Come for the politics, stay for the snark.

The next time the wall street journal editorial board speaks the truth will be the first.

The truth is, these are not very bright guys, and things got out of hand.

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

Good lord, these people are nuts.

They’re not red states to be hated; they are voter suppression states to be fixed.

Thanks to your bullshit, we are now under siege.

Pessimism assures that nothing of any importance will change.

Nothing worth doing is easy.

I have other things to bitch about but those will have to wait.

Wake up. Grow up. Get in the fight.

The choice is between normal and crazy.

“Cheese and Kraken paired together for the appetizer trial.”

Innocent people don’t delay justice.

Everything is totally normal and fine!!!

Republicans: “Abortion is murder but you can take a bus to get one.” Easy peasy.

I’d try pessimism, but it probably wouldn’t work.

Republicans want to make it harder to vote and easier for them to cheat.

Baby steps, because the Republican Party is full of angry babies.

It’s not hopeless, and we’re not helpless.

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

They love authoritarianism, but only when they get to be the authoritarians.

“When somebody takes the time to draw up a playbook, they’re gonna use it.”

People are complicated. Love is not.

I desperately hope that, yet again, I am wrong.

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Joe Manchin Defects

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I figure that if I post, Cole will bigfoot me with his West by God Virginia take. Or I hope he will. I feel helpless sitting here in a blue as blue state.

He actually, really, yes, says he will vote against HR-1/S-1. His reasoning seems to be that bipartisanship is so important that if Republicans won’t vote with Democrats, he will have to vote with the Republicans.

There is a massive Twitter silence from Democratic politicos, who I hope are putting their heads together on how to deal with this.

Meanwhile, we need to start thinking about demonstrations and other ways to show our desire for fair and open elections.

Open thread!

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North Carolinians need Medicaid expansion now more than ever

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Guest post by two of my friends, collaborators and coauthors; Drs. Paul Shafer and  Brad Wright:

As we approach an Election Day unlike any other in our history, North Carolina is one of only 12 states that has yet to expand Medicaid under the Affordable Care Act. Half a million North Carolinians stand to gain access to health care if we expand, almost all of it funded by the federal government. Instead we have watched for years, as rural hospital closures have reduced access to care and nearly 200,000 North Carolinians have fallen in the coverage gap, unable to qualify for Medicaid or receive financial help to purchase private insurance on HealthCare.gov. That was before the COVID pandemic hit. Now, one in five adults in the state are uninsured, tied for 7th highest in the nation. The state faces a stark choice at the ballot box this November.

In this election, the two leading candidates for Governor are current Gov. Roy Cooper (D) and Lt. Gov. Dan Forest (R). Gov. Cooper has consistently advocated for Medicaid expansion but has become particularly vocal in his support amidst the pandemic, noting that expanding Medicaid would not only provide coverage for those who have lost jobs but would also bring more federal funds into the state, bolstering the economy. By contrast, Lt. Gov. Forest is opposed to Medicaid expansion. He claims it would promote dependency and bankrupt the state. And, unlike other states, North Carolina cannot pursue Medicaid expansion by referendum so whom you vote for matters even more.

As members of a research team from Duke University, the University of North Carolina at Chapel Hill, and Boston University, we have been evaluating the performance of North Carolina’s Medicaid program as the pandemic has evolved. Medicaid is a critical part of the health care safety net, providing no-cost health insurance to low-income individuals and others in need. Ideally, it would prevent people from being uninsured if they lost their job during the pandemic. However, in states like North Carolina that haven’t expanded Medicaid, it is incredibly difficult for non-disabled adults who aren’t pregnant women or parents to qualify for coverage regardless of how little they earn.

Between February and August of this year, nearly 140,000 North Carolinians lost their jobs, while over 150,000 gained Medicaid coverage. At first glance, this might seem reassuring but over half of these new Medicaid enrollees were children (72,300) or women receiving only family planning services (7,950). The bottom line is that many North Carolinians became uninsured when they—or a family member through whom they were insured—lost their job, because they weren’t eligible for Medicaid.

States that didn’t expand Medicaid, like North Carolina, are seeing large increases in their adult uninsured rate, with adults in families suffering a job loss having nearly three times the increase in uninsured rate. The sad truth for North Carolinians in households earning less than the federal poverty line ($12,490 for an individual, $25,750 for a family of four) and without children at home is that they have to choose between paying the full cost of private health insurance or being uninsured. Of course, this “choice” is not really a choice at all because most people cannot afford the price of insurance on their own without help.

Medicaid expansion is long overdue in North Carolina. The COVID pandemic has shown us that the best—and only—way to solve the economic crisis is to first solve the public health crisis. Denying people the care and medications they need to stay healthy doesn’t help anyone, especially not during a pandemic. Health insurance is on the ballot in November. Make sure your voice is heard.

Bios

Paul Shafer is an assistant professor of health law, policy, and management and co-director of the Medicaid Policy Lab at the Boston University School of Public Health. Brad Wright is an associate professor and Director of Health Services and Outcomes Research in the Department of Family Medicine and co-directs the Program on Healthcare Economics and Finance at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.

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Virginia’s bill against Silver Spamming

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Silver-Spamming is the practice of an ACA exchange insurer offering two nearly identical silver plans as the cheapest plan and the second cheapest silver plan. This strategy compresses the silver spread between the benchmark and cheapest silver.  Smaller spreads reduce the affordability margin between the cheapest plan available to the benchmark plan when compared to a counterfactual universe where the benchmark silver plan is significantly higher.  This higher benchmark could be because of monopolist pricing strategies designed to maximize enrollment or the benchmark being offered by a second insurer.  Silver-spamming is bad for subsidized enrollees as it raises relative prices of all plans except for the benchmark plan. Silver spamming as a strategy is a choice by the low cost insurer to accept a larger proportion of a smaller and sicker enrolled population.

Virginia has a bill that seeks to make Silver Spamming less plausible as an actual strategy:

“Narrow network plan” means a silver-level plan offered on the exchange that includes fewer than 20 percent of the health care providers in the geographic region in which such plan is offered as in-network providers.

“Silver-level plan” has the same meaning as provided in 1302(d) of the Patient Protection and Affordable Care Act, P.L. 111-148, as amended.

B. No health carrier that offers a narrow network plan in a geographic region shall offer any additional narrow network plan in the same geographic area if any two narrow network plans offered by such health carrier in the geographic region would have the two lowest monthly premiums of any silver-level plans offered by the health carrier in the geographic region.

A very narrow network insurer can offer multiple silver plans in a given region. An insurer can offer a broad network and a very narrow network. That broad network can have a dozen different plans layered on top of it. The theory is that when all else is equal, a narrow network will be lower premium than a network with more providers.

I think that a 20% of available providers definition of a “narrow network” is a very low bar to clear as a network. Important work by Weiner and Polsky from 2015 applied a “T-shirt” size system to networks. They defined a Medium network at 40% of available providers. Applying a “medium” threshold to this law would make it much harder for an insurer to offer a 15% of local provider network and a 21% local provider network that would just clear the requirement to effectively silver spam the region. An insurer could still offer a 15% network and a 41% network but the premium spread is far more likely to be significant due to the broader network.

States have significant capability to shape their individual marketplaces to be more or less friendly to buyers. States can find ways to manage spreads and product quality to achieve local goals. Higher benchmark premiums can and often will lead to greater affordability for buyers.

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So make sure when you say you’re in it but not of it

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Don’t forget to vote in your local elections today if you have them. Where I live, in Monroe County, the Republicans have dominated county politics for years, but there’s been a big shift in registration in the past three years, amounting to a 3-4% net gain for Democrats. I asked a friend if Dems have a chance this year and he said no because they don’t turn out for county elections.

Commenter MikeJ once said that too many liberals were

too cool to actually approve of anything. The whole thing smacks of effort, man. Democrats are also famous for only liking the first album (or better yet, the unreleased demos.)

Don’t be that guy. Go out and vote Democrat today no matter how uninspiring your candidates are.

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Oklahoma Medicaid Expansion and the ballot

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Right now, it looks like the signature drive to get Medicaid Expansion on the Oklahoma ballot will collect more than enough valid signatures:

This is first step for the expansion effort. The second step is to win the vote. The third step is to win the implementation.

That third step is tricky. Three states’ voters west of the Mississippi River passed Medicaid Expansion in the November 2018 general election.

Utah has engaged in a complex series of expansion waiver efforts. The state government started with a proposed partial expansion to only 100% Federal Poverty Line. The Center for Medicare and Medicaid Services (CMS) rebuffed that waiver. Now Utah has a roll-out of full expansion but with significant work requirements and benefit clawbacks via waiver.

Idaho has submitted a number of waivers. They will not be getting a straight up expansion via state plan amendment that the voters approved.

Nebraska has taken their time. The first enrollment in the Medicaid Expansion approved in November 2018 won’t happen until October 1, 2020. Nebraska will also have a complex system of benefits, reporting requirements and paperwork friction:

Winning a spot on the ballot is a necessary but grossly insufficient step to implementing Medicaid Expansion when state elites are strongly dis-interested in that policy choice.

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New Jersey and the policy counterfactual for outreach

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New Jersey has a Democratic trifecta since January 2018. The legislature and governor have been active.

  • Reinsurance waiver funded by
  • State based mandate
  • Transitioning to a State-Federal Partnership exchange

So what are the effects?

This is a bit convoluted.  New Jersey projects that without the policy changes, that started in 2019, 2020 premiums would be 30% higher in 2020 than they are in 2019 instead of the 8.7%.

The transition to their own exchange is also having impact:

One of the big advantages of a state running their own exchange is that they don’t count on federal advertising or outreach funds.  Instead, locally raised money can be spent locally to achieve state objectives.  In 2018 and 2019, New Jersey had a “small” dose of navigator and advertising dollars.  In 2020, the navigator dose will be six times larger and potentially better targeted.  The same may be true for advertising dollars where there will be more spent and potentially spent more effectively.

The theory of change is that this will lead to more enrollment and lower premiums than if New Jersey had stayed on Healthcare.gov.  The idea is that the most marginal buyers who are currently flipping a coin and having it come up tails and therefore they are deciding to not buy any insurance are relatively healthy and cheap to cover folks.  Advertising and navigation assistance will change the weight of the coin and push at least some of these marginal decision makers into the ACA pool where they will cost significantly less than average which brings down premiums.  California claims that their advertising and outreach delivers massive premium reductions through this mechanism.

From a causal identification strategy point of view, the boundary states provide a lot of potential matched pairs for a difference in difference analysis.  Pennsylvania and Delaware are constant Healthcare.gov states with no changes in governing structure since 2017.  Maryland and New York run their own exchanges.  Maryland will be changing their enrollment process by easing administrative burden next year.  Since New Jersey has rolled out some of the policy changes in stages (mandate/reinsurance 2019, more advertising/navigation 2020…) dis-entangling impact should be easier than if all of this happened at once.

New Jersey should be the source of a dozen really cool papers by 2023 that will bring insight into what drives individual market enrollment.

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Medicaid expansion and zero premium exchange plans

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The Civitas Institute of North Carolina is arguing against Medicaid expansion. They contend that Medicaid expansion will throw thousands of people off of their current zero premium plans that they can buy on the Exchange.

The expansion population is composed of working age, able-bodied adults, 78 percent of whom have no dependent children. Working full time at minimum wage, these individuals would be eligible for fully-subsidized, no-cost-to-them plans on the federal exchange….

Expansion will force approximately 146,000 North Carolinians off of their private plans and move them onto the state’s Medicaid rolls. It will also disqualify an additional 120,000 uninsured people from the fully-subsidized plans for which they are currently eligible, but of which they are not taking advantage.

Zero premium plans are common. However, they are incredibly different in the benefit structure and financial exposure borne by someone who earns between 100% to 138% FPL to compared to Medicaid Expansion.

Zero premium plans happen when a plan is priced below the silver benchmark and the relative premium spread is bigger than the individual’s expected personal contribution. For the 100-138% cohort, the personal contribution for a single individual ranges from $22/month to about $55 per month for the benchmark silver plan. The benchmark plan is a silver plan with 94% AV CSR benefits. That translates into a deductible ranging from zero to a few hundred dollars and an out of pocket max of less than $2,000. Compared to a baseline silver, this is a great improvement in the quality of the benefit. It is still significantly worse than Medicaid if we assume appointments can be found.

However, silver plans are not guaranteed to be zero premium. There could be a “tight spread” between the cheapest silver plan in a county and the benchmark which often happens if the region is a competetitive region with strategically adept insurers or if there is a monopoly and the monopolist for some reason or another only offers a single silver plan as both the benchmark and the cheapest silver. Instead, the vast majority of time, the zero premium plan are bronze plans. In Orange County, North Carolina, the bronze plans all have deductibles over $6,000. If someone is earning 138% FPL, that is over a third of their annual income before the insurer actually starts paying for catastrophic expenses. Bronze plans, in this scenario, are hit by a meteor protection.

I am using Robert Woods Johnson Foundation HIX Compare data for the map below. I am looking to see what is the highest metal level (with CSR benefits included) that is available at a zero premium for a single fifty year old.

For someone at the top of Medicaid eligiblity, the zero premium plan requires them to spend several months of income before they get any non-preventive services covered by the insurer. If we hold the income constant and make the person younger, zero premium plans that are not bronze are even less likely. Older and larger families are more likely to see a non-bronze zero premium plan. At 100% FPL, zero premium silver plans are available for all single fifty years thoughout North Carolina.

If we make the assumption that plan quality matters and cost sharing attributes matter for significant elements of the 100-138% FPL cohort, then zero premium exchange plans, even zero premium 94% CSR Silver plans are, on some critical financial attributes, significantly inferior to Medicaid and zero premium Bronze plans are grossly inferior on those financial attributes compared to Medicaid. For these to be equalized, there has to be an incredible assumed quality differential between exchange plans that are offered by private insurers and Medicaid plans that will be soon be offered by most of the same private insurers as North Carolina transitions to Medicaid managed care. That assumption has to be heroic and so far unobserved.

Zero premium exchange plans have some really nifty attributes but they are not a near substitute for Medicaid expansion for the 100-138% FPL groups.

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