How about a national reporter hotline for Coronavirus balance billing?

Subscribe to xpostfactoid via box at top right

It's been a running joke on healthcare Twitter for some time that Americans' best defense against egregious surprise billing and relentless hospital debt collection is to call a reporter.

With Sarah Kliff (now at the NYT) crowd-sourcing outrageous emergency room bills at Vox and Kaiser Health News maintaining a Bill of the Month series, there's been saturation coverage of these practices that render health insurance effectively illusory for tens for millions of Americans.

With almost comic frequency, ERs caught out billing patients thousands for minimal work and hospital systems exposed for suing thousands of low income patients have forgiven bills or announced that they are changing their dunning practices after being exposed in the national press. For example....

Zuckerberg San Francisco General rolls back a $20,000 ER bill sent to an insured patient after a bicycle accident -- then reviews its practice of balance-billing every privately insured patient brought to its doors. A behemoth dialysis provider cancels a half-million dollar bill. A week after KHN's Jay Hancock reports that University of Virginia has sued 36,000 patients, garnished thousands of paychecks and put liens on homes, the hospital admits it was too aggressive and revamps its financial aid guidelines. Just today we learn that another predatory debt collector in Virginia, VCU Health, will stop garnishing wages and putting liens on people's houses.

Coronavirus alert: How about an emergency Special Enrollment Period for the ACA marketplace?

Subscribe to xpostfactoid via box at top right

Update, 3/12: As noted in the updates at bottom, as of now five state-based marketplaces are running Special Enrollment Periods open to all, two of them triggered by the coronavirus emergency. CMS should do it for the healthcare.gov states. 3/14: Rhode Island makes six. 3/16: New York comes on board. 3/17: Nevada is in. 3/18: Connecticut announces SEP. And Colorado will announce imminently. 3/20: Covered California, already open via a tax-season SEP, available to anyone who affirms they were not aware of the state's new individual mandate, today makes it unconditional with an emergency SEP open to all. And it's open through June 30, by far the longest emergency SEP. 3/20 II: MNSure announces a SEP running March 23 - April 1. 3/20 III: Vermont comes on board, sort of.

Every SBE except Idaho now has enrollment open to the uninsured.

If the coronavirus causes major economic disruption, as now seems likely, the ACA marketplace (including Medicaid enrollment) is likely to get a major stress test.

As I've noted previously, the marketplace has never experienced a recession; the unemployment rate has dropped steadily since it launched in 2014, and enrollment has been basically flat since 2016. It stands ready as a shock absorber when people are laid off.  Those who lose insurance through their jobs are eligible for a Special Enrollment Period.  The machinery for processing SEP requests had better be smooth.

Since subsidy eligibility depends on annual income, the earlier in the year layoffs begin, the more people will qualify for marketplace subsidies (annual income up to $49,960 for an individual) or Medicaid ($17,236). In Medicaid expansion states, even those who have crossed those earnings thresholds should be eligible for Medicaid one month forward if their income is below the monthly Medicaid threshold.* Under various emergency authorities, governors and the president can extend Medicaid eligibility and expedite enrollment, as was done in the wake of 9/11, Hurricane Katrina, and the Flint water crisis.

The marketplace also might be put to more immediate use.  CMS should declare a national Special Enrollment Period for the marketplace (Medicaid enrollment is year-round).

Employer-sponsored insurance is deteriorating. What about fixing it rather than replacing it?

Subscribe to xpostfactoid via box at top right --->

Medicare for All's main political liability, as the presidential campaign has made clear, is loss aversion: most Americans are insured,  most are reasonably satisfied with their coverage, and a significant minority consider their top-drawer coverage a major asset. Americans also have ample cause to doubt their government's capacity to completely remake the country's healthcare system and serve as the sole source of major medical insurance to everybody.

At the same time, Medicare for All speaks to a current reality: employer-sponsored insurance (ESI), which covers the majority of Americans under age 65, is deteriorating, and Americans know it.  Kaiser Family Foundation tracking poll results released last week neatly capture the core household worries related to healthcare:

About two-thirds of Americans say they are either “very worried” (35%) or “somewhat worried” (30%) about being able to afford unexpected medical bills. This is larger than the share that say they are worried about affording a variety of expenses, including other types of health care costs as well as other household expenses. About half of insured adults say they worry about being able to afford their health insurance deductible (49%) and four in ten (40%) worry about being able to afford their premiums. More than four in ten adults overall worry about affording prescription drug costs (45%).

The ACA at 10: The navigators' tale (preview)

Subscribe to xpostfactoid via box at top right --->

As the tenth anniversary of the ACA's passage approaches, Health Affairs is out with a landmark series of articles examining the law's history and impact.

To mark the occasion myself, I have interviewed five "navigators" -- nonprofit enrollment assisters chartered by the ACA -- who were in at the birth of the marketplace and have been helping people enroll since fall 2013.

These veterans have assisted thousands of mostly low income people in need of affordable health insurance and have been integral to the enrollment assistance infrastructure of their states -- Florida, South Carolina, West Virginia and Texas, which together account for 28% of all marketplace enrollment. All of these states use the federal HealthCare.gov platform and so have been subject to the Trump administration's 84% cut to navigation funding.

I have completed my writeup of the debriefing of these resilient, tough, devoted professionals and am currently shopping the article draft, which may yet end up here on xpostfactoid. It's a slow process. To ease my impatience, I'm here offering a snippet view of key points.

The ACA at 10: Resilient, yes, but...

Subscribe to xpostfactoid via box at top right --->

To mark the ACA's tenth anniversary, Sabrina Corlette, Linda Blumberg and Kevin Lucia - three of the nation's leading scholars and architects of healthcare policy -- have written a detailed and entertaining account of the tumultuous history of the ACA marketplace and its impact to date.

Strap in and relive the rough ride through grandmothered pre-ACA plans, the risk corridor massacre, the market correction of 2017, the repeal drive of 2018, the individual mandate repeal and promotion of the medically underwritten short-term market...and relative enrollment stability through it all.

The authors' conclusions are fair but, perhaps necessarily, oversimplify a bit. Let's take the catalog of successes one at a time.

Will Americans' fear of high medical bills hinder Coronavirus containment?

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

On Wednesday, I noted that the high out-out of pocket costs that most insured Americans under age 65 are exposed to might deter people who contract the Coronavirus (or suspect they may have contracted it) from seeking treatment.

In employer-sponsored insurance, the average single-person deductible in 2019 was $1,655, according to the Kaiser Family Foundation. 28% of covered workers had a single -person deductible over $2,000.  The median annual maximum out-of-pocket (MOOP) limit (after which the plan pays 100% of covered expenses) was $4,000 (the maximum allowable is $8,100). About two thirds of employer plans require coinsurance for inpatient hospital stays, averaging 20%.

Today, Sarah Kliff reports that an American father and daughter who were subject to mandatory quarantine when they returned from Wuhan province in China were also subject to two mandatory stays in an isolation unit at a nearby children's hospital after the child was heard coughing. After release, "they found a pile of medical bills waiting: $3,918 in charges from hospital doctors, radiologists and an ambulance company."  The father's employer provided health coverage in China, where he had been working, but does not provide it in the U.S.

The card spells MOOP: Will Covid-19 expose Americans to financial risk?

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

The Miami Herald reports that a man who developed flu-like symptoms after a business trip to China did what he felt was the right thing and went to the hospital to get tested for the Coronavirus. Hospital officials wanted to give him a CT-scan, but since he knew his insurance was limited, he asked for a flu test first.  Smart move. He tested positive for flu, and that was that -- except for the $3,270 bill that came later, with more to come.

The hospital told him that his share of the bill was $1,400. The story then focused on the fact that this man was in a short-term, limited duration plan that demanded he supply three years of medical records to prove that he didn't have a "pre-existing condition," i.e., a recent prior bout of flu.

That's outrageous, but it misses a broader point about Americans' financial exposure when the Coronavirus spreads. If this individual's medically underwritten policy does pay out, he's not necessarily in a worse financial position than the average insured American who walks into a hospital with suspected Covid-19.

The one executable healthcare reform plan put forward by a presidential candidate

Subscribe to xpostfactoid via box at right

If I may cannibalize my Twitter thread, a reaction to last night's debate in four tweets:

Healthcare in last night's debate: More blah blah blah about public option vs. M4A and nary a word about Republican intentions to void the ACA, gut Medicaid, bring back medical underwriting, uninsure tens of millions and cut at least $1 trillion in HC spending in first decade.

You have to have goals, yes. But they remind me of old-time communists arguing about who'll clean the toilets when the state withers away.

"Everyone must have access to Medicare-plus, but you can keep your wonderful employer plan if you prefer!" "No, everyone must have free access to everything!" Meanwhile...

It'll be a minor miracle if we're not living in authoritarian austerity state and if a Dem president can wring Medicare drug negotiation, balance billing ban and improvements to ACA subsidies/access through a 51-49 senate.

Six years later: Some stuff we've learned (or think we've learned) about the ACA marketplace

Subscribe to xpostfactoid via box at right

The ACA marketplace is in its seventh year -- not a baby any more. I was just musing about some things we've learned, or think we've learned. Some are well understood, some are little recognized, some are tentative hypotheses. In no particular order:

• The marketplace came of age during a period of steadily rising employment. That's good news for the country, but has constituted a steady headwind for enrollment. ACA subsidies are on standby as a shock absorber for the next recession (if the courts don't kill the law).


• Since 2018, silver loading* has partly offset factors depressing enrollment, including massive cuts to outreach and advertising, rising incomes and employment, and rising premiums (in 2017-18) and out-of-pocket costs. As of 2019 silver loading had probably boosted enrollment by about 500,000.


• Those out-of-pocket costs have risen relentlessly. That's inevitable in a system where a fixed percentage of income buys a fixed actuarial value, since healthcare costs continue to rise far faster than inflation.  In 2014, the top allowable out-of-pocket maximum for a single enrollee was $6,350.  In 2021, it will be $8,550. The average silver plan deductible (for those who don't qualify for CSR) was $2,425 in 2014 and $4,544 in 2020.

Bronze plans are terrible. Bronze plans are often the best choice.

Subscribe to xpostfactoid via box at top right

In discussion of the ACA marketplace (and health insurance generally), deductibles are often used as a stand-in for out-of-pocket costs. Now here cometh David Anderson to remind us that a plan's maximum out-of-pocket cost (MOOP) can be just as important -- and that the MOOP often does not particularly correspond to metal level.

The highest allowable MOOP at all metal levels is $8,150 (a travesty by international rich country standards).  Here is David's mapping of the range of MOOP for gold plans in HealthCare.gov states.  Dark green is $2,500 MOOP; dark red is $8,150.

As David points out, bronze plans will be a better deal for anyone who knows they'll hit the out-of-pocket max. As he's pointed out elsewhere (and in passing here), it takes a lot more spending to hit the high max in a gold plan -- say, $30,000 -- than in a bronze plan. That's because once you meet your deductible (likely to be relatively low in a gold plan with high MOOP), a high percentage of ensuing costs will be covered in a gold plan until the MOOP is reached, at which point coverage goes to 100% for ensuing costs (if you stay in network).

But love grows old and waxes cold: #HealthPolicyValentines 2020

A healthy Valentine's Day to all! As the rule of law in the U.S. erodes, and the Trump administration comes up with ever new ways to reduce enrollment, services, and affordability in public insurance programs, I can't forbear but to add some, shall we say, antivalentines to this year's mix. They follow the sweeter kind.

Cold wax, not to be confused with waxing cold

Health wonks are sweet,
their rhyming is cute.
Poetic meter
is not their strong suit.

          *     *     *

On hold with the hospital
in some endless billing tiff?
Put down the receiver
and dial @sarahkliff.

States seeking to reduce their uninsured populations must beware a Catch-22

By David M. Anderson, Charles Gaba, Louise Norris and Andrew Sprung

Note: this post is the third joint effort by David, Charles, Louise and me. Others here and here.

State policymakers have been prolific and creative in putting forward measures to strengthen their ACA marketplaces. Measures enacted since 2017 or in progress now include reinsurance programs, which reduced base premiums by an average of 20% in their first year in the first seven states to implement such programs; new or renewed state-based exchanges, which capture insurance user fees that can be used for advertising and outreach; state premium subsidies to supplement federal subsidies; and state-based individual mandates, which can provide funding for all of the above.

Policymakers must recognize, however, that these choices entail tradeoffs — and not just in budgetary constraints. Specifically, built into ACA marketplace architecture is a pricing dynamic that bedevils state attempts to improve ACA marketplace performance: reductions in premiums for unsubsidized enrollees tend to raise premiums for subsidized enrollees. Because premium subsidies are designed so that enrollees pay a fixed percentage of income for the benchmark (second cheapest silver) plan, premium increases also increase subsidies — and tend to increase the difference, or "spread," between the benchmark plan and cheaper plans.

The year after: Does reinsurance boost marketplace enrollment?

Subscribe to xpostfactoid via box at top right --->

I have written on various occasions about a Catch-22 that bedevils state governments trying to improve affordability and boost enrollment in their ACA marketplaces: reductions in premiums for unsubsidized enrollees tend to raise premiums for subsidized enrollees. Because premium subsidies are designed so that enrollees pay a fixed percentage of income for the benchmark  plan, premium increases also increase subsidies — and tend to increase the  "spread" between the benchmark plan and cheaper plans, creating discounts. Premium reductions reduce those spreads and discounts.

