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2018 MIDTERM ELECTION

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Unfortunately, the full article is locked behind the paywall, but Taegan Goddard's WonkWire reports that "some" of the 36 states being run through HC.gov are taking various measures just in case the Halbig decision is ultimately upheld:

Wall Street Journal: “A number of states are scrambling to show that they—not the federal government—are or will soon be operating their insurance exchanges under the 2010 health law, in light of two court decisions this week.”

“The efforts are aimed at ensuring that millions of consumers who get insurance through the exchanges would be able to retain their federal tax credits if courts ultimately rule against the Obama administration.”

“Amid the uncertainty, some of the 36 states in which the federal government has a role in the exchanges are moving to shore up their status. Some are saying publicly that their exchanges have always been state-operated. Others are trying to make the case that they should be considered to have state exchanges regardless of federal involvement. Still others, such as Arkansas, are pushing ahead to take over their exchanges, which would likely free them from the effects of any court decision.”

The last time I updated the Kentucky numbers, all I had to go on was a rough number of around 450,000 people enrolled via Kynect, without any breakdown between private QHPs and Medicaid enrollees. At the time, I took the official 4/19 numbers and then assumed a 90/10 Medicaid/QHP split for the additions since then. This gave me an estimated breakdown of around 87K QHPs & 363K Medicaid.

Today, while there's no updated numbers provided, Joe Sonka over at LEO Weekly brings a hard breakdown of how the 4/19 Medicaid numbers break out:

Yes, 49 people is pretty tiny even for a state with as low an uninsured population as Hawaii, but it's still further evidence that the drop in QHP enrollments in the first week or so of July was either a typo or a data entry glitch, as the total has since risen for 2 weeks straight. SHOP enrollments haven't changed since 7/15:

Connector Updates as of July 19, 2014

33,042 Applications completed in the Individual Marketplace
9,724 Individuals and families enrolled in the Individual Marketplace
689 Employers applied to SHOP Marketplace
1071 Employees and dependents enrolled via SHOP Marketplace*

* as of July 15, 2014

While all the fuss & bother over the Halbig case continues to get bopped around by every pundit under the sun (including me? Do I count as a pundit now?), the ACA itself continues to actually, you know, work as another 8,400 people are added to Medicaid via the expansion program here in Michigan:

Healthy Michigan Plan Enrollment Statistics

Beneficiaries with Healthy Michigan Plan Coverage: 334,599
(Includes beneficiaries enrolled in health plans and beneficiaries not required to enroll in a health plan.)

*Statistics as of July 21, 2014 
*Updated every Monday at 3 p.m.

(Note that this is actually as of a week ago...there should be another update later this afternoon...)

As there are an estimated 500K eligible for the expansion program, this means that Michigan has already reached 2/3 of the total in less than 4 months.

A whole lot more has been & is being written about the Halbig decision & implications for the future of the ACA exchanges; here's three pieces I find most noteworthy:

First, Joey Fishkin at Balkinization expresses my "domain & a splashpage" workaround solution far more eloquently than I did:

So one important practical question Halbig raises is this: what makes a state exchange a state exchange?  If the view of the 2-1 majority in Halbig were to prevail at the Supreme Court (a prospect I’d still consider unlikely, because the reading of the statute is so wildly implausible), then what is the minimum a state can do that counts as a “state exchange” for purposes of receiving the federal subsidies? 

Nice find by Esther F. The main focus of the story is that a 5th insurance company has decided to join 4 others on New Mexico's ACA exchange, which is of course good news for competition, the free market and so forth...

The newest insurer is CHRISTUS Health Plan of Texas, Franchini said during a meeting of the NMHIX board in Santa Fe.

“CHRISTUS is a nonprofit and they will be on the exchange. They will be the fifth carrier on the exchange,” Franchini said.

CHRISTUS will join New Mexico Health Connections, Presbyterian Health Plan, Blue Cross and Blue Shield of New Mexico and Molina Healthcare of New Mexico as the firms that will sell in the individual exchange.

...however, Esther notes a potentially far more significant section of the story farther down. The backstory is this: New Mexico has been planning on running their own exchange for the 2nd year of open enrollment, but has more recently been having second thoughts given the various technical issues faced by some of the other state exchanges. Therefore...

So, this morning's big Halbig-related development is that Reason.com has dug up a video of a presentation by MIT economist Jonathan Gruber from January 2012. Gruber was one of the main architects of the health insurance law in Massachusetts (RomneyCare) and the national version (the ACA, aka Obamacare). In his presentation, Gruber states:

What’s important to remember politically about this is if you're a state and you don’t set up an exchange, that means your citizens don't get their tax credits—but your citizens still pay the taxes that support this bill. So you’re essentially saying [to] your citizens you’re going to pay all the taxes to help all the other states in the country. I hope that that's a blatant enough political reality that states will get their act together and realize there are billions of dollars at stake here in setting up these exchanges. But, you know, once again the politics can get ugly around this. [emphasis added]

OK, yup, that is indeed what he said at the time.

Some of the various state-run exchanges continue to experience assorted technical issues, ranging from minor to serious. I may be rooting for the ACA to work, but as a website developer and a member of the Reality-Based Community, I do need to fully acknowledge that it's not all sweetness & light on the tech side these days. These issues will be resolved eventually, but you can't just ignore them either. So, without further ado...

VermontVPR (Vermont NPR), 07/23/14: Lawmakers Angered By Continuing Problems At Health Exchange

 Snowballing technological problems at Vermont’s online insurance exchange are drawing new scrutiny. And advocates warn that the situation for many customers who bought plans through Vermont Health Connect is becoming increasingly dire.

Washington State: Union Bulletin, 07/22/14: Washington state health-care exchange sounds alarm

OK, with all the fuss about the Halbig decision, people have been flooding me with a bunch of stories about both that as well as other ACA-related topics. I can't address them all fully, so here they are in bite-sized format:

Tara Culp-Ressler, Think Progress, 07/24/14: Obamacare Has Helped Americans Save Nearly $2 Billion On Their Insurance Premiums

Millions of Americans can expect to get a refund from their insurance companies this year, at an average of about $80 dollars per family, thanks to a little-known Obamacare provision that’s helping people save money on their premiums. According to a new report released by the Health and Human Services Department on Thursday, Americans across the country have received a total of $1.9 billion dollars in rebates since this provision first took effect in 2011.

Amy Fried, Bangor Daily News, 07/24/14: Supreme Court already said DC Court was wrong on Obamacare subsidies

Normally this would be a lengthy entry, but given that there have already been 4 other major national surveys saying the same thing, the latest news is just locking things down.

The New England Journal of Medicine just published a new report which concludes (shocker) that there's been a net reduction in the number of uninsured U.S. adults by around 10.3 million since the ACA exchanges went into effect:

As compared with the baseline trend, the uninsured rate declined by 5.2 percentage points by the second quarter of 2014, a 26% relative decline from the 2012–2013 period. Combined with 2014 Census estimates of 198 million adults 18 to 64 years of age,19 this corresponds to 10.3 million adults gaining coverage, although depending on the model and confidence intervals, our sensitivity analyses imply a wide range from 7.3 to 17.2 million adults.

OK, I've had a chance to download the actual Excel file with the raw data and a handy graph already set up; I've cleaned up and color-coded the graph, and it's fascinating to look at, both during open enrollment as well as since it ended The things which stand out the most:

  • The obvious dead zone in October and most of November, finally coming to live around Thanksgiving time
  • The gradual rise in December, culminating in a large spike on Christmas Eve (the "official" deadline for January 1st coverage, although that varied in some states)
  • The massive spike in late March, culminating in a nearly off-the-chart peak on the "official" open enrollment deadline of March 31st, which saw over 200,000 transactions by itself

Yes, I'm quoted in this breaking story; Mr. Ornstein contacted me earlier today to ask my thoughts on his scoop, and I agreed to keep mum until it went public:

For months, journalists and politicians fixated on the number of people signing up for health insurance through the federal exchange created as part of the Affordable Care Act. It turned out that more than 5 million people signed up using Healthcare.gov by April 19, the end of the open-enrollment period.

But perhaps more surprising is that, according to federal data released Wednesday to ProPublica, there have been nearly 1 million transactions on the exchange since then. People are allowed to sign up and switch plans after certain life events, such as job changes, moves, the birth of a baby, marriages and divorces.

Now, before everyone jumps on the "1 million" figure, a few important things:

When I posted my dumb-simple solution/workaround to resolve the Halbig decision back on July 2nd (assuming that it's upheld, which is by no means guaranteed), I meant it seriously, but figured that no one else would. I mean, really...the salvation of the most important healthcare law of the past 50 years and the single most important accomplishment of the Obama administration could end up being as simple as registering 3 dozen domain names and putting up a splashpage?

First, remember the news from yesterday that the ACA had lopped California's uninsured rate in half, from 22% down to 11% as of June? 22% of 38 million people = about 8.36 million; half of that is 4.18 million.

Next, remember that massive backlog of 900,000 new Medicaid (aka Medi-Cal) enrollees that California was working with as of the end of May?

Well, guess what?

For months, the state has labored under the largest such pile-up in the country, with 900,000 pending cases reported in May—the combined result of unexpectedly high application numbers and bug-ridden computer systems.

Regular readers of this site know that I have a checkered history with Forbes writer Chris Conover. It's been mostly on the hostile side, but he's also occasionally brought up a valid point which I've incorporated into my estimates; in particular, the "Sub26er" estimate has been changed from a flat 3.1 million to a range between 1.6 - 3.1 million in part due to his information (as well as Glenn Kesslers'). I believe the term which applies on both of our parts is "grudging respect" though I could be wrong at his end.

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