Good morning —
For the RTP-ers in the readership, let’s meet at Ponysaurus Brewing Company for beer and bites this Wednesday at 5:30. I will have green balloons on the back of my chair.
219 HOOD STREET, DURHAM, NC 27701
Dave
I am a student in the doctoral program at the Duke University Department of Population Health Sciences. I am working towards my my doctorate in Health Services Research with a policy focus. I am fundamentally fascinated by insurance markets, consumer choice and the navigation of complex choice environments. I'm currently RA-ing at the Duke Margolis Center for Health Policy.
I used to be Richard Mayhew, a mid-level bureaucrat at UPMC Health Plan. I started writing here and have not found a reason to stop.
Conflicts of interest: Previously employed at UPMC Health Plan until 12/31/16. I also worked full time as a research associate at the Duke University Margolis Center for Health Policy. I have received direct funding from the National Institute for Healthcare Management, and I have been on projects funded by the Rockefeller Foundation, Kate B. Reynolds Charitable Trust, Gordan and Betty Moore Foundation, Duke University Health System, CMMI, and various value based payment consortiums. I serve as a consultant on a grant from the Commonwealth Fund and have acted as a consultant to several ACA insurers.
Research Production is here: https://scholar.google.com/citations?user=zof9b4IAAAAJ&hl=en
David Anderson has been a Balloon Juice writer since 2013.
by David Anderson| 23 Comments
This post is in: Meetups and social events
Good morning —
For the RTP-ers in the readership, let’s meet at Ponysaurus Brewing Company for beer and bites this Wednesday at 5:30. I will have green balloons on the back of my chair.
219 HOOD STREET, DURHAM, NC 27701
Dave
by David Anderson| 17 Comments
This post is in: Anderson On Health Insurance
The most important health policy law that is not the Social Security Act or its amendments is one that operates in the background. The 1974 Employee Retirement Income Security Act is the 800 pound gorilla that controls employer plans that are organized on a self-payment basis. Self-insured plans cover roughly 60% of all people who get their insurance via work. ERISA has a legal concept of pre-emption where ERISA overrules all state laws regarding regulation on self-insured employer plans. This ranges from benefit requirements to whether or not a self-insured plan has to send a claims file to a state all-payer claims database.
It is the 800 pound gorilla that lurks in the back ground ready to smash barrels and throw bananas at state based reforms.
Jon Walker at Shadowproof has a series of posts that is trying to lay out a path to single payer. He is grappling with complexity and faces the scope of the problem that ERISA has:
State-based health care reform would be fairly easy if the state could simply require every employer to buy their employees the state-based, Medicare-like insurance policy or pay a large tax.
Back in 1974, Hawaii adopted a strong employer mandate law that required good private coverage before Congress adopted ERISA so it is exempt from the federal law. The Hawaii plan was fairly straightforward and worked well. ERISA prevents anything like that from happening now.
Unable to directly regulate most employer-sponsored health plans, state based reform plans tie themselves in knots trying to work around it. Most state single-player plans would indirectly but strongly encourage companies to drop insurance benefits and increase wages to make up for it.
ERISA is a straitjacket on state level reforms. Jon looks at options that are viable work-arounds ranging from a comprehensive national ERISA waiver system to incremental improvements.
ERISA can also be used as a measure of how big of a change a proposal wants to be. If there are two reasonably well thought out proposals on the table and one opens up ERISA and one does not, the proposal that touches ERISA is far more likely to be a big system transformation bill. The bill that does not touch ERISA is more likely to be an incrementalist bill.
by David Anderson| 185 Comments
This post is in: 2020 Elections, C.R.E.A.M., Election 2016, Election 2018, All we want is life beyond the thunderdome
Josh Marshall makes a very good point this morning about Trump’s toxicity:
Every president has these industry councils like the ones we’ve been talking about in recent days. They range from meaningless to not terribly important. They’re mainly symbolic. With everything that’s happened in recent days, I don’t want to make it out like the decisions of a small number of CEOs is the biggest news. Still, we should recognize that it is entirely unprecedented to have a sitting president become so toxic that corporate America feels unable to publicly associate with him. That is totally, totally new territory.
Last November, the Brookings Institute looked at the election and they made a very key point. The areas of the country where there was both population density and wealth voted for Clinton.
Visibly enraging not-Trump voters is a money loser.
This post is in: Anderson On Health Insurance, Politics
Andrew Sprung at Xpostfactoid has pushed back on my argument that Democrats have the advantage of inertia on the CSR funding argument. He raises an excellent point.
1. Cost. CBO projects premium increases of 20% right off the bat in 2018 and 25% by 2020. Higher premiums mean more people qualify for subsidies, and those subsidies are bigger. CBO projects a 10-year cost of $194 billion — to increase coverage by 1 million. In 2026, that 1-million coverage boost would cost a cool $37 billion. CBO’s 2016 projection for spending on marketplace subsidies in 2026 is $106 billion. Imagine the effects of increasing that spending by 36% in more rational ways. Compare, for example, the comprehensive set of subsidy sweeteners proposed by Urban’s Blumberg and John Holahan in 2015 — which included raising the AV of benchmark plans to 80%, reducing the percentage of income paid at every level and capping premiums for all buyers at 8.5% of income. The authors estimated the ten-year price tag at $221 billion over ten years.
This is a very good point. The coverage gains bought by loading all CSR costs onto Silver only are an extraordinarily inefficient way to expand coverage and improve the law. I am not disputing that at all. There are better ways to spend the money to increase coverage. The same coverage increase can be bought far more cheaply by tweaking Medicaid matching rates or encouraging some creative 1332 waivers.
In Health Affairs, Steven Chen has a good blog post on how states could use the CSR windfall to improve coverage via a 1332 waiver. He uses California and 2016 numbers for his example:
Using California as an example, Covered California showed that the termination of CSR payments by the Federal government would cause insurance premiums for silver plans in the individual market to increase by 16.6 percent in 2018. The study also showed an inverse relationship between CSR and APTC: The Federal government paid $750 million in CSR payments in 2016, but if it were to defund CSR payments, not only would it not receive any savings, it would incur an additional $976 million in APTC spending. Using these figures as illustration, if the Federal government had terminated CSR payments in 2016 and if California had provided CSR payments through a 1332 Waiver, under this scenario California would have to pay $750 million in CSR payments, but it would receive $976 million from the Federal government in lost APTC payments—payments California would have otherwise received without waiver—ending up with a total net profit of $226 million!
The ACA needs a technical corrections bill. It needs a “it’s been live for four to eight years and some things work and some things didn’t, let’s push the things that work and fix or drop the duds… bill”
Not funding CSR sets a plausible outcome absent of an agreement. It is a boundary condition. Deals get made when all sides of a deal believe that they have an outcome that is better through an agreement than the outcome which would occur without an agreement. I can easily and readily see deals.
There could be a trade where CSR is funded and $75 billion dollars are allocated to reinsurance and $30 billion dollars are allocated to increasing subsidies for people who make between 200% and 500% FPL. There could be a trade where $100 billion dollars are spent to up CSR 73 to CSR 80 and then adding a new tier of CSR for people making between 250% and 325% FPL so their Silver is now has an actuarial value of 75%. There could be a trade where Medicaid 1115 waivers can be integrated with 1331 (Basic Health Plan) and 1332 (State Innovation) ACA waivers as well as additional funding for safety net hospitals and community health centers. There could be dozens of deals that spend less money, cover more people and fix known problems. But all of these deals are premised that the outcome due to no agreement is a significant albeit inefficient Democratic policy victory.
by David Anderson| 66 Comments
This post is in: Beer Blogging, Open Threads
My little girl is getting bigger every day.
I just needed to share one of my prouder parenting moments as a momentary break from current event craziness:
Baby’s first keg stand from oh so long ago.
Open thread
by David Anderson| 97 Comments
This post is in: Hail to the Hairpiece, #notintendedtobeafactualstatement, Good News For Conservatives
Axios is getting fed a line of bull:
The White House chief strategist has told associates he never intended to do an “interview” with an editor at the American Prospect, a left-wing publication.
Bannon has told associates that he admired the author’s stance on China, and so called the journalist, Robert Kuttner, on Tuesday, to discuss his piece. Apparently Bannon never thought that the journalist might take his (very newsworthy) comments and turn them into a story. It’s Anthony Scaramucci all over again (minus the curse words.)
Bull.
I’m a health policy analyst with some press contacts but I am a virtual no one in the grand scheme of things.
I know that everything I say starting with “Hello” is on the record unless both parties specifically agree that a conversation or part of a conversation is either off the record, for background or not for attribution. Yes, I know that some of my comments will never be printed. Those are often comments regarding how freaking adorable the puppy pictures on Twitter are but everything can be printed.
Several months ago, I was in DC for work. I try to get my work down and I also try to meet with people I talk to on Twitter so I can put names and voices to Twitter accounts. I arranged a coffee with a reporter. We met and as soon as I finished stirring my coffee, the reporter had a tape recorder out just in case we discussed anything super interesting. Did that shape how I expressed some ideas? Yes, but we still had a great conversation and we both came out of it with a better understanding of the other. That’s life when talking with a reporter.
by David Anderson| 229 Comments
This post is in: Hail to the Hairpiece, All we want is life beyond the thunderdome, Bring on the Brawndo!, Fucked-up-edness, Go Fuck Yourself, Good News For Conservatives
A statement by the President: pic.twitter.com/liWE4rlleF
— Real Press Sec. (@RealPressSecBot) August 16, 2017
Update Thank you to Adam for finding live footage of Trump’s current Cabinet meeting: