At Health Action 2018, a focus on racial discrimination in healthcare

Last week I attended Health Action 2018, Families USA's annual gathering of healthcare advocates, ACA navigators, healthcare wonks and politicos.  I have a post in progress probing where the conference suggests Democrats may be headed next on the healthcare front.

One piece of that puzzle is how directly Democrats focus on equity issues -- specifically racial and ethnic inequities.  These present something of a political conundrum in that, as longtime former Senate aide (and healthcare adviser in the Obama administration ) Chris Jennings put it, "equity doesn't sell."  Proposals pitched to help the disadvantaged, Jennings asserted, arouse suspicions among many that others' gain will be their loss. People value programs that seem to treat everyone equally. "Medicare for all" polls well because it's perceived as a system that all pay into and all benefit from.

Notwithstanding that reality -- or perceived reality -- Families USA, to its credit, is training its focus on equity issues, and the conference reflected that in two plenary sessions in particular. Below is an an outtake of sorts from my broader conference overview in progress, focused on those panels -- and on Cory Booker's speech, which also focused on equity.

Elizabeth Warren is faking it on healthcare

Delivering a keynote at Families USA's annual Health Action conference, Elizabeth Warren signaled either that she hasn't studied U.S. healthcare very closely or that she cares to attack only politically convenient targets on this front.

Warren lambasted the travesty that American families are one sickness away from financial ruin -- a major early discovery of hers - and that's great.  She excoriated the country's major private insurers as faithless partners in the Affordable Care Act, and that's fair enough (though the U.S. government has in turn been a faithless partner of the insurers). She suggested that those insurers who want the privilege of participating in the profitable Medicare Advantage and managed Medicaid markets should be required to participate in the ACA marketplace, and that's reasonable, at least in outline.

But she also presented the unaffordability of healthcare in the U.S., and the huge out-of-pocket costs that many insured Americans face, as purely a product of insurance industry rapine. Not a word about pricing-gouging by hospitals and doctors; the fine science of upcoding; the loopholes allowing self-dealing; the privileging of expensive procedures; the outsourcing to hedge fund- and private equity-backed price maximizers; the predatory balance billing. Providers got a total pass. I sentence Senator Warren to read Elisabeth Rosenthal's An American Sickness, which meticulously documents all these cost inflators and their evolution

Subsidy-eligible, but unsubsidized

Updated 1/22 with California discussion corrected - please see note 2 at bottom.

Reading about Gallup's latest finding that 3.2 million more Americans were uninsured in 2017 than in 2016, I wondered about a particular (small) group of ACA marketplace enrollees: those with incomes in subsidy range who are nevertheless unsubsidized. Such people might be expected to have a particularly hard time with the steep premium increases of 2017 (not to say 2018 and 2019), as premiums take a huge share of their income.

I wanted to look at this group because Gallup's findings raised some riddles. Gallup found the sharpest increases in the uninsured among people with incomes under $36,000 -- but also found no change in the percentage of people insured by Medicaid. Among types of insurance obtained, the sharpest drop was among those who say they bought their own insurance (although Gallup's numbers for this population are weirdly inflated).  In the ACA marketplace the large majority (84%) who obtained premium subsidies were largely insulated from the year's steep premium hikes -- though reduced competition may have made choices less viable for some. Overall,  marketplace enrollment was down about 5%, or 500,000 in 2017.

The drop in off-marketplace individual market enrollment was doubtless steeper.  But most of those who buy off-exchange are presumably more affluent. It doesn't all seem to quite add up -- hence my interest in the almost invisible low-income unsubsidized individual market enrollees.

How Phil Murphy can counteract ACA sabotage in New Jersey

I've suggested before that states can protect their individual markets for health insurance by passing their own individual mandates -- and using the revenue to further shore up their individual markets. In NJ Spotlight, I make the case specifically for New Jersey.

