Post-King fallout: Waiting for Superwaiver?

I have a post up at healthinsurance.org that recounts opposing forecasts from two moderate conservatives about likely Republican behavior if the Supreme Court rules for the plaintiffs in King v. Burwell.  invalidating subsidies credited through healthcare.gov.

First up is Stuart Butler, generally considered the father of the individual mandate, long at Heritage, now at Brookings. The other is Christopher Condeluci, a former Republican Senate Finance Committee staffer who was involved in that committee's efforts to report out a bill with bipartisan backing (he has said that there was agreement between Republicans and Democrats on the committee on about 80% of the substance of what became the ACA).

The two were on a panel on likely post-King fallout at the Health Insurance Exchange Summit in D.C. last week. Here's the upshot of their disagreement:

Stuart Butler.. suggested that Democrats who wanted to preserve the ACA's core framework and Republicans looking to alter it might find "Houdini-like" escape from their impasse by taking inspiration from the ACA's "innovation waivers." These waivers empower states to propose alternative schemes that meet the ACA's coverage and affordability goals by different means...Butler spoke hopefully of a "superwaiver process" that would speed up the timeline and ease the application process,  giving states more freedom to shape their health insurance markets with less oversight from the federal government.

Obama and Warren: A contrast in rhetorical styles

Over the years, I've on several occasions been moved to summarize Obama's economic master narrative. Here's one more pass:

America has at various key points in its history committed itself to investments in shared prosperity and to widening the circle of opportunity to groups previously excluded. These include Lincoln's investment in railroads and infrastructure, FDR's in social welfare and education, and Eisenhower's in the interstate highway system.  In the Reagan years -- or in some speeches, in the Bush Jr. years -- the country took a wrong turn and the gains of economic growth started going disproportionately to the top. Many feel "the American dream is slipping away."  Fortunately, democracy gives America the capacity for self-correction, and his election and re-election bespeak a renewed commitment to shared prosperity and investments that will foster sustainable growth. It's a seductive narrative, highly idealized, but with enough acknowledgment of weakness and injustice to make it credible.

Lord knows I've been a longtime admirer of Obama's rhetoric -- of  the nuanced understanding of cause and effect he takes pains to articulate, of his Lincolnesque view of American history as a continuous, never-completed drive to fulfill the promises expressed in its founding documents, of his embrace of incremental, nonlinear progress. It's been often noted that he doesn't do sound bites, or leave us with memorable single phrases. I've argued before that Obama works both above and below the level of the single phrase: below, with musical, repetitive phrasing, and above, with conceptual clarity and coherence.

This is all by way of too-long introduction to the fact I heard Elizabeth Warren speak at the American Prospect birthday fundraiser on May 13, and her rhetorical strengths are..different from Obama's. Telling broadly the same economic story as Obama has been telling these past eight years, of investments in shared prosperity derailed by the Reagan Revolution, her narrative line was simpler -- and cleaner.

Barbara Pym's quote-happy Brits

My wife has taken to constantly rereading Barbara Pym, and sometimes when I grab the Kindle I tool read a few pages. When I did so a few minutes ago, I was struck, again, by Pym's rather sardonic relationship with the English canon. Here is an alter ego of sorts -- a pragmatic, unassuming writer of fiction and nonfiction for women's magazines, pausing over a pinch of high Victorian sentiment:

She imagined women under the drier at the hairdresser’s, turning the pages lazily and coming to ‘The Rose Garden’ by Catherine Oliphant. They would read the first page, the one that had the drawing of a girl standing with a rose in her hand and a man, handsomer than any real man could possibly be, standing behind her with an anguished expression on his face: but would they turn to the back of the magazine, where the continuation and ending were to be found? Catherine wondered gloomily. Dear as remembered kisses after death, she typed idly, but was it likely that her hero would have read Tennyson or quoted the line aloud like that? Not very, she thought, getting up and walking about the room (Less than Angels, Chapter 2).

A modest post-King proposal

Political science blogger Jonathan Bernstein is one King v. Burwell watcher who does not discount the likelihood that Republicans in Congress will come under intense pressure to keep the subsidies flowing through healthcare.gov if the Supreme Court rules for the plaintiffs, Knowing this, I was nonetheless a bit surprised to read this morning that he thinks a more or less unconditional Republican surrender is a real possibility.

Imagine, Bernstein writes, that Republicans write a bill restoring the subsidies along with a poison pill like repeal of the individual mandate, and Obama vetoes it. What then? With most GOP senators and House reps wishing the "opportunity" to throw 8 or 9 million people off their insurance plans to go away, the party could swing either way:

We've seen similar cases in the last Congress: Republicans eventually decided to allow Superstorm Sandy relief and the Violence Against Women Act to pass, while they never permitted votes on a comprehensive immigration plan or on a bill prohibiting employer discrimination based on sexual orientation or identity. In each case, most Republicans wanted to oppose the measure in the event of a vote, though there were enough votes to pass it anyway. The question was whether enough Republicans wanted the legislation to pass while publicly voting "no." And they probably didn't know what they would do until the situation played out.

And here's his call;

My guess is that if this does happen (the court may, and should, rule the administration has read the health-care law properly), Republicans would be under heavy pressure to allow a simple fix to pass, and would probably give in. But it's hardly certain.

I think there's a third possibility: with both sides under heavy pressure and public opinion as to who's to blame hanging in the balance, Republicans might settle for amending the ACA in a conservative direction without destroying it. (See Michael Leavitt, Bush Jr.'s HHS Secretary, on this.) But how much amendment would be enough to satisfy the wrath of the party's base?

Here's one possibility: detoxify Bernstein's poison pill a bit. Give each state the option of repealing the individual mandate.

Any low income readers from PA out there?

A brief update on this post: I have learned that CMS prepared for Pennsylvania health officials a list of 141,000 households containing QHP enrollees who are now eligible for Medicaid. That means that close to half -- or half, depending on attrition -- of PA's 2014 QHP enrollees had incomes under 138% FPL. Wow. Meanwhile, according to HHS stats published in March, fewer than 40,000 of the state's 2014 QHP enrollees had disenrolled by that point. So let's just say for the present that the state's Medicaid expansion, snarled in part by the "private option" complication now being unsnarled, has a ways to go.

Meanwhile, I am desperately seeking a 2014 QHP enrollee from Pennsylvania who is now eligible for Medicaid who either remains enrolled in a QHP or took a good long while to transition to Medicaid. Anyone? 

The ACA and the Working Class - Kevin Drum Festschrift

My festschrift contribution for Kevin Drum, who's recovering from a stem cell transplant in treatment for multiple myeloma, is up on Mother Jones. Kevin, give thanks, is doing very well, and managing to keep blogging on policy as well as track his treatment experience.

For those interested in the editing process -- as anyone who's ever edited inevitably is -- I thought my piece was skillfully shaped by Mother Jones managing editor Clint Hedler. Mostly he cut caveats and qualifications, which I've highlighted in the full draft below. Left to my own devices, I would leave the first and last highlighted sections in place and let the other cuts stand -- and I can see the case for all of them. I should be better at doing this to myself, as I spend half my day-job hours doing it to other people's articles.
---------------

One thing I've always appreciated about Kevin is that his commitment to economic justice is grounded in political realism.  That balance was on display in his postmortem on the Democrats' drubbing in November:

when the economy stagnates and life gets harder, people get meaner. That's just human nature. And the economy has been stagnating for the working class for well over a decade—and then practically collapsing ever since 2008.

So who does the WWC [white working class] take out its anger on? Largely, the answer is the poor. In particular, the undeserving poor. Liberals may hate this distinction, but it doesn't matter if we hate it. Lots of ordinary people make this distinction as a matter of simple common sense, and the WWC makes it more than any. That's because they're closer to it. For them, the poor aren't merely a set of statistics or a cause to be championed. They're the folks next door who don't do a lick of work but somehow keep getting government checks paid for by their tax dollars. For a lot of members of the WWC, this is personal in a way it just isn't for the kind of people who read this blog.

