2025 Activism

The Centers for Medicare and Medicaid Services released a notice for proposed rulemaking last night to substantially modify how the ACA is regulated and implemented. The goal, as shown in Tables 16 and 17 is to decrease the number of people who have health insurance:

CMS is justifying the rule as deterring fraudulent enrollment which they mean low income individuals who live in Medicaid non-expansion states are estimating that their income just goes over 100% Federal Poverty Level so that they can gain coverage.

we note that coverage losses are expected to be concentrated in nine States where erroneous and improper enrollment is most noticeable (that is, Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and Utah), although we also expect minor coverage losses across all States as the administrative burdens associated with this rule would be applied uniformly across the country.

This is a proposed rule. There is a 30 day comment window that opens once the proposal is officially published. Comment on the rule. Point out where the rule has consequences that it is not addressing, point out where the rule contradicts itself and is based on flawed logic and shady evidence. CMS has to address relevant and on-topic comments or it creates substantial legal vulnerability. There are several proposals within the rule that got smacked down by judges in 2019 because they were arbitrary and capricious.

I have several comments that I will need to write — especially on proposals to change 155.335 (J) and 155.315(f)7 as those things directly touch on some of my favorite papers.

But I want to step back for a second.

This proposal rule is thermostatic politics. One party likes something so they interpret a law in one direction and then the other party comes in and tweaks the interpretation in the other direction. A lot of the proposed rule tries to move things back to the 2019 policy environment. It is very explicit that the population of interest and concern for this CMS is the upper-income, non-subsidized enrollees. Almost everything in this rule is justified as an effort to bring down gross, non-subsidized premiums.

And that has tremendous real world consequences. But it is within the realm of normal politics and normal policy-making and not abnormal politics. An abnormal rule would have been one that declined to pay advanced premium tax credits or otherwise violate black letter law. This rule, if implemented will lead to millions to lose health insurance and for the quality of their insurance to decline, but it is not an abnormal rule in an abnormal time.

Fewer people with health insurance: ACA editionPost + Comments (10)

Marginal House Republicans voted for a budget resolution that instructed the House Committee on Energy and Commerce to cut spending under its jurisdiction by $880,000,000,000 over a decade.  These members have said that this was not an instruction for cuts to Medicaid spending.  Anyone who knows how to read a budget called BS.

The Congressional Budget Office lays out the programs that are under E&C jurisdiction with current law spending projections over a decade:

Dear Ranking Member Boyle and Ranking Member Pallone:

In response to your request, this letter provides information about projections of mandatory spending for the 2025–2034 period for the list of programs, excluding Medicare, that you indicated are under the jurisdiction of the House Committee on Energy and Commerce. In CBO’s January 2025 baseline budget projections, mandatory outlays for the accounts you asked about total $8.8 trillion for the 2025–2034 period. Medicaid outlays account for $8.2 trillion, or 93 percent, of that amount (see Table 1).

You also asked for two subtotals of projected outlays

• Outlays other than for Medicaid total $581 billion through 2034.

• Outlays other than for Medicaid and CHIP total $381 billion over the 10‑year period.

If we assume that everything not MEDICAID has a 100% cut including the Childrens’ Health Insurance Program , that implies a $299 billion dollar cut to Medicaid.

Now let’s look at that pretty table 1:
Risk

Risk Adjustment is revenue neutral as insurers pay into a different committee of jurisdiction the same amount of funds that E&C pays out. CHIPS is computer chip manufacturing subsidies.

Yeah, $880,000,000,000 is almost entirely going to be coming from health insurance for kids and Medicaid.

Not Medicaid under the Energy and Commerce Committee’s JurisdictionPost + Comments (34)

A decent chunk of my research agenda over the past four or five years has been on how to reduce administrative burdens to provide health insurance. A lot of that work has been focused on the barriers to care a token premium ($1 for instance) imposes. I don’t spend any formal time on Social Security as there are plenty of other people doing excellent work in that space as they have paid the decade long price to develop deep expertise. But administrative burden is real in that field.

So when I see this:

DOGE has announced a total of 45 Social Security field office closures–so far.

SSA has 1,200 field offices where people can receive in-person help getting benefits, updating records, enrolling in Medicare & more.

They served 30M applicants & beneficiaries in 2023 — nearly 120K *per day*.

— Kathleen Romig (@kathleenromig.bsky.social) February 26, 2025 at 4:56 PM

I immediately think about administrative burden as the lens to look at things.

Social Security is a complex bureaucracy with numerous rule-in and rule-out criteria for anything other than a normal retirement age retirement collection. It is confusing. It is tough. And people need help.

Eliminating help by decreasing the number of customer service reps in a call center and thus increasing wait times or shutting down offices means fewer people will get the help and the services that they are legally entitled to.

And the people who lose out are not uniformly nor randomly distributed. Well educated individuals with money and good social connections will do fine. Christensen et al looked at the distribution of administrative burden in 2020:

 Integrating insights from various disciplines, this article focuses on one aspect of human capital: cognitive resources. The authors outline a model that explains how burdens and cognitive resources, especially executive functioning, interrelate. The article then presents illustrative examples, highlighting three common life factors—scarcity, health problems, and age-related cognitive decline. These factors create a human capital catch-22, increasing people‘s likelihood of needing state assistance while simultaneously undermining the cognitive resources required to negotiate the burdens they encounter while seeking such assistance. The result is to reduce access to state benefits and increase inequality.

Administrative burden was weaponized in the first Trump administration; for instance immigration applications were deemed incomplete if any cell was left empty even if that cell was not relevant to the applicant. We will see more of this going forward.

Weaponizing administrative burdenPost + Comments (60)