Revenue from the mandate

could be dedicated to strengthening the state’s individual health insurance market. One possibility would be direct financial help for people who don’t qualify for ACA premium subsidies — a group hit particularly hard by the premium hikes of the past two years. Another option is to spend the money on enrollment assistance and outreach, which the federal government radically cut in 2017. A third option is to dedicate the funds to a state-based reinsurance program.

Mandate revenue would not fully fund a reinsurance program, and New Jersey is in terrible fiscal shape.

But the state can also seek federal reinsurance funding via an ACA “innovation waiver”, as HHS specifically suggested last spring. Funding may be granted as a “pass-through” of savings derived from lower premiums — since lower premiums mean lower subsidies, which are paid by the federal government.

The rest, once more, is here.

There's Martin Luther King's dream. Then there's his American reality principle

Martin Luther King's finest hour may have come when he took a stand against the Vietnam War, breaking with the president with whom he'd partnered to pass epochal civil rights legislation.

Returning to the speech in which King took that stand, I find myself taking a weird kind of solace in his clearheaded denunciation of the violence that tore at two societies. It's a reminder, in the Trump era, that American betrayal of American ideals is continual, that backlash is continual, that mass violence inflicted on foreign populations is continual, and systemic injustice inflicted on minorities at home is continuous.

Why does that reminder offer solace?  Because along with the failure, success has also been continual: we have recovered from, and partially redressed, so many past self-inflicted wounds. Somehow, this account of how the triumphs of the civil rights movement turned to ashes reminds also that there was a residue of progress -- and also some lessons learned from Vietnam that held in some measure for 20-30 years.

Here is the core indictment in King's speech against the war delivered at Ebenezer Baptist Church on April 30, 1967:

Choosing a metal level in the CSR-addled Maryland marketplace: Not bad, enrollees!

In Maryland's ACA marketplace, as in much of the country, Trump's cutoff of reimbursement to insurers for Cost Sharing Reduction (CSR) drove huge premium increases for unsubsidized buyers -- but also bizarre bargains for the subsidy-eligible.

Throughout the state, all subsidy-eligible* enrollees with incomes below 200% of the Federal Poverty Level (FPL) could obtain an bronze plan for under $20 per month. Most at this income level -- e.g., everyone over 30 -- could get a bronze plan for under $4 per month. In the state's most populous counties, subsidy-eligible buyers could get a gold plan for just a few dollars more than a silver one.  And in several rural counties, an enormously expensive benchmark (second cheapest) silver plan, which determines subsidy size, rendered silver and gold plans as well as bronze plans free for many enrollees.

The effects of these pricing anomalies on the subsidized were mostly beneficial, as you might expect. Discounted (not to mention free) gold plans are a real boon to enrollees with incomes over 200% FPL, for whom silver plans have high out-of-pocket costs (sharply reduced for those up to 200% FPL by strong CSR). And free bronze plans are better than nothing, even with the $6200 deductible they carry in the most populous counties.

But anomalous pricing also can create problems. Some enrollees eligible for strong CSR might be tempted to choose  bronze plans (deductible $6200) over silver (deductible $0). Some enrollees under 200% FPL might also have been tempted by gold plans that cost slightly more than the cheapest silver -- not recognizing that CSR-enhanced silver plans cover more of their out-of-pocket costs than gold (i.e., are just straight-out more valuable).

So how did enrollees' choices shake out? Courtesy of the Maryland Health Connection, I have a breakout of enrollees metal level choices at different income levels, posted below.  And they look pretty good:

A few observations:

Subsidized ACA marketplace enrollment ROSE 2% in Maryland in 2018

ACA marketplace enrollment in Maryland for 2018 was down only slightly (2.6%) in 2018 That's a strong performance, as I noted earlier this week, "given the shortened enrollment period, radically cut federal funding for enrollment outreach and advertising, and general confusion generated by administration sabotage."

I also speculated that the drop-off may have been concentrated in unsubsidized prospective enrollees -- the only ones materially hurt by the state's enormous premium spikes (which actually benefited subsidized enrollees by inflating subsidies).  That is in fact the case.

In 2018, 32,171 enrollees in on-exchange private plans in Maryland were unsubsidized, according to numbers sent to me by the Maryland Health Connection (the state's ACA marketplace). That's out of 153,584 total enrollees (21%). In 2017, as of the end of Open Enrollment, 38,903 were unsubsidized out of a total of 157,832 enrolled (25%), according to Public Use Files published by CMS.*

That is, subsidized enrollment for 2018 was up about 2% -- to 121,413, compared to 118,928 in 2017. That jibes with the Maryland exchange's reporting that African American enrollment was up 12%, Hispanic enrollment up 10%, and rural enrollment up about 10%.

You may balance-bill me at will: This hospital contract is literally bulletproof

I went to our local community hospital for some routine blood work today. The new wing is open! From the plain former reception desk, you're directed down a long space age-y corridor to the new reception office, a warren of glass cubicles that looks like a customs and immigration area in a shiny new airport. After presenting your insurance card and i.d., you're asked to wait until you're called into one of these cubicles for a one-on-one encounter in which you're compelled to sign your life away.

That is, you are presented with four (4) disclosures and contracts of adhesion to sign (contracts, that is, in which the terms are dictated entirely by one party). You sign under the gaze of the hospital employee across the desk, and you do not sign the paper. The contracts are encased in plexiglass, perhaps because I'm not the only smart-ass on the planet who sometimes alters them. You sign on an electronic pad like those that take your credit card in retail stores. The hard case enclosing the paper contracts makes them literally bulletproof.

And what you agree to, most notably, is to let any of the multitude of "independent contractors" who may breeze by your bed (if you're an inpatient) bill as much as they friggin' please, and send the bill to you. Here's the deal you can't refuse:

Maryland ACA enrollment spotlights effects of Trump's CSR sabotage

Maryland announced late last week that its ACA marketplace enrollment for 2018 totaled 153,571, down 2.6% from 2017 -- a good result, given the shortened enrollment period, radically cut federal funding for enrollment outreach and advertising, and general confusion generated by administration sabotage.

Maryland reports, further, that African-American enrollment was up 12 percent, Hispanic enrollment up 10 percent, and enrollment in rural areas up around 10 percent. Those increases suggest that enrollment drop-off may be concentrated in the unsubsidized population, which has historically been high in wealthy Maryland -- 25% of on-exchange enrollment in 2017, compared to 16% nationwide.

That makes sense, considering that in Maryland a) premiums soared a weighted average 43.8%, according to Charles Gaba's blog, with much of the hike attributable to Trump's cutoff of CSR reimbursement, and b) Maryland insurers concentrated the added cost of CSR on on-marketplace silver plans, with cheaper silver plans available off-exchange.  Thus some unsubsidized 2017 enrollees may have been priced out by huge premium increases, and some may have moved off-exchange to find somewhat cheaper plans.

Steep as the average premium hikes were, the increase in the federal government's subsidy bill was even steeper, and that's worth looking at more closely:

In which Idaho offers a quarter loaf to its uninsured poor

Thanks to Dylan Scott for flagging a draft ACA innovation waiver proposal published by the Idaho Department of Insurance this past November. Someone in the ensuing Twitter stream called the proposal "creative" -- and it is, in the sense that repeal of the ACA individual mandate is creative. That is, it "saves" money by insuring fewer people at higher per-person cost than the ACA default structure -- in this case, proposing a private alternative to Medicaid expansion.

More specifically, the proposal would newly insure one fifth as many Idaho residents as would Medicaid expansion at about one third of the added cost. That's notwithstanding the fact that while Medicaid expansion would cost about $300 million more per year in total than the status quo arrangement, the federal government would pay five sixths of the added cost.*

That's genuinely creative when you allow that the more cost-effective alternative -- Medicaid expansion -- has proven to be a political impossibility in the state. It's also an implicit confession that a Republican state government prefers to spend more per person while leaving a larger percentage of its population uninsured -- without any attempt to argue that the more-expensive insurance is better for enrollees or yields other social (as opposed to ideological) benefits.

A Tralfamadorian view of the U.S. economy from James C. Scott

 I have been reading James C. Scott's Seeing Like a State, which argues repeatedly that centrally planned communities and economies cannot subsist without the unsanctioned return of small-scale, below-the-radar activity of people forced to circumvent the master plan.

The quick-fire examples below, offered in a final-chapter overview, brought me up short. The workarounds prompted by a "formal command economy" have been elaborated in depth and reiterated throughout the book. What got my attention is the throwaway final sentence, asserting something that has been not elaborated at all in preceding chapters:

Many modern cities, and not just those in the Third World, function and survive by virtue of slums and squatter settlements whose residents provide essential services. A formal command economy, as we have seen, is contingent on petty trade, bartering, and deals that are typically illegal. A formal economy of pension systems, social security, and medical benefits is underwritten by a mobile, floating population with few of these protections (p. 352, Kindle edition).

2017: A year of healthcare combat

2017 was the fourth year in which xpostfactoid focused mostly on healthcare access -- and more specifically, on ACA implementation (and, this year, on de-implementation, threatened and actual).

It was a year of intense combat (to be continued...) and high drama, and I participated not only via writing, but as an advocate in New Jersey working to help ward off ACA repeal, and as a Certified Application Counselor during Open Enrollment.

Below is a look back at a few posts, roughly one per month, that I hope might have contributed something to our understanding of where we've been and where we're headed in the struggle toward (or away from) universal healthcare access. These include:

• Statistical measures of the extent to which Republican repeal-and-replace bills (AHCA, BCRA) would reduce subsidies to low income Americans (and relatedly, at the contrasting structure and aims of Democratic and Republican healthcare spending cuts).

• Previewing the paradoxical effects of Trump's cutoff of federal reimbursements for Cost Sharing Reduction subsidies, then spotlighting the actual effects in counties where marketplace enrollment is heaviest.

• Snapshots of who's benefited most (1, 2) and who's been left out (1,2,3) by ACA offerings.

• A couple of passes (1, 2) at my vision of how U.S. healthcare might most plausibly and profitably evolve.

Here they are in chronological order, earliest first:

Joshua Peck looks back at HealthCare.gov's evolution

Part of the credit for surprisingly strong enrollment in the ACA marketplace this season probably should go to the smooth functioning of HealthCare.gov, the federal online marketplace that serves 39 states.

In the runup to open enrollment, market watchers wondered whether hostility to the ACA at the top of HHS and CMS would extend to the website's functioning. Three weeks prior to kickoff, though, I noted that the information flow from the HealthCare.gov home page was effective, steering people both to the plan preview tool and to a quick determination whether they'd likely be eligible for Medicaid or subsidies.

On November 1 (launch day) the "see plans and prices" option disappeared from the home page. The "see plans" tool  enables a user to anonymously enter a handful of data points (zip code, ages of household members, income) and see a complete menu of available health plans, with prices that include the user's estimated subsidy. Its near invisibility led (some weeks later) to  Twitter chatter about possible sabotage. I noted that the preview tool had also been submerged in previous open enrollments -- which had baffled and frustrated me from early 2015 on. At which point Joshua Peck, HealthCare.gov's Chief Marketing Officer before the Trump administration took office, weighed in:

Joshua Peck‏ @JoshuaFAPeck Dec 9MoreWhile counterintuitive, more consumers are more likely to ultimately find a plan and enroll if they go through the app vs. See Plans. It's not an evil plot, though when I look for it myself it can feel that way.  Direct messageThat

That led to a phone conversation. The "see plans and prices" feature is a terrific tool.  It takes less than a minute to get a sense of what you need to pay for coverage. Since multiple surveys show that large percentages of the uninsured do not know what kind or degree of financial help is available to them, the plan preview tool has always struck me as particularly valuable.