And who is it that's responsible for this infuriating flow of government money to the shiftless? Democrats. We fight to save food stamps. We fight for WIC. We fight for Medicaid expansion. We fight for Obamacare. We fight to move poor families into nearby housing.

This is a big problem because these are all things that benefit the poor but barely touch the working class. 

As Kevin acknowledges, this is an age-old problem for Democrats. It's "unfair" in that there's overwhelming evidence that safety-net programs like food stamps, Medicaid and the Earned Income Tax Credit "have positive effects on health, educational attainment, earnings and employment years later," as Jared Bernstein recently wrote. Conversely, programs popular with the middle class, such as the mortgage tax credit and tax-sheltered college savings plans, bestow the bulk of their benefits on the affluent. The distinction between "the poor" and "the working class" may also be too neat, given the volatility of Americans' incomes and the erosion of stable jobs at working class pay levels. An awful lot of working people access the benefits that Kevin lists, or have family members who do, (e.g., a large majority of food stamp beneficiaries). All that said, the perception that Kevin fingers is a political force, and partly grounded in reality, in that safety net programs (for the non-elderly at least) do most directly benefit those at the bottom of the income distribution.

The conversation shifts toward wages

If I may indulge myself in a quick note at a busy time: today's lead NYT editorial marks a kind of watershed to me.  Aptly titled Picking Up the Tab for Low Wages, it begins by noting the divergence between productivity gains and wage gains since the 1970s and then alleges a primary cause:

These dynamics are not inevitable. Low-wage employers, in particular, pay low wages because they can and the main reason they can is that Congress has failed, over decades, to adequately update the minimum wage and other labor standards, including rules for overtime pay, employee benefits and union organizing.

Why inner city hospitals move to greener pastures

Kaiser Health News' Phil Galewitz has a story about inner city urban hospitals that are moving, or seeking to move, to greener pastures -- that is, into nearby suburbs:

By moving to wealthier areas, hospitals can reduce the percent of uninsured and lower-paying Medicaid patients, while increasing the proportion of privately insured patients—what hospitals refer to as attracting better “payer mix."

The "payer mix" concept reminds me of the old joke about economists. A research team made fifty people sit on blocks of ice and another fifty on radiators. On average, they were comfortable.

Hospitals serve people whose payers pay too much and others who pay too little. On average, if their administrators jigger things right (and their location allows, or can be changed), they're comfortable -- often very comfortable, nonprofit or no. The mix includes providing as many high margin procedures as possible -- "such as transplants, cardiac surgery, cancer treatments, and CT, MRI, and other imaging," as Ezekiel Emanuel summarizes in Reinventing American Healthcare (2014). But it also includes minimizing charity care and Medicaid and, to a lesser extent, Medicare in favor of privately insured -- or, best case, wealthy foreign uninsured -- patients.

ACA customer satisfaction: it's the prices

J.D. Power released a health insurance satisfaction survey this past week in which a headline finding was that customers who bought private insurance plans on ACA exchanges expressed slightly higher average satisfaction than people in employer-sponsored plans* - 696 to 679 on a 1000-point scale.

Power polled plan holders both on their satisfaction with the plan itself and with the enrollment process.  A few notes on specific findings:

1. Regarding the sources of satisfaction with the plans themselves, Power reports, "Cost is the most influential attribute driving satisfaction among Marketplace plan members" but also that "plan members are most satisfied with the provider selection and claims processing attributes." I'm not sure how those findings fit together. Perhaps plan members gave selection and claims processing the highest absolute ratings but also said that cost was the most important factor to them? I'll see if I can find out. [UPDATE 4/27: Rick Johnson, senior director of the health care practice at J.D. Power, confirms that the inference above is correct: respondents rated price their top concern, but gave the highest scores to provider selection and claims processing.]

2. Re the satisfaction related to cost: 87% of marketplace customers qualified for premium subsidies, and among those, the federal government paid 72% of the premium on average, leaving the customer with an average premium share of  $101. Small wonder if those low premiums were a source of satisfaction.

Scrap the ACA's awkward dual subsidy system?

I have devoted a lot of blog space to trying to figure out what proportion of low-income private health plan buyers on ACA exchanges have availed themselves of powerful Cost Sharing Reduction (CSR)  subsidies by buying silver plans -- silver being the only metal level at which CSR is available. I'd like to step back and ask knowledgeable readers: why is CSR sold separately, so to speak? 

As the ACA is now constructed, these subsidies are vital for buyers with incomes under 200%  of the Federal Poverty Level in that they lower out-of-pocket costs to something approaching affordability. For those with incomes under 150% FPL, CSR raises the plan actuarial value to 94%, better than most employer-sponsored plans. That generally puts the deductible in the $0--500 range. For those in the 150-200% range, CSR raises actuarial value to 87%. Deductibles might run $0 (rarely) to $1500.

The catch is that silver plans for CSR-eligible buyers can be expensive -- $118 per month for a single person earning $23,000 -- whereas bronze plans can be almost free, particularly for older buyers. But bronze plans usually carry deductibles over $5000; their actuarial value is just 60%. For a lot of low-income buyers, a lot of bronze plans are close to worthless.

Troubled by that bronze temptation, I proposed once that CSR attach to bronze plans as well, at proportional levels.  Richard Mayhew, an insurance professional involved in plan design and a blogger at Balloon Juice, has done me one better, proposing that CSR be integrated into the cost of plans at all metal levels. Richard's sketch -- which he floats as a potential "innovation waiver" proposal for a blue state -- is below.

Program note: Kevin Drum festschrift

I will be contributing to the Kevin Drum festschrift organized by Mother Jones as Kevin undergoes treatment -- thankfully, going quite well so farm and endured with grit and good humor --  for multiple myeloma. Kevin has perhaps been surprising himself with pretty active blogging through his chemo rounds, while Mother Jones staff and outsiders pitch in. Work on my contribution (finished, and running next week) along with this project has left this blog pretty fallow this week.

I note in the Mother Jones piece that I've always appreciated that Kevin's commitment to economic justice is tempered by political realism. His perceptions and assessments of Obama these past six years have also tracked pretty closely with -- and no doubt helped shape -- my own. That is, he sees Obama as "a sober, cautious, analytic, mainstream Democrat" who's substantively advanced a lot of progressive priorities while necessarily also disappointing liberal hopes on other fronts.

Where I've parted company from Kevin (and this is not the focus of next week's piece) is in reaction to Obama's rhetoric. He sees Obama's 2008 speeches and catch-phrases as "nothing more than typical campaign windiness." I see his rhetoric as an expression of the pragmatism Drum admires, articulating a nuanced, incremental sense of how progressive change occurs. That argument played out here and here.

New York to make health insurance *really* affordable for low-income residents

Very quickly, as I'm leaving the house in 40 minutes, big news (via Charles Gaba, natch)  from New York: it's becoming the second state to offer a Basic Health Plan (BHP) for lower-income insurance seekers, as enabled by the Affordable Care Act. A BHP is a low-cost, low-premium offering for buyers with incomes between the Medicaid eligibility cutoff (100% or 138% of the Federal Poverty Level*) and 200% FPL.   The premiums and cost-sharing compare very favorably with the mainstream private health plans offered on ACA exchanges as previously priced for low-income buyers. New York's BHP will have two tiers, with virtually no cost for plan holders with incomes between 100% and  150% FPL and just a $20 monthly premium and minimal cost-sharing for buyers in the 150-200% FPL range.

The 100% FPL starting point presumably means that the upper end prior Medicaid-eligibles (100-138% FPL) will be transitioned in. The benefit summary is below the jump. The plans will be available in 2016; enrollment will begin in November. The state will contract with private insurers to deliver the benefits.

While this is excellent news for New Yorkers with incomes under 200% FPL, it may raise challenges for the private insurance market in New York. In 2014, 53% of private health plan buyers had incomes under 200% FPL, so the market is being sliced more than in half. Minnesota, which has had a low-cost option for residents under 200% FPL since the launch of the ACA markets (and in somewhat similar form, before the launch), has struggled to meet enrollments targets. Enrollments are currently just under 62,000; the state is now aiming for 95,000 private plan enrollments by the end of next year, versus early projections at least twice as high.. The state's lowest-cost insurer in 2014 exited the market this year.

Preview: Lots of Medicaid-eligible Pennsylvanians re-enrolled in QHPs

I have drafted and am now shopping an article positing that tens of thousands of Pennsylvanians who renewed private plan coverage on healthcare.gov for 2015 are now eligible for Medicaid -- and so, theoretically at least, are ineligible for the private plan subsidies they obtained last year and are counting on this year. Pennsylvania launched a "private option" Medicaid expansion (now in process of being converted back to traditional Medicaid) effective Jan. 1, 2015.

Here's the calculation.  Of the roughly 318,000 Pennsylvanians who were enrolled in private coverage via healthcare.gov as of May 1, 2014, probably about 30% are eligible for Medicaid. That is roughly the percentage of of private-plan enrollees in non-expansion states on healthcare.gov who would have been eligible for Medicaid if their states had expanded (that is, the percentage of enrollees with incomes between 100% and 138% of the Federal Poverty level).  If Pennsylvania enrollees' income profile roughly matched that of all the non-expansion states in aggregate, there were about 95,000 Medicaid-eligibles within that original group. Yet the number of Pennsylvanians who re-enrolled in private coverage for 2015 was just shy of 279,000 -- less than 40,000 fewer than the peak enrollment total.

Does inequality make us more conservative? Maybe, but so does liberal policy enactment

Thomas Edsall cites disturbing research indicating that as inequality has grown in the U.S. over the last forty years, Americans' support for policies that redistribute wealth has shrunk. Specifically, more recently, support for universal healthcare has declined over the period in which the ACA was debated, passed and enacted:

The erosion of the belief in health care as a government-protected right is perhaps the most dramatic reflection of these trends. In 2006, by a margin of more than two to one, 69-28, those surveyed by Gallup said that the federal government should guarantee health care coverage for all citizens of the United States. By late 2014, however, Gallup found that this percentage had fallen 24 points to 45 percent, while the percentage of respondents who said health care is not a federal responsibility nearly doubled to 52 percent.

This shorter term shift is unsurprising.  As I've noted before, Henry Aaron and Gary Burtless calculated in early 2014 that the ACA would directly distribute income only to Americans in the lower 20-25% of the income distribution. Data recently published by HHS bears this out: 68% of the 11.6 million private plan buyers on the ACA exchanges have incomes below 200% of the Federal Poverty Level -- and all 12 million beneficiaries of the ACA Medicaid expansion have incomes under 138% FPL. We all stand to benefit if the ACA really is helping to control healthcare cost growth, as from the certainty of available (and, in periods of low income, affordable) insurance -- pre ACA, a third of the population in a three-year period suffered periods of uninsurance. Large portions of the population also suffer periods of poverty. But the perception that the ACA right now is primarily benefiting the poor is grounded in reality.

Obamacare customers "stick with" healthcare.gov

Enrollment in private health plans on healthcare.gov seems to have been very sticky.  For the 37 states using healthcare.gov, the renewal rate for those who were enrolled in plans just prior to the start of open season for 2015 was over 90%..

Last week, Avalere Health published a study of renewal rates that found an average of 79% renewals among existing enrollees in private plans (so-called Qualified Health Plans, or QHPs) on healthcare.gov and 65% on the state exchanges. But Avalere tracked attrition from the end of the first open season, in April 2015, until the end of the second one, in March 2015.  The methodology was simple:

Why did Healthcare.gov outdraw the state exchanges in 2015?

Avalere Health has found, in a study of 2015 ACA private plan enrollment data, that healthcare.gov outperformed state exchanges on two measures: retention of 2014 enrollees and enrollment of new customers.

To explain the lower retention in states that ran their own exchanges, Avalere floats the possibility* that those states (all but one of which expanded Medicaid) may have had more churn into Medicaid than states using healthcare.gov (where over 70% of enrollees were in states that refused the Medicaid expansion). I'll cite some evidence below that many states that expanded Medicaid did not have low retention in the private plan market.  But I do think that Medicaid enrollment may partly explain the second discrepancy -- why state-based exchanges had lower private-plan enrollment growth in 2015 than states on healthcare.gov.

An Israeli moderate's breathtaking sense of entitlement

As the Netanyahu cabinet unites in full-voiced opposition to the framework agreement with Iran and gears up to pull its strings in the U.S. Congress, the relative sobriety of former head of Israeli military intelligence Amos Yadlin, who would have been defense minister if Zionist Camp had won the March 17 election, offers a sharp contrast.  Yadlin, a major general who was one of the pilots who bombed the Iraqi reactor in 1981, allows that compared to realistic alternatives, the framework is "not a bad agreement,"  Acknowledging in an interview with Al-Monitor's Ben Caspit  that the Iranians have adhered to the terms of the interim agreement, he offers this conditional support:

If they implement the principles of the agreement presented yesterday in the same way, then for the next 15 years they will be frozen at a point of being one year away from a nuclear bomb, and I think this is not a negligible achievement...Let’s think: After all, even a US attack will not distance Iran for 15 years from a nuclear bomb, so why not freeze it in place for the same time — without a war?

Give his relative pragmatism and moderation, the window that Yadlin opens on Israel's assumptions about the terms of the country's relations with the U.S. is all the more striking. If Netanyahu had been savvier, he suggests, he would be in position to influence the shape of the ultimate deal -- and brought home additional bacon for Israel. My emphasis below:

Why do more people say the ACA has harmed than helped them?

One ongoing frustration for ACA supporters in public opinion polling is the fact that the number of people say that the ACA has directly harmed them and their families consistently outstrips the number who say it has directly helped them.

Now that the ACA is directly subsidizing health insurance for about 20 million people, that particular perception has narrowed but not closed. Here's a graph from the Kaiser Family Foundation, which polls on this question regularly:

Since last May, the gap has narrowed from 24-14 to 22-19. But it's still there, and the question is where the perception (and/or reality) of direct harm comes from.

Sharing the cost-shifting

Small businesses and their employees pay more for health insurance than larger ones, and after many years of relentless price increases, many of them are tapped out. While the ACA has not so far caused those yearly price increases to spike, it's added new costs and new pressures.

I have an article up at SHRM.org examining how some small businesses are coping and options they're examining -- including sending workers to the ACA exchanges. One interesting part concerns the various ways employers can, so to speak, share the cost-shifting to employees by partially funding tax-favored savings accounts dedicated to out-of-pocket medical costs:

Affordable health insurance vs. affordable health care

One of the flaws of the Affordable Care Act is that it partially (not entirely!) confuses affordable insurance with affordable health care.

On the plus side, for insurance purchase purposes, the ACA benchmarks affordability to silver-level plans and calibrates the out-of-pocket costs these plans impose on buyers to income, via Cost Sharing Reduction (CSR) subsidies, which raise the plans' actuarial value to 94% for buyers with incomes under 150% of the Federal Poverty Level and to 87% for buyers under 200% FPL.

On the minus side, CSR fades to near-insignificance at 201% FPL; silver plan premiums slope toward unaffordability for a lot of buyers somewhere over 150% FPL; and the ACA dangles cheaper bronze plans with deductibles north of $5,000 in front of low-income buyers, for many of whom many of those plans will do very little good.

Also on the downside, for the purposes of determining whether a person or family has access to "affordable" insurance (and so whether they are subject to the mandate to purchase it), the ACA benchmarks affordability to the cheapest available bronze plan -- which, again, is likely to have a per-person deductible and out-of-pocket maximum in the $5000-6,600 range. Some bronze plans offer some services, such as low-copay doctor visits or generic drugs, before the deductible is reached, but many (my spot-checks make me suspect most) do not. They do offer mandated free preventive services, but those are a patchwork.

1.9 million private plan enrollees on Healthcare.gov would have been eligible for Medicaid if their states had accepted the expansion

In a post on healthinsurance.org, I report that almost 2 million of the private plan enrollees on Healthcare.gov would have qualified for Medicaid if their states had embraced the ACA Medicaid expansion.

That is, about a third of the six million-plus private plan enrollees in non-expansion states and about 22% of all ACA private plan signups would have been in Medicaid if the Supreme Court had not made the expansion optional or if every state had embraced it voluntarily. In that case, there would probably be fewer than 10 million signups in the "Qualified Health Plans" (QHPs) offered on the exchanges today.

In their furious rejection of everything associated with the ACA, and cruel denial of insurance to millions of their constituents, red state governors and legislatures gave the QHP markets in their states a vital boost.

In the healthinsurance.org post, I explore the weakness in exchange offerings that these statistics imply. In brief, because exchange offerings are so much cheaper and offer such dramatically better coverage at the lower end of the subsidy-eligible income range, takeup is dramatically better among the lowest-income eligible uninsured than among the uninsured in higher subsidy-eligible income bands, as Avalere recently concluded.

Here I just want to add some support to my calculation that about 1.9 QHP enrollees in non-expansion states had incomes in the 100-138% FPL range, which would have put them in the Medicaid pool in expansion states.

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

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

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

Too many poor buyers of bronze plans

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

"Obamacare, Obamacare! stay a little. Ha!*

As Greg Sargent never tires of reminding us, Republicans have been promising an ACA replacement plan for 50 months now and haven't been able to deliver. Ergo, Sargent asserts, claims by Republican legislators that they are developing a plan to replace the ACA and keep premium subsidies flowing should the Supreme Court rule for the plaintiffs in King are a ruse, designed to convince swing justices that chaos won't erupt if the court invalidates subsidies credited through the federal exchange.

That is probably at least partially true, as Republicans have long proven themselves unable to unite behind a plan that would replace a large portion of ACA benefits while creating different winners and losers. But there are plans and plans (and motives and motives), and elected officials don't yank away existing benefits lightly. While Republicans may well be paralyzed by a Supreme Court decision that gives them what they say they want, there are elements in the plans they're floating that could find their way, sooner or later, into a post-King settlement.  Republicans' lack of unity could lead them to punt, perhaps declaring victory with relatively modest gains while restoring most of the status quo.

Most interesting in this regard are Republican proposals to freeze or patch the the current system while they devise a fix. Here's how one very sympathetically worded account describes such a measure:

Israelis read Obama right. Well, half right.

I have been arguing that the Obama administration's promise to reassess its approach to the Israeli-Palestinian conflict in light of Netanyahu's late-election disavowal of a two-state solution is not an expression of pique but the seizing of an opportunity. A report from the New York Times' Jodi Rudoren suggests that a lot of Israelis agree with me:

Several Israeli analysts said the administration’s criticism of Mr. Netanyahu seemed like a pretext for a longstanding plan to change the United States’ policy of protecting Israel in international forums, which the administration has said it will reassess. Others suspect a ploy to undermine Israel’s lobbying efforts against the American negotiations for a nuclear accord with Iran.

I don't know that there was a longstanding plan; policymaking is usually more reactive than people assume. But any rational U.S. actor (see Baker, James) would look for an opportunity to alter the U.S.'s one-sided relationship with Israel -- the U.S.'s near-total absence of leverage, the political imperative to provide unconditional support no matter how thoroughly Israel undercuts U.S. policy, the impossibility of imposing consequences such as limiting aid or joining the rest of the world in condemning Israeli settlement activity.

I see Giora Eiland, a former Israeli national security adviser (cited by Rudoren), as half right here:

Chastising Netanyahu: Fury or cold calculation?

Characterizing the Obama administration's reaction to Netanyahu's late-election comments denigrating Arab voters and promising to prevent formation of a Palestinian state, the New York Times' Jodi Rudoren and Julie Davis echo a comment them in asserting

the White House issued a new signal that it remained furious with Mr. Netanyahu for campaign comments that also appeared to close the door on a two-state solution to the Palestinian conflict.

and

there was no sign of any softening from the administration over its anger with Mr. Netanyahu over his comments about the Palestinian question.

Perhaps Obama, Kerry et al really were personally incensed by Netanyahu's comments. I've read at least one account quoting anonymous sources who claimed they were. Perhaps they find it useful to project "fury."  But I see the reaction more as seizing an opportunity than as an expression of pique.

On U.S. support for Israel, Obama is turning the battleship a few degrees

As Obama discussed U.S. policy with respect to Israel in his recent sit-down with Huffington Post's Sam Stein, there were a couple of surprise turns -- at least, surprising to me as a transcript reader.

First, this:

OBAMA: Well, I had a chance to speak to Prime Minister Netanyahu yesterday, congratulated his party on his victory

'Congratulated...his party.' Not Netanyahu himself, not for the campaign he ran. Every word that Obama has said in response to Netanyahu's late-stage campaign comments and the election results has been calibrated to pressure the prime minister to prove by deeds, not words, that he is walking back his campaign promise to forestall a Palestinian state on his watch. Congratulation of the party, rather than the man, arguably advances that aim: "So we’re evaluating what’s taking place. I think Prime Minister Netanyahu still has to form a government; we’ll be in close consultation with them."  On the plus side, Netanyahu's surprise success came at the expense of parties on his right, so should he reverse tone and course he has some room to maneuver.

No one expects him to, though. Which leads to the second surprise turn of a sentence:

Obama's America, and mine

Not to be narcissistic or nuttin', but Obama's celebrated "we are..." riff at Selma, which widened the circle of national inclusion to encompass the Lost Boys of Sudan and (implicitly) undocumented immigrants crossing the Rio Grande, as well as "the Tuskeegee Airmen, Navajo code-talkers, and Japanese-Americans who fought for this country even as their own liberty had been denied," reminded me of a children's poem I wrote in the mid-nineties. It reflects a children's book canon (and a little extracurricular YA reading at the end) from the sixties and early seventies that perhaps Obama shared in part:

American Child 

I've heard a lot of stories, I'm from everywhere.

I'm Abe Lincoln splitting logs, one swing for each,

Alone, speechifying the squirrels.

I'm a redbacked Hebrew slave, gathering straw

Under a red Egyptian sun.

I'm the old slave Joe, head bending low,

Crossing cottonfields, heading home.

I'm an Indian girl, gathering berries,

Administration rebuke to Netanyahu name-checks those "indissoluble bonds"

Obama often alludes to "indissoluble" or "unbreakable" bonds between the U.S. and Israel. I've long thought this unseemly, a dangerous sign of unconditional support. If the United Kingdom went fascist in ten years, would our bonds with that longtime ally be indissoluble? Relations between countries should never be unconditional (though arguably, I guess, "bonds" could endure when political alliances fray).

It's worth noting that in rebuking Netanyahu's election rhetoric seeming to delegitimize the Arab vote and disavowing commitment to a Palestinian state,  the Obama administration name-checked those "bonds":

“The United States and this administration is deeply concerned about rhetoric that seeks to marginalize Arab-Israeli citizens," Earnest told reporters aboard Air Force One. "It undermines the values and Democratic ideals that have been important to our democracy and an important part of what binds the United States and Israel together.”

More substantively, Earnest implied that the basis in international law for the U.S.'s constant protection of Israel in the U.N. is also cracking:

Medicaid expansion means a richer QHP buyer pool on ACA exchanges

In my close look at silver plan selection in 2015 among healthcare.gov customers who were eligible for Cost Sharing Reduction (available only with silver plans). I expressed some disappointment that CSR takeup had apparently dipped a bit on the federal exchange from 2014 to 2015 (HHS did not provide CSR takeup numbers for states operating their own exchanges). Disappointment on that particular point may have been misplaced.

While I continue to believe that too many low income ACA private plan buyers selected bronze plans, CSR takeup probably did not decline from 2014 to 2015. In fact, since silver plan selection across all exchanges ticked up a bit, from 65% in 2014 to 67% in 2015, CSR takeup probably did too.

My perception that CSR takeup dropped on healthcare.gov in 2015 stemmed from a drop in silver plan selection from 76% to 74% by buyers eligible for any kind of subsidy --including those eligible for premium subsidies but not CSR. But that drop may just reflect a shift in the composition of the market using healthcare.gov -- specifically, it may reflect a higher percentage of customers in healthcare.gov states being placed in Medicaid in 2015. This happened because two states that dropped their own exchanges and joined healthcare.gov in 2015, Oregon and Nevada, had expanded Medicaid, while three other states on the federal platform implemented the Medicaid expansion at some point during 2014 (Michigan and New Hampshire) or as of Jan. 1, 2015 (Pennsylvania).

The poorer the buyer pool, the higher the CSR takeup

States that expanded Medicaid generally have lower CSR takeup because their buyer pool for private health plans is wealthier. In states that refused the expansion, the buyer pool starts at 100% of the Federal Poverty Level (FPL); in states that embraced the Medicaid expansion, it starts at 138% FPL. In hc.gov states that refused the Medicaid expansion, consequently, an astounding 50% of private plan buyers had household incomes under 150% FPL; in expansion states, just 25% had incomes below that level.

Minnesota's "public option"

Ever since I read in fall 2013 that ACA bronze plan deductibles average over $5,000 per person, I have been concerned about the availability of such essentially catastrophic coverage at tempting low premium prices to low income ACA buyers -- who we now know are the vast majority of ACA private plan buyers (83% of buyers on healthcare.gov have household incomes under 250% of the Federal Poverty Level).

Hence my preoccupation with Cost Sharing Reduction subsidies, available only with silver-level plans, which reduce out-of-pocket costs to less prohibitive levels.  A silver plan has an actuarial value of 94% for buyers under 150% FPL and 87% for those at 200-250% FPL. But silver plans are expensive for low income people. The benchmark second-cheapest silver plan costs 4% of income for buyers with incomes in the  138-150% FPL range and about  6% for buyers with incomes at 150-200% FPL. That's a lot --  $118 per month for a single person earning $23,000. And  a plan at that price may still carry a per-person deductible as high as $1,500 for those in the 150-200% FPL range.

The ACA allows for a more truly affordable option, but only one state has taken it -- in fact, has long had it. That's Minnesota, which since 1992 has had a program similar to Medicaid, MinnesotaCare, serving residents with incomes up to 200% FPL.  As of Jan. 1, 2015, MinnesotaCare was approved as a Basic Health Plan (BHP) under the ACA -- that is, a state-run plan serving residents with incomes between 138%  and 200% FPL (those below 138% qualify for Medicaid, known in Minnesota as Medical Assistance). Under ACA rules, the federal government pays 95 percent of the ACA subsidies to which enrollees in the plan would have been entitled if they enrolled in private QHPs.

A reduced ACA spending projection that no one should celebrate

Early this month the Congressional Budget Office released an updated ACA baseline that once again reduced projected spending from 2015-2025, to general celebration. Among the items forecast to cost less were Cost Sharing Reduction (CSR) subsidies that reduce deductibles and out-of-pocket costs for low income buyers. Projected CSR spending was forecast at $136 billion over ten years, down $11 billion from from a prior reduction forecast just this January, which CBO based on data suggesting that more low-income buyers than HHS had previously expected were buying bronze plans "that minimize their monthly premium payments, even if the amounts they ultimately pay for health care (including out-of-pocket payments) exceed what they would pay under silver plans."

This particular line item is no cause for celebration. Those costs are simply being shifted to low-income buyers who fail to avail themselves of CSR by buying silver-level plans on the ACA exchanges.

CBO's latest reduced CSR forecast might float on a raft of fresh data released by HHS on March 10 about 2015 enrollment in private health plans offered on ACA exchanges. The percentage of buyers choosing silver plans -- which must be purchased to access CSR -- is down a bit since 2014, from 69% to 67%,  and the percentage of bronze plan buyers is up, from 20% to 22%. On healthcare.gov, among subsidy-eligible buyers, bronze plan selection rose from 15% in 2014 to 21% this year. That's not good, since bronze plans carry average per-person deductibles of over $5,000 and the vast majority of buyers on healthcare.gov, the federal exchange, have incomes under 250% of the Federal Poverty Level (FPL).

Bronze plan buyers with incomes under 250% FPL are leaving a valuable benefit on the table, as CSR attaches only to silver plans.  CSR subsidies reduce deductibles and out-of-pocket expenses massively for those under 200% FPL, more weakly for those in the 200-250% FPL range.

As readers of this blog know, I have gone to considerable effort to divine CSR takeup rates -- particularly for buyers under 200% FPL, for whom the benefit most strongly boosts the relative value of silver. Evidence has been fragmentary, as in the past HHS did not break out metal level selection by income band, though a handful of states did.

Now HHS has provided income level information, though not specific breakouts of metal level selection by income band. The data for the 37 states using healthcare.gov as I read it is a bit disappointing for two reasons: 1) silver plan selection among subsidy-eligible buyers went down from 2014-2015, and 2) silver selection among buyers eligible for CSR in the 37 states using Healthcare.gov is lower than I had inferred for buyers under 200% FPL -- about 81--83% rather than 88-90%. I had based that inference largely on 2014 data published by the state-run exchange in New York, which seemed to me for reasons explained below likely to be comparable to healthcare.gov on this front,   About half that difference is probably due to the uptick in bronze plan selection in 2015, the other half in differences between the New York market and that of the healthcare.gov states.

The numbers

In the 37 states using healthcare.gov in 2015, a (to me) astonishing 83% of buyers for whom HHS has income data had incomes under 250% FPL and so were eligible for CSR if they bought silver. (HHS has income data for 94% of buyers, 8.31 million out of 8.84 million. Larry Levitt of the Kaiser Family Foundation speculates that the "unknowns" likely earn too much to qualify for subsidies, an assumption adopted here. Hence that 83% (of 8.31 million) suggests 6.89 million buyers under 250% FPL.)  60% of all buyers, or 5.3 million, accessed CSR. That is, about 77% of CSR-eligible buyers (5.3m out of 6.9m) bought silver plans and so accessed CSR.

Timothy Jost Discusses an ACA Provision that Should Kill the King Suit

In the vast web of the ACA, there is only one provision that directly identifies the federal exchange as a creditor of subsidies. That provision is cited in the government's brief but did not come up in oral argument last week. It is one that should put to rest the claim -- acknowledged as a possibly winning argument by Justice Kennedy  -- that the ACA unambiguously authorizes the crediting of subsidies through the state exchanges alone.

I spoke on March 6 to Timothy Stolzfus Jost, a law professor at Washington and Lee University, about this provision, which he first highlighted in September 2011, immediately after one of the King masterminds, Jonathan Adler, published the nucleus of the King case. The exchange was prompted by an  IRS rule, proposed in August 2011 and finalized in May 2012, that authorized the federal exchanges to award premium subsidies.

How to love America, by Barack Obama

Obama gave another great speech on race today, on the Edmund Pettus Bridge in Selma on the 50th Anniversary of "Bloody Sunday. He told a story of America that he's always told, but he expanded its range and spoke with a steely urgency that bespoke battles fought and still to come.

