Housekeeping note: Pennsylvania story in progress

A note re slow blogging: I've been engaged in my Pennsylvania project -- that is, exploring the implications of some odd enrollment figures in the state.. Specifically, though there's apparently over 140,000 Pennsylvania 2014 QHP enrollees who are now eligible for Medicaid, less than 40,000 2014 QHP enrollees had disenrolled as of March (or at least, to HHS's knowledge as of March). I've had the chance to interview one person newly eligible for Medicaid in 2015 who discovered that fact in February but only applied this month, in the interim paying over $300 per month for an unsubsidized private plan. The resulting story is written but not yet placed (or edited; I've got to cut it by 60%). I've learned a ton in the process.

One useful sidelight: an enrollment counselor at the Pennsylvania Health Access Network tells me that more than half of the people they enrolled in QHPs in 2014 did in fact have household incomes under 138% FPL and so are now eligible for Medicaid. While you might expect that a social service agency's client base might tilt toward lower income buyers, PHAN works all over the state, and that percentage is consistent with CMS's estimate of 141,000 households with QHP enrollees likely to be eligible for Medicaid in 2015.

Victims of an ACA subsidy cutoff may live mainly in Republican districts -- but will they vote?

At Jonathan Cohn's request, Families USA calculated that two thirds of those who stand to lose their health insurance subsidies if the Supreme Court rules for the plaintiffs in King live in Republican Congressional districts (4.2 million subsidized buyers on healthcare.gov live in Republican districts, vs. 2.1 million in Democratic districts).

Those numbers appear to support the hypothesis that a Supreme Court decision cutting off subsidies to those who obtained their insurance on insurance on the federal exchange, healthcare.gov, may politically damage Republicans, who supported the King plaintiffs' claim that the ACA authorized subsidies to flow only through exchanges "established by a state."  But even if Republican attempts to blame the cutoff on Democrats' poor legislating fail utterly, the demographic profile of those who bought subsidized plans on healthcare.gov may moderate the political fallout somewhat.

Hillary's short history of inequality is too short

A few weeks ago, I contrasted Elizabeth Warren's critique of income inequality in America with Obama's. The critiques are substantively similar, laying primary responsibility for the widening wealth and income gaps on Republican tax, labor and regulatory policy and citing similar stats showing that virtually all productivity and output gains over the last several decades have gone to the wealthiest. But Warren is more laser-focused on Republican and Wall Street malfeasance: Obama acknowledges contributing causes as diverse as global competition and domestic racism. And interestingly, where Obama cites four stats to illustrate the growing gap, Warren concentrates her fire with one pair:

Since 1980, how much did the 90% get of income growth in this economy -- from 1980 to 2012, the 90% got zero. None. Nothing.

Zero. None. Nothing. You could hang a campaign on that, no?

Now what about Hillary Clinton, who officially kicked her campaign off with a speech on Roosevelt Island yesterday?

Molly Ball points out quite rightly that Clinton is being credited with a more full-throated populism than she voiced:

Five under-reported facts about the ACA

It just popped into my head to consolidate a few facts about the ACA that I think I know and that seem to be pretty widely unrecognized. I just delved into the first one today, and I've flogged many or most of them several times, but here goes:

1. Silver plans are usually more than silver: 85% of silver plans sold on ACA exchanges are enhanced by Cost Sharing Reduction subsidies that raise the actuarial value from a baseline of 70% to 73%, 88%, or 94%, depending on the buyer's income. Two thirds of silver plan buyers have the stronger forms of CSR -- AV 87% or 94%.  On the other hand...

2. Half of those buying plans in the individual market are off-exchange, and many of those are doubtless buying silver plans with AV 70% (the metal levels are in use in ACA-compliant plans sold off exchange).

3. Most of those buying off-exchange are paying more than they would have pre-ACA, but perhaps 20-50% of them have a pre-existing condition or have a family member with one. Many of those buyers are paying less than they would have pre-ACA, and some would not have been able to buy or afford insurance at all.

4  ACA coverage rules are not the main reason that the law raised the price of unsubsidized individual market insurance.  Republicans have made the ACA's mandatory Essential Health Benefits their favorite whipping boy, but the real price driver is guaranteed issue -- the prohibition against basing the price of a plan (or eligibility) on the would-be buyer's medical history. And most Republicans profess (rather vaguely) to support that.

On ACA exchanges, silver is usually not silver

I have a post up on healthinsurance.org that calls out yet another story about high out-of-pocket costs in ACA exchange plans that neglects to mention that 85% of silver plan buyers get Cost Sharing Reduction that lowers deductibles, co-pays, and yearly out-of-pocket maximums.

The story in question is under the auspices of Kaiser Health News, which generally gets its facts right, and there's no literally wrong fact in it. It makes sense, too,  to highlight that silver plans as well as bronze ones can offer pretty skimpy coverage. The lead below is referring to silver plans:

A key goal of the Affordable Care Act is to help people get health insurance who may have not been able to pay for it before. But the most popular plans – those with low monthly premiums – also have high deductibles and copays. And that can leave medical care still out of reach for some.

Indeed it can. But two thirds of silver plan holders (the "most popular plans", as the story subsequently clarifies)  have plans with actuarial values of 87% or 94%.  That doesn't mean that too many ACA customers aren't faced with too-high out-of-pocket costs. But casting silver plans unenhanced by CSR as the silver norm is like citing full retail prices at Macy's (where sales are so pervasive that the folks at the register often won't let you pay full price).

A few thoughts that didn't make it into the post:

John Barrasso's tell: King is a fraud

In his determination to accent the negative in characterizing the ACA, Senator John Barrasso has exposed the absurdity -- in fact the fraud -- at the heart of the King v. Burwell suit.

Here's how Barrasso characterizes the IRS rule allowing subsidies to flow through the federal exchange:

“Instead of bullying the Supreme Court, the president should spend his time preparing for the reality that the court may soon rule against his decision to illegally issue tax penalties and subsidies on Americans in two-thirds of the country,” he said in a statement. “Congress will not pass a so-called ‘one-sentence’ fake fix.”

The fix is "fake" because, according to this party line, Congress never intended for the federal exchange to be empowered to credit subsidies. But Barrasso leads with "penalties" because it's more fun to emphasize the stick than than the carrot. The individual mandate is the flip side of the subsidies: without subsidies, the vast majority of the uninsured would be exempt because coverage would not be affordable.

Connecticut continues to crush it on Cost Sharing Reduction

Connecticut's ACA exchange, Access Health Connecticut, has provided me with a breakout of private plan buyers' metal level selection sorted by income level. The data makes clear that Connecticut continues to lead the way among ACA exchanges in helping low income buyers make choices that will provide them with the strongest financial protection.

There's two things to keep in mind about metal level selection. The first is that bronze plans, the cheapest level with the lowest premiums, usually have deductibles in the $5,000-6,600 range for an individual.  The second is that the Cost Sharing Reduction (CSR) subsidies available to low income buyers are available only with silver plans. CSR reduces deductibles, co-pays and maximum out-of-pocket costs radically for buyers with family incomes below 200% of the Federal Poverty Level (FPL) and much more weakly for buyers in the 200-250% FPL range. Bronze plans are almost always a terrible choice for buyers under 200% FPL -- those buyers are leaving a large extra subsidy on the table and rendering most healthcare unaffordable for themselves.

ACA exchanges vary widely in how effectively they get that information across. The key measure is the percentage of buyers with incomes under 200% FPL who choose silver plans.

In Connecticut, 89% of 2015 private plan buyers with incomes under 200% FPL chose silver.  I had preliminary numbers indicating as much back in December, and the ratio held steady through the end of open season and to June 1. Slightly more than a third of all enrollees, 34,601, have incomes under 200% FPL, and 30,641 of them bought silver and accessed CSR.* Just 6% bought bronze plans. That is a real triumph. 4% bought gold.

Times reporters call bullshit on senators' surveillance claims

In recent weeks, as Congress moved toward passage of a law limiting the NSA's access to phone metadata, I've appreciated the bullshit buffer that Times reporters Jennifer Steinhauer and Jonathan Weisman have inserted into their coverage.

Back on May 23, when the Senate rejected the House bill it eventually passed on June 23, Steinhauer reported a garden variety Senatorial security alarm, then, a few paragraphs later, provided a little factual context:

"Strong enough to be self-critical": Obama's handwritten additions to Selma speech

As I noted at the time of Obama's Selma speech,, the idea he expressed there that riveted respondents -- that America's greatest strength is its capacity to self-correct, in a never-finished drive to fulfill the promise embedded in its founding documents --  -- was not only not new, but was the same story that Obama's been telling continually since he first appeared on the national stage, and probably before. He did take that message to a new level of clarity at Selma, while expanding the circle of those he credited with fighting that fight and advancing the "always perfecting, never perfected" narrative.

