ACA Sabotage

2018 MIDTERM ELECTION

Time: D H M S

About 90% of my focus here at ACASignups.net is on the two biggest sections of the ACA: The Individual Market (3-legged stool, exchanges, subsidies, etc.) and Medicaid expansion. I tend not to write much about Medicare, "traditional" Medicaid or the Employer-Sponsored Insurance (ESI) market, which mainly consists of the Large Group Market (companies with 50 employees or more) and the Small Group Market (companies with fewer than 50 employees). As it happens, the ESI market covers nearly half the U.S. population (roughly 155 million Americans, give or take).

Under the ACA, individual market policies have to include the following "Blue Leg" provisions to be considered ACA-compliant:

 

(Image via "Turtle Fart w/Loud Lord" on SoundCloud)

This is utter horseshit:

McConnell on Trump’s decision to support the Texas lawsuit that would invalidate Obamacare:

"Everybody I know in the Senate, everybody, is in favor of maintaining coverage for preexisting conditions. There's no difference in opinion about that whatsoever."

— Sahil Kapur (@sahilkapur) June 12, 2018

Even if you ignore the multiple times over the years that he's promised (and voted) to "defund Obamacare" and "repeal it out root & branch"...

...there's still the matter of last year, when Senate Republicans introduced the "Better Care Reconciliation Act plan" (BCRAp), which looked something like this:

 

By far, the most popular provisions of the Affordable Care Act is that it mandates Guaranteed Issue (GI) and Community Rating (CR) rules to all major medical healthcare insurance policies in most of the United States (all 50 states, plus DC...most ACA provsions don't apply in Puerto Rico, Guam and other U.S. Territories). These provisions state, quite simply, that insurance carriers can no longer discriminate against enrollees based on their physical or mental health status or history, their gender and so on, and can therefore no longer use medical underwriting to either cherry-pick who their enrollees are or how much they're charged in premiums for a given policy.

 

It's time once again to talk about stools. Not step stools, but the Three-Legged Stool.

I posted this video explainer about the Affordable Care Act's "Three-Legged Stool" works last winter. The first 9 minutes or so covers why it exists, how it's supposed to work, how well it's actually working, the most obvious problems with it and the basics of how to fix them. The second half goes into the details of the half-dozen different awful repeal/replace bills that Congressional Republicans tried to push through throughout 2017.

Below is a condensed transcript version of the first half of the slideshow.


First of all, who is in the Individual Market? Well, what you're looking at right now is something a friend of mine dubbed The Psychedelic Donut. It's actually a depiction of the healthcare coverage, by type, of the entire U.S. Population...all 320 million or so of us.

One of the big stories over the past few months has been the Trump Administration's attempts to strip away regulations on non-ACA compliant "Short-Term, Limited Duration" plans (by making them neither short-term nor of limited duration) and "Association Health Plans" (by recategorizing them from state-regulated, Small Group plans to mostly unregulated Large Group plans).

However, a couple of months ago I wrote about a brand-new law in Iowa which would take a third route towards skirting ACA compliance: Farm Bureau plans:

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.

 

(*credit to Nicholas Bagley for coining "Texas Fold'em")

Ut-oh. I've only written one blog post about this one (back in February) because the argument behind it is so idiotic that it actually makes King vs. Burwell seem like Marbury v. Madison by comparison.

Here's the short version:

Texas is suing the federal government over President Barack Obama's landmark health law — again.

In a 20-state lawsuit filed Monday in federal court, Attorney General Ken Paxton argued that after the passage of the GOP's tax plan last year — which also repealed a provision of the sweeping legislation known as "Obamacare" that required people to have health insurance — the health law is no longer constitutional.

UPDATE 4:30pm: (sigh) As I expected, the stripped-down version of SB897 passed the state House

SB 897, to impose Medicaid work requirements, passed the House 62-47. #mileg

— Lindsay VanHulle (@LindsayVanHulle) June 6, 2018

The revised version of the bill still has to be kicked back over to the state Senate for a final vote, but that's almost certain to pass, so the only thing stopping it at this point is the possibility of Gov. Rick Snyder vetoing it, which is what I figured it would come down to in the the first place.

UPDATE 6/11/18: So much for that prospect:

A couple of months ago, I sounded a (semi-muted) alarm about the future of Silver Loading and Silver Switching of Cost Sharing Reduction costs when CMS Administrator Seema Verma not only failed to state flat-out that she wouldn't attempt to stop these workarounds, but started giving indications that she was actively considering doing just that.

If this were to happen, then it would be devastating to millions of people while helping almost no one, as my colleagues Dave Anderson, Andrew Sprung, Louise Norris and I explained in Health Affairs a few weeks back.

Well, it appears that this particular bullet will be dodged for at least one year, anyway:

HHS won’t ban silver-loading this year, Azar admits after being pressed. No time to write broad-loading regs for 2019 plan year.

The past two days have brought a flurry of 2019 premium rate change filings, with Washington, New York, Maine, DC and Pennsylvania putting their preliminary cards on the table. These join 5 other states which had already posted their early numbers, so I now have 10 compiled.

Now that I have a solid amount of state data to work with, I figured I should write up a tutorial to explain my methodology. This has become especially important the past two years since there's some new factors to consider.

This is huge news given that Pennsylvania is the 5th largest state in the country (and a swing state to boot)...but it's also incredibly frustrating due what isn't included. From an official Pennsylvania Insurance Dept. Press Release:

Health Insurance Plan Rates Stabilize, Offer More Choice for Consumers Despite Federal Government Sabotage

Harrisburg, PA – Insurance Commissioner Jessica Altman today announced that health insurance rates in Pennsylvania have moderated significantly, counter to the national trend, after Wolf Administration efforts to combat the effects of sabotage on health insurance markets by the federal government and specifically the Trump Administration to dismantle the Affordable Care Act (ACA). Importantly, the filings indicate that rate increases in Pennsylvania will be significantly more modest in 2019 than other states and many consumers will see more choices in their local markets as a result of Pennsylvania's efforts to increase competition.

Shout-out to Mitchell Stein for this heads up: The Maine Bureau of Insurance has posted their preliminary 2019 individual and small group policy premium rate filings.

One important twist: A few months back I remember reading that Maine, like several other states, was considering establishing some type of reinsurance program along the lines of successful programs in Alaska, Minnesota and Oregon. I also remember reading that the Maine version was unusual--it would actually involve reestablishing an old, discontinued state program which was still on the books but had been mothballed for years. However, I never got around to doing a write-up about it.

Anyway, it looks like the program (Maine Guaranteed Access Reinsurance Association, or MGARA for short), is indeed being ramped back up:

Hot on the heels of Washington State releasing their preliminary 2019 individual market rate hike request comes a similar press release out of the New York Department of Financial Services...and neither the carriers nor the state regulators are making any bones about the reason for next year's rate increases:

PROPOSED 2019 HEALTH INSURANCE PREMIUM RATES FOR INDIVIDUAL AND SMALL GROUP MARKETS

Health insurers in New York have submitted their requested rates for 2019, as set forth in the charts below.  These are the rates proposed by health insurers, and have not been approved by DFS.

The good news? As I reported a week or so ago, every county in Washington State will have at least one carrier on the ACA exchange next year.

The bad news? As expected, thanks in large part to sabotage of the ACA by Donald Trump and Congressional Republicans, the average requested 2019 premium increase for unsubsidized enrollees is 19.1%:

OLYMPIA, Wash. – Eleven health insurers filed 74 health plans for Washington state’s 2019 individual and family health insurance market, with an average proposed rate increase of 19.08 percent. There are no bare counties, although 14 counties will have only one insurer selling through Washington’s Exchange, Washington Healthplanfinder. 

Several quick tidbits out of the District of Columbia from the DC Health Benefit Exchange Authority May board meeting:

  • Their preliminary 2019 premium rate filings were originally due by May 1st, but this was bumped out until June 1st. Not available publicly yet, however.

PLEASE NOTE IMPORTANT UPDATES BELOW.

I just received the following from a healthcare broker, who I trust from past communication exchanges, who wishes to remain anonymous. I'm presenting it as sent, with the only changes being breaking it out into paragraphs for readability & with their state's identifying information removed.

Glossery:

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