ShortAssPlans

Well, for good or for bad, it's finally here: The stripped-down-but-bipartisan COVID19 relief bill.

You can read the whole thing here...if you have a LOT of spare time on your hands. It's 5,600 pages long, 1.1 million words. For context, the entire Lord of the Rings trilogy is only half that length (576,000 words).

There's 1,000 explainers being written today about the most obvious stuff (the $600 direct relief checks, the extended & enhanced unemployment funding, etc etc), most of which falls far short of what's actually needed. Instead, I'm focusing on the ACA-related provisions. I already wrote about the surprise billing prohibition this morning, of course, but a quick initial scan of the text (which isn't easy...again, 5,600 pages...) reveals several other items directly related to the Affordable Care Act, so let's take a look! (Note: I'm sure I'm missing a few):

Page 4,206:

I've only written about Montana State Auditor (which includes acting as the Insurance Commissioner, as far as I can tell) Matt Rosendale a couple of times before. The first was in October/November 2017, when he pulled a cynical, disingenuous dick move by deliberately framing a non-profit insurance carrier into losing money for purely political reasons:

Montana commissioner chides insurance companies for raising rates, despite earlier offers to help

BOZEMAN — Montana's insurance commissioner chided two companies for raising rates on health insurance policies offered under the Affordable Care Act after federal subsidies ended, despite earlier telling them they could modify their rates if circumstances changed, the Bozeman Daily Chronicle reported.

...Matt Rosendale said he was "extremely disheartened" that PacificSource and the Co-op increased their premiums, adding that he had been assured by the companies that with or without the cost-sharing reduction payments they would be able to honor the rates they first submitted.

SHOT (if you can afford one):

!! Azar refuses to promise a coronavirus vaccine will be affordable for anyone:

"We would want to ensure that we work to make it affordable, but we can't control that price, because we need the private sector to invest.. Price controls won't get us there."

— Michael McAuliff (@mmcauliff) February 26, 2020

CHASER:

If the U.S. Preventive Services Task Force recommended a coronavirus vaccine, the ACA would require that all insurance plans cover it with no patient cost-sharing. (That wouldn't apply to short-term plans expanded by the Trump administration, which do not comply with ACA rules). https://t.co/OK7SOm22Wh

— Larry Levitt (@larry_levitt) February 26, 2020

A few weeks ago, I did a write-up about a concerning development at HealthCare.Gov: The growing push under the Trump Administration to not only partner with 3rd-party web brokers (which has been done since the first days of the ACA under the Obama Administration), but to actively promote those third-party brokers over HealthCare.Gov itself.

In and of itself, this wouldn't be too problematic as long as people are still ultimately enrolling in fully ACA-compliant policies and receiving ACA subsidies if they're eligible for them. Hell, one of these 3rd-party authorized web brokers even has a banner ad at the top of my website...which I only allow because this particular one only sells on-exchange ACA-compliant policies.

Over at the Washington Post, reporter Yasmeen Abutaleb has a disturbing-sounding story which immediately caught my eye and raised major internal alarms within the healthcare wonk/advocate community:

Critics say ‘junk plans’ are being pushed on ACA exchanges

The Trump administration has encouraged consumers to use private brokers, who often make more money if they sell the less robust plans.

The Trump administration is encouraging consumers on the Obamacare individual market to seek help from private brokers, who are permitted to sell short-term health plans that critics deride as “junk” because they don’t protect people with preexisting conditions, or cover costly services such as hospital care, in many cases.

So far, this is nothing new; I've been warning people about this since day one...it's the 2nd item on my "Seven Important Things to Remember" blog post from November 1st:

I've written a lot over the past nearly three years about the damage caused to ACA policy enrollment caused by the Trump Administration's slashing of 90% of HealthCare.Gov's marketing, awareness and outreach budgets.

A significant portion of the reduction in ACA exchange enrollment in 2017, 2018 and 2019 can be blamed squarely on this.

