A quibble on Alexander-Collins

Jonathan Cohn at the Huffington Post has a good piece going over the bleached bones of the Alexander-Collins ACA bill. I agree with most of it and he does a really nice job of de-geeking the Silver Load work-around with CSR. But I have one major quibble and it is not a quibble with Jonathan, it is a quibble with the underlying analysis:

Many Republicans still aren’t willing to vote for any proposal that might appear to prop up Obamacare, otherwise known as the Affordable Care Act, which they and many of their supporters would rather just repeal.

Objectively speaking, Alexander-Collins pulls money out of the ACA and decreases enrollment. Neither outcome is stabilizing.

Putting the estimates together, CBO expects the package to reduce coverage, but also reduce the deficit. That’s the same basic tradeoff that often arises: we can spend less on coverage programs if we’d like, but typically at the cost of more uninsured.

— Matt Fiedler (@MattAFiedler) March 20, 2018

Funding CSR and reinsurance makes non-subsidized buyers much better off at the cost of making subsidized buyers significantly worse off. The CBO estimates on net that more people will be uncovered if Alexander-Collins passed than under current policy and law.

I think that one of the big challenges to any stabilization bill that needed to be voted on after the CSRs were terminated last October and there was no mass exodus from the marketplaces by the insurers is that the reality on the ground changed. As I noted last August:

Democrats have no reason to trade CSR funding for policies that they don’t prefer. Inaction gives them an incredible policy victory. Conservatives are the ones who need to make concessions to fully fund CSR.

The Congressional Budget Office projects that most states will allow insurers over the long run to load the cost of their obligated but not reimbursed CSR obligations to only their Silver plans….
it is an incredible policy victory that will be cemented into place by inaction, giving it up for short term funding of a secondary set of subsidies would be counterproductive.

That is the reality that we are living in today. Silver loading was common for 2018 and will be even more common in 2019 as one of the few states that had no CSR response, Vermont, officially adopted Silver Switching going forward.

Anything that can get 60 votes in the Senate has to acknowledge the reality on the ground that Silver Loading and Silver Switching has changed the dynamic and added significant enrollment support to the law despite significant other headwinds.