UPDATE 9/29/20: There have been several important developments in the #TexasFoldEm case since I posted this back in June.

For one thing, another 81,000 Americans have died of COVID-19 and another 4.7 million Americans have tested positive for it.

For another, Supreme Court Justice Ruth Bader Ginsburg has passed away, and Donald Trump has already formally nominated an ultra-right wing zealot who is on the record as wanting the ACA to be struck down to replace her. His nominee's confirmation hearings have already been scheduled to start in mid-October, meaning that there's a very good chance that she'll be confirmed by the GOP-controlled Senate before Election Day...in which case the Texas Fold'em case to strike down the entire ACA could end up being the very first case she hears as a U.S. Supreme Court Justice on November 10th.

With this in mind, I figured this would be a good time to re-up the analysis below.

Back in late August, the Florida Office of Insurance Regulation posted preliminary 2021 individual & small group market rate filings. At the time, the weighted average increases were around 1.8% on the individual market and 3.3% for small group plans. Unfortunately, the actual enrollment data for each carrier is protected as a trade secret in Florida, but the FLOIR did post those weighted statewide averages.

Last month (I'm a bit behind) they posted the approved, final rate filings. The average individual market increases actually went up a bit, which is unusual (usually they're whittled down a few points), while the small group market average is exactly the same (oddly, they had it as 3.3% in August but say that the preliminary average was 3.4% now):

 

So Donald Trump decided, against all sanity, to break his agreement with 60 Minutes and post the full, unedited, raw footage of his interview with Leslie Stahl.

I bravely watched it so you don't have to. Here's the full segment about the ACA and the Trump/GOP lawsuit to strike it down, set to be heard by the Supreme Court on November 10th:

(starting around 15 minutes in):

STAHL: "You promised that there was gonna be a new health package.

TRUMP: "Yeah."

STAHL: "You said it was gonna be great, you said it'll be ready, it'll be here in two weeks, it was gonna be like nothing you've ever seen before...and of course we haven't seen it...so why didn't you develop a health plan?"

TRUMP: "It is developed. It is fully developed, it's going to be announced very soon, when we see what happens with Obamacare, which is not good. And...when we see what happens with Obamacare.

STAHL: "But...if the Supreme Court...

Back in late July, the Colorado Insurance Dept. released the preliminary 2021 Individual and Small Group Market rate filings. At the time, they came in averaging around +2.2% on the individual market and +5.7% on the small group market.

The final/approved rates have recently been posted, and rates in both markets have been significantly cut down: Individual market rates are now averaging a 1.4% reduction while the increase on the small group market is down to 3.8%.

Via the Alabama Insurance Dept:

The Alabama Department of Insurance (ALDOI) has approved the final 2021 premium rates for the Affordable Care Act Individual Market in Alabama. The rates will be effective on January 1, 2021. The two carriers in the Alabama individual market are Blue Cross Blue Shield of Alabama (BCBS) and Bright Health Insurance Company of Alabama (BHIC). In general, rates for BCBS increased five percent and rates for BHIC increased 22 percent. The actual rates and the supporting material may be found by clicking on the links below.

Unfortunately, the linked documents are still redacted and thus don't include the enrollment numbers for Bright (and this press release says nothing about the small group market), but as far as I can tell this doesn't change the averages of either market much from the preliminary filings. Assuming Bright still only has a tiny part of the market, even its 22% average increase doesn't move the needle much.

I've written at least a dozen explainers about what I've termed the Risk Corridor Massacre over the past five years, starting with this one from 2015, and I pray to God that this is the last time I have to do so. Here we go:

  • The Affordable Care Act made massive changes to many parts of the U.S. healthcare system, but by far the most radical changes were made to the individual, or "non-group" market. This is health insurance for people who aren't covered by Medicare or Medicaid but who also don't have coverage through their employer (or who are self-employed, as I am).
  • Before the ACA, individual market carriers could cherry-pick their enrollees, either denying coverage to those with pre-existing conditions, covering them but charging massively higher rates for doing so, or covering them but exempting themselves from coverage of the very conditions which were most in need of treatment.

The data below comes from the GitHub data repositories of Johns Hopkins University, except for Rhode Island, Utah and Wyoming, which come from the GitHub data of the New York Times due to the JHU data being incomplete for these three states. Some data comes directly from state health department websites.

Note that a few weeks ago I finally went through and separated out swing districts. I'm defining these as any county which where the difference between Donald Trump and Hillary Clinton was less than 6 percentage points either way in 2016. There's a total of 198 Swing Counties using this criteria (out of over 3,200 total), containing around 38.5 million Americans out of over 330 million nationally, or roughly 11.6% of the U.S. population.

With these updates in mind, here's the top 100 counties ranked by per capita COVID-19 cases as of Saturday, October 10th (click image for high-res version). Blue = Hillary Clinton won by more than 6 points; Orange = Donald Trump won by more than 6 points; Yellow = Swing District

A month ago, incumbent Democratic Senator Gary Peters of Michigan and his Republican challenger John James were both interviewed as part of a Detroit Regional Chamber series on several issues, including healthcare policy and the ACA.

As I noted at the time:

  • James called for no-cost primary care to be mandated...which is already included in the ACA.
  • James called for coverage of pre-existing conditions to be mandated...which is already included in the ACA.
  • James accused Peters of supporting Medicare for All...which Peters explicitly doesn't, which James was called out for during the segment.
  • James, who has repeatedly called the ACA a "nightmare" he wants repealed, now says that he wants to keep "the part that works"...namely it's coverage of pre-existing conditions.

Most curiously, however, when asked how he intends to guarantee coverage of pre-existing conditions if the ACA is struck down en masse, James rattled off a short list of head-scratchers, including "tort reform".

Nolan Finley is the conservative editorial page editor of The Detroit News.

On July 29th, he tweeted this out in response to criticism of the COVID-19 policy recommendations by himself and Michigan Republican legislative leadership:

Florida 20 million population, 6100 deaths. Michigan 10 million population, 6400 deaths. https://t.co/O1tNoyWwB0

— Nolan Finley (@NolanFinleyDN) July 29, 2020

That was late July.

Let's take a look at mid-October, shall we?

Here's a graph of official COVID-19 positive test cases and fatalities per capita for both Michigan and Florida. Cases are per 1,000 residents; deaths are per 10,000 in order to make the trendlines more visible:

My 2021 Rate Change project isn't complete yet for two reasons: First, I only have the final/approved 2021 rate filings for 18 states as of today (vs. preliminary rates for all 50 states + DC). Second, a higher-than-usual number of carriers have made it impossible (or at least highly difficult) to dig up their effectuated enrollment data for 2020.

Without that number, I have no way of running weighted averages for that state's individual market; those are listed in grey below. In a few cases (like Florida), the state insurance dept. actually provided the weighted average but I still had to guess at the total enrollment number (also in grey).

This is a bigger problem than you might think. Let's say a state has 3 carriers requesting a 5% rate reduction, a 2% increase and a 15% increase. The unweighted average would be +4%....but if it turns out that the first carrier holds 90% of the market share this year, the weighted average would be more like -4%. You see the problem here.

At long last, I've finally wrapped up my 50-state (+DC) 2021 Rate Change project...or at least the preliminary rate filings; I have the final/approved rate changes for 18 states as of this writing.

I'm finishing things off with New Jersey, and unlike the past half-dozen or so states, I am able to run a properly weighted average for both the individual and small group markets in the Garden State even though, like many other states, the actuarial memos are either unavailable or heavily redacted.

I'm able to do this thanks to NJ's policy of providing public quarterly reports tracking their individual and small group market enrollment, including breakouts by carrier (they also break it out by metal level, HMO vs. PPO and so forth, which is awesome for data wonks).

In any event, based on the Q2 2020 report (which includes enrollment data updated through the end of June), 2021 enrollees in New Jersey's individual market are looking at average premium increases of around 4.1%, while small group plans are going up by roughly 2.6% on average.

Massachusetts, which is arguably the original birthplace of the ACA depending on your point of view (the general "3-legged stool" structure originated here, but the ACA itself also has a lot of other provisions which are quite different), has ten different carriers participating in the individual market. MA (along with Vermont) has merged their Individual and Small Group risk pools for premium setting purposes, so I'm not bothering breaking out the small group market in this case.

Getting a weighted average is tricky. On the one hand, only one or two of the rate filings included actual enrollment data. On the other hand, the Massachusetts Health Connector puts out monthly enrollment reports which do break out the on-exchange numbers by carrier. This allowed me to run a rough breakout of on-exchange MA enrollment. I don't know whether the off-exchange portion has a similar ratio, but I have to assume it does for the moment.

Louisiana joins the disturbingly-long list of states where the 2021 individual & small group market rate filings are either completely missing or heavily redacted, thus making it impossible for me to break out the market share by carrier and thus running a weighted average rate change.

I really hope this trend is reversed in the future, whether via HHS transparency regulations or through legislation.

In any event, the unweighted average rate increase for the Louisiana indy market is around 6.9%, and for the small group market it's roughly 5.2%.

Once again, I'm afraid the actuarial memos for Kansas' 2021 individual and small group market carriers are either absent or redacted, so I have to run unweighted average rate changes, which are likely off significantly (for instance, the individual market is +7.8% unweighted, but if it turns out that, say, Oscar Insurance has 95% of the market share, the weighted average would be more like a 7% decrease).

Unfortuantely, without knowing the actual enrollment data for each carrier, this is the best I can do for now. The small group market's unweighted average increase is 8.2%.

(sigh) Once again, I only have actual enrollment data for a one of the five carriers offering individual market policies in Illinois next year, and for two of the eleven selling small group plans. That means I can't run a weighted average rate change for either market, just unweighted ones.

That being said, the unweighted average change on the individual market is a 1.8% premium reduction, while the small group market is increasing by 5.2%.

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