OE6

2018 MIDTERM ELECTION

Time: D H M S

In my Tennessee 2019 rate filing analysis last month, I noted the good, the bad and the ugly:

  • The good news was that average unsubsidized 2019 ACA individual market premiums were expected to drop by about 5.7% after years of double-digit rate hikes.
  • The bad news was that due specifically to various types of deliberate sabotage by the Trump Administration and Congressional Republicans (primarily repeal of the individual mandate and expansion of #ShortAssPlans), that 5.7% drop was still a good 12 points or so higher than it otherwise would have been.
  • The ugly news was that due specifically to the Trump Administration's utterly unnecessary decision to freeze Risk Adjustment fund transfers in response to a lawsuit out of New Mexico, 2019 premiums would be hundreds of dollars higher still than they should have been for Blue Cross Blue Shield of Tennessee's 113,000 enrollees:

UPDATE: As noted in the comments below, it looks like Anthem won't be expanding to cover the entire state after all. Even so, this is a major improvement in the situation.

Every year, Virginia is the first state out of the gate with their preliminary healthcare premium rate changes for the following year, posting the initial rate requests in early May. For 2019, it originally looked like the carriers were asking for a statewide average increase of 15.2%, but I later corrected this to 13.4%.

However, these were just preliminary numbers. The requests still have to go through the rate review process, and the carriers often make other changes as well before the final deadlines pass.

Annnnnnnnd finally, the least-populated state of them all...which also happens to be suffering from the highest average monthly premiums for unsubsidized individual market enrollees: Wyoming.

There's only a single carrier in the Equality State (seriously...that's their motto; who knew?), Blue Cross Blue Shield. They're actually looking to lower rates by just a smidge (0.25% on average).

However, once again, the Urban Institute projected that there'd be roughly an 18.6% increase factor due to the ACA's individual mandate being repeale and short-term & association plans being expanded by the Trump administration.

Assuming just 2/3 of that to play it safe, that still means that unsubsidized enrollees would have been looking at roughly a 12% drop in their 2019 premiums without those measures...a difference of over $120/month, or a whopping $1,400 more apiece next year. Ouch.

The most noteworthy thing about West Virginia's 2019 filings that I can see is that CareSource is expanding their state coverage from 10 counties to 35 counties, and the confirmation that West Virginia will remain one of the few states sticking with a Broad Load CSR strategy for reasons unknown next year (the state insurance commissioner might change their tune, however, now that CMS has done a complete 180 degree turn and has officially come out in favor of Silver Switching).

In any event, the statewide average premium hike appears to be around 14.9%...but once again, much of this is due to the ACA's individual mandate being repealed and Trump opening the floodgates on #ShortAssPlans.

At $843/month, West Virginia has one of the highest average monthly premiums in the country...and instead of only going up nominally next year, thanks to #ACASabotage, unsubsidized enrollees will likely have to pay a whopping $1,300 more apiece next year.

South Dakota has two ACA indy market carriers, Avera and Sanford. The relative enrollment market shares are based on last year's numbers. The 14.4% #ACASabotage impact assumes 2/3 of the Urban Institute's projections to err on the side of caution.

THe average unsubsidized SD indy market enrollee pays $624/month this year; instead of that dropping by around $68/month, it's expected to increase by $22...for a total monthly difference of $90.

Assuming that's accurate, this means unsubsidized SD residents will be paying over $1,000 more apiece next year than they'd otherwise have to.

North Dakota was one of only two states (the other one was Vermont) which didn't allow their insurance carriers to add any additional premium load into their 2018 rates to account for Donald Trump's cut-off of Cost Sharing Reduction (CSR) reimbursement payments.

In direct response to this, Medica Health Plans dropped out of the ND on-exchange individual market this year to avoid taking the CSR hit. They hung around the off-exchange market, however, and therefore still have about 600 enrollees in the state.

As a result of this, my estimated impact of ACA sabotage efforts by the Trump Administration and Congressional Republicans has to include the factors from both 2017 and 2018: Cost-Sharing Reduction cut-off (9%) as well as Mandate Repeal and Short-Term Plan expansion (13.8%).

New Hampshire is perhaps the most striking example of both insurance carriers significantly overshooting the mark for 2018 premiums while also proving my point that just because premiums are dropping next year, #ACASabotage is still causing unsubsidized enrollees to pay a lot more than they'd have to otherwise.

All three of the carriers offering ACA policies on New Hampshire's individual market are reducing their 2019 premiums, by anywhere from 7.4% for Harvard Pilgrim to a whopping 15.2% in the case of Ambetter/Celtic.

THe enrollee market share numbers come from the monthly report from the New Hampshire insurance department (I'd love it if every state required one of these...it includes both on and off-exchange enrollees). The "PAP" column refers to NH residents enrolled in their "private option" Medicaid expansion program...but those are still part of the same risk pool as the other enrollees, so they still have to be factored into the market share formula.

Nebraska is about as simple as it gets--there's only one carrier offering ACA individual market plans. Unfortunately, they've redacted the combined average rate change request between their two plan entries, so all I can do is split the difference and assume around a 1% average increase.

The Urban Institute projected that Nebraska rates would see a whopping 20.4 percentage point increase due to #MandateRepeal and #ShortAssPlans, which are both referenced in Medica's filing. Since they don't get more specific than that, I'm assuming 2/3 of Urban's estimate, or a 13.6% increase.

Unsubsidized Nebraska enrollees are currently paying an average of $854/month, so if accurate, that's a difference of around $116/month or nearly $1,400 for the year. Ouch.

Mississippi is pretty easy: Only two carriers. I have no idea what their relative market share is (the enrollment data along with a lot of other stuff is redacted in their filings), but in this case it really doesn't matter because both of the carriers are requesting nearly identical rate changes anyway...which is to say, just about no change whatsoever.

The Urban Institute projected that #MandateRepeal and #ShortAssPlans would add a 17.2 percentage point rate hike factor in Mississippi. I generally knock 1/3 off of their estimates to err on the side of caution (11.4%), but given Ambetter specifically stating that they didn't add any increase to account for #ShortAssPlans (why?? interesting!), I'm shaving off a bit more and assuming a flat 10% impact.

This means that unsubsidized Mississippi enrollees would likely have saved a good $800 apiece next year without Trump/GOP efforts to undermine the ACA this year.

NOTE: The good news is that I don't have to worry about any sabotage impact for Massachusetts in 2019 (thanks to the state still having their pre-ACA individual mandate penalty in place and banning #ShortAssPlans outright). This obviously makes that part of my analysis very easy--I can just enter "0%" across the board in the "2018 sabotage factor" columns.

The bad news is that determining the market share for each carrier in Massachusetts is a royal pain in the ass. only two of the twelve carriers offering individual market plans actually state what their enrollment numbers are, and this is further confused by the fact that several of them (Fallon, Harvard Pilgrim and Tufts) have two or three different listings for different divisions of the company.

In addition, Massachusetts is one of just two states where the individual and small group market risk pools are merged, making it even more difficult to separate out the two for market share purposes.

Kansas is pretty frustrating. There's only three carriers offering ACA individual market policies, but two of the three have heavily redacted actuarial memos, so I don't know what their market share is...and the same two were new (or "semi-new") to the exchange this year so I can't even use last year's effectuated enrollment as a guideline. In light of that, I had to split the estimate right down the middle to get an estimated overall market share.

In addition, Medica is the only one of the three to specifally mention mandate repeal and/or #ShortAssPlans as a contributing factor; that's also redacted in the filings for the other two. Therefore, instead of assuming 2/3 of the Urban Institute's sabotage projection, I'm being extra-cautious and assuming just half (9.6% instead of 19.2%). This gives a rough statewide average increase of around 6.1%, which would likely be closer to a 3.5% premium reduction without mandate repeal and short-term plan expansion.

Illinois has the same four ACA indy market carriers participating next year as they do this year. All four rate filings specificlaly call out Mandate Repeal and #ShortAssPlans as significant factors in their rate requests, but none of them break out the actual amount, so I'm relying on my standard assumption of 2/3 of the Urban Institute's projections.

In Illinois' case, that's 2/3 of 19.4%, or around a 12.9% #ACASabotage premium increase for unsubsidized enrollees.

I should also note that only one of the four carriers (Health Alliance) specifies just how many enrollees they have; for the other three I'm basing my estimates on last year's numbers for now. The two carriers with what I assume are still the largest market share (BCBS and Celtic) are basically keeping rates flat year over year, while the other two are 7.5% and 10% apiece, for an average rate increase of just 0.7% statewide.

Unsubsidized Illinois residents are currently paying $644/month on average, so a 12.9% sabotage effect means that each of them will have to pay nearly $1,000 extra next year. Ouch.

As you may recall, the New York carriers had originally requested an average 2019 rate increase of 24%...fully half of which they pegged specifically on the ACA's individual mandate being repealed by Congressional Republicans.

On Monday afternoon, there was a rather surreal and surprising announcement made by New York Governor Andrew Cuomo:

Gov. Cuomo just announced that he has directed Supt. Vullo to reject any individual market rate increase that included an increase to compensate for the repeal of the individual mandate

...Assuming that nothing else changes during the rate review process, this makes carriers that didn't associate a % of their rate request with the loss of the mandate big winners...and those who did, not so much.

I noted at the time that while this may seem insane on the face of it, there may be a simple explanation:

March 20, 2018:

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

HHS Secretary Alex Azar said that he has not been involved in discussions about blocking ‘silver-loading’ plans in 2019 and is not aware of any agency discussions about ending the practice at the moment.

...In recent weeks, some stakeholders have speculated that the Trump administration could block silver-loading in 2019. Several pro-ACA experts say that even though the administration may have authority to stop silver-loading, it would be a self-destructive move, especially leading up to the November midterm elections.

CMS Administrator Seema Verma told reporters on Thursday (March 22) that she was “very concerned” about certain aspects of ‘silver loading’ plans, namely that it raises costs for unsubsidized consumers and the federal government. Verma did not commit to allowing or blocking the process for the 2019 plan year.

Idaho's insurance department website displays their annual rate filing summaries in a unique way--they don't publish the actual enrollment numbers, but they do post breakouts of the rate hikes for different metal levels (handy!) as well as the premiums brought in and claims paid out, which gives some refreshing insight into just how profitable (or not) some fo the carriers are (if I'm reading the screenshot correctly, it looks to me like BCBS and Mountain Health did just fine last year, but the other three carriers ended up in the hole (especially SelectHealth...ouch).

The state website also claims the overall weighted averge rate increase being requested in 8% even though my own spreadsheet brings it in at 9.4%. This could be due to my misestimating SelectHealth's enrollment number, or it could be because Regence Blue Shield cays they're raising rates 3.9% but the state claims it's 7% (although that should actually result in a higher average from the state, not lower...)

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