2018 MIDTERM ELECTION

Time: D H M S

A couple of weeks ago I reported that the state legislature and governor of deep red Utah has agreed to partly expand Medicaid under the ACA...

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.

...but with two major caveats:

This morning I was contacted on Twitter by a woman in Louisville, Kentucky who appears to be in pretty dire straits:

On 7/1/18, in Ky, my Medicaid/ ACA will be canceled. I may still need a brain shunt, LP #8, RXs, PT, etc. I was informed that my PCP could write a letter stating I was "Medically Fragile" but even then the provider has final say. Like fox guarding hen house. Please help me/DM

Here's her story according to her GoFundMe page (I've cleaned up the formatting a bit for easier readability):

I am a disabled attorney living with my 76-year-old mother who takes care of me. In 2011, I was bitten by a tick and was infected with Ehrlichiosis Chaffeensis and Rickettsia. A week later, I contracted Coxsackie B4 virus. Because I was kept on antibiotics for 19 years, I had no immune system to fight these illnesses.

A few days ago I noted that Maryland Governor Larry Hogan had signed a bipartisan bill into law which creates a $380 million reinsurance fund which should cancel out up to 21% of next year's looming individual market premium hikes.

However, I forgot to mention the other important thing that the same bill does: Evidently it would also head off Donald Trump's attempt to open the floodgates on the type of minimally-regulated "short-term" and "association" plans which would further damage the ACA-compliant individual market risk pool:

(C) THIS SUBTITLE APPLIES TO ANY HEALTH BENEFIT PLAN OFFERED BY AN ASSOCIATION, A PROFESSIONAL EMPLOYEE ORGANIZATION, OR ANY OTHER ENTITY, INCLUDING A PLAN ISSUED UNDER THE LAWS OF ANOTHER STATE, IF THE HEALTH BENEFIT PLAN COVERS ELIGIBLE EMPLOYEES OF ONE OR MORE SMALL EMPLOYERS AND MEETS THE REQUIREMENTS OF SUBSECTION (A) OF THIS SECTION.

I've noted before that now that the Republicans in Congress have repealed the ACA's much-hated (but vitally necessary) individual mandate penalty (effective 2019), the odds of it being reinstated at the federal level are virtually zilch. Even if there's a massive blue wave in November and the Democrats are able to retake both the House and Senate, they're extremely unlikely to be willing to face the same type of firestorm/backlash that they did back in 2009-2010 over it.

If you need proof of this, take a look at the "ACA 2.0" bills recently proposed by both the House and Senate Dems. Both versions check a whole bunch of items off of my "If I Ran the Zoo" wish list...but neither one includes restoring (much less increasing) the Individual Mandate penalty at the federal level.

As I noted last month, the Republican-controlled Michigan State Senate is planning on jumping on board the pointless, wasteful, cruel "work requirement" bandwagon which is all the rage among the GOP types these days.

Sure enough, they're planning on ramming it through within the next week: The Michigan Senate’s Competitiveness Committee is expected to hold a hearing on SB 897, a bill that would impose a work requirement on over 670,000 adult Michiganders with Medicaid health coverage...or nearly 7% of the state population.

The committee chair and the bill’s sponsor, Senator Mike Shirkey (SD-16) is planning on pushing the committee vote through ASAP and then kicking it over to the full state Senate right away.

A few weeks ago I posted an entry title, "Will Trump's HHS Dept. do the stupidest thing possible? Reply Hazy; Try Again Later."

The "stupidest thing possible" being referred to was whether or not CMS Administrator Seema Verma is planning on putting the kibosh on Silver Loading and the Silver Switcharoo starting in 2019:

The head of the Centers for Medicare and Medicaid Services would not say Thursday if the Trump administration is considering setting limits on how insurers that sell Obamacare plans structure subsidies for their customers.

"I'm not going to comment on the agency's deliberations," CMS Administrator Seema Verma said when asked by the Washington Examiner about rumors that had circulated about the issue. When pressed about whether any conversations had occurred, Verma said, "I'm just going to leave it at that."

 

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.

The total individual/family policy health insurance market was roughly 10.6 million people in 2013. This included people enrolled in either "grandfathered" policies (i.e., policies enrolled in prior to the ACA being signed into law in 2010) or in "transitional" policies (those enrolled in between 2010 and late 2013, just before the ACA required all new individual market policies to be fully compliant with the new healthcare law.

