• Menu
  • Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar

Before Header

  • About Us
  • Lexicon
  • Contact Us
  • Our Store
  • ↑
  • ↓

Balloon Juice

Come for the politics, stay for the snark.

Despite his magical powers, I don’t think Trump is thinking this through, to be honest.

You come for women, you’re gonna get your ass kicked.

“The defense has a certain level of trust in defendant that the government does not.”

The most dangerous place for a black man in America is in a white man’s imagination.

Come for the politics, stay for the snark.

Let’s delete this post and never speak of this again.

It’s all just conspiracy shit beamed down from the mothership.

A snarling mass of vitriolic jackals

I conferred with the team and they all agree – still not tired of winning!

Just because you believe it, that doesn’t make it true.

New McCarthy, same old McCarthyism.

When do we start airlifting the women and children out of Texas?

Republicans are radicals, not conservatives.

We’re not going back!

Stop using mental illness to avoid talking about armed white supremacy.

Spilling the end game before they can coat it in frankl luntz-approved dogwhistles.

Historically it was a little unusual for the president to be an incoherent babbling moron.

Republicans can’t even be trusted with their own money.

if you can’t see it, then you are useless in the fight to stop it.

Take hopelessness and turn it into resilience.

Ron DeSantis, the grand wizard, oops, governor of FL

And now I have baud making fun of me. this day can’t get worse.

Cole is on a roll !

My years-long effort to drive family and friends away has really paid off this year.

Mobile Menu

  • Winnable House Races
  • Donate with Venmo, Zelle & PayPal
  • Site Feedback
  • War in Ukraine
  • Submit Photos to On the Road
  • Politics
  • On The Road
  • Open Threads
  • Topics
  • Balloon Juice 2023 Pet Calendar (coming soon)
  • COVID-19 Coronavirus
  • Authors
  • About Us
  • Contact Us
  • Lexicon
  • Our Store
  • Politics
  • Open Threads
  • War in Ukraine
  • Garden Chats
  • On The Road
  • 2021-22 Fundraising!
You are here: Home / Archives for David Anderson

I am a student in the doctoral program at the Duke University Department of Population Health Sciences. I am working towards my my doctorate in Health Services Research with a policy focus. I am fundamentally fascinated by insurance markets, consumer choice and the navigation of complex choice environments. I'm currently RA-ing at the Duke Margolis Center for Health Policy.

I used to be Richard Mayhew, a mid-level bureaucrat at UPMC Health Plan. I started writing here and have not found a reason to stop.

Conflicts of interest: Previously employed at UPMC Health Plan until 12/31/16. I also worked full time as a research associate at the Duke University Margolis Center for Health Policy. I have received direct funding from the National Institute for Healthcare Management, and I have been on projects funded by the Rockefeller Foundation, Kate B. Reynolds Charitable Trust, Gordan and Betty Moore Foundation, Duke University Health System, CMMI, and various value based payment consortiums. I serve as a consultant on a grant from the Commonwealth Fund and have acted as a consultant to several ACA insurers.

Research Production is here: https://scholar.google.com/citations?user=zof9b4IAAAAJ&hl=en

David Anderson has been a Balloon Juice writer since 2013.

David Anderson

North Carolina Medicaid Expansion for December 1st

by David Anderson|  September 25, 20231:19 pm| 3 Comments

This post is in: Anderson On Health Insurance

The state of North Carolina will start paying Medicaid claims for enrolled individuals ages 19-64 who earn under 138% Federal Poverty Level (FPL) as of December 1, 2023.

 

North Carolina Medicaid Expansion for December 1st

This will mean a lot of folks who likely would have been determined to be ineligible for full benefits for Medicaid will be redetermined to be eligible for Medicaid Expansion as of 12/1/23. It will mean a lot of folks who are currently eligible for zero premium Silver CSR plans with $500 deductibles will be moved to Medicaid as of January 1, 2024. Medicaid has been shown to have substantially lower cost-sharing than Exchange plans for folks who are barely eligible on either side of the income switch line.