That's not just my opinion; it's been supported by detailed analysis as well as the corresponding increase in enrollment on state-based exchanges, which operate their own marketing/outreach budgets.

The following graph compares the two over the first six Open Enrollment Periods. I've had to adjust for the fact that since 2014, several states have switched from state exchanges to the federal one or vice-versa, but even so, the contrast is dramatic and clear:

 

I've written endlessly about #ShortAssPlans for several years now. Hell, I even put together a crude video explainer (see above) to explain what "Short-Term, Limited Duration plans" and "Association Health plans" are and why they should be tightly regulated, if not eliminated altogether.

However, the truth is that for all of my blog posts and warnings about these types of substandard policies, about 90% of my focus has been on how opening up the floodgates on them would negatively impact the ACA-compliant risk pool. It's a bit of a zero-sum game, after all: The more healthy people who leave one, the more sick on average the other one is, which means a higher risk pool of enrollees, which means higher premiums, which leads to more healthy people dropping out and so on...the infamous "death spiral".

What I've written much less about, however, is the other reason why #ShortAssPlans generally suck...namely, the plans themselves tend to...well, suck.

Today, Zeke Faux, Polly Mosendz and John Tozzi have a devastating new story over at Bloomberg Businessweek about #ShortAssPlans:

Back in March, I noted that a federal judge had shot down the Trump Administration's attempt to expand so-called "Association Health Plans", which are quasi-ACA compliant but which also have a long, ugly history of fraud and other abuses:

There is a long history of shady and inept operators of association health plans and related multiple employer welfare arrangements, with dozens of civil and criminal enforcement actions at the state and federal levels. The U.S. Government Accountability Office identified 144 "unauthorized or bogus" plans from 2000 to 2002, covering at least 15,000 employers and more than 200,000 policyholders, leaving $252 million in unpaid medical claims. Some were run as pyramid schemes, while others charged too little for premiums and became insolvent.

...Powerful words from DC District Court Judge John Bates in holding a Trump DOL rule unlawful: "The Final Rule was intended and designed to end run the requirements of the ACA, but it does so only by ignoring the language and purpose of both ERISA and the ACA."

This story got a lot of play a week or so ago, but I didn't get a chance to write anything up about it until today. Via Reed Abelson of the New York Times:

One Ohio resident paid $240 a month for health insurance that she later learned didn’t cover her knee replacement. Saddled with $48,000 in medical bills, she decided not to get the other knee replaced.

...A Kansas resident paid premiums on a policy for two years, then found out his insurance would not cover surgery for a newly diagnosed cancer.

The two policyholders have filed a lawsuit in federal court against Health Insurance Innovations, based in Tampa, Fla., accusing the company of misleading them about the kind of policy they were buying.

They say they believed they were purchasing Affordable Care Act plans that include coverage guarantees. But they were sold much less comprehensive coverage that left them vulnerable to tens of thousands of dollars in unpaid medical bills, according to the lawsuit.

Hot on the heels of Washington State locking in pretty much every "Blue Leg" ACA protection in a single bill today, the Connecticut state House of Representatives passed their own bill covering some ACA protections (via CT News Junkie):

Connecticut’s House of Representatives voted Wednesday to strengthen state health insurance laws by making sure residents with pre-existing conditions are protected.

House Bill 5521 passed unanimously by a 146-0 vote, and now goes to the Senate.

Well, now. I guess Connecticut Republicans are smarter than Congressional Republicans, anyway...

 

Sorry, I'm a little behind the 8-ball today...a few hours ago, the House Education & Labor Committee voted on and approved H.R.1010, which would reverse the Trump Administration's executive order which removed restrictions placed on so-called "short-term, limited duration" (STLD) healthcare policies, commonly known as "junk plans" since most ACA regulations/requirements don't apply.

Again, the short version (no pun intended) is this: Under the Obama Administration, STLDs were restricted to no more than 3 months at a time, and forbid them from being renewed within the same calendar year. They were always intended to be just that: Short-term only, and of limited duration, for certain people in special circumstances only.

