2018 MIDTERM ELECTION

Time: D H M S

Charles Gaba's blog

Whew! OK, Texas was a bear for obvious reasons...13 different carriers (well, 12 really...Centene is new to their market). Several more are dropping out (Aetna, Allegian, Cigna, Humana, Memorial Hermann and Prominence), but suposedly theyonly have around 64,000 enrollees in TX combined. Texas's total individual market is actually closer to 1.6 million, so I'm obvoiusly missing a big chunk of enrollees below (and before my regular commenters say it: Yes, I'm sure the off-exchange TX indy market has shrunk this year, but I find it hard to believe it's shrunk by over 60% already).

Anyway, I've managed to plug in one hard request percent for each carrier--the FULL Trump Tax for 3 of them, the NO/PARTIAL Trump Tax for most. In Vista's case, they're off-exchange only so the CSR issue isn't a factor anyway. Unfortunately, I can't seem to find the enrollment number for Community Health Choice, so I don't know what their share of the market is, which could make a big difference if they have high enrollment. I've plugged in a flat 100,000 enrollees for the moment, but will change that if I'm able to track the actual number down.

Another fairly straightfoward state: Three carriers, two of which (CareFirst and Health Plan of Upper Ohio Valley) appear to be assuming CSR payments will be paid; the third, Highmark BCBS (which holds the vast bulk of the individual market) openly states that they assume they won't be made and that the mandate won't be enforced to boot. I'm once again assuming roughly 2/3 of Kaiser Family Foundation's "Silver CSR hike", which in this case would be about 10%, giving the following: 17.8% if CSR payments are made, 27.8% if they are:

Louise Norris gave me a heads up that the Kentucky Insurance Dept. has posted their 2018 rate hike filings as well. The individual market is pretty straightforward...and pretty grim: Both individual market carriers, CareSource and Anthem, are asking for pretty steep rate hikes even if CSR payments are locked in next year, averaging around 30.8%, while assuming another 13.5 points on top of that (71% of Kaiser's 19% Silver average) would bring the average up to around 44.3%. Not much else to say about this one for the moment.

The states filings are piling up quickly...Arkansas is pretty straightforward. Interestingly, four of the five carriers seem to be assuming that CSR payments will be made, and have submitted their rate filings accordingly; the fifth (and largest), USAble Mutual (aka Blue Cross Blue Shield of AR) is the only one to break it out specifically. In order to estimate the CSR factor for the other 4 carriers, I'm assuming 2/3 of Kaiser's 15% Silver plan bump estimate, or around 10 percentage points. That brings things in at around 10% even without CSR sabotage or nearly 18% with the CSR factor.

One other important thing to keep in mind regarding Arkansas: Their total individual market, including grandfathered and transitional plans, is something like 430,000 but they only have around 70,000 officially enrolled in ACA exchange policies. The main reason for this is that they have another 320,000 people enrolled in exchange policies via their "Private Medicaid Option"...which is Arkansas' version of ACA Medicaid expansion. For some reason, those folks aren't counted as ACA exchange enrollees even though it's my understanding that the only distinction between them and the 70K official enrollees is where the payments/subsidies come from.

In late May, I noted that Blue Cross Blue Shield of North Carolina, which holds a near monopoly on the individual market in NC with around 95% of total enrollment, had submitted an initial rate hike request for 2018 averageing 22.9% overall. What was remarkable at the time is that while most carriers were pussyfooting around using euphamisms about the reasons for their excessive increase requests, BCBSNC was among the first to come right out and state point-blank that it's the Trump Administration's deliberate sabotage of the market--primarily via the threats to cut off CSR payments and to not enforce the individual mandate--that are responsible for over 60% of the increase. This is from their blog, not mine:

 

48 hours ago I posted this analysis/explainer of the "Silver Switcharoo", the goofy, bass-ackwards workaround which insurance carriers and state regulators could (if necessary) use to resolve Donald Trump's impending threat to pull the plug on Cost Sharing Reduction subsidy reimbursement payments.

There's been a whole bunch of additional CSR-related developments since then:

Congressional Republicans have finally started to come around and realize they need to formally appropriate the payments:

Congressional Republicans moved on Tuesday to defuse President Trump’s threat to cut off critical payments to health insurance companies, maneuvering around the president toward bipartisan legislation to shore up insurance markets under the Affordable Care Act.

Alabama, Alaska and Wyoming only have a single insurance carrier participating in each of their individual markets. While this is a bad thing from a competitiveness POV, it cetainly makes things easier for me from a tracking-average-rate-hikes POV.