States face this Catch-22 when considering reinsurance programs, for which federal funding is available. By reimbursing insurers for costs incurred by their most expensive enrollees, reinsurance reduces premiums by predictable amounts, averaging 20% in the first year of implementation as of 2019, according to Avalere Health. That helps unsubsidized enrollees but sometimes hurts the subsidized.

By 2018, states faced intense pressure to help the unsubsidized. A federal reinsurance program helped control premiums nationally in the marketplace's first three years of operation, 2014-2016. When the program sunset in 2017, premiums skyrocketed, as they did in 2018 (other factors included insurers' initial underpricing in a new market, which was manifest by 2017, and political turmoil in advance of the 2018 enrollment season). From 2016 to 2018, average benchmark premiums increased by an average of 61%.  By 2019, unsubsidized enrollment in ACA-compliant plans was down about 50% from 2016.

Let's take a look at how enrollment fared in ten of the twelve states that have stood up reinsurance programs (as CMS has encouraged states to do) since 2018 (Rhode Island has not yet reported 2020 totals, and Maine's 2019 enrollment was affected by late implementation of the ACA Medicaid expansion).

Everything changes: Demographics inside and outside the ACA marketplace

Every year at this time I bind sheaves of four blog posts for two submissions to the National Institute of Health Care Management's Digital Health Care Media Awards. Here I'd like to post an outtake: a series of posts probing some under-the-radar facts about the the ACA marketplace and its prospective enrollees.  That is:

• The ACA marketplace and Medicaid expansion have never been tested by recession but stand ready as an economic shock absorber.
• U.S. income gains since 2014 have affected marketplace participation.
• Yearly apparent declines in on-exchange enrollment since 2016 are largely illusory.
• Nonetheless, persistent low takeup bespeaks inadequate subsidies.
• A recent increase in the uninsured population is concentrated at higher incomes.

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Eye of the hurricane? The ACA marketplace in 2020

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)---->;

While open enrollment in the ACA marketplace has 1-7 days to run in a handful of state-based exchanges (SBEs), and other SBEs haven't reported their data, the overall picture is clear: enrollment in 2020 was essentially flat. Enrollment in the 38 states using HealthCare.gov was down 1.4%, while enrollment in the 13 SBEs will be up 2.6%, leaving total enrollment down 0.3%, according to Charles Gaba's projection.

The big picture is perhaps relatively simple. Premiums were down slightly on average; insurers did not register major impact from the zeroing out of the individual mandate in 2019; the market in aggregate was stable.  But the ACA marketplace is really 50 marketplaces -- or thousands, if you count each rating area -- and a lot of change is bubbling under the surface, from Medicaid expansions in red states to new state-based subsidies in blue states.  Nationally, too, the initial tally sparks several questions:

Frederick Isasi: Three healthcare trends, three power struggles

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

At Families USA's Health Action conference last week, FUSA executive director Frederick Isasi, in a presentation for attending media, identified three healthcare trends for 2020.  It struck me that at the heart of each enumerated "trend" is a looming political battle, each of them central to the U.S.'s current existential struggle between oligarchy and renewed democracy. Let's look at each in turn.

1. Value. Describing Americans' demand for "value" in healthcare, Isasi was not speaking primarily about "value-based care," i.e. outcomes-based alternatives to fee-for-service payment. He focused rather on out-of-control prices paid to providers that are rendering care unaffordable to tens of millions. He pointed out that healthcare costs have climbed 600% in the last 40 years and nearly tripled as a percentage of GDP, rendering care unaffordable for tens of millions.  "Almost half of Americans say they have trouble affording healthcare," he said. "People are more scared of paying for getting sick than they are of getting sick."

As to the cause of runaway costs, Isasi blamed the market power of the various healthcare industries: "it's a highly subsidized sector with almost no government oversight." The struggle to hold down costs is less technocratic than political: forcing powerful industries to accept curbs on their pricing power.  Potentially enabling that struggle is a sea change in public attitudes: While coverage has eroded in recent years, Isasi noted, the ACA has wrought a sea change in Americans' expectations: "acceptance of the right to access is a new societal norm."

At Health Action 2020: Once more unto the breach, dear friends

I've had my yearly fix from Health Action 2020, Families USA's annual conference for healthcare advocates, policy people, scholars, and, most importantly I think, front-line ACA enrollment counselors.

I attended my first Health Action conference in January 2017, days after Trump was "sworn," aka perjured, into office. Republicans were promising swift ACA repeal -- "repeal and delay" was their watchword of the moment, meaning they would sunset the marketplace and Medicaid expansion swiftly and fill in the details later. The conference was composed of several hundred people devoted to preventing that. "Our action should lead to their inaction," declared incoming FUSA president Frederick Isasi. And mirabilis, that's exactly what happened.

In 2017 I felt keenly that the conference was run and attended by people who had devoted years or decades to expanding healthcare access in the U.S. -- all now faced with the prospect that their work would be unraveled. I wrote about an emanation of collective strength, institutional and individual, from the participants.  And this year I kept flashing back.

Since the impeachment process got into gear this year, I have often felt that American democracy is going down. It's terrifying to watch the entire Republican party fall in behind Trump to neuter Congress's power to hold a corrupt would-be autocrat accountable for on-the-record abuse of power.  Once again, the people on the stage and in the room reminded me that despite the grave threat to democracy posed by a party in power that's given up on democracy, the country has huge reserves for resistance: people who know how to be free; institutions that know how to wield political influence in service of the common good; courts that at least sometimes uphold the rule of law.

No mandate penalty, no problem? The jury's still out

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

The Kaiser Family Foundation is peerless as a source of data and analysis of the ACA marketplace, and indeed of all U.S. healthcare markets. So it's probably foolish of me to question a simple, unequivocal and important conclusion by KFF president and CEO Drew Altman. Still...

Altman, who has a regular column conforming to Axios' radically short format, begins his latest with this declarative:

The Affordable Care Act’s insurance market has not been materially affected by the elimination of the individual mandate penalty.

Evidence: premiums are down in 2020, marketplace insurers are profitable, the risk pool has not apparently worsened, enrollment is more or less stable, and the Medicaid expansion appears to have been "largely unaffected."

That's a lot of evidence in short space. The marketplace, and the Medicaid expansion are clearly functioning without the mandate. But still, I think it's too soon to declare the effect of zeroing out the mandate negligible.  Caveats:

Juice it, Jersey: What silver loading anemia looks like

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

I have noted before that New Jersey's implementation of an individual mandate and a reinsurance program in its ACA marketplace in 2019 illustrates the tradeoffs involved in reducing premiums in the ACA marketplace. In brief: unsubsidized premiums down, subsidized premiums up.

I have also noted that in New Jersey, silver loading is underpowered -- that is, it has produced weaker-than-average discounts in bronze plans and no discounts in gold plans, which accounted for an anemic 2% of enrollment in 2019.

