2018 MIDTERM ELECTION

Time: D H M S

UPDATE 5/19/17: I'm dusting this off again because it looks like (shocker) Trump has changed his mind again regarding whether or not he'll have HHS continue making CSR payments or not. According to Politico:

Trump said to favor move that could destabilize Obamacare

President Donald Trump has told advisers he wants to end payments of key Obamacare subsidies, a move that could send the health law's insurance markets into a tailspin, according to several sources familiar with the conversations.

Many advisers oppose the move because they worry it will backfire politically if people lose their insurance or see huge premium spikes and blame the White House, the sources said. Trump has said that the bold move could force Congressional Democrats to the table to negotiate an Obamacare replacement.

Lawyers and other administration officials are trying to thread the needle.

via Kayla Tausche of CNBC:

The House of Representatives and Department of Justice plan to ask the DC federal appeals court to keep on hold for another 90 days a lawsuit that questions the legality of cost-sharing subsidies in the Affordable Care Act, according to four people familiar with the matter.

The White House, during that time, will continue to make payments to insurers, according to a senior administration official.

OK, assuming they do indeed ask for this, and assuming the court grants a third 90-day extension, this means that CSR reimbursement payments can continue for another 3 months. That's the good news.

Insurers planning to offer plans on the exchanges in 2018 must submit their pricing in the coming days and weeks.

This is the actual headline of an actual article posted on Breitbart.com right now:

I'm loathe to link to the article itself (I did include one somewhere on this page, feel free to look for it), but a Google search will bring it up. Even more remarkably for Breitbart, much of it is actually pretty darned accurate:

Obamacare will go into a death spiral on May 22 if the Trump administration chooses not to continue fighting in court to preserve cost-premium subsidies that were ruled illegal last year.

On May 12, 2016, U.S. District Court Judge Rosemary M. Collyer ruled House v. Burwell that the Obama Administration’s payment of cost-sharing subsidies without congressional approval was a violation of the Constitution’s Appropriations Clause.

 

About 5 weeks ago I noted that organizations representing pretty much the entire healthcare industry sent urgent letters to Donald Trump, HHS Secretary Tom Price, Treasury Secretary Steven Mnuchin, OMB Director Mick Mulveney and current CMS Administrator Seema Verma...basically, every major healthcare-related administration figure...practically begging them to fund the goddamned Cost Sharing Reduction reimbursements.

They made it crystal clear how vitally important doing this was, and Trump grudgingly went ahead and made the April payment, then later indicated that he was "probably" going to keep reimbursing carriers for the CSR funds legally owed to them on an ongoing basis, at least until the House vs. Price (formerly House vs. Burwell) lawsuit appeal process was completed.

The District of Columbia is the 6th state (OK, it's not a state but it's considered one legislatively for purposes of the ACA) to post their initial 2018 rate filings (h/t to Louise Norris for the heads up). For 2017, the weighted average rate increase for the individual market was a mere 7.3%, highly unusual for this year, while the small group market increase was almost non-existent: Just 0.4% overall.

Over at the L.A. Times, Noam Levey has a fantastic story which underscores everything I've been shouting from the rooftops for months now regarding Trump/GOP sabotage of the ACA exchanges, through both active and passive measures:

Health insurers and state officials say Trump is undermining Obamacare, pushing up rates

Health insurers across the country are making plans to dramatically raise Obamacare premiums or exit marketplaces amid growing exasperation with the Trump administration’s erratic management, inconsistent guidance and seeming lack of understanding of basic healthcare issues.

At the same time, state insurance regulators — both Democrat and Republican — have increasingly concluded they cannot count on the Trump administration to help them ensure that consumers will have access to a health plan next year.

As noted in my last post, it turns out that if the CBO score of the final version of the AHCA (that is, the one which passed two weeks ago) doesn't project the law to save at least $2 billion over a 10 year period, the House Republicans would have to start over again from scratch and re-vote on yet another version of their bill.

Now, the good news for them is that the CBO projected the prior version to save $150.3 billion over that period, so they have $148.3 billion worth of wiggle room, right? What are the odds of the CBO's new projection assuming that the passed version would eat up that much more money?

The key is does CBO assume lots of states waive benefits/community rating, and lots of healthy people use tax credits for skimpy insurance. https://t.co/vLx28MT5Bv

— Larry Levitt (@larry_levitt) May 18, 2017

Here's what Levitt is talking about:

 

Hey, remember this?

Cases upon cases of beer just rolled into the Capitol on a cart covered in a sheet. Spotted Bud Light peeking out from the sheet

— Alexandra Jaffe (@ajjaffe) May 4, 2017

Yeah, well, about that...

via Billy House of Bloomberg News:

House May Be Forced to Vote Again on GOP's Obamacare Repeal Bill

House Republicans barely managed to pass their Obamacare repeal bill earlier this month, and they now face the possibility of having to vote again on their controversial health measure.

One of the biggest Achilles' heels of the ACA exchanges has always been that participation in them by private insurance companies is completely voluntary. There's nothing compelling any particular carrier to offer policies on the exchanges aside from them hoping to make a profit by doing so thanks to the additional policy enrollees, mostly from people who are receiving subsidized coverage via Advance Premium Tax Credits (APTC) and/or Cost Sharing Reduction (CSR) assistance.

This Axios piece by Caitlin Owens is extremely short...a mere 139 words in all...so sticking with a "fair use" quote is tricky, but I'll do my best:

Senate Finance Committee chairman Orrin Hatch says he could support delaying the repeal of the Affordable Care Act's individual mandate for a while, or even indefinitely, as a way to stabilize the marketplaces. "I wouldn't mind" postponing the repeal until after 2020, he told reporters this afternoon. "It all comes down to budgetary concerns and how it's going to be written." And he didn't rule out keeping it even longer:

"I'd like to not have it at all, but you know, it all comes down to, what's the art of the doable?"

Think about this for a moment.

A few days ago, CMS announced that they're retooling the ACA's SHOP program (at least on the federal exchange) so that instead of small businesses using HealthCare.Gov for eligibility verification, enrollment and payments, going forward it will only be used for verification, with the businesses then being kicked over to the actual insurance carrier website in order to actually enroll in the policies and make payments.

Although the Trump Administration and HHS Secretary Tom Price are hell bent on killing off the ACA altogether, this move didn't bother me for several reasons. For one thing, the SHOP program has always been kind of a dud anyway, with only around 230,000 people being enrolled in it nationally. For another, a business signing up their employees for coverage is a very different animal from an individual signing their family up for a policy. Finally, for several reasons, SHOP enrollment across the dozen or so state-based exchanges is actually higher than it is across the 3 dozen states covered by HC.gov, and the state-based exchanges aren't impacted by this policy anyway.

While poking around in the SERFF rate filing database for different states, I occasionally find filings which DON'T apply to ACA-compliant policies or enrollees but which are of interest to healthcare nerds such as myself. I've decided to bundle these into a single post as they pop up, so check this entry once in awhile.

IOWA: Big Kahuna carrier Wellmark submitted a filing for non-ACA compliant small group policies (either grandfathered or transitional) which have effective/renewal dates of July, August or September 2017. The requested rate increase is 7.0% on average, which is pretty typical for small group plans, and it appears that Wellmark had 51,003 people enrolled in such policies as of 12/31/16. Nothing odd there.

What interested me, however, was this sentence:

Julie McPeak is the Tennessee Insurance Commissioner. She was appointed by a Republican Governor, Bill Haslam, and while the position itself appears to be nonpartisan, I've found several links indicating that yes, she's a Republican herself. This is hardly surprising in Tennessee, of course, and there's nothing wrong with it...but it's noteworthy given that Tennessee is among the 19 states which has been fairly hostile towards the ACA in general over the years (no state exchange, no Medicaid expansion, total GOP control and so forth).

I've noted repeatedly that while every year brings some amount of premium rate hikes and/or carriers dropping out of the exchanges (or off the entire individual market), there's a major new factor impacting both this time around: The Trump/GOP Sabotage/Uncertainty Factor. This includes, but isn't limited to:

Oregon is the 5th state to post their initial 2018 rate filings. Last year their weighted average increase was roughly 26.5% across 10 individual market carriers. This year I only see 8 carriers offering policies on the indy market, but the two missing are "Trillium" and "ZOOM", neither of which had more than a handful of enrollees to begin with.

As you can see, ATRIO Health Plans was refreshingly clear in their rate justification letter, not only listing the key numbers (covered lives, average increase) but the reasons for it: 4% due to the reinstatement of the ACA's carrier tax; 1% due to them choosing to shrink their own coverage area from 6 counties to just 2; an increase for smokers., etc. They list 4,250 people being impacted by the increase; I don't know the population of the other 4 counties they're pulling out of, but assuming they're roughly equal, around 8,000 current enrollees will have to shop around this fall.

Regular readers know that generally speaking, I support the ACA overall. They also know that I also have significant criticisms of the law, and have compiled a lengthy list of fixes/improvements both small and large which I feel are necessary to stabilize the individual market. I've also written on occasion about the SHOP provision of the ACA: The small business version of the ACA exchanges.

The idea was to give small businesses with fewer than 50 employees an open marketplace to comparison shop, similar to the individual exchanges, and also to provide some amount of financial assistance to them along the lines of APTC for indy market enrollees. The ACA requires businesses with over 50 full-time employees to provide coverage, but it's voluntary for those under 50, so SHOP has always been more of a courtesy program than a necessary one.

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