Nevada had filed a combined public option(ish) and reinsurance Section 1332 waiver last December. The state just wrote to CMS to pause the application:
The State of Nevada is writing to formally request that the U.S. Department of the Treasury and U.S. Department of Health and Human Services pause its consideration of our pending 1332 State Innovation Waiver application.
The State is currently developing an amendment to its application to reflect more accurate actuarial assumptions and evolving program design. Upon the submission of these changes, the State will request consideration of the application resume….
Doing a quick scan through the public comments, insurers don’t like the proposal because it is calling for substantial rate cuts and consumer advocates are pointing to some of my recent research that shows that reinsurance waivers and other mechanisms that lower gross premiums likely increase the minimum cost of coverage for subsidized waivers.
This is going to be an interesting kerfluffle.
Mousebumples
Interesting!
On the insurance front, my job has been working through CMS, which considers weight loss meds to not be Part D eligible, deciding Wegovy (semaglutide, the weight loss brand is Saxenda) now IS Part D eligible for the newest FDA approved indication.
I don’t have the wording handy, but it’s related to the new prevention of new MACE outcomes in overweight or obese persons with a history of active cardiovascular disease (eg past heart attack, stroke, ongoing angina, etc.).
Definitely a big change in the status quo, with likely insurance coverage ripple effects outside of the Medicare eligible population.
David Anderson
@Mousebumples: Yeah, those drugs are going to be an incredible policy and health shock…. I’m not sure what to expect (I’ve stayed rationally ignorant on Rx pricing matters for a long time) but I’m working on a few Part D projects right now so this will become important
Mousebumples
@David Anderson: Lilly and Novo (mfg for Wegovy and Zepbound) both have tons of studies in progress that I think are aimed at proving the weight loss = XYZ long term benefit. Cancer prevention maybe, etc.
Lots of money they’re making. I’m not saying insurance coverage will change public perception and stigma (see also, mental health needs), but getting people care they need to improve their quality of life is good.
Just a messy road to get there.
Martin
So, wanted to give a little personal account on changes to our exchange plan, and our most recent use of it.
I’m retired but only 55, so we have a decade of a gap to cover before Medicare kicks in. We moved our insurance to the exchange in 2021 picking up an almost identical gold plan to what my work offered. California public agencies reworked employee health plans to align well with exchange plans. This helped employees who left their jobs to more smoothly transition to an exchange plan and I suspect from other conversations that it helped the exchange insurers as the public employees provided a sizable and well understood risk pool for the same actuarial value of what was on the exchange.
The exchange subsidies create some unusual incentives. The subsidies are based on income, not assets, so we were incentivized to minimize income, so we paid off the house, since we would need to take income to pay the mortgage. This dropped out out of pocket for 3 people (my daughter is on our plan still, my son has employer provided insurance) to about $650/mo, which was about a quarter of our annual expenses, but to me a reasonable amount. Our plan is with Kaiser Permanente, and I really like their integrated approach. Their behavior health is understaffed, but our experience with the rest of KP is very good.
This last cycle we were part of the silver shift – we were automatically moved from our gold to a silver KP plan. I looked it over and it was still quite good – and we decided to give it a shot for a year. The cost after subsidy was much lower – down to $130/mo out of pocket. California is doing this interesting thing where they are trying to align MediCal (our Medicaid system) with the exchanges so it’s easier for people to move between them. The application for the exchange is half of the MediCal application, leaving off the asset check. Because we reduced our income by paying off the house, we’re actually pretty close to the transition between MediCal and the Exchange but with substantial assets making us unqualified for MediCal.
Starting in 2024, however, CA has eliminated the asset requirement entirely, so we *would* qualify for MediCal. We’ve actually been taking additional income just to stay on the exchange (it really feels wrong to be on MediCal when we are quite not poor – we should be paying into this system). This also eliminates the other part of that applications so that now I believe the Exchange application and the MediCal application are entirely the same, and CA residents can move easily from one to the other. The state has also opened MediCal to all undocumented residents. In effect, the state is creating a Frankenstein single-payer system simply by making administrative changes around the margins to get these systems in alignment, backstopping with a LOT of taxpayer money – like, CA dumps almost as much cash into its health systems as any other state spends on *everything*.
Anyway, back to the story. We’re on the presumably Pareto optimal exchange silver plan with KP and thought we’d go along for a year and see how it went, expecting our usual usage of preventative care. But we started the year off with Ms Martin getting a breast cancer diagnosis – and I started to panic a bit because that is not how I wanted to run this experiment. But so far, it’s gone great. Our out-of-pocket costs so far have been $165. $150 was our copay for her mastectomy surgery, and five prescriptions which cost $3 each. We’re waiting on whether chemo will be needed so we’re expecting additional expenses, but probably not large ones.
In a nod to why health policy matters – California law requires that health providers cover whatever reconstructive surgery that women getting mastectomies what. Want implants – that’s covered. A fancy plastic surgery option (which Ms Martin chose) – that’s covered. Want tattoos as part of that reconstruction – that’s covered. Knowing that she could choose whatever avenue she wanted and was getting all of those options as part of her advise and consultation with doctors was really helpful. We’d have paid for whatever she wanted, that was never a factor, but knowing that lawmakers considered this and everyone in the system could advise her without bias made the process a lot easier.
Her surgery was yesterday and it went really well. She’s recovering remarkably quickly. We still need to wait for the lab to test the excised cancerous material to see if more treatment is needed, but so far this has gone really well. She had priority appointments – she had an appointment the day after the diagnosis and 1-2 appointments each day thereafter. Surgery would have been within 2 weeks of diagnosis if not for the fancy procedure she asked for which required getting multiple schedules to align, which added a couple more weeks. We didn’t face a massive copay for this. The state removed a bunch of cost-saving opportunities by requiring them to provide whatever treatment she wanted.
So that’s our story so far.
CaseyL
@Martin: Wow, California’s insurance/healthcare system sounds incredible! (Amazing what legislatures can do when just Democrats are in charge.)
I don’t know how Washington State’s Exchange measures up because I am still working and get insurance through my employer. The good news is, my employer is Washington State so I can get the UMP plan. The bad news is, when I retire in a few years I can stay on the UMP plan for $500/month, or take my chances with either a MediGap or Exchange plan. (I will do my best to stay away from Medicare Advantage plans; hopefully MediGap will still be an option.)
Best of luck to Ms. Martin in her recovery.
Marcopolo
@Martin: And this is one reason why Gavin Newsome can say despite higher income taxes, the average Californian is better off overall (financially & quality of life) than folks living in say, FL or TX.
Question to David: have there been any state requested waivers to the ACA that are just really slam dunk beneficial/improvements for that state’s residents getting their insurance through it? Or are they all just some form of making it cheaper for the state, giving the insurers leave to charge more for less, etc…?
delphinium
@Mousebumples: @David Anderson: Funny my coworker and I were just discussing this yesterday. She is on a weight loss drug and following a weight watchers type diet program (she has had weight issues since she was a teen). She is frustrated that these drugs are so expensive. We were wondering if any insurance plans would consider covering some of the costs since it would seem to lead to lower healthcare costs overall given that obesity is connected to so many health issues/diseases.
ETA: Especially given that weight loss is not always easy or the same for everyone.
delphinium
@Martin: Best wishes to your wife for her recovery.
KrackenJack
I’m curious how many states with existing waivers are likely to modify them based on the same data that is driving Nevada to modify their request. It’s great to see facts driving policy. I’d guess some won’t want reopen that discussion if they have a hostile legislature.
Chris T.
@Mousebumples: I am on semaglutide (branded as “Ozempic”) for diabetic blood sugar reasons. I have been taking it since January. The list price is roughly $1k/mo (which I know insurance doesn’t actually pay to Novo Nordisk, but I don’t know how much they do pay) and my after-insurance price is under $100/mo, so I “save” about $900/mo here alone. (This, plus the Jardiance discount, justifies the nearly $1500/mo I pay in premiums for myself: I save about that same amount on the two drugs that are keeping my blood sugar in the healthy range.)