North Carolina Medicaid Expansion for December 1stPost + Comments (3)

Medicaid Expansion in North Carolina is finally coming

by David Anderson|  September 22, 202312:12 pm| 19 Comments

This post is in: Anderson On Health Insurance

Last spring, North Carolina passed a law that would expand Medicaid to 138% FPL as part of the ACA.  Medicaid Expansion’s start date was up in the air.  The law did not set a date.  Instead Medicaid Expansion start was dependent on a state budget getting passed.  The state government took steps to make the gap between initial authorization and go-live as small as possible.  But even with front-running, the binding constraint was the state budget.

As of this morning, that is not the case any more.  The state has a budget and Medicaid Expansion is going live.

From WRAL:

 North Carolina Gov. Roy Cooper announced Friday he would let the state budget bill coming to his desk become law without his signature, opening the way for Medicaid coverage for 600,000 low-income adults, with some receiving the government health insurance within weeks.

There is no definite go-live date.  I know the state will do everything it can to make the go-live date as early as possible.  I have heard rumbles of ambitious 2023 start dates.  I would be shocked if the go-live is later than January 1.

10 more states to go.

 

Medicaid Expansion in North Carolina is finally comingPost + Comments (19)

Senator Menendez (D-NJ) indicted for corruption (again)

by David Anderson|  September 22, 202310:43 am| 107 Comments

This post is in: Open Threads, Politics

The Department of Justice released a sealed indictment of Senator Menendez this morning.  Here is the first paragraph of the allegations:

From at least 2018 up to and including in or bout 2022, MENENDEZ and his wife, NADINE MENENDEZ, a/k/a “Nadine Arslanian,” the defendant, engaged in a corrupt relationship with three New Jersey associates and businessmen—WAEL HANA, aka “Will Hana,” JOSE URIBE, and FRED DAIBES, the defendants—in which MENENDEZ and NADINE MENENDEZ agreed to and did accept hundreds of thousands of dollars of bribes in exchange for using MENENDEZ’s power and influence as a Senator to seek to protect and enrich HANA, URIBE, and DAIBES and to benefit the Arab Republic of Egypt. Those bribes included cash, gold, payments toward a home mortgage, compensation for a low-or-no-show job, a luxury vehicle, and other things of value,

 

Jersey Jackals, start calling Trenton and DC to pressure this jagoff to resign.

Senator Menendez (D-NJ) indicted for corruption (again)Post + Comments (107)

Medicaid Redetermination Mulligan

by David Anderson|  September 22, 20238:21 am| 5 Comments

This post is in: Anderson On Health Insurance

A few weeks ago, we talked about the wildly varying and conflicting eligibility limits that a single family or household could have for Medicaid eligibility.  We worked through an example for a family of 4 in North Carolina.

Mom and Dad are both 40.  Kid 1 just turned 6 and Kid 2 is 11 months old.

Dad loses coverage if family income goes over 41% Federal Poverty Level (FPL) and/or assets are over $3000.

Mom loses full coverage if family income goes over 41% FPL and/or assets are over $3000 AND she loses limited post-partum coverage if family income goes over 196% FPL.

Kid 1 loses full coverage if family income goes over 133% FPL.

Kid 2 loses full coverage if family income goes over 210% FPL.

This matters. Right now, the nation is currently redetermining eligibility for Medicaid for tens of millions of people who gained coverage during the public health emergency. Millions are losing coverage, and millions more are expected to lose coverage.

States SHOULD be redetermining each individual’s eligibility. In North Carolina, if the above household’s income goes to 42%, Dad loses coverage, Mom bumps to post-partum coverage with limited benefits and the kids keep what they have. That is how it should work. That is how it is working in North Carolina, at least until the state legislature passes a budget that expands Medicaid to 138% FPL for adults. North Carolina is doing the re-determination process right.

