Jibbers Crabst on a stick. Any time University of Michigan Law Professor Nicholas Bagley begins his Twitter threads with a screenshot of legalese, it's bad news.

First, here's his full thread:

The panel in the Fifth Circuit that's about to hear Texas v. United States has just asked for further briefing on standing -- and in particular on whether the intervenor states and the House of Representatives can properly appeal the case.

— Nicholas Bagley (@nicholas_bagley) June 26, 2019

I know I rip on Republicans a lot here at ACASignups.net, and I stand by pretty much all of it. Once in a while, however, a GOP member of Congress does do (or tries to do) something useful when it comes to healthcare policy...and the name most often attached to that is Senator Lamar Alexander of Tennessee. Alexander happens to be retiring, I should note. These two facts may or may not be connected, but I digress.

In any event, Sen. Alexander and Democratic Senator Patty Murray of Washington State have been working together for quite some time now on several healthcare bills to help stabilize the ACA, reduce drug prices and so forth, to varying degrees of success. I may not have agreed with most of Alexander's ideas, but he seems to be genuinely interested in improving the situation...and of course I can't say enough good things about Sen. Murray.

*(OK, probably not, but...well, read on...)

Regular readers may have noticed that I didn't post a single blog entry on Tuesday even though there's been a ton of healthcare policy stuff going on. No, I didn't take the day off; I started poring over a spreadsheet at around 10am and was working on it almost nonstop all day.

On Monday, along with posting their decisions on several important federal cases, the U.S. Supreme Court announced that, much to the surprise of many healthcare wonks, they will take up the long-gestating (and presumed dead) Risk Corridor Massacre lawsuit:

Big news: SCOTUS is taking up the ACA risk corridors case. GOP's decision to stymie that program arguably did the most damage to the ACA marketplaces. https://t.co/VeMRcd5MYn

— Bob Herman (@bobjherman) June 24, 2019

 

Long-time readers of this site may recall the infamous Risk Corridor Massacre of 2014-2015. Here's a very simplified backstory:

  • When the ACA was first developed and voted on, lawmakers knew that the disruption to the individual health insurance market was going to be pretty rocky for the first few years, so they put three types of market stabilization programs into place. They were known as the "Three 'R's"...Risk Adjustment, Reinsurance and Risk Corridors:

...Risk adjustment interrupts these cycles by doing exactly what its name implies. It adjusts for differences in the health of plans’ enrollees by redistributing funds from companies with healthier-than-average customers to plans with sicker-than-average customers. Such transfers could occur within or across health plan tiers in the exchanges (bronze, silver, gold, platinum). All the redistributed monies come from insurance companies in the marketplaces. No taxpayer bailout here.

I'm neither an attorney nor a Constitutional expert, so this may not have any legal significance beyond confirming what everyone already knew about the Trump Administration. Then again, perhaps it will.

Just a little over two weeks from now, the United States Court of Appeals for the Fifth Circuit will be hearing oral arguments in the Texas vs. Azar case, otherwise known as #TexasFoldEm. As a reminder:

If the entire ACA were to be repealed:

  • 16 million people would lose Medicaid
  • 9 million people would lose subsidized private ACA exchange coverage
  • 850,000 would lose BHP coverage in Minnesota & New York
  • Medicare Part D donut hole? Reopened.
  • Children being allowed to stay on their parents plans until age 26? Gone.
  • Discrimination against those with preexisting conditions? Back.
  • Annual & lifetime limits on coverage? Back.
  • Caps on out of pocket expenses? Gone.

...and much, much more.

Various healthcare wonks, including myself, have been warning for years that imposing work requirements on Medicaid enrollees would be pointless, ineffective, wasteful, expensive and cruel.

Several studies, including this one from just the other day, have driven home this point clearly: Adding work requirements to Medicaid expansion enrollees serves no useful purpose other than to kick tens of thousands of people off of their healthcare coverage (which, of course, is the whole point from the POV of those who add the requirements).

As for the one positive-sounding goal (increasing employment) which supporters always use to try and justify them, that's a complete joke:

The first major study on the nation’s first Medicaid work requirements finds that people fell off of the Medicaid rolls but didn’t seem to find more work.

As I've noted several times, one of the biggest flaws in the Affordable Care Act is a very simple one on paper: The Subsidy Cliff. People who enroll in ACA exchange policies are entitled to financial assistance on a sliding scale...but only if their household incomes fall between 100-400% of the Federal Povery Level. Those below the lower threshold (actually, below 138% FPL) are expected to enroll in Medicaid, but those over the upper threshold of 400% FPL (around $50,000/year for a single person, roughly $103,000/year for a family of four) are completely on their own.

