Addled by the metal level

Austin Frakt has a series of posts (1,2,3) reviewing research that highlights what a hard time most people have making good choices among insurance plans -- mainly in balancing premium against deductibles and copays. One such study, by a team led by Peter Ubel, highlights (to my mind) a defect in ACA marketplace design:

...two of us recruited a convenience sample of participants from public buses in Durham, North Carolina, and asked them which category of plans they would look at first if they were shopping for health insurance. To half the people, we described the gold plans as having higher monthly premiums and lower out-of-pocket costs — the language used by many exchanges. For the other half, we switched the gold and bronze plans, describing the gold plans as having lower monthly premiums and higher out-of-pocket costs.

...among participants who were below the median in mathematical ability, the majority said they preferred gold plans over bronze plans, regardless of which plan was labeled as gold.

In real life, of course, labeling skimpier plans "gold" would be deceptive marketing, and labeling superior plans with a less-valuable metal would be just plain stupid. But for about two thirds of marketplace customers, that latter mislabeling is pretty much what the marketplace does.

Mysteries of the Maryland Marketplace

(Update post here)

As I've noted before, Connecticut's ACA exchange has been a market leader in steering private plan buyers whose incomes qualifying them for Cost Sharing Reduction (CSR) subsidies into silver-level plans (CSR is available only with silver). Also noted, back in January: When Maryland cloned Connecticut's technology and web interface in 2015, silver plan takeup improved.

Now, Maryland Health Connection, the state's ACA exchange, is reporting a market-leading level of silver plan selection among CSR-eligible buyers -- that is, buyers with incomes up to 250% of the Federal Poverty Level (FPL).  Nationally, about 76% of private plan enrollees who qualify for CSR buy silver plans and obtain the benefit (coincidentally, CSR-eligibles also make up about three quarters of all marketplace customers). Yesterday, Maryland announced that 86% of CSR-eligible enrollees in the state bought silver and accessed the benefit.

That's all the more the more striking in that just 62% of all buyers on the Maryland exchange selected silver, versus 68% nationally. The numbers indicate:

So, ACA marketplace, how're you doin so far? [Updated 10/14]

[Update, 10/14/15: This week Kaiser estimated that about 7.1 million uninsured people are currently eligible for private plan subsidies in the ACA marketplace. As of June, the marketplace had 8.3 million active subsidized enrollees. Thus the marketplace has reached about 54% capacity among the subsidized, if Kaiser's estimate of the uninsured population is on point. The Kaiser estimate, like a recent HHS estimate of the 2016 target market, indicates that CBO's projections of what will constitute full marketplace capacity may be too high. ]
---
A dispiriting backdrop for those assessing the progress of the ACA private plan marketplace is the Kaiser Family Foundation's estimate that state marketplaces have enrolled just 35%  of the "potential marketplace population." 28 million are eligible; 9.9 million have enrolled.

That stat is easy to misinterpret, though, in that the "potential eligible population" encompasses those who earn too much to qualify for subsidies -- including those who buy plans off-exchange. Taking off-exchange buyers into account*, probably about 17 million of Kaiser's 28 million "potential" enrollees are currently insured in the individual market.

Subtracting about 2.5 million who are in "grandfathered" or "grandmothered" pre-ACA plans, perhaps 14.5 million are in the unified risk pools that insurers who participate in the state marketplaces must establish for all their customers in each state who are enrolled in ACA-compliant plans.

Spotlight on the subsidy-eligible

What about the percentage of potentially subsidizable marketplace customers reached thus far? They're the real target market of the marketplaces. If you earn too much to qualify for ACA subsidies, there's little reason** to buy your plan via an exchange.

"You oughta be in Medicaid" revisited

Charles Gaba and I have at different times both taken a shot at estimating how many of the private plan buyers in the ACA Marketplace would have been eligible for Medicaid had their states not refused to implement the ACA Medicaid expansion. In 2015, slightly more than half of Marketplace customers were in states that had refused the expansion.

Our estimates were based on HHS's March 2015 report of the percentage of healthcare.gov buyers whose incomes were between 100% and 150% of the Federal Poverty Level (FPL). That's a frustratingly blurry frame, since it includes both buyers who would and would not have been eligible for Medicaid in "nonexpansion" states. Buyers up to 138% FPL would have been eligible for Medicaid (as they are in "expansion" states).

Now, the Commonwealth Fund has added an  equivocal hint. I'll get to that in a minute. First, the current estimates.

"Are marketplace plans affordable?"

Last week the Commonwealth Fund released a report* comparing the experiences of people who bought health plans in the ACA marketplace to that of people who get health insurance through their employers. Commonwealth surveyed nearly 5,000 adults between March and May of this year, asking questions about their income, their insurance status, plan features, usage and affordability.

With respect to out-of-pocket costs, here's the top-line takeaway as framed in the Commonwealth press release:

Overall, larger shares of adults with marketplace plans had per-person deductibles of $1,000 or more than did those with employer plans (43% vs. 34%). The differences were widest among those with higher incomes: in this group, over half (53%) with marketplace plans had high deductibles, compared to about one-third (35%) with employer plans. In the survey, people with high deductibles were less confident than those with lower deductibles that they could afford needed care.

What's equally salient, in my view, is that the subsidized marketplace has narrowed the longstanding coverage gap between employer-sponsored insurance (ESI) and nongroup market insurance for lower-income buyers. Compare those with incomes under 250% of the Federal Poverty Level (FPL) to those with ESI:

The Pope's swift turns of thought

I knew before this week that the Pope is a man of good will. As I read his speech to Congress, it dawned too that his is a mind of extraordinary subtlety.

He is the opposite of a fundamentalist. He sees the mix of good and evil in all -- in persons, political systems, historical events.  As he speaks, he keeps flipping the Janus head:  Every chastisement is an affirmation. Every affirmation -- of, say, an inherited national virtue -- is a challenge.

The Pope's paragraphs take swift turns.You think he's headed one way, and he goes into reverse -- present to past, praise to reproach, abortion to death penalty.  He sees six sides to everything.

