Friday, May 26, 2017

AHIP puts Medicaid first in "do no harm" plea to Republicans

Early this week, in a letter to Senate Finance Committee Chair Orrin Hatch, the America's Health Insurance Plans (AHIP), the largest association of private health insurers, basically begged Republicans to stop threatening to uninsure tens of millions in the name of reform. 

AHIP voiced support for community rating, guaranteed issue, income- and age-based subsidies, and an enforcement measure sufficient to induce people to buy insurance. In other words, for preserving the ACA marketplace with a few regulatory teaks  -- and with the AHCA's $138 billion in federal funding for state reinsurance or other "stability" measures tossed in.

Striking on its face though the health insurance industry's renunciation of medical underwriting may be, the most remarkable part of the letter comes early, in its reframing of what healthcare "reform," Republican-style, is all about. AHCA opponents have been screaming for months that at the bill's core is a $900 billion tax cut* paid for by an $800+ billion Medicaid cut. It's been hard to break through the noise with that core equation, given the AHCA drafters' high-strung debates about various proposed malformations of the individual market. AHIP puts the pieces in perspective:

Thursday, May 25, 2017

CBO: Some states will kill protections for those with pre-existing conditions -- and oh yes, the AHCA still eviscerates Medicaid

In late April, Matthew Fiedler explained in a Brookings brief that the MacArthur amendment to the AHCA, which allowed states to subject people who fail to maintain continuous coverage to medical underwriting, would not just affect those who fail to maintain continuous coverage. Fiedler's summary:
...the framework created by the waiver would allow states to effectively eliminate community rating protections for all people seeking individual market coverage, including people who had maintained continuous coverage.

In brief, healthy people would have a strong incentive to “opt out” of the community-rated pool and instead pay a premium based on health status. With healthy enrollees opting out of the community-rated pool, community-rated premiums would need to be extremely high, forcing sicker individuals—including those with continuous coverage—to choose between paying the extremely high community-rated premium or being underwritten themselves. Either way, people with serious health conditions would face prohibitively high premiums. As a result, community rating would be eviscerated—and with it any meaningful guarantee that seriously ill people can access coverage.
The CBO analysis of the amended AHCA released yesterday reproduces this argument:

Wednesday, May 24, 2017

Medical Billing: The Ten Do-well Commandments (after Elisabeth Rosenthal)

Elisabeth Rosenthal, reporter of the monumental Paying Till it Hurts series in the New York Times and author of  An American Sickness: How Healthcare Became Big Business and How You Can Take it Back, has been out front with the "Ten Economic Rules of the Dysfunctional Medical Market" with which the book leads off -- e.g., on Twitter and on Medium.

To those of us who have saturated themselves in Lin-Manuel Miranda's Hamilton (which already feels like a relic of a bygone era), "10 rules"  inescapably conjure up The Ten Duel Commandments. So I have set them to imagined music below. At bottom, the rules as Rosenthal worded them.

A disclaimer: While the rules in isolation may seem excessively cynical, I don't think Rosenthal's point is that all providers follow them all the time, but that the incentives in our dysfunctional system pull them this way.  Another disclaimer: I haven't read the book yet. Too much current bad news to absorb. But I'll get there.

The Ten Billing Commandments

1. The treatment. More is always better.
Feed the bottom line, be a real go-getter.

2. Keep 'em coming. More is always more.
A lifetime of treatment trumps a simple cure.

3. Amenities and marketing are the way it's done.
Look like Cedars-Sinai and the battle is won.

Tuesday, May 23, 2017

Single Payer in CA? The impediments are mountainous

The widely reported topline of the analysis of California's single payer bill released by the state Senate Appropriations Committee is a highly uncertain forecast that the state would need to roughly double its revenue to pay for the benefit. That is, the total cost of care could run to $400 billion per year,  offset by up to  $200 billion in existing federal funding for Medicaid and Medicare -- if  HHS granted basically every waiver sought to transfer that funding from multiple programs. The spending would also replace an estimated $100-150 billion in employer-sponsored insurance. Funding it would require an estimated 15% payroll tax or equivalent revenue.

That level of spending, and cost-shifting from the private to the public sector, could be defensible, in the abstract. But the report, released under the name of committee chair Ricardo Lara and consultant Brendan McCarthy, asserts a host of practical impediments to implementation, including:

1. No cost control: The Healthy California Act imposes no premiums, no deductibles and no copays on enrollees (who include every resident in the state) and mandates no gatekeeping functions -- any enrollee can contract with any accredited provider and get 100% coverage for service.  Payment is essentially on a fee-for-service basis:
While the bill would allow for other forms of payment, the basic requirement in the bill that payments be cost-based and requirements in the bill that patients are able to see any willing provider of services would make it difficult for the Board to create capitated payment systems that would work under those constraints.
Consequently, and given the participation of every provider in the state, "the analysis assumes a 10% in health care service utilization over fee-for-service Medi-Cal...likely a conservative assumption."

Saturday, May 20, 2017

My letter to the Senate Finance Committee about ACA repeal legislaton

Topher Spiro, veep for health policy at the Center for American Progress and a forceful ACA advocate on Twitter (@topherspiro), got hold of a letter from Senate Finance Committee Chair Orrin Hatch to healthcare "stakeholders," inviting their input by May 23 on Republican senators' efforts to write an ACA repeal bill. Hatch asked that letters be sent to

Since the Republican senators' bill-writing process is as secretive and rushed as the House's, Spiro seized the opportunity to encourage non-privileged "stakeholders" -- all of us -- to send their two cents to the email address provided. He has offered to tweet any letters tweeted at him, with a screenshot.

Here's mine:

Dear Members of the Senate Finance Committee:

As a constituent, husband and father of two adult children, son and son-in-law of four aged parents, member of a community and citizen of a nation with many people who lack affordable, reliable access to health insurance or are at risk of losing newly obtained insurance, I urge you
  • not to eviscerate Medicaid by imposing per capita caps on federal funding or imposing a block grant formula; 
  • not to phase out the ACA Medicaid expansion or reduce the enhanced federal funding that enables it;
  • not to end income-based subsidies for premiums and out-of-pocket medical expenses that render individual market coverage and actual healthcare affordable to millions of low-and moderate-income Americans; 
  • not to compromise the ACA's ban on medical underwriting or mandating of guaranteed issue or requirement that health plans provide Essential Health Benefits; and 
  • not to repeal the ACA taxes that have enabled some 20 million Americans thus far to gain insurance coverage.

Friday, May 19, 2017

CMS's warmup for AHCA-world: Guidance on ACA innovation waivers

CMS recently issued guidance to states seeking ACA Section 1332 "innovation waivers," by which states can apply to alter or even thoroughly redesign their ACA marketplaces.

The checklist offers explicit encouragement to states to seek federal funding for reinsurance programs or high risk pools:
In particular we welcome the opportunity to work with states to pursue Section 1332 waivers incorporating a high-risk pool/state-operated reinsurance program. State-operated reinsurance programs have a demonstrated ability to help lower premiums, and if the state shows a reduction in federal spending on premium tax credits a state could receive Federal pass-through funding to help fund the state’s reinsurance program. 
Encouragement to states to implement a reinsurance program is good news, as reinsurance does keep down premiums, and the expiration of the ACA's federal reinsurance program after 2016 contributed to the 2017 premium spike. Including the high risk pool (HRP) option is a bit of a mystery, since 1332 waivers cannot be used to waive the ACA's ban on medical underwriting or guaranteed issue. (The waivers can be used to alter the ACA's Essential Health Benefits required of all qualified health plans, as well as subsidy formulas and the individual and employer mandates.)

Thursday, May 18, 2017

A Sparer means to universal health insurance

Last November Michael Sparer, chair of Columbia's Mailman School of Public Health, proposed that managed Medicaid programs be used as a fallback for regions of the country in which no insurer was participating in the ACA marketplace.  Today Sparer went one better and proposed, in a NYT op-ed, that managed Medicaid replace the ACA marketplace:
Some liberals have proposed using Medicare, the federal health care program for the elderly and disabled, as the basis for providing universal health insurance. But Medicaid is the better fit. It has a more generous benefits package, is less costly and is developing more innovative care-management strategies. Moreover, the integration of the Obamacare exchanges into Medicaid would be relatively seamless: Many health plans are already in both markets...

Moderates in both parties recognize that the chance of success for an insurance marketplace that serves only the self-employed, part-time workers and small businesses, as Obamacare does now, is small. So why not eliminate the insurance exchanges — enabling Mr. Trump to claim he “repealed” Obamacare — while allowing exchange beneficiaries to buy into Medicaid, using tax credits to pay the premiums. Recent surveys showing that Medicaid beneficiaries are generally satisfied with their coverage, more so than their exchange counterparts, makes the case even more persuasive.
Of course this excites me, since so far as I can tell the only person who has consistently suggested that managed Medicaid, or something close to it, is the best way to serve those currently dependent on the individual market I have argued that using a solo public option to push private insurers' costs down is pushing on a string; that marketplace enrollees have given ample testimony to Medicaid envy; that insurers are happier in markets in which government effectively sets rates (happier than in the individual market, at any rate); and that managed Medicaid is the only path to fulfilling Trump's healthcare promises (not that those promises are worth anything).

Wednesday, May 17, 2017

The Beatles mourn Republican moderates

Okay, this is silly, but...
Every time I hear or think "Cassidy-Collins" I hear "Eleanor Rigby." So...

Pick up the vibes from a House
Where a bill has been passed.
Relevant at last...
Work on the sidelines
Hauling in one or two Dems as they walk by the door...
Come, let's make law...
Ah the lonely moderates,
Where do they all come from?
Ah the lonely moderates,
Where do they all belong?

Also undead: Cassidy-Collins

Rising out of the grave with the monstrous AHCA, or at least wriggling its toes a little, is the more moderate Cassidy-Collins ACA remake bill, dubbed the Patient Freedom Act. That bill, introduced in January, preserves the ACA's funding base and allows states to maintain the Medicaid expansion and, if they wish, their ACA marketplaces in their current form.  

Back in March, in the New York Times online, I urged Senate Democrats to engage on the Cassidy-Collins, if only to shore up Republican Senate moderates in their efforts to stave off roughly matching trillion-dollar cuts to benefits and revenue. I submitted the piece on March 13, and it appeared on March 24, hours before House Republicans pulled the AHCA without a vote. When Paul Ryan declared that "Obamacare will be with us for the foreseeable future," the op-ed seemed insta-obsolete. No more.

Saturday, May 06, 2017

An ill-timed vacation

Back in prehistory, in October, my wife and I booked a long-postponed trip to Italy -- for now. So here I am, watching the ACA apparently about to get gutted, from a distance.  I saw last night the horrible posse of senators assigned to task. I imagine the only glimmer of hope is that moderates will balk, and I've always considered them squish. Glimmer 2: House and Senate can't agree. Glimmer 3: some crisis, hopefully not world- or democracy-ending, distracts everyone.  Ping me if any such glimmer peeks through.

Tuesday, May 02, 2017

Medicaid is cheaper. Ergo...

In Inside National Health Reform (2012), John McDonough, a former Senate aide who was in at the birth of the ACA, recounts how the ACA's threshold for expanded Medicaid eligibility came to be set at 133% of the Federal Poverty Level (de facto 138% FPL, as everyone gets 5% of income discounted). In so doing he highlights a rather obvious fact about Medicaid: it's cheap.
The decision to go higher than 100 percent of the federal poverty level in the Senate and the House were driven by dollars. The Congressional Budget Office, the nonpartisan congressional advisory body, estimated much higher costs to cover individuals through an exchange rather than through Medicaid because the latter pays medical providers much less than private insurers can get away with and because Medicaid administrative costs are much lower. In the early summer of 2009, when Senate Majority Leader Harry Reid and the White House pressured Baucus to abandon plans to tighten the federal health insurance tax exclusion as a financing source, Senate Finance leaders and staff scrambled to find new revenues and to hold down costs—moving from 100 to 133 percent of the FPL for Medicaid eligibility was one important step in that direction. Why not 150 percent? Finance officials knew there were existing Medicaid populations at 133 percent of the FPL, including children up to age six and pregnant women, while there were none at 150 percent of the FPL—it would be a more difficult and complex change. Further, governors and some Democratic senators felt going higher than 133 percent of the FPL was a line they were not willing to cross: 133 was it.

Monday, May 01, 2017

Start over, MacArthur

Decry his poor policymaking and gaslighting, but give Rep. Tom MacArthur this: he painstakingly crafted an intraparty compromise that got the Freedom Caucus behind the American Health Care Act. The MacArthur amendment allows states to re-instate medical underwriting -- charging people different rates for health insurance based on the medical history -- if they either establish a high risk pool or create a reinsurance program. It also allows states to alter the Essential Health Benefits that the ACA mandates to be covered by all qualified health plans.

