2018 MIDTERM ELECTION

Time: D H M S

Charles Gaba's blog

UPDATE: ALL 435 CONGRESSIONAL DISTRICTS NOW INCLUDED (broken out by state)

As regular readers know, earlier in the year I embarked on a project to break out the total number of people who would likely lose their healthcare coverage if & when the ACA were to be fully repealed without any replacement whatsoever (i.e., a "clean repeal"). When the dust settled, I estimated the grand total would come in at around 24 million people. I broke this out by state and even attempted to do so by both County and individual Congressional District. Since the GOP hadn't actually come up with any sort of a replacement plan for the ACA, I could only assume that they had a "clean repeal" in mind and work it from that angle.

 

So, like everyone else, yesterday I was poring over the BCRAP text, and one of the first things which caught my eye was the individual market tax credit structure table, to see how it compares with the ACA's formula. Here's how it stands under the ACA...again, these percentages are based on the benchmark Silver policy...

...and here's the BCRAP table, based on the benchmark Bronze policy:

After reviewing it for a few minutes late yesterday morning, I posted a tweet noting that under the ACA, a 60-year old earning about 300% of the Federal Poverty Line...roughly $37,000/year...only has to pay up to around $3,600/year in premiums for a Silver plan (9.69% of their income)...but under BCRAP, that same 60-year old would have to pay up to $6,000/year for a Bronze plan (16.2% of their income).

The tweet went viral...I think it was retweeted like 1,000 times or so over the next few hours.

The CBO score of the GOP Senate's #BCRAP bill is expected to be released early next week, just days (or, who knows, hours?) ahead of Mitch McConnell's rushed-through vote.

The biggest question from a process POV (that is, whether Senaterules will allow the bill to be crammed thorugh the reconciliation process) is financial; as David Anderson summarized the other day:

a) The Parliamentarian is most likely going to be stripping out significant non-germane to the budget items
b) $1 billion in savings must come from each of two committees (HELP and Finance)
c) Anything the Senate passes must meet or beat the $119 billion in budget window deficit reduction that the House AHCA was scored at.

However, from a political POV, the bigger question is how many people the CBO projects will lose coverage by 2026 if BCRAP becomes law.

Back in December, the CBO posted the following:

OK, this metaphor will take a bit, but bear with me.

On March 16, 1981, CBS aired the 17th episode of Season 9 of M*A*S*H. For those of you too young to remember, M*A*S*H, set at a U.S. Army medical camp in Korea during the Korean War, was one fo the most successful TV shows in history, running 11 seasons. I believe the series finale remains the most highly-viewed broadcasts in history. While M*A*S*H started out primarily as a sitcom, it evolved over the years into more of a drama with comedic moments.

Anyway, in S9 Ep17, "Bless You, Hawkeye", the main character, Dr. Benjamin Franklin "Hawkeye" Pierce (played by Alan Alda) finds himself stricken with a sudden, unexplained and violent allergic reaction to something. He spends much of the episode trying standard medical solutions, but his fits of sneezing and coughing become so bad that eventually a recurring character, psychiatrist Dr. Sydney Freedman, is brought in to see if there might be a psychological cause.

Freedman asks Hawkeye about his childhood, and Hawkeye, among other things, mentions his cousin Billy.

 

Back in 2011, when Paul Ryan and House Republicans first attempted to privatize Medicare, a progressive PAC ran the ad above. In it, "America the Beautiful" plays as we see a young, Paul Ryan-ish looking young man pushing an elderly, wheelchair-bound woman down a nature path...and eventually pushing her right off of a cliff. Needless to say, it caused quite a bit of controversy at the time.

Earlier today, as the GOP Senate's BCRAP bill was released, this happened:

HERE'S PART ONE.

I spent almost all of Part One discussing the butchering that the GOP Senate's BCRAP bill does to the individual market, because that's the primary focus of my work here at ACA Signups, but the truth is by far the worst fallout will be on the Medicaid side of things...and most of the damage doesn't even have a damned thing to do with the ACA itself, since it relates to pre-ACA Medicaid.

I'll get to the Medicaid side in depth in Part Three. However, there are still a few more things I need to discuss regarding the individual market: The sub-100% FPL population and how it relates to Medicaid expansion.

 

Yes, that's right: The official name of the Senate GOP's Trumpcare Plan is "The Better Care Reconciliation Act" Plan...otherwise known as "BCRAP".

There's a lot to absorb here, but this is the bottom line:

  • MEDICAID: It's MORE draconian and cruel to Medicaid enrollees than the House version...but delays the worst of it by a few more years.

Seriously, that's it in a nutshell. It phases out the ACA's Medicaid expansion more gradually...but as the years pass, would eventually squeeze even more people off their coverage...mainly via non-ACA Medicaid, which means that this bill really has little to do with "repealing Obamacare" and is mainly about giving massive tax cuts to the ultra-rich at the expense of the poor and low-income workers.

OK, so this is what the "Three-Legged Stool" of the ACA is supposed to look like for the individual market:

Of course, I say "supposed to" because two of the three legs are simply too short, causing it to lean over somewhat.

