Now that we've passed the 9/27 contract signing deadline for 2018 carrier participation on the ACA exchanges, the state insurance departments are posting their approved final rates pretty quickly. Arkansas has done a fantastic job of clearly laying out not just what the rate changes will be, but is explicitly stating how much of those increases are due to the GOP's refusal to formally appropriate CSR reimbursement payments next year:
Insurance companies offering individual and small group health insurance plans are required to file proposed rates with the Arkansas Insurance Department for review and approval before plans can be sold to consumers. The Department reviews rates to ensure that the plans are priced appropriately. Under Arkansas Law (Ark. Code Ann. § 23-79-110), the Commissioner shall disapprove a rate filing if he/she finds that the rate is not actuarially sound, is excessive, is inadequate, or is unfairly discriminatory. The Department relies on outside actuarial analysis by a member of the American Academy of Actuaries to help determine whether a rate filing is sound.
Insurance Commissioner approves rates insurers filed for 2018; Cost to cover CSRs has been added to silver plan premiums
On September 20, the Tennessee Department of Insurance and Commerce (TDIC) announced that the state had approved the rates that insurers had filed for 2018. However, the announcement indicated that Cigna’s approved average rate increase was 42.1 percent, which was based on the filing Cigna submitted in June 2017. An updated filing, with an average rate increase of 36.5 percent, was submitted in August, and TDIC confirmed by phone on September 21 that the updated filing was approved. The slightly smaller rate increase is due to Cigna’s decision to terminate some existing plans and replace them with new plans).
The following average rate increases were approved for 2018 individual market coverage:
New Mexico Health Connections, the nonprofit co-op insurance company formed under the Affordable Care Act, is selling its small group and commercial business to a for-profit company under a restructuring plan that will create a new insurance company that will be able to go after business the struggling nonprofit couldn’t.
...The Washington, D.C.-based Evolent will acquire NMHC’s 22,000 commercial members. NMHC will continue to exist with a few employees and presumably continue to sell individual policies on the New Mexico Health Insurance Exchange. NMHC has 10,000 individual members through the insurance exchange.
...Hickey told ABQ Free Press that the deal will allow the new firm to go after business that NMHC couldn’t, things like Medicare Advantage, federal employees and, eventually, Medicaid. It also gives the new firm capital reserves that NMHC didn’t have, he added.
In August I wrote that the situation in North Dakota was pretty straightforward: Three carriers on the individual exchange (BCBS, Medica and Sanford), requesting average rate hikes of around 24%, 19% and 12% respectively for an average increase of 23% assuming CSR payments are made, or a bit higher (28%) if they aren't.
Yesterday, however, with the final contract signing deadline having passed on the 27th, Louise Norris reports that one of the three carriers, Medica, was forced to drop out of the market at the last moment...not because they wanted to, but because the ND insurance dept. insisted on carriers pricing 2018 premiums on the assumption CSRs will be paid for the full year.
Medica understandably refused to take that risk (the odds of CSRs being guaranteed are virtually nil, and the odds of them being paid each and every month, as they're supposed to, is only so-so), so they dropped out instead.
Back in August, I reported that thanks to their just-approved federal reinsurance program, Alaska (which has only a single individual market carrier with the most expensive premiums in the country) is looking at an impressive 22% average decrease in their indy market premiums next year. However, that was based on the assumption that CSR reimbursement payments would not be made (or at least not guaranteed).
Alaskans buying health insurance on the individual market will see a decrease of 26.5 percent in rates next year, the sole insurer in the state announced Tuesday.
Alaskans had been paying some of the highest premiums in the nation.
The White House approved the use of military aircraft for multi-national trips by Health and Human Services Secretary Tom Price to Africa and Europe this spring, and to Asia in the summer, at a cost of more than $500,000 to taxpayers.
The overseas trips bring the total cost to taxpayers of Price’s travels to more than $1 million since May, according to a POLITICO review.
CMS Announces Special Enrollment Periods for Americans Impacted by Recent Hurricanes Agency provides special open enrollment periods for 2017 Medicare and Exchange coverage
As a result of Hurricanes Harvey, Irma, and Maria, the Centers for Medicare & Medicaid Services (CMS) will make available special enrollment periods for all Medicare beneficiaries and certain individuals seeking health plans offered through the Federal Health Insurance Exchange. This important step gives these individuals and families who have been impacted by the hurricanes the opportunity to change their Medicare health and prescription drug plans and gain access to health coverage on the Exchange immediately if eligible for a special enrollment period.
More to the point, however: What other significance does not including CSR funding have?
Well, first of all, is it possible that they'll slip CSRs in before the vote? I suppose so, but consider this:
The final deadline for the insurance carriers to actually sign their contracts for 2018 is Sept. 27th, just 8 days from now.
The end of the 2017 fiscal year (i.e., the deadline for the GOP to try and cram through Graham-Cassidy with only 50 Senate votes) is Sept. 30th.
The CBO is "aiming" to provide a "preliminary assessment" of Graham-Cassidy "early next week" which I presume means Monday the 25th or Tuesday the 26th.
I assume the other steps (parlimentary ruling, vote-a-rama, etc) would take place on Wednesday the 27th, the same day the contracts have to be signed.
Yom Kippur is the evening of the 29th, running through Saturday the 30th. I can't imagine even McConnell would be that much of a dick to schedule the vote then.
That leaves Thursday the 28th or Friday the 29th for the actual vote itself.
That's a day or two after the carrier contracts have been signed.
Then, just this week, after Senators Collins, McCain, Paul—and potentially Murkowski—announced their opposition to the bill, the GOP leadership announced that the Senate would not vote on Graham-Cassidy. Given budget reconciliation rules, the Senate only has until September 30th to pass a repeal bill with just 50 votes (Vice President Pence then casting the tie-breaking vote). Thus, it would appear that repeal efforts will be delayed until the spring of 2018 when fiscal year 2019 begins, and new budget reconciliation rules are established. All of that said, I am sick and tired of sitting on pins and needles as this process has unfolded. Based on the submissions I received this week, many of my colleagues seem to share my sentiments, as very few posts focused on Graham-Cassidy. In recognition of that, I present you with the “Repeal Fatigue” edition of the Health Wonk Review.
INSURANCE DEPARTMENT RELEASES PROPOSED RATES FOR 2018 HEALTHCARE EXCHANGE
Atlanta – Insurance Commissioner Ralph Hudgens announced today that his office had submitted proposed 2018 health insurance rates to the Centers for Medicare and Medicaid Services (CMS) for the federally-facilitated Healthcare Exchange for final federal approval.
“Today my office submitted 2018 Obamacare rates to Washington D.C. for approval,” Hudgens said. “In its fifth year, Obamacare has become even more unaffordable for Georgia’s middle class with potential premium increases up to 57.5 percent. I am disappointed by reports that the latest Obamacare repeal has stalled once again and urge Congress to take action to end this failed health insurance experiment.”
Trump administration abruptly drops out of Obamacare events in Mississippi
“It’s clearly sabotage.”
For the past three years, the US Health and Human Services Department has partnered with a health advocacy group in Mississippi on an education tour before Obamacare enrollment started. They would meet around the states with groups that sign people up for coverage — state officials, health centers, insurance brokers, and the like — to prepare for open enrollment.
Up until Monday, Roy Mitchell, executive director of the Mississippi Health Advocacy Program, thought these events were going forward in the coming weeks as planned. He had even asked HHS just last week for biographies of the officials they’d be sending.
More to the point, however: What other significance does not including CSR funding have?
...That means that even if there's a last minute change to the bill, at this point, CSR payments are virtually certain not be guaranteed next year.
...I wouldn't be at all surprised to see more 11th-hour drop-outs next week. Donald Trump and the Republican Party's open sabotage of the ACA will likely bear even more fruit.
Anthem leaving Maine ACA marketplace, citing uncertainty
Anthem Blue Cross Blue Shield has withdrawn nearly all of its offerings from Maine’s Affordable Care Act health insurance marketplace, and the insurer is citing market uncertainty and volatility as the reasons.
There's no denying the Individual health insurance market has endured its fair share of challenges. In order for this segment to be sustainable there must be adequate membership and a balanced risk pool, slow growth in healthcare spending while maintaining quality of care and enough health insurer participation and plan offerings to bolster consumer choice. The volatility of the Affordable Care Act's (ACAs) exchange program forced many insurers to significantly raise premiums to make up for financial losses due to imbalanced risk pools, or withdraw from the exchanges altogether. In 2016, insurance premiums exceeded medical care costs for many insurers; however, segment profitability was still elusive to most plans. MFA's assessment of mid-year 2017 profitability for the Individual market indicates improved overall results.
Price’s private-jet travels included visits with colleagues, lunch with son
Health and Human Services Secretary Tom Price took a government-funded private jet in August to get to St. Simons Island, an exclusive Georgia resort where he and his wife own land, a day and a half before he addressed a group of local doctors at a medical conference that he and his wife have long attended.
The St. Simons Island trip was one of two taxpayer-funded flights on private jets in which Price traveled to places where he owns property, and paired official visits with meetings with longtime colleagues and family members. On June 6, HHS chartered a jet to fly Price to Nashville, Tennessee, where he owns a condominium and where his son resides. Price toured a medicine dispensary and spoke to a local health summit organized by a longtime friend. He also had lunch with his son, an HHS official confirmed.
...and the immediate fallout as summarized below...
I've spent the past two weeks posting about almost nothing besides the Graham-Cassidy debacle, so haven't had a chance to keep on top of the approved 2018 rate changes as I usually do. Fortunately, Louise Norris of healthinsurance.org has stayed on the rate hike job, and reports the final numbers out of Washington State:
2018 rates: 24% approved rate increase, due in large part to federal uncertainty — and higher backup rates will be implemented if CSR funding is cut mid-year
Insurers in Washington had to file rates and plans for 2018 by June 7, 2017. On June 8, Kreidler’s office published a summary of what had been filed (rate filings are available here, and that page will show final rate changes for the individual market once they’re approved), and publicized the filing details on June 19. The average proposed rate increase in Washington, before any subsidies are applied, was 22.3 percent.
Back in August it looked as though Florida carriers were looking at either 15.5% unsubsidized rate increases on the individual market if CSR reimbursement payments were guaranteed next year, or around 35.5% if they weren't. Well, the official rates have been released by the Florida Dept. of Insurance, and it's even uglier than that for unsubsidized enrollees:
Office Announces Submission of Proposed Rates for 2018 Federal PPACA Health Insurance Plans
Republican leaders have decided not to vote on Obamacare repeal legislation this week, effectively ending the party’s latest effort to wipe away the 2010 health care law.
When, and whether, they will try again remains to be seen. But for now, a defining cause of the Republican Party, including President Donald Trump, lies in tatters.
And at least for the moment, insurance coverage for many millions of Americans who rely on Medicaid or the Affordable Care Act’s federal subsidies remains intact ― although insurance markets in some states remain unstable, and the Trump administration’s willingness to manage the program remains unclear.
(sigh) When I last checked in on Virginia, things were looking up a bit (relatively speaking), as Anthem Blue Cross Blue Shield (aka "HealthKeepers") had announced that they were jumping back into the state in order to cover the 60-odd counties which would otherwise be left bare by Optima Health Insurance dropping out of half the state a week or so earlier.
As many see their options for health plans dwindle down to one insurer, premiums are simultaneously set to rise by an average of 57.7 percent next year in Virginia’s individual marketplace.
The increase is “unquestionably the highest we’ve ever seen,” David Shea, health actuary with Virginia’s Bureau of Insurance, told lawmakers Monday.
Yesterday was a Graham-Cassidy (or "Grassidy", as former CMS Administrator Andy Slavitt keeps trying to push) Fest, with all sorts of Grassidy-centric happenings, including the one-and-only Senate hearing on the bill; the Congressional Budget Office releasing their preliminary/partial score of G-C (the prior version, not the later version); Senator Susan Collins releasing her statement opposing the bill; and last night's CNN healthcare debate between Senators Graham & Cassidy vs. Senators Sanders and Klobucher. I might write something about these items later today, but right now I want to look at another development.
Last week I broke the story (later picked up by Axios, NY Magazine and Vox.com) that the Graham-Cassidy bill would make thousands of current insurance policies illegal starting on January 1, 2018...just 98 days from now.
Why? Because, as noted at the link, while the current ACA structure (exchanges, tax credits, etc) would stay mostly in place for 2 more years, some provisions would be repealed immediately...including a nationwide ban on any exchange policy offering abortion coverage.
This morning JP Massar (who called my attention to the 1/1/18 effective date the first time) inquired as to whether that had changed with the new version of G-C. As you can see on pages 2 & 3 of the new bill...nope. It’s still in place.
Here's direct links to the bill itself and to the GOP's table showing what they claim would be the net federal funding changes from 2020-2026 for each state relative to current law...but they pulled one hell of a fast one.
it's pretty rare for the entire medical, hospital and insurance industry to agree on just about anything...and yet here we are (emphasis in the original):
The following statement was jointly released on September 23, 2017 by the American Medical Association, American Academy of Family Physicians, American Hospital Association, Federation of American Hospitals, America's Health Insurance Plans and the BlueCross BlueShield Association regarding the Graham-Cassidy-Heller-Johnson legislation.
We represent the nation's doctors, hospitals and health plans. Collectively, our organizations include hundreds of thousands of individual physicians, thousands of hospitals, and hundreds of health plans that serve tens of millions of American patients, consumers and employers every day across the United States.
Anyone who's followed me either here at ACASignups.net or over at Twitter over the past eight months knows that no one has been sounding the alarm louder or more frequently than me about both the real and potential sabotage of the ACA being carried out (or at least attempted) by the GOP in general and Donald Trump/Tom Price specifically. Hell, back in July, I even warned of a half-dozen things to look out for, several of which have since already been proven true:
This brings me to the main point of this entry: This is likely just the beginning. I'm not going to say that any or all of the following will happen--it's possible that Trump/Price/Verma will show some level of restraint--but I wouldn't be at all surprised to see any or all of these happen during this fall's Open Enrollment Period (which runs from Nov. 1st - Dec. 15th, by the way):
The past few weeks, while trying to push the Godawful "Graham-Cassidy" ACA repeal bill, Louisiana Republican Senator Bill Cassidy has used the following as one of his standard talking points:
.@BillCassidy shares the story of a Louisiana man paying more than $40,000 for his special needs son’s health care under Obamacare. pic.twitter.com/AaZ0IQIfF7
Credit where due. Last time around McCain made everyone hold their breath in suspense (then again, in his defense, he had just been diagnosed with a brain tumor and had to schlep all the way back from Arizona to DC for the vote a day or so earlier).
This time around he’s being more clear and up front about it: He says he likes the idea of the bill in general, and would be influenced by AZ Gov. Ducey’s support of it, but the process has stunk and continues to stink from top to bottom:
Seriously, good for him. He’s being quite clear about not just his decisions but his reasons...and while it would be nice if he opposed the bill on the merits (it stinks), his actual reasons make perfect sense as well.
It's time to once again dust off the Three-Legged Stool visual aid to help explain just what the Graham-Cassidy bill would do to the individual insurance market. It's important to note that none of this has anything to do with Medicaid (expansion or traditional), the group market, Medicare and so forth; just the individual market.
Once again, here's what the "3-Legged Stool" was supposed to look like under the Affordable Care Act:
Here's what it actually looks like today, with some rather obvious gaps in the red (enrollee responsibility) and green (government responsibility) legs:
As the final deadline for final 2018 individual market rates to be locked in and the contracts signed, more states are coming into focus, and the pattern continues to be remarkably consistent.
In Mississippi, I originally pegged the requested rate hikes across the two individual market carriers (technically three, but "Freedom Life" is a phantom carrier with only 2 alleged enrollees) at 16.1% if CSR payments are made and 39.6% if they aren't. It turns out I was off by a bit, however, because I didn't realize that BCBS of Mississippi was only selling policies off-exchange next year. That means the CSR issue won't impact them either way, since none of their enrollees would receive the assistance anyway.
Alaska (along with Hawaii) will continue to receive Obamacare’s premium tax credits while they are repealed for all other states. It appears this exemption will not affect Alaska receiving its state allotment under the new block grant in addition to the premium tax credits.
Delays implementation of the Medicaid per capita caps for Alaska and Hawaii for years in which the policy would reduce their funding below what they would have received in 2020 plus CPI-M [Consumer Price Index for Medical Care].
Provides for an increased federal Medicaid matching rate (FMAP) for both Alaska and Hawaii."
Well, now.
Bird doesn't have the actual legislative text, but they threw Hawaii in there as well (not to win their votes...Dems Brian Schatz and Mazie Hirono are solid NOs no matter what). That means that the wording is probably along the lines of:
The Congressional Budget Office stated that they won't be able to provide a full score of the projected 10-year impact of the Graham-Cassidy bill for "at least several weeks". Instead, they expect to provide a partial score, focusing purely on the budget-related stuff necessary to "count" towards Senate reconciliation voting rules "early next week".
What won't be included are some pretty damned important details, like:
Impact on the federal deficit
Impact on insurance premiums, and of course...
Impact on the number of people with health insurance coverage
Unfortunately, Mitch McConnell and Senate Republicans are insisting on squeezing the vote on Graham-Cassidy through within the next 10 days, before the fiscal year ends on Sept. 30th, since that's the only way they have a chance at passing it using 50 votes (after the 30th, they would require 60 votes, which of course they have no chance at getting).
I've embedded screen shots below, but there's various interactive stuff you can do at the site itself; LA did a very nice job, I'd love it if every state put up a similar "dashboard" style website.
In short:
434,594 Louisianans enrolled in Medicaid via ACA expansion
126,229 have received preventative care
22,058 women have received breast cancer screenings
225 women have been diagnosed with breast cancer as a result of ACA Medicaid expansion
13,994 adults have received a colon cancer screening
4,337 have averted colon cancer by having polyps removed
199 have been diagnosed with colon cancer thanks to ACA Medicaid expansion
3,774 have been diagnosed with diabetes
9,575 have been diagnosed with hypertension
32,912 are receiving outpatient mental health services
6,025 are receiving inpatient mental health services
5,559 are receiving outpatient substance abuse services
6,026 are receiving residential substance abuse services
As NBC News reporter Hallie Jackson notes, there are too many quotable lines to count in this Vox piece, in which Jeff Stein tracked down 9 Republican Senators to ask them what the hell the purpose of the Graham-Cassidy bill actually is. The responses pretty much say it all.
Jeff Stein: Senator, I wanted to ask you for a policy-based explanation for why you’re moving forward with the Graham-Cassidy proposal. What problems will this solve in the health care system?
Pat Roberts: That — that is the last stage out of Dodge City...I’m from Dodge City. So it’s the last stage out to do anything. Restoring decision-making back to the states is always a good idea, but this is not the best possible bill — this is the best bill possible under the circumstances.
If we do nothing, I think it has a tremendous impact on the 2018 elections. And whether or not Republicans still maintain control and we have the gavel.
Jeff Stein: But why does this bill make things better for Americans? How does it help?
The fact that the Graham-Cassidy bill, like all of the prior Republican "replacement" healthcare bills, screws over people on both Medicaid and the individual market starting in 2020 is hardly news. A few provisions of the ACA are stripped out and/or bastardized immediately (and some, like the individual mandate penalty, are even repealed retroactively), but for the most part the pain doesn't start for another 2 years, well after the midterms are over.
However, JP Massar called something to my attention this morning:
Regular readers know that one of the issues I've spent the better part of the past year yammering on about endlessly is the importance of Congress formally appropriating Cost Sharing Reduction reimbursement payments to the insurance carriers on the individual market exchanges.
Thanks to the ongoing/pending ruling in the federal House vs. Burwell Price lawsuit, Donald Trump has the ability to pull the plug on CSR payments pretty much whenever he wants to (and he's threatened to cut them off every month since around March or April so far). CSR payments hang like a Sword of Damocles over the heads of every exchange-based insurance carrier each month, with them never knowing whether they'll get reimbursed or not.
CBO aims to provide preliminary assessment of Graham-Cassidy bill by early next week
CBO is aiming to provide a preliminary assessment of the Graham-Cassidy bill by early next week. That assessment, which is being prepared with the staff of the Joint Committee on Taxation, will include whether the legislation would reduce on-budget deficits by at least as much as was estimated for H.R. 1628, the American Health Care Act, as passed by the House on May 4, 2017; whether Titles I and II in the legislation would each save at least $1 billion; and whether the bill would increase on-budget deficits in the long term. CBO will provide as much qualitative information as possible about the effects of the legislation, however CBO will not be able to provide point estimates of the effects on the deficit, health insurance coverage, or premiums for at least several weeks.
OK, Indivisible is all over the Graham-Cassidy disaster, so rather than try and cobble together my own action list, I'm cribbing from their email missive. I'll also be posting the latest Graham-Cassidy developments throughout the day.
STOP THE RETURN OF TRUMPCARE. TrumpCare is back and Republicans are as close as they’ve ever been to passing it. There are 12 days left for the Senate to ram healthcare through reconciliation with just 50 votes. This is TrumpCare’s last stand. Call your senators ASAP and tell them to vote no on “Graham-Cassidy” using all the latest resources at TrumpCareTen.org.
TrumpCare is back. REPEAT: TrumpCare is back. We really hoped we’d never have to say that, but you should know by now that this is the bill that just won’t die. Because of the rules of reconciliation, the special process Republicans are using to jam TrumpCare through the Senate, they have until September 30 to finish the job of repealing the Affordable Care Act. That gives them 12 more days to make good on their seven-year promise to repeal the Affordable Care Act. And nothing motivates Congress like a deadline.
Anthem said Friday afternoon it planned to scale back statewide individual coverage in Virginia on the public exchange under the Affordable Care Act amid inaction by the Donald Trump White House on cost-sharing reduction subsidies.
Anthem, which operates under the Blue Cross and Blue Shield plan in 14 states, has already scaled back its Obamacare offerings in Indiana, Ohio and Wisconsin amid an unstable individual market for plans operating under the ACA.
“Today, planning and pricing for ACA-compliant health plans has become increasingly difficult due to a shrinking and deteriorating Individual market, as well as continual changes and uncertainty in federal operations, rules and guidance, including cost sharing reduction subsidies and the restoration of taxes on fully insured coverage,” Anthem said in a statement Friday afternoon. “As a result, the continued uncertainty makes it difficult for us to offer Individual health plans statewide in Virginia.”
Just a few days ago I noted that Michigan's Dept. of Insurance issued the semi-final 2018 individual market rate changes for the 10 carriers offering indy policies in the state (9 of which are on the ACA exchange; one of them is only offering plans off-exchange). At the time, the breakout was roughly 16.8% average increases assuming CSR payments are made next year or 26.8% assuming they aren't made.
A major health insurer is leaving Michigan’s individual marketplace, ending its policies offered here under the Affordable Care Act as the federal government slashes funding for enrollment and outreach groups.
Hey Michigan Residents! Do you live in the SAGINAW area?
If so, come on out to Saginaw on Saturday, September 16th, and join former State Senator (and current gubernatorial candidate) Gretchen Whitmer, State Representatives Vanessa Guerra & Adam Zemke, Chief Public Health Advisor for Flint Dr. Pam Pugh and myselfas we explain what the latest craziness is regarding the ACA, the GOP attempts to repeal and/or sabotage it and healthcare policy in general from 10:00am - 12:00pm at IBEW Local 557 at 7303 Gratiot Road.
For the next two weeks, ALL HEALTHCARE-RELATED ATTENTION needs to be on the following three issues:
FIRST:September 27th is the final deadline for ACA exchange insurance carriers to actually sign the contracts to participate in the 2018 Open Enrollment Period. Yes, the deadline to submit their rate filings already passed a week or so ago, and most of them are fairly settled in for next year, but until they actually sign the contract, they can still bail from the individual and/or small business exchanges...and given the massive uncertainty over Cost Sharing Reduction reimbursements and other sabotage efforts of Trump and Tom Price as well as the ongoing repeal/replace saga by the Congressional GOP, many (most?) of the carriers are deliberately waiting until the last possible minute to do so.
Well this was unexpected, although I suppose I should have expected it given all the insanity surrounding the impending deadlines for insurance carriers to sign contracts (Sept. 27th, I believe); the end of the fiscal year on Sept. 30th (which is also the last chance for the GOP to try and squeeze through the hideous Cassidy-Graham Hail Mary repeal/replace bill); and the start of Open Enrollment on November 1st.
The CBO has issued a 17-page report with their latest projections for the types of healthcare coverage and federal spending on healthcare programs including Medicaid, CHIP, ACA tax credits and so forth over the next decade. here's what they foresee:
The federal government subsidizes health insurance for most Americans through a variety of programs and tax provisions. In 2017, net subsidies for people under age 65 will total $705 billion, CBO and the staff of the Joint Committee on Taxation (JCT) estimate.
Louisiana was one of the last states I ran rate hike analysis on just a month ago: Three carriers on the exchange (plus the "Freedom Life" phantom carrier), averaging around 21.4% rate increases on the assumption that CSR payments won't be made. According to the Kaiser Family Foundation, loading CSRs onto Silver plans only would bump them up by an additional 20 points; this translates into roughly 14.2 points if spread across all metal levels on & off the exchange. Based on that, I estimated LA's rate increases at 21.4% without CSRs but only 7.2% if they actually are paid.
I ran an updated analysis of the requested average rate hikes for Connecticut last month. At the time, the only two carriers operating on the CT exchange next year (Anthem and ConnectiCare) were still noncommittal about actually committing to doing so. Statewide, it looked like the carriers were asking for rate increases averaging around 23.8% if CSR payments were guaranteed or 33.5% if they weren't.
As reported by Louise Norris today, the Connecticut insurance dept. reported that both carriers have now committed to sticking around next year, and the approved average rate increases now assume that CSR payments won't be made after all. In the end, the statewide average looks like roughly 28.4% (Norris pegs it at 29.3%, but that's because she generally only includes individual market carriers participating on the ACA exchanges, while I also include carriers and plans offered off-exchange as well).
I've written not one, not two, but three different blog entries in the past 24 hours about Bernie Sanders' just-announced "Medicare for All" proposal...but the reality is, I shouldn't have. Frankly, while it's a discussion/debate that we do need to have, making a big thing about it right this moment is, the more I think about it, terrible timing, because the Affordable Care Act is still in being attacked and at risk in several ways:
FIRST: The CSR issue still hasn't been resolved, although at this point it's extremely unlikely that Patty Murray and Lamar Alexander are going to pull a CSR/reinsurance rabbit out of their hats after all. Last week things looked somewhat promising, but this week it appears to have gone off the rails again...and with just 17 days left in the fiscal year (and, I believe, only 14 days before the contracts have to be signed by carriers for 2018 exchange participation), there's almost no time left to get even a minor stabilization bill pushed through.
SECOND: On a related note, Bill "so much for the Jimmy Kimmel test!" Cassidy and Lindsey Graham are still trying to cram through their pile-of-garbage Hal Mary Trumpcare bill, which is at least as bad as the GOP's failed AHCA/BCRAP bills were earlier this year and even worse in some ways. Again, there's only 17 days left to pull it off, but remember what happened with AHCA last spring...anything's possible. Here's a summary of the impact of the Cassidy-Graham bill via Andy Slavitt and the Centers for Budget & Policy:
OK, here it is. I've linked to a PDF with the full legislative text at the bottom of this blog entry; here's the summary version, with some notes:
TITLE I—ESTABLISHMENT OF THE UNIVERSAL MEDICARE PROGRAM
Establishes a Universal Medicare Program for every resident of the United States, including the District of Columbia and the territories. Guarantees patients the freedom to choose their health care provider. Provides for the issuance of Universal Medicare cards that all residents may use to get the health care they need upon enrollment. Prohibits discrimination against anyone seeking benefits under this act.
OK, so it apparently would cover undocumented immigrants, and every doctor/hospital/clinic/etc. would be required to participate, with anyone in the country being covered by any healthcare provider nationally.
The official announcement is scheduled for Wednesday, presumably with much hoopla accompanying it (and a dozen or so Democratic Senators co-sponsoring it, many of whom are considered likely 2020 POTUS candidate prospects). Over at the Washington Post, Dave Weigel has a sneak peak. I'll wait until I've had a chance to read through the actual text of the bill itself to write up a full response/analysis, so I'll just post a few key excerpts from Weigel's piece for now:
Sanders’s bill, the Medicare for All Act of 2017, has no chance of passage in a Republican-run Congress. But after months of behind-the-scenes meetings and a public pressure campaign, the bill is already backed by most of the senators seen as likely 2020 Democratic candidates — if not by most senators facing tough reelection battles in 2018.
For the past year and a half, of all the proxy battles between "Team Hillary" and "Team Bernie" on the left side of the aisle, no issue has been more repsentative of both how passionate people are or how much each "side" misunderstands the other than the future of the American healthcare system.
"Team Bernie", in essence, consisted of progressives (and Democrats) who believe that while the ACA may have improved things to some degree in some ways, it not only isn't enough long-term, it isn't nearly enough short-term either; the next step (and for many, the only acceptable next step) must be moving the entire U.S. population over to a universal Medicare-style Single Payer system, with everyone in the country being covered through a single, comprehensive healthcare program funded entirely (or nearly entirely) by taxes.
It appears that a formal letter was sent to HHS Secretary Tom Price and CMS Administrator Seema Verma from the Energy & Commerce Committee of the House of Representatives...it's 6 pages long, and unfortunately the text isn't selectable, so I had to embed the pages as images. I'm happy to report that I contributed to their inquiry.
If you look at the top of the website today, you'll notice a couple of new graphics, both relating to the Indivisible ACA Signup Project.
The short version is this:
Donald Trump is cutting ACA outreach, so we've started an Indivisible-based, state-by-state sign-up project group to counter the sabotage.
All you need to do (should you agree) is use social media to update people (on your advocacy and/or personal pages) in your state on key issues and dates/deadlines for sign-ups.
That's pretty much the whole thing in a nutshell, at least so far. It's a closed Facebook Group which you need to request permission to join, but they obviously want the materials to be disseminated as widely as possible (that's kind of the whole point!), so I've agreed to set up a permanent, public link for folks to access them.
...and believe me, it wasn't on purpose; I've simply been swamped the past couple of weeks with other stuff, and somehow I just never got around to writing anything up about it.
I should have, though. Everyone thinks the existential threat to the ACA was over back on July 28th, and now it's simply a matter of "stabilizing the market" and "stopping Trump from sabotaging Open Enrollment". For the most part this is true, but for whatever reason, Louisiana GOP Senator Bill Cassidy and South Carolina GOP Senator Lindsey Graham simply won't let it go already, and are insisting on trying one final, desperate Hail Mary play to squeeze through an ACA repeal/Trumpcare bill as the final seconds run out on the 2017 Fiscal Year (which ends September 30th).
Since I'm so late to the party on this and there's so little time to stop it, instead of my own explainer I'm going to simply crib a bit from former CMS head Andy Slavitt's USA Today column in which he gives the lowdown:
A week ago, Vox's Sarah Kliff reported that the Trump Administration was slashing the 2018 Open Enrollment Period advertising budget by 90% and the navigator/outreach grant budget by nearly 40%. As I noted at the time, the potential negative impact of these moves on enrollment numbers this fall--coming on top of the period being slashed in half, the CSR reimbursement and mandate enforcement sabotage efforts of the Trump/Price HHS Dept. and the general confusion and uncertainty being felt by the GOP spending the past 7 months desperately attempting to repeal the ACA altogether could be significant. In states utilizing the federal exchange (HealthCare.Gov), 2017 enrollment was running neck & neck with 2016 right up until the critical final week...which played out under the Trump Administration, which killed off the final ad/marketing blitz.
Result? A 5.3% total enrollment drop (or 4.7% if you don't include Louisiana, which expanded Medicaid halfway through the year) via HC.gov, while the 12 state-based exchanges--which run their own marketing/advertising budgets--saw a 1.8% increase in total enrollment year over year.
Michiganders purchasing health insurance through the federal marketplace will see an average rate increase of 27.6 percent in 2018, the Michigan Department of Insurance and Financial Services announced Friday.
One reason for the big increase: Uncertainty over whether President Trump will continue to fund Cost-Sharing Reduction payments, which subsidize plans for low- and moderate-income households.
Idaho is a bit of an odd duck when it comes to the ACA. On the one hand, they're the only state completely controlled by Republicans to set up their own ACA exchange (Kentucky's much-lauded "kynect" exchange was created by Democratic Governor Steve Beshear by executive order...and was then promptly scrapped the moment that incoming GOP Governor Matt Bevin took office). On the other hand, they're also the only state with their own exchange not to expand Medicaid. (As an aside, ID is also the only state to start out on the federal exchange the first year before breaking out onto their own exchange website).
We Can Talk About is a fun, informative, engaging weekly podcast dedicating to taking back the narrative in American politics. For too long we've let the other side set the terms of the conversation and it's about time we promote our own nurturant values.
We spent an hour or so discussing the CSR reimbursement brouhaha, the ACA in general, and especially my ongoing battle to get people to understand the distinction between phrases like "single payer", "Medicare for All", "universal care" and so on in an episode entitled "The Road to Single-Payer Healthcare". Check it out!
Anthem on Wednesday continued reducing its Obamacare business, as the big insurer said it will cut in half the number of counties in Kentucky where it sells individual health plans next year.
Virginia was the very first state whose 2018 rate filings I analyzed, way back in early May. At the time, the initial filings amounted to 9 carriers on the individual market with an average rate increase request of around 30%. At the time I hadn't started distinguishing between "with CSR payments" or "without CSR payments", so I don't really know which scenario that 30% reflected; it was probably a mix of both depending on the carrier. 61,000 Aetna enrollees would have to shop around for a new carrier since they had previously announced they were pulling out of the individual market.
Back in January, I was pleasantly surprised to be included (sort of) in an actual comic book (OK, a "graphic novel") drawn/written by a skilled artist named Michael Goodwin. He did an excellent job of explaining the basics of how the ACA was supposed to work, some of the problems it's had, what the GOP was trying to push as a replacement, why that replacement sucked so badly and so forth. I was honored to learn that he had utilized some of my own data in putting together the project.
Well, Goodwin is back with a follow-up. This one isn't as long, and it focuses mainly on the sabotage efforts being attempted by Donald Trump and the GOP to undermine the ACA as much as possible. Once again, he's included some of my info/analysis as part of the comic, which I'm greatly flattered by. Here's a sample; click through for the whole thing:
Up at the top of the site is a big yellow button leading directly to the ongoing 2018 Rate Hike project. Let's face it, though: It's an awful lot of updates to scroll through. In addition, now that we're past the (extended) rate filing deadline, I've been able to make a lot of updates over the past few days (shoutout to Louise Norris, who did much of the grunt work on these).
As of today (September 6th), I now have average requested 2018 rate changes for the individual market across all 50 states + DC, and have made updates/corrections to several of these.
More importantly, I also now have approved 2018 rate changes for 6 states. They only represent around 9% of the population, though, so I wouldn't focus very much on the "national average" for the approved states yet; that will jump around a lot as more states are added to the mix, and likely won't start to settle in until at least half the states are included.
Having said that, here's what things look like as of today:
(sigh) Colorado's state insurance division just released their approved 2018 rate increases (busy day!), and the situation appears to be similar to Maine: The average requested rates which I thought already assumed no CSR reimbursements appear to have assumed CSRs would be paid after all:
Division of Insurance approves health insurance premiums for 2018
Commissioner: Measures to stablize market for 2018 must happen by Sept. 30
DENVER (Sept. 6, 2017) – The Colorado Division of Insurance (DOI), part of the Department of Regulatory Agencies (DORA), has approved the individual and small group health insurance plans for 2018. Average premium changes within each market - individual and small group - as well as the average change for each insurance company are listed below.
The state of Maine's insurance regulatory agency has announced the approved 2018 individual market rate hikes for the three carriers operating in the state. Louise Norris beat me to the punch:
Regulators in Maine published rate proposals for the three Maine exchange insurers in June, and finalized the rates in early September. Insurers proposed two sets of rates: one that assumes cost-sharing reduction (CSR) funding will continue, and another that assumes the federal government will not fund CSRs in 2018.
The Maine Bureau of Insurance initially rejected all three insurers’ rate proposals on August 10, and asked them to submit new rates. The revised rate filings were then approved on September 1. These average approved rate increases all assume that CSR funding will continue in 2018:
Vermont was one of the first states I analyzed back in the late spring; obvoiusly a lot has changed since then, so I updated/revised my analysis of their requested rate hikes for 2018 a couple of weeks ago, with requested average increases of 11.9% if CSR payments are made or 21.6% if they aren't.
Yesterday, Louise Norris gave me a heads up that the Vermont regulators have issued their approved rate increases for the two carriers operating on the individual and small group markets in the tiny state. This makes Vermont the 4th state to announce their approved rates for next year, joining Oregon, Maryland and New York.
Nevada is the final state to post their requested rate hikes for 2018 (or at least they're the last one I tracked down, anyway). I've now done at least a rough analysis of all 50 states + DC, and while some of the data is a bit outdated (remember, I started doing this back in late April/early May), most of it should still be fairly close to the present situation...at least in terms of requested rate hikes.
In Nevada, after much concern that a bunch of rural counties wouldn't have any exchange carriers at all, Centene stepped in to cover them. They aren't listed in the table below, but since I believe they're new to the state, that shouldn't matter in terms of rate increases since there's no base rates to compare against anyway.
Thanks to Louise Norris of healthinsurance.org for saving me the trouble of tracking all of the state exchange deadlines down. It's possible that a few more state-based exchanges (CT, ID, MD, NY & VT) could also extend their open enrollment deadlines beyond the official one on the federal exchange, but here's where things stand as of today (I'll update the graphic as necessary). Feel free to share widely.
Update 9/7/17: Two more state-based exchanges have chimed in: Vermont has clarified that they're sticking with December 15th, 2017; New York issued a press release that they're joining California & DC in extending Open Enrollment all the way through January 31st, 2018. The graphic below has been updated to include the New York extension.
Did CMS execute a last-minute reversal on navigator program? That's what independent blogger Charles Gaba is reporting, posting what appear to be internal CMS documents that show the agency was poised to essentially renew last year's funding for this year's ACA open enrollment.
One document posted by Gaba indicates that Randy Pate — tapped by the Trump administration to run Medicare's Center for Consumer Information and Insurance Oversight — signed off on $60 million in program funding on Aug. 24. More. However, CMS ultimately funded the program at less than $37 million for the upcoming enrollment, a 41 percent cut from last year.
Utah has also finally released their requested 2018 individual market rate increases. There are six carriers offering individual policies next year, but only 2 of them are participating on the ACA exchange (and the 4 off-exchange carriers hold less than 4% of the total market combined). In fact, two of the off-exchange-only carriers are barely participating at all: BridgeSpan has only 8 enrollees, while "National Foundation" (a "phantom carrier" which also goes by "Freedom Life" in other states) once again supposedly only has a single "enrollee". Molina has a few hundred off-exchange enrollees, but the bulk of their 70,000-person membership are in exchange-based policies, and they're dropping off the exchange next year, so those 70K will have to choose from one of the two remaining exchange carriers: SelectHealth and the University of Utah.
As I noted back in June, there are 3 carrers on the KS individual market this year: Medica, Blue Cross Blue Shield of Kansas Solutions and Blue Cross Blue Shield of Kansas City. Any confusion between the BCBS names was made moot, however, as BCBS of KC announced they were dropping out of the indy market anyway.
That leaves Medica and BCBSKS, both of whom filed plans to stay on the market...but only Medica appears to have actually submitted rate requests, for a mere 7,600 enrollees:
ACA Signups isn't normally known for "big scoop" stories. Yes, I'm often the first one to openly post analysis and/or debunking of information/data/claims which have already been made public, but I'm not usually the first one to actually make the underlying data itself public in the first place.
I've confirmed the veracity of these documents, and the claims related to them seem to be on the level.
According to my source, these are signed orders instructing the grant awarding officer to distribute $60,000,000 in grants with an effective date and time of August 31st, first thing in the morning.
My 2018 Rate Hike project petered out a few weeks back with the requested rate increases posted for 46 out of 50 states (along with DC). Unfortunately, the last 4 states (Kansas, Missouri, Nevada and Utah) decided to keep their cards close to their chest, delaying any public viewing of even the requested rate increases for awhile longer.
