98 to 58

Andrew Sprung at Xpostfactoid notes one group of low income people who could be better off under the BCRA; poor people who would have been Medicaid expansion eligible if they lived in states that expanded Medicaid. The subsidy structure of the BCRA sells the baseline plan at 2% of income for people up to 100% of Federal Poverty Line. The Benchmark plan is 58% actuarial value.

The BCRA does toss a bone to the dis-insured poor by offering private-market subsidies to those who are shut out of Medicaid. Under the ACA, in the 31 states plus D.C. that accepted the law’s Medicaid expansion (rendered optional to states by the Supreme Court), anyone whose household income is below 139% of the Federal Poverty Level (FPL) qualifies for Medicaid, and so not for subsidies in the private plan marketplace (with one class of exceptions*). In states that refused the expansion — a possibility not envisioned by the law’s drafters — eligibility for Marketplace subsidies begins at 100% FPL, and those below that level are left out in the cold — because their state’s governors and legislatures wanted it that way. The BCRA allows people with incomes in 0-100% FPL range to buy a “benchmark” plan for 2% of income, and those in 100-133% FPL range** to buy one for no more than 2.5% of income…

For low income enrollees [ACA] – the majority of marketplace enrollees — silver plans are enhanced by Cost Sharing Reduction (CSR) subsidies that raise AV to 94% ….That usually means deductibles in the $0-250 range for people with incomes up to 150% FPL…
The Senate bills drops the AV of a benchmark plan to 58% — below that of the ACA Marketplace’s bottom-level bronze plans, which have an AV of 60%. Bronze plans generally have single-person deductibles over $6,000

Prof. John Graves from Vanderbilt has a great illustration of comparative actuarial value:

The value of these plans mainly accrue to providers and hospitals.

It is very hard to design a 58% AV plan given the lack of change in out of pocket maximum where there are any services excluded from cost sharing. Donut designs where a few PCP visits and low cost generic drugs are no cost sharing are plausible at 60% or 61% AV. Using the 2018 AV calculator, I could only get a 59% AV Bronze plan with a $7,150 deductible that applied to everything.

There is some money allocated to bring down out of pocket expenses. If it is used as a state based CSR, it is grossly insufficient compared to current funding. There is less money and a larger gap. Someone who makes 100% FPL today receives a 24 AV point bump to get to a 94% plan with a $100 deductible and $1000 out of pocket maximum. That same 24 point bump produces an 82% AV plan with an $1825 deductible that applied to everything. That person is still massively underinsured as the out of pocket exposure of 10% of their income.

So when someone who earns 100% of FPL or less has a catastrophic event, the benefits will be in the form of unpayable debt and care for them. The doctors and hospitals will have a fixed limit of unpayable debt. If there is matched CSR, it might be $1,825. If there is no CSR, it could be $7,500. For diagnoses that routinely generate $100,000 claims over the course of treatment in a year, this is an acceptable discount. For PCPs and low level specialists, this will be 100% bad debt.

This has an interesting risk pool aspect. Third party payment of premiums will be quite common for patients who are guaranteed to run up $50,000 or more claims. Paying a few hundred dollars to minimize the amount of bad debt an oncology practice incurs is a smart business decision. It will make the risk pool even uglier.

So yes, there will be some poor people who are better off because their states have refused to accept significant federal funds to provide 98% actuarial value insurance. Now they will be getting 58% actuarial value insurance for 2% of their income. But they won’t be able to use it for common care as they can’t come up with out of pocket first dollar cost sharing.

Open Thread: You Come At the Queen…

Cue the Somewhat Soiled Lady, a day late and a hot-take short — “Nancy Pelosi Tells Democratic Critics, ‘I Think I’m Worth the Trouble’”:

The House Democratic leader, Nancy Pelosi, strolled before the cameras on Thursday with defeat at her back once more, projecting a well-worn swagger — brash, defiant, more than a little off key — as she insisted that her moment had not passed…

With six words, Ms. Pelosi, 77, demonstrated the self-assurance that has powered her as one of the most successful congressional leaders in the modern era. Yet even as Democrats enjoy a surge of grass-roots energy that could resurrect their House majority, some members of Ms. Pelosi’s own party are impatient for her to give up her 15-year grip on power.

