Last laugh for Republicans in the SCOTUS session that was

Democrats were still in their happy dance over Supreme Court decisions preserving ACA subsidies and legalizing gay marriage throughout the U.S. when, in its final orders of the year, the Court agreed to hear cases poised to gut pubic unions and affirmative action.

In Friedrichs v. California Teachers Association, ten California teachers are challenging a requirement that they pay fees to the teachers union for nonpolitical services, chiefly collective bargaining. That's the type of provision that Scott Walker killed in Wisconsin; without it, pubic sector unions wither. As Mark Joseph Stern at Slate points out, "there is virtually no chance" that the Supreme Court will rule against the teachers:

An add-on health benefit for same-sex couples who marry

Jay Hancock of Kaiser Health News notes that the Supreme Court decision granting same-sex couples the right to marry in any state is likely to boost employer coverage of same-sex couples:

The logic is simple. Fewer than half of employers that offer health benefits make the insurance available to same-sex partners who aren’t married. Virtually all of them offer coverage to spouses.

By marrying partners with employer health plans, people in same-sex relationships are likely to get coverage in states that banned gay marriage until now, as well as in those that welcomed it. Thanks to rapidly shifting legal ground, 37 states recognized gay marriage before last week’s ruling, up from nine in 2012.

Footnote: as-yet-unmarried gay employees whose employers do currently offer health insurance to partners will, if they marry, be able to get that coverage on a tax-free basis.

Obama's eulogy for Clementa Pinckney was also autobiography

Obama's eulogy for Clementa Pinckney yesterday was, among many other things, a compressed autobiography -- or spiritual autobiography, a review of what life has taught him. It sent me back to the remarkable Chicago chapters of Dreams from My Father. 

When I first read that book, in maybe 2007, I wondered, could a man with this experience and orientation really be president of the United States? Six years into that presidency, it seems no less remarkable. Three strands of the experience recorded there struck me as being compressed into yesterday's speech.

First was Obama's ode to empathy, his tribute to the connection that comes from truly listening to people. Second, the extent to which in his engagement with people on Chicago's South Side he'd taken the full measure of the devastation wrought by institutional racism. Third, his discovery of the community of black churches as the most powerful resource for countering those ravages. In each of those themes there were echoes of his personal narrative.

Obama was in a sense speaking about himself, or rather, speaking from personal recognition and memory, in this tribute:

For my own scrapbook...

I swore off Scotusblog on Thursday morning, but a couple of minutes after 10 the time startled me and over I went just in time, and...

And so this fraudulent frivolous cruel destructive suit goes into the dustbin of history where it belongs.

— xpostfactoid (@xpostfactoid1) June 25, 2015

My call on King

I hope I don't end up thrashing myself for wishful thinking, but I think the Supreme Court will rule for the government in King -- no odds on whether it's Chevron deference (the law is ambiguous, and the IRS interpretation is reasonable) or that the law's intent to provide subsidies to all states is unambiguous. I would hope that my bias -- I think the case is a fraud -- is balanced by superstition --an unwillingness to predict what I wish (overridden by being asked, as part of a list).

I can't wrap my mind around both Roberts and Kennedy agreeing to a) blow up the economy and b) credit the plaintiffs' bogus narrative that Congress intended a form of coercion that no one recognized and that the law does not spell out (a state only gets premium subsidies if it establishes its own exchange).  On both counts I take some reassurance from the dissent as well as the majority opinion in NFIB v. Sebelius, the challenge to the ACA's constitutionality ruled on in 2012.

The dissent in that case shows both thorough awareness of the interdependence of the ACA's core provisions and a wariness of causing massive economic disruption:

A quarter of those who stand to lose ACA subsidies should be in Medicaid

Greg Sargent and Charles Gaba have been pointing out repeatedly (after a prompt from Jonathan Cohn) that the majority of healthcare.gov private plan buyers who stand to lose their subsidies if the Supreme Court rules in favor of the King plaintiffs are in Republican congressional districts. I have noted that most of them are low income -- 83% of healthcare.gov private plan buyers have incomes below 250% of the Federal Poverty Line (FPL). That may affect the degree to which Republicans consider them constituents.

There's an irony in that low income profile. In states that refused to expand Medicaid, all but one of which rely on healthcare.gov, private plan enrollments were swelled by those who would have been at the upper end of Medicaid eligibility if their states had accepted the expansion.  In expansion states, residents with incomes below 138% FPL are eligible for Medicaid, and eligibility for subsidized private plans begins at that threshold. In states that refused the expansion, eligibility for private plan subsidies begins at 100% FPL; all those with incomes below that level are left out in the cold.

In states using healthcare.gov that expanded Medicaid, 34% of enrollees had income under 150% FPL.  In states that refused to expand Medicaid, 50% had incomes below 150% FPL. I have calculated that some two thirds of them would have been Medicaid-eligible had their states expanded. That estimate may be low: in Pennsylvania, which refused the Medicaid expansion in 2014 but implemented it in 2015, CMS determined about half of 2014 enrollees had incomes that would qualify them for Medicaid in 2015 (that is, incomes between 100 and 138% FPL).

Polling reflects the ACA's tough tradeoffs

A couple of thoughts* about Kaiser's recent analysis of its most recent survey of those who bought their insurance in the individual market in 2015, on exchange or off-exchange, ACA-compliant or not. To review some key points first (some from the original survey report, others from the analysis):

For ACA marketplaces, the near-poor have been the sweet spot

The just-released National Health Interview Survey for 2014 confirms that the chief beneficiaries of the ACA private plan marketplaces were those defined by the survey as "near-poor," with incomes between 100% and 200% of the Federal Poverty Level (FPL).

The NHIS found that among near-poor adults aged 18-64 (those with incomes from 100-200% FPL),

the percentage who were uninsured decreased from 38.5% to 30.9%, the percentage with public coverage increased from 26.6% to 29.6%, and the percentage with private coverage increased from 36.4% to 41.2% between 2013 and 2014. 

In states that expanded Medicaid, those with incomes up to 138% FPL became Medicaid-eligible -- hence the substantial rise in those in this income group with public insurance. But the jump in private insurance is really substantial, By comparison, private coverage for adults 18-64 with incomes over 200% FPL rose  from 81.2% in 2013 to 83.9%, and for the poor, from 19.0% to 21.9%* (while public coverage for the poor rose from 42.4% to 46.6%).

Why the ACA remains unpopular, cont.

Over at the Huffington Post, Jonathan Cohn has teamed up with pollster Mark Blumenthal for a deep dive into why the ACA's approval ratings remain underwater* and why more people continue to say that the law has personally harmed than helped them (though the gap had narrowed. to 22-19 when Kaiser last polled this question in March).

There are two main takeaways: 1) polling results are overwhelmingly partisan, and Republicans are more passionate in their hatred of the law than Democrats are in support of it, and 2) Americans tend to attribute any changes in their health plans -- usually price hikes or coverage cutbacks -- to the ACA. That's especially true of people with employer-sponsored insurance, a third of whom said they'd been hurt by the law.**

While those conclusions are spot-on, and Cohn and Blumenthal provide a nuanced overview of the ACA's effects on various groups, I'd like to throw one sidelight and add a couple of caveats.

First, the sidelight. Noting that the largest category of those who say the law hurt them say it drove their costs up, Cohn and Blumenthal suggest that the perception is not accurate:

Housekeeping note: Pennsylvania story in progress

A note re slow blogging: I've been engaged in my Pennsylvania project -- that is, exploring the implications of some odd enrollment figures in the state.. Specifically, though there's apparently over 140,000 Pennsylvania 2014 QHP enrollees who are now eligible for Medicaid, less than 40,000 2014 QHP enrollees had disenrolled as of March (or at least, to HHS's knowledge as of March). I've had the chance to interview one person newly eligible for Medicaid in 2015 who discovered that fact in February but only applied this month, in the interim paying over $300 per month for an unsubsidized private plan. The resulting story is written but not yet placed (or edited; I've got to cut it by 60%). I've learned a ton in the process.

One useful sidelight: an enrollment counselor at the Pennsylvania Health Access Network tells me that more than half of the people they enrolled in QHPs in 2014 did in fact have household incomes under 138% FPL and so are now eligible for Medicaid. While you might expect that a social service agency's client base might tilt toward lower income buyers, PHAN works all over the state, and that percentage is consistent with CMS's estimate of 141,000 households with QHP enrollees likely to be eligible for Medicaid in 2015.

Victims of an ACA subsidy cutoff may live mainly in Republican districts -- but will they vote?

At Jonathan Cohn's request, Families USA calculated that two thirds of those who stand to lose their health insurance subsidies if the Supreme Court rules for the plaintiffs in King live in Republican Congressional districts (4.2 million subsidized buyers on healthcare.gov live in Republican districts, vs. 2.1 million in Democratic districts).

Those numbers appear to support the hypothesis that a Supreme Court decision cutting off subsidies to those who obtained their insurance on insurance on the federal exchange, healthcare.gov, may politically damage Republicans, who supported the King plaintiffs' claim that the ACA authorized subsidies to flow only through exchanges "established by a state."  But even if Republican attempts to blame the cutoff on Democrats' poor legislating fail utterly, the demographic profile of those who bought subsidized plans on healthcare.gov may moderate the political fallout somewhat.

Hillary's short history of inequality is too short

A few weeks ago, I contrasted Elizabeth Warren's critique of income inequality in America with Obama's. The critiques are substantively similar, laying primary responsibility for the widening wealth and income gaps on Republican tax, labor and regulatory policy and citing similar stats showing that virtually all productivity and output gains over the last several decades have gone to the wealthiest. But Warren is more laser-focused on Republican and Wall Street malfeasance: Obama acknowledges contributing causes as diverse as global competition and domestic racism. And interestingly, where Obama cites four stats to illustrate the growing gap, Warren concentrates her fire with one pair:

Since 1980, how much did the 90% get of income growth in this economy -- from 1980 to 2012, the 90% got zero. None. Nothing.

Zero. None. Nothing. You could hang a campaign on that, no?

Now what about Hillary Clinton, who officially kicked her campaign off with a speech on Roosevelt Island yesterday?

Molly Ball points out quite rightly that Clinton is being credited with a more full-throated populism than she voiced:

Five under-reported facts about the ACA

It just popped into my head to consolidate a few facts about the ACA that I think I know and that seem to be pretty widely unrecognized. I just delved into the first one today, and I've flogged many or most of them several times, but here goes:

1. Silver plans are usually more than silver: 85% of silver plans sold on ACA exchanges are enhanced by Cost Sharing Reduction subsidies that raise the actuarial value from a baseline of 70% to 73%, 88%, or 94%, depending on the buyer's income. Two thirds of silver plan buyers have the stronger forms of CSR -- AV 87% or 94%.  On the other hand...

2. Half of those buying plans in the individual market are off-exchange, and many of those are doubtless buying silver plans with AV 70% (the metal levels are in use in ACA-compliant plans sold off exchange).

3. Most of those buying off-exchange are paying more than they would have pre-ACA, but perhaps 20-50% of them have a pre-existing condition or have a family member with one. Many of those buyers are paying less than they would have pre-ACA, and some would not have been able to buy or afford insurance at all.

4  ACA coverage rules are not the main reason that the law raised the price of unsubsidized individual market insurance.  Republicans have made the ACA's mandatory Essential Health Benefits their favorite whipping boy, but the real price driver is guaranteed issue -- the prohibition against basing the price of a plan (or eligibility) on the would-be buyer's medical history. And most Republicans profess (rather vaguely) to support that.

On ACA exchanges, silver is usually not silver

I have a post up on healthinsurance.org that calls out yet another story about high out-of-pocket costs in ACA exchange plans that neglects to mention that 85% of silver plan buyers get Cost Sharing Reduction that lowers deductibles, co-pays, and yearly out-of-pocket maximums.

The story in question is under the auspices of Kaiser Health News, which generally gets its facts right, and there's no literally wrong fact in it. It makes sense, too,  to highlight that silver plans as well as bronze ones can offer pretty skimpy coverage. The lead below is referring to silver plans:

A key goal of the Affordable Care Act is to help people get health insurance who may have not been able to pay for it before. But the most popular plans – those with low monthly premiums – also have high deductibles and copays. And that can leave medical care still out of reach for some.

Indeed it can. But two thirds of silver plan holders (the "most popular plans", as the story subsequently clarifies)  have plans with actuarial values of 87% or 94%.  That doesn't mean that too many ACA customers aren't faced with too-high out-of-pocket costs. But casting silver plans unenhanced by CSR as the silver norm is like citing full retail prices at Macy's (where sales are so pervasive that the folks at the register often won't let you pay full price).

A few thoughts that didn't make it into the post:

John Barrasso's tell: King is a fraud

In his determination to accent the negative in characterizing the ACA, Senator John Barrasso has exposed the absurdity -- in fact the fraud -- at the heart of the King v. Burwell suit.

Here's how Barrasso characterizes the IRS rule allowing subsidies to flow through the federal exchange:

“Instead of bullying the Supreme Court, the president should spend his time preparing for the reality that the court may soon rule against his decision to illegally issue tax penalties and subsidies on Americans in two-thirds of the country,” he said in a statement. “Congress will not pass a so-called ‘one-sentence’ fake fix.”

The fix is "fake" because, according to this party line, Congress never intended for the federal exchange to be empowered to credit subsidies. But Barrasso leads with "penalties" because it's more fun to emphasize the stick than than the carrot. The individual mandate is the flip side of the subsidies: without subsidies, the vast majority of the uninsured would be exempt because coverage would not be affordable.

Connecticut continues to crush it on Cost Sharing Reduction

Connecticut's ACA exchange, Access Health Connecticut, has provided me with a breakout of private plan buyers' metal level selection sorted by income level. The data makes clear that Connecticut continues to lead the way among ACA exchanges in helping low income buyers make choices that will provide them with the strongest financial protection.

There's two things to keep in mind about metal level selection. The first is that bronze plans, the cheapest level with the lowest premiums, usually have deductibles in the $5,000-6,600 range for an individual.  The second is that the Cost Sharing Reduction (CSR) subsidies available to low income buyers are available only with silver plans. CSR reduces deductibles, co-pays and maximum out-of-pocket costs radically for buyers with family incomes below 200% of the Federal Poverty Level (FPL) and much more weakly for buyers in the 200-250% FPL range. Bronze plans are almost always a terrible choice for buyers under 200% FPL -- those buyers are leaving a large extra subsidy on the table and rendering most healthcare unaffordable for themselves.

ACA exchanges vary widely in how effectively they get that information across. The key measure is the percentage of buyers with incomes under 200% FPL who choose silver plans.

In Connecticut, 89% of 2015 private plan buyers with incomes under 200% FPL chose silver.  I had preliminary numbers indicating as much back in December, and the ratio held steady through the end of open season and to June 1. Slightly more than a third of all enrollees, 34,601, have incomes under 200% FPL, and 30,641 of them bought silver and accessed CSR.* Just 6% bought bronze plans. That is a real triumph. 4% bought gold.

Times reporters call bullshit on senators' surveillance claims

In recent weeks, as Congress moved toward passage of a law limiting the NSA's access to phone metadata, I've appreciated the bullshit buffer that Times reporters Jennifer Steinhauer and Jonathan Weisman have inserted into their coverage.

Back on May 23, when the Senate rejected the House bill it eventually passed on June 23, Steinhauer reported a garden variety Senatorial security alarm, then, a few paragraphs later, provided a little factual context:

"Strong enough to be self-critical": Obama's handwritten additions to Selma speech

As I noted at the time of Obama's Selma speech,, the idea he expressed there that riveted respondents -- that America's greatest strength is its capacity to self-correct, in a never-finished drive to fulfill the promise embedded in its founding documents --  -- was not only not new, but was the same story that Obama's been telling continually since he first appeared on the national stage, and probably before. He did take that message to a new level of clarity at Selma, while expanding the circle of those he credited with fighting that fight and advancing the "always perfecting, never perfected" narrative.

Today the Washington Post is out with a hand-edited draft of the speech. It turns out that Obama handwrote-in the most direct expression of its core idea. And he pointed it directly at his most recent critics -- e.g., Giuliani, who had recently charged that Obama doesn't love America -- contrasting his brand of patriotism with a cardboard boosterism "based stock photos or airbrushed history."

