA deliberately barred subsidies from flowing through any exchange set up by the federal government is a claim that "Ben Nelson made them do it," Here's David Catron in The American Spectator (retailed without value-add by the Wall Street Journal's James Taranto):

Jonathan Cohn advises his New Republic readers, “Like other journalists who were following the process closely, I never heard any of them suggest subsidies would not be available in states where officials decided not to operate their own marketplaces.”

This is an odd statement indeed considering that high-profile publications were reporting a lively debate over this very issue. And Ben Nelson’s name was frequently mentioned. In January of 2010, for example, Politico reported that he regarded federal control of Obamacare’s exchanges as “a dealbreaker.” Nelson said that too much federal involvement would inevitably lead to government-run health care: “I wouldn’t support something that would start us down the road of federal regulation of insurance and a single-payer plan.”

He reiterated his objection to federal exchanges in this 2010 video, wherein Greta Van Susteran presses him to provide a legitimate motive for ultimately voting in favor of health care “reform.” Nelson vehemently insists that no one bought his vote: “I had requirements… no government-run plan, no federal exchange… and adequate language to deal with abortion. Those were requirements, but no one was buying any vote.” Nelson clearly implies that these conditions had been met and this is why he flip-flopped and voted for the bill.

These statements prove nothing, and indicate nothing.There was precisely zero public debate over whether the Senate bill allowed a federal exchange to credit subsidies. Catron strips the context out of the Politico article, which in fact indicates the opposite of what Catron and Taranto imply.

Michael Cannon gives the game away, cont.*

The Halbig plaintiffs and their allies would have you believe that the titanic struggle in the Supreme Court in 2012 over the constitutionality of the ACA's individual mandate was a fight over nothing. Or, alternatively, that the government had a bulletproof defense of the law's constitutionality that it inexplicably left on the table.

According to the Halbig plaintiffs, the ACA's framers deliberately barred any exchange established by the federal government from crediting subsidies to qualified buyers of health plans offered on the exchanges. Only an exchange "established by a state can do that. Thus, the ACA could only function in a state that established its own exchange.  The law's creators and proponents have been protesting for three years that this claim is preposterous on its face, as a federal exchange would be worthless without the ability to credit subsidies, but that is the suit's  contention.