You'll have to forgive me my poor metaphor below, but it's the best I can think of at the moment. I've been awake for 29 hours straight now, as I woke up at 5am yesterday for a 15-hour shift as a poll worker in Pontiac, Michigan, and, like many of you I'm sure, I was unable to sleep at all last night. I just got off a devastating phone call with my son who's a freshman in college who doesn't understand why what just happened...happened.
There's going to be a mountain of digital & physical ink spilled and a cacophony of talking heads on the Sunday morning shows yapping about What Went Wrong, yadda yadda yadda. Most of it will be bullshit. Some of it will be accurate.
Since writing about healthcare is my thing, and writing about the ACA specifically is very much in my wheelhouse, I'm going to put my take on this into healthcare risk pool terms. Besides, assuming the GOP also keeps control of the House, the ACA is likely gone (and even if they don't, it's about to be radically gutted via regulatory actions anyway), so I might as well.
I've spent the past couple of weeks up to my ears in 2025 annual healthcare policy rate filing analysis, so I haven't gotten around to addressing JD Vance's recent appearance on NBC in which he finally explained exactly what Donald Trump's "concept of a plan" for healthcare is:
When Donald Trump stammered at the recent presidential debate that he had “concepts of a plan” for Americans’ health care, he came across like a child who had forgotten his homework. But thanks to his campaign and his running mate JD Vance, we know now the Republican ticket really does have some “concepts.” Those concepts are bringing health care into the election — and presenting a tremendous opportunity to Vice President Kamala Harris.
Last Sunday, Vance raised the eyebrows of anyone familiar with health care policy when he told NBC’s Kristen Welker about Trump’s “deregulatory agenda.”
Trump administration finalizing Medicaid block grant plan targeting Obamacare
The plan is guaranteed to enrage critics and invite attacks from Democrats in an election year.
The Trump administration is finalizing a plan to let states convert a chunk of Medicaid funding to block grants, even as officials remain divided over how to sell the controversial change to the safety net health program.
CMS Administrator Seema Verma plans to issue a letter soon explaining how states could seek waivers to receive defined payments for adults covered by Obamacare's Medicaid expansion, according to seven people with knowledge of the closely guarded effort. An announcement is tentatively slated for the end of next week, more than one year after Verma and her team began developing the plan.
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.
D.C. residents are among tens of thousands of Americans left uninsured by a health insurance scam that collected more than $100 million in premiums for junk plans.
A special enrollment period from now through Aug. 30, via the DC Health Benefits Exchange Authority, has been earmarked for residents who bought the junk plans from a Florida-based operation that was recently shut down by a federal court.
Two states in two days...just 24 hours after the Washington State Insurance Commissioner pulled the plug on the "Aliera Healthcare" and "Trinity Healthshare" healthcare sharing ministries for fraud, the New Hampshire Insurance Dept. is issuing a similar warning (although they don't appear to be actually shutting the operation down just yet):
Consumer Alert on Potential Unlicensed Health Insurance Company
CONCORD, NH – As a result of a recent Georgia court order, the New Hampshire Insurance Department is advising consumers that Aliera, a company that markets itself as a health care sharing ministry, may be operating illegally in New Hampshire.
At first it looked like CMS was planning on allowing doctors to "balance bill" Medicare patients. Balance billing is already a controversial issue with private insurance; it's the practice of a doctor/hospital charging the patient directly for the difference between what the doctor wants to be paid and what the insurance company agrees to pay them.
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.
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).
Regular readers know that I've developed a tradition over the past three years of tracking the average unsubsidized premium rate increases for the ACA-compliant individual market, painstakingly poring over the rate filings for every carrier in every state and running a weighted average by their market share.
Every year there are numerous challenges and headaches which get in the way, including things as obvious as "not every carrier publishes the number of enrollees they have covered" to complex situations like "carrier X is dropping out of the on-exchange market in half the counties of the state but is sticking around in the off-exchange market". In addition, many carriers submit an initial rate request...followed a few months later by a revised one...neither of which might end up matching the final premium changes approved by state regulators. Sometimes there may be 2-3 more revised filings along the way which muddy the waters even further.