Last week, David Anderson and Coleman Drake published a study indicating that the widespread availability of free bronze plans, a major byproduct of silver loading*, has had a particularly strong impact on enrollment.  The authors noted that this effect is conspicuously lacking in Jersey, and suggested a reason:

New Jersey restricts cost-sharing variation within metal levels. In 2019 New Jersey bronze plans were required to have an actuarial value of 64 percent—higher than the 58.5 percent minimum allowed by federal law. This regulation limited the financial exposure of existing enrollees by preventing them from selecting plans with higher cost sharing. However, it also limited the premium spread between the benchmark silver plan and bronze plans, which reduced the availability of zero-dollar premium plans in the state and thereby reduced enrollment. A trade-off thus exists between reducing enrollees’ financial exposure by increasing minimum actuarial value levels and increasing insurance coverage via the zero-price effect.

Has silver loading reduced mortality?

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

In early 2017, the IRS sent letters to 3.9 million taxpayers who had paid the ACA's individual mandate penalty in 2015, encouraging the recipients to obtain health insurance and avoid the penalty.  A study of the results* published last month found that 1) those who received the letter were 1.3 percentage points likelier to enroll in coverage in the year following than penalty payers who did not receive it, and 2) that receiving the letter reduced mortality  over the next two years among 45-64 year-olds -- by about six deaths per ten thousand, a significant result.

Drilling into the data-set of millions, the authors infer that in this heart attack and cancer-prone age group, "each month of coverage (on average) reduces baseline mortality among those who enroll in coverage by approximately 2.4%." As to how insurance might have this effect among 45-64 year-olds who lacked coverage in the previous year, the authors posit:

For coverage to reduce mortality over this time horizon, it must affect conditions that: (1) can cause death quickly if left untreated or unmanaged, and (2) for which treatment or management can prevent or delay mortality. For example, individuals lacking health insurance may delay seeking care when experiencing symptoms of acute conditions (e.g., heart attack or stroke), and such delays increase the likelihood of short-term mortality (Smolderen et al., 2010; Medford-Davis et al., 2016)... Separately, obtaining coverage may reduce mortality by causing the diagnosis of certain chronic conditions for which treatment has rapid protective effects. For example, cardiovascular drugs have been observed to reduce mortality from heart disease within months of beginning treatment.

While attracting young adults into the ACA marketplace would improve the risk pool and so put downward pressure on premiums, attracting older adults saves lives. It is likely that silver loading, the pricing practice that's generated windfall discounts in bronze and gold plans in the ACA marketplace since 2018, has boosted enrollment more among older enrollees than among younger ones.

Is "free" a magic word in the ACA marketplace?

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Healthcare scholars David M. Anderson and Coleman Drake have published a study that analyzes the impact of free bronze plans, which became available to millions of prospective ACA marketplace plans in 2018, on enrollment.

Ubiquitous free bronze is one result of "silver loading," the byproduct of Trump's October 2017 cutoff of direct federal reimbursement to insurers for the Cost Sharing Reduction (CSR) subsidies they are required to provide to low income marketplace enrollees who select silver plans. Faced with the cutoff at the brink of open enrollment for 2018, most state insurance departments allowed or encouraged insurers to price CSR into silver premiums only. Since premium subsidies, designed so that the enrollee pays a fixed percentage of income, are set to a silver plan benchmark (the second cheapest silver plan), inflated silver premiums create discounts for subsidized buyers in bronze and gold plans. As a result of silver loading, $0-premium bronze plans available to millions.

Perhaps the most striking finding in Anderson and Drake's paper is the sheer ubiquity of free bronze plans, particularly for enrollees over age 45 (since premiums rise with age, and the benchmark plan costs subsidized enrollees a fixed percentage of income regardless of age, older enrollees have larger subsidies to cover plans that cost less than the benchmark). The authors divined the availability of free bronze by matching enrollment data, which CMS breaks out by county, income, age and metal level in the 38 states that use HealthCare.gov, with pricing data, which CMS also provides. 

Free bronze, they found,was available in 2019 to almost every marketplace enrollee with an income below 150% of the Federal Poverty Level (FPL) -- that is, to about 3 million enrollees in HealthCare.gov states, more than a third of all enrollees. It was available to most enrollees at 150-200% FPL, and to a large majority of enrollees over age 45 in the 200-250% FPL income bracket.

2019: Medicare at Will, Warren in the whirlpool, silver loading Year 2....

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Below, a look back at some xpost focal points in 2019. Short version: the posts below index multiple posts on recurring themes:

Elizabeth Warren's healthcare toggle switch
Two years of rather quavery support for Medicare for All

Medicare for all who want it: Potential and pitfalls 
Scrutinizing the Medicare for America bill

Silver loading and 2019 enrollment
What impact has silver loading had so far? What can be done to increase its impact -- that is, to further boost ACA subsidies?

*          *          *

Early this year, I assumed that as the Democratic presidential candidate field was winnowed, the surviving candidates would converge on a "Medicare for all who want it" model for next-gen healthcare reform.

Whither humanity? Three NYT snapshots

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

*         *         *

The front page of today's print New York Times greeted Sunday breakfasters with what feels like a typical trio of world-going-to-hell headlines above the fold:

• Nearly 80 Die As Blast Strikes Somali Capital
• As It Detains parents, China Weans Children From Islam
• Trump Eroding Role Of Science In Government

As antidote, in the op-ed pages Nicholas Kristof offered up his annual reminder that by quantitative material measures the human condition continues to improve; extreme poverty, debilitating disease and child mortality are declining, literacy is growing, hundreds of thousands climb out of extreme poverty daily. 

In the same op-ed section, Ross Douthat leads with a truly arresting take on the last decade:

Assessing 2020 ACA marketplace enrollment? Don't forget Virginia's 2-year Medicaid expansion shakeout

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

In assessing total ACA marketplace enrollment for 2020, it's important to keep in mind that the fallout from Medicaid expansion expansion in Virginia continued into a second year.

As I've noted before, that's generally been the case in states that have enacted belated Medicaid expansions after the ACA's core programs launched in 2014.

Marketplace enrollment drops when a state implements the Medicaid expansion (rendered voluntary to states by the Supreme Court in 2012) because the lowest-income marketplace enrollees become eligible for Medicaid -- and therefore no longer eligible for marketplace plans, at least theoretically.

In expansion states, people with incomes up to 138% of the Federal Poverty Level (FPL) are eligible for Medicaid -- and so, not for marketplace subsidies. In states that have refused the expansion (e.g., Virginia until Jan. 2019), eligibility for marketplace coverage begins at 100% FPL.

Michael Bloomberg's healthcare plan eats its own tail

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Michael Bloomberg's just-released health coverage plan would do some good if enacted. It's introduced, however, with a false premise.

