Will Trump's HHS Dept. do the stupidest thing possible? Reply Hazy; Try Again Later.

2018 MIDTERM ELECTION

Time: D H M S

A few days ago I warned Congressional Democrats that while I agree that appropriating CSR reimbursement payments at this point would be a net negative move thanks to the clever Silver Load/Silver Switcharoo workaround developed last year, there's one possible cloud surrounding that silver lining, so to speak: What if the Trump Administration were to attempt to put the kibosh on Silver Loading altogether?

I don't know the legality of such a move, mind you, but It has been thrown around the rumor mill of late, so I figured I should remind them to keep that possibility in mind.

Well, today I received some reassurance...

Azar Says He Is Not Aware Of Discussions On Blocking ‘Silver-Loading’ in 2019

HHS Secretary Alex Azar said that he has not been involved in discussions about blocking ‘silver-loading’ plans in 2019 and is not aware of any agency discussions about ending the practice at the moment.

...In recent weeks, some stakeholders have speculated that the Trump administration could block silver-loading in 2019. Several pro-ACA experts say that even though the administration may have authority to stop silver-loading, it would be a self-destructive move, especially leading up to the November midterm elections.

...During a Tuesday (March 20) briefing with reporters at the Humphrey Building, Azar said he has not discussed such action.

...Meanwhile, many Democrats and consumer advocates that had strongly pushed for CSR funding last year now say that the status quo is a better deal and oppose the funding. On Monday, the Congressional Budget Office estimated that funding CSRs would result in fewer exchange enrollees, and would particularly affect people earning from 200 to 400 percent of poverty.

...although not really; just because he "hasn't discussed/isn't aware of" any discussions doesn't mean that it's not going to happen.

On the other hand, whatever other concerns or problems I may have about Alex Azar, this doesn't seem like his style (to be honest, I have no idea whether it would be his call or CMS Administrator Seema Verma's decision anyway). If Tom Price was still at HHS I'd be more concerned about it, but I just don't get that vibe from Azar.

Then again, he did voluntarily go to work for Donald Trump, so who knows?

UPDATE: Welp. Now that it appears CSRs will not be restored anytime soon (in the end neither the Alexander-Collins section nor any other ACA stabilization provisions were included in the Omnibus Bill), this question has taken on even more significance.

If silver loading were to be forbidden next year (and again, I'm not even sure if that would be legal since states generally have the authority to approve/deny health insurance premium rates), many--possibly even all--ACA exchange carriers would drop out of the market en masse...and this would happen just ahead of the midterms.

On the one hand, Trump would finally have gotten his wish ("blowing up" the ACA exchanges). On the other hand, the GOP's midterm problems would immediately increase tenfold, since 9 million more people would immediately be utterly screwed.

Of course, that assumes that "forbidding" the load would mean not allowing carriers to load the extra CSR cost at all. As Dave Anderson points out, a more likely scenario would/could be for Silver loading/switching to be made verboten, but broad loading to still be allowed (this is how Colorado, Delaware, Indiana, Mississippi, Oklahoma and West Virginia handled it this year).

Broad loading means that the CSR load is spread across every metal level on and off the exchange. It also means that the only ones who don't get hit with the extra CSR cost (or at least who don't lose their "bonus" tax credits) are...those receiving CSR assistance, ironically. Broad loading is the worst way to handle the CSR load situation, so I'm afraid there's a chance the Trump Administration might attempt to make that mandatory. I doubt it will happen now, however.

UPDATE: DANGER WILL ROBINSON: (sigh) Welp. This may not mean anything, but it certainly doesn't set my mind at ease either:

.@SeemaCMS also said she has to follow the law so a state can expand Medicaid "if they want to expand." She wouldn't comment on lifetime limits for Medicaid, or whether there were discussions of trying to crack down on silver-loading

— Peter Sullivan (@PeterSullivan4) March 22, 2018

"SeemaCMS" aka Seema Verma, the CMS Administrator.

Here's more details from a Washington Examiner article by Kimberly Leonard:

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."

Questions have been circulating about whether the Trump administration plans to block states from “silver loading” their coverage options so that premiums of Obamacare plans do not rise significantly for all of their customers.

...“It charges the government more and if it’s done the other way it can charge people more," Verma said. "It does have an impact, not only on what the federal government is paying, but it also has an impact on the unsubsidized population. That is where we really continue to be concerned about the folks that are not being subsidized, where they are going.”

...Health and Human Services Secretary Alex Azar said this week that discussions about blocking the common practice, if they have happened, haven’t reached him.

"It's not an issue that has come to me yet,” he said Wednesday. “I'm not aware of that. I can't tell you any discussions, deliberations around that issue aren't going on, it just hasn't come to me."

Killing off Silver Loading would be an incredibly stupid move on Verma's part (even if it's legal to do so which, again, I doubt), but stranger things have happened.

UPDATE 2: OK, this writeup by Ariel Cohen over at Inside Health Policy includes a quote from Verma which simply makes zero sense whatsoever (thanks to Andrew Sprung for the heads up):

CMS Administrator Seema Verma told reporters on Thursday (March 22) that she was “very concerned” about certain aspects of ‘silver loading’ plans, namely that it raises costs for unsubsidized consumers and the federal government. Verma did not commit to allowing or blocking the process for the 2019 plan year.

...“That’s where we continue to be very concerned about the folks that are not being subsidized and where they’re going. We’re very concerned about the 27 million people, as the premiums go up where do they go?” Verna added.

First of all, the unsubsidized ACA-compliant individual market only consists of perhaps 5-6 million people at most (around 1-2 million on exchange policies plus 4-5 million off-exchange). There's perhaps 1-2 million more people still enrolled in "grandfathered" or "transitional" policies, but those aren't part of the ACA risk pool anyway and therefore aren't impacted by CSR costs one way or the other.

The only people who "27 million" can possibly refer to are the unsubsidized population (actually more like 29 million today)...who aren't currently on any policy at all, and fully 75% of them are either eligible for Medicaid or CHIP; eligible for exchange tax credit subsidies; caught in the Medicaid Gap or aren't eligible to enroll at all due to being undocumented immigrants. That leaves only around 6.6 million uninsured who could potentially be impacted by CSR Silver Loading or Switching, or a grand total of perhaps 12 million at most could even potentially be hit by it.

Secondly, only unsubsidized Silver enrollees are impacted, and in 20 states which have gone the full "Silver Switcharoo" route, they can avoid the CSR hit entirely by switching to an off-exchange Silver plan which is virtually identical to the on-exchange version. This is a bit annoying and kind of a hassle, I admit, but it provides a way of avoiding hundreds or thousands of dollars in extra premium costs.

In the 16 states which "only" did "partial" Silver Loading, unsubsidized Silver enrollees on and off the exchange are hit with CSR costs...but only if they insist on sticking with a Silver policy. They can still upgrade to Gold or downgrade to Bronze to avoid the CSR load. Again, I'm not saying this is ideal by any means, but it is possible for anyone to stay enrolled in a fully ACA-compliant healthcare policy without having to pay the CSR load.