So, did I miss anything?

Tuesday morning I left on a quickie family vacation to Mackinac Island; we got back into town last night, so I was gone for just 4 days. In that time, here's some of the bigger developments on the ACA/healthcare policy front:

• The Congressional Budget Office issued their formal projection of the 10-year (9-year, really) impact of terminating CSR reimbursement payments permanently starting in January 2018. Their major takeaways are pretty much the same as what I and most other healthcare wonks have been projecting, with a few twists:
  • The fraction of people living in areas with no insurers offering nongroup plans would be greater during the next two years and about the same starting in 2020
  • Gross premiums for silver plans offered through the marketplaces would be 20 percent higher in 2018 and 25 percent higher by 2020—boosting the amount of premium tax credits according to the statutory formula
  • Most people would pay net premiums (after accounting for premium tax credits) for nongroup insurance throughout the next decade that were similar to or less than what they would pay otherwise—although the share of people facing slight increases would be higher during the next two years
  • Federal deficits would increase by $6 billion in 2018, $21 billion in 2020, and $26 billion in 2026
  • The number of people uninsured would be slightly higher in 2018 but slightly lower starting in 2020.

In general, their projections on the impact on premiums (unsubsidized and subsidized) is similar to what I, the Kaiser Family Foundation, Oliver Wyman and others have been saying all along: Around 20 percentage point increases across all Silver plans (which would be the equivalent of around 14-15% if spread out across all plans on & off the exchanges.

As I noted in a quickie update Tuesday night:

Where I was way off, however, was in my projection of just how much more this scenario would cost the federal government in terms of additional APTC assistance. I assumed it'd be around $20 billion more between now and 2026. The CBO projected a net increase of a whopping $194 billion during that time period. There's actually a rather obvious reason for this: My $20 billion assumption assumes no net additional subsidized enrollees...but whereas I assumed there would only be a net increase in subsidized enrollees under the #SilverSwitcharoo scenario, the CBO is pretty confident that after dropping by about 1 million enrollees next year, exchange enrollment would increase by anywhere from 2-4 million each year beyond what it otherwise would, mostly due to small employers choosing not to provide ESI coverage and instead kicking their employees over to heavily subsidized exchange policies.

The CBO report averages around 2.3 million additional exchange enrollees per year. Assuming 85% of these are subsidized, that'd be around 2 million more receiving APTC each month. In 2017, this is already averaging around $371/month, so that'd be another $9 billion per year even at 2017 levels WITH CSR funding. That'd be $81 billion between 2018 - 2026 even without taking inflation or the CSR load itself into account for those 2 million people.

Once you add inflation and the extra CSR funding into the mix, you can easily see how that'd swell to another $170 billion or so over the next 9 years. Add that to the $12 - $27 billion I estimated without those 2 million additional people and voila, you're up to around $190 billion more in APTC being spent by the federal government.

In other words, once again, in theory, killing the CSR payments without making any other policy changes should shift 2-3 million people over to individual exchange policies, resulting in little net impact on total coverage one way or the other while costing the government an average of around $21 billion per year. However, given the massive confusion this would cause and the potential impact on BHP funding in New York/Minnesota and the potential for more carriers to throw their hands in the air and bail on the individual market altogether as an effect and the high likelihood of additional negative policies resulting from such a change, it'd still probably be better for Congress to simply appropriate the CSR payments anyway.

OK, what else?

• Well, the official 2018 Open Enrollment Period for the federal ACA exchange (HealthCare.Gov) is being cut in half this year, from 92 days to just 6 weeks (November 1st - December 15th). However, many of the state-based exchanges have decided to tell HC.Gov to go pound sand. Louise Norris has compiled a list of the Open Enrollment Period deadlines for many of the SBMs:

• California: 11/01/17 - 01/31/18
• Colorado: 11/01/17 - 01/12/18
• District of Columbia: 11/01/17 - 01/31/18
• Minnesota: 11/01/17 - 01/14/18
• Rhode Island: 11/01/17 - 12/31/17 (for coverage effective 01/01/18)
• Washington State: 11/01/17 - 01/15/18

This means that, assuming none of the other SBMs announce enrollment extensions, even after the other 45 states have stopped counting ACA exchange enrollments, 5 states + DC which made up over 17% of all ACA exchange enrollments this year will still be signing people up...and remember, there's usually a big last-minute enrollment surge the final few days of the Open Enrollment Period. That means that the enrollment numbers will likely be somewhat "back-loaded" in those states.

