CSR won’t be paid

According to Politico:

President Donald Trump plans to cut subsidy payments to insurers in his most aggressive move yet to undermine Obamacare after months of unsuccessful repeal efforts on Capitol Hill, according to two sources.

I’ve been working with Charles Gaba, Louise Norris, Andrew Sprung and a few others trying to inventory how states are allowing insurers to deal with the uncertainty of whether or not Cost Sharing Reduction (CSR) payments would be made.  The preliminary data is here This is a living document that we will be modifying as we learn more.

We are missing Washington DC, New York, Oklahoma and Texas.  As you hear more, please tell us.  Below is the map of our best estimate as of tonight.  WARNING: THIS MAP IS PRELIMINARY AND SUBJECT TO CHANGE AS NEW INFORMATION COMES IN



No CSR Strategy: Assumes CSR will be paid
Broad Load: CSR costs spread to all plans in all metal bands
Silver Load: CSR costs placed only on Silver plans
Silver Switch: CSR costs placed only on-Exchange Silver Plans

Mixed Strategies: Multiple strategies being used like in New Mexico and Georgia.
Reserve: States assume that CSR will be paid in first filing but had a plan in place if CSR is not paid. Plans vary widely.

57 replies
  1. 1
    Corner Stone says:

    When do insurance companies just come right out and say Trump is a madman and has to go?

  2. 2
    Fair Economist says:

    I’m surprised any state not run entirely by Republican nuts lacks a CSR default plan. Oregon, really?

    I don’t know the numbers, but I expect this will be particularly brutal for Alaska.

  3. 3

    @Fair Economist: Actually no, Alaska is projecting massive premium decreases because of a re-insurance program.

  4. 4
  5. 5
    amygdala says:

    @Corner Stone: Give it time. This dropped fairly late. The big hospital association and American College of Physicians (which represents internists) have come out against it already. I would expect the pediatricians, family docs, OB/Gyns and public health community to follow suit pretty quickly. And probably the AMA, even though they suck.

    Just wondering if we need to chip in for a fire extinguisher for David/Richard. I think we may be out of them here in the Bay Area, though.

  6. 6
    Jim, Foolish Literalist says:

    any advice on what we should say to our MoCs tomorrow, hive mind?

  7. 7
    Patricia Kayden says:


  8. 8

    @Patricia Kayden: Don’t worry the generals will save us.

  9. 9

    Unsurprising but still disappointing.

  10. 10
    Jeffro says:

    @Jim, Foolish Literalist: yup – “You Swore An Oath”

  11. 11
    Jim, Foolish Literalist says:

    Matthew Yglesias‏Verified account @ mattyglesias 29m29 minutes ago
    CBO says this latest Trump move will raise ACA premiums by 20 percent and add 1 million people to the ranks of the uninsure. Terrific!
    Because premiums are federally subsidized, refusing to make CSR payments actually causes federal spending to rise along with them.
    So in the end, the government will be spending more to cover fewer people.
    The art of the deal!

  12. 12
    Jeffro says:

    He’s signaling pretty hard that he’s willing to destroy everything as he continues to plummet to earth.

    South Korea, Japan, west coast USA, take note. (Puerto Rico, I know you already have)

    Your move, GOP

  13. 13
    Ohio Mom says:

    @Jim, Foolish Literalist: My first instinct is to play dumb and ask how this will affect our state and wait for an answer. I’ll probably keep playing dumb — “What will people with cancer who are poor do?” — just to mess with the interns. They don’t know much and after calling them all summer, I’ve grown to hate them. I like watching them squirm when they don’t know what to say. I’ll finish up by saying how horrified I am by the EO.

    But I await hearing other answers to your question.

  14. 14
    Citizen_X says:

    Is this…um, legal?

  15. 15
    Omnes Omnibus says:

    @schrodingers_cat: Give it a fucking rest.

  16. 16
    rikyrah says:

    Thanks for being on top of this, Mayhew

  17. 17

    @Citizen_X: Who’s gonna stop if it ain’t?

  18. 18
    AliceBlue says:

    That’s my question too. I don’t understand how he can unilaterally do this.

  19. 19
    amygdala says:

    @Citizen_X @AliceBlue:
    IANAL, but here’s one perspective on some of the legal options.

    Maybe that means calling our state AG, in addition to our Reps and Senators.

  20. 20
    Timurid says:

    For those of you who missed the end of the last thread… type “hurricane” into a Google search and notice what’s in the list of suggestions it gives you. Or rather, what’s not in it. Just another day in Wasfstan.

  21. 21
    Chris says:

    @Ohio Mom:

    I normally disapprove of being mean to the help, but this is one case where I’m totally on your side. Anybody who’s interning with a senior Republican politician is either a solid committed ideologue or a crook/climber who’s willing to back the psychos. They deserve all the squirming you put them through and more.

  22. 22
    Patricia Kayden says:

    @schrodingers_cat: If only.

  23. 23
    Jim, Foolish Literalist says:

    I’d recommend everybody hit resist-bot tonight. Let them find a bunch of faxes waiting for them in the morning

  24. 24

    @Patricia Kayden: If they can stop nuclear war (VSPs here and elsewhere are expecting them to), this is surely child’s play.

    ETA: FWIW I think you are right, they can’t. The only solution to the T problem is with the R Congress if they choose to act.

  25. 25
    Patricia Kayden says:

    @Omnes Omnibus: Well someone keeps talking about the dang generals keeping Trump in check. It’s a bunch of nonsense but it’s out there.

  26. 26
    kindness says:

    We can (and will) go on about the vindictiveness of Trumps actions but what I really wonder is if John Q Public & the MSM will blame Trump and Republicans when everyone’s insurance starts to spike. I may be shielded a little out here in CA but it’ll ripple here too.

  27. 27
    p.a. says:

    tRump is a know-nothing. This move, I would guess, with my usual complete lack of factual data, comes from Pasty Pence and his cohort of parasitic worms.

  28. 28
    Omnes Omnibus says:

    @Patricia Kayden: I am familiar with the meme. It also has fuck-all to do with healthcare.

  29. 29
    Ohio Mom says:

    @Chris: I was nice, and even warm to them in the beginning of the summer. They earned my disgust with them fair and square.

    I just found a good Vox article by goggling “Vox CSR.” It is a good primer on what just happened, and offered a little hope.

  30. 30
    Jim, Foolish Literalist says:

    @kindness: I hope/think they’ve talked about it long enough and loud enough that people get that it’s the Rs’ watch, but who the fuck knows

  31. 31
    John Revolta says:

    Just fucking great.
    My insurance co. is pulling out of my state at year’s end leaving me only one (probably unaffordable) option. Now this. How soon can this happen?

  32. 32
    Bill Arnold says:

    Aren’t any policy price increases due to lack of CSR payments a “Trump Surcharge”?
    Will any insurance companies have the nerve to explain it this way prominently (like first sentence, using 4th-grade English) in their written documentation?
    Trump will call these Trump-caused price increases “massive, massive, Obamacare price increases” or similar. Will there be pushback, by the insurance companies and by the media?

  33. 33

    @Omnes Omnibus: The meme that the generals were supposed to be a voice of reason and moderation in the current regime has so far remained a mirage. They are T’s men. They do what he wants.

    ETA: They have been as effective as Ivanka.

  34. 34
    BruceJ says:

    @Bill Arnold:

    Trump will call these Trump-caused price increases “massive, massive, Obamacare price increases” or similar. Will there be pushback, by the insurance companies and by the media?

    Not in the slightest. This has been answer number 10,765 in the ongoing series “Simple answers to obvious questions”.

    Welcome to drowning in the bathtub. The Oligarchs have succeeded in repealing the 20th century.

  35. 35
    West of the Rockies (been a while) says:

    Mr. Trump, with all sincerity…


    Die, you fat, useless pig.

  36. 36
    Omnes Omnibus says:

    @schrodingers_cat: The horse is dead. Why do you keep beating it?

  37. 37
    Steve in the ATL says:

    @Omnes Omnibus: tenderizing the meat for steak à cheval?

  38. 38
  39. 39
    Steve in the ATL says:

    @Omnes Omnibus: oui. Moi, je ne mange pas du viande rouge. Et je ne mange jamais des chevaux.

  40. 40
    Duane says:

    Trump doesn’t care how many people he harms.His hatred of Obama outweghs any other considerations. The President is psychotic His actions demand removal from office.

  41. 41
    Omnes Omnibus says:

    @Steve in the ATL: I was given a leather jacket made of horse-hide that had belonged to a grandfather who felt it no longer suited his lifestyle. The hide was very stiff. OTOH, it made a weird counterpoint to khakis, boat shoes, and LL Bean sweaters.

  42. 42
    ProfDamatu says:

    Long time reader, first time commenter….

    I’m wondering if I fully understand the Silver Loading strategy – I thought I did, but perusing the rate data I downloaded for Virginia from the SERFF database makes me think I’ve got it mixed up somehow. (Shout-out to, IIRC, Charles Gaba’s site; one of the percentage rate increase tables there had a footer pointing to SERFF, and when I poked around, I was able to find the actual rate filings. Nothing like finding out a few weeks early just how badly you’re going to get screwed! Anyway…)

    I compared the base rates for roughly comparable Bronze, Silver, and Gold plans offered in my rating area (can’t be exact, because it looks like the plan designs are changing a lot, but I tried to do apples to apples) in 2017 with the base rates for 2018, and Bronze went up by 33%, Silver by 60%, and Gold by 77%. I also looked at the 2018 rates for Anthem, and the spread in 2018 premiums is similar (didn’t check the increase from 2017 tho). Virginia shows on the map as a Silver Load state, but this looks like more of a broad load strategy. So, clearly I’m missing something – any idea what it is, Mayhew/Anderson :-) ? (BTW – I got the Mayhew reference first time I saw it – first time in ages running across someone who’s heard of Neverwhere!)

    Oh, to clarify a bit: the rates I’m looking at are for the parts of the state that Anthem and Optima are splitting next year – the places where only one or the other of the two companies will be offering plans, which I guess might have an effect. Also, Optima is offering a couple of off-exchange Silver plans that are priced between the on-exchange Bronze and Silvers, which appear to be Optima’s only off-Exchange plans; I don’t see any off-Exchange plans listed for Anthem.

  43. 43

    @ProfDamatu: This is what we were basing Virginia’s Silver Load on:


    Anthem seems to be assuming a Silver Load strategy.
    I will move to Mixed tomorrow morning.

  44. 44
    Chris says:

    @Ohio Mom:

    Good article, but if the hope for the future depends on Congress getting its shit together and funding this, I find it hard to be too hopeful. Just getting three people to vote “no” on repeal was like pulling teeth with blunt tweezers. Getting them to not just refuse to inflict harm, but affirmatively do something good and that would save the ACA, is asking even more than that.

  45. 45
    Omnes Omnibus says:

    @ProfDamatu: You may find it more profitable to take your question up to the new thread. More likely to get a proper response there.

    Also too, welcome aboard. Comment at will.

  46. 46
    Omnes Omnibus says:

    @Chris: Who controls Congress? We can’t talk about Congress; we have to talk about the GOP Congress.

  47. 47
  48. 48
    Omnes Omnibus says:

    @Chris: No, my point is that we pin every bit of shit on the GOP. Every time we can.

  49. 49
    ProfDamatu says:

    @David Anderson: Ah, I see! I wonder if maybe Anthem filed an update just before the deadline, because the base rates on the document I downloaded have Bronze from $325-344; Silver from $396-468; and Gold at $597.52. (The PDF file name has 20170915 at the end, like the Optima document, so I’m interpreting that as September 15, 2017.) I apologize for coming across as obnoxious and argumentative, especially as a total non-expert; I’m just trying to make sure I understand exactly what’s going on. I’m kind of a double whammy on this – I’m a scientist who loves data, and someone for whom access to insurance is a life and death concern, so…maximum investment, maximum obnoxiousness! :-)

    @Omnes Omnibus – thanks for the welcome!

  50. 50
    justawriter says:

    I’m not sure you can list North Dakota as “no strategy.” I think they had a definite strategy to favor the incumbent largest provider. I posted a link in an earlier post about Medica leaving the ACA market because they were denied a double digit increase. According to info from the state insurance commish, ND BCBS is getting a 22 percent rate increase while the other three insurers in the state will have a low single digit increase or get out of the ACA individual market altogether (two of the four). Right wing legislators (we have few of any other kind) had a collective ragegasm a few years ago when the governors office negotiated a better deal for employees with Sanford Medical instead of ND BCBS (which I think has seen its share of the insurance market drop for 90% to 75% in the decade since Sanford entered the market). The legislature set up a study resolution to investigate self insuring state employees with what I am sure will be a contract that miraculously only ND BCBS qualifies to run.

    Or I might just be paranoid.

  51. 51
    rikyrah says:

    @Ohio Mom:
    Make the muthaphuckas squirm

  52. 52
    Kay says:

    People who want single payer should sell the simplicity of it. A couple more years of chaos and people will grab it like a life raft, just so they don’t have to work so hard to get health insurance. It’s like a part time job.

  53. 53
    kindness says:

    @Kay: Until someone can fully map out the costs and revenue sources of Single Payer we won’t get one. And all the spreadsheets I’ve seen so far make it a very expensive proposition. MediCare for all is more do-able because MediCare already exists and people trust it works. imho.

  54. 54
    jskdn says:

    The Silver Switch is clearly so advantageous for the insured in the individual market, why would any state not choose it?

  55. 55
    Dan Carnese says:

    This is Covered California’s response: CSR surcharge only for on-exchange Silver plans.

    Californians who do not get financial help and buy individual coverage directly from their health insurance company will not be charged the CSR surcharge. In addition, Covered California consumers with Silver plans who do not receive financial help to pay their premium can also avoid paying the surcharge by switching to a different metal tier or buying near-identical Silver coverage directly from a health insurance company. Covered California has approximately 65,000 unsubsidized consumers enrolled in Silver plans.

  56. 56
    Karen Johnson says:


    in 2017 with the base rates for 2018, and Bronze went up by 33%, Silver by 60%, and Gold by 77%. I also looked at the 2018 rates for Anthem, and the spread in 2018 premiums is similar

    With rates going up that much, it’s almost like the health care insurance industry is trying to make up for “lost time” during the 3 years Obamacare premium costs stabilized (for most people). Health care insurance shouldn’t be a profit-making enterprise.

  57. 57
    Norm Spier says:

    Actually, in MA, where I live, your table indicates CSRs paid, and “a waiver will be sought”, but the Globe suggests today they may have gone to “silver load” or “silver switcheroo”.

    I am using this article, https://www.bostonglobe.com/business/2017/10/19/state-health-connector-reacting-trump-move-cut-subsidies-sharply-raises-rates/oQAYQ9FN2EbaAc99VcovyL/story.html , which is in flux (as they put in more details), and at the moment has “The biggest rate hikes apply to midlevel “silver” plans”. This does not prove they going with “silver load” or “silver switcheroo”., but suggests it. (I can’t find any more specific clarification in the Globe.).

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