How bronze plans offer fool's gold to the Treasury

I have more than once expressed frustration that HHS, when urging the uninsured to buy health plans in the ACA marketplace, emphasizes low premiums at the expense of good coverage. For example, CMS's snapshot of plan prices for the Open Season beginning today leads like this:

The next Open Enrollment period for the Health Insurance Marketplace begins on November 1, 2015 for coverage starting on January 1, 2016. According to an HHS analysis, about 8 out of 10 returning consumers will be able to buy a plan with premiums less than $100 dollars a month after tax credits; and about 7 out of 10 will have a plan available for less than $75 a month.

Only perhaps 5 out of ten returning customers will be able to buy a silver plan for under $100 per month, and many of those who slip beneath that round-number threshold by buying bronze plans will be forgoing the Cost Sharing Reduction (CSR) subsidies that are available only with silver plans.  Yet the messaging about CSR on healthcare.gov and in HHS's communications is confusing and underemphasized.

Perhaps the ambivalence or inattention to CSR stems in part from a financial conflict of interest between the federal government and shoppers on the ACA exchanges.  When a CSR-eligible shopper selects a bronze plan, the Treasury saves not only on the forgone CSR subsidy, but also, in some cases, on the premium subsidy. Bronze plans are in some regions priced so low that the full unsubsidized premium is less than the premium subsidy to which the buyer is entitled, which is calculated to leave her paying a fixed percentage of income for the second-cheapest silver plan available. That's likeliest to be the case for older buyers, for whom unsubsidized premiums can be up to three times as high as for young buyers

This pricing permutation is very much in play in California in 2016. In 2015, 53.5% of California's subsidized enrollees were between the ages of 45 and 64 -- and again, for older buyers, premium subsidies often cover the whole cost of a bronze plan, and then some.

Forecast: Bronze plan takeup will rise in California in 2016

I fear that more health plan buyers on Covered California are going to buy bronze plans, with their $6,000 deductibles, in 2016 than in 2015.

That probably means that more low-income buyers are likely to forgo Cost Sharing Reduction (CSR) subsidies, which are available only with silver plans. Under California's standardized benefit design in 2016, silver plans have a $75 deductible for buyers with incomes under 150% of the Federal Poverty Level ($17,655 for a single person) and a $550 deductible for buyers up to 200% FPL ($23,540).

Silver plan premiums can be hard for low income people to afford, particularly at the upper reaches of eligibility (weaker CSR is available up to 250% FPL). For someone earning $23,000, the benchmark second-cheapest silver plan costs $121 per month.

In some regions the cheapest silver plan is considerably less, though, and bronze plan prices vary widely. In a prior post, I demonstrated that in California regions where the price difference between cheapest silver and cheapest bronze was smallest,  silver plan selection was highest. In parts of LA County where the spread was just $20 for a 40 year-old earning $23,000, 70.5% of enrollees bought silver and 18.3% bought bronze. In the Eastern Counties, where the spread was generally over $100, just 41.5% bought silver and 55.8% bought bronze.

In 2016, bronze-silver spreads have widened, at least in the 12 of 19 pricing regions I spotlighted earlier. In some regions silver "discounts" narrowed, because the cheapest silver plan is closer to the benchmark; in others, cheaper bronze plans are on offer in 2016 than in 2015; and in some, both changes have taken place (in some regions, too, one change or the other is in the opposite direction).

Affordable underinsurance? That's where healthcare.gov's new total cost estimator may steer you

Buying health insurance is hard, experts tell us. Even highly educated customers have trouble weighing monthly premium vs. deductibles and copays - especially since many Americans don't know offhand what terms like "deductible" and "coinsurance" mean.  To help, many have called for a "total cost estimator" that will ask users about their current medical usage and then estimate what their total yearly costs are likely to be under each plan.

This year, healthcare.gov has delivered. The "Preview Plans and Prices" feature, which asks a handful of questions about age, income and household size before delivering price quotes, now includes a total yearly cost calculator. It's optional, easy to use, and only adds one question before showing plans and prices (two, if you count the question whether you want to use it).

I don't like it. At least, I don't like its prominent placement; I think it should be a Step 2 offering, after you see plans and prices. I fear it will make some people focus on the wrong number, and the wrong question.  It leaves out a core factor in the insurance equation: risk.

