Charles Gaba's blog

Now that the Democrats have officially retaken control of the U.S. House of Representatives, everyone's expecting them to try and save and improve the ACA. I stress "try", of course, because without the Senate, it's unlikely that any bill to protect or improve the law will get passed...and even if it did somehow, the odds are high that it would then be vetoed by Donald Trump (or Mike Pence, in the unlikely-but-still-conceivable event that Trump is removed from office before January 20, 2021).

HOWEVER...they can certainly at least try. With a likely 235:200 advantage in the House and a caucus which is far more progressive on healthcare issues than it was a decade ago, the Dems shouldn't have too much trouble passing a fairly robust healthcare reform package even knowing that it's unlikely to go anywhere in the Senate. The question is how robust?

I've written about the CSR Saga so many times that I'm getting tired of explaining the backstory. However, once again, here's the short version:

Once again, the very short version is this:

  • The contract insurance carriers sign when they offer policies on the ACA exchanges is to cover a chunk of low-income enrollee deductibles, co-pays and other out-of-pocket costs which would normally be the enrollees' responsibility. These are called Cost Sharing Reductions (CSR).
  • The carriers then submit their CSR invoices to the federal government, which is supposed to reimburse the insurance carriers every month.
  • Donald Trump cut off contrctually-required CSR reimbursement payments to insurance carriers in October 2017...and hasn't made any payments since.

(I'm not going to rehash how Trump was able to cut off those payments with a Thanos-like snap of his fingers; suffice to say it's connected to a lawsuit filed so long ago that John friggin' Boehner was still Speaker of the House at the time).

Back in early December, I noted that while I applauded both New Jersey and the District of Columbia for creating their own individual healthcare coverage responsibility requirements (aka, The Individual Mandate) in response to Congressional Republicans repealing the ACA's federal penalty, doing so also required making sure that residents of NJ/DC *knew* they had done so:

There's only one problem with this: The impact of the mandate penalty is completely psychological in nature. It only works (to the extent that it does at all) if people know that they'll be penalized financially for not complying with the mandate.

Two weeks ago, I posted a semi-final state-by-state 2019 Open Enrollment Period breakout which had the total at 11,430,438 QHP selections nationally.

At the time, I projected:

I still expect the final national QHP selection tally to increase by around 35,000 more when the dust settles, including perhaps 1,000 more from DC, 5K - 10K more from New York and around 28,000 from Vermont (which hasn't reported anything so far this Open Enrollment Period). If so, the official total should end up around 11.47 million nationally, with the 12 State-Based exchanges coming in around 1.6% higher than last year (an all-time high for them collectively) vs. the 39 states on the federal exchange, which dropped another 3.8% this year. Nationally, the official total should end up around 280,000 enrollees short of last year.

Since then I've plugged in the final numbers from New York (which indeed added around 6,700 more enrollees), the District of Columbia (which added over 3,000 more) and, just this morning, Vermont (which only added 25,000 more, with a caveat). Net increase? 34,889 QHP selections.

That indeed brings the grand total to 11,465,327 QHP selections nationally...or 11.47 million...with the state-based exchanges increasing 1.6% year over year, and the national total dropping 285,000 enrollees.

At long last, the final piece of the puzzle can be added: I just received the final 2019 Open Enrollment Period numbers from Vermont Health Connect.

Before looking at it, it's important to understand that Vermont has a unique way of reporting ACA-compliant healthcare policy enrollments.

For the first two years of Open Enrollment, the state didn't allow any off-exchange (or "direct") enrollments for the individual market (or the small business market, I believe). That means all indy market enrollments were done through the exchange. Due to technical problems (and possibly for other reasons as well), however, starting in 2016 they started allowing direct/off-exchange enrollment as well, as every other state does (the District of Columbia is the only other ACA exchange which has no off-exchange market). However, Vermont still requires the insurance carriers to report those off-exchange enrollees to them and they report them as well.

I wish every state reported their enrollment data this way; it would make it much easier for me to do my job, since as it stands the off-exchange market is a bit of a mystery in most states.

Until now, I've been missing the final 2019 Open Enrollment Period numbers for two state-based exchanges: Vermont and the District of Columbia. VT is still radio silent, but last night the DC exchange authority held their monthly meeting and released their latest data report.

There's a bunch of handy demographic data included in the report...but some of it is also confusing and difficult to get an accurate year-over-year measurement due to a difference of time periods and enrollment status.

I've put in a request to sort some of this out and will update this entry if/when I receive clarification.

For instance, the DC exchange says that they have the following number of residents currently effectuated as of February 10th:

The contrast in how a completely Republican-held state government like Utah and a completely Democratic-held state government like New Mexico deal with Medicaid is pretty astonishing.

In Utah, just four months ago the public voted, clearly and unequivocally, to enact a full expansion of Medicaid to all adults earning up to 138% of the Federal Poverty Line...but the GOP state House, Senate and Governor decided to ignore the voters and override their will by cutting the expansion down to a 100% FPL cap, including work requirements, which will cover tens of thousands fewer people while costing the state $50 million more.

In New Mexico, meanwhile, a newly-enabled Democratic trifecta (I believe both houses of the state legislature were already held by Dems, but the Governorship flipped from Republican Susana Martinez to Democrat Michelle Lujan Grisham) has been on a tear in their first month and a half:

via Greg Bluestein & Ariel Hart of the Atlanta Journal-Constitution:

Gov. Brian Kemp will ask the Georgia Legislature and the federal government for flexibility to improve access to government-funded health insurance for the state’s poor and middle class.

His administration told The Atlanta Journal-Constitution on Thursday that it will back a measure that seeks two separate federal “waivers” to Medicaid and the Affordable Care Act to tailor new programs to Georgia’s needs.

This sounds potentially promising, but...

...The ACA waiver, which he outlined on the campaign trail, aims to stop premiums on the health insurance exchange market from rising so fast. A second push, which emerged after his election, would raise the possibility of a partial expansion of Medicaid to some of Georgia’s poorest residents.

Hmmmm...

 

I noted last week that Congress held not one, not two but three full hearings regarding various ACA-related issues, at which a couple of friends of mine testified (and a couple more were on the other side of the microphone, as sitting members of Congress).

Well, prepare for another one tomorrow (Wednesday, February 13th):

HEARING ON “STRENGTHENING OUR HEALTH CARE SYSTEM: LEGISLATION TO REVERSE ACA SABOTAGE AND ENSURE PRE-EXISTING CONDITIONS PROTECTIONS”

Date: Wednesday, February 13, 2019 - 10:30am
Location: 2322 Rayburn House Office Building
Subcommittees: Health (116th Congress)

The Subcommittee on Health of the Committee on Energy and Commerce held a legislative hearing on Wednesday, February 13, 2019, at 10:30 a.m. in room 2322 of the Rayburn House Office Building. The bills to be the subject of the legislative hearing are as follow:

As always, Louise Norris has the skinny:

In September 2018, the New Mexico Office of the Superintendent of Insurance (OSI) and Health Action NM (an advocacy group for universal access to health care) presented details about potential state actions to stabilize the individual market. OSI has the authority to regulate some aspects of the plans, including maximum duration, but they noted that legislation would be needed for other changes, including minimum loss ratios and benefit mandates.

New Mexico’s insurance regulations were amended, effective February 1, 2019, to define short-term plans as nonrenewable, and with terms of no more than three months. The regulations also prohibit insurers from selling a short-term plan to anyone who has had short-term coverage within the previous 12 months.

I wrote about this a week ago...

The full expansion initiative passed last fall, of course, is supposed to cover Utah residents earning up to 138% of the poverty line, or around 150,000 people...without any work requirements.

The bill barreling through the Utah Legislature was “an effort to override the will of the people,” said Matthew Slonaker, the executive director of the Utah Health Policy Project, a nonprofit group that supported the full expansion of Medicaid.

Utah lawmakers, worried that the sales tax increase might not fully cover the costs, are rushing through a bill that would limit the expansion of Medicaid to people with incomes less than or equal to the poverty level, about $12,140 for an individual.

State officials say that the bill, which is estimated to cover 90,000 people, could be on the desk of Gov. Gary R. Herbert, a Republican, in a week or two.

 

Light posting for the next two weeks as I'm dealing with my kid's upcoming bar mitzvah and some other personal stuff, but this one literally hits home.

You may recall that last spring, Republicans in the Michigan legislature attempted to push through a bill to change the state's current ACA Medicaid expansion program (which is close to "vanilla" Medicaid with a few minor tweaks) by tacking on pointless, ineffective and (in an earlier draft) blatantly racist work requirement provisions:

White, Rural GOP Counties Get Exempted from Medicaid Legislation

Republicans in the legislature are working to change Medicaid in Michigan, but only for certain people, as they have tailored the language of pending legislation to exempt some of their constituents from being affected.

I only met John Dingell once, at a fundraiser for my friend and colleague Chris Savage's Eclectablog a few years back. I introduced myself, we shook hands, exchanged pleasantries and that was it. I've met Rep. Debbie Dingell a handful of times besides that evening, at various local Democratic Party events.

I was born and raised not just in Michigan but in the suburbs of Detroit, so while I don't have any special insight into The Dean, I can say that his shadow has loomed large over the region and state in addition to the entire nation for decades.

Anyone who knows anything about U.S healthcare policy knows the gigantic role he played in pulling America (sometimes kicking and screaming) forward towards universal healthcare coverage over a career that spanned 60 years. Every other media outlet is already posting in-depth tributes and retrospectives on the massive loss which the nation experienced today, so I'm just going to repost a few of his best tweets.

My deepest sympathies to his loving wife Rep. Debbie Dingell, his children, grandchildren and the rest of his family; and his many friends and colleagues on their (and all of our) loss. May his memory be a blessing now and forever.

 

 

It's amazing what a difference flipping the U.S. House of Representatives can make.

Yesterday, two friends of mine (Peter Morley and Elena Hung) testified before Congress in two different hearings, while my own Representative Andy Levin and his next-district neighbor Representative Haley Stevens, both of whom I consider friends, sat on the other side of the table in yet a third hearing.

Sadly, I wasn't able to watch most of any of the hearings myself yet (they add up to over 8 1/2 hours total) but I plan on doing so over the next few days. I'm incredibly proud of all of them.

In the video above, Peter Morley spoke in front of (this is a mouthful) the House Appropriations Committee Subcommittee on the Departments of Labor, Health and Human Services, Education, and Related Agencies (the audio level is set way too low...you have to crank up your volume to hear this one).

 

via Clarisse Loughrey of The Independent:

Early concept art has revealed a very different look for Toy Story's dynamic duo, Woody and Buzz Lightyear.

Pixar's first feature started life as a full-length take on their short Tin Story, which saw a mechanical drummer attempting to navigate his way through a baby's playroom. The drummer was soon ditched for a more glamorously conceived "space toy" named Lunar Larry, later renamed Buzz Lightyear in honour of famed astronaut Edwin "Buzz" Aldrin.

The original concept pitched its drummer against an antagonistic ventriloquist's dummy, who gradually evolved into a pull-string cowboy doll named Woody, inspired by Western actor Woody Strode.

Yes, Woody was originally the bad guy; though his character didn't prove popular with his voice actor Tom Hanks, who reportedly shouted "This guy is a jerk!" while recording lines for the story reel.

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