Saturday, April 29, 2017

Will Medicaid drown in a high risk pool? (updated)

Update, 5/3/17: $100 billion over ten years for high risk pools, as speculated below? Ha ha ha -- a HRP patch has been proposed, and it's all of $8 billion over 5 years. That's after a $15 billion "invisible risk" fund was tacked onto a $115 billion state stability fund... the math outlined below still broadly applies. As Larry Levitt said of the $15b infusion, it's all chump change. And they're making the ACA look simple.
Rumor has it that Republican leadership may lure "moderates" holding out against AHCA passage by throwing perhaps $100 billion over ten years into high risk pools. Moderates could then declare themselves satisfied that prospective individual market enrollees who have pre-existing conditions will have access to coverage.

Leaving aside the historic poor performance of high risk pools, this reinforces my fear that all the public hand-wringing about medical underwriting is a smokescreen, giving moderates cover to eventually sign onto a bill that still rolls back the Medicaid expansion and cripples all Medicaid via per capita caps.

In fact, the patchwork of funding grants slapped onto the bill via amendment  (pregnant women and addiction! invisible risk! more medical expense deduction!) can be used to obfuscate and only modestly soften the original AHCA's basic math: over ten years, $1.2 trillion in healthcare spending cuts offsetting $880 in revenue loss stemming from repeal of the ACA's taxes and mandates. In the original bill, the spending cuts include:

Friday, April 28, 2017

The pre-existing condition smokescreen

In a snappy summary by Axios's David Nather of  the latest AHCA stall-out, this caught my eye:
The holdouts are mainly worried about weakening coverage for sick people. Rep. Ryan Costello of Pennsylvania: "Protections for those with pre-existing conditions without contingency and affordable access to coverage for every American remain my priorities for advancing healthcare reform, and this bill does not satisfy those benchmarks for me."
What this tells me is that the moderates will ultimately go along with ending the ACA Medicaid expansion and girdling all federal Medicaid spending with per capita caps.  I have long worried that Republican relative moderates will go squish on Medicaid if AHCA damage to the individual market is moderated past a certain threshold.

Now more than ever, the bottom line remains what Andy Slavitt said it was two months ago:

Thursday, April 27, 2017

Sing away the AHCA

For months, New Jersey activists have been staking out the local offices of New Jersey Rep. Rodney Frelinghuysen (NJ-11), a onetime Republican moderate pulled relentlessly right in recent years. While voting for almost all of the Trump agenda, Frelinghuysen stunned the world on March 24 with a pivotal statement against the AHCA on  grounds that the bill "would place significant new costs and barriers to care on my constituents in New Jersey. In addition to the loss of Medicaid coverage for so many people in my Medicaid-dependent state, the denial of essential health benefits in the individual market raise serious coverage and cost issues."

Noble words, but now Frelinghuysen is wavering -- with Ryan reportedly threatening to strip him of his treasured chairmanship of the House Appropriations Committee -- and Jersey progressives are going all-out to provide the counter-pressure, as in this petition.  With the AHCA risen from an unquiet grave, we are reviving old (month-old) arguments. So why not a months-old songbook? Here's one that I had to serenade solo in Morristown upon one freezing day. I can't say it's "sung to the tune of Hamilton's My Shot, but it's intoned to something like the rhythm of it:

Our Shot 

We are not throwing away our...SHOT
We are not throwing away our..SHOT
Ya know, we're just like Obama,
all action, no drama,
and we're not throwing away our..SHOT.

We're gonna stand outside your windows, Frelinghuysen
chantin singin make-all-kinda-noisin
until you let us freezin girlz and boyz in
to prove to you that Ryancare is poison --

Tuesday, April 25, 2017

The Kaiser misunderstanding

The Kaiser Family Foundation has a useful measure of how close to capacity the ACA marketplace is operating. Well, check that...Kaiser has two measures, and one has generated some confusion for some time.

The more useful measure is a national and state-by-state estimate of  Marketplace Enrollees Receiving Financial Assistance as a Share of the Subsidy-Eligible Population. For this, Kaiser combines analysis of enrollment data provided by CMS with Census data on income and insurance status. Importantly, Kaiser accounts for people whose income would qualify them for subsidies but who are disqualified by an offer of employer insurance, as well as people disqualified by immigration status.

As of  March 31, 2016*,  Kaiser estimated that 64% of those eligible for premium subsidies nationally were enrolled. State scores ranged from 92% in Florida, which has developed a culture of enrollment, with plenty of assistance available and advertised, to 31% in Colorado.** Kaiser estimated last October that 5.3 million of the uninsured were eligible for marketplace subsidies.

Friday, April 21, 2017

Tom MacArthur doesn't want you to know he's ready to uninsure millions

Defending his support of the ACA repeal bill, the American Health Care Act (AHCA), Rep. Tom MacArthur scolds a constituent who accused him of hypocrisy for "partisan finger-pointing." Yet MacArthur's rebuttal is riddled with obfuscations and errors.

1) MacArthur claims that a court found the ACA's Cost Sharing Reduction subsidies, which reduce out-of-pocket costs for low income enrollees, unconstitutional. Not true. A lower court agreed that if Congress does not allocate funds for those subsidies, as the ACA drafters intended and for which they budgeted, the executive branch lacks authority to pay insurers for them. If Congress allocates the funds, they are unambiguously legal. There is nothing inherently unconstitutional about them, and the Republican Congress's refusal to appropriate the budgeted funds is pure sabotage.

2) MacArthur implies that he's protecting the 11 million Americans and 500,000 New Jerseyans who gained coverage through the ACA's Medicaid expansion. Yet he supports repeal of enhanced federal funding for new expansion enrollees as of 2020. That effectively ends the expansion, as people typically churn in and out of Medicaid at short intervals. The Congressional Budget Office (CBO) forecast that if that cut occurs, the higher federal payments will apply to just 5% of enrollees by 2024.

Thursday, April 20, 2017

Tom MacArthur's faith-based waiver for the AHCA

Representative Tom MacArthur, R-NJ, has taken the lead in advancing amendments to the AHCA designed to bring both the Freedom Caucus and the moderate Tuesday Group aboard.  For the moderates, MacArthur writes that there will be an additional $160 billion in funding over 10 years to increase tax credits for older buyers and preserve Medicaid coverage for new mothers (was that on the block?!) and addiction treatment. For the conservatives, an amendment has been published  that would allow states to opt out of prohibiting medical underwriting or requiring insurers to cover the ACA's Essential Health Benefits.

Actually, the amendment begins by purporting to restore EHBs, community rating and guaranteed issue, the prohibition on denying coverage or charging more to people with pre-existing conditions. But it then tacks round and enables states to seek "limited waivers" to amend the EHBs, community rating -- and medical underwriting, if the state establishes a high risk pool.

