David Anderson

Bhanja et al have a new JAMA Health Forums article that asks a very important question:

For people who barely qualify for Medicaid Expansion instead of ACA CSR (Cost-Sharing Reduction) plans, are there differences in enrollment rates?

The short answer is YES!!!!

In this cross-sectional study with a regression discontinuity analysis of 87 542 US adult enrollees in Medicaid and private insurance, marketplace enrollment was 81.3% lower than Medicaid enrollment in 2014 and 88.6% lower in 2015 among those close to the eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults.

These are huge differences (80%+) where a few hundred dollars of additional income can dramatically change the probability of being insured.

Younger individuals were more likely to not be enrolled in ACA plans if they were just above the income threshold.

Individuals with significant pre-existing conditions were slightly more likely to be enrolled in ACA if they were above the income threshold.

But no matter how the data is sliced, the drop-off in coverage for people who are just eligible for Medicaid Expansion to people who are just eligible for only CSR ACA plans is massive.

So what is going on here?

There could be a couple of different things. Medicaid does not have premiums. ACA Silver plans have premiums of 2% to 4% of income for the group in question. Medicaid has little to no cost-sharing while even a CSR-94 Silver plan has significant cost-sharing for someone earning under 150% FPL. This same research team had found significant cost-sharing differences between folks who were just Medicaid eligible and just ACA eligible during the same time period from a January 2021 manuscript. The ACA plans were new during this research study so there was also a lot of learning by doing on finding a new pathway into a new system.

It seems like, at least early on, that there were a massive number of barriers to access and enrollment for individuals who were just barely eligible for ACA plans. Improvements in the consumer shopping experience and the proliferation of zero premium plans through ARA enhanced subsidies likely has removed some of these barriers but they are likely to remain as the entire process is predicated on constant choice and multiple points where an individual who wants health insurance can screw up. Expanding Medicaid eligibility further up the income scale is a possible improvement path by lowering barriers to enrollment, decreasing consumer cost-sharing and likely decreasing federal spending. Individuals and the federal government would be likely winners, while state general funds would be a loser if there is not a waiver to pass-through ACA funds to further Medicaid expansion, and clinicians would also likely see a reduction in income.

Enrollment differences between Medicaid and CSR plansPost + Comments (4)

This morning, the Supreme Court in a 7-2 decision ruled that none of the plaintiffs in the suit Texas v California had standing to sue, and therefore the suit that had sought to toss the entire ACA should never have been brought or ruled upon. The ACA survives.

BREAKING: The Supreme Court rejects the constitutional challenge to Obamacare in 7-2 opinion. The court tosses the lawsuit because the challengers do not have legal standing to sue. https://t.co/meuQgPE50Z

— SCOTUSblog (@SCOTUSblog) June 17, 2021

The theory of the case that the plaintiffs brought was that the Republican tax cut bill signed in December 2017 zeroed out the individual mandate penalty and therefore made the mandate more coercive and not a tax. From here, they argue that the individual mandate is unconstitutional. And they then argued that the individual mandate was critical to the rest of the law, and thus it was not severable from any part of the law and the entire law must then be tossed.

The court’s majority opinion, written by Justice Breyer, said a zero dollar mandate penalty with no enforcement mechanism is not an injury, it is effectively a statement that puppies are awesome and ice cream is yummy, and thus the individual plaintiffs had no particular injuries. The state plaintiffs have no standing because their complaint is about other aspects of the ACA that causes paperwork requirements and policy outcomes that they don’t like, and it can not be traced directly to the individual mandate that a state by definition never paid.

There are a few other legal challenges to the ACA; most notably the role of the bodies that places some services into the no cost sharing tier of essential health services. But right now the ACA insures 30 million people and it is here to stay.

The ACA survives at the Supreme Court (Part Trois)Post + Comments (87)

Earlier this week, I presented the following virtual poster at Academy Health’s 2021 Annual Research Meeting (ARM-21). I’m part of a team centered at Duke Margolis and funded by the Kate B. Reynolds Foundation to examine North Carolina Medicaid policy. As part of this remit, we looked at patterns of disenrollment and churn (coverage loss and then fairly rapid regain) for adults from 2016-2018. This poster focuses on Medicaid churn for post-partum women.

Medicaid pays for a significant number of all births in the country. Pregnant women have looser income qualification criteria for Medicaid than most other forms of Medicaid. In North Carolina, a single woman with no kids and in good health can not qualify for Medicaid at any income level. However, a pregnant woman can qualify for pregnancy Medicaid if she earns less than 196% Federal Poverty Level (FPL). This pregnancy eligibility expires 60 days after birth. At this point, a mother will either be moved to a different Medicaid eligibility group such as income based caregiver Medicaid where she can earn up 41% FPL for a family of two (or more) or she is disenrolled.

Not every woman who gives birth while insured by Medicaid is eligible via the pregnancy channel. Does this matter for disenrollment and churn?

Yes!

Individuals who gave birth while eligible via the Aged, Blind, Disabled channel had a far lower risk of losing coverage at any point than any one else.

Individuals who were income qualified at the moment of birth have reasonably stable enrollment through the year post-partum.

Individuals who were on pregnancy Medicaid had significant coverage losses at the end of 60 days. Roughly a quarter of these individuals were disenrolled immediately at the end of sixty days. Three fifths were redetermined into the income qualified group.

We then looked at who disenrolled and came back.

Sicker individuals who lost coverage were more likely to re-enroll. Women who were covered in either income or the ABD eligibility groups were more likely to churn.

Why does this matter?

Insurance disruptions are care disruptions. The US has a significant maternal mortality problem. Churn (coverage loss and then coverage regain in a short time period) is likely indicative of administrative frictions rather than true eligibility losses. Fixing churn likely means more people will get insurance that they qualify for. The American Rescue Plan allows states to file a State Plan Amendment to extend the post-partum Medicaid eligibility period from 60 days to 1 year. This likely will reduce disenrollment and churn.

More on maternal Medicaid churn post-partumPost + Comments (9)

A few weeks ago in comments, I was asked if the United States would ever have universal or at least near universal coverage.  My response was that we already have it; it is just very unevenly distributed.  Massachusetts and Hawaii have 96% to 97% coverage rates at any one time.  We have a variety of means and programs and pathways to get to near universal coverage and we have proof of concept in several states.  Conversely, Texas has an 18% uninsurance rate.

This is not a problem amenable to modest technocratic tinkering.  It is a fundamentally a give a damn problem that once a damn is given, there are numerous technocratic pathways to solving the problem.

This is even more readily apparant in a new paper by Dr. Jamie Daw et al in JAMA Health Forum.  They examine the variation in post-partum uninsurance rates for women who gave birth while covered by Medicaid.  Medicaid pays for a large plurality of all births in the United States and its coverage rules allow for women with higher incomes than legacy Medicaid.  Pregnancy Medicaid goes for sixty days post-birth at which point the woman has to be redetermined into either another category of eligibility for Medicaid or is disenrolled from Medicaid.  The American Rescue Plan allows states to file a state plan amendment to extend the sixty days of post-partum eligibility at standard federal cost reimbursement to one year; many states either have or are looking to take up that option.

But there was one line that leaped out at me in this article:

This is fundamentally a give a damn problem.

Insurance coverage and give a damnPost + Comments (5)

Last week, the FDA approved a new drug, aduhelm, for Alzheimer’s Disease.  The evidence that this drug does much, if anything, for patients is extremely thin.  It is also going to be priced at $56,000 per person per year, with several million people who are eligible to receive the drug.  In the Friedman-Weiner framework, this is a Type 2 drug (New, not very effective drugs that are expensive.) This drug, and the issues it raises, will be a massive health policy story for the next five years.

 

1/ OK, everyone, buckle up. @RESachs and I have a piece @TheAtlantic about Aduhelm.

It’s about how the law links FDA approval to payment policy, which means we’re likely to spend through the nose for a drug that may not work.https://t.co/rGfD67IQn6 pic.twitter.com/QB8dgVaPAB

— Nicholas Bagley (@nicholas_bagley) June 11, 2021

I am not qualified to speak on the linkage between the FDA approval  and CMS payment policy.  I will defer to others on that.

My first thought when I heard that this drug had been approved is that it is going to play merry hell with risk adjustment.  My second thought is that this is going to get prior-authorized to death.

Risk adjustment systems rely on previous years of experience to predict recurring, predictable average costs for a group of people with a condition or a cluster of conditions.  Claims are examined and then run through a big set of regressions and corrections to get an expected incremental cost of a disease.  Risk adjustment is always only going to be okay-ish when measured at the individual level.  Some people with a condition will cost a lot more to treat than statistically similar other people.  Conversely, some people are also comparatively cheap to treat.  Insurers care about the cost to cover individuals only net of risk adjustment.  There are plenty of ACA insurers that actively seek to enroll chronically ill individuals because risk adjustment makes covering a very sick person no more risky, and potentially more profitable than covering a healthy person.

Insurers want to find ways to cover folks who, individually, are overpaid in risk adjustment.  Insurers want to find ways to not cover folks who are underpaid after risk adjustment.

Aduhelm, if it is widely prescribed, is going to play merry hell with risk adjustment.  It has the potential to add a whole lot of costs to some people in an idiosyncratic manner.  It is likely that prescribers who are not under any risk based contracts will be more likely to prescribe Aduhelm than prescribers who are employed by organizations that take on the full cost of care.  In the next couple of years, individuals with Alzheimers will likely be estimated to be much more expensive and thus their risk adjustment transfers will increase even though the best evidence based protocols will not have changed.

I’m not sure what the games that will be played with risk adjustment, but given a huge technological/regulatory shock, it is likely that weird things will be happening in risk adjustment in a few years.

Technological and regulatory shocks with risk adjustmentPost + Comments (28)