Here's the current federal premium subsidy formula (the precise premium cap percentages change slightly from year to year...and the Trump Administration is even messing with that a bit, so I'm not sure what it'll be in 2020):

Some Guy, 2015:

In other words, only about 10% (at most) of those still in the Medicaid Gap could even remotely match the GOP's cliche of a "lazy, good-for-nothing layabout" type who's able-bodied, has no serious extenuating circumstances and so forth. The "get off your ass and work!" requirements appear to be nearly as big a waste of time and resources as the infamous "drug testing for welfare recipients" bandwagon which a bunch of states jumped on board over the past few years.

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.

The state of Maine's Bureau of Professional & Financial Regulation has released their preliminary 2020 rate filings for the Individual and Small Group markets. Overall, the three carriers participating in their individual market are seeking a weighted average rate increase of 4.7% vs. last year. If approved as is, that would bring the average unsubsidized premium up from $675/month to $707/month, or around $381/year.

It's important to keep in mind why premiums are going up. I've included screenshots of the rate filing memos--Maine Community Health Options, which holds over 50% of the individual marketshare, clarifies that the combination of the individual mandate being repealed and the expansion of #ShortAssPlans are causing an 11% increase. They also note that Maine's recent Medicaid expansion implementation may be a factor, although normally that reduces premiums since lower-income populations tend to be less healthy than higher-income populations, so I'm not sure what to make of that.

Last month, the U.S. House of Representatives passed eight different healthcare-related bills. Three of them related to regulating prescription drugs and/or reducing drug prices; the other five composed about half of the dozen or so "ACA 2.0" bill package.

As a reminder, here's the eight bills which passed the full House:

H.R. 938, the "Bringing Low-cost Options and Competition while Keeping Incentives for New Generics (BLOCKING) Act of 2019," introduced by Reps. Kurt Schrader (D-OR) and Buddy Carter (R-GA), would discourage parking of 180-day exclusivity by a first generic applicant that is blocking the approval of other generics.

H.R. 1499, the "Protecting Consumer Access to Generic Drugs Act of 2019," introduced by Rep. Bobby Rush (D-IL), would make it illegal for brand-name and generic drug manufacturers to enter into agreements in which the brand-name drug manufacturer pays the generic manufacturer to keep a generic equivalent off the market.

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

Bill expanding ‘Insure Oklahoma’ program passes Senate committee

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

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

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

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

Last year, I noted several times that regardless of what your opinion may be of the ACA's Individual Mandate Penalty (which was, until this year, either $695 per adult/$348 per child or 2.5% of your household income, unless you received an exemption), one of the key things to keep in mind about the penalty is that any impact it has on encouraging people to go ahead and enroll in ACA-compliant healthcare coverage is entirely dependent on two things:

Last May, I noted that Vermont was supposedly joining Massachusetts, New Jersey (and later in the year, the District of Columbia) in reinstating the ACA's Individual Mandate Penalty, which added an additional tax to people who don't enroll in ACA-compliant healthcare coverage (whether private or public) and who don't qualify for an exemption due to an affordability threshold, hardship or some other qualifying reason.

I also noted at the time, however, that Vermont seemed to be dragging their heels on the mandate penalty itself:

Strike One: Vermont's mandate won't go into effect until 2020, leaving a one-year gap. This bill getting signed is still good news, but mostly irrelevant for 2019. The "coordinated outreach efforts" part is really more of a counter to the Trump Administration's slashing of the ACA's marketing/outreach budget...but not really, since Vermont already runs their own exchange and should have their own marketing/outreach budget anyway. So this is more of a token gesture, I'd guess.

Along with Massachusetts and Vermont, the District of Columbia merges their Individual and Small Group markets for purposes of risk pools and risk adjustment. This does not, however, necessarily mean that their Indy and Sm. Group average premium changes are identical. For one thing, there are more carriers which offer small group plans than individual market plans; for another, the market share ratios between the two differ.

A week ago, the DC Dept. of Insurance, Securities and Banking (DISB) issued preliminary 2020 rate filings along with this press release:

Washington, DC – The District of Columbia Department of Insurance, Securities and Banking (DISB) received 181 proposed health insurance plan rates for review from Aetna, CareFirst BlueCross BlueShield, Kaiser Permanente and United Healthcare in advance of open enrollment for plan year 2020 on DC Health Link, the District of Columbia’s health insurance marketplace.

Pages