Whats going to happen today?

The short answer is mass chaos.

The longer answer is we will seeing some non-controversial bills come up under suspension rules this morning.  Around 10:00 AM, the Rules Committee will vote on the most recent set of changes that were placed in the bill overnight.     Those changes (stripping or punting EHB mainly) are probably going to cost a quarter of a trillion dollars and could lead to millions more not getting coverage but they are not waiting for a CBO score.  Once a special accelerated rule is voted on, the actual voting starts.

My opinion is that we are in good shape if there is an immediate blocking coalition of 23 Republican No votes in the first six or seven minutes.  At that point, the internal logic of the Republican caucus makes voting Yes and seeing the bill Fail become a no reward position so we could see a cascade towards No.  If we don’t see that, I would not be optimistic.

My gut feeling is that AHCA either passes by less than three votes or fails by more than fifteen. I can’t see the incentive structure for a narrow failure as the House leadership will hold the vote open for hours to arm twist a couple of hold-outs.

So call the House one last time.

Update 1:

 

He is from New Jersey, part of leadership and as of this morning he was in the New York Times Undecided/Unclear column. So him moving to a clear No is intriguing.



Good news

Right now the whip counts are going in the right direction. New York Times is up to 31 Republican No’s. I am reluctant to have too much faith in that number as a good number are House Freedom Caucus who can be bought off by making the bill atrocious through provisions that will get stripped in reconciliation. But every minute that they have to spend defending this monstrosity of a bill is a win for liberals, progressives, Democrats and people who either currently need or may at any point need the protections of the ACA.

I don’t know if we’re going to win, but we’re doing a whole lot better today than I thought we would have been on November 10, 2016.

If you have a chance, call Congress.

If you have a solid No, thank them. Their interns will appreciate it.
If you have a lean No, remind them they really don’t want to throw pregnant women off of coverage nor grandparents out of nursing homes.
If they are a solid Yes, remind them that this bill has 17% support in the general public and under 40% support in Republican circles and that 2018 is not that far away.

Update 1

Feedback works people. Let Congress know that their jobs are at stake because our lives or the lives of our friends are at stake.



Call Congress

There is a chance that we can win tomorrow.

Let’s work to increase that chance. Call Congress. If you are represented by a Democrat or a Republican who is on the 100% No list as maintained by the New York Times , thank them, or their interns.

If you are represented by an Undecided or Concerned Republican, encourage them to vote No.

If you are represented by a highly probable yes Republican, tell them to have fun losing in November of 2018.

There is no guarantee that we can win tomorrow. There might be a seven hour vote as arms get twisted and bribes concessions are offered to flip votes. But I would rather try and fail then resign myself to learned helplessness. So call.

Here is the House Rep finder:

Update 1 For the waverers, they will vote to be on the winning side. If there are twenty three or more quick GOP NO votes, we will see a cascade of No Votes as there is no upside to be a Yes and Fail. If there is only 10-20 GOP NO votes in the first 12 minutes, we’re in for a long afternoon of arm twisting.



Context in Arkansas Medicaid

Last night in the open thread, Rikyrah asked about what was going in Arkansas’s Medicaid program. It looks bad, but what is happening?

The governor’s proposal would lower the income requirement for Medicaid eligibility from 138 percent of the federal poverty level to 100 percent. That change would reduce the income cutoff for an individual from $16,643 to $12,060, and reduce the income cutoff for a family of four from $33,948 to $24,600.

If Hutchison’s amendments are approved by the federal government, around 60,000 Arkansas residents enrolled in Medicaid would no longer be eligible for the program.

Details matter here. This is fundamentally a state budgetary cost shifting. If an individual is on Medicaid Expansion , the state of Arkansas is on the hook for 5% of the cost of their care in 2017 and 6% of the cost in 2018. Eventually the state would be responsible for 10% of the cost of care. The Federal government pays the 90% to 95% of the cost of care for Medicaid Expansion. If an individual is on Exchange, the Feds pick up the entire subsidization costs.

Individuals who make more than 100% of the Federal Poverty line and are not eligible for Medicaid receive cost sharing and premium assistance subsidies. The Feds pay all of those costs. The individual is no worse off in Arkansas as the 1115 waiver for Medicaid expansion treated the individuals who made more than 100% FPL as if they were on Exchange for premium and cost sharing obligations. Individuals who make between 100% FPL and 138% FPL will see no difference in Arkansas. The biggest change may be a new ID card where the group or corporate policy number changes. That change will be meaningless to anyone who is not employed by an insurer or the ID card vendor.

This is an extremely low priority change to fight. It is merely an aggressive cost shifting from state budgets to federal budgets with no beneficiaries made worse off. On a scale of 1 (acknowledge)-10 (massive civil disobediance), this is a 1 on the fight scale.

Now if other states that did not have a private option 1115 waiver tried to do this, the situation would be different as beneficiaries who make more than 100% FPL would be made worse off with higher premiums and higher deductibles. But given the situation in Arkansas, this is a nothingburger.








An open letter to insurance commissioners regarding baseline maximization

To any Insurance Commissioner:

This is an open letter to insurance commissioners who believe it is their legal and moral duty to protect the citizens of their state in the face of increasing policy uncertainty.  I strongly urge that the following actuarial guidance be sent to all carriers that are considering submitting rates for the individual market for the 2018 rate year as this will provide significant protection for subsidized individuals in 2018 and potential long term insulation from several of the policy changes that are currently being debated in Washington.

“All carriers that wish to submit rates for qualified health plans for the 2018 shall use the assumption for all on-Exchange plans that the individual mandate will not be enforced.  An alternative secondary submission shall be prepared with the assumption that there is no material change in the enforcement of the individual mandate.”

Furthermore, states should seek to reduce the number of plans that are offered, approved and authorized for sale on Exchange, specifically on the Silver metal band.  Increasing the difference in price between the least expensive Silver plan on the Exchange and the second least expensive Silver plan will lead to far lower post-subsidy premiums and a healthier risk pool.  

These strategies will help protect residents and citizens of your state in 2018 within the current uncertain political and policy environment.  This protection emerges from two directions.  First it will give permission to carriers to realistically budget and plan for the next plan year which should increase the probability that carriers will offer plans in all markets even if there are significant rate increases needed to counteract any potential off-Exchange death spirals in the non-subsidized portion of the individual common risk pool.

Secondly, there are several bills that are being mooted about that seek to block grant future health insurance subsidies on a state by state basis where the baseline for the funding will be CBO projected subsidy spending under PPACA as it is currently written and implemented.  If the law is changed to reflect this, it is in the best interest of your state to have as high of a baseline as possible in order to guarantee the best coverage for as many of your citizens as possible.  If your department determines that the individual mandate enforcement is not certain and authorizes very large premium increases for on and off Exchange plans this summer, the baseline spending allocation will be significantly higher for your state than if you authorize very low rate increases which could lead to carriers withdrawing en masse which would be a human tragedy in 2018 with decades of repercussions.

Aggressively asking for actuarial sound scenarios will further your charge to protect your state’s insurance market and citizens.  



Today In Be Careful What You Wish For: Not So Strange Bedfellows Edition II

Shortly after the election the American Jewish Congress and the Islamic Society of North America formally entered into a civil rights protection and promotion and civil society defense agreement. Today, in response to yesterday’s violence and vandalism at St. Louis’s Chesed Shel Emeth Cemetery, Linda Sarsour and Tarik El-Messidi have started a fundraising campaign to help repair the damage done.

You may remember Linda Sarsour, the Executive Director of the Arab American Association of New York, as one of the co-chairs for the Women’s March. Tarik El-Messidi is the founder of Celebrate Mercy, an educational outreach program intended to inform both Muslims and non-Muslims about Islam and the life of Prophet Muhammed.

So well done currently unknown dickheads and domestic terrorists – your stupidity has just drawn Muslim and Jewish Americans closer together. Give yourselves a round of applause for achieving exactly the opposite of what you intended to achieve: to scare Americans of different faiths and ethnicities in order to drive them apart and make them easier to prey upon in the future. Morons!

 



A BFD that passed amongst the chaos

In most strands of the multi-verse, the below would have sent the health wonk community ablaze. Instead in this strand, we spent all day yesterday talking about a proposed rule from CMS and generally shaking our head as our government continues to say “Hold my beer and watch this….”

But this is normally a BFD:

What does this mean?

Repeal and Replace or Repeal and Delay and Pray is dead. There is no coherent coalition of 218 and 51. The Republican Senate caucus can afford to lose two votes (assuming Democrats are healthy and have everyone show up). The 2016 ACA Repeal bill defunded Planned Parenthood and knocked out Medicaid Expansion. Either of those elements will cost the Republicans at least two votes. Combined, those two provisions probably cost the Republicans six to ten votes. That is a blocking coalition when combined with Democrats.

In the House, Speaker Ryan would like to pass anything with only Republican votes in order to not be hung out to dry like former Speaker Boehner (remember he has tough votes on the debt ceiling coming up). That means he needs 90% of his caucus on board with anything. The Republican House Freedom Caucus has enough members to deny Ryan a Republican only majority. The HFC is demanding a word for word replica of the 2016 bill.

This is a Big Biden Deal as the status quo bias works in our favor for the avalanche approach that I feared in November can’t get started. Long, boring committee meetings, calls to the CBO, wonks ripping apart a plan to help advocates find very sympathetic people to tell true stories with high emotional punch is where we’re going for anything more complicated than a technical correction bill or rebranding.