Must-Read: Richard Mayhew: County Level Inequities in the ACA

Must-Read: Richard Mayhew: County Level Inequities in the ACA: “Health wonks like to say that the ACA is not a single program but fifty-one programs… works well in some states (California) and poorly in others (Arizona) and muddles through in most…

…This is… good… but… incomplete….  The ACA as experienced has some state level components… Medicaid… risk pool/risk adjustment… but the Exchanges are… at the zip code and county level…. Tennessee is an extreme example…. Perry County… [has] an extreme Silver gap at $97.62… a single carrier, Blue Cross and Blue Shield of Tennessee that offers two Silver plans. Roane County… a single carrier… Humana. However Humana is offering only a single Silver plan…. There is no chance of a good deal for a Silver below benchmark….

In Perry county, a 40 year old earning $25,000 a year, which is slightly more than 200% Federal Poverty Level (FPL), saves $100 a month or roughly 5% of their income because of the Silver Gap compared to the same individual in Roane County…. From a risk pool perspective, Perry County should be extremely healthy. The subsidies are rich enough that almost everyone can afford a plan even if it is a minimal Bronze plan. Roane County will see good uptake among people who earn under 150% FPL and decent uptake to 200% FPL. Above those income levels, there will be significant adverse selection as the deals just aren’t too good for healthy people, so the population will be fairly sick and expensive…. People in Perry County who are getting subsidized will see the ACA working really well. They have good, cheap health insurance.  However their cousins across the state are getting a raw deal… especially… as we move up the income scale…