In nearly a dozen Republican-dominated states, either the governor or conservative legislators are seeking to add work requirements to Obamacare Medicaid expansion, much like an earlier generation pushed for welfare to work.
The move presents a politically acceptable way for conservative states to accept the billions of federal dollars available under Obamacare, bringing health care coverage to millions of low-income people. But to the Obama administration, a work requirement is a non-starter, an unacceptable ideological shift in the 50-year-old Medicaid program and a break with the Affordable Care Act’s mission of expanding health care coverage to all Americans. The Health and Human Services Department has rejected all requests by states to tie Medicaid to work.
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.
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.
The states filings are piling up quickly...Arkansas is pretty straightforward. Interestingly, four of the five carriers seem to be assuming that CSR payments will be made, and have submitted their rate filings accordingly; the fifth (and largest), USAble Mutual (aka Blue Cross Blue Shield of AR) is the only one to break it out specifically. In order to estimate the CSR factor for the other 4 carriers, I'm assuming 2/3 of Kaiser's 15% Silver plan bump estimate, or around 10 percentage points. That brings things in at around 10% even without CSR sabotage or nearly 18% with the CSR factor.
One other important thing to keep in mind regarding Arkansas: Their total individual market, including grandfathered and transitional plans, is something like 430,000 but they only have around 70,000 officially enrolled in ACA exchange policies. The main reason for this is that they have another 320,000 people enrolled in exchange policies via their "Private Medicaid Option"...which is Arkansas' version of ACA Medicaid expansion. For some reason, those folks aren't counted as ACA exchange enrollees even though it's my understanding that the only distinction between them and the 70K official enrollees is where the payments/subsidies come from.
The feds would have to approve the state's waiver proposal in order to enact the governor's plan, but the feds will only move forward if legislation is already in place. That's the reason for the special session: The governor will ask the legislature to pass laws granting him the authority to seek the waiver and his plan will be spelled out, in broad terms, in legislative language in these laws. Most expect that the governor will be able to get legislative approval relatively easily (he needs a simple majority). Note that some of the fine print will still have to wait for the state's actual waiver proposal and the terms and conditions if the Trump administration grants the waiver.
Here are some of the changes that Hutchinson will be pushing in the special session:
This is a minor update, but with all the bad rate hike news this year, I'll take any good news I can get. A couple of weeks ago, the Arkansas Insurance Dept. approved rate hikes for the 4 carriers participating in the ACA exchange next year, including significant reductions for all of them:
In mid-August, all of the carriers that offer plans in the Arkansas exchange proposed new rate increases for 2017, all of which were lower than their initially filed rates. Rate increases were then reduced even further for QualChoice and QCA:
Lots of stuff happening fast & furious these days as #OE4 approaches. Instead of individual posts, I'm gonna cram 7 state updates into a single one...and am also cheating a bit by cribbing off of excellent work by Louise Norris over at healthinsurance.org (which is fair, since she also gets some of her data from me as well):
ALABAMA: Here's what my requested rate hike table looked like for Alabama on August 1st:
There are a few states which have technically expanded Medicaid under the ACA, but have done so using an approved waiver which allows them to actually enroll expansion-eligible residents in private Qualified Health Policies (QHPs)...using public Medicaid funding to do so. To be honest, this has always struck me as being essentially no different than someone simply receiving 99.9% APTC/CSR subsidies for enrolling in an exchange policy anyway; it's just a question of which pool of federal funds the subsidies come from. The two states which I know for a fact do it this way are Arkansas and New Hampshire, with Arkansas calling their "Private Medicaid Option" program the "Health Care Independence Program".
In any event, AR "Private Option" enrollees may be categorized as "Medicaid expansion" in the official reports, but for purposes of estimating the risk pool, they're included in with every other ACA-compliant private individual policies, whether on or off the ACA exchange.
So just last Friday I posted the weighted average requested rate hikes for the Arkansas individual market; it came in at 14.9% overall, which is actually one of the lower statewide averages this year. As a reminder, here's what how the breakout looks:
OK, so 3 major carriers asking to jack up rates 15-24%, plus one at 8.5% and two others with just 7 enrollees between them (one of which is, once again, Freedom Life Insurance). So what?
Arkansas was a little weird...while the rate filings for 5 carriers are listed over at RateReview.HealthCare.Gov, the carrier with the largest individual market share in the state, BCBS (aka "USAble Mutual") is nowhere to be seen (there's a sm. group listing for them, but not individual). However, when I went directly to the AR SERFF database, there they were--and it's listed specifically as "2017 Individual QHP Rates", so there's no question here about whether they plan on offering ACA-compliant policies in 2017.
Anyway, between the HC.gov site and the SERFF site I was able to cobble together pretty much all of Arkansas' indy market. The numbers seem about right; AR's indy market was around 303K in 2014; while it's likely up to 375K or so today, the "missing" 70K can easily be attributed to UnitedHealthcare dropping out and/or grandfathered/transitional enrollees.
At 14.9% on average, this is actually good news for 2017, relatively speaking.
UnitedHealth Group will stop offering plans on Arkansas' health insurance exchange next year, a spokesman for the Arkansas Insurance Department said Thursday.
The Minnetonka, Minn.-based insurer offered plans this year for the first time, but it didn't submit plans to the department for 2017, department spokesman Ryan James said.
The deadline for insurers to submit such plans was April 1, he said.
This is hardly unexpected news for a couple of reasons. First, UHC made huge waves last November by making a big, dramatic announcement that they might very well drop out of the ACA exchanges altogether next year after taking large losses on exchange enrollees in 2015. As you may recall, this was a very oddly-timed announcement given that they had issued a glowing quarterly report just a month earlier which made it sound like everything was hunky-dory.