2018 MIDTERM ELECTION

Time: D H M S

Over at LinkedIn, George Kalogeropoulos has and Shandon Fowler have a fascinating piece about employer-based coverage and the relationship it has to public healthcare coverage:

Here is our call to action for employers: Guide employees of any eligibility status to health coverage, whether employer-sponsored or government-supported, because it will benefit both employees and your company.

The main thrust of the article is that while most employers offer some sort of healthcare coverage option to their employees (in fact, most did so before the ACA mandated it), most of them don't appear to make a whole lot of effort to actually get the employees to enroll in that coverage...and even fewer make any sort of effort to encourage their staff to enroll in other types of healthcare coverage outside of the employer plan.

They include several charts and graphs, but this is the key one to me:

via the Salt Lake Tribune:

Gov. Gary Herbert signed a measure Tuesday to give more than 70,000 needy Utahns access to government health coverage, ending years of failed attempts on Capitol Hill to expand Medicaid in the state.

But whether House Bill 472 ever takes effect still remains uncertain. Under President Obama’s signature Affordable Care Act (ACA), the Utah law needs approval by the federal Centers for Medicare and Medicaid Services (CMS), which has sent mixed signals on whether it will fully sign off.

Even if CMS does approve HB472, it will likely be about a year — even on an aggressive schedule — before the state can begin enrolling people for coverage. Meanwhile, a competing Utah citizens initiative that would expand Medicaid coverage more widely than HB472 also continues to gather signatures for a spot on November’s ballot.

A couple of weeks ago, I noted that Iowa had come up with an ingenious plan to resolve their troubled individual health insurance market: Start offering junk plans for everyone and damn the consequences:

Well, sure enough, just yesterday the Iowa state Senate voted to allow unregulated junk plans to be sold to...pretty much anyone in the state:

The Iowa Senate voted Wednesday to let the Iowa Farm Bureau Federation and Wellmark Blue Cross & Blue Shield sell health insurance plans that don't comply with the federal Affordable Care Act.

The new coverage could offer relatively low premiums for young and healthy consumers, but people with pre-existing health problems could once again be charged more or denied coverage.

Christina Lechner Goe has written up a detailed explainer going over the various types of NON-ACA-Compliant healthcare policies available and how each of them impacts the individual and small group markets. The report was commissionerd by consumer representatives of the National Association of Insurance Commissioners (NAIC):

Wowsers! The Kaiser Family Foundation released their latest monthly tracking poll a few days ago, and while there's tons of interesting/important findings, it's the last question which leaps out at me the most:

MEDICARE-FOR-ALL PROPOSALS

While many want Democrats in Congress to focus on improving the way the ACA is working rather than trying to pass a national health care plan, there is support for such a proposal. This month’s Kaiser Health Tracking Poll finds six in ten (59 percent) favor a national health plan, or Medicare-for-all, in which all Americans would get their insurance from a single government plan.

OK, that's great news: 59% of the country now supports a mandatory Bernie Sanders/John Conyers-style Medicare for All/Single Payer program. I'm sure they'll be touting this all over, and that's perfectly fine.

HOWEVER, keep reading:

Via Inside Health Policy; the rest of the article is locked behind a paywall, but you can guess the gist of it:

MILWAUKEE -- State insurance commissioners and officials coming out of a closed-door meeting with CMS said the administration announced it will not finalize the rule on longer duration short-term plans until the fall and will delay implementation of that rule until January 2019 -- though CMS disputed this characterization of the meeting when asked by Inside Health Policy . Several sources stressed that the delay of the rule means that issuers will be unable to factor in the potential impact...

Sam Baker of Axios has a little more detail:

This morning I took a look at the "Short Term, Limited Duration" policies (aka "Short-Term Plans"). Now comes the other half of Donald Trump's #ShortAssPlans executive order: "Association Plans".

I've obviously already written a bunch of stuff about this, including links to a few impact projection analyses, but this one was put together by Avalere Health on behalf of America's Health Insurance Plans (AHIP), which is one of the two major insurance carrier lobbying groups (the other one is BCBSA). On the surface you may expect a whitewash: "Oh, look at that, a report commissioned by Big Insurance is releasing a report claiming that these policies would be awesomesauce, big surprise!"

However, the actual analysis is quite different than what you might expect:

For some time now, I've been railing against Donald Trump's executive order pushing for the expansion of both "Short Term, Limited Duration" plans as well as "Association Plans". I've scornfully referred to his EO with the hashtag #ShortAssPlans.

