Monday Afternoon Open Thread

Looks like we’re all wicked busy. Here’s a song from the great La Lupe to tide you over:

Please feel free to discuss whatever!

Three Clowns

I expect we’ll get this inside scoop on Joe and Mika from Trump right after we hear back from his Hawaiian birth certificate investigation team, but damn! Will Trump get away with this because he is Trump, or will a personal attack like this create blow-back from the Beltway press, which likely takes a dim view of references to infotainment celebrity side salads?

And really, MIKA is the insecure one? Joe Scarborough sulks like a toddler if anyone contradicts him or implies that one of his many stupid and uninformed opinions are rooted in ignorance. He’s an insecure bully, like Trump, so it’s unsurprising Trump is blind to it. Morons, the lot of them.

APTC Hacks — defining terms

Advanced Premium Tax Credits (APTC) are how people get subsidized to buy Qualified Health Plans (QHP) on Exchange.  They are based on an individual’s income as determined by their family unit’s Federal Poverty Line (FPL) percentage and the cost of the second least expensive Silver plan offered on Exchange in their area.  The subsidy arrangement means that individuals with the same exact financial situation will pay the same amount post-APTC subsidy for the second lowest Silver plan across the country.  The APTC is a fixed amount for an individual.  If they choose to buy a cheaper plan, the APTC eats up a higher percentage of the plan premiums.  If they choose a more expensive plan, the individual buyer pays more to “top-off” the purchase.

This only applies to on-Exchange, subsidized plans.

This subsidy design is hackable.  I’ve identified two major types of hacks/business strategies that I’ll want to explore more this week which exploit the subsidy structure for insurance company ends.

The first is what I call Silver Spam.  Ambetter in Chicago is my case example.

For a 40 year old non-smoker, Celtic/Ambetter offers the 1st and 2nd Silver at $195 and $198, as well as the next four Silvers.  The first non Celtic/Ambetter Silver is priced at $249.

The Celtic/Ambetter Silvers are all HMOs, and they all are sharing the same very narrow network.  The benefit configuration (deductibles and co-insurance) change, but the out of pocket maximums are all tightly clustered.  From my point of view, these six plans are functionally similar plans.  The business decision to introduce these six plans, and more importantly the #2 Silver at just a few bucks more than #1 is a membership recruitment decision.

The goal of an insurer in the Silver Spam strategy is to offer the #1 and #2 silver plans in the region with a very small gap between those two.   Furthermore if they can keep the price of the second Silver significantly lower than the price of the first Silver plan offered by a competitor, they’ll be very happy.  The objective of the Silver Spam strategy is to take away choice.  The relative value of the APTC when applied to the purchase of the 1st Silver is not much higher than it is when applied to the #2 benchmark Silver.  If there is a large gap between the Silver Spammer’s Silver plans and the next best offer, the Silver Spammer will capture a large proportion of the market for Silver and should (all else being equal) capture a decent proportion of the Bronze market.

It is a membership and healthy risk capture strategy.

On the other extreme is what I call the Silver Gap strategy.  It is also a manipulation of the space between the #1 and the #2 Silver.  But instead of an insurer minimizing the space, the insurer maximizes the space between those two price points.  The goal is to maximize the relative value of the APTC.  This can be done with an insurer offering both the #1 and #2 Silvers or with seperate insurers offering the plans.  Molina in California’s Region 16 in 2016 is a good case example of a double insurer Silver Gap outcome.

Region 16 that Molina made its play and gained its share. Molina put up both the cheapest silver and the  cheapest bronze plans in that region — massively undercutting the benchmark silver plan, and thus offering buyers a major discount on the Cost Sharing Reduction (CSR) subsidies available only with silver. For a 40 year-old earning $23,000, a shared under 200% of the Federal Poverty Level (FPL), Molina silver is just $74 per month in Region 16 in  2016, vs. the benchmark silver’s $119 (Health Net).  Molina’s bronze plan at that age and income level is just $1 per month, vs. $55 for the nearest competitor.

In 2017, early indicators are that some insurers are aggressively pursuing a one sided Silver Gap strategy.   Carriers would offer a low price Silver and then a higher priced Silver as the benchmark.

This strategy is designed to drive people to the #1 Silver plan as it will be comparatively cheaper than the #2 Silver.  It will also have the ability to drive people to very low premium Bronze plans.

There are other exchange strategies that don’t rely as much on manipulating APTC structures.  Some carriers are not as price conscious.  Instead they are targeting risk adjustment plays by offering people with high risk adjustment scoring conditions insurance where the gamble is the insurer can manage their care and outcomes to be better and cheaper than the combined sum of premiums and risk adjustment inflows.  Others are still throwing mud against the wall.

I’m fascinated by the APTC hacking strategies because as major players pull out of the markets, more regions are seeing either only a single carrier offer plans or two carriers offer plans.  Depending on how the plans are offered we could see consumers be either very happy or extremely pissed off.  If carriers are offering a narrow network, low price Silver as the #1 and a broad network Silver at a significantly higher premium as the #2 benchmark Silver, people will be, on the whole, very happy.  If carriers offer a narrow network HMO with miniscule benefit configuration tweaks as Silver #1 through #8 people will be extremely pissed off.  The ACA story devolves into a story about the experience of individual counties at this point.

A CAP in Illinois

What is the situation and why am I thinking it is an adverse selection event if anyone offers to write credits for the Land of Lincoln members.

Land of Lincoln was a Co-Op. It was placed under state oversight in July. It’s reserves had gotten too low due to a higher than expected risk adjustment bill and no compensating risk corridor asset. Coverage for people on the individual market will terminate on 9/30/16. That means people will be running without coverage from October 1 to December 31.

New York had a similar experience in 2015 when Health Republic was liquidated in the fall of 2015.

Normally regulators would prefer to allow an insurer under oversight to run until the next open enrollment period. That would allow their members to have continuous coverage with the least amount of disruption and added stress. However Land of Lincoln and Health Republic could not make it to the end of the current policy year. Instead, they ended mid-contract. This triggers a Special Enrollment Period as the members lost coverage due to no fault of their own.

In New York, there was an arrangement that people who were on Health Republic who signed up for a month of coverage would have their deductibles and out of pocket expenses credited to their new policies.

That is now not the case in Illinois. Blue Cross and Blue Shield is refusing to enter into a voluntary arrangement to credit deductible and out of pocket spending for any new policies it rights for any qualifying event. That is their right to do so. However, their refusal to do so pretty much forces every other Illinois insurer to also refuse to extend deductible credits.

Adverse selection is the cause of this race to mutually assured ugliness.

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Monday Morning Open Thread: Moving Forward

For a bracing start to the new week, from the Washington Post, company paper in the town where the monopoly industry is national politics:

Hillary Clinton’s increasingly confident campaign has begun crafting a detailed agenda for her possible presidency, with plans to focus on measures aimed at creating jobs, boosting infrastructure spending and enacting immigration reform if current polling holds and she is easily elected to the White House in November…

While careful not to sound as if she is measuring the draperies quite yet, Clinton now describes what she calls improved odds for passage of an overhaul of immigration laws — the first legislative priority she outlined in detail last year — and what could be a bipartisan effort to rebuild the nation’s roads, bridges, airports, rail system and ports.

She also could be immediately confronted with a choice about a Supreme Court vacancy that could set the tone for her relationship with Congress, and she plans to immediately champion new measures on campaign-finance reform and ending legal immunity for gun manufacturers.

Her campaign’s to-do list includes assembling a Cabinet that has women in roughly equal numbers to men and that otherwise reflects American diversity, and lobbying has intensified for those and scores of other jobs that Clinton would fill in her administration.

Some Clinton boosters remain concerned that, with an election focused so heavily on Trump’s deficiencies, she could enter the White House without a clear mandate. But Clinton’s team is hopeful that a trouncing of her Republican opponent in November could soften the ground for a robust set of proposals that could be implemented both with and without congressional action…

Apart from dodging the Media Village Idiots groping for their fainting couches, what’s on the agenda for the day?

Open Thread: Meanwhile…

So I was reading Josh Barro’s twitter feed, and he retweeted this exchange from “Kasich strategist” John Weaver:

Ruffini seems to be a playa among the professional Repub #NeverTrumps, but if this tweet-string is indicative of that clan’s “thinking”, I’m not sure they are equipped to deal with the combovered cuckoo in their snug little nest…

“There’s our problem, guys — we’ve just been too bloody subtle with our dogwhistle pandering to racists, xenophobes & misogynists! If only we’d had the marketing genius to go full Breitbart before Trump beat us to it!”

Really? You guys think all you needed to win was an “authentic” demagogue? Someone with the “common touch” who could “appeal” to your willfully clueless voters?

And then you accuse Hillary Clinton of despising her own base!

Open Thread: Trump Berates African-American Voters

Apparently it has been discovered that some people, despite Trump’s explicit appeal to “my African-American,” do not realize voting for Deadbeat Don is their last chance at the lottery ticket to a better life. (His new campaign manager, after all, runs a site well known for being not at all hostile to people of color.) The Washington Post dissects Trump’s latest appeal to African-Americans with far more seriousness than it actually deserves — “It’s hard to imagine a much worse pitch Donald Trump could have made for the black vote”:

Consider: Black Americans are not “living in poverty” as a general rule. A quarter of the black population is, according to data from the Kaiser Family Foundation, about the same as the percentage of Hispanics. In Michigan, the figure is slightly higher. Most black Americans don’t live in poverty, just as most white Americans don’t.

Consider: The unemployment rate in the black community is higher than that in the white community, as it has been since the Department of Labor started keeping track. Among young blacks, though, the figure is not 59 percent — unless (as PolitiFact noted) you consider not the labor force but every young black American, including high school students…

Consider: Black voters are perfectly able to evaluate candidates on qualities other than their political parties. Black voters began supporting the Democratic Party heavily thanks to the Civil Rights Act of 1964. Since then, they have consistently voted for the party — a party that is one-fifth black and which since 1964 has elected the vast majority of the black members of Congress…. Democrats win the support of black voters consistently because those voters like the work that they do and like the fights that they fight…

Apart from {facepalm} x n, what’s on the agenda for the end of the weekend?

Guest Post: End of Life Doulas

By: Prescott Cactus

plural noun: doulas

a woman who is trained to assist another woman during childbirth and who may provide support to the family after the baby is born.

The word “doula” comes from the ancient Greek meaning “a woman who serves” and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth.

Elena Gooray over at Pacific Standard Magazine writes about End-of-Life Doulas. She spoke with Deanna Cochran, 55, Austin, Texas, an end-of-life doula, hospice nurse, and founder of the End of Life Practitioners Collective. It’s an international organization that provides support for family and a community for practitioners.

What Deanna is trying to do is open up to the world to the conversations about death in an all encompassing way. Giving birth is a 9 month ritual culminating with bringing a life into the world. Death can be a sharp pain, a cold body and a financial transaction with a funeral parlor. . . If we let it be.

The birth experience includes OB-GYN’s, maternity wards, pre-natal care, sonograms and baby showers. Deanna’s organization tries to expand our lives to include the same richness / fullness to death that birth currently receives. Her organizations site even has a Podcast devoted to Palliative Care and every modality or idea that could possibly relieve suffering at the end of life.

Time marches on and we as a society embrace new life with vigor, but death with fear and apprehension. This won’t change unless we expand ourselves. Take a look around Deanna’s site. With years of hospice experience, I’m learning some new things.

Special thanks to valued front pager Richard Mayhew for the heads up on the article and valued commenter raven who recently lost a good friend JA.

Prescott Cactus

Sunday Afternoon Open Thread

I’ve had this song stuck in my head for days — God only knows why. I used to think the arrangement was odd — that the horns were out of place with the 60s pop flavor of the rest of the song. Now I think it’s genius. YMMV.

Something I’ve discovered this week: it’s breathtakingly expensive to send a kid off to college, even if the tuition is already paid. The price of books is just fucking outrageous! Stupidly, I thought maybe books had become cheaper since I went to school, what with mobile devices and the internet and all. Nope.

Also, stuff like parking permits — ridiculous! And setting up a human being in another household, even if you make use of thrift stores, etc., when possible — absurd! I find myself admiring my parents’ gutsy call when I graduated from high school, which was to wish me luck and wash their hands of me financially.

Now that the mister and I are the sole occupants of our nest, I have decreed that 2:30 PM Eastern time on a Sunday is an appropriate time for a cheap champagne brunch. I went to the store a while ago for supplies, forgetting that the hideous mega-church down the street had just let out.

All the congregants had streamed into the grocery store ahead of me, and I had to fight cart traffic in every aisle to acquire mimosa makings and biscotti baking supplies. Now I’m just waiting for the champagne to get cold so I can follow its fine example and chill the fuck out myself. You?

Sunday Morning Open Thread


All-American koan:

What’s on the agenda as we wrap up the weekend?

Overnight Open Thread

Have at it!

You Rang?

I thought I heard Tamara call my name.

I Want The Fairy Tale

Looks like there needs to be a new open thread. I’m halfway through season one of A Place To Call Home and completely hooked. So if you need me, that’s where I’ll be.

Have at it….John will probably pop up in a couple of minutes with a fun thread, so be on the lookout.

Open Thread: Hasn’t Baton Rouge Suffered Enough?

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Saturday Afternoon Open Thread: ‘But Our Horse Race!…

We need to GOTV and run up Clinton’s totals, because the hierophants of the Conventional Wisdom are pushing as hard as the Republicans for a Donald Trump win.

Possibly harder, given how dispirited Reince & Ryan seem at the moment.

What’s on the agenda for the afternoon?