Yesterday afternoon, the Department of Health and Human Services released a report stating that states are consistently not running their redeterminations correctly:

Thirty states and territories (including the District of Columbia) indicated they are not conducting automatic renewals at the individual level or are still
working to reinstate affected individuals. Impact of this issue varies widely from state to state, and many states are continuing to assess their programs and the impact of the
issue. States that provided estimates reported a wide range in the numbers of individuals impacted or potentially impacted.

Those thirty states are big states, and small states. Those thirty states are red states and blue states and purple states. Those thirty states have generous Medicaid programs and skimpy Medicaid programs. There is no obvious order as to why some states are doing redetermination correctly and others are not.

The states that are screwing things up need to re-redetermine disenrolled individuals at the individual level and hopefully play catch-up to get the likely to be eligible folks back into coverage.

Medicaid Redetermination MulliganPost + Comments (5)

Challenges of paying monthly?

by David Anderson|  September 21, 202310:32 am| 24 Comments

This post is in: Anderson On Health Insurance

In Health Affairs Forefront, Paul Shafer, Michal Horny, Stacie Dusetzina and I published a short blog post on the challenges of commercial plans requiring monthly deductible resets instead of annual resets.  Paul, Michal and Stacie have been playing with these ideas for a couple of years and I had been in the peanut gallery heckling the authors on pragmatic considerations.  So we tried to work out what we’re all thinking together.

We’re in an era of substantial first dollar cost sharing.  People have big deductibles.  The median American does not have the liquid assets to pay off their deductible.  We have fragmented policies that address some of the affordability challenges for some situations and some diseases.

For years, proponents of value-based insurance design have tried to make patients’ out-of-pocket costs more directly related to the value of care—with higher-value care costing less. For example, the Affordable Care Act (ACA) made certain high-value preventive services free to patients, although this policy is currently under threat in Braidwood v. Becerra. Another example is the monthly copayment cap on insulin costs for Medicare beneficiaries in the Inflation Reduction Act, which has helped nearly four million Americans. The White House is pushing Congress to make this policy applicable to all insured individuals, and nearly half of all states have passed insulin copayment caps to date.

Deductibles are intended to make individuals far more cost and value conscious users of healthcare.  This is problematic on a pragmatic basis as people are bad shoppers. When faced with a deductible, people just stop using services without considering the value of those services.  Additionally, there are substantial information gaps between what people think they are paying and what they actually are paying.  Finally, there is a simple problem.  Most people don’t use much if any healthcare services in a year.  Deductibles barely do anything to change incentives for folks in the bottom half of the spending distribution.  Deductibles also don’t bind or change incentives for people in the last quartile as their spending is often too damn high.  Deductibles may influence spending for people in the 3rd quartile of spending but there is not a ton of money there.  And most of this spending is likely to occur in a single event:

In a prior study of commercially insured US patients, we found that a hypothetical $500 monthly cap on in-network services would lower in-network out-of-pocket costs for nearly a quarter (24.1 percent) of commercially insured Americans, with those affected seeing their median annual out-of-pocket costs cut almost in half (-45.5 percent). For those in high-deductible health plans, the benefits would be even greater.

Monthly caps are simpler.  A number resets at the end of the month.  We also think it improves the incentive features as right now, people have a bad event early in the year that maxes out their deductible and then they schedule a lot of services for December at no marginal cost.  Monthly caps could change this dynamic.  It also improves equity as the current patchwork and caps rewards some conditions and diseases while a monthly cap treats all conditions the same.

We think that this makes the most sense in the commercial, self-insured market which is mostly large group employers.  These plans are regulated by ERISA so there is substantial benefit design flexibility. They also don’t have to worry about risk adjustment or actuarial value.  We are worried that if we hold actuarial value constant, maximum out of pocket expenses for individuals with chronic conditions could plausibly increase.  If we hold maximum out of pocket limits constant, premiums likely increase as actuarial value increases.  This is a tough trade-off.

We’re not sure if this is the way forward.  We think that this could be a way forward.

 

Challenges of paying monthly?Post + Comments (24)

Patient administrative burden and the new COVID 19 vaccine

by David Anderson|  September 19, 20237:53 am| 34 Comments

This post is in: Anderson On Health Insurance

Adam texted me yesterday about a problem he was having with getting his COVID-19 booster.  I’m transcribing a portion of the text-chain with his permission as it highlights administrative burdens:

“INSURANCE will not cover the new covid booster”

RAGE FACE

“The system has not processed the new code for the new booster”

“Yet”

“So I’m going to pay for it and then submit for reimbursement once it is added to the insurance company system….”

 

There were a couple of other things, including the mechanics of generating new CPT-4 codes and then implementing the benefit structure to activate payment for a new code, but I want to focus on administrative burden.

Adam (and many tens of thousands of others) has to do a lot to get a “free” shot. Everyone has to make the normal time and attention carve out an appointment.  Normally, there is no transaction at the point of service.  There might be a paper or a screen to sign/initial and then the insurer pays the bill.

Even in this fairly smooth system, my colleagues and I found substantial variation in the uptake of no cost-sharing preventive services by both actuarial metal level (higher implies more care seeking or risk averse behaviors) and income as lower income individuals with high CSR Silver plans had different uptake.

But it was not a smooth process for Adam and others.  Instead they now have to figure out where to send a claim, get the right set of forms, fill them out, find a stamp and then get it in the mail.  These steps are substantial burdens.  Things fall through both known and unknown cracks.   In the context of the ACA, we found that the process of setting up a payment account to pay a $1 or $2 monthly premium instead of nothing makes people lose about a month of insurance coverage on average per year.  I would assume that over the long run, many people who have to get reimbursed will get reimbursed.

However, the cost of burdens are not evenly distributed.  Kyle and Frakt found substantial gender, education and income disparities on burden.  More marginalized populations faced higher costs and higher likelihoods of foregoing care.  A little bit less concretely, I would speculate/hypothesize that the existence of these burdens likely acts as a deterrent from individuals seeking care as they know that they don’t have the time/ability/willingness to deal with this shit.

And that is bad.  Especially when we’re dealing with infectious diseases.

 

Patient administrative burden and the new COVID 19 vaccinePost + Comments (34)

Risk bearing and commercial prices in health insurance

by David Anderson|  September 11, 202311:43 am| 10 Comments

This post is in: Anderson On Health Insurance

There are two major flavors of private, commercial health insurance contracts.  The first is “fully insured” or “FI” where the health insurance company takes on the full risk of claims coming in above expectations.  If that happens, the insurer loses money.  If claims come in low, the insurer makes money.  The ACA individual market, the ACA regulated small group market, Medicare Advantage, and Medicaid Managed Care are all fully insured products.  The other contract structure is “self-insured” “SI” which is also known as as an “Administrative Services Only” (ASO) contract.  An SI plan has a plan sponsor contract with an insurer to run a plan and administer the claims but the sponsor takes on the full risk of unexpected expenses.  The most common plan sponsor is an employer like Duke University or Ford or Intel.  Unions are also common plan sponsors.

Insurance companies routinely offer both FI and SI plans.  From a consumer’s point of view, the only difference might be a few letters on their ID card.  But these contract structures might create different incentives for the insurance company when they build out networks and contracts.

Does this matter on how much a given service costs?

There had been evidence from Massachusetts that there was modest within hospital-insurer differences in prices paid for SI and FI patients.

We measure negotiated prices for hospital-payer pairs in Massachusetts and characterize price variation. Between-payer price variation is similar in magnitude to between-hospital price variation. Administrative-services-only contracts, in which insurers do not bear risk, have higher prices.

And now there is some new evidence from a much broader data set. Sen et al in Health Affairs looks at national hospital-payer prices to see if there is a difference between FI and SI contracts:

Using the Health Care Cost Institute’s data set of claims for one-third of the US population with employer-sponsored insurance, we found that unadjusted prices were higher in self-insured plans for most of the services we studied, with the largest differences found for endoscopies (approximately 8 percent higher in self-insured plans), colonoscopies (approximately 7 percent), laboratory tests (approximately 5 percent), and moderate-severity emergency department visits (4 percent). When patient characteristics, plan type, and geography were adjusted for, differences were generally smaller but were consistent with these findings.

What does this mean?

The short take-away is that insurance companies negotiate harder against hospitals when their profitability is on the line.  SI/ASO contracts are situations where insurers merely act as pass-through entitites for the plan sponsors.  An extra 2% on the charge does not change the profitability of the insurer.  That 2% on a FI contract could be the difference between breaking even on a contract or making enough to pay for good hookers and lots of blow.

Backing this out a bit more, this offers another reason to think that there is a space for Individual Contribution Health Reimbursement Accounts (ICHRA).  An ICHRA is basically a 401-K for health insurance.  Employers allocate a lump sum distribution that can vary on the basis of age, family size, geography and work group to employees for the express purpose of buying a health insurance plan from the ACA.  ACA plans are fully insured designs so insurers make money if they can keep costs low.  Some of that costs low component is per-unit cost control.  We know that there are a lot of ACA plans which offer narrow networks priced at a bit above Medicare while standard commercial SI/ASO rates are 150% or 200% or 250% Medicare in a given area.

I think that most of the past 15 years of health policy has been moving towards putting more dollars at risk of gains and losses to entities that plausibly can assert some control on spending and have enough expertise to actually do something.  Most employers fail on one or both of those counts.  I think movement to more fully insured products is likely on the margin.

 

 

Risk bearing and commercial prices in health insurancePost + Comments (10)

  • Go to page 1
  • Go to page 2
  • Go to page 3
  • Interim pages omitted …
  • Go to page 427
  • Go to Next Page »

Primary Sidebar

Political Action

Postcard Writing Information

Recent Comments

  • frosty on Helping Ajabu, Take Two! (Sep 26, 2023 @ 5:20pm)
  • Subsole on Biden on the Picket Line (Sep 26, 2023 @ 5:19pm)
  • WaterGirl on Helping Ajabu, Take Two! (Sep 26, 2023 @ 5:18pm)
  • Jeffro on Biden on the Picket Line (Sep 26, 2023 @ 5:18pm)
  • Barbara on Biden on the Picket Line (Sep 26, 2023 @ 5:17pm)

🎈Keep Balloon Juice Ad Free

Become a Balloon Juice Patreon
Donate with Venmo, Zelle or PayPal

Balloon Juice Posts

View by Topic
View by Author
View by Month & Year
View by Past Author

Featuring

Medium Cool
Artists in Our Midst
Authors in Our Midst
We All Need A Little Kindness
What Has Biden Done for You Lately?

Balloon Juice Meetups!

All Meetups
Talk of Meetups – Meetup Planning

Fundraising 2023-24

Wis*Dems Supreme Court + SD-8

Calling All Jackals

Site Feedback
Nominate a Rotating Tag
Submit Photos to On the Road
Balloon Juice Mailing List Signup
Balloon Juice Anniversary (All Links)
Balloon Juice Anniversary (All Posts)

Twitter / Spoutible

Balloon Juice (Spoutible)
WaterGirl (Spoutible)
TaMara (Spoutible)
John Cole
DougJ (aka NYT Pitchbot)
Betty Cracker
Tom Levenson
TaMara
David Anderson
Major Major Major Major
ActualCitizensUnited

Join the Fight!

Join the Fight Signup Form
All Join the Fight Posts

Balloon Juice for Ukraine

Donate

Cole & Friends Learn Español

Introductory Post
Cole & Friends Learn Español

Site Footer

Come for the politics, stay for the snark.

  • Facebook
  • RSS
  • Twitter
  • YouTube
  • Comment Policy
  • Our Authors
  • Blogroll
  • Our Artists
  • Privacy Policy

Copyright © 2023 Dev Balloon Juice · All Rights Reserved · Powered by BizBudding Inc