This article originally appeared on The Conversation. You can read it here.
With an eye on replacing the Affordable Care Act, the Trump administration took one particularly critical action in October 2017. It discontinued cost-sharing reduction subsidy payments to health insurers participating in the ACA marketplaces.
But the response to those cuts was likely not what President Trump expected. State insurance commissioners and insurers used them to make marketplace health plans more affordable.
Premium decreases were large – so large that 4.2 million potential enrollees had the option to purchase a marketplace plan for free in 2019.
These changes made us wonder: Did President Trump's effort to sabotage the Affordable Care Act backfire? I'm a health economist at the University of Pittsburgh. Along with my colleague David Anderson, a policy expert on the Affordable Care Act, we tried to answer that question shortly after the payment cuts. We discovered that more than 200,000 people, using the Healthcare.gov platform in 2019, gained insurance in 37 states due to the Trump administration's actions. This finding may even be more important now as massive unemployment from the coronavirus pandemic leads to huge losses of employer-based insurance coverage – and ultimately more people enrolling in the marketplaces.
Subsidies and silver loading
People who sign up for a plan in the Health Insurance Marketplaces may qualify for two types of subsidies. The first type is the advanced premium tax credit, which reduces the premium paid by the enrollee; lower-income enrollees receive larger premium tax credits. The second type is the cost-sharing reduction subsidy, which decrease deductibles and co-pays.
Premium tax credits may be applied to any marketplace plan, though they're based on silver plan premiums, which cover 70% of an average enrollee's health care expenses. Cost-sharing reduction subsidies can only be applied to silver plans; that means qualifying enrollees in less generous bronze plans and more generous gold plans don't benefit from reduced deductibles and co-pays provided by these subsidies.
When Trump ended those payments, marketplace insurers were suddenly in a bind. They are legally required to provide cost-sharing reduction subsidies to enrollees whether or not the federal government was paying. The expectation: marketplace insurers, forced to make up the lost revenue, would either increase premiums or exit the marketplaces altogether. And Obamacare would implode.
But that's not what happened. Why did the plans become more affordable? Insurers increased only the premiums of their silver plans. That approach – known as silver loading – did two things. First, the cost of silver plan premiums rose drastically. Second, premium tax credits increased along with premiums. So those enrollees receiving premium tax credits saw no increase in the premiums of their silver plans.
At the same time, non-silver plans became cheaper. Many bronze plans, already costing less, became so cheap they were free after applying premium tax credit subsidies. Lower-income enrollees benefited the most.
The silver lining in silver loading
In 2019, 4.2 million enrollees could enter the marketplace for free through a zero-dollar bronze plan, largely due to silver loading. Without those zero-premium plans, our analysis showed more than 200,000 lower-income marketplace enrollees would have gone uninsured.
Another 60,000 would have gained insurance had California and New Jersey eliminated regulations that prohibited zero premium plans — and if Indiana, Mississippi and West Virginia had adopted silver loading. Many more likely got coverage in states not included in our study.
All this is clearly not what the Trump administration had in mind when it cut subsidy payments. Other changes to the marketplaces probably masked some coverage gains that occurred. Notably, cuts in the public outreach for Healthcare.gov, along with the elimination of the individual mandate, decreased enrollment. But the popularity of zero premium plans resulting from silver loading likely stopped much of the damage – and Trump's attempt to destabilize the marketplaces.
Increasing health coverage post-2020
Now states can take advantage of the attractiveness of zero premium plans to increase health coverage through the marketplaces. One way: States requiring marketplace insurers to provide extra benefits – again, like California and New Jersey – can pick up the small tab for those extras. For example, California enrollees pay for abortion coverage through a one-dollar monthly premium surcharge. This is not covered by premium tax credits. By shifting premiums from even one dollar to zero dollars, our estimates indicate enrollment would increase by approximately 13% among those with lower incomes.
Another way: States without silver loading should adopt it. This is not a partisan issue. Conservative states – or at least, GOP-controlled states like Alabama, Wyoming and Florida – have silver-loaded. State governments pay nothing, revenue for