The two-track individual market for health insurance

[Update/correction - This post originally included an important error: the RWJF breakout of off-marketplace metal levels referred to plans offered, not plans selected. While leaving that data in place, I've added survey data from the Commonwealth Fund regarding off-marketplace enrollees' metal level selections that also is not based on actual selection data but does also look rather similar to metal level selection among unsubsidized on-marketplace enrollees, as reported by HHS.]
---
There are basically two individual markets for health insurance in the United States: one for subsidy-eligible people earning under 201% of the Federal Poverty Level (FPL), and one for everyone else.

Subsidy-eligible marketplace shoppers with incomes up to 200% FPL are eligible for Cost Sharing Reduction (CSR) subsidies that radically reduce deductibles, copays and maximum out-of-pocket costs. CSR subsidies are available only to those who buy silver plans, as something over 80% of enrollees with incomes up to 200% FPL do.  CSR weakens sharply at 201% FPL and phases out at 251% FPL.

Some time ago I calculated that the weighted average actuarial value for plans sold on the marketplace in 2016 was just about 80%, (The actuarial value is the percentage of the average enrollee's yearly medical costs that the plan is designed to pay.)   80% AV is close to the average for employer-sponsored health plans, and it sounds good, but it masks a sharp division. For those with incomes up to 200% FPL, the average AV was 86%. For the unsubsidized, it was 69%. For those who obtained premium subsidies but had incomes over 200% FPL, it was also 69%.

While average AV was similar for the unsubsidized and the over-200% FPL-subsidized, their choices were somewhat different. About 60% of the over-200%-FPL subsidized group chose silver plans -- in part because weak CSR attaches to silver plans for those in the 200-250% FPL bracket. Among the unsubsidized, only 39% chose silver, but AV was boosted by 18.5% of this more affluent group choosing gold plans, and 3.3% choosing platinum.

This week, the Robert Wood Johnson Foundation published a study, reported by Modern Healthcare's Harris Meyer, that details plan choices offerings (and prices) in the off-marketplace ACA-compliant individual market. [Update: per note above, see Commonwealth Fund data below.] And it turns out, unsurprisingly, that the choices made by those who bought their plans off-marketplace -- by definition, unsubsidized -- look much like the choices of unsubsidized marketplace enrollees: a lot of bronze, but also a lot of gold and platinum.  Below is the breakout of metal level selections offerings off-marketplace for 2016 according to RWJF.*

Actuarial Value	Percent of Off-marketplace enrollees plan offerings
90 (platinum)	7.0**
80  (gold)	21.6
70 (silver)	33.7
60 (bronze)	33.1
57 (catastrophic)	4.6**
69.6 (Weighed AVG)

Their choice pattern [insofar as it reflects plan offerings]  is pretty close to that of unsubsidized enrollees on HealthCare.gov:

Actuarial Value	Percent of unsubsidized hc.gov enrollees
90 (platinum)	3.3
80  (gold)	18.5
70 (silver)	39.0
60 (bronze)	33.0
57 (catastrophic)	6.8
68.9 (Weighed AVG)

See plans and prices -- and get buttonholed for Cost Sharing Reduction -- on HealthCare.gov

Healthcare.gov has launched its "shop-around" feature for 2017 -- that is, the screen where you can enter a few basic facts about yourself and then preview plans and prices, with your subsidy built into the price estimate.

As in past years, the shoparound has been redesigned. The new design has plusses and minuses in my view. As always, my primary focus is on how well the app communicates about Cost Sharing Reduction (CSR) subsidies, which are available only with silver plans, and only to people with a household income up to 250% of the Federal Poverty Level (FPL).

CSR radically lowers deductibles and copays for buyers with incomes up to 200% FPL and offers a more marginal benefit to those in the 200-250% FPL range. Because the benefit comes only with silver plans, the silver level provides the best value in absolute terms to CSR eligibles.

Because it makes silver plans more valuable than gold plans for anyone with an income up to 200% FPL, CSR is inherently counterintuitive. And because silver plans cost more than bronze, they are easy to miss when plans are ranked by premium, lowest first.

Some state-run ACA marketplaces "default to silver" for CSR-eligible shoppers -- that is, they automatically show silver plans first in the display of available plans. HealthCare.gov appears to have thought long and hard about doing this. Current CEO Kevin Counihan ran Connecticut's ACA marketplace, which has "defaulted to silver" since its launch in 2014. Connecticut has had an unusually high CSR takeup rate.

What Hc.gov decided for 2017 was a kind of optional default to silver. If you're CSR-eligible, the screen below appears before you move on to view available plans (apologies for the cut off phrase at top: it should read "only if you pick a silver plan"):

Since this screen is meant to highlight the benefits of CSR, there's a disconnect in fronting the "estimated total yearly costs." That estimate derives from a prior screen, in which you forecast whether you'll need a low, medium or high level of medical care. The estimate above is for a "low" user.

There may be an appropriate place for that information, but this is not it. What's not highlighted is the radical difference in bronze vs. silver deductibles and copays -- a disproportionate difference, thanks to the CSR subsidy added to silver alone. The light-text explanation at bottom appears to fly in the face of the cost estimate -- which of course presumes that the buyer will be a light user as expected. Risk is left out of the equation implied by the bolded text, as is the extra value added by CSR.

A second flaw is in the contrast of the average premium at each metal level. That average can be skewed by some very expensive options. Most marketplace enrollees consider only the cheapest plans available at each metal level.  In this zip (07079) and income level $23k), the cheapest-plan contrast for a 40 year-old would be between a bronze plan at $69 per month with a $3,000 deductible and a silver plan at $104 with a $300 deductible. That would make a more compelling and coherent contrast:

The good news is, I got that comparison from the shop-around's excellent "compare plans" feature. But I had to first pick through the bronze selections to find the first silver (which, to make matters more confusing, was cheaper than several bronze plans in this zip code). The contrast of CSR-enhanced silver with bronze should be clearer in the intro screen.

A third flaw is that if you go back and edit your information, for example to change the income estimate, you don't get the CSR filter screen the second time around.  You just get plans ranked by premium, and the only alternative filter available at first blush is to rank them by deductible, which can yield off-putting results if there are gold plans at premiums that quintuple lower-cost bronze or silver.

There is in fact an additional "refine results" filter that enables screening for a host of options, but it's in a different color and took me several passes to notice it (I can be a very thick user, but I'm sure I'm not alone in that).

As in previous years, once you've input your basic information and before the screen discussed above appears there's an overview screen that also provides an explanation of CSR. But it's  in light type at the bottom of the page, very subordinate to the centerpiece focused on the tax credit:

The broader shoparound tradeoff is between keeping it short and simple, so that users get a quick view of what they're likely to pay, or slowing the process by adding more information, such as plans that cover the shopper's drugs and have her doctors and hospitals in-network.  This year's shoparound takes  a bit longer to get through  than last year's, which was slower than 2015's. Added this year is a filter to indicate whether one is eligible for subsidies at all, e.g., whether the user has an offer of affordable insurance from an employer, which renders him subsidy-ineligible.

In my view that is a worthy feature, as are the drug and doctor filters, and, if properly contextualized, the total cost estimator, which varies according to whether the user anticipates low, medium or high use of medical services. But I wonder whether a two-tier process mightn't be appropriate. In 2015, you could view plans and prices, with your subsidy priced in, within 30 seconds of visiting the home page.Perhaps the shoparound should start with the most basic info -- zip code, household members with their ages, and family income -- give the price quotes, and then prompt for the additional info in a second stage.  In particular, I'm wary of total cost estimators, which tend to push the cost of unexpected accident or illness out of view. I think the results should be carefully hedged, perhaps with views of what you'll pay under alternative scenarios.

Still, the current shoparound gets you results reasonably fast, and I can't say it ignores CSR, the workings of which are notoriously difficult to communicate. We'll see how it works out for users.

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

HHS projects no growth in individual market for health insurance in 2017

The salient point about HHS's enrollment projection for the ACA marketplace in 2017 is that it does not project any growth in the individual market as a whole.

The ASPE brief laying out the forecast projects 13.8 million enrollments in the ACA marketplace by the end of open enrollment 2017, an increase of 1.1 million over the end of the 2016 enrollment period. That estimate includes 1.1 million people expected to move from off-marketplace coverage into the marketplace -- a projection based on HHS's recent estimate that 2.5 million off-marketplace enrollees are potentially eligible for marketplace subsidies.

Since insurers' ACA-compliant off-marketplace plans share a risk pool with their on-marketplace plans, a total market that stays flat will not improve insurers' risk pools, except to the extent that those who come on-marketplace switch from pre-ACA grandfathered and grandmothered plans (as far as I can tell, the ASPE brief does not clarify whether some of the anticipated transfers will come from such plans, which are phasing out). Thus the individual market as a whole may not be any more attractive to insurers next year than this year, except to the extent that this year's price hikes cover last year's losses, or the pent-up demand for medical care on the part of previously uninsured marketplace enrollees starts to level off, or regulatory and risk adjustment changes have a positive effect.

On the other hand, as Kaiser's Cynthia Cox pointed out on Twitter, a transfer from off-marketplace to on-marketplace may reduce insurers' temptation to end their marketplace participation and sell off-marketplace only in some regions.

Chipping away at the uninsured: What about those who can't afford employer-sponsored insurance?

Last week, I explored  why HHS's estimate that 9 million of the uninsured may be eligible for ACA marketplace tax credits is so much larger than the Kaiser Family Foundation's estimate of 5.4 million. In brief, the chief differences seem to be a) Kaiser takes into account those among the uninsured who have an offer of insurance from an employer, most of whom are probably ineligible for tax credits, and b) Kaiser also estimates and excludes those with incomes in the 250-400% FPL range who are "potentially" tax credit eligible but in fact ineligible because the unsubsidized premium for the benchmark silver plan in their area is deemed affordable by ACA criteria (i.e., costs under 8-10% of income).

Today, Kaiser updated its 2015 estimates, published in January 2016, of various categories of uninsured. The first thing to note is that the pool has shrunk: Kaiser now estimates 27.2 million nonelderly uninsured in 2016, down from 32.3 million in 2015. Next, the estimated percentage of uninsured who are eligible for financial assistance -- either Medicaid or marketplace subsidies -- is down from 49% to 43%.

That's due in large part to Medicaid enrollment: The estimate of uninsured people eligible for Medicaid is down from 8.9 million in 2015 to 6.4 million at present. But the estimate of the uninsured who are eligible from marketplace tax credits is also down, from 7.0 million in 2015 to 5.3 million now (an estimate Kaiser had already published, with minimal difference, earlier this year, and which I cited in the prior post).

As the ACA marketplace and the larger individual market with which it shares a risk pool wobble this fall, a key question is how close to capacity those linked markets are. Kaiser's new estimates suggest that not only has the pool of uninsured and potentially subsidizable marketplace candidates shrunk, but so has the pool of those who earn too much to qualify for subsidies yet remain uninsured -- from 3.7 million in 2015 to 3.0 million this year. (One thing to watch this year is whether premium spikes reverse that progress among the unsubsidized.)

Put the two together, and the pool of uninsured who might buy health insurance in the individual market has shrunk from 10.7 million to 8.7 million.

Michelle Obama opens the doors of perception

For the second time* in this election season, Michelle Obama riveted the country and the world with moral clarity, in a speech delivered yesterday in New Hampshire. She named Donald Trump before the world. She detailed the effects of his sexual predation -- on herself, voice shaking a little, and on a series of concentric audiences -- the one before her, the nation's children, the world. As she did at the convention, she set Trump's manifest depravity against an idealized portrait of American values as she (or her husband) strives to embody them.

The denunciation was as carefully structured as it was deeply personal. She began, by way of contrast, with a norm as she experiences it, American values that she strives to advance, as expressed in an International Day of the Girl event at the White House  (part of her Let Girls Learn program). There she "had the pleasure of spending hours talking to some of the most amazing young women you will ever meet, young girls here in the U.S. and all around the world." That opened a window on the ravages of male dominance throughout human society - and the route out:

Are 2.5 million off-exchange health plan enrollees subsidy-eligible?

A recent HHS ASPE* analysis of the ACA marketplace and the uninsured found that an estimated 2.5 million people currently enrolled in health plans bought in the off-exchange individual market are potentially eligible for premium subsidies in the ACA marketplace. That is, 2.5 million people may have foregone subsidies by buying off-exchange or may be eligible for them in 2017. That's a pretty eye-popping number -- indicating that 70% of those currently enrolled in the individual market (on- and off-exchange) are subsidy-eligible.

HHS further estimated that 9 million of the uninsured are potentially eligible for subsidies in the ACA marketplace, and that a total of 20.9 million people are subsidy-eligible -- more than double the 9.4 million enrolled in subsidized marketplace plans as of March 31 of this year. Those estimates are markedly different from those of the Kaiser Family Foundation, which estimates that 5.4 million of the uninsured are potentially subsidy-eligible, and pegs the total subsidy-eligible population at 14.9 million.

The HHS analysis is based on different survey data than the Kaiser estimate: HHS uses the National Health Interview Survey (NHIS) while Kaiser relies on the Current Population Survey (CPS). But HHS's higher estimates may stem in large part from two more fundamental differences.

Bill Clinton's other "craziest thing in the world"

I have a post up at healthinsurance.org that looks at an apparent slip from Bill Clinton's political id regarding Obamacare. No, not that "craziest thing in the world" slip -- the one about allowing those who earn too much to qualify for subsidies in the ACA marketplace to buy into Medicaid.

To buy into what? Who suggested that? Certainly not Hillary. But it -- or something very like it  -- might not be such a bad idea. Please take a look.

My last several posts at healthinsurance.org explore outside-the-box ideas for strengthening and/or amending the ACA. They include a Medicare buy-in that Republicans might like and a way to get public option pricing into the ACA marketplace without the 'public' part. Also pointing possible alternate paths: a close look at the Basic Health Programs and proposals to expand them in Minnesota and New York.

Hillary, speak to service workers

In this aphorism by Binyamin Appelbaum lies latent, I think, the organizing principle, articulated or not (okay, not), of Hillary Clinton's economic agenda:

Soon, we will be living in the United States of Home Health Aides, yet the candidates keep talking about steelworkers. 

Let's back up for some context. While U.S. manufacturing output is at an all-time high,  80% of Americans work in the service sector, Appelbaum reports, Yet politicians of both parties keep romanticizing and prioritizing manufacturing jobs:

In which Obama feels the pain of the price tag he imposed on the ACA

In an interview with Jonathan Chait, President Obama rather casually ticked off his first priority for shoring up the ACA:

In my mind the [Affordable Care Act] has been a huge success, but it’s got real problems. They’re eminently fixable problems in terms of strengthening the marketplace, improving the subsidies so more folks can get it, making sure everybody has Medicaid who was qualified under the original legislation, doing more on the cost containment. But you hit a point where if Congress just is not willing to make any constructive modifications and it’s all political football, then you’re getting a suboptimal solution. 

By now, the imperative to enrich the marketplace subsidies is a matter of consensus among progressive healthcare scholars and officials. Out-of-pocket costs are just too high for prospective enrollees with incomes over 200% of the Federal Poverty Level (FPL)*, the cutoff for strong Cost Sharing Reduction (CSR) subsidies, and premium subsidies leave buyers paying too high a percentage of their income -- between 6.4% and 9.7% of income for those in the 200-400% FPL range. In August 2015, Urban Institute scholars Linda Blumberg and John Holahan put out a detailed proposal for subsidy enrichment that included raising the actuarial value of the benchmark plan to 80% from the current 70% , with richer CSR extending further up the income ladder, as well as capping premiums at 8.5% of income for all income levels. Hillary Clinton's rather vague proposal for subsidy enrichment is apparently based on Blumberg and Holahan's. ACA improvement proposals by Timothy Jost and Harold Pollack and Sabrina Corlette and Jack Hoadley also prominently feature subsidy boosts.

The inadequacy of marketplace subsidies was evident to progressives from the beginning. Complaints began when Max Baucus's Senate Finance Committee released its bill in fall 2009, with a subsidy schedule that was far skimpier than that of the House bill.** In his 2011 book about the battle to pass the ACA, Richard Kirsch, national campaign manager from 2008-12 for Health Care for America Now (HCAN), an  umbrella group formed by unions and progressive nonprofits to advocate for universal health care, pins responsibility for the skimpy subsidies primarily on Obama:

Blumberg and Holahan on belling the healthcare cost cat

This week, Urban Institute healthcare scholars Linda Blumberg and John Holahan published a report, Designing a Medicare Buy-In and a Public Plan Marketplace Option: Policy Options and Considerations.

The report demonstrates that while designing a Medicare buy-in would be dazzlingly complex (cf. my modest proposal for simplifying it), designing a "strong" public option would be relatively simple. For both programs, the rationale is also simple: moving part (or potentially all) of the individual market population into plans that pay Medicare rates to healthcare providers.  That, the authors note in conclusion, is is basically a sine qua non of healthcare cost control:

Regardless of the approach taken, providers are likely to resist new insurance options that may move more patients into plans paying lower rates. While this is to be expected, it highlights the perpetual quandary of health care cost containment. Health care spending and its growth cannot be reduced without either paying less, on average, per unit of service rendered or reducing the quantity of services provided. No matter the strategy for containing costs, achieving that goal will take money out of the pockets of providers. To protect providers financially means abdicating cost-containment efforts of any type.

Healthcare scholars who propose means of cutting payments to providers know that they're in the position of mice who propose putting a bell on the cat that stalks them. No one in elected office is willing to bell the cat.

The other side of John Sides' debate skepticism

Those of us who've enjoyed the blogging and tweeting of political scientists in recent years often tease them as the "nothing matters" crowd. As measured by polling, in the normal course of things, gaffes don't matter, campaign ads don't matter...usually even gender doesn't matter.

As for debates...the ur-text for data-driven skepticism about their impact is John Sides'  Do Presidential Debates Really Matter?, published in September 2012.  The subtitle gives you the rhetorical thrust: Remember all the famous moments in past debates that changed the outcome of those elections? Well, they didn’t.

As a preview for tonight's debate, Sides offers an update/recap.  On the skeptical side of the ledger, here are the takeaways:

Mean vs.Median in post-ACA health insurance

This from Princeton's Paul Starr, speaking about the rise in deductibles in employer-sponsored health plans, rang a bell:

Since the ACA, there has been no overall increase in cost sharing. There are higher deductibles, but the ACA has also eliminated most annual and lifetime limits. It has provided for more complete coverage of preventive care.
So, people actually have benefited from the ACA in some ways. But I do not think they understand that...

I think many policy analysts, looking at this objectively, would say this is actually a very good shift. That it makes sense to cover those preventive costs. It makes sense to protect against catastrophic risks. The offset to that is that people have more exposure to routine medical costs up to their deductible. 

Actually, it rang two bells. I noticed this apparent paradox myself in a 2015 Commonwealth Fund survey of underinsurance: deductibles had risen, but the percentages of enrollees going without needed care or having difficulty paying medical bills hadn't. 

More to the point, though, it reminded me of the core claim in a study by Brookings' Loren Adler and Paul Ginsburg of the post-ACA individual market: that premiums are lower than they would have been absent the ACA (and lower than forecast by CBO, even accounting for this year's spike).

"The political magic of C.S. Lewis" went just so far

In a NYT op-ed, Christian conservative Peter Wehner, whose principled opposition to Trump is worthy of respect, holds up C. S. Lewis as a repository of conservative political wisdom:

Professors Dyer and Watson write that Lewis had “a very limited view of government’s role and warrant,” was skeptical of its capacity to inculcate virtue and worried about its paternalistic tendencies. The duty of government was to restrain wrongdoing. Because he believed in the fallen nature of humanity, Lewis was concerned by the concentration of political power. “It is easy to think the State has a lot of different objects — military, political, economic, and what not,” Lewis wrote. “But in a way things are much simpler than that. The State exists simply to promote and to protect the ordinary happiness of human beings in this life.”

Lewis was wary of “morals legislation.” For example, during a period when the criminalization of homosexuality was considered by many to be justified, Lewis asked, “What business is it of the State’s?” Nor did he believe it was the duty of government to promote the Christian ideal of marriage. “A great many people seem to think that if you are a Christian yourself you should try to make divorce difficult for everyone,” he wrote in “Mere Christianity.” “I do not think that. At least I know I should be very angry if the Mohammedans tried to prevent the rest of us from drinking wine. My own view is that the Churches should frankly recognize that the majority of the British people are not Christians and, therefore, cannot be expected to live Christian lives.”

Wehner's portrayal of what Andrew Sullivan would call Lewis' "conservatism of doubt" is accurate as far it goes. That doubt was tonic in some ways. Lewis recognized that theocracy is the worst form of government; that God could be dragooned into support almost any political agenda; and that democracy was necessary to check the corrupting influence of power.

These points reflect Lewis' fundamental sanity and humility. They leave out, however, the limitations of his political perspective.

Medicare buy-in, Republican style

At healthinsurance.org, I explore a possible future political deal to amend the ACA, with help from Jack Hoadley of Georgetown and Harold Pollack of the University of Chicago:

One might assume that Republicans would never go for a Medicare buy-in, as it would expand the ranks of those who get "government-run" insurance.  But what if the buy-in were limited to Medicare Advantage plans, the GOP's beloved Medicare stepchild?

Republicans might view a buy-in limited to Medicare Advantage as a gateway drug. At present, only 2% of Medicare Advantage enrollees switch to traditional Medicare, so those who came in via a buy-in would probably stay in. Increasing MA's already-growing market share from the current 30% toward or beyond parity with traditional Medicare might be tempting to GOP lawmakers.

A few statistical anomalies in healthcareville

Struggling with a difficult post, I just made a little list in my mind of some statistical oddities I've stumbled across in the past year or so in the wonderful world of U.S.  health insurance. Some are mysteries, some are apparent errors, and some involve frames that may give the wrong impression. In no particular order:

1)  In 2016, CBO changed the way it counts Medicaid enrollees under age 65. No, there was not a surge of 16 million unanticipated enrollments, as reported more than once. Rather, CBO started counting "dual eligibles" under age 65 in the Medicaid total, along with enrollees in various limited benefit programs.  More here.

2. Oft-quoted stat: In 2017, the ACA marketplace may have only one insurer in almost one third of U.S. counties. Less quoted: 19% of the population lives in those counties. 72% of the population lives in counties with 3-8 insurers (Kaiser). This is not to sugar-coat bad news, but the effect of recent pullbacks on people should take priority over its effect on acreage.

Hastening to be slaves and tyrants

Here is C.S. Lewis' charming Screwtape, senior devil, who spends his time teaching"junior devils" how to tempt humans to hell. Last line is a blueprint for Trump and his minions:

The use of Fashions in thought is to distract the attention of men from their real dangers. We direct the fashionable outcry of each generation against those vices of which it is least in danger and fix its approval on the virtue nearest to that vice which we are trying to make endemic. The game is to have them running about with fire extinguishers whenever there is a flood, and all crowding to that side of the boat which is already nearly gunwale under. Thus we make it fashionable to expose the dangers of enthusiasm at the very moment when they are all really becoming worldly and lukewarm; a century later, when we are really making them all Byronic and drunk with emotion, the fashionable outcry is directed against the dangers of the mere “understanding”. Cruel ages are put on their guard against Sentimentality, feckless and idle ones against Respectability, lecherous ones against Puritansm; and whenever all men are really hastening to be slaves or tyrants we make Liberalism the prime bogey.

Scoping out a Medicare buy-in

Hillary Clinton's raft of healthcare policy proposals includes enabling 55-64 year-olds to "opt in" to Medicare. No detail is provided.

I have a piece in progress that looks at a variant of a Medicare buy-in. This is a scratch-pad post, to help me clarify for myself who might or might not benefit.

When Clinton first verbally expressed a willingness to consider a Medicare buy-in, Avalere Health scoped out the potential market, but they did it for a wider age group, 50-64, as Clinton first mentioned 50 or 55 as a threshold.  Avalere's Caroline Pearson and Chris Sloan were kind enough to provide me with a breakout of their calculations for 55-64 year-olds. As it's based on the 2014 American Community Survey, I have updated where possible, as explained in notes below.

Presumably the buy-in would not be offered to roughly 24 million people in the 55-64 age group who have access to employer-sponsored insurance -- including retirees with ESI, whom Kaiser estimated to number 5.3 million in 2012.  I doubt there's a single member of Congress, Senator or potential president other than Bernie Sanders with a more than theoretical interest in shaking up employer-sponsored insurance

The buy-in would be open to the uninsured in the 55-64 age band, who currently number about 3.4 million,* and to those who currently get their insurance in the individual market, of whom there are probably a bit over 5 million. That includes a shade under 3 million in the ACA marketplace, and probably another two million-plus buying off-exchange. About 2.4 million marketplace enrollees in the age group are subsidized, if. the marketplace income breakouts reported by CMS apply proportionately to this age group.**

New York Times calls out four Trump lies in one day

There seems to be a common thread in the New York Times' campaign coverage today. First, the lead story:

Donald Trump Clung to ‘Birther’ Lie for Years, and Still Isn’t Apologetic

It was not true in 2011, when Donald J. Trump mischievously began to question President Obama’s birthplace aloud in television interviews. “I’m starting to think that he was not born here,” he said at the time.

It was not true in 2012, when he took to Twitter to declare that “an ‘extremely credible source’” had called his office to inform him that Mr. Obama’s birth certificate was “a fraud.”

 It was not true in 2014, when Mr. Trump invited hackers to “please hack Obama’s college records (destroyed?) and check ‘place of birth.’” It was never true, any of it. Mr. Obama’s citizenship was never in question. No credible evidence ever suggested otherwise.

As more Americans move out of poverty, will some move into ACA marketplace?

Data from the Census Bureau's just-released Current Population Reports for 2015 records a trifecta for the U.S. economy: incomes soaring (after years of stagnation and shrinkage), poverty reduced, health insurance rates rising.

A thought occurred to me while reading this part of economist Jared Bernstein's overview:

The official poverty rate fell from 14.8 percent in 2014 to 13.5 percent last year, a decline of 3.5 million people in households whose incomes put them below the poverty threshold for their family type (the poverty threshold for a single parent with two children was around $19,000 in 2015). 

The thought: Families rising out of poverty could be pushing ACA marketplace enrollment from the bottom up, particularly in states that refused the ACA Medicaid expansion.

Give Republicans this: They know how to make insurers happy

After Aetna's threat to pull back from the ACA marketplace if its merger with Humana was contested by the Justice Dept came to light, I noted that even in CEO Mark Bertolini's Springtime for the ACA aria last April, there was an equivocal note. That is, 'this market can work if Congress does its work':

we see this as a good investment, hoping that we have an administration and a Congress that will allow us to change the product like we change Medicare every year, and we change Medicaid every year.

But we haven't been able to touch this product because of the politics. But if we can get to that point, we believe we are in a very good place to make this a sustainable program (my emphasis).

Why Bertolini might have thought "we can get to that point" in the foreseeable future, barring a Democratic blowout in the November elections, is anyone's guess.  Notwithstanding, that "if" gave him at least rhetorical pivot space. When Elizabeth Warren, Bernie Sanders and allied senators challenged the Aetna pullback this week, Aetna neatly foreclosed on the "if":

How bout adding a Medicare advantage to the ACA Marketplace?

The main purpose of the public option was to dive down the cost of insurance in the individual market by making it available through a plan that would pay Medicare rates to providers, rather than the much higher rates usually paid in the commercial market.

There are other ways to do that. In the Medicare Advantage program, insurers pay providers rates that are by all accounts very close to those paid by traditional Medicare. At healthinsurance.org, I delve into a proposal to accomplish that goal by indirection, via a relatively simple rule change. The proposal comes from  Jon Kingsdale, a health insurance industry veteran who was the founding executive director of the Massachusetts Connector, the insurance exchange established under Romneycare, prototype of the ACA marketplace. Here's the upshot:

The World Turned Upside Down: Risk adjustment and its discontents

In Kimberly Leonard's US News story about the quest to bring more young adults into the ACA marketplace, this input from Caroline Pearson of Avalere Health made my head spin:

Pearson says another phenomenon is contributing to the problem: Insurers don't receive adequate help in paying for this population from the government.

"There is an adverse incentive to aggressively recruit younger healthier people because insurers aren't being compensated adequately for them," she says, adding that this is something the administration could address without Congress.

That's counterintuitive, in that healthy young adults famously cost far less to insure that sicker older adults (or sicker younger ones, but the odds are with the young, as Leonard points out).  Indeed, a longstanding complaint about the marketplace from conservatives such as Avik Roy is that the oldest enrollees can only be charged three times as much as the youngest adult participants, compared to a prior industry norm of 5-to-1.  That is, conservatives argue that marketplace premiums should be lower for young adults, and higher for older ones.

The marketplace, however, is a tended garden, not a wilderness, and its plants are pruned by government shears, a.k.a. risk adjustment. In an email, Pearson explains what kind of compensation she was alluding to:

My take on the ACA marketplace

FWIW, here is a sort of global take on the ACA marketplace, its place in U.S. healthcare delivery, and how I'd change it if I could (unless those who are better informed convinced me otherwise).

1. The experience of basically every wealthy country in the world in distinction from the U.S. suggests that the sine qua non of effective healthcare cost control is some form of government rate-setting -- that is, government control over or oversight of a more or less uniform pricing schedule for medical services and drugs. Whether the government pays providers directly, sets rates for private insurers, or provides oversight  as insurers collectively negotiate rates, some uniformity and oversight is essential to keep healthcare providers from dividing and conquering payers.

2. The ACA marketplace leaves insurers to negotiate their own rates, as in the much larger employer market, but with pricing pressures that render the market viable only for those that pay government rates -- e.g., insurers whose primary business has been managed Medicaid.

In 2016, CBO started counting Medicaid enrollment differently

CORRECTION, 6/6/17: Somehow, I missed an email response to my query from CBO (and asked them again twice after receiving the email). In 2016, they did not count partial benefit enrollees in their Medicaid totals; rather, the difference was that they counted people with multiple sources of coverage, including Medicaid, as Medicaid enrolled, whereas in past years they counted only the coverage source deemed primary. I was correct that in 2016 they started counting dual eligibles in both Medicaid and Medicare.

In a US News article by Kimberly Leonard about why the ACA private plan marketplace is not meeting enrollment expectations, while the ACA as a whole is reducing the ranks of the uninsured more or less on schedule, this claim did not compute:

Under Obamacare, states were allowed to expand the program to many more people, but many states have opted not to. Despite that, 16 million people more than expected enrolled in Medicaid and the Children's Health Insurance Plan, including in states that did not expand the program. Many people, it turns out, realized that they could have qualified for Medicaid even before the passage of the health care law.

Similarly, last March, when the Congressional Budget Office published its latest forecast of the ACA's effects, The New York Times' Robert Pear reported:

Yes, the ACA marketplace needs to grow. But it also needs to shrink

As major health insurers cut back their participation in the ACA marketplace, observers have drawn the obvious conclusion that the market is too small to be viable. The CBO forecast year after year from 2010 through 2015 that 21-22 million people would be enrolled in marketplace plans in 2016; only 11 million currently are. The risk pool is older and too sicker than it should be; the marketplace needs an influx of younger and probably wealthier (and therefore healthier) enrollees.

All true. But it's probably also true that the marketplace needs to shrink even as it grows.

Our failures of political rhetoric are asymmetric

The study of rhetoric can yield great insights into the way power is structured and masses of people are moved. But those who study rhetoric closely are prone to mixing up cause and effect.

So it is with an essay by New York Times CEO Mark Thompson that usefully traces The Dark History of Straight Talk -- that is, of politicians' claims to authentically channel the mystical will of the people. Simpson begins with Shakespeare's rendition of Mark Anthony's funeral oration for Caesar, in which he claims to be "no orator," but a "plain, blunt man," eschewing the rhetoric that was the chief marker of political authority in Rome. He moves on to reaction against the rationalist language of the Enlightenment, to the hookup of "anti-rhetoric" with nationalism and Heidegger's fetishization of "authentic" language, culminating in his embrace of Hitler. Finally he focuses on the anti-elitism and demonization of out-groups by the current crop of authoritarians in western democracies, culminating (for the moment) in Trump.

All good so far. But here's where I think Thompson confuses conditions that make large numbers people responsive to "authenticism" with the current condition of rhetoric itself:

What we have lost and must strive to regain is a conception of rhetoric that strikes a balance between the demands of reason, character and empathy, and that strives for genuine truthfulness rather than theatrical “authenticity.”

That makes me wonder whether Thompson has ever listened to a certain Barack Obama, who won the presidency by sheer force of rhetoric -- and whose rhetoric has arguably balanced "reason, character and empathy" as powerfully as any president's since Lincoln (whose rhetoric Obama constantly, consciously channels).

Re the qualities Thompson thirsts for: for empathy, I suggest watching Obama tear up when speaking of the Sandy Hook shooting, or listening to him sing Amazing Grace after the Charleston, or read how he delineates the emotional logic of those who perceive reverse racism in his More Perfect Union speech in March 2009*, or lays out the plights of individuals who lack health insurance in his speech to rescue the health reform bill in September 2009.**

HHS markets to the lower income brackets

I have complained more than once about HHS's mantra that most ACA marketplace shoppers can find a plan for under $75 per month. My beef has been that the message overemphasizes premium price at the expense of balancing premium with out-of-pocket costs. That's particularly perverse since most shoppers have to buy silver plans to access Cost Sharing Reduction subsidies that render silver a better value than bronze.

Well, CMS is at it again, and in light of the marketplace's recent travails -- insurer losses, insurer exits, premium price spikes -- I was struck by another problem with the "most can get plans for under $75" assurance.

Today HHS released a brief emphasizing that since 85% of HealthCare.gov enrollees qualified for premium tax credits in 2016, that same overwhelming majority will be protected from premium price hikes in 2017. The premise is simple: if you're subsidy-eligible, you pay a fixed percentage of your income for the benchmark silver plan in your area, regardless of its sticker price. When prices rise, subsidies rise, and the spread between benchmark silver plans and cheaper bronze plans will widen slightly, slipping slightly more applicants in under the $75 and $100 thresholds.* Hence this highlight:

In a hypothetical scenario in which all Marketplace qualified health plan premiums
were to increase by 25 percent from 2016 to 2017:
          o 73 percent of consumers could find coverage for $75 or less.
          o 78 percent of consumers could find coverage for $100 or less.

Okay, but all this "most-people" messaging also brings home the fact that HHS anticipates marketplace enrollment remaining concentrated in lower income brackets -- mainly under 200% of the Federal Poverty Level (FPL). In 2016, somewhere between 61% and 66% of HealthCare.gov enrollees had incomes below that level.   HHS estimates that 70% of enrollees could have bought plans for under $75 per month, which suggests that about 70% had incomes under, say, 220% FPL.**

What if a public option were added to the ACA marketplace now?

Aetna's sudden sharp cutback in its participation in the ACA marketplace has renewed discussion of how the marketplace might be stabilized. The most obvious fix is to boost the subsidies and thus lower subsidized  enrollees' premiums and out-of-pocket costs. At present, Kaiser estimates that about 64% of people eligible for subsidies are enrolled in marketplace coverage. Many of the subsidy-eligible uninsured find the offered coverage unaffordable. If the marketplace were attracting 90% of those eligible the risk pools would be much deeper. That would in turn moderate the pending price hikes for the unsubsidized.

The premium hikes and large-insurer pullbacks have also renewed calls to create the public option -- a government-run plan competing on equal terms with private insurers in the marketplace. In the runup to the ACA's passage, progressives regarded the public option as a linchpin, an essential means of keeping private insurers from price-gouging. Its absence from the final bill was regarded as a major defeat.

What would be the likely effects of adding a national public option now, if it were politically possible? A few points:

1. Before risk adjustment and reinsurance are factored in, ACA-compliant plans were calculated to have paid out an average 110% of premiums collected in medical claims in 2014 and, for  the entire individual market 4th-largest health insurer HCSC* in 2015,, 117% .  Those negative loss ratios have driven average weighted average premium increases of 24% this year (though the increases will likely prove lower for the plans most people will buy). Those losses have led to exits and pullbacks that, according to Avalere Health, will leave 55% of rating areas nationally with two or fewer competitors (though that number disproportionately includes low-population areas, and so most buyers will probably have more choices).  In many regions, if a public option managed to significantly underprice the competition, it might well become the only option.

In which Gingrich sums up his whole career

Via Brendan Nyhan, I happened on a July 22 CNN interview with Newt Gingrich in which that Trump precursor was astonishingly open about his theory of fact.

The interviewer was Alyson Camerota, and the subject was Trump's convention speech. Here's a transcript (my emphasis). Video clip at bottom.

CAMEROTA: Some people think it was too bleak. That he painted too bleak a picture of where we are in America. Crime is down in America. Violent crime is down. The economy is picking up --

GINGRICH: It is not down in the biggest cities.

[08:35:01] CAMEROTA: Violent crime, murder rate is down. It is down.

GINGRICH: Then how come it's up in Chicago, up in Baltimore, and up in --

CAMEROTA: There are pockets where certainly we --

GINGRICH: Your national capital, your third biggest city --

CAMEROTA: But violent crime across the country is down. We're not under siege in the way that we were in say, the 80s.

Underlying Aetna's ACA pullback: Despair of Congress?

In a major scoop, Jonathan Cohn and Jeffrey Young of the Huffington Post obtained via FOIA a July 5 letter from Aetna CEO Mark Bertolini to the Justice Department spelling out that Aetna would cut back its participation in the ACA marketplace if Justice moved to block the company's pending merger with Humana.

Citing Aetna's losses in the ACA marketplace to date and the costs of a busted merger, Bertolini wrote that if  DOJ opposed the merger -- as it did two weeks later -- Aetna would cancel plans to expand its participation in the ACA marketplace from 15 states to 20, and instead cut back to 'no more than 10 states" --- and probably exit the market entirely in future years.

Cohn and Young provide a balanced view of partisan perceptions that Aetna is, in one view, engaging in regulatory hardball (or blackmail) or, in the other, responding to real losses and difficulty in the ACA marketplace.. Probably a bit of both, as Nicholas Bagley suggests  While Bertolini expressed conditional optimism about the ACA marketplace as recently as an April earnings call, Cohn and Young cite an Aetna spokesman's claim that losses have accelerated since then.

Regardless of the precise mix of Aetna's motives and calculations, Bertolini's response to a question about the ACA marketplace* in the April call, quoted by Cohn and Young, is interesting in retrospect. Below is a longer excerpt from his response, with the portion cited by Cohn and Young bolded.

Let me just give you a different basis to think about our participation in the exchanges. We have 911,000 members on the public exchange as individual. We have 1.2 million members that are exchange or ACA compliant.

If we were to go out and buy those members, it would cost us somewhere around $1.2 billion to acquire them. If we were to build out 15 markets, it would cost us somewhere between $600 million to $750 million to enter those markets and build out the capabilities necessary to grow that membership.

So in the broad scheme of things, we are well, well below any of those numbers from the standpoint of losses we've incurred in the first two-and-a-half years of this program. So we see this as a good investment, hoping that we have an administration and a Congress that will allow us to change the product like we change Medicare every year, and we change Medicaid every year.

But we haven't been able to touch this product because of the politics. But if we can get to that point, we believe we are in a very good place to make this a sustainable program.

While Bertolini's letter to DOJ cites the sunk costs of the merger as a reason to cut losses in the marketplace, this earlier statement cites the costs of getting established in the marketplace as a relative bargain (which would in turn become sunk costs if Aetna exits altogether).

So that's one side of the equation. On the other is Bertolini's rueful closing comment about the politics of the ACA.  He suggests that a public benefits program can't be frozen in amber: it requires constant adjustment. Unspoken: Republicans' rooted enmity against the ACA is making such adjustment impossible.

The same point was made implicitly in a report issued yesterday by Georgetown healthcare scholars Sabrina Corlette and Jack Hoadley, laying out Lessons from Medicare as a source of strategies to stabilize the ACA marketplace. The chief (implicit) lesson: get a Congress willing to fix problems as they arise.

The report usefully illustrates that the price spikes and insurer exits that the ACA marketplace is currently experiencing are far from unique, and are in fact par for the course for insurance markets. Similar gyrations have occurred in the Federal Employees Health Benefits Program, state Medicaid managed care programs, and Medicare Advantage. The history of MA is particularly instructive:

 Between 1998 and 2002, the predecessor to today’s MA program (called Medicare+Choice) faced insurers’ decisions to terminate nearly half of the existing Medicare contracts.13 These terminations meant that between 300,000 and 1,000,000 enrollees annually could not stay in the plans they had selected. Terminations occurred disproportionately in rural counties where payment rates were lower. Total enrollment dropped between 1999 and 2003 from 6.4 million to 4.6 million. When Congress increased payment rates, the market stabilized and enrollment grew rapidly. In 2016, there were 17.2 million beneficiaries in Medicare Advantage...

In the wake of high-profile market exits in the Medicare Advantage program, policymakers were able to entice insurers back into the program by increasing payment rates. The Medicare Modernization Act (MMA) of 2003 changed the method Medicare uses to pay plans to a system in which plans bid against a benchmark price that varies geographically. Overall, the new system led to payments to plans that were approximately 10 percent higher relative  to local fee-for-service (FFS) costs from about 2006 to 2010.

These changes, together with other changes described below, led many insurers to re-enter markets they had departed and brought other insurers into the program. Whereas 31 percent of Medicare beneficiaries had no private plan option available in 2000, by 2006, nearly every Medicare beneficiary had access to at least one MA plan. Enrollment more than doubled from 2005 to 2010.

Fixes are (relatively) easy when no one hates a program. A functional equivalent of raising MA payments to insurers in the ACA marketplace would be to improve the premium and cost-sharing subsidies, which many prospective buyers find too skimpy to render coverage attractive -- particularly those with incomes above 200% of the Federal Poverty Level (FPL), the current cutoff for strong Cost Sharing Reduction (CSR) subsidies. At present, most subsidized buyers with incomes over 200% FPL can't afford a plan with an actuarial value higher than 73%, or over 70% for those with incomes above 250% FPL. The latter generally AV translates to deductibles in the $3000-5000 range. To take an example from the Chicago marketplace: If you're a single mother earning $32,000, you just may be willing to pay $175 for a benchmark silver plan for yourself (with your child placed in CHIP) -- but a deductible of $3,500 or $4,500 may make that plan seem close to useless. Boosting the subsidies is one of Corlette and Hoadley's "lessons."

Subsidies were sweeter in the version of the ACA passed by the House in November 2009, which could not be properly reconciled with the Senate bill after Democrats lost their filibuster-proof majority in January 2010.  In the House bill, the benchmark plan for those with incomes in the 200-250% FPL range would have been 85%, vs. 73% in the enacted ACA, and 78% for those in the 250-300% FPL band, vs. 70% in the ACA. Premium subsidies in the House bill were higher for those under 200% FPL, though not for those much above that threshold (and in fact somewhat lower for those over 300% FPL). For those not eligible for cost sharing reduction subsidies, three levels of coverage were available, at actuarial values of 70%, 85% and 95%.There was no AV 60% tier equivalent to ACA bronze, which carry prohibitively high deductibles and copayments for low income buyers.

Improving ACA subsidies would cost money, of course. A Dec.2009 Urban Institute-RWJF analysis estimated that House-level subsidies would cost about 16% more than those included in the bill introduced by Senate leadership in November 2009, which had a subsidy schedule close to that enacted by in the ACA, though with somewhat weaker CSR.  But part of the cost would be offset by improving the risk pool, helping to prevent steep premium hikes.

Other than being funded adequately, there's a more fundamental way the ACA marketplace could be made more like Medicare Advantage: the federal government could be the ultimate payer. In MA, the government sets a benchmark capitated rate for each region, calculated so that insurers can be profitable paying something close to traditional Medicare rates to providers. MA is therefore really neither a "public option" nor a private one; it's a menu of public-private options.  The great advantage is that provider payment rates are controlled, at one remove, by the government. The same is true -- at lower payment levels -- for managed Medicaid plans, and for the Basic Health Plans run under the ACA by New York and Minnesota. I've argued before (once, twice) that the ACA marketplace should be structured this way.

In addition to proposing subsidy sweeteners, Corlette and Hoadley suggest other incremental reforms, such as easing network adequacy requirements for new entries in a a market, or to create a "fallback plan" for markets left with no regular market entrants, or rendering the reinsurance program permanent.

All of those changes, except perhaps the network adequacy requirements, are premised on a Congress motivated to make the marketplace work better. As Bertolini suggested, the first requirement for a program like the marketplace is that it be treated as a perpetual work-in-progress.  It's hard to see that requirement being fulfilled in the foreseeable future. Perhaps the dominant element in Aetna's exit is political despair.

---
* Posed by Anne Gupte of Leerink 

Could the ACA help the Democrats take Florida?

The latest battleground state polls show Trump trailing Clinton by a narrow margin in Florida, a must-win state for him. One factor tilting the Florida field against Trump is surging voter registration among Latinos.  As flagged by Greg Sargent, Politico's Marc Caputo reports:

Since the 2012 presidential election, Florida’s voter rolls have grown by 436,000 — and only 24 percent of that increase is from non-Hispanic white voters while non-whites grew by 76 percent, according to new voter registration numbers released in advance of the Aug. 30 primary.

The number of Hispanic voters leaped by 242,000, which was 55 percent of the increase. Latinos are now 15.4 percent of the voter rolls, up from 13.9 percent overall in 2012, when President Barack Obama narrowly carried Florida thanks to the outsized backing of minority voters.

Recent Florida polls show Trump is losing the Hispanic vote by historic margins to Hillary Clinton after the Republican’s incendiary comments about illegal immigrants, which offended a broad array of Latino leaders, including many in his own party.

Latino voters have no shortage of reasons to reject Trump.  But what about positive motives to come out for Clinton and the Democrats generally? The Affordable Care Act -- generally a political loser for Democrats to date -- could be a factor. Latinos in particular, and minorities generally, have benefited hugely from the ACA in Florida. Here are the salient enrollment facts:

The fastidious fascist strikes again

Being criticized makes Donald Trump's skin crawl:

If the disgusting and corrupt media covered me honestly and didn't put false meaning into the words I say, I would be beating Hillary by 20%

— Donald J. Trump (@realDonaldTrump) August 14, 2016

We've been here before. We know that Trump's mission in life is to cleanse the world of forces that corrupt the country's fortunes and his own pristine image:

Trump on Kasich: 'Never seen a human being eat in such a disgusting ...

thehill.com/.../277519-trump-on-kasich-i-have-never-seen-a-human-being-ea...

The Hill

Apr 25, 2016 - "It's disgusting. ... RealDonaldTrump, we were looking for some Trump steaks for the governor, but no one seems to sell ... Tags: Donald Trump.

Donald Trump Calls Clinton's Bathroom Break 'Disgusting' | TIME

time.com/4158303/donald-trump-hillary-clinton-disgusting-schlonged/

Time

Dec 21, 2015 - Donald Trump used strong language Monday to describe Hillary ... “I know where she went — it's disgusting, I don't want to talk about it,” Trump ...

Trump Says Protests at University of Missouri Are "Disgusting," School ...

https://mic.com/.../trump-says-protests-at-university-of-missouri-are-disgusting-school...

Nov 12, 2015 - I think it's disgusting," Trump told Bartiromo Thursday morning. ... has been updated to reflect the exact wording of Donald Trump's quotes.

Trump: 'It's disgusting what's happening to our country" | Boston Herald

www.bostonherald.com/.../trump_its_disgusting_whats_happening_to_...

Boston Herald

Sep 15, 2015 - DALLAS — Republican presidential candidate Donald Trump is renewing his campaign against illegal immigration, telling a cheering crowd of ...

Yes We HCAN, sort of: Richard Kirsch's blow-by-blow account of the grassroots battle for health reform

I have been picking my Twitter-induced-ADHD-addled way through Richard Kirsch's Fighting for Our Health: The Epic Battle to Make Health Care a Right in the United States, published in 2012. Kirsch, a lifelong public action exec trained by Ralph Nader, was national campaign manager from 2008-12 for Health Care for America Now (HCAN), a massive umbrella group formed by unions and progressive nonprofits to advocate for universal health care. The book is a blow-by-blow account of the organizing and lobbying efforts that built support for the ACA and pushed it over the finsih line.

This is one of those blog-as-you-read posts, which you could make a case against, but which I enjoy doing as a book pulls me in various directions. I'm on vacation this week and will not trouble myself with excerpts. So far (I'm a bit more than halfway through), the two themes dominate:

o The ACA would not have been possible without massive, coordinated grassroots organizing -- meeting constantly with congressional reps, recruiting people who suffered for lack of health insurance access to tell their stories, raising large numbers of demonstrators to counter the Tea Party at Town Halls, calibrating support for and pressure on wavering reps, etc.

o Squishiness on the public option on the part of Obama and the Democratic Party as a whole was a self-inflicted wound that gravely weakened reform. I do not entirely buy into this, and I have much more yet to read about how that fight played out. That said, a few takeaways and preliminary thoughts:

1. The Tea Party's hysterical, misinformation-fueled, rage-filled hijackings of congressional reps' town hall meetings focused on health care in the summer of 2009 anticipate the Trump rallies of today -- with reps shouted down and drowned out by chants, disabled citizens testifying about their health care struggles booed off the stage, posters of Obama with a Hitler mustache, and equations of end-of-life counseling with genocide.  The funding of these oppo efforts by the Kochs' Americans for Prosperity trace a line from hardcore ideological libertarianism to Trumpian fascism, the common denominator being the sabotage of fact-based discourse.

The system is blinking red at Trump

There is as yet no cascade of elected Republican officials disowning Trump -- that is, stating that they won't vote for him or support his campaign to be president. Still, denunciations of him by conservative and (allegedly) nonpartisan partisan establishmentarians are growing ever less inhibited. Below, some remarkable indictments.

First, knee-jerk neocon Charles Krauthammer, who never met a proposed military action he didn't like, but can recognize a personality who will up-end the U.S.-dominated world order:

Of course we all try to protect our own dignity and command respect. But Trump’s hypersensitivity and unedited, untempered Pavlovian responses are, shall we say, unusual in both ferocity and predictability.

This is beyond narcissism. I used to think Trump was an 11-year-old, an undeveloped schoolyard bully. I was off by about 10 years. His needs are more primitive, an infantile hunger for approval and praise, a craving that can never be satisfied. He lives in a cocoon of solipsism where the world outside himself has value — indeed exists — only insofar as it sustains and inflates him.

Next, David Brooks, self-appointed moral arbiter, finding a true north with his often erratic moral compass:

On-exchange or off-exchange, the unsubsidized seem to make similar choices

Back in April, I set out to compare the coverage obtained by subsidized enrollees in health insurance plans in the ACA marketplace in 2016 with the coverage obtained by unsubsidized buyers. The measure compared was actuarial value (AV) -- the percentage of the average enrollee's annual medical costs paid by the insurer.

Long story short: the average weighted AV for subsidized buyers in the 38 states using HealthCare.gov was 81.4%, right in line with estimated averages for employer-sponsored insurance. For the 15% of HealthCare.gov enrollees who did not qualify for subsidies, average weighted AV was 68.9%. Averages in the state-based exchanges are probably about the same. The more comprehensive coverage obtained by subsidized enrollees stems from the fact that about two thirds of them also access secondary Cost Sharing Reduction (CSR subsidies, available only with silver plans.

I also inferred that the coverage obtained by those who bought ACA compliant plans outside the marketplace was roughly comparable to that obtained by  unsubsidized marketplace enrollees.  And I've just happened on some corroboration.

Obama calls Trump unfit for the presidency. Republican react in outrage, right?

Yesterday, Obama called Trump "unfit to serve" as president. In fact, he made the case at length.

Using the formal backdrop of a joint news conference with Prime Minister Lee Hsien Loong of Singapore, Mr. Obama suggested that Mr. Trump would not abide by “norms and rules and common sense” and questioned whether he would “observe basic decency” should he reach the Oval Office.

The president said he would have been disappointed to lose in 2008 or 2012, but added that he had never doubted whether his Republican rivals in those races, John McCain and Mitt Romney, could function as president or had the knowledge to make government work.

“That’s not the situation here,” Mr. Obama said.

Alarm bells went off for those familiar with basic political dynamics (or schooled, like me, by political scientists contributing to mainstream journalism in recent years).  Presidents polarize. When the president comes out in favor of something, the out-party turns agin it, by reflex. That goes triple in the Obama era, when the right wing scream machine has demonized the president's every move, including his birth.