June 13, 2017: CMS releases the following propaganda press release:

County by County Analysis of Current Projected Insurer Participation in Health Insurance Exchanges

The Centers for Medicare & Medicaid Services (CMS) is releasing a county-level map of 2018 projected Health Insurance Exchanges participation based on the known issuer participation public announcements through June 9, 2017. This map shows that insurance options on the Exchanges continue to disappear. Plan options are down from last year and, in some areas, Americans will have no coverage options on the Exchanges, based on the current data.

Back on November 15, 2016, one week after the election, I posted the following:

IMPORTANT: I cannot guarantee accurate federal data after 1/20/17.

...Most of the actual staff...the career employees at CMS/HHS, many of who've been there through more than one administration, will likely remain, and will do their jobs to the best of their ability, including trying to compile and publish data as accurately as possible.

HOWEVER, their bosses...the HHS Secretary and, I presume, the head of CMS...will be appointed by Donald J. Trump and confirmed by a 100% Republican-controlled Senate.

Given Trump's long, disturbing history of flat-out misstatements (aka "making sh*t up out of whole cloth"), and the type of sycophants he's likely to put into place, I can't guarantee with any certainty that the numbers spouted off by them are going to bear any connection with reality. Maybe they'll be accurate. Maybe they'll be off slightly. Maybe they'll be completely removed from any actual numbers. Who the hell knows?

An eternity ago (aka back in January/February), I attempted to compile and break out estimates of how many people would likely lose healthcare coverage in the event of a full, "clean" repeal of the Affordable Care Act (that is, a complete repeal of the ACA without any replacement healthcare policy whatsoever). I concluded that the total added up to roughly 24 million people nationally: Around 8.2 million highly-subsidized Individual Market enrollees, nearly 15 million Medicaid expansion enrollees and 750,000 Basic Health Plan enrollees (NY & MN only). I then attempted to break these out by both County and Congressional District​. I went with a "clean" repeal because there wasn't any actual replacement plan available to compare with.

Things are looking pretty precarious in Iowa for 2018, with Wellmark and Aetna bailing entirely on the state's individual market.

The good news, such as it is, is that Medica has stepped up to the plate as the sole insurance carrier filing to offer indy market policies (on the ACA exchange or off, I believe) across all 99 counties next year.

The bad news--although I can't really say that I blame them under the circumstances--is that they're insisting that they'll need a big rate hike to do so.

Here's the thing, though: First check out the headline in this story about it from The Hill:

Only ObamaCare insurer in most Iowa counties to hike premiums by 43.5 percent

One of the last insurers on Iowa's ObamaCare exchanges announced Monday it would sell plans in 2018 but proposed an average rate increase of 43.5 percent.

Earlier this year, in response to popular demand, I put together an extensive list of serious proposals to actually repair, improve and strengthen the ACA itself, as opposed to a) tearing it apart and replacing it with the GOP's Godawful pile of crap or b) tearing it apart and attempting to replace it with a total single payer system (which simply is not going to happen in the near future no matter what).

I came up with some of these ideas on my own (though I'm sure others have made similar suggestions), but most of them have been widely discussed by various heatlhcare wonks over the past few years. Some would require additional funding, but others are simply regulatory and wouldn't cost a single state or federal dime.

One of these seems to be catching on pretty quickly...number 12:

12. LEGALLY TIE MEDICARE ADVANTAGE/MANAGED MEDICAID CONTRACTS TO EXCHANGE PARTICIPATION.

h/t to Rebecca Stob for the heads up:

OLYMPIA, Wash. - Eleven health insurers filed 71 health plans for Washington state’s 2018 individual and family health insurance market, with an average proposed rate increase of 22.3 percent. No health insurer filed plans in two counties – Klickitat and Grays Harbor.

Insurance Commissioner Mike Kreidler has been reaching out to insurers since they filed their plans on June 7 to see if one or more will reconsider offering plans in the bare counties.

“I’m very concerned by the proposed changes we’re seeing,” Kreidler said. “I know these numbers will be extremely upsetting to people who buy their own health insurance. They’re upsetting to me. We’re going to spend the next several months reviewing every assumption insurers have made to make sure their proposed increases are justified.

OK, this was a bit unexpected.

Last week I analyzed the monthly enrollment effectuation numbers through all 4 years of ACA Open Enrollment (2013 - 2017), to help visualize how the enrollment numbers flow throughout the year (and to also show how misleading the Trump CMS "attrition" report from last week was).

Then, on Thursday, I wrote about a CMS powerpoint presentation from last year which provided a Holy Grail of sorts for me: Not only did it provide the monthly effectuation numbers for 2015, it broke them out by starting and ending month. That is, it divided the numbers into how many enrollees for that month had originally enrolled starting in January, in February and so forth. This is really, really important because having "an average" of 100,000 enrollees each month doesn't mean much if it's a different 100,000 people every month--that is, if a lot of people are signing up, having expensive treatments and then dropping out and then replaced by someone else, that hurts the risk pool, since the original batch aren't paying for the other months of the year when they don't require treatment.

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