Earlier this year, I crunched a mountain of numbers to try and put together an estimate of just how many people are at risk of losing healthcare coverage completely if & when the Affordable Care Act is "cleanly" repealed--that is, a full and complete repeal of the entire law, without any other significant healthcare law replacing it whatsoever. My rough estimate? Around 24 million people, broken out by Congressional District.

Sometime after that, the Congressional Budget Office ran the numbers to see just how many people they expected would lose healthcare coverage if the GOP's American Health Care Act (Trumpcare) "Obamacare replacement plan" were to be signed and put into effect. Their conclusion? ALSO around 24 million people.

UPDATE 4/04/17: Yes, I've added yet another item to the list and have also decided to make each entry separate (instead of piggy-backing a few of them onto others) bringing the total up to an even 20. I should be noted that in a few cases, one or two of these ideas could potentially take the place of one or two of the others. For instance, a properly financed and structured reinsurance program (#10, just added) could potentially make raising the income threshold on APTC assistance (#6) moot...or at least lessen the need for it. It's also possible that if a bunch of these were to be implemented, a couple of the others, such as increasing the individual mandate (#7, which I can't imagine would ever happen anyway) might no longer be necessary.

UPDATE: If you scroll all the way to the bottom, I've added a completely updated state/national-level table as well, reflecting both the "clean repeal" and Trumpcare scenarios.

As I noted a few days ago, the Center for American Progress has outdone me. I crunched the numbers and broke out roughly how many people would lose healthcare coverage assuming the Affordable Care Act were to be fully repealed, with immediate effect and no replacement healthcare legislation whatsoever--that is, kicking nearly 15 million Medicaid expansion enrollees, over 750,000 Basic Health Plan enrollees and roughly 8.2 million significantly-subsidized individual market exchange enrollees off of their policies all in one shot. Add it all up and it comes to roughly 24 million people nationally.

As I posted yesterday, here's a rough overview of what total Individual Market Enrollment has looked like since 2010, and how Trump's threat to cut-off CSR reimbursements would impact it:

The blue section is off-exchange enrollees...around 7 million people today, all of whom are paying full price. This includes perhaps 1.8 million people still enrolled in Grandfathered or Transitional plans (which are part of a separate risk pool), although that number is highly speculative.

A couple of weeks ago, I crunched the numbers from a major state-by-state study by the Milliman actuarial firm and concluded that the overall individual market was somewhat smaller than I had previously thought, and was likely around 17.7 million people total as of today. The key thing to keep in mind is that the enrollment numbers can fluctuate quite a bit over the course of the year due to the high churn rate and other factors. As a result, the average annual enrollment can be quite different from the snapshot in time total.

Case in point: Here's what healthcare analytical firm Mark Farrah Associates had to say as of last September:

Those who appreciate irony will love this one.

If you enroll in an ACA exchange policy via HealthCare.Gov (or any of the state-based exchanges), you have three options for the Advance Premium Tax Credits:

  1. You can decline to even see if you're eligible (if your income is high enough that you're certain that you won't qualify)
  2. You can see if you're eligible, and if so, choose to apply some or all of the APTC directly to your monthly premium
  3. You can see if you're eligible, and if so, choose not to apply any of the APTC to your monthly premium, choosing instead to pay full price up front and then receive the full annual tax credit when filing your taxes the following year.

While the ACA is working very well for millions of people, there are also two groups for whom it has serious problems.

The first are those caught in the Medicaid Gap...incomes below 100% FPL, living in the 19 GOP-controlled states which chose not to expand Medicaid.

Standard & Poor's, December 22, 2016:

Well THAT figures: Insurance carriers finally breaking even on ACA exchanges just in time for GOP to tear up the law.

Health insurers may finally be seeing improved results on their Obamacare plans just as a newly elected president is poised to follow through on promises to end the controversial coverage program, a new report suggests.

An analysis out Thursday says that health insurers are expected in 2016 "to start reversing" financial losses on their Obamacare business after "hitting bottom" in 2015.

And 2017 "will likely see continued improvement" for those insurers selling individual health plans, "with more insurers getting close to breakeven or better," according to the report by Standard and Poor's Global Ratings.

Last year Virginia was the first state out of the gate with their initial 2017 individual & small group market rate filings. I'm not sure if this is chance or if they simply have the earliest filing deadline. I'm guessing the latter, because, as Zach Tracer noted earlier today, Virginia is again the first state to list their 2018 Individual and Small Group Market participants. Remember, these are initial filings only, and very much subject to change throughout the summer and early fall. Here's who Tracer says has stated is committing to being on the ACA exchanges this fall...at the moment, anyway:


UPDATE: ...or, perhaps not. Latest word is that there's basically little to see here; lots of big talk about pushing forward but very little action. Or perhaps there will be next week, who the heck knows? Wash, rinse, repeat.

On March 24th, just after the AHCA (Trumpcare) bill was yanked from the House floor with literally minutes to go, I posted the following headline:

CELEBRATE A FEW HOURS. Then come back and read this.

Well, according to Matt Fuller and Jonathan Cohn of the Huffington Post, Trumpcare 2: Electric Boogaloo may indeed be a go:

As far as I can tell, even the amazing Louise Norris hasn't caught this one yet (and it's a month old, too!). If I'm wrong and she has done a write-up on it, of course, I'll eat my words:

Medicaid for all

Democratic [Nevada] Assemblyman Mike Sprinkle has introduced a bill, AB374, to open up the state’s Medicaid program to anyone, regardless of their income level.

Individuals would be able to purchase coverage through Medicaid on the healthcare exchange for an annual premium set at 150 percent of the median expenditure paid on behalf of Medicaid enrollees in the preceding fiscal year. Though none of the current federal or state dollars going to fund Medicaid would be used to cover any portion of the new enrollees, they would still be entitled to the same benefits provided to other Medicaid recipients.


Watch the 4-minute clip above and weep.

If you can't hear it, here's the transcript of California Democratic U.S. Senator Diane Feinstein's response when asked how (not if, mind you...how) she would support moving to a Single Payer healthcare system:

She starts out by making an incredibly tone-deaf and inaccurate statement about single payer:

"If by ‘single payer’ you mean that it’s going to be a complete takeover by the government, of healthcare, then I am not there.

As most people know by now (well, most people in Tennessee, anyway), Humana decided a full two months ago to bail on the entire individual market, across the board--every state, both on and off the exchange, the works. This stung in quite a few counties across 11 different states, but the one which everyone is freaking out about is Tennessee...because there are 16 counties where Humana was the only carrier participating on the ACA exchange. Here's the list of Tennessee counties Humana is available in this year; note that there's an additional 14 counties where there's one other carrier available at the moment.

While I've been embroiled in the sturm und drang at the national level, Louise Norris of healthinsurance.org has been reporting on some important stuff happening at the state level:


Hawaii no longer has a SHOP exchange; Lawmakers consider bill to preserve the ACA and expand Medicaid to 250% FPL

As of 2017, Hawaii no longer has a SHOP exchange for small businesses. The State Department of Labor and Industrial Relations has an FAQ page about this.

...Hawaii’s waiver aligns the ACA with the state’s existing Prepaid Health Care Act. Under the Prepaid Healthcare Act, employees who work at least 20 hours a week have to be offered employer-sponsored health insurance, and can’t be asked to pay more than 1.5 percent of their wages for employee-only coverage (as opposed to 9.69 percent under the ACA in 2017). 


Exactly one month ago, I asked a rhetorical question:

How High will Initial 2018 Rate Hike Filings Be?

...and then went on to conclude that, given the insane amount of uncertainty and confusion about what Donald Trump, Tom Price and the Congressional GOP in general has in mind for the 2018 insurance market, on top of normal stuff like inflation, an aging population and so on, that there are five likely scenarios:

Now, put yourself in the position of an insurance carrier executive and/or one of their actuaries. The level of uncertainty in the air is mind boggling. You have five choices for your initial filing:


Tom Cotton at townhall: still supports repealing ACA but commits to protecting coverage for 300k Arkansans dependent on Medicaid expansion.

— David Ramsey (@ArkDavey) April 17, 2017

(says this is key reason he opposed AHCA, which would have eliminated the Medicaid expansion altogether)

— David Ramsey (@ArkDavey) April 17, 2017

Just so we're clear here: