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Charles Gaba's blog

I've spent the past two months painstakingly crunching the numbers in an attempt to project just how many people would likely lose their healthcare coverage if the ACA were to be: a) fully repealed; b) with immediate effect; and c) without any substantive replacement policy put into its place.

My conclusion, after much analysis, double-checking and updating, is that the grand total would be roughly 24 million people: Around 8.2 million current exchange enrollees, nearly 15 million via Medicaid (expansion or otherwise), and the 750,000+ people enrolled in BHP programs in Minnesota and New York.


I told the following story about two years ago. It bears repeating for a different reason:

When I was 18 years old, my father died of a brain tumor. 

A few weeks after the funeral, I left for college at Michigan State University. Freshmen were required to room blind, so I had no idea who my roommate would be. When I met him, a tall blonde guy named Brian, I was still wearing the Kriah ribbon--a small torn piece of black cloth.

We shook hands, introduced ourselves, and then Brian asked me what the torn ribbon was for. I explained that my father had recently passed away, and that Jewish custom was for mourners to wear torn black cloth as part of the mourning process.

His response?

"Oh, I'm sorry to hear that he's burning in hell right now."

I should note that this was less than 5 minutes after we had met. I was assigned to live in the same room as this guy for the next 9 months.

For 2017, the weighted, average, unsubsidized (that's critical!) premium rate increase for ACA-compliant individual market healthcare policies was roughly 25% nationally.

There were plenty of reasons for this, including normal inflation/healthcare costs; the discontinuation of two of the three stabilization programs (Reinsurance and Risk Corridors, although the RC program had already been sabotaged a year earlier anyway); correction for under pricing by many carriers in the first couple of years of the ACA exchanges; and, of course, the fact that the ACA exchange risk pool continues to be worse than hoped for in numerous states/counties.

Of course, for the roughly 10 million exchange enrollees who are receiving tax credits, this didn't really impact them much at all:

On average, ACA marketplace consumers receiving tax credits are literally paying exactly the same this year as last year -- $106 per month. pic.twitter.com/WzqA6DsWRN

You may have noticed that I haven't been posting as many blog entries the past week or two. This has been partly due to our 5-day power outage, of course, as well as various other personal odds & ends. The main reason, however, is that I've been driving around the metro Detroit area giving a PowerPoint presentation about the ACA and Trumpcare to various groups. Last night was my 4th or 5th presentation, and while it was kind of sloppy and scattershot the first few times, I'm streamlining and modifying for each new event.

Even so, I'm cramming a lot of information into an hour or so, and several people at each event have asked if I could upload the slideshow to the website for easy download.

Therefore, I present: The Affordable Care Act and Repeal/Replace: Where Things Stand (pdf).

Me, February 3:

Of course, it's impossible to prove that the Trump executive-order/ad-kill combo was the cause of the numbers petering out at the end of the enrollment period...but I have some pretty strong evidence that it did.

How? Well, remember, the 12 state-based exchanges, which cover around 1/4 of all Qualified Health Plan (QHP) selections nationally, were not hurt by the ads being killed. The executive order might have had some impact, but the actual HC.gov ads being yanked shouldn't have hurt them much since these exchanges have their own, separate branding, marketing budgets and outreach programs.

I therefore decided to compare how the 39 HC.gov states performed relative to the 12 state exchanges...the results are pretty telling.

...UPDATE 3/16/17: I've updated the tables and chart below with the final, official 2017 Open Enrollment Period numbers from CMS.

As I noted earlier today, CMS has released the official 2017 Open Enrollment Period report, along with a whole mess of State, County and Zip Code-level breakouts and related demographic information, including APTC/CSR recipients, Metal Levels, Income Levels and so on.

This means I now have to dive back into my "How Many Could Lose Coverage?" project and update/revise the numbers for every state, county and Congressional district. Fun times!

On the one hand, this will take some time, so please bear with me. It took nearly 2 months to compile this data for all 50 states; it might take another week or so to update them with the latest numbers. Also note that it may only be the 39 states on the federal exchange which get updated, unless some of the state-based exchanges release their own updated reports.

On the other hand, it's important to note that for most counties/congressional districts, the numbers are likely to be fairly close to where they already are. For example, I've already completed Michigan; here's a before/after comparison:

Moments ago, CMS released the official 2017 Open Enrollment Period final enrollment report. They also released a nice set of bonus data sets at the state, county and even zip code levels, which was unexpected (usually they don't release these until later in the year).

Back in mid-November, I made a Big Deal® about being extremely mistrustful of any official data being released by the federal government after the Trump adminstration took over. I concluded, however, with the following:

In addition, unless I'm mistaken, 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.

Yesterday the CBO pretty much torpedoed the Trumpcare bill. Everyone from across the political spectrum now seems to agree that it's a complete disaster, with the exception of Paul Ryan and Tom Price (hell, even an internal Trump White House analysis apparently concluded that even more people would lose coverage than the CBO did...26 million vs. the CBO's 24 million).

However, there's one part of the AHCA which should be kept: The $100 billion that they currently have allocated to throw at the states to stabilize the individual market. As the CBO noted:

After five days, my power still hasn't been restored, and it's no fun typing with freezing fingers on a cold keyboard, but I had to make an exception for this: The CBO has officially scored the Trumpcare bill.

I'll be writing much more about it over the next few weeks, of course, but for the moment, my initial overview can be found in my latest article for healthinsurance.org. Take a look!


As noted this morning, our power is out and isn't expected to be back up for several days, so my posts will be spotty and brief while we deal with stuff like our kid being out of school, keeping the generator running, etc. However, I just had to post this one.

You've probably already seen this clip, but it's so staggeringly idiotic that I have to repost it here.

Do I even need to explain how gob-smackingly stupid this claim by Paul Ryan is?

...things have been a little hectic around these parts...

I'll try to post an update later this afternoon but, power might not be restored until as late as Sunday, so I have to deal with a whole mess of stuff (including my official day job, of course).

UPDATE 3/13/17: Nope, still out.

UPDATE 3/14/17:


Yup, as of 8:12pm Monday evening, we finally got our power back. Yeesh.


Statements rolling in from advocacy, patient groups. American Health Association, American Hospital Association both won’t support AHCA.

— Sarah Kliff (@sarahkliff) March 7, 2017

Hospitals, nursing homes, physicians, patient advocates all releasing statements that AHCA is unworkable.

AMA's letter is below. pic.twitter.com/lhnbVrc87g

— Andy Slavitt (@ASlavitt) March 8, 2017

Trumpnation day 48-Fallout continues over Trumpcare bill. AMA, AHA, AARP, FAH, AAP, APA, some republicans and all democrats are now opposed.

--Khepri (@khepricorn) March 8, 2017

Has the American Heart Association or American Homerbrewers Association chimed in yet? 

Back in January, being a spreadsheet guy but not being a particularly good graphic artist, I put together a crude table which attempted to give a general idea of which groups of people the Affordable Care Act is, in general, working out for fairly well vs. which groups the ACA isn't working for, by income threshold. A couple of days ago, with details about the GOP's "replacement plan" popping up all over, I posted a similar version of the table which tried to compare the winners/losers between the two plans, and the contrast was remarkable: Nearly a complete reversal.

Last night, with the GOP's plan finally, officially revealed, I made some minor adjustments so that the two tables were more of an apples-to-apples and came up with the following:

Well, the early reviews are in, and it ain't pretty.

Democrats, progressives and patient advocates hate TrumpubliCare, which obviously surprises no one.

The American Health Association and American Hospital Association both hate TrumpubliCare (hoping the American Heart Association chimes in as well so I can make it an "AHA, AHA & AHA hates AHCA" trifecta).

Conservatives hate TrumpubliCare (for very different reasons, of course), which is perhaps more surprising.

So, it's finally here. After seven years and over 100 entries, Huffington Post healthcare reporter Jeffrey Young can finally shut down (or at least archive) his famous "JUST IN TIME!" Storify collection, which has been chronicling the endless empty promises of the Republican Party insisting that their "replacement plan" for the Patient Protection and Affordable Care Act was going to be revealed at any moment.

Yes, after seven years, it's finally here (Part 1) and here (Part 2). It has a catchier title than the ACA ("The American Health Care Act"), which is typical of Republican bills. Remember George W. Bush's "Healthy Forests Initiative", which actually opened previously protected forest areas to logging, often unnecessarily or under false pretense? See, it has the word "American" right there in the title, so it must be good, right? I'll be abbreviating tthis as "AHCA", although they're already annoying me by spelling "healthcare" as two words (I strongly believe it should be one).

Here's the stuff which CAN'T be changed via the reconciliation process, and is therefore not touched...yet. That is, these are changes which would either require 60 votes in the Senate or would require the GOP to kill the filibuster entirely to push through:

  • Guaranteed issue (no pre-existing condition denials)
  • Community rating (can't charge different people more for the same policy outside of a tight set of parameters)
  • The ACA's preventative benefits (I'm not sure if this list changes, but I'd imagine not)
  • No lifetime or annual limits on coverage (a few people have stated otherwise, but this seems to be the consensus)
  • Required essential benefits for every plan on the private market (ie, group or individual)
  • Limits on out-of-pocket costs for enrollees
  • Young adults 19-25 being allowed to stay on their parents' plan (I've noted before that I always suspected this would survive any repeal effort)
  • "Removing the lines" to allow carriers to "sell insurance across state lines" (at least not any more so than the ACA already allows them to)
  • The "Grassley Amendment": Congressional staffers will still have to enroll via the DC exchange in order to receive tax credits.
  • The 80/20 Medical Loss Ratio (requires insurance carriers to refund the difference to enrollees if they spend more than 20% of premium costs on anything other than actual, legitimate medical care)

All of the above sounds great at first glance...but again, keep in mind that for the most part this is only because they can't touch them without 8 Democratic Senators agreeing to do so...or killing the filibuster, which they could still do. That's a hell of a Sword of Damocles to be hanging over everyone's head.

OK, so what would change via the AHCA, assuming they manage to pass it with simple majorities in the House and Senate, and Trump signs it (which I'm certain he would)?