Something which has gotten lost in the shuffle, however, is that I don't think short-term plans should necessarily be scrapped altogether, at least until we're able to achieve a comprehensive, universal coverage system in the future. Under our current patchwork heatlhcare system, I do think they serve a purpose for certain people in certain circumstances. I just think they need to be strongly regulated and limited in scope, partly to prevent siphoning off healthy people from the individual market risk pool...but partly to prevent people from being hit with financial catastrophe in the event of unexpected high medical expenses.

The problem is that Trump's executive order--which would effectively open the floodgates for them to be mutated into year-round plans, completely destroying one of the major points of the ACA in the first place.

 

Yesterday morning, Larry Levitt of the Kaiser Family Foundation posted this tweet:

Our polling suggests the public is most likely to blame President Trump and Republicans in Congress for any problems in the insurance market going forward.

— Larry Levitt (@larry_levitt) March 26, 2018

Something about this pie chart seemed awfully familiar to me...

With all the discussion about subsidized enrollees, unsubsidized enrollees, short-term plans, association plans, health sharing ministries and so forth swirling around the ACA stabilization/CSR reimbursement payment/Silver Loading debate, I just wanted to take a quick moment to remind everyone that "The Uninsured" isn't a single amorphous blob; it consists of several fairly specific subsets.

The good news is that the Kaiser Family Foundation is among the most reliable sources for this sort of data in the business. The bad news is that their estimates are out of date--this analysis/breakout was last updated in October 2017, but the actual survey data is from 2016. Needless to say, a lot has changed in the intervening year and a half...namely, the Trump Administration and two full ACA Open Enrollment Periods.

A note about the headline: I originally referred to "ACA 2.0 vs. Trumpcare", but the more I thought about it, the more I realized that as of this moment, Donald Trump and the GOP have only partially mutated the Affordable Care Act into their own warped vision. They've managed to scare off carriers, confuse enrollees, cause unsubsidized premiums to shoot up an extra 18%, and with the repeal of the individual mandate (and potentially the massive expansion of #ShortAssPlans via #RegulatorySabotage) starting next year are about to cause those same premiums to jump another 16% or so on average.

 

TODAY IS THE 8TH ANNIVERSARY OF THE AFFORDABLE CARE ACT.

On March 23, 2010, President Barack Obama signed into law the Patient Protection & Affordable Care Act.

Since then, despite a number of real problems with the law and an endless series of ferocious attacks by the GOP, the ACA is still standing. It’s beaten and bloodied, but it’s still the law of the land, and it’s resulted in the uninsured rate being slashed from 48 million Americans in 2013 to 29 million today. 16 million people have been added to Medicaid coverage via ACA expansion, and 9 million are receiving subsidized healthcare coverage via the ACA exchanges.

Thanks to the ACA, no one can be denied coverage based on their medical condition. Women can’t be charged more for their gender. Maternity and mental health services now have to be covered. People undergoing chemotherapy and premature infants requiring neonatal care no longer eat up their lifetime coverage maximum cap within a few months.

OK, this is kind of beating a dead horse since the Alexander-Collins bill is dead anyway, but just for completeness sake:

Last week I pointed out that aside from everything else that's problematic about the abortion restriction language included in the A-C bill, it would also have run into a big legal problem because three states (California, New York and Oregon) legally mandate that major medical healthcare policys cover abortion, in direct opposition to the A-C provision which would deny federal subsidies, CSR assistance or reinsurance funds to...any healthcare policy which covers abortion.

Well, today I can add a fourth state to this list:

OLYMPIA, Wash. (AP) — Gov. Jay Inslee has signed a measure that requires Washington insurers offering maternity care to also cover elective abortions and contraception.

Over a month ago I posted what I assumed was the final 2018 Open Enrollment Report from the Washington HealthPlan Finder. However, it appears that was just a partial report. Today they announced the official version:

The Washington Health Benefit Exchange today announced that 209,802 customers used Washington Healthplanfinder to purchase a Qualified Health Plan (QHP) for 2018 coverage during the most recent open enrollment period. This total is a nearly three percent increase over last year and is 50 percent higher than the number of enrollees recorded following the first open enrollment period in 2014.

A year ago I wrote up my own "wish list" of 22 recommendations for fixing, improving, strengthening and expanding the Affordable Care Act (it's officially 20 items but two of them really should have been split into two entries apiece). I called it "If I Ran the Zoo", and it received quite a bit of praise, even though I didn't come up with most of them myself; it was mostly a compilation of ideas which had been floating around progressive healthcare wonk circles for awhile.

In any event, now that the Republican "ACA stabilization bill" (Alexander-Collins) appears to be dead and buried, I figured it might be helpful to line up both the House and Senate versions of the ACA 2.0 bills to see how they compare to each other as well as to my own list of recommendations.

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