Trumpcare

The good news is that Wisconsin has one of the most robust and competitive exchange markets in the country. The bad news is that, contrary to popular opinion, "competition" doesn't by itself magically lower prices, at least not by enough. Both Anthem and Molina are leaving the ACA exchange (although Anthem is technically sticking around off-exchange), but there's over a dozen other carriers still duking it out.

According to the 11 carriers I have enrollment numbers for, the statewide average rate increase being requested is around 20.8% assuming CSR payments are made; using the Kaiser Family Foundation estimates, that translates into roughly 32.4% assuming they aren't made. Unfortunately, I can't seem to dig up the enrollment data for four carriers: Aspirus, Compcare, Wisconsin Physician Service and WPS (I think the last two are actually subsidiaries fo the same company). Wisconsin's total individual market should be roughly 280,000 people, and when you add up all the numbers I have (including Anthem/Molina) it only comes to around 180,000, so there appear to be roughly 100,000 enrollees missing among those 4 carriers, or over 35%.

I admit to being a bit confused about the distinction between BCBSSC and BlueChoice HealthPlan, which is also a BCBS carrier...I'm guessing one is for HMOs, the other for PPOs or something. In any event, BlueChoice plans appear to only be available off-exchange, and are thus not subject to the CSR issue. BCBSSC is, however, and the Kaiser Family Foundation estimates that their Silver plans would have to go up 23% if CSR payments are cut off. 87%% of SC exchange enrollees are on Silver plans, so that should be roughly 20.2% across all policies.

If CSR payments are made, South Carolina is looking at around a 13.2% average rate hikes; if they aren't, it's an uglier 32.5%.

We're heading into the home stretch now, with the only remaining "supersize" state, FLORIDA. FL has the largest exchange-based individual market enrollment, and the 2nd largest total individual market enrollment of any state in the country, surpassing California for a variety of local economic/demographic reasons. The Kaiser Family Foundation estimates that FL carriers would have to add about 25% to their Silver plan premiums in order to make up for CSR reimbursements if Trump pulls the plug and/or Congress doesn't formally appropriate them. Since 80% of FL exchange enrollees are on Silver plans, that translates to roughly a 20% additional "Trump Tax" for the CSR factor alone. Note that while none of the carriers mention the CSR issue (meaning they all assume the payments will be made), Molina does call out the individual mandate enforcement issues as being part of their 37.5% rate increase request. Unfortunately, they don't put a hard number on this.

With Blue Cross Blue Shield of Nebraska declining to participate in the Nebraska exchange, that leaves just Medica as the sole individual market carrier. They're asking for a 16.9% average rate hike, 

Interestingly, while Medica's rate filing letter clearly states that the 16.9% request assumes CSR payments will be made and the mandate will be enforced, they also list "unprecedented uncertainty/risk inherent in the marketplace" as one of the key drivers of the increase.

The Kaiser Family Foundation estimates the CSR issue as adding around 15% to NE Silver plans, which translates into roughly a 10% additional increase if spread across all polices, or 26.9% overall.

There's only two carriers participating in Mississippi's individual market next year (plus Freedom Life, which once again is just a shell company here). They're asking for 16.1% average rate hikes, and since there's no mention in any of the filings about CSR payments not being made or the mandate not being enforced, I'm assuming that increase doesn't account for those factors.

The Kaiser Family Foundation estimates MS carriers would have to jack up Silver plans by a whopping 27% to cover lost CSR reimbursements. 87% of MS exchange enrollees receive CSR help, so that amounts to a stunning 23.5% average rate hike if spread across all individual policies. As a result, assuming they aren't made, I estimate Mississippi's average rate increase would be an ugly 39.6%.

Massachusetts has one of the stablest statewide insurance markets, no doubt in large part due to their having instituted the precursor to the ACA, "RomneyCare", 4 years earlier. Massachusetts also merged their small business and individual market risk pools, which helps stabilize things. As a result, they have a high number of carriers participating in their ACA exchange and are among the few states with single-digit average rate hikes...assuming CSR payments are forthcoming and the individual mandate is properly enforced.

Assuming CSR payments aren't made, I used the Kaiser Family Foundation's 19% average estimate for Silver plan hikes due to the CSR factor. Since a whopping 92% of MA's exchange enrollees chose Silver plans (it looks like MA's unique "ConnectorCare" plans are considered Silver as well), that means an average CSR factor of around 17.5 points across the entire individual market.

Louisiana has 3 individual market carriers for 2018 (technically there's 4, but "Freedom Life" is basically just a shell company with a placeholder filing). Officially, they're requesting average rate increases averaging around 21.4%...but all three carriers state point-blank in their filing letters that a huge chunk of their request is due specifically to the CSR reimbursement and mandate enforcement issues. The Kaiser Family Foundation estimates the CSR issue alone adds around 20 points to Silver plans, and 71% of Louisiana exchange enrollees chose Silver, so that translatest into roughly 14.2 points across the whole market. This results in just a 7.2% average rate hike if CSR payments are made vs. 21.4% if they aren't:

South Dakota is another fairly straightforward state: Two carriers, around 31,000 total ACA-compliant enrollees on & off exchange. Neither filing indicates whether they're assuming CSR payments will be made or not, so I'm assuming they're based on them being paid.

Another major state: Illinois. I've decided to scrap the "Low/High Increase" columns since they just confused people and made the table too wide, but replaced them with a new column showing the CSR factor estimate according to the Kaiser Family Foundation. Note that the percent listed will be smaller than Kaiser's estimate for each state, because their numbers only apply to silver plans, not all metal levels.

For instance in Illinois, Kaiser estimates that carriers would have to raise rates by 14% on Silver plans to cover their CSR losses. However, only 64% of Illinois exchange enrollees have silver plans to begin with, so I'm only plugging in about 9%. There are 5 carriers operating on the Illinois individual market (well, really 4, since "Freedom Life" doesn't count). I have the hard enrollment numbers for 4 of the 5; for Health Alliance Medical Plans I used 30,000 based on their 2016 number. Overall, Illinois is looking at around 11.3% w/partial sabotage, 20.3% with full sabotage:

Whew! OK, Texas was a bear for obvious reasons...13 different carriers (well, 12 really...Centene is new to their market). Several more are dropping out (Aetna, Allegian, Cigna, Humana, Memorial Hermann and Prominence), but suposedly theyonly have around 64,000 enrollees in TX combined. Texas's total individual market is actually closer to 1.6 million, so I'm obvoiusly missing a big chunk of enrollees below (and before my regular commenters say it: Yes, I'm sure the off-exchange TX indy market has shrunk this year, but I find it hard to believe it's shrunk by over 60% already).

Anyway, I've managed to plug in one hard request percent for each carrier--the FULL Trump Tax for 3 of them, the NO/PARTIAL Trump Tax for most. In Vista's case, they're off-exchange only so the CSR issue isn't a factor anyway. Unfortunately, I can't seem to find the enrollment number for Community Health Choice, so I don't know what their share of the market is, which could make a big difference if they have high enrollment. I've plugged in a flat 100,000 enrollees for the moment, but will change that if I'm able to track the actual number down.

Another fairly straightfoward state: Three carriers, two of which (CareFirst and Health Plan of Upper Ohio Valley) appear to be assuming CSR payments will be paid; the third, Highmark BCBS (which holds the vast bulk of the individual market) openly states that they assume they won't be made and that the mandate won't be enforced to boot. I'm once again assuming roughly 2/3 of Kaiser Family Foundation's "Silver CSR hike", which in this case would be about 10%, giving the following: 17.8% if CSR payments are made, 27.8% if they are:

Louise Norris gave me a heads up that the Kentucky Insurance Dept. has posted their 2018 rate hike filings as well. The individual market is pretty straightforward...and pretty grim: Both individual market carriers, CareSource and Anthem, are asking for pretty steep rate hikes even if CSR payments are locked in next year, averaging around 30.8%, while assuming another 13.5 points on top of that (71% of Kaiser's 19% Silver average) would bring the average up to around 44.3%. Not much else to say about this one for the moment.

The states filings are piling up quickly...Arkansas is pretty straightforward. Interestingly, four of the five carriers seem to be assuming that CSR payments will be made, and have submitted their rate filings accordingly; the fifth (and largest), USAble Mutual (aka Blue Cross Blue Shield of AR) is the only one to break it out specifically. In order to estimate the CSR factor for the other 4 carriers, I'm assuming 2/3 of Kaiser's 15% Silver plan bump estimate, or around 10 percentage points. That brings things in at around 10% even without CSR sabotage or nearly 18% with the CSR factor.

One other important thing to keep in mind regarding Arkansas: Their total individual market, including grandfathered and transitional plans, is something like 430,000 but they only have around 70,000 officially enrolled in ACA exchange policies. The main reason for this is that they have another 320,000 people enrolled in exchange policies via their "Private Medicaid Option"...which is Arkansas' version of ACA Medicaid expansion. For some reason, those folks aren't counted as ACA exchange enrollees even though it's my understanding that the only distinction between them and the 70K official enrollees is where the payments/subsidies come from.

