Idaho’s ambitious waivers

Idaho is odd. It is a Republican tri-fecta state. It runs its own state based Exchange for the ACA. It has not expanded Medicaid. It has a pair of fascinating waivers that they want to submit to the Center for Medicare and Medicaid Services.

The first waiver is a Section 1115 Medicaid Waiver. They are not asking for an ACA Medicaid Expansion. Instead, they are asking for the authority to create a high-risk pool in Legacy Medicaid for about 1,500 people who have certain severe, high-cost conditions including hemophilia, cystic fibrosis, and certain cancers. These folks would see lower cost sharing and lower premiums. Idaho would pay their normal state match. Cost of care would go down as Idaho pays their Medicaid providers roughly 95% of Medicare rates and Medicare tends to pay providers significantly less than commercial rates.

The objective is to pull a small number of chronically ill and very expensive people out of the ACA individual market risk pools. With those people out of the risk pool, average claims costs go down by 19% which makes insurance a whole lot cheaper for non-subsidized buyers. This makes the non-subsidized market better off as a lot of people who are reasonably healthy and currently deterred from buying because the plans are too expensive will see cheaper plans. This would lead to more people covered and an even healthier risk pool.

If this was the only waiver, it would be a good waiver. However, Idaho is more ambitious. They are also planning a 1332 waiver that will allow people under 100% Federal Poverty Level (FPL) (<$12,060 for an individual) to claim that their income is actually 100% FPL and thus qualify for Advanced Premium Tax Credits and CSR Silver plans. This is a back-door Medicaid-esque expansion along the Arkansas Model but with the Federal government and the individual paying all of the cost without the state needing to commit new money to the coverage expansion.

Idaho wants to use the savings from pulling out the patients with high cost chronic diseases to fund the state pass-through amount for this 1332 waiver. It is an elegant solution if one starts with an assumption that Medicaid Expansion is politically non-viable in Idaho. It will lead to roughly half the currently uncovered population who are in the Medicaid gap to receive coverage. I am concerned that this cohort will be sicker and more expensive than the people who don’t buy this coverage but earn under 100% FPL. I am not sure how this would play with the risk pool improvement from more non-subsidized buyers entering the market. The signs are in opposition to each other but I don’t know magnitude.

I have mechanical worries about these waivers. I don’t think that the initial financial estimates are fully accounting for how CMS scores waivers. We know from Iowa that CMS will count the loss of individual mandate penalties against a state’s budget neutrality calculation. I don’t know if CMS will allow the sequencing that Idaho needs for budget neutrality. I think that this type of waiver is innovative and creative. It solves several problems but the mechanics are tough under the 2015 Section 1332 guidance. Here is a where an Alexander-Murray waiver modification could make a lot of sense.

I am intrigued by what Idaho is trying to do. I am just not sure that they will be allowed to do what they want to do or at least receive as much money as they think they should receive to do what they want to do.

Local and State: How’s It Going?

Toward the tail-end of one of our open threads yesterday, there was some discussion about how the Democratic Party is performing at the local and state level. I suspect many of us care deeply about this and are involved in our districts. But we don’t discuss it a lot here because this is a sprawling, global, almost-top-10K blog, and these issues are hyper-local.

But it’s worth discussing because the party has lost a shit-ton of ground at the local and state level over the years. There are many reasons for that, including a concerted effort by Republicans to destroy unions, which used to form a pillar of institutional support for Democrats, and a hyper-national focus among party members. We have to address it, and I know many of us are involved in that struggle.

So let’s talk about it: How’s it going in your local meth laboratory of democracy? Is your county-level party effective? How about the state level? Is the DNC helpful, or are they AWOL? What’s your understanding of their role? How do you see governor and state legislature campaigns shaking out? How are you directing contributions, if any? What non-party political organizations do you support?

I’ll start us off by answering these questions for my area. Our county party has done a terrific job; we’ve steadily made progress electing Democrats and ousting Republicans. After the election, the party had to find larger meeting spaces because so many more people became involved. There have been challenges harnessing all that new energy, but I am hopeful.

At the state level, I’m worried, but that’s nothing new. We’ve fielded such crappy candidates for governor that an obvious crook like Rick Scott was able to win not once but twice, albeit with less than 50% of the vote both times. And it looks like we might be getting ready to screw the pooch again, unless the state’s most famous ambulance chaser decides to throw his hat in the ring as a celebrity candidate for the Democrats. We could do worse, to be honest, but it frustrates me that we can’t do so much better.

I believe the outlook at the state legislative level is better. We recently won a special election in a district that Republicans thought was safe and where the Democrat was heavily outspent. County parties did phone banking across the state to help make that happen, and disgust with Trump is thought to have been a key factor too.

As for the DNC, I confess I don’t really know how much to expect of them at the state and local level. Maybe someone who understands how that’s supposed to work can enlighten me. I was an early supporter of Tom Perez for party chair, but the jury is out on his performance so far, IMO. Since I focus on ground-level stuff, I have no real sense what’s going on there except what I read in the media, which is geared toward peddling “Dems in Disarray!” narratives.

In addition to my local party, I’m involved in political organizations that support women’s rights, LGBTQ equality and immigrants’ rights, and I donate paltry sums to those causes. I also contribute to and volunteer for organizations that protect enfranchisement. (Reading this over, I realize it sounds like I do a lot, but that’s not really true — I probably spend more time watching cooking shows and sports than I do on all of these activities combined. I should be doing more.)

Anyhoo, before turning it over to you, a plea: Let’s not rehash the 2016 primary in this thread. I realize lingering hard feelings among factions within the party might be relevant to your response, and if so, please feel free to describe that. But gratuitous bashing will just derail the thread, so can we not? Thanks!

Tuesday Morning Open Thread: Not the Onion, edition 3,567

As if Texas needed any more grief right now!…

… Sen. Lindsey O. Graham (R-S.C.), who has been involved in previous bipartisan immigration reform efforts, said he would support Trump’s plan to end DACA after a six-month delay. In a statement, Graham said the program amounted to “presidential overreach” by President Barack Obama, who created it by executive action in 2012…

House Minority Leader Nancy Pelosi (D-Calif.) said Trump is poised to “break the hearts and offend the morals of all who believe in justice and human dignity.” She called on Republicans to pursue legislation to protect dreamers “from the senseless cruelty of deportation and shield families from separation and heartbreak.”

Trump’s decision to include a six-month delay could be a bid to shift some of the political pressure and consequences over the dreamers onto congressional Republicans. House Speaker Paul D. Ryan (Wis.), Sen. Orrin G. Hatch (Utah) and several other GOP leaders have urged Trump not to end the program and to let Congress pursue its own course of action.

The president and his senior advisers continued to deliberate Monday afternoon, and aides cautioned that Trump could still change his mind ahead of the announcement. Important details such as whether the administration would continue to accept DACA applications and issue renewals for two-year work permits during the six-month delay remained unresolved…

Meanwhile, leading Democrats have said privately that they think Trump has been boxed in politically. His inability to secure funding for the border wall is wearing down support among his base, these Democrats said, while his hard-line immigration rhetoric is hurting him with moderates.

When rumors about Trump’s expected actions on DACA first surfaced nearly two weeks ago, Senate Minority Leader Charles E. Schumer (D-N.Y.) tweeted that dreamers “are not a bargaining chip for the border wall” funding or to pay for an “inhumane deportation force.” …

Apart from bracing for fresh horrors, what’s on the agenda as we start an abbreviated work week?

More From Arizona…

Update: I swear that when I started writing this DougJ’s post was not in the queue.  Anyway…we’re all grownups here (Schpeake Fer Yerself!–ed) so I’m guessing we can read one piece and then another.  Or not. Enjoy!


Joe Arpaio is now on his way to being an old lag, and if that conclusion is decades late, it still behoves us to get our schadenfreude on:

The longest-serving lawman of the state’s most populous county, where he became a national figure known for immigration raids and sweeps aimed at rounding up illegal migrants, was found guilty Monday of contempt of court. He faces up to six months in jail.

Arpaio’s crime, you’ll probably recall, was to keep on doing what he’d been doing after a federal judge told him to stop:

Arpaio had conducted the sweeps under the federal 287 G Program, which enables some local law-enforcement offices to act as quasi-immigration agents. In 2009, the federal government rescinded this power, but Arpaio refused to stop. In 2012, Arizona U.S. District Court Judge Murray Snow, ordered an injunction against Arpaio’s office aimed at ending the sweeps, but still, Arpaio refused.

I fortunately don’t have any personal experience here, but I have it on good authority that judges really, really don’t like it when you ignore them.

Arpaio tried two lines of defense:

During the criminal trial, which consisted of a five-day trial in June and July, Arpaio’s attorney’s argued that Snow’s order was unclear and that though the sheriff had made mistakes, they weren’t willful violations of the order. He also argued that Arpaio delegated much of of the enforcement responsibilities to his subordinates, and that he should not be held responsible for their actions.

Again, I don’t think telling a judge that they f**ked up in their legal writing is a terribly persuasive strategy, and as for the “my employees suck, I don’t” argument, I’m reminded once again that the Party of Personal Responsibility™ is a f**king crock.  Hence, the man’s a convict.

It is, alas, apparently unlikely that white supremacist poster child Arpaio will actually go to jail for his crime.

But whatever his sentence, this outcome makes me smile.


Here’s Loki, the Trickster God, in the glass I’ll raise when the clock hits 0-whiskey-00 this evening.

Image:  Egon Schiele, The Door is Open, 1912.

Iowa is covered

The Des Moines Register reports that Medica is planning to stay in Iowa. They are requesting a 43% rate increase for the individual market.

“When you find yourself as the only ones between people getting access to care and people not getting access to care, your view of the situation becomes very different,” Medica Vice President Geoff Bartsh said in a prepared statement. “We’ve filed with the intent to provide access to insurance for all Iowans, whether they are farmers, small business owners or other individuals who need coverage.”

The relatively small, Minnesota-based carrier told Iowa regulators Monday that in order to stay in the market, they would need to increase premiums by an average of 43.5 percent….
Monday was the deadline for carriers to file proposed rates for individual health-insurance policies in Iowa for 2018. Medica was the only carrier to file, state regulators said.

I was wrong on being wrong. Iowa is now a single carrier state. There are no risk adjustment problems. The only risk that Medica is bearing is that their actuaries are projecting the state market wrong or there is a cavalcade of clown cars crashing. It is a rational solution to a market design problem.

The single carrier can raise their rates high enough to cover this catastrophic claim while the post-subsidy price is low enough to actually attract normal risk as well. The off-exchange market can be competitive especially if the single on-Exchange carrier splits their filing IDs so they can use different actuarial assumptions for a more normal market.

I am not seeing anything saying that Medica is splitting their plan into an on-Exchange entity and an off-Exchange only entity. So the people who are not subsidized will be paying a lot more for their insurance.

They also need to change their strategy. In 2017, in all counties in Iowa, they offered two Silver plans. The two Silver plans have the same regulatory actuarial value at 70.7%. The two plans have minor differences in price. For a 40 year old in Warren County, there is a $6 spread between the least expensive and the new Benchmark Silvers offered by Medica. With the price increase, that will lead to a $9 spread. Medica should offer a low actuarial value plan at 66% or 67% AV with a higher deductible and keep one of the two current plans as the actual benchmark. This will lead to s bit less price shock for the off-Exchange buyers and a better deal for subsidized buyers.

The last thing of interest to me is that this makes the 1332 waiver that Iowa wants as a “rescue mission” even more contradictory in their assumptions.

There are four major guide posts for a 1332 waiver. The waiver must provide at coverage at least as comprehensive as the baseline ACA, with cost sharing protections at least as good as the ACA to at least the same number of people at no more net federal costs than the ACA.

Iowa’s argument is one of choosing a favorable counterfactual. Their counterfactual will be that their plan will meet the coverage requirements of at least as good for as many people as the ACA if one assumes that the ACA will cover no one on the Exchange because there will be no insurers on the Exchange. That is a plausible counter-factual. It is one that can be defended with a straight face.

However, let’s think about the implication of that counterfactual. In this scenario, the ACA will cover no one. Covering no one means the federal government spends no money….

Iowa has a lot of money that could be available for state innovation or BHP programs with Medica staying in the market. But now they can’t meet the qualification that the cost sharing be no worse for people under a 1332 than under the ACA. If Iowa continues down the path of a 1332, there will be even more lawyers.

Show me the waiver

The California State Senate passed the single payer bill. This is hopefully the start of the process of exploring what that actually means and how it can actually be done in a state with resources and technical sophistication.

Michael Hiltzik in the LA Times identifies the key implementation challenges:

Under the Senate bill, the “Healthy California” program would take over payment for almost all medical spending in the state. It would absorb funding currently going to federal and state programs, and relieve employers, their workers and buyers in the individual market of premiums, deductibles and co-pays….

They need multiple waivers from the federal government to refashion Medicaid (known in California as Medi-Cal), Medicare and other federally funded health programs and redirect federal dollars into their own systems….(emphasis mine)

Show me the waivers.

If there aren’t waivers, this plan is vaporware.
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States, single payer and recessions

New York and California are both advancing single payer plans through their legislatures. I have a lot of questions. They both assume incredible waiver authority will be given to them. These hypothetical waivers would direct federal program funding** to a state operated pass through entity to pay for healthcare. But each of these proposals will rely on some state level general taxation.

How do these programs work in a recession?

Depending on how one does the counting, between forty six and forty nine states have a balanced budget constraint. California and New York have balanced budget constraints. There is wiggle room for a bad year or two on the margins but it is incremental.

State tax revenue tends to be cyclical. Consumption and income taxes tend to go up when the economy is growing and down when the economy is in a recession. California heavily relies on capital gains taxation. New York relies on taxing Wall Street bonuses. Both of those are cyclical revenue sources.

Healthcare demand is responsive to recessions as well. Bad times lead to fewer elective surgeries and for more things to be deferred until they really are needed. The primary channel for that is through the increase in cost-sharing. The California and New York proposals don’t have the cost sharing that could shift demand in time.

So my question is what happens to a state with a reasonably strong balanced budget constraint and state run single payer when there is a significant recession? Demand and costs will stay roughly constant. Revenue crashes. This dynamic opens a big financing gap. That gap must be closed. The methods to close that gap are massive provider payment cuts, increased taxes (which is probably a bad choice on a cyclical basis), increased cost-sharing, eliminating some covered services or borrowing for operational reasons. States have some wiggle room to borrow for operational costs but they don’t have the ability to borrow 20% of their operational budget in a year for several years straight. Is it reasonable to assume that the states can access federal fiscal capacity to borrow as they have already accessed all federal healthcare money in a hypothetical waiver?

How does this work in a recession?

Help me out here, please!

** By the way, does that federal waiver money come with Hyde restrictions?

*** Any state single payer proposal post should always end in a Cato-esque “ERISA delenda est”