Thursday, February 15, 2018

On, CSR takeup rose steadily from 2015 through 2017

One aspect of ACA marketplace enrollment that's intrigued me ever since HHS started producing enrollment statistics is "CSR takeup" -- the percentage of enrollees who are eligible for Cost Sharing Reduction (CSR) subsidies who access the benefit by selecting silver plans, the only level at which CSR is available.

Silver can be expensive for low income enrollees -- a benchmark silver plan costs an enrollee with an income at 200% of the Federal Poverty Level about $125 per month. At the same time, up to 200% FPL, CSR dramatically reduces out-of-pocket costs. (The benefit is much weaker for those in the 200-250% FPL range, and silver plan selection tapers off accordingly among enrollees over 200% FPL.)

One fact that's escaped me until now: CSR takeup rose steadily from 2015 through 2017, at least in the states using the federal exchange, (as 37 states did in 2015 and 39 in 2017). That's been somewhat obscured by the fact that the percentage of all enrollees with CSR has not risen. But enrollees' income mix on the federal platform has shifted upward as states on the platform enacted late Medicaid expansion, and as two states that expanded Medicaid early, Hawaii and Kentucky, came on board the federal platform. In 2015, 78% of enrollees were known to have incomes under 251% FPL. In 2017, 74% were below that threshold.

Monday, February 12, 2018

Health Policy Valentines 2018

Wait, no, this can't be my fifth year of #HealthPolicyValentines.* But yes: here is Love Knows No Repeal (2017),  Love in the Time of Obamacare (2016), love, 2015, and first love, 2014.

And who'd have thought we'd have at least two Trump-era V-days with the ACA unrepealed? But here we are...

Spite is served hot,
Revenge is served cold.
Trump cut off CSR,
We got cheap bronze and gold.

     *      *      *

Replace came up empty,
Repeal served up zeroes.
We love you, Little Lobbyists,
True national heroes.

     *      *      *

Heller was craven,
Capito, afraid.
Collins, McCain, Murkowski
saved our Medicaid.

*      *      *

Thursday, February 08, 2018

Think ACA enrollment is complicated? Try Medicare

One of the early and persistent raps against the ACA is that the benefit structure and application process are too complex. There's a lot of questions to answer. It takes a half hour to an hour -- if you're not called on to provide extra verification for your identity or immigration status or income. There are benefit cliffs -- between Medicaid and the marketplace; between marketplace enrollees who qualify for strong Cost Sharing Reduction and those who don't; and, most precipitous (for older enrollees), between those who qualify for premium subsidies and those who don't. As for plan offerings, in some markets a dominant insurer will throw up a half-dozen minutely differentiated plans, sowing confusion.

All this is true. But I'd like to take a first pass here at a myth that I'd like to explore more fully later: that by comparison, Medicare is a blessed zone of simplicity, equity and benefit adequacy.

Monday, February 05, 2018

We won, now what? My account of Health Action 2018 at Crooked Media

The Affordable Care Act's passage through 2017 was a bit like Odysseus' ship sailing past the six-headed monster Scylla: six men gone, but the ship sails on (only to be destroyed by thunderbolt a few episodes later, but never mind that part). 

Health Action 2018, Families USA's annual confab of healthcare activists, was largely devoted to taking the measure of the political power somewhat miraculously tapped by a wave grassroots passion and action that staved off repeal -- and groping toward a path by which Democrats can build on or move beyond the ACA in years ahead.

I have an article up at Crooked Media that examines what kinds of next steps - or false starts -- the conference conversations point toward:

Friday, February 02, 2018

What I learned at Health Action 2018

Below, a few notes from Health Action 2018, Families USA's annual conference -- things I learned, or learned in more detail, or was forcefully reminded of. [Update: my report about what the conference suggested about where Democrats may be headed on the healthcare front is up at Crooked Media.]

         Re Medicare:
  • Many low income sixtysomethings face a "Medicare cliff" at age 65. They've had all their medical expenses paid by Medicaid;  now, suddenly, they're faced with Medicare's 20% copays, drug costs, etc. (Leslie Fried, National Council on Aging)

  • Medicare Savings Programs (MSPs), a variety of programs through which low-income Medicare enrollees' premiums or out-of--pocket costs are picked up by Medicaid, are all underutilized. Only about half of those eligible are enrolled. Funding for State Health Insurance Assistance Programs (SHIP), which provide enrollment assistance to seniors, is grossly inadequate and at risk. Susan Collins has stood up for SHIP. (Leslie Fried).  I plan to learn more/post more about the Medicaid-->Medicare cliff.

Wednesday, January 31, 2018

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.

Friday, January 26, 2018

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