In other words, even if the other 45 states enroll the exact same number of people by December 15th as they did this year, the 6 remaining states will likely appear to be coming up short by that date even if they eventually hit or surpass the 2017 numbers. Basically, The Graph is gonna look pretty screwy this year.

Then again, given the massive sabotage efforts which are already being implemented by Tom Price, Seema Verma and Donald Trump, the odds are that enrollment will come up short anyway.

• Centene, which has been expanding like mad into the counties being abandoned by other carriers (Humana, Aetna, Anthem, etc) continues to fill in the "bare counties", agreeing to cover 14 counties in Nevada which were otherwise at risk of not having any carriers offering coverage on the ACA individual exchange:

Only two very small counties in the United States remain without an Obamacare insurer planning to sell health coverage next year after Centene on Tuesday said it will offer coverage in Nevada's remaining 14 "bare" counties in 2018.

There are fewer than 400 people who currently buy Obamacare coverage though the federal HealthCare.gov marketplace in the two counties, in Ohio and Wisconsin, that remain at risk of not having an insurer next year, according to a map maintained by the Kaiser Family Foundation.

"This is not even a fraction of a percent of the people" in the U.S., said Cynthia Cox, associate director for Kaiser's Program for the Study of Health Reform and Private Insurance.

In late June, according to federal health officials, there were 49 counties nationally that did not have an insurer committed to sell plans on a government-run Obamacare marketplace in 2018.

But since then, the number has fallen as insurers have agreed to offer coverage in most of those areas.

Now, to be honest, I know almost nothing about Centene (which also operates under the names Ambetter and Celtic...for God's sake, guys, pick a name and stick with it...) in terms of network size/strength, customer service, pricing and so forth. They may be great, they may stink. But at least they're covering the gaps, and they've decided to zig when other carriers are zagging. I gotta figure 2018 will either be their best or worst year ever.

Oh, and finally...

• Trump backed off yet again on his threat to cut off Cost Sharing Reduction reimbursement payments for August:

Everyone and their doctor has asked President Donald Trump to continue funding Obamacare cost-sharing reduction (CSR) payments. After flirting with eliminating these payments to insurance companies, he finally agreed to pay them for the month of August. A White House spokesman told multiple news sources on Wednesday that the Trump administration will make the payment.

...Trump may have agreed to pay the subsidies Wednesday, but the wavering decision-making process signals a troublesome tactic to potential partners looking to strike deals with the federal government. “How can any company in any sector trust the United States after seeing health insurers treated so shabbily?” asked health experts Craig Garthwaite and Nicholas Bagley, when Republicans in Congress were undermining the ACA. The question still rings true.

Yup, that's about the size of it. Donald Trump has somehow managed to make health insurance corporations seem genuinely sympathetic. Think about that for a second. As I've noted many times before, the insurance carriers may be guilty of a long list of sins, but at the end of the day they are trying to run a business here. In any event, the Sword of Damocles continues to dangle for one more month. The carriers are already baking potential CSR non-payments into their 2018 rate hikes, of course, so the biggest remaining question is now about the last 4 months of 2017.

If Trump makes those 4 payments--which will likely amount to perhaps $2.5 billion collectively--then from the carrier POV, it doesn't really matter whether they're paid in 2018 or not (OK, that's overstating it a bit). If the payments aren't made, they're covered; if they are made, the carriers will see a huge profit windfall...which, under the terms of the ACA's 80/20 MLR rule, they would theoretically have to pay a chunk back to enrollees a couple of years down the line (the MLR rule uses 3-year averages for determining how much the carriers have to rebate to enrollees).

If Trump doesn't make the last 4 payments for 2017, however, that still has the potential to set off shock waves. Larger carriers can absorb the losses while they sue in federal court to get them back, but smaller carriers without a lot of cash on hand would likely be screwed...just like what happened with the Risk Corridor Massacre a couple years back, so there you have it.

I also had a personal healthcare/insurance related incident last week, but I'll save that for a separate blog post...

I'm sure there's been a whole mess of other developments as well, but those are the big ones which come to mind.