A major divide in the ACA individual market for health insurance

In my last post, I calculated that the average private health plan obtained by ACA marketplace enrollees for 2016 provides coverage equivalent to a gold-level plan, and also roughly comparable to the average employer-sponsored plan.  That is, the average actuarial value (AV) of plans sold in the marketplace is just about 80%, thanks in large part to the Cost Sharing Reduction (CSR) subsidies available to buyers with incomes under 250% of the Federal Poverty Level (FPL) who buy silver plans.

While an 80% average actuarial value sounds pretty good -- better, I think, than most people would guess, based on media coverage -- it covers a lot of unevenness. There are two great divides in the post-ACA individual market. The first is between the subsidized and the unsubsidized. The second is between enrollees with incomes up to 200% FPL -- the phase-out point for strong CSR subsidies -- and everyone else. Let's look at average AVs for the different groups.

First up is a breakdown of the subsidized buyers on the federal marketplace, HealthCare.gov. CSR raises the AV of silver plans to 94% for enrollees with incomes up to 150% FPL, to 87% for those with incomes in the 150-200% FPL range, and to 73% for those from 200-250% FPL.*  More than two thirds of subsidized buyers on the federal exchange get CSR of some kind.

On average, ACA marketplace plans are gold equivalent

Kevin Drum has led me, indirectly, to an interesting fact about the ACA marketplace: the coverage in private plans sold there is not as skimpy as people tend to assume.

In a post published today, Kevin considers a Blue Cross Blue Shield analysis of their large ACA marketplace customer base. BCBS finds that marketplace enrollees on average are sicker and access more care than pre-ACA customers in the individual market, and also, to a lesser extent, than enrollees in employer-sponsored insurance (ESI).

Drum's response is basically hurrah -- people who were previously shut out of the individual market based on their medical history are now accessing the care they need (and insurers knew that they would be needier than existing customers in both markets; they just underestimated how much).

Drum notes that the health gap is much narrower between marketplace enrollees and those with ESI than between marketplace enrollees and those in the pre-ACA individual market. He then wonders:

Oddly, the BCBS report concludes that Obamacare enrollees used more medical services and ran up higher bills compared to those in employer plans. That's a little hard to make sense of, since Obamacare enrollees are no sicker than average and generally have higher deductibles and copays than people in employer plans, which should motivate them to use fewer medical services. One possibility is that this is related to heart disease, the one area where Obamacare enrollees really do seem to be sicker than average. Another possibility is that this is a one-time thing: lots of people had been putting off medical care, and when Obamacare kicked in they spent the next year or two making up for it.

Drum is not wrong in asserting that Obamacare enrollees on average "have higher deductibles and copays than people in employer plans" if you include those who buy ACA-compliant plans outside the marketplace, as the BCBS study does. Within the marketplace, however, it's only marginally true. And among the 83% of marketplace enrollees who receive subsidies, it's not true at all [updated 3/31 -- more below].

Are some Medicaid-eligible Indianans still in subsidized private health plans?

Phil Galewitz of Kaiser Health News has a progress report on Indiana's conservative-flavored Medicaid expansion, which obligates all enrollees to make small monthly payments ($1-29) into a health savings account. If they don't pay, they either lose benefits for a period or lose dental and vision coverage provided to paying enrollees.

Critics decry the bureaucratic complexity and also worry that the payments discourage some from participating. And enrollment has apparently not been as gangbusters as in some states:

Since Indiana’s expansion began in February 2015, more than 235,000 previously uninsured able-bodied adults have signed up. As of late February, the plan covered more than 370,000 people total, many with extremely low incomes. Another 190,000 adults are eligible but not enrolled, according to state estimates, though some who are above the poverty line may be in subsidized private plans.

It's true that some states swiftly exceeded their enrollment targets upon expansion, Michigan and Ohio among them. Galewitz relays some possible inhibiting factors:

CBO: Individual insurance market (including ACA marketplace) at about 83% capacity

In its yearly projections of the effect of the ACA on insurance coverage, CBO has always had a category called "nongroup and other" that I found frustratingly opaque. Included were  off-exchange individual (nongroup) market enrollees, people on disability Medicare, and a miscellany including student health plans and Indian Health Service coverage.

In new projections released today, CBO breaks out the major component parts of this grab-bag -- for the first time, as far as very close watchers whom I checked with can remember. The breakout is illuminating in a couple of respects.  Here are the numbers for 2016:

These tallies shed some light -- more or less by negation -- on CBO's past overestimates of the number of exchange enrollees.

Hawaii's ACA enrollment mystery

In the 38 states using HealthCare.gov, the federal ACA marketplace, just 3% of enrollees have incomes below 100% of the Federal Poverty Level (FPL), a threshold below which most applicants are ineligible for premium subsidies.  In Hawaii, 29% of enrollees have incomes under 100% FPL. No other state has more than 4% of enrollees in that income category. What gives?

Under the ACA, legally present noncitizens who are barred from Medicaid are eligible for private plan premium subsidies even if their income is below 100% FPL.  The 1996 welfare reform legislation barred legally present noncitizens from federally-funded Medicaid eligibility if they had been in the country less than five years.  While subsequent legislation gave states the option of covering children and pregnant women with a federal contribution, the bar is still in place for most adults.

While those subject to the five-year bar (or even longer-term bars passed by some states) make up the bulk nationally of subsidized ACA enrollees under 100% FPL, there are other categories of legally present noncitizens barred from federally funded Medicaid. Hawaii home to a substantial share of one such group: Pacific islanders who are legally present under the Compact of Free Association. (COFA) which governs relations between the U.S. and three Pacific Island Nations -- the Federated States of Micronesia, the Marshall Islands, and Palau. The federal government will not fund Medicaid for COFA residents.

Electoral epigrams, 2015-2016 (GOP edition)

One per candidate:

Walker faced down a recall crisis
which voters declined to equate with ISIS.

Bush was judged dull, to his mishap:
He needed a bigger dose of clap.

Optimism flash

Trump is scary for sure.* But after all the shit is shoveled in this shameful election season, the U.S. will probably have elected its first woman president, after twice electing its first black president. And both are arguably about the best choices a country could make. fit to govern the world's most powerful country.

"Arguably"...I have always had doubts and qualms about Clinton -- her judgment, her ties to powerful interests, her political communication skills. But she probably has as good a grasp of policy -- issue by issue, detail by detail -- as any elected official in the country. She could be a disappointment -- or even, if she gets pulled into a stupid war, a disaster. But she could be great, too. Obama, early in his presidency, defined his task as turning the battleship of state a few degrees on multiple fronts. He's done that, and Clinton would (or should) ensure that we stay the corrected course.

----
* I would have thought that Trump was too obviously fraudulent, infantile and incompetent to be scary in himself. What's scary is that a substantial chunk of the electorate finds him credible -- or, if those who respond to infantile rage are always with us, that our media and political system give such a buffoon oxygen.

How many girls? Zero?

I'd like to borrow the "how many girls" picture-puzzle pinging around the Internet (click through; I don't have permission to use) as a long-sought illustration of this children's poem:

Mirror, Mirror

On my crayon box is a picture

of a little goldi-locks

drawing a perfect picture

of a girl with a crayon box.

And on that box is a picture

of a little girl drawing a picture

of a little girl drawing a picture

of a girl with a crayon box.

And I really have to wonder,

no matter how lifelike I feel,

if I sit down and draw that picture,

how will I know I'm real?

The origin of this was some long-forgotten toy with a picture on the front of a kid using the toy. Also: the old Flexible Flyer sled, which had a picture of an eagle carrying the sled with a visible image of the eagle carrying the sled on it.

How's New York's ACA marketplace doing? (updated)

In Kaiser's newly updated estimates of  the percentage of potentially eligible residents each state has enrolled in health plans through its ACA marketplace, New York gets short shrift.

According to Kaiser's measure, New York's health exchange is at just 26% capacity. But that's because the state launched a Basic Health Plan (BHP) that provides ultra low-cost insurance* to residents with incomes up to 200% of the Federal Poverty Level (FPL) who are not eligible for Medicaid. About 155,000 enrollees in the BHP (dubbed the Essential Plan) would have been eligible for subsidized private plans had the state not launched the BHP.

As I mentioned yesterday, Kaiser's more meaningful measure is the percentage of the subsidy-eligible population that each state has enrolled in subsidized private plans (because those who don't qualify for subsidies mainly buy off-exchange).Kaiser updates that metric bi-annually, but hasn't done so yet in the wake of the 2016 enrollment period. But based on its last estimate of the subsidy-eligible population in each state, we can take a stab at New York's current success rate.

