Virginia

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.

Virginia is usually the first state to publicly post their preliminary annual individual/small group market health insurance premium rate filings; historically they've published them as early as mid-April. This year, however, due primarily to the COVID-19 pandemic, I presume, they didn't actually post them until mid-August.

The average premium changes for 2021 on the individual market range from a 13% drop to a 7.7% increase, with the statewide weighted average coming in at around a 7.2% reduction. For the small group market, premiums are increasing by around 3.6% on average, ranging from a 2.4% drop to a 10.9% increase.

Two other noteworthy items: First, Optimum Choice is expanding into VA's individual market (this isn't the same as Optima Health); secondly, VA's indy market has dropped from over 300,000 last year to around 256,000 this year, presumably due to the lingering effects of Medicaid expansion enrollees shifting over from subsidized private plans.

Over a year ago, I wrote an analysis of H.R.1868, the House Democrats bill that comprises the core of the larger H.R.1884 "ACA 2.0" bill. H.R.1884 includes a suite of about a dozen provisions to protect, repair and strengthen the ACA, but the House Dems also broke the larger piece of legislation down into a dozen smaller bills as well.

Some of these "mini-ACA 2.0" bills only make minor improvements to the law, or make improvements in ways which are important but would take a few years to see obvious results. Others, however, make huge improvements and would be immediately obvious, and of those, the single most dramatic and important one is H.R.1868.

The official title is the "Health Care Affordability Act of 2019", but I just call both it and H.R.1884 (the "Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019") by the much simpler and more accurate moniker "ACA 2.0".

Last March I wrote an analysis of H.R.1868, the House Democrats bill that comprises the core of the larger H.R.1884 "ACA 2.0" bill. H.R.1884 includes a suite of about a dozen provisions to protect, repair and strengthen the ACA, but the House Dems also broke the larger piece of legislation down into a dozen smaller bills as well.

Some of these "mini-ACA 2.0" bills only make minor improvements to the law, or make improvements in ways which are important but would take a few years to see obvious results. Others, however, make huge improvements and would be immediately obvious, and of those, the single most dramatic and important one is H.R.1868.

The official title is the "Health Care Affordability Act of 2019", but I just call both it and H.R.1884 (the "Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019") by the much simpler and more accurate moniker "ACA 2.0".

Coming on top of not one, not two, but three other states either scrapping or "delaying" implementation of Medicaid expansion work requirements (Arizona, Indiana and Montana), this one isn't particularly surprising given that Democrats hold the governor's seat and just flipped both the state House and Senate. Still welcome, though!

Gov. Ralph Northam has directed Virginia's Medicaid program to "pause" negotiations with the federal government on approval of a work requirement that was central to a political deal that allowed the state to expand eligibility for the program's health care benefits to hundreds of thousands of uninsured Virginians.

Northam cited the Democratic takeover of both chambers of the General Assembly in legislative elections last month. He also referred to litigation that has faced other states that have tried to link Medicaid health benefits to requirements that program participants seek work, training, education or other forms of civic engagement.

A few weeks ago I noted the following press release from Democratic Virginia Governor Ralph Northam, just ahead of the critical state legislative elections:

It took me a couple of days to post this, but it's an important development, especially on the cusp of the Virginia legislative election next month which could flip both the state House and Senate to the Democrats; thanks to Esther Ferington for the heads up:

Governor Northam Signs Executive Directive to Ensure Access to Affordable, Quality Health Care Coverage for All Virginians

“Health coverage should be both meaningful and affordable, but unfortunately, policies from Washington threaten to increase the number of families who are uninsured or underinsured,” said Governor Northam. “It’s more important than ever that we identify and implement policies at the state level that control costs and ensure that Virginians can afford to buy health insurance that covers their health care needs.”

It took me a couple of days to post this, but it's an important development, especially on the cusp of the Virginia legislative election next month which could flip both the state House and Senate to the Democrats; thanks to Esther Ferington for the heads up:

Governor Northam Signs Executive Directive to Ensure Access to Affordable, Quality Health Care Coverage for All Virginians

RICHMOND—Governor Ralph Northam today issued Executive Directive Five, directing actions to increase the number of Virginians enrolled in quality, affordable health care coverage.

This year, Medicaid expansion is providing access to health coverage for more than 325,000 eligible Virginians who have enrolled, positively impacting their health. But meaningful health coverage remains unaffordable for too many Virginians, due in large part to federal policies that have increased cost and decreased the quality of available coverage.

via Becker's Hospital Review:

Cigna extended its individual healthcare exchange products for the 2020 plan year, the insurer said Sept. 18.