ALSO IMPORTANT: The HHS Dept. is also starting to upload the rate filings to the official RateReview.Healthcare.Gov database, which should make things easier for me going forward (assuming that the data is uploaded properly and isn't messed with, which is a distinct possibility when it comes to the Trump Administration)

Officially, Alabama has the infamous "Freedom Life" phantom plan which is asking for a whopping 71.6% rate hike...to allegedly cover exactly one (1) person statewide. Un-huh.

Aside from that, however, it's Blue Cross Blue Shield across all three states...and they're asking for the following:

This isn't a full analysis, since I only have 2018 rate hike data for one of Arizona's carriers so far...on the other hand, AZ only has a couple of carriers on the individual market these days anyway. From AZCentral:

The Affordable Care Act insurer in 13 of Arizona's 15 counties plans to raise average rates across all plans a moderate 7.2 percent next year.

But Blue Cross Blue Shield of Arizona officials said the rate increases would be flat if President Donald Trump's administration did not plan to eliminate a key Affordable Care Act funding source.

7.2% isn't bad at all...of course, that comes after last years massive 57% average rate hike. Still, 0% would obviously be much better than 7%...

Trump suggested in a weekend tweet that " ... bailouts for insurance companies and bailouts for members of Congress will end very soon" unless Congress acts quickly on a new health bill.

Here it is...the Big Kahuna! Covered California just issued a detailed press release and accompanying PDF brochure breaking out their proposed 2018 market participation and rate changes:

Covered California Releases 2018 Rates: Continued Stability and Competition in the Face of National Uncertainty

Covered California remains stable, with an average weighted rate change of 12.5 percent. The change is lower than last year and includes a one-time increase of 2.8 percent due to the end of the health insurance tax “holiday.”

The competitive market allows consumers to limit the rate change to 3.3 percent if they switch to the lowest-cost plan in the same metal tier.

For 2017, unsubsidized enrollees on the Minnesota individual market faced massive rate hikes averaging 57%. It was so bad that the only way they could convince some carriers to participate in the market was to allow most of them to put a cap on how many people they'd enroll (with the balance being shunted over to Blue Plus, the HMO division of BCBSMN). This resulted in a massive initial surge of enrollment, as it was on a first-come, first-serve basis...but also left off-exchange and unsubsidized exchange enrollees high and dry.

In response, the state scrambled to pull together a $300 million package to help supplement premiums for those folks...knocking a flat 25% off of their premiums for 2017. This helped ease the problem in the short term, but the larger issue still loomed going forward.

It feels almost silly for me to spend so much time crunching the average 2018 rate hike numbers at this point. Between the (supposedly failed?) GOP repeal effort and Donald Trump's ongoing sabotage efforts--including what could be him officially pulling the plug on CSR reimbursements as early as sometime today--it's probably a bit of a futile effort. Besides, a dozen other wonks/analyses have already confirmed what the Kaiser Family Foundation projected months ago and which I've been proving on a state-by-state basis for months now: The CSR threat is causing average rate hikes of around 20 points on average, and the threats to individual mandate enforcement are tacking on another 4-5 points on top of that, beyond the ~10 points which rates would normally be increasing on average.

However, I've plugged in 21 states, so I might as well finish the job. With that in mind, the state of Idaho has done most of the dirty work for me:

(Special thanks to folks like Josh Schultz, David Anderson, Andrew Sprung, Amy Lotven, Wesley Sanders and others for helping me make heads or tails out of the CSR brouhaha)

NOTE 5:30pm: See update at the bottom of page.

  • Mark Farrah Associates estimates the total individual market was roughly 17.6 million people as of early 2017.
  • Of that, I estimate that roughly 1.6 million are probably still enrolled in "grandfathered" or "transitional" policies, which are not ACA compliant and are part of a completely separate risk pool.
  • That leaves around 16,000,000 people enrolled in ACA-compliant policies at the moment.
  • As of March, around 10.7 million were enrolled in ACA exchange policies, the other 5.3 million or so in off-exchange policies.
  • Roughly 9.1 million of the exchange enrollees receive APTC subsidies; around 6.1 million also receive CSR subsidies.
  • That leaves roughly 3 million receiving APTC but not CSR and 6.9 million not receiving either (1.6 million on exchange, 5.3 million off exchange)

Based on these ratios, here's a scenario for you:

Let's suppose you run an insurance company currently offering a Bronze, Silver, Gold and Platinum individual market plan both on and off the ACA exchange. You currently (2017) have a total individual market enrollment of exactly 16,000 people, broken out as follows (the on exchange breakout is based on actual OE4 enrollment data; the off exchange breakout is unknown, but Andrew Sprung thinks it's roughly a 40/40/20 Bronze/Silver/Gold split, which sounds about right to me).

 

Well, now...suddenly it feels like putting together this video series isn't such a waste of time after all!

Last week I posted the first in a video slideshow explainer series giving an overview of the pre-ACA landscape, circa 2009.

It was pretty crude, but I was scrambling to upload it ahead of the big Senate repeal/replace vote...and frankly, I felt a little silly bothering afterwards, since there was a very good chance that none of this would matter soon anyway.

Fortunately, late last night, something unexpected happened...and it now appears that the ACA will indeed live on for awhile, albeit still with serious issues to work out.

That being the case, I've recorded and uploaded the second slideshow video in the series...and yes, this one includes the (in)famous Three-Legged Stool.

Enjoy (well, as much as anyone can enjoy a dull 18-minute slideshow about healthcare policy, anyway).

As always, support is appreciated!

Here's Part One again:

Those were Democratic Senate Minority Leader Chuck Schumer's words tonight in response to Republican Senate Majority Leader Mitch McConnell's claims that those on the left were "celebrating" the defeat of his Godawful "Skinny Repeal" bill late Thursday night. And that's a perfect description of how I feel, for several reasons:

  • 1. This wasn't so much a case of an "Actively Positive" thing happening (as was the case with, say, the Obergefell v. Hodges Supreme Court decision) as it was stopping a negative thing (as was the case with the King v. Burwell SCOTUS decision, which actually was announced the very same day as Obergefell). That is to say, it's not that a good piece of legislation passed, it's that a bad piece of legislation was blocked. This isn't to minimize the importance of what just happened tonight (not just in terms of healthcare policy, but also the state of our democratic process, legislative norms and of course the ramifications for the rest of this ongoing nightmare we call the Trump Administration), but it does tend to dampen my emotional response a bit.
  • 2. As I keep stressing: There are real problems with the ACA as it currently stands, and some of them require more than simple "tweaks" as some ACA defenders are prone towards describing them. All of these problems are definitely fixable, but most of those solutions still won't be easy to push through. Furthermore, these issues are exacerbated by two other problems:
  • 3. THE CLOCK IS TICKING for 2018: The final carrier rate filing deadline is rapidly approaching; the carriers need to make their final decisions about how much to charge next year soon...assuming they decide to stick around the individual market next year at all, which isn't a guaranteed thing, especially due to...
  • 4. THE TRUMP SABOTAGE FACTOR will now almost certainly go into overdrive. I'm about 90% certain that Trump will indeed pull the plug on Cost Sharing Reduction reimbursement payments staring next month (August), which could still devastate the indy market almost instantly. Of course, Congressional Republicans could resolve the CSR issue in about 5 minutes with a simple, 87-word bill which would receive unanimous consent from every Democrat in both the House and Senate as long as it was either standalone or not attached to some other poison pill piece of legislation.

    For that matter, while the individual mandate repeal died with the "Skinny Repeal" bill failing, House Republicans have also started pushing through a different bill which would prevent the IRS from enforcing the individual mandate anyway, causing the exact same problems. And even if that doesn't happen, HHS Sec. Tom Price could simply start issuing hundreds of thousands of highly-questionable "hardship exemptions" letting pretty much everyone off the hook for the mandate penalty anyway...which, once again, would amount to the same fallout.

...and so on and so forth.

HOWEVER, having said all of that, for the moment, I'm going to allow myself the most basic of celebration anyway. I think we've earned it...

For the past six months, I've been giving a PowerPoint presentation to various activist clubs/meetings around Southeast Michigan about the Affordable Care Act and Republican attempts to repeal it, including the basics of how the ACA was supposed to work, which parts are and aren't working (and why), how I'd recommend fixing the real problems and, of course, just what the heck the GOP has been trying to do to tear it all apart.

Many people have requested an online version of the slideshow. I posted an earlier version of it this past spring, but obviously things have changed dramatically over the past few months.

I've updated and enhanced about 3/4 of the slideshow. Unfortunately, I haven't had a chance to update the GOP repeal section yet--it's sort of a mish-mash of AHCA and BCRA slides right now, but I thought it was more important to get it posted for the moment under the circumstances.

Then again, that section keeps changing every five minues anyway, so perhaps it's just as well if I hold off on that part. I'll swap out this version for a newer one at a later date.

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