How are those waivers limited? There's the rub. Beginning in 2017, the Affordable Care Act enables states to seek waivers to change the structure of their ACA marketplaces, but requires that the state's alternative plan "provide coverage that is at least as comprehensive and affordable, to at least a comparable number of residents, as this title would provide; and that it will not increase the Federal deficit."

Sunday, April 16, 2017

Trump logic, self-defined

A nation in which 40-plus percent of voters would choose for president a man who wildly insults anyone who criticizes or crosses him is a nation where emotional intelligence, let alone political judgment, is severely impaired.

Trump would presumably never admit, obvious as it is, that his insults and praise are determined purely by whether the party in question has been nice to him -- that "failed," "crooked," "cheating," "dumb" etc. simply means "criticized or crossed me."

Except that he just did:

Friday, April 14, 2017

Cutting off CSR is a war on the near-poor

Most coverage of the Trump administration's threats to stop paying Cost Sharing Reduction (CSR) subsidies focuses on the effect of withdrawal on insurers. And rightly so: insurers can't foot the bill for those subsidies on their own without massively raising premiums. If the federal funding is withdrawn, they will exit the ACA marketplace en masse.

It's worth stepping back to notice, though, that from an enrollee point of view, the marketplace can't function without CSR -- at least, not for the 50% of current enrollees who access strong doses of it. Without CSR, the marketplace wouldn't be even marginally serviceable for prospective customers with incomes below 200% of the Federal Poverty Level -- as 55% of uninsured Americans were in 2013, before the marketplace opened.

The average employer-sponsored plan has an actuarial value (AV) of about 82% -- that is, it covers about 82% of the average enrollee's medical costs. CSR raises the AV of a silver plan to 94% for enrollees with incomes below 150% FPL, and to 87% for enrollees in the 150-200% FPL range.& Over 60% of current marketplace enrollees are below the 200% FPL threshold, and about 85% of them select silver plans and so access the benefit, which is available only with silver.

At AV 94%, CSR generally reduces the deductible of a silver plan to the $0-250 range, and at AV 87%, to the $500-1000 range. Deductibles for silver plans without CSR average over $3,500 in 2017.

The AHCA, Paul Ryan's ACA "replacement" bill, is grossly inadequate to the needs of lower income customers, not only because its premium subsidies don't adjust for income and don't adjust adequately for age, but because it also does not adjust exposure to out-of-pocket costs according to income. That's a main reason why, for someone with an income below 150% FPL, the ACA picks up between 2 and 5.5 times as much of the total cost of healthcare (premium plus out-of-pocket expense) as does the AHCA. Because subsidies are available to people higher up the income scale in the Ryan plan, the individual market would shed lower income enrollees and pick up higher income ones should the bill be enacted (it would also shed older enrollees and pick up younger ones).

Thursday, April 13, 2017

Of index investing and traditional Medicare

For some time, a kind of inverted analogy between index fund investing and Traditional Medicare has been flickering round the edges of my mind, so let's see where it leads.

I was very impressed by a forecast I heard almost exactly eight years ago (Suzanne Duncan of the IBM Institute for Business Value)  that within 20 years, 85-90% of assets under management would be invested in passive vehicles -- that is, index funds or institutional equivalents. And in fact, in 2015, passive funds accounted for a third of U.S. mutual fund assets, up from a quarter three years prior.

For individual investors, and for most institutional investors, the shift to passive investment makes excellent sense. It's almost impossible for a portfolio of actively managed funds to beat an index portfolio over time. Just today, the Wall Street Journal reports, "Over the 15 years ended in December 2016, 82% of all U.S. funds trailed their respective benchmarks, according to the latest S&P Indices Versus Active funds scorecard."  And of course, index funds retain a huge fee advantage, since they don't have to pay managers for their acumen -- the funds change their investments automatically to mirror a predetermined basket of equities or bonds.

Someone has to make active decisions that determine prices, however, thereby creating the indexes that passive investors rely on. That means investing in research, complex mathematical analysis, and, sometimes at least, intuition born of lived experience.  What happens when the indexed values are produced by managers investing, say, just 5% of all assets under management? Isn't that a rather small brain moving a dinosaur? Is a smaller herd of decision-makers likelier to stampede in destructive directions?

Conversely, Medicare Advantage -- what you might call actively managed healthcare for seniors -- is grabbing a growing share of the Medicare market, now up to 32% of the whole, up from 22% in 2008.

Tuesday, April 11, 2017

New Jerseyans with pre-existing conditions, by Congressional District

Seeking to win buy-in from the Freedom Caucus for Paul Ryan's ACA repeal bill, the American Health Care Act, Republicans are considering removing protections for people with pre-existing conditions. According to an HHS analysis, over 130 million Americans, or 51% of the non-elderly population, have pre-existing conditions that could have made it impossible for them to obtain coverage in the pre-ACA individual market for health insurance -- or that, more precisely, "could have resulted in denial of coverage, exclusion of the condition, or higher premiums for individuals seeking individual market coverage before the ACA protections applied" (see Note 1 below).

Building on that analysis, which broke out the frequency of pre-existing conditions by age group, the Center for American Progress has produced estimates of the percentage and total number of people with such conditions in every Congressional District in the country (based on the age breakout in every district, not on regional health differences).

Charles Gaba has begun mapping the percentage with pre-ex conditions in each district (usually close to  50% ) to marketplace enrollment, estimating how many would be at risk from medical underwriting should guaranteed issue be repealed.  Since it will take the Gabacus a while to reach New Jersey, I've produced a breakout for the state, with a couple of methodological variations:

Monday, April 10, 2017

Oklahoma points the way to healthcare peace

Last week, Paul Howard and Yevgeniy Feyman of the Manhattan Institute highlighted a point often missed about the Freedom Caucus's latest demands for the AHCA, Paul Ryan's so-far-rejected ACA repeal bill:
The Washington Post reported that Freedom Caucus Chairman Mark Meadows said one “solid idea” that emerged at the meeting was allowing states to ask for waivers from Obamacare regulations like essential health benefits. The idea has sound roots, ironically, in the Affordable Care Act.

Health and Human Services Secretary Tom Price holds broad authority over administration of the Affordable Care Act, including the power to give additional flexibility to states and insurers under the law. Section 1332 of the ACA allows HHS to offer “state innovation waivers” for that allow states to waive some (but not all) of Obamacare’s insurance regulations in return for a block grant of ACA funding. States that want to keep the ACA status quo could do so, while Republican-led states could go in a different direction...

Friday, April 07, 2017

If Republicans had created the ACA marketplace...

