2018 MIDTERM ELECTION

Time: D H M S

Pennsylvania

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

I noted in February that enrollment in the ACA's Medicaid expansion program had increased by around 35,000 people across just 4 states (LA, MI, MN & PA). By the end of March, the numbers in these 4 states had gone up by another 19,300.

It's the end of April now, so I checked in once more, and sure enough, the numbers continue to grow:

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:

Over the past month or so, I've been tallying up the number of people who would lose their healthcare coverage if and when the GOP actually does proceed with repealing the Affordable Care Act, breaking the totals out by both County and Congressional District in every state.

While this project has received high praise as a useful resource, one problem with it is that the numbers aren't static--between the high churn rate of the individual market and Medicaid, as well as the fact there's no limited enrollment period for Medicaid (you can sign up year-round), the enrollment figures are constantly changing.

Case in point: As of January 20th,, roughly 706.000 Pennsylvanians were enrolled in ACA Medicaid expansion. As of February 17th that number had increased to over 716,000.

I don't have a county-level breakout of the updated number, but I'm assuming that each county/congressional district has increased roughly proportionately:

I haven't posted an update on Pennsylvania's implementation of the ACA's Medicaid Expansion provision since last May, when it stood at around 625,000 enrollees.

Just moments ago, PA Governor Tom Wolf announced that enrollment has now broken the 700,000 milestone:

Over 700,000 Additional Pennsylvanians Enrolled in Governor Wolf’s Medicaid Expansion Plan
February 02, 2017

Harrisburg, PA – In February of 2015, Governor Wolf expanded Medicaid to ensure that Pennsylvanians can receive affordable, straightforward, accessible healthcare without unnecessary delays and confusion. Today, Governor Wolf announced that over 700,000 Pennsylvanians have enrolled in HealthChoices, Pennsylvania’s mandatory managed care Medicaid program, since expansion occurred two years ago. U.S. Census data shows that the commonwealth’s uninsured rate has dropped from 10.2 percent in 2010 to 6.4 percent in 2015.

Hey, remember back in August 2016 when Aetna, just three months after saying how great things were going for them on the ACA exchanges (to the point that they might even expand into several additional states), did a complete 180º by announcing that they were instead going to leave 11 of the 15 states they had been participating in?

At the time, it seemed awfully suspicious; as I noted on 8/15/16:

Oh. Well, I'm sure that was just a sheer coincidence, right? No doubt Aetna will clear this up with an unequivocal statement to put any speculation to...

From Peter Sullivan of The Hill:

Asked if the DOJ’s actions on the merger had any relation to Monday’s announcement, Aetna spokesman TJ Crawford did not directly say yes or no.

(thanks to commenters "M E" and "joe" for the heads up).

The state Dept. of Insurance has released their approved rate hikes for 2017, and it's bad news in two different ways. First, the overall full-price average rate increase looks like it'll be roughly 32.5%...over 8 points higher than the original rates requested by the carriers. Secondly, even with those higher increases, two more indy market carriers (Keystone Health Plan and Geisinger Quality Options) are pulling off the exchange, although both will continue to offer off-exchange plans.

It's important to be careful with the full carrier names here, because they often operate under several different very similar ones (Keystone Health Plans vs. Keystone Health Plan East, for instance, which is not pulling off the exchange).

So here's what's happening with each:

Yesterday I hobbled together the weighted average rate hikes (either requested or approved) for the ACA-compliant small group markets across 15 states. In 4 of these states, I hadn't yet tallied the weighted average, so I temporarily used the median increase for each. In the case of Pennsylvania, the range was from a 3.8% decrease to a 33% increase, with a midpoint of around 14.6%.

Today, however, I've actually plugged in the enrollment numbers for each sm. group carrier in Pennsylvania based on their 2017 rate request filings, and have come up with a weighted average of just 7.9%:

Last year, the insurance carriers in Pennsylvania asked for a weighted average 15.6% rate increase for individual market policies...but in the end state regulators knocked these down by over 1/5th to around 12% overall.

This year the picture is uglier, as expected. While four of the filings are for rate hikes of under 10%, this is misleading because one of them appears to be brand new while the other 3 have a combined enrollment of...7 people. Not 7,000, not 700...seven.

The rest of the filings range from 16% to a whopping 48% increase request from Highmark Health Insurance for over 20,000 enrollees. Ouch.

Overall, the weighted state-wide average requested rate hike on the individual exchange is 23.6%.

I was fascinated when I saw this phenomenon happen here in Michigan last year, but it's repeated itself in several other states since then. State and federal officials crunched their demographic data and came up with estimates of the maximum number of residents who they expected to be eligible for the ACA's Medicaid expansion provision a couple of years back, along with the number of those expected to enroll in the program in the first year. They're then caught offguard when not only does the actual number eligible turn out to be far higher than they expected, but far more of those eligible go ahead and sign up in the first year than expected.

In Michigan, estimates ranged from 477K - 500K being eligible; instead, the number broke 600,000 the first year, where it's hovered around ever since (as of last week it stood at 615,536).

Until this year, most of the ACA exchanges, including HealthCare.Gov, would simply report how many people selected QHPs through the exchange, whether paid up or not. There's nothing wrong with this as long as it's made clear at some point how many people actually paid their premiums and had their policies effectuated; the argument over this issue was the entire basis of the infamous "But how many have PAID???" fuss back in 2014. It was such a Big Deal that the Republicans on the House Energy & Commerce Committee even published the results on a laughably garbage-filled "survey" they had sent out to a portion of the insurance carriers.

(Note In the end, it turned out to be roughly 85-90% depending on the state/carrier in 2014; for 2015 the payment rate nudged up to around 90% overall, which is where it will likely stand going forward).

Unlike the exchange QHP enrollments, which will always continue to be the heart and soul of this website (it's right there in the name, after all), I've kind of gotten away from trying to track Medicaid expansion on a granular level over the past few months. The main reason for this is that in many of the expansion states, they've simply maxed out on enrollees, and the numbers from week to week or even month to month are simply holding steady at this point.

At last!! It's been extremely frustrating trying to lock down the 2016 average premium hikes for Pennsylvania, especially because their Insurance Dept. website has actually been very good about posting every requested rate change in an easy-to-read, comprehensive fashion.

The problem with PA's rate filings hasn't been on the percentage change side, it's on the covered lives side. I was able to compile enrollment numbers for some carriers but not others...including First Priority, which was requesting a 29.5% rate hike. Without knowing whether they had a huge chunk of the market or not, posting the "average" rate hikes without including theirs was kind of meaningless, since it could potentially jack that average up or down dramatically.

So, I finally kind of gave up on it, figuring that even when the approved rates were posted, they probably still wouldn't include the number of covered lives for each insurance company.

Thankfully, it turns out I was wrong!

Last year, GOP Governor Tom Corbett pushed through a poorly-conceived, overly-cumbersome "Republican alternative" Medicaid expansion program called Healthy PA, which didn't go into effect until late in the year. He was defeated by Democrat Tom Wolf, who vowed to scrap the "alternative" version and simply expand Medicaid to residents below 138% of the Federal Poverty Level, as the ACA had intended.

This transition was messy, but has now been completed...and is saving the people of Pennsylvania a boatload of money:

Department of Human Services Sec. Ted Dallas Tuesday announced the end of the transition from Healthy PA to traditional Medicaid expansion—known as HealthChoices in Pennsylvania—as the last of the expansion insurance plans took effect.

According to Sec. Dallas, 440,000 Pennsylvanians are enrolled in Medicaid expansion insurance plans with the last group of enrollees coming out of Healthy PA’s primary coverage options into Medicaid expansion.

“With that last group of folks moving over, the Medicaid expansion is now complete,” Sec. Dallas told reporters.

When I last checked in on Pennsylvania's year-late-but-certainly-welcome addition to the ACA Medicaid expansion club, newly inaugurated Governor Tom Wolf was in the process of replacing his predecessor's poorly-conceived, overly-complicated "Conservative version" of the expansion program with "official" Medicaid expansion to up to 600,000 state residents. At the time (early May), they had hit roughly 250,000 people.

I'm happy to report that according to today's Pittsburgh Post-Gazette, the dust has settled on the transition, and enrollment has been on a tear, with the tally now standing at roughly 439,000 Pennsylvanians.

About 439,000 Pennsylvanians have enrolled in expanded Medicaid, which provides health insurance coverage to the poor and disabled, since the beginning of the year, according to figures released last week by the state’s Department of Human Services.

Over at Balloon Juice, Richard Mayhew has posted a great piece illustrating, once again, the importance of looking past the scary headlines to find out 1) what the true picture is (ie, taking all of the rate changes into account--not just the biggest ones--and weighting them by proportionate market share), and 2) what's going on with your situation, not someone else's:

As expected, the initial ask by insurers is being revised down. It is easier for insurers to get state regulators to agree to a lower number from the initial than to get the regulators to agree to a higher number than the initial ask. That allows regulators and their champions to point to a clear example of their effectiveness at protecting the public. This is a bit of a kabuki. In my state, when Mayhew Insurance and our competitors submit rates, there is a de facto implicit fudge factor built into the rates (usually as excess reserve accumulation) that everyone expects to be cut by the third round of review.

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