Friday, December 08, 2017

Planning a two-step retirement, because health insurance

My last post looked at the various ways that self-employed people in particular can limit their taxable income to stay on the right side of the ACA subsidy cliff, which has reached untenable heights for people in their late 50s and early 60s. We're at the point where getting on the wrong side of the subsidy-eligible line can mean $10,000-plus in extra health insurance costs for older shoppers in the individual market for health insurance.

The situation reflects broader societal dysfunction. We have a gaping hole in the safety net patched by an insanely diverse panoply of tax-sheltered accounts -- which some lucky and nimble affluent-but-not-rich people may hopscotch across to safety.

Take the case of a couple of 58 year-olds in a northeast city where the cost of living is high -- their modest dwelling is worth over $600k and taxed accordingly. The wife, Samara, is a hospital nurse, and the husband, Aman, is a solo consultant of some kind. Both have earnings in the $75k range. Thanks to assiduous feeding of their 401k retirement accounts (they've saved a bit over $1 million between them), their Adjusted Gross Income (AGI) is about $110,000 -- far below their gross, but far above the ACA's subsidy eligibility threshold of $64,960. That's not an issue for now, because they get good insurance through Samara's hospital job.

But what if Samara is hoping by age 62 or so to...not retire, but work per diem, or try an encore career? An unsubsidized ACA-compliant two-person bronze plan with per person deductibles in the $6-7000 range  might cost them $1500 or $2000 a month by age 62.  Can the couple get below the subsidy line without a radical cut in income? Can Samara escape health insurance-induced job lock?

Wednesday, December 06, 2017

Steering clear of the subsidy cliff in the ACA marketplace

It's plain this year that the individual market for health insurance is unaffordable for many of the unsubsidized, particularly those in their late fifties or early sixties. The subsidy cliff has reached a fatal height for many.

This week Kaiser Health News reporter Rachel Bluth spotlighted a stark example: A 62 year-old woman in Chattanooga, Tennessee who earned $80,000 working for a consultancy deliberately cut her hours, reducing her income by a third to get herself and her husband below the subsidy line ($64,080 for a two-person household in 2017). The total household income was $92,000.  The woman, Anne Cornwell, cut her income by $24,000 -- and her insurance bill by $27,000.

This drastic solution set me thinking about ways to keep on the right side of the subsidy cliff, i.e., 400% of the Federal Poverty Level. In 2018, that's a  Modified Adjusted Gross Income (MAGI)  of $48,240 for an individual, $64,960 for a couple, and $98,400 for a family of four.

Many but not all resources for reducing MAGI are available only to the self-employed. They include the following.

Saturday, December 02, 2017

Where we're at now

Just a brief and not particularly original thought as I try to process Senate passage of this travesty of a tax bill.

While Trump's election has the feel of a perfect storm catastrophe, perfect storms are usually the result of a a long sequence of dysfunctions, and the total corruption of the Republican party was bound to lead to catastrophe at some point. I recall Jonathan Chait saying as much as an episode of debt ceiling legislative terrorism loomed in (IIRC) 2013. His point was not that that particular crisis would lead to default, but that a party always willing to go to the brink in defense of an ideology cooked up to serve the narrow interests of the superrich would lead us over the cliff at some point. Put another way, if it had not been completely evident before, it was evident after Obama's reelection that the fever would not break.

In some ways it's a consolation to view our plight not as an accident that a breath of wind could blown off course but as a reckoning with pathologies we've been collectively grappling with at least since the Reagan era (and far earlier, as every origin has multiple origins behind it).

Thursday, November 30, 2017

Late Days of Empire Edition: Health Wonk Review

We're addled on many fronts here in Trumpville, and this week's Health Wonk Review reflects that. We have snapshots of a country that continues to trail its peers in population health measures; an opioid vendor looking to short-circuit potential tobacco industry-level liability; an individual market for health insurance offering unaffordable plans to many of the unsubsidized, and freakish bargains to some of the subsidized; and, for a little futuristic relief, a human resources tech vendor that may chain healthcare data to a block, where it shall remain unaltered forever and ever.

At Workers' Comp Insider, Tom Lynch  looks at what the U.S. gets for spending 41% more on health care than our wealthy nation peers in the OECD and 81% more than the entire 35-nation OECD average. Spoiler: not much. We're "sort of like a big-market baseball team spending gazillions more for players than any other team, only to finish out of the running."

At Managed Care Matters, Joe Paduda notes that Purdue Pharma is trying to strike a deal to resolve all state claims relating to opioids. He warns:

Tuesday, November 28, 2017

The marketplace isn't all roses for the subsidized, either

Sam Baker has an insightful take on the bifurcation of the individual market between the subsidized and the unsubsidized, exacerbated by Trump. I want to offer a caveat, though.

Of the fallout from Trump's cutoff of Cost Sharing Reduction (CSR) reimbursement -- premium spikes for the unsubsidized, bronze and gold bargains for some subsidized -- Baker writes:
All of this has compressed the ACA's benefits. The law was initially designed to move a lot of people into the same system, in which even the people who didn't get a subsidy would benefit from a competitive marketplace to shop for coverage.

Instead, we're ending up in a place where the poorest consumers can get even cheaper coverage than the ACA intended, especially if they choose less comprehensive care, while wealthier consumers increasingly don't have much incentive to get covered at all. Those trends will only grow more pronounced if Republicans successfully repeal the individual mandate in their tax bill, leaving the law with only its carrot, and no stick.
There's nothing inaccurate here. But in general discourse if not here, the perceived bonanza for the subsidized stemming from inflated subsidies may be somewhat overstated.

Wednesday, November 22, 2017

A Medigap for the Marketplace?

It's well known by now that Trump's cutoff of federal funding for Cost Sharing Reduction (CSR) subsidies in the ACA marketplace has had the paradoxical effect of making free bronze plans widely available to subsidy-eligible marketplace enrollees.

The blessing is something of a mixed one for many buyers with incomes up to 200% of the Federal Poverty Level (FPL), however. Silver plans up to the 200% FPL level come with strong CSR that reduces average deductibles to under $300 (for enrollees up to 150% FPL) or under $1000 (for those in the 151-200% FPL range). That's in contrast to bronze plan deductibles that average over $6,000.  Other out-of-pocket cost differences are commensurate. More than half of current marketplace enrollees have incomes under 200% FPL, and most can probably now find free bronze plans.

CSR was designed to make actual healthcare affordable to low income enrollees -- who, again, constitute more than half of all marketplace enrollees (and more than half of the uninsured; as of 2013, 55% of the uninsured had incomes under 200% FPL). $6,000 deductibles are not generally appropriate for low income people (or arguably, for almost anyone).

On the other hand, a benchmark silver plan for a solo buyer with an income of $24,000 just under 200% FPL costs $126 per month -- versus $0, in many cases now, for bronze.

Since CSR costs the enrollee nothing, CSR-enhanced silver plans used to be worth considerably more in absolute terms than bronze, providing more actuarial value for the buck. That's not necessarily true any more. And a fair number of bronze plans do not subject services such as doctor visits and generic drugs to the deductible. The yearly out-of-pocket maximum for a bronze plan, on the other hand, is $7,350 for an individual -- versus $2,450 for a CSR-enhanced silver plan for enrollees with incomes up to 200% FPL. The out-of-pocket maximum represents an enormous amount of risk for a low income person.

There is an existing market resource, however, that could give some enrollees in free or very cheap bronze plans significant relief from high out-of-pocket costs. That's so-called gap insurance, which offers first-dollar coverage for a range of expenses up to a limit of, say, $5,000 or $10,000. It's not available everywhere, coverage for preexisting conditions is excluded, and coverage is not comprehensive -- it's for named perils such as accidents and critical illness, as commenter Bob Herz cautions below [I have updated here to make those limitations clearer].  But for a healthy enrollee, plans of this sort may provide coverage up to the bronze out-of-pocket maximum and beyond. [Update, 11/23: Comment by Bob Hertz below is on point -- the policy featured below is for named perils only, e.g., accident, heart attack/stroke/"invasive"cancer, plus limited hospital indemnity.]

Monday, November 20, 2017

The tax bill from hell

Let it not be said that I take forecasts as gospel. But three forecasts about the Senate tax bill from our appointed Congressional arbiters, the Joint Committee on Taxation and the Congressional Budget Office, do form a remarkable trifecta. Over ten years, the bill is forecast to
  • Increase the deficit by $1.4 trillion
  • Raise taxes on every income band up to $50-75,000
  • Uninsure 13 million people.
If they teach legislating in hell, this is what you'd learn to come up with.

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