ACA Sabotage

2019 OPEN ENROLLMENT ENDS (most states)

Time: D H M S

Minnesota, currently entering their second year of their official reinsurance waiver program to help keep unsubsidized premiums down, announced their preliminary 2019 rate hikes way back in June. At the time, the carriers were looking at roughly an 8% average reduction in rates next year...although they would be dropping prices by more like 15% if not for the ACA's individual mandate being repealed and the expansion of #ShortAssPlans.

Today the Minnesota Dept. of Commerce posted the approved 2019 premium changes, and there's been some dramatic reductionsfor three of the five carriers offering policies in the state. Group Health and Medica were approved as is, but Blue Plus was told to drop their rates a whopping 27.7% instead of the 11.8% they were planning on. Ucare was shaved down from a 7 point reduction to 10 points, and PreferredOne (which only sells individual market policies off-exchange and only has 300 enrollees anyway) was knocked down from a 3-point reduction to 11 points.

Today at 11am CST (I think that's Noon EST?), HHS Secretary and Donald Trump's Used Car Salesman Alex Azar will give a Big Speech to the Nashville Health Care Council in Tennessee:

Tomorrow, HHS Secretary Azar will join Governor Haslam in Nashville, Tennessee to deliver remarks at an event hosted by the Nashville Health Care Council.

Secretary Azar will share news regarding the Affordable Care Act marketplace and reflect on lessons for healthcare reform.

In advance of tomorrow, here are a few excerpts of Secretary Azar’s remarks (as prepared for delivery):

“The previous administration’s major healthcare achievement, the Affordable Care Act, was an attempt to use more government regulation and intervention to improve American healthcare.

“As we all know, the results were disastrous, with skyrocketing costs and disappearing choices.

“But today, I am here to share with you some good news.

via U.S. News & World Report:

Later Wednesday, [Democratic Governor Gina] Raimondo held her own news conference to sign an executive order that, among other steps, directs the state to seek to codify in state law protections for people with preexisting conditions, dependents up to age 26, prescription drug benefits and maternity coverage in case federal action is taken to weaken the Affordable Care Act.

Rhode Island has one of the highest insured rates in the country, and Raimondo said she was defending "Rhode Islanders' access to high-quality, affordable health coverage."

I'm not quite sure what an executive order has to do with codifying ACA protections into law, since that's really up to the state legislature to do, but I guess it at least kicks their butts into gear?

This is also refreshing to hear from a Republican challenger:

As I noted last month when I first analyzed the requested 2019 rates for North Dakota insurers, ND was somewhat unique last year in that it was one of only two states (the other was Vermont) which didn't tack on any extra premium increases for 2018 to account for the lost Cost Sharing Reduction reimbursement revenue after Donald Trump cut off those payments last October.

This led to one of North Dakota's three carriers, Medica, dropping off the ACA exchange altogether, though they still ended up enrolling a few hundred people directly via the off-exchange market.

As I noted back in July, in addition to the Trump Administration's Centers for Medicare & Medicaid (CMS) chopping down the marketing budget for HealthCare.Gov by 90% last year, they also slashed the navigator/personal outreach budget by over 40% as well, from $63 million down to $36 million...and this year have cut it by another $26 million, to just $10 million across all 34 states which rely on HealthCare.Gov to host their ACA exchange open enrollment functionality (there are 5 more states which are hosted by HC.gov, but which I believe operate their own exchange and navigator budget: Oregon, New Mexico, Nevada, Kentucky and Arkansas). Combined, that makes an 84% reduction in navigator funding over a 2 year period.

This is a pretty minor update, but I'm trying to lock in all of the approved 2019 rate changes as they come in. Last month, South Dakota's two carriers, Avera and Sanford, posted requested rate increases which I thought were 2.6% and 10.0% at the time. I also estimated their relative enrollment at around 27,000 and 4,000 enrollees apiece for market share calculations, which gave a statewide average increase of around 3.5%.

I checked the South Dakota Insurance Division website again today, and it certainly looks like the filings have been approved by the state insurance regulators...however, when I double-checked the filings themselves, it looks like they were actually slightly lower than I thought: 2.5% and 9.7% respectively.

In addition, I was able to find the hard enrollment numbers for each...the total is pretty close to what I had it at (29,180 vs. 31,000), but the splut is quite different. Insetad of Avera still having an 87% market share, it looks ike the split is more like 63/37 this year. Since Sanford is requesting a significantly higher increase than Avera, that means the weighted statewide average is higher as well...around 5.2% instead of 3.5%.

I posted Montana's preliminary/requested 2019 ACA indiividual market rate change requests back in late June. At the time, they were seeking average rate increases of 6.0% statewide, and I estimated that the GOP's repeal of the ACA's individual mandate penalty, combined with the Trump Administration's expansion of #ShortAssPlans, accounted for about 9.9 percentage points of that.

More recently, the state insurance commissioner's website published approved 2019 rate changes. The average increases have been sliced down slightly (from 6.0% to 5.7% on average), and I've lowered my estimate of #ACASabotage impact from 9.9% to 6% based on the lack of either factor being prominently mentioned in the actual carrier rate filings. If accurate that means rates would have been flat year over year on average in 2019 if not for those factors.

Unsubsidized Montana enrollees are paying an average of $637/month this year, so that's roughly a $38/month difference, or around $460 for the full year.

When Maryland insurance carriers originally submitted their proposed 2019 premium changes back in May, it looked pretty grim...they were expected to average around 29.5% statewide for the ACA-compliant individual market., increasing from around $631/month on average to roughly $817/month for unsubsidized enrollees.

Thanks to swift, bipartisan action on the part of the Democratically-controlled Maryland state legislature and the Republican Governor, Maryland was able to pass several bills which partially negated or cancelled out Trump/Congressional Republican sabotage of the Affordable Care Act. In particular, they passed laws which locked in current restrictions on both short-term plans and association health plans (the types of "junk policies" which Trump is pushing hard to expand upon)...along with an extremely robust reinsurance program.

Back in July, I wrote about a lawsuit filed by twelve state Attorneys General against the Trump Administration over their attempt to vastly expand "Association Health Plans" as an alternative to ACA-compliant healthcare policies:

A group of 11 states and Washington, D.C., are suing the Trump administration in an attempt to roll back a regulation that allowed for the expansion of certain health plans that skirt ObamaCare regulations.

The lawsuit, led by New York Attorney General Barbara Underwood (D) and Massachusetts Attorney General Maura Healey (D), alleges that the Department of Labor violated the Administrative Procedures Act when it wrote a rule expanding access to association health plans.

Association health plans allow small businesses and other groups to band together to buy health insurance. The rule allows more groups to join together to form associations.

The move is part of a broader Trump administration effort to open up skimpier, cheaper plans as an alternative to ObamaCare plans.

 

via Nicholas Bagley of The Incidental Economist:

Maryland files suit to protect health reform from Texas.

... the Maryland attorney general today filed a separate lawsuit in a Maryland district court. Among other things, he’s seeking an injunction requiring the continued enforcement of the law. Depending on how quickly the Maryland case moves, it’s possible we could see dueling injunctions—one ordering the Trump administration to stop enforcing the law, the other ordering it to keep enforcing.

That’s an unholy mess just waiting to happen. Now, it may not come to that. My best guess is that the Texas lawsuit will fizzle: any injunction will likely be stayed pending appeal, either by the Fifth Circuit or the Supreme Court, and the case is going nowhere on the merits. The Maryland lawsuit will likely prove unnecessary.

I don't have much to add to this other than to note how much this case underscores just how much power and importance state attorneys general have.

As I just noted earlier this afternoon, Massachusetts is NOT expecting the repeal of the ACA's individual mandate to impact their 2019 individual market enrollment or premiums for a simple reason: The Bay State never formally repealed their own, pre-ACA mandate penalty. They basically mothballed it once the ACA's version went into effect, and are simply dusting it off for 2019 and beyond now that the federal mandate has been formally repealed.

However, the two mandate penalties don't work quite the same way. For the federal mandate, unless you qualify for an exemption (and there's a whole bunch of those), the penalty for not having ACA-compliant healthcare coverage is (or has been up until now) as follows:

This Just In...

Ready for Open Enrollment, Health Connector sets 2019 plans with lower premium increases, selects community organizations to provide in-person support to residents

Boston – September 13, 2018 – The Massachusetts Health Connector Board of Directors today approved 57 Qualified Health Plans from nine carriers for individuals and families, with new plan designs that create better value for members and premium increases that average under 5 percent from 2018.

Unfortunately, the press release doesn't specify what "under 5%" means, nor does it break that out by carrier/market share. I've put in a request for those details and will update this as soon as I hear back from them. They sent me the following chart, but this only includes enrollees earning between 300-400% of the Federal Poverty Level, which means the marketshare across the entire individual market is likely somewhat different. I'm assuming the 4.4% overall average applies to the entire market but could be wrong about that as well:

For months now, I've been trying to get people to understand that when it comes to sabotage of the Affordable Care Act, especially in terms of individual market premium increases, you have to include the impact of actions taken by Donald Trump and Congressional Republicans in BOTH 2017 and 2018, not just 2018 alone.

In 2017, the single largest factor in the ~28% average national unsubsidized premium increase for ACA plans was Donald Trump's cutting off of Cost Sharing Reduction (CSR) reimbursement payments to carriers. This alone accounted for fully half of the 2018 increase. However, there were other, smaller actions taken which added up to another 3% or so: Slashing the Open Enrollment Period in half, CMS slashing the marketing budget for the federal exchange down 90%, slashing the outreach/navigator budget down 40% and so on.

“But the plans were on display…”
“On display? I eventually had to go down to the cellar to find them.”
“That’s the display department.”
“With a flashlight.”
“Ah, well, the lights had probably gone.”
“So had the stairs.”
“But look, you found the notice, didn’t you?”
“Yes,” said Arthur, “yes I did. It was on display in the bottom of a locked filing cabinet stuck in a disused lavatory with a sign on the door saying ‘Beware of the Leopard.”

--Douglas Adams, The Hitchhiker's Guide to the Galaxy

Yesterday CMS Administrator Seema Verma posted this on Twitter...

I’m excited by the partnerships that Arkansas has fostered to connect Medicaid beneficiaries to work and educational opportunities, and I look forward to our continued collaboration as we thoroughly evaluate the results of their innovative reforms. #TransformingMedicaid

— Administrator Seema Verma (@SeemaCMS) September 13, 2018

Way back on January 20, 2017, the very day Donald Trump was inaugurated, he issued an Executive Order which started the process of undermining the Affordable Care Act. As David Anderson of Balloon Juice succinctly put it:

yes individual mandate exemptions will be passed out like pacifiers at a rave

— David Anderson (@bjdickmayhew) January 21, 2017

section 2 is the meat. Defangs individual mandate by passing out hardship exemptions like candy on Halloween

— David Anderson (@bjdickmayhew) January 21, 2017

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