• Measuring Coverage Rates in a Pandemic

      10/27/2020
      Adrianna McIntyre

    My coauthors (Matt Brault and Ben Sommers) and I published a piece in JAMA Health Forum yesterday laying out the challenges inherent to evaluating how the COVID-19 pandemic has affected health coverage. We’ve also put together a table of surveys used to study coverage—including national, nongovernmental surveys fielded by private organizations in response to the pandemic—as a general resource.

    The usual-suspect national surveys (ACS, CPS, NHIS) won’t make 2020 data available for months yet. The Census (in coordination with BLS and CDC) did the herculean task of standing up and fielding a rapid-response survey starting in April, but the first wave of the survey had a worryingly low response rate and it’s hard to assess the reliability of its estimates without a pre-pandemic baseline. Private organizations have stepped up to field fast national surveys, but those necessarily obscure important regional variation. Local surveys have sprung up in some places—SHADAC has a great resource of available surveys—but they can’t be directly compared. The pandemic itself has affected survey administration (government surveys were paused in the early spring) and response rates.

    Most worryingly, the gold-standard government surveys use coverage metrics that make it hard to understand when in the year someone lost coverage, which will hamper future research. In ordinary times, coverage rates averaged across the year may not be particularly bothersome. But when we’re talking about evaluating a pandemic-recession that has ebbed and flowed across the country, averages  fall short of meeting research needs.

    Fortunately, better data is possible:

    Currently, the CPS Annual Social and Economic Supplement public files report coverage at the time of interview and ever having had coverage in the prior year. The survey collects more granular data—not included in public files—about coverage in each month of the year prior to the interview. The ACS measures coverage at the time of interview and surveys respondents throughout the year but does not disclose the month of interview in its public data release. But a data set that provides a blended average of coverage rates from January, May, and December 2020 obscures the most critical effects of the COVID-19 pandemic. If the Census Bureau released the CPS longitudinal file and the ACS month of interview (or even quarter of interview), with appropriate confidentiality protections in place, this would immeasurably improve researchers’ ability to identify coverage changes before, during, and after the pandemic.

    There is precedent for this kind of change in public use files under extraordinary circumstances: for the 2005 ACS, the Census made flags available so that researchers could distinguish between people interviewed before and after Hurricane Katrina in the affected Gulf region. It’s possible that the Census is already considering this kind of accommodation, but we thought that this issue—and available solution—should be on the radar of the broader health services research community.

    You can read the full piece here.

    Adrianna (@onceuponA)

     
      Uncategorized
      COVID-19, insurance, uninsured
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  • Public opinion on competing approaches to health reform

      06/30/2020
      Adrianna McIntyre

    Following on the heels of Austin’s post from yesterday, I’d like to share my contribution to JHPPL’s Affordable Care Act at 10 edition. Along with my coauthors (Bob Blendon, John Benson, Mary Findling, and Eric Schneider), I evaluated how preferences for different approaches to health reform relate to variations in underlying political attitudes and self-reported experiences with and judgment of the health care system. You can click through to a brief thread of highlights below, or download the full PDF (currently ungated)  here.

    Adrianna (@onceuponA)

     
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  • NEJM: Partial Medicaid Expansions Under the ACA

      08/10/2017
      Adrianna McIntyre

    Nick Bagley, Allan Joseph, and I have a new perspective piece up at the New England Journal of Medicine evaluating implications of Arkansas’s latest waiver application. Among other proposals, the state has requested to move to a “partial expansion” model, shifting the population with incomes between 100 and 138% FPL from Medicaid into the exchanges.

    Multiple states proposed partial (or phased-in) expansions before the ACA’s coverage provisions took effect, but the Obama administration rebuffed these efforts.

    Why were states interested in these partial expansions? Starting in 2020, states are responsible for covering 10% of the costs associated with the Medicaid expansion. Because of a drafting mistake, however, the ACA says that the 100-to-138 population can receive subsidies to purchase a private health plan on the exchanges — but only if they are ineligible for Medicaid. For those people, the federal government bears the entire cost of subsidizing private coverage, with no contribution from the states. As a result, the states save money for every beneficiary whom they can move from Medicaid into their exchanges.

    Though the justification against partial expansion was legal in nature—CMS contended at the time that the ACA “does not provide for” limited or phased-in expansions—the current administration might perceive broader flexibility.