Take the case of a single 40 year-old man earning $17,000 a year in Las Vegas (gender and age affect the estimated medical cost calculus). Here's the cheapest bronze offering -- the first result the user (let's call him Vince) will see:

More on Charles Gaba's "Two glaring errors in the WSJ anti-Obamacare editorial"

Charles Gaba has caught a couple of glaring errors in a Wall Street Journal editorial claiming that the ACA private plan marketplace is on the road to failure. The most important error misrepresents the state of the current and potential nongroup market -- that is, the pool of people who buy or could buy their health insurance on their own, with or without ACA subsidies.

Gaba captures the main point: that contra WSJ assertions, most of those who buy their insurance off-exchange are not subsidy eligible, and are mingled in the same risk pools as those who buy on-exchange. I'd like to further clarify, though, how much progress those markets have made toward full capacity, and to what extent those who are eligible for subsidies have so far enrolled.

Here's the WSJ editorial board's "state of the market" overview:

Surprise! Where silver plans are cheaper, more people buy them

Math test! Should you buy a health plan that costs $70 per month with a $5,000 deductible, or a plan that costs $90 per month with a $500 deductible?  Easy, right?

Try this one, then.  The plan with the $500 deductible costs $109 per month, versus three dollars per month for the $5,000 deductible plan.  Also factor in that the $5,000-deductible plan allows three doctor visits before the deductible kicks in. Not so simple  -- unless perhaps you know that you'll need a lot of medical care.

Those are actual choices facing 40 year-olds earning $23,000 and seeking solo insurance in 2015 in different regions of California's ACA marketplace, Covered California.  The first choice is between the cheapest silver and cheapest bronze plans available in half of Los Angeles County. The second is cheapest silver versus cheapest bronze in San Mateo.

The spread between deductibles for bronze and silver plans ($500 vs. $5,000) is so stark because a silver plan for a person earning $23,000 in 2015 is enhanced with Cost Sharing Reduction (CSR) subsidies -- available only with silver. Without CSR, the silver plan deductibles in both cases above would be $2,000. CSR-eligible buyers who choose any metal level but silver are leaving a valuable benefit on the table.

As for the spread between premiums, California enrollment data indicates that buyers are quite sensitive to it. In regions where the spread between cheapest bronze and cheapest silver is narrowest, more people buy silver and so access CSR (statewide, two thirds of buyers are CSR-eligible, as are 80% of those who select silver).

Hillary homes in on antitrust enforcement

Hillary Clinton is putting antitrust enforcement front and center as a tool to fight income inequality, fingering industry consolidation as a major driver of said inequality. As I noted recently, antitrust enforcement was perhaps also the most important, if little-noticed, plank in the healthcare reform package Clinton put forward last month.

This is a big deal. Clinton is tying together high prices in key industries -- pharma and healthcare chief among them -- outsized compensation for the top 1%, including via stock buybacks, and the weakening of labor:

Who leaves employer-sponsored insurance on the table?

The Kaiser Family Foundation's latest estimate of the still-uninsured population in the U.S. includes about 4.8 million whose employers offer health insurance that they decline to buy.

Some are locked out by the ACA's so-called "family glitch," which denies marketplace subsidies to those for whom an employer's insurance offering would cost less than 9.5% of income for individual coverage, even if the family coverage offered by the employer costs far more than that. But many low income workers find even individual employer-sponsored insurance (ESI) unaffordable. Probably the bulk of Kaiser's estimated 4.8 million who forgo ESI could do well in the ACA marketplace if the ESI offer didn't disqualify them from subsidies.

The New York Times' Stacy Cowley has a good story that spotlights the plight of those who can't afford insurance offered by their employers:

The opposite of Bernie Sanders

Dressed up like Bernie Sanders, Larry David on SNL looked and sounded almost exactly like Bernie Sanders. But that's not why he was funny. Or rather, that's only half of why he was funny. 

In his public persona at least, Sanders focuses relentlessly on problems that in his telling threaten the future of American democracy and humanity itself: galloping income inequality and climate change. Larry David's humor focuses relentlessly on life's trivialities: tuck or don't tuck your shirt, slip a water bottle into a theater, suffer the consequences of  new pants tenting around the crotch.

The joke was that David looked and sounded like Sanders but acted (or thought) like Larry David's character on Curb Your Enthusiasm. 