Christmas for ACA advocates

Healthcare Twitter was on edge today, as final open enrollment figures for HealthCare.gov were running a day late:

Maybe no one will notice how good the numbers are if they’re dumped on the Friday before Christmas...

— Lori Lodes (@loril) December 21, 2017

That triggered a bout of galloping Twitter procrastination on my part:

Twas the Friday before Christmas
and atop CMS
a late enrollment surge
was causing distress.

MEWAs were hung
on the chimney with care,
and Santa'd made the mandate
vanish in thin air.

And Seema in her kerchief,
and Price in his cap,
had worked to bend enrollment
until it would snap.

When all of a sudden I heard such a clatter
I sprang to my screen to see what was the matter.

In which I fire a popgun against balance billing

When I went to the doctor last week, I tried a little experiment while filling out the paperwork:

That's a little hard to read. I crossed out the services for which I was asked to agree to be financially responsible should my insurer fail to pay in full. I should have also crossed out the preceding - "I agree that I am financially responsible for any unpaid balance." But this was just testing whether anyone in the office would notice/object. They didn't.

Sabotage judo: States can turn individual mandate repeal to their advantage

With repeal of the ACA's individual mandate apparently imminent, health law scholar Nicholas Bagley urges states to mitigate the damage by...getting their own damn mandate:

Adopting mandates at the state level would help stabilize insurance markets, thereby keeping premiums in check and forestalling coverage losses. It would also provide a welcome source of revenue: Some people will still prefer to pay a penalty than buy insurance. Plus, the states don’t need to stick with the precise terms of the federal mandate, which has been reviled (from different quarters) both for heavy-handedness and its ineffectuality. Stiffer state-level penalties would still be unpopular, but at least they’d work better.

I'd like to suggest that states take this a step further. Why not use the revenue collected from the state mandate to partially fund a reinsurance program?  Reinsurance has repeatedly proven  to sharply reduce premiums  (leading Susan Collins to propose an underfunded federal program to offset the effects of mandate repeal).

CBO projects that mandate repeal will cost the federal government $5 billion per year in forgone penalty payments by 2020 and $6 billion per year by 2025 (while saving the government more than 10 times as much in premium subsidies). States can capture that revenue for themselves by implementing their own mandates. California, with 12% of the nation's population, might collect $600 million per year in 2020 (to the extent that mandate revenue is proportionate to population). New York, with 6% of the population, might pull in $300 million. Jersey might manage $135 million; Minnesota, $85 million. These are crude calculations, but they give some idea of scope.

On tax bill, Josh Gottheimer's Problem Solving is a problem

Josh Gottheimer, the member of Congress from New Jersey's 5th District (rural west and suburban north Jersey), beat a Tea Party incumbent in 2016 and so has to be cut some centrist slack. He has made bipartisanship his brand and co-leads the self-named Problem Solvers, a caucus of about 40 reps, half Republican and half Democrat. In the summer, after ACA repeal bills failed in the Senate, the Problem Solvers put forth an ACA marketplace stabilization proposal that looked rather like the Alexander-Murray bill that later took shape in the Senate (discussed in this post). It got no traction but did no harm.

In tax bill season, though, Gottheimer's bipartisan shtick is turning dangerous, IMO.  He has said he wants to "get to yes" on a tax cut bill; he's put out a proposal, in concert with NJ Republican Leonard Lance, that avoids the most direct harm to New Jersey (restoring SALT and mortgage deductions) while ignoring the bill's overall devastation of the federal budget and disfiguration of the tax code. This too will probably do no harm...but if the bill that comes out of House-Senate conference does mostly restore the SALT and mortgage deductions, a few Democratic votes in support would be a very bad thing.

That's my working assumption, anyway - and I have a letter in NorthJersey.com arguing as much. Gottheimer's claims that his plan provides "deficit reduction" particularly stick in the craw:

What I've learned as an ACA assister

This Open Enrollment period I've been volunteering a few hours per week as a Certified Application Counselor (CAC) for the ACA marketplace, at an office in Newark, NJ. I haven't had as much experience as I would have liked, but here, very generally, are a few things I've learned.

• The government could save a lot of money by opening Medicare and Medicaid to all legally present immigrants*.  Marketplace premiums for Medicare-age immigrants are sky-high -- and often paid entirely by the federal government. Oddly, marketplace plans may actually be better than traditional Medicare for elderly immigrants -- if they stay in network, e.g., if their middle-aged children can find them in-network providers. That's because marketplace plans, unlike traditional Medicare, have an out-of-pocket maximum. Then again, dual eligibles would be better of Medicare/Medicaid.


• Similarly, legally present immigrants with Medicaid-eligible income but subject to the 5-year bar for Medicaid eligibility cost the government more in marketplace plans than they would in Medicaid (as does anyone; see Private Option, Arkansas). They would also be better off in Medicaid -- the out-of-pocket costs attached to silver plans, even with strong Cost Sharing Reduction attached, are a high bar for people with Medicaid-eligible incomes.

Planning a two-step retirement, because health insurance

My last post looked at the various ways that self-employed people in particular can limit their taxable income to stay on the right side of the ACA subsidy cliff, which has reached untenable heights for people in their late 50s and early 60s. We're at the point where getting on the wrong side of the subsidy-eligible line can mean $10,000-plus in extra health insurance costs for older shoppers in the individual market for health insurance.

The situation reflects broader societal dysfunction. We have a gaping hole in the safety net patched by an insanely diverse panoply of tax-sheltered accounts -- which some lucky and nimble affluent-but-not-rich people may hopscotch across to safety.

Take the case of a couple of 58 year-olds in a northeast city where the cost of living is high -- their modest dwelling is worth over $600k and taxed accordingly. The wife, Samara, is a hospital nurse, and the husband, Aman, is a solo consultant of some kind. Both have earnings in the $75k range. Thanks to assiduous feeding of their 401k retirement accounts (they've saved a bit over $1 million between them), their Adjusted Gross Income (AGI) is about $110,000 -- far below their gross, but far above the ACA's subsidy eligibility threshold of $64,960. That's not an issue for now, because they get good insurance through Samara's hospital job.

But what if Samara is hoping by age 62 or so to...not retire, but work per diem, or try an encore career? An unsubsidized ACA-compliant two-person bronze plan with per person deductibles in the $6-7000 range  might cost them $1500 or $2000 a month by age 62.  Can the couple get below the subsidy line without a radical cut in income? Can Samara escape health insurance-induced job lock?

Steering clear of the subsidy cliff in the ACA marketplace

It's plain this year that the individual market for health insurance is unaffordable for many of the unsubsidized, particularly those in their late fifties or early sixties. The subsidy cliff has reached a fatal height for many.

This week Kaiser Health News reporter Rachel Bluth spotlighted a stark example: A 62 year-old woman in Chattanooga, Tennessee who earned $80,000 working for a consultancy deliberately cut her hours, reducing her income by a third to get herself and her husband below the subsidy line ($64,080 for a two-person household in 2017). The total household income was $92,000.  The woman, Anne Cornwell, cut her income by $24,000 -- and her insurance bill by $27,000.

This drastic solution set me thinking about ways to keep on the right side of the subsidy cliff, i.e., 400% of the Federal Poverty Level. In 2018, that's a  Modified Adjusted Gross Income (MAGI)  of $48,240 for an individual, $64,960 for a couple, and $98,400 for a family of four.

Many but not all resources for reducing MAGI are available only to the self-employed. They include the following.