As House Republicans paint the fingernails of the AHCA zombie with a little reinsurance gloss, let's take a 20-second irony timeout.

An amendment layered into the zombie AHCA yesterday would create an "invisible risk" program, funded with  $15 billion for the years 2018-2026, that would pick up costs above a certain threshold (as yet undefined; perhaps $1,000,000) for enrollees in individual market health plans.

That program would exist "within" the AHCA's Patient and State Stability Fund (PSSF) program, which allocates $115 billion over nine years for states to spend as they will to stabilize their markets. State options, as summarized by Avalere Health, include "providing financial assistance for high cost individuals, incentivizing insurer participation in their markets, reducing the cost of insurance, promoting access to preventive services, and reducing out-of-pocket costs for patients." The $15 billion allocated to the "invisible risk" fund is additional. Thus, $130 billion is allocated to stabilize markets from 2018-2026.

As was immediately obvious when the AHCA text was released, the ACA marketplace's problems would essentially be over if Republicans allocated $100 billion ( later raised to $115 and now to $130 billion) from 2018-26 for states to use to stabilize their markets.  At least, its problems would be over in states that chose to take their allocation and provide the required match, which does rise over the funding period. And all states would probably do so if the marketplace were no longer a focus of Republican hatred.

Wednesday, April 05, 2017

Single payer by inches?

File this under Half-baked Ideas and What's a Blog For?....

Dave Anderson, Louise Norris and I were noodling about stability funds, reinsurance, high risk pools, and the probably minuscule chance that Republicans would demand something acceptable in exchange for coughing up some federal "stability" money for states without repealing the ACA when a thought emerged...

What if the federal government undertook to foot the bill for all truly catastrophic claims -- say, those over $200,000 a year -- for all insurers, paying Medicare rates for care?

For hospitals and doctors, that would mean status quo ante payments for patients already on Medicare; a severe haircut for patients covered by commercial insurance; but a corresponding bump-up for patients on Medicaid. The rate (Medicare plus or minus a bit) could be calibrated to net out even, or a bit less than even in exchange for giving providers the certainty of getting major claims paid.

The tradeoff would be reduced rates for commercial insurance in exchange for a universal tax increase -- say, added to the Medicare payroll tax. In FY 2015, the 2.9% Medicare tax yielded $234 billion, so perhaps every additional 1% would yield another $80 billion, adjusted for growth and inflation.  If the reinsurance brought down commercial rates, that should translate into lower premiums and out-of-pocket costs for employees and/or higher wages.

Monday, April 03, 2017

Kaiser and me, on average AV

Drew Altman, president and CEO of the Kaiser Family Foundation, wrote on March 22 that under Ryan's ACA repeal plan, the average deductible in the individual market for health insurance would rise $1550 from current levels in the ACA-compliant market.

That was based on an estimate that the average actuarial value in the current market is 72%, vs. a norm of 65% that CBO calculated for Ryan's bill. Actuarial value (AV) is the percentage of the average user's yearly medical costs covered by plan. It's calculated according to a formula mandated by the ACA.

The 72% average AV figure jumped out at me, because in April 2016 I calculated the average weighted AV in the individual market as 75.5%.  Altman's piece cites an average AV in the ACA marketplace of 79%.That's exactly what I initially calculated, though I later bumped my estimate to 80%, based on likely silver plan selection by enrollees eligible for Cost Sharing Reduction at different income levels (see note at first asterisk, here).

The difference in the overall estimate appears to stem from estimates of metal level selection (bronze, silver, etc., with AV set by statute at each level) in off-marketplace enrollment, which is something of a black box. I used unsubsidized enrollees in the ACA marketplace as a proxy and calculated their average weighted AV at 68.7%.  According to an as-yet unpublished methodology note forwarded to me, Kaiser appears to have relied on 2016 data from the online broker eHealth, which included  a metal level breakout among their customers indicating an average weighted AV of 65.8%:

Friday, March 31, 2017

The cost of single payer: roughing it out

With sweeping ACA repeal apparently off the table for the moment, the Democratic imagination is turning once again toward some version of single payer, or Medicare for all.

I thought I'd try an overview from more than 30,000 feet -- say, from space -- of the tax revenue that might be required to move those now covered by commercial insurance into some kind of public insurance program.  That is, converting about a third of current total healthcare spending from private to public.  I hope this is not too general, or too vaguely informed, to be useful, but here goes...

1. According to the National Health Estimate, in 2015:
  • Medicare spending was $646.2 billion, or 20 percent of total NHE.
  • Medicaid spending was $545.1 billion, or 17 percent of total NHE.
  • Private health insurance spending was $1,072.1 billion, or 33 percent of total NHE.
  • Out of pocket spending was $338.1 billion, or 11 percent of total NHE.
2. Private health insurance covers more people than Medicare and Medicaid -- about 170 million (combining the employer and individual markets) vs. 120 million.* But it costs less in total -- about $1.1 billion vs. $1.2 billion.

3. At the same time, private insurance pays far higher rates to healthcare providers -- no one knows exactly how much more, but I've heard estimates in the 160% of Medicare range. Medicaid, in contrast, pays about two thirds of Medicare rates on average. [Update, 4/1: It's been pointed out to me that MEDPAC reports commercial rates for physician payments to be about 128% of Medicare -- that is, Medicare pays 78% of commercial rates on average. See p. 98 here. OTOH (added 4/4), a brand new CBO report estimates that commercial rates for hospital inpatient services average about 188% of Medicare, with wide variation. Hospital services accounted for a bit over $1 trillion in spending in 2015, compared to $635 billion for physician and clinical services.]

Affordable Care Anthem

In the fight against ACA repeal, the healthcare committee of our local advocacy group, BlueWaveNJ, cooked up some songs to warm the rallies and vigils aimed at the state's five Republican members of Congress -- four of whom came out against the AHCA, Ryan's repeal bill. Here's one of my contributions, with some local references -- e.g. to Rep. Rodney Frelinghuysen, NJ-11, chair of the House Appropriations Committee.  Here's a snippet from the local NBC affiliate that includes us singing outside his office.

The tune is This Land is Your Land....

After an election
we got a health scare:
Extremists tried to
take away our healthcare.
But we're united,
and they're divided...
Healthcare's a right for you and me.


Healthcare is your right,
healthcare is my right,
Ii they try to take it,
we're gonna fight fight.
Tax breaks for the wealthy
won't make us healthy,
Healthcare's a right for you and me.

Uninsuring millions                                De-localized alt:
is a pill quite poison,                              should be rejected
so hear our voices,                                by those who hope to
Rep Frelinghuysen!                               be re-elected.
We sing in chorus:
Don't un-insure us...
Healthcare's a right for you and me.

Thursday, March 30, 2017

"Medicaid expansion is the jewel of the ACA"

As Trump gleefully forecasts -- and thereby threatens to trigger -- the implosion of the ACA marketplace, methinks Democrats are starting to emotionally decouple from it. "You break it you own it" is a preemptive strike in messaging -- and potentially, a step toward planning the next phase when Democrats are in a position to shape public policy.

The AHCA's double-barreled assault on Medicaid -- repealing the ACA expansion and imposing per capita caps -- helped Democrats to see the ACA whole.  Hours before the bill hit, Andy Slavitt provided some clarity:
Now enter Harold Pollack, who has a granular sense of how Medicaid functions in U.S. society, chronicling how Republican governors' support for the ACA expansion helped sink the AHCA. Pollack, like Slavitt, reframes the ACA -- at least in public discussion forever obsessed with the private plan marketplace:
In political and human terms, Medicaid expansion is the jewel of the ACA. Within the states that embrace it, Medicaid expansion is the most important public health advance in decades.
Medicaid, Medicaid...made in the shade with a garden spade. Better yet once ACA'd...

More startling still is Pollack's conclusion:

Wednesday, March 29, 2017

What comes after "catastrophic success"? Larry Jacobs on Democrats' healthcare choices

Now that the Republicans' main thrust to repeal the ACA's core benefits has failed for the present, what should Democrats do next?

I asked Lawrence Jacobs, a professor of politics and policy at the University of Minnesota who has closely studied the dynamics and incentives of legislative and presidential politics.

Here were the core questions:

Given unrelenting Republican hostility toward the ACA, and given that Republicans control the administration of its core programs as well as both houses of Congress, can Democrats do anything to shore up a stressed marketplace that needs a) competent administration committed to making it work and b) legislative fixes to improve the risk pool and keep insurers from bolting?

Should Democrats pursue legislative compromise that would alter marketplace structure more to conservatives' liking in exchange for, say, federal funding for reinsurance or other state programs designed to foster stability? (for more about possible components of such a deal, see my prior post.) Or should they step back and declare, in effect: the marketplace was more or less stable before the Trump administration began sabotaging it. Republicans now own it. We are going to look forward and propose bold measures to make insurance affordable for all that can be implemented when the American people return us to power.

Tuesday, March 28, 2017

What's next for Democrats in the healthcare wars?

While the ACA appears to have escaped repeal for the time being, the ACA marketplace remains under apparent and threatened assault from the Trump administration -- which, after all, has to administer it.

The avowals of Trump and other Republican leaders, including Ryan and McConnell, that the marketplace will implode or is in a death spiral; the withdrawal of advertising for the marketplace in the closing weeks of open enrollment last January; the threat not to enforce the individual mandate; the possibility of destroying the marketplace immediately by stopping federal payments to insurers for Cost Sharing Reduction subsidies; and, most recently, the walk-back of avowals that Ryan's repeal bill is dead -- all these factors have left insurers and therefore the marketplace in a shaky position. Insurers may withdraw, and premiums are likely to spike, as they did last year.

Even if Hillary Clinton had won the presidential election, the marketplace would be in need of fixes. The risk pool is sicker, older and smaller than originally envisioned. The subsidies are smaller than they should be. Millions whose employers offer nominally "affordable" individual insurance but unaffordable family insurance are denied marketplace subsidies through the family glitch. The trio of risk control programs designed to smooth insurers' losses in a new kind of market expired too quickly, and one -- the risk corridor program -- was sabotaged by Republicans.

Given the need for fixes, and the at least momentary acknowledgment by Republican leadership that "we're going to be living with Obamacare for the foreseeable future," as Paul Ryan rather astonishingly put it last Friday, a number of progressives have started to scope out possible means by which Democrats in Congress could win Republican support for legislation that would improve competition, participation and affordability in the marketplace. If such a deal were possible, it would entail agreeing to provisions that would reshape the marketplace more to Republicans' liking. These might include:

Sunday, March 26, 2017

Progressives, don't forget: The Freedom Caucus killed the AHCA

Defenders of the ACA are right to take some satisfaction and pride in the failure of Paul Ryan's repeal bill, the American Health Care Act.  All those packed Town Halls, jammed phone lines and floods of mail had their effect. Dozens of Republican reps and senators, moderate and not so moderate, expressed qualms about un-insuring tens or hundreds of thousands of their constituents -- and tens of millions of Americans.

As we consider next steps, though, it's important to take full measure of the rather mind-bending fact that it's the Freedom Caucus that really sank the bill. They reportedly killed it partly because Trump managed somehow to trivialize their concerns even as he caved to most of them -- but more fundamentally, because it left some ghost of the ACA tax credits and consumer protections intact for those seeking insurance in the individual market.

For these zealots (and their right-wing think tank backers), the AHCA wasn't harsh enough.  It didn't cut the taxes that fund Obamacare benefits fast enough. It didn't uninsure beneficiaries of the Medicaid expansion fast enough. It didn't kill the concept of subsidized private insurance dead enough. It didn't take us back to the future of medical underwriting and health "insurance" that would render unaffordable coverage for such incidentals as childbirth and mental health treatment.

Saturday, March 25, 2017

Trump threatens ACA marketplace collapse and nuclear blame war

In one sense, it may have been the worst-timed op-ed of all time. I argued in a piece published in the online NYT yesterday (submitted back on March 13!) that Senate Democrats should engage with sponsors of the Cassidy-Collins ACA reform bill to shore up Republican moderates who I thought likely to ultimately pass some lightly sanded version of the AHCA, or otherwise act to eviscerate Medicaid in particular.

While there was obviously a good chance the AHCA would not pass the House this week, I never dreamed the Republicans would simply give up for the present. For me the truly astonishing moment was when I saw Ryan quoted on Twitter saying "“We’re going to be living with Obamacare for the foreseeable future,”

That's the Trump factor. Just as he swung wildly and obliviously into the Freedom Caucus camp to allow them to pull any fig leaves of rationality from the AHCA, when thwarted he swung wildly back to call off the whole thing.

But it's that very swing that leaves my core point relevant: Democrats still need to find a way to win a measure of Republican buy-in to the ACA, because the Trump administration can kill it administratively -- swiftly or slowly, subtly or obviously. That goes in part for Medicaid, via a rush of work requirements and administrative harassment, as well as for the marketplace, which can be destroyed at a stroke by stopping CSR payments or by a host of more gradual means, already begun, nicely chronicled by Dan Diamond.

That's where Trump's at just now.  Check out last night's insanity:

Thursday, March 23, 2017

The semi-satisfied unsubsidized

I have a post up on delving into the experience of four unsubsidized enrollees in the ACA marketplace who have pre-existing conditions, or children with pre-existing conditions.

None of them regarded their coverage as perfect. All were glad to have it – and confident that they would have fared worse if the ACA had not become law. Yet the piece does highlight that the status quo is unsatisfactory -- and deteriorating -- for a likely majority of the 8-10 million unsubsidized buyers in the individual market.

Here is a sliver of one person's experience:

Sunday, March 19, 2017

AHCA vs. ACA: Total subsidized shares of costs at different income levels and ages

Late last year I cooked up a simple measure of the value of any given health insurance subsidy: the percentage of the premium paid multiplied by the actuarial value (AV) of the insurance obtained. AV is the estimated percentage of the average enrollee's medical costs paid for by the insurance.

In traditional Medicare, for example, for all but the highest-earning 5% of enrollees, the federal government pays about 85% of the combined premium for Parts A,B and D - which have a combined actuarial value a bit north of 80%. Hence the total subsided share of costs (can we call it TSS?) is about 69%.  Employers, according to the Kaiser Family Foundation, pay an average of 82% of the premium for individual insurance and 71% for family coverage. Given an average AV of 82% -- also a Kaiser estimate -- that yields a TSS of 66% for individual coverage and 58% for family.

I've previously estimated (see first link above) that the average subsidized ACA marketplace enrollee obtains a TSS of 59% -- with the federal government picking up an average of 73% of the premium for insurance with an average AV of 81%. Subsidies vary tremendously, however, ranging from 0% for the half of individual market enrollees who don't qualify for any help to over 90% for the lowest income enrollees obtaining silver plans enhanced with Cost Sharing Reduction.

Now, with the help of CBO analysis of the House repeal-and-replace bill, the American Health Care Act, it's possible to compare the federal TSS for people of varying income and ages under the ACA and the AHCA.

Friday, March 17, 2017

Christopher Ruddy's alt-Trump

Christopher Ruddy, Trump buddy and CEO of the gaslight site Newsmax, wantonly misrepresents the ACA while proposing what he regards as a Tumpian alternative to "Ryan Care II" (for which Trump has now gone all-in, flaunting his powers of intimidation even as he yields to right-wing demands that the bill un-insure millions more swiftly).

Let's leave the lie-specking for later (see bottom).  Buddy Ruddy does Trump the doubtless undeserved honor of crediting his stated intentions for health reform as expressed in, for example, Trump's January 15 Washington Post interview:
“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”
Also promised: "lower numbers, much lower deductibles."

There is only one mode of healthcare delivery in the U.S. that can deliver on those promises. And lo, Ruddy makes it his centerpiece -- Point 4 in a 7-point program:

Tuesday, March 14, 2017

David Frum for HHS Secretary

For ten years now, David Frum has wowed me with the clarity of his critiques of Republican extremism, notwithstanding the craziness of some of his own policy prescription (most in foreign policy; he is, after all, Mr. Axis of Evil).  He's been a hero dissecting and crying out against emerging U.S. authoritarianism for the past year. And in fact, he was doing that too back in 2009/10. Here's from his famous post-mortem on the passage of the ACA in March 2010:
I’ve been on a soapbox for months now about the harm that our overheated talk is doing to us. Yes it mobilizes supporters – but by mobilizing them with hysterical accusations and pseudo-information, overheated talk has made it impossible for representatives to represent and elected leaders to lead. The real leaders are on TV and radio, and they have very different imperatives from people in government. Talk radio thrives on confrontation and recrimination. When Rush Limbaugh said that he wanted President Obama to fail, he was intelligently explaining his own interests. What he omitted to say – but what is equally true – is that he also wants Republicans to fail. If Republicans succeed – if they govern successfully in office and negotiate attractive compromises out of office – Rush’s listeners get less angry. And if they are less angry, they listen to the radio less, and hear fewer ads for Sleepnumber beds.

So today’s defeat for free-market economics and Republican values is a huge win for the conservative entertainment industry. Their listeners and viewers will now be even more enraged, even more frustrated, even more disappointed in everybody except the responsibility-free talkers on television and radio. For them, it’s mission accomplished. For the cause they purport to represent, it’s Waterloo all right: ours.
Back then, Medicaid expansion was a bad thing from Frum's conservative point of view -- something Republicans could have avoided had they negotiated the ACA in good faith:

Monday, March 13, 2017


The meme that Republican senators in states that have embraced the ACA Medicaid expansion will block the House repeal bill from passing substantially as is and save the expansion continues. Here's Politico's Burgess Everett with news of a closed-door meeting in Nevada:
Sen. Dean Heller panned House Speaker Paul Ryan's bill to repeal and replace Obamacare during a closed meeting with constituents on Saturday, according to audio obtained by POLITICO.

The remarks by Heller, the most vulnerable GOP senator on the ballot next year, are another sign of the difficult prospects the House bill faces in the other chamber. Already, more than a half-dozen senators have criticized the bill, and Republicans can afford to lose only two votes.
Hail defender! As Nevada's Republican governor, Brian Sandoval, boasted in a letter to the House leadership in January, Nevada has slashed its uninsured rate almost in half since ACA enactment, from 23% to 12% -- mainly through the Medicaid expansion, which has increased Medicaid enrollment by 288,000 since September 2013 in a state with 2.5 million residents. Plenty to defend!

So what is Heller's promise to Nevadans? Back to Politico:

Thursday, March 09, 2017

"Moderate" Republican opposition to AHCA is looking very squishy

Hours before House Republicans published a full draft of their ACA repeal-and-replace bill, the so-called American Health Care Act, four Republican senators in states that have expanded Medicaid -- Portman, Capito, Gardner and Murkowski -- sent a letter to Mitch McConnell from warning that the repeal bill should provide "stability" for beneficiaries of the expansion.

Given the letter's timing, and its expressed concern for beneficiaries of the Medicaid expansion, some accounts of the repeal bill's release (e.g., Chait's) interpreted it as opposition to the bill. But it was not that. In fact it may have been the opposite. Those who are anticipating rejection of the House bill by Senators who have expressed qualms about un-insuring expansion beneficiaries should take warning.

Tuesday, March 07, 2017

Psst, Democrats: Help Republicans out of the repeal box via Cassidy-Collins

I don't want to be prematurely optimistic, but the House ACA repeal bill, the so-called American Health Care Act, seems despised from all sides -- so much so that both Jonathan Chait and Jonathan Bernstein speculate that it's designed to fail. It's being denounced by Tea Partiers as Obamacare Lite and by progressives -- and conservatives with any commitment to extending insurance access -- as certain to un-insure millions to tens of millions of low income ACA beneficiaries.

More to the point, its release was immediately preceded by a letter to Mitch McConnell from four Republican senators in states that have expanded Medicaid -- Portman, Capito, Gardner and Murkowski -- warning that the repeal bill should provide "stability" for beneficiaries of the expansion.

Still, perceptions of the way things are likely to fall out change quickly. Leadership in both the House and Senate have declared they want to move quickly -- McConnell indicating he'd give the House bill a quick floor vote in the Senate, though later half-walking that back. Underlying the process is the enormous pressure Republicans have built under themselves over seven years to rip the ACA apart. If the bluster from the far right about faux repeal blows over, the moderates defending Medicaid could go wobbly. In fact, they've left themselves space to. Look at the language with which they've "defended" the expansion (my emphasis):

Monday, March 06, 2017

Do we have to repeal the ACA to find out what's in it?

No one is claiming that the ACA led us into health access paradise. The ACA marketplace and wider individual market as open enrollment for 2017 began. But they were (and are) troubled markets, in need of adjustment, e.g. along lines sketched by scholars at Georgetown and the Urban Institute. The networks keep narrowing, premiums and out-of-pocket costs have spiked, and choice has narrowed in many markets. The roughly half of marketplace enrollees with strong Cost Sharing Reduction subsidies are partly but not wholly insulated from this deterioration.  Those who are unsubsidized or lightly subsidized have in many cases been hit hard.

The Medicaid expansion has been a clear boon to those who gained access through it, as well as to state budgets, state economies, state public health, and access to drug treatment. It's also, to some extent, highlighted the law's political weakness, apparently triggering a fair amount of Medicaid envy and resentment among the somewhat more affluent and the fact that the ACA's most direct beneficiaries are generally the poor and near-poor.

As mentioned in a prior post, I have a piece shopping that spotlights very mixed experiences of unsubsidized marketplace enrollees with pre-existing conditions -- grateful for access but dealing with rising costs.

Another piece relaying a wide variety of experience and perception, by Jay Hancock of Kaiser Health News, is a striking contrast to the polarized praise/denunciations that used to be common fare in ACA coverage. There is a really striking degree of nuance in these mostly Republican reflections, as well as a refreshing awareness in some cases of the ACA's different component parts. If nothing else, the rough number of people who have gained insurance through the law seems finally to have been hammered home. I hope Hancock doesn't mind my extracting all of the article's citizen testimony, as I do think it has a strong cumulative effect:

Saturday, March 04, 2017

Short history of the decline and fall of American democracy

I switched on Twitter for 15 minutes at 7:00 a.m. this morning and felt I was watching democracy die before my eyes as a fascist and possibly traitorous president threatened to prosecute Obama.

That led me to a flash review of our decline and fall as the narrative has taken shape in my mind in recent years:
  • The Kochs plotted long and hard, building their network of extremist think tanks, fake news sources, astroturf advocacy groups and corporate lobbying groups.

  • Reagan ripped the lid off inequality and disinherited the middle class with a cocktail of tax cuts for the wealthy, deregulation, weakened antitrust enforcement and union-bashing.

  • Rupert Murdoch and Roger Ailes prepped 30-40% of the population for fascism with twenty years of progressively more extreme gaslighting.

Friday, March 03, 2017

Pre-ACA, patchwork protections worked for the lucky

The pre-ACA individual market was not entirely devoid of protections for people with pre-existing conditions. These varied widely by state, however. Five states -- Maine, Massachusetts, New Jersey, New York, and Vermont -- had guaranteed issue and community rating, meaning that insurers could not deny coverage based on medical history or charge more to people on the basis of their medical history. In New Jersey, an insurer could bar coverage for the applicant's pre-existing condition for up to twelve months, though that period could be reduced or eliminated if the person had maintained continuous coverage prior to applying. In the other 45 states, the rules according to which insurers could ascribe a pre-existing condition to an applicant varied.

HIPAA, the Health Insurance Portability and Accountability Act of 1996, though focused mainly on rules governing employer-sponsored plans, provided some "continuous coverage" protection in the individual market, though the degree of protection varied by state. In some states, if you had maintained continuous coverage in a group health plan or via COBRA for eighteen months, any insurer selling individual coverage in the state had to offer you coverage, though HIPAA did not regulate how much the insurer could charge. Different states offered different degrees of protection, however.

Recently, a well-informed retired attorney in Atlanta, Gary Ratner, recounted to me how HIPAA, enhanced by Georgia state law, enabled him and his wife to maintain good if eventually very expensive coverage...not in the individual market per se, but as individuals without access to conventional group coverage, until they qualified for Medicare. Gary's tale makes an interesting counterfactual for older current enrollees in the individual market who wonder how they may have fared pre-ACA. Gary and his wife fared pretty well -- though if they were in the ACA-compliant individual market today, as his calculations below indicate, they would fare comparably. And they were lucky. They threaded a couple of needles.

Wednesday, March 01, 2017

"Where the hell are you?"

For the three or four people who may be wondering why I haven't blogged for a near a week: I've been taking testimony, so to speak, from a bunch of people who are buying unsubsidized health insurance in the individual market -- but who, thanks to pre-existing conditions, are more or less grateful for what they can get and worried about what the future may hold.

Some are members of of a political advocacy group here in North Jersey, whose tales I'm collecting for a story bank; others from Georgia Maine and Michigan as well as Jersey, have recounted their experiences for an article I hope to place elsewhere. In age they range from 20s to 60s. Because of their pre-existing conditions, or their propensities as people aware of risk, or their political sympathies, or all of the above, all are people who value insurance at its actual cost.

Virtually all of those who have been in the marketplace (or individual market) for some years have suffered premium increases, and out-of-pocket increases, and narrowing of networks, and in some cases, narrowing of choices. The collective picture of how the market's changed from 2014 to this year isn't pretty. And yet all are sensible of what the market was like, or will be like, without guaranteed issue and mandated comprehensive benefits.

Saturday, February 25, 2017

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.

Thursday, February 23, 2017

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

Monday, February 20, 2017

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  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

Monday, February 13, 2017

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:

Friday, February 10, 2017

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.

Wednesday, February 08, 2017

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.

Monday, February 06, 2017

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.

Wednesday, February 01, 2017

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.

Monday, January 30, 2017

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.

Friday, January 27, 2017

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 -- 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.

Thursday, January 26, 2017

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.

Tuesday, January 24, 2017

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, 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.

Monday, January 23, 2017

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).

Friday, January 20, 2017

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.