Here is that passage with the handwritten addition bolded, an omitted portion in strike-through, and a later addition in red type:

...Selma is not some outlier in the American experience. Even today, we continue have debate about what it means to love this country, to be a true patriot. But what greater expression of faith in the American idea, what greater form of patriotism is there, than to believe that America is not yet finished, that it is strong enough to be self-critical, that each generation can look upon its imperfection and say we can do better.  That’s why it’s not a museum or static monument to behold from a distance. It is instead the manifestation of a creed written into our founding documents: "We, the People....in order to form a more perfect union."

New data on Cost Sharing Reduction in ACA marketplaces

The latest ACA enrollment snapshot from CMS shed some new light on the extent to which ACA private plan buyers accessed Cost Sharing Reduction (CSR) subsidies. CSR reduces deductibles, copayments and maximum out-of-pocket costs for plan buyers with incomes under 250% of the Federal Poverty Level (FPL) -- but only if they buy silver plans (and forego the often much cheaper bronze plans).

CSR takeup is especially important for buyers under 200% FPL, because below that income level it raises the actuarial value of a silver plan from 70% to 94% (for buyers under 150% FPL) or 87% (for buyers in the 150-200% FPL range). At 200-250% FPL, CSR weakens, raising the AV just 3 points to 73%. Silver plan selection accordingly drops suddenly at 201% FPL.

The new report doesn't deliver any great surprises on the CSR front, but it does for the first time provide overall CSR numbers for the 13 states plus D.C. that run their own exchanges. The percentages of buyers accessing CSR in state-based marketplaces (SBMs) have always been lower than in the states using healthcare.gov, for several reasons

1. All the SBMs except Idaho have expanded Medicaid, which means that subsidized private plan eligibility begins at 138% FPL rather than 100% FPL.  The lower the income, the higher the CSR takeup rate - especially below 138% FPL, where the benchmark silver plan premium can't exceed 2% of income.
2. States with SBMs are generally wealthier, so a lower overall percentage of private plan enrollees are eligible for CSR.
3. Several SBMs do a much poorer job than healthcare.gov of highlighting CSR for those eligible -- though conversely, several SBMs do a better job than hc.gov on this front.

All that said, here are some new facts, along with some extrapolation from info that was in HHS's March report but not updated in this one.

1) In states using healthcare.gov (federal facilitated marketplaces, or FFMs) 60% of enrollees accessed  CSR -- 4,550,205* out of a total enrollment of  7,524,234.  In the SBMs, 49% accessed CSR -- 1,300,731 out of 2,662,964.

Too many choices on ACA exchanges?

The Health Exchange Summit held in Washington, D.C. May 11-13 brought together many of the people most directly engaged in implementation of the Affordable Care Act. All, excepting Michael Cannon,  mastermind of the King v. Burwell suit seeking to cripple the ACA, are committed to extending access to affordable and effective health care to as many Americans as possible and to to making the ACA work effectively.

Given that commitment, I was struck by a persistent chord of uneasiness about the complexity of insurance choices facing Americans. That uneasiness was literally the keynote, delivered by Princeton healthcare economist Uwe Reinhardt, whose  presentation might have been titled, "Why we can't have nice things like the Swiss."  Switzerland's health insurance system served as something of a model for the ACA, as citizens are mandated to purchase private health insurance on an exchange, with the help of means-tested premium subsidies. Reinhardt's presentation drove home the dazzling simplicity of a Swiss health insurance exchange, displayed on screen -- in which  dozens of insurers compete but all offer a standard benefit package

Reinhardt suggested that Americans are unduly enamored by choice, which breeds complexity. Research shows he said, that "People can't choose among more than 5 items. Offering 130 health plans is a prescription for disaster." The Swiss, he said, have never heard of an insurance broker. and the U.S. system would not need navigators if the choice were simple enough. He mocked federalist claims that states need to develop solutions that fit local conditions by flashing photos of identical McDonald's in Massachusetts and Tennessee.

Reinhardt is fond of expressing exasperated bemusement at all things American. Perhaps more surprising was the wistfulness expressed by the second keynote, healthcare consultant Jon Kingsdale, who was the founding executive director of the Massachusetts Connector when Romneycare was implemented. When the Massachusetts Connector first went live, Kingsdale said, "people would come up to me at parties and say, 'this is great -- it's so easy.'" Not so with the ACA.  Gearing up for Year 3, "instead of focusing on how to delight customers, we're still worried about how to get the goddamned back end working."