Last September, before New York launched the Essential Plan, Kaiser estimated that the state had 532,000 residents potentially eligible for private plan subsidies. The Essential Plan currently has 379,559 enrollees. But 225,000 of them are in a special category: they are legally present noncitizens that the state was previously enrolling in Medicaid purely on its own dime (see note below**). Roughly 155,000 Essential Plan enrollees would have fit Kaiser's "potentially eligible population" for subsidized private plans last fall. In fact, most of them probably were in private plans.***

In addition, in 2016, New York enrolled 271,964 residents in private plans through its ACA exchange. According to HHS' spreadsheet of state level data, 54% of those private plan enrollees were subsidized, or a little shy of 147,000.  Add that to the 155,000  Essential Plan enrollees who would have been eligible for subsidized private plans last year, and approximately 302,000 enrollees in the two programs meet Kaiser's "potentially eligible" criteria.  That's 56.7% of 532,000, Kaiser's previous "subsidy-eligible" estimate. In other words, about 57% of New York's population that would have been eligible for subsidized private plans as of last fall are now enrolled either in such plans or in the Essential Plan [updated and corrected, 3/19 -- previously I missed the spreadsheet data].

Fun with Kaiser!

The Kaiser Family Foundation today published its updated state-by-state estimate of "Percent of Potential Marketplace Population Who Have Selected a Marketplace Plan."   Kaiser's Larry Levitt tweeted thusly about Florida, the state with the highest marketplace enrollment:

Two-thirds of potential ACA enrollees in Florida have now signed up for health insurance. Top state in the country.https://t.co/bsKI2e1jdl

— Larry Levitt (@larry_levitt) March 15, 2016

Two thirds is very high indeed, since Kaiser's "potential population" includes those who earn too much to qualify for subsidies, and most of them buy their coverage off-exchange. So I went back to Kaiser's last estimate of each state's potential subsidy-eligible marketplace population and compared the estimate for Florida to the number of 2016 Florida enrollees (as of the end of open enrollment) who obtained premium subsidies. Lo, the results:

Potentially subsidy-eligible:                          1,556,000 (Kaiser, Sept. 30, 2015)
Enrolled with premium subsidy for 2016*:   1,585,965   (HHS final enrollment report, 2016)
Percent of potentially subsidy-eligible pop:  102%

Yup -- more Floridians are enrolled with subsidies, or were as of the end of open enrollment on Feb. 1, than Kaiser estimated to be eligible for subsidies last fall. That's amusing. Let's keep in mind:

In which Hillary Clinton is confronted by a likely ACA loser (UPDATED)

[Please see 3/16 and 3/17 updates at bottom]

In last night's Democratic town hall forum, an audience member, Teresa O'Donnell of Powell, Ohio, told Hillary Clinton that she voted for Obama, "but then my health insurance skyrocketed, from $490 a month to $1,081 a month, for a family of 4." Charles Gaba has the clip, his own transcription, and an analysis here.

The question's a toughie, because Clinton couldn't very interrogate Ms. O'Donnell to determine all the factors behind her claim.  She did ascertain that the family had previously bought their insurance in the individual market. She then faintly intimated that perhaps O'Donnell hadn't fully checked out her options; credited the ACA with getting costs down generally (though not for all); stressed that she wanted to work to better contain costs; and implicitly blamed the absence in many markets of nonprofit insurers for much of continued cost hikes.

Learning by buying in the ACA marketplace

An analysis of data from the Urban Institute's quarterly Health Reform Monitoring Survey by Rice University researchers, focusing specifically on Texas, finds widespread ignorance of basic insurance terms like premium, deductible and copay.  About a quarter of all Texas respondents reported a lack of confidence in those most basic terms, with higher percentages for terms like co-insurance and max out-of-pocket.

Not surprisingly, percentages reporting lack of confidence in their understanding of these terms was much higher among the uninsured, the poor or near-poor (under 139% FPL), and Hispanics. The uninsured "no confidence" rates were more than double those of the insured, as were rates for those with incomes under 139% FPL compared to those above that level. Hispanic "no confidence" rates ranged from double to triple those of whites.

While the rates are disturbing  the Rice scholars* provide an interesting hypothesis about the knowledge gap between the insured and uninsured:

It is possible that people who do not understand health insurance terminology are less likely to obtain insurance. A more likely explanation is that people who are able to obtain insurance have the opportunity and need to become familiar with the terms.

