Basic Health Plans and hoping for chaos

States that want to start a Basic Health Plan in 2019 have an incentive to root for non-fatal market chaos in 2018 rate filings.

The Basic Health Plan (BHP) is effectively enhanced Medicaid Managed Care for the Exchange population that earns less than 200% of the Federal Poverty Level. States receive 95% of the funds that would have been spent on Exchange premium and cost sharing subsidies with geographic and demographic adjustments.

Currently, we are hearing that insurers may file very high rates because they don’t know what the 2018 on-Exchange rules or risk pool will look like. Very high rates will be composed of the combination of increasing medical trend which is a normal part of a rate filing and an uncertainty component. The uncertainty component will be large enough to cover an insurer’s obligations if they are required to offer Cost Sharing Reduction (CSR) actuarial value boosts without getting paid for them. The uncertainty component will be large enough to cover a risk pool that shrinks significantly as outreach by is curtailed or ineffective and mandate enforcement messaging disappears. The uncertainty component is the insurance insurers will take out to cover themselves from sabotage.

The uncertainty component is specific and limited to only the individual market.

The current rules are from the February 29, 2016 Federal Register. BHP subsidies are not adjusted for changes in premiums due policy uncertainty. The assumption in the current rules is that Exchange costs increases are driven only by medical trend.

This produces an opportunity for states that want to start a BHP in 2019. If we assume the ACA’s structure fundamentally exists in 2019 states could receive a cash windfall if they elect to build a BHP using 2018 QHP rates as the funding baseline. 2018 QHP rates will be very high and most of that increase will be due to policy uncertainty and not underlying medical trend. The current rules do not recognize a policy uncertainty adjustment so the states would get a block grant equal to 95% of the inflated Exchange expense. The underlying trend of expenses in a BHP would be normal and the block grant would be more than sufficient to cover expenses. The surplus could either be used to enhance benefits with a BHP, provide a one shot infusion of funds to opioid efforts or other public health/social determinants of health programs.

By 2020, the uncertainty premium is most likely wrung out of the baseline Exchange rates that drives the BHP funding stream so it is only a one or two year play but there is a good chance a lot of extra money is out there for states that want to start their own Basic Health Plan in 2019.

Third time’s a harm

The Huffington Post has the outline of yet another Republican healthcare deal:

he deal, brokered between House Freedom Caucus chairman Mark Meadows (R-N.C.) and Tuesday Group co-chairman Tom MacArthur (R-N.J.), would allow states to get waivers eliminating the so-called community rating provision ― the rule that prohibits insurers from charging higher premiums to people with pre-existing conditions. In order to obtain the waiver, states would have to participate in a federal high-risk pool or establish their own, and satisfy some other conditions.

In exchange for that conservative concession, the amendment would reinstate the Essential Health Benefits that were already taken out of the bill ― though, again, states could waive those provisions as well if they were able to show that doing so would lower premiums, increase the number of people insured, or “advance another benefit to the public interest in the state.”

What does this mean?
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Thursday Morning Open Thread: “Make This Fight Your Fight”

Some people are gonna be disappointed she didn’t call the other candidate in the 2016 Dem primaries out, but that’s not Sen. Warren’s style.

(I was originally gonna post Maddow’s latest interview with Sen. Warren, but FYWP isn’t cooperating.)

Apart from continuing to fight all the good fights, what’s on the agenda for the day?

And a reminder, because I’m allergy-addled and cranky, from Mr. Charles P. Pierce — “Why Trump Won”:

[O]ne of the more interesting sidelights of what certainly will be a deluge of post-mortems regarding the 2016 presidential campaign is the widely held notion that Hillary Rodham Clinton was gifted with a uniquely easy opponent. This idea is central to the narrative that holds that HRC’s campaign was a uniquely bad one, and she a uniquely bad candidate. She couldn’t even beat a reality-show star who doesn’t know North Korea from East Hampton. True, there were a number of things that HRC and her campaign did badly, but they did get three million more votes than did Trump, which counts for something…

Consider this: Whatever you may think of how he won the presidency, and we’ll get to that in a minute, Trump took on a Republican field composed of what was alleged to be the best that party had to offer, the deepest part of its allegedly deep bench, and he utterly destroyed it. Scott Walker, popular scourge of middle-school history teachers, never even made it to the starting gate. Rand Paul, brogressive libertarian heartthrob, was reduced to invisibility. Chris Christie was demolished as a national political figure. Marco Rubio—The Republican Savior, according to Time—is still wandering the political landscape looking, as Abraham Lincoln said of General Hooker after Chancellorsville, like a duck that’s been hit on the head. And, when he finally got around to it, he took the heart out of Tailgunner Ted Cruz in Indiana, alleging on the morning of the primary that Cruz’s father hobnobbed in New Orleans with Lee Harvey Oswald.

That Trump never paid a price in the eyes of his voters for that kind of meretricious goonery is the best evidence there is that, in 2016, anyway, he was in every sense a formidable political force. And, let it not be forgotten that he brought with him a Republican Senate, a Republican House, and massive gains out in the states as well.

Moreover, and I owe a hat tip to Scott Lemieux here, it’s likely in retrospect that Trump’s plan of action, while unconventional in the extreme and relentlessly eccentric, also was based in a kind of mad logic. There really was a big slice of the electorate, concentrated in states that were vital in the Electoral College, that was uniquely susceptible to Trump’s appeal. He and his people spotted it and campaigned accordingly.

The myth of Trump’s vulnerability has two sources, I think. The first is the apparently irresistible impulse in some quarters to score some sort of final victory over the Clinton family… The other is the reluctance of Republicans—and of the elite political classes at large—to accept the reality that Trump is merely a cruder manifestation of the political prion disease that has afflicted conservatism and the Republican Party since it first ate the monkeybrains 35 years ago. It was all leading to someone like Trump, and something like last year’s election.

So many people had been driven away from the voting booths — deliberately or not — and so many other people at both ends of the political spectrum had allowed themselves the luxury of believing that their votes were tickets to an entertaining spectacle… that all it took was a few million rubles’ worth of monkey-mischief and the deliberate collusion of the FBI to hand the Oval Office over the Donald Effing Trump. But none of the guilty parties, least of all in Our Major Media, are willing to accept their share of the blame; ergo, it must be That Woman’s fault. Mom should’ve made us not drink a mixture of bleach and ammonia, what a horrible failure she is for assuming that telling us it was poison & we’d regret it later would be enough to deter us!

That’s not how it works, fellas. You’re (putative) grownups now, and you have to take responsibility for your own failures. And, no, those of us with better sense are not gonna ‘get over it’ any time in the immediate future, nor make the mistake of trusting you further than we can see you.

On The Road

Good Morning All,

This weekday feature is for Balloon Juicers who are on the road, travelling, etc. and wish to share notes, links, pictures, stories, etc. from their escapades. As the US mainland begins the end of the Earth day as we measure it, many of us rise to read about our friends and their transient locales.

So, please, speak up and share some of your adventures, observations, and sights as you explore, no matter where you are. By concentrating travel updates here, it’s easier for all to keep up-to-date on the adventures of our fellow Commentariat. And it makes finding some travel tips or ideas from 6 months ago so much easier to find…

Have at ’em, and have a safe day of travels!

Should you have any pictures (tasteful, relevant, etc….) you can email them to or just use this nifty link to start an email: Start an Email to send a Picture to Post on Balloon Juice

After the fold!

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Late Night Open Thread: Everyone’s A Cynic Now

It is tree-pollen season here, and while I have a bunch of Serious Constructive articles tabbed up to post about, all I want to do is take another mouth-breathing, stunned-into-submission nap!

Annals of Strategic Communication: The Carl Vinson Task Force Miscommunication

Joint Publication 5-0/Joint Operation Planning defines strategic communication as:

Focused United States Government efforts to understand and engage key audiences to create, strengthen, or preserve conditions favorable for the advancement of United States Government interests, policies, and objectives through the use of coordinated programs, plans, themes, messages, and products synchronized with the actions of all instruments of national power.

The misstatements and miscommunications regarding where the USS Carl Vinson Task Force is and what it is doing have made US strategic communication, both in general and in regard to the DPRK, much, much harder and much more problematic.

I think, however, that the Occam’s Razor explanation for what happened is the most likely one. Here’s what I think happened:

  1. Admiral Harris, Commander US Pacific Command (USPACOM), informed Secretary of Defense Mattis that he had issued a Fragmentary Order cancelling the Carl Vinson Task Force’s port call in Australia and redirecting the strike group to the Sea of Japan to show the colors.
  2. The DOD notified the White House – most likely either through the Liaison Officer or through the National Security Staff.
  3. A copy of the Fragmentary Order was filed.
  4. Secretary Mattis misspoke on 11 April, because he hadn’t actually seen the FRAGORD, that the Carl Vinson Task Force was headed immediately to the Sea of Japan.
  5. The President was briefed, without any specific details, because no one on the National Security Staff had them, that the Carl Vinson Task Force was headed to the Sea of Japan.
  6. The President stated the Carl Vinson Task Force was headed to the Sea of Japan in his Fox Business News interview.
  7. The Carl Vinson Task Force steamed south from Singapore, as ordered, to take part in a scheduled exercise with the Australian Navy.
  8. As is often the case, the US Navy, through the Public Affairs Office, released pictures of the Carl Vinson Task Force passing through the Sunda Strait – 3,500 miles from the Sea of Japan off of the Korean peninsula.

Talking Points Memo has a full timeline at this link.

How did all this miscommunication happen? Simply put – there are almost no political appointees at the Pentagon (or anywhere else in the US government) right now. Secretary of Defense is, essentially, working without a team. He has no deputy, under, assistant deputy, and deputy assistant secretaries, nor does he have any directors, deputy directors, and/or special assistants at the Department of Defense – though several designees have been named for some of these positions. He also does not have any Service Secretaries in place  – though we have have three designated nominees. And none of the deputy, under, assistant deputy, and deputy assistant secretaries, nor does he have any directors, deputy directors, and/or special assistants at each of the Services. All the Secretary of Defense has is whichever Trump campaign and transition personnel are on the DOD and Service Beachhead Teams – none of whom have been chosen by Secretary Mattis. Right now you have a DOD Secretary, the DOD and Service Beachhead Teams from the transition, and then the career civil servants (both Senior Executives and General Schedule) and uniformed military personnel. Basically the entire layer of politically appointed managers, senior to junior, are completely missing. As a result, things are going to fall between the cracks, such as the exact nature of Admiral Harris’s FRAGORD to reposition the Carl Vinson Task Force.

Aside from the bog standard embarrassment of having the President, the Secretary of Defense (a retired USMC 4 Star), and the White House Press Secretary (a US Navy Reserve Commander) not knowing where a carrier strike group is, this is also a significant strategic communication problem. This morning the Associated Press reported (h/t and via: Talking Points Memo) that both our Asian-Pacific partners and competitors are disconcerted and wary given the President and the Administration’s seeming inability to communicate accurate information.

SEOUL, South Korea (AP) — Unpredictable. Unhinged. Dangerous.

Many South Koreans are using those words to describe the president of their most important ally, rather than the leader of their archrival to the North. They worry that President Donald Trump’s tough, unorthodox talk about North Korea’s nuclear program is boosting already-high animosity between the rival Koreas.

The Kyunghyang Shinmun newspaper said recently that Trump is playing a “dangerous card” with his verbal threats, risking a miscalculation by Pyongyang and a war on the peninsula.

What the US is currently strategically communicating in regard to the ongoing DPRK nuclear weapon and missile development programs is not exactly inspiring confidence on the Korean Peninsula.

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Wednesday Evening Open Thread: Where Are the Patriots?

The class clown showed up, though!…

Shows for Bros

You know who I wouldn’t want to trade jobs with right now? DNC chair Tom Perez. The first big test of his leadership is apparently gonna be how successfully he channels the Bern. Will he succeed? Does it make sense to pursue this strategy out of the gate? Fuckifino.

Perez and Sanders are doing a roadshow in red and purple states to gin up enthusiasm for rebuilding the party and taking on Trump. It’s officially called the “Come Together and Fight Back” tour. There’s an account of the first rally in Maine in the Portland Herald Press. A couple of quotes:

Perez: “The mission of the new DNC is not simply to elect the president of the United States. It is to elect Democrats from the school board to the Senate.”

Sanders: “Our job is to radically transform the Democratic Party . . . into a 50-state party and a party that does not continue to ignore half of the states in our country. Our job is to create a democratic party, a grassroots party where decisions are made up from the bottom on up, not from the top on down.”

As a neoliberal shill in the pocket of Big Democrat, I am immune to Sanders’ appeal. But I’m not the roadshow’s intended audience. The Democrats don’t have to coddle me to ensure I turn up to vote, but the Sandersites are more loosely affiliated. I’m trying to temper my reaction to the aspects of the roadshow I find irritating accordingly.

In that spirit, I will note that we’ve complained for years about the party’s too-narrow focus on federal offices (though we’ve quibbled over what the DNC’s proper role is in state party affairs). I agree with what Perez says above, and Sanders’ statement basically amounts to the same thing, with extra finger-wagging and pointing.

I’m going to trust that Perez knows what he’s doing and have faith that this roadshow is just the opening salvo, with different forms of outreach targeting women, minorities, etc., and robust voter suppression countermeasures to follow. Because dog knows, we can’t afford to fuck this up by fighting the last war.

There’s a very strange vibration piercing me right through the core

Score another one for the liberal fascists and their campaign against free speech:

The Murdochs have decided Bill O’Reilly’s 21-year run at Fox News will come to an end.

I have a feeling we haven’t seen the last of this asshole.

Chaffetz Is Done

Well, this is an interesting development! Via WaPo:

House Oversight chairman Jason Chaffetz says he will not seek reelection in 2018

The Republican congressman from Utah, who became chairman of the House Oversight and Government Reform Committee in 2015, has been criticized for a lack of action in investigating the Trump administration and President Trump’s potential conflicts of interest. He reversed his position on Trump’s candidacy several times in 2016, and recently faced an angry crowd at a town-hall meeting that criticized his tenure as Oversight chairman.

“For those that would speculate otherwise, let me be clear that I have no ulterior motives. I am healthy. I am confident I would continue to be re-elected by large margins. I have the full support of Speaker Ryan to continue as Chairman of the Oversight and Government Reform Committee. That said, I have made a personal decision to return to the private sector,” Chaffetz said in a statement on Facebook.

During the Obama administration, Chaffetz undertook probes of the 2012 Benghazi attack and Hillary Clinton’s use of a private email server.

I don’t believe for a second there are no ulterior motives. So let’s indulge in rampant speculation about why the pig-faced prick is declining to stand for reelection, shall we?

Did Chaffetz get wind of a looming Trump bombshell? Has he seen poll numbers that foretell electoral doom? Is a 19-year-old Piggly-Wiggly cashier about to hire Gloria Allred and announce that Chaffetz fathered her pig-faced baby?

As the saying goes, it would be irresponsible NOT to speculate!

Open Thread: Who’s Going to A Science March?

Note from commentor Quinerly, whose Travels with Poco enlivened many early-morning threads:

It would be cool if a Front Pager would throw up a dedicated Meet Up thread maybe on a Wednesday before these marches. People could pipe in with their areas, pick places for Juicers to meet, if they wanted to….no pressure, no planning clusterfucks. Just a suggestion.

Look forward to meeting you [St. Louis, Missouri]. I just put up an invite on my Book of Faces page to generate some interest. My neighborhood peeps pretty much hang at Howards on Saturday and Sunday anyway. Soulard is a neighborhood of misfits, hippies, and derelicts….we like our music and cocktails…Ozark will attest to it from his days in the area.

I know various commentors from a number of cities/states have expressed their intentions over the past several weeks. If you’d like to meet up with other Balloon Juicers, or have questions, leave a comment below. (Or you can email me at annelaurie dot verizon dot net, but don’t expect to hear back until late afternoon or early evening.)

More churn than a butter factory

Two conservative health policy wonks are outlining an auto-enrollment option that is philosophically aligned with what is in the Collins-Cassidy draft bill state option. I don’t have an intrinsic problem with auto-enrollment with an opt-out. I have a major pragmatic problem with their proposal. But let’s look at the core of their program:

Congress should also help policyholders avoid breaks in coverage. Lawmakers could require insurers to offer products whose premiums match the value of the federal tax credits. If the basic, age-adjusted federal tax credit for a 40-year-old man in a given state is, say, $3,000, then every insurer in the state would have to make a policy available for such customers with a $3,000 premium.

Insurers would adjust the upfront deductibles in these plans as necessary to ensure that the premium equals the credit….

As with other benefit programs, many Americans wouldn’t use the credits for which they are eligible, out of inertia or lack of information. To solve that problem, the states could automatically place eligible households into the no-premium option, randomly assigning them to one of several competing insurance plans and then notifying policyholders of their coverage.

They are identifying a real problem with a reasonable way of minimizing the problem. Recent estimates have the Medicaid Woodwork effect contributing to 30% of the total decline in uninsurance i 2015. The Woodwork Effect is when people who were eligible but not signed up for Legacy Medicaid hit the Exchanges as health insurance enrollment became a major topic of public discussion and found out that they were always Medicaid eligible. This happened in Expansion states, it happened in non-Expansion states, it happened in Red states, it happened in Blue states.

I have a major pragmatic objection to their program design.

How do we figure out who is not otherwise covered in any given month?

The entire non-employer sponsored insured, non-government sponsored insured group can be roughly divided into four groups. The first is non-documented immigrants, this plan most likely will exclude this cluster for political reasons. This would not be a major change.

The other three groups are the problem.

The first group are people who will be in good health but need insurance on the individual market for a long time period. This group are the artists,the consultants, the very small business owners, the people who are fairly reliable buyers. If they were healthy, this class was in the individual market in 2009. They may switch carriers for cost and network purposes but they actively participate in the market year over year.

The second group is also a group that was in the individual market in 2009. It is people who just need some coverage until something better came along. When I was laid off in 2009, my wife and I bought a catastrophic policy that covered us for a few months until we were able to get back onto employer sponsored coverage. My daughter was on that policy for two months until we got her on CHIP (best insurance I’ve ever had, great network, low premium, no stress). These are the policies which function as holding areas until something better comes along.

The final group in the ACA individual market are people with significant health conditions who were previously underwritten or priced out of the market. As a cohort, these individuals are also very stable in participation. A hemophiliac or an individual with MS will make sure that they sign up for coverage as they burn through any deductible by the third week of the policy year.

The first and third groups aren’t a major source of my pragmatic objection. The second group is a major source.

For relatively healthy people who are mainly insuring against catastrophic expense (hit by a meteor coverage) they are likely to churn. With an auto-enrollment system some level of government will need to track eligibility of every single potential covered life on a day to day basis. If someone is laid off on the 14th and their employer has a coverage cut-off on the 15th of the month, are they covered if they have a heart attack on the 16th? They probably would be on a retrospective claims basis but coverage churn is a major concern unless there are either massive back ends claims reconciliation for retrospective eligibility, states absorb the first sixty days of costs of a patient who is not part of a prospective assignment, or some other churn identification.

There are work-arounds but the pragmatic challenge of churn is real and it is big.

Going out west where I belong

With all the excitement around Jon Ossoff, let’s not forget about the special in Montana. You can give to Rob Quist here.

Goal Thermometer

Who is your Doctor

Who is your doctor?

That should be an easy question to answer.  It’s not.

Most of the time, it is a fairly straightforward question.  A person’s primary care provider (PCP) is responsible for quarterbacking the individual’s care pathways and is supposed to be looking at the big picture as well as the day to day flows of a patient.  For most people who see their doctor and thus have a claim, the person that the claims analysis system says is their PCP and who they say is their PCP is the same individual.  But not always.

There are a couple of cases where there is significant areas of conflict.  The first is when a person indicates that Provider A is their PCP but they have been seeing Provider B, who fits normal PCP criteria, numerous times in the recent pass.  This could be driven because their is a slight misclassification where Provider B is acting as a specialist.  That is not too uncommon for Ob-Gyn and some infectious disease specialties where a provider will be dual classified as both a specialist and a PCP.  Geriatricians are slowly becoming more likely to be dual credentialed as a PCP and a common specialty like cardiology.

Another case of confusion is when a person does not routinely see a provider for primary care.  My dad did not see a PCP for most if not all of my childhood.  My wife has not had a PCP appointment in years as she gets her only regular interaction with the medical system through her OB/Gyn or at the urgent care for an annual flu shot.  These are not profoundly unusual situations.  Most people in most years barely touch the medical system.  Finally, there are cases where people are in flux for their care patterns where there is a major discontinuity in their utilization.  This can be done through either an insurance switch or a disease burden transition.

A new study** highlights the problems of trying to guess who a person’s doctor really is.

The study sample included 15,624 patient-years from 3658 older adults with diabetes. Agreement was higher for algorithms based on primary care visits (range, 78.0% for majority match without a tie breaker to 85.9% for majority match with the longest time from first to last visit) than for claims to all visits (range, 25.4% for majority match without a tie breaker to 63.3% for majority match with the amount billed tie breaker). Percent agreement was lower for nonwhite individuals, those enrolled in Medicaid, individuals experiencing a PCP change, and those with >10 physician visits.

85.9% is pretty good but the last 14% is a major policy problem.

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On The Road

Good Morning All,

This weekday feature is for Balloon Juicers who are on the road, travelling, etc. and wish to share notes, links, pictures, stories, etc. from their escapades. As the US mainland begins the end of the Earth day as we measure it, many of us rise to read about our friends and their transient locales.

So, please, speak up and share some of your adventures, observations, and sights as you explore, no matter where you are. By concentrating travel updates here, it’s easier for all to keep up-to-date on the adventures of our fellow Commentariat. And it makes finding some travel tips or ideas from 6 months ago so much easier to find…

Have at ’em, and have a safe day of travels!

Should you have any pictures (tasteful, relevant, etc….) you can email them to or just use this nifty link to start an email: Start an Email to send a Picture to Post on Balloon Juice

Today is an anniversary of so many horrors. Keep the victims and survivors, their loved ones and lost opportunities close to your soul today.

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