Over at Politico, Paul Demko has an extensive article (with an assist from Adam Cancryn, Jennifer Haberkorn and Rachana Pradhan) which confirms many of the things I've been saying for awhile now...although it also weakens one of my arguments as well. In an odd way, that's entirely in keeping with the overall theme of the article itself. That is, every one of the following statements appears to be true simultaneously:

  • The Trump administration is deliberately sabotaging the ACA exchanges.
  • The Trump administration is sort of trying to shore up the ACA exchanges.
  • Congressional Republicans are full-speed ahead on repealing the ACA.
  • Congressional Republicans are putting the brakes on repealing the ACA.
  • The Individual Market isn't in a Death Sprial yet, but could be next year.
  • The Individual Market is already in a Death Spiral in some states but doing just fine in others.
  • A full replacement plan is ready to go at any moment.
  • A full replacement plan hasn't even made it past the first stages yet.

As Demko puts it:

In a classic case of trying to have it both ways, the Trump Administration is simultaneously taking every action it can to damage/kill the ACA while also taking actions which are supposedly attempting to stabilize it. This is leading to some very...interesting...results, such as this press release sent out an hour or so ago:

CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients. This proposed rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements; and announces upcoming changes to the qualified health plan certification timeline.

After their attempted merger with Aetna was roundly shot down by the federal government, insurance giant Humana issued a press release today with some major news:

Regarding the company’s individual commercial medical coverage (Individual Commercial), substantially all of which is offered on-exchange through the federal Marketplaces, Humana has worked over the past several years to address market and programmatic challenges in order to keep coverage options available wherever it could offer a viable product. This has included pursuing business changes, such as modifying networks, restructuring product offerings, reducing the company’s geographic footprint and increasing premiums.

On Tonight's Episode of As the Stomach Churns...Three ACA repeal-related stories hit the web practically on top of each other.

First, from Sahil Kapur of Bloomberg Politics:

Republicans' Struggles to Replace Obamacare Feel Like Deja Vu All Over Again

Republicans in Congress are hitting roadblocks as they try to devise a plan to replace Obamacare, stuck over issues like how to structure tax breaks they want to give people to buy insurance.

...Republicans, who have spent more than six years vowing to smash the Affordable Care Act, swept into control of the White House and Congress pledging a swift repeal. But they’ve made little progress in deciding how to do that, or what should come next.

...Republicans agreed on vague concepts such as tax breaks, letting insurers sell across state lines and letting states run Medicaid.

But then they hit a wall.

Hey, remember the #RiskCorridorMassacre?

...In fairness, as Adam Cancryn noted in his epic Risk Corridor Autopsy piece, there were a lot of other factors which caused half of the Co-Ops to fail in the first two years. It's possible that some of them would have gone under even with the RC money, and there's no guarantee that all of the remaining ones will thrive or even survive. But there's no denying that the RC payments they were counting on were a major factor, and at least a few of them would almost certainly have survived if not for having the rug yanked out from under them.

So, to review, the end result of Marco Rubio's shenanigans are:

  • up to 800,000 people nationally lost their insurance coverage, on very short notice, and were forced to scramble to find alternate coverage
  • the new coverage these people ended up with is generally more expensive, and in many cases has worse networks
  • the federal government has to therefore pay out more in premium subsidies to cover the increased costs as benchmark plans were increased
  • over a dozen insurance carriers went out of business, meaning hundreds of people lost their jobs
  • the loss of over a dozen carriers means less competition in those markets, therefore less competition, therefore higher premiums, therefore even more cost to the federal government in subsidies to make up the difference
  • since all of the carriers which went out of business were little guys, this also means the big kahunas suck up even more market share
  • the original $2.5 billion which Rubio was supposedly trying to "save" taxpayers ends up being paid out anyway; and
  • it's possible that, in addition to all of this, assuming the government decides to just concede the point (which, by all rights, they should), it's conceivable that Marco Rubio's "genius" stunt from December 2014 could also very well end up costing taxpayers $2.5 billion MORE than it would have to just let the government make the payments they were supposed to in the first place.

...all so that Marco Rubio could earn a couple of political brownie points to help him win the GOP nomination for President...which he appears to be failing at anyway.

The Washington Post features an interesting story by Robert Samuels about Idaho's ongoing failure to come up with a solution to their self-imposed "Medicaid Gap" problem:

Here in Idaho, Gov. C.L. “Butch” Otter, a Republican, vowed to come up with a replacement after declining to fully embrace the Medicaid expansion that was offered as part of the Affordable Care Act. He’s tried to persuade his heavily Republican legislature to set aside their hands-off views about the government on this issue. Studies have been conducted. Proposals have been put forward. But after four years, lawmakers have come up with no alternative.

“While it is clear there is broad agreement on the fact there is a problem, agreement on what to do about it is another story,” Otter wrote in a statement to The Washington Post.

It's official: Tom Price is the nation's 23rd Secretary of Health and Human Services.

— Dan Diamond (@ddiamond) February 10, 2017

Price confirmed for HHS Sec at 2:11am

— David Dayen (@ddayen) February 10, 2017

Over the past week or so, there've been several eyebrow-raising videos posted from Republican Congressional Town Hall meetings across the country. They show huge crowds of protesters demanding that the ACA be saved, ironically remnisicent of the Tea Party protests which showed up at Democratic Town Hall meetings just 7 years earlier.

There were two in particular from last night which caused Twitter to explode, however. The first is of Jason Chaffetz of Utah:

Cong Chaffetz being drowned out by angry crowd at his town hall @UtahIndivisible @IndivisibleTeam pic.twitter.com/AvBz14u0Yj

— Kyung Lah (@KyungLahCNN) February 10, 2017

The second, while quieter, is even more stunning to watch, especially for those who follow this site:

Seriously urge everyone to watch this entire question from a woman at GOP #Obamacare townhall in Tennessee: pic.twitter.com/8mBGE1z6Rj

I've written a lot about the negative impact on enrollment this year due to deliberate sabotage efforts on the part of Donald Trump and the Congressional GOP, and I stand by it. I've run the numbers and honestly believe that I've proven pretty conclusively that these efforts--in particular, the last-minute yanking of millions of dollars' worth of HC.gov "Final Deadline!" advertising--had a significant negative impact, to the tune of several hundred thousand "lost" enrollments.

However, I've also repeatedly stressed that there were most definitely other factors as well which can't be pinned on Trump's efforts. Some of these are quantifiable and pretty obvious:

NOTE: I have to attend a field trip with my kid this morning so won't be able to post about the Minnesota results until around noon, but here's an overview:

There are only 2 states which still haven't announced their final 2017 Open Enrollment Period totals: Vermont and Minnesota. Vermont isn't likely to have anything too noteworthy to say (I've confirmed ~29K QHPs...they'll probably top out at ~30K), but Minnesota has a very special situation.

Minnesota confirmed ~106,000 QHP selections as of January 10th, so they probably tacked on another 5K - 10K during the last 3 weeks of open enrollment, for a total of perhaps 115,000. This would be impressive already, since they only enrolled 83.5K people last year.

However, they're also wrapping up (even as I type this) an 8-day Special Enrollment Period piggybacked onto the end of January, and those who enroll during this SEP could receive a 25% discount on their premiums depending on their income. Here's the backstory.

The table below is a slightly-modified version of the one I've been using for my "Trump Sabotage Effect" post. This version ignores all of that and simply presents all 50 states (+DC) together.

A few days ago I assumed the grand total would come in between 12.3 - 12.4 million, but I was misreading California's total based on their previous report which had made it look like they would break 1.6 million. Instead, they came in 44K below that mark, so the national total now stands at exactly 12,227,442 QHP selections, or 3.6% below 2016's final total. There's only 2 states missing data now: Minnesota and Vermont.

Your Health Idaho just released their final OE4 enrollment tally, and it's not bad at all:

A record number of Idahoans signed up for health insurance coverage through the statebased health insurance exchange during the latest open enrollment period, which ended on January 31.

“Over the last three months, more than 105,000 people selected a health insurance plan through the exchange,” said Pat Kelly, executive director of Your Health Idaho. “We have never seen more interest in Your Health Idaho. We know changes are coming to the health insurance marketplace but we want our customers to know our entire team remains committed to serving them and providing them with access to affordable health insurance options.”

In total, 105,977 Idahoans signed up for coverage through Your Health Idaho during the 2017 open enrollment period.

For the past three years, Idaho has been the leader in per-capita enrollments for state-based exchanges. YHI is currently waiting on nationwide enrollment numbers to determine how it ranks for the 2017 open enrollment period.

Oof. Regular readers know that I've compiled plenty of evidence showing that while the 39 states run through the federal exchange (HC.gov) showed a ~5% enrollment drop this year, the state exchanges have been showing an overall net increase of roughly 2% over 2016. Rhode Island, however, is the odd man out on this front, as shown in this email I just received (not up on their website yet):

Despite facing a unique set of challenges this open enrollment, 29,420 individuals selected 2017 coverage through HealthSource RI during open enrollment period (November 1, 2016 – January 31, 2017). As of January 31, 27,395 of those individuals paid, and are therefore confirmed, in 2017 coverage. We do anticipate these number will change as payments are made through the February 23 payment deadline and also as HealthSource RI remedies account issues incurred during the open enrollment period. It is difficult to point to one clear cause for this year-over-year drop in enrollment, but we believe several factors might have played a role:

1. System and service issues

Over the past few weeks I've compiled increasingly solid evidence (supported by a separate analysis by David Anderson of Balloon Juice) showing that yes, a significant portion of the reduced 2017 ACA exchange enrollment was due specifically to sabotage efforts on the part of Donald Trump and the GOP.

I've mainly focused on the last-minute "ad kill" stunt pulled by the Trump administration, in which they yanked millions of dollars worth of TV ads reminding people fo the deadline during the critical last 5 days, and the evidence is pretty telling: Enrollment across the 39 states run through the federal exchange (HC.gov) dropped by about 5% from last year, while enrollment on the other 12 state exchanges increased by over 2% (there's still final enrollment data to be added from ID, MN, RI & VT).

The reason this is so significant is that the state exchanges have their own marketing budgets, ad campaigns, outreach efforts and most significantly, branding. Ads promoting "Covered California" are gonna have a far bigger impact on enrollment for the residents of CA than ads for "HealthCare.Gov". There's some residual effect, because some people visit HC.gov first and are then redirected to CoveredCA from there, but for the most part, the state exchange branding is completely separate. (As an aside, this can sometimes have negative consequences, as in the case of "kynect" in Kentucky, which did such a bang-up job of isolating their brand from "Obamacare" that most of the state hasn't the foggiest idea that the two were the exact same law, but that's a separate discussion).