She is the Democrat most crucial to determining whether her party can take back the House and torpedo President Trump’s agenda — an avatar of the kind of coastal excess that Republicans abhor and that some progressives have come to view suspiciously in an age of ascendant populism.

“Everybody wants leaders,” she said in an interview in her office at the Capitol, during which she was often as dismissive of critics in her own party as she was of the Republican opposition. “Not a lot of people want to be led.”
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Why were insurers so hot and bothered for HIT

Dylan Scott in Vox yesterday looked at what the health insurance lobby got from not actively fighting against the BCRA/AHCA in the Senate:

The major health insurance companies made a tactical decision to work with Republicans on their plan to repeal and replace Obamacare rather than lobby to stop it….

For insurers, at least for now, there is a lot to like in the Senate plan. It repeals Obamacare’s tax on health plans, a $144 billion tax cut over 10 years, per an analysis of the House bill. It provides $50 billion in federal funding in the short term to shore up the private insurance market and $62 billion over the longer term for state programs that help stabilize their insurance markets.

I don’t grok this.

I’m looking at things through the lens of profitability not total revenue.

The individual market so far has been a break even at best business for most insurers. 2017 is looking better with very low MLR in quite a few states for a wide variety of providers. But it is not boringly profitable. Medicaid managed care is boringly profitable. A barely competent MCO should scrape out a consistent 1% or 2% per year. When I worked at UPMC Health Plan, we budgeted for 2% profits and as I was leaving we were looking at 5%+ profitability for FY17. Medicaid is getting whacked. One of the first things states will do to compensate for less federal funding is squeeze MCO profit margins by reducing rates while mandating a year to hold providers harmless. Medicaid anyways is a much bigger market than the individual market.

The thing that I really don’t get is the push to eliminate the health premium tax. It is a tax that all fully insured plans pay. This basically means small and medium group employer sponsored plans, individual policies, and Medicare Advantage plans pay. Large, self insured, employer groups don’t pay, traditional Medicare fee for Service does not pay. If we assume a perfectly elastic market, I could see the self-interested push to eliminate the tax as it would make going fully insured marginally less expensive than going to self-insured ASO contract arrangements for medium size employers or make Medicare Advantage bids slightly more attractive. But in the individual market all of the carriers in the 2018 rate filings indicate that the insurers assume it is a market with low elasticity of demand. The tax incidence is overwhelmingly borne by the buyer and does not eat into the operating margins of the insurer.

Most of the tax savings will accrue to the policy buyers not the insurers in competitive markets. In non-competitive markets like Alabama with a dominant Blue, more the tax savings can be captured by the insurer. But I am trying to figure out exactly how much more profitable this tax cut makes insurers. It will be billions but it will not be a hundred billion dollars of additional profitability.

I’m having a hard time grokking the actual incremental profitability that insurers got out of the BCRA compared to the assured losses they will be taking on Medicaid managed care cuts.

On The Road

Good Morning All,

This weekday feature is for Balloon Juicers who are on the road, travelling, etc. and wish to share notes, links, pictures, stories, etc. from their escapades. As the US mainland begins the end of the Earth day as we measure it, many of us rise to read about our friends and their transient locales.

So, please, speak up and share some of your adventures, observations, and sights as you explore, no matter where you are. By concentrating travel updates here, it’s easier for all to keep up-to-date on the adventures of our fellow Commentariat. And it makes finding some travel tips or ideas from 6 months ago so much easier to find…

Have at ’em, and have a safe day of travels!

Should you have any pictures (tasteful, relevant, etc….) you can email them to picstopost@balloon-juice.com or just use this nifty link to start an email: Start an Email to send a Picture to Post on Balloon Juice

Two Blue Damselflies

Two Blue Damselflies, Colorado

This was my pond, and these damselflies were born and raised in it. It was scary the first time I ran into the aquatic stage of this glorious creature – they look like mean-ass water bugs you shouldn’t mess with. I learned to carefully preserve them when I did major pond cleanings to ensure their lives weren’t snuffed out too soon.

And now, back to Italy….

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Quick Thoughts after Reading the GOP “Health Care” Bill

I can’t believe more people aren’t talking about the last page of the Senate bill:


Late Night Open Thread

Here’s a picture of Steve sitting in the dark at the top of the stairs bitching for food. He perches there so if I make any movement towards the stairs, he can race downstairs and be prepared for to inhale whatever I give him.

He’s not getting anything until tomorrow morning.

Only a fool would think someone could save you

I think that repealing Obamacare would be a disaster for Republicans. You could argue that the takeaway from GA-6 and the other specials is that, while things aren’t great for Republicans in 2018, they have a good chance to hold the House unless some crazy shit happens. Repealing Obamacare qualifies as crazy shit and then some.

So I can see reasons why McConnell, who’s a shifty one, might be happy if repeal fails. That said, all the Senators expressing “concerns” about the bill looks and smells like kabuki to me. Jim Newell is probably right:

If he’s sticking to the script, McConnell has a list of giveaways that he saved to offer members later so that they can argue they only voted for the bill after extracting concessions:

This bill could fail, but that would be an abrupt last-minute rewrite of a script from which none of the players, so far, have deviated. Conservatives are organized, coordinated, and eager to share with the press their early objections. They will move the bill further to the right. Moderates are disorganized and press-shy, keeping their objections within the family. They will get offered a few more bucks or state-specific carve-outs and then draw straws to determine who has to vote for it. The Senate sequel to the House bill process is playing out like the most disciplined scene-by-scene retread since Home Alone 2. Don’t expect a surprise ending.

The so-called moderates always cave. I’m not a fan of calling people cucks but if anyone deserves it, it’s so-called moderate Republicans in Congress.

The GOP Is Becoming A Domestic Terrorist Organization

They’re tryng to be responsible for the suffering and death of thousands of Americans, and they’re proud of their efforts. Not so proud they aren’t lying as fast as they can talk, of course…

Healthcare, Birthday, and other Bullshit

It’s truly impressive that the Republicans managed to make the House health bill care worse. But they got rid of the individual mandate and rich and healthy people benefit and will get tax cuts, so WINNING! I have nothing going on the next few days so may actually try to find protests and go march in front of Capito’s local offices. I am not a protest person, but this shit requires drastic measures. Of course, the bill is not evil enough for the Zodiac killer and his cadre.

Speaking of healthcare, I turned 47 today. I’m not a person prone to celebration- I think this irritates ABC a touch because I’m not one to get really excited about things. I’m really not a hot or cold person (despite my irate ramblings), I just cruise along comfortably at the speed of grumpy. I mean, I am not miserable. I’m generally a happy person (ask people who know me IRL). I feel like I am defending myself too vigorously.

At any rate, mom and dad wanted to go out to dinner tonight, and I was not feeling it. I initially agreed, but then thought about it and cancelled. I decided I would rather stay and home and putz around the house, cook a nice dinner with a ribeye, and so I pushed back the plans until tomorrow night. I bought a steak and planned a nice dinner, and then had leftover fajitas that Christion and I made yesterday. Because who says I am not spontaneous?

Back to health and healthcare. Every summer as I head toward a new birthday I schedule a lot of health related events. I’ve had sleep apnea since 2005 (if you snore, get yourself checked- it will change and maybe save your life), and have not had a test since, so I scheduled a new sleep study. I had a friend die of pancreatic and colon cancer this past year, so I scheduled my first colonoscopy. I had another friend die of a heart attack, so I am headed to get a stress chest and a cardiac check up just because I don’t want to die before my parents so they don’t accidentally see the contents of my hard drives. I had my b-annual physical and labs. I went for my six month checkup at the dentist, had a crown replaced, a cleaning, and bought a night guard because I grind my teeth. I had my eyes checked and got new glasses two months ago. All in all, it cost about $2500 out of pocket (eyes and dental were the worst), which is a lot, but I’ll have it all paid off by the time I have to go in next year.

None of that would be possible without health insurance. None of it. And again, I am one of the upper tiers as far as lucky goes when it comes to health insurance. I’m having this shit done. A shit ton of Americans can’t, and that’s before the Republicans have their way and dismantle the ACA. What they want to do is cruel, inhuman, and flat out evil. The slashing of funds to deal with the opiod epidemic and things like that will stand out, but all of it is uniformly vile and awful. They are just horrible people beyond redemption. They sicken me emotionally, and they intend to sicken the nation physically, all just to throw a couple more bucks to the already rich. I don’t know how these reptilian motherfuckers sleep at night.

In house related news, my water filter needed to be replaced on my fridge. So I went and bought a new one. I installed it. The warning light was still on. I read the manual from cover to cover. I googled. Couldn’t find help anywhere. So I called GE and I spent an hour on the phone to have a person tell me to turn my unplug/plug my fridge back in to get rid of the warning light. He called it a “factory reset” to justify his existence and for me to not feel like a stupid asshole who is confused by household appliances.

I also found another board on the back deck (right next to the one I fell through) that needs to be replaced, so now I am wondering if I should have another expert come in and check the entire damned thing. I think it is too big to begin with, but I am not financially prepared to rip it out and replace it, so mending will have to be all I do.

The garden is weeded and up looking good. I did not put in raised beds yet because $$$, and I had a large portion of the yard where the ground was really uneven and nothing but shitty weeds were growing, a remnant of the yard being in disrepair so long. Remember, the weeds were chest high when I bought the place. So what I did this year was just plow up a big section of it and plant a garden right in the damned middle where I know I will have to level next year, and I am using that. It is unsightly, but it works. Next year I will get a dumptruck of topsoil and fill that in and seed it.

Also next summer I have decided I am going to ring the outside of the fence with native flowers and the like. The front yard has shrubbery and all that, and i will plant some bulbs and some other stuff there, but around the sides the length of the house I am going to plant day lilies, snap dragons, sage, milkweed, black eyed susan’s, milkweed, and use that and have a more free look than the paean to Prussian order that is my front yard. I figure I will have those around the whole yard and then I can plant a solid butterfly/bee garden in the back yard with a little butterfly pond. Under the pines I am going to put in blueberry and blackberry bushes.

The front yard is looking ok, but I apparently have swarms of ground bees (they are yellowjackets), so I bought some thing I have to pour into the nests to kill them. I don’t like pouring chemicals into the ground for obvious reasons, but I also don’t want swarms of bees attacking ABC’s kids when they come down.

Today while getting the water filter at Lowe’s, I picked up a flag mount for the front porch and a nice nylon flag. Is there a specific etiquette to where you hang it- if you are facing the house, to the right or to the left? I know neither adheres to official flag regulations, but I was wondering if there was an informal rule.

Finally, I got a fern. For some reason, I love ferns, but everyone says “don’t get a fern they are a pain in the ass.” They are probably right, but I have Thurston, so my definition of pain in the ass might be a little bit different than other people. At any rate, I am hanging it from the ceiling on the landing of the stair case in between the first and second floor by the window. I just think it will look good there, especially with pictures lining the staircase walls. Now I am looking for a neat pot hanger to go with it. I like this, but it seems kind of expensive:

Any thoughts? I thought it would go well with the colors of the house.

That’s about it for me. Guess I will sit down and start searching netflix and amazon prime for something to binge.

“Fundamental Meanness”

President Obama posted a heartfelt plea on Facebook asking legislators to rethink their support of the heinous Trumpcare bill and encouraging citizens to speak out. An excerpt:

I recognize that repealing and replacing the Affordable Care Act has become a core tenet of the Republican Party. Still, I hope that our Senators, many of whom I know well, step back and measure what’s really at stake, and consider that the rationale for action, on health care or any other issue, must be something more than simply undoing something that Democrats did…

I was careful to say again and again that while the Affordable Care Act represented a significant step forward for America, it was not perfect, nor could it be the end of our efforts – and that if Republicans could put together a plan that is demonstrably better than the improvements we made to our health care system, that covers as many people at less cost, I would gladly and publicly support it.

That remains true. So I still hope that there are enough Republicans in Congress who remember that public service is not about sport or notching a political win, that there’s a reason we all chose to serve in the first place, and that hopefully, it’s to make people’s lives better, not worse.

But right now, after eight years, the legislation rushed through the House and the Senate without public hearings or debate would do the opposite. It would raise costs, reduce coverage, roll back protections, and ruin Medicaid as we know it. That’s not my opinion, but rather the conclusion of all objective analyses, from the nonpartisan Congressional Budget Office, which found that 23 million Americans would lose insurance, to America’s doctors, nurses, and hospitals on the front lines of our health care system.

The Senate bill, unveiled today, is not a health care bill. It’s a massive transfer of wealth from middle-class and poor families to the richest people in America. It hands enormous tax cuts to the rich and to the drug and insurance industries, paid for by cutting health care for everybody else. Those with private insurance will experience higher premiums and higher deductibles, with lower tax credits to help working families cover the costs, even as their plans might no longer cover pregnancy, mental health care, or expensive prescriptions.

Discrimination based on pre-existing conditions could become the norm again. Millions of families will lose coverage entirely.
Simply put, if there’s a chance you might get sick, get old, or start a family – this bill will do you harm. And small tweaks over the course of the next couple weeks, under the guise of making these bills easier to stomach, cannot change the fundamental meanness at the core of this legislation.

He’s right. Toward the end of the essay, President Obama says, “this debate has always been about something bigger than politics. It’s about the character of our country – who we are, and who we aspire to be.”

That’s what worries me — that the “fundamental meanness” at the core of the GOP bill reflects the selfishness of Americans all too well.

I’ll make my daily calls, show up at meetings and continue to support candidates and programs that make people’s lives better — even stupid people who think the way to give “elites” the finger is to vote for a buffoon in a golden tower who craps in a golden toilet.

But at some point, the people who keep enabling this shit have to suffer the consequences. I’m not talking about morons like Trump, ghouls like Ryan or money-grubbing pricks like McConnell; I’m talking about the voters who put them office.

Maybe when they hit the lifetime cap on their crappy insurance plan, sell everything they own, alienate family members and friends with constant begging and their cancer-stricken child still dies because they can’t afford treatment, they’ll get it. Maybe when their dementia-riddled, incontinent grandmother is ejected from the assisted living facility for non-payment and dumped on their doorstep, they’ll understand.

Or maybe they’ll never get it. Maybe this really is who we are, and who we aspire to be — or enough of us to make those of us who hope for something better irrelevant. If we let these bastards get away with robbing millions of people of healthcare access, if they don’t pay with their jobs, I really don’t know how we can argue otherwise.

Mitch McConnell Will Not Hesitate to Abuse People with Disabilities

Literally. As long as he doesn’t have to show his face on camera, of course.

I doubt McConnell does think he’s a good guy, actually; he figures he’s defending his cushy “leadership” job, and whatever it takes to accomplish that is just fine by him.

Take me to the airport

A lot of Senators are flying home tonight out of Washington National Airport. This is a pretty sweet way to let them know what we think of their shitty health care bill.

See Ya In Court, Jackass

Or probably not, as this will quickly get thrown out:

A Republican coal baron is suing John Oliver, HBO, Time Warner, and the writers for Oliver’s show over the most recent episode of Last Week Tonight.

The suit, filed on June 21 in the circuit court of Marshall County, West Virginia, holds that Oliver and his team “executed a meticulously planned attempt to assassinate the character of and reputation of Mr. Robert E. Murray and his companies” by airing an episode that ripped into him. Murray runs the country’s largest privately owned coal company, Murray Energy Corporation.

“They did this to a man who needs a lung transplant, a man who does not expect to live to see the end of this case,” reads the complaint, which also lists Murray’s companies as plaintiffs.

The lawsuit isn’t a surprise to Oliver. In fact, the British comic said on the episode of his show that aired on June 18 that he expected it, noting that Murray has sued several other media outlets in the past (including, in May, the New York Times). In the episode, Oliver criticized Murray’s business practices, saying he doesn’t do enough to protect his miners’ safety. Oliver also noted that his team contacted Murray’s company before the episode aired, and that the company sent a cease-and-desist letter––the first time that had ever happened to his show.

In the interest of full disclosure so Mr. Murray will not sue me and because I am a big fan of the Streisand effect, here is the entire Last Week Tonight piece:

Screw Murray.

Good manners and bad breath will get you nowhere

You all know by now that SC-5 ended up being closer than GA-6. You probably also know that SC-5 is full of hopeless rural idiots whereas GA-6 is full of well-educated suburbanites who just need a little non-ideological persuasion to start voting Democrat. David Atkins nails it:

The lesson of the special elections around the country is clear: Democratic House candidates can dramatically outperform Clinton in deep red rural areas by running ideological, populist campaigns rooted in progressive areas. Poorer working class voters who pulled the lever for Trump can be swayed back to the left in surprisingly large numbers—perhaps not enough to win in places like Kansas, Montana and South Carolina, but certainly in other more welcoming climes. Nor is there a need to subvert Democratic principles of social justice in order to accomplish this: none of the Democrats who overperformed Clinton’s numbers in these districts curried favor with bigots in order to accomplish it.

But candidates like Clinton and Ossoff who try to run inoffensive and anti-ideological campaigns in an attempt to win over supposedly sensible, wealthier, bourgeois suburban David-Brooks-reading Republican Romney voters will find that they lose by surprisingly wide margins. There is no Democrat so seemingly non-partisan that Romney Republicans will be tempted to cross the aisle in enough numbers to make a difference.

The way forward for Democrats lies to the left, and with the working classes. It lies with a firm ideological commitment to progressive values, and in winning back the Obama voters Democrats lost to Trump in 2016 without giving ground on commitments to social justice. It does not lie in the wealthy suburbs that voted for Romney over Obama in 2012, or in ideological self-effacement on core economic concerns.

I think it’s quite possible to run different kinds of campaigns in different areas, and I’m not faulting Ossoff for running the campaign he did. But I do think there’s something fucked up about the Democratic party’s idea that it should run civil, non-ideological campaigns. We’re not running to be the president of Fred Hiatt.

No amount of civilitude and centrist common sense is going to get suburban upper-middle class white voters who have spent their entire lives voting Republican to reconsider their obsession with tax cuts and become Democrats en masse (yes, you can pick off a few I’m sure).

The whole non-ideological civilitude thing smacks of class bullshit. We don’t need to fight, we’re all reasonable here, not like the poors! That’s what it sounds like to me, at least. Republicans have gotten lower-income white Americans to vote Republican by feeding them xenophobia and resentment. Xenophobia doesn’t pay your medical bills. Obamacare does. We just can’t cede rural America to Republicans, not when Republicans are offering so little to rural America policy-wise.

The summary of the Senate AHCA

Here is the TLDR of the Senate AHCA draft.

There are a lot of details that matter (I even like Sec. 102-b-1-B-II) but that is the fundamental difference.

CPI-U comes into play for Medicaid funding in FY 2025.
Per Capita Caps are in play for Medicaid
Enrollment caps for block grants for Medicaid are in play.

Old people in Alaska will be paying 16% of their income in premiums before receiving subsidy assistance.

Taxes are being cut massively with no incentive effect intentions.

There are massive work disincentives embedded in multiple spots throughout the bill

Deductibles are going up

Silver and Gold plans will be hideously priced and hyper narrow networks to dodge sick people

Section 1332 waiver protections are gutted

Any federal dollar can not be in the same zip code as a dollar that is used for abortion

New York is getting hit hard on both the Buffalo Kickback and the Basic Health Plan as immigration status is tightly defined.