Tuesday morning I left on a quickie family vacation to Mackinac Island; we got back into town last night, so I was gone for just 4 days. In that time, here's some of the bigger developments on the ACA/healthcare policy front:

• The Congressional Budget Office issued their formal projection of the 10-year (9-year, really) impact of terminating CSR reimbursement payments permanently starting in January 2018. Their major takeaways are pretty much the same as what I and most other healthcare wonks have been projecting, with a few twists:
  • The fraction of people living in areas with no insurers offering nongroup plans would be greater during the next two years and about the same starting in 2020
  • Gross premiums for silver plans offered through the marketplaces would be 20 percent higher in 2018 and 25 percent higher by 2020—boosting the amount of premium tax credits according to the statutory formula
  • Most people would pay net premiums (after accounting for premium tax credits) for nongroup insurance throughout the next decade that were similar to or less than what they would pay otherwise—although the share of people facing slight increases would be higher during the next two years
  • Federal deficits would increase by $6 billion in 2018, $21 billion in 2020, and $26 billion in 2026
  • The number of people uninsured would be slightly higher in 2018 but slightly lower starting in 2020.

In general, their projections on the impact on premiums (unsubsidized and subsidized) is similar to what I, the Kaiser Family Foundation, Oliver Wyman and others have been saying all along: Around 20 percentage point increases across all Silver plans (which would be the equivalent of around 14-15% if spread out across all plans on & off the exchanges.

Hey Michigan Residents! Do you live in Michigan's 1st Congressional District? Are you sick of Jack Bergman (MI-01) refusing to even talk to you about their "replacement" healthcare bill, which would tear away healthcare coverage for millions of Americans and hurt the coverage of countless millions more?

If so, come on out to Traverse City TOMORROW, Sunday, August 20th, and join State Representatives Christine Greig (appearing in person) and myself (appearing via Skype) as we explain what the latest craziness is regarding the ACA, the GOP attempts to repeal and/or sabotage it and healthcare policy in general from 10:30am - 11:30am at the Workshop Brewery, 221 Garland St. in Traverse City:

Tomorrow afternoon, CBO expects to release a report, which is being prepared with the staff of the Joint Committee on Taxation, about the effects of terminating payments for cost-sharing reductions. The analysis will include effects on the federal budget, health insurance coverage, market stability, and premiums.

Unfortunately, I'm not going to be in a position to write anything up about the CBO report, as I'm going on a long-overdue mini-vacation to visit Mackinac Island for a few days. I'm sure I'll be chiming in via Twitter when possible, but my wife will kill me if I try to write a full blog post, so that'll be about it.

Therefore, here's my thoughts about what the CBO is likely to conclude:

The effect on the budget will depend heavily on how many carriers decide to (or are allowed to) go the "Silver Switcharoo" route with their revised/final rate filings:

As I explained a couple of weeks ago, even if CSR payments aren't made next year, there are five different paths a given insurance carrier can take for 2018:

• 1. Drop out of the on-exchange market so you're not at risk of having any CSR enrollees; stick around the off-exchange market.
• 2. Drop out of the entire individual market, both on and off exchange.
• 3. Preemptively cover your anticipated 2018 CSR losses by spreading them out across all plans on and off exchange.
• 4. Preemptively cover your anticipated 2018 CSR losses by loading them onto Silver plans only both on and off exchange.
• 5. Preemptively cover your anticipated 2018 CSR losses by loading them onto on-exchange Silver plans only.

Some carriers, tragically, have already thrown their hands up in the air and decided to wash their hands of the whole thing by choosing either #1 or 2 above. This includes Humana, Aetna, Wellmark and, most recently, Anthem, which is drastically scaling back their 2018 individual market participation levels.

Once upon a time there were 23 health insurance cooperatives created via ACA provisions, spread across a similar number of states (a few operated in more than one, while some states had more than one co-op operating within it).

The first one to fall was CoOportunity, which operated in Iowa and Nebraska. Their enrollments were halted in the middle of the 2nd Open Enrollment period, and they were liquidated before OE2 even finished.

As noted in the Virginia and Maryland updates, I've started going through the earlier state rate filings and revising them to include:

• Updated/revised carrier rate filings;
• Additional market withdrawls and/or expansions;
• Corrections to CSR factor impact, etc.

The original versions of each state writeup includes screen shots of the actual filing documents and explainers behind specific requests; I don't have time for that with most of the updates, so I'm bundling several states together. Here's Connecticut, Oregon and Vermont's revisions:

As noted the other day, now that I've compiled the initial 2018 rate filing requests for 46 states + DC (the remaining 4 states aren't public yet), it's time to go back to the earlier states I analyzed and see whether there's been any updates/corrections to my original estimates. I started running the numbers back in early May, and a lot has changed since then, with carriers dropping out of the exchanges, expanding to fill the gaps or simply refiling with revised pricing requests.

Maryland was the second state I analyzed; I originally came up with the following average:

This strikes me as rather ominous...

Date: August 10, 2017
Title: Information on Risk Adjustment Methodology and Rate Filing Deadlines

Question: What changes will be made to the risk adjustment methodology to account for recent rating practices that assume issuers of silver-level QHPs facing increased liability for enrollees in cost-sharing reduction plan variations?

For the past two years, Virginia has been the first state in the nation to post their initial rate filings for the following year. I originally compiled their individual market 2018 change requests back in early May, and came up with the following at the time:

UnitedHealthcare had previously announced they were dropping out of Virginia, but I didn't have an enrollee number for them, and Aetna had also just announced their withdrawl from the state. I hadn't yet finalized my "CSR/Mandate Penalty" factor layout yet; at the time I assumed the 30.6% weighted average requested assumed full CSR/mandate sabotage and reduced that number by 17 points based on the Kaiser Family Foundation's "19% national average CSR rate hike" estimate analysis, which estimated the CSR impact at 17 points for Virginia.

Regular readers know that I've spent the past 4 months painstakingly tracking and analyzing the 2018 individual market rate filings for pretty much every insurance carrier in every state across the country.

I've completed this process for 46 states + DC. I've confirmed (well, really, Louise Norris confirmed for me) that the filing data for the four missing states--Kansas, Missouri, Nevada and Utah--won't be made available publicly for another couple of weeks, which is irritating...but those four states combined only make up about 5% of the total population anyway; unless their average rate increase requests are significantly higher (or lower) than the average of the rest of the states, they aren't gonna move the needle up or down by more than a tenth of a point or so.