State discretion and the ACA

At Health Services Research**, I have a commentary out this morning that looks at the wide amount of discretion that states have in promoting a wide variety of goals for their specific individual health insurance market.  The ACA has always been a story of 51 states (including DC) and 3,000 counties but since October 2017 with the termination of CSR payments, the possibility space has widened dramatically.

Here the big decisions state regulators and elites can make:

  • Expanding Medicaid to 138% FPL instead of not expanding or expanding only to 100% FPL — Yes lowers non-subsidized premiums and slightly increases subsidized net premiums
  • Silver loading and/or Silver Switching vs Broad Loading — 3 states broad load which raises costs for everyone and lowers enrollment
  • Managing Monopoly and spread games
  • Messaging support and advertising
  • Reinsurance and subsidization to support net prices paid by people earning over 400% FPL
  • Managing the allowable parallel markets such as Short Term Plans and Farm Bureau Plans

State regulators and insurers have tremendous discretion to shape their states’ markets however they wish.  Some states will make choices that I normatively like and others will make choices that make me gag.  The ACA requires states to make decisions and states will choose who to prioritize and how to do so from a very wide toolbox.




9 replies
  1. 1
    Another Scott says:

    You’re just churning out the papers! Way to go!

    Paywall, though. Boo. :-(


  2. 2

    @Another Scott: I had a huge bolus of submissions from late February to mid-April of this year. Stuff is starting to come out and the revise and resubmits are starting to head back.

    Here is my peer review pipeline:
    Accepted — Palliative Care paper probably published this fall
    Revised and Resubmitted — 2 ACA papers — feeling good about 1 of them as I should hear back any day now and the other one just went back to the journal this week

    In process of revision — ACA/outreach paper for Spring 2020′

    Being bundled together — 2 Accountable Care Organization (ACO) papers that should find a good to very good home by the end of this year

    Needs Major revision — 1 ACA/Financial toxicity paper that I think is really two papers that are co-exisiting very uncomfortably in the same body. The authorship group is meeting early next week

    Currently Being Written: 1 ACA paper that was a solicited abstract and 1 Pediatric Medicaid paper — both should be shopped by end of the summer

    In pipeline: 2 Palliative Care, 1 financial toxicity, 2 ACA papers

  3. 3
    Ohio Mom says:

    Very impressive list!
    (Even if I am not sure what most of it is about — that is meant only as a reflection on me).

  4. 4
    Philbert says:

    I just bumped into an article that promoted Trump changes to HRA accounts. These accounts supposedly are a step beyond HSA’s, and the employer funds them and the employee can pick what plan they want. I like to concept at first glance but I assume it’s crap because it said Trump did something good . I am interested in your thoughts.

  5. 5
    Duane says:

    @David Anderson: Obamacare would work even better if not for Republican sabotage. Expanded Medicaid is a joke in Missouri. My insurance through the exchanges is a good deal.

  6. 6

    @Duane: Missouri never expanded Medicaid

  7. 7
    Duane says:

    @David Anderson: Thanks for correcting that. Medicaid in Missouri is a joke. Its sad we are still governed by assholes who don’t give a damn about the people of Missouri.

  8. 8
    Ohio Mom says:

    @Philbert: IANADavidAnderson but my suspicion is that this is the first step to doing to employer-provided health coverage what was done to defined-benefit pension plans. You’re going to end up with a health coverage version of a 401k.

    It would be one thing if employers shed their responsibility for providing health coverage because the federal government was taking over (with a public option, or Medicare for All or whatever).

    But this will be the worst of both worlds because you’ll be dealing with your private insurer as an individual. It will be you against them. You won’t even have the chance that HR will try to pull a few strings on your behalf. Good luck with that.

  9. 9

    @Philbert: New post on Friday morning!

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