    Now that repeal of the ACA’s Medicaid expansion seems unlikely, will the Trump administration allow partial expansions? Arkansas’s waiver request will force an answer to that question. Because Arkansas is already operating under a unique waiver that allows it to enroll Medicaid beneficiaries in exchange plans, partial expansion would have relatively muted effects in the state: it would just rejigger state–federal financing arrangements. Nonetheless, acceding to Arkansas’s request would set a precedent with extraordinary practical, budgetary, and political consequences.

    The budget-gimmicky nature of partial expansion is laid bare in the special case of Arkansas, which already enrolls its expansion population in exchange plans, using Medicaid dollars. Moving the enrollees more formally into the exchange primarily serves to remove state dollars from the funding equation. And in service of this goal, partial expansion imposes greater cost-sharing on beneficiaries while eliminating certain Medicaid-specific protections, like presumptive and retrospective eligibility. If the administration approves Arkansas’s request, they will be hard-pressed to reject similar waivers from other states, who will see the same budgetary appeal.

    You can read the whole thing here.

    Waivers are a matter of administrative discretion, but widely-implemented partial expansions could prove harder to unwind than other changes sought by states. Though they were beyond the scope of our piece, Arkansas’s waiver application—as well as applications from other states—would limit Medicaid enrollment in other ways, by imposing work requirements and strictly narrowing or eliminating presumptive and retrospective eligibility. Absent further congressional action, Medicaid waiver decisions will be among the most consequential health policy developments in the coming months.

    I would like to acknowledge and thank Dave Anderson of Duke University and the Balloon Juice blog, who helped me navigate 2017 premium data (from which I was able to extract cost-sharing information for plans with cost-sharing reductions). Also, for completeness: due to editorial constraints, we weren’t able to include a sixth citation for the analysis comparing exchange premiums in expansion and non-expansion states, which was published by ASPE in 2016. 

    Adrianna (@onceuponA)

     
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  • Bloggingheads on repeal and replace

      02/01/2017
      Adrianna McIntyre

    Earlier this week, Kevin Glass, director of policy at the Franklin Center and contributor at The Washington Examiner, invited me to chat on his Bloggingheads show about the future of the ACA. We touch on the scope and implications of Trump’s executive order, the Cassidy-Collins plan, and the difficult politics of repeal and (particularly) replace. We also spend a fair bit of time talking about the market uncertainty created by those politics, which threatens to undermine access to coverage in 2018, regardless of policy outcome.

    The full video runs about 40 minutes, and you can watch it here.

    @onceuponA

     
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  • What might a minimum “replacement” plan look like?

      11/11/2016
      Adrianna McIntyre

    Supporters of the Affordable Care Act have a tendency to say that Republicans have no plans for comprehensive health reform. That’s not quite right; they have a great many plans—one, two, three, four, five, six at least—but have coalesced around none. Repeal and replace, if the GOP decides to pursue it in earnest, will be incredibly challenging.

    At least since the 2012 election, repeal has never actually seemed within reach for Republicans; repeal and replace was a political mantra. As recently as Monday, Paul Ryan conceded that the expected Clinton victory would be the final death knell for repeal efforts, though the rhetoric would persist.

    But Monday was four days ago; we’re in a different era now. The new question of interest is this: What policy changes would be minimally necessary for Republicans to claim that they’ve succeeded in “replacing” Obamacare? I posed the question to Twitter, and also laid out my own guesses. Some of you asked me to turn that into a blog post, so here goes. I think the following policy changes—leaving most of the individual market infrastructure in place—would be seen as sufficient to rebrand the law. (None of this is intended to suggest that I endorse the provisions.)

    1. Turn the individual mandate into a continuous-coverage mandate. On Friday, Trump stated that he wants to maintain the ACA’s protections for people with pre-existing conditions, which are favored by two-thirds of Americans. Of course, these protections are why the individual mandate exists, to ensure that the risk pool has an adequate number of healthy people to balance out the sick. But it seems politically untenable for Republicans to leave the individual mandate intact after making it the central constitutional challenge to the law. The American Enterprise Institute advanced the idea of a “continuous-coverage mandate” in their 2015 white paper, making guaranteed issue and community rating contingent upon people carrying insurance without any lapses in coverage. This, of course, is problematic for many people with chronic conditions and volatile incomes. Redesigning the mandate would require legislation (though repealing the mandate could be done through reconciliation).

    2. Block-grant Medicaid (but otherwise preserve expansion). Though it doesn’t purport to keep expansion in place at current funding levels, a central feature of Speaker Paul Ryan’s “Better Way” plan is to turn Medicaid into a block grant (funding would be structured using per capita, not global, spending caps). But unwinding Medicaid expansion would put governors in many red states in a bind, and would be out of step with Trump’s populist message. Trump has condemned the individual market, but hasn’t really attacked Medicaid. My bet is that Republicans don’t want to claw back coverage, but to rebrand the program they’ll insist on restructuring its financing. CBPP has estimated that block grants proposed by Paul Ryan in the past would dramatically inflate the number of under- and uninsured. This would require legislation.

    3. Narrow essential health benefits. The law enumerates 10 categories of “essential health benefits” that insurers are required to cover. However, those categories are broad—”hospitalization” and “prescription drugs,” for example—and the Secretary is given responsibility for more explicitly defining EHBs. The Obama administration punted this obligation to the states, but a Trump administration could plausibly redefine each category much more narrowly through the regulatory process, with or without congressional support. This could include, as Sarah Kliff has noted, withdrawing copay-free coverage for birth control.

    4. Reduce minimum actuarial value permitted on the individual market. Right now, bronze plans offer an actuarial value of 60 percent; enrollees can, on average, expect that the plan will cover 60 percent of their medical expenses. For reference, employer plans tend to have actuarial values north of 80 percent. However, if you lowered actuarial values, you would commensurately lower premiums, and Republicans would likely label these plans “catastrophic” insurance (though many folks consider the current bronze level to be near-catastrophic). Avik Roy proposed reworking the metal tiers in the ACA to have actuarial values of 40, 55, 70, and 85 percent for bronze, silver, gold, and platinum plans, respectively. Expect anything like this to be paired with policies around HSAs. Actuarial value levels are written into the statute, so this would require legislation.

    5. Loosen the age band. The Burr-Hatch-Upton plan would establish a 5:1 band; Roy’s plan would make it an even wider 6:1. Based on an analysis by the Urban Institute, this is unlikely to change premiums much for people in the middle half of the age range, but could make coverage considerably cheaper for young adults (and commensurately more expensive for the near-elderly). This would be the least controversial of the reforms I’ve suggested might surface, but would still need to be legislated.

    There are three other things worth keeping an eye on: the Cadillac tax, IPAB, and CMMI. The Cadillac tax was already delayed for two years and—given that economists are its only cheerleaders—it seems likely the Congress will either keep delaying or outright repeal it. It seems likely that IPAB, the so-called “death panel,” is on the chopping block, too. I’m less convinced that Republicans will maintain their eagerness to repeal CMMI under a Republican president, but any aggressive action using CMMI will have to contend with the party’s reaction to the Medicare Part B proposal.

    Everything requiring legislation will be a battle, as long as the filibuster remains intact. However, Republicans could use reconciliation to “sunset” key parts of the ACA, imperiling the stability of the individual market, and use that to pressure legislators into passing “replacement” provisions. It’d be a risky and ugly game of chicken, with lives literally hanging in the balance. But this is 2016, so I’m not ruling anything out.

    On the other hand…

    Adrianna (@onceuponA)

     
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  • Surprising new insight on individual market premiums

      07/22/2016
      Adrianna McIntyre

    Loren Adler and Paul Ginsburg, both of the Brookings Institution, have published a fascinating new post on the Health Affairs blog, examining the impact of the Affordable Care Act on individual market premiums. Loren’s a personal friend, so I happen to know that this isn’t a typical blog post; this analysis has been in process for several months.

    Their central finding is that average premiums in the individual market would likely be higher absent the health reform law.

    To address this issue, we draw on Congressional Budget Office estimates of average individual market premiums in 2009 (the most recent pre-ACA year for which CBO provides an estimate), largely based on data from the Medical Expenditure Panel Survey (MEPS) and adjusted for insights from their Health Insurance Simulation Model and observed data. We then adjust this estimate downward to account for it being based on pre-2009 data, by the ratio of actual 2009 employer-provided plan premiums for single coverage (from MEPS) to CBO’s predictions at the time.

    Therefore, we estimate that the average annual premium in the individual market in 2009 was $3,480 (or $290 per month), which was for a plan that on average covered roughly 60 percent of an enrollee’s covered health expenses — an actuarial value of 60 percent.

    By comparison, the average premium in 2014 for the SLS plan was $3,800according to CBO, only 9 percent higher despite the passage of five years. Adjusting for the difference in actuarial value, this premium was actually lower in nominal dollars than that in 2009.

    Moreover, by any measure, individual market premiums had grown enough by 2013 such that the $3,800 average SLS plan premium in 2014 represented a sharp drop from the previous year, despite covering a higher percentage of enrollee costs and offering a broader set of health benefits.

    Another key takeaway is that average post-ACA premiums are lower than we would expect average individual market premiums to be in the land of counterfactuals, where the ACA was never acted. This remained true under conservative assumptions.

    Adler_Exhibit3

    I strongly recommend reading the post in full, especially given how counterintuitive the findings seem; conventional wisdom has long held that the ACA increased individual market premiums simply as a function of benefit generosity and guaranteed issue. Importantly, their analysis is uses up-front premium estimates, before accounting for premium tax credits and cost-sharing reductions.

    For those who remain skeptical, Loren walked through some plausible explanations on Twitter (click through, as this goes on for several more tweets):

    To be clear, the post deals in averages; there is variation around the mean, and the variation pre-ACA would have been much higher pre-ACA than post, because of the new community rating and 3:1 age band. The available data also couldn’t be used to evaluate changes to cost-sharing design (like deductible size) or provider networks. Data on pre-ACA individual market coverage is notoriously difficult to come by; this analysis uses CBO data (which hasn’t been widely used outside CBO for analyses like this), supplemented by information from MEPS.

    Even with these caveats, the analysis offers surprising, new, and important information. Go read it!

    Adrianna (@onceuponA)

     
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  • Some thoughts on third-party payment for dialysis

      07/07/2016
      Adrianna McIntyre

    On Saturday, the New York Times ran a story about an issue that has been (mostly) quietly simmering with little attention from the popular press: third-party payment of insurance premiums. The hook for this story is a new lawsuit brought by UnitedHealthcare against a dialysis chain:

    The suit accuses American Renal Associates, a public company that operates nearly 200 dialysis clinics across the country, of fraudulently billing millions of dollars since the beginning of the year. UnitedHealthcare is trying to recoup that money.

    The insurer argues that the effort was aided by the American Kidney Fund, a nonprofit patient advocacy group, which paid the patients’ premiums for private insurance. The insurer said American Renal Associates “earmarked donations” to the kidney fund to pay for the coverage, violating anti-kickback laws in the process. The lawsuit also says that the company’s patients were not told that the kidney fund would stop paying their premiums if they received a kidney transplant.

    The story highlights real and noteworthy issues about the conflicts that can emerge when charitable organizations are funded by industry; dialysis companies (who provide most of AKF’s revenue) certainly stand to gain from seeing more privately insured patients instead of Medicare/Medicaid enrollees. I don’t know enough to comment on the anti-kickback allegation; for their part, the American Kidney Fund asserts that enrollee choices about plans and providers are independent from their financial assistance.

    And it brings up real risk pool issues that can arise when high-cost patients are directed from Medicare—where they have eligibility as ESRD patients regardless of age—into exchange plans. CMS finalized rules in March permitting insurers to decline third-party payments (with certain exceptions, like the Ryan-White program). This creates a collective action problem: if one insurer in a market refuses third-party payments, the other insurers feel compelled to do the same, lest they be the only one accepting these payments—and all of the “bad risks.”

    All of those are real issues. But I think the Times story missed the most compelling counterargument: the cost of Medicare coverage for ESRD enrollees. The Kaiser Family Foundation estimates that these individuals face annual out-of-pocket costs of $6,918 in 2010, on average (that’s $7,622 in today’s dollars). People forget that traditional Medicare doesn’t have an out-of-pocket maximum like the $6,550 cap for private insurance under the Affordable Care Act. Medicare Advantage plans have a cap, but ESRD patients generally aren’t eligible for MA plans, unless they were already enrolled prior to developing their disease. Medigap plans are another way to shield against catastrophic costs—but in many states, Medigap plans can refuse to enroll ESRD beneficiaries.

    Moving these folks into private plans that help pad dialysis companies’ bottom lines might not be the ideal policy solution. But leaving some of Medicare’s most vulnerable patients exposed to these kinds of out-of-pocket burdens doesn’t seem ideal, either.

    Adrianna (@onceuponA)

     
      Health Policy
      ESRD, Medicare, third-party payment
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  • America’s Bitter Pill

      06/16/2015
      Adrianna McIntyre

    I was recently invited to review Steven Brill’s book on health reform, America’s Bitter Pill, for the quarterly journal Democracy. 

    As someone who came started following the reform debate relatively late—after the ACA had been passed—I thought the book offered a rich and useful political history of the law. The policy recommendations at the end of the book left me a bit perplexed, though.

    On the first day that the federal insurance exchange was online, just six people were able to register for coverage. The site struggled to work for months. But when open enrollment finally ended in April 2014, after several extensions from the Administration, more than eight million people had found coverage through the state and federal insurance exchanges, surpassing projections from the Congressional Budget Office. In America’s Bitter Pill, Steven Brill deftly chronicles this disaster and recovery with a depth of reporting that day-to-day coverage didn’t provide. With the benefit of hindsight and the space of 455 pages of text, Brill is able to trace the stubborn and complex confluence of pressures, inescapable trade-offs, and fallible actors that brought us the nation’s most sweeping health reform in half a century.

    But Brill, the celebrated investigative journalist, proves to be fallible, too: Rather than stick to reporting, he chooses to play pundit and issue ill-informed prescriptions for our health-care system. His recommendations demonstrate a certain hubris about our understanding of the system’s failures—a hubris that is all too commonplace in political rhetoric around health reform.

    Go read the rest here.

    Adrianna (@onceuponA)

     
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  • ‘Pennhurst:’ Reason for optimism in King, or reason for worry in other areas of the law?

      03/04/2015
      Adrianna McIntyre

    With oral arguments in King this week—today!—I’ve temporarily reprised my my Vox-writer role. Yesterday, I published a piece on Pennhurst, a legal doctrine that could prove consequential. Like Chevron, it hinges on the justices reading the law as ambiguous, but Pennhurst is a doctrine that demonstrates deference to the states—not to federal agencies—so it might prove more palatable to the conservative justices.

    The government does have one legal doctrine, however, that might be especially persuasive to right-leaning judges. It’s called the Pennhurst doctrine, and its all about ensuring that the federal government doesn’t violate state rights.

    Legal scholars defending Obamacare think this argument may resonate with the court’s conservative wing, but some worry that a ruling on Pennhurst grounds could have implications that stretch far beyond health reform.

    The rest is here.

    For a really interesting, more historical take on the doctrine, you should absolutely read Noam Levey.

    Adrianna (@onceuponA)

     
      Health Policy
      King
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  • Weekly roundup of health policy news and research

      01/09/2015
      Adrianna McIntyre

    The internet says that email newsletters are experiencing a “renaissance,” and the internet is never wrong. At any rate, I’ve decided to start one, capturing the top headlines and research of the week. It isn’t intended to be a TIE roundup—though TIE links will surely find their way into it.

    Interested? You can subscribe here. I’ve pasted content from the first newsletter below.

     

    NEWS YOU CAN USE

    2015 is the year we all decided to care a lot about one university modestly tweaking health benefits. Read Robert Pear’s Harvard story, if you haven’t already. My thoughts, grounding Harvard in the expansive tangle that is employer-sponsored coverage, are here.

    Harvard’s benefits guide points to the ACA as a culprit for the changes, but is that right? Gaming out premium growth at different levels, the numbers don’t add up—Harvard isn’t likely to face the Cadillac tax until the late 2020s. (Other benefit requirements are unlikely to change much in already generous large-employer plans.)

    Steven Brill’s new book America’s Bitter Pill was released Monday. Malcolm Gladwell’s review at The New Yorker is the most thorough I’ve seen. Only just started the book myself, so I’m not sure yet whether I agree with Gladwell. Brill went on The Daily Show to promote.

    The House passed a bill that would redefine “full-time work” for the employer mandate. This is bad policy: CBO estimates it would induce a far greater number of employers to drop coverage, increasing the ranks of the uninsured by 500,000 and increasing federal deficits by $53.2 billion over ten years, as more people collect subsidies. President Obama promised to veto any such legislation that crosses his desk.

    More red states are eyeing Medicaid expansion under waiver. Texas hasn’t taken an “alternative” expansion totally off the table, though it remains a long shot. Utah and Tennessee are the other two states that seem to be on deck.

    2014 was the biggest jobs-growth year in the health care sector since 2008. Today’s report also has non-health employment up to pre-recession levels, after seven years.

     

    THE WEEK IN RESEARCH

    The January issue of Health Affairs* is out and full of interesting stuff—too much to cite here. Link takes you to the table of contents.

    Implications of a Supreme Court Finding for the Plaintiff in King vs. Burwell: 8.2 Million More Uninsured and 35% Higher Premiums (RWJF/Urban Institute)

    Viewpoint: The Role of Private Payers in Payment Reform* (JAMA)

    Effect of Medicare’s Nonpayment for Hospital-Acquired Conditions: Lessons for Future Policy (JAMA)

    Effect of Expanding Medicaid for Parents on Children’s Health Insurance Coverage Lessons From the Oregon Experiment* (JAMA) — Parent’s randomization to Medicaid increased children’s odds of coverage.

    A Prospective Examination of Whether Childhood Sexual Abuse Predicts Subsequent Sexual Offending* (JAMA) — The evidence says no.

    * Content behind paywall

     
      Health Policy
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