Oklahoma

NOTE: This is an updated version of a post from a couple of months ago. Since then, there's been a MASSIVELY important development: The passage of the American Rescue Plan, which includes a dramatic upgrade in ACA subsidies for not only the millions of people already receiving them, but for millions more who didn't previously qualify for financial assistance.

Much has been written by myself and others (especially the Kaiser Family Foundation) about the fact that millions of uninsured Americans are eligible for ZERO PREMIUM Bronze ACA healthcare policies.

I say "Zero Premium" instead of "Free" because there's still deductibles and co-pays involved, although all ACA plans also include a long list of free preventative services from physicals and blood screenings to mammograms and immunizations with no deductible or co-pay involved.

Much has been written by myself and others (especially the Kaiser Family Foundation) about the fact that millions of uninsured Americans are eligible for ZERO PREMIUM Bronze ACA healthcare policies.

I say "Zero Premium" instead of "Free" because there's still deductibles and co-pays involved, although all ACA plans also include a long list of free preventative services from physicals and blood screenings to mammograms and immunizations with no deductible or co-pay involved.

If you have a fairly healthy year, you really could go the entire year without paying a dime in healthcare costs while still taking advantage of many of these free services, and also having the peace of mind that in a worst-case scenario, at least you wouldn't go bankrupt. Not perfect, but a lot better than going bare especially since you wouldn't pay a dime in premiums.

A month ago the Oklahoma Insurance Department posted the preliminary 2021 individual & small group market rate filings, including the following press release:

Oklahoma Consumers to Have More Health Options for 2021 ACA Plans

OKLAHOMA CITY – Insurance Commissioner Glen Mulready announced today the 2021 preliminary rate filings for health insurance plans under the Affordable Care Act (ACA). Insurers that currently offer coverage through the Oklahoma Marketplace filed plans requesting average statewide increases of 2.7 percent.

via the Oklahoma Insurance Dept:

Oklahoma Consumers to Have More Health Options for 2021 ACA Plans

OKLAHOMA CITY – Insurance Commissioner Glen Mulready announced today the 2021 preliminary rate filings for health insurance plans under the Affordable Care Act (ACA). Insurers that currently offer coverage through the Oklahoma Marketplace filed plans requesting average statewide increases of 2.7 percent.

The same three insurers that offered individual health plans on the 2020 Exchange will return for 2021 — Blue Cross Shield of Oklahoma (BCBSOK) , Bright Health and Medica Insurance Company. In addition, Oscar Health, UnitedHealthCare (UHC) and CommunityCare Oklahoma (CCOK) will join the marketplace in Oklahoma for 2021 allowing consumers to have more choices. BCBSOK and Medica offer statewide plans while Bright Health, CCOK, Oscar and UHC serve limited areas of the state.

Moderate rate increase requests and new insurers looking to offer plans in Oklahoma revealed that the Oklahoma insurance market is stable and able to offer multiple health insurance options for all Oklahomans.

Five states held their primary elections for non-Presidential races yesterday, including Missouri...and Missouri also had another important measure on the statewide ballot:

On Tuesday, August 4, all Missourians will have the chance to vote Yes On 2 to bring more than a billion of our tax dollars home from Washington every year – money that’s now going to places like California and New York instead.

By bringing our tax dollars home, we can protect thousands of frontline healthcare jobs, help keep rural hospitals open, and deliver healthcare to Missourians who earn less than $18,000 a year. That includes thousands of veterans and their families, those nearing retirement, working women who don’t have access to preventive care, and other hardworking Missourians whose jobs don’t provide health insurance.

Back in 2018, I was all over the trend of deep red states putting ACA Medicaid expansion on the ballot after getting fed up with years of their elected leaders refusing to do so. Idaho, Utah and Nebraska voters all did exactly that, passing it by solid margins. Unfortunately, state Republicans got in the way (or at least tried to) in all three states, adding hurdles, barriers and caveats which have either delayed or partly weakened them.

Nonetheless, Utah and Idaho have both implemented Medicaid expansion to low-income residents (and thank God, given the current ongoing COVID-19 pandemic), while as far as I can tell, Nebraska is scheduled to launch their expansion program (called "Heritage Health") starting this October.

I wrote about this several times last year, but I'm a bit embarrassed to say that I haven't revisited the status of Oklahoma's Medicaid expansion ballot proposal since November:

In Red State Oklahoma, Medicaid Expansion Nears 2020 Ballot

A campaign in Oklahoma to expand Medicaid via the ballot box far eclipsed the necessary number of signatures needed to put the measure before voters next November 2020, supporters said Thursday.

The submission of 313,000 signatures to put a constitutional amendment on next year’s general election ballot shattered the required 178,000 needed by the Oklahoma Secretary of State’s office, organizers said. Media reports in Oklahoma said supporters of Medicaid expansion broke a state record when it comes to signatures needed for a statewide ballot initiative.

The recent elections in Virginia, Kentucky and Louisiana had two things in common: The first is that all three were huge victories for Democrats (they took control of both the state House and Senate in Virginia, flipped the Governor's seat in Kentucky and held onto it in deep red Louisiana).

The second is that all three elections were won in large part based on...Medicaid expansion.

As Greg Sargent notes in the Washington Post:

Yet Edwards won, in large part, by also stressing his implementation of the Affordable Care Act’s Medicaid expansion in the state during his first term. Indeed, Edwards’s lead pollster, Zac McCrary, told me during an interview that no single issue was more important in driving the governor’s victory.

Oklahoma has three carriers on the Individual Market these days. Once again, all three rate filing memos are redacted, but I was able to dig up the number of current policy holders for one of them (CommunityCare HMO).

The final/approved rate changes are exactly the same as the requested changes from a few months back, but I've managed to lock down the actual enrollment numbers for two of the three carriers. Assuming I'm close on the third one (Medica), the weighted average rate increase statewide should be around 2.7%:

MLR rebate payments for 2018 are being sent out to enrollees even as I type this. The data for 2018 MLR rebates won't be officially posted for another month or so, but I've managed to acquire it early, and after a lot of number-crunching the data, I've recompiled it into an easy-to-read format.

But that's not all! In addition to the actual 2018 MLR rebates, I've gone one step further and have taken an early crack at trying to figure out what 2019 MLR rebates might end up looking like next year (for the Individual Market only). In order to do this, I had to make several very large assumptions:

Oklahoma has three carriers on the Individual Market these days. Once again, all three rate filing memos are redacted, but I was able to dig up the number of current policy holders for one of them (CommunityCare HMO).

I've bumped that number up a bit to account for the total number of covered lives to an even 2,000. For the other two carriers, I'm assuming Blue Cross Blue Shield still holds the lion's share of enrollees and that the total on+off-exchange market is around 187,000 people.

If this is all correct, the weighted average rate increase for unsubsidized enrollees is around 1.4% statewide.

Meanwhile, the unweighted average rate hike for the small group market is 6.5%.

As I noted back in February, this one was pretty unexpected:

Bill expanding ‘Insure Oklahoma’ program passes Senate committee

A Senate bill seeking to expand the Insure Oklahoma program has advanced out of committee Monday morning.

Senate Bill 605, authored by Sen. Greg McCortney, R-Ada, directs the Oklahoma Healthcare Authority to implement "the Oklahoma Plan" within Insure Oklahoma. An agency spokesperson said the program provides premium assistance to low-income working adults employed by small businesses.

The latest numbers from Insure Oklahoma show less than 19,000 are enrolled.

According to McCortney, the intent of his bill is to provide insurance for Oklahomans who would qualify for Medicaid in states which opted to expand but are currently not insured.

Huh. As Joan Alker of the Center for Children and Families at the Georgetown University Health Policy Institute just put it, here's one I wasn't expecting:

Bill expanding ‘Insure Oklahoma’ program passes Senate committee

A Senate bill seeking to expand the Insure Oklahoma program has advanced out of committee Monday morning.

Senate Bill 605, authored by Sen. Greg McCortney, R-Ada, directs the Oklahoma Healthcare Authority to implement "the Oklahoma Plan" within Insure Oklahoma. An agency spokesperson said the program provides premium assistance to low-income working adults employed by small businesses.

The latest numbers from Insure Oklahoma show less than 19,000 are enrolled.

According to McCortney, the intent of his bill is to provide insurance for Oklahomans who would qualify for Medicaid in states which opted to expand but are currently not insured.

It isn't often that I write about anything Oklahoma-related, and it's rarer still that I post good news out of the...um..."labor omnia vincit" state (that's their slogan, I looked it up...), so today's a rare day indeed.

A couple of weeks ago I noted that at least 9 more states will be jumping onboard the #SilverSwitcharoo train for 2019, bringing the total to 30:

Oklahoma is pretty clear cut: BCBSOK holds nearly all of the ACA-compliant market share, with CommunityCare HMO having a small number of off-exchange enrollees (the numbers are estimates based on last year's figures).

The Urban Institute projected an 18.4% rate increase due to #MandateRepeal and #ShortAssPlans. BCBSOK doesn't go into specifics about the impact, but does list both of these as significant factors. Knocking 1/3 off this projection gives around 12.4%.

Unsubsidized Oklahoma enrollees are paying an average of $694/month in 2018. Without ACA sabotage, they'd likely see this drop to around $595; instead, they're likely looking at paying roughly $681/month, or an additional $1,033 apiece.

A couple of weeks ago, a joint letter was sent to all four Congressional leaders from AHIP (America's Health Insurance Plans), the BlueCross BlueShield Association, the American Academy of Family Physicians, the AMA, the American Hospital Association and the Federation of American Hospitalsm warning them, in no uncertain terms, of what the consequences of repealing the individual mandate would be:

We join together to urge Congress to maintain the individual mandate. There will be serious consequences if Congress simply repeals the mandate while leaving the insurance reforms in place: millions more will be uninsured or face higher premiums, challenging their ability to access the care they need. Let’s work together on solutions that deliver the access, care, and coverage that the American people deserve.

A week or so ago, the American Academy of Actuaries sent a similar letter to Republican Senate Majority Leader Mitch McConnell stating pretty muc the same thing, but in more vivid detail:

With 43 states accounted for, Open Enrollment itself looming just 6 days from now and HealthCare.Gov's window shopping tool now open for business anyway, there aren't likely to be too many surprises left for my 2018 Rate Hike project. For that matter, healthcare consulting firm Avalere Health just published their own analysis which confirms my own closely: They have the 2018 on exchange average increase at 29.1%, while I currently have the combined on & off-exchange average (for 43 states) at 29.2%.

Still, I don't like loose ends, and those 8 missing states are bugging me, so I still want to fill them in for completeness' sake. The only big state remaining is Texas, but I'm also missing Alabama, Hawaii, Iowa, Missouri, New Hampshire, Oklahoma and Wyoming.

Last year, Blue Cross Blue Shield of Oklahoma, as the only carrier participating on the ACA exchange in the state, jacked up their premiums by a jaw-dropping 76%. This resulted in the highest statewide average rate hike in the country of 71% overall.

Well, that certainly seems to have done the trick: This year BCBSOK (still the only on-exchange player and holding over 99% of the market anyway) is requesting a (relatively) modest 8.3% average rate increase...and their filing specifically calls out both the CSR and mandate enforcement factors as being major reasons. Assuming the Kaiser Family Foundation's estimates are accurate, that means that if the CSR payments were guaranteed for 2018, BCBSOK should actually be lowering their rates slightly, to the tune of around 2.4%.

Adding in the steep hikes from off-exchange only CommunityCare (which only has 1,400 enrollees) brings the averages in at a 1.9% rate drop if CSRs are paid, and an 8.7% increase if they aren't.

While I've been embroiled in the sturm und drang at the national level, Louise Norris of healthinsurance.org has been reporting on some important stuff happening at the state level:

HAWAII:

Hawaii no longer has a SHOP exchange; Lawmakers consider bill to preserve the ACA and expand Medicaid to 250% FPL

As of 2017, Hawaii no longer has a SHOP exchange for small businesses. The State Department of Labor and Industrial Relations has an FAQ page about this.

...Hawaii’s waiver aligns the ACA with the state’s existing Prepaid Health Care Act. Under the Prepaid Healthcare Act, employees who work at least 20 hours a week have to be offered employer-sponsored health insurance, and can’t be asked to pay more than 1.5 percent of their wages for employee-only coverage (as opposed to 9.69 percent under the ACA in 2017). 

As I noted when I crunched the numbers for Texas, it's actually easier to figure out how many people would lose coverage if the ACA is repealed in non-expansion states because you can't rip away healthcare coverage from someone who you never provided it to in the first place.

My standard methodology applies:

I mentioned a couple of weeks ago that Blue Cross Blue Shield of Oklahoma, which had originally asked for an already-ugly 51% average rate hike, had bumped that up to a jaw-dropping 76% ask. Well, earlier this week, they got it:

Obamacare premiums will raise a staggering 76 percent on average for Oklahoma residents, and the state's top insurance regulator says the state's insurance exchange set up by the law is on "life support."

Oklahoma's Insurance Department said on Tuesday that increases in individual marketplace plans will range from 58 percent to 96 percent.

"These jaw-dropping increases make it clear that Oklahoma's exchange is on life support," said Insurance Commissioner John Doak, in a statement. "Health insurers are losing massive amounts of money. If they don't raise rates they'll go out of business. This system has been doomed from the beginning."

Lots of stuff happening fast & furious these days as #OE4 approaches. Instead of individual posts, I'm gonna cram 7 state updates into a single one...and am also cheating a bit by cribbing off of excellent work by Louise Norris over at healthinsurance.org (which is fair, since she also gets some of her data from me as well):

ALABAMA: Here's what my requested rate hike table looked like for Alabama on August 1st:

Updates: Norris Confirms that:

Oklahoma's entire individual market (including grandfathered/transitional plans) was around 172,000 people in 2014. Assuming it's grown roughly 25% (in line with the national increase), it should be up to perhaps 215,000 people by today, of which perhaps 195K are ACA-compliant.

This is significant because there appear to be only 3 carriers offering individual policies in Oklahoma next year...one of which is the infamous "Freedom Life Insurance Co." which I wrote about last night. Since Freedom Life has (as usual) only a single enrollee in the state, it's really a nonfactor for calculating the weighted rate hike average.

That leaves Blue Cross Blue Shield of Oklahoma, which has a whopping 170,000 enrollees...and CommunityCare (which is in turn broken into HMO and PPO divisions)...unfortunately, their rate filing doesn't include their enrollment number; all it says is that it's "too small to be credible" to be used as the basis of their rate hike request. In addition, UnitedHealthcare is dropping out of the OK indy market; I don't know how many enrollees they actually have.

The conventional wisdom when it comes to taxes is that Republicans are always for cutting 'em while Democrats are always for raising 'em. The reality, of course, can be far more complicated--it's not just about cutting or raising taxes, it's also about who's getting the increase/decrease and what the money would/no longer would be used for. Even so, this is an odd-sounding story at first glance.

Just last week, the Big News Shocker out of Oklahoma was the blood-red Republican-controlled state legislature and governor were actually considering a) raising taxes (!!!) and b) expanding Medicaid via the ACA (!!!) in order to dig themselves out of their self-dug financial hole:

So, in what would be the grandest about-face among rightward leaning states, Oklahoma is now moving toward a plan to expand its Medicaid program to bring in billions of federal dollars from Obama's new health care system.

What's more, GOP leaders are considering a tax hike to cover the state's share of the costs.

Amazing, but utterly predictable:

Despite bitter resistance in Oklahoma for years to President Barack Obama's health care overhaul, Republican leaders in this conservative state are now confronting something that alarms them even more: a huge $1.3 billion hole in the budget that threatens to do widespread damage to the state's health care system.

So, in what would be the grandest about-face among rightward leaning states, Oklahoma is now moving toward a plan to expand its Medicaid program to bring in billions of federal dollars from Obama's new health care system.

What's more, GOP leaders are considering a tax hike to cover the state's share of the costs.

"We're to the point where the provider rates are going to be cut so much that providers won't be able to survive, particularly the nursing homes," said Republican state Rep. Doug Cox, referring to possible cuts in state funds for indigent care that could cause some hospitals and nursing homes to close.

In a classic case of missing the forest for the trees, I posted two very wonky, detailed entries over the past couple of days about Minnesota and Connecticut's latest enrollment numbers...but completely missed one crucially important data point.

Investor's Business Daily's Jed Graham picked up on some of my work for his post today, including the enrollment data for both Minnesota and Connecticut...but in addition to that extra data point (which I'll come back to in a moment), he also nabbed the latest number out of a third state, Oklahoma, from one of Adam Cancryn's updates on what I'm calling the UnitedHealthcare Disenrollment Odometer:

Over the past week or so, UnitedHealthcare started making good on their threat last fall to drop out of the ACA exchanges in at least some of the 33 states that they offer individual market policies in. On April 8th they said they were pulling up stakes in Arkansas and Georgia (although they're keeping a small presence in Atlanta via their experimental "Harken Health" division). Then, last Friday, they said they were dropping off the Michigan exchange as well...and just today, Adam Cancryn noted that they're pulling the plug on Oklahoma, while Zachary Tracer says they're pulling out of Louisiana. Ugh.

In Michigan, 15,000 children and pregnant women poisoned by lead and other toxic chemicals in their water supply from penny-pinching austerity measures by Republican Governor Rick Snyder and his GOP colleagues in the state legislature are finally being enrolled in Medicaid. So, you know, yay.

In Oklahoma, meanwhile, 111,000 dirt-poor adults (mostly women) are being kicked to the curb thanks to...penny-pinching austerity measures by Republican Governor Mary Fallin and her GOP colleagues in the state legislature:

Just how grim the state’s budget situation has become was apparent Wednesday morning as the state House of Representatives discussed and ultimately agreed to a bill that would cut 111,000 Oklahomans, most of them women, from Medicaid.

Oklahoma is an example of how frustrating this rate review stuff can be, even when there's only a handful of companies involved and much of the data is easily accessible.

According to RateReview.Healthcare.Gov, Oklahoma only has a single company asking for rate hikes greater than 10%: Blue Cross Blue Shield of OK.

The main listing gives the requested rate increase as a jaw-dropping 43.95%...but the description below it says that "the range of rate increases by product is 22% to 34%".

Now, there are two additional BCBSOK listings on the Rate Review site which do appear to be included in the first one (all 3 list the total "members affected" as exactly 137,506)...but the other two have 22.64% and 33.83% listed as the "official" requested rate increase, both of which are still well below 44%.

How on earth you can have the individual product rate hikes range from 22-34% but average 43.95%, I have no idea. Obviously I'm missing something here.

At first, this article in the Washington Times doesn't look like anything special...it's basically one of dozens of stories about the potential political and real-world impact of the King v. Burwell decision on a specific state...in this case, Oklahoma:

OKLAHOMA CITY (AP) - While the U.S. Supreme Court considers a key case related to the Affordable Care Act, officials in Oklahoma have taken little action to prepare for a ruling that could threaten the tax subsidies nearly 90,000 residents are using to purchase health insurance.

HOWEVER, it's the next couple of paragraphs which made me do a double-take:

Because Oklahoma opted not to create a state exchange where residents could shop for health insurance, Oklahomans instead purchased their plans through a federal exchange, but opponents who are challenging the law, including Oklahoma Attorney General Scott Pruitt, argue the law only allowed for the subsidies through state exchanges.

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