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They are lying in pursuit of an agenda.

Nothing worth doing is easy.

“Squeaker” McCarthy

The words do not have to be perfect.

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They think we are photo bombing their nice little lives.

Incompetence, fear, or corruption? why not all three?

Consistently wrong since 2002

JFC, are there no editors left at that goddamn rag?

I see no possible difficulties whatsoever with this fool-proof plan.

Come on, man.

They traffic in fear. it is their only currency. if we are fearful, they are winning.

The GOP is a fucking disgrace.

Wow, you are pre-disappointed. How surprising.

Give the craziest people you know everything they want and hope they don’t ask for more? Great plan.

And we’re all out of bubblegum.

I’d hate to be the candidate who lost to this guy.

Since when do we limit our critiques to things we could do better ourselves?

Take your GOP plan out of the witness protection program.

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

Accused of treason; bitches about the ratings. I am in awe.

New McCarthy, same old McCarthyism.

I’ve spoken to my cat about this, but it doesn’t seem to do any good.

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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.

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

DACA and the ACA

by David Anderson|  April 13, 20238:55 am| 14 Comments

This post is in: Anderson On Health Insurance

The Associated Press is reporting that the Biden Administration is rewriting regulations at the Department of Health and Human Services (HHS) to allow DACA recipients access to the ACA and to ACA premium subsidies:

The action will allow participants in the Obama-era Deferred Action for Childhood Arrivals program, or DACA, to access government-funded health insurance programs. The officials spoke on the condition of anonymity to discuss the matter before the formal announcement on Thursday…

Charles Gaba has an estimate of who might be newly eligible:

There’s roughly 580,000 immigrants who have DACA status as of today. While all of them would presumably become eligible for ACA enrollment (and, therefore, federal ACA subsidies) via the change in their residency status, that doesn’t mean 580K new ACA exchange enrollees. According to the Kaiser Family Foundation, around 39% of them are currently uninsured, or roughly ~230,000, give or take. The rest have other types of healthcare coverage just like most other Americans do.

Besides salami slicing some of the population that remains uninsured, what does this do to the ACA markets?

Individuals with DACA status are, by definition, fairly young. A couple hundred thousand fairly young and likely to be healthy individuals entering the ACA risk pools likely brings down the average risk score by a smidge. If premiums were automatically reflected of the likely risk pool, premiums are likely to drop a little bit. However, the premium setting cycle is pretty slow. The 2024 rates are being set right now with modest tweaks allowed through the summer but rates lock in for all of 2024 in September 2023 based mostly on 2021-2022 and some 2023 data.

Some states will have disproportionally more individuals with DACA status than other states. We would expect bigger (still small but bigger) changes in premiums here in either 2024 or more likely 2025. If there is not a rapid adjustment to the calculation of premium, we would think that we should see lower Medical Loss Ratios in the states with more DACA recipients than in states with fewer DACA recipients.

DACA and the ACAPost + Comments (14)

Abortion going back to SCOTUS soon

by David Anderson|  April 7, 20237:55 pm| 79 Comments

This post is in: The War On Women, Women's Rights

In the past couple of hours, two district court judges issued rulings on RU-486/medication abortion. One, based in Washington State, told the Food and Drug Administration that it was to maintain the status quo. The other, a district court judge in a single judge sub-division in North Texas who every reactionary crank goes to because he is predictable inclined to favor reactionary plaintiffs, found that the FDA has been out of compliance with the regulatory laws for twenty years and ordered a national injunction pulling this drug from the market. The decision is stayed for a week.

The FDA is being told to do two very contradictory things by the same level of authority.

Abortion going back to SCOTUS soon

Abortion going back to SCOTUS soonPost + Comments (79)

Urgent care and induced demand

by David Anderson|  April 6, 20239:20 am| 34 Comments

This post is in: Anderson On Health Insurance

Urgent care centers have sprouted like weeds over the past two decades.  These centers can be almost anywhere.  The one that my family used for years was in a strip mall between a Panera and an Ann Taylor’s Loft.  The center typically had one or two physician assistants or certified nurse practicioners on duty plus a few nurses and a med tech.  It was convenient for low to mid-acuity things such as needing a prescription for antibiotics for one hell of a nasty sinus infection but it was limited for things with moderate to high acuity such as a 4 year old’s asthma attack that was not responsive to the first drowning of albuterol.

There is a big question in the economics literature — do these urgent cares save money?  Do they prevent expensive services — either hospitalizations or Emergency Department (ED) visits that don’t result in admissions — or do they offer value by convenience but does not divert enough/any hospital based care?

Janet Currie et al ask and answer this question in the current issue of the Journal of Health Economics:

  When residents of a zip code are first served by a UCC, total Medicare spending rises while mortality remains flat. In the sixth year after entry, 4.2% of the Medicare beneficiaries in a zip code that is served use a UCC, and the average per-capita annual Medicare spending in the zip code increases by $268, implying an incremental spending increase of $6,335 for each new UCC user. UCC entry is also associated with a significant increase in hospital stays and increased hospital spending accounts for half of the total increase in annual spending. These results raise the possibility that, on balance, UCCs increase costs by steering patients to hospitals.

There can be a solid argument that urgent cares create value for patient acting as a consumer for preference based purposes. But these are unlikely to be cost-saving.

Urgent care and induced demandPost + Comments (34)

Preventive Care and Actuarial Value in the ACA

by David Anderson|  April 5, 20238:16 am| 7 Comments

This post is in: Anderson On Health Insurance

On Monday, Health Affairs published a study that I co-wrote with Dr. Alexandra Mahkoul taking the lead position from the team consisting of researchers from Vanderbilt, Penn, Wakely Consulting and Duke.  We wanted to know how did people use the no-cost sharing preventive care services in the ACA and how much same-day cost-sharing happens when someone gets one of those services.  We looked at four services; flu shots, annual wellness visit, mammograms for recommended populations and colonoscopies for recommended populations.    We identified individuals by the metal level that they chose (Bronze, Silver, Gold, Platinum) as well as the three Silver Cost-Sharing Reduction (CSR) levels (94%, 87%, 73%).

So what did we find?

  • There are huge variances in the take-up of preventive care services

For the standard metal plans without CSR benefits, we see a pattern where the probability of using a service goes in the same direction as the actuarial value.  We are not saying anything causal.  It is an interesting association.  I think it could be a reflection of the unobserved information and/or risk preferences of individuals.  People who buy Gold plans are different than people who buy Bronze plans.  However, that relationship is non-existent when we look at CSR plans.  Higher values of actuarial value are mechanically linked to lower incomes.  I think this could be a reflection of

Preventive Care and Actuarial Value in the ACA

That is interesting

  • Cost-sharing from other services received on the same day varies a lot by metal and service

Preventive Care and Actuarial Value in the ACA 1

We find that as AV increases without regard for CSR or not CSR status, cost-sharing goes down for people who have any same day cost sharing.  We also see that the office visit services tend to have a lot less cost sharing on the same day than the cancer screening services.  These services vary a lot. Some of the common flu shot services were vaccine administration and 20 minute office visit codes.  These hint that the flu shot was an “add-on” instead of the only intended service for that day.  However colonoscopies had substantial anesthesia and surgical pathology charges.  These were far rarer but way more expensive.

We only see people who received preventive services.  We don’t see the behaviors of folks who would have gotten preventive care services if things were different somehow.  We observed relatively low uptake of preventive care services as seen from claims files even when the services were cost-sharing free.  People may not make that distinction if there are other cost-sharing events that happen on the same day/visit or if there are other barriers to care.

 

 

Preventive Care and Actuarial Value in the ACAPost + Comments (7)

Risk and Metal Selection in the ACA

by David Anderson|  April 3, 202312:17 pm| 6 Comments

This post is in: Anderson On Health Insurance

Last week, JAMA Network Open published a new manuscript led by Graham Treasure which examined metal tier selection in the Affordable Care Act (ACA) by out of pocket spending and risk scores.  We used the 2019 Wakely risk adjustment database to describe the on and off exchange members who had a full year of data. We characterized 1.3 million unique individuals by their Hierarchical Condition Category (HCC) risk score and metal selection as well as by the Cost-Sharing Reduction (CSR) level that they are in.

Ideally we should see pretty aggressive sorting among the non-CSR tiers.  People with low risk should mostly be in Bronze plans, and people with higher levels of risk should be in Gold and Platinum plans.  This gets messier with CSR.  A lot of low risk people will be in CSR-94 and CSR-87 plans because those plans are comparatively affordable AND offer a lot of risk protection relative to lower premium plans.  The eligible groups for these CSR plans likely don’t have a ton of assets nor income so risk protection is very valuable.

We mostly see this.

2019 ACA metal level chosen by each percentile of HCC score. Higher HCC scores lead to less Bronze selection

Around the 75% percentile is where the first coded condition that generates a risk score lies.  Below that percentile the risk score is made up of only demographic (age-sex) characteristics.  The lowest risk folks are 22 year old men with no diagnosis or prescription drug codes that trigger a score.  But at the 75th percentile where the first low level conditions are triggered, we see way less Bronze plans being bought.  We see a smidge more platinum, gold and silver being bought.  It is not inherently a wrong decision for someone with a high risk score to buy a Bronze plan.  The first scenario is they entered the year healthy and then got told really bad news mid-year which generated a massive risk score.  The second scenario is that they entered the year knowing they were likely to have huge medical expenses and a big risk score but a Bronze plan had the lowest total cost of premium and out of pocket expenses for a given network that they wanted.  But directionally, we’re seeing choice that mostly makes sense-ish.

Now we also look at out of pocket (OOP) spending by risk score decile and plan selection:

Risk and Metal Selection in the ACA

Again, we basically see what we expect.  Higher AV plans have lower OOP spending as risk increases.  Platinum and Silver CSR plans track pretty closely to each other (this is mostly CSR-94 and CSR-87 which are effectively Platinum Plus and Platinum Minus plan designs).  Gold matters only in the last decile.  Bronze, Catastrophic, and Silver (non-CSR) all look roughly alike.

This is the first of two fairly descriptive papers that we’ve published in the past week looking at the Wakely risk adjustment data.  We see patterns that we mostly expected to see.  I would think that the CSR to platinum lines would be even more similar in 2023 due to ARPA/IRA but the proliferation of zero premium Bronze might create incentives or reasons for people with risk scores that are both demographic AND medical risk to buy more Bronze plans.

 

Risk and Metal Selection in the ACAPost + Comments (6)

Preventive care ruling

by David Anderson|  March 31, 202310:02 am| 31 Comments

This post is in: Anderson On Health Insurance

Yesterday, a federal district court judge in North Texas handed down the remedy to his Fall 2022 ruling that the preventive care and PrEP (pre-exposure prophyslasis preventive pills for HIV infection avoidance) no-cost sharing benefit mandates in the ACA were either unconstitutional or illegal.  The PrEP rule was struck on religious liberty grounds of the plaintiff but only for the plaintiff.  The preventive care ruling was struck nationwide on constitutional grounds for everything that was added to the list after 2010.

We have a preventive care mandate because if it is not there, there are few incentives in one year contracts with the option to leave or renew at the end of a year for insurers to pay for prevention.  Anything more complex than a flu shot will not be cost-effective in a year from the payer’s point of view.  Many preventive care services are value enhancing but not cost-saving.  Mandates get around this problem.  They are not completely effective at getting people preventive care (paper coming out next week on that topic!) but they help.

I am going to extensively quote Nick Bagley, a University of Michigan heath and admin law professor and a co-author of mine, as he explains things in a Health Affairs Forefront blog post:

Judge O’Connor hasn’t backed down. Earlier today, he issued a decision preventing the government from enforcing one of the ACA’s most significant and popular features: a requirement that all insurers cover certain preventive care services without asking patients to pay anything out of pocket. The U.S. Department of Health and Human Services estimates that about 150 million individuals in private health plans and 80 million individuals with Medicare and Medicaid have benefited from the policy….

The principles of value-based insurance design were embedded in section 2713 of the ACA. Under that provision, health insurers can’t require patients to pay anything out of pocket for preventive care services that have an A or a B rating from a federal advisory committee called the U.S. Preventive Services Task Force. That care must be free (or, rather, its costs are folded into your insurance premium).

Over the years, the Task Force has given more than 50 services an A or a B rating, including screenings for depression and cancer, medications to help people quit smoking, and drugs to reduce the odds of contracting HIV. Because of section 2713, those services are now available to patients for free…

Braidwood’s main legal claim rests on an obscure but significant provision of the U.S. Constitution called the Appointments Clause. Simplifying a bit, the Appointments Clause says that legally significant government decisions must be made by federal officers who are appointed by the president or by a department head. Braidwood argues that, because the members of the Preventive Services Task Force aren’t so appointed, they aren’t federal officers. Instead, they’re private experts who, by law, “shall be independent and, to the extent practicable, not subject to political pressure.”

That last part is not a banana pants argument to make given the past decade of Supreme Court rulings.

So what happens?

It depends.

I would be shocked if the Department of Justice is not filing for stays at any and all levels it can.

There is likely disparate outcomes based on the type of insurance and the regulatory umbrellas your coverage operates under.  The two basic types of insurance and thus regulatory regimes are fully insured where the insurer takes on full financial risk in return for a set premium over a constract length.  Fully insured plans, including ACA policies, are mostly regulated by states.  Self-insured plans use the insurer to run the administrative side of things while the employer takes on the financial risk of paying claims.  Self-insured plans are mostly ERISA regulated.  ERISA is almost anything goes.  (My classmates in my health law class are putting their heads into their hands and groaning at my flippancy now).

Self-insured plans can do almost whatever they want if it is not expressly forbidden by federal law or a contract.  Self-insured plans could plausibly contact their insurance company that merely acts as administrators and implement a mid-year benefit change to put some or all preventive care to cost-sharing of some sort.  It might take a week or two to do the back end testing but that is purely a plumbing problem.

Fully insured contracts are almost always a year long contract.  Individual contracts run through December 31, 2023.  Small group contracts usually expire at the end of a quarter.  I don’t think mid-year benefit changes can readily occur.

I would recommend that if you’re looking to get a preventive care service to both call your insurer to confirm the cost-sharing status AND get it down sooner rather than later.

Congress can step in and act.  It would be a two section law.  The first section would be to incorporate all recommendations from 2010 to present from the USPCTF into the no-cost sharing service requirement.  The second section would be a mandate that the Secretary of Health and Human Services would have final approval on incorporating new USPCTF recommended services into the no cost sharing bucket with the ability to reject the recommendation.

This is probably a 2 page bill if Congress wants to fix the problem.

 

 

Preventive care rulingPost + Comments (31)

Correlated risk in risk adjustment?

by David Anderson|  March 31, 20238:02 am| 2 Comments

This post is in: Anderson On Health Insurance

Last week, Texas seized the assets of Friday Health Plan in Texas because the insurer is insolvent as Modern Healthcare reports.  More interesting to me is the risk-adjustment correlated risk problem:

Friday Health estimates it will owe $535.9 million in risk-adjustment payments to other Texas insurers for 2022…. Bright Health Group, for example, estimates it will owe a $723 million in risk-adjustment payments to other Texas insurers for last year, according to financial filings…Oscar Health, which announced a new CEO Tuesday, expects to owe $1.5 billion in risk-adjustment payments across multiple states including in Texas, according to financial filings.

OSCAR has a national footprint, but between Friday and Bright, there is $1.25 billion dollars in risk adjustment payables that are liabilities of companies that are in really poor financial health.  Risk adjustment payables occur when an insurer covers a population that codes as lower expected cost/better health than the state wide average.  The other insurers in Texas were (mostly) covering people who as a population code as sicker than average and thus the insurers were expecting to get $1.25 billion dollars from low risk insurers in the state.  If all or a substantial chunk of the money either never gets paid or gets paid only after several years of litigation, smaller insurers that did well on their own and managed their finances appropriately might be in trouble.

Correlated risk is a nasty thing.

Correlated risk in risk adjustment?Post + Comments (2)

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