GRAHAM-CASSIDY REPEAL BILL DEADLINE:

Time: D H M S

Here it is in all it's glory gory...

Note: The following notes are mostly cribbed from Larry Levitt of the Kaiser Family Foundation via Twitter, plus a few from other folks or tidbits I dig up myself...

  • Still cuts off tax credits at 350% FPL instead of the ACA's 400% FPL. Pass.
  • Still bases tax credits on a 58% AV Bronze plan instead of the ACA's 70% AV Silver plan. Pass.
  • Throws another $70 billion onto the "state stabilization fund" pile for a total of $132 billion
  • Throws another $70 billion on to "offset costs for high-risk patients" (I presume this means reinsurance?)
  • Yes, it includes the Cruz/Lee "Separate but Unequal" amendment; carriers could indeed go back to offering unregulated plans: No guaranteed issue, no community rating, no essential benefits, as long as they also offer a fully ACA-compliant plan
  • Tax credits couldn't be used for the unregulated plans, nor would they be attached to the risk adjustment program. In other words: Segregated risk pools
  • Catastrophic plans would be "counted" the same as other plans (ie, tax credits could be used for them), but they'd amount to the same as Bronze plans now anyway
  • It includes a #BakedAlaska giveaway to win over Lisa Murkowski...1% of funds have to go to "any state where premiums are 75% higher than average" (i.e., Alaska)

Last week, and then earlier today, I crunched some more numbers (with a big assist from the Kaiser Family Foundation) to figure out just what the impact of Ted Cruz's "Consumer Choice" #BCRAP amendment would be on the individual market, and the results weren't pretty. Here's what it boiled down to (rough estimates for all numbers):

n other words, Kaiser estimates the breakout of the individual market as something like this:

New Mexico's Insurance Superintendent has released their 2018 rate hike request filings.

The database at the link above doesn't include the enrollee market share numbers; for that I had to dig up the actual filings at the SERFF database. Blue Cross Blue Shield and Presbyterian seem to be assuming no significant TrumpTax next year (which makes sense, since both will be off-exchange only, thus not subject to CSR payment concerns). Molina's filing is kind of odd--they seem to assume that CSR payments will be made...but that the individual mandate won't be enforced, which seems rather backwards to me (most TrumpTax filings assume neither will be enforced, or that the mandate will but CSR payments won't).

Over at Vox, Sarah Kliff has a nice exclusive:

A small group of Democratic legislators will do something unusual Wednesday morning: hold a press conference to talk about the parts of Obamacare that are broken.

Ten House Democrats will unveil a new plan to fix Obamacare, highlighting the parts of the law that have struggled to work and offering modest steps to improve them. The proposal includes more funding to help insurance plans cover the sickest patients, along with possibly changing the timing of the open enrollment season in hopes of attracting more Americans to sign up for insurance.

These Democrats are agitating for a new strategy, one where they speak openly about the health law’s weak spots — particularly the individual market — and how to shore them up. The party has so far been reticent to highlight Obamacare’s problems at a moment when Democrats are fighting against Republican efforts to repeal parts of the law.

A shout-out to Jeremy Johnson for the heads up: The Montana Commissioner of Securities & Insurance has released their preliminary 2018 rate requests for the individual and small group markets...and it's pretty darned straightforward. As a nice bonus, they even saved me the trouble of digging up the effected enrollee numbers. In fact, the only critical data missing are the "Part II Justification" files, which hopefully clarify how the CSR payment/mandate enforcement situation plays into these requests.

Judging by the requests, it looks like at least 2 of the 3 on the individual market are assuming that CSR payments will continue and the mandate penalty will be enforced. As for the third (BCBSMT), they're asking for a 23.1% rate hike, so I honestly don't know whether that includes the TrumpTax or not. For the moment I'll assume it doesn't, but will change this later if I'm wrong about that.

Last week I noted that Ted Cruz's proposed amendment to the GOP Senate's BCRAP bill is a big pile of crap all by itself, since it would effectively turn the ACA-compliant market into a massively underfunded High Risk Pool, while likely turning the non-compliant individual market into a wasteland of subprime junk insurance (or at best, plans which are reasonable right up until you get truly sick, in which case you're screwed).

To help explain how this would happen, I used this bar graph from the Kaiser Family Foundation to show how medical expenses are actually split up by different subsets of the population:

Based on these averages, I put together several scenarios showing what typical premiums might be for "ACA Enrollees" and "Cruz Enrollees" depending on how the market was split up:

(sigh) I'm never gonna get any work done in my day job, am I?

Senate Majority Leader Mitch McConnell (R-KY) announced Tuesday that he is canceling half of Congress’ annual month-long August recess, keeping lawmakers in town to finish their drawn-out and so far unsuccessful effort to repeal the Affordable Care Act and tackle other pressing matters.

“Once the Senate completes its work on health care reform, we will turn to other important issues including the National Defense Authorization Act and the backlog of critical nominations,” he wrote.

Meanwhile...

Tensions are rising between Senate Majority Leader Mitch McConnell’s leadership team and his party’s ideological factions, with a renewed sense of pessimism creeping into the Senate GOP’s efforts to repeal Obamacare.

In the latest "ACA Sux" propaganda blitz being carried out by Tom Price's HHS Dept, a press release came out today claiming that:

Fewer issuers apply to participate in Health Insurance Exchanges for 2018

Fewer issuers apply to participate in Health Insurance Exchanges for 2018
Less choice for consumers as issuer health plan applications drop 38 percent from last year

The Centers for Medicare & Medicaid Services (CMS) today announced 141 individual market qualified health plan (QHP) issuers submitted initial applications to offer coverage using the Federally-facilitated Exchange eligibility and enrollment platform in 2018. At the initial filing deadline last year, 227 issuers submitted an application compared to 141 this year, a 38 percent drop in filings.

For months now, I've been noting that multiple analyses by the CBO, S&P and others kept agreeing that as ugly as 2017's average unsubsidized rate hikes were (around 25% overall nationally, ranging from just 1.3% in Rhode Island and North Dakota to a whopping 76% in Oklahoma), they did appear to do the trick in terms of finally bringing individual market premiums in line with actual medical expense claims, thus stabilizing the overall risk pool. Yes, there are still many areas of the country where this isn't the case yet, but overall it looked like the dust had finally started to settle, allowing a clear picture of what needs to be done next to improve the situation.

Rhode Island just released their 2018 Individual and Small Group market rate hike requests, and they're pretty straightforward. For the small group market, I don't have the weighted market share for each carrier, but overall it ranges from 5.8 - 12.8%, with an unweighted average of 8.8%.

On the individual market, as with 2017, there's only two carriers participating in 2018: BCBS of RI and Neighborhood Health Plan. They're asking for a 13.8% and 5.0% increase respectively, with a weighted average of 10.5%.

BCBS gave their enrollment as around 27,000; for Neighborhood, I estimated theirs based on dividing their projected total member months by 12 to get 16,345. RI's on-exchange enrolment was 29,456 during Open Enrollment this year, so that would leave roughly 12,800 off-exhange enrollees, for roughly a 2:1 on/off-exchange ratio, which sounds about right.

Including Georgia, I've now compiled initial 2018 unsubsidized individual market rate hike requests for 17 states...and Georgia's carriers are asking for by far the highest overall average increase, even assuming no Trump/GOP sabotage tax.

There appear to be four carriers which have filed to sell individual market plans in Georgia next year: Alliant, Ambetter (aka Celtic, aka Centene...for God's sake, pick one name, guys, willya??), Anthem Blue Cross Blue Shield and Kaiser Health Plan.

I'm a couple of days late to the party on this one, but it still bears repeating:

New data have been released contradicting Republican propaganda about the “failing” Affordable Care Act. What may be more embarrassing to the hardliners pushing repeal is that it comes from the government, specifically the Department of Health and Human Services.

Under Secretary Tom Price, the department has been a fount of anti-ACA rhetoric. But in an annual report about the ACA’s risk-management provisions issued Friday, Health and Human Services established that the key programs are “working as intended,” protecting insurers from unexpectedly large risks and moderating premiums for consumers.

Not only that, the data “would seem to refute the commonly held belief that the marketplace population is becoming sicker,” observes health economist Timothy Jost, writing in Health Affairs. In fact, according to the figures from 2016 in the latest report, the customer base is getting healthier and the risk pools have been stabilizing.

So the Big News this week is that Ted Cruz has come up with what he thinks is a brilliant solution to the GOP Senate's BCRAP problem:

His proposal, which he’s circulating to his colleagues on typed handouts, wouldn’t explicitly create and fund the special insurance markets, as the House bill did. Instead, insurance experts said, it would create a sort of de facto high risk pool, by encouraging customers with health problems to buy insurance in one market and those without illnesses to buy it in another.

...There is no public legislative language yet, but here’s how Mr. Cruz’s plan appears to work, based on his handout and statements: Any company that wanted to sell health insurance would be required to offer one plan that adhered to all the Obamacare rules, including its requirement that every customer be charged the same price. People would be eligible for government subsidies to help buy such plans, up to a certain level of income. But the companies would also be free to offer any other type of insurance they wanted, freed from Obamacare’s rules.

At the top of the website I have a button linking to an article I wrote for Cracked.com back in May in which I explored about a half-dozen reasons why making major changes to healthcare policy in the U.S. is such a royal pain in the ass. I'm a Single Payer advocate at heart, so it was mostly written from that perspective, but really, most of the points I made would apply to any major policy change.

One thing you may notice in reading the piece is that at no point do I address the cost/payment side of moving the entire U.S. over to a universal, federally-funded Single Payer system; I stick mostly to the logistical side of things (What to do with 2-3 million industry workers? What about the Hyde Amendment? Etc, etc). These are all reasons why I'm convinced that achieving such a system would have to be done in stages. That doesn't mean tiny stages, mind you; "incremental" simply means "more than one step", so it could be, say, 4-5 stages phased in over 20 years or whatever...just not all in one shot.

As longtime readers know, I've often separated the problems with the ACA into several categories:

  • Some were inherent in the original bill as signed into law.

Yes, many of these only exist because of futile attempts to win over support from Republicans (or a handful of blue dog Dems), but the Democrats are still responsible for them. This includes things like the APTC tax credits being too skimpy, the "family glitch", the "skinny ESI glitch" and so forth. In these cases, the GOP can certainly be criticized for refusing to help resolve those issues, but that's a matter of "passive" obstruction as opposed to overtly doing so.

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