Today the Washington Post is out with a hand-edited draft of the speech. It turns out that Obama handwrote-in the most direct expression of its core idea. And he pointed it directly at his most recent critics -- e.g., Giuliani, who had recently charged that Obama doesn't love America -- contrasting his brand of patriotism with a cardboard boosterism "based stock photos or airbrushed history."

Here is that passage with the handwritten addition bolded, an omitted portion in strike-through, and a later addition in red type:

...Selma is not some outlier in the American experience. Even today, we continue have debate about what it means to love this country, to be a true patriot. But what greater expression of faith in the American idea, what greater form of patriotism is there, than to believe that America is not yet finished, that it is strong enough to be self-critical, that each generation can look upon its imperfection and say we can do better.  That’s why it’s not a museum or static monument to behold from a distance. It is instead the manifestation of a creed written into our founding documents: "We, the People....in order to form a more perfect union."

New data on Cost Sharing Reduction in ACA marketplaces

The latest ACA enrollment snapshot from CMS shed some new light on the extent to which ACA private plan buyers accessed Cost Sharing Reduction (CSR) subsidies. CSR reduces deductibles, copayments and maximum out-of-pocket costs for plan buyers with incomes under 250% of the Federal Poverty Level (FPL) -- but only if they buy silver plans (and forego the often much cheaper bronze plans).

CSR takeup is especially important for buyers under 200% FPL, because below that income level it raises the actuarial value of a silver plan from 70% to 94% (for buyers under 150% FPL) or 87% (for buyers in the 150-200% FPL range). At 200-250% FPL, CSR weakens, raising the AV just 3 points to 73%. Silver plan selection accordingly drops suddenly at 201% FPL.

The new report doesn't deliver any great surprises on the CSR front, but it does for the first time provide overall CSR numbers for the 13 states plus D.C. that run their own exchanges. The percentages of buyers accessing CSR in state-based marketplaces (SBMs) have always been lower than in the states using healthcare.gov, for several reasons

1. All the SBMs except Idaho have expanded Medicaid, which means that subsidized private plan eligibility begins at 138% FPL rather than 100% FPL.  The lower the income, the higher the CSR takeup rate - especially below 138% FPL, where the benchmark silver plan premium can't exceed 2% of income.
2. States with SBMs are generally wealthier, so a lower overall percentage of private plan enrollees are eligible for CSR.
3. Several SBMs do a much poorer job than healthcare.gov of highlighting CSR for those eligible -- though conversely, several SBMs do a better job than hc.gov on this front.

All that said, here are some new facts, along with some extrapolation from info that was in HHS's March report but not updated in this one.

1) In states using healthcare.gov (federal facilitated marketplaces, or FFMs) 60% of enrollees accessed  CSR -- 4,550,205* out of a total enrollment of  7,524,234.  In the SBMs, 49% accessed CSR -- 1,300,731 out of 2,662,964.

Too many choices on ACA exchanges?

The Health Exchange Summit held in Washington, D.C. May 11-13 brought together many of the people most directly engaged in implementation of the Affordable Care Act. All, excepting Michael Cannon,  mastermind of the King v. Burwell suit seeking to cripple the ACA, are committed to extending access to affordable and effective health care to as many Americans as possible and to to making the ACA work effectively.

Given that commitment, I was struck by a persistent chord of uneasiness about the complexity of insurance choices facing Americans. That uneasiness was literally the keynote, delivered by Princeton healthcare economist Uwe Reinhardt, whose  presentation might have been titled, "Why we can't have nice things like the Swiss."  Switzerland's health insurance system served as something of a model for the ACA, as citizens are mandated to purchase private health insurance on an exchange, with the help of means-tested premium subsidies. Reinhardt's presentation drove home the dazzling simplicity of a Swiss health insurance exchange, displayed on screen -- in which  dozens of insurers compete but all offer a standard benefit package

Reinhardt suggested that Americans are unduly enamored by choice, which breeds complexity. Research shows he said, that "People can't choose among more than 5 items. Offering 130 health plans is a prescription for disaster." The Swiss, he said, have never heard of an insurance broker. and the U.S. system would not need navigators if the choice were simple enough. He mocked federalist claims that states need to develop solutions that fit local conditions by flashing photos of identical McDonald's in Massachusetts and Tennessee.