He echoed Lincoln, as he likes to do, and he answered his stupidest critics as he defined in his own way what it means to love America, and he sought to recommit his fellow citizens to fulfill the promise of the nation's founding documents, reiterating his favorite theme: faith in the power of democracy to continuously create a more perfect, never perfected union. He laid out his most inclusive vision ever of who built America and who America is for and who America is.

He echoed and updated Lincoln in (at least) three ways. He borrowed Lincoln's diction of dedication at Gettysburg while explicitly extending the concept of devotion to heroes of peace -- and in particular, of nonviolent resistance -- as well as to heroes of war. And as he always does, channeling Lincoln, he cast that heroism as a devotion to fulfilling the ideals expressed in the nation's founding documents. And as Lincoln did at Gettysburg, he sought to inspire those listening to emulate those commemorated in their devotion to extending the promise of freedom and opportunity to all.

Here is the expanded concept of heroism:

And now for something completely frivolous..

This tweet by ER doc Seth Trueger, pointing to a blog post by ACA stats guru Charles Gaba, got me feeling singy, as Winnie-the-Pooh would put it:

how many types of health insurance are there in the US now? by @charles_gaba; @louisenorris @_kjkelly @xpostfactoid1 http://t.co/rjQpNHfp9P
— Seth Trueger (@MDaware) March 7, 2015

Resulting in this serial-tweet nonsense:

How many roads must man walk down
before you call him insured?
How many frivolous suits must fail
before health reform is secured?
How many deaths will it take till we know
our health system still isn't cured?
The answer, my friend,
is forecast by Sean Trende,
the answer is forecast by Sean Trende.

You don't think Trende belongs here? He wanted to come in, as Pooh would say.

Nicholas Bagley parses the oral arguments in King v. Burwell

Over at healthinsurance.org, I have an interview up with Nicholas Bagley, post-morteming today's oral arguments in King v. Burwell, the lawsuit aiming to gut the ACA exchanges. Bagley,  a former appellate attorney at DOJ and currentl health law professor at the University of Michigan, is co-author of two amicus briefs in support of the government in King, both addressing issues that Anthony Kennedy probed in some depth in today's hearing.

Kennedy lifted the spirits of ACA supporters early on by questioning whether the plaintiffs' claim that the law aimed to essentially force states to form their own health exchanges by not authorizing premium subsidies to be credited through the backup exchange would render the law unconstitutionally coercive.That was the upshot of one Bagley brief. But he then turned around and suggested that the law might be, in effect, both unambiguous (in denying credits through the federal exchange) and (potentially) unconstitutional.

Much later, Kennedy explored a more obscure point. While the Supreme Court generally holds that if a law is ambiguous, the courts should defer to the interpretation of the agency charged with implementing it, that might not be the case here:

Well, Ezra Klein, Republicans may not have "plan" to save insurance markets after King. But they may deal

Republican Senators Orrin Hatch Lamar Alexander John Barrasso are out today with a lightly sketched "plan" to salvage premium subsidies credited through the ACA's federal exchange if the Supreme Court rules for the plaintiffs in King v. Burwell.  The proposal closely resembles the  possible post-King negotiation that former HHS Secretary Michael Leavitt outlined to me. Here's Hatch et al:

First and most important: We would provide financial assistance to help Americans keep the coverage they picked for a transitional period. It would be unfair to allow families to lose their coverage, particularly in the middle of the year....

Second, we will give states the freedom and flexibility to create better, more competitive health insurance markets offering more options and different choices. Republicans understand that what works in Utah is different from what works in Tennessee or Wyoming. We want to give states the time and flexibility to design health-care systems that work for them, not for the bureaucrats in Washington.

People who live in states that have state exchanges will continue to be subject to Obamacare’s costly mandates and rules, along with the subsidies. But their states could also have the benefit of our solution. Every state would have the ability to create better markets suited to the needs of their citizens.

And here's Leavitt last week:

Republican can do what they will to American healthcare -- by accepting the Affordable Care Act

Ask Republicans how they will reform the health insurance market if they succeed in repealing the Affordable Care Act and you will not get a substantive "replace" plan. You will, however, hear three desiderata: 1) give states more control of their insurance markets; 2) give insurers more freedom to design plans outside ACA-imposed constraints; and 3) give consumers in the individual insurance market more choice (though the ACA marketplace shelves in most regions at present are not what you would call bare).

If Republicans were sincere about changing the market in this direction, they would have enormous leverage to do so, both by working within the ACA's essentially federalist (or "state-deferential") structure and by negotiating changes to the law that Democrats would surely accept in exchange for an end to dead-end opposition.

Let's count the ways that Republicans in state government and Congress could shape the health insurance markets to their liking, starting with the tamest and moving toward the most aggressive.

Three signs the ACA private plan marketplace is working

Over at healthinsurance.org, I've noted them: 1) more "active renewals" than expected; 2) relatively low churn; and 3) a high level of takeup for Cost Sharing Reduction (CSR) subsidies -- that is, silver plan selection by buyers with incomes under 200% of the Federal Poverty Level. My takeaway:

Many healthcare professionals and scholars worry that a market providing choice from a large selection of private health plans with a complex array of features and coverage rules offers too much complexity for typical buyers, most of whom are on the lower end of the income scale.

King v. Burwell and Congress v. P5 + 1

Reading friend-of-the-hawks reporter Josh Rogin's account of the difficulties Obama may have getting Iran to agree to a deal that bypasses the U.S. Congress, and so could be overturned by a future (GOP) president, I was reminded of GOP demands that the administration float "contingency" plans in case  the Supreme Court destroys the Affordable Care Act by ruling for the plaintiffs in King v. Burwell.

In both cases, bad-faith opposition to vital and viable policy, the product of immense collective effort and years in the making, may well succeed. In both cases, the saboteurs are demanding a collaboration they've rendered impossible.

Gallup misreads its state ACA data: state-run marketplaces no better at reaching uninsured

Gallup does a great service in tracking the decline in the uninsured rate state-by-state since ACA implementation. But they draw a misleading conclusion from their latest data set:

Collectively, the uninsured rate in states that have chosen to expand Medicaid and set up their own state exchanges or partnerships in the health insurance marketplace declined significantly more last year than the rate in states that did not take these steps. The uninsured rate declined 4.8 points in the 21 states that implemented both of these measures, compared with a 2.7-point drop across the 29 states that have implemented only one or neither of these actions.

In fact, the superior overall performance of these states in reducing un-insurance is due entirely to the Medicaid expansion. Collectively, their exchanges did not perform particularly well with regard to enrolling subsidy-eligible residents in private health plans.

Compare Gallup's chart highlighting state leaders in reaching the uninsured population by both means (Medicaid and private plans) with the Kaiser Family Foundation's snapshot of states that reached the highest percentage of subsidy-eligible private plan buyers. [Update: The initial comparison is of uninsured rates from poll data taken by Gallup throughout 2014 with Kaiser's up-to-date ranking of performance in the QHP market (through 2/15/15). Kaiser's 2014 ranking appears at bottom.]

Michael Leavitt envisions a post-King negotiation to amend the ACA

If the Supreme Court upholds the plaintiffs in King v. Burwell and thus cripples the ACA exchanges in three quarters of the states, what then? Neither side is talking about how they might compromise to avoid de-insuring 7 million Americans and crippling the insurance market. But Michael Leavitt -- former HHS Secretary under George W. Bush, former 3-term governor of Utah, current CEO of an eponymous healthcare consultancy -- goes there, in an interview with me, now up on healthinsurance.org. Here's the core of what he envisions:

[A] possibility would be to take the current subsidy structure, but allow people who qualify for a subsidy to get it not just in a state exchange but in a private exchange that may be authorized by the state. Multiple private exchanges might begin to pop up. You’d end up with  a competitive marketplace with many more exchanges and lots more innovation.

I hope you'll read the whole thing.  And then, perhaps, a prior interview I conducted with Leavitt last June about the scope for state innovation in healthcare that the ACA does provide. And while you're at it, a  January 2014 Leavitt interview with Julie Appleby of KHN in which he expressed considerable empathy for the HHS officials trying to get the ACA implemented.

P.S. My own take on conservative demands for less regulation and more "innovation" in health insurance, probably inspired in part by this interview (though more immediately by Ross Douthat's column on conservative policy proposals), is in the prior post.

Conservative reform of the ACA: cutting strings at different ends

When those few conservatives who would genuinely like to see affordable health insurance available to all Americans -- and the many Republican office holders who pretend to -- float alternatives to the Affordable Care Act, they talk about making insurance more affordable, about offering more choice and flexibility to insurers and hence to customers.

Giving insurers more flexibility generally means three things. First, reducing or eliminating the ACA's federally mandated Essential Health Benefits (EHBs) -- which include mental health, drug treatment, childbirth and children's dental coverages that many people might plausibly protest they don't need. Second, allowing sale of plans with lower actuarial values -- the percentage of the average user's annual medical costs paid by the plan -- than the ACA allows. The law sets a floor of 60% AV in both the employer and individual markets and, in the exchanges, establishes silver-level 70% AV plans as the benchmark to which subsidies and Cost Sharing Reduction subsidies (boosting AV for lower income buyers) are tied. Third, widening the allowable price variation according to the plan holder's age and allowing price variation according to sex.

There's much less here than meets the eye.

Obama's seductive love for America

The irony in this "Obama doesn't love America" crap is that Obama got himself elected by holding up  to Americans a flattering mirror that was suited to the moment.

The national narrative that Obama put forward in 2007/8 had two salient points (okay, may it had three or four or five, but two come to mind here). It was, first, a bid to move the political center to the left -- to cast American history as a progression in which Americans at various crux points demanded and obtained new common investments in shared shared prosperity and new extensions of equal opportunity to an ever-widening and more inclusive circle -- African Americans, women, gays. In Obama's telling, the nation had veered off-course for eight or thirty years, but democratic self-correction was also part of the long historical pattern and would come with him.

That's a kind of "whig history" for America, and it resonated in the wake of a disastrous conservative presidency.  It was also a message essentially common to all Democrats and would have worked for almost any Democrat.

The real contest in 2008 was in the Democratic primary, and perhaps Obama beat Hillary by making this whig history sing, tapping a deep American mysticism previously tapped by Lincoln and -- somewhat more caustically -- by Martin Luther King. This second element was captured by Obama's "more perfect union" trope.  That is: America's founding documents expressed principles for the best ordering of human society, and while the nation has never lived up to these ideals, its democratic engine draws it ever closer -- ever more perfect, never perfected. Those ever-widening circles of inclusive opportunity are bending the arc of history toward justice. Martin Luther's famous "check" of equal opportunity, returned for insufficient funds, is being paid on a very long mortgage schedule.

The disappearing shoparound on Healthcare.gov

While enrollment figures in the ACA's first open season ultimately exceeded expectations, a disturbing number of those who remained uninsured remained ignorant of federal aid that would make insurance affordable for most of them. A McKinsey & Co survey conducted in April 2014 found that two thirds of subsidy-eligible respondents who'd tried to use Healthcare.gov and cited unaffordability as the reason they remained uninsured were unaware that they were eligible for subsidies. In a more recent Kaiser Family Foundation survey, almost half of still-uninsured respondents who said they were "told" they were ineligible for aid appeared to be aid-eligible at the time of the survey (a few months later).

While there are many ways that an applicant in Healthcare.gov or the state exchanges could get that false impression, it would appear that a well-designed, prominently placed "shoparound" feature could go a long way toward remedying the problem. Healthcare.gov has such a feature, and it's pretty easy to use. Punch in your zip code, the number of members of your household with their ages, and your annual income, and within a minute of starting you get a complete list of available plans with subsidy-inclusive prices. That is, you very quickly know the least amount you can pay as a monthly premium (or if you're likely to be eligible for Medicaid) -- that is, if you accurately estimate your income. There's a lot still to figure out -- but you're not likely to be slapped with the full sticker price and think that you're on the hook for all of it, as may have happened to many people who started an application and somehow disqualified themselves for a subsidy while applying (e.g., by saying that they did not plan to file a tax return).

Healthcare.gov did put up a shoparound in the first open season, but it wasn't fully functional until December, and even then it was easy to miss if you weren't looking for it. Therefore I rejoiced when, in the runup to the second open season this November, the new and improved shoparound was one of just two buttons on the home page, labeled "see plans and prices."

That was then. In the course of open season, the shoparound faded from view. By February it was three pages deep.  Its use declined accordingly. In its weekly enrollment summaries, HHS tracked "window shopping Healthcare.gov users" as well as overall site visitors.   Here's three snapshots:

The case against King, by Scalia, Kennedy et al

The plaintiffs in King v. Burwell claim that the ACA's creators intended to coerce states into setting up their own exchanges by authorizing state-established exchanges alone to credit subsidies to buyers -- denying that power to the backup federal exchange.

In response to this manifestly absurd assertion of intent, the law's supporters have pointed out that no one involved in the law's design, passage or implementation understood such coercion to exist; that laws that make federal grants to the states conditional on specific state action invariably spell out the consequences of non-participation; that the ACA's clear intent is to provide near-universal coverage; and that the ACA's core provisions were designed to be interdependent, so that denying subsidies to residents of some states would render the law inoperable.

On  all of these points, no participant has been so eloquent as the four dissenting Supreme Court justices in NFIB v. Sebelius, the suit challenging the law's constitutionality, who asserted that the entire law should be struck down.

In their dissent, Justices Scalia, Kennedy, Thomas and Alito argued repeatedly that to strike down any core provision -- e.g., the individual mandate or the Medicaid expansion -- was to thwart the intent of the law's creators and render the remaining parts of the law unworkable -- hence the imperative to strike down the whole law.

Abbe Gluck has highlighted the dissenters' most direct assertions of interdependence of parts, laying particular stress on their observation that the law's "system of incentives collapses if the federal subsidies are invalidated" because without the subsidies, "the exchanges would not operate as Congress intended and may not operate at all" (dissent, p. 60).

Equally striking is the dissenters' argument that making the Medicaid expansion fully voluntary, as the Court majority did, would also thwart Congress's manifest intent to provide universal coverage and would thus render the entire scheme unworkable.

No, Clinton and Frist, ACA marketplace coverage will not render CHIP unnecessary

In an otherwise eloquent plea by Hillary Clinton and former GOP Senate majority leader Bill Frist for Congress to renew funding for the Children's Health Insurance Program (CHIP), one paragraph brought me up short. It's not strictly speaking inaccurate, but it resorts to a shorthand that, in the way of 750-word op-eds, leaves a misleading impression:

Of course, the American health care landscape has changed significantly since CHIP started. Under the Affordable Care Act, many families with children are now receiving financial help to enroll in private health coverage through the new health insurance marketplace. But while it is possible that private, family-wide policies offered by employers and marketplaces may one day render CHIP unnecessary, for now substantial gaps still exist — and too many children can still fall through them.

In fact, the ACA puts the kids in CHIP in most families in which the adults qualify for private-plan premium subsidies. CHIP eligibility operates independently from adult eligibility for subsidized private plans or Medicaid under the ACA.  Every state sets its own eligibility for CHIP, ranging from 170% of the Federal Poverty Level (FPL) in North Dakota to 405% FPL in New York. The median eligibility is 255% FPL (see this Kaiser Family Foundation chart).

Love in the time of Obamacare

Ah, mid-February, when love and ACA open enrollment both come to climax. Tis the (second annual) season for #Healthpolicyvalentines:

Affordable insurance?
I don't have any.
You are my only
Essential Health Bennie.

        *     *     *

I've turned 26
But what does my Mama care?
She knows I'll stay covered
Thanks to Obamacare.

      *     *     *

Bronze plans are skimpy,
Golds rake your bucks in.
Silver is sweet
with Cost-Sharing Reduction.

     *     *     *

Obama soft-focuses our domestic ills

I usually find Obama interviews, especially long ones, reassuring. His understanding of issues is nuanced and multi-tiered. But his responses to Ezra Klein's questions about domestic issues and trends struck me as disappointingly unfocused, or off-focus, on several fronts. For example:

1. Asked about the causes of growing inequality, he back-loaded labor law:

Now, there are a whole bunch of reasons for that [stagnant middle class wages]. Some of it has to do with technology and entire job sectors being eliminated — travel agents, bank tellers, a lot of middle management — because of efficiencies with the internet and a paperless office. A lot of it has to do with globalization and the rest of the world catching up. Post-World War II, we just had some enormous structural advantages because our competitors had been devastated by war, and we had also made investments that put us ahead of the curve, whether in education or infrastructure or research and development.

Hey, HHS, you're boasting about the wrong metric

If you read the inimitable Elisabeth Rosenthal's account of unhappy ACA plan holders this weekend, you know that high deductibles and out-of-pocket costs are one serious weakness of the coverage offered to many buyers on ACA exchanges.*

One mitigating factor is that most buyers with incomes under 200% of the Federal Poverty Level get Cost Sharing Reduction (CSR) subsidies that strongly reduce deductibles and maximum out-of-pocket costs, to levels superior to those offered by most employer-sponsored plans.  CSR is only available with silver plans, but as I've labored to deduce, best evidence suggests that over 80%** of buyers with incomes under 200% FPL do buy silver, resisting the temptation of lower-premium bronze plans that would leave them on the hook for huge out-of-pocket (OOP) costs.

Given this partial success, I find it baffling that all of HHS' reports of enrollment data are written as if nothing matters but premium -- the lower the better. The report released today boasts:

Narrow networks: a painful of tourniquet on a bleeding healthcare system

Stories of bad buyer experiences with ACA exchange plans often induce me to push back a bit. I can't do that with Elisabeth Rosenthal's laser strike on patients' troubles with ACA plans' narrow networks and mazes of separate copays and coninsurance for different procedures.  Rosenthal is too nuanced, too thorough with context, and too precise in her accounts of buyers' experiences to quibble with. A sampling:

Alison Chavez, 36, who is self-employed, signed up for a marketplace plan in October 2013 that she hoped would be an improvement on her previous plan. She had recently been given a diagnosis of breast cancer and was just beginning therapy, so she was careful to choose a policy on the Covered California marketplace that included her physicians.

But in March, while in the middle of treatment, she was notified that several of her doctors and the hospital were leaving the plan’s network. She was forced to postpone a surgery as she scrambled to buy a new commercial policy that included her doctors. “I’ve been through hell and back, but I came out alive and kicking (just broke),” she wrote in an email

Sail on, Sullydish

I have had a hard time getting my thoughts and feelings together since Andrew Sullivan announced the shuttering of the Dish, happening tomorrow. Like many, I imprinted what political blogging was in large part from Andrew; my own blog grew in part out of interior response -- often opposition -- to  the Dish. As many have noted, one of Sullivan's cardinal virtues is that he will engage with anyone who engages him in good faith -- and will link to anyone he thinks worth reading. Because of that openness, I've been privileged to keep up a running dialogue with him -- here, on the Dish, and via email.  Because the two-way dialogue is real, it always continues for me solo when I read the Dish, and that's what I'll really miss.

Obviously I'm not alone. The Dish crew has had fun with a flood of farewell reader mail this last week. One curated outpouring brought this raucous parting to mind:

“But the wild things cried, “Oh please don’t go - we’ll eat you up - we love you so!”
And Max said, “No!”
The wild things roared their terrible roars and gnashed their terrible teeth and rolled their terrible eyes and showed their terrible claws but Max stepped into his private boat and waved goodbye.”

Image here.


So sail on, Sullydish. I trust we''l hear from Chris, Patrick et al soon, and elsewhere. As for Andrew, after a longish or shortish hibernation I trust he'll yawn awake when the skies clear and grow lank with longing to re-engage the world..  

Yes, Ta-Nehisi Coates, it's good to be right

The Twittersphere -- at least, my Twittersphere -- is widely commending Ta-Nehisi Coates' tribute to Andrew Sullivan.  I can sort of see why -- it captures what Andrew himself has often presented as his core virtue -- but it also seems to me to be based on a perverse premise.

Back when I started blogging, there was an annoying premium on "public smartness" and "being right" among pundits, journalists, and writers. Likely, there is still one today. The need to be publicly smart and constantly right originates both in the writer's ego and in the expectation of incurious readers. The writer gets the psychic reward of praise—"Such and such is really smart" or "Such and such was 'right' on Libya." And the incurious reader gets to believe that there is some order in the world, that there is a stable of learned (mostly) men who will decipher the words of God for them. The incurious readers is not so much looking for writers, as prophets.

Too many aid-eligible ACA applicants say they were "told" otherwise

A Kaiser Family Foundation survey of 10,000 low- and moderate-income Americans conducted last fall finds, disturbingly, that half of those who say they were "told" that they did not qualify for government help obtaining coverage do appear to have in fact been eligible.

It's not entirely clear what respondents meant when they said they were "told" they did not qualify for aid. Many apparently sought outside help.  But it's all too easy to get a "false negative" from the exchanges themselves -- and ACA master navigator Kate Kozeniewski detailed for me several ways this could happen. My writeup is at healthinsurance.org;  a sampling of Kate's list is below. Note that the weak points extend in part to the phone hotline: in Kate's experience, you have to get a supervisor to deal with issues of any complexity.

1. No tax return/no subsidy: At the very outset, Healthcare.gov asks whether the applicant plans to file a tax return – which many people who earn too little to owe income tax habitually do not do. If you click “no,” however it’s “no subsidy for you,” Kozeniewski notes ruefully. There is no warning about this – if you say that you’re not going to file a tax return, you simply move on through the application, and learn at the end that you are ineligible for help paying for coverage.
2. Married? Then file jointly: If you’re married and file separately, you’re not eligible for subsidies. Here too, the website does not warn you that you’re forfeiting subsidies if you put down that you file singly. Kozeniewski has seen a surprising number of single filers. “It seems there’s a decent number of people estranged from their partners who have not gone through the steps of getting a legal divorce. We also see immigrants whose spouses are living in another country. There’s even a fair amount who are married and living in the same household, but who file separately for whatever reason.”

Read the rest here.

The real world case against King: Should the Supreme Court impose "risks and uncertainties" on U.S. economy?

Leave aside for a moment the frankly ridiculous question of whether the text of the ACA authorizes premium subsidies to flow through the federal exchange. .Timothy Jost, surveying 30 amicus briefs filed to support the IRS' reading of the law to that effect, first covers those primarily engaging with the text of the law then turns to those from stakeholders that detail the real-world effects of gutting the ACA.

A note before looking at Jost's powerful survey of these pleadings. Some would argue that these real world effects are immaterial: either the law authorizes subsidies to be credited through Healthcare.gov or it doesn't. As I noted once before, though, the conservative justices who dissented against  the 2012 decision that upheld the constitutionality of the ACA  demonstrated their sensitivity to the real world effects of Supreme Court decisions in that very dissent.

Justices Scalia, Kennedy,Thomas and Alito argued that since the individual mandate was unconstitutional the whole law must be struck down because all its key provisions were interdependent and many of them would wreak economic havoc if left to operate with a core provision removed.  They were quite specific about the potential consequences of disfguring the law without killing it: