Charles Gaba's blog

If you've been reading the site recently, you know that I've been obsessed for the past 2-3 weeks with nothing but the 2018 Medical Loss Ratio rebate payments.

Now that I've completed posting my analyses of all 50 states (+DC), I'm wrapping it up with a table summarizing the the totals for the entire country, how it compares with the Kaiser Family Foundation's similar report posted a few days ago, and some additional thoughts and observations which have come to mind in doing this project.

First of all, as noted, the Kaiser Family Foundation published their own report analyzinng the 2018 MLR rebates when I was about halfway done posting my own state-by-state analyses. They made sure to give me a nice shout-out, anyway:

We at KFF put out an analysis today of how much insurers will be paying in rebates to consumers and employers later this month. @charles_gaba also has very good information on this, and we all benefit from his tireless tracking. https://t.co/uPX2SPklcY

Back in mid-June, the DC Health Benefit Exchange Authority posted the preliminary, requested average unsubsidized 2020 premium changes for the Individual and Small Group markets:

Overall individual rates increased an average of 9.0 percent and small group rates increased an average of 10.5 percent. In the individual market, CareFirst proposed an average increase of 7.7 percent for HMO plans, and 15.6 percent for PPO plans. Kaiser proposed an average increase of 5.0 percent. For small group plans, CareFirst filed average rate increases of 13.5 percent for HMO plans and 18.5 percent for the PPO plans. Kaiser small group rates proposed an average increase of 3.0 percent. Aetna filed for an average increase of 16.1 percent for HMO plans and 5.0 percent for PPO plans. Finally, United proposed an average increase of 13.0 percent and 7.4 percent for its two HMOs and 11.2 percent for its PPO plans.

This is what it looked like at the time:

via Becker's Hospital Review:

Cigna extended its individual healthcare exchange products for the 2020 plan year, the insurer said Sept. 18.

For 2020, individuals can purchase individual health plans in 19 markets across 10 states. The expansions will take place in counties in Kansas, South Florida, Utah, Tennessee and Virginia. The other states include Arizona, Colorado, Illinois and North Carolina.

The plans will be available for purchase on the individual marketplace during the 2020 open enrollment period, which begins Nov. 1. Plans will take effect Jan. 1.

via Bruce Japsen of Forbes:

I'm a bit late to the game on this due to being backlogged, but for the record (via Abby Goodnough of the NY Times):

Speaker Nancy Pelosi on Thursday released her long-awaited plan to curb soaring prices of prescription drugs, a political chess move that could prod the Senate to move and heat up congressional negotiations with the White House on a popular but elusive goal.

Ms. Pelosi’s plan, which she was to lay out at a morning news conference, would allow the government to negotiate the price of as many as 250 name-brand drugs for Medicare beneficiaries — an idea that many Republicans hate but that President Trump embraced during his 2016 campaign. Drug companies would also have to offer the agreed-on prices to private insurers or face harsh penalties, which could give the package broader appeal with voters.

Back in May, Maryland was the very first state to publicly release their preliminary 2020 individual and small group market rate change requests. For 2019, thanks to several laws passed by the state legislature and signed by Gov. Hogan, including a robust ACA Section 1332 reinsurance waiver program, instead of increasing by another 30%, premiums dropped by 13.4% this year.

For 2020, the preliminary rates looked pretty good: Average rates were expected to drop by around 3% or so.

Well, today the Maryland Insurance Department announced the approved rates for 2020...and it's even better than that:

I haven't written much about South Bend, Indiana Mayor and presidential candidate Pete Buttigieg. The biggest mention I've given him until now was back in March, when he stated that he's an advocate for a robust Medicare-like public option plan.

Today, however, "Mayor Pete," as he's come to be known, rolled out his official healthcare overhaul plan, and sure enough, it centers on...a robust Medicare-like public option. He calls it "Medicare for All Who Want It":

BECAUSE HEALTH CARE IS A HUMAN RIGHT, GUARANTEE UNIVERSAL COVERAGE THROUGH MEDICARE FOR ALL WHO WANT IT.

The Medicare for All Who Want It public alternative will help America reach universal coverage by providing an affordable insurance option to the currently uninsured. The public alternative will provide the same essential health benefits as those currently available on the marketplaces and ensure that everyone has access to high-quality, comprehensive coverage.

(Yes, that's my own selfie with Sen. Warren from Netroots Nation, July 2014)

A few months ago, I noted a rather jarring shift in Sen. Elizabeth Warren's rhetoric when it comes to achieving universal heatlhcare coverage between her CNN Town Hall in March and her first official Presidential Debate appearance in late June.

In March, she gave a detailed, thoughtful, 5-minute answer which mentioned the importance of protecting the Affordable Care Act from Trump & the GOP's sabotage, including specifically calling out the looming #TexasFoldEm lawsuit which threatens to wipe out the entire law.

DISCLAIMER: ACASignups.net has a long-term paid banner ad arrangement with The Robert Wood Johnson Foundation.

I spent most of the past month knee-deep in combing through the Medical Loss Ratio rebate filings of thousands of health insurance carriers. Now, the Robert Wood Johnson Foundation has made it much easier to keep track of which of those carriers are participating in the ACA individual market:

Interactive tracker helps tell the story of insurer participation in the ACA market.

The seventh open enrollment season is almost upon us, and all signs point to growing stability, as measured by moderate premium increases and increased participation by health plans. The tracker shows the change over time in participation at the county level, and allows users to follow individual companies or categories of health insurers. The data reveal a business narrative that has been closely intertwined with the political story of the Affordable Care Act (ACA) marketplace.

Back in July I posted the written Congressional testimony of my friend Rebecca Wood. Rebecca is a staunch "Medicare for All" advocate whose daughter Charlie has complex medical issues.

Today, I'd like to present a Twitter thread by another friend I've met online, Lori, who also has a daughter with complex medical needs named Savannah. While their children both have serious medical issues which need constant care, Lori has a slightly different perspective on the issue of the best route towards achieving universal coverage. This was all in response to my own tweet, which was in response to a comment by Parker Malloy about people who "love" their private insurance:

Who are these people some candidates speak of who just absolutely love their insurance? https://t.co/JD3IEy1Kk9

— Parker Molloy (@ParkerMolloy) September 18, 2019

A few weeks ago, I threw a bit of cold water water on the Medicare for All vs. Public Option brouhaha by pointing out that:

  • a) No complete overhaul of the U.S. healthcare system is going to happen before 2021 at the very earliest anyway; and
  • b) Regardless of what the hypothetical overhaul ended up looking like (M4All, Med4America, or a Public Option), it would likely take a couple of years of going through the legislative and regulatory process before actually going into effect; and that therefore...
  • c) In the short term (i.e., the next 2-3 years at least) what we should really be focusing on is protecting, repairing and strengthening the ACA itself, via a robust ACA 2.0 bill package.

As I reminded folks, there are two excellent ACA 2.0 bills which have already been introduced in both the House and Senate, with many overlapping provisions: In the House, it's H.R. 1884...which has also in turn been broken out into about a dozen smaller, standalone bills (several of which have already passed through the full House). In the Senate, it's S.1213, the Consumer Health Insurance Protection Act or CHIPA. As far as I know, the Senate version is a single package bill and has not been broken out into smaller chunks.

 

I've written endlessly about #ShortAssPlans for several years now. Hell, I even put together a crude video explainer (see above) to explain what "Short-Term, Limited Duration plans" and "Association Health plans" are and why they should be tightly regulated, if not eliminated altogether.

However, the truth is that for all of my blog posts and warnings about these types of substandard policies, about 90% of my focus has been on how opening up the floodgates on them would negatively impact the ACA-compliant risk pool. It's a bit of a zero-sum game, after all: The more healthy people who leave one, the more sick on average the other one is, which means a higher risk pool of enrollees, which means higher premiums, which leads to more healthy people dropping out and so on...the infamous "death spiral".

What I've written much less about, however, is the other reason why #ShortAssPlans generally suck...namely, the plans themselves tend to...well, suck.

Today, Zeke Faux, Polly Mosendz and John Tozzi have a devastating new story over at Bloomberg Businessweek about #ShortAssPlans:

I spent the past few weeks up to my ears in Medical Loss Ratio analyses, so a lot of ACA/healthcare developments slipped by or got backlogged. There were stories which are technically separate but which are pretty obviously joined at the hip...and the fact that they both came out right on top of each other is pretty telling.

First, this story by Paige Cunningham at the Washington Post:

The Health 202: White House may have given up on health plan it says it is writing

A former White House staffer and several congressional aides and activists say they’ve been told the Trump administration has moved away from seeking an Obamacare replacement and is instead focused on damage control should a judge rule next month to topple the entire law.

OK, OK, I know I said I was sick of writing about MLR rebates, but there's one more important point I need to mention...and while I'm at it, I also said "to hell with it" and recompiled the rebate tables for all 50 states into a single massive table listing every carrier offering rebates in every state.

While I applaud the ACA's Medical Loss Ratio Rebate provision overall, there's one important flaw in how it works. I've made allusions to this before, and last week David Anderson wrote a blog post specifically about it, but it bears repeating here: Due to an oversight in the wording of the section of the ACA devoted to laying out MLR rebates, some subsidized individual market enrollees are actually PROFITING off the program.

The reason why is pretty simple: The individual market MLR rebate payments are sent, in full, to the policyholder regardless of whether or not their premiums are being subsidized by the federal government or not.

One of the interesting quirks of how the Affordable Care Act's enhancement of our crazy patchwork heatlhcare system works is that there's something of a zero-sum game when it comes to enrollment numbers.

For instance, Virginia's ACA exchange enrollment numbers dropped by 18% this year, from 400,000 to 328,000, due primarily to the state finally getting around to expanding Medicaid to enrollees earning less than 138% of the Federal Poverty Level. Since people earning between 100-400% FPL are eligible for ACA subsidies if they enroll through the exchange, that means there's an overlap for those in the 100-138% range which these folks fell into. The same thing happened in Louisiana, even more dramatically, after they expanded Medicaid halfway through 2016...the following year exchange enrollment dropped by 33%.

Last month I noted that North Dakota had posted their requested 2020 premium rate change requests, including two different filings: One assuming the states' ACA Section 1332 Reinsurance Waiver didn't get approved, the other assuming it did. It was pretty unlikely that their waiver would be denied, however, so the general assumption was that they'd be looking at a significant rate reduction, especially compared with the rate increase if the waiver didn't go through.

At the time, I didn't have access to the actual enrollment figures for the three carriers on North Dakota's individual market, so I had to go with an unweighted average rate change, and came up with a drop of 7.9%.

Since then, however, the state regulators have reviewed and approved the 2020 premium changes, and thanks to Louise Norris, I don't even have to dig up the enrollment data:

Average rates dropping by nearly 6% in 2020 (without reinsurance, they’d have increased by nearly 15%)

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