David did spoof Sanders on the big picture: We're doomed! But it was funny precisely because he made no distinction between the momentous and the trivial:

Eh, not a fan of the banks. They trample on the middle class. They control Washington. And why do they chain all their pens to the desks? Who's trying to steal a pen from a bank? It makes no sense!

In ACA marketplace, low-hanging fruit is more than half picked

My long two-pointed ladder's sticking through a tree

Toward heaven still,

And there's a barrel that I didn't fill

Beside it, and there may be two or three*

Apples I didn't pick upon some bough.

Goddamn it, don't stop apple-picking now!

(Apologies, Robert Frost)

* or 7 or 8 million

Gearing up for the ACA's third enrollment season, HHS has released an analysis estimating 10.5 million uninsured individuals are eligible to buy private plans in the ACA marketplace. In a separate brief, HHS forecasts that between 2.8 and 3.9 million from this pool  will select marketplace plans in 2016 -- which sounds low until you pick through the numbers a bit.

HHS estimates that 48% of the 10.5 million live in households with incomes under 250% of the Federal Poverty Level (FPL) -- qualifying them for both premium subsidies and Cost Sharing Reduction (CSR) subsidies. Another 30% have incomes between 250% and 400% FPL and so "may qualify" for premium subsidies. But not all of them do.*  And buyers in that range, who are expected to pay at least 8% of income for the benchmark second-cheapest silver plan in their region, have proved a tough sell to date.

About three quarters of all current marketplace enrollees and 88% of subsidized enrollees -- about 7.4 million -- (as of June 30) have incomes under 250% FPL*  If half of the estimated 5 million marketplace-eligible uninsured people with incomes under 250% FPL enroll in plans, and if they constitute about 75% of new enrollees (as they do of current ones), that suggests 3.3 million new enrollees -- almost exactly the midpoint in HHS's forecast range.

Rational choice in the ACA marketplace - Santa Cruz edition

[reposted]

Attention, ACA shopper #1: You can buy a silver health plan  for $117 per month with a $500 deductible, or a bronze plan that costs $22 per month -- with a $5,000 deductible. What'll it be?

Attention, ACA shopper #2: Same choice as for shopper #1, but in your case the silver plan is just $88 per month, and the bronze, $22.

The shrinking subsidizable ACA private plan buyer pool

This week the Kaiser Family Foundation estimated that among 32.3 million non-elderly uninsured U.S. adults, 22%, or 7.1 million, should be eligible for subsidized private plans in the ACA marketplace. HHS estimates a total of 10.5 million uninsured who are eligible for marketplace coverage, almost 80% of whom are subsidy-eligible.*

There were 8.3 million subsidized marketplace enrollees as of June, suggesting a total pool of about 15-16 million who lack access to employer-sponsored or other insurance and are eligible for subsidies. The Congressional Budge Office's most recent forecast is that by 2017, 18 million people will be buying subsidized plans in the marketplace.  Allowing for a bit of population growth, why the apparent overshoot?

The answer may lie in expectations about employer response to the ACA. CBO's 2015 projection estimates that employer-sponsored insurance will be down 6 million from the pre-ACA baseline in 2016 (and down 1 million this year).

Hey, Jeb! Who's getting those "huge new subsidies" under the ACA?

Touting his new ACA replacement plan, which would wipe out ACA coverage rules for insurers and replace means-tested ACA private plan subsidies with tax credits for catastrophic coverage available at any income level, Bush asserted:

Obamacare created huge new subsidies for low-income Americans, but it left middle-income Americans facing higher premiums and higher out-of-pocket costs.

There are some grains of truth to that.  People who 1) get their insurance in the individual market,  2) earn too much to qualify for subsidies (that is, over 300-400% of the Federal Poverty Level (FPL)), and 3) don't have pre-existing conditions pay more  than they would have pre-ACA.* You could argue, too, that the ACA has driven up out-of-pocket medical costs, if not premiums, for people with employer-sponsored insurance (ESI) -- or at least that it will do so once the Cadillac Tax kicks in, if it ever does. The claim is highly contestable, though, as neither premiums nor out-of-pocket costs have risen faster in ESI than in pre-ACA years and myriad factors are at work. Really, it's simply too early to tell.

But Bush's statement, like most Republican claims to speak in defense of "the middle class," reveals a top-heavy view of what "middle class" means. His sneer at "huge subsidies" is also a sneer at huge swaths of the U.S. population -- where the uninsured are concentrated.

