Saturday, March 25, 2017

Trump threatens ACA marketplace collapse and nuclear blame war

In one sense, it may have been the worst-timed op-ed of all time. I argued in a piece published in the online NYT yesterday (submitted back on March 13!) that Senate Democrats should engage with sponsors of the Cassidy-Collins ACA reform bill to shore up Republican moderates who I thought likely to ultimately pass some lightly sanded version of the AHCA, or otherwise act to eviscerate Medicaid in particular.

While there was obviously a good chance the AHCA would not pass the House this week, I never dreamed the Republicans would simply give up for the present. For me the truly astonishing moment was when I saw Ryan quoted on Twitter saying "“We’re going to be living with Obamacare for the foreseeable future,”

That's the Trump factor. Just as he swung wildly and oblivious into the Freedom Caucus camp to allow them to pull any fig leaves of rationality from the AHCA, when thwarted he swung wildly back to call off the whole thing.

But it's that very swing that leaves my core point relevant: Democrats still need to find a way to win a measure of Republican buy-in to the ACA, because the Trump administration can kill it administratively -- swiftly or slowly, subtly or obviously. That goes in part for Medicaid, via a rush of work requirements and administrative harassment, as well as for the marketplace, which can be destroyed at a stroke by stopping CSR payments or by a host of more gradual means, already begun, nicely chronicled by Dan Diamond.

That's where Trump's at just now.  Check out last night's insanity:

Thursday, March 23, 2017

The semi-satisfied unsubsidized

I have a post up on delving into the experience of four unsubsidized enrollees in the ACA marketplace who have pre-existing conditions, or children with pre-existing conditions.

None of them regarded their coverage as perfect. All were glad to have it – and confident that they would have fared worse if the ACA had not become law. Yet the piece does highlight that the status quo is unsatisfactory -- and deteriorating -- for a likely majority of the 8-10 million unsubsidized buyers in the individual market.

Here is a sliver of one person's experience:

Sunday, March 19, 2017

AHCA vs. ACA: Total subsidized shares of costs at different income levels and ages

Late last year I cooked up a simple measure of the value of any given health insurance subsidy: the percentage of the premium paid multiplied by the actuarial value (AV) of the insurance obtained. AV is the estimated percentage of the average enrollee's medical costs paid for by the insurance.

In traditional Medicare, for example, for all but the highest-earning 5% of enrollees, the federal government pays about 85% of the combined premium for Parts A,B and D - which have a combined actuarial value a bit north of 80%. Hence the total subsided share of costs (can we call it TSS?) is about 69%.  Employers, according to the Kaiser Family Foundation, pay an average of 82% of the premium for individual insurance and 71% for family coverage. Given an average AV of 82% -- also a Kaiser estimate -- that yields a TSS of 66% for individual coverage and 58% for family.

I've previously estimated (see first link above) that the average subsidized ACA marketplace enrollee obtains a TSS of 59% -- with the federal government picking up an average of 73% of the premium for insurance with an average AV of 81%. Subsidies vary tremendously, however, ranging from 0% for the half of individual market enrollees who don't qualify for any help to over 90% for the lowest income enrollees obtaining silver plans enhanced with Cost Sharing Reduction.

Now, with the help of CBO analysis of the House repeal-and-replace bill, the American Health Care Act, it's possible to compare the federal TSS for people of varying income and ages under the ACA and the AHCA.

Friday, March 17, 2017

Christopher Ruddy's alt-Trump

Christopher Ruddy, Trump buddy and CEO of the gaslight site Newsmax, wantonly misrepresents the ACA while proposing what he regards as a Tumpian alternative to "Ryan Care II" (for which Trump has now gone all-in, flaunting his powers of intimidation even as he yields to right-wing demands that the bill un-insure millions more swiftly).

Let's leave the lie-specking for later (see bottom).  Buddy Ruddy does Trump the doubtless undeserved honor of crediting his stated intentions for health reform as expressed in, for example, Trump's January 15 Washington Post interview:
“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”
Also promised: "lower numbers, much lower deductibles."

There is only one mode of healthcare delivery in the U.S. that can deliver on those promises. And lo, Ruddy makes it his centerpiece -- Point 4 in a 7-point program:

Tuesday, March 14, 2017

David Frum for HHS Secretary

For ten years now, David Frum has wowed me with the clarity of his critiques of Republican extremism, notwithstanding the craziness of some of his own policy prescription (most in foreign policy; he is, after all, Mr. Axis of Evil).  He's been a hero dissecting and crying out against emerging U.S. authoritarianism for the past year. And in fact, he was doing that too back in 2009/10. Here's from his famous post-mortem on the passage of the ACA in March 2010:
I’ve been on a soapbox for months now about the harm that our overheated talk is doing to us. Yes it mobilizes supporters – but by mobilizing them with hysterical accusations and pseudo-information, overheated talk has made it impossible for representatives to represent and elected leaders to lead. The real leaders are on TV and radio, and they have very different imperatives from people in government. Talk radio thrives on confrontation and recrimination. When Rush Limbaugh said that he wanted President Obama to fail, he was intelligently explaining his own interests. What he omitted to say – but what is equally true – is that he also wants Republicans to fail. If Republicans succeed – if they govern successfully in office and negotiate attractive compromises out of office – Rush’s listeners get less angry. And if they are less angry, they listen to the radio less, and hear fewer ads for Sleepnumber beds.

So today’s defeat for free-market economics and Republican values is a huge win for the conservative entertainment industry. Their listeners and viewers will now be even more enraged, even more frustrated, even more disappointed in everybody except the responsibility-free talkers on television and radio. For them, it’s mission accomplished. For the cause they purport to represent, it’s Waterloo all right: ours.
Back then, Medicaid expansion was a bad thing from Frum's conservative point of view -- something Republicans could have avoided had they negotiated the ACA in good faith:

Monday, March 13, 2017


The meme that Republican senators in states that have embraced the ACA Medicaid expansion will block the House repeal bill from passing substantially as is and save the expansion continues. Here's Politico's Burgess Everett with news of a closed-door meeting in Nevada:
Sen. Dean Heller panned House Speaker Paul Ryan's bill to repeal and replace Obamacare during a closed meeting with constituents on Saturday, according to audio obtained by POLITICO.

The remarks by Heller, the most vulnerable GOP senator on the ballot next year, are another sign of the difficult prospects the House bill faces in the other chamber. Already, more than a half-dozen senators have criticized the bill, and Republicans can afford to lose only two votes.
Hail defender! As Nevada's Republican governor, Brian Sandoval, boasted in a letter to the House leadership in January, Nevada has slashed its uninsured rate almost in half since ACA enactment, from 23% to 12% -- mainly through the Medicaid expansion, which has increased Medicaid enrollment by 288,000 since September 2013 in a state with 2.5 million residents. Plenty to defend!

So what is Heller's promise to Nevadans? Back to Politico:

Thursday, March 09, 2017

"Moderate" Republican opposition to AHCA is looking very squishy

Hours before House Republicans published a full draft of their ACA repeal-and-replace bill, the so-called American Health Care Act, four Republican senators in states that have expanded Medicaid -- Portman, Capito, Gardner and Murkowski -- sent a letter to Mitch McConnell from warning that the repeal bill should provide "stability" for beneficiaries of the expansion.

Given the letter's timing, and its expressed concern for beneficiaries of the Medicaid expansion, some accounts of the repeal bill's release (e.g., Chait's) interpreted it as opposition to the bill. But it was not that. In fact it may have been the opposite. Those who are anticipating rejection of the House bill by Senators who have expressed qualms about un-insuring expansion beneficiaries should take warning.