Follow the switchbacks in this passage appealing to our better angels:

Hillary Clinton's pocket patches for healthcare costs

Hillary Clinton's  just-released package of proposed health reform proposals is very...Hillary Clinton. It's got a lot of moving parts and takes incremental whacks at a pervasive problem -- ever-rising out-of-pocket medical costs for the insured -- from multiple angles.  On the one hand, it layers complexity on complexity. On the other hand, its patches are tailored to provide complementary plugs to different holes in coverage that deter people from obtaining needed care and drain thousands from their earnings. And by the way, the most powerful ideas are are well below the top line.

Pocket patches

The  two lead proposals are aimed directly at the relentless rise in health plan holders' out-of-pocket costs for care. To reduce insureds' "skin in the game" that has become in many cases a pound of flesh, Clinton would

ACA exchanges in 2016: targeting just 6.4 million subsidy-eligible uninsureds?

In a speech at Howard University College of Medicine today, HHS Secretary Sylvia Burwell laid out a few facts about the target market for the ACA exchanges -- those still uninsured and eligible for private plan coverage. A couple of key points:

• About 10.5 million uninsured Americans are eligible for Marketplace coverage in the upcoming open enrollment.


• Almost 40 percent of the uninsured who qualify for Marketplace plans are living between 139 and 250 percent of the federal poverty level (about $34,000 to $61,000 for a family of four).

HHS has confirmed for me that the 10.5 million estimate is not limited to the subsidy-eligible. At present, according to Kaiser estimates, about half of those who have bought plans in the nongroup market are ineligible for subsidies, and most of the subsidy-ineligible have bought their plans off-exchange. 

Does that, then, suggest a target market of just 5 million subsidy-eligible uninsureds? Not quite.* HHS's estimate of the target market between 139% and 250% FPL (4.2 million or a bit less) provides a basis for estimating the size of the subsidizable target market.  In 2015, about 76% of private plan buyers on the exchanges had incomes under 251% FPL.*  According to HHS's most recent enrollment snapshot, 83.7% of all exchange enrollees qualified for premium subsidies. Thus 91% of subsidy-eligible buyers were under 251% FPL. Not all of them, however, fit HHS's "40 percent" category of 139-250% FPL - because in states that refused the Medicaid expansion, eligibility for subsidized marketplace coverage begins at 100% FPL.*** In 2015, about 15% of all enrollees**** (and 20% of those under 250% FPL) were under 139% FPL and so outside HHS's category. Those between 139% and 250% FPL thus constituted about 60% of total enrollment. If that percentage holds in 2016, that would suggest that about 7 million of the 10.5 million in the target market are subsidy eligible.

But the percentage of potential buyers under 139% FPL will probably be considerably lower this year. Takeup among that group was disproportionately high: Avalere Health estimated that 76% of eligible buyers from 100-150% FPL did in fact enroll, and the percentage was probably still higher under 139% FPL (and dramatically lower for all higher income bands). Moreover, two (small states) have accepted the Medicaid expansion for 2016. If, in 2016, 10% rather than 20% of those under 250% FPL are also under 139% FPL, then that suggests about 580,000 fewer subsidizable targets. Since we're now in the realm of educated guesswork, let's say that HHS's estimate of the 139-250% market suggests that about 6.4 million of their 10.5 million overall target market is subsidizable.

At present, 83.7% of 9.9 million exchange enrollees are subsidized. If there indeed are only about 6.4 million subsidy-eligible uninsured still out there, then about 57% of the subsidy-eligible target market has been enrolled. That doesn't sound right. Kaiser has pegged the percentage of potential exchange population enrolled through June 20 at 35%.Though that estimate is not limited to the subsidy-eligible, uninsured rates are much higher in lower income brackets.

The 10.5 million estimate excludes the Medicaid-eligible and -- I assume but have not confirmed -- those in the Medicaid gap, who theoretically could buy unsubsidized plans on the exchanges. Those who earn too little to qualify for premium subsidies are unlikely to pay full price for plans on the marketplace -- although, confusingly (to me), the just-released census report on health insurance showed greater gains in private coverage than in government insurance for those whose incomes should qualify them for Medicaid under the ACA expansion.

The still uninsured: can't afford coverage or don't know what's on offer? (Or both?)

With respect to reaching the still-uninsured, Burwell cited findings from a PerryUndem study that reflect a tension between two key factors:

• About half of the uninsured have less than $100 in savings.

• Nearly three in five of the uninsured are either confused about how the tax credits work or don’t know that they are available.

The first point is a proxy for several points highlighting the financial precariousness of the uninsured. Another: 58% of respondents report having less than $100 left over each month after paying bills. In other words, many would have a very tough time with the average premium paid for marketplace plans, net of subsidies: $101 per month. At the same time, most who consider coverage unaffordable do not know what's on offer.

I have noted the same tension in data from the Urban Institute, and in other surveys of the uninsured. If the still-uninsured who qualify for premium and cost-sharing subsidies knew what was on offer, would they still consider it unaffordable? Doubtless some would and some would not. The proportion in each camp will go a long way toward determining how viable the ACA private plan marketplace will prove over the long haul.

Researchers at the Urban Institute and healthcare reporter Jed Graham have argued that the ACA subsidy structure is too skimpy to meet the needs of large percentages of the uninsured.  To whatever extent that's true overall, it's increasingly true as you move up the income scale -- as Avalere Health's analysis of takeup rates at different income levels indicates. Avalere estimated that about 76% of the subsidy-eligible uninsured with incomes under 150% FPL bought subsidized private plans, compared to 41% for those from 151-200% FPL, 30% for those from 201-250% FPL, 20% of those from 251-300% FPL, and so on down.  The threshold for really strong Cost Sharing Reduction, 200% FPL, is one dividing line between strong and weak aid.  The ACA works best for those up to that income level. At the same time, that's where most of the uninsured are concentrated.

P.S. The PerryUndem study, conducted in May 2015 and surveying some 1,270 adults, is full of interesting info about the finances and priorities of the uninsured.

UPDATE, 10/14/2015: Kaiser yesterday estimated that 7.1 million uninsured people are eligible for subsidized private plans in the ACA marketplace.

----
* I originally oversimplified this calculation, simply taking the percentage of exchange buyers under 250% FPL. Correction is in this paragraph.

** I calculated the percentage of exchange enrollees with incomes under 251% FPL in this post.

*** Thanks to Jed Graham for pointing out that HHS's estimate began at 139% FPL (rather strangely, when you consider the doubtless still-sizable number of uninsureds between under 139% FPL in states that refused the Medicaid expansion. Also among subsidized buyers under 139% FPL: legally present immigrants who are time-barred from Medicaid; they are eligible for premium subsidies even if their income is under 100% FPL (in nonexpansion states) or 139% FPL (in expansion states).

**** See this post for a calculation of 2015 exchange customer with incomes under 139% FPL. In this post, I've slightly dropped the estimate, from 16% of all buyers to 15%, in light of the recent purge of those who failed to verify their state income when asked.

Why does the Census show such small gains among the poor in government-provided health insurance?

If I may reiterate: it seems quite strange to me that the Census health insurance surveys show a net gain for 2014 of just 1.3 million people with incomes under 138% of the Federal Poverty Level enrolled in government insurance plans -- whereas according to HHS, Medicaid enrollment increased by over 9 million in 2014, thanks to the ACA expansion. 138% FPL is the eligibility threshold for Medicaid under the ACA expansion.

The second half of this post provides more detail. According to the Census surveys, those with incomes under 138% FPL showed much stronger gains in private insurance than in public, while those in higher income brackets showed stronger gains in public insurance than in private. That's odd.

The difference may in large part be due to differences in how households are defined: the ACA marketplaces determine eligibility according to who is included in a household tax filing, while the Census surveys (CPS and ACS) consider who lives under one roof. Many other factors are in play, including a modest acceleration in Medicare eligibility and higher income thresholds for children in CHIP than for adults in Medicaid. But none appear on the face of things (as far as I can see) to explain the very low recorded gains in government insurance among adults under 138% FPL (and even more strikingly, under 100% FPL).

Again, there's more detail below the second subhead here (along with some updates added over the weekend). This post is simply to unbury the lead a bit, as I look into the state data.

Sure, Kasich hates the ACA and the Iran deal

I, Democrat, think John Kasich is the Republican presidential candidate best qualified to be president. Ergo, he's doomed.

It's become a cliche that Kasich is this cycle's Jon Huntsman, a GOP candidate who seems borderline sane to Democrats and hence is a total political anaphrodisiac to Republicans. Kasich is more formidable than Huntsman and getting a better response from GOP audiences, at least in New Hampshire. But the principle does apply.

I'm not the closest observer in the political audience but that's why I'm so sure. In a year, I've sopped up two subtexts from Kasich: the ACA is okay, and so is the Iran deal. He'd deny both, but he's pricked my political pituitary twice. First, on the ACA. Last October Kasich told the AP:

The Census on health insurance gains: who got what and how?

This week the Census reported on changes in Americans' health insurance rates from 2013 to 2014, based on results of its two yearly surveys, the Current Population Survey and the American Community Survey. The two together show what is probably the most dramatic drop in the percentage of people without insurance since Medicare and Medicaid were implemented. The drop in the ranks of uninsured was steepest among the roughly one third of the population living in households with incomes under 200% of the Federal Poverty Level (FPL) -- where lack of insurance is most concentrated.

In my grand personal tradition of burying the lead, I discuss an apparent oddity in the data under the second subhead below. Feel free to skip! If you're well-versed in these matters, it may be no mystery to you.

The near-poor gain most

The ranks of the uninsured dropped more steeply for the near-poor than for those below the poverty line, and for the part-time employed than for the nonworking population,  The pattern does not hold for educational level: the uninsured rate dropped most for those without a high school diploma and next most for high school grads, with smaller drops at each level of educational attainment.

Kaiser tracks modest premium increases for benchmark plans -- which means what to whom?

The Kaiser Family Foundation has updated an analysis of 2016 premium changes in 12 states and the District of Columbia, the only states (and, um, District) where complete information was available. Rather than focus on average rate increases across all plans, Kaiser focuses on the benchmark second-cheapest silver and cheapest silver plans This is useful in a number of ways, outlined below. Kaiser spotlights the largest city in each state.

The headline is a quite modest average increase in the benchmark plan -- 3.1% -- and a somewhat larger spike in the average cheapest silver plan in each city, 4.2%. The average covers a wide range of variation, from a 22.8% benchmark hike in Portland, OR to a 10.1% drop in Seattle, WA.

Prices changes in the ACA marketplace (including the off-exchange nongroup market) affect different constituencies is different ways -- as do different measures of price changes. I've outlined a few of the permutations below. Point #3 is most interesting, in my view (bury the lead, squawk squawk, bury the lead...).

First, here's Kaiser's flagship chart:

The feds are taking cost sharing and premium subsidies away from many ACA private plan enrollees

CMS's latest snapshot of private plan enrollment in ACA marketplaces shows significant attrition, from 10,197,187 total enrollments as of March 31 to 9,949,079 as of June 30, a drop of 2.4%. That's mainly -- in fact entirely -- because of stepped-up enforcement of citizenship or immigration status.

That increased vigilance also explains an apparent anomaly that jumped out at me from the numbers: the drop in plan holders whose plans are enhanced with Cost Sharing Reduction (CSR) subsidies is larger than the drop in enrollment among silver plan holders. Since CSR is available only with silver plans, one might have assumed that a drop in CSR enrollment would simply reflect a drop in silver plan enrollment among those with incomes under 250% FPL, the cutoff for CSR eligibility. Yet CSR enrollment dropped by 278,103 -- 4.8% -- compared to a silver enrollment drop of 142,336 (2.0%).

It turns out that the marketplaces are cracking down on enrollees whose stated income doesn't match other data, presumably mainly from tax returns, and reducing or withdrawing CSR benefits as well as premium subsidies when enrollees don't verify their income claims. That's in tandem with increased enforcement with respect to immigration or citizenship status. Here's the explanation:

Some low-income ACA shoppers bought gold plans*

* But not enough to cover Avalere's estimate of CSR-forfeiters

On August 19, Avalere Health published an analysis spotlighting ACA private plan buyers who failed to access the Cost Sharing Reduction (CSR) subsidies that are available to applicants with incomes up to 250% of the Federal Poverty Level (FPL) -- but only if they buy silver plans. Avalere estimated that about 27% of CSR-eligible buyers forfeited the subsidy by buying plans in metal levels other than silver -- usually the cheapest bronze plans, which carry very high deductibles.

In a response, I argued that Avalere had somewhat lowballed CSR takeup by overestimating the number of private plan buyers who were eligible for CSR. The numerator of the equation is not in doubt: an ACA enrollment update published by CMS in June pegged total CSR enrollment at 5,850,936 as of March 31. But the denominator (CSR-eligibles) is based on extrapolations from incomplete income breakouts of ACA private plan customers, provided by HHS in March for healthcare.gov states alone. Avalere assumed that 8.1 million of those still enrolled as of March 31 were CSR-eligible; I estimate that about 7.7 million enrollees were eligible, and that therefore, about 76% of CSR-eligibles accessed the benefit.

The difference stems from two factors: what you assume about the roughly 6% of enrollees for whom income data was unavailable, and how you estimate the percentage of CSR-eligibles in state-based exchanges, for whom income data was not included in federal enrollment reports. I assume that income distribution in the SBMs is closer to that of those healthcare.gov states that accepted the Medicaid expansion than to the overall average for healthcare.gov states, which is dominated by states that refused to expand Medicaid.

CSR-eligibles who bought neither silver nor bronze

I was struck today by additional evidence that Avalere somewhat overestimated the number of private plan holders who are eligible for CSR. According to their analysis, 2.2 million plan holders renounced the benefit by buying non-silver plans. The assumption is that those who leave CSR on the table mostly buy bronze plans, which have lower premiums. But the total number of bronze plan buyers is a known quantity: 2,164,116.  And we know that bronze plan buyers are more concentrated at higher income levels. Among buyers eligible for any kind of subsidy (not all of whom were CSR-eligible), 19% bought bronze. Among those who earned too much to qualify for subsidies, 35% chose bronze.

Obama overcompensates for winning

Obama's defense of the Iran deal in an interview with the Jewish Daily Forward's editor-in-chief Jane Eisner was marked by bulletproof logic and and impressive grasp of nuance. It was marred, however, by grotesque overcompensation for having beaten back Netanyahu's attempt to control U.S. policy on this front. Obama foreclosed on the the possibility of a fundamental divide in interests, not to say values, in terms inappropriate to relations between nations:

There are always going to be arguments within families and among friends. And Israel isn’t just an ally, it’s not just a friend — it’s family.

And then:

The ACA's uncertain shield against underinsurance: A CSR compendium

Note, 2/16/18: This post, and the index of posts it introduces, originated long before the legal challenge to federal CSR reimbursement began to directly affect policy and the shape of the ACA marketplace. The focus until the 2016 election was mainly on CSR takeup and the factors that affected it. In 2017, Trump's threats to cut off CSR reimbursement, executed in October, reshaped the ACA marketplace, driving up costs for the unsubsidized while providing windfalls for many of the subsidy eligible. That is a separate story, and posts relating to those effects are listed in a new section at the top of the index.

Updated 10/9/15, 4/6/16, 4/14/17

Cost Sharing Reduction (CSR) subsidies are the ACA marketplace's best defense against underinsurance for private plan buyers. That's why I've been so interested in who accesses or fails to access CSR and why -- and why takeup varies widely from state to state.

Thanks to CSR, half of marketplace enrollees obtain coverage that covers a higher percentage of the average enrollee's costs than the average employer-provided plan. That is, about 49% of enrollees are enrolled in CSR-enhanced silver plans that raise the plan's actuarial value -- the percentage of the average user's costs covered by the insurer --  to either 94% or 87% (see The Rosetta Stone of CSR takeup*).  The average in employer sponsored insurance is about 82%, or at least it was as of 2011, according to a Kaiser analysis. Another 5% of enrollees are in gold or platinum plans, with AV 80% and 90% respectively [paragraph added 4/14/17].

Below is an index of my posts examining the factors affecting CSR takeup, along with some posts questioning whether the benefit ought to be restructured.  I've done a fair number of single-state snapshots, and they're listed separately at bottom. The top two posts focused on California highlight price sensitivity; the Connecticut, New York, Maryland, Rhode Island Washington posts show how website design can shape the choice; and the posts on southern states mostly illustrate that lower income buyers, for whom the CSR benefit is strongest and the cost of silver lowest, are likeliest to access CSR.

Overall, according to the most recent enrollment figures for 2015, 56% of marketplace private plan buyers in all states accessed CSR (Update, 4/14/17: 58% in 2017).  About 85% of them reported a household income under 201% of the Federal Poverty Level (FPL) and so received a strong version of the benefit, raising the actuarial value of their silver plans to 94% (up to 150% FPL) or 87% (151-200% FPL). Another 7% of all buyers bought gold (AV 80%) and 3% bought platinum (AV 90%) plans. 21% bought bronze plans (AV 60%) with their sky-high deductibles, usually ranging from $5,000-6,600 per person. (Update: in 2017, the breakout was 4% gold, 1% platinum, 71% silver and 23% bronze.)

Here's a sampling of my posts on the subject.

Effects of Trump's CSR cutoff (added 2/16/18, updated 4/27/18)

If Seema Verma bans silver loading, how many marketplace enrollees will suffer? (4/12/18)

Choosing a metal level in the CSR-addled Maryland marketplace (1/17/18)

For whom the bronze bell tolls in the ACA marketplace (11/16/17)

Hey, Republicans: Auto-enrollment is within reach (11/10/17)

Free bronze or CSR-boosted silver? The choice in 5 top ACA marketplaces (11/4/17)

CSR windfall: Will it have a bronze or gold cast? (10/27/17)

Bronze and gold discount plans in California, 2018 (10/20/17)

States vary in response to CSR uncertainty (with David Anderson, Charles Gaba and Louise Norris) (10/11/17)

Covered California to midde-class enrollees: There may be gold in them thar hills (10/7/17)

Go ahead, Trump, cut off CSR payments -- starting in 2018 (7/20/17)

National CSR takeup (and implications)

"Strong" CSR takeup dropped modestly on HealthCare.gov in 2018 (4/3/18)

On HealthCare.gov, CSR takeup rose steadily 2015-2017 (2/15/18)

The real cost of benchmark silver for BCRA enrollees (7/1/17)

ACA vs. AHCA: Total subsidized shares of costs at different income levels and ages (3/19/17)

The Rosetta Stone of CSR takeup (1/9/17)

ACA afflicted by a deductible cliff (12/21/16)

Cutting off CSR subsidies will hit red state enrollees especially hard (12/5/16)

Two major divides in the post-ACA individual market (4/1/16)

Supporting the biggest decision for ACA marketplace shoppers (11/3/15)

How bronze plans offer fool's gold to the Treasury (11/1/15)

Surprise! When silver plans are cheaper, more people buy them (10/24/15)

Addled by the metal level (10/5/15)

"Are marketplace plans affordable?" - on Commonwealth Fund survey (9/28/15)

The feds are taking CSR and premium subsidies away from many enrollees (9/8/15)

Five factors shaping CSR takeup on ACA exchanges (9/1/15)

A quibble with Avalere over CSR takeup (8/20/15; updated, 9/3/15)

Is Obamcare's bronze trap widening? (on healthinsurance.org (8/12/15)

Income levels and CSR takeup in states that refused Medicaid expansion (8/23/15)

No man is an island -- but the GOP is

Yesterday, in a speech in Anchorage starkly laying out the current and future effects of climate change, Obama rhetorically placed his opposition on an island unto themselves, as besieged intellectually as Alaskan islanders now are physically. That reminded me of something. Here's the passage:

But if those trend lines continue the way they are, there’s not going to be a nation on this Earth that’s not impacted negatively.  People will suffer.  Economies will suffer.  Entire nations will find themselves under severe, severe problems.  More drought; more floods; rising sea levels; greater migration; more refugees; more scarcity; more conflict.

That’s one path we can take.  The other path is to embrace the human ingenuity that can do something about it.  This is within our power.  This is a solvable problem if we start now.

And we’re starting to see that enough consensus is being built internationally and within each of our own body politics that we may have the political will -- finally -- to get moving.

So the time to heed the critics and the cynics and the deniers is past.  The time to plead ignorance is surely past.  Those who want to ignore the science, they are increasingly alone.  They’re on their own shrinking island. 

Here's the association. Defending the Iran deal in early August, Obama similarly quarantined the opposition: 

Five factors driving (or inhibiting) CSR takeup in ACA private plan markets

I want to lay out some notes here for a regression analysis of what drives takeup (or the lack of takeup) of Cost Sharing Reduction (CSR) subsidies among buyers of private health plans on ACA exchanges. CSR reduces out-of-pocket costs for buyers with incomes under 251% of the Federal Poverty Level (FPL).  The benefit is quite strong up to 200% FPL, but almost negligible in the 201-250% FPL range.

CSR is best understood not as some obscure secondary benefit but as the ACA's best defense against underinsurance -- that is, against leaving plan holders on the hook for more medical expenses than they can afford. Thanks mainly to CSR, about 60% of buyers on ACA exchanges buy insurance with an actuarial value of 80% or higher - - coverage comparable to or more comprehensive than that offered by most employers. Without CSR, only 10% of exchange customers would access that AV level. CSR provides insurance with AV 87% or 94% to about half of ACA exchange customers.

CSR is a leaky vessel, however, Only about three quarters of those who are eligible access the benefit, including probably a bit over 80% of those eligible for "strong" CSR (AV 87% or 94%). Silver plan premiums can be a hard swallow for low income buyers. In 2015, somewhere between 15% and 20% of buyers under 201% FPL probably opted for cheaper bronze plans with their sky-high deductibles (usually over $5,000 per individual).

CSR takeup among all eligible buyers varies quite a bit from state to state, most commonly between 70% and 80%, more broadly between about 68% and 85% -- discounting a few states that have layered their own benefit structures on the national ACA template (e.g., Vermont and Massachusetts).  In various posts, I've spotlighted factors that have an impact (or may have an impact) on CSR takeup levels, though none form a basis for consistent predictions. Below, I've listed those factors in what I would guess to be descending order of likely impact.

Name Ohio "McKinley" -- and don't stop there!

Republicans, particularly Ohio Republicans, are of course up in arms about the Obama administration's announcement that it would use its executive authority to restore Mount McKinley (named in 1896 by a gold prospector who heard of the president-to-be's nomination) to its historic name, Denali, "the high one," as it had been known for centuries. Alaskans have requested the change for decades (and changed the name themselves via the state Board on Geographic Names in 1975), and (Republican) Senator Lisa Murkowski recorded a video thanking Obama for the change, but never mind.*  John Boehner, whose district is in Ohio, is "deeply disappointed" that McKinley's "great legacy" is losing a monument. Senator Rob Portman bemoans the diss of a "proud Ohioan" (while erroneously deeming the McKinley naming a post-assassination honor).

These complaints are disappointingly circumspect. It's time for presidential candidates to up the ante against the pandering president. Why focus on mere isolated slags of stone? Scratch a bit, and it seems a bunch of squish multiculturalists got hold of state naming boards when this country was young. Why not name all these states that ignore our European heritage and great legacy after (GOP) presidents?**

Alabama (Muskagean)
Alaska (Aleut)
Arkansas (Sioux)
Connecticut (Algonquian)
Hawaii (Polynesian)
Idaho (Comanche)

Why Trump wants a wall

There's a prototype for Trump's wall along the Mexican border:

If you're going to build an 1800-mile wall, why not stuff it with apartments?  And of course, Mexicans can come through the "beautiful door" and build it..and have their remittances taxed to pay for it.  It will have not only gorgeous views of the Rio Grande. but the best lawns.

As president, Trump can set up a public-private partnership with himself. The U.S. can be renamed Trump Place. What's not to like?

Which insured Americans get no subsidy whatsoever?

Who are the Americans who get no help from the federal government paying for their health insurance?

The uninsured, of course. Also, those who buy their insurance in the nongroup market (on- or off-exchange) and a) earn too much to qualify for subsidies, and b) are not self-employed.

It's important to recognize that the self-employed do get a subsidy: the self-employment health insurance deduction. If your health insurance costs less than your total self-employed earnings, you can deduct the whole cost from your earnings. A recent study indicates that this deduction takes an average of 22% off the average self-employed tax filer's health insurance bill.

My question: what percentage of buyers in the nongroup market are not subsidy eligible and not self-employed? They are the only insured Americans who get no government aid paying for insurance. Most of them, that is: there is also a medical expense deduction available to any household that spends more than 10% of its Adjusted Gross Income on medical expenses, including insurance. Only expenses over 10% of AGI can be deducted.

Biden in Pilgrimage to Democrats' Matron Saint

In honor of James Fallows' found art department: The NYT 'weekend briefing' on my phone had the image below directly beneath the headline below

Biden, Considering White House Bid, Meets with Elizabeth Warren



Let us hope he found what he was seeking.

Article here. The image was actually attached to this one.

How many of the uninsured know what's on offer? Not many, Urban finds

With ACA private plan market enrollment lagging initial CBO projections, one key question is whether those who qualify for aid but remain uninsured are doing so because they can't afford what's on offer or because they still don't know what's on offer.

The Urban Institute's latest Health Reform Monitoring Survey (HRMS), conducted in March 2015, indicates that both factors are at work, but comes down more on the side of ignorance of what's on offer. That's "good news" in the sense that ignorance can be rectified for less money than too-skimpy offerings -- though an Urban analysis released earlier this week warns that outreach and marketplace operations are underfunded, as are the subsidies intended to make coverage affordable.

The HRMS found that 43.1% of still-uninsured have household incomes that may be* in the range that qualify them for subsidized private plans on ACA exchanges. Another 27.7% have incomes that would qualify them for Medicaid under the ACA expansion and live in states that have accepted the expansion (including an unmeasured percentage of both undocumented and legally present immigrants** who do not qualify). 22.6% are in the "coverage gap," earning under 100% of the Federal Poverty Level in states that have refused to expand Medicaid. Just 6.6% of the uninsured earn too much to qualify for any aid.

Fully 60% of those likely to qualify for aid say they remain uninsured because costs are too high or they can't afford coverage. But... here is the key point, in my view:

A quibble with Avalere over CSR takeup

9/3/15: See update at bottom for Avalere's response to questions posed here 

I may have to "never mind" this post if I'm missing something basic, but...it seems to me that Avalere Health lowballed Cost Sharing Reduction (CSR) takeup a little in an analysis released today.

Avalere's calculation is simple: 5.9 million buyers of private plans on ACA exchanges bought plans with Cost Sharing Reduction subsidies, available only to buyers with incomes under 250% of the Federal Poverty Level (FPL), and only if they selected silver plans.  8.1 million buyers were eligible for CSR, according to Avalere; hence about 2.2 million left the benefit on the table; most of them probably brought bronze plans with sky-high deductibles. The CSR takeup rate comes to just 72.8%,

Avalere says that it derived these numbers from HHS's March enrollment report,which broke out enrollees by income level in the 37 states using healthcare.gov, and a CMS update released in June, which adjusted for attrition (mostly no-pays) as of March 31.

We know where the 5.9 million figure for those who accessed CSR came from: the June update, which reported 5,850,936 enrollees with CSR. But what about the denominator, the 8.1 million? That's trickier. We know there were 10,187,197 enrollees as of March 31. But how many were CSR-eligible?

A tough progressive critique of the ACA

Over at The Incidental Economist, I have a review of IBD reporter Jed Graham's e-book analyzing flaws in the ACA and proposing a package of fixes. Here's the opening*:

Those who have closely followed the drama of Affordable Care Act implementation as it's unfolded in the media over the past two years may be familiar with the sharp criticisms of Jed Graham, a reporter at Investor's Business Daily. These include a list of cuts to work hours and jobs prompted by the employer mandate, and spotlights on the sky-high deductibles taken on by the approximately one fifth of ACA private plan buyers who chose the lowest tier bronze plans.

Given the title of Graham's e-book assessing the law, ObamaCare is a Great Mess, a sometime reader of Graham's articles might assume that he's one of the ACA's many implacable ideological opponents. That would be to ignore the subtitle, A View of the Affordable Care Act Without Partisan Blinders & How to Fix It, as well as its substantive criticisms and recommendations. Graham identifies the law's shortcomings from an essentially progressive perspective, highlighting what he presents as the regressive impact of its mandates and  the limited affordability of its offerings for many buyers.  "The heart of the ACA is basically sound," he writes. "The goal of reform should be to unclog the arteries and let the heart do its job."

Graham's proposed fixes are well worth considering (well, some of them, in my view), and there's a potential venue for trying them out (or variants that could be cast as revenue-neutral): the ACA's innovation waivers inviting states to submit alternative schemes, starting in 2017 that meet the ACA's standards for affordability and coverage at comparable cost.  The book is also a useful antidote to the triumphalism that's taken hold of many supporters since the King v. Burwell nightmare went away.

--
* More or less: these paragraphs were edited down a bit for TIE.

The Urban Institute's Medicaid expansion proposal could help the ACA private plan market

The Urban Institute has released a report* proposing that the federal government spend an extra half-trillion dollars over ten years to boost the affordability and uptake of the Affordable Care Act's health insurance offerings. The core premise is that for far too many uninsured Americans, private plans offered on ACA exchanges are either unaffordable or offer too-skimpy coverage.

The headline proposal is to boost premium and cost-sharing subsidies for the private plans offered on ACA exchanges.  I'd like to spotlight a side effect of a secondary proposal, designed to entice some of the 21 states that have thus far refused the ACA Medicaid expansion to embrace it. It's this:

Although some of the currently nonexpanding states may choose to participate in the future, many others may continue to refuse to do so, maintaining the tremendous inequity that provides federal financial assistance to some people with incomes at or above the federal poverty level but denies assistance to many adults who are actually poor. One option to address this hole in the ACA’s reach is to give states the option of expanding Medicaid coverage up to 100 percent of FPL rather than requiring them to expand to 138 percent of FPL if they expand at all.

As the ACA mandate bites harder, will a Bronze Age follow?

I have a post up at healthinsurance.org responding to a forecast by Investor's Business Daily reporter Jed Graham,to the effect that as the individual mandate clubs more people into the ACA exchanges, more low income shoppers will buy bronze plans.

Graham assumes that most of those who have remained uninsured have looked at what's on offer and decided it's too expensive, or that only bronze is affordable and that the sky-high bronze deductibles render those plans a poor value.  While that's doubtless true for some, I point to survey data indicating that large percentages of the still-uninsured don't know what's on offer.

I want to skip here to a somewhat fuller discussion of solutions Graham offers to what he calls "the bronze trap" in his just-released e-book, Obamacare is a Great Mess: A View of the Affordable Care Act Without Partisan Blinders & How to Fix It, which is well worth a read.

Pet insurance: permission to spend?

Sarah Kliff has a good article about pet insurance that poses the right two questions at the outset -- courtesy of Jennifer Fitzgerald, co-founder of an excellent online insurance market called PolicyGenius:

The first question is the easier one: How much can I afford to spend on my pet? If I got a really expensive bill, maybe something upward of $5,000, would I be able to pay it off myself? If the answer is yes, she says, you might not need pet insurance: You could take a gamble and essentially act as your own insurance company. But if the answer is no, then there's a follow-up question:

How much am I willing to spend to save my pet's life? Don't think about the constraints of your budget for a moment — think about whether you'd think it was worth it to pay $5,000, $10,000, maybe even $20,000 to save your pet's life.

I have been mulling the second question on and off for some years. When we adopted our dear departed beagle mutt Merlin fourteen years ago, I used to joke that he had a $2,000 lifetime health savings account. That was because I was bemused by tales of people paying for cancer operations for their dogs -- $5k or $10k.  I thought that was ridiculous. But changing cultural norms have a tidal pull. When we adopted the beguiling dachshund mutt Walter two years ago, I started testing my mental limits for what I'd be willing to pay down the line -- especially as we read that dachschunds are prone to spinal troubles (we hope the 1/4 pit bull in him may spare him that).

Best tool against inequality: antitrust enforcement? (of two kinds?)

[Update, 10/28: An updated version of Einer Elhauge's article is available here.]

The Wall Street Journal reports today that activist shareholders, who force management and operational changes in public companies to boost "shareholder value," are increasingly enlisting large mutual fund companies as allies and thus winning more battles. Their aims generally: "share buybacks, cost-cutting and asset sales."

That boost to shareholder activism, taking place over the last decade, recalls a theory of what's driving growing economic inequality recently advanced by Harvard law professor Einer Elhauge. According to Elhauge, increased consolidation of public company ownership by institutional investors like BlackRock, Vanguard, Fidelity, and State Street leads to a phenomenon called "horizontal shareholding," in which these mega-investors own major stakes in all the major players in a given industry and thus provide incentives to those companies to collude rather than compete -- or more exactly, to act in ways that boost share prices across the industry rather than relative to their competitors.

Elhauge's analysis is prompted by the fact that "the increasing share of stock held by institutional investors...has grown from 34% of all stock in 1980 to 67% of all stock in 2010." He links that rise to the often-cited drop in the percentage of corporate revenue going to wages and capital investment:

What if Congress rejects the Iran deal? Ex-Mossad chief Halevy fills in the blanks

There's one incontrovertible point in the argument against the Congress rejecting and invalidating the nuclear agreement with Iran. Even if you think the deal was poorly negotiated, if the U.S. walks away the sanctions regime will immediately fall apart and Iran will gain everything it could ever gain either by cheating on the deal or stepping up its enrichment and weapons program when various constraints expire. 

Obama has made this point repeatedly, minus the "even if you think..." part. The shorthand is "what is your alternative?" -- and there is none. Implicitly recognizing this, Chuck Schumer, in the most self-negating policy statement I've ever read, could barely bring himself to sketch in (in the statement's last breath) an alleged alternative path:

Five Republicans who are not democrats

Leave aside for a moment the favored policies of the ten Republican presidential candidates in the prime-time debate and the seven in the second-tier happy hour debate.  While there were very few actual policy differences, at least five candidates expressed startling contempt or disregard for the core structure of U.S. government, democratic constraints on the executive, international law, or the most basic standards of evidence for assertions made in public. 

Here's a quick look at five violations of the norms of democratic government as understood in the U.S. and internationally.

1. International law banning torture is not "brain surgery." Here's neurosurgeon Ben Carson responding to a question from Megyn Kelly: "As president,....would you bring back waterboarding?"

Alright. You know, what we do in order to get the information that we need is our business, and I wouldn't necessarily be broadcasting what we're going to do.(APPLAUSE)

We've gotten into this -- this mindset of fighting politically correct wars. There is no such thing as a politically correct war. (APPLAUSE)

Obama against the warmongers

Obama's speech yesterday in support of the Iran deal had one obvious structure: taking on objections to the deal point-by-point, in substantive detail. It had a parallel thematic structure: opposing the tradition of American multilateral diplomacy to the drum-beating of hegemonists, proponents of preemptive war. 

Casting himself in the former tradition, which he portrayed as the longstanding consensus position of U.S. foreign policy, he repeatedly invoked first Kennedy and then Reagan, intertwining the words and deeds of both. On the hegemonist side, he invoked one counterfactual and one actual disaster: first-strike proponents against the Soviets, and Iraq war proponents, whom he linked to opponents of the Iran deal.

The definition of chutzpah

A few step-back observations about national "debate" over the Iran deal:

1. It is the definition of chutzpah to hype the danger of a nuclear Iran for years and decades, then complain that the deal only addresses Iran's nuclear program. It's also the definition of warmongering. You can't negotiate away all your differences with an adversary at once.

2. In the same vein, it's disingenuous to reject the deal on grounds that the removal of sanctions designed to induce such a deal will fund other activities we don't like.

3. We can pretend that there's a substantive debate about the merits of the deal, but that's obviously not what's going on.  The evidence of that is in the terms in which prominent Democrats declare their support.  According to Huffington Post's Sam Stein, Senators Kaine, Warren and Nelson felt empowered to support the deal after a meeting with ambassadors from the P5 + 1 group that negotiated with the U.S. against Iran:

...the conversation lingered largely on a hypothetical: What would happen if the agreement fell through?

According to one Senate Democratic aide, the ambassadors were emphatic that this would amount to a forfeiture of a successful diplomatic endgame.

