Thread by @bjdickmayhew

1/23 Tweetstorm incoming
Congressional Democrats need to realized that #CSR termination is a net enrollment booster on the #ACA.

Riffing on @pauldemko great article about the new Democratic House's health policy oversight and agenda.

The decreased subsidies are CSR.

2/N CSR applies to people earning between 100-250% Federal Poverty Level (FPL) and was designed as a narrow, tightly targeted means tested program to reduce out of pocket expenses. Only applies to people who buy a Silver plan on the Exchange.

3/N President Trump suspended normal payments to insurers for CSR in October 2017.

Disaster?

4/N

5/N Actually not paying CSR directly is a great price support for the ACA

It made post subsidy prices a lot cheaper and improved the value to many more subsidized to more potential buyers.

6/N Insurers and states overwhelmingly responded by a #Silverload strategy which put the cost of CSR into only Silver plans. (@urbaninstitute thought this up)
Premium subsidies are built from a Silver plan benchmark. #Silverload upped benchmark faster than everything else.

7/N @KaiserFamFound tracked premium increases from 2017 to 2018:

Bronze: Up 17%
Silver: Up 32%
Gold: Up 18%

kff.org/health-costs/i…

8/N This leads to huge discounts for subsidized buyers who move to either Bronze or Gold plans and away from Silver.
Counties on HC.Gov where a Gold plan is less expensive than the Silver Benchmark:
2017: 5
2018: 595
2019: 1,115

9/N $0 Bronze plans are available now for a single 40 year old earning $40,000

2017: 0 counties
2018: 97 counties
2019: 138 counties

Bigger families, lower FPL or older buyers will see more $0 net of subsidy plans

10/N $0 plans matter a lot; preliminary work with @cdrake219 shows the presence of a $0 plan increases enrollment in a county much more than we would expect just due to the price. The effect is strongest on younger buyers. We hypothesize that this improves the risk pool

11/N ASPE (part of CMS) shows proliferation of more affordable options
aspe.hhs.gov/pdf-report/hea…

12/N @xpostfactoid and I believe that the pricing support of CSR termination and the response to #Silverload upped enrollment by ~5 to ~6 points for people earning 200-400% FPL

healthaffairs.org/do/10.1377/hbl…

13/N We hypothesize that this counter-attacked some of the changes in messaging, shorter open enrollment periods, outreach changes by offering folks who did not qualify for strong CSR much better net of subsidy premiums. People took good deals

14/N We see higher retention in 2019 over 2018 during the most recent Open Enrollment Period as people still stuck with good priced deals. This counter-acted lower new enrollments that may have been partially driven by repeal of the mandate.

15/N So CSR termination upped subsidized enrollment compared to what would have happened with no CSR changes. Doesn't this hurt the non-subsdized buyers ?

16/N CSR #SilverLoad always left the Gold and Bronze non-subsidized buyers no worse off. They saw higher premiums because the underlying costs were higher.

Silver buyers could be worse off. Many states adopted #SilverSwitch to protect non-subsidized Silver buyers

17/N #SilverSwitch cloned Silver plans that had the CSR bump and put them off-Exchange without the CSR bump.

Non-subsidized buyers could buy Silver plans at "regular" premiums instead of the CSR compensation higher premiums.

18/N So most states have either protected their markets or made their individual insurance markets offer far better deals/value propositions of lower premiums for lower deductible plans because CSR has been terminated.

19/N In more aggressive states, the ACA markets now (post CSR termination) now look more like the vision of the 2009 House bills than the 2014-2017 realities. Effectively the benchmark in many states now buys at least a Gold plan.

20/N IF Democrats want to improve the functionality of the ACA marketplaces, then they should be looking at improving outreach as @shaferpr @sarahgollust @efranklinfowler et al have shown that advertising matters a lot
ncbi.nlm.nih.gov/pubmed/30361198

21/N OR look at any @CMSGov decision to ban #Silverload and only allow a #Broadload which would take away most of the pricing advantage generated for subsidized buyers by CSR Termination

healthaffairs.org/do/10.1377/hbl…

22/23 As I argued in the @nytimes President Trump could have declared victory on a campaign promise to get more people better insurance at lower premiums....
nytimes.com/2017/10/20/opi…

23/23 and argued in August 2017 that the non-funding of CSR would move the ACA in liberals' preferred direction

This is an opportunity to pocket a policy win by doing nothing.
balloon-juice.com/2017/08/15/csr…

two updates:

Not @Pauldemko but @adamcancryn and @AliceOllstein writing the great article at Politico:

Linked: politico.com/story/2019/01/…