Trumpcare

I've spent the past two weeks posting about almost nothing besides the Graham-Cassidy debacle, so haven't had a chance to keep on top of the approved 2018 rate changes as I usually do. Fortunately, Louise Norris of healthinsurance.org has stayed on the rate hike job, and reports the final numbers out of Washington State:

2018 rates: 24% approved rate increase, due in large part to federal uncertainty — and higher backup rates will be implemented if CSR funding is cut mid-year

Insurers in Washington had to file rates and plans for 2018 by June 7, 2017. On June 8, Kreidler’s office published a summary of what had been filed (rate filings are available here, and that page will show final rate changes for the individual market once they’re approved), and publicized the filing details on June 19. The average proposed rate increase in Washington, before any subsidies are applied, was 22.3 percent.

Back in August it looked as though Florida carriers were looking at either 15.5% unsubsidized rate increases on the individual market if CSR reimbursement payments were guaranteed next year, or around 35.5% if they weren't. Well, the official rates have been released by the Florida Dept. of Insurance, and it's even uglier than that for unsubsidized enrollees:

Office Announces Submission of Proposed Rates for 2018 Federal PPACA Health Insurance Plans

 

As you've probably heard fby now, Mitch McConnell has formally/officially pulled the latest incarnation of Trumpcare, aka "Graham-Cassidy" (or "Graham-Cassidy-Heller-Johnson" for those who love hyphens) from being voted on this week before the September 30th reconciliation deadline:

Republican leaders have decided not to vote on Obamacare repeal legislation this week, effectively ending the party’s latest effort to wipe away the 2010 health care law.

When, and whether, they will try again remains to be seen. But for now, a defining cause of the Republican Party, including President Donald Trump, lies in tatters.

And at least for the moment, insurance coverage for many millions of Americans who rely on Medicaid or the Affordable Care Act’s federal subsidies remains intact ― although insurance markets in some states remain unstable, and the Trump administration’s willingness to manage the program remains unclear.

(sigh) When I last checked in on Virginia, things were looking up a bit (relatively speaking), as Anthem Blue Cross Blue Shield (aka "HealthKeepers") had announced that they were jumping back into the state in order to cover the 60-odd counties which would otherwise be left bare by Optima Health Insurance dropping out of half the state a week or so earlier.

Unfortunately, while this did resolve the "bare county" problem for VA, it didn't resolve the other big problem: Major rate hikes for unsubsidized individual market enrollees:

As many see their options for health plans dwindle down to one insurer, premiums are simultaneously set to rise by an average of 57.7 percent next year in Virginia’s individual marketplace.

The increase is “unquestionably the highest we’ve ever seen,” David Shea, health actuary with Virginia’s Bureau of Insurance, told lawmakers Monday.

Yesterday was a Graham-Cassidy (or "Grassidy", as former CMS Administrator Andy Slavitt keeps trying to push) Fest, with all sorts of Grassidy-centric happenings, including the one-and-only Senate hearing on the bill; the Congressional Budget Office releasing their preliminary/partial score of G-C (the prior version, not the later version); Senator Susan Collins releasing her statement opposing the bill; and last night's CNN healthcare debate between Senators Graham & Cassidy vs. Senators Sanders and Klobucher. I might write something about these items later today, but right now I want to look at another development.

Last week I broke the story (later picked up by Axios, NY Magazine and Vox.com) that the Graham-Cassidy bill would make thousands of current insurance policies illegal starting on January 1, 2018...just 98 days from now.

Why? Because, as noted at the link, while the current ACA structure (exchanges, tax credits, etc) would stay mostly in place for 2 more years, some provisions would be repealed immediately...including a nationwide ban on any exchange policy offering abortion coverage.

This morning JP Massar (who called my attention to the 1/1/18 effective date the first time) inquired as to whether that had changed with the new version of G-C. As you can see on pages 2 & 3 of the new bill...nope. It’s still in place.

 

Late Sunday night, Axios managed to get ahold of a copy of the revised version of the Graham-Cassidy bill...and it's a complete and utter travesty.

Here's direct links to the bill itself and to the GOP's table showing what they claim would be the net federal funding changes from 2020-2026 for each state relative to current law...but they pulled one hell of a fast one.

