Will Alexander-Murray be resurrected

Alexander-Murray was a bipartisan attempt to fund Cost Sharing Reduction (CSR), add reinsurance, change 1332 waiver regulations, mandate outreach funding to be distributed via the states from HHS central control and doing something funkily unproductive with rebranding Catastrophic plans as Copper plans.

It failed to advance despite having 60 Senators sponsor or support it.

There have been rumors of it coming back in some form.

this may mean some brief eventual opening for a new version of what we used to call alexander-murray – to stabilize the exchanges. Still iffy chances and way off on the horizon… (and abortion language could easily make it all fall apart again) https://t.co/SBe8PlCrlY

— Joanne Kenen (@JoanneKenen) November 7, 2018

I have always argued that since late summer 2017, the threat and then the reality of terminating CSR payments is both a fundamental rewriting of the ACA individual market mechanics and a movement towards preferred Democratic/liberal policy objectives.

The lack of direct CSR funding has fundamentally changed the market and the lived experienced of subsidized individuals buying on the Exchanges. We see this in the pricing strategies on Exchange in 2019:

• Way more Gold Gapping in 2019 than 2018 (at least in counties, I have not population weighed)
  • 2018: 595 counties had at least 1 Gold plan less expensive than Benchmark
  • 2019: 1,136 counties had at least 1 gold plan less expensive than Benchmark
• More really big Silver Gaps (Counties with at least a $100 Silver gap between benchmark and least expensive Silver)
  • 2018: 174
  • 2019: 198

There are no premium plans in Oklahoma. 

States that are actively caring or insurers that have actuaries and product pricing analysts who are not sleeping at their job have well known and well publicized routes to hold non-subsidized buyers harmless from CSR shenanigans. 

As I argued repeatedly, the ACA has changed.

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.  This will have an incredible change in the dynamics of the market.

And more recently in March 2017 I commented on Alexander-Collins:

We have a real, pragmatic baseline of reality as it is today; CSR has mostly been rolled up into premiums. This led to the Silver Loading and Gold Gapping where people who earn between 200% to 400% Federal Poverty Level (FPL) ($24,040-$48,080 for a single individual) got really good deals on subsidized Bronze and Gold plans this year. This reality is the alternate analysis. And from there, funding CSR takes $32 billion dollars out of the ACA.

So the bill is a net cut to the ACA and a major reduction in female reproductive autonomy.

I could see an agreement zone on reinsurance, I could see an agreement zone on 1332 rules, I could see an agreement on catastrophic plans (although I don’t see the point of that policy).

I don’t see an agreement zone on CSR given the pragmatic changes of the lived experience of the ACA.