ACA Sabotage

2018 MIDTERM ELECTION

Time: D H M S

 

WARNING: LOTS OF WONKY NUMBER-CRUNCHY STUFF BELOW.

Skip to the end if you just want to see my findings for every state, but be warned that there's a bunch of caveats/disclaimers involved.

UPDATE: To clarify, you're looking for the VERY LAST TABLE. Not that one...no, not that one either...the one at the very bottom of the post. I've added a highlighted note right above it.

A month ago I noted that along with a whole mess of other crap, Congressional Republicans were attempting to effectively starve the ACA out by simply cutting off funding of the law via the recent "must pass" omnibus spending bill:

Republicans also want to use the funding bill to go after Obamacare. They would prohibit funding for administering or enforcing the health care law, prohibit the administration from collecting a fee from insurance companies to run the insurance exchanges and eliminate more than half a billion dollars in funding for managing the program at the Centers for Medicare and Medicaid Services.

(sigh) I'm not quite sure how "prohibiting funding for administration" differs from "eliminating funding for managing the program", but it amounts to the same thing: They're trying to shut down CMS's ability to actually run the ACA.

The good news is that none of that ended up making it into the omnibus bill.

Regular readers know that I've developed a tradition over the past three years of tracking the average unsubsidized premium rate increases for the ACA-compliant individual market, painstakingly poring over the rate filings for every carrier in every state and running a weighted average by their market share.

Every year there are numerous challenges and headaches which get in the way, including things as obvious as "not every carrier publishes the number of enrollees they have covered" to complex situations like "carrier X is dropping out of the on-exchange market in half the counties of the state but is sticking around in the off-exchange market". In addition, many carriers submit an initial rate request...followed a few months later by a revised one...neither of which might end up matching the final premium changes approved by state regulators. Sometimes there may be 2-3 more revised filings along the way which muddy the waters even further.

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.

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:

A few days ago I warned Congressional Democrats that while I agree that appropriating CSR reimbursement payments at this point would be a net negative move thanks to the clever Silver Load/Silver Switcharoo workaround developed last year, there's one possible cloud surrounding that silver lining, so to speak: What if the Trump Administration were to attempt to put the kibosh on Silver Loading altogether?

I don't know the legality of such a move, mind you, but It has been thrown around the rumor mill of late, so I figured I should remind them to keep that possibility in mind.

Well, today I received some reassurance...

Azar Says He Is Not Aware Of Discussions On Blocking ‘Silver-Loading’ in 2019

*(OK, much of it is already here, actually)

Former CMS representative and current healthcare policy advisor for Sen. Brian Schatz, Aisling McDonough, made an important point last night:

If you have a pre-existing condition and live in a rural area, especially in VA, TN, OH, IN, MO, IA, or NV, then I'm worried there might not be a plan available for you next year.

(I pulled those states from this KFF brief: https://t.co/WgCWO16wOa)

— Aisling McDonough (@AislingMcDL) March 12, 2018

People should be worried about bare ACA counties in 2019 b/c of GOP sabotage.

Between mandate repeal, short-term plans, health ministries, farm bureaus, etc, the guaranteed $ for the lone ACA insurer is getting smaller. It's not the same calculus as it was in 2017 & 2018.

— Aisling McDonough (@AislingMcDL) March 12, 2018

UPDATE 4/11/18: I posted this piece about a month ago; I don't have any specifics, but I have reason to believe that the Michigan state legislature could be moving on this any day now. If you live in Michigan, CALL YOUR STATE SENATOR OR REPRESNTATIVE AND TELL THEM *NOT* TO IMPOSE WORK REQUIREMENTS ON "HEALTHY MICHIGAN" ENROLLEES!

h/t to Annette Prentice for the heads up on this. Via Michigan Public Radio:

State Senate introduces bill to add work requirements to Medicaid

The bill would require able-bodied adults to work or be in school for 30 hours a week in order to receive Medicaid.

Some lawmakers in Lansing want people to work to get Medicaid. The Senate introduced a bill Thursday. It would add work requirements to the Medical Assistance Program, or Medicaid.

...If passed, able-bodied adults would be required to work or continue school for 30 hours per week as a condition of receiving medical assistance.

 

(sigh) They. Will. Never. Let. It. Go. Via Kimberly Leonard of the Washington Examiner:

Top Republican looks to codify move to short-term healthcare plans

Sen. John Barrasso, R-Wyo., introduced legislation Wednesday that would let more people enroll in short-term health insurance plans, an idea that builds off a Trump administration proposal issued last month.

The Improving Choices in Health Care Coverage Act would allow people to stay on less expensive, short-term medical plans for as long as 364 days and allow them to renew for subsequent years.

Yes, that's right: "Improving Choices in Health Care Coverage Act", or ICHCCA. I'm going with #IckyJunkPlan instead, it rolls off the tongue better.

In other words, this would codify Donald Trump's executive order into federal law. It might even trump (no pun intended) state laws against #ShortAssPlans, although perhaps not.

*(except people who are actually sick, that is) --h/t Anne Paulson

I've written a lot about Idaho's decision to simply ignore ACA regulations by allowing non-ACA compliant healthcare policies which would destabilize the individual healthcare market even worse than it already is today.

A couple of weeks ago, University of Michigan law professor and ACA expert Nicholas Bagley explained how the bigger danger here is that if this move is allowed to stand, it won't be limited to just Idaho:

But it would be a mistake to ignore what Idaho is up to. If the Trump administration doesn’t intervene, other red states will surely follow in its footsteps. The result will be widespread disregard of the law and the rise of state-to-state inequalities in the private market similar to those that already exist in Medicaid.

In a move which should surprise exactly no one, Congressional Republicans are attempting to defund Planned Parenthood AGAIN:

House Republicans are demanding a series of controversial abortion and health care policies in the annual health spending bill, setting up a showdown with Democrats and threatening passage of an omnibus spending package to keep the government open.

Democrats are vowing to block the slew of long-sought conservative priorities. The riders would cut off federal funding to Planned Parenthood, eliminate a federal family planning program and ax the Teen Pregnancy Prevention Program, according to sources on Capitol Hill. Republicans also want to insert a new prohibition on funding research that uses human fetal tissue obtained after an abortion.

In 2018, unsubsidized premiums for ACA-compliant individual healthcare policies have shot up by around 30% on average nationally. Around 18 points of this (60% of the total) is due specifically to policy decisions by the Trump Administration and Congressional Republicans, primarily the cut-off of Cost Sharing Reduction reimbursement payments and the (accurate, as it would later develop) anticipation, by some carriers, of the ACA's individual mandate being repealed.

What about 2019, however? The 2-3 points tacked on out of concern for the mandate being repealed was only a small portion of the full impact insurance carriers expect it to have, and of course there's the further undermining of the ACA via Donald Trump's "Short Term" and "Association Plan" executive orders. Finally, there's the impact of what is assumed to be another year of the advertising/outreach budget being starved by the Centers for Medicare & Medicaid.

 

Back in June 2016, the Obama Administration rightly clamped down on "Short-Term Plans", limiting them to, you know, a "short term"...no more than 3 months out of the year, while also making them non-renewable; that is, you couldn't get around the 3-month limit by simply renewing the policy every three months:

 

From the Cabinet Meeting scene in the comedy "Dave":

DAVE: Now the Commerce Department..,

SECRETARY OF COMMERCE (sitting erect): Yes, Mr. President?

DAVE (from a card): You're spending forty-seven million dollars on an ad campaign to... (reading) 'Boost consumer confidence in the American auto industry.'

SECRETARY OF COMMERCE: Um...yes, sir...it's designed to bolster individual confidence in a previous domestic automotive purchase.

DAVE: So we're spending forty-seven million dollars so someone can feel better about a car they've already bought?

SECRETARY OF COMMERCE: Yes, sir, but I wouldn't characterize it that way...

DAVE (indignant): Well I'm sure that's really important, but I don't want to tell some eight- year-old kid he's got to sleep in the street because we want people to feel better about their cars. (beat) Do you want to tell him that?

SECRETARY OF COMMERCE (quietly): No sir...(looks at TV cameras)...no sir, I sure don't.

 

Hot Off the Presses, via Kimberly Leonard of the Washington Examiner...

President Trump’s budget plan released Monday endorsed an Obamacare repeal and replace bill that gives funding to states and makes cuts to Medicaid.

...Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., are behind the legislation that takes Obamacare’s funding for the Medicaid expansion and tax subsidies for lower premiums and gives it to states through block grants. The senators introduced the bill in September along with Sens. Ron Johnson, R-Wis., and Dean Heller, R-Nev.

The bill would end the Medicaid expansion under Obamacare but supporters say states can implement it individually if they want. However, the bill makes cuts to Medicaid overall by capping federal funding per beneficiary.

The bill failed to get enough support in Congress in September, as some senators from expansion states worried about Medicaid cuts and protections for people with pre-existing conditions.

(sigh) One More Time, folks...

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