ACA marketplace is pricing out gold and platinum plans, while silver selection stays stable

HHS released its full report* on ACA marketplace enrollment for 2016. My primary interest as usual is in metal level selection. That is, mainly, whether the percentages of buyers selecting bronze plans (with their sky-high deductibles) and silver plans (required to access Cost Sharing Reduction subsidies, available to those with incomes under 250% of the federal poverty level) are shifting significantly.

Overall, metal level selection hasn't changed much since 2015. In all states combined, including those using their own exchanges, 23% bought bronze and 68% bought silver this year, compared to 22% bronze and 67% silver in 2015.

So wait, how did both percentages manage to uptick? That's the first of several points worth noting:

• The sharp rise in (unsubsidized) premiums in 2016 has priced a lot of people out of gold and platinum plans. In 2015, in all states combined, 7% bought gold and 3% bought platinum. In 2016, 6% bought gold and 2% bought platinum.

Chewing over the future of health care reform

I've submitted a proposal to Netroots Nation for a panel on the future of healthcare reform, together with ACA Signups maven Charles Gaba, progressive activist and physician Paul Song,of the Courage Campaign, and Inside Heath Policy reporter Amy Lotven, a veteran of the ACA legislative wars.

The Netroots Nation conference is in St. Louis, July 14-17.  Sessions are chosen by member vote, at least in the first round; you can view sessions and vote (after a short signup if you're not a member) here.  Our session is Getting to Zero Percent Uninsured: Small Steps and Large Goals. Here's the pitch:

Panel Description

Obamacare has cut the uninsurance rate almost in half, but it's still left a bit more than 10% of the adult population uninsured, and a larger chunk underinsured. Where do we go from here? How can we make quality healthcare affordable to all without busting federal and state budgets?

That question suggests two others: what healthcare system would be ideal, and how can we move toward it given current US political realities? Combining long- and short-term thinking, we will consider healthcare reform 2.0 under the following circumstances:

1) What can a Democratic president do administratively? (more than you'd think)
2) What can be done with a GOP Congress?
3) What could be done with a Democratic Congress??
4) What could be done with a large Democratic majority?

Getting medical care like it's 1999

In the past year or two, job growth has returned to late-1990s levels. Wage growth has not. But thanks doubtless in large part to the ACA, access to needed medical care has also taken us back to the late Bill Clinton years, more or less.

Below is a chart of one measure of healthcare access from the latest data release of the National Health Interview Survey, including responses from January-September 2015. It's a brief history of lack of access to needed medical care in the U.S.:

Clinton's afterthought is Sanders' lead

Hillary Clinton laid out her economic vision in a speech in Detroit on Friday (March 4). There's a lot to like in it.  She's focused on wage growth, reducing income inequality, shifting back to labor the share of corporate profits it's lost over the last four decades. And of course she has a laundry list of proposals designed.to foster domestic manufacturing, boost wages support unions, and steer investment toward troubled regions.

I find her big picture narrative still a bit unfocused, or mis-focused, though.  Here's the heart of it (my emphasis):

Now, some of the blame for these changes in the economy rest with big, historic forces, like trade and technology.  Wall Street and some of our corporations also, however, bear a lot of responsibility.  Too many in the financial industry forgot that the purpose of banking is to get capital to main street to invest in new businesses or expand successful ones like this of any size, and to increase the opportunity for home ownership and community development.

It is not to create huge riches for a select few at the expense of everyone else.  And meanwhile, too many leaders in corporate America are prioritizing their short-term stock price over their workers and their communities.  And we can’t forget the damage caused by trickle-down economics and right-wing ideologues who believe in weakening government oversight, massive tax cuts for the rich, ripping away the safety net, and breaking the backs of unions.

What you "can't forget" is an afterthought, and it should be the lead. To my mind, Clinton has the optimal emphasis of causes exactly backwards: 1) big historic forces 2) bad corporate behavior, 3) trickle-down economic policy.

Kaiser: ACA marketplace at 70% capacity among subsidy-eligible

The Kaiser Family Foundation has published an updated assessment of ACA marketplace enrollment to date and what full capacity would look like.  At present, total signups for private plans in the marketplace nationwide stands at 12.7 million, a total that's likely to drift down to somewhere between 10 and 11 million by year's end.  Kaiser estimates that if the national marketplace matched the performance of the 10 best-performing states to date, 16.3 million would be signed up by the end of open enrollment, drifting down to about 14.7 million by year's end.

There's a lot to unpack here. At the outset, I want to highlight a couple of noteworthy findings, discussed in more detail below. The first one is not actually spelled out in this report.

