Texas

It was just four days ago that Bright Healthcare, which had been aggressively expanding their individual market coverage area footprint as recently as a year ago, suddenly announced that they were doing a complete 180 and instead pulling out of virtually the entire individual & small group markets nationally starting in January 2023.

This shouldn't have been as much of a surprise as people thought, however; Bright had already announced back in April of this year that they were pulling out of five states, and healthcare analyst Ari Gottlieb had written an impressively-researched post about the warning signs surrounding Bright's plight back in August, which I expanded upon here at the time.

(Note: Most of this is a shortened version of my post from seven weeks ago...with a pretty important update at the end):

Just over a year ago, Bright HealthCare, which was only founded in 2016, announced that they were dramatically expanding their operations around the U.S.:

Bright HealthCare Expands Affordable Plans in 42 New Markets Next Year Including in Texas, Georgia, Utah and Virginia

Sherman, set the Wayback Machine to 2015:

MICHIGAN: Another One (Mostly) Bites The Dust; 12th CO-OP Drops Off Exchange, May Go Belly-Up

It appears that East Lansing-based Consumers Mutual Insurance of Michigan could wind down operations this year as it is not participating in the state health insurance exchange for 2016.

But officials of Consumers Mutual today are discussing several options that could determine its future status with the state Department of Insurance and Financial Services, said David Eich, marketing and public relations officer with Consumers Mutual.

Consumers Mutual CEO Dennis Litos said: "We are reviewing our situation (financial condition) with DIFS and should conclude on a future direction this week.”

While Eich said he could not disclose the options, he said one is “winding down” the company, which has 28,000 members, including about 6,000 on the exchange.

Going forward, it looks like I'm going to have to do some educated guesses for a lot of carrier enrollment numbers for the states which haven't made their full 2023 rate filing data publicly available either on their own insurance dept. sites or even via the SERFF database.

The federal Rate Review site includes the average rate increases for each individual carrier, but most of the enrollment data is still redacted.

Texas' annual health insurance rate filings are kind of a mixed bag in terms of transparecy. Hardly any of the carriers have Uniform Rate Review Template (URRT) forms or Rate Filing Justification Form Part II available (these are the documents which generally include the actual number of people enrolled in the policies for each market for that insurance carrier), and the Actuarial Memorandum (Part III) is heavily redacted for most of them, making it very difficult to lock in the actual enrollment numbers.

I talked about it endlessly throughout 2017 & 2018, but it's been awhile since I last discussed the ACA's quirky Silver Loading pricing strategy in detail.

In order for the rest of this entry to make sense, we need to review what Silver Loading is and how it works:

• The ACA includes two types of financial subsidies. Advance Premium Tax Credits (APTC) reduce monthly premiums for low- and moderate-income.

• Cost Sharing Reductions (CSR), meanwhile, reduce deductibles, co-pays and other out-of-pocket expenses for low-income enrollees.

• In 2017, Donald Trump cut off CSR reimbursement payments in a failed attempt to sabotage the ACA, thinking this would cripple the ACA exchanges. Instead, insurance carriers implemented a very smart alternative pricing mechanism to make up for their CSR losses, which came to be known as "Silver Loading."

• The carriers basically calculated how much they expected owe in CSR expenses the following year...and then simply added that amount to their premiums for the following year instead.

• While there's several ways that carriers can add the extra CSR cost to their premiums, "Silver Loading" involves doing so by adding 100% of the extra cost to Silver plans only, as opposed to spreading it out across Bronze, Silver, Gold & Platinum plans.

As I noted last night, thanks to the federal Rate Review website finally being updated to include the final, approved 2022 rates for both the individual and small group markets in all 50 states (+DC), I've been able to fill in the missing data for my annual ACA Rate Change Project.

As I note there, the overall weighted average looks like it'll be roughly +3.5% nationally.

Normally I write up a separate entry for both the preliminary and approved rate changes in each individual state, but it seems like overkill to create 14 separate entries at once. Besides, in many of these states there's been few if any changes between the preliminary and approved rate changes.

Texas' annual health insurance rate filings are kind of a mixed bag in terms of transparecy. Hardly any of the carriers have Uniform Rate Review Template (URRT) forms or Rate Filing Justification Form Part II available (these are the documents which generally include the actual number of people enrolled in the policies for each market for that insurance carrier), and the Actuarial Memorandum (Part III) is heavily redacted for most of them, making it very difficult to lock in the actual enrollment numbers.

On the other hand, a few of them do offer one or both of the former documents, and in a few cases I was able to get the policyholder figures via the SERFF database. I'm operating on the assumption that each individual market policy has roughly 1.5 covered lives apiece on average.

Unfortunately, without having even that estimate available for half the carriers offering policies in Texas, I can't run a weighted average increase (it comes to +4.9% using what I have available), so I'm left (once again) with an unweighted average of around +1.5% on the individual market and +6.1% for small group policies.

I've once again relaunched my project from last fall to track Medicaid enrollment (both standard and expansion alike) on a monthly basis for every state dating back to the ACA being signed into law.

For the various enrollment data, I'm using data from Medicaid.gov's Medicaid Enrollment Data Collected Through MBES reports. Unfortunately, they've only published enrollment data through December 2020. In most states I've been able to get more recent enrollment data from state websites and other sources. I'm using estimates based on raw data from the Texas Dept. of Health & Human Services for January 2021 and beyond.

Texas is one of 12 states which still hasn't expanded Medicaid eligibility under the ACA (13 if you include Missouri, whose voters expanded the program last year...but which the state legislature refuses to fund)...and by far the largest.

 Now that I've developed a standardized format/layout & methodology for tracking both state- and county-level COVID vaccination levels by partisan lean (which can also be easily applied to other variables like education level, median income, population density, ethnicity, etc), I've started moving beyond my home state of Michigan.

Here's Texas:

• 2020 Presidential Election results via TX Secretary of State's office (thru Wikipedia)

• Vaccination data via Texas Health Dept.

NOTE: The CDC lists ~110,000 Texas residents (1.1% of the total fully vaccinated) whose county of residence is unknown.

March 2, 2021:

The ACA's language didn't account for the possibility that some states might not expand Medicaid, which is why the lower-end range of exchange plan subsidy eligibility starts off at 100% FPL...

Unfortunately, those earning less than 100% FPL are still stuck without any viable options besides either "going bare" and praying they don't get sick or injured or possibly buying a junk plan of some sort. According to the Kaiser Family Foundation, there's around 2.2 million Americans still caught in the "Medicaid Gap", where they don't qualify for Medicaid but don't earn enough to be eligible for subsidized ACA exchange policies (Kaiser estimates another 1.8 million uninsured adults in these states in the 100 - 138% "overlap" cateogory, plus around 356,000 who are eligible for Medicaid but still haven't enrolled for one reason or another).