Yesterday, I briefly discussed a new working paper that I’m co-first authoring with Rebecca Myerson. We wonder if ACA market insurers changed their television advertising in response to decreases in navigator funding. Our hypothesis going into the project was that we should see advertising increase as navigator funding decreased as we thought these two information channels may be substitutes for each other.
We were wrong.
Right now, we’re finding strong, consistent null results no matter what we do to the data. We did event studies — nada. We did difference in difference with 2015 as the start of the run — nada. We did difference in difference with 2016 as the start of the run — nada. We dropped each state from the analysis one by one to see if there was a single state warping everything — and we got nothing.
Why does this matter?
It matters because of Georgia.
Georgia has filed and received approval for a two part Section 1332 waiver for the ACA. A 1332 waiver allows a state to make significant changes to the ACA health insurance markets as long as guardrails of coverage, access, affordability to consumers and federal costs are met. The first part is — an interesting only to health economists — a reinsurance program that has some really fascinating within state and year county level payment variation. The Centers for Medicare and Medicaid Services has and will approve similar waivers for reinsurance from other states. As a general reminder, there is often a thin line between “exceedingly clever” and “fraud” when dealing with weird boundary condition rules.
The second part of the Georgia waiver is called the “Georgia Access Model.” The state proposes to shut down Healthcare.gov and not replace it with a state based marketplace. Instead, private entities would do all of the outreach, assistance and marketing while the state would verify incomes and assign subsidies. This part of the waiver was approved in November 2020. The current CMS leadership believes that changing legislative and policy circumstances could lead to the Georgia Access Model failing to meet one or more of the guardrails.
Georgia has argued that the private sector will be more efficient and effective at assisting and enrolling people than a government run website and/or navigator program. The forthcoming work at the American Journal of Health Economics by Myerson and Li show that enrollment of marginalized populations declined when counties experienced larger navigator funding cuts while our current working paper shows that insurers are not responding to the decline in navigator funding by increasing advertising as an information channel compensatory buff.
Insurers have a different set of objectives than the government when it comes to enrollment. Insurers want to enroll people who are highly likely to be profitable. The government wants to enroll people who are highly likely to need insurance and who may or may not be profitable after risk adjustment.
WaterGirl
Dave, is there a way for people like you to weigh in on waivers like that? It sure seems like there should be.
David Anderson
@WaterGirl: Regulation.Gov is usually a good spot. For this particular request, there is a call for comments by January 9th to be e-mailed to the department.
https://www.cms.gov/files/document/1332-ga-access-public-comment-request.pdf
For more information, including details on what the Departments are requesting comment on, please refer to the Request for Comment on the Georgia Access Model (PDF). Comments can be submitted from November 9, 2021 through January 9, 2022. Please submit comments to [email protected] and include “Georgia section 1332 waiver comments” in the subject heading. Please include your name, organization (if any), and email address with the comments.
narya
That waiver request is infuriating to me. We maintained navigators even when funding went away, and it’s really valuable in terms of helping folks who come to a community health center–the very population that private insurers do NOT want to see. Insurers have little to no interest in making sure that people actually get the care they need. (Yes, I’m extra annoyed at insurers today because I just happened to be reading through my benefits and realized I need pre-auth for something scheduled for Friday, and I’m trying to make that happen.)
Victor Matheson
This is a nice piece of work and thank you to “Dr.” Anderson for coming to Holy Cross last month to present his joint research. Glad we got in a beer before even everyone vaccinated in the state of MA started to get COVID.
Rocks
Regarding Georgia’s contention that the private sector provides better benefits to consumers. We lived in Georgia from1991 through 2005. About 2000 the Republicans got control of the state legislature, and one of the first things they did was privatize our local natural gas utility. The result? Our natural gas bills tripled. Thanks for nothing, Republicans.
David Fud
Thanks to David Anderson for doing this timely research, on behalf of all Georgians who need our healthcare to remain as intact as possible. Georgia has allowed many rural hospitals to die by not allowing expansion here, so every incremental thing we can do to maintain coverage is important.
taumaturgo
Greedy Profits before Healthcare Insurers = 1
Working Poor in Georgia = 0
WaterGirl
@David Anderson: Are you and your co-authors sending in comments on this? It sure seems like your research would have some bearing on the subject!
Lobo
“Georgia has argued that the private sector will be more efficient and effective at assisting and enrolling people than a government run website and/or navigator program.”
What is their rationale behind this? What does more efficient and effective mean? Enrolling what kind of people? What incentives drive behavior?
I know we can all answer this, but sometimes you have to go the long way to say “water is wet.”
trollhattan
@Lobo:
This is like California declaring “investor-owned utilities offer the best service, lowest prices and safest infrastructure to their customers.” 1/reality.
Urza
@David Anderson:
I’d be curious if you could do a writeup on this. I was reading about the increase in deaths of people within a year of having Covid, but I don’t know how much those numbers match to this. It also mentions an increase in disability claims due to long Covid.
https://www.thecentersquare.com/indiana/indiana-life-insurance-ceo-says-deaths-are-up-40-among-people-ages-18-64/article_71473b12-6b1e-11ec-8641-5b2c06725e2c.html
David Anderson
@Urza: Actuaries rule the world.
Urza
@David Anderson: How are the death numbers being hidden from Covid tallies though. It might be hard but someone should figure out the numbers of post-Covid deaths that are directly related to issues caused by Covid. The first year or two would be the best time to match those numbers as other health concerns would creep in over time.
David Anderson
@Urza: The numbers aren’t being hidden. The CDC death certificate database significantly lags reality (which is fine as it always has) and there are measurement issues (local coroners, usually elected, get a lot of discretion as to what goes on a death certificate.) The insurer is usually called within a week of death and they care about dead/not dead so their data is often fresher but not as granular as they have to pay out the claim relatively quickly for funeral expenses at the very least.
JaneE
The “private enterprise does it better” line has been falsified more times than I can count, especially when the cost of worse includes human lives. Since the GOP values human lives as a negative, that means that the more lives lost the better private enterprise is considered to do. I really wish that last sentence was just a crabby old lady smarting off, but it does seem that no amount of evidence to the contrary keeps Republicans from trotting out private enterprise does it better. That is not to say that private enterprise could not do a good job, maybe even a better job, if it had a reason to. But, like the man said, their goals are not the same.
Another Scott
@JaneE: Yup.
Private enterprise is great at figuring out new ways to do things and new widgets involving commerce. It’s horrible at equitably dividing resources among everyone (healthcare, utilities), or creating a system to generate new knowledge that benefits everyone (basic research), or even controlling its excesses (monopolies).
People who (claim to) think it’s good for every problem have an agenda that isn’t supported by the facts.
Cheers,
Scott.
J R in WV
ProPublica media is reporting today that Chase Bank has resumed auto-issuing affidavits — aka “Robo-Signing” — regarding their customers and the amounts owed to the bank, in order to facilitate suits against those customers. This was a common and illegal practice in the days of the last real estate crash of 2007-2008, and the bank was required to stop that practice until the end of 2020.
Private banking: sue your customers to make more money!
Private health insurance: take money from your customers to provide health care, then don’t provide any care!
Georgia needs evidence that private insurance performs better than government insurance.
For example… I mean, privately funded pensions are WAY better than Social Security, amirite? Oh, wait, those all went away so the owners of the companies could take all that money!
I think the only thing worse than unregulated capitalism is probably actual feudalism, where the workers are serfs owned by the Lairds. I’m willing to concede that well regulated capitalism may be as good as state socialism, but I would like to try that socialism stuff out for myself. Without moving to the EU. Although that move would be OK.
Thanks for calling this scam to our attention. Perhaps the evidence collected by the new Georgia system can be used to set Georgia straight the next year. And if private health insurance doesn’t work as promised, maybe we can prosecute the management (and politicians) responsible for stealing good health from the poor people of Georgia. The deep south can’t get over their historic love for feudal lords, can they?
StringOnAStick
It was a Healthcare.gov Navigator that showed us that as long as we had very little income, we could get a subsidized plan while we pass those last two years until the magic age of 65. I have doubts that a private health plan salesperson would have known as much of the ins and outs of the ACA to be able to assure us of that since they just want to make a sale. Also, since the first thing the minions of the Beast tried when they got in place was to kill all advertising for ACA sign ups. one suspects there was corporate pressure behind that choice.