Here's the original table...

 

it's pretty rare for the entire medical, hospital and insurance industry to agree on just about anything...and yet here we are (emphasis in the original):

The following statement was jointly released on September 23, 2017 by the American Medical Association, American Academy of Family Physicians, American Hospital Association, Federation of American Hospitals, America's Health Insurance Plans and the BlueCross BlueShield Association regarding the Graham-Cassidy-Heller-Johnson legislation.

We represent the nation's doctors, hospitals and health plans. Collectively, our organizations include hundreds of thousands of individual physicians, thousands of hospitals, and hundreds of health plans that serve tens of millions of American patients, consumers and employers every day across the United States.

Anyone who's followed me either here at ACASignups.net or over at Twitter over the past eight months knows that no one has been sounding the alarm louder or more frequently than me about both the real and potential sabotage of the ACA being carried out (or at least attempted) by the GOP in general and Donald Trump/Tom Price specifically. Hell, back in July, I even warned of a half-dozen things to look out for, several of which have since already been proven true:

This brings me to the main point of this entry: This is likely just the beginning. I'm not going to say that any or all of the following will happen--it's possible that Trump/Price/Verma will show some level of restraint--but I wouldn't be at all surprised to see any or all of these happen during this fall's Open Enrollment Period (which runs from Nov. 1st - Dec. 15th, by the way):

It's time to once again dust off the Three-Legged Stool visual aid to help explain just what the Graham-Cassidy bill would do to the individual insurance market. It's important to note that none of this has anything to do with Medicaid (expansion or traditional), the group market, Medicare and so forth; just the individual market.

Once again, here's what the "3-Legged Stool" was supposed to look like under the Affordable Care Act:

Here's what it actually looks like today, with some rather obvious gaps in the red (enrollee responsibility) and green (government responsibility) legs:

As the final deadline for final 2018 individual market rates to be locked in and the contracts signed, more states are coming into focus, and the pattern continues to be remarkably consistent.

In Mississippi, I originally pegged the requested rate hikes across the two individual market carriers (technically three, but "Freedom Life" is a phantom carrier with only 2 alleged enrollees) at 16.1% if CSR payments are made and 39.6% if they aren't. It turns out I was off by a bit, however, because I didn't realize that BCBS of Mississippi was only selling policies off-exchange next year. That means the CSR issue won't impact them either way, since none of their enrollees would receive the assistance anyway.

Haley Byrd of The Independent Journal Review has the skinny about the latest attempt to bribe Alaska Senator Lisa Murkowski into voting for the Graham-Cassidy bill:

  • Alaska (along with Hawaii) will continue to receive Obamacare’s premium tax credits while they are repealed for all other states. It appears this exemption will not affect Alaska receiving its state allotment under the new block grant in addition to the premium tax credits.
  • Delays implementation of the Medicaid per capita caps for Alaska and Hawaii for years in which the policy would reduce their funding below what they would have received in 2020 plus CPI-M [Consumer Price Index for Medical Care].
  • Provides for an increased federal Medicaid matching rate (FMAP) for both Alaska and Hawaii."

Well, now.

Bird doesn't have the actual legislative text, but they threw Hawaii in there as well (not to win their votes...Dems Brian Schatz and Mazie Hirono are solid NOs no matter what). That means that the wording is probably along the lines of:

The Congressional Budget Office stated that they won't be able to provide a full score of the projected 10-year impact of the Graham-Cassidy bill for "at least several weeks". Instead, they expect to provide a partial score, focusing purely on the budget-related stuff necessary to "count" towards Senate reconciliation voting rules "early next week".

What won't be included are some pretty damned important details, like:

  • Impact on the federal deficit
  • Impact on insurance premiums, and of course...
  • Impact on the number of people with health insurance coverage

Unfortunately, Mitch McConnell and Senate Republicans are insisting on squeezing the vote on Graham-Cassidy through within the next 10 days, before the fiscal year ends on Sept. 30th, since that's the only way they have a chance at passing it using 50 votes (after the 30th, they would require 60 votes, which of course they have no chance at getting).

Here's the latest enrollment data from the Louisiana Department of Health.

I've embedded screen shots below, but there's various interactive stuff you can do at the site itself; LA did a very nice job, I'd love it if every state put up a similar "dashboard" style website.

In short:

  • 434,594 Louisianans enrolled in Medicaid via ACA expansion
  • 126,229 have received preventative care
  • 22,058 women have received breast cancer screenings
    • 225 women have been diagnosed with breast cancer as a result of ACA Medicaid expansion
  • 13,994 adults have received a colon cancer screening
    • 4,337 have averted colon cancer by having polyps removed
    • 199 have been diagnosed with colon cancer thanks to ACA Medicaid expansion
  • 3,774 have been diagnosed with diabetes
  • 9,575 have been diagnosed with hypertension
  • 32,912 are receiving outpatient mental health services
  • 6,025 are receiving inpatient mental health services
  • 5,559 are receiving outpatient substance abuse services
  • 6,026 are receiving residential substance abuse services

 

As NBC News reporter Hallie Jackson notes, there are too many quotable lines to count in this Vox piece, in which Jeff Stein tracked down 9 Republican Senators to ask them what the hell the purpose of the Graham-Cassidy bill actually is. The responses pretty much say it all.

Jeff Stein: Senator, I wanted to ask you for a policy-based explanation for why you’re moving forward with the Graham-Cassidy proposal. What problems will this solve in the health care system?

Pat Roberts: That — that is the last stage out of Dodge City...I’m from Dodge City. So it’s the last stage out to do anything. Restoring decision-making back to the states is always a good idea, but this is not the best possible bill — this is the best bill possible under the circumstances.

If we do nothing, I think it has a tremendous impact on the 2018 elections. And whether or not Republicans still maintain control and we have the gavel.

Jeff Stein: But why does this bill make things better for Americans? How does it help?

9/25/17: SEE IMPORTANT UPDATE BELOW!

The fact that the Graham-Cassidy bill, like all of the prior Republican "replacement" healthcare bills, screws over people on both Medicaid and the individual market starting in 2020 is hardly news. A few provisions of the ACA are stripped out and/or bastardized immediately (and some, like the individual mandate penalty, are even repealed retroactively), but for the most part the pain doesn't start for another 2 years, well after the midterms are over.

However, JP Massar called something to my attention this morning:

Graham-Cassidy, Sections 102 and 103:

Section 102: Modification and Repeal of Premium Tax Credits

 

Regular readers know that one of the issues I've spent the better part of the past year yammering on about endlessly is the importance of Congress formally appropriating Cost Sharing Reduction reimbursement payments to the insurance carriers on the individual market exchanges.

Thanks to the ongoing/pending ruling in the federal House vs. Burwell Price lawsuit, Donald Trump has the ability to pull the plug on CSR payments pretty much whenever he wants to (and he's threatened to cut them off every month since around March or April so far). CSR payments hang like a Sword of Damocles over the heads of every exchange-based insurance carrier each month, with them never knowing whether they'll get reimbursed or not.

Just posted on the Congressional Budget Office's official blog:

CBO aims to provide preliminary assessment of Graham-Cassidy bill by early next week

CBO is aiming to provide a preliminary assessment of the Graham-Cassidy bill by early next week. That assessment, which is being prepared with the staff of the Joint Committee on Taxation, will include whether the legislation would reduce on-budget deficits by at least as much as was estimated for H.R. 1628, the American Health Care Act, as passed by the House on May 4, 2017; whether Titles I and II in the legislation would each save at least $1 billion; and whether the bill would increase on-budget deficits in the long term. CBO will provide as much qualitative information as possible about the effects of the legislation, however CBO will not be able to provide point estimates of the effects on the deficit, health insurance coverage, or premiums for at least several weeks.

Lovely.

OK, Indivisible is all over the Graham-Cassidy disaster, so rather than try and cobble together my own action list, I'm cribbing from their email missive. I'll also be posting the latest Graham-Cassidy developments throughout the day.

STOP THE RETURN OF TRUMPCARE. TrumpCare is back and Republicans are as close as they’ve ever been to passing it. There are 12 days left for the Senate to ram healthcare through reconciliation with just 50 votes. This is TrumpCare’s last stand. Call your senators ASAP and tell them to vote no on “Graham-Cassidy” using all the latest resources at TrumpCareTen.org.

TrumpCare is back. REPEAT: TrumpCare is back. We really hoped we’d never have to say that, but you should know by now that this is the bill that just won’t die. Because of the rules of reconciliation, the special process Republicans are using to jam TrumpCare through the Senate, they have until September 30 to finish the job of repealing the Affordable Care Act. That gives them 12 more days to make good on their seven-year promise to repeal the Affordable Care Act. And nothing motivates Congress like a deadline.

August 11, 2017:

Anthem said Friday afternoon it planned to scale back statewide individual coverage in Virginia on the public exchange under the Affordable Care Act amid inaction by the Donald Trump White House on cost-sharing reduction subsidies.

Anthem, which operates under the Blue Cross and Blue Shield plan in 14 states, has already scaled back its Obamacare offerings in Indiana, Ohio and Wisconsin amid an unstable individual market for plans operating under the ACA.

“Today, planning and pricing for ACA-compliant health plans has become increasingly difficult due to a shrinking and deteriorating Individual market, as well as continual changes and uncertainty in federal operations, rules and guidance, including cost sharing reduction subsidies and the restoration of taxes on fully insured coverage,” Anthem said in a statement Friday afternoon. “As a result, the continued uncertainty makes it difficult for us to offer Individual health plans statewide in Virginia.”

Just a few days ago I noted that Michigan's Dept. of Insurance issued the semi-final 2018 individual market rate changes for the 10 carriers offering indy policies in the state (9 of which are on the ACA exchange; one of them is only offering plans off-exchange). At the time, the breakout was roughly 16.8% average increases assuming CSR payments are made next year or 26.8% assuming they aren't made.

Just moments ago, however, the Detroit News reported that Health Alliance Plan (HAP) is out at the last minute:

A major health insurer is leaving Michigan’s individual marketplace, ending its policies offered here under the Affordable Care Act as the federal government slashes funding for enrollment and outreach groups.

For the next two weeks, ALL HEALTHCARE-RELATED ATTENTION needs to be on the following three issues:

FIRST: September 27th is the final deadline for ACA exchange insurance carriers to actually sign the contracts to participate in the 2018 Open Enrollment Period. Yes, the deadline to submit their rate filings already passed a week or so ago, and most of them are fairly settled in for next year, but until they actually sign the contract, they can still bail from the individual and/or small business exchanges...and given the massive uncertainty over Cost Sharing Reduction reimbursements and other sabotage efforts of Trump and Tom Price as well as the ongoing repeal/replace saga by the Congressional GOP, many (most?) of the carriers are deliberately waiting until the last possible minute to do so.

Louisiana was one of the last states I ran rate hike analysis on just a month ago: Three carriers on the exchange (plus the "Freedom Life" phantom carrier), averaging around 21.4% rate increases on the assumption that CSR payments won't be made. According to the Kaiser Family Foundation, loading CSRs onto Silver plans only would bump them up by an additional 20 points; this translates into roughly 14.2 points if spread across all metal levels on & off the exchange. Based on that, I estimated LA's rate increases at 21.4% without CSRs but only 7.2% if they actually are paid.

Thanks once again to Louise Norris for doing the grunt work regarding the approved rate changes, which are...pretty much identical to what was requested by the carriers:

Proposed 2018 rates much higher than they would have been if CSR funding had been appropriated early in 2017

I ran an updated analysis of the requested average rate hikes for Connecticut last month. At the time, the only two carriers operating on the CT exchange next year (Anthem and ConnectiCare) were still noncommittal about actually committing to doing so. Statewide, it looked like the carriers were asking for rate increases averaging around 23.8% if CSR payments were guaranteed or 33.5% if they weren't.

As reported by Louise Norris today, the Connecticut insurance dept. reported that both carriers have now committed to sticking around next year, and the approved average rate increases now assume that CSR payments won't be made after all. In the end, the statewide average looks like roughly 28.4% (Norris pegs it at 29.3%, but that's because she generally only includes individual market carriers participating on the ACA exchanges, while I also include carriers and plans offered off-exchange as well).

I've written not one, not two, but three different blog entries in the past 24 hours about Bernie Sanders' just-announced "Medicare for All" proposal...but the reality is, I shouldn't have. Frankly, while it's a discussion/debate that we do need to have, making a big thing about it right this moment is, the more I think about it, terrible timing, because the Affordable Care Act is still in being attacked and at risk in several ways:

  • FIRST: The CSR issue still hasn't been resolved, although at this point it's extremely unlikely that Patty Murray and Lamar Alexander are going to pull a CSR/reinsurance rabbit out of their hats after all. Last week things looked somewhat promising, but this week it appears to have gone off the rails again...and with just 17 days left in the fiscal year (and, I believe, only 14 days before the contracts have to be signed by carriers for 2018 exchange participation), there's almost no time left to get even a minor stabilization bill pushed through.
  • SECOND: On a related note, Bill "so much for the Jimmy Kimmel test!" Cassidy and Lindsey Graham are still trying to cram through their pile-of-garbage Hal Mary Trumpcare bill, which is at least as bad as the GOP's failed AHCA/BCRAP bills were earlier this year and even worse in some ways. Again, there's only 17 days left to pull it off, but remember what happened with AHCA last spring...anything's possible. Here's a summary of the impact of the Cassidy-Graham bill via Andy Slavitt and the Centers for Budget & Policy:

It appears that a formal letter was sent to HHS Secretary Tom Price and CMS Administrator Seema Verma from the Energy & Commerce Committee of the House of Representatives...it's 6 pages long, and unfortunately the text isn't selectable, so I had to embed the pages as images. I'm happy to report that I contributed to their inquiry.

If you look at the top of the website today, you'll notice a couple of new graphics, both relating to the Indivisible ACA Signup Project.

The short version is this:

Donald Trump is cutting ACA outreach, so we've started an Indivisible-based, state-by-state sign-up project group to counter the sabotage.

All you need to do (should you agree) is use social media to update people (on your advocacy and/or personal pages) in your state on key issues and dates/deadlines for sign-ups.

That's pretty much the whole thing in a nutshell, at least so far. It's a closed Facebook Group which you need to request permission to join, but they obviously want the materials to be disseminated as widely as possible (that's kind of the whole point!), so I've agreed to set up a permanent, public link for folks to access them.

...and believe me, it wasn't on purpose; I've simply been swamped the past couple of weeks with other stuff, and somehow I just never got around to writing anything up about it.

I should have, though. Everyone thinks the existential threat to the ACA was over back on July 28th, and now it's simply a matter of "stabilizing the market" and "stopping Trump from sabotaging Open Enrollment". For the most part this is true, but for whatever reason, Louisiana GOP Senator Bill Cassidy and South Carolina GOP Senator Lindsey Graham simply won't let it go already, and are insisting on trying one final, desperate Hail Mary play to squeeze through an ACA repeal/Trumpcare bill as the final seconds run out on the 2017 Fiscal Year (which ends September 30th).

Since I'm so late to the party on this and there's so little time to stop it, instead of my own explainer I'm going to simply crib a bit from former CMS head Andy Slavitt's USA Today column in which he gives the lowdown:

A week ago, Vox's Sarah Kliff reported that the Trump Administration was slashing the 2018 Open Enrollment Period advertising budget by 90% and the navigator/outreach grant budget by nearly 40%. As I noted at the time, the potential negative impact of these moves on enrollment numbers this fall--coming on top of the period being slashed in half, the CSR reimbursement and mandate enforcement sabotage efforts of the Trump/Price HHS Dept. and the general confusion and uncertainty being felt by the GOP spending the past 7 months desperately attempting to repeal the ACA altogether could be significant. In states utilizing the federal exchange (HealthCare.Gov), 2017 enrollment was running neck & neck with 2016 right up until the critical final week...which played out under the Trump Administration, which killed off the final ad/marketing blitz.

Result? A 5.3% total enrollment drop (or 4.7% if you don't include Louisiana, which expanded Medicaid halfway through the year) via HC.gov, while the 12 state-based exchanges--which run their own marketing/advertising budgets--saw a 1.8% increase in total enrollment year over year.

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