Saturday, March 17, 2018

Who'd be hurt by restored federal CSR funding? A snapshot from Maryland

Based on 2017 ACA marketplace enrollment data, Aviva Aron-Dine of the Center on Budget and Policy Priorities estimates that as many as 36% of marketplace enrollees might be harmed if federal funding for Cost Sharing Reduction (CSR) payments is restored by Congress. That's an upper bound, if all who could potentially benefit in 2018 by switching from silver plans to other metal levels did so. It comes to about 22% of all individual market enrollees, since about 40% of those in ACA-compliant plans bought their plans off-exchange -- and so are ineligible for subsidies.

One sample of data already available for 2018 -- Maryland's -- indicates that Aron-Dine's estimates are on target. I have something of a quibble with how the potentially harmed population is defined, however.

Wednesday, March 14, 2018

Inflation that tracks your march to death

As the ACA-compliant individual market shuddered under a second consecutive round of premium hikes averaging well north of 20% in 2018, I took in an earful of stories from people in their fifties and sixties who were paying full freight, partly recounted here.

One thing that struck me somewhere along the way is the impact of the personal inflation hit induced simply by aging. In the best of markets, late-middle-agers will pay 4-5% more in many years simply for getting a year older. that's  a turbo-charge to double-digit hikes for everyone (particularly for couples).

David Anderson, who may do a more analytical post about this, was kind enough to pull an ACA age rating chart for me. I begin at age 45,  just before price increases accelerate. This is for one bronze plan in Arizona:

Monday, March 12, 2018

We're not in ACA Repeal-and-Replaceville. We're in Cassidy-Collinstown

Peter Suderman argues that The GOP Accidentally Replaced Obamacare:
Republicans, having failed to repeal Obamacare, have stumbled, almost accidentally, into replacing it. For better and for worse, and with little coherent vision at work, they are making Obamacare their own. And over time, they are likely to embrace it.
There's a good degree of truth in this. Suderman runs through the panoply of Republican legislative and administrative whacks at the ACA's structure and benefits on the federal and state level: individual mandate repeal; creation of a parallel market of non-ACA-compliant plans; regulatory hurdles to Medicaid enrollment aimed particularly at the ACA Medicaid expansion population; repeal of the Independent Payment Advisory Board for Medicare. And Suderman adds a creative future-cast twist: If Democrats take power and pursue a fully or quasi-single payer system, Republicans may end up defending the relatively moderate -- and Republican-moderated (or adulterated) -- status quo, i.e. the ACA.

Suderman's neat conceit leaves a core factor out of the equation, though: funding.

Thursday, March 08, 2018

Can Medicare Advantage plans lower enrollees' out-of-pocket costs? A talk with Kaiser's Juliette Cubanski

A month ago, I took a look at the resources available -- or unavailable -- to Medicaid enrollees who face a "Medicare cliff" when they turn 65 -- that is, a transition from having basically all their medical expenses covered to a program that carries a monthly premium for most of $134, requires 20% copays for most medical services and potentially huge outlays for inpatient hospital care, and has no cap on out-of-pocket costs.

Some 10.7 million Medicare enrollees are "dual eligibles" of one kind or another -- enrolled either in ABD (Aged/Blind/Disabled) Medicaid, which provides comprehensive coverage,  or in Medicare Savings Programs (MSPs), which offer more partial coverage, or in some cases both.  But the income thresholds for all of these programs are lower than for Medicaid in states that accepted the ACA expansion, and the asset tests for the MSPs are quite low -- $7560 for an individual, excluding home and car.  The application process is complex, and help and outreach are underfunded.  (For a useful overview, see Josh Schultz.)

For the many seniors of quite limited means who don't qualify for MSPs, I wondered to what extent Medicare Advantage (MA) plans might function as a de facto discount plan. About one third of current Medicare enrollees are in MA plans. MA plans usually incorporate a Part D drug plan, and often the premium is lower than the combined premium for Medicare Parts B and D (e.g., in zero-premium plans, in which enrollees pay only their Medicare Part B premium).  MA plans may offer extra benefits, such as dental, vision or hearing coverage (often quite limited). Perhaps most importantly, they cap out-of-pocket costs at a maximum of $6,700 per year. The main tradeoff is acceptance of a limited provider network -- often quite limited.