Deeming "a Medicare-like public option" the "first step," the plan outline pronounces:

A public insurance option would improve consumer choice and increase competition in the private insurance market, pushing down everyone’s premiums. People of modest means who buy the public option would be eligible for the same subsidies that would apply on the health insurance exchanges.

As students of the ACA marketplace know, however, within the marketplace structure, when base (pre-subsidy) premiums shrink, the premiums paid by subsidized enrollees tend to go up. That's because the subsidies are designed so that the enrollee pays a fixed percentage of income (rising with income) for the benchmark (second cheapest silver) plan. If you buy a plan that's cheaper than the benchmark, your subsidy goes further (and these days, thanks to silver loading*, may cover the whole premium). When premiums go down, price spreads between the benchmark and cheaper plans tend to shrink, reducing discounts for the cheapest silver plan and for bronze plans. If a public option reduces premiums, as Bloomberg promises, it will increase them more often than otherwise for subsidized buyers. Ditto for reinsurance, proposed to reduce premiums another 10%.

The Cadillac Tax: An idea whose time never came

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

To the surprise of no one, it looks like the ACA's long-postponed Cadillac ax, an excise tax on employer-sponsored health plans that exceed a certain cost threshold,  is slated for legislative execution, along with the medical device tax.

Against the vociferous opposition of unions and employers, Obama fought to preserve the Cadillac Tax, a linchpin of the ACA's efforts to control healthcare costs. CBO estimates that repeal will cost the treasury $200 billion over ten years.

On one level, it's sad that Congress can't make taxes with powerful opponents stick. Medical device tax repeal is a dead giveaway.  But the Cadillac Tax was based on two false premises.

Uninsurance goes (slightly) upscale, Kaiser edition

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

In September, the annual Census Bureau update on health insurance coverage in the U.S. reported a 0.5% rise  in the uninsured population in 2018 -- an increase of 1.9 million uninsured. I noted at the time:

Affluent uninsured population spikes. Notwithstanding a drop of 2 million  (0.7%) in Medicaid enrollment, the sharpest increases in the uninsured were at high incomes. At 300-399% FPL, the insured rate dropped a full percentage point, from 92.9% to 91.9%, and at over 400% FPL, the rate dropped 0.8%, from 97.3% to 96.6%. Together, these two income groups account for 55% of the population. Particularly striking, the number of uninsured at incomes over 300% FPL increased 23.8% (from 6.631 million in 2017 to 8.215 million in 2018).  The spike in uninsured children at high income levels seems congruent with this drop.

These losses were concentrated in private insurance, down 1.3% percentage points at both income levels. The private insurance losses stem in part from the individual market, where unsubsidized enrollment dropped by 1.8 million in 2018, according to the Kaiser Family Foundation's estimate.  That drop is part of a longer term free-fall, from 9.1 million unsubsidized in the individual market in in the first quarter of  2016  to 4.7 million in Q1 2019, according to Kaiser.

Yesterday, the Kaiser Family Foundation released an updated analysis of the uninsured population. Kaiser finds a smaller increase in the uninsured in 2018 than did the Census, 500,000.  In contrast to the Census, Kaiser finds equal increases in the uninsured at 100-199% of the Federal Poverty Level and at over 200% FPL, with a statistically insignificant decrease at incomes below 100% FPL.  Regarding the increase at not-poor incomes, a couple of points from the analysis stand out:

Forget free bronze plans: millions of uninsured are eligible for CSR silver

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

The Kaiser Family Foundation is out with an analysis estimating that 4.7 million uninsured Americans are eligible for free bronze plans in the ACA marketplace. That's a bit less than half of the uninsured who are eligible for marketplace subsidies, according to a 2017 Kaiser estimate.

These estimates have emerged as a Kaiser tradition in the Trump era , which in ACA terms is the silver loading era. "Silver loading" is the byproduct of Trump's October 2017 cutoff of direct federal reimbursement to insurers for the Cost Sharing Reduction (CSR) subsidies they are required to provide to low income marketplace enrollees who select silver plans. Faced with the cutoff at the brink of open enrollment for 2018, most state insurance departments allowed or encouraged insurers to price CSR into silver premiums only. Since premium subsidies, designed so that the enrollee pays a fixed percentage of income, are set to a silver plan benchmark (the second cheapest silver plan), inflated silver premiums create discounts for subsidized buyers in bronze and gold plans. One result is $0-premium bronze plans available to millions.

Arguably, "free bronze" is useful chiefly as a marker of the extent of bronze plan discounts, which are more popular at the upper income end of ACA subsidy eligibility, 200-400% of the Federal Poverty Level (FPL) than at the lower end, 100-200% FPL, which still accounts for the majority of on-exchange enrollees. At upper income levels, bronze plans are likelier to be cheap than free.

In 2019, 89% of enrollees with incomes in the 100-150% FPL range in the 39 states using HealthCare.gov  selected silver plans. At 300-400% FPL, just 24% selected silver, vs. 58% for bronze and 17% for gold. Cheap bronze is more of a lure than free bronze. At low incomes, the value of CSR outstrips the value of bronze discounts generated by silver loading.

Ross Douthat and the "expert-fashioned architecture" of the ACA

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Credit where due: Ross Douthat is a creative thinker, capable of carving new conceptual boundaries across familiar landscapes.  Today, claiming that Democratic voters have tired of Clinton- and Obama-style technocracy, he identifies the competing approaches to policy as moral (Bernie Sanders) and transactional (Joe Biden).

On the healthcare front, citing ""widespread left-wing disappointment with what the Obama-era politics of expertise produced," Douthat asserts:

This disappointment has been strongest on health care, where Obamacare’s most popular provision was the simple socialism of the Medicaid expansion rather than the complicated, expert-fashioned architecture of the exchanges.

He's right on the merits.  The Medicaid expansion accounts for probably 75% or more of the net coverage gains achieved by the ACA.  Enrollee satisfaction is far higher in Medicaid, which covers all of enrollees' costs, than in the marketplace, where satisfaction is inversely proportionate to out-of-pocket cost exposure, and at least half of enrollees are subject to high deductibles and out-of-pocket costs.*

Should Snoopy be your editor?

There is a Peanuts comic series in which Snoopy is working on a novel, and Lucy volunteers to draw a cover for it. Snoopy makes very specific demands, and Lucy returns with the finished product:

Lucy (handing the work product up to Snoopy on dog house): I've finished the drawing for the  cover of your new novel.

Lucy (as Snoopy examines): See? It shows a bunch of pirates and Foreign Legionnaires fighting some tigers and elephants leaping through the air toward a girl who is tied to a submarine.

 Linus (addressing Lucy as she walks away staring at her drawing): Did he like your drawing?

 Lucy: It needs more tigers. 

It needs more tigers. This often comes to mind when I am on the receiving or giving end of editorial input.

