Kaiser and me, on average AV

Drew Altman, president and CEO of the Kaiser Family Foundation, wrote on March 22 that under Ryan's ACA repeal plan, the average deductible in the individual market for health insurance would rise $1550 from current levels in the ACA-compliant market.

That was based on an estimate that the average actuarial value in the current market is 72%, vs. a norm of 65% that CBO calculated for Ryan's bill. Actuarial value (AV) is the percentage of the average user's yearly medical costs covered by plan. It's calculated according to a formula mandated by the ACA.

The 72% average AV figure jumped out at me, because in April 2016 I calculated the average weighted AV in the individual market as 75.5%.  Altman's piece cites an average AV in the ACA marketplace of 79%.That's exactly what I initially calculated, though I later bumped my estimate to 80%, based on likely silver plan selection by enrollees eligible for Cost Sharing Reduction at different income levels (see note at first asterisk, here).

The difference in the overall estimate appears to stem from estimates of metal level selection (bronze, silver, etc., with AV set by statute at each level) in off-marketplace enrollment, which is something of a black box. I used unsubsidized enrollees in the ACA marketplace as a proxy and calculated their average weighted AV at 68.7%.  According to an as-yet unpublished methodology note forwarded to me, Kaiser appears to have relied on 2016 data from the online broker eHealth, which included  a metal level breakout among their customers indicating an average weighted AV of 65.8%:

The cost of single payer: roughing it out

With sweeping ACA repeal apparently off the table for the moment, the Democratic imagination is turning once again toward some version of single payer, or Medicare for all.

I thought I'd try an overview from more than 30,000 feet -- say, from space -- of the tax revenue that might be required to move those now covered by commercial insurance into some kind of public insurance program.  That is, converting about a third of current total healthcare spending from private to public.  I hope this is not too general, or too vaguely informed, to be useful, but here goes...

1. According to the National Health Estimate, in 2015:

• Medicare spending was $646.2 billion, or 20 percent of total NHE.
• Medicaid spending was $545.1 billion, or 17 percent of total NHE.
• Private health insurance spending was $1,072.1 billion, or 33 percent of total NHE.
• Out of pocket spending was $338.1 billion, or 11 percent of total NHE.

2. Private health insurance covers more people than Medicare and Medicaid -- about 170 million (combining the employer and individual markets) vs. 120 million.* But it costs less in total -- about $1.1 billion vs. $1.2 billion.

3. At the same time, private insurance pays far higher rates to healthcare providers -- no one knows exactly how much more, but I've heard estimates in the 160% of Medicare range. Medicaid, in contrast, pays about two thirds of Medicare rates on average. [Update, 4/1: It's been pointed out to me that MEDPAC reports commercial rates for physician payments to be about 128% of Medicare -- that is, Medicare pays 78% of commercial rates on average. See p. 98 here. OTOH (added 4/4), a brand new CBO report estimates that commercial rates for hospital inpatient services average about 188% of Medicare, with wide variation. Hospital services accounted for a bit over $1 trillion in spending in 2015, compared to $635 billion for physician and clinical services.]

Affordable Care Anthem

In the fight against ACA repeal, the healthcare committee of our local advocacy group, BlueWaveNJ, cooked up some songs to warm the rallies and vigils aimed at the state's five Republican members of Congress -- four of whom came out against the AHCA, Ryan's repeal bill. Here's one of my contributions, with some local references -- e.g. to Rep. Rodney Frelinghuysen, NJ-11, chair of the House Appropriations Committee.  Here's a snippet from the local NBC affiliate that includes us singing outside his office.

The tune is This Land is Your Land....

After an election
we got a health scare:
Extremists tried to
take away our healthcare.
But we're united,
and they're divided...
Healthcare's a right for you and me.

Chorus

Healthcare is your right,
healthcare is my right,
Ii they try to take it,
we're gonna fight fight.
Tax breaks for the wealthy
won't make us healthy,
Healthcare's a right for you and me.

Uninsuring millions                                De-localized alt:
is a pill quite poison,                              should be rejected
so hear our voices,                                by those who hope to
Rep Frelinghuysen!                               be re-elected.
We sing in chorus:
Don't un-insure us...
Healthcare's a right for you and me.

"Medicaid expansion is the jewel of the ACA"

As Trump gleefully forecasts -- and thereby threatens to trigger -- the implosion of the ACA marketplace, methinks Democrats are starting to emotionally decouple from it. "You break it you own it" is a preemptive strike in messaging -- and potentially, a step toward planning the next phase when Democrats are in a position to shape public policy.

The AHCA's double-barreled assault on Medicaid -- repealing the ACA expansion and imposing per capita caps -- helped Democrats to see the ACA whole.  Hours before the bill hit, Andy Slavitt provided some clarity:

When #ACA replacement bill is out, don't get distracted by exchanges.

The big issue is dramatic cuts in Medicaid to pay for huge tax cuts.

— Andy Slavitt (@ASlavitt) March 6, 2017

Now enter Harold Pollack, who has a granular sense of how Medicaid functions in U.S. society, chronicling how Republican governors' support for the ACA expansion helped sink the AHCA. Pollack, like Slavitt, reframes the ACA -- at least in public discussion forever obsessed with the private plan marketplace:

In political and human terms, Medicaid expansion is the jewel of the ACA. Within the states that embrace it, Medicaid expansion is the most important public health advance in decades.

Medicaid, Medicaid...made in the shade with a garden spade. Better yet once ACA'd...

More startling still is Pollack's conclusion:

What comes after "catastrophic success"? Larry Jacobs on Democrats' healthcare choices

Now that the Republicans' main thrust to repeal the ACA's core benefits has failed for the present, what should Democrats do next?

I asked Lawrence Jacobs, a professor of politics and policy at the University of Minnesota who has closely studied the dynamics and incentives of legislative and presidential politics.

Here were the core questions:

Given unrelenting Republican hostility toward the ACA, and given that Republicans control the administration of its core programs as well as both houses of Congress, can Democrats do anything to shore up a stressed marketplace that needs a) competent administration committed to making it work and b) legislative fixes to improve the risk pool and keep insurers from bolting?

Should Democrats pursue legislative compromise that would alter marketplace structure more to conservatives' liking in exchange for, say, federal funding for reinsurance or other state programs designed to foster stability? (for more about possible components of such a deal, see my prior post.) Or should they step back and declare, in effect: the marketplace was more or less stable before the Trump administration began sabotaging it. Republicans now own it. We are going to look forward and propose bold measures to make insurance affordable for all that can be implemented when the American people return us to power.

What's next for Democrats in the healthcare wars?

While the ACA appears to have escaped repeal for the time being, the ACA marketplace remains under apparent and threatened assault from the Trump administration -- which, after all, has to administer it.

The avowals of Trump and other Republican leaders, including Ryan and McConnell, that the marketplace will implode or is in a death spiral; the withdrawal of advertising for the marketplace in the closing weeks of open enrollment last January; the threat not to enforce the individual mandate; the possibility of destroying the marketplace immediately by stopping federal payments to insurers for Cost Sharing Reduction subsidies; and, most recently, the walk-back of avowals that Ryan's repeal bill is dead -- all these factors have left insurers and therefore the marketplace in a shaky position. Insurers may withdraw, and premiums are likely to spike, as they did last year.

Even if Hillary Clinton had won the presidential election, the marketplace would be in need of fixes. The risk pool is sicker, older and smaller than originally envisioned. The subsidies are smaller than they should be. Millions whose employers offer nominally "affordable" individual insurance but unaffordable family insurance are denied marketplace subsidies through the family glitch. The trio of risk control programs designed to smooth insurers' losses in a new kind of market expired too quickly, and one -- the risk corridor program -- was sabotaged by Republicans.

Given the need for fixes, and the at least momentary acknowledgment by Republican leadership that "we're going to be living with Obamacare for the foreseeable future," as Paul Ryan rather astonishingly put it last Friday, a number of progressives have started to scope out possible means by which Democrats in Congress could win Republican support for legislation that would improve competition, participation and affordability in the marketplace. If such a deal were possible, it would entail agreeing to provisions that would reshape the marketplace more to Republicans' liking. These might include:

Progressives, don't forget: The Freedom Caucus killed the AHCA

Defenders of the ACA are right to take some satisfaction and pride in the failure of Paul Ryan's repeal bill, the American Health Care Act.  All those packed Town Halls, jammed phone lines and floods of mail had their effect. Dozens of Republican reps and senators, moderate and not so moderate, expressed qualms about un-insuring tens or hundreds of thousands of their constituents -- and tens of millions of Americans.

As we consider next steps, though, it's important to take full measure of the rather mind-bending fact that it's the Freedom Caucus that really sank the bill. They reportedly killed it partly because Trump managed somehow to trivialize their concerns even as he caved to most of them -- but more fundamentally, because it left some ghost of the ACA tax credits and consumer protections intact for those seeking insurance in the individual market.

For these zealots (and their right-wing think tank backers), the AHCA wasn't harsh enough.  It didn't cut the taxes that fund Obamacare benefits fast enough. It didn't uninsure beneficiaries of the Medicaid expansion fast enough. It didn't kill the concept of subsidized private insurance dead enough. It didn't take us back to the future of medical underwriting and health "insurance" that would render unaffordable coverage for such incidentals as childbirth and mental health treatment.

Trump threatens ACA marketplace collapse and nuclear blame war

In one sense, it may have been the worst-timed op-ed of all time. I argued in a piece published in the online NYT yesterday (submitted back on March 13!) that Senate Democrats should engage with sponsors of the Cassidy-Collins ACA reform bill to shore up Republican moderates who I thought likely to ultimately pass some lightly sanded version of the AHCA, or otherwise act to eviscerate Medicaid in particular.

While there was obviously a good chance the AHCA would not pass the House this week, I never dreamed the Republicans would simply give up for the present. For me the truly astonishing moment was when I saw Ryan quoted on Twitter saying "“We’re going to be living with Obamacare for the foreseeable future,”

That's the Trump factor. Just as he swung wildly and obliviously into the Freedom Caucus camp to allow them to pull any fig leaves of rationality from the AHCA, when thwarted he swung wildly back to call off the whole thing.

But it's that very swing that leaves my core point relevant: Democrats still need to find a way to win a measure of Republican buy-in to the ACA, because the Trump administration can kill it administratively -- swiftly or slowly, subtly or obviously. That goes in part for Medicaid, via a rush of work requirements and administrative harassment, as well as for the marketplace, which can be destroyed at a stroke by stopping CSR payments or by a host of more gradual means, already begun, nicely chronicled by Dan Diamond.

That's where Trump's at just now.  Check out last night's insanity:

The semi-satisfied unsubsidized

I have a post up on healthinsurance.org delving into the experience of four unsubsidized enrollees in the ACA marketplace who have pre-existing conditions, or children with pre-existing conditions.

None of them regarded their coverage as perfect. All were glad to have it – and confident that they would have fared worse if the ACA had not become law. Yet the piece does highlight that the status quo is unsatisfactory -- and deteriorating -- for a likely majority of the 8-10 million unsubsidized buyers in the individual market.

Here is a sliver of one person's experience:

AHCA vs. ACA: Total subsidized shares of costs at different income levels and ages

Late last year I cooked up a simple measure of the value of any given health insurance subsidy: the percentage of the premium paid multiplied by the actuarial value (AV) of the insurance obtained. AV is the estimated percentage of the average enrollee's medical costs paid for by the insurance.

In traditional Medicare, for example, for all but the highest-earning 5% of enrollees, the federal government pays about 85% of the combined premium for Parts A,B and D - which have a combined actuarial value a bit north of 80%. Hence the total subsided share of costs (can we call it TSS?) is about 69%.  Employers, according to the Kaiser Family Foundation, pay an average of 82% of the premium for individual insurance and 71% for family coverage. Given an average AV of 82% -- also a Kaiser estimate -- that yields a TSS of 66% for individual coverage and 58% for family.

I've previously estimated (see first link above) that the average subsidized ACA marketplace enrollee obtains a TSS of 59% -- with the federal government picking up an average of 73% of the premium for insurance with an average AV of 81%. Subsidies vary tremendously, however, ranging from 0% for the half of individual market enrollees who don't qualify for any help to over 90% for the lowest income enrollees obtaining silver plans enhanced with Cost Sharing Reduction.

Now, with the help of CBO analysis of the House repeal-and-replace bill, the American Health Care Act, it's possible to compare the federal TSS for people of varying income and ages under the ACA and the AHCA.

Christopher Ruddy's alt-Trump

Christopher Ruddy, Trump buddy and CEO of the gaslight site Newsmax, wantonly misrepresents the ACA while proposing what he regards as a Tumpian alternative to "Ryan Care II" (for which Trump has now gone all-in, flaunting his powers of intimidation even as he yields to right-wing demands that the bill un-insure millions more swiftly).

Let's leave the lie-specking for later (see bottom).  Buddy Ruddy does Trump the doubtless undeserved honor of crediting his stated intentions for health reform as expressed in, for example, Trump's January 15 Washington Post interview:

“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

Also promised: "lower numbers, much lower deductibles."

There is only one mode of healthcare delivery in the U.S. that can deliver on those promises. And lo, Ruddy makes it his centerpiece -- Point 4 in a 7-point program:

David Frum for HHS Secretary

For ten years now, David Frum has wowed me with the clarity of his critiques of Republican extremism, notwithstanding the craziness of some of his own policy prescription (most in foreign policy; he is, after all, Mr. Axis of Evil).  He's been a hero dissecting and crying out against emerging U.S. authoritarianism for the past year. And in fact, he was doing that too back in 2009/10. Here's from his famous post-mortem on the passage of the ACA in March 2010:

I’ve been on a soapbox for months now about the harm that our overheated talk is doing to us. Yes it mobilizes supporters – but by mobilizing them with hysterical accusations and pseudo-information, overheated talk has made it impossible for representatives to represent and elected leaders to lead. The real leaders are on TV and radio, and they have very different imperatives from people in government. Talk radio thrives on confrontation and recrimination. When Rush Limbaugh said that he wanted President Obama to fail, he was intelligently explaining his own interests. What he omitted to say – but what is equally true – is that he also wants Republicans to fail. If Republicans succeed – if they govern successfully in office and negotiate attractive compromises out of office – Rush’s listeners get less angry. And if they are less angry, they listen to the radio less, and hear fewer ads for Sleepnumber beds.

So today’s defeat for free-market economics and Republican values is a huge win for the conservative entertainment industry. Their listeners and viewers will now be even more enraged, even more frustrated, even more disappointed in everybody except the responsibility-free talkers on television and radio. For them, it’s mission accomplished. For the cause they purport to represent, it’s Waterloo all right: ours.

Back then, Medicaid expansion was a bad thing from Frum's conservative point of view -- something Republicans could have avoided had they negotiated the ACA in good faith:

Squish!

The meme that Republican senators in states that have embraced the ACA Medicaid expansion will block the House repeal bill from passing substantially as is and save the expansion continues. Here's Politico's Burgess Everett with news of a closed-door meeting in Nevada:

Sen. Dean Heller panned House Speaker Paul Ryan's bill to repeal and replace Obamacare during a closed meeting with constituents on Saturday, according to audio obtained by POLITICO.

The remarks by Heller, the most vulnerable GOP senator on the ballot next year, are another sign of the difficult prospects the House bill faces in the other chamber. Already, more than a half-dozen senators have criticized the bill, and Republicans can afford to lose only two votes.

Hail defender! As Nevada's Republican governor, Brian Sandoval, boasted in a letter to the House leadership in January, Nevada has slashed its uninsured rate almost in half since ACA enactment, from 23% to 12% -- mainly through the Medicaid expansion, which has increased Medicaid enrollment by 288,000 since September 2013 in a state with 2.5 million residents. Plenty to defend!

So what is Heller's promise to Nevadans? Back to Politico:

"Moderate" Republican opposition to AHCA is looking very squishy

Hours before House Republicans published a full draft of their ACA repeal-and-replace bill, the so-called American Health Care Act, four Republican senators in states that have expanded Medicaid -- Portman, Capito, Gardner and Murkowski -- sent a letter to Mitch McConnell from warning that the repeal bill should provide "stability" for beneficiaries of the expansion.

Given the letter's timing, and its expressed concern for beneficiaries of the Medicaid expansion, some accounts of the repeal bill's release (e.g., Chait's) interpreted it as opposition to the bill. But it was not that. In fact it may have been the opposite. Those who are anticipating rejection of the House bill by Senators who have expressed qualms about un-insuring expansion beneficiaries should take warning.

Psst, Democrats: Help Republicans out of the repeal box via Cassidy-Collins

I don't want to be prematurely optimistic, but the House ACA repeal bill, the so-called American Health Care Act, seems despised from all sides -- so much so that both Jonathan Chait and Jonathan Bernstein speculate that it's designed to fail. It's being denounced by Tea Partiers as Obamacare Lite and by progressives -- and conservatives with any commitment to extending insurance access -- as certain to un-insure millions to tens of millions of low income ACA beneficiaries.

More to the point, its release was immediately preceded by a letter to Mitch McConnell from four Republican senators in states that have expanded Medicaid -- Portman, Capito, Gardner and Murkowski -- warning that the repeal bill should provide "stability" for beneficiaries of the expansion.

Still, perceptions of the way things are likely to fall out change quickly. Leadership in both the House and Senate have declared they want to move quickly -- McConnell indicating he'd give the House bill a quick floor vote in the Senate, though later half-walking that back. Underlying the process is the enormous pressure Republicans have built under themselves over seven years to rip the ACA apart. If the bluster from the far right about faux repeal blows over, the moderates defending Medicaid could go wobbly. In fact, they've left themselves space to. Look at the language with which they've "defended" the expansion (my emphasis):

Do we have to repeal the ACA to find out what's in it?

No one is claiming that the ACA led us into health access paradise. The ACA marketplace and wider individual market as open enrollment for 2017 began. But they were (and are) troubled markets, in need of adjustment, e.g. along lines sketched by scholars at Georgetown and the Urban Institute. The networks keep narrowing, premiums and out-of-pocket costs have spiked, and choice has narrowed in many markets. The roughly half of marketplace enrollees with strong Cost Sharing Reduction subsidies are partly but not wholly insulated from this deterioration.  Those who are unsubsidized or lightly subsidized have in many cases been hit hard.

The Medicaid expansion has been a clear boon to those who gained access through it, as well as to state budgets, state economies, state public health, and access to drug treatment. It's also, to some extent, highlighted the law's political weakness, apparently triggering a fair amount of Medicaid envy and resentment among the somewhat more affluent and the fact that the ACA's most direct beneficiaries are generally the poor and near-poor.

As mentioned in a prior post, I have a piece shopping that spotlights very mixed experiences of unsubsidized marketplace enrollees with pre-existing conditions -- grateful for access but dealing with rising costs.

Another piece relaying a wide variety of experience and perception, by Jay Hancock of Kaiser Health News, is a striking contrast to the polarized praise/denunciations that used to be common fare in ACA coverage. There is a really striking degree of nuance in these mostly Republican reflections, as well as a refreshing awareness in some cases of the ACA's different component parts. If nothing else, the rough number of people who have gained insurance through the law seems finally to have been hammered home. I hope Hancock doesn't mind my extracting all of the article's citizen testimony, as I do think it has a strong cumulative effect:

Short history of the decline and fall of American democracy

I switched on Twitter for 15 minutes at 7:00 a.m. this morning and felt I was watching democracy die before my eyes as a fascist and possibly traitorous president threatened to prosecute Obama.

That led me to a flash review of our decline and fall as the narrative has taken shape in my mind in recent years:

• The Kochs plotted long and hard, building their network of extremist think tanks, fake news sources, astroturf advocacy groups and corporate lobbying groups.


• Reagan ripped the lid off inequality and disinherited the middle class with a cocktail of tax cuts for the wealthy, deregulation, weakened antitrust enforcement and union-bashing.


• Rupert Murdoch and Roger Ailes prepped 30-40% of the population for fascism with twenty years of progressively more extreme gaslighting.

Pre-ACA, patchwork protections worked for the lucky

The pre-ACA individual market was not entirely devoid of protections for people with pre-existing conditions. These varied widely by state, however. Five states -- Maine, Massachusetts, New Jersey, New York, and Vermont -- had guaranteed issue and community rating, meaning that insurers could not deny coverage based on medical history or charge more to people on the basis of their medical history. In New Jersey, an insurer could bar coverage for the applicant's pre-existing condition for up to twelve months, though that period could be reduced or eliminated if the person had maintained continuous coverage prior to applying. In the other 45 states, the rules according to which insurers could ascribe a pre-existing condition to an applicant varied.

HIPAA, the Health Insurance Portability and Accountability Act of 1996, though focused mainly on rules governing employer-sponsored plans, provided some "continuous coverage" protection in the individual market, though the degree of protection varied by state. In some states, if you had maintained continuous coverage in a group health plan or via COBRA for eighteen months, any insurer selling individual coverage in the state had to offer you coverage, though HIPAA did not regulate how much the insurer could charge. Different states offered different degrees of protection, however.

Recently, a well-informed retired attorney in Atlanta, Gary Ratner, recounted to me how HIPAA, enhanced by Georgia state law, enabled him and his wife to maintain good if eventually very expensive coverage...not in the individual market per se, but as individuals without access to conventional group coverage, until they qualified for Medicare. Gary's tale makes an interesting counterfactual for older current enrollees in the individual market who wonder how they may have fared pre-ACA. Gary and his wife fared pretty well -- though if they were in the ACA-compliant individual market today, as his calculations below indicate, they would fare comparably. And they were lucky. They threaded a couple of needles.

"Where the hell are you?"

For the three or four people who may be wondering why I haven't blogged for a near a week: I've been taking testimony, so to speak, from a bunch of people who are buying unsubsidized health insurance in the individual market -- but who, thanks to pre-existing conditions, are more or less grateful for what they can get and worried about what the future may hold.

Some are members of of a political advocacy group here in North Jersey, whose tales I'm collecting for a story bank; others from Georgia Maine and Michigan as well as Jersey, have recounted their experiences for an article I hope to place elsewhere. In age they range from 20s to 60s. Because of their pre-existing conditions, or their propensities as people aware of risk, or their political sympathies, or all of the above, all are people who value insurance at its actual cost.

Virtually all of those who have been in the marketplace (or individual market) for some years have suffered premium increases, and out-of-pocket increases, and narrowing of networks, and in some cases, narrowing of choices. The collective picture of how the market's changed from 2014 to this year isn't pretty. And yet all are sensible of what the market was like, or will be like, without guaranteed issue and mandated comprehensive benefits.

Two comparisons of Price plan vs. ACA marketplace are roughly congruent

Late last year, I put forward a simple measure of the value (to the beneficiary) of a government subsidy for health insurance in various programs: multiply the percentage of premium covered by subsidy by the actuarial value of the insurance obtained. (A somewhat more streamlined version of the comparison is here at HIO).

For the ACA marketplace, I multiplied the average premium subsidy as reported by HHS (73% of premium) by the weighted average actuarial value obtained by subsidized marketplace enrollees (81%, my calculation) to come up with 59% total subsidized costs.

I then calculated that Tom Price's replacement plan, which has subsidies based on age not income, would on average cover about 40% of ACA benchmark silver plan premiums. I estimated that those flat subsidies would cover about 60% of premium for the cheaper plans to be offered in Price's deregulated market, to which I charitably ascribed an average AV of 60% -- coming up with a total average subsidized cost of 35% or 36%.  Of course, that's for all buyers, whereas only about half of current individual market enrollees are subsidized. Thus Price's plan radically redistributes subsidies from low-income toward higher income prospective enrollees.

Yesterday David Cutler, a Harvard health economist, John Bertko, chief actuary for Covered California, and Topher Spiro, veep for health policy at CAP, published in Vox a more nuanced and sophisticated comparison of the ACA-governed individual market and Tom Price's plan that ended up in pretty much the same place.

Triage, Sister Simone, triage

In a q-and-a session at Health Action 2017 last week, I suggested that Democrats might be savvy to engage with the Cassidy-Collins ACE "replacement" bill, which merely breaks the ACA's fingers rather than disemboweling it. When incoming Families USA exec director Frederick Isasi implied that this could potentially make sense, Sister Simone Campbell, a heroine of ACA passage and defense, rebuked him (and so, by proxy, me):

I have to confess, Frederick, after that great presentation I wanted to … say don’t you dare engage Collins-Cassidy because it’s based on Health Savings Accounts, and only 30 percent of our nation’s families have any savings. So let’s be real.

I don't like HSAs any more than Sister Simone does, but... I have a response up on healthinsurance.org

Health Action 2017: Times that try our souls

I attended Families USA's annual Health Action conference last week and found it deeply moving. My overview is up on healthinsurance.org.  Here's an upshot of sorts:

The conference, to my mind, fulfilled the deepest purpose of such events. It was not so much a matter of convincing the troops that the goal of preventing the repeal of the ACA and further evisceration of Medicaid through block-granting is attainable. Some marquee speakers argued forcefully that those goals are achievable, others implied that the odds are long.

Strength lay more in the collective demonstration of expertise and commitment, evident as much in breakout workshops as in plenary sessions...

Then, zooming out to the plenaries, a highlight was outgoing (outgone?) acting CMS head Andy Slavitt's call to the assembled healthcareniks to respond to

More than half of ACA marketplace enrollees are in states that refused to expand Medicaid

I have noted on multiple occasions that in states that refused the ACA Medicaid expansion, marketplace enrollment has been bolstered by a large contingent of people who "should have" been enrolled in Medicaid. That is, over 2 million marketplace enrollees in those 19 states have incomes between 100% and 138% of the Federal Poverty Level (FPL) -- incomes that would have qualified all of them except for certain legally present noncitizens for Medicaid had their states accepted the expansion.

To review a few facts about these low income enrollees:

• In nonexpansion states, 36% of enrollees had incomes in the 100-138% FPL range. In mid-2016 that came to about 2.1 million enrollees.


• Close to 90% (or more*) of those low-income enrollees selected silver plans and so accessed Cost Sharing Reduction (CSR) subsidies that raised the actuarial value of their plans to 94%. That generally translates to a deductible of $0-250.


• Customer satisfaction in the ACA marketplace is much higher among enrollees who are not in high deductible plans (defined by survey conductor Kaiser as under $1500 for an individual). In Kaiser's 2016 tracking survey, 74% of enrollees in lower deductible plans rated their plans good or excellent, vs. 59% of those in higher deductible plans. And again, the vast majority of enrollees in the 100-138% FPL range are in low deductible plans.

All that said, a fact hiding in plain sight (to me, anyway) is the extent to which nonexpansion states are over-represented in the ACA marketplace. This is not surprising, since a third of enrollees in those states should have been eligible for Medicaid. Nonetheless, I find it rather startling, based on state-by-state data released by HHS in December, that as of the end of the first quarter of 2016, the 19 nonexpansion states contained:

Love knows no repeal: HealthPolicyValentines 2017

Update 2/15: below is this year's complete harvest, as it grew from Feb. 10-14. Last year's trove is here. Love, 2015, here. First love, 2014, here.

----

I felt this afternoon I was getting quick-pitched on HealthPolicyValentines. But matron saint of the tradition, Emma Sandoe, tells me it's always kicked off on the Thursday before V-Day. So, like a loved one rushing to the scene of elopement, here am I (and see bottom for past years):

With this ring I thee wed;
with this kiss doth thou grace me.
Now promise you'll never
repeal and replace me.

     *      *      *

I can't call you true
on this true lovers' day.
You swapped my CSR
for this crummy HSA.

     *      *      *

Affordability and access!
We could eat our cake and have it
if we put our healthcare system
in the hands of Andy Slavitt.

Absent: A Novel speaks to our American present

Since the election, I've stopped reading the print newspaper in the morning. I can't take it in the early morning quiet. I inch into the news by degrees, via Twitter, at intervals throughout the day. I also miss a lot. 

I haven't read much fiction in recent years, so, in the void left by the paper, I resolved to take a tour of the world through fiction.  I thought I'd start with Najuib Mahfouz. But somehow along the way Amazon caught me with Absent by Betool Khedairi, a novel set in Baghdad during the sanctions period in the wake of the first Gulf War.  It's exactly what I wanted -- a day-by-day of life elsewhere. It's grown on me by degrees. It's magnificent.

It's one of those quiet and apparently plotless novels, built encounter by encounter, vignette by vignette, though it's plainly trending somewhere. The "quiet" is quiet desperation. People are slowly starving, or decaying for want of medicine or sanitation or employment (though everyone finds some way to scrape some kind of living). The backdrop is adults' memories of the Days of Plenty, the period before the blockade, and the first Gulf War, and the Iraq-Iran war -- when children going to school had pencils and uniforms, and crosswalks were repainted at intervals, and refrigerators had food in them and stayed on all day.

ACA doctors (of the law): What would you do with $3-5 billion per year?

Republicans in power certainly don't want the ACA marketplace to thrive. But for the most part they don't want it to precipitously collapse, either -- though it's not hard to imagine the Trump administration pushing it off a cliff and then trying to blame Democrats ("it was collapsing already...").

While Republicans have no real wish to make adequate health insurance affordable for lower income people, they may prove somewhat receptive to the wishes insistences of insurers, out of long habit and because, again, they don't want the market to collapse. The Trump administration is reportedly considering a package of short-term stabilizers that includes enabling by administrative fiat a minor increase to age banding (the multiple by which older enrollees can be charged more than younger ones); allowing insurers to cut off coverage for late payers after just 30 days instead of the current 90; and tightening the standards and verification for those seeking "Special Enrollment Periods" (SEPS) outside of open enrollment.

Repair, not replace -- rebranding, or real change? Watch the Medicaid expansion

The battle over ACA repeal-or-whatever is going to go through a lot of twists and turns and bold assertions that will fade like morning dew. Still, the latest Republican messaging and positioning seems at least potentially significant. From The Hill's Peter Sullivan:

Key Republican lawmakers are shifting their goal on ObamaCare from repealing and replacing the law to the more modest goal of repairing it...

“I'm trying to be accurate on this that there are some of these provisions in the law that probably will stay, or we may modify them, but we're going to fix things, we're going to repair things,” House Energy and Commerce Committee Chairman Greg Walden (R-Ore.), a key player on healthcare, told reporters Tuesday.

In a fraudster's grip

This is just to note that today Paul Krugman caught the essence of the Trump presidency in 80 words:

Our government hasn’t always done the right thing. But it has kept its promises, to nations and individuals alike.

Now all of that is in question. Everyone, from small nations who thought they were protected against Russian aggression, to Mexican entrepreneurs who thought they had guaranteed access to our markets, to Iraqi interpreters who thought their service with the U.S. meant an assurance of sanctuary, now has to wonder whether they’ll be treated like stiffed contractors at a Trump hotel.

Anyone over the age of five, regardless of political propensity or education level, should have been able to see that this is what Trump would deliver. Those who couldn't see it, driven by whatever passion or need, willfully shut their ears and eyes. His depravity was as manifest as Hitler's. Whether his will to evil is as intense, we'll learn.

Help me tell ACA stories

Greetings, dear readers: I would like to tell stories about people's experiences with lesser-known ACA benefits -- or shortcomings. Writeups may appear elsewhere -- healthinsurance.org or other publications -- or here.  These are the categories I have in mind:

1) Donut hole: I'd like to speak to Medicare enrollees who have benefitted (or not so much) from the ACA's gradual closing of the "donut hole" in prescription drug coverage.

2) Lifetime coverage caps: pre ACA, in 2009, 59% of people insured through employers were subject to lifetime caps on coverage -- typically $2 million by 2009, but often $1 million. The ACA banned lifetime and annual caps.  In a recent post, I  dug up a 2007 study finding that 20,000-25,000 people would hit lifetime caps by 2009.and forecasting that 300,000 would max out by 2019 if the caps were not raised. I'd like to speak to anyone who ever hit the caps, or was saved from the caps by the ACA, or is worried about hitting the caps (because of an expensive chronic condition) post-ACA.

If ACA is repealed, how many will max out on restored lifetime coverage caps?

In the waning days of his noble tenure as acting CMS director -- perhaps the last era in which CMS and HHS will function as fact-based agencies dedicated to improving healthcare delivery -- Andy Slavitt became a forceful Twitter advocate for the ACA, the payment reforms initiated under the ACA and MACRA, and other programs that require money, effort and commitment.

Among those tweets was one that listed 19 benefits that would be lost under ACA repeal, most of them little-known, including this:

That set me wondering: how many people would hit the coverage caps? And lo, an estimate exists. In our till-now-at-least-partially-fact-based-society, it sometimes seems that someone (or some interest group) has looked into almost any question that can be posed.

An exit ramp for Republican senators queasy about ACA repeal-and-delay

Yesterday, two Republican senators who have been most vocal about the dangers of repealing the ACA without replacement, Bill Cassidy of Louisiana and Susan Collins of Maine, introduced a "replacement" bill that looks something like the compromise envisioned by many healthcare wonks, giving states the freedom to accept or redesign the core ACA benefit structure. Senators Shelley Moore Capito, R-WV, and Johnny Isakson, R-GA, are co-sponsors. Vitally, it does not repeal the taxes that fund ACA benefits. Full text is here; a one page summary, here

The plan is offspring of a bill Cassidy introduced in 2015*, when the possibility loomed that the Supreme Court would rule for the plaintiffs in King v. Burwell and ban the federal exchange HealthCare.gov, from granting premium subsidies. It allows states to either keep their ACA marketplace as is, or opt for a conservative alternative based on subsidized Health Savings Accounts (HSAs) and catastrophic plans offered in a deregulated market. It also leaves intact the ACA's "innovation waivers" allowing states to cook up their own coverage schemes to deploy comparable dollars to cover comparable numbers of people. A Republican HHS would presumably be disposed to wave through such alternative schemes if they have a conservative cast.

Losers and winners under medical underwriting

This post is a by-product of my prior post de-gaslighting Betsy McCaughey's ridiculous claim that only 500,000 people would be affected by repeal of the ACA's protections for people with pre-existing conditions seeking insurance in the individual market.   I believe I have a sharpened view of who's been helped and who's been hurt in the post-ACA individual market.

Spoiler alert: in the pre-ACA individual market, more than half of those who needed insurance were either denied coverage, discouraged from applying, offered insurance that excluded coverage for their pre-existing condition, or offered coverage at above-market rates.

McCaughey's argument was built on misrepresenting a 2010 report issued by Henry Waxman and Bart Stupak, then-chairs of the House Energy and Commerce Committee, that drew on data elicited from the four large health insurers in the 2009 individual market , The main takeaways in this study were that coverage denials on the basis of applicants' prior medical history rose rapidly from 2007 to 2009, and that the denial rate reached 15.3% in 2009. That latter figure is roughly at the midpoint between the result of a 2009 AHIP survey of member insurers, which found a denial rate of 12.7%, and the Kaiser Family Foundation's 2013 estimate that 18% of applicants were denied (perhaps the denial rate continued to rise after 2009).

The Waxman-Stupak report  also cited an internal document from one of the insurers articulating a common assumption: that in reality about one third of applicants were effectively shut out of the market, as many were discouraged from applying by brokers, or past experience. The report further noted that one of the four insurers provided 15% of its customers with polices that excluded coverage for their pre-existing condition. While it did not provide an overall estimate for such targeted exclusions, the AHIP survey reports that 6% of coverage offers included such exclusions (and some participating insurers did not report on this question).

Betsy McCaughey, mother of the death panel myth, is gaslighting the ACA again

Betsy McCaughey, chief gaslighter of the Clinton health reform plan in 1993, and originator of the groundless charges in 2009 that blossomed into Sarah Palin's viral lie that the ACA was creating death panels, is out with fresh nonsense about the current individual market for health insurance and how Republicans might improve it.

In a Wall Street Journal op-ed, McCaughey claims that high risk pools could easily and effectively protect those with pre-existing conditions and so safely return the individual market to medical underwriting -- that is, basing health insurance pricing and availability on the health of each applicant.

McCaughey's claim that only about 500,000 Americans would be "in jeopardy" if ACA protections for those with pre-existing conditions were repealed is off by a probable factor of 10. Her argument in favor of high risk pools as a panacea is false in every particular.

To get to 500,000, McCaughey cites a 2010 report issued by Henry Waxman and Bart Stupak, then-chairs of the House Energy and Commerce Committee, finding that the four largest health insurers denied some 257,000 people coverage in 2009 on the basis of pre-existing conditions. She suggests that that was the total number of denials in that year, then adds in 70,000 reported by the four insurers to have been denied coverage for specific claims on the basis of "riders" excluding coverage for their pre-existing conditions, and 225,000 covered by pre-ACA high risk pools, to get her estimate.

That estimate is ridiculous on its face. The Waxman-Stupak report spells out explicitly that the four insurers provided data representing only a slice of the market -- somewhere between 10 and 30%, most likely.* The key finding was that 15.3% of applicants were denied coverage by medical underwriting. The report further cites an internal insurance company document to suggest that about one third of applicants were effectively shut out of the market, as many were discouraged from applying by brokers, or past experience.

Fight ACA insta-repeal: Contact strategically placed friends and family

Congressional aides and other political insiders often say that elected officials pretty much discount calls and letters from those outside their own constituency. Taking that received wisdom to heart, I have been pitching friends and family in states with Republican senators to call or email those senators and urge them to reject ACA "repeal-and-delay" -- and encouraging people in my local advocacy group, BlueWaveNJ, to do the same.

Using what comes to hand, I thought I'd share my template letters here -- that is, letters to friends and family in Texas and Pennsylvania. Texas first, because interesting news prompted me to cook it up yesterday.  But the PA letter  is more of a general template, with more resources and context Ohio is next for me. Each one includes contact info and state health facts, courtesy mainly of Families USA's tool to pull same.

So if you've read this far, would you please call or write Unc in Ohio or former college roommate in Louisiana and ask them to call/email their senators? Please use/share/adapt the PA template letter (below the TX one) if it's useful - or maybe just the link library at the end of it.  Thanks...

*          *          *

Dear AUNTIE IN TEXAS:

Texas Senator John Cornyn today said something very interesting about ACA repeal:

A group of Republican governors met with Republican members of the Senate Finance Committee on Thursday, and some expressed concerns about the number of people who could lose insurance once GOP lawmakers repeal the Affordable Care Act.

One of the top concerns is what will happen to individuals who became eligible for Medicaid with its expansion under Obamacare. The Senate's No. 2 Republican, however, promised that no one who got coverage under Medicaid expansion will lose it.

When Cornyn was asked if he was concerned about people who've benefited from Medicaid expansion losing coverage, he said it was a shared concern.

"Were all concerned, but it ain't going to happen," Cornyn said. "Will you write that down... It ain't gonna happen."

A good day for the ACA

While there will doubtless be many shifts and turns in the battle over the ACA, the road to repeal has seemingly got steeper for Republicans in the last couple of days. Some good developments:

1) Trump blew in with his promises to cover everyone, with low deductibles, and to enact his magic replacement at the same time as ACA repeal. That would seem to make it harder for Republicans in Congress to proceed with repeal-and-delay.

2) The Congressional Budget Office, traditionally the arbiter of the fiscal viability of proposed legislation, did the Urban Institute one better and estimated that the repeal-and-delay bill Republicans passed in late 2015 (vetoed by Obama) would un-insure 32 million people in a decade.

3) Media coverage pretty universally noted that the Jan. 15 rallies reflected deep support for the ACA and stiff resistance to repeal from its proponents. The NYT's Robert Pear, generally caustic about the ACA, put it this way:

ACA defenders don't need to "learn from" the Tea Party. They beat them in 2009-10

The fight to save the ACA is on, and all across the land, progressive groups large and small are mobilizing the law's supporters to let their senators and reps know the cost of dis-insuring 20 million people -- more, if Republicans block-grant Medicaid and/or collapse the individual market, less if they pass some poorly funded and designed facsimile of the ACA.

In reaction to the 35 "protect our care" rallies staged across the land on Sunday (Jan. 15), I keep seeing sentiments to the effect of  "progressives are learning from the Tea Party."  That's a half-truth at best, in that supporters of the ACA-in-progress fought protestors at least to a draw in 2009-2010 (proponents won in the sense that they got the ACA passed, but they did (briefly) have a 60-vote Senate majority and a large House majority). The ACA would never have got anywhere near the finish line without the most massive grass-roots advocacy ever achieved.

The Tea Party protests against the ACA-in-progress at Town Hall meetings in the long hot summer of 2009 have become part of American political lore. What’s less well known is that progressive groups supporting health reform fought back on the spot, often with equal or superior manpower and local impact. The media preferred the screamers, of course.

There was a massive coordinated effort led by Health Care for American Now (HCAN), an umbrella organization for groups committed to universal healthcare, formed in the runup to the 2008 election. Member groups’ ability to muster supporters provided vital support that kept many representatives and senators committed to passing the bill that became the ACA.

TrumpCare's coming! What kind of garbage in a gold box awaits us?

The Washington Post's Robert Costa published the gist of an interview with Trump last night in which Trump claimed that his administration is putting the finishing touches on a health reform plan that would provide universal access to affordable, low deductible coverage. This is so apparently out of keeping with existing Republican ACA replacement plans that it's hard to know what to make of it. Here are three possibilities:

1) Trump's plan will depend heavily on "mini-med" plans for low income people -- that is plans with low up-front costs but tight caps on how much the plan will pay (annual caps, lifetime caps or both).  An ACA replacement plan put forward by Senator Bill Cassidy (R-Louisiana) and Rep. Pete Sessions (R-Texas) features such plans for the poor.

2) Trump will offer a plan that proposes something very like Medicaid for people higher up the income chain than the ACA does with something very like Tom Price's plan for people with somewhat higher incomes -- that is, relatively small tax credits, unadjusted for income, to be spent in a deregulated insurance market. I've proposed this myself, and I think it's too good to be Trump.

It's up to you to save the ACA

I have a piece up on healthinsurance.org, arguing that Republicans' ACA insta-repeal train can be derailed, and how-to-ing the basic forms of citizen action by which we can all do our part.

It's mostly the nuts and bolts of how to phone, write, tweet, etc., but here's my closing argument that it's all eminently worth doing:

Any and all Republican senators are worth contacting with a “no repeal without delay” message. Taking away constituents’ existing benefits is not in senators’ job description. Almost none of them want to do it, though they have almost all promised to in some form. Those who have expressed doubts include some of the hardest core conservatives (Cotton, Paul).

Some may stealthily work against a swift repeal even if they’re publicly for it. Some may also work to mitigate the effects if it does pass – for example, by delaying repeal of the taxes along with the benefits. If that happens, the ACA may in effect be “renewed” indefinitely.

Remember – just three Republican senators are needed to kill passage via reconciliation. It’s also possible that the “queasies” will insist that repeal of key features such as taxes that the fund benefits or the individual mandate be delayed along with the premium subsidies and Medicaid expansion – and that the hard-core right wing may then in turn balk, on grounds that the bill is a “repeal” only in name.

By hook or crook, supporters of the law should be able to help Democrats in Congress find a way to preserve the vast improvement the ACA has wrought in millions of Americans’ lives.

Hope you'll take a look.

Careful with that study! A second look at enrollment decisions in Covered California

A study of the buying decisions of enrollees in California's ACA marketplace, Covered California, in 2014, suggests that a lot of people left benefits on the table:

The Affordable Care Act includes financial assistance that reduces both premiums and cost-sharing amounts for lower-income Americans, to increase the affordability of health insurance coverage and care. To receive both types of assistance, enrollees must purchase a qualified health plan through a public insurance exchange, and those eligible for the cost-sharing reduction must purchase a silver-tier plan. We estimate that 31 percent of individual-market enrollees in California who were likely eligible for financial assistance purchased plans that were not silver tier or that were not sold on the state’s exchange and thus missed opportunities to receive premium or cost-sharing assistance or both. Lower-income enrollees who chose plans not eligible for subsidies had two to three times higher odds of reporting difficulty paying premiums and out-of-pocket expenses during the year, compared to those who chose eligible plans. Regardless of how the structure of the individual market evolves in the coming years, efforts are likely needed to steer lower-income enrollees away from financially suboptimal plan choices.

The study, just published in Health Affairs, lead author Vicki Fung of Harvard and Mass General, is based on  survey responses from 2103 enrollees and has some very interesting results regarding the difficulty (or lack thereof) that enrollees experienced paying premiums and out-of-pocket expenses at different income levels and benefit levels. But while the authors are quite thorough in enumerating the study's limitations, some caveats are worth elaborating.* In brief: CSR takeup is higher at income levels where the benefit is strong, and many of those deemed potentially eligible for subsidies are not in fact eligible.

Let's look more closely at the more specific claims.

The Rosetta Stone of Cost Sharing Reduction takeup in the ACA marketplace

I don't know why it's taken me so long to notice, but something I've always wanted to know about ACA enrollment has been hiding in plain sight since July.

The question is what percentage of marketplace enrollees at different income levels who are eligible for Cost Sharing Reduction (CSR) subsidies do in fact access the benefit by selecting silver plans, the only metal level at which CSR is available. This is important, because out-of-pocket expenses for lower income enrollees -- which means most enrollees -- are basically only manageable in CSR-enhanced plans.

CSR raises the actuarial value of a silver plan from a baseline of 70% to 94% for those with incomes up to 150% FPL; to 87% for those in the 150-200% FPL range, and to just 73% for those between 200% and 250% FPL.  Conversely, the percentage of income required to buy a silver plan rises with income -- disproportionately, to judge from takeup, which is higher at lower income levels.  Those who opt for a lower premium by buying bronze plans are leaving a valuable benefit on the table and letting themselves in for deductibles generally north of $6,000.

Every year since the launch of the ACA marketplace for 2014, HHS has published ever-more specific enrollment data (for HealthCare.gov states in particular). But CSR takeup at different levels has had to be extrapolated from various not-quite-complete hints, including data published by states that run their own marketplaces.

That was the case, that is, until this past July, when a CMS data brief  appeared with a CSR Rosetta Stone wrapped in the middle. And I'm going to take a little credit for that, as well as drawing conclusions.

Medicaid envy in the rust belt

Yesterday, Drew Altman, president of the Kaiser Family Foundation, published an op-ed in the New York Times in which he reported results of focus groups that KFF conducted with Trump voters in rust belt states who are enrolled in Medicaid and ACA marketplace plans.  One set of complaints from marketplace enrollees is worth pondering:

They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance — for which they were eligible for subsidies — saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it.

While Medicaid enrollees may have difficulty finding an in-network provider for a given need, they generally not only pay little-to-nothing in premiums and out-of-pocket costs, but also are shielded from balance billing to greater or lesser extent by state law*, Medicaid beneficiaries generally rate their coverage higher than marketplace enrollees -- although, as Altman points out, large majorities of marketplace enrollees also generally rate their coverage at least satisfactory (Trump voters are likely less satisfied than the average). While no one likes a narrow network, it may be the case that what people dislike most is not a narrow choice of providers, but the risk that an out-of-network provider will inflict himself on you, or more exactly, on your checkbook.

Who are the "20 million" insured via the ACA?

In references to the roughly 20 million people the ACA has said to have insured, three things tend to be conflated: 1) the net increase in the insured population since ACA enactment (roughly 20 million), 2) the number insured through the ACA marketplace (10-11 million at present), and 3) the number insured through the individual market (18-20 million, about half of them subsidized).

Below, a few points aiming to clarify who's benefiting and to what degree. Teaser: don't miss my slicing of CPS data in the chart below.

1. The contributing streams to the 20 million increase in insured Americans include  a) an increase of 17 million in Medicaid enrollment since July-Sept. 2013, including nearly 12 million categorized by states as rendered newly eligible by the ACA; b) 8-9 million subsidized enrollees in the ACA marketplace, contributing to an increase in overall individual market enrollment of roughly the same size;c)  2-3 million adults under age 26 added to their parents' health plans; and 4) a possible moderate increase in enrollment in employer-sponsored plans.

How Democrats might lose the ACA insta-repeal battle and win the war

In the interview I posted last week with Chris Condeluci, who was counsel to Republicans on the Senate Finance Committee when the ACA was being drafted,  I foregrounded the most urgent point at present: ACA proponents have a very short window to deter lightning passage of a repeal-and-delay bill, and at least a handful of Republican senators may be responsive to pressure and balk at repeal with no replacement. Three defections would kill insta-repeal, if Democrats hold together.

I think this possibility has been underplayed. 21 Republican senators are in states that have enacted the Medicaid expansion, and many of those states have slashed their uninsurance rates by 40% or more.

Still, odds are probably that Republicans will go through with a repeal-and-delay, in which they preserve the ACA Medicaid expansion and marketplace subsidies for at least 2-3 years while they allegedly craft a replacement plan.

If that's the case, there's still a high-stakes battle to be fought. Its outline can be discerned in the detailed options menu Condeluci laid out for Republicans (or their aides) racing to draft a repeal bill. Since that interesting material was buried rather deep in the prior post, I've reposted it below.

The sticking point (to my mind) is whether repeal of the taxes that largely fund ACA benefits is delayed along with repeal of the benefits. If not, the Medicaid expansion is probably dead, along with marketplace subsidies that make coverage affordable for lower-income buyers. The negotiations with Democrats over a replacement bill that Condeluci envisions are really only possible if substantial tax revenue is still coming in.

The Appian road to autocracy

For Christmas, my wife bought me an excellent new history of ancient Rome, SPQR by Mary Beard, which has proved the best kind of present -- something I never would have bought myself that I'm enjoying immensely. It has the twin virtues of constantly acknowledging uncertainty and ambiguity while articulating a few memorable interpretive themes.

One of these should bring any American living in this moment up short. Previewing her treatment of a century of civil war leading to the end of the Republic, Beard writes:

Looking back over the period, Roman historians regretted the gradual destruction of peaceful politics. Violence was increasingly taken for granted as a political tool. Traditional restraints and conventions broke down, one by one, until swords, clubs and rioting more or less replaced the ballot box. At the same time, to follow Sallust, a very few individuals of enormous power, wealth and military backing came to dominate the state -- until Julies Caesar was officially made 'dictator for life' and then within weeks was assassinated in the name of liberty. When the story is stripped down to its barest and brutal essentials, it consists of a series of key moments and conflicts that led to the dissolution of the free state, a sequence of tipping points that marked the stages in the progressive degeneration of the political process, and a succession of atrocities that lingered in the Roman imagination for centuries (p. 216).

Universal health insurance: A civilized society's single checkout line

This from Richard Mayhew triggered a flash image connected to a pet peeve:

Insurance (of any sort) has two major economic value propositions.  First, it pools risk so that unpayable costs become payable.  This encourages productive risk taking in the face of tail risk. Secondly, because of the pooling function, it reduces the variance faced by any individual in the pool.   Lower variance means more predictability which means less uncertainty.

The image is the single checkout line* in a New York Whole Foods, complete with lights signaling which of about 20 registers are free. That is, there's one line for all registers -- as at the post office, Barnes & Noble and elsewhere.

The pet peeve is large retail stores with lines at each register. There's a little anxiety cost for me in having to choose a line by eyeballing. It feels like defeat if someone in the line I've chosen asks to have the price of an item checked or uses a credit card that doesn't work.

The thought is that true universal health insurance is the unified checkout line of civilized life. What the single line does with customers' time, universal insurance does with money: spread the losses. More checkout counters equals a deeper risk pool. When there's twenty registers, the effect of one person's fifteen minute delay gets spread widely among the customers on the one line.  Ditto with one person's long-term kidney dialysis or diabetes management or multiple chemo rounds in a deep enough risk pool.

#NoRepealWithoutReplace: Tweet to save the ACA

A quick review of the cliff's edge the ACA is up against -- and (perhaps) how to back off it:

1. Republicans are vowing to use budget reconciliation to repeal the core elements of the ACA by February, delaying the defunding of some or all benefits for 2-3 years while they allegedly craft and enact a replacement..

2. As Republicans will have a 52-48 majority in the 115th Congress, insta-repeal can be stopped if three or more Republican senators balk at repeal-and-delay, calling instead for simultaneous repeal-and-replace (none of them will take a stand outright for preserving and amending the ACA).

3. Eighteen Republican senators represent states that have enacted the ACA's Medicaid expansion, which has by itself cut the ranks of the uninsured by about 20% nationwide -- and by more than that in many expansion states.

The ACA's fate may be determined this week

While Republicans have made amply clear their intention to swiftly pass an ACA repeal-and-delay bill in early 2017, it seems to me that a few facts about this looming prospect have not fully sunk in.

The first is that success is not a foregone conclusion. If three Republican senators balk at ripping up the ACA without a replacement in hand -- or at least, without a clear blueprint of how to get to replacement without throwing the individual market for health insurance into turmoil -- then the process slows, and the damage may be mitigated or avoided entirely.

Second, Republicans will never pass "repeal" and "replace" together -- unless perhaps they win 60 senate seats in 2018. Repeal-and-delay is their only option for delivering on their promises.

Third,  the time to stop the train is now -- in the coming week, between Christmas and New Year's, when senators and members of Congress will be home. The ACA had its long hot summer of rabid town halls, demonstration and counter-demonstration. ACA repeal gets a cold short week. And a lot of action is in planning.

These rather basic points were confirmed to me by Christopher Condeluci, a healthcare consultant who was tax and benefits counsel to Republicans on the Senate Finance Committee in 2009, when the ACA was being drafted.

The other subsidy for those who buy their own health insurance

Troubled by the high price of unsubsidized health insurance in the individual market, I have wondered for some time what percentage of those who buy their own insurance without benefit of subsidy are self employed and so claim the self-employed health insurance tax deduction.

I needn't have speculated. Back in October, a google search quickly brought me to detailed estimates provided by the IRS. I've written up the upshot over at healthinsurance.org:

In 2014, 4.2 million tax filers took the self-employed health insurance deduction, deducting a total of $28.1 billion from taxable income, according to a yearly estimate published by the IRS. That comes out to about $6,700 per filer, which indicates that a significant number are deducting premiums for more than one person. $6700 is a bit less than what a pair of 40 year-olds would pay for the average silver-level plan offered in the ACA marketplace 2014.

Hmmmm...Team Trump queasy about ACA insta-repeal?

I credit nothing said by Team Trump...but this does not sound like ACA repeal:

“The enrollment numbers announced today show just how important health care coverage is to millions of Americans,” said Phillip J. Blando, a spokesman for the Trump transition team. “The Trump administration will work closely with Congress, governors, patients, doctors and other stakeholders to fix the Affordable Care Act’s well-documented flaws and provide consumers with stable and predictable health plan choices.”

ACA afflicted by a deductible cliff

The Atlantic's Olga Khazan recently went to Trump country in central Pennsylvania, near Harrisburg, and asked people what they thought of the Affordable Care Act.  A lot of the not-poor were resentful about the Medicaid expansion. Here's the owner of a hair salon who earns too much to qualify for a marketplace subsidy and is old enough to pay near-peak premiums:

Things got even worse for her this year, when several insurers pulled out of Pennsylvania’s Obamacare exchange, leaving her with just a few options, she said. Now, she pays $655 a month, and her deductible is $10,000. “Welcome to my shoes,” she said...

The wealth and health of states, cont.

In my most recent post at healthinsurance.org, I noted that the five states highlighted by the Kaiser Family Foundation as those with the highest percentages of residents with "declinable pre-existing conditions" under pre-ACA rules were also the five poorest states in the nation as measured by median household income. That is, by these broad measures, the sickest states are the poorest states. (Those with "declinable pre-existing conditions" are those who, according to Kaiser, would likely have been unable to obtain health insurance in the individual market prior to ACA enactment. Kaiser conservatively estimates that 27% of U.S. adults under age 65 have DPCs.)

The correlation between state wealth and health carries pretty well through the fifty states. The chart below plots the percentage of residents in each state with declinable pre-existing conditions (DPC, y-axis) against 2015 median household income, according to the Census Bureau.

Obama, dis-illusioner in chief

Obama's year-end press conference on Friday was preceded by breathless expectations, half-voiced, that he would, I don't know, call the election results illegitimate, suspend transition, call on electors not to cast their votes for Trump...the hopes were inchoate.  And the despair when Obama launched into his characteristic slow-talking, methodical, low-drama point-by-points was the Twitter equivalent of Lamentations.

Listening while watching Twitter (twistening?), at first I shared the disillusionment. But gradually I began to feel that Obama's performance was literally that -- dis-illusionment. Obama was telling us some hard truths about the degradation of our institutions. His meta-message was: Russia didn't do this to us - we did it to ourselves.

In fact he was explicit on that point. Here is where my own (wavering) reaction tipped from "he's explaining away his soft-touch response to Russian meddling" to "he's telling us the truth":

Where #the27percent are the 33 percent (with "declinable pre-existing conditions")

The Kaiser Family Foundation has released a report finding that at least 27% of American adults under age 65 have pre-existing conditions that likely would have made it impossible for them to obtain health insurance in the pre-ACA individual market. That's generated a hashtag mainly devoted to testimonials by those with pre-existing conditions (or loved ones who have them ) -- #the27percent.

At healthinsurance.org, I explore a corollary:  the states with the highest concentrations of "declinable pre-existing conditions are also the poorest states in the nation:

Of the six states with the highest “declinable pre-existing conditions”...as of 2015, Mississippi ranks last among the 50 states in median household income, Kentucky 49th, Arkansas 48th, West Virginia 47th, Alabama 46th and Tennessee 40th, according to the Census Bureau.

...and of course, the poorest states are the ones in most dire need of the benefits provided by the ACA. Of the six above, three have accepted the ACA Medicaid expansion -- and cut their uninsurance rates in half. In the other three, over 40% of marketplace enrollees have incomes under 139%, the cutoff for Medicaid eligibility in states that accepted the expansion.

Hope you'll take a look at the related points.

A mantra for Democrats in ACA 'replace' negotiation: "Save Medicaid First"

There's a lot of speculation just now over whether Democrats in the Senate will work with Republicans to pass an ACA replacement after swift repeal. While repeal can substantively be done with just 51 votes via reconciliation, a replacement bill would require 60 votes, and hence eight Democrats. Per Politico:

Twenty-five Democrats are on the ballot in 2018, including 10 in states that Donald Trump just won. The GOP is betting that many or most in the latter group will be under irresistible pressure to back an Obamacare replacement, if the alternative is leaving millions of people in the lurch without insurance.

Greg Sargent responds that if Republicans put forward a plan that covers far fewer people that the ACA (as expected), Democrats can counter that  "they will only support a more generous replacement plan that covers a lot more people than the GOP replacement would.

It seems to me that the major barrier to bipartisan cooperation is the Medicaid expansion. The Medicaid rolls have increased by 16 million since 2013. By Charles Gaba's estimate (updating Kaiser's), 12.3 million new enrollees were rendered eligible by the ACA, which makes Medicaid available to adults with incomes up to 138% of the Federal Poverty Level in states that opt to implement the expansion (as 31 plus DC have done to date).

Up and coming

I have a post up at healthinsurance.org that's frankly a more streamlined version of a prior post here -- comparing the average total value of government subsidies for health insurance in Medicare, the ACA and Tom Price's ACA replacement bill. I'm sure Price would be tickled pink by my conclusion:

In fact, the Price subsidy could be a welcome addition to the ACA if it were grafted onto the current subsidy structure as a kind of alternative minimum subsidy, available perhaps to shoppers with incomes up to, say, 600 percent FPL

 And coming soon (from me)  at healthinsurance.org: a sidelight on Kaiser's finding that thanks to pre-existing conditions, 27% of Americans would likely be denied coverage in the individual market under pre-ACA rules. Hint: the states with the highest percentages of residents with  "declinable pre-existing conditions" are also the states with the lowest median family income -- and so with the most heavily subsidized ACA beneficiaries.  

Give PriceCare to the not-poor

As I noted last week, Tom Price's 2015 ACA repeal-and-replace bill, dubbed the Empower Patients First Act, is a grossly inadequate offering for the 20-plus million mostly poor and near-poor people who have so far gained health insurance through the Affordable Care Act.  Its limited premium subsidies for shoppers in the individual market, adjusted for age but not income, would leave coverage unaffordable for most of the 9 million subsidized enrollees in the ACA marketplace. Worse, by repealing the ACA's Medicaid expansion, it would un-insure virtually all of the roughly 12 million who have gained coverage through the ACA's expansion of eligibility.

Price's EPFA does, however, provide significant aid to those who earn too much to qualify for ACA marketplace credits -- which includes some younger buyers with incomes as low as 250% FPL and a considerable number in the 300-400% FPL range. Insurance seekers who are subsidy-ineligible (or close to it) but not wealthy fare worst under the ACA, as the Urban Institute's Linda Blumberg and John Holahan have highlighted:

Price's subsidies would cover, on average, about 40% of the premium for the average benchmark silver plan offered in the ACA marketplace, and a higher percentage of the premium for the skimpier plans that would be on offer in the deregulated individual market his replacement bill would create. Coupled with an HSA, and possibly with full tax deductibility for any plan purchased in the individual market (as Trump's campaign website proposed), and with continuous coverage protection, it's a program that could work for the modestly affluent (at least, with some compromise preserving essential health benefits as a broad outline while giving states more autonomy to flesh them out).

Cutting off CSR subsidies will hit red state enrollees especially hard

As Republicans gear up to repeal the ACA,  the Kaiser Family Foundation has helpfully broken out how many of the 9.4 million subsidized enrollees in the ACA marketplace (as of March 31) live in each state, and what share of an estimated $32.8 billion to be paid out in premium tax credits this year will be paid out for enrollees in each state.

Greg Sargent, assessing the potential political fallout of cutting off those subsidies, notes:

Some of the states with the highest populations of people getting subsidies are represented by GOP Senators. This includes Florida (more than 1.4 million); Texas (more than 913,000); North Carolina (more than 499,000); Georgia (more than 427,000); and Pennsylvania (more than 321,000). Many other states with GOP senators also have sizable populations getting subsidies.

Today also happens to be the day when a federal appeals court delayed further proceedings in House Republicans' suit to stop the executive branch from funding the Cost Sharing Reduction (CSR) subsidies that reduce out-of-pocket costs for 57% of marketplace enrollees. Since a lower court upheld the suit in May, but stayed any action to cut off the payments, the delay effectively leaves it up to the Trump administration whether to drop the Obama administration's appeal and thus cut off those subsidies, effectively crippling the marketplace instantly* (and disrupting Congressional Republicans' alleged "repeal-and-delay" plans, which would keep the marketplace functioning until a replacement plan is enacted).

It therefore seems appropriate to note that CSR subsidies are particularly prevalent in the 19 states that have refused to enact the ACA's Medicaid expansion -- most of which are Trump country. That's because in those states, a subset of those whom the ACA intended to make eligible for Medicaid, people with incomes between 100% and 138% of the Federal Poverty Level (FPL), are instead eligible for subsidized marketplace coverage.   And since they are in the lowest income bracket eligible for subsidized marketplace coverage, they get the highest level of CSR support for the lowest price.

Tom Price will probably cut your health insurance subsidy in half

Last week, I noted that the federal government pays a bit more than two thirds of total medical costs for the average traditional Medicare enrollee. That is, the government pays about 85% of the premium(s) for insurance that covers a bit more than 80% of the average user's annual medical costs (that latter percentage is known as a health plan's actuarial value). Subsidies for those who chose Medicare Advantage plans are comparable.

In a followup post, applying the same calculation to subsidized enrollees in the ACA marketplace and prospective enrollees in HHS Secretary nominee Tom Price's ACA repeal-and-replace plan, I came up with the following total subsidy values:

Traditional Medicare:  85% of premium paid for AV 81% coverage = 69% of costs

Subsidized ACA marketplace: 73% of premium paid for AV 81% = 59% of costs (highly variable)

Tom Price ACA replacement: 59% of premium paid for AV 60% coverage = 35% of costs