In early 2018, Maryland state legislators introduced a bill which included a twist on the coverage mandate penalty--those who failed to sign up had another option: They could either pay the penalty or they could choose to have the penalty amount be used to automatically enroll them in the lowest-cost insurance policy available. If they qualified for ACA subsidies, those would even be baked into the equation as well. This was a clever way of softening the blow, while also increasing enrollment and helping out the ACA risk pool.
Every year for 4 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 projected to increase or 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 next to impossible to find the specific data I need.
The actual data I need to compile my estimates are actually fairly simple, however. I really only need three pieces of information for each carrier:
Last April, Maryland was one of several states which took action to counteract portions of the Trump Administration's attempts to sabotage the Affordable Care Act. In particular, Maryland (which has a Democratically-controlled state legislature but a moderate (by today's standards) Republican Governor) passed and signed into two important bills:
This makes the sixth state-based exchange in a row to post their 12/15 enrollment totals this afternoon...and it's the FIRST report of any sort to come out of Maryland. Fortunately, the news is quite good:
NEARLY 157,000 MARYLANDERS ENROLLED THROUGH MARYLAND HEALTH CONNECTION FOR 2019
Enrollments both on and off exchange exceeded estimates for how ‘reinsurance’ would stabilize Maryland’s individual insurance market
Oooh...now that's a treat for a data wonk like me...official off-exchange data is difficult to come by in most states...
BALTIMORE (DEC. 17, 2018) – A total of 156,963 Marylanders enrolled in private health coverage for 2019 during the open enrollment that concluded Saturday on Maryland Health Connection, the state-based health insurance marketplace.
Last spring, both New Jersey and Maryland were among the states which were the most pro-active about passing lesiglation to cancel out Donald Trump's attempts to deliberately sabotage the Affordable Care Act. Both states passed laws cracking down on non-ACA compliant short-term and association health plans (NJ actually already didn't allow short-term plans before the ACA anyway), both states established robust reinsurance programs, and both states tried to pass bills reinstating the ACA's Individual Mandate Penalty which Congressional Republicans repealed last winter in different ways.
When Maryland insurance carriers originally submitted their proposed 2019 premium changes back in May, it looked pretty grim...they were expected to average around 29.5% statewide for the ACA-compliant individual market., increasing from around $631/month on average to roughly $817/month for unsubsidized enrollees.
Thanks to swift, bipartisan action on the part of the Democratically-controlled Maryland state legislature and the Republican Governor, Maryland was able to pass several bills which partially negated or cancelled out Trump/Congressional Republican sabotage of the Affordable Care Act. In particular, they passed laws which locked in current restrictions on both short-term plans and association health plans (the types of "junk policies" which Trump is pushing hard to expand upon)...along with an extremely robust reinsurance program.
Maryland files suit to protect health reform from Texas.
... the Maryland attorney general today filed a separate lawsuit in a Maryland district court. Among other things, he’s seeking an injunction requiring the continued enforcement of the law. Depending on how quickly the Maryland case moves, it’s possible we could see dueling injunctions—one ordering the Trump administration to stop enforcing the law, the other ordering it to keep enforcing.
That’s an unholy mess just waiting to happen. Now, it may not come to that. My best guess is that the Texas lawsuit will fizzle: any injunction will likely be stayed pending appeal, either by the Fifth Circuit or the Supreme Court, and the case is going nowhere on the merits. The Maryland lawsuit will likely prove unnecessary.
I don't have much to add to this other than to note how much this case underscores just how much power and importance state attorneys general have.
CMS Administrator Seema Verma is difficult to get a read on. On the one hand, she glories in trashing the ACA every chance she gets while happily endorsing nearly every effort to undermine or sabotage it, including repeal of the individual mandate, slashing the marketing and outreach budgets and so forth. Last year she was even busted trying to (effectively) blackmail the insurance carriers at large by offering to push through CSR reimbursement payment in return for them supporting the GOP's Obamacare repeal bill.
I admit to not knowing a whole lot about how Maryland's "All-Payer" system works aside from every payer (Medicare, Medicaid, private insurance) having to pay the same amount for the same services at a given hospital. Here's a general summary from Wikipedia:
All-payer rate setting is a price setting mechanism in which all third parties pay the same price for services at a given hospital. The system does not imply that charges are the same for every hospital. It can be used to increase the market power of payers (such as private and/or public insurance companies) to mitigate inflation in health care costs. All-payer characteristics are found in the health systems of France, Germany, Japan, and the Netherlands. Maryland also uses such a model.
Insurers selling Obamacare plans in Maryland are again seeking huge rate increases for 2019, but they could be knocked down significantly by a reinsurance program the state hopes to implement for next year.
CareFirst BlueCross BlueShield wants to increase rates on average by 18.5 percent on its HMO plans, which account for more than half of the individual market this year.Kaiser Permanente, the only other insurer selling on the exchange, is seeking a 37.4 percent average increase on its HMO plans, which cover just over a third of Obamacare customers.
A few days ago I noted that Maryland Governor Larry Hogan had signed a bipartisan bill into law which creates a $380 million reinsurance fund which should cancel out up to 21% of next year's looming individual market premium hikes.
However, I forgot to mention the other important thing that the same bill does: Evidently it would also head off Donald Trump's attempt to open the floodgates on the type of minimally-regulated "short-term" and "association" plans which would further damage the ACA-compliant individual market risk pool:
(C) THIS SUBTITLE APPLIES TO ANY HEALTH BENEFIT PLAN OFFERED BY AN ASSOCIATION, A PROFESSIONAL EMPLOYEE ORGANIZATION, OR ANY OTHER ENTITY, INCLUDING A PLAN ISSUED UNDER THE LAWS OF ANOTHER STATE, IF THE HEALTH BENEFIT PLAN COVERS ELIGIBLE EMPLOYEES OF ONE OR MORE SMALL EMPLOYERS AND MEETS THE REQUIREMENTS OF SUBSECTION (A) OF THIS SECTION.
Maryland Governor Larry Hogan signed a bipartisan bill on Thursday that state officials say will help keep healthcare premiums from spiking again next year.
The bill creates what’s known as a reinsurance program for the state’s health insurance marketplace, which was created as part of the Affordable Care Act.
...Without the fix or any action in Washington, Maryland officials predicted that healthcare premiums in 2019 could jump up to 50 percent, driving more of the 150,000 people to abandon the state’s marketplace — possibly leading to its collapse.
So there you have the enrollment results of full-bore on-exchange silver-loading of CSR costs in one state. In all, 49,993 on-exchange enrollees with incomes up to 400% FPL chose plans other than silver. About 48,000 of them were subsidized. That's 31.2% of all enrollees, within striking distance of Aron-Dine's upper bound of 36% for all marketplace enrollees.
Now that the 2018 Open Enrollment period is officially over in every state +DC, I've started compiling more detailed demographic breakouts of the data on a state-by-state basis. The official CMS report from the Assistant Secretary for Planning & Evaluation (ASPE) report should be released at some point in the next couple of weeks, but until then, I'll have to settle for whatever reports I can patch together from some of the state-based exchanges.
So far I've dug up final (or near final) data for six states: Colorado, Connecticut, Idaho, Maryland, Minnesota and Washington State. Collectively, these states only represent about 890,000 2018 exchange enrollees, or roughly 7.5% of the 11.8 million total, so I have no idea how representative they are nationally, but it's all I have to work with for the moment.