• According to Kaiser's estimates, nationwide, at present about 70% of the subsidy-eligible potential marketplace customer base have signed up for marketplace plans. That will probably drift down to somewhere around 60% by year's end. Of 12.7 million total enrollees, 82%, or 10.4 million, were subsidized. According to Kaiser's Sept. 30, 2015 estimate, 14.8 million Americans were potentially eligible for premium subsidies at that time.


• Kaiser's findings as to which income groups are cutting their uninsurance rates most dramatically* raise questions about the prevailing understanding of who finds the marketplace most attractive, at least by implication. Both Avalere Health and the Urban Institute have found that eligible marketplace shoppers with the lowest incomes have high takeup rates, which drop sharply and steadily with income. Kaiser finds that people in the lowest income bracket, below 150% FPL, have the second-lowest reduction in their uninsured rate among the income groups -- just an 18% reduction, compared to 33% reduction at 150-200% FPL, 23% at 200-300%, and 22% for those above 400% FPL (and so subsidy ineligible).

Ever made someone whole, Donald?

Donald Trump professes confusion in response to Hillary's new slogan:

She wants to make America whole again and I’m trying to think what is that all about?

Among other things, Donald, it means that when you unjustly or incompetently take people's money, you restore to them what they've lost. Something you've never done.

At the risk of stating the obvious: "make America whole again" is a double entendre* -- and I think a kind of brilliant one. Hillary is going motherly on us (or Bush Sr. on us), talking about restoring love and kindness as core political values. But "make America whole" has a hard financial edge, and speaks to 40 years of one-percenter capture of all the country's productivity growth -- as well as countering Trump's fascist scapegoating of Hispanics and Muslims.  At the same time, it's a pitch to the rust belt and the white working class:

Trump the Incompetent

The Times reports the welcome news that Hillary Clinton's brain trust is taking the Trump threat very seriously and studying approaches to convince the disaffected that his promises are empty. Here's the emerging Democratic thinking, according to Amy Chozick and Patrick Healy:

The plan has three major thrusts: Portray Mr. Trump as a heartless businessman who has worked against the interests of the working-class voters he now appeals to; broadcast the degrading comments he has made against women in order to sway suburban women, who have been reluctant to support Mrs. Clinton; and highlight his brash, explosive temper to show he is unsuited to be commander in chief.

One potential problem, as Greg Sargent argues this morning, is that the "heartless businessman" attack used on Romney may not work in this case, because the nature of Trump's appeal is different. His followers respond to his assertions of "strength" -- and past heartlessness may only reinforce that. It might be more effective, as Kevin Drum has suggested, to point out Trump's serial business failures -- emphasizing not just that he hurt people, but that his promises were empty, his judgment comically bad, his execution terrible.

The Washington Post's account yesterday of the rise and swift fall of Trump Mortgage (founded in 2006!) provides a distilled essence of Trump's art of the debacle. Here's the Rise and Fall pattern, recounted by Tom Hamburger and Michael Kranish:

1. Ignore market signals

“I think it’s a great time to start a mortgage company,”  Trump told a CNBC interviewer in April 2006, adding that “the real estate market is going to be very strong for a long time to come.”

Godwin's Law is obsolete: Roger Cohen sounds the fascist alarm

Like most people with any pretense to argumentative discipline, I've long subjected myself to a broad version of Godwin's Law -- that any comparison of a current situation to Hitler's rise is likely to be fatuous, sloppy, alarmist.  A more general stricture: you don't let loose with the ultimate f-bomb, fascist -- so often a catch-all for any alleged impingement on liberty.

No more. As Trump's promises of mass violence and discrimination against Mexicans and Muslims sprouted this fall, and his hold on a growing chunk of the electorate grew, the question of whether he's a fascist got some serious media scrutiny. Robert Paxton, one of the foremost scholars of fascism, essentially answered yes and no a few weeks ago. In brief, while Trump is too purely narcissistic to put forward a developed mystical vision of tribalized national glory -- his "vision" of America is basically "follow me and win win win like me" -- he has all the other core elements: a narrative of national decline, scapegoating of marginalized groups, theatrical deployment of violence and promise of more violence, intimidation of media, refusal to accept losses, grandiose self-display.

As Trump has established a near-lock on the Republican nomination, his support swelling and solidifying, it's become clear that Godwin's Law is obsolete, as I tweeted a few days ago. Today an establishment stalwart, the New York Times's Roger Cohen, ventriloquizing all of Europe  sounds the alarm, full-blast: