Some sidelights on Covered California's modest rate increases for 2016

Covered California, the state's ACA health insurance exchange, is boasting today with some justice that the state held 2016 rates down to an average weighted increase of 4%. Other talking points: the average (unweighted) increase of the cheapest silver plan in each region went up just 1.5%, and the average consumer can save 4.5% if she switches to the cheapest plan in the same metal tier.

That last point is somewhat...selective: the apples-to-apples question is what will happen to current holders of the cheapest plan in each metal tier if they switch to 2016's cheapest plan.  On the other hand...there are two other hands.

First, the talking point about switching to the cheapest plan in one's metal level has some extra validity in California, where benefits for all plans in each metal tier are standardized. In other words, the only substantial variable other than price is network quality. Hence, price shopping -- balancing premium versus benefits -- is likely to be less fraught and easier to get right in California than in most states.

Second, it's good news that the cheapest silver plan in each region went up an average of just 1.5%-- but the import of that factoid depends in part on a second data point. That would be the average increase for the second cheapest silver plan in each region, which is the benchmark according to which premium subsidies are set. That is, a buyer's premium is calculated to leave him paying a fixed percentage of his income for the second cheapest silver plan available to him. If the benchmark silver plan goes up more than the cheapest silver plan, that's good for the buyer: it increases the affordability of silver-level coverage.  Covered California's full rate report shows that the benchmark plans went up an average of 1.8%, very modestly (on average) increasing the spread and so the affordability of the cheapest silver plan. It also shows that the cheapest bronze plan went up an average of 3.3% -- making the cheapest silver relatively (albeit slightly) more attractive.

The source of Huckabee's Holocaust porn

President Obama quite rightly read Mike Huckabee's disgusting, inflammatory assertion that the nuclear deal with Iran "will take the Israelis and march them to the door of the oven” as "an effort to push Mr. Trump out of the headlines. "  Most observers see it in that context: Trump is leading GOP contenders on a dive to a new bottom.

But where did the hysteria compressed in Huckabee's sound byte come from? Who writes the GOP's tune on dealings with Iran and middle east policy generally?

Netanyahu, natch.

To mark Holocaust Memorial Day back in April, "in a speech," The Washington Examiner's Paul Bedard noted, "already winning attention in Washington," Netanyahu "compared Washington's deal with Iran to Europe's appeasement of Adolf Hitler which led to the Holocaust and world war."

New light on QHP enrollees' income levels in states that refused to expand Medicaid

Below are some state-by-state numbers for private health plan enrollment in the 21 Healthcare.gov states that refused to expand Medicaid.  The state enrollment totals at different income levels are extracted from the county-by-county data released by HHS in early July. I've sandwiched those tallies between the states' median household incomes as of 2013 and Kaiser's estimates of the percentage of potential private plan enrollees that each state has enrolled as of March 31, 2015.*

What I'm after is possible causes of state variations in the percentage of enrollees eligible for Cost Sharing Reduction (CSR) subsidies who accessed that benefit by buying silver plans, the only metal level at which CSR is offered. CSR is available to buyers of Qualified Health Plans (QHPs) whose household incomes are below 251% of the Federal Poverty Level (FPL). In nonexpansion states, that's fully 80% of QHP buyers.**

In the chart below, states are listed in ascending order of median household income. I track the percentage of buyers in each states whose household incomes are between 100% and 150% FPL, for reasons explained below, as well as those who are CSR-eligible (0-250% FPL***). The next-to-last column tracks the percentage of CSR-eligible buyers who selected silver plans and so obtained the benefit.****

Utah and Alaska are on course to expand Medicaid. Are their eligibility estimates inflated? (Updated)

Both Alaska and Utah seem to be on course to implement the ACA Medicaid expansion. In Alaska, Governor Bill Walker is asserting his authority to do so without the approval of the legislature. In Utah, Governor Gary Herbert has struck a deal with legislative leaders -- still perhaps facing a rocky course toward legislative approval -- to seek a waiver for a "private option" form of the expansion.