How many of those 10.6 million people are still enrolled in grandfathered (GR) or transitional (TR) policies today? Unfortunately, there seems to be very little available data about just how many people are still in these policies. The Kaiser Family Foundation gave a rough estimate of around 2.1 million people last year, which sounded about right to me. However...Kaiser didn't include a state-level breakout of their estimates, and of course it's a year later so that number, if accurate, has probably shrunk a bit more.

Last month I noted that while Congressional Republicans spent all of 2017 desperately attempting to "blow up" the Affordable Care Act via a combination of legislation, the Trump Administration simultaneously tried to tear down the law via various regulatory sabotage efforts. This year the GOP Congress appears to have mostly given up on their mischief (they did manage to partially wound the ACA by repealing the individual mandate), the Trump Administration is doubling down on regulatory sabotage, laying what I've termed "Regulatory Siege" to the law.

In my mind, "phase one" included the non-legislative stuff Trump did last year, including stuff like cutting off CSR reimbursements, slashing the Open Enrollment Period in half, slashing marketing funding by 90%, slashing the outreach budget by 40% and so on. "Phase two" includes the previously-announced #ShortAssPlans executive order, CMS allowing work requirements for Medicaid and so forth (individual mandate repeal belongs here as well, although that was legislative, not regulatory...although there's overlap as you'll see below).

Yesterday brought Phase Three.

via Christopher Snowbeck of the Star-Tribune:

Positive Blue Cross results trigger rebates to consumers
It is legally required to return about $30 million of its 2017 profit to subscribers.

After three years of losses in the state’s market where individuals buy health insurance, Blue Cross and Blue Shield of Minnesota made so much money last year that it has to give some back.

The Eagan-based carrier, which is the state’s largest nonprofit health plan, disclosed last week that it expects to provide $30 million in consumer rebates as required by rules in the federal Affordable Care Act (ACA).

Analysts said that Blue Cross likely isn’t alone in having overshot with rates last year, since insurers across the country have been struggling to figure out how much premium revenue they need to cover the cost of medical bills in the individual market.

In Minnesota, rebates driven by big margins are a surprising cap to a year that started with fears that mounting losses would cause a market collapse.

Maryland Governor Larry Hogan signed a bipartisan bill on Thursday that state officials say will help keep healthcare premiums from spiking again next year.

The bill creates what’s known as a reinsurance program for the state’s health insurance marketplace, which was created as part of the Affordable Care Act.

...Without the fix or any action in Washington, Maryland officials predicted that healthcare premiums in 2019 could jump up to 50 percent, driving more of the 150,000 people to abandon the state’s marketplace — possibly leading to its collapse.

As you may have noticed, I'm on a bit of a grandfathered/transitional plan data kick this week (there's a reason for it which you'll understand next week). These numbers are tricky to hunt down, since they aren't tracked by the ACA exchanges. Most states either don't track them at all or don't make it easy for the public to locate, and it's even treated as a proprietary trade secret in a few states.

The Kaiser Family Foundation gave a rough estimate of around 2.1 million people still being enrolled in GF/TR plans last year, but they never broke it out by state. Plus, of course, that was last summer; since no one can newly enter these types of policies, their numbers continue to gradually shrink year after year.

OK, I'm just seeing this now so I could be seriously misreading the article, but if I'm not, this is quite the eye-opener:

Virginia is on the cusp of expanding Medicaid to 400,000 low-income residents, after a veteran Republican state senator said Friday that he is willing to split with his party and help Democrats realize a goal they have been chasing for years.

Virginia state Sen. Frank Wagner (Virginia Beach) said he supports allowing more poor people to enroll in the federal-state healthcare program on two conditions.

He wants the plan structured so that Medicaid recipients do not suddenly lose coverage if their earnings rise. And he wants a tax credit or some other help for middle-income people who already have insurance but are struggling to pay soaring premiums and co-pays.

Earlier today I wrote an extensive post about California's individual market, specifically breaking out the number of off-exchange policies, including a rare look at some hard grandfathered plan enrollment numbers.

I've also managed to dig up a fascinating document from 2010 buried on the Alabama Insurance Department's website, which provides quite a bit of demographic insight into Alabama's overall health insurance market. While all of this info is now 8 years out of date (and even precedes the first ACA open enrollment period), it does provide a few clues into estimating what's going on in Alabama today.

This first table shows exactly what Alabama's individual market looked like: 164,404 people were enrolled in pre-ACA "major medical" policies in 2010:

Pages