2018 MIDTERM ELECTION

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Charles Gaba's blog

Hey Michigan Residents! Do you live in Michigan's 8th or 11th Congressional District? Are you sick of Mike Bishop (MI-08) and Dave Trott (MI-11) refusing to even talk to you about their "replacement" healthcare bill, which would tear away healthcare coverage for millions of Americans and hurt the coverage of countless millions more?

If so, come on out to either Plymouth (MI-11) or Orion Township (MI-08) TOMORROW, Sunday, July 16th, and join me, MI-05 Congressman Dan Kildee and State Representatives Christine Greig / Brian Elder as we explain just WTF is going on with the GOP's healthcare debacle (click links below to RSVP):

From 11am - 1pm I'll be joining U.S. Rep. Kildee and State Rep. Greig at the Plymouth Elks Lodge, 41700 Ann Arbor Rd. E. in Plymouth, MI 48170:

MI-11 includes the following major cities:

Right on top of the American Academy of Actuaries' open letter explaining the extreme danger of the GOP passing their BCRAP bill (particularly the Godawful Cruz-Lee amendment) comes this joint letter sent to GOP Senate Majority Leader Mitch McConnell (well...and Chuck Schumer, since he is the Senate Minority Leader) from both America's Health Insurance Plans and the Blue Cross Blue Shield Association (h/t to Sahil Kapur and Topher Spiro...not sure who posted it on Twitter first):

 

Yes, that's GOP Speaker of the House of Representatives, 2nd in line to the Presidency, utterly clueless about the basic concept of how health insurance (or any type of insurance, really) works.

The American Academy of Actuaries has chimed in on the GOP Senate's #BCRAP Obamacare replacement bill, and I have to imagine that they had to bite their tongues clean through while composing this primer explaining the most rudimentary concepts behind "insurance", "risk pools" and "adverse selection" to Paul Ryan, Ted Cruz, Mike Lee and Mitch McConnell:

Risk Pooling: How Health Insurance in the Individual Market Works

What is risk pooling?

The Colorado Dept. of Regulatory Agencies has made it pretty simple for me:

Division of Insurance releases preliminary 2018 health insurance information
Final approval expected in late September / early October

DENVER (July 14, 2017) – The Colorado Division of Insurance, part of the Department of Regulatory Agencies (DORA), today released the preliminary information for proposed health plans and premiums for 2018 for individuals and small groups. From this point until August 4, Colorado consumers can comment on these plans.

All counties in Colorado
As the Division of Insurance noted in its June 21 news release, based on the plans filed, there is at least one insurance carrier planning to offer individual, on-exchange plans in every Colorado county. However, the insurance companies have indicated to the  Division that they may be forced to reevaluate their participation in the marketplace if the lack of clarity at the federal level continues.

 

So the latest #BCRAP b-crap being pulled by the Senate GOP is that they supposedly "forgot" to include the Cruz-Lee Amendment with the rest of the revised BCRAP bill that they sent over to the Congressional Budget Office to score next week. Topher Spiro of the Center for American Progress posted a twitter thread this morning which started off like so...

1: Senate Republicans are about to do something unprecedented that will break the Senate.

2: They claim they forgot to send the Cruz amendment to CBO on time. I think it was purposeful.

Now, this raised my eyebrows because I hadn't heard about this tidbit; when I asked for clarification, Spiro responded:

there was some mixup - McConnell staff blaming Cruz staff and vice versa. All staged.

I've been writing for months now about the impact of the Trump/GOP Sabotage Effect on 2018 rate hikes. Generally speaking, premium increases will be due to four things:

Medical Inflation: That is, the actual increases in charges by hospitals, doctors, medical equipment, prescription medication, administrative overhead and so on. In a perfect world, this would be the only reason rates ever go up.

Reinstatement of the Health Insurance Providers Fee: One of the ACA's funding sources is a broad-based fee placed on health insurance companies themselves. Basically, a small portion of all premiums for all enrollees (including the total nongroup (on & off-exchange), small group and large group markets) is paid as a tax to the federal government which in turn uses it to partially fund the ACA's tax credits, CSR payments and Medicaid expansion provisions. The carrier tax was waived for 2016-2017, but is scheduled to be reinstated next year, so premiums wiill go up a bit accordingly. It's supposed to total around $14 billion next year.

Both of these are unfortunate, but make total sense in an ACA world: Healthcare costs do rise year to year (though at a slower pace since the ACA passed), while the carrier tax helps cover a chunk of the subsidies and Medicaid expansion funding.

Here it is in all it's glory gory...

Note: The following notes are mostly cribbed from Larry Levitt of the Kaiser Family Foundation via Twitter, plus a few from other folks or tidbits I dig up myself...

  • Still cuts off tax credits at 350% FPL instead of the ACA's 400% FPL. Pass.
  • Still bases tax credits on a 58% AV Bronze plan instead of the ACA's 70% AV Silver plan. Pass.
  • Throws another $70 billion onto the "state stabilization fund" pile for a total of $132 billion
  • Throws another $70 billion on to "offset costs for high-risk patients" (I presume this means reinsurance?)
  • Yes, it includes the Cruz/Lee "Separate but Unequal" amendment; carriers could indeed go back to offering unregulated plans: No guaranteed issue, no community rating, no essential benefits, as long as they also offer a fully ACA-compliant plan
  • Tax credits couldn't be used for the unregulated plans, nor would they be attached to the risk adjustment program. In other words: Segregated risk pools
  • Catastrophic plans would be "counted" the same as other plans (ie, tax credits could be used for them), but they'd amount to the same as Bronze plans now anyway
  • It includes a #BakedAlaska giveaway to win over Lisa Murkowski...1% of funds have to go to "any state where premiums are 75% higher than average" (i.e., Alaska)

Last week, and then earlier today, I crunched some more numbers (with a big assist from the Kaiser Family Foundation) to figure out just what the impact of Ted Cruz's "Consumer Choice" #BCRAP amendment would be on the individual market, and the results weren't pretty. Here's what it boiled down to (rough estimates for all numbers):

n other words, Kaiser estimates the breakout of the individual market as something like this:

New Mexico's Insurance Superintendent has released their 2018 rate hike request filings.

The database at the link above doesn't include the enrollee market share numbers; for that I had to dig up the actual filings at the SERFF database. Blue Cross Blue Shield and Presbyterian seem to be assuming no significant TrumpTax next year (which makes sense, since both will be off-exchange only, thus not subject to CSR payment concerns). Molina's filing is kind of odd--they seem to assume that CSR payments will be made...but that the individual mandate won't be enforced, which seems rather backwards to me (most TrumpTax filings assume neither will be enforced, or that the mandate will but CSR payments won't).

Over at Vox, Sarah Kliff has a nice exclusive:

A small group of Democratic legislators will do something unusual Wednesday morning: hold a press conference to talk about the parts of Obamacare that are broken.

Ten House Democrats will unveil a new plan to fix Obamacare, highlighting the parts of the law that have struggled to work and offering modest steps to improve them. The proposal includes more funding to help insurance plans cover the sickest patients, along with possibly changing the timing of the open enrollment season in hopes of attracting more Americans to sign up for insurance.

These Democrats are agitating for a new strategy, one where they speak openly about the health law’s weak spots — particularly the individual market — and how to shore them up. The party has so far been reticent to highlight Obamacare’s problems at a moment when Democrats are fighting against Republican efforts to repeal parts of the law.

A shout-out to Jeremy Johnson for the heads up: The Montana Commissioner of Securities & Insurance has released their preliminary 2018 rate requests for the individual and small group markets...and it's pretty darned straightforward. As a nice bonus, they even saved me the trouble of digging up the effected enrollee numbers. In fact, the only critical data missing are the "Part II Justification" files, which hopefully clarify how the CSR payment/mandate enforcement situation plays into these requests.

Judging by the requests, it looks like at least 2 of the 3 on the individual market are assuming that CSR payments will continue and the mandate penalty will be enforced. As for the third (BCBSMT), they're asking for a 23.1% rate hike, so I honestly don't know whether that includes the TrumpTax or not. For the moment I'll assume it doesn't, but will change this later if I'm wrong about that.

Last week I noted that Ted Cruz's proposed amendment to the GOP Senate's BCRAP bill is a big pile of crap all by itself, since it would effectively turn the ACA-compliant market into a massively underfunded High Risk Pool, while likely turning the non-compliant individual market into a wasteland of subprime junk insurance (or at best, plans which are reasonable right up until you get truly sick, in which case you're screwed).

To help explain how this would happen, I used this bar graph from the Kaiser Family Foundation to show how medical expenses are actually split up by different subsets of the population:

Based on these averages, I put together several scenarios showing what typical premiums might be for "ACA Enrollees" and "Cruz Enrollees" depending on how the market was split up:

(sigh) I'm never gonna get any work done in my day job, am I?

Senate Majority Leader Mitch McConnell (R-KY) announced Tuesday that he is canceling half of Congress’ annual month-long August recess, keeping lawmakers in town to finish their drawn-out and so far unsuccessful effort to repeal the Affordable Care Act and tackle other pressing matters.

“Once the Senate completes its work on health care reform, we will turn to other important issues including the National Defense Authorization Act and the backlog of critical nominations,” he wrote.

Meanwhile...

Tensions are rising between Senate Majority Leader Mitch McConnell’s leadership team and his party’s ideological factions, with a renewed sense of pessimism creeping into the Senate GOP’s efforts to repeal Obamacare.

In the latest "ACA Sux" propaganda blitz being carried out by Tom Price's HHS Dept, a press release came out today claiming that:

Fewer issuers apply to participate in Health Insurance Exchanges for 2018

Fewer issuers apply to participate in Health Insurance Exchanges for 2018
Less choice for consumers as issuer health plan applications drop 38 percent from last year

The Centers for Medicare & Medicaid Services (CMS) today announced 141 individual market qualified health plan (QHP) issuers submitted initial applications to offer coverage using the Federally-facilitated Exchange eligibility and enrollment platform in 2018. At the initial filing deadline last year, 227 issuers submitted an application compared to 141 this year, a 38 percent drop in filings.

For months now, I've been noting that multiple analyses by the CBO, S&P and others kept agreeing that as ugly as 2017's average unsubsidized rate hikes were (around 25% overall nationally, ranging from just 1.3% in Rhode Island and North Dakota to a whopping 76% in Oklahoma), they did appear to do the trick in terms of finally bringing individual market premiums in line with actual medical expense claims, thus stabilizing the overall risk pool. Yes, there are still many areas of the country where this isn't the case yet, but overall it looked like the dust had finally started to settle, allowing a clear picture of what needs to be done next to improve the situation.

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