Is the U.S. uninsured rate at an all-time low?

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Enough states have reported Medicaid tallies through February to posit that the pandemic has increased enrollment by more than ten million nationally since February 2020. Adjusting for the usual difference* between CMS's official totals (now posted through November**) and my sample below (based on state monthly reports), year-over-year enrollment growth since February 2020 is likely about 14.8%, and total enrollment likely stands at about 81.7 million. A quarter of the U.S. population is enrolled in Medicaid.

I don't think we've fully fathomed the effect on access to health insurance of the pandemic, the battered and flawed but still functioning and funded ACA programs in place as the pandemic hit, and pandemic relief measures.  Consider...

The Families First Act effectively required states to pause Medicaid disenrollments for the duration of the Covid-19 emergency, and enrollment will continue to grow until that moratorium ends.***  Enrollment growth among those rendered eligible by the ACA Medicaid expansion is close to 30%. In the ACA marketplace, average monthly enrollment in 2021 will probably exceed 2019 enrollment by at least a million, perhaps more, spurred by extended Special Enrollment Periods and subsidies enhanced by the American Rescue Plan Act. As the population ages, Medicare enrollment grows by about 1.5 million yearly. Meanwhile, the huge job losses triggered by the pandemic appear to have had only a modest effect on employer-sponsored insurance: enrollment through September was down by just 2-3 million, according to a KFF estimate.

Will 60-64 year-olds have a choice between Medicare and Obamacare? What will that look like?

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I turned 62 recently. Yesterday, for the first time, I took seriously the possibility that my wife and I might be enrolled in Medicare before we turn 65.

According to the Wall Street Journal's Stephanie Amour and Kristina Peterson, the Democrats' next healthcare initiative, envisioned for spring 2022, is likely to contain

measures to reduce drug prices and expand health coverage, lawmakers said. Proposals to expand Medicare eligibility from age 65 to 60 and to enable the federal government to negotiate drug prices in the health program for seniors—both of which President Biden supported on the campaign trail—are also likely to be included.

I can think of a lot of reasons these measures -- paired so that the prescription drug savings will finance the expanded eligibility -- may not happen.  But the odds that they will be enacted are not negligible. Democrats' success holding together to pass the $1.9 trillion Covid relief package have made a lot of bold initiatives seem possible.

If Democrats do manage to drop the Medicare eligibility age, they are also likely to make permanent the major increases to premium subsidies in the ACA marketplace enacted through 2022 in the Covid relief bill, the American Rescue Plan Act. And the two initiatives could overlap -- or clash -- to some degree.

The possibility of passing all of the above raises questions: will Medicare be offered to 60-65 year-olds on the same terms as Medicare for people over age 65?  Will enrollment delayed past age 60 be penalized on the same terms as enrollment delayed past age 65 at present? If enrollment at 60-65 is optional, will those who lack access to employer-sponsored insurance also be eligible for subsidized ACA marketplace coverage? -- will they have a choice between the two programs?

If Medicare is indeed subsidized as heavily at ages 60-64 as at age 65 and over, and if enrollment is optional, and if the ARPA subsidy schedule for the ACA marketplace (or something close to it) becomes permanent, some 60-65 year-olds will have a tough choice to make between Medicare and marketplace coverage. 

Broadly speaking, those with incomes up to 200% of the Federal Poverty Level (FPL) will likely find lower costs in the marketplace -- if they're not dually eligible for Medicare and Medicaid. Those with incomes over 400% FPL will likely favor Medicare.  In between is a gray area, with tradeoffs that are charted and discussed below.

An American Rescue Plan benefit you'll have to wait for

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UPDATE: On April 9, the IRS solved the problem described, announcing that 2020 marketplace enrollees who received APTC do not have to file Form 8962. 

The Internal Revenue Service announced today that taxpayers with excess APTC for 2020 are not required to file Form 8962, Premium Tax Credit, or report an excess advance Premium Tax Credit repayment on their 2020 Form 1040 or Form 1040-SR, Schedule 2, Line 2, when they file.

Those who filed prior to the passage of the American Rescue Plan Act and paid back excess APTC do not have to file an amended return; the IRS will reimburse them.

----

In addition to increasing premium subsidies for 2021 and 2022 in the ACA marketplace, the American Rescue Plan Act signed into law by President Biden on March 11 provides an important benefit to 2020 marketplace enrollees. Section 9662 of ARPA stipulates that those enrollees who underestimated their income and so would normally have to pay back some the Advanced Premium Tax Credits (APTC) received will not have to pay back the excess APTC. 

That includes people who estimated their incomes at below 400% of the Federal Poverty Level, the cap for APTC eligibility, but ended up with a declared income above that threshold. Normally, they would have to pay back all APTC received. This year, they owe nothing.

That is not a trivial benefit. According to IRS estimates,* in 2019 3.2 million tax filing households paid back a portion of the APTC they received in 2018, with paybacks totaling $4.4 billion, or about $1,375 per household.  Estimating 1.7 enrollees per filing household** suggests payback of about $800 per enrollee. Similarly, the CBO report*** on the costs of ARPA estimated that APTC forgiveness for 2020 (when total enrollment was nearly identical to that of 2018) would cost $4.7 billion in 2021. (See Charles Gaba's detailed analysis here.)

Should younger enrollees in the ACA marketplace be more heavily subsidized?

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Enrollment in the ACA marketplace skews old.  In 2020, only 26% of enrollees were in the 18-34 age range, while 28% were over age 55. That creates two problems: 1) a lot of uninsured young adults, and 2) a high-cost risk pool, which means higher costs for the federal government in premium subsidies.

The healthcare provisions in the American Rescue Plan (ARP) signed into law by President Biden on March 11 radically reduce the percentage of income paid by ACA marketplace enrollees for a benchmark silver plan (the second cheapest silver plan in each rating area). But the reductions are most stark at the bottom and top of the income scale, as the table below (from the CBO's February analysis of the legislation in progress) illustrates.

Enrollees with incomes ranging from 250% FPL up to, say, 600% FPL may still find premiums a heavy lift -- and younger adults are disproportionately likely to forego them. A bill introduced in the House by Florida Democrats Stephanie Murphy and Donna Shalala, HR 6545, the Health Insurance Marketplace Affordability Act, aims to entice younger adults into the marketplace by increasing subsidies for younger adults in inverse ratio to the increase in premiums as age rises. The bill will soon be reintroduced to mesh with the ARP.

Medicaid expansion enrollment grew nearly 30% year-over-year in 19-state sample

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Time for an update on Medicaid expansion enrollment growth since the pandemic struck. Below is a sampling of 19 expansion states through January of this year, and 14 states through February.

Maintaining the assumption, explained here, that relatively slow growth in California would push the national total down by about 2.5 percentage points, these tallies still point toward year-over-year enrollment growth pushing 30% from February 2020 to February 2021. If that's right, then Medicaid enrollment among those rendered eligible by ACA expansion criteria (adults with income up to 138% FPL) may exceed 19 million nationally and may be pushing 20 million.  That is, if this sampling of a bit more than a third of total expansion enrollment represents all expansion states more or less accurately, again accounting for slower growth in California.

The American Rescue Plan Act makes free coverage available to many below 100% FPL in nonexpansion states

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An odd provision  the American Rescue Plan Act that President Biden signed yesterday provides that anyone who receives any unemployment insurance income this year will be deemed to have income of no more than 133% of the Federal Poverty Level (FPL), qualifying them for a free silver plan in the ACA marketplace. 

Silver plans at that income come with the highest Cost Sharing Reduction (CSR), raising the plan's actuarial value to 94%, which translates to an average deductible of about $200 and an average cap on annual out-of-pocket costs of about $1100. The plan is free because ARPA zeroes out premiums for a benchmark silver plan at incomes up to 150% FPL.

When I first read about this provision, I thought that maybe it was intended in part as one more way to chip away at the "coverage gap" in the twelve remaining states that have refused to enact the ACA Medicaid expansion (rendered optional to states by the Supreme Court in 2012). In those states, eligibility for ACA marketplace subsidies begins at 100% FPL, and families with incomes below that threshold get no help obtaining coverage. The Kaiser Family Foundation estimates that about 2.2 million people in nonexpansion states (chief among them Texas, Florida, Georgia and North Carolina) are in the coverage gap.

In Memoriam: Jules B. Sprung

My father, Jules Sprung, died this past Saturday after a short hospital stay -- of kidney failure specifically, and old age generally. He was very frail, but alert and engaged until his very last days in the hospital. My mother has taken meticulous loving care of him as he very gradually lost the ability to take care of himself. 

We miss him dearly but are at peace with the conclusion of a life well lived. An obituary is below. Thanks to Dan Woog, author of the blog 06880, a chronicle of daily life in Westport, CT, for publishing a skillfully edited version.

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Jules B. Sprung, a resident of Westport with his wife Barbara since 1976, died on March 6 in Norwalk Hospital. The cause was kidney failure. He was 92.

Jules founded and ran two mail-order office supply companies, Hudson Pen, Inc. and Sarand, Inc., selling the latter in 1988 and working afterward as a marketing consultant. Sarand, based in New York City, employed dozens of people from the mid-seventies through the 1980s.

In his retirement, Jules taught swimming classes for children for many years at the Westport YMCA, where he was an honored presence at the pool until the pandemic curtailed operations in 2020.  He was also president of the Indian River Green condo complex on Saugatuck Road in Westport, where he and Barbara moved in 2002.

The ACA as it should have been -- sort of, for a while at least

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Strictly speaking, by my my lights, "the ACA as it should have been" would be "Medicare for all who want it": a public plan paying Medicare rates to providers, accepted by all providers who accept Medicare, with competing private plans paying similar rates to providers and probably offering somewhat more generous coverage as a tradeoff for limitations in provider choice. These plans would be available to all, including those with access to employer-sponsored insurance. Oh, and add an OOP cap -- a cap on annual out-of-pocket costs -- to the public plan -- as we should do for traditional Medicare.

In the political universe we're bound by, however, "the ACA as it should have been" denotes the ACA more or less as is, but with subsidies generous enough to make coverage in the ACA marketplace truly affordable to most Americans who lack access to other insurance -- excluding (always, alas) undocumented immigrants.  

And that is about to happen! -- temporarily at least -- when Biden signs the American Rescue Plan Act of 2021 later this week (see Section 9661).   It's an eye-rubbing moment for progressives who've dreamed fruitlessly for a decade of an Affordable Care Act offering affordable coverage to almost all comers.

The Kaiser Family Foundation is trying to tell us something

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The Kaiser Family Foundation is one of the most reliable and comprehensive source of healthcare data and analysis in the U.S. Its authority rests in part on maintaining an implicit policy neutrality, letting facts speak for themselves. But sometimes facts speak loudly, and that's the case with a remarkable brief detailing the extent to which the United States' failure to set payment rates for providers, or compel all payers to negotiate common rates, drives our out-of-control spending on healthcare, and our failure to provide affordable access to all.

The brief is an emperor-has-no-clothes declaration, aggregating facts well known to healthcare scholars and simply spotlighting the consequences of our collective failure -- unique among wealthy countries -- to curb the market (and political!) power of hospitals and doctors by forcing them to deal with all payers as a unit. It's a slingshot aimed at an industry Goliath preparing a nuclear arsenal of lobbying and propaganda against any initiative that aims to expand the footprint of government payment rates.

Does mandatory maximum silver loading require a risk adjustment fix?

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I want to address a somewhat technical issue concerning regulatory action to require that gold plans in the ACA marketplace be priced below silver plans -- that is, regulatory action on the state or federal level mandating maximal silver loading.

Gold plans should be priced below silver plans because silver plans --on average -- carry a higher actuarial value than gold plans. "Actuarial value" refers to the percentage of the average enrollee's costs covered by the plan, according to a formula created by CMS (that formula could use adjustment, but that's another story). Gold plans have an AV of 80%, plus or minus a few percentage points. Silver plans have a baseline AV of 70%, but that's only for enrollees with incomes above 250% of the Federal Poverty Level (FPL). Below that threshold a secondary subsidy, Cost Sharing Reduction (CSR), available only with silver plans, boosts AV to 73%, 87%, or 94%, rising as income falls.  Most silver plan enrollees obtain AV of 94% or 87%.

In Health Affairs: The Biden administration should complete the silver loading revolution

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The Covid relief legislation making its way through Congress would vastly increase premium subsidies in the ACA marketplace for two years but would not touch out-of-pocket costs. Premium subsidies would still be set against a silver benchmark -- that is, designed to make the second-cheapest silver plan "affordable." At incomes over 250% FPL, silver plans have deductibles averaging $4816.

In Health Affairs, David Anderson and I have a post positing that the Biden administration can complement the subsidy boosts by requiring insurers to price gold plans below silver plans. That is, by requiring full "silver loading."

In The American Prospect: My Take on Jonathan Cohn's The Ten Year War

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I have a review in The American Prospect of Jonathan's Cohn's inside-the-creators' heads chronicle of the ACA's embattled formation and enactment:

Jonathan Cohn, a leading contemporaneous chronicler of the ACA’s formation and enactment, and now author of The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage, is well aware of these shortcomings and faulty assumptions, as well as of the law’s resilience and partial success, such as reducing the uninsured population by about 35 to 40 percent. The book’s chief value, for me at least, lies in illuminating the creators’ perspectives at various crunch points in the law’s conception and enactment.

Cohn takes us back to a long time ago, in a galaxy far, far away, in which Democrats still hoped to win Republican support for major legislation...

The nuance with which Cohn captures the various players' assumptions and motives, and the pressures brought to bear on them, provides some real retroactive clarity, from what already feels like a substantial historical distance. I hope you'll read the review, which relies on substantial excerpts.

Medicaid enrollment likely reaches 81 million in January

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Chart updated 3/3/21

This is an update to my recent post estimating total national Medicaid enrollment at upwards of 80 million through December, up from 71.2 million in February 2020, the last month before the pandemic struck the economy.

I've added December updates from four states -- including the big one, California -- to the sample, as well as adding Nebraska, which enacted the ACA Medicaid expansion beginning in October. As I forecast, continued relatively slow growth in California drops the full-sample rate of increase by about two and a half percentage points.  

As always, the official CMS tally for all states, currently stuck in September, is likely to show a somewhat smaller increase than my sample. For September, my sample showed an increase of 9.7% over February, while CMS currently shows a 9.4% increase in the same period.  Conservatively, then, I'll posit that CMS will show a 12.5% increase from February through December 2020, which would put national enrollment at 80.1 million.  (The sample consists of states for which I can find monthly enrollment reports.)[Update, 4/5/21: CMS's preliminary November total shows an increase of 11.6% since February, as I forecast on New  Year's Eve, compared to the 12.0% increase for the same period charted in my sample below.*]

Obama's assumptions about healthcare reform, in 2009 and today

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Jonathan Cohn today published an adapted excerpt from his book about the Affordable Care Act, The Ten Year War, coming out on Tuesday. The article's centerpiece is Obama's own assessment of what went right and wrong in the design, passage, and enactment of the ACA.  Of the ACA's basic design, which had become a consensus Democratic by the time Obama was elected, Cohn notes, "It was a far cry from the government-run insurance plan that Harry Truman once championed, but Democratic leaders embraced it as the best they could get..."

 ― and so did Obama, who repeated in our interview his belief that something like a government-run, “single-payer” system would probably work best, but creating one right away would be too difficult. 

“We have a legacy system that is one-sixth of the economy,” Obama said. “The idea that you could, in some way, dismantle that entire system ― or even transition it entirely ― to a single payer system looked politically impractical and probably really disruptive. ... The best chance to actually get people healthier was going to be to design a system that acknowledged 85% of the American people have health insurance and that plugged the gap for those 15% who don’t.”

Obama's neat foreclosure of other possibilities here reminds me of the technique deployed throughout his memoir, A Promised Land, of showcasing his undeniable rationality within a framework bound by self-imposed limits, or limits imposed by his choice of advisers, or -- sometimes -- by what was politically possible.  I see two fallacies here.

A public option by inches: Bennet and Kaine's Medicare-X

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This week Democratic Senators Michael Bennet (CO) and Tim Kaine (VA) introduced an updated version of their Medicare-X Choice Act, first introduced in 2017 and again in  2019 (summary here, bill here). The bill would introduce a strong public option into the ACA marketplace and small group markets, paying Medicare rates to providers in most markets, though up to 150% Medicare in rural markets. It would also improve subsidies at every income level on a schedule that's become the Democratic legislative default -- e.g., in the Coronavirus relief legislation. Enrollees would pay the following percentages of income for a benchmark silver plan:

Note that benchmark coverage is free at incomes up to 150% FPL (currently about $19k/year for an individual), and there is no income cap on subsidies: no one who lacks access to other insurance (e.g., an employer-sponsored plan) would pay more than 8.5% of income for benchmark silver. The 2019 version capped subsidies at 13% of income -- a measure of how far Democrats have come in adjusting their concept of affordability.

Compared to the healthcare reform plan Joe Biden introduced as a candidate in 2020, the bill has two major limitations. First, it does not offer subsidy eligibility to people who have access to other "affordable" insurance, including an offer of insurance from an employer with a premium below 9.5% of income. (The bill does fix the family glitch, offering subsidy eligibility to employees with families if the employer's family plan costs more than 9.5% of income.) It is not "Medicare for all who want it," notwithstanding presidential candidate Bennet's past claims to the contrary.  

Health Policy Valentines 2021: Institutional edition

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Americans don't have much faith in government, and it's hard to think of our society as one that's pulling together in the face of the pandemic and its revelation of our systemic inequities. But it's not all dysfunction, oligarchy, rising fascism and disregard for the common good.  And we do have a serious new bid from the Biden administration for good government.

This year's #healthpolicyvalentines are from various organs of government and other institutions to the American people.

From the Biden Coronavirus task force

Producing and dispensing fact
is our core Defense Production Act

From SCOTUS

Inseverable?
Did I hear Roberts scoff?
The vestigial mandate
will be cut off.

Obama's inside-out view of the public option

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I have been slowly working my way through Obama's memoir with a kind of wariness of being emotionally sucked in. Like all political memoirists, Obama presents himself as having made the best decisions he could given what he knew at the time. True, in the sense that his motives were good, his process was good, and his intellect is good. But still self-serving, and sometimes disingenuous.  

For all Obama's solicitation of a wide range of views, his narrative presents the predominance of certain views and voices as a given.  For example, regarding the size of the stimulus, Obama recounts this mid-December exchange:

Immediately after the election, examining the worsening data, we had raised the number to $500 billion. The team now recommended something even bigger. Christy mentioned a trillion dollars, causing Rahm to sputter like a cartoon character spitting out a bad meal. “There’s no fucking way,” Rahm said. Given the public’s anger over the hundreds of billions of dollars already spent on the bank bailout, he said, any number that began “with a t” would be a nonstarter with lots of Democrats, not to mention Republicans. I turned to Joe, who nodded in assent.

And that's it: political reality foreclosed, while Larry Summers foreclosed on the economic argument for more stimulus-- and Christine Romer's input is reduced to a "mention."  In Obama's telling, the stimulus his administration proposed was audaciously gargantuan by any current standard. 

Under Covid relief bill, no Obamacare enrollee should have coverage less than valuable than gold

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It's here! After five years in which progressives have dreamed of boosting the generosity of subsidies in the ACA marketplace, the framework for half the Covid relief bill released by the House Ways and Means yesterday would do so temporarily, for 2021 and 2022. The subsidy schedule is even more generous than that of the Affordable Care Enhancement Act passed by the House last June (and left to die in the Senate, natch). Here are the percentages of income required to purchase a benchmark (second cheapest) silver plan (Part 7, beginning on p. 83):

Keep in mind that Cost Sharing Reduction (CSR) raises the actuarial value of a silver plan from a baseline of 70% (which leaves very high out-of-pocket costs) to 94% at incomes up to 150% FPL (where it's free) and to 87% -- better than most employer-sponsored plans at incomes ranging from 150-200% FPL.  This radical change may happen fast, and be effective immediately. The implications are kind of dizzying. Three notes:

Raised minimum wage creates an imperative to improve ACA marketplace subsidies at low incomes

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David Dayen flags a paper by UC-Berkeley economist Michael Reich that finds a budget impact from raising the minimum wage (which should render eligible for the reconciliation bill). The paper

found $65.4 billion per year in savings, through a combination of increased tax revenues on higher wages and reduced federal expenditures on safety net programs due to eligibility thresholds. 

As Dayen points out, the federal savings are not in themselves something to cheer about:

Increased taxes on higher wages still put a worker out ahead, to be sure. But reductions in federal benefits could create a treadmill effect, with the government taking away what the private sector is forced to pay out. As $15 an hour isn’t really a living wage in much of the country, clawing back benefits isn’t a perfect scenario. 

One of the benefits that some people will earn themselves out of as the minimum wage rises is Medicaid. Eligibility for Medicaid as expanded by the ACA is offered to adults with incomes up to 138% of the Federal Poverty Level ($1,468 per month for an individual, $1,303/month for a family of four). To date, 38 states plus D.C. have enacted or will soon enact the expansion, with the last two of those, Oklahoma and Missouri, scheduled to expand eligibility in July of this year.)

Estimate: ACA Medicaid expansion enrollment may have grown 25% from February to December 2020

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As Covid-19 burned its swath through the U.S. in December, Medicaid enrollment in the ACA expansion category (adults with monthly incomes up to 138% of the Federal Poverty Level) continued the rapid growth that started with the pandemic.

Enrolment increased 2.7% from November in the 17 states for which I've been able to locate monthly expansion-category enrollment reported through December. In those 17 states, enrollment increased 27.6% from February 2020 -- the last month in which the economy was unaffected by the pandemic -- through December.