In late May, I noted that Blue Cross Blue Shield of North Carolina, which holds a near monopoly on the individual market in NC with around 95% of total enrollment, had submitted an initial rate hike request for 2018 averageing 22.9% overall. What was remarkable at the time is that while most carriers were pussyfooting around using euphamisms about the reasons for their excessive increase requests, BCBSNC was among the first to come right out and state point-blank that it's the Trump Administration's deliberate sabotage of the market--primarily via the threats to cut off CSR payments and to not enforce the individual mandate--that are responsible for over 60% of the increase. This is from their blog, not mine:

Alabama, Alaska and Wyoming only have a single insurance carrier participating in each of their individual markets. While this is a bad thing from a competitiveness POV, it cetainly makes things easier for me from a tracking-average-rate-hikes POV.

ALSO IMPORTANT: The HHS Dept. is also starting to upload the rate filings to the official RateReview.Healthcare.Gov database, which should make things easier for me going forward (assuming that the data is uploaded properly and isn't messed with, which is a distinct possibility when it comes to the Trump Administration)

Officially, Alabama has the infamous "Freedom Life" phantom plan which is asking for a whopping 71.6% rate hike...to allegedly cover exactly one (1) person statewide. Un-huh.

Aside from that, however, it's Blue Cross Blue Shield across all three states...and they're asking for the following:

This isn't a full analysis, since I only have 2018 rate hike data for one of Arizona's carriers so far...on the other hand, AZ only has a couple of carriers on the individual market these days anyway. From AZCentral:

The Affordable Care Act insurer in 13 of Arizona's 15 counties plans to raise average rates across all plans a moderate 7.2 percent next year.

But Blue Cross Blue Shield of Arizona officials said the rate increases would be flat if President Donald Trump's administration did not plan to eliminate a key Affordable Care Act funding source.

7.2% isn't bad at all...of course, that comes after last years massive 57% average rate hike. Still, 0% would obviously be much better than 7%...

Trump suggested in a weekend tweet that " ... bailouts for insurance companies and bailouts for members of Congress will end very soon" unless Congress acts quickly on a new health bill.

Here it is...the Big Kahuna! Covered California just issued a detailed press release and accompanying PDF brochure breaking out their proposed 2018 market participation and rate changes:

Covered California Releases 2018 Rates: Continued Stability and Competition in the Face of National Uncertainty

Covered California remains stable, with an average weighted rate change of 12.5 percent. The change is lower than last year and includes a one-time increase of 2.8 percent due to the end of the health insurance tax “holiday.”

The competitive market allows consumers to limit the rate change to 3.3 percent if they switch to the lowest-cost plan in the same metal tier.

For 2017, unsubsidized enrollees on the Minnesota individual market faced massive rate hikes averaging 57%. It was so bad that the only way they could convince some carriers to participate in the market was to allow most of them to put a cap on how many people they'd enroll (with the balance being shunted over to Blue Plus, the HMO division of BCBSMN). This resulted in a massive initial surge of enrollment, as it was on a first-come, first-serve basis...but also left off-exchange and unsubsidized exchange enrollees high and dry.

In response, the state scrambled to pull together a $300 million package to help supplement premiums for those folks...knocking a flat 25% off of their premiums for 2017. This helped ease the problem in the short term, but the larger issue still loomed going forward.

It feels almost silly for me to spend so much time crunching the average 2018 rate hike numbers at this point. Between the (supposedly failed?) GOP repeal effort and Donald Trump's ongoing sabotage efforts--including what could be him officially pulling the plug on CSR reimbursements as early as sometime today--it's probably a bit of a futile effort. Besides, a dozen other wonks/analyses have already confirmed what the Kaiser Family Foundation projected months ago and which I've been proving on a state-by-state basis for months now: The CSR threat is causing average rate hikes of around 20 points on average, and the threats to individual mandate enforcement are tacking on another 4-5 points on top of that, beyond the ~10 points which rates would normally be increasing on average.

However, I've plugged in 21 states, so I might as well finish the job. With that in mind, the state of Idaho has done most of the dirty work for me:

UPDATE 9/27/17: It now looks extremely likely that CSR reimbursement payments will not be guaranteed for 2018 (they may or may not be paid, mind you, but it's unlikely that they'll be legislatively appropriated, which amounts to the same thing as far as most insurance carriers are concerned). With this in mind, I'm re-upping this rather wonky/in-the-weeds tutorial about the #SilverSwitcharoo, since it looks like at least 6 states (California, Connecticut, Florida, Idaho, North Carolina and Pennsylvania) are likely to end up using it this fall.

UPDATE 10/12/17: Welp. Sure enough, Donald Trump is indeed officially planning on pulling the plug on CSR reimbursement payments. Several healthcare wonks, including myself, have been tracking how different states are handling the CSR load issue; so far it looks like 22 are "Silver Loading" and 10 are going "full Silver Switcharoo". This may change over the next week or so, however.

The states we know (or at least are pretty certain) are Silver Switcharooing are: California, Connecticut, Florida, Georgia*, Hawaii, Idaho, Minnesota, Nevada, South Carolina and Washington State.

*(At least one carrier in Georgia)

(Special thanks to folks like Josh Schultz, David Anderson, Andrew Sprung, Amy Lotven, Wesley Sanders and others for helping me make heads or tails out of the CSR brouhaha)

NOTE 5:30pm: See update at the bottom of page.

Those were Democratic Senate Minority Leader Chuck Schumer's words tonight in response to Republican Senate Majority Leader Mitch McConnell's claims that those on the left were "celebrating" the defeat of his Godawful "Skinny Repeal" bill late Thursday night. And that's a perfect description of how I feel, for several reasons:

  • 1. This wasn't so much a case of an "Actively Positive" thing happening (as was the case with, say, the Obergefell v. Hodges Supreme Court decision) as it was stopping a negative thing (as was the case with the King v. Burwell SCOTUS decision, which actually was announced the very same day as Obergefell). That is to say, it's not that a good piece of legislation passed, it's that a bad piece of legislation was blocked. This isn't to minimize the importance of what just happened tonight (not just in terms of healthcare policy, but also the state of our democratic process, legislative norms and of course the ramifications for the rest of this ongoing nightmare we call the Trump Administration), but it does tend to dampen my emotional response a bit.
  • 2. As I keep stressing: There are real problems with the ACA as it currently stands, and some of them require more than simple "tweaks" as some ACA defenders are prone towards describing them. All of these problems are definitely fixable, but most of those solutions still won't be easy to push through. Furthermore, these issues are exacerbated by two other problems:
  • 3. THE CLOCK IS TICKING for 2018: The final carrier rate filing deadline is rapidly approaching; the carriers need to make their final decisions about how much to charge next year soon...assuming they decide to stick around the individual market next year at all, which isn't a guaranteed thing, especially due to...
  • 4. THE TRUMP SABOTAGE FACTOR will now almost certainly go into overdrive. I'm about 90% certain that Trump will indeed pull the plug on Cost Sharing Reduction reimbursement payments staring next month (August), which could still devastate the indy market almost instantly. Of course, Congressional Republicans could resolve the CSR issue in about 5 minutes with a simple, 87-word bill which would receive unanimous consent from every Democrat in both the House and Senate as long as it was either standalone or not attached to some other poison pill piece of legislation.

    For that matter, while the individual mandate repeal died with the "Skinny Repeal" bill failing, House Republicans have also started pushing through a different bill which would prevent the IRS from enforcing the individual mandate anyway, causing the exact same problems. And even if that doesn't happen, HHS Sec. Tom Price could simply start issuing hundreds of thousands of highly-questionable "hardship exemptions" letting pretty much everyone off the hook for the mandate penalty anyway...which, once again, would amount to the same fallout.

...and so on and so forth.

HOWEVER, having said all of that, for the moment, I'm going to allow myself the most basic of celebration anyway. I think we've earned it...

 

(yes, I know she actually says "bumpy night"...I'll update the title this evening if need be...)

OK...here's where things stood as of last night...

UPDATE 7/27/17 12:00pm: OK, here's the latest (at least, as of around noon, anyway):

Apparently, in order to win over a few more votes and squeeze the bill in under the "budget savings" wire, they're now planning on scrapping repeal of the medical device tax and delaying repeal of the employer mandate (but still repealing it eventually). They're also going to throw in defunding Planned Parenthood even though that was previously scrapped by the Senate parlimentarian.

Finally, they're apparently bringing back the Essential Health Benefit State Waiver provision, which would, once again, blow a massive hole in the "Guaranteed Issue and Community Rating" rules.

 

UPDATE: Hey, who's that up there? Why it's the guy who Republicans wanted to become President just 5 years ago, explaining why, if you're going to guarantee solid health insurance policies to everyone regardless of their medical history and without discriminating on price, you have to include some sort of incentive for them to do so: A carrot and a stick. The tax credits and out of pocket maximums are the carrot. The individual mandate and open enrollment period are the stick.

(sigh) I debated whether to even write a post about the last-minute "Skinny Repeal" plan slapped together by Mitch McConnell yesterday morning for a couple of reasons: First, because even if it passes, the sole purpose of "Skinny Repeal" is to get past the 50-vote Senate threshold...at which point it would be scrapped and replaced with whatever Godawful pile of garbage McConnell comes up with via reconciliation afterwards anyway.

Second, and more to the point, they're supposed to be voting on "Skinny Repeal" within the next few hours, so it's possible that it could be a moot point before anyone even reads this.

OK. Here we go. First, just as a refresher: Here's what the Individual Market was supposed to look like under the Affordable Care Act:

Here's what it actually looks like for a variety of reasons, including both legitimate glitches in the ACA itself as well as a whole lot of flat-out sabotage by the GOP over the past 7 years. While there are plenty of other issues which need to be addressed, the most obvious ones are that the tax credits need to be beefed up and applied to enrollees over the 400% FPL threshold, and the mandate penalty should really be increased. In short, two legs of the stool need to be lengthened...to continue the metaphor, we need a couple of shims. Around $12 billion per year or so should do the trick on the tax credit side. As it happens, one of the few useful parts of most of the GOP plans is that they do include a good $120 billion or so in "reinsurance/stabilization" funding over 10 years...which, in practice, would amount to about the same thing. The key is that this funding would have to be added to the existing ACA funding, not replacing it, which is what these plans do instead:

NOTE: The original focus of this diary was on the deliberate sabotage by the Trump Administration/HHS Dept. under Tom Price of the individual insurance market in general and HealthCare.Gov in particular, but the screen shot mentioned in passing in the diary below is actually far more important and disturbing the more I think about it than I had originally thought.

As noted below, it's an anonymous note sent to me on Thursday. Since it was sent I’ve confirmed the identity of the sender. This doesn’t prove that their specific claim is true, but there’s absolutely no reason I can think of for this person to risk their job and reputation by lying about this issue, and it matches everything else in the diary.

Several professional journalists have since contacted me and I’ve gotten them in touch with the sender. Stay tuned, this could be a big deal.

via Gawker, November 2013:

Only Six People Signed Up on Healthcare.gov's First Day

(sigh) I'm not really sure what the point of even writing about this is since it doesn't include the Cruz-Lee amendment which is supposedly the only thing keeping the ultra-conservative wing of the GOP Senate on board with BCRAP in the first place, but whatever:

CBO and the staff of the Joint Committee on Taxation (JCT) have prepared an estimate of the direct spending and revenue effects of the version of H.R. 1628, the Better Care Reconciliation Act, posted today on the Senate Budget Committee’s website.

By the agencies’ estimates, this legislation would lower the federal budget deficit by reducing spending for Medicaid and subsidies for nongroup health insurance. Those effects would be partially offset by the effects of provisions not directly related to health insurance coverage (mainly reductions in taxes), the repeal of penalties on employers that do not offer insurance and on people who do not purchase insurance, and spending to reduce premiums and for other purposes.

 

I actually used this exact same headline seven months ago, and now we've apparently come full circle and are right back where we started:

The New York Times, December 2nd:

“The idea that you can repeal the Affordable Care Act with a two- or three-year transition period and not create market chaos is a total fantasy,” said Sabrina Corlette, a professor at the Health Policy Institute of Georgetown University. “Insurers need to know the rules of the road in order to develop plans and set premiums.”

Having talked to a number of CEOs & states, @SabrinaCorlette is right, if not understating.https://t.co/Ri5TtkHz7Z

— Andy Slavitt (@ASlavitt) December 3, 2016

 

Flashback to November 2016:

But actually, he thought as he re-adjusted the Ministry of Plenty’s figures, it was not even forgery. It was merely the substitution of one piece of nonsense for another. Most of the material that you were dealing with had no connexion with anything in the real world, not even the kind of connexion that is contained in a direct lie. Statistics were just as much a fantasy in their original version as in their rectified version. A great deal of the time you were expected to make them up out of your head.

 

Thanks to Emily Gee and the Center for American Progress for this:

This isn't a full/official New Jersey rate hike update, as it only refers to one carrier, and rounds things off a bit, but in the video above, if you watch from around 37:30 to 41:00, you'll hear New Jersey Congressman Frank Pallone talk about the negative impact that the CSR reimbursement threat/uncertainty/sabotage effect is having on Horizon Blue Cross Blue Shield...and since Horizon BCBS happens to hold something like 70% of the New Jersey individual market share (which is confirmed by Pallone in the video), the statewide weighted average rate hike will end up being largely determined by theirs.

The most relevant part:

"So Horizon, which is something like 70% of our market in New Jersey, filed like a 24% increase. And I asked the president (of Horizon) "why are you filing with a 24% increase?" I can't imagine that health insurance costs have gone up that much. And he said "Oh, they haven't, Congressman." I said, "well, what is this?"

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