ACA

The shutdown drags on, but the shape of a deal is forming

It was quite a week for the ongoing government shutdown over the ACA tax credits. On Monday, the President seemed to indicate he was open to making a deal on the ACA extensions, though he walked this back later on. Then, Marjorie Taylor Greene, Republican representative of the Georgia 14th, went on CNN to say that her phone was ringing off the hook with constituents asking that the subsidies be extended. Meanwhile, Republican Speaker of the House, Mike Johnson, keeps saying the deadline for extending the subsidies is an eternity away, which isn’t quite accurate, as I discussed with some actuaries this week. Renewal letters are going out, the window shopping period starts next week, but some plans filed two sets of rates in states for extension and no extension scenarios, so a deal sooner would be better than a deal in late December if there was going to be a deal at all.

Which there might be! InsideHealthPolicy is reporting:

Analysis

I was last working in Congress in any capacity about 15 years ago (summer intern), so grains of salt all around, but I suspect a two-year extension of the subsidies with income limits is probably sufficient to peel off enough Democrats to break the filibuster.

A two-year extension gives everyone a little more certainty on what’s going on and punts the renewal question until after the midterm elections, which a 1 year extension would not.

The income limits being discussed are an interesting case because the number being floated is around $200k. Looking at CMS’s open enrollment files, only about 3% of ACA enrollees are above 500% of the poverty line, which, for a family of four, is about $160k a year. And if you’re at $200k a year in income, an unsubsidized bronze plan is probably right in line with the enhanced subsidy premium limits. Basically, that’s an easy deal for the Democrats to make because basically no one will be impacted by it.

If you’re curious about the electoral implications of the subsidies, you can take a look at the excellent enrollment data by congressional district file put together by Charles Gaba at acasignups.net. I believe MTG when she says she’s getting calls, but notably, her margin of victory in the last election is larger than the total number of ACA enrollees in her district, so I think it’s fair to say she's standing on principle here, and it isn’t just her being concerned about re-election.

On the hill

Oscar “applauds” the introduction of pro-ICHRA bills on the hill

Oscar published a blog post celebrating the introduction of two bills in Congress that, in Oscar’s view, will accelerate the adoption of Individual Coverage Health Reimbursement Arrangements, also known as ICHRAs.

The first is called the CHOICE Arrangement Act, which turns ICHRA from a regulatory to statutory policy and offers two years of incentives to employers who adopt the arrangements.

The other bill is the Small Business Health Options Awareness Act, which directs the Small Business Administration to do more outreach and education on the arrangements as an alternative to traditional employer-sponsored health plans.

Analysis

People have strong opinions on ICHRA as a matter of business and of policy. I cannot say that I do. I think it seems like a reasonable way to redesign a health care system (i.e., vaguely Swiss!); it has trade-offs that are real, but so does every health care policy, and if we could get consensus that this was the path, it would be fine.

What I don’t understand is the push for ICHRAs right now with all the volatility and uncertainty in the individual market. In many ways, this would be a bad year to ask your employees to go out and buy insurance on the individual market because options are limited and prices are really high because no one knows what’s going on with the enhanced subsidies.

If we want to push everyone to the individual market, we should stabilize and subsidize the individual market first. Bringing on a bunch of healthy folks currently covered by group plans would certainly do a lot to help them, but it’s a big ask for employers to do it in a year where the main thing people know about the individual markets is that premiums are skyrocketing. It’s a real cart before the horse situation in my mind.

CMS

Dr. Oz shares his vision of Medicare, Medicaid, and the marketplaces at the Aspen Institute’s Public Health Grand Rounds

During a Q&A with Bertha Coombs of CNBC, CMS Administrator Dr. Oz laid out his theory of the case for the future of health care programs under his purview. If you’ve got an extra 1.5 hours, it’s worth a watch or listen, but some highlights for me were:

• Reiterating the position he laid out in his WSJ op-ed with FDA administrator Marty Makary about using the government as a place to convene private businesses to work on problems outside of the regulatory process

• Laying this out as the carrot, he also described the various sticks he has as a regulator, including being “loaded, ready to go” with AI tools for monitoring Medicare Advantage plans

• The urgent need for transformation in rural health, citing the Rural Health Transformation Program as a unique opportunity to leverage technology to rationalize the costs of rural care delivery

• Supply side initiatives like the $75m CMS is investing in training nurses and nurse assistants, and also encouraging states to license pharmacists to prescribe medication.

• Shouting out Kaiser’s integrated system and Highmark’s Gold Card program as alternatives to prior authorization.

Analysis

Admittedly, I have a pro-experienced bureaucrat bias for jobs like CMS Administrator, or perhaps an anti-television personality bias for these jobs, because I didn’t have particularly high hopes for Dr. Oz administering CMS, but watching this talk has caused me to revise my beliefs. A clear benefit of bringing someone with his background into the role is that he is a very effective communicator on really complicated issues. As we seem to be entering an age of orality (as opposed to literacy), it seems like Dr. Oz is the model rather than a wonky bureaucrat because being able to talk about risk adjustment in an animating way is what the role requires.