For 2020, individuals can purchase individual health plans in 19 markets across 10 states. The expansions will take place in counties in Kansas, South Florida, Utah, Tennessee and Virginia. The other states include Arizona, Colorado, Illinois and North Carolina.

The plans will be available for purchase on the individual marketplace during the 2020 open enrollment period, which begins Nov. 1. Plans will take effect Jan. 1.

via Bruce Japsen of Forbes:

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:

Just hours after explaining what a dramatic impact the nearly-flat average 2020 premium changes are going to have on this year's (and next year's) Medical Loss Ratio rebate payments, I've discovered that rates are going to be increasing even less than I thought nationally.

Back in late May, Virginia was one of the first states to post their preliminary 2020 premium rate filings. At the time, the 10 carriers participating in VA's individual market (one of which is new for 2020) were asking for average increases of 2.9% statewide:

Virginia is traditionally the first state to release their preliminary individual (& small group) market healthcare policy rate changes, but this year the state insurance regulatory body delayed the initial deadline by a couple of weeks. As a result, three other states (Maryland, Vermont and Oregon) beat Virginia to the punch this year.

The extended VA deadline passed last week, however, and so I'm now able to dig up the preliminary 2020 rate filings for the ACA market. It's important to remember as always that these are preliminary requests only; some of them are bound to change at least once between now and late September, when the final rate changes are locked in and the contracts are signed for the 2020 calendar year (and Open Enrollment Period).

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.

When I last checked in to see how Virginia's newly-enacted ACA Medicaid expansion program was doing, they had already enrolled around half of the 400,000 estimated residents eligible to do so statewide.

Last fall, I estimated that perhaps 85,000 of those newly eligible to enroll in Medicaid would actually be "cannibalized" from the existing ACA exchange enrollee population...and sure enough, when the 2019 Open Enrollment numbers were posted, exhange enrollment in Virginia was down by 72,000 people, putting them dead last nationally in terms of year over year performance (down 18% from 2018).

Unfortunately, without an income demographic breakout, there's no way of being certain how much of that dropoff was due to Medicaid expansion as opposed to middle-income enrollees simply choosing to drop their coverage.

Today, however, Virginia state delegate Danica Roem posted the following update, which includes a link to a very nifty interactive graphic Medicaid expansion dashboard:

This happened while I was out of town, but it's welcome news nonetheless...

Governor Northam Announces Medicaid Expansion Hits Milestone with More Than 200,000 Enrolled
Virginians can apply at any time of the year

RICHMOND—Governor Ralph Northam announced Friday that more than 200,000 Virginia adults are now enrolled and will have health coverage starting January 1. The achievement marks a major milestone in the Medicaid expansion initiative approved last summer.

“This bipartisan initiative has empowered men and women across the Commonwealth to take an active role in improving their health,” said Governor Northam. “The historic response from our citizens demonstrates the need for access to health coverage that will benefit our families, our communities and Virginia’s economy. I encourage uninsured individuals to learn more about this new health coverage opportunity and to apply today.”

This Just In...

Governor Northam Announces Over 182,000 Virginians Enrolled in New Health Coverage

  • SNAP recipients and parents of children with Medicaid coverage can use three-question application until January 4

The new coverage is available to men and women ages 19 through 64 who are not eligible for Medicare and who meet income requirements, which vary by family size. For example, a single adult with an annual income at or below $16,754 may be eligible for coverage. An adult in a three-person family with a total household annual income at or below $28,677 may be eligible.

SNAP recipients and parents whose children are currently receiving Medicaid coverage have the opportunity to use a short-form application to sign up if they do so by January 4, 2019. These individuals were notified by letter earlier this fall, and a follow-up postcard was recently mailed to potentially eligible adults in these categories.

With all the attention being paid to the midterm elections causing ACA Medicaid expansion to be passed in Utah, Nebraska and Idaho (while also now being at risk in Alaska and Montana), I've kind of lost track of the situation in Virginia, where it was expanded last May to over 400,000 Virginians.

Thankfully, Esther F. linked me to this article from the Virginia Mercury, which brings me up to speed on the actual implementation of the VA expansion program:

Less than two weeks after Virginia opened registration for its expanded Medicaid program, officials say they’ve already drawn thousands more applicants than initially anticipated.

The state had expected the new program to enroll 300,000 over the next year and a half. They now expect that number to reach 375,000. The new estimates won’t alter the total expansion population, which the state has said will be about 400,000.

 

Just in case anyone thinks state insurance regulatory boards can't be hard-core badasses, consider the Optima Health situation in Virginia which I wrote about a couple of weeks ago:

By early September, it was clear that Trump would indeed be cutting off CSR funding. With just a few weeks left before the final deadline to sign 2018 ACA exchange contracts, Optima suddenly announced that they were not only jacking up rates a whopping 81%, they were also pulling out of a large chunk of the state, leaving large areas at risk of "going bare" without any ACA carriers whatsoever.

...Then, on September 14, with just days to spare and thanks to what I assume were some pretty intense backroom deals being made, Anthem suddenly announced that they were back in the game after all!

Last year, Virginia residents experienced massive amounts of heartburn and ulcers as two major insurance carriers, Optima (Sentara Health) and Anthem (HealthKeepers) played musical chairs with both their 2018 rate filings and which areas of the state they offered plans on.

In May 2017, things didn't look too bad: Both Anthem and Optima were available in fairly large chunks of the state, and while Anthem wanted to raise rates an ugly 38% on average, Optima was only looking to increase rates by around 10-11%.

When I first ran the preliminary 2019 ACA individual market rate filings for Virginia way back in May, I concluded that the average premium increase will be around 13.4%. However, a lot has changed since then.

For one thing, Virginia expanded Medicaid to 400,000 low-income residents, which should help improve the ACA risk pool and in turn knocked the average rate increase down by 2.2 points, to around 11.3%.

For another, Anthem made a last-minute decision to expand their coverage areas in the state dramatically, which also provides much-needed competition for Optima in the Charlottesville area, among others.

Hot on the heels of Anthem's announcement that they're significantly expanding their ACA market coverage throughout Virginia comes another piece of welcome news:

Gov. Ralph Northam’s administration will convene a new work group on Monday to consider options to stabilize soaring premiums in Virginia’s health insurance market.

The Virginia Market Stability Group will consider a wide range of options to lower insurance premiums expected to average more than $833 a month next year, making coverage unaffordable to people who don’t qualify for federal subsidies for premiums or out-of-pocket expenses in the marketplace established by the Affordable Care Act.

...But one option could trump all others — a state budget plan to request a federal waiver for a “re-insurance” program in Virginia that would help defray the costs for the most expensive patients and relieve the expense for others by lowering the risk.

UPDATE: As noted in the comments below, it looks like Anthem won't be expanding to cover the entire state after all. Even so, this is a major improvement in the situation.

Every year, Virginia is the first state out of the gate with their preliminary healthcare premium rate changes for the following year, posting the initial rate requests in early May. For 2019, it originally looked like the carriers were asking for a statewide average increase of 15.2%, but I later corrected this to 13.4%.

However, these were just preliminary numbers. The requests still have to go through the rate review process, and the carriers often make other changes as well before the final deadlines pass.

Several weeks ago I wrote about a bit of a bombshell development in Virginia:

Members of local advocacy group Charlottesville For Reasonable Health Insurance had provided testimony at the Virginia General Assembly and organized an email campaign, helping to ensure passage of the bill through the legislative session. Introduced by Sen. Creigh Deeds and effective July 1 2018, SB672 will allow self-employed people to take advantage of the much more affordable health plans in the small group business marketplace, without having to hire employees.

...Charlottesville and surrounding counties (Albemarle, Green, Fluvanna) have by far the most expensive healthcare premiums in the nation in 2018. Rates more than tripled for consumers buying coverage on the ACA Individual Exchange, making comprehensive insurance unaffordable for people who do not qualify for subsidy assistance. A typical family of four is being charged $3000 per month for high deductible plans.

Apparently it still has to be kicked back to the state Assembly for a final vote, but it appears to be a done deal at last:

The Virginia Senate just passed Medicaid expansion, which three Republicans joining all 19 Democrats voting in favor. The House, which already passed expansion, has to vote again. We'll have more later, but here's the backstory. https://t.co/ldFEb5vYyt

— Jeffrey Young (@JeffYoung) May 30, 2018

There's one downer, of course:

Elections have consequences: To get enough GOP votes, this Medicaid expansion includes a work requirement and premiums above the poverty line, which will cut into coverage gains. Virginia must continue the fight.

— Topher Spiro (@TopherSpiro) May 30, 2018

Two big developments (or in one case, a lack of development) out of Virginia this evening.

First: Just yesterday I was noting that it looked as though after 8 years, Virginia's state legislature might finally be going ahead and expanding Medicaid under the ACA as soon as today:

The stage is set for a showdown in the Virginia Senate on Tuesday over a budget compromise negotiated by Senate Finance Co-Chairman Emmett Hanger, R-Augusta, and House Appropriations Chairman Chris Jones, R-Suffolk, to expand the state’s Medicaid program and pay for the state’s share through a new tax on hospital revenues that also would boost Medicaid payments for inpatient provider care.

Unfortunately...that didn't happen:

Governor Northam Statement on Virginia Senate Budget Process

Several stories like this throughout Monday afternoon/evening (via Michael Martz of the Richmond Times-Dispatch:

The stage is set for a showdown in the Virginia Senate on Tuesday over a budget compromise negotiated by Senate Finance Co-Chairman Emmett Hanger, R-Augusta, and House Appropriations Chairman Chris Jones, R-Suffolk, to expand the state’s Medicaid program and pay for the state’s share through a new tax on hospital revenues that also would boost Medicaid payments for inpatient provider care.

(The article goes into all the other non-Medicaid related stuff in the budget as well, of course, although some of it is obviously healthcare-related.)

Having a doctor holding elected office is kind of hit or miss (former HHS Secretary Tom "Fly Me!" Price was an orthopedic surgeon, for instance, while Rand "Kneel before Aqua Buddha!" Paul is supposedly a "self-certified" opthamologist), but once in awhile it can be a very good thing.

Case in point: Ralph Northam, the new Governor of Virginia, a former Army doctor and pediatric neurologist, who just formally vetoed not one, not two, but four different GOP-passed healthcare bills, each of which would have further weakened and damaged the ACA individual market risk pool:

RICHMOND—Governor Ralph Northam today vetoed Senate Bills 844, 934, 935, and 964, which would put Virginians at risk of being underinsured, result in rapidly increasing Marketplace premiums, and undermine key protections in the Affordable Care Act. Governor Northam remains committed to expanding health care for nearly 400,000 uninsured Virginians, return millions to the state budget, and reduce Marketplace premiums. The Governor’s full veto statements are below.

Holy smokes. A huge shout-out to Esther F. for the heads up on this. I have no idea how this story slipped under my radar the past few months:

Northam signs healthcare bill to provide relief to Virginia entrepreneurs
Published Wednesday, Apr. 11, 2018, 12:42 pm

Gov. Ralph Northam signed a new healthcare bill into law that will provide relief to many small business owners currently struggling with the Central Virginia insurance premium crisis.

Members of local advocacy group Charlottesville For Reasonable Health Insurance had provided testimony at the Virginia General Assembly and organized an email campaign, helping to ensure passage of the bill through the legislative session. Introduced by Sen. Creigh Deeds and effective July 1 2018, SB672 will allow self-employed people to take advantage of the much more affordable health plans in the small group business marketplace, without having to hire employees.

A couple of days ago, I posted that Virginia has become the first state out of the gate with their preliminary 2019 premium rate requests for ACA individual policies. However, I made sure to emphasize that these are preliminary requests only; carriers often resubmit their rate change requests more than once over the course of the summer/fall, and even that may not match whatever the final, approved rate changes are by the state insurance commissioner.

In addition, I generally try to make it understood that there's alotof room for error here--the weighted averages are based on the number of current enrollees, but of course that number can change from month to month as people drop policies or sign up during the off-season (via Special Enrollment Periods). Even then, the rate filing paperwork is often vague or confusing about just how many enrollees they actually have in these plans. Sometimes wonks are reduced to taking the number of "member months" and dividing by 12 to get a rough idea of how many people are enrolled in any given month. Sometimes the only number of enrollees available are from last year, which could bear zero resemblence to how many are currently enrolled. Sometimes the only number available is how many people the carrier expects to enroll in their policies next year. And so on.

...and to absolutely no one's surprise, GOP sabotage of the ACA will be directly responsible for a significant chunk of the individual market premium increases.

Every year for 3 years running, I've spent the entire spring/summer/early fall painstakingly tracking every insurance carrier rate filing for the following year to determine just how much average insurance policy premiums on the individual market are going to increase (or, in a few rare instances, actually decrease).

The actual work is difficult due to the ever-changing landscape as carriers jump in and out of the market, their tendency repeatedly revise their requests, and the confusing blizzard of actual filing forms which sometimes make it easy to find the specific data I need and sometimes make it next to impossible.

What the heck, I'll make this Medicaid Expansion News Day:

Virginia’s Republican-led legislature is on the verge of doing something that would’ve been almost unthinkable just a year ago: approving legislation that would use money from the Affordable Care Act to expand Medicaid to as many as 400,000 people.

That coverage expansion would come at a price for Democratic legislators, progressive activists and low-income Virginians, however. Any Medicaid expansion bill that makes it out of the General Assembly will carry with it new work requirements for Medicaid enrollees, a priority for the GOP at large and for President Donald Trump’s administration.

Democrats in the Virginia legislature have tried in vain for six years to persuade their GOP counterparts that accepting federal dollars to extend Medicaid coverage to poor adults is the right thing to do. Accepting a work-requirements policy that would create bureaucratic obstacles to eligible Virginians appears to be the compromise needed to win the bigger fight.

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