Reinhardt is fond of expressing exasperated bemusement at all things American. Perhaps more surprising was the wistfulness expressed by the second keynote, healthcare consultant Jon Kingsdale, who was the founding executive director of the Massachusetts Connector when Romneycare was implemented. When the Massachusetts Connector first went live, Kingsdale said, "people would come up to me at parties and say, 'this is great -- it's so easy.'" Not so with the ACA.  Gearing up for Year 3, "instead of focusing on how to delight customers, we're still worried about how to get the goddamned back end working."

Republican conundrum: Can the federal government subsidize private health insurance without regulating it?

Two moderate conservatives, neither of them averse to a federal effort to make health insurance affordable for all Americans, walk into a conference session and disagree about likely Republican behavior should the Supreme Court rule for the plaintiffs in King v. Burwell, thus cutting off subsidies for some eight million Americans who bought their health plans on healthcare.gov.

This happened earlier this month at the Health Insurance Exchange Summit in Washington, D.C. The disagreement was between Stuart Butler, a longtime Heritage Foundation scholar now at the Brookings Institute, and Christopher Condeluci, who was tax and benefits counsel to the Senate Finance Committee while the ACA was being drafted.

Butler, generally considered the father of the individual mandate (though he has renounced his brainchild and its bastard stepchild, the ACA), kicked off the session by sketching out a post-King settlement that he hoped might lead to a "kumbaya moment" and win 400 votes in the House.  That settlement would build on the ACA's existing "innovation waivers," provided in Section 1332, which empower states to propose alternative schemes that meet the ACA's coverage and affordability goals by different means.

Section 1332 puts everything up for grabs -- the individual and employer mandates, health plan coverage rules, exchange structure, and subsidy allocations. Since alternative schemes must meet ACA standards for coverage and affordability, however, Republicans complain that Section 1332 takes away with the left hand the freedom it proffers with the right. Butler proposed that in a post-King negotiation Republicans and Democrats might negotiate a "superwaiver" process that would loosen the ACA standards and lighten HHS oversight while also moving up the timeline -- at present, approved state proposals can't take effect until 2017.

Condeluci, who has said that Republicans on the Senate Finance Committee had signed off on 80% of the bill that eventually became the ACA, agreed that Republicans post-King would look to "1332-like" alterations to the ACA. But he said that Republicans would not accept the waiver structure as a framework. Instead they would invite states to opt into a Republican alternative that would include repeal of the individual and employer mandates as well as of the essential health benefits that every plan qualified under the ACA must provide.

Afterward, I asked Condeluci whether the plan he envisioned would give states free reign to take federal subsidy money and reorder their insurance markets as they saw fit, or rather to opt into a prepackaged Republican scheme that would lay out new coverage rules. He said, in effect, either/or. His answer spotlights an important...let's call it tension in Republican thinking about healthcare reform.

Underinsurance: What's offsetting the rise in deductibles?

On the weekend, I posed a few questions raised by the Commonwealth Fund survey of underinsurance released this week. I've since heard from Commonwealth's Sara Collins, VP of health care coverage and access, the lead researcher in the study. Her answers highlight some significant unknowns about what's going on in employer-sponsored insurance.*

To recap, Commonwealth found that among those American adults under age 65 who were insured for a full twelve months, 23 percent were underinsured – that is, their deductibles and copays were high enough to cause severe financial strain. That top line is almost unchanged since 2010; the real damage on this front was done from 2005 to 2010, when employers started shifting costs en masse to employees. Among those who get insurance from an employer, the Commonwealth found an underinsurance rate of 20%, unchanged since 2012 and up from 17% in 2010.

LBJ before Selma: wait -- no, go

After seeing Ava DuVernay' Selma a few weeks ago, I bought Nick Kotz's Judgment Days: Lyndon Baines Johnson, Martin Luther King, Jr. and the Laws that Changed America (2005). It's a digest of LBJ and King's interactions, beginning in fruitful if sometimes tense collaboration and ending in tragic enmity.  I can't say how central a source this book itself was for the movie, but the encounters it records indicate that those who claim that Johnson was more supportive of the voting rights campaign than their early encounter in the movie implies and those who claim that the scene is an accurate depiction of a pre-Selma encounter are both right.

LBJ and King had exquisitely attuned political antennae -- King with a genius for staging and calibrating confrontations to move public opinion, Johnson for how and when to move Congress. In the early stage of Johnson's presidency, sometimes their antennae were attuned, and sometimes they were in tension. Following his landslide reelection in November 1964, LBJ did ask King to ease up on the voting rights campaign so he could first get his antipoverty program passed. But within a few weeks, he began to think that the time might also be ripe for voting rights legislation, and he alternately tapped the gas and brake as the campaign gained momentum.

LBJ met King alone a week after King had been awarded the Nobel Prize, on December 18, 1964 -- less than three months before the first march on Selma on March 7, 1965 and LBJ's speech introducing the Voting Rights Act to a joint session of Congress on March 15. The upshot, as described in Judgment Days, is the basis of the LBJ-King White House meeting dramatized in Selma:

Mysteries of underinsurance in the Commonwealth Fund survey

A Commonwealth Fund survey released this week found that among those American adults under age 65 who were insured throughout 2014, 23 percent were underinsured – that is, their deductibles and copays were high enough to cause severe financial strain. That top line is almost unchanged since 2010; the real damage on this front was done from 2005 to 2010, when employers started shifting costs en masse to employees.

I have several questions about the report, to which I'm seeking answers from the authors. If you have any insight, please let me know (email address is in profile to right).

In the questions below, please keep in mind Commonwealth's definition of underinsured: 1) total out-of-pocket costs exceed 10% of annual income, or 5% if the person's household income is under 200% of the Federal Poverty Level (FPL), or 2) the plan deductible exceeds 5% of the beneficiary's annual income.

1. While deductibles in employer-sponsored plans continue to rise, most notably among those with less than 100 employees, the underinsurance rate actually dropped among large employers from 2012 to 2014, from 16% to 14%.  In the same period, the percentage of large-firm employees whose deductible exceeded 5% of annual income rose from 6% to 8%.  What's offsetting that rise in the ranks of those whose deductibles alone classify them as underinsured? Do the free preventive services mandated by the ACA play a role? Or rather, since "the out-of-pocket cost component of the measure is only triggered if a person uses his or her plan," could reluctance to use (and pay for) any medical services be inhibiting the underinsured total?

2. More generally, , among all insured Americans under age 65, Commonwealth finds an increase of 7 million since 2010 in those whose deductibles qualify them as underinsured, but a net increase in underinsureds of only 2 million . Again, something seems to be offsetting the relentless rise in deductibles. Since 2010,

Commonwealth and Kaiser on underinsurance

This week, the Commonwealth Fund put out a new survey of underinsurance among American adults under age 65, while Kaiser released a new survey of buyers in the individual market, both on- and off-exchange. Over at healthinsurance.org, I find that Kaiser indirectly indicates that Cost Sharing Reduction subsidies are somewhat leveling the underinsurance playing field. CSR is a leaky vessel, but it's carrying maybe 6 million souls across the underinsurance chasm. Hope you'll have a look.

Your money or your life

Last September, the Times' Elisabeth Rosenthal spotlighted the manifold ways in which hospitals impose out-of-network billing charges on patients even when the patients have contracted with an in-network physician in an in-network hospital.

Rosenthal documented how hospital ORs and EDs operate 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.

She's made me extremely wary to enter a hospital for any purpose  -- a reluctance that I suppose could in itself be dangerous to my health (or, conversely, salubrious; see point 3 here). But I had evidence today that the virus, so to speak, has spread to physician practices, which hospitals are relentlessly buying up and contracting with. In my primary care physician's office, I was confronted with a form requiring me, theoretically at least, to put all I own in hoc to the parent parent company, a certain Atlantic Health System:

FINANCIAL ARRANGEMENTS
I understand the Hospital charges do not include the fees of my treating physician, or the fees for services provided by Emergency Department physicians, anesthesiologists, cardiologists, neonatologists, obstetricians, pathologist, radiologists, surgeons, the on call physician, other consultants, and other Voluntary Medical Staff  who may treat men. I understand that I am financially responsible for the payment of my physician fees and these fees may not be covered by my insurance plan.

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.