Oklahoma Medicaid expansion is on the ballot

Oklahoma activists are going the same route as Utah, Idaho and Nebraska activists successfully used in the 2018 election cycle: They are trying to get enough signatures to get Medicaid expansion on the ballot.



If you live in Oklahoma, this question needs slightly more than 177,000 valid signatures to appear on the 2020 ballot.

Odds are that even if it passes, there will be follow-on shenanigans as we have seen in Utah, Nebraska and Idaho to either delay or water down the expansions. In my opinion, a bad expansion is better than a perfect non-expansion. I assess the counterfactual as no expansion instead of a full expansion so people with different reasonable counterfactuals will vehemently disagree with me.

The ballot box is not the only way that Medicaid expansion of some sort may come to Oklahoma. There is a bananpants county level expansion proposal floating out there.

Here the scheme would be two or more bordering counties could expand Medicaid. The state share of the expansion (10% of costs) would be funded by local taxes. This would be wonderful for health and public finance economists and a complete cluster for everyone else.

Idaho, Medicaid Expansion and optionality

Idaho’s voters passed an unrestricted Medicaid Expansion last November as state law.

Idaho’s Republican led legislature passed a convoluted Medicaid Expansion this week.

Idaho’s Republican governor signed the convoluted bill on Tuesday.

There is a lot going on in the law that requires significant policy waivers from the federal government. Work requirements are de rigeur and will likely be challenged in court.

The interesting, to me, segment concerns optionality of Exchange versus Medicaid coverage for people who earn between 100-138% Federal Poverty Level.

Another piece of the bill would put people on private health insurance, through the Your Health Idaho exchange, by default. If someone wanted Medicaid coverage instead, they could opt in. The carve-out would apply only to people with incomes between 100% and 138% of poverty level — $12,490 to $17,236 for a single person.

It’s a lighter version of Utah’s “bridge” expansion — a federally approved plan to expand Medicaid in Utah only up to the poverty line, leaving people who are slightly above poverty out of Medicaid but allowing them to get private insurance on Utah’s exchange.

Supporters said Idaho’s carve-out would save Idaho money, since those people would be getting insurance paid for by federal tax credits.

This idea is not shocking. Idaho has been playing around with partial expansions and carve-outs to pull people with high medical costs out of the Exchange risk pool before. If this optionality is approved, it would lead to a complex set of choices for people who make between 100% and 138% FPL.

Within the context of previous Idaho initiatives, this optionality makes local sense given local assumptions.

Staying on Exchange means no work requirements, continuation of network and some predictable cost sharing and premiums. Looking at the RWJF HIX Compare data, Idaho has few low net of subsidy Silver plans as the Silver Gap is minimal in most rating areas. Premiums will be a little higher.

An individual who elects Medicaid would face potentially more restrictive networks and potentially face work requirements and eligibility requirements but would gain lower premiums and lower cost sharing.

I am not sure which way the risk will flow if this waiver is approved. I could see an argument that high cost individuals would move to Medicaid as they would be eligible for a work requirement exemption and see their premiums and cost sharing go down. I could see an argument that low cost individuals would move to Medicaid as they would see their premiums go down and since they don’t use medical services all that much, networks and cost sharing are almost irrelevant.

The actuaries have to be sweating bullets. And the academics have to be submitting data requests to Idaho Medicaid and the Idaho exchange board for de-identified, risk stratified microdata for the 2020 policy year already.

BHP funding and wasted APTC

The Center for Medicare and Medicaid Services (CMS) released a proposed rule on funding the Basic Health Plan (BHP) for 2020.  They propose a rule that will lead to about a 3% reduction in federal spending to be counter-acted by a dollar for dollar increase in state spending.  BHPs are a part of the Affordable Care Act where states could run a program for people who earn under 200% of the Federal Poverty Level instead of running the exchange.  The BHP is funded by a block grant that is equal to 95% of what the federal government would have spent on premium and cost sharing reduction subsidies for the people who enroll in the BHP.

The termination of CSRs led to CMS cutting the CSR component of funding.  Minnesota and New York sued and a settlement was found where CMS attributed Silver Loading incremental premium increases to the BHP payments.  Dr. Lynn Blewett of the University of Minnesota and I examined this rule last year in a Health Affairs blog:

The BHPs in New York and Minnesota will receive almost half a billion dollars more in funding than they were told to expect in December 2017….

We can assume that 2019 BHP payment rules will continue to incorporate some type of plan adjustment factor that relies on an estimate of the silver increment due to the continued obligation of insurers to provide cost-sharing reduction payments without direct federal reimbursement. …

The plan adjustment factor in the proposed rule is the same exact plan adjustment factor as it was in the settlement rule. However CMS introduced a new factor this year; Metal Tier Selection Factor (MTSF) which is a multiplier to the rest of the formula that reduces what CMS owes.

After the discontinuance of the CSR payments in October 2017, several changes occurred that increased the expected impact of enrollees’ plan choices on the amount of PTC paid. Silver-level QHP premiums for the 2018 benefit year increased substantially relative to other metal-tier plans in many states (on average, by about 20 percent). We believe this contributed to an increase in the percentage of enrollees with lower incomes choosing bronze-level plans, despite being eligible for CSRs in silver-level plans, because many were able to purchase plans and pay $0 in premium; according to CMS data, the percentage of persons with incomes between 0 percent and 200 percent of FPL eligible for CSRs (those who would be eligible for the BHP if the state operated a BHP) selecting bronze plans increased from about 11 percent in 2017 to about 13 percent in 2018. In addition, the likelihood that a person choosing a bronze-level plan would pay $0 premium increased (and the difference between the bronze-level QHP premium and the available PTC widened). Between 2017 and 2018, the ratio of the average silver plan premium to the average bronze plan premium increased from about 117 percent to 133 percent;

Okay, that is a whole lot going on. Basically,CMS is saying that due to Silverloading, the gap between the benchmark silver plans and the cheapest Bronze plans increased significantly. 20% more people in 2018 who earned under 200% FPL bought Bronze plans because they were likely to be low or no premium. If the Bronze plan is a zero premium plan, it is very likely that the buyer “wasted” some eligible premium tax credits. CMS is trying to claw that “wasted” premium tax credits back.

Comments are needed by the first week of May if you want to tell CMS what you think can be done to this formula.

Idaho, Partial Medicaid Expansion and the 400% FPLers

Medicaid is primarily health insurance for poor people or very sick people.

Idaho’s legislature is monkeying around with the voter approved straight-up Medicaid expansion to 138% of the Federal Poverty Level (FPL).


This will harm middle class Idaho families who need community rated, guaranteed issue insurance from the individual market.

How does that work if Medicaid is health insurance for poor people?

Cost Sharing Reduction (CSR) work-arounds of Silverloading and differential morbidity matter.

Adrianna MacIntyre and I argued in a Health Affairs blog that full expansion has two paths to decreasing premiums for people earning over 400% FPL that are not available if a state elects and receives a waiver for a partial expansion to only 100% FPL.

 evidence found that Medicaid expansion improved the risk pool of state individual markets, suggesting that the population between 100 and 138 percent FPL is sicker and more expensive, on average, than other exchange enrollees. Insuring this cohort through Medicaid is associated with a seven to eleven percentage point decrease in individual market premiums. …

household incomes between 100 percent and 150 percent FPL, those that would be eligible for 94 percent AV silver plans.  This income bracket overlaps the Medicaid expansion income group significantly.  States that fully expand Medicaid end up with far fewer people in the most generous CSR bucket, as they have moved the 100-138 percent population to Medicaid

CSR 94 Enrollment by all APTC receiving enrollees 2018 Healthcare.gov

Keeping a cohort that is more expensive than the rest of the ACA individual market risk pool in the risk pool raises premiums. Pulling the 100-138% population out of the ACA risk pool lowers market premiums as long as this group is more expensive than average. Furthermore while Idaho has engaged in the Silver Switcheroo, Silverloading increases premiums for folks who want a Silver plan and buy it on Exchange either because they don’t know if they will be just over or just under the subsidy cut-off point of 400% FPL or they can’t access an off-Exchange plan that meets their requirements.

Full Medicaid expansion reduces the premium pain of the middle class. Partial expansion continues the pricing pain for the middle class.

Single insurer plan offering choices and implications

I contend that monopolistic insurers in the ACA market are able to shape their risk pool. They have multiple means to implement a strategy. They can use networks. They can use benefit design. They can use formularies.

Starfish made a good comment:

In Mississippi, you cannot play a lot of the games that can be played with a healthy pool in other places. Is a narrow network going to eliminate your town’s only hospital? Are people really driving to Children’s Hospital if they do not live near it or have a child with cancer or some other major issue that can only be addressed there?

Really good comment, and I want to highlight one strategy an insurer can use. They can play spread games. I will make the simplifying assumption that actuarial value correlates to premium level and we’re using a single unified actuarial value scale instead of metal specific scales. I am also assuming a single network and the same plan type for all plans (it could be an EPO, HMO or a PPO, does not matter). I am isolating on plan designs.

The first strategy is a low AV and low spread strategy.

Here the benchmark Silver Plan is near the bottom of the allowable actuarial value range for Silver plans. The cheapest Silver is barely below the benchmark while the insurer is only offering a single Bronze plan. Since we are looking at a monopolistic insurer, there is no competetive pressure that dictates these choices. These choices result in high out of pocket costs for everyone, and since subsidized premiums are predicated on premium spreads, the lowest actuarial value plans won’t be too much cheaper than the benchmark. The healthy and risk embracing won’t see too many good deals.

The other strategy stretches everything out.

Here, the benchmark Silver is near the top of the allowable range. The cheapest Silver is near the bottom of the allowable range. There is a big spread here which means the Silver Gap is large. More importantly, the carrier is offering two Bronze plans. One is still near the top of the Bronze range. The other is near the bottom of the Bronze range. This means that there is a huge actuarial value gap between the cheapest plan offered and the benchmark. Consequently, the healthiest and most risk taking folks will see very low to no dollar premiums if they qualify for subsidies.

It does not matter if the insurers are Silver Loading or Broad Loading their CSR response. It does not matter if they are offering an HMO or a PPO. It does not matter if they are in a high cost state or a low cost state. A single insurer state can strategically choose the premium spreads between the benchmark and least expensive Silver and non-Silver plans.

Wyoming has chosen a big spread strategy. Mississippi has chosen a small spread strategy. These are deliberate choices.


2019 Premium Spread from Benchmark to least expensive plan in each metal band 40 year single non-smoker
StateCountyMetal LevelMaximum Benchmark Spread
WYLaramieExpanded Bronze($265.00)