Back in January I reported that the state of Colorado is joining several other states in cracking down on non-ACA compliant so-called "Short-Term, Limited Duration" healthcare policies. As of April 1st, STLDs:

  • Can last no longer than 6 months/year (still longer than the 3-mo limit under Obama)
  • Have to stick to the ACA's 3:1 age band limit on premiums
  • Must be guaranteed issue (no more medical underwriting)
  • They can still exclude coverage of pre-existing conditions, but there's a limit of 12 months on the lookback timeframe
  • Must cover all 10 of the ACA's Essential Health Benefits
  • Must follow other ACA community rating requirements (limiting variances to age, tobacco use and geographic area)
  • A minimum Medical Loss Ratio of 80% to match the ACA's MLR (currently CO only requires a 60% MLF)

In other words, Colorado just made STLDs follow most of the same rules as ACA-compliant policies.

Virginia Governor Ralph Northam has been out of the national news for the past month or so, keeping a low profile since the media frenzy over the "med school blackface photo" debacle subsided. Rightly or wrongly, in the end, in spite of pretty much everyone under the sun demanding that he resign, he stuck it out and outlasted the scandal by simply...not.

He isn't up for reelection (and in fact under Virginia law he can't run again anyway), he didn't actually commit any crimes or anything else impeachable, so it sounds like the state has pretty much just sort of accepted that he's gonna stick it out for another couple of years. In fact, according to this article in the Virginian-Pilot, he seems to have regained some of his pre-scandal stature:

Two months after a blackface photo in an old yearbook nearly ended the political career of Virginia Gov. Ralph Northam, his life seems mostly back to normal.

There's been so many Big Important Breaking News stories about healthcare this week I haven't been able to keep up. On top of the ACA 2.0 rollout and Trump's kamikaze #TexasFoldEm maneuver via the Dept. of Justice memo and the release of the 2019 Open Enrollment Period report and a major judicial ruling which torpedoed Medicaid expansion work requirements in Kentucky (again) and Arkansas which also had immediate implications for Idaho and Iowa...and potentially other states as well!!

And then, this evening, THIS just happened:

This happened yesterday:

Senate OKs small business health-care bill
By Richard Craver Winston-Salem Journal

The state Senate gave initial approval Wednesday to a Senate bill that would allow small-business employers to offer an association health-insurance plan, or AHP, that could provide lower premium costs.

Senate Bill 86 received a 40-8 vote on second reading, but an objection to a third reading kept it on the Senate calendar until at least today.

The GOP holds a majority in the NC Senate, but only by 29 to 21, so stopping this there was apparently a lost cause. They also hold a 65 to 54 majority in the state House. I'm not sure whether SB 86 has already been voted on there or not. If it passes both, it would be up to Democratic Governor Roy Cooper to veto the bill.

Over the past year or so, ever since Donald Trump issued an executive order re-opening the floodgates on non-ACA compliant "short-term, limited duration" (STLD) healthcare policies (otherwise known as "junk plans" since they tend to have massive holes in coverage and leave enrollees exposed to financial ruin in many cases), numerous states have passed laws locking in restrictions on them or, in a few cases, eliminating them altogether:

A big shout-out to Josh Dorner for providing a roundup of the current status of a five different lawsuits (six, really, although two of them are on the same topic in two different states) fighting back against GOP/Trump Administration sabotage of the Affordable Care Act, including:

There's also the various CSR reimbursement payment lawsuits filed by various insurance carriers. Those should have been a fairly minor issue only relating to about $2 billion in payments dating back to the 4th quarter of 2017...but as I explained in detail here, these suits may instead turn into an even more massive headache for the Trump Administration, and rightly so.

A couple of weeks ago, Louise Norris gave me a heads up that not only has the New Mexico Insurance Dept. restricted the sale of non-ACA compliant "short-term, limited duration" plans to be...you know...both short term and of limited duration via regulation...

In September 2018, the New Mexico Office of the Superintendent of Insurance (OSI) and Health Action NM (an advocacy group for universal access to health care) presented details about potential state actions to stabilize the individual market. OSI has the authority to regulate some aspects of the plans, including maximum duration, but they noted that legislation would be needed for other changes, including minimum loss ratios and benefit mandates.

New Mexico’s insurance regulations were amended, effective February 1, 2019, to define short-term plans as nonrenewable, and with terms of no more than three months. The regulations also prohibit insurers from selling a short-term plan to anyone who has had short-term coverage within the previous 12 months.

 

I noted last week that Congress held not one, not two but three full hearings regarding various ACA-related issues, at which a couple of friends of mine testified (and a couple more were on the other side of the microphone, as sitting members of Congress).

Well, prepare for another one tomorrow (Wednesday, February 13th):

HEARING ON “STRENGTHENING OUR HEALTH CARE SYSTEM: LEGISLATION TO REVERSE ACA SABOTAGE AND ENSURE PRE-EXISTING CONDITIONS PROTECTIONS”

Date: Wednesday, February 13, 2019 - 10:30am
Location: 2322 Rayburn House Office Building
Subcommittees: Health (116th Congress)

The Subcommittee on Health of the Committee on Energy and Commerce held a legislative hearing on Wednesday, February 13, 2019, at 10:30 a.m. in room 2322 of the Rayburn House Office Building. The bills to be the subject of the legislative hearing are as follow:

As always, Louise Norris has the skinny:

In September 2018, the New Mexico Office of the Superintendent of Insurance (OSI) and Health Action NM (an advocacy group for universal access to health care) presented details about potential state actions to stabilize the individual market. OSI has the authority to regulate some aspects of the plans, including maximum duration, but they noted that legislation would be needed for other changes, including minimum loss ratios and benefit mandates.

New Mexico’s insurance regulations were amended, effective February 1, 2019, to define short-term plans as nonrenewable, and with terms of no more than three months. The regulations also prohibit insurers from selling a short-term plan to anyone who has had short-term coverage within the previous 12 months.

Last year I briefly attempted to keep track off the dozens of various state-based "ACA 2.0" protection/improvement bills flying around various state legislatures. I eventually abandoned this project since it became too difficult to keep up with, but I'm still reporting case studies as they come to my attention...and Louise Norris has just alerted me to some pretty big changes going into effect in Colorado this April.

First up: Short-term plans are being heavily neutered. In addition to being limited to 6 months per year (which is still longer than the Obama Administration's 3-month cut-off)...

Short-term plans will have to charge older adults no more than three times as much as they charge younger adults. Short-term plans are generally not available after a person is 64, but a quick check of plans currently available in Colorado show that some insurers are charging a 64-year-old up to seven times as much as a 21-year-old. That will have to stop as of April.

Last April, Maryland was one of several states which took action to counteract portions of the Trump Administration's attempts to sabotage the Affordable Care Act. In particular, Maryland (which has a Democratically-controlled state legislature but a moderate (by today's standards) Republican Governor) passed and signed into two important bills:

The combined effect of these changes was dramatic: Maryland's individual market insurance carriers, which had been planning on jacking up their average premiums by a whopping 30%, instead ended up lowering their 2019 premiums by over 13%. This is a net swing of around $3,200 per enrollee for the year (around $266 per month). In other words, instead of seeing unsubsidized 2019 premiums go up by $2,200 apiece, they dropped around $1,000.

Michigan was pretty much Ground Zero for the 2018 Blue Wave midterm elections. In addition to Democrats flipping the Governor's seat (and holding onto Debbie Stabenow's U.S. Senate seat), they also flipped the Attorney General, Secretary of State, one of two state Supreme Court seats, both of the state Board of Education seats which were up and all six state University Board seats which were up. In addition, they picked up two U.S. House seats, five state Senate seats and five state House seats.

It was a complete and utter repudiation of both Republican governance and their agenda.

You might expect the Michigan GOP to accept the clear will of the voters. You would be very, very wrong.

As Democratic candidates prepare to take three statewide offices on Jan. 1 — governor, attorney general and secretary of state — Republican lawmakers introduced bills Thursday to challenge their authority.

A couple of weeks ago I noted that the Illinois state Senate unanimously overrode outgoing Governor Rauner's veto of their bill restricting the sale of non-ACA compliant short-term, limited duration healthcare plans.

Today, I'm happy to report that the state House has followed up and overrode the veto as well:

Breaking: Just got word that the Illinois legislature has overridden the veto on SB1737 which limits short term plans to 6 months and bans rescissions of short term plans. @GtownCHIR h/t @stephanibecker

— Dania Palanker (@DaniaPal) November 27, 2018

This is welcome news...

Illinois Senate voted unanimously to override the Governor's veto of a bill to limit short-term health plans to 6 months. Protecting consumers and insurance markets from long-term short-term plans does not appear to be a partisan issue. https://t.co/fJ4NVV4LRQ

— Dania Palanker (@DaniaPal) November 15, 2018

As I noted a few days ago, now that the 2019 ACA Open Enrollment Period is actually underway and the approved individual market premium rate changes have been posted publicly for every state, I'm finally able to go back and wrap up my 2019 Rate Hike Project for the nine states which I was still missing final numbers for.

As I further noted, the approved rates in most of those states didn't change much compared to the preliminary/requested rate changes I had already analyzed earlier this year:

I realize this may seem a bit late in the game seeing how the 2019 ACA Open Enrollment Period has already started, but I do like to be as complete and thorough as possible, and there were still 9 states missing final/approved premium rate change analyses as of yesterday which I wanted to check off my 2019 Rate Hike Project list.

Fortunately, RateReview.HealthCare.Gov has finally updated their database to include the approved rate changes for every state, which made it easy to take care of most of these.

Nebraska has a slightly confusing siutation, which is surprising since Medica is the only carrier offering ACA policies in the state, When I first took a look at the requested premium changes for 2019 back in August, it looked like the average was around 1.0%...that was based on splitting the difference between the 3.69% and -2.60% listings, since the filing form was redacted and I didn't know what the relative market split was between Medica's product lines.

I realize this may seem a bit late in the game seeing how the 2019 ACA Open Enrollment Period has already started, but I do like to be as complete and thorough as possible, and there were still 9 states missing final/approved premium rate change analyses as of yesterday which I wanted to check off my 2019 Rate Hike Project list.

Fortunately, RateReview.HealthCare.Gov has finally updated their database to include the approved rate changes for every state, which made it easy to take care of most of these.

West Virginia's requested average rate increase was among the highest in the country for 2019--a weighted average of around 14.9%.

However, while state insurance regulators left one of the three carriers offering individual market policies alone, they knocked the other two down substantially: CareSource was lowered from around 13.1% to 9.5%, while Highmark Blue Cross Blue Shield was lowered from an average of 15.9% to 9.0%.

I realize this may seem a bit late in the game seeing how the 2019 ACA Open Enrollment Period has already started, but I do like to be as complete and thorough as possible, and there were still 9 states missing final/approved premium rate change analyses as of yesterday which I wanted to check off my 2019 Rate Hike Project list.

Fortunately, RateReview.HealthCare.Gov has finally updated their database to include the approved rate changes for every state, which made it easy to take care of most of these. In addition, in a few states the insurance department has also posted their own final/approved rate summary.

This is about as minor a rate filing update as I've had, but I'm posting it separately in the interest of completeness.

Insurance carriers in my home state of Michigan originally submitted their requested 2019 ACA individual market rate filings back in June. At the time, the average premium increase being asked for was pretty nominal, around 1.7%, with a smaller-than-average #ACASabotage factor of around 5% due to the ACA's Individual Mandate being repealed and #ShortAssPlans being expanded by the Trump Administration.

Today, just two days before the 2019 Open Enrollment Period actually begins, the Michigan Dept. of Financial Services finally posted the approved 2019 rate filings...and practically nothing ended up changing.

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