2018 MIDTERM ELECTION

Time: D H M S

Charles Gaba's blog

UPDATE 4:30pm: It's out:

(I don't have time for a full analysis right now, so I'm just highlighting some key points and making a couple of notes for the moment...plenty of other reporters/bloggers/wonks are furiously writing analysis right now as well, of course)

The Congressional Budget Office and the staff of the Joint Committee on Taxation (JCT) have completed an estimate of the direct spending and revenue effects of the Better Care Reconciliation Act of 2017, a Senate amendment in the nature of a substitute to H.R. 1628. CBO and JCT estimate that enacting this legislation would reduce the cumulative federal deficit over the 2017-2026 period by $321 billion. That amount is $202 billion more than the estimated net savings for the version of H.R. 1628 that was passed by the House of Representatives.

Louise Norris gave me a heads' up regarding the Indiana 2018 rate filings. Anthem BCBS and MDwise, which currently have around 46,000 and 30,800 exchange enrollees each, are dropping out next year, meaning nearly 77,000 people will have to shop around. Anthem is sticking around the off-exchange market....but only in a handful of counties. Norris indicates around 64,687 total Anthem enrollees; minus the 46K on-exchange, that leaves roughly 18.7K off-exchange enrollees, virtually all of whom are expected to drop due to Anthem dropping out of all but 5 counties (plus, of course, the large rate hike).

The other day it looked like the GOP Senate's BCRAP bill was going to take a hatchet to all 3 legs of the ACA's "three-legged stool", by getting rid of some provisions outright (CSR assistance and the Individual Mandate), weakening and slashing others in half (premium tax credits) and, most cynically, allowing virtually open-ended waivers which would allow individual states to wipe out many others (essential health benefits, minimum AV ratings, annual/lifetime benefits and the ACA's cap on maximum out of pocket costs). Here's what I figured this would make the "stool" metaphor look like:

 

So, like everyone else, yesterday I was poring over the BCRAP text, and one of the first things which caught my eye was the individual market tax credit structure table, to see how it compares with the ACA's formula. Here's how it stands under the ACA...again, these percentages are based on the benchmark Silver policy...

...and here's the BCRAP table, based on the benchmark Bronze policy:

After reviewing it for a few minutes late yesterday morning, I posted a tweet noting that under the ACA, a 60-year old earning about 300% of the Federal Poverty Line...roughly $37,000/year...only has to pay up to around $3,600/year in premiums for a Silver plan (9.69% of their income)...but under BCRAP, that same 60-year old would have to pay up to $6,000/year for a Bronze plan (16.2% of their income).

The tweet went viral...I think it was retweeted like 1,000 times or so over the next few hours.

The CBO score of the GOP Senate's #BCRAP bill is expected to be released early next week, just days (or, who knows, hours?) ahead of Mitch McConnell's rushed-through vote.

The biggest question from a process POV (that is, whether Senaterules will allow the bill to be crammed thorugh the reconciliation process) is financial; as David Anderson summarized the other day:

a) The Parliamentarian is most likely going to be stripping out significant non-germane to the budget items
b) $1 billion in savings must come from each of two committees (HELP and Finance)
c) Anything the Senate passes must meet or beat the $119 billion in budget window deficit reduction that the House AHCA was scored at.

However, from a political POV, the bigger question is how many people the CBO projects will lose coverage by 2026 if BCRAP becomes law.

Back in December, the CBO posted the following:

OK, this metaphor will take a bit, but bear with me.

On March 16, 1981, CBS aired the 17th episode of Season 9 of M*A*S*H. For those of you too young to remember, M*A*S*H, set at a U.S. Army medical camp in Korea during the Korean War, was one of the most successful TV shows in history, running 11 seasons. I believe the series finale remains the most highly-viewed broadcasts in history. While M*A*S*H started out primarily as a sitcom, it evolved over the years into more of a drama with comedic moments.

Anyway, in S9 Ep17, "Bless You, Hawkeye", the main character, Dr. Benjamin Franklin "Hawkeye" Pierce (played by Alan Alda) finds himself stricken with a sudden, unexplained and violent allergic reaction to something. He spends much of the episode trying standard medical solutions, but his fits of sneezing and coughing become so bad that eventually a recurring character, psychiatrist Dr. Sydney Freedman, is brought in to see if there might be a psychological cause.

Freedman asks Hawkeye about his childhood, and Hawkeye, among other things, mentions his cousin Billy.

 

Back in 2011, when Paul Ryan and House Republicans first attempted to privatize Medicare, a progressive PAC ran the ad above. In it, "America the Beautiful" plays as we see a young, Paul Ryan-ish looking young man pushing an elderly, wheelchair-bound woman down a nature path...and eventually pushing her right off of a cliff. Needless to say, it caused quite a bit of controversy at the time.

Earlier today, as the GOP Senate's BCRAP bill was released, this happened:

HERE'S PART ONE.

I spent almost all of Part One discussing the butchering that the GOP Senate's BCRAP bill does to the individual market, because that's the primary focus of my work here at ACA Signups, but the truth is by far the worst fallout will be on the Medicaid side of things...and most of the damage doesn't even have a damned thing to do with the ACA itself, since it relates to pre-ACA Medicaid.

I'll get to the Medicaid side in depth in Part Three. However, there are still a few more things I need to discuss regarding the individual market: The sub-100% FPL population and how it relates to Medicaid expansion.

 

Yes, that's right: The official name of the Senate GOP's Trumpcare Plan is "The Better Care Reconciliation Act" Plan...otherwise known as "BCRAP".

There's a lot to absorb here, but this is the bottom line:

  • MEDICAID: It's MORE draconian and cruel to Medicaid enrollees than the House version...but delays the worst of it by a few more years.

Seriously, that's it in a nutshell. It phases out the ACA's Medicaid expansion more gradually...but as the years pass, would eventually squeeze even more people off their coverage...mainly via non-ACA Medicaid, which means that this bill really has little to do with "repealing Obamacare" and is mainly about giving massive tax cuts to the ultra-rich at the expense of the poor and low-income workers.

OK, so this is what the "Three-Legged Stool" of the ACA is supposed to look like for the individual market:

Of course, I say "supposed to" because two of the three legs are simply too short, causing it to lean over somewhat.

June 13, 2017: CMS releases the following propaganda press release:

County by County Analysis of Current Projected Insurer Participation in Health Insurance Exchanges

The Centers for Medicare & Medicaid Services (CMS) is releasing a county-level map of 2018 projected Health Insurance Exchanges participation based on the known issuer participation public announcements through June 9, 2017. This map shows that insurance options on the Exchanges continue to disappear. Plan options are down from last year and, in some areas, Americans will have no coverage options on the Exchanges, based on the current data.

Back on November 15, 2016, one week after the election, I posted the following:

IMPORTANT: I cannot guarantee accurate federal data after 1/20/17.

...Most of the actual staff...the career employees at CMS/HHS, many of who've been there through more than one administration, will likely remain, and will do their jobs to the best of their ability, including trying to compile and publish data as accurately as possible.

HOWEVER, their bosses...the HHS Secretary and, I presume, the head of CMS...will be appointed by Donald J. Trump and confirmed by a 100% Republican-controlled Senate.

Given Trump's long, disturbing history of flat-out misstatements (aka "making sh*t up out of whole cloth"), and the type of sycophants he's likely to put into place, I can't guarantee with any certainty that the numbers spouted off by them are going to bear any connection with reality. Maybe they'll be accurate. Maybe they'll be off slightly. Maybe they'll be completely removed from any actual numbers. Who the hell knows?

An eternity ago (aka back in January/February), I attempted to compile and break out estimates of how many people would likely lose healthcare coverage in the event of a full, "clean" repeal of the Affordable Care Act (that is, a complete repeal of the ACA without any replacement healthcare policy whatsoever). I concluded that the total added up to roughly 24 million people nationally: Around 8.2 million highly-subsidized Individual Market enrollees, nearly 15 million Medicaid expansion enrollees and 750,000 Basic Health Plan enrollees (NY & MN only). I then attempted to break these out by both County and Congressional District​. I went with a "clean" repeal because there wasn't any actual replacement plan available to compare with.

Things are looking pretty precarious in Iowa for 2018, with Wellmark and Aetna bailing entirely on the state's individual market.

The good news, such as it is, is that Medica has stepped up to the plate as the sole insurance carrier filing to offer indy market policies (on the ACA exchange or off, I believe) across all 99 counties next year.

The bad news--although I can't really say that I blame them under the circumstances--is that they're insisting that they'll need a big rate hike to do so.

Here's the thing, though: First check out the headline in this story about it from The Hill:

Only ObamaCare insurer in most Iowa counties to hike premiums by 43.5 percent

One of the last insurers on Iowa's ObamaCare exchanges announced Monday it would sell plans in 2018 but proposed an average rate increase of 43.5 percent.

Earlier this year, in response to popular demand, I put together an extensive list of serious proposals to actually repair, improve and strengthen the ACA itself, as opposed to a) tearing it apart and replacing it with the GOP's Godawful pile of crap or b) tearing it apart and attempting to replace it with a total single payer system (which simply is not going to happen in the near future no matter what).

I came up with some of these ideas on my own (though I'm sure others have made similar suggestions), but most of them have been widely discussed by various heatlhcare wonks over the past few years. Some would require additional funding, but others are simply regulatory and wouldn't cost a single state or federal dime.

One of these seems to be catching on pretty quickly...number 12:

12. LEGALLY TIE MEDICARE ADVANTAGE/MANAGED MEDICAID CONTRACTS TO EXCHANGE PARTICIPATION.

Pages