Name Ohio "McKinley" -- and don't stop there!

Republicans, particularly Ohio Republicans, are of course up in arms about the Obama administration's announcement that it would use its executive authority to restore Mount McKinley (named in 1896 by a gold prospector who heard of the president-to-be's nomination) to its historic name, Denali, "the high one," as it had been known for centuries. Alaskans have requested the change for decades (and changed the name themselves via the state Board on Geographic Names in 1975), and (Republican) Senator Lisa Murkowski recorded a video thanking Obama for the change, but never mind.*  John Boehner, whose district is in Ohio, is "deeply disappointed" that McKinley's "great legacy" is losing a monument. Senator Rob Portman bemoans the diss of a "proud Ohioan" (while erroneously deeming the McKinley naming a post-assassination honor).

These complaints are disappointingly circumspect. It's time for presidential candidates to up the ante against the pandering president. Why focus on mere isolated slags of stone? Scratch a bit, and it seems a bunch of squish multiculturalists got hold of state naming boards when this country was young. Why not name all these states that ignore our European heritage and great legacy after (GOP) presidents?**

Alabama (Muskagean)
Alaska (Aleut)
Arkansas (Sioux)
Connecticut (Algonquian)
Hawaii (Polynesian)
Idaho (Comanche)

Why Trump wants a wall

There's a prototype for Trump's wall along the Mexican border:

If you're going to build an 1800-mile wall, why not stuff it with apartments?  And of course, Mexicans can come through the "beautiful door" and build it..and have their remittances taxed to pay for it.  It will have not only gorgeous views of the Rio Grande. but the best lawns.

As president, Trump can set up a public-private partnership with himself. The U.S. can be renamed Trump Place. What's not to like?

Which insured Americans get no subsidy whatsoever?

Who are the Americans who get no help from the federal government paying for their health insurance?

The uninsured, of course. Also, those who buy their insurance in the nongroup market (on- or off-exchange) and a) earn too much to qualify for subsidies, and b) are not self-employed.

It's important to recognize that the self-employed do get a subsidy: the self-employment health insurance deduction. If your health insurance costs less than your total self-employed earnings, you can deduct the whole cost from your earnings. A recent study indicates that this deduction takes an average of 22% off the average self-employed tax filer's health insurance bill.

My question: what percentage of buyers in the nongroup market are not subsidy eligible and not self-employed? They are the only insured Americans who get no government aid paying for insurance. Most of them, that is: there is also a medical expense deduction available to any household that spends more than 10% of its Adjusted Gross Income on medical expenses, including insurance. Only expenses over 10% of AGI can be deducted.

Biden in Pilgrimage to Democrats' Matron Saint

In honor of James Fallows' found art department: The NYT 'weekend briefing' on my phone had the image below directly beneath the headline below

Biden, Considering White House Bid, Meets with Elizabeth Warren



Let us hope he found what he was seeking.

Article here. The image was actually attached to this one.

How many of the uninsured know what's on offer? Not many, Urban finds

With ACA private plan market enrollment lagging initial CBO projections, one key question is whether those who qualify for aid but remain uninsured are doing so because they can't afford what's on offer or because they still don't know what's on offer.

The Urban Institute's latest Health Reform Monitoring Survey (HRMS), conducted in March 2015, indicates that both factors are at work, but comes down more on the side of ignorance of what's on offer. That's "good news" in the sense that ignorance can be rectified for less money than too-skimpy offerings -- though an Urban analysis released earlier this week warns that outreach and marketplace operations are underfunded, as are the subsidies intended to make coverage affordable.

The HRMS found that 43.1% of still-uninsured have household incomes that may be* in the range that qualify them for subsidized private plans on ACA exchanges. Another 27.7% have incomes that would qualify them for Medicaid under the ACA expansion and live in states that have accepted the expansion (including an unmeasured percentage of both undocumented and legally present immigrants** who do not qualify). 22.6% are in the "coverage gap," earning under 100% of the Federal Poverty Level in states that have refused to expand Medicaid. Just 6.6% of the uninsured earn too much to qualify for any aid.

Fully 60% of those likely to qualify for aid say they remain uninsured because costs are too high or they can't afford coverage. But... here is the key point, in my view:

A quibble with Avalere over CSR takeup

9/3/15: See update at bottom for Avalere's response to questions posed here 

I may have to "never mind" this post if I'm missing something basic, but...it seems to me that Avalere Health lowballed Cost Sharing Reduction (CSR) takeup a little in an analysis released today.

Avalere's calculation is simple: 5.9 million buyers of private plans on ACA exchanges bought plans with Cost Sharing Reduction subsidies, available only to buyers with incomes under 250% of the Federal Poverty Level (FPL), and only if they selected silver plans.  8.1 million buyers were eligible for CSR, according to Avalere; hence about 2.2 million left the benefit on the table; most of them probably brought bronze plans with sky-high deductibles. The CSR takeup rate comes to just 72.8%,

Avalere says that it derived these numbers from HHS's March enrollment report,which broke out enrollees by income level in the 37 states using healthcare.gov, and a CMS update released in June, which adjusted for attrition (mostly no-pays) as of March 31.

We know where the 5.9 million figure for those who accessed CSR came from: the June update, which reported 5,850,936 enrollees with CSR. But what about the denominator, the 8.1 million? That's trickier. We know there were 10,187,197 enrollees as of March 31. But how many were CSR-eligible?

A tough progressive critique of the ACA

Over at The Incidental Economist, I have a review of IBD reporter Jed Graham's e-book analyzing flaws in the ACA and proposing a package of fixes. Here's the opening*:

Those who have closely followed the drama of Affordable Care Act implementation as it's unfolded in the media over the past two years may be familiar with the sharp criticisms of Jed Graham, a reporter at Investor's Business Daily. These include a list of cuts to work hours and jobs prompted by the employer mandate, and spotlights on the sky-high deductibles taken on by the approximately one fifth of ACA private plan buyers who chose the lowest tier bronze plans.

Given the title of Graham's e-book assessing the law, ObamaCare is a Great Mess, a sometime reader of Graham's articles might assume that he's one of the ACA's many implacable ideological opponents. That would be to ignore the subtitle, A View of the Affordable Care Act Without Partisan Blinders & How to Fix It, as well as its substantive criticisms and recommendations. Graham identifies the law's shortcomings from an essentially progressive perspective, highlighting what he presents as the regressive impact of its mandates and  the limited affordability of its offerings for many buyers.  "The heart of the ACA is basically sound," he writes. "The goal of reform should be to unclog the arteries and let the heart do its job."

Graham's proposed fixes are well worth considering (well, some of them, in my view), and there's a potential venue for trying them out (or variants that could be cast as revenue-neutral): the ACA's innovation waivers inviting states to submit alternative schemes, starting in 2017 that meet the ACA's standards for affordability and coverage at comparable cost.  The book is also a useful antidote to the triumphalism that's taken hold of many supporters since the King v. Burwell nightmare went away.

--
* More or less: these paragraphs were edited down a bit for TIE.

The Urban Institute's Medicaid expansion proposal could help the ACA private plan market

The Urban Institute has released a report* proposing that the federal government spend an extra half-trillion dollars over ten years to boost the affordability and uptake of the Affordable Care Act's health insurance offerings. The core premise is that for far too many uninsured Americans, private plans offered on ACA exchanges are either unaffordable or offer too-skimpy coverage.

The headline proposal is to boost premium and cost-sharing subsidies for the private plans offered on ACA exchanges.  I'd like to spotlight a side effect of a secondary proposal, designed to entice some of the 21 states that have thus far refused the ACA Medicaid expansion to embrace it. It's this:

Although some of the currently nonexpanding states may choose to participate in the future, many others may continue to refuse to do so, maintaining the tremendous inequity that provides federal financial assistance to some people with incomes at or above the federal poverty level but denies assistance to many adults who are actually poor. One option to address this hole in the ACA’s reach is to give states the option of expanding Medicaid coverage up to 100 percent of FPL rather than requiring them to expand to 138 percent of FPL if they expand at all.

As the ACA mandate bites harder, will a Bronze Age follow?

I have a post up at healthinsurance.org responding to a forecast by Investor's Business Daily reporter Jed Graham,to the effect that as the individual mandate clubs more people into the ACA exchanges, more low income shoppers will buy bronze plans.

Graham assumes that most of those who have remained uninsured have looked at what's on offer and decided it's too expensive, or that only bronze is affordable and that the sky-high bronze deductibles render those plans a poor value.  While that's doubtless true for some, I point to survey data indicating that large percentages of the still-uninsured don't know what's on offer.

I want to skip here to a somewhat fuller discussion of solutions Graham offers to what he calls "the bronze trap" in his just-released e-book, Obamacare is a Great Mess: A View of the Affordable Care Act Without Partisan Blinders & How to Fix It, which is well worth a read.

Pet insurance: permission to spend?

Sarah Kliff has a good article about pet insurance that poses the right two questions at the outset -- courtesy of Jennifer Fitzgerald, co-founder of an excellent online insurance market called PolicyGenius:

The first question is the easier one: How much can I afford to spend on my pet? If I got a really expensive bill, maybe something upward of $5,000, would I be able to pay it off myself? If the answer is yes, she says, you might not need pet insurance: You could take a gamble and essentially act as your own insurance company. But if the answer is no, then there's a follow-up question:

How much am I willing to spend to save my pet's life? Don't think about the constraints of your budget for a moment — think about whether you'd think it was worth it to pay $5,000, $10,000, maybe even $20,000 to save your pet's life.

I have been mulling the second question on and off for some years. When we adopted our dear departed beagle mutt Merlin fourteen years ago, I used to joke that he had a $2,000 lifetime health savings account. That was because I was bemused by tales of people paying for cancer operations for their dogs -- $5k or $10k.  I thought that was ridiculous. But changing cultural norms have a tidal pull. When we adopted the beguiling dachshund mutt Walter two years ago, I started testing my mental limits for what I'd be willing to pay down the line -- especially as we read that dachschunds are prone to spinal troubles (we hope the 1/4 pit bull in him may spare him that).

Best tool against inequality: antitrust enforcement? (of two kinds?)

[Update, 10/28: An updated version of Einer Elhauge's article is available here.]

The Wall Street Journal reports today that activist shareholders, who force management and operational changes in public companies to boost "shareholder value," are increasingly enlisting large mutual fund companies as allies and thus winning more battles. Their aims generally: "share buybacks, cost-cutting and asset sales."

That boost to shareholder activism, taking place over the last decade, recalls a theory of what's driving growing economic inequality recently advanced by Harvard law professor Einer Elhauge. According to Elhauge, increased consolidation of public company ownership by institutional investors like BlackRock, Vanguard, Fidelity, and State Street leads to a phenomenon called "horizontal shareholding," in which these mega-investors own major stakes in all the major players in a given industry and thus provide incentives to those companies to collude rather than compete -- or more exactly, to act in ways that boost share prices across the industry rather than relative to their competitors.

Elhauge's analysis is prompted by the fact that "the increasing share of stock held by institutional investors...has grown from 34% of all stock in 1980 to 67% of all stock in 2010." He links that rise to the often-cited drop in the percentage of corporate revenue going to wages and capital investment:

What if Congress rejects the Iran deal? Ex-Mossad chief Halevy fills in the blanks

There's one incontrovertible point in the argument against the Congress rejecting and invalidating the nuclear agreement with Iran. Even if you think the deal was poorly negotiated, if the U.S. walks away the sanctions regime will immediately fall apart and Iran will gain everything it could ever gain either by cheating on the deal or stepping up its enrichment and weapons program when various constraints expire. 

Obama has made this point repeatedly, minus the "even if you think..." part. The shorthand is "what is your alternative?" -- and there is none. Implicitly recognizing this, Chuck Schumer, in the most self-negating policy statement I've ever read, could barely bring himself to sketch in (in the statement's last breath) an alleged alternative path:

Five Republicans who are not democrats

Leave aside for a moment the favored policies of the ten Republican presidential candidates in the prime-time debate and the seven in the second-tier happy hour debate.  While there were very few actual policy differences, at least five candidates expressed startling contempt or disregard for the core structure of U.S. government, democratic constraints on the executive, international law, or the most basic standards of evidence for assertions made in public. 

Here's a quick look at five violations of the norms of democratic government as understood in the U.S. and internationally.

1. International law banning torture is not "brain surgery." Here's neurosurgeon Ben Carson responding to a question from Megyn Kelly: "As president,....would you bring back waterboarding?"

Alright. You know, what we do in order to get the information that we need is our business, and I wouldn't necessarily be broadcasting what we're going to do.(APPLAUSE)

We've gotten into this -- this mindset of fighting politically correct wars. There is no such thing as a politically correct war. (APPLAUSE)

Obama against the warmongers

Obama's speech yesterday in support of the Iran deal had one obvious structure: taking on objections to the deal point-by-point, in substantive detail. It had a parallel thematic structure: opposing the tradition of American multilateral diplomacy to the drum-beating of hegemonists, proponents of preemptive war. 

Casting himself in the former tradition, which he portrayed as the longstanding consensus position of U.S. foreign policy, he repeatedly invoked first Kennedy and then Reagan, intertwining the words and deeds of both. On the hegemonist side, he invoked one counterfactual and one actual disaster: first-strike proponents against the Soviets, and Iraq war proponents, whom he linked to opponents of the Iran deal.

The definition of chutzpah

A few step-back observations about national "debate" over the Iran deal:

1. It is the definition of chutzpah to hype the danger of a nuclear Iran for years and decades, then complain that the deal only addresses Iran's nuclear program. It's also the definition of warmongering. You can't negotiate away all your differences with an adversary at once.

2. In the same vein, it's disingenuous to reject the deal on grounds that the removal of sanctions designed to induce such a deal will fund other activities we don't like.

3. We can pretend that there's a substantive debate about the merits of the deal, but that's obviously not what's going on.  The evidence of that is in the terms in which prominent Democrats declare their support.  According to Huffington Post's Sam Stein, Senators Kaine, Warren and Nelson felt empowered to support the deal after a meeting with ambassadors from the P5 + 1 group that negotiated with the U.S. against Iran:

...the conversation lingered largely on a hypothetical: What would happen if the agreement fell through?

According to one Senate Democratic aide, the ambassadors were emphatic that this would amount to a forfeiture of a successful diplomatic endgame.

Underinsured and deep in debt: which cracks did this family fall through?

USA Today has a story today, by Jayne O'Donnell, highlighting the plight of (under)insured Americans who face crippling out-of-pocket healthcare costs. The lead example raises a couple of question marks about exactly how this family fell through various cracks:

Christian and Jaycee Garcia of Silver Spring, Md., have been hard hit by medical bills, even with their out-of-pocket maximum of $6,350 a year for each family member. Their 20-month-old son, CJ, was born with the rare genetic disorder Eagle Barrett Syndrome and severe scoliosis. He will have his 13th surgery in August, with two more to follow in September, all to rebuild his digestive system and urinary tract and to insert metal rods next to his spine so he can sit up without a brace.

Although Christian Garcia earns $60,000 a year as a restaurant manager, the more than $700 monthly insurance premiums for his work plan and another privately purchased plan for his wife and kids plus other monthly bills make paying the family's share of the hospital bills impossible. The couple have $11,000 in medical bills they are paying $270 a month on, and bills from two other hospitals have gone to collections. Monthly expenses, including the payment on his medical bills, are about equal to his take-home pay of about $3,000 a month.

Rejoice, Uticans! A shower of silver shall rain upon you in 2016.

UPDATE: I'm afraid I have to retract the gist of this post, which comes mainly near the end: we don't actually know the spread between the benchmark and cheapest silver plans in each New York region for 2016.  Looking at the spread between the silver-plan prices posted by the different insurers, it escaped me that a given insurer could put up the cheapest and second cheapest silver plan in a given area -- so the difference between insurers' average silver prices, as reported by the state, is not the spread between benchmark and cheapest silver. The posted averages do not reveal the benchmark. I apologize to anyone who absorbed the misinformation.

P.S. I discovered the error when I went to check 2015 prices and how a "cheapest silver" windfall would affect them. Of course I might have known, as I've done a lot of "shopping" on healthcare.gov and have rarely seen a really significant gap between cheapest- and second-cheapest silver. I think I was thrown off by California's just-published 2016 rate chart, which explicitly highlights some very large spreads between benchmark and cheapest silver, with one plan price quoted for each insurer. That's presumably because benefits in CA are standardized for each metal level.

P.P.S. I also seem to have forgotten for the moment that NY is launching a Basic Health Plan in 2016, thereby wiping out the under-200% FPL market and rendering the issue of CSR takeup all but moot, as CSR is negligible at 200-250% FPL. That'll teach me to post in haste before rushing out on a Friday evening reverse commute to hang over the balconies at the new Whitney Museum:

New Whitney

So, never mind, except for the general principle:
--------------

Today New York posted 2016 rates for health insurance plans offered on NY State of Health, the state's ACA exchange. I was planning to write about the factors that affect what subsidized ACA private plan buyers will actually pay, when the rates posted for Utica, NY brought me up short. They are a stark illustration how the spread between certain plans offered in one market matters more to subsidized buyers than the sticker price of a given plan -- if they're willing to buy the cheapest plan at a given actuarial value.

On ACA exchanges, premium subsidies are set as a fixed percentage of a buyer's income, benchmarked to the second cheapest silver-level plan in the buyer's market. In 2016, solo buyers who earn exactly 200% of the Federal Poverty Level (FPL) will all pay $124 for the second cheapest silver plan available to them, regardless of where they live. Buyers earning 150% FPL will pay $59 for the benchmark plan.

New York's ACA exchange publishes takeup rates for Cost Sharing Reduction

NY State of Health, the state's ACA health insurance marketplace, released detailed enrollment data today (hat tip to who else but Charles Gaba?). With regard to my own little preoccupation -- the degree to which those private plan buyers eligible for Cost Sharing Reduction (CSR) subsidies access the benefit by buying silver plans -- New York is (as far as I know) the first state to do the basic math for me:

The majority of QHP consumers who completed the enrollment process and were eligible for APTC with cost-sharing reductions chose Silver plans in which they can use costsharing reductions. Among those eligible for cost-sharing reductions, enrollment in Silver plans was higher for those eligible for greater levels of subsidy. Ninety-seven percent of those eligible for costsharing reductions at the 94 percent actuarial value level enrolled in a Silver plan, compared with 83 percent at the 87 percent actuarial value level, and 62 percent at the 73 percent actuarial value level. Overall, 78 percent of those who are eligible for cost-sharing reductions, enroll in a Silver plan with that benefit. The remaining 22 percent enroll in different metal levels. These trends are consistent with the
2014 open enrollment period, when overall, only a slightly higher share of cost-sharing reduction eligible enrollees—80 percent—enrolled in these products. 

Last year, I had to tweeze these numbers out of the NY enrollment report myself.  Since they redounded to the state's credit, and a NYSOH spox confirmed them for me, I'd like to think I gave them a nudge toward highlighting the takeup themselves this time around.

Pennsylvania Medicaid expansion enrollment jumps; have newly Medicaid-eligible 2014 private plan enrollees jumped with it?

Pennsylvania's somewhat rocky Medicaid expansion, for which enrollment began on December 1 and coverage on January 1, seems now to be firing on all burners. The state's Department of Human Services reported last week that enrollment is up to 439,000, more than two thirds of the state's target of 605,000.

The expansion began slowly. After Pennsylvania declined to expand in 2014, then-Governor Tom Corbett negotiated with HHS to create the kind of "private option" expansion popular with Republican governors. The "Healthy Pennsylvania" plans that were hastily constructed in fall 2014 had different terms for Medicaid-eligibles at different income levels, and eligibility criteria different from the state's existing programs. Adding to the confusion, existing state Medicaid programs required applicants to list their assets as well as their income; the ACA excludes such information from the Medicaid application process. Systems snarled and applications backlogged, though not as radically as in many states.

A transition back to traditional Medicaid initiated by the state's new Democratic Governor, Tom Wolf, kicked off on April 27. That transition will be complete by the end of this month, though some "private option" enrollees will be double-enrolled until September 1. By late April most applications were being processed in a timely manner, meeting the state's 30-day standard, enrollment counselors told me at the time.  Kait Gillis, a DHS spokeswoman, tells me that 150,000 have been enrolled since the transition to traditional Medicaid kicked off.

Some sidelights on Covered California's modest rate increases for 2016

Covered California, the state's ACA health insurance exchange, is boasting today with some justice that the state held 2016 rates down to an average weighted increase of 4%. Other talking points: the average (unweighted) increase of the cheapest silver plan in each region went up just 1.5%, and the average consumer can save 4.5% if she switches to the cheapest plan in the same metal tier.

That last point is somewhat...selective: the apples-to-apples question is what will happen to current holders of the cheapest plan in each metal tier if they switch to 2016's cheapest plan.  On the other hand...there are two other hands.

First, the talking point about switching to the cheapest plan in one's metal level has some extra validity in California, where benefits for all plans in each metal tier are standardized. In other words, the only substantial variable other than price is network quality. Hence, price shopping -- balancing premium versus benefits -- is likely to be less fraught and easier to get right in California than in most states.

Second, it's good news that the cheapest silver plan in each region went up an average of just 1.5%-- but the import of that factoid depends in part on a second data point. That would be the average increase for the second cheapest silver plan in each region, which is the benchmark according to which premium subsidies are set. That is, a buyer's premium is calculated to leave him paying a fixed percentage of his income for the second cheapest silver plan available to him. If the benchmark silver plan goes up more than the cheapest silver plan, that's good for the buyer: it increases the affordability of silver-level coverage.  Covered California's full rate report shows that the benchmark plans went up an average of 1.8%, very modestly (on average) increasing the spread and so the affordability of the cheapest silver plan. It also shows that the cheapest bronze plan went up an average of 3.3% -- making the cheapest silver relatively (albeit slightly) more attractive.