2018 MIDTERM ELECTION

Time: D H M S

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.

Vermont is the 4th state to post their initial 2018 rate filings. Vermont has a couple of unusual policies re. their healthcare market: First, while they do technically have an off-exchange individual market, those policies are all fully ACA-compliant QHPs and are tracked exactly the same as on-exchange QHPs, meaning this dashboard report from February includes just about all of their individual market enrollees: 28,775 on exchange + 5,662 off-exchange, for a total of 34,437 ACA-compliant enrollees. Vermont didn't allow transitional plans, so aside from an unknown number still enrolled in grandfathered plans, that should represent their entire individual market.

  • Total U.S. Population as of 2009: Around 306 million people
  • Total # of Mothers in U.S. as of 2009: Around 85.4 million
  • Assuming this ratio hasn't shifted much over the past 8 years, around 28% of the total U.S. population are mothers,

Of course, women over 64 (mostly on Medicare) are much more likely than the general population to be mothers...but girls under 18 are far less likely to be (well...under 16, anyway...the birth rate varies from state to state, of course), so I'm assuming that these cancel each other out, resulting in that 28% rate being roughly accurate.

If so, this means that out of the estimated 24 million people who would lose their healthcare coverage if GOP's "American Health Care Act" were to be signed into law, roughly 6.7 million would likely be moms.

I pretty much stole that headline from Politico, but how else was I supposed to word it?

Senate Republicans are working on a potential breakthrough that could help push through an Obamacare repeal bill – by making insurance subsidies look a lot like Obamacare.

There’s growing support for the idea of pegging the tax credits in the House repeal bill to income and making aid more generous for poorer people. But those moves — while they may win consensus among Senate moderates — are unlikely to sit well with House conservatives.

The financial assistance in the House bill “is just not robust enough to make sure that low-income individuals can actually afford a [health] plan,” said Sen. John Hoeven (R-N.D.). “If you bring those income limits down for people who really need the help, you can give them more help.”

Over the past year or so, Andrew Sprung of Xpostfactoid, Michael Hiltzik of the L.A. Times and I have repeatedly noted that as much as most insurance carriers may be griping about the individual market, their bread and butter is generally in other divisions, including the large group market but especially Managed Medicaid and Medicare Advantage:

The expansion of Medicaid benefits, thanks largely to the Affordable Care Act, helped increase enrollment in private health plans by 3.4 million in the last year,according to a new report from consulting firm PwC.

...PwC said 73% of Medicaid beneficiaries — or 54.7 million of the 75.2 million Americans covered by the health benefit program for the poor – are enrolled in private plans that contract with the Medicaid program.

...But the growth in the last year wasn’t as fast as 2015 when health plans added more than 8 million Medicaid beneficiaries as more states agreed to expand such coverage under the ACA.

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