Two comparisons of Price plan vs. ACA marketplace are roughly congruent

Late last year, I put forward a simple measure of the value (to the beneficiary) of a government subsidy for health insurance in various programs: multiply the percentage of premium covered by subsidy by the actuarial value of the insurance obtained. (A somewhat more streamlined version of the comparison is here at HIO).

For the ACA marketplace, I multiplied the average premium subsidy as reported by HHS (73% of premium) by the weighted average actuarial value obtained by subsidized marketplace enrollees (81%, my calculation) to come up with 59% total subsidized costs.

I then calculated that Tom Price's replacement plan, which has subsidies based on age not income, would on average cover about 40% of ACA benchmark silver plan premiums. I estimated that those flat subsidies would cover about 60% of premium for the cheaper plans to be offered in Price's deregulated market, to which I charitably ascribed an average AV of 60% -- coming up with a total average subsidized cost of 35% or 36%.  Of course, that's for all buyers, whereas only about half of current individual market enrollees are subsidized. Thus Price's plan radically redistributes subsidies from low-income toward higher income prospective enrollees.

Yesterday David Cutler, a Harvard health economist, John Bertko, chief actuary for Covered California, and Topher Spiro, veep for health policy at CAP, published in Vox a more nuanced and sophisticated comparison of the ACA-governed individual market and Tom Price's plan that ended up in pretty much the same place.

Triage, Sister Simone, triage

In a q-and-a session at Health Action 2017 last week, I suggested that Democrats might be savvy to engage with the Cassidy-Collins ACE "replacement" bill, which merely breaks the ACA's fingers rather than disemboweling it. When incoming Families USA exec director Frederick Isasi implied that this could potentially make sense, Sister Simone Campbell, a heroine of ACA passage and defense, rebuked him (and so, by proxy, me):

I have to confess, Frederick, after that great presentation I wanted to … say don’t you dare engage Collins-Cassidy because it’s based on Health Savings Accounts, and only 30 percent of our nation’s families have any savings. So let’s be real.

I don't like HSAs any more than Sister Simone does, but... I have a response up on healthinsurance.org

Health Action 2017: Times that try our souls

I attended Families USA's annual Health Action conference last week and found it deeply moving. My overview is up on healthinsurance.org.  Here's an upshot of sorts:

The conference, to my mind, fulfilled the deepest purpose of such events. It was not so much a matter of convincing the troops that the goal of preventing the repeal of the ACA and further evisceration of Medicaid through block-granting is attainable. Some marquee speakers argued forcefully that those goals are achievable, others implied that the odds are long.

Strength lay more in the collective demonstration of expertise and commitment, evident as much in breakout workshops as in plenary sessions...

Then, zooming out to the plenaries, a highlight was outgoing (outgone?) acting CMS head Andy Slavitt's call to the assembled healthcareniks to respond to

More than half of ACA marketplace enrollees are in states that refused to expand Medicaid

I have noted on multiple occasions that in states that refused the ACA Medicaid expansion, marketplace enrollment has been bolstered by a large contingent of people who "should have" been enrolled in Medicaid. That is, over 2 million marketplace enrollees in those 19 states have incomes between 100% and 138% of the Federal Poverty Level (FPL) -- incomes that would have qualified all of them except for certain legally present noncitizens for Medicaid had their states accepted the expansion.

To review a few facts about these low income enrollees:

• In nonexpansion states, 36% of enrollees had incomes in the 100-138% FPL range. In mid-2016 that came to about 2.1 million enrollees.


• Close to 90% (or more*) of those low-income enrollees selected silver plans and so accessed Cost Sharing Reduction (CSR) subsidies that raised the actuarial value of their plans to 94%. That generally translates to a deductible of $0-250.


• Customer satisfaction in the ACA marketplace is much higher among enrollees who are not in high deductible plans (defined by survey conductor Kaiser as under $1500 for an individual). In Kaiser's 2016 tracking survey, 74% of enrollees in lower deductible plans rated their plans good or excellent, vs. 59% of those in higher deductible plans. And again, the vast majority of enrollees in the 100-138% FPL range are in low deductible plans.

All that said, a fact hiding in plain sight (to me, anyway) is the extent to which nonexpansion states are over-represented in the ACA marketplace. This is not surprising, since a third of enrollees in those states should have been eligible for Medicaid. Nonetheless, I find it rather startling, based on state-by-state data released by HHS in December, that as of the end of the first quarter of 2016, the 19 nonexpansion states contained:

Love knows no repeal: HealthPolicyValentines 2017

Update 2/15: below is this year's complete harvest, as it grew from Feb. 10-14. Last year's trove is here. Love, 2015, here. First love, 2014, here.

----

I felt this afternoon I was getting quick-pitched on HealthPolicyValentines. But matron saint of the tradition, Emma Sandoe, tells me it's always kicked off on the Thursday before V-Day. So, like a loved one rushing to the scene of elopement, here am I (and see bottom for past years):

With this ring I thee wed;
with this kiss doth thou grace me.
Now promise you'll never
repeal and replace me.

     *      *      *

I can't call you true
on this true lovers' day.
You swapped my CSR
for this crummy HSA.

     *      *      *

Affordability and access!
We could eat our cake and have it
if we put our healthcare system
in the hands of Andy Slavitt.

Absent: A Novel speaks to our American present

Since the election, I've stopped reading the print newspaper in the morning. I can't take it in the early morning quiet. I inch into the news by degrees, via Twitter, at intervals throughout the day. I also miss a lot. 

I haven't read much fiction in recent years, so, in the void left by the paper, I resolved to take a tour of the world through fiction.  I thought I'd start with Najuib Mahfouz. But somehow along the way Amazon caught me with Absent by Betool Khedairi, a novel set in Baghdad during the sanctions period in the wake of the first Gulf War.  It's exactly what I wanted -- a day-by-day of life elsewhere. It's grown on me by degrees. It's magnificent.

It's one of those quiet and apparently plotless novels, built encounter by encounter, vignette by vignette, though it's plainly trending somewhere. The "quiet" is quiet desperation. People are slowly starving, or decaying for want of medicine or sanitation or employment (though everyone finds some way to scrape some kind of living). The backdrop is adults' memories of the Days of Plenty, the period before the blockade, and the first Gulf War, and the Iraq-Iran war -- when children going to school had pencils and uniforms, and crosswalks were repainted at intervals, and refrigerators had food in them and stayed on all day.

ACA doctors (of the law): What would you do with $3-5 billion per year?

Republicans in power certainly don't want the ACA marketplace to thrive. But for the most part they don't want it to precipitously collapse, either -- though it's not hard to imagine the Trump administration pushing it off a cliff and then trying to blame Democrats ("it was collapsing already...").

While Republicans have no real wish to make adequate health insurance affordable for lower income people, they may prove somewhat receptive to the wishes insistences of insurers, out of long habit and because, again, they don't want the market to collapse. The Trump administration is reportedly considering a package of short-term stabilizers that includes enabling by administrative fiat a minor increase to age banding (the multiple by which older enrollees can be charged more than younger ones); allowing insurers to cut off coverage for late payers after just 30 days instead of the current 90; and tightening the standards and verification for those seeking "Special Enrollment Periods" (SEPS) outside of open enrollment.

Repair, not replace -- rebranding, or real change? Watch the Medicaid expansion

The battle over ACA repeal-or-whatever is going to go through a lot of twists and turns and bold assertions that will fade like morning dew. Still, the latest Republican messaging and positioning seems at least potentially significant. From The Hill's Peter Sullivan:

Key Republican lawmakers are shifting their goal on ObamaCare from repealing and replacing the law to the more modest goal of repairing it...

“I'm trying to be accurate on this that there are some of these provisions in the law that probably will stay, or we may modify them, but we're going to fix things, we're going to repair things,” House Energy and Commerce Committee Chairman Greg Walden (R-Ore.), a key player on healthcare, told reporters Tuesday.

In a fraudster's grip

This is just to note that today Paul Krugman caught the essence of the Trump presidency in 80 words:

Our government hasn’t always done the right thing. But it has kept its promises, to nations and individuals alike.

Now all of that is in question. Everyone, from small nations who thought they were protected against Russian aggression, to Mexican entrepreneurs who thought they had guaranteed access to our markets, to Iraqi interpreters who thought their service with the U.S. meant an assurance of sanctuary, now has to wonder whether they’ll be treated like stiffed contractors at a Trump hotel.

Anyone over the age of five, regardless of political propensity or education level, should have been able to see that this is what Trump would deliver. Those who couldn't see it, driven by whatever passion or need, willfully shut their ears and eyes. His depravity was as manifest as Hitler's. Whether his will to evil is as intense, we'll learn.

Help me tell ACA stories

Greetings, dear readers: I would like to tell stories about people's experiences with lesser-known ACA benefits -- or shortcomings. Writeups may appear elsewhere -- healthinsurance.org or other publications -- or here.  These are the categories I have in mind:

1) Donut hole: I'd like to speak to Medicare enrollees who have benefitted (or not so much) from the ACA's gradual closing of the "donut hole" in prescription drug coverage.

2) Lifetime coverage caps: pre ACA, in 2009, 59% of people insured through employers were subject to lifetime caps on coverage -- typically $2 million by 2009, but often $1 million. The ACA banned lifetime and annual caps.  In a recent post, I  dug up a 2007 study finding that 20,000-25,000 people would hit lifetime caps by 2009.and forecasting that 300,000 would max out by 2019 if the caps were not raised. I'd like to speak to anyone who ever hit the caps, or was saved from the caps by the ACA, or is worried about hitting the caps (because of an expensive chronic condition) post-ACA.

If ACA is repealed, how many will max out on restored lifetime coverage caps?

In the waning days of his noble tenure as acting CMS director -- perhaps the last era in which CMS and HHS will function as fact-based agencies dedicated to improving healthcare delivery -- Andy Slavitt became a forceful Twitter advocate for the ACA, the payment reforms initiated under the ACA and MACRA, and other programs that require money, effort and commitment.

Among those tweets was one that listed 19 benefits that would be lost under ACA repeal, most of them little-known, including this:

That set me wondering: how many people would hit the coverage caps? And lo, an estimate exists. In our till-now-at-least-partially-fact-based-society, it sometimes seems that someone (or some interest group) has looked into almost any question that can be posed.

An exit ramp for Republican senators queasy about ACA repeal-and-delay

Yesterday, two Republican senators who have been most vocal about the dangers of repealing the ACA without replacement, Bill Cassidy of Louisiana and Susan Collins of Maine, introduced a "replacement" bill that looks something like the compromise envisioned by many healthcare wonks, giving states the freedom to accept or redesign the core ACA benefit structure. Senators Shelley Moore Capito, R-WV, and Johnny Isakson, R-GA, are co-sponsors. Vitally, it does not repeal the taxes that fund ACA benefits. Full text is here; a one page summary, here

The plan is offspring of a bill Cassidy introduced in 2015*, when the possibility loomed that the Supreme Court would rule for the plaintiffs in King v. Burwell and ban the federal exchange HealthCare.gov, from granting premium subsidies. It allows states to either keep their ACA marketplace as is, or opt for a conservative alternative based on subsidized Health Savings Accounts (HSAs) and catastrophic plans offered in a deregulated market. It also leaves intact the ACA's "innovation waivers" allowing states to cook up their own coverage schemes to deploy comparable dollars to cover comparable numbers of people. A Republican HHS would presumably be disposed to wave through such alternative schemes if they have a conservative cast.

Losers and winners under medical underwriting

This post is a by-product of my prior post de-gaslighting Betsy McCaughey's ridiculous claim that only 500,000 people would be affected by repeal of the ACA's protections for people with pre-existing conditions seeking insurance in the individual market.   I believe I have a sharpened view of who's been helped and who's been hurt in the post-ACA individual market.

Spoiler alert: in the pre-ACA individual market, more than half of those who needed insurance were either denied coverage, discouraged from applying, offered insurance that excluded coverage for their pre-existing condition, or offered coverage at above-market rates.

McCaughey's argument was built on misrepresenting a 2010 report issued by Henry Waxman and Bart Stupak, then-chairs of the House Energy and Commerce Committee, that drew on data elicited from the four large health insurers in the 2009 individual market , The main takeaways in this study were that coverage denials on the basis of applicants' prior medical history rose rapidly from 2007 to 2009, and that the denial rate reached 15.3% in 2009. That latter figure is roughly at the midpoint between the result of a 2009 AHIP survey of member insurers, which found a denial rate of 12.7%, and the Kaiser Family Foundation's 2013 estimate that 18% of applicants were denied (perhaps the denial rate continued to rise after 2009).

The Waxman-Stupak report  also cited an internal document from one of the insurers articulating a common assumption: that in reality about one third of applicants were effectively shut out of the market, as many were discouraged from applying by brokers, or past experience. The report further noted that one of the four insurers provided 15% of its customers with polices that excluded coverage for their pre-existing condition. While it did not provide an overall estimate for such targeted exclusions, the AHIP survey reports that 6% of coverage offers included such exclusions (and some participating insurers did not report on this question).

Betsy McCaughey, mother of the death panel myth, is gaslighting the ACA again

Betsy McCaughey, chief gaslighter of the Clinton health reform plan in 1993, and originator of the groundless charges in 2009 that blossomed into Sarah Palin's viral lie that the ACA was creating death panels, is out with fresh nonsense about the current individual market for health insurance and how Republicans might improve it.

In a Wall Street Journal op-ed, McCaughey claims that high risk pools could easily and effectively protect those with pre-existing conditions and so safely return the individual market to medical underwriting -- that is, basing health insurance pricing and availability on the health of each applicant.

McCaughey's claim that only about 500,000 Americans would be "in jeopardy" if ACA protections for those with pre-existing conditions were repealed is off by a probable factor of 10. Her argument in favor of high risk pools as a panacea is false in every particular.

To get to 500,000, McCaughey cites a 2010 report issued by Henry Waxman and Bart Stupak, then-chairs of the House Energy and Commerce Committee, finding that the four largest health insurers denied some 257,000 people coverage in 2009 on the basis of pre-existing conditions. She suggests that that was the total number of denials in that year, then adds in 70,000 reported by the four insurers to have been denied coverage for specific claims on the basis of "riders" excluding coverage for their pre-existing conditions, and 225,000 covered by pre-ACA high risk pools, to get her estimate.

That estimate is ridiculous on its face. The Waxman-Stupak report spells out explicitly that the four insurers provided data representing only a slice of the market -- somewhere between 10 and 30%, most likely.* The key finding was that 15.3% of applicants were denied coverage by medical underwriting. The report further cites an internal insurance company document to suggest that about one third of applicants were effectively shut out of the market, as many were discouraged from applying by brokers, or past experience.

Fight ACA insta-repeal: Contact strategically placed friends and family

Congressional aides and other political insiders often say that elected officials pretty much discount calls and letters from those outside their own constituency. Taking that received wisdom to heart, I have been pitching friends and family in states with Republican senators to call or email those senators and urge them to reject ACA "repeal-and-delay" -- and encouraging people in my local advocacy group, BlueWaveNJ, to do the same.

Using what comes to hand, I thought I'd share my template letters here -- that is, letters to friends and family in Texas and Pennsylvania. Texas first, because interesting news prompted me to cook it up yesterday.  But the PA letter  is more of a general template, with more resources and context Ohio is next for me. Each one includes contact info and state health facts, courtesy mainly of Families USA's tool to pull same.

So if you've read this far, would you please call or write Unc in Ohio or former college roommate in Louisiana and ask them to call/email their senators? Please use/share/adapt the PA template letter (below the TX one) if it's useful - or maybe just the link library at the end of it.  Thanks...

*          *          *

Dear AUNTIE IN TEXAS:

Texas Senator John Cornyn today said something very interesting about ACA repeal:

A group of Republican governors met with Republican members of the Senate Finance Committee on Thursday, and some expressed concerns about the number of people who could lose insurance once GOP lawmakers repeal the Affordable Care Act.

One of the top concerns is what will happen to individuals who became eligible for Medicaid with its expansion under Obamacare. The Senate's No. 2 Republican, however, promised that no one who got coverage under Medicaid expansion will lose it.

When Cornyn was asked if he was concerned about people who've benefited from Medicaid expansion losing coverage, he said it was a shared concern.

"Were all concerned, but it ain't going to happen," Cornyn said. "Will you write that down... It ain't gonna happen."

A good day for the ACA

While there will doubtless be many shifts and turns in the battle over the ACA, the road to repeal has seemingly got steeper for Republicans in the last couple of days. Some good developments:

1) Trump blew in with his promises to cover everyone, with low deductibles, and to enact his magic replacement at the same time as ACA repeal. That would seem to make it harder for Republicans in Congress to proceed with repeal-and-delay.

2) The Congressional Budget Office, traditionally the arbiter of the fiscal viability of proposed legislation, did the Urban Institute one better and estimated that the repeal-and-delay bill Republicans passed in late 2015 (vetoed by Obama) would un-insure 32 million people in a decade.

3) Media coverage pretty universally noted that the Jan. 15 rallies reflected deep support for the ACA and stiff resistance to repeal from its proponents. The NYT's Robert Pear, generally caustic about the ACA, put it this way:

ACA defenders don't need to "learn from" the Tea Party. They beat them in 2009-10

The fight to save the ACA is on, and all across the land, progressive groups large and small are mobilizing the law's supporters to let their senators and reps know the cost of dis-insuring 20 million people -- more, if Republicans block-grant Medicaid and/or collapse the individual market, less if they pass some poorly funded and designed facsimile of the ACA.

In reaction to the 35 "protect our care" rallies staged across the land on Sunday (Jan. 15), I keep seeing sentiments to the effect of  "progressives are learning from the Tea Party."  That's a half-truth at best, in that supporters of the ACA-in-progress fought protestors at least to a draw in 2009-2010 (proponents won in the sense that they got the ACA passed, but they did (briefly) have a 60-vote Senate majority and a large House majority). The ACA would never have got anywhere near the finish line without the most massive grass-roots advocacy ever achieved.

The Tea Party protests against the ACA-in-progress at Town Hall meetings in the long hot summer of 2009 have become part of American political lore. What’s less well known is that progressive groups supporting health reform fought back on the spot, often with equal or superior manpower and local impact. The media preferred the screamers, of course.

There was a massive coordinated effort led by Health Care for American Now (HCAN), an umbrella organization for groups committed to universal healthcare, formed in the runup to the 2008 election. Member groups’ ability to muster supporters provided vital support that kept many representatives and senators committed to passing the bill that became the ACA.

TrumpCare's coming! What kind of garbage in a gold box awaits us?

The Washington Post's Robert Costa published the gist of an interview with Trump last night in which Trump claimed that his administration is putting the finishing touches on a health reform plan that would provide universal access to affordable, low deductible coverage. This is so apparently out of keeping with existing Republican ACA replacement plans that it's hard to know what to make of it. Here are three possibilities:

1) Trump's plan will depend heavily on "mini-med" plans for low income people -- that is plans with low up-front costs but tight caps on how much the plan will pay (annual caps, lifetime caps or both).  An ACA replacement plan put forward by Senator Bill Cassidy (R-Louisiana) and Rep. Pete Sessions (R-Texas) features such plans for the poor.

2) Trump will offer a plan that proposes something very like Medicaid for people higher up the income chain than the ACA does with something very like Tom Price's plan for people with somewhat higher incomes -- that is, relatively small tax credits, unadjusted for income, to be spent in a deregulated insurance market. I've proposed this myself, and I think it's too good to be Trump.

It's up to you to save the ACA

I have a piece up on healthinsurance.org, arguing that Republicans' ACA insta-repeal train can be derailed, and how-to-ing the basic forms of citizen action by which we can all do our part.

It's mostly the nuts and bolts of how to phone, write, tweet, etc., but here's my closing argument that it's all eminently worth doing:

Any and all Republican senators are worth contacting with a “no repeal without delay” message. Taking away constituents’ existing benefits is not in senators’ job description. Almost none of them want to do it, though they have almost all promised to in some form. Those who have expressed doubts include some of the hardest core conservatives (Cotton, Paul).

Some may stealthily work against a swift repeal even if they’re publicly for it. Some may also work to mitigate the effects if it does pass – for example, by delaying repeal of the taxes along with the benefits. If that happens, the ACA may in effect be “renewed” indefinitely.

Remember – just three Republican senators are needed to kill passage via reconciliation. It’s also possible that the “queasies” will insist that repeal of key features such as taxes that the fund benefits or the individual mandate be delayed along with the premium subsidies and Medicaid expansion – and that the hard-core right wing may then in turn balk, on grounds that the bill is a “repeal” only in name.

By hook or crook, supporters of the law should be able to help Democrats in Congress find a way to preserve the vast improvement the ACA has wrought in millions of Americans’ lives.

Hope you'll take a look.

Careful with that study! A second look at enrollment decisions in Covered California

A study of the buying decisions of enrollees in California's ACA marketplace, Covered California, in 2014, suggests that a lot of people left benefits on the table:

The Affordable Care Act includes financial assistance that reduces both premiums and cost-sharing amounts for lower-income Americans, to increase the affordability of health insurance coverage and care. To receive both types of assistance, enrollees must purchase a qualified health plan through a public insurance exchange, and those eligible for the cost-sharing reduction must purchase a silver-tier plan. We estimate that 31 percent of individual-market enrollees in California who were likely eligible for financial assistance purchased plans that were not silver tier or that were not sold on the state’s exchange and thus missed opportunities to receive premium or cost-sharing assistance or both. Lower-income enrollees who chose plans not eligible for subsidies had two to three times higher odds of reporting difficulty paying premiums and out-of-pocket expenses during the year, compared to those who chose eligible plans. Regardless of how the structure of the individual market evolves in the coming years, efforts are likely needed to steer lower-income enrollees away from financially suboptimal plan choices.

The study, just published in Health Affairs, lead author Vicki Fung of Harvard and Mass General, is based on  survey responses from 2103 enrollees and has some very interesting results regarding the difficulty (or lack thereof) that enrollees experienced paying premiums and out-of-pocket expenses at different income levels and benefit levels. But while the authors are quite thorough in enumerating the study's limitations, some caveats are worth elaborating.* In brief: CSR takeup is higher at income levels where the benefit is strong, and many of those deemed potentially eligible for subsidies are not in fact eligible.

Let's look more closely at the more specific claims.