I spoke to Juliette Cubanski, Associate Director of the Program on Medicare Policy at the Kaiser Family Foundation and lead author of a recent Kaiser report on healthcare spending in Medicare households, about the appeal, real or perceived, of Medicare Advantage plans for lower income Medicare enrollees.  An edited q-and-a is below.

xpostfactoid: Does Medicare Advantage often offer effective de facto discounts over traditional Medicare?

Tuesday, March 06, 2018

Getting creamed in New Jersey: Testimony of the unsubsidized

As noted in my last post  (and called for in my January op-ed), a bill introduced in the New Jersey Senate  (S-1877) last month would implement a state individual mandate and earmark the penalty revenue for a state reinsurance program. A companion bill (S-1878) would authorize pursuit of an ACA innovation waiver to seek federal funding for the reinsurance, as Alaska, Oregon and Minnesota* have successfully done.

BlueWaveNJ, a grassroots group for which I volunteer, supports these paired bills. We have lots of members who insure themselves through the individual market -- many subsidized, and many unsubsidized. In support of the bills, we collected testimony from the latter group -- who were slammed by this year's premium increases. Yesterday, I submitted their testimony at a hearing of the state Senate's Budget and Appropriations Committee, which approved amended versions of both bills.

The testimony is posted here, on the BlueWaveNJ website. As the personal narratives indicate:
These are individuals in their fifties and sixties now facing premiums in the $600-1000/month range and family premiums north of $2000.  They describe tough choices between narrow network coverage and still-higher premiums, or between narrow networks and down-sizing to bronze plans that offer basically catastrophic coverage. Subsidized members are faced with a similar choice between ultra-narrow networks and steep premium increases or reduced coverage.

Saturday, March 03, 2018

New Jersey bill aims to block Trump admin's proposed rule for Association Health Plans

New Jersey is relatively well defended against the Trump administration efforts to fragment the individual and small group health insurance markets by allowing short-term plans to be sold for year-long terms and easing the path for association health plans (AHPs) to be deemed employers in their own right and so gain large group status.

New Jersey bans short-term plans outright, and tightly regulates association plans (the main species of  multiple employer welfare arrangements, or MEWAs, that is, plans that cover the employees of two or more unrelated employers). In Jersey, MEWAs are regulated as small group plans,even if they're self-funded. (While self-funded plans generally are subject to federal oversight under ERISA, which preempts state law, there has long been an exception enabling states to exert all but full  regulatory control over MEWAs.)

As small group plans, MEWAs in New Jersey are subject to the full suite of ACA coverage rules, including Essential Health Benefits. Small group plans are not available to self-employed individuals, or to small businesses that have no employees other than owner and spouse.. Under the Department of Labor's proposed rule for AHPs, these self-employed individuals and small business owners would be eligible to enroll in AHPs that gain large group status.

Does the proposed rule threaten New Jersey's current regulation of AHPs? That's not clear. On the one hand, "The proposed rules also would not modify the States’ authority to regulate health insurance issuers or the insurance policies they sell to AHPs" (p. 42). At the same time, Kevin Lucia, a professor in Georgetown University's Health Policy Institute, cites concern among experts "that this is potentially going to have to be litigated. If you're an association and you set up in Oklahoma, if you read these regulations, you think, well I can sell everywhere -- and yet, California tells me I can't come in?"

Bottom line for Lucia: "It's a big question whether states will be able to maintain their authority to regulate MEWAs."

That uncertainty likely drives a provision addressing MEWAs in a bill introduced in the New Jersey legislature, S-1877, that would establish a state individual mandate to replace the federal mandate effectively repealed by the Republican Congress.

Tuesday, February 27, 2018

Hey Senator Warren, Medicare Extra fills your prescription

Last month, at the Health Access 2018 conference, Elizabeth Warren decried rising out-of-pocket costs required in employer-sponsored health plans and demanded that a new round of healthcare reform "require private insurers to be just as affordable as public insurers like Medicare and Medicaid.”  (I discussed the speech at some length here.)

That formulation struck me as problematic in several ways: 1) Medicaid and Medicare offer very different levels of affordability (except where they're merged for dual eligibles); 2) employer-sponsored insurance, on average, is "just as affordable" as Medicare and in fact provides better protection against crushing out-of-pocket costs than traditional Medicare; and 3) Warren bashed insurers alone for price-gouging without mentioning provider payment rates, which would have to be squashed down if commercial insurance were subject to stricter affordability mandates.

Perhaps, though, Warren had some inkling of the Medicare-for-all-who-need-or-want-it plan that was brewing at the Center for American Progress, released yesterday.