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For some time now, I've been railing against Donald Trump's executive order pushing for the expansion of both "Short Term, Limited Duration" plans as well as "Association Plans". I've scornfully referred to his EO with the hashtag #ShortAssPlans.

Something which has gotten lost in the shuffle, however, is that I don't think short-term plans should necessarily be scrapped altogether, at least until we're able to achieve a comprehensive, universal coverage system in the future. Under our current patchwork heatlhcare system, I do think they serve a purpose for certain people in certain circumstances. I just think they need to be strongly regulated and limited in scope, partly to prevent siphoning off healthy people from the individual market risk pool...but partly to prevent people from being hit with financial catastrophe in the event of unexpected high medical expenses.

The problem is that Trump's executive order--which would effectively open the floodgates for them to be mutated into year-round plans, completely destroying one of the major points of the ACA in the first place.


Yesterday morning, Larry Levitt of the Kaiser Family Foundation posted this tweet:

Our polling suggests the public is most likely to blame President Trump and Republicans in Congress for any problems in the insurance market going forward.

— Larry Levitt (@larry_levitt) March 26, 2018

Something about this pie chart seemed awfully familiar to me...

With all the discussion about subsidized enrollees, unsubsidized enrollees, short-term plans, association plans, health sharing ministries and so forth swirling around the ACA stabilization/CSR reimbursement payment/Silver Loading debate, I just wanted to take a quick moment to remind everyone that "The Uninsured" isn't a single amorphous blob; it consists of several fairly specific subsets.

The good news is that the Kaiser Family Foundation is among the most reliable sources for this sort of data in the business. The bad news is that their estimates are out of date--this analysis/breakout was last updated in October 2017, but the actual survey data is from 2016. Needless to say, a lot has changed in the intervening year and a half...namely, the Trump Administration and two full ACA Open Enrollment Periods.

A note about the headline: I originally referred to "ACA 2.0 vs. Trumpcare", but the more I thought about it, the more I realized that as of this moment, Donald Trump and the GOP have only partially mutated the Affordable Care Act into their own warped vision. They've managed to scare off carriers, confuse enrollees, cause unsubsidized premiums to shoot up an extra 18%, and with the repeal of the individual mandate (and potentially the massive expansion of #ShortAssPlans via #RegulatorySabotage) starting next year are about to cause those same premiums to jump another 16% or so on average.



On March 23, 2010, President Barack Obama signed into law the Patient Protection & Affordable Care Act.

Since then, despite a number of real problems with the law and an endless series of ferocious attacks by the GOP, the ACA is still standing. It’s beaten and bloodied, but it’s still the law of the land, and it’s resulted in the uninsured rate being slashed from 48 million Americans in 2013 to 29 million today. 16 million people have been added to Medicaid coverage via ACA expansion, and 9 million are receiving subsidized healthcare coverage via the ACA exchanges.

Thanks to the ACA, no one can be denied coverage based on their medical condition. Women can’t be charged more for their gender. Maternity and mental health services now have to be covered. People undergoing chemotherapy and premature infants requiring neonatal care no longer eat up their lifetime coverage maximum cap within a few months.

OK, this is kind of beating a dead horse since the Alexander-Collins bill is dead anyway, but just for completeness sake:

Last week I pointed out that aside from everything else that's problematic about the abortion restriction language included in the A-C bill, it would also have run into a big legal problem because three states (California, New York and Oregon) legally mandate that major medical healthcare policys cover abortion, in direct opposition to the A-C provision which would deny federal subsidies, CSR assistance or reinsurance funds to...any healthcare policy which covers abortion.

Well, today I can add a fourth state to this list:

OLYMPIA, Wash. (AP) — Gov. Jay Inslee has signed a measure that requires Washington insurers offering maternity care to also cover elective abortions and contraception.

Over a month ago I posted what I assumed was the final 2018 Open Enrollment Report from the Washington HealthPlan Finder. However, it appears that was just a partial report. Today they announced the official version:

The Washington Health Benefit Exchange today announced that 209,802 customers used Washington Healthplanfinder to purchase a Qualified Health Plan (QHP) for 2018 coverage during the most recent open enrollment period. This total is a nearly three percent increase over last year and is 50 percent higher than the number of enrollees recorded following the first open enrollment period in 2014.

A year ago I wrote up my own "wish list" of 22 recommendations for fixing, improving, strengthening and expanding the Affordable Care Act (it's officially 20 items but two of them really should have been split into two entries apiece). I called it "If I Ran the Zoo", and it received quite a bit of praise, even though I didn't come up with most of them myself; it was mostly a compilation of ideas which had been floating around progressive healthcare wonk circles for awhile.

In any event, now that the Republican "ACA stabilization bill" (Alexander-Collins) appears to be dead and buried, I figured it might be helpful to line up both the House and Senate versions of the ACA 2.0 bills to see how they compare to each other as well as to my own list of recommendations.

NOTE: I've modified the headline to clarify that it's CSR reimbursements which are dead, not the actual CSR subsidies. Those eligible for CSR assistance will still receive it from the insurance carriers..it's just that the carriers aren't/won't be reimbursed for doing so. In response, they've jacked up the premium rates on others to cover their losses.

And in the end...neither Alexander-Collins, Alexander-Murray, Collins-Nelson or any other "ACA stabilization bill" was included in the final version of the "must-pass" omnibus bill last night.

As I understand it, this means that unless a standalone bill of some sort passes, there will be no significant legislative changes to the ACA exchange/individual market status for the 2019 Open Enrollment Period at the federal level...and that's extremely unlikely to happen this year.

A couple of weeks ago, several Democratic members of the House of Representatives introduced a new bill designed to significantly improve, strengthen and expand the Affordable Care Act. It's officially titled "H.R. 5155: Undo Sabotage and Expand Affordability of Health Insurance Act of 2018", but I shortened this to simply "ACA 2.0", because that's pretty much what it is.

The House ACA 2.0 bill would check off a half-dozen or so of the 20 items on my (now outdated) wish list of ACA fixes/improvements...but also includes another half-dozen provisions on top of that (many of the additional items would cancel out Trump/GOP sabotage efforts which hadn't even happened when I wrote my "If I Ran the Zoo" wish list a year ago).

A few days ago I warned Congressional Democrats that while I agree that appropriating CSR reimbursement payments at this point would be a net negative move thanks to the clever Silver Load/Silver Switcharoo workaround developed last year, there's one possible cloud surrounding that silver lining, so to speak: What if the Trump Administration were to attempt to put the kibosh on Silver Loading altogether?

I don't know the legality of such a move, mind you, but It has been thrown around the rumor mill of late, so I figured I should remind them to keep that possibility in mind.

Well, today I received some reassurance...

Azar Says He Is Not Aware Of Discussions On Blocking ‘Silver-Loading’ in 2019

Two pieces of welcome news out of the Green Mountain state via Louise Norris at healthinsurance.org:

New legislation will allow Vermont insurers to load cost of CSR only onto on-exchange silver plans for 2019

For 2018 coverage, Vermont, North Dakota and the District of Columbia were the only states that didn’t allow insurers to add the cost of cost-sharing reductions (CSR) to premiums after the Trump Administration cut off federal funding for CSR. In most states, insurers were allowed to either add the cost of CSR to all silver plan premiums, to all on-exchange silver plan premiums, or, in a few cases, to all metal-level plan premiums. But in Vermont, North Dakota and DC, insurers simply had to absorb the cost of CSR, estimated at $12 million a year in Vermont.

As a reminder, for 2018:

It's not about healthcare. It's not about "freedom". It's not about "tyrrany". It's not about "choice". It's about a tiny cadre of absurdly wealthy plutocrats being upset about a tiny fraction of their hoard being used to help out the least-fortunate among us. Via the Congressional Budget Office (graph via Axios):

Huh. This is kind of odd.

Minnesota's 2018 Open Enrollment Period was a month longer than the official half-length period pushed by HealthCare.Gov, but was still over 2 weeks shorter than it had been in prior years, ending on January 14th, 2018. Even so, they reported a slight increase in year-over-year policy enrollees, ending OE5 with 116,358 QHP selections.

Typically, you'd see the official QHP selection number drop off noticeably by the end of the first quarter...usually by around 13% or so. Roughly 10% of those who select policies don't ever actually pay for their first monthly premium, and another 2-3% generally drop off after only paying for the first couple of months.

I'm not sure how I of all people managed to miss this, but Connect for Health Colorado released their official 2018 Open Enrollment Period report over a week ago:

We released our End of Open Enrollment report this week, our most detailed look at the impact we are having across Colorado. This year, you will see that more of our customers are receiving help through the Advance Premium Tax Credit – 69 percent, compared to 61 percent last year – and the average level of monthly tax credit help climbed to $505 from $369 last year.

Not surprising...the 34% average rate increases (about 6 points of which is due specifically to CSR reimbursement payments being cut off...much lower than most states) meant that a lot more people qualified for tax credits in the first place, and of course the amount of credits went up accordingly...a bit more, actually (37% on average).