GetCoveredNJ hits cable TV with its first ad

This time last year, an email correspondent who closely watches the New Jersey ACA marketplace was tearing his hair out for the lack of TV advertising by state agencies working to boost enrollment. New York was flooding the airwaves with ads; NJ was invisible.*

The then-young Murphy administration entered Open Enrollment season flying high on a newly enacted reinsurance program and state-based individual mandate that together had reduced individual market premiums 9% below 2018 levels. While the Trump administration had gutted federal spending on enrollment assistance, from $1.9 million in 2016 to $300,000, the state was kicking in $800,000 for assistance and outreach.

Yet on-exchange enrollment lagged 2018 totals, finishing 7% down, compared to a 4% average drop in 39 states using the federal exchange, HealthCare.gov. By this point (week 5), it was down 14% year-over-year (in all 9 HealthCare.gov states, a calendar discrepancy between 2017 and 2018 led to a sharp closing of the apparent gap in the final week).

Fewer Americans qualify for ACA marketplace subsidies

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Regardless of whether ACA marketplace enrollment for 2020 is lagging 2019 totals, one persistent marketplace headwind that should get more attention is the long economic recovery. In an article by Bloomberg's Sara Hansard, Andrew Strohman of the American Action Forum puts one finger to this wind:

Unemployment is now about 3.6%, compared with 4% in January. “You could see some more people taking up employer-sponsored insurance rather than enrolling in the individual market,” Strohman said.

Regardless of whether more people are in jobs that offer affordable insurance, the population with incomes in ACA subsidy range (100-400% of the Federal Poverty Level in states that have refused the Medicaid expansion, 138-400% FPL in states that have implemented it) has shrunk since the ACA marketplace launched in 2014. At the same time, the population with incomes above 400% FPL (and so ineligible for ACA subsidies) has swelled.

Just how poor is ACA marketplace takeup?

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

If you hadn't looked at the Kaiser Family Foundation's Marketplace Enrollment as a Share of the Potential Population for a while, or the variant for subsidy-eligible enrollment, you would get the impression that the takeup of marketplace offerings has fallen sharply.

That's true, among the unsubsidized, who accounted for 42% of marketplace enrollment in 2016 vs. just 27% this year (see Figure 3 here).  And the picture has never been pretty. But marketplace failure is not as dire as these charts might lead you to believe. And the apparent falloff in enrollment takeup among the subsidy-eligible is an illusion, born of changing methodology and snapshots of different points in the yearly enrollment cycle.

The Kaiser charts that were live through 2017 (and maybe later) reflected enrollment as of March 31, 2016, i.e. after CMS's first-quarter effectuated enrollment snapshot for that year, at which point 87% of those who had selected plans as of the end of Open Enrollment had effectuated (and maintained) coverage. Reported takeup among the population estimated to be eligible for subsidies was 64%. Takeup among all who were eligible for marketplace coverage (i.e., lacking access to employer coverage or public programs like Medicaid and Medicare) was estimated at 40%.  In the current charts, based on enrollment in December 2018, takeup among the subsidy-eligible is estimated at 46%, and among all who might buy marketplace plans at 34%. 

Yow. But...

The Kaiser Family Foundation is shaping (or showing the shape of) our healthcare debate

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

There is a subtext to Abby Goodnough's excellent overview of voters' preference for a public option or Medicare buy-in over Medicare for All:  the extent to which the Kaiser Family Foundation and its tracking poll of voters' healthcare concerns and perceptions are shaping the debate.

Voters cited in Goodnough's piece reflect the concerns about M4A flagged in Kaiser polls:

About two-thirds of voters like the idea of a public option or Medicare buy-in, according to several recent national polls. This month, the Kaiser Family Foundation tracking poll, which has asked voters about the plan four times since July, found that 65 percent of the public favors the idea, compared with 53 percent who support “Medicare for all.” Large majorities of Democrats and independents favored a public option in Kaiser’s November poll, as did 41 percent of Republicans — roughly the same level as earlier Kaiser polls found but down from an unusual spike of 58 percent in October....

In Health Affairs: Silver loading goes into reverse, cont.

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

A Health Affairs blog post by David Anderson, me, and Coleman Drake probes the likely impact of reduced silver loading effects in the ACA marketplace this year. In brief, there are fewer counties nationwide where plans below the benchmark are free to many enrollees, and fewer counties where gold plans cost less than benchmark silver. 

One profound impact may be where potential spreads are narrowest: between benchmark silver and the cheapest silver plan in each region.

The reduced silver spread, while small in dollars, may have a profound impact. At incomes up to 200 percent of poverty, the value of CSR—a free added benefit—exceeds the value of most bronze and gold plan discounts generated by silver loading. Accordingly, enrollees with incomes in the 100–200 percent of poverty range—56 percent of all enrollees in HealthCare.gov states in 2019—have mostly stuck to silver plans: According to Aron-Dine, 84 percent of enrollees in this income bracket selected silver in 2019, down slightly from 87 percent in 2017. In that same period, enrollees with incomes in the 200–400 percent of poverty range, for whom CSR is unavailable or negligible, took broad advantage of discounts in bronze and gold plans, reducing their silver selection from 60 percent in 2017 to 35 percent in 2019.

Another Hanukkah miracle due in Week 7 of ACA Open Enrollment for 2020?

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Last year, enrollment in the ACA marketplace in the 39 states using HealthCare.gov trailed the prior-year enrollment pretty dramatically in each of CMS's "weekly enrollment snapshots."  By the end of Week 6, enrollment was at 88.3% of the total at the same point in December 2017.  Then lo, at the end of Week 7 the gap had shrunk from 12% to 4%.  What caused the late surge?

The surge was illusory. Week 1 was a day short last year. That was no mystery, and trackers accounted for it, noting that first-week enrollments stood at about 125,000 per day. What was not fully accounted for in advance was that the extra day made up in Week 7, which had seven enrollment days last year vs. just six in 2017, carried a lot more weight than the shorted November day, as enrollment is much heavier at the end of the season. As I noted at the time:

Hey blue states: How about offering a public option off-exchange only?

Louise Norris, clearest of expositors, has some mildly ambiguous wording here that set off a lightbulb:

Colorado enacted legislation in 2019 that directed the state to explore ways to create a public option health insurance program that could offer a lower-cost alternative for people who buy their own health insurance.

Eureka: Why doesn't a state offer a public option off-exchange only? That would solve the dilemma caused by the ACA's underfunded subsidies: measures that reduce ACA marketplace premiums for unsubsidized  buyers tend to raise them for subsidized buyers.  (Colorado is not moving toward this option.) N.B. in most states, ACA-compliant plans are offered off-exchange as well as on-exchange. This public option would be ACA compliant.

I almost got snared in the short-term health insurance market

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Sarah Gantz, a Philadelphia Inquirer reporter, has done some great work spotlighting people who were snared by sales pitches for short-term health plans that left them with huge bills when they got seriously ill or injured. Her latest concerns a woman who got stuck with a $36,000 bill when her fixed indemnity plan covered only a small fraction of the tab for surgery after she broke her wrist and back (!) -- (the latter doesn't seem to have caused lasting damage):

Martin thought she’d bought a comprehensive health insurance plan through the government-regulated Affordable Care Act marketplace, healthcare.gov. But she really visited a website cunningly crafted to look like an ACA portal, which put her in contact by phone with a salesman. He sold her plan that turned out to offer only minimal coverage, and when Martin needed help, his number was disconnected.

The larger point is that since the Trump administration changed the rules to enable so called short-term, limited duration (STLD) plans to extend plan terms to up to a year, and touted them as a cheap alternative to ACA-compliant plans, deceptive marketing for such plans has exploded. Robocalls, websites meant to snare people seeking HealthCare.gov (with help from Google ads), and hard-sell-quick-sell phone techniques are well chronicled by Gantz.

Louise Norris, a broker of individual market insurance who puts her clients' interests first (and has compiled a virtual encyclopedia on the subject at healthinsurance.org), acknowledges that there is a role for STLD plans, and that not all of them are terrible. But the market is honeycombed with coverage traps.  In fact, Louise helped me, and someone I was helping, avoid perhaps the subtlest of snares in the STLD market.

Elizabeth Warren crosses a rhetorical Rubicon

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

For almost two years, I have complained at intervals that Elizabeth Warren is faking it on healthcare --- that is, blaming U.S. healthcare dysfunction entirely on the rapine of health insurers and pharma, while giving healthcare providers a pass.

In presenting her plan to finance Bernie-brand Medicare for All, Warren leads with this rhetorical reflex but then, finally, departs from it. She has to, as the plan's viability depends on cutting off providers' most lucrative revenue sources.

Warren's first rhetorical strike in this manifesto is against the usual suspects:

Elizabeth Warren's healthcare two-step

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

I owe a debt of gratitude to a Jacobin writer, Tim Higginbotham, who lambastes Elizabeth Warren for a) going into what he regards as unproductive detail about the financing of Medicare for All and b) signaling that she doesn't intend to enact M4A any time soon.

It's the latter that interests me. It solves something of a riddle. And unlike Higginbotham, I approve of this message. I think there may be a kind of deep realism in it, not severable from real commitment to major structural change.

Higginbotham notes that Warren's pay-fors depend in part on enacting other major legislation, and that her language accordingly projects Medicare for All into an..eventuality:

Warren’s remaining financing methods bring us to the biggest problem with her plan: its clear lack of urgency. Warren argues that her plan for comprehensive immigration reform could free up $400 billion toward Medicare for All over ten years, while cutting the dangerous military slush fund will free up another $798 billion.

On their own these are important goals, but using major political fights like these to cobble together funding for Medicare for All is a fairly good tell that Warren’s plan is not designed to be implemented anytime soon. This is further evidenced by the language in Warren’s Medium post about her plan: she describes Medicare for All as a “long-term” goal seven times, while couching the rest of the post in similar language (such as saying she wants to move to a Medicare for All system “eventually”).

That's absolutely right. And in fact, near the end of her Medium piece introducing her M4A funding plan, Warren makes it explicit that she won't be fighting to enact BernieCare from day 1, 2021:

Of course, moving to this kind of system will not be easy and will not happen overnight. This is why every serious proposal for Medicare for All contemplates a significant transition period.

How would a 20% drop in base ACA marketplace premiums affect enrollment?

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

My last post delved into the paradox of reinsurance in the ACA marketplace: lower base premiums tend to produce higher premiums for subsidized buyers who select plans that cost less than the benchmark (second cheapest silver) plan. Lower premiums also tend to reduce bronze plan discounts generated by silver loading* -- though potentially increasing gold plan discounts.

Just how much do premiums reductions reduce discounts in below-benchmark plans? The effects can be sampled with reference to the average premium nationwide for the lowest cost plan (LCP) at each metal level in 2020, courtesy of the Kaiser Family Foundation.

Below, I compare net-of-subsidy premiums for those averages to net-of-subsidy premiums when those base premiums are cut by 20%. That's the average reduction effected by the seven state reinsurance programs already in operation, according to Avalere. The 20% reduction is compared to what premiums would have been absent the reinsurance, not what they were in the previous year.  In New Jersey, for example, reinsurance cut premiums by 15% in 2019, and a state individual mandate by an additional 7% -- but premiums were 9% below 2018 levels. Still, let's stick with 20% to make the effect easily visible.

Should states pursue reinsurance for their ACA marketplaces?

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

While sabotaging the ACA marketplace on multiple fronts, the Trump administration has from the beginning supported one means of keeping premiums down: encouraging states to submit waiver proposals seeking federal funding for reinsurance programs.

These programs partially reimburse insurers for costs incurred by individual enrollees that cross a certain threshold. In New Jersey for example, the program pays 60% of an enrollee's costs exceeding $40,000 per year, up to a threshold of $250,000. To date, CMS has approved 12 state reinsurance waiver proposals, 7 of them implemented by 2019.

The ACA marketplace began life with a national federally funded reinsurance program, but it sunset after three years (2014-2016). Not coincidentally, premiums nationwide rose by about 25% in that year -- a year of correction, in which insurers also recognized that they had significantly underpriced coverage in the ACA's first three years. They recovered profitability in 2017.

By reducing premiums, reinsurance also reduces premium subsidies. Trump's HHS has proved willing to pass much of the savings through to the states, providing tens-to-hundreds of millions of dollars annually to the approved programs.

The case against reinsurance

Some progressives, however, have concluded that reinsurance is a poor use of state resources. The ACA benefit structure subjects these programs to a Catch-22: Reducing base premiums tends to raise premiums for subsidized enrollees.

Looks like New Jersey's reinsurance trade-off paid off

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

New Jersey's Department of Banking and Insurance has published second quarter enrollment numbers for the state's individual market for health insurance. Some upside surprises:

New Jersey Individual Market Enrollment, Second Quarter 2018 to Second Quarter 2019

Venue	Q2 2019	Q2 2018	# change	% change
On-exchange	220,217	222,696	(2,479)	-1.1%
Off-exchange	92,798	85,361	7,437	+8.7%
Total	313,015	308,057	4,958	+1.6%

• Off-exchange enrollment is up from the first quarter -- unusual, because anyone enrolling after December 15, 2018 would have to qualify for a Special Enrollment Period. In Q1, off-exchange enrollment was up 2.98% year-over-year. In Q2, it's up 8.7% over Q2  2018, to 92,798. 


• On-exchange enrollment, which was down a disappointing 7.1% as of the end of Open Enrollment, has had much lighter attrition than in previous years. It's down just 1.6% since Q1, compared to an average Q1-to-Q2 drop of  6.8% in the three previous years. Accordingly, it's down just 1.1% from Q2 2018.


• Total individual market enrollment is up 1.6% compared to Q2 2018.  That's all in ACA-compliant plans, as New Jersey bans the lightly regulated, medically underwritten short-term plans promoted by the Trump administration.

New Jersey's 2019 experience is something of a case study for what you might call the reinsurance tradeoff.

Silver loading 2020 update: The sky isn't falling

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Last week I noted that the discounts for subsidized ACA marketplace enrollees generated by silver loading (see explanation at bottom)* are likely to be somewhat reduced in 2020, given that a) average unsubsidized premiums are down 3-4%, b) and average premiums for the benchmark silver plan are down more sharply (-4%) than average premiums for the cheapest plan at each metal level (-3%).

Let's see how price spreads and discounts at each metal level have changed in the counties with the highest marketplace enrollment nationwide. Together, these 9 counties hold 16% of all on-exchange ACA marketplace enrollment.

Oscar throws a wild card into the 2020 ACA marketplace

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Re the premise of my prior post -- that discounts in bronze and gold plans will be weaker in the 2020 ACA marketplace:  I've stumbled on a wild card, and it's pretty wild. Let's start where we did yesterday:

CMS has published ACA marketplace premiums for 2020.  The top-line news is that premiums have dropped 3-4%.  The key point for subsidized enrollees (69% of the ACA-compliant market) is that silver loading has gone into reverse -- and consequently there will be fewer discounted plans available. That's because benchmark silver plan premiums -- the second-cheapest silver plan in each market, which determines subsidy size -- have dropped more sharply (-4%)  than average premiums for the cheapest plan at each metal level (-3%).

Okay, so discounts stemming from silver loading* may be reduced on average, and in particular, discounts in cheapest silver may be the most impaired. Now for the wild card: Oscar is offering a $0 deductible bronze plan in Florida and Texas (and maybe elsewhere, but those two states account for a quarter of all ACA marketplace enrollment). In Miami, for a 40 year-old at an income of $17,300 -- about 140% FPL -- it's zero premium too; at $24,900 income (just below 200% FPL) it's $79/month.

Silver loading goes into reverse in 2020

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

CMS has published ACA marketplace premiums for 2020.  The top-line news is that premiums have dropped 3-4%.  The key point for subsidized enrollees (69% of the ACA-compliant market) is that silver loading has gone into reverse -- and consequently there will be fewer discounted plans available. That's because benchmark silver plan premiums -- the second-cheapest silver plan in each market, which determines subsidy size -- have dropped more sharply (-4%)  than average premiums for the cheapest plan at each metal level (-3%).

Silver loading, recall, is the byproduct of Trump's October 2017 cutoff of direct federal reimbursement to insurers for the Cost Sharing Reduction (CSR) subsidies they are required to provide to low income marketplace enrollees who select silver plans. Faced with the cutoff at the brink of open enrollment for 2018, most state insurance departments allowed or encouraged insurers to price CSR into silver premiums only. Since premium subsidies, designed so that the enrollee pays a fixed percentage of income, are set to a silver plan benchmark (the second cheapest silver plan), inflated silver premiums create discounts for subsidized buyers in bronze and gold plans.

What is Elizabeth Warren cooking up?

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

Quick, what's the difference in the way the Des Moines Register and the New York Times quoted Elizabeth Warren's recent I'll-have-a-plan promise?

Des Moines:

"Right now, the cost estimates on Medicare for All vary by trillions and trillions of dollars. And the different revenue streams for how to fund it — there are a lot of them," she said to a crowd of about 475 at Simpson College. "So this is something I’ve been working on for months and months and it’s got just a little more work until it's finished."

New York:

“I plan over the next few weeks to put out a plan that talks about, specifically, the cost of Medicare for all and, specifically, how we pay for it,” she told the crowd at the event, held at Simpson College.

On Trump's fight to uninsure people

Up now on healthinsurance.org:
Courts resist Trump's assault on benefits for immigrants and the poor - so far

Rule of law, for now

It is contingently heartening that Trump administration's most egregious and damaging attempts to restrict government-supported access to healthcare for immigrants and low income people have so far been slapped down by the courts.  That is, Medicaid work requirements in Kentucky and Arkansas, and the public charge rule, stayed nationally for now.

The counterpoints are many: these stays were all imposed by Clinton and Obama appointees; the Supreme Court could overturn all; the stayed public charge rule is still having a chilling effect, inducing immigrants to forgo vital services for their children as well as themselves; and an ideologically blinkered 5th Circuit may be on the brink of striking down or impairing the ACA - in which case its fate may depend on aged liberal justices surviving through next June.  Our institutional resilience is the sound of one hand clapping.

I have a post in progress for healthinsurance.org to this effect -- this one's a placeholder.  [update, 10/22: here it is].

Privatizing Medicare: Paul Ryan's soul goes marching on

ICYM the prior post on Trump's executive order aiming to advance the privatization of Medicare on multiple fronts, I've had the chance to refine it twice, on BlueWaveNJ and at medicareresources.org (hence the blogging drought here).

The short version (from the medicareresources.org post):

Issued on October 3, Trump’s order instructs the Secretary of Health and Human Services (HHS) to take steps aiming to

• “Voucherize” Medicare in the manner proposed by Paul Ryan – that is, let private Medicare Advantage plans set prices for traditional Medicare, rather than vice versa as at present.

• Create a private insurance market outside of Medicare for wealthy seniors that would likely lure doctors away from participation in Medicare.

• Subject Medicare enrollees to the joys of “balance billing” – getting billed by providers for amount in excess of their normal share of the Medicare bill.

Trump's bid to destroy Medicare

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

It's clear that Trump is working to destroy U.S. democracy -- selling U.S. aid and favors to countries in exchange for pursuing trumped-up charges against his political opponents.

Now he's following up via executive order with a bid to destroy Medicare.

In the runaway train that is U.S. healthcare costs, Medicare (and Medicaid) is the only substantial brake, in that the government sets prices paid to providers, albeit with outsized provider input. Medicare hospital rates are about half* those paid on average by commercial insurers. Rates paid to physicians average about 78% of commercial rates -- and in high-demand specialties and regions with few providers, commercial insurers often pay four, five and six times Medicare rates.

In countries that successfully offer universal coverage, the government either serves as the sole payer, sets rates for all payers, or oversees all-payer negotiations. The U.S. alone leaves commercial insurers to be divided and conquered by payers. That's the main reason U.S. healthcare costs average about double the OECD average.

In an executive order that begins with a deranged preamble slandering Medicare for All proposals, Trump orders the Department of Health and Human Services to prepare the ground for ending Medicare rate-setting: