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Nevada

A week ago, Vox's Sarah Kliff reported that the Trump Administration was slashing the 2018 Open Enrollment Period advertising budget by 90% and the navigator/outreach grant budget by nearly 40%. As I noted at the time, the potential negative impact of these moves on enrollment numbers this fall--coming on top of the period being slashed in half, the CSR reimbursement and mandate enforcement sabotage efforts of the Trump/Price HHS Dept. and the general confusion and uncertainty being felt by the GOP spending the past 7 months desperately attempting to repeal the ACA altogether could be significant. In states utilizing the federal exchange (HealthCare.Gov), 2017 enrollment was running neck & neck with 2016 right up until the critical final week...which played out under the Trump Administration, which killed off the final ad/marketing blitz.

Result? A 5.3% total enrollment drop (or 4.7% if you don't include Louisiana, which expanded Medicaid halfway through the year) via HC.gov, while the 12 state-based exchanges--which run their own marketing/advertising budgets--saw a 1.8% increase in total enrollment year over year.

Nevada is the final state to post their requested rate hikes for 2018 (or at least they're the last one I tracked down, anyway). I've now done at least a rough analysis of all 50 states + DC, and while some of the data is a bit outdated (remember, I started doing this back in late April/early May), most of it should still be fairly close to the present situation...at least in terms of requested rate hikes.

In Nevada, after much concern that a bunch of rural counties wouldn't have any exchange carriers at all, Centene stepped in to cover them. They aren't listed in the table below, but since I believe they're new to the state, that shouldn't matter in terms of rate increases since there's no base rates to compare against anyway.

So, I got back from my trip to the NIHCM awards dinner in DC late last night, and am groggily attempting to bone up on all the healthcare stuff which happened while I was gone (ironic, of course, given that I was attending a healthcare-related event filled with other healthcare wonks/reporters).

In the past 2 days...

Of the 31 states which have expanded Medicaid under the Affordable Care Act, only a handful issue regular monthly or weekly enrollment reports.

I noted in February that enrollment in the ACA's Medicaid expansion program had increased by around 35,000 people across just 4 states (LA, MI, MN & PA).

It's early June now, so I checked in once more, and the numbers have continued to grow. I have the direct links for 5 states now (including New Hampshire)...

Hardly surprising given they made good on their "Give us our merger or we're out of here!" threat last year, followed by further drop-outs from both Iowa and Virginia announced for next year over the past few weeks, but the final Aetna shoe has just dropped:

.@Aetna will not offer on- or off-exchange individual plans in DE or NE for 2018, and at this time has completely exited the exchanges.

— T.J. Crawford (@TJatAetna) May 10, 2017

T.J. Crawford is apparently Aetna's head of media relations, so yeah, that seems pretty definitive.

A bit more courtesy of Peter Sullivan of The Hill:

Last month I wrote up a list of 20 fixes/improvements to the ACA, many of which wouldn't cost taxpayers a dime. One fo them was...

12. LEGALLY TIE MEDICARE ADVANTAGE/MANAGED MEDICAID CONTRACTS TO EXCHANGE PARTICIPATION.

Andrew Sprung, Michael Hiltzik and I have all written about this before. I have no idea whether it's even legally feasible/practical or not, but if so, it makes a lot of sense to me: Remember, many of the same carriers whning about losing hundreds of millions of dollars on the individual market are simultaneously making billions of dollars in profit off of their other divisions...which include fat federal and state contracts to manage Medicare and/or Medicaid plans. If they want to play in the managed care sandbox, make exchange participation a requirement as well. I'm not saying they should have to treat it as a loss leader--they'd still be able to raise their premiums at an actuarially responsible rate as appropriate--but they should have to at least participate.

As far as I can tell, even the amazing Louise Norris hasn't caught this one yet (and it's a month old, too!). If I'm wrong and she has done a write-up on it, of course, I'll eat my words:

Medicaid for all

Democratic [Nevada] Assemblyman Mike Sprinkle has introduced a bill, AB374, to open up the state’s Medicaid program to anyone, regardless of their income level.

Individuals would be able to purchase coverage through Medicaid on the healthcare exchange for an annual premium set at 150 percent of the median expenditure paid on behalf of Medicaid enrollees in the preceding fiscal year. Though none of the current federal or state dollars going to fund Medicaid would be used to cover any portion of the new enrollees, they would still be entitled to the same benefits provided to other Medicaid recipients.

Nevada's Medicaid expansion data has been tricky to track down; the most recent hard number I had until now was 187,000 people statewide, and that was as of September 2015. According to this January 2017 article in the Las Vegas Review-Journal, however, that number has since grown to around 320,000 Nevadans.

In Nevada, , 89,000 people enrolled in exchange policies as of the end of January. Of these, I estimate around 62,000 of them would be forced off of their private policy upon an immediate-effect full ACA repeal, plus the additional 320,000 enrolled in Medicaid expansion, for a total of 382,000 Nevadans kicked to the curb.

Last year, the average full-price rate hikes approved by state regulators tended to be several percentage points lower overall than the increases requested by carriers. This year, there's been very little of that; in most case so far, the regulators have pretty much authorized the premium rate increases as requested by carriers...and in many cases have approved higher increases than requested. As a result, the overall national averages approved have been pretty close to the requests (around 24-25% nationally).

However, Nevada is an exception to this trend. Back in early June, the weighted average increases requested were just over 15% state-wide (this was confirmed by the NV DOI a month later). Yesterday, however, the DOI released the approved rate hikes, and I'm happy to report that they lopped about 1/3 off the average hikes:

Just a quickie here: Last month I cobbled together the 2017 requested rate filings for the individual market in Nevada and calculated that the weighted average hike request was around 15.0% even. According to an local news article from Saturday, I was dead on target...and they also helpfully noted that the average request for the small group market for next year is just 4%:

LAS VEGAS (AP) — Health insurance costs for about 240,000 Nevadans who buy individual or small-group plans are expected to rise next year, and state officials want consumers to offer feedback before the proposed rates are locked in in coming weeks.

As regular readers know, I'm currently in the thick of my state-by-state analysis of the requested, weighted average rate changes for 2017 by insurance carriers for the entire ACA-compliant individual market. As of this writing, the overall average looks like it's just a hair over 20% across 28 states + DC.

Does the first sentence above include a lot of clarifiers? Yes, yes it does...and with good reason. I try to be very specific when I discuss this stuff, because it's very easy to get confused about what a given number is actually referring to.

For instance, a few days ago, Avalere Health released their own analysis which concludes that the average requested/proposed premium rates are around 12%. If I left it at that, you might think that either my average is 8 percentage points too high...or that Avalere's is 8 points too low.

Can I first say that I absolutely love the way Nevada's rate filing database is set up, especially their (apparently proprietary and mandatory) filing format system?

Unlike the standard SERFF database, which is comprehensive but also can be confusing as hell, Nevada's system is simple, clean, easy to navigate and, most of all, every single carrier filing listed displays the number of current enrollees clearly. This is a huge pet peeve of mine, which is understandable given what I'm trying to do here!

OK, that said, here's what things look like in the Silver State:

This is really just a summary of my last 4 posts. I've combed through the SERFF databases for every state which uses the system for rate filings, and while very few have the actual 2017 rate filing requests listed yet, at least 4 of them have official individual market exit letters submitted for 2017 from Jane Rouse, the Product Compliance Process Owner for Humana Insurance Co:

This list may grow as additional state filing data and/or press releases come out from Humana, but assuming these are the only 4 states Humana is bailing on, the news isn't quite as bad as it appears at first.

To keep things in perspective, add the 4 numbers above up and it's 25,512 people across 4 states with a combined population of 21.8 million. Put another way, these 25.5K people represent only 2.9% of the 875,700 people Humana currently has enrolled in individual policies (both on & off exchange) nationally.

To be clear, I'm not saying this is a good development; when you combine it with the recent UnitedHealthcare Dropout Odometer it's more of a drip-drip-drip sort of thing. But it isn't disasterous for the exchanges either (at least not yet).

UPDATE: I've been informed by a reliable source that Humana is also dropping out of the individual market in Nevada next year, although I don't have any actual enrollment data there. Humana is not currently participating on the Nevada exchange, however, so any dropped enrollments would be OFF-exchange only. In fact, I'm pretty sure that the only individual market enrollees Humana has in Nevada are grandfathered policies anyway, so the numbers should be pretty nominal there.

As anyone who's been following the ACA exchange saga over the past few years knows, the original idea was that all 50 states (+DC) would establish their own, individual healthcare exchange, including their own website/technology platform for enrolling residents in private policies (QHPs), Medicaid (supplementing or replacing whatever existing Medicaid system they already had) and small business policies (the ACA's SHOP program). In addition, each state exchange would also have their own board of directors, marketing department, support call center, fee structure for covering the cost of operations and so on.

If things had worked out that way, there would have been 51 different websites where people would enroll in ACA policies, each one independently branded.

About a month ago, I crunched Nevada's individual and small group rate hike numbers and concluded that the overall weighted average hike in the Silver State next year (assuming everyone stays put and doesn't shop around) will be roughly 9.6% on the individual market and just 5.3% for small businesses.

Today, the Nevada Appeal ran a story claiming the ACA exchange-only average individual rate hike will be around 8.7%.

Now, it's not the lower rate which caught my eye; the 8.7% figure only includes exchange-based carriers, of which there's only three this year, versus the dozen or so who operate throughout the state (there are 9 more insurance carriers who are only operating off of the exchange).

What I'm puzzled by is this part...which also includes some good news:

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