AHCA impact in North Carolina

North Carolina is a high cost state for health insurance.  Under the Affordable Care Act, people who receive subsidies on Healthcare.gov are shielded from price increases because the subsidy is tied to the cost of the second least expensive Silver plan on Exchange and the individual pays a fixed amount dependent on their income.  The personal contribution amount is fixed based on the person’s income defined by the Federal Poverty Level.  That means a 21 year old who is subsidized will pay the same post-subsidy premium to the insurer as a 64 year old with the same income.

The American Health Care Act (AHCA) bill that was released on Monday night changes the subsidy formula.  Subsidies are no longer tied to the cost of insurance or the individual’s income.  Instead any qualified individual who makes less than $75,000 per year receives a fixed subsidy amount determined by age.  A 21 year old receives a $2,000 subsidy.  A 64 year old receives a $4,000 subsidy.  In the ACA premiums are allowed to be three times higher for a 64 year old compared to a 21 year old.  In the proposed AHCA, premiums are allowed to be five times as high for a 64 year old than for a 21 year old.

Since the subsidy grows far slower than the premium, this means the 64 year old, for a given deductible, will pay far more for their coverage.  I’ve used the 2017 Exchange data to see how much a 60 year old in each county in North Carolina would have to pay after their subsidy every month to buy the least expensive Bronze plan currently offered.  Bronze plans tend to have deductibles of at least $6,500 with out of pocket maximums of $7,150. The circles are larger for counties with more enrollment as of 1/31/17.
NC least expensive Bronze 2017

60 year old residents in Nash County are the best off.  They would only pay $439 per month after the newly revised subsidy is applied. Currently, someone earning $20,000 a year in Nash County would pay nothing for the least expensive Bronze plan and only $31 a month for a low deductible Silver plan.

60 year old residents in Bladen, Cumberland, Harnett, Hoke, Richmond, Robeson and Scotland counties are the worst off by this change.  They would pay $754 for a Bronze plan under the AHCA fixed age based subsidies.  Under the ACA, someone earning $20,000 a year would pay the same as a Nash county resident.  Someone who is age 60 and earning $40,000 a year would pay $110 a month for a Bronze plan and $283 per month for a Silver plan under the current ACA income and plan cost based subsidies.

High cost states with a large number of older residents will be significantly worse off under fixed age based subsidies.

There is one caveat. I’ve intentionally underestimated the costs for all counties.  I used the current 3:1 age band for premiums instead of the 5:1 premiums as that change is unlikely to survive in the Senate under current legislative rules.  If 5:1 premiums are used, all figures should increase by approximately 20 to 30%

Data: Enrollment data from Charles Gaba  sourced by Kaiser Family Foundation

Pricing data from CMS

Subsidy data from the legislative text

 



Why we need to fight

First a story from Jacy:

I had a catastrophic plan the first year — which was the year I was diagnosed with ovarian cancer that July. Living in Louisiana, I fell into the “Jindal Hole,” where I made too much money for Medicaid but not enough money to qualify for a subsidy. It was a nightmare. Out-of-pocket cap was supposed to be $6,300 after a $4,200 deductible (which was a fortune that I couldn’t afford anyway…), but having a major diagnosis meant that I racked up bills so fast that they couldn’t even process the claims to figure out when the insurance would kick in. Fast forward to October, where I was standing at the reception desk of the oncologist’s office, crying, because I couldn’t pay the $5,000 copay to get the chemotherapy I was scheduled for that day. I was paying almost $500 a month for insurance, had spent borrowed and spent nearly $7,000 in copays and deposits to meet my deductible and and out-of-pocket cap, but none of that mattered. I had to postpone chemotherapy and spent the next several days on the phone trying to get someone to authorize treatment or find some way to come up with thousands of more dollars on the spot.

The next year, I made enough money to get a silver plan, and I was paying $128 a month in premiums, with a $200 deductible, after which everything was totally covered. I would not have survived another year on the catastrophic plan.

And then a story from the truly bad old days as written in the LA Times:

 

When Steve and Leslie Shaeffer’s daughter, Selah, was diagnosed at age 4 with a potentially fatal tumor in her jaw, they figured their health insurance would cover the bulk of her treatment costs.

Instead, almost two years later, the Murrieta, Calif., couple face more than $60,000 in medical bills and fear the loss of their dream home. They struggle to stave off creditors as they try to figure out how Selah can keep seeing the physician they credit with saving her life.

“We’re in big trouble,” Leslie said.

Shortly after Selah’s medical bills hit $20,000, Blue Cross stopped covering them and eventually canceled her coverage retroactively, refusing to pay for treatment, including surgery the insurer had authorized in advance.

The company accused the Shaeffers of failing to disclose in their coverage application an undiagnosed bump on Selah’s chin and physician visits for croup. Had that been disclosed, the company said in a letter, it would not have insured Selah.

(h/t Charles Gaba)

Let’s avoid the bad old days.



This Is How Republicans Are Going To Get People Killed

This happened:

A hearing in El Paso County in Texas went from ordinary to “unprecedented” last week when half a dozen Immigration and Customs Enforcement agents showed up at a courthouse where an undocumented woman was seeking a protective order against the boyfriend she accused of abusing her.

The woman, a citizen of Mexico who was living in El Paso had been driven to the courthouse by a victim’s advocate from the Center Against Sexual and Family Violence, a shelter for victims of domestic abuse where she had been living.

She left under arrest.

This is a disgrace, and an incredibly dangerous one.

Most obviously: anyone w/out documents facing a threat from their partner, former or present, has just been told that the legal system, cops, anyone, are no longer available to them. They’re on their own. They’ve got a target on them, as their abusers now know that they can act without fear of official action.

Some of them will die. One third of the murders of women in the US are committed by an intimate partner.

Increasing the pressure to stay in an abusive relationship tees up more victims.  Making it harder — or impossible — to seek official help locks people in danger.

The chilling effect extends beyond the home.  If reporting a crime puts you in contact with officialdom; if agreeing to testify does so…and so on. You get the idea. The risks of trying to engage public safety resources have just shot up for immigrant and minority communities — from an already no-fun base.

ICE, Trump, and the Republican party:  accessories before the fact to harm, murder and misery.

Every day, down every avenue, these folks have got to named, shamed, and fought.

Image: Unknown artist, A Very Bad Man — on the trial of Ephraim K. Avery for the murder of Sarah Maria Cornell. 1833.



America’s Food Sourcers: The Common Clay of the New West

Actually, I don’t think the farmers in the following articles are idiots — they’re just ideologues. To the point of religious obsession. Sure, superior people like us are motivated by monetary rewards, but you can’t expect dumb minimum-wage workers to respond to such refined incentives!…

From the NYTimes, another sad story of Trump supporters who took him seriously-not-literally — “California Farmers Backed Trump, but Now Fear Losing Field Workers“:

MERCED, Calif. — Jeff Marchini and others in the Central Valley here bet their farms on the election of Donald J. Trump. His message of reducing regulations and taxes appealed to this Republican stronghold, one of Mr. Trump’s strongest bases of support in the state.

As for his promises about cracking down on illegal immigrants, many assumed Mr. Trump’s pledges were mostly just talk. But two weeks into his administration, Mr. Trump has signed executive orders that have upended the country’s immigration laws. Now farmers here are deeply alarmed about what the new policies could mean for their workers, most of whom are unauthorized, and the businesses that depend on them.

“Everything’s coming so quickly,” Mr. Marchini said. “We’re not loading people into buses or deporting them, that’s not happening yet.” As he looked out over a crew of workers bent over as they rifled through muddy leaves to find purple heads of radicchio, he said that as a businessman, Mr. Trump would know that farmers had invested millions of dollars into produce that is growing right now, and that not being able to pick and sell those crops would represent huge losses for the state economy. “I’m confident that he can grasp the magnitude and the anxiety of what’s happening now.”…

Dude, the old man can barely grasp how to work a light switch. You think he cares about your troubles, now that he’s sitting in the Oval Office (possibly in the dark)?
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The timeline to run

The Republican Party does not have the luxury of time to get their act together on health policy. They have maybe fifty days to get a coherent plan with the possibility of passage before external actors move to foreclose on Republican policy option space:

Below is the Center for Medicare and Medicaid Services plan filing timeline.

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Trump’s EO on the ACA

The Trump administration issued its first executive order. The subject is the ACA. The order seeks to destabilize the non-subsidized and off-Exchange portions of the risk pool by minimizing enforcement of the individual mandate.  Dan Diamond at Politico had the first link to the actual order that I saw:

Section 2 is the critical component for the individual market. Section 3 has significant impact for both Exchanges and Medicaid.

Analysis below the fold:
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Government, Meet Bathtub

It’s easy to run a government that does (next to) nothing.

Here’s where Trumpism — or really Pence-ism, or really, exactly what the GOP has been promising (threatening) will have its most immediate, and quite possibly its most damaging impact:

Staffers for the Trump transition team have been meeting with career staff at the White House ahead of Friday’s presidential inauguration to outline their plans for shrinking the federal bureaucracy, The Hill has learned.

The departments of Commerce and Energy would see major reductions in funding, with programs under their jurisdiction either being eliminated or transferred to other agencies. The departments of Transportation, Justice and State would see significant cuts and program eliminations.

The Corporation for Public Broadcasting would be privatized, while the National Endowment for the Arts and National Endowment for the Humanities would be eliminated entirely.

Overall, the blueprint being used by Trump’s team would reduce federal spending by $10.5 trillion over 10 years.

The NEH and NEA cuts are at once symbolic — the GOP is killing stuff liberals like, which is reward enough in those quarters — and, I think, intended to distract from other hugely reckless choices:

The Heritage blueprint used as a basis for Trump’s proposed cuts calls for eliminating several programs that conservatives label corporate welfare programs: the Minority Business Development Agency, the Economic Development Administration, the International Trade Administration and the Manufacturing Extension Partnership. The total savings from cutting these four programs would amount to nearly $900 million in 2017.

At the Department of Justice, the blueprint calls for eliminating the Office of Community Oriented Policing Services, Violence Against Women Grants and the Legal Services Corporation and for reducing funding for its Civil Rights and its Environment and Natural Resources divisions.

At the Department of Energy, it would roll back funding for nuclear physics and advanced scientific computing research to 2008 levels, eliminate the Office of Electricity, eliminate the Office of Energy Efficiency and Renewable Energy and scrap the Office of Fossil Energy, which focuses on technologies to reduce carbon dioxide emissions.

Under the State Department’s jurisdiction, funding for the Overseas Private Investment Corporation, the Paris Climate Change Agreement and the United Nations’ Intergovernmental Panel on Climate Change are candidates for elimination.

The single most important point I can make is that this is the Kansas-ification of America.  This isn’t a Trump policy choice.  This is Mike Pence shepherding plans the Republican Party has been trying to implement for years, decades even.  I doubt it will all get through, but much of it will, I’d guess, and when it does we will need to hang every shitty outcome and terrible choice around the neck of every Republican officeholder.

This is what they want. This is what they told us they wanted. They’re likely going to get it, to some approximation.  And they’re going to have to own it, so that once again, Democrats can come in and fix the serial catastrophes we’re going to witness very damn soon.

Also, too — who wants to bet all the pieties about the deficit and restoring balance to the budget will fall to the tax cuts to come?

Fuck it.  I’m heading back to the seventeenth century.

Image: Francesco de Rossi, Bathesheba at her Bath1552-1554.