Anyway, it has also had its salutary effect on my personal body mass, but this is not without its tradeoffs. Fortunately I already do enough gym work that I haven’t lost strength / lean-body-mass. The digestive side effects are not that much fun though.
If you don’t exercise, you’ll lose lean and fat mass together, and that’s especially bad in older people. So I wonder a bit about this. Cardioprotective would certainly be good though, given my family history of cardiovascular issues (great-grandfather died of heart attack, grandfather died of heart failure and pacemaker failure, father had pacemaker installed a couple of years before death after long series of strokes, etc).
Lobo
David,
Would CA be a nice case study for other states?
Anonymous At Work
@Chris T.: Relative got put on one last year and she lost of ton of weight. She wasn’t a spring chicken but all the evident risk factors, aside from inactivity/muscle loss/osteoporosis, are gone/significantly diminished. There is huge upside here that people like, say, David Anderson, will be measuring and trying to quantify before and certainly after the Patent Exclusivity period ends.
Mousebumples
@delphinium: yeah, the long term benefits are good, but this is where the US system of employer provided healthcare isn’t great. Will you have the same employer in 5+ years? Definitely possible, but not a given. It’s a class of drugs with long term benefits… But will the current payor benefit from today’s expense?
Not the first time healthcare has dealt with this (see also the Hepatitis C antiviral therapies), but I expect to see similar rationing of care until the costs become more manageable… Whatever that means.
@Chris T.: yeah, they’re not perfect, any means, and the shortages are part of the challenge. I expect there are lots of rebate dollars out there for PBMs/employers, depending on how contracts work. But rebate dollars aren’t what I work with (I’m more on the clinical side vs financial), but it’s A Thing.
Lots of changes in the diabetic space. I think a weekly insulin injection is anticipated later this year (summer?), but shorter acting agents may still be needed.
Mousebumples
@Anonymous At Work: related, Victoza/Saxenda (daily product, similar to Ozempic/Wegovy otherwise) should have biosimilars (like a generic, but for biologic products… Humira had biosimilars first launch last year) in the next year or two. So there should be a cheaper option for daily injections… Provided the suppliers can keep up with demand.
Martin
@CaseyL: I wouldn’t say incredible, but CA democrats definitely see it as a work in progress with certain goals in mind. Each year has seen substantial changes in terms of MediCal expansion to cover undocumented residents, shoring up and expanding women’s health. They seem minor, but requiring the public university system to offer chemical abortions to students and expanding sexual assault support have substantial benefits, expanding who can prescribe to PAs and NPs, etc.
There is definitely a view that the free market is not here to save us, and that everyone deserves health care, and that health care is critical to the state economy.
Martin
@Lobo: He’s written about CA quite a bit. The state had been investigating single-payer when ACA was proposed and CA was asked by the Obama admin to throw their weight behind ACA, so CA did in an active way – moreso than most any other state. Covered California regulates the exchanges a bit more than other states – they don’t let insurers spam the marketplace and work pretty hard to make the marketplace have meaningful choices, keep insurers in the market, etc. KP being a big insurer in the state has been helpful with this stability, but our Blue Cross and Blue Shield are separate entities, so there’s a lot of choices there.
The state dropped the university managed student health insurance plans and put all of those students (up to 3 million) onto the exchanges so there was this young population in the pool. They state pretty aggressively aligned public employee plans to the exchanges. They really worked hard to make this work.
Sure Lurkalot
@CaseyL: I have trad Medicare with Part G and D supplementals for a cost of about $310/ month, $330/month including averaging out the $240 deductible. I’m 69 with no major health issues yet.
Anonymous At Work
@Mousebumples: I work in research compliance, so I make the Sign of the Evil Eye when I see “biologics” but, yes, biosimilars or generics will be great.
As would be products that aren’t high threats for pancreatitis.
David Anderson
@Marcopolo: New York is going live with a 1332 waiver next week that transitions its Section 1331 Basic Health Plan (Essential Plan is the NY state branding) that is currently available to folks under 200% FPL to an ACA replacement at zero premium to 250% FPL
The money plumbing there is weird but this is going to cover several tens of thousands more people at the same or lower cost to the government and at no premium and minimal cost-sharing.