The Feds, tightening and 2018

Just an interesting thing to note for the 2018 elections.

The Federal Reserve is in a tightening cycle (for what reason, I’m not sure as the data does not support a need to tighten). If the short term interest rates are above neutral, that means the economy will be worse than it otherwise would have been. A bad economy is bad for incumbent parties that hold all responsibility (see 2010 for Democrats).

So



Time to call Congress

The AHCA has more lives than a serial killer in a horror movie franchise.

The House Freedom Caucus has an agreement to make the bill worse by allowing states to completely opt out of guarantee issue and essential health benefits.

Steven Dennis of Bloomberg has a good fast analysis of the changes:

Most of the House Freedom Caucus is most likely on board with this bill. That reduces the firm no’s that are not in the HFC down to about 20. The No’s from March need to hear from you again. The unknowns and the shaky yeses need to hear from you.

They also need to be reminded of the following:

There is a minimal blocking coalition of Republican representatives who sit in seats that voted for them and Hillary Clinton. Time to remind them that they can’t survive an electorate that is nine points more Democratic in 2018 than it was in 2016. They know that, but let’s remind them.

So time to call Congress again.

I am convinced that any Republican only health care bill will either pass by 3 votes or fail by at least 15 votes.



Third time’s a harm

The Huffington Post has the outline of yet another Republican healthcare deal:

he deal, brokered between House Freedom Caucus chairman Mark Meadows (R-N.C.) and Tuesday Group co-chairman Tom MacArthur (R-N.J.), would allow states to get waivers eliminating the so-called community rating provision ― the rule that prohibits insurers from charging higher premiums to people with pre-existing conditions. In order to obtain the waiver, states would have to participate in a federal high-risk pool or establish their own, and satisfy some other conditions.

In exchange for that conservative concession, the amendment would reinstate the Essential Health Benefits that were already taken out of the bill ― though, again, states could waive those provisions as well if they were able to show that doing so would lower premiums, increase the number of people insured, or “advance another benefit to the public interest in the state.”

What does this mean?
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Super Ugly Waiver (It’s back)

The AHCA is not yet dead. It was just resting for a bit before joining the choir invisible.

The New York Times reports that the White House and the House Freedom Caucus (the hard right flank of the House GOP) have been talking and thinking they have the contours of a deal.

The terms, described by Representative Mark Meadows, Republican of North Carolina and the head of the Freedom Caucus, are something like this: States would have the option to jettison two major parts of the Affordable Care Act’s insurance regulations. They could decide to opt out of provisions that require insurers to cover a standard, minimum package of benefits, known as the essential health benefits. And they could decide to do away with a rule that requires insurance companies to charge the same price to everyone who is the same age, a provision called community rating…..

In simple terms, a carrier can’t deny a hemophiliac coverage but they can charge an actuarial fair premium of $90,000 per year. A carrier can’t deny a young woman who either is or intends to become pregnant. They just don’t have to cover the prenatal or labor and delivery costs.

It is effectively a slightly modified option 3 of Cassidy-Collins where states can return to the 2009 status quo if they so actively elect to do so. If we combine a single state choosing this route and sell across state lines, it would lead the entire country’s individual market back to 2009.

I may be reading too much into the conditional language but to me this is a SUPER (ugly) WAIVER provision. It modifies Section 1332 guard rails to basically meaninglessness. States could then choose to do whatever the hell that they want without concern for coverage requirements. Currently Section 1332 and other waivers in health policy have an equality clause where the states’ preferred options must be at least as good for beneficiaries. This rule would render that null. And I don’t think many/any states would actually take the Feds up on this option as the localized consequences are too immediate and real but if the goal was to design a bill that could get 12% support instead of 17% support, this would be it.

Update 1 This sounds about right to me:

I have no idea how the Tuesday Group stays on board. They were a sufficient blocking coalition under AHCA V1 once the flood gates were starting to open up. The politics of health reform are nasty in the best bills and this is a devolution of a very bad bill. The marginal members of a majority sitting in opposite party or break even districts are the first ones to get hit in a wave.



ACHA EHB CBO state of play

Right now there are three primary possibilities for the ACHA tomorrow:

1) No vote is taken as more wrangling and tweaking occurs
2) Vote fails as the combination of Tuesday Morning Group Republicans and the House Freedom Caucus vote against the bill from both ends of the Republican caucus. This is where we were most likely to have been at at 1800 EST on March 22, 2017
3) ACHA advances as the House Freedom Caucus gets a major policy concession, the elimination of Essential Health Benefit requirements.

#3 is what I want to discuss. It would produce a massive cluster. The bill needs to go through the Senate as a reconciliation bill with several significant requirements. One of those requirements is the items are germane to the budget. Since the other parts of the bill have stripped the link between premiums and subsidies, lower premiums are not germane to the budget. It will get stripped.

More importantly, the optics will look ugly. The Congressional Budget Office

If there were no clear definition of what type of insurance product people could use their tax credit to purchase, some of those insurance products would probably not provide enough financial protection against high medical costs to meet the broad definition of coverage that CBO and JCT have typically used in the past—that is, a comprehensive major medical policy that, at a minimum, covers high-cost medical events and various services, including those provided by physicians and hospitals.

IF Essential Health Benefits are dropped from the bill, the CBO will project that insurers will respond by offering very skinny benefit packages (no maternity or substance abuse inpatient services for instance as both qualify as high cost events) that are targeted to be priced at precisely the subsidy value. If there is no regulation as to what a carrier needs to include with a given maximum out of pocket requirement, two things will happen. A lot of people who otherwise would not use their subsidy would use their subsidy. And most people who are buying mostly on price will be buying policies that the CBO does not deem to be insurance.

Jed Graham has been bird-dogging this angle hard:

Because the GOP bill would mostly retain ObamaCare coverage rules, insurance would be unaffordable for lower-income and older adults with the new, smaller tax credits on offer, so some 30 million people wouldn’t claim the GOP tax credit averaging $3,000 in 2020 and rising with inflation. That would add up to more than $600 billion in unclaimed subsidies through 2026, or roughly the same $600 billion amount by which House Speaker Paul Ryan’s plan cuts taxes. Those unspent subsidies go a long way to explaining why CBO found that the American Health Care Act would reduce deficits by $323 billion over a decade.

So the end result if Title 1 is the price of passage is the following:

  • Guarantee failure in the Senate
  • Adds to the deficit immediately
  • Adds millions more people to the ranks of the uninsured as defined by the CBO over and above the 24 million that is the current score

/Dave Anderson +3

Update 1:
And it looks like Option #3 is on the table

 

Update 2

Dave +3.5



Punitive 1115 waivers will be approved

The Medicaid 1115 waiver program allows states to apply for and receive permission from the Center for Medicare and Medicaid Services (CMS) to waive certain federal guidelines for Medicaid. Almost every state has a 1115 waiver for something. They are most commonly known as the alternative pathway for Medicaid Expansion for Red states.

CMS just released a letter last night indicating that it has new guidance and new desired boundaries for 1115 waivers that it will now approve. CMS is looking for more punitive waiver applications as well as indicating that it is willing to take Indiana HIP 2.0 HSA based Medicaid expansion to a national scale.

Deprioritizing etc — Really — your administration wants to cut $880 billion from Medicaid over a decade for upper income tax cuts so please cut the sanctimony.

Here is the work requirement.

The Obama Administration would not tie Medicaid to work requirements. Medicaid is a medical program. There are other work search and job training programs that are optimized as such.

This is a combination of splitting the poor into the deserving and non-deserving as well as an introduction of friction to decrease enrollment. Most people on expansion are either working, looking for work, in school or a primary care giver for dependents with significant needs. There are very few lazy lay-abouts. Instead these requirements create more hurdles that people have to jump, more hoops they have to shimmy through and more opportunities for their paperwork to be messed up. It aligns with the ritualistic humiliation of drug testing requirements for unemployment and TANF benefits. It is an assertion of power.

It won’t significantly reduce costs. The Kentucky 1115 application that was submitted last summer is good proof of that.
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Bronze is a great age

I want to look at one element of the CBO score. It is the offered actuarial value of plans. Under the House Bill, out of pocket maximums would be fixed but there would be no age banding. The CBO sees this having an interestingly low effect.

Beginning in 2020, the legislation would repeal those requirements, potentially allowing plans to have an actuarial value below 60 percent. However, plans would still be required to cover 10 categories of health benefits that are defined as “essential” under current law, and the total annual out-of-pocket costs for an enrollee would remain capped. In CBO and JCT’s estimation, complying with those two requirements would significantly limit the ability of insurers to design plans with an actuarial value much below 60 percent.

Mechanically, under the House bill without a follow-on phase 2 or phase 3 bill, insurers can probably design plans that have at least 55% actuarial value (AV) coverage as the minimum level of coverage. Bronze right now is 60% +/-2 points of AV.

It will be very hard for people to buy a non-Bronze plan because insurers won’t offer them except at exorbirant prices. Let’s work through my logic.

Insurers are currently required to offer at least one Silver and one Gold plan if they want to sell on Exchange. Those plans are age rated at 3:1 with subsidies absorbing almost all of the local price increase risk for the Silver plan. Under the AHCA, those requirements are not in place and the subsidy is not tied to local pricing. Young buyers who are healthy will either opt out or buy the lowest actuarial value coverage possible because it will cost them very little.

Insurers then have to look at the people who actually need coverage and cost money to cover. They’ll offer a Bronze plan to get the young people in. But if they see a 58 year old asking for a Silver or Gold plan, they know that this person is going to be hyper expensive to cover as they have just self-identified as being high risk and high expense. Insurers won’t offer actuarial value levels above the minimum requirements because they will lose money on those policies.

So we will quickly see a proliferation of $6,000 to $9,000 deductible plans and very little else. That means the 64 year old who is seeing a $10,000 a year premium increase will also see their deductibles increase by $4,000 to $7,000 a year.