You may have noticed that among my 16 recommendations for repairing/improving the ACA, I foolishly failed to include one of the most important/obvious ones: Reinsurance. I didn't include it for two reasons: Partly because, quite frankly, I simply forgot about it and feel bad about myself now.

So far, two states (Alaska and Minnesota) have already established their own state-based reinsurance programs; in both cases, it was done as an act of sheer desperation...and, in both cases were put through in a bipartisan fashion (both states have GOP-held legislatures, but Minnesota's Governor is Democratic while Alaska's is Independent):

Alaska: Approved *unsubsidized* 2017 indy mkt rate hikes: 7.3%

There was a time, just a few months ago, when it looked like Alaska, which had already suffered from massive rate hikes the past 2 years due to their unique healthcare situation, might have a complete catastrophe on their hands with a third year of massive individual market rate hikes.

This morning, I posted the following:

...the assumption is that as long as insurance carriers either a) know they'll make a profit in a given market or b) think they'll make a profit at some point in the near future, they'll participate in that market, right?

However, that's not necessarily the case. As we saw last year in the case of Aetna, profitability itself doesn't necessarily guarantee participation. Aetna pulled out of 11 states, and while they were losing money on the indy market in most of them, there were at least 2 states (Pennsylvania and Florida) where they were making a profit, yet bailed anyway. In fact, in Florida, the only reason they were making a profit in the indy market was because of their exchange business (they were losing money off-exchange).

I see that I've been thrown into the crossfire of a wonk debate between John Cochrane (who I've never actually heard of before today) and Brad DeLong/Paul Krugman (both of whom I very much have heard of!) regarding the question of whether the individual healthcare market is or isn't in a Death Spiral and/or whether it will/won't enter one next year.

Back in January, the Congressional Budget Office concluded that, overall, they didn't see any death spiral forming if the ACA is kept mostly intact...but also concluded that growth of the exchange population has likely plateaued; around 13 million appears to be the enrollment ceiling barring any significant changes to the law. Interestingly, however, a couple of weeks ago they concluded that there would also be no death spiral if the GOP's AHCA "replacement" plan were to become law either.

Meanwhile, over at the Brookings Institute, Matthew Fiedler ran his own analysis of the exchange risk pool and concluded "No Death Spiral!" there either:

According to the official CMS report for the 2017 Open Enrollment Period, 53,024 New Hampshire residents "selected a Qualified Health Plan" from the ACA exchange as of January 31st.

Of course, as I (and others on both sides of the political spectrum) have written about many, many times, not everyone who selects a QHP (either on or off the exchanges) actually pays their first premium, and therefore is never actually enrolled in an active, effectuated policy. This amounted to roughly 12-13% of all QHP selections in 2014, but has improved over the past 3 years as people got used to how the system works and technical improvements were made. I've been using a 10% non-payment rate as a general rule of thumb for some time now.

Of the 31 states which have expanded Medicaid under the Affordable Care Act, only a handful issue regular monthly or weekly enrollment reports.

Back on February 28th I noted that ACA Medicaid expansion enrollment across three states (Michigan, Louisiana and Pennsylvania) had grown by about 35,000 people since mid-January, to 667K, 406K and 716K people respectively.

Today, a month later, I decided to take another look at all three states, along with Minnesota (which I forgot to check last month). Sure enough, enrollment has continued to grow in all four, albeit at a slower pace:

 

(This is an updated version of a post from February 1st):

COSMO: When I was in prison I learned that everything in this world, including money, operates not on reality...

MARTY: ...but on the perception of reality.

COSMO: Posit: People think a bank might be financially shaky.

MARTY: Consequence: People start to withdraw their money.

COSMO: Result: Pretty soon it is financially shaky.

MARTY: Conclusion: You can make banks fail.

COSMO: Bzzzzt! I've already done that. Maybe you've heard about a few? Think bigger.

MARTY: Stock market?

COSMO: Yes.

MARTY: Currency market?

COSMO: Yes.

MARTY: Commodities market?

COSMO: Yes.

MARTY: Small countries?

COSMO: I might even be able to crash the whole damned system.

Friday, January 20th:

As noted a few weeks ago, Humana has already decided that regardless of what actions Donald Trump, Tom Price or Congressional Republicans end up doing (or not doing), they expect the 2018 individual market to be a big mess they want no part of...either on or off the exchanges:

...based on its initial analysis of data associated with the company’s healthcare exchange membership following the 2017 open enrollment period, Humana is seeing further signs of an unbalanced risk pool. Therefore, the company has decided that it cannot continue to offer this coverage for 2018. Through the remainder of 2017, Humana remains committed to serving its current members across 11 states where it offers Individual Commercial products. And, as it has done in the past, Humana will work closely with its state partners as it navigates this process.

Again, it's important to stress that Humana isn't just bailing on exchange participation, but to the best of my knowledge, they're pulling up stakes off-excahnge as well.

via TV Tropes:

Synthetic Plague

So The Plague is wreaking havoc on the world's population. Maybe Super Flu has killed millions, or some unknown biological agent is causing people to snap and kill each other. Heck, maybe we even have a good old fashioned Zombie Apocalypse on our hands. Either way, it's safe to say that for most of humanity, these are not fun times. How could things get much worse, you ask?

By the revelation that the disease in question has been manufactured by genetic engineering, and possibly is distributed by humans. The untold amount of death and destruction has been directly caused by the foolish or malicious action of Man himself.

It may have been designed for use as a biological weapon, or an unexpected result of an experiment gone wrong. Perhaps we just shouldn't have let monkeys watch TV for too long. However it came to be, it has now been unleashed on humanity at large, and has almost certainly gone far beyond what its designers had originally intended.

There's been a lot of talk, by myself and others, about just which populations would be screwed over by a full repeal of the Affordable Care Act. Analysts, reporters and pundits have sliced and diced the numbers every which way...by race, income level, geography and of course political leanings.

Of course, this gets awfully messy right out of the gate because some ACA provisions apply to everyone in the country, such as the cap removal on annual/lifetime coverage limits; the reassurance that you can't be denied coverage for having pre-existing conditions (which applies to those covered by employer insurance as well, I should note, since many of them may have to switch jobs or be without one at some point in their lives), and so on. Other benefits apply to subgroups which aren't talked about much, such as the Medicare fund being extended by years and the Medicare Part D "donut hole" being closed.

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.

Politico, January 26th:

The Trump administration has pulled the plug on all Obamacare outreach and advertising in the crucial final days of the 2017 enrollment season, according to sources at Health and Human Services and on Capitol Hill.

Even ads that had already been placed and paid for have been pulled, the sources told POLITICO.

...Individuals may still sign up for Obamacare plans until the Jan. 31 deadline — but the Trump administration isn't advertising that fact any longer.

It is also halting all media outreach designed to spur signups in the days leading up to the deadline. Emails are no longer being sent out to individuals who visited HealthCare.gov, the enrollment website, to encourage them to finish signing up. Those emails had proven highly successful in getting stragglers to complete enrollment before the deadline.

Ron Pollack, executive director of Families USA, a consumer group that supports the law, called the decision "a mean-spirited effort that can only result in fewer people getting coverage who need it."

 

Robert Costa in the Washington Post:

President Trump called my cellphone to say that the health-care bill was dead

President Trump called me on my cellphone on Friday afternoon at 3:31 p.m. At first I thought it was a reader with a complaint since it was a blocked number.

Instead, it was the president calling from the Oval Office. His voice was even, his tone muted. He did not bury the lede.

“Hello, Bob,” Trump began. “So, we just pulled it.”

...The Democrats, he said, were to blame.

...Trump said he would not put the bill on the floor in the coming weeks. Instead, he is willing to wait and watch the current law continue and, in his view, encounter problems. And he believes Democrats will eventually want to work with him on some kind of legislative fix to Obamacare, although he did not say when that would be.

Late last night, just a few hours ahead of the actual vote in the House of Representatives, the House GOP released their final changes to the American Health Care Act (AHCA), otherwise known as Trumpcare. The last-minute changes range from pointless to insulting to disastrous:

  • It tacks on an additional one-time $15 billion to the "State Stability Fund", supposedly to cover maternity, newborn care and mental health services.
  • It pays for the above by holding onto the existing 0.9% Medicare tax on people earning over $200,000 for another 6 years
  • And, most significantly, it would get rid of the requirement that all qualifying healthcare policies cover the 10 Essential Health Benefits mandated by the federal government.

I want to take a moment to address the first two bullet points above, because they're basically the exact same thing that Paul Ryan did a few days earlier.

The original version of the AHCA would have resulted in older Americans having to pay exhorbitant premiums due to the idiotic restructuring of the tax credit system and the 5:1 age band change. This led the AARP to unleash their army to understandable scream bloody murder at Congressional town halls nationwide.

In response, the GOP added an oddly-worded amendment which "instructed" the Senate to pony up $85 billion which would be used to "increase tax credits for 50-64 year olds" in some vague fashion. Why they didn't simply cross out "$4,000" and replace it with "$10,000" in the language of their own text I have no idea, but whatever. The point is that they gummed up the works for older enrollees, got screamed at for it, and responded by throwing a boatload of cash at those folks to get them to STFU.

 

If it was any other politician, I'd call this a strategic bluff to try and get the bill to pass:

UPDATE: 7:42 p.m.: President Donald Trump is demanding a vote Friday in the House on the Republican plan to repeal and replace Obamacare, White House Budget Director Mick Mulvaney said. If the bill fails, Trump is prepared to move on and leave Obamacare in place, Mulvaney said.

In the case of Donald Trump, however, he could mean it. He doesn't actually give a rat's ass about healthcare or helping people anyway; the only reason he wants to repeal the ACA is because a) it'd let him stick it to Barack Obama; b) it'd give him another tax cut and c) he'd get to brag about "winning" by finally slaying the mighty Obamacare Beast, etc.

A couple of weeks ago, the Congressional Budget Office projected that Trumpcare 1.0, aka the "American Health Care Act" or AHCA would kick 14 million people off their healthcare coverage next year alone, followed by an additional 10 million getting the boot by 2026. It would, however, save the federal government around $336 billion over that time period, which was pretty much the only positive part of their analysis.

Unfortunately, it also meant that a 64-year old earning $26,500 per year would end up having to spend about 60% of their entire gross income in order to pay for health insurance even after their tax credits.

This didn't go over too well with the "moderate" wing of the House GOP, as the AARP crowd wouldn't stop screaming at them during town halls nationwide. Meanwhile, the "Freedom Caucus" (basically, the ultra-batcrap insane wing as opposed to the only-kinda-insane members) was angry because the Trumpcare bill didn't hurt enough people quickly enough.

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