In both states, as in any state, pro and con arguments over expansion are based on cost estimates which are in turn based on estimates of how many state residents will gain eligibility for Medicaid. It's noteworthy that in both states, in 2015, the Kaiser Family Foundation radically cut its 2014 estimate of those in the "coverage gap" -- that is, those whose incomes would have qualified them for Medicaid had their states accepted the expansion but are too low to qualify them for subsidized private plan coverage on ACA exchanges.*

In Alaska, Kaiser's estimate of the Medicaid gap population shrank from 17,290 as of March 31, 2014 to 10,500 as of  April 17 of this year. In Utah, the drop was from 57,850 in 2014 to 30,000 in 2015. These estimate cuts are mainly due to a redesign of insurance questions in the Census Bureau's Current Population Survey, intended to address previous under-reporting of respondents' insurance coverage.** While Kaiser cut its estimates for every state, the reductions in Utah and Alaska were far and away the largest. In both states, though, state officials' estimates of the "gap" population are closer to Kaiser's earlier estimates than to the newly reduced ones. In both states, in fact, working estimates are higher than Kaiser's 2014 figures.

For ACA plan buyers, it's not the price, it's the price spread

There's good news and bad news in this forecast by Avalere Health of average premium increases in 2016 for health plans sold on ACA exchanges:

...premiums for the lowest and second lowest cost silver plans in the eight states analyzed will increase on average 4.5 percent and 1.0 percent respectively, compared to a 5.8 percent across all silver exchange plans. 

There was similar good news/bad news in HHS's report on actual premium increases from 2014 to 2015:

Premiums for the benchmark (second-lowest cost) silver plan will increase modestly, by 2 percent on average this year before tax credits, while premiums for the lowest-cost silver plan will increase on average by 5 percent. The plans offering the lowest prices have sometimes changed from 2014 to 2015, so consumers should shop around to find
the plan that best meets their needs and budget.

Call me naive, but...

the assurance in the last sentence of the first paragraph of the Joint Comprehensive Plan of Action between Iran and the E3/EU+3, while obviously not sufficient in itself, is not insignificant either:

Iran reaffirms that under no circumstances will Iran ever seek, develop or acquire any
nuclear weapons.

That's reaffirmed,  by the way, because Iran has asserted repeatedly that Khamenei declared as much in a fatwa, though that fatwa was allegedly never written down. Now, there it is, and again, standing alone as the third numbered provision in the document's preamble:

iii. Iran reaffirms that under no circumstances will Iran ever seek, develop or
acquire any nuclear weapons.

Where are Pennsylvania's low-income 2014 private plan enrollees?

As I've noted before,  I've been been trying to determine what happened to Pennsylvania's apparently large number of  low-income 2014 private plan enrollees who became eligible for Medicaid when the state belatedly enacted the ACA Medicaid expansion, effective Jan. 1 2015. My working hypothesis has been that large numbers of them stayed auto-enrolled in QHPs -- or re-enrolled prior to the expansion kickoff in December. Detailed enrollment data released by HHS early this month calls that notion into question however.

Here was the original premise. Most of Pennsylvania's 2014 enrollees in private plans (so-called Qualified Health Plans, or QHPs) re-enrolled for 2015.  As of May 2014, Pennsylvania had 318,000 enrollees. As of the end of open enrollment in mid-Feburary 2015, 276,732 were re-enrolled, according to the breakout HHS published this month. A large percentage of those re-enrollees might now be Medicaid-eligible -- and so theoretically ineligible for private plan subsidies. I had originally estimated that about one third of QHP enrollees as of late 2014 -- perhaps 90,000 -- had incomes under 138% of the Federal Poverty Level (FPL), which would qualify them for Medicaid. Then I learned that by February, CMS had compiled a a list of 141,000 Pennsylvania households with at least one QHP enrollee determined to be Medicaid-eligible (CMS has confirmed this for me.)  If accurate, that's close to or more than half of PA's QHP enrollees as of late 2014 (Those households had some 175,000 members).

Moreover, for 2015 the state had 160,961 auto-enrollments - enrollees who took no action and so were automatically re-enrolled in their 2014 plan or a substitute provided by their insurer.  That suggests a large potential pool of people who may not have noted or chose to ignore their eligibility for what was originally Pennsylvania's "private option" Medicaid expansion, which was quite rocky at the outset.

Why am I now questioning this premise? The current income distribution of Pennsylvania's QHP enrollees, revealed in the data HHS published in early July, looks more like that of an expansion state than a nonexpansion state. As of of the end of open enrollment in mid-February 2015, 131,470 out of a total of 472,697 Pennsylvania QHP enrollees, or 28%, had incomes in the 100-150% FPL range.

Saved from the Medicaid Gap

Prompted in part by my observation last week that at least a third of Florida's 1.4 million private plan enrollees on healthcare.gov would have been Medicaid-eligible if the state had accepted the ACA Medicaid expansion, Richard Mayhew poses a question (or rather, elaborates on one posed in a comment on my post):

Liberal technocrats have been assuming that the states which refuse to expand are giving up massive amounts of money and thus economic growth by refusing to expand Medicaid will eventually expand.  However, are we accounting for the additional cash flow coming in as premium and cost sharing subsidies for people making between 100% and 138% Federal Poverty Line.

Leaving aside the financial question, we can make some reasonable estimates as to what percentage of those who would have been eligible for Medicaid had their states not refused the expansion are now in subsidized private health plans purchased on healthcare.gov. (All but one of the states that refused the expansion use the federal exchange).

On one side of the equation, we have Kaiser's state-by-state estimates of how many people fall in the Medicaid gap -- that is, have household incomes under 100% of the Federal Poverty Level (FPL) but are shut out of Medicaid in their state. On the other side is the number of subsidized private plan buyers in non-expansion states who have incomes in the 100-138% FPL range -- those who would have been eligible for Medicaid if their states had accepted the expansion.

ACA in Mississippi: Low incomes, high silver selection, high attrition -- and no Medicaid

The first thing to note about Mississippi's ACA private plan marketplace enrollment is that attrition after initial signup was terrible. As of the end of open season in mid-February, the state had 104,523 enrollments through healthcare.gov; as of March 31, the total had dropped to 80,011, just 77% of the February total. On all 37 states using healthcare.gov, 87% of initial enrollees were still aboard by March 31.

The high attrition is particularly distressing in that Mississippi's enrollment population is about as low-income as they come -- and consequently, enrollees' premiums were comparatively low and the actuarial value of their plans quite high. Of those who were enrolled as of mid-February, 89% had incomes under 250% of the Federal Poverty Level* (FPL) and so were eligible for Cost Sharing Reduction (CSR) subsidies if they bought silver plans. Among those eligible, 85% did select silver and so access CSR.

Alabama's Obamacare buyers ride a Silverado

Spotlight here is on Alabama in my continuing close look at how many low income ACA private plan buyers accessed Cost Sharing Reduction (CSR) subsidies by buying silver plans. (Yesterday, HHS released detailed county-level data about buyers of private plans on healthcare.gov, the federal exchange, enabling a close look at state stats.)

CSR is available to buyers with household incomes below 251% of the Federal Poverty Level (FPL), and strongest for buyers under 201% FPL. It is available only with silver plans, the second-cheapest of four metal levels available on ACA exchanges -- a fact that's less than obvious to the average shopper, Buyers under 201% FPL are leaving a really strong benefit on the table if they don't buy silver plans (see the note at bottom for more detail). I consider the percentage of buyers under 201% FPL who select silver an important measure of how well the exchange is functioning in a given state. (Those in the 201-250% FPL range are likelier to have good cause to forego the relatively negligible CSR provided at that level.)

Refusal to expand Medicaid swelled Florida's private plan ACA signups

Today CMS released detailed county-by-county enrollment data for private plans signups in the 37 states using healthcare.gov in 2015, as of February 22, just past the end of open enrollment,*. State-by-state income and metal level selection figures can be toted up from the county data Let's take a quick look at Florida and specifically Miami-Dade county, site of 2015's strongest signup surge.

We already knew that Florida -- which to date has refused to enact the ACA Medicaid expansion -- became the state with the most private plan enrollments, logging just shy of 1.6 million by the end of open season in February. According to the Kaiser Family Foundation, the state had enrolled 57% of its potential marketplace population as of March 31, 2015 (at which point Kaiser shows private plan enrollment at 1.4 million), second best in the country.  Of the 1.6 million state enrollees reported by HHS, 392,000 were in Miami-Dade County. Kaiser's research has previously spotlight Hialeah, a mainly Hispanic region just outside Miami (and in Miami-Dade County), as home to the zip code with the largest number of signups in the U.S.  Enrollment fever took hold there -- "Consumers can sign up for coverage in a mall, at a discount store, at a shoe store, and even at a barber shop," reported the Miami Herald in January.

"You oughtta be in Medicaid..."

Today's data release confirms that as in states that refused the Medicaid expansion generally, Florida's and Miami-Dade's private plan enrollments were swelled by enrollees who would have been eligible for Medicaid if the state had accepted the expansion. In Florida, 856,092 private plan enrollees -- more than half (53.6%) of the total -- had incomes between 100% and 150% of the Federal Poverty Level (FPL).  That compares with 47% in all states using healthcare.gov that refused to expand Medicaid, and just 22% in expansion states.

Those with incomes in 100-138% FPL range would be Medicaid-eligible if the state had expanded. We don't know exactly how many there are, but my prior analysis of national enrollment numbers suggests that at least two thirds of the 856k in the 100-150% FPL range are Medicaid-eligible -- a bit more than a third of all private plan enrollees in the state (and maybe a good deal more).

In Miami-Dade, the proportion of low-income enrollees is even more eye-popping. Fully two thirds of enrollees -- 259,000 out of 392,000 -- had incomes in the 100-150% FPL range.  Some 85% had incomes under 200% FPL, the threshold below which really strong Cost Sharing Reduction (CSR) subsidies are available with silver-level plans.

The president's left hand

In response to those who paint Richard Nixon as a master of liberal domestic policy, Elizabeth Drew cites his approach to formation of the Environmental Protection Agency:

He’s given credit for signing into law several bills to improve the environment, including establishing the Environmental Protection Agency. But in fact, Nixon wasn’t very interested in the subject and he fobbed it off on his aides to handle, saying at one point: “Just keep me out of trouble on environmental issues.” He privately called the then-rising environmental movement “crap” for “clowns.” 

That jogged a memory.  according to Nick Kotz in Judgment Days: Lyndon Baines Johnson, Martin Luther King, Jr. and the Laws that Changed America, shortly after the Kennedy assassination, LBJ met with U.S. ambassador to Vietnam Henry Cabot Lodge and told him, "I am not going to lose Vietnam."  Afterward,

Last laugh for Republicans in the SCOTUS session that was

Democrats were still in their happy dance over Supreme Court decisions preserving ACA subsidies and legalizing gay marriage throughout the U.S. when, in its final orders of the year, the Court agreed to hear cases poised to gut pubic unions and affirmative action.

In Friedrichs v. California Teachers Association, ten California teachers are challenging a requirement that they pay fees to the teachers union for nonpolitical services, chiefly collective bargaining. That's the type of provision that Scott Walker killed in Wisconsin; without it, pubic sector unions wither. As Mark Joseph Stern at Slate points out, "there is virtually no chance" that the Supreme Court will rule against the teachers:

An add-on health benefit for same-sex couples who marry

Jay Hancock of Kaiser Health News notes that the Supreme Court decision granting same-sex couples the right to marry in any state is likely to boost employer coverage of same-sex couples:

The logic is simple. Fewer than half of employers that offer health benefits make the insurance available to same-sex partners who aren’t married. Virtually all of them offer coverage to spouses.

By marrying partners with employer health plans, people in same-sex relationships are likely to get coverage in states that banned gay marriage until now, as well as in those that welcomed it. Thanks to rapidly shifting legal ground, 37 states recognized gay marriage before last week’s ruling, up from nine in 2012.

Footnote: as-yet-unmarried gay employees whose employers do currently offer health insurance to partners will, if they marry, be able to get that coverage on a tax-free basis.

Obama's eulogy for Clementa Pinckney was also autobiography

Obama's eulogy for Clementa Pinckney yesterday was, among many other things, a compressed autobiography -- or spiritual autobiography, a review of what life has taught him. It sent me back to the remarkable Chicago chapters of Dreams from My Father. 

When I first read that book, in maybe 2007, I wondered, could a man with this experience and orientation really be president of the United States? Six years into that presidency, it seems no less remarkable. Three strands of the experience recorded there struck me as being compressed into yesterday's speech.

First was Obama's ode to empathy, his tribute to the connection that comes from truly listening to people. Second, the extent to which in his engagement with people on Chicago's South Side he'd taken the full measure of the devastation wrought by institutional racism. Third, his discovery of the community of black churches as the most powerful resource for countering those ravages. In each of those themes there were echoes of his personal narrative.

Obama was in a sense speaking about himself, or rather, speaking from personal recognition and memory, in this tribute:

For my own scrapbook...

I swore off Scotusblog on Thursday morning, but a couple of minutes after 10 the time startled me and over I went just in time, and...

And so this fraudulent frivolous cruel destructive suit goes into the dustbin of history where it belongs.

— xpostfactoid (@xpostfactoid1) June 25, 2015

My call on King

I hope I don't end up thrashing myself for wishful thinking, but I think the Supreme Court will rule for the government in King -- no odds on whether it's Chevron deference (the law is ambiguous, and the IRS interpretation is reasonable) or that the law's intent to provide subsidies to all states is unambiguous. I would hope that my bias -- I think the case is a fraud -- is balanced by superstition --an unwillingness to predict what I wish (overridden by being asked, as part of a list).

I can't wrap my mind around both Roberts and Kennedy agreeing to a) blow up the economy and b) credit the plaintiffs' bogus narrative that Congress intended a form of coercion that no one recognized and that the law does not spell out (a state only gets premium subsidies if it establishes its own exchange).  On both counts I take some reassurance from the dissent as well as the majority opinion in NFIB v. Sebelius, the challenge to the ACA's constitutionality ruled on in 2012.

The dissent in that case shows both thorough awareness of the interdependence of the ACA's core provisions and a wariness of causing massive economic disruption:

A quarter of those who stand to lose ACA subsidies should be in Medicaid

Greg Sargent and Charles Gaba have been pointing out repeatedly (after a prompt from Jonathan Cohn) that the majority of healthcare.gov private plan buyers who stand to lose their subsidies if the Supreme Court rules in favor of the King plaintiffs are in Republican congressional districts. I have noted that most of them are low income -- 83% of healthcare.gov private plan buyers have incomes below 250% of the Federal Poverty Line (FPL). That may affect the degree to which Republicans consider them constituents.

There's an irony in that low income profile. In states that refused to expand Medicaid, all but one of which rely on healthcare.gov, private plan enrollments were swelled by those who would have been at the upper end of Medicaid eligibility if their states had accepted the expansion.  In expansion states, residents with incomes below 138% FPL are eligible for Medicaid, and eligibility for subsidized private plans begins at that threshold. In states that refused the expansion, eligibility for private plan subsidies begins at 100% FPL; all those with incomes below that level are left out in the cold.

In states using healthcare.gov that expanded Medicaid, 34% of enrollees had income under 150% FPL.  In states that refused to expand Medicaid, 50% had incomes below 150% FPL. I have calculated that some two thirds of them would have been Medicaid-eligible had their states expanded. That estimate may be low: in Pennsylvania, which refused the Medicaid expansion in 2014 but implemented it in 2015, CMS determined about half of 2014 enrollees had incomes that would qualify them for Medicaid in 2015 (that is, incomes between 100 and 138% FPL).

Polling reflects the ACA's tough tradeoffs

A couple of thoughts* about Kaiser's recent analysis of its most recent survey of those who bought their insurance in the individual market in 2015, on exchange or off-exchange, ACA-compliant or not. To review some key points first (some from the original survey report, others from the analysis):

For ACA marketplaces, the near-poor have been the sweet spot

The just-released National Health Interview Survey for 2014 confirms that the chief beneficiaries of the ACA private plan marketplaces were those defined by the survey as "near-poor," with incomes between 100% and 200% of the Federal Poverty Level (FPL).

The NHIS found that among near-poor adults aged 18-64 (those with incomes from 100-200% FPL),

the percentage who were uninsured decreased from 38.5% to 30.9%, the percentage with public coverage increased from 26.6% to 29.6%, and the percentage with private coverage increased from 36.4% to 41.2% between 2013 and 2014. 

In states that expanded Medicaid, those with incomes up to 138% FPL became Medicaid-eligible -- hence the substantial rise in those in this income group with public insurance. But the jump in private insurance is really substantial, By comparison, private coverage for adults 18-64 with incomes over 200% FPL rose  from 81.2% in 2013 to 83.9%, and for the poor, from 19.0% to 21.9%* (while public coverage for the poor rose from 42.4% to 46.6%).

Why the ACA remains unpopular, cont.

Over at the Huffington Post, Jonathan Cohn has teamed up with pollster Mark Blumenthal for a deep dive into why the ACA's approval ratings remain underwater* and why more people continue to say that the law has personally harmed than helped them (though the gap had narrowed. to 22-19 when Kaiser last polled this question in March).

There are two main takeaways: 1) polling results are overwhelmingly partisan, and Republicans are more passionate in their hatred of the law than Democrats are in support of it, and 2) Americans tend to attribute any changes in their health plans -- usually price hikes or coverage cutbacks -- to the ACA. That's especially true of people with employer-sponsored insurance, a third of whom said they'd been hurt by the law.**

While those conclusions are spot-on, and Cohn and Blumenthal provide a nuanced overview of the ACA's effects on various groups, I'd like to throw one sidelight and add a couple of caveats.

First, the sidelight. Noting that the largest category of those who say the law hurt them say it drove their costs up, Cohn and Blumenthal suggest that the perception is not accurate:

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.