Over the past eighteen months, my role as an academic has changed in a few ways beyond going back for my doctorate.
I’ve been teaching a poli-sci heavy health policy class, I’m advising masters students on a variety of projects, and I’ve taken the senior author role on a couple of papers. The senior author role is more guidance and direction rather than writing and analysis. I’ve been co-authoring as a senior author with several awesome people on a couple of really cool ACA related questions.
One of the questions that every project generates is how to think about time in the ACA individual markets. How long should we look back for a particular question and is there a reason to exclude the current years or the early years or 2018 or something else? There are justifications for including everything, including only recent or excluding the recent years for each of these questions.
As part of this conversation and a lot of walks to get coffee where these decisions marinated in my head… there are three basic eras of the ACA individual market analytically speaking with one fuzzy boundary.
Getting Started with Training Wheels: 2014-2016
The ACA individual market was just getting going. There were substantial temporary supports with federal reinsurance and risk corridors. Reinsurance paid a substantial chunk of high cost claims for the first three years with non-premium revenues. Risk Corridors were intended to correct for actuarial oopsies in either direction where insurers that lost a lot of money were expected to get some of that money back and insurers that made a lot of money were expected to pay some of that money to the federal government. The 2014 CROMNIBUS mandated that the risk corridors were revenue neutral which effectively meant most of the insurers who had big losses were only getting a sliver of what they thought they were entitled to until they sued and won in the Supreme Court several years later.
During this time period, there were a ton of new insurers, including the Co-Ops, and a lot of insurers jumping into a market that they did not understand well. Lots of insurers lost a lot of money very quickly from either trying to undercut the market and buy marketshare with the expectations that the enrollees would be sticky over the long run as the risk corridors would pay most of the marketing budget and loss leader pricing. Conversely, some insurers were just wrong about the market and the winner take all subsidy linked pricing system creamed them.
Politically, there was massive resistance to the ACA. The law was going to court every week it seemed. States either quickly expanded Medicaid, mostly liberal states, or dragging their feet.
Wobbly riding without outside assistance: 2017
2017 was a transition year. All of the temporary supports stopped. Lots of insurers had left the market either because they had been forced out by state regulators who were freaking out about capital and liquidity concerns (most of the co-ops) or because they were losing too much money. There were concerns for “bare counties” in summer 2016 (really going to be a big thing in July 2017). Prices had skyrocketed to cover both the loss of supports such as reinsurance and to accurately price for higher risk. These decisions were made in the summer of 2016.
Firehose of federal subsidy spending: 2018-present
The biggest common thread from 2018 to present is that the premium subsidies got double buffed. The first substantial increase is “Silverloading” which started in October 2017 when the Cost Sharing Reduction (CSR) subsidies were no longer directly paid by the federal government to insurers. Insurers instead put the expected incremental cost of these mandated benefits into only the silver premiums. This jacked up the benchmark premium which set subsidies which made the non-silver premiums way cheaper for subsidized buyers. At the same time, states were starting to file for reinsurance waivers which indirectly subsidized upper income individuals who were facing full price of premiums in the individual market.
These subsidies are odd and inefficient and dumb but they benefit from the political value of inertia. There primary value is for people who don’t buy silver plans.
In 2021, the passage of the American Rescue plan had an across the board subsidy boost that was not restricted by metal level and it removed the income cap for subsidy eligibility. Affordability for subsidized individuals is much better today than it was in 2017. More upper income Americans receive a subsidy that kicks in once they spend more then 8.5% of their income on health insurance so we won’t see stories of a family earning low six figures spending $45,000 a year on insurance. Instead they might spend $10,000 or $15,000 on insurance.
One can always caveat out that 2018 was fundamentally weird and should be its own era or merged with 2017. It is fundamentally weird because there was incredible political and policy uncertainty. No one knew if the ACA market would exist in the long run due to repeal and replace. No one knew what was going to happen with CSR payments. Insurers either ran like hell or jacked up their rates. Structurally, I think the actual experience of 2018 aligns nicely with the increased subsidy era, but I can understand an argument that when the decisions were being made for plan offerings in 2017, no one was sure what the hell was going on.
This is how I’m thinking about the ACA individual market in my emerging role as a senior author.
CaseyL
Ah, you hinted at this over at Mastodon, that your role was changing. Congrats on being first author!
The retrospective view is fascinating: a new social program is rolled out, into a headwind, and how those headwinds affected its development.
Is there similar scholarship around programs we take for granted now, like Social Security? Or Medicare, when I know the RW/Republicans really really didn’t want to see that one enacted, either? My guess would be they tried many of the same sabotage techniques the ACA has faced (and continues to face).
It’s a testament to how much ACA’s advocates want the program to succeed that they managed to come up with ways to keep it alive and useful through the Trump Administration/GOP Congress yanking the CSR support.
David Anderson
@CaseyL: 1st authorships is what I’ve been doing for a while and still doing for a couple of projects. I’m taking on more senior authorship roles where I do less writing but more shaping and shepherding the papers along
Brachiator
Congratulations on your new role as senior author.
And thanks for the continuing posts on ACA. Consistently good stuff.
CaseyL
@David Anderson:
I didn’t realize first author and senior author were different things! Kudos (again)!
Another Scott
@CaseyL: The senior author/group leader is (at least in my field) usually listed last. It is a coveted slot!
Congrats, David. Well done!
Cheers,
Scott.
StringOnAStick
The ACA saved our family ‘s bacon, that’s for sure. Thanks for being part of the, what can we call it? The mass of involved people that keeps it afloat in one way or another? Because academic study is part of the “mass” that makes it into a social norm now.
David Anderson
@CaseyL: Weird cultural/institutional norms. In my home field (policy analysis), there are four marked roles for authors (not every paper will have all four roles):
1st author/lead author —They do most of the drafting and writing as well as a decent portion of the analysis grunt work.
2nd author — a lot like the lead author, just less of it!
Senior/last author — the driver and vision of the project, often will have come up with the idea for the paper and did most of the conceptual work.
Middle author — they did something useful and contributed to the project in a meaningful way including the writing/revision — middle author contributions vary wildly depending on the project, team and scope. Even within a paper, middle author contributions can vary wildly.
In my field, junior folks typically take the 1st and 2nd author roles, senior folks are the last author. Professionally 1st and Last authorships count a lot more than middle authorships. Middle authorships are a sign that one plays nicely with others, but going on the job market (with equal quality of papers), someone with only middle authorships on a lot of papers is probably behind someone who has fewer total papers but a decent fraction of 1st authorships on papers. I love being second author. That is just my happy place. Right now, I’m pretty heavy on small authorship group papers (2 or 3 total writers) with ~10 1st authorships over 4 years. Building out a few senior authorships will demonstrate that I can build teams that can do cool shit.
Other fields do things differently. Econ just lists names alphabetically or randomly so figuring out who had outsized contributions on a paper is tough.