Monday, May 21, 2018

Four ways states can leverage ACA sabotage

Sabotage of the ACA by the Trump administration and the Republican Congress will partially reverse the ACA's coverage gains, causing hardship to millions. But it differs from Republicans' failed legislative repeal in a fundamental way: The ACA's funding streams and mechanisms remain in place.

Not only can states that retain the will to make the ACA work continue to tap federal funding -- if they're willing to be creative, they can tap revenue streams created and inflated by the sabotage. Each form of sabotage has created new opportunities. There are at least four ways that states can not only fight off sabotage, but leverage funding opportunities that sabotage has created.

Tuesday, May 15, 2018

In Health Affairs: If CMS ends silver loading

I've co-authored with David Anderson, Charles Gaba and Louise Norris a blog post in Health Affairs that surveys the fallout from Trump's cutoff of federal funding for Cost Sharing Reduction subsidies in 2018 and considers the likely effects if the Trump administration moves to block the current effective strategies that most states have employed for dealing with that cutoff.

That is, what happens if CMS administrator Seema Verma and/or HHS Secretary Alex Azar move to block states from allowing or instructing insurers in the individual market to price CSR into silver plans only, a strategy that has created discounts in gold and bronze plans?

Part one recounts the history of how states and insurers found their way to silver loading. Part two quantifies how many people likely benefited from discounted bronze and gold plans. Part three reviews the impact of the CSR cutoff on unsubsidized premiums. And Part four considers the likely effects on plan pricing and enrollment if HHS/CMS either forces individual market insurers to spread the cost of CSR evenly among all ACA-compliant plans or to spread it evenly among all plans sold on-exchange only.

Hope you'll take a look.

Friday, May 11, 2018

Melt like wax into God or be born into her womb?

Continuing vacation posting of old non-political bits...

Kierkegaard, Julian, Obama

(5/5/13) -- Who knows what governs how a moderately engaged undergraduate makes sense of abstruse philosophic texts? As a sophomore, my mind settled on a basic dichotomy: Hegel bad, Kierkegaard good. This was probably what you might call a gendered thought. Hegel's basic How-Things-Work was to my mind aggressive, imperialist, male: thesis absorbs antithesis in new synthesis. Man slays dragon, eats its heart, becomes (relative) superman. Kierkegaard, by contrast, kept apparently irreconcilable opposites in eternal balance, on an eternal toggle switch whereby they could be seen alternately as part of a unity and eternally distinct.

I can't tell you at this distance whether my abstract caricature is accurate, but it has stayed with me all my life, and I tend to class thinkers on one side or the other of this divide. In retrospect, I'm sure that I placed the subject of my dissertation, the medieval mystic Julian of Norwich (an achoress, i.e. a nun in self-imposed solitary confinement) on the Kierkeaardian side of the ledger, though I never zoomed up the centuries to probe the association. *

Julian had a brilliant trick of subordinating the harsh elements of Catholic dogma that she didn't like (the damned are damned forever) to those that she felt by force of direct revelation to be true (all will be well, and all will be well, and all manner of things will be well).  Her basic dynamic was that God-as-man maintains two "cheres," or points of view: the human, limited one, whereby we must see and condemn our own sin, and the "inward, more ghostly" and more strictly divine one, whereby no one does anything except by God's will, and God is delighted with all, and sin is merely an instrument of human self-education.

Thursday, May 10, 2018

"New Jersey is poised to fight off ACA sabotage. Is Gov. Murphy on board?"

As Ive noted before, while the New Jersey legislature has passed bills establishing a state individual mandate and a reinsurance program, Gov. Murphy has not committed to signing them. I have an op-ed up on NJ Spotlight arguing that the need is urgent.:
The Congressional Budget Office forecast that mandate repeal in itself would generate premium increases of 10 percent per year throughout the next decade. An analysis of the impact on states commissioned by Covered California the state's ACA marketplace, put New Jersey in the highest risk category, where premiums are forecast to rise as much as 90 percent over three years if action is not taken to strengthen the markets. Early insurer rate requests filed in Virginia and Maryland are showing sky-high increases. Maryland's insurance commissioner is warning of a death spiral and placing hope on the state's reinsurance waiver proposal.
If there's any sticking point, it's probably related to cost. Here is an outtake with someone more detail than I had space for:

Outside our diseased political realm...

Good morning! I'm going to be on vacation for a week-plus, and probably not blogging healthcare. In the interlude, I thought I'd re-post a few non-political entries. The first, below, is from January 2010. I also have a couple of healthcare articles placed elsewhere (one a co-byline) that should drop during my time away. I'll post links when that happens.

A Cliff note for deconstruction

(1/8/10) -- Deconstruction, the literary theory that "attempts to demonstrate that any text is not a discrete whole but contains several irreconcilable and contradictory meanings" (Wikipedia - a definition as good as any) has been popularly regarded as an arcane, perverse bit of wizardry on the border between fraud and rocket science. I always felt that it demonstrated itself pretty well empirically (though logically, it should also unravel its own propositions...).

One Shakespeare sonnet, No. 24, always seemed to me to capture the idea in a line - the one bolded below.

Mine eye hath played the painter and hath stelled
Thy beauty's form in table of my heart.
My body is the frame wherein 'tis held,
and perspective it is best painter's art.
For through the painter must you see his skill
To find where your true image pictured lies,
Which in my bosom's shop is hanging still,
That hath his windows glazed with thine eyes.

Monday, May 07, 2018

Virtually no enrollment loss in state-based ACA exchanges in 2018

I imagine it's been noted before, but states that run their own ACA exchanges collectively had virtually no enrollment losses in 2018, while enrollment in the 39 states shrank 5%.

The loss even among unsubsidized exchange enrollees in the state-based exchanges (SBEs) was very slight, just 1% -- compared to 10% in the states. After Trump cut off federal funding for Cost Sharing Reduction (CSR) subsidies, most of the SBEs silver-loaded CSR costs on-exchange, and allowed insurers to offer silver plans off-exchange with no CSR priced in (for an explanation, see note below). That includes California, which accounts for almost half of SBE enrollment. It might therefore have been expected that more unsubsidized enrollees in the SBEs would have moved off exchange. And where unsubsidized on-exchange enrollment did drop, it will be hard to determine if many may have enrolled in ACA-compliant plans off-exchange.

Saturday, May 05, 2018

Will Trump's cutoff of CSR reimbursement boost ACA enrollment by 2-3 million, per CBO?

Trump's cutoff of federal funding for Cost Sharing Reduction subsidies (CSR) last October created discounts in bronze and gold plans for many subsidized enrollees in the ACA marketplace, as explained below.  The availability of these discounts partly offset other forms of sabotage, so that on-exchange enrollment was down a relatively modest 5%.

On May 3, CBO Director Keith Hall estimated in a blog post that the CSR cutoff has boosted or will boost marketplace enrollment by an astonishing 2-3 million. The verb tense and time frame is ambiguous, per below (my emphasis). The estimate surely does not apply to 2018 -- I doubt the enrollment boost this year exceeded 500,000, for reasons explained below. 

Here's Hall's explanation of how the CSR discounts came about and their likely effects:
On the basis of an analysis of insurers’ rate filings, CBO and JCT estimate that gross premiums for silver plans offered through the marketplaces are, on average, about 10 percent higher in 2018 than they would have been if CSRs were funded through a direct payment. The agencies project that the amount will grow to roughly 20 percent by 2021.

Tuesday, May 01, 2018

Silver loading yields some gold dividends in Kansas

Quick: what changed in the Kansas ACA marketplace in 2018, besides a shortened enrollment period?

Metal Level Selection in Kansas, 2018 vs. 2017


% of total enrollment
Number enrolled


% of total enrollment
Number enrolled

Yup. For two thirds of enrollees, the cheapest gold plan was cheaper than the cheapest silver -- the exceptions being those in Johnson and Wyandotte counties (adjacent to each other), together home to two thirds of the state's marketplace enrollees.* Hence gold enrollment nearly tripled statewide, whereas gold takeup was half the statewide total in Johnson County (10.5%) and one third in Wyandotte (6.5%).*