A recent Census report** indicates that in 2014 the ACA caused large drops in the uninsured rate among Americans with incomes under 100% FPL ( a 4.2 point drop, from 23.5% to 19.3%), 100-199% FPL (a 5.3 point drop) and 200-299% FPL (4.2 points.).

Cost Sharing Reduction in Covered California

(I'm hoping that dry title sounds like a pop song lyric.)

Covered California today released private plan enrollment data updated to June 2015. The report (available here under "June 2015 profile") shows that California's CSR takeup rate is in line with national averages.

By CSR takeup, I mean the rate at which California buyers whose incomes qualify them for Cost Sharing Reduction (CSR) subsidies selected silver plans and so accessed the benefit, which is available only with silver plans. As in the country at large, 76% of all CSR-eligibles in California bought silver.

Since I've described how CSR works dozens of times, I'd like to cut to the chart here. A quick rundown of the basics is below.

Income level	CSR-eligible	CSR accessed	% CSR accessed
Under 150% FPL (AV 94%)	219,260	195,090	88.9%
150-200% FPL (AV 87%)	438,730	345,720	79.3%
200-250 FPL (AV 73%)	221,310	125,650	56.8%
Total Under 200% FPL	657,990	540,810	82.2%
Under 250% FPL (Total CSR eligible)	879,300	666,460	75.8%

Mysteries of the Maryland ACA Marketplace, cont.

As I noted on Oct. 3, Maryland Health Connection, the state's ACA exchange, sent me enrollment data indicating that Maryland may have the highest "CSR takeup rate" in the country. That is, in 2015, Maryland private plan buyers whose incomes qualify them for Cost Sharing Reduction (CSR) subsidies, which are available only with silver plans, chose silver and access the benefit at market leading rates. In Maryland, 86% of CSR-eligible buyers chose silver, compared to a national average of about 76%. That's doubtless in large part because Maryland cloned the web interface of the Connecticut exchange, which does an excellent job steering CSR-eligibles toward silver.

There are some peculiarities in the Maryland data, though, and they're thrown into sharper relief by the raw numbers of silver plan enrollees at each income level, which I did not have when I posted last week. Chief among them is a relatively huge number of buyers, 22%, with incomes low enough to qualify them for Medicaid, unless they're lawfully present non-citizens not yet eligible for Medicaid because they've been in the country less than five years.

What's a "typical" silver plan? Not what Emory researchers say it is

Nothing drives me battier than to see silver-level health plans unenhanced by Cost Sharing Reduction (CSR) subsidies presented as the "average" offering, either of silver plans or of all plans offered in ACA marketplaces. Over 80% of silver plan buyers in ACA marketplaces get CSR. Of those, about 80% have incomes under 201% FPL, which means their plans have an actuarial value of either 94% or 87% --  better than the average employer-sponsored plans.

An Emory University study purporting to show that "in the ACA Marketplaces, "out-of-pocket expenses for medications in a typical silver plan are twice as high as they are in the average employer-sponsored plan" is particularly frustrating because the researchers, led by Kenneth Thorpe, Chair of Emory's health research department, are well aware of how CSR is functioning in the marketplaces. Deep in the text, they acknowledge that 87%* of silver buyers in the marketplaces have CSR attached to their plans -- yet they persist in constructing a "typical" silver plan with AV 70% and very high pharma cost-sharing -- and compare the typical ESI plan exclusively with that construct.

Their rationale: The study considers the likely ill effects on pharma usage if employers drop insurance and dump their employees onto the exchanges. Because over 80% of employees with ESI have incomes over 250% FPL, the authors assert briefly that CSR is irrelevant. They don't address the fact that CBO projections of modest ESI losses assume that those losses will be among lower income workers.

I have a post up on healthinsurance.org that contrasts patient drug costs in the Emory researchers' "typical" silver plan with those of actual silver plans on the marketplaces available to buyers with incomes under 201% FPL -- again, almost two thirds of silver plan buyers in the marketplaces. Hope you'll take a look.

--
Now 82% after attrition and a federal audit of those whose income statements on their ACA applications did not match tax data.

UPDATE, 10/8: As originally worded, this summary could be read to imply deliberate obfuscation on the part of the study's authors. That was not my intent, and I regret if I gave that impression. I have have edited accordingly.

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. ]
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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.

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* 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.