Schadenfreude. It’s what’s for breakfast*

Which is to say that there are few people in American politics I loathe so much as the wholly owned Koch subsidiary operating under the name Scott Walker.  There are plenty of folks doing more national damage, but few, if any, with the utter, total, almost heroic lack of redeeming qualities as the man Charlie Pierce epithets** as the goggle-eyed homunculus.

So his pain is the sugar in my coffee this a.m.:

“The Far Left” — thanks for the proper nouning** there, btw; I didn’t know we were a franchise operation — as in a decisive majority of Wisconsin voters. “Anger and hatred” — nothing like the mild mannered folks on the right,*** amirite? “Outside special interest money.” Child, please.

But, if it’s all projection with these guys, well we knew that. That subterranean pleasure you feel this morning is that all the faffing in the world can’t hide the genuine panic flowing through Walker like you-know-what through a goose.

And because we need something pretty to wash the memory of Walker’s pallid, grasping mug from our brains, here’s a bird that one-ups that poor goose:

And w/that…open thread.

*That or coke on your Wheaties.

**I verb sometimes. Sue me.

***Very, VERY far from the worst, as we all know, but selected for its exceptional combination of absurdity and cowardice.

Image: John James Audubon, Cygnus buccinator, Trumpeter Swan1838.

Utah’s partial expansion request

Utah’s governor just signed a bill that authorizes a 1115 Medicaid demonstration waiver. The waiver combines work requirements with a request. This is interesting on several levesl.

KUER reports:

The new law would ask the federal government to allow Utah to widen it’s low-income health insurance program. Right now, a single adult with Medicaid coverage can only make about $600 per year — essentially homeless. Under the new law, the same individual could be covered if they make anything up to the poverty level, approximately $12,000 per year.

It also adds a work requirement for those who qualify. If an individual is unemployed and wants Medicaid coverage, they’ll have to do things like get job training, volunteer or take classes.

This is interesting on several levels. First it is a red state with a Republican trifecta trying to expand Medicaid. They are asking for a work requirement but as far as I can tell the requirement would only apply to the expansion population. This is still a lot of people who make very little money so the vagaries of scheduling and intermittent work will be a massive implementation challenge but the work requirement is less restrictive than several that have been requested.

Far more interesting to me is that Utah is asking for a partial expansion. We’ve talked about partial expansions before.

The distributional consequences are important. For people who earn between 100-138% FPL in states that have not expanded Medicaid, nothing will change for them. They are no worse off. People who live on less than 100% FPL in these states will be dramatically better off as they will have Medicaid for their coverage….

More interestingly to me is that CMS recently turned down Arkansas’s request to change the enhanced match rate Medicaid expansion to 100% Federal Poverty Level (FPL) instead of the current 138% FPL. However there is a very critical difference: Arkansas had already fully expanded Medicaid. They went for the most expensive and convoluted system of expansion possible by sending most of the healthy population into the Exchange pool. That system costs 24% more than a straight up expansion of Medicaid but it got local buy-in. However Arkansas is now paying a fraction of the cost of expansion and they’ve been moving more of their private option population back into the less expensive legacy Medicaid system. The Arkansas proposal to shift the 100-138% FPL cohort to the Exchanges and off of Medicaid was an attempt to dodge previously obligated committments.

Utah has never expanded Medicaid. The 100-138% cohort is already on the Exchange and they are already eligible for federal subsidies. Expanding Medicaid to only 100% has no increase in costs for the Federal government on the Exchange side of the ledger. If there is only a partial expansion, the Feds are paying for the 100-138% cohort and if there is no expansion the Feds are still paying. This is a very different fact pattern than Arkansas so there is a chance that CMS could approve the waiver.

And if that is the case, then several more hold-out states would probably seek the same waiver.


Update on the WV Teacher Strike

Over the weekend, there was some movement in the Senate, along with some hysterical shenanigans. Basically, WV Senate Republicans are as incompetent as national Republicans, and after an amendment came out of the Finance committee for a 4% raise, lower than the 5% the governor and teachers agreed to, and lower than the 5% the House voted 98-1 for (comically, the one no vote was Saira Blair, the young Republican college student and daughter of Senator Craig Blair, and she claims she pushed the wrong button).

Quick interlude- Craig Blair is one of those “special” Republicans, who this weekend infuriated basically everyone by reacting to this CNN story about WV teachers packing lunches for their students who go hungry without school lunch programs before going on strike by stating something to the effect of “If they can afford to feed their kids, how desperate are they for a raise.” Yeah, he’s one of THEM.

At any rate, the Senate voted on a 4% raise, which was dead in the water in the House of Delegates, and immediately after the vote Senate leadership went through a bunch of procedures to have the vote removed. Apparently the clown caucus had filed the wrong amendment, and they had all voted for a 5% increase, not the 4% they intended. Normally parliamentary procedures would dictate a 2/3 vote to remove that previous vote, but being Republicans they said to hell with it and just did party line votes and then advanced the 4% bill instead. Democracy, fuck yeah.

So where we are now is there is a legislative conference committee set to meet at 4pm to resolved the differences. The committee includes 3 members from the House of Delegates (2R, 1D) and 3 members (2R, 1D). Notably, the House delegation has all been told to stand strong and presumably will lobby for the 5% they voted for (part sticking to their initial bill, part being told by membership what to do, and part dick-measuring contest between the House and Senate. The Senate Democrat will presumably go for the 5% increase.

This would lead one to presume that the 5% increase would carry the day. They would meet, majority would vote 4-2 for the 5%, and then the bill would be advanced to the Governor. You would be wrong. The majority members of the Senate are going to be Sen. Ryan Ferns, the Senate Majority Leader, and Mitch Carmichael, the President of the Senate, the aforementioned senator Blair and they too are special kinds of Republicans. What they may do is simply refuse to sign the conference committee report. So even though the vote would be 4-2, simply refusing to sign it would basically kill it. They’re the special kind of assholes who would do something like that, and the Senate Republicans done it before, just not with this much attention focused on them.

It wouldn’t surprise me if they do this to try and drag this strike out and have AG Morrisey cook up some sort of legal action against the teachers or to try and swing popular opinion against the teachers. The problem for them is everyone knows a teacher and likes them. The same can not be said for the Senate, Justice, or AG Morrisey.

In other news, the Senate Republicans refuse to meet with Governor Justice, who is now officially hated by Republicans as much as by Democrats, and the PEIA commission is set to meet on the 13th and has 24 members, 23 of whom need to be appointed.

In other words, there probably isn’t going to be school this week. The teachers and service personnel have their blood up and are sick of the bullshit.

*** update ***

The House Democrats send this notice:

“It has been brought to our attention that Senator Blair scheduled a Finance Committee meeting for 3:00 today. In his speech on the floor earlier today, Senator Blair stated that the Finance Committee will take up the budget bill and they will not adjourn until they are finished, even if it takes them until MIDNIGHT! Senator Blair is on the conference committee for HB 4145, the pay raise bill, and the conference committee scheduled for 4:00 today cannot meet until Senator Blair and Senator Ferns adjourn from the 3:00 Senate Finance meeting. This is political gamesmanship at its worst. They clearly have no intention of holding the conference committee for the pay raise bill today.”

A few things on the West Virginia strike

Farzad Mostashari went into the weeds to look at the price drivers in the state employee health plan that is the basis of the current teacher strike.  He sees two big things that stood out to him.

It seems like the PEIA is doing a good job of keeping a many people as possible out of the hospital. Managed care entities including HMOs, ACOs, SSP, ASO and several other three letter acronyms will usually try to divert people out of hospitals and to some other location that can’t bill with a hospital code. Yet it is still a matter of prices. The hospitals are doing a lot less and still getting paid more. What is going on here?

I want to thank Farzad for chasing the data as this is meaningful and illuminating as to what the strike actually boils down to.

The billion dollar counterfactual

New York and Minnesota both run Section 1331 Basic Health Plans for people who make between 138% and 200% Federal Poverty Level (FPL) ($16588-24,040 for a single individual). This is an option from the ACA. The states filed a waiver that passes through 95% of the combined Advanced Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR) that individuals would otherwise be entitled to. These states use this money to basically create an enhanced Medicaid program for this cohort. It provides lower premiums and lower deductibles than Exchange plans because these plans pay doctors and hospitals less.

New York and Minnesota approved rates for 2018 ACA plans on the basis of the actual risk pool. This means their ACA markets have a very small component of people who qualified for Silver plans with CSR. The weak Silver CSR bumps Silver plans from 70% nominal value to 73% actuarial value. Silver loading in these two states added an extra point or two to the rates. Similar states without BHPs added twenty or more points to their rates to cover the cost of CSR in the index rates.

The Trump Administration stopped paying CSR in October. The Trump Administration contends that the BHP payments should be reduced to the proportion of the BHP funding that could be directly attributed to APTC. This is leading to a billion dollar short fall in 2018 for the New York Essential Plan and a $100 million dollar or more gap for Minnesota.

And then the one thing that I am sure about the ACA occurred: There will be lots of lawyers. New York and Minnesota sued.

New York and Minnesota tried to file revised, Silver loaded rates as if their entire population was on the Exchange instead of in the BHP. They believe that the BHP calculation is based on the counterfactual of what would happen if the entire population was on Exchange. And from here, they estimate that if CSR had to be built into the rates, they would Silver Load and see a 20%-25% increase which would bring them even on net.

The Center for Medicare and Medicaid Services (CMS) did not respond to this argument. Instead they are acting as if BHP funding is based on the actual and thus there is a billion dollar hole in the New York budget. From 2014-2017, the counterfactual and the factual are very close to each other and not worth fighting about.

I think BHP funding is based on the counterfactual. Here is the 2018 regulation for BHP funding:

Section 1331(d)(3)(A)(ii) of the
Affordable Care Act specifies that the payment determination shall take into account all relevant factors necessary to determine the value of the premium tax credits and CSRs that would have been provided to eligible individuals, including the age and income of the enrollee, whether the enrollment is for self-only or family coverage, geographic differences in average spending for health care across rating areas, the health status of the enrollee for purposes of determining risk adjustment payments and reinsurance payments that would have been made if the enrollee had enrolled in a qualified health plan through an Exchange, and whether any reconciliation of PTC and CSR would have occurred if the enrollee had been so enrolled. This payment methodology takes each of these factors into account. [my dual emphasis]

“Would have been provided” implies a counterfactual. We are supposed to imagine the New York and Minnesota markets as if there was no BHP. From here,a projection of premiums is made. And from that premium projection, the number of people who earn between 138% and 200% FPL is calculated. That number is then discounted by 5% to act as the maximum pass-through to the state for their BHP.

“individuals” is the second key word. Everyone agrees that the individual is entitled to CSR benefits. The federal government has argued in court that Silver loading is an acceptable practice if insurers are not to be reimbursed for CSR benefits to individuals.

New York and Minnesota are arguing that they were not treated fairly by CMS compared to all other states that Silver Loaded. CMS is paying on the factual instead of the counterfactual for no good reason despite their own regulations saying that the BHP payment is a counterfactual payment.

There will be a lot of lawyers involved, but I think the counterfactual will eventually win.