Time: D H M S

(note: too many updates in too short a period for me to even keep track of...)

At first, most healthcare reporters thought this was a fairly meaningless "mission statement" without much impact...

Trump also issued a memo to all agencies requesting that they begin to "ease the burden of Obamacare as we transition from repeal to replace," Spicer said. He declined to provide specifics on what various agencies might do in response to the president's directive.

HOWEVER, David Anderson (formerly Richard Mayhew) notes that Section 2, which instructs the HHS Secretary to "waive, defer, grant exemptions from or delay" any "fiscal burdens" o sounds an awful lot like telling them to be absurdly lenient regarding granting "hardship exemptions" from the individual mandate:

@annaedney @ZTracer yes individual mandate exemptions will be passed out like pacifiers at a rave

— David Anderson (@bjdickmayhew) January 21, 2017


I embedded this song into a blog post back on April 30, 2014, after the dust had settled from the first Open Enrollment Period.

I posted it again on May 4, 2015, after the second enrollment period...and then a third time on June 29, 2015, right after the King v. Burwell Supreme Court decision was announced.

I was debating whether to hold off on doing so yet again until after January 31st, since that's the last day of the 2017 Open Enrollment Period...but upon further reflection, today is really more appropriate.

I've committed to keeping the site operating through at least April 30, 2017...which is also around the point that pretty much all of the final reports from HHS, CMS, ASPE and so forth documenting the OE4 numbers should have been released. I'm also assuming that we'll have some idea about just where the hell the ACA repeal/replacement direction is at that point...although who the hell knows?

Anyway, the answer to the question "Where do we go from here?" is, quite the fuck out of me.

To everyone who has donated in the past...or submitted data, or offered suggestions, or reposted/retweeted links to the site over the past 3 1/2 years...thank you.

I'm not closing up shop or anything (yet)...but if anyone's in a position to pony up a few bucks to help keep the site going for as long as possible, this is as good a time as any to do so.


(Update: Thanks to Griffin Cupstid, MD for the link to the CNN transcript, which allowed me to make some minor wording edits below).

I wrote up a long-ass Twitter thread last night. I've reformatted it for a blog entry this morning:

So, I watched the ACA-related segments of Republican House Speaker Paul Ryan's CNN Town Hall thing last night. He took several questions about the ACA (Obamacare, remember) and Medicare, but I'm just gonna focus on the first one here. The questioner was a self-described lifelong Republican who used to hate the idea of the ACA...right up until he was diagnosed with cancer and given just months weeks to live. Pre-ACA he would have been denied coverage for the pre-existing condition and would have died. He profusely praised the ACA and flat-out thanked President Obama for saving his life. The actual question was "why would Ryan repeal the ACA without a replacement in place."

QUESTION: I was a republican and I worked for the Reagan and Bush campaigns. Just like you, I was opposed to the Affordable Care Act. When it was passed, I told my wife we would close our business before I complied with this law. Then, at 49, I was given six weeks to live with a very curable type of cancer. We offered three times the cost of my treatments, which was rejected. They required an insurance card. Thanks to the Affordable Care Act, I'm standing here today alive.

Being both a small business person and someone with pre-existing conditions, I rely on the Affordable Care Act to be able to purchase my own insurance. Why would you repeal the Affordable Care Act without a replacement?

RYAN: Oh, we -- we wouldn't do that. We want to replace with something better. First of all, I'm glad you're standing here. I mean, really -- seriously.

QUESTION: Can I say one thing? I hate to interrupt you...I want to thank President Obama from the bottom of my heart, because I would be dead if it weren't for him.

01/12/17: PLEASE NOTE: I know there's a whole bunch of updates/revisions below; this is because I'm constantly updating both the Medicaid expansion and exchange policy numbers daily, in real time as I'm able to compile the most recent enrollment numbers. In most cases the numbers are quietly increasing, although in a few cases I've revised them downward.

I operate this site by myself and I do have a day job, family, etc, so if I haven't updated your state, be assured I'll get to it as soon as possible.

Earlier today I noted that a bunch of Republican--yes, Republican--governors have chimed in in defense of the Affordable Care Act (or, at least the Medicaid expansion provision). They had a big powwow with GOP Congressional big shots to air their case.

Well, Republican U.S. Senator John Cornyn, the Majority Senate Whip (and therefore one of the biggest shots in the Senate) shot off quite a promise about the concerns regarding up to 32 million people potentially losing their healthcare coverage in the event the ACA is repealed:

One of the top concerns is what will happen to individuals who became eligible for Medicaid with its expansion under Obamacare. The Senate's No. 2 Republican, however, promised that no one who got coverage under Medicaid expansion will lose it.

When Conrnyn was asked if he was concerned about people who've benefited from Medicaid expansion losing coverage, he said it was a shared concern.

I've decided that for all future ACA enrollment data reports, I'm going to tack on "...on brink of possible ACA repeal" to the headline. Seems appropriate.

It's been quite awhile since I've written much of anything about the ACA's SHOP programs, which are the small business counterpart to the individual/family exchanges. The reason is pretty simple: SHOP enrollment is mostly a rounding error compared to either the ACA's Individual exchange enrollments or Medicaid expansion numbers.

SHOP enrollment (a mere 120K - 170K nationally, as far as I can tell) is even dwarfed by BHP program enrollment (around 700,000)...and that's only available in 2 states (Minnesota and New York). Heck, I don't even bother tracking them on my spreadsheets or graphs (I tried in 2014 but gave up on it the following year).

Still, once in awhile there's a bit of SHOP news to report, and this press release out of Minnesota is such an occasion:


Record Number of Idahoans Select Insurance through Your Health Idaho
Lawmakers Get Update on State’s Health Insurance Exchange

BOISE, Idaho – Your Health Idaho (YHI) executive director Pat Kelly went before lawmakers on Wednesday to give them an update on the third year of operations for Idaho’s state-based health insurance exchange. YHI set new records for enrollment during 2016 and led state-based exchanges across the country in per capita enrollment.

“Lawmakers’ choice to keep the federal government out of Idaho’s health insurance decisions and to do things our way has benefited Idaho immensely,” said Kelly. “Your Health Idaho gives consumers options when it comes to selecting a health insurance plan and we keep more money in Idahoans’ pockets by having lower assessment fees than the federal government.”

In federally managed states, consumer fees are set at 3.5percent. In 2016, YHI’s board of directors set the state’s assessment fee at 1.99 percent. To date, lower health insurance assessment fees have saved Idahoans more than $15 million.

I, and many others, have suggested (sometimes jokingly, sometimes not) that Donald Trump and the GOP's "terrific!" replacement for the Affordable Care Act could very well be to simply rebrand it as "TrumpCare", declare victory and call it a day.

I'm realize that Paul Ryan and Tom Price have other (terrible) ideas, but reading the latest goat entrails which make up Donald Trump's blathering suggest that he's now decided to do pretty much that (granted, that could have easily changed while I was typing that last sentence). Via Maggie Fox of NBC:

President-elect Trump just promised that private insurance companies can help lower costs and get health insurance to more Americans.

Not sure if the sender wants public credit or not, but a few Republican Goverors have some things to say about repealing the Affordable Care Act...especially Medicaid expansion:

Today, Republican Governors will meet with GOP Congressional leaders in DC to discuss – you guessed it –the Affordable Care Act. Medicaid expansion is a key factor in this discussion because, as Governors will tell you, Medicaid expansion is leading to lower uninsured rates, higher rates of care, and critical treatment for people fighting opioid use disorders. And if Republicans repeal the ACA without a replacement plan in the same bill, CBO would score a subsequent bill restoring Medicaid expansion funding as an almost $1 trillion spending increase over 10 years. Interestingly, a number of GOP Senators broke with their party on expansion related vote-a-rama measures last week, and Governors from both parties have spoken out about this issue, as well as about the dangers of repeal and delay.


OK, the guest host is actually Cliff Schecter, but I'll be a guest on the Leslie Marshall radio talk show this afternoon from 3:00 - 3:30pm EST today, talking ACA, repeal and so forth.

Listen to the Live Stream here!

You can also listen to the podcast after the show here.

OK, given the impending End of the World As We Know it (and, on a smaller scale, the potential End of the Affordable Care Act), this is a pretty minor thing, but worth noting.

This afternoon I did a write-up about today's Week 10/11 HealthCare.Gov Snapshot Report, which showed nearly flat enrollment growth from 12/31 to 1/14...two solid weeks with barely 64,000 additional signups across 39 states. As I noted, this particular stretch of Open Enrollment was expected to be pretty quiet, but even so, the numbers were still far lower than I expected.

In the Weeks 8/9 Snapshot Report, HHS reported exactly 8,762,355 QHP selections as of New Year's Eve via HealthCare.Gov specifically (which only includes 39 states).

Then, last week, the ASPE department released their "Mid-Season Report", which included more detailed enrollment data for every state...but cut off a week earlier (only through Christmas Eve). After filling in all the blanks, I concluded:

For weeks now, I (and many others) have been crunching the numbers and making projections to see just what the fallout would be on the individual market (and the total uninsured rate) if the GOP were to follow through with their promise to repeal the Affordable Care Act.

There's a lot of variables at play, and there's also no way of knowing what (if any) replacement plan they'd come up with instead, but there are two main scenarios to consider: First, what would things look like if the ACA were to be fully repealed (without a half-decent replacement ready to swoop in); second, what would happen if the ACA were to be partially repealed via the reconciliation process (ie, killing off the subsidies, individual/employer mandates, Medicaid expansion and so forth, but keeping the guaranteed issue, community rating and other regulatory provisions in place, which is what would happen if the Republicans were to continue on their present course).

With the Republicans scrambling to come up with a plan, any plan to replace the Affordable Care Act at the same time that they repeal it (as opposed to, you know, simply not repealing it, at least until they actually have a reasonable plan, which they could certainly do if they wished to), there was a huge amount of buzz generated Sunday night over this story from Robert Costa and Amy Goldstein of the Washington Post:

Trump vows ‘insurance for everybody’ in Obamacare replacement plan

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody,” while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid.

Drug negotiations aside, the rest of the article is exactly what you'd expect:


No, I'm not accusing him of murdering anyone (well, unless his ACA replacement bill becomes law, that is), but it's starting to look like the Senate would have to be on drugs to confirm orthopedic-surgeon-turned-Congressman Tom Price as the new HHS Secretary:

Exhibit A, via Manu Raju of CNN:

Trump's Cabinet pick invested in company, then introduced a bill to help it

Rep. Tom Price last year purchased shares in a medical device manufacturer days before introducing legislation that would have directly benefited the company, raising new ethics concerns for President-elect Donald Trump's nominee for Health and Human Services secretary.

...Less than a week after the transaction, the Georgia Republican congressman introduced the HIP Act, legislation that would have delayed until 2018 a Center for Medicare and Medicaid Services regulation that industry analysts warned would significantly hurt Zimmer Biomet financially once fully implemented.