Underinsured and deep in debt: which cracks did this family fall through?

USA Today has a story today, by Jayne O'Donnell, highlighting the plight of (under)insured Americans who face crippling out-of-pocket healthcare costs. The lead example raises a couple of question marks about exactly how this family fell through various cracks:

Christian and Jaycee Garcia of Silver Spring, Md., have been hard hit by medical bills, even with their out-of-pocket maximum of $6,350 a year for each family member. Their 20-month-old son, CJ, was born with the rare genetic disorder Eagle Barrett Syndrome and severe scoliosis. He will have his 13th surgery in August, with two more to follow in September, all to rebuild his digestive system and urinary tract and to insert metal rods next to his spine so he can sit up without a brace.

Although Christian Garcia earns $60,000 a year as a restaurant manager, the more than $700 monthly insurance premiums for his work plan and another privately purchased plan for his wife and kids plus other monthly bills make paying the family's share of the hospital bills impossible. The couple have $11,000 in medical bills they are paying $270 a month on, and bills from two other hospitals have gone to collections. Monthly expenses, including the payment on his medical bills, are about equal to his take-home pay of about $3,000 a month.

Rejoice, Uticans! A shower of silver shall rain upon you in 2016.

UPDATE: I'm afraid I have to retract the gist of this post, which comes mainly near the end: we don't actually know the spread between the benchmark and cheapest silver plans in each New York region for 2016.  Looking at the spread between the silver-plan prices posted by the different insurers, it escaped me that a given insurer could put up the cheapest and second cheapest silver plan in a given area -- so the difference between insurers' average silver prices, as reported by the state, is not the spread between benchmark and cheapest silver. The posted averages do not reveal the benchmark. I apologize to anyone who absorbed the misinformation.

P.S. I discovered the error when I went to check 2015 prices and how a "cheapest silver" windfall would affect them. Of course I might have known, as I've done a lot of "shopping" on healthcare.gov and have rarely seen a really significant gap between cheapest- and second-cheapest silver. I think I was thrown off by California's just-published 2016 rate chart, which explicitly highlights some very large spreads between benchmark and cheapest silver, with one plan price quoted for each insurer. That's presumably because benefits in CA are standardized for each metal level.

P.P.S. I also seem to have forgotten for the moment that NY is launching a Basic Health Plan in 2016, thereby wiping out the under-200% FPL market and rendering the issue of CSR takeup all but moot, as CSR is negligible at 200-250% FPL. That'll teach me to post in haste before rushing out on a Friday evening reverse commute to hang over the balconies at the new Whitney Museum:

New Whitney

So, never mind, except for the general principle:
--------------

Today New York posted 2016 rates for health insurance plans offered on NY State of Health, the state's ACA exchange. I was planning to write about the factors that affect what subsidized ACA private plan buyers will actually pay, when the rates posted for Utica, NY brought me up short. They are a stark illustration how the spread between certain plans offered in one market matters more to subsidized buyers than the sticker price of a given plan -- if they're willing to buy the cheapest plan at a given actuarial value.

On ACA exchanges, premium subsidies are set as a fixed percentage of a buyer's income, benchmarked to the second cheapest silver-level plan in the buyer's market. In 2016, solo buyers who earn exactly 200% of the Federal Poverty Level (FPL) will all pay $124 for the second cheapest silver plan available to them, regardless of where they live. Buyers earning 150% FPL will pay $59 for the benchmark plan.

New York's ACA exchange publishes takeup rates for Cost Sharing Reduction

NY State of Health, the state's ACA health insurance marketplace, released detailed enrollment data today (hat tip to who else but Charles Gaba?). With regard to my own little preoccupation -- the degree to which those private plan buyers eligible for Cost Sharing Reduction (CSR) subsidies access the benefit by buying silver plans -- New York is (as far as I know) the first state to do the basic math for me:

The majority of QHP consumers who completed the enrollment process and were eligible for APTC with cost-sharing reductions chose Silver plans in which they can use costsharing reductions. Among those eligible for cost-sharing reductions, enrollment in Silver plans was higher for those eligible for greater levels of subsidy. Ninety-seven percent of those eligible for costsharing reductions at the 94 percent actuarial value level enrolled in a Silver plan, compared with 83 percent at the 87 percent actuarial value level, and 62 percent at the 73 percent actuarial value level. Overall, 78 percent of those who are eligible for cost-sharing reductions, enroll in a Silver plan with that benefit. The remaining 22 percent enroll in different metal levels. These trends are consistent with the
2014 open enrollment period, when overall, only a slightly higher share of cost-sharing reduction eligible enrollees—80 percent—enrolled in these products. 

Last year, I had to tweeze these numbers out of the NY enrollment report myself.  Since they redounded to the state's credit, and a NYSOH spox confirmed them for me, I'd like to think I gave them a nudge toward highlighting the takeup themselves this time around.

Pennsylvania Medicaid expansion enrollment jumps; have newly Medicaid-eligible 2014 private plan enrollees jumped with it?

Pennsylvania's somewhat rocky Medicaid expansion, for which enrollment began on December 1 and coverage on January 1, seems now to be firing on all burners. The state's Department of Human Services reported last week that enrollment is up to 439,000, more than two thirds of the state's target of 605,000.

The expansion began slowly. After Pennsylvania declined to expand in 2014, then-Governor Tom Corbett negotiated with HHS to create the kind of "private option" expansion popular with Republican governors. The "Healthy Pennsylvania" plans that were hastily constructed in fall 2014 had different terms for Medicaid-eligibles at different income levels, and eligibility criteria different from the state's existing programs. Adding to the confusion, existing state Medicaid programs required applicants to list their assets as well as their income; the ACA excludes such information from the Medicaid application process. Systems snarled and applications backlogged, though not as radically as in many states.

A transition back to traditional Medicaid initiated by the state's new Democratic Governor, Tom Wolf, kicked off on April 27. That transition will be complete by the end of this month, though some "private option" enrollees will be double-enrolled until September 1. By late April most applications were being processed in a timely manner, meeting the state's 30-day standard, enrollment counselors told me at the time.  Kait Gillis, a DHS spokeswoman, tells me that 150,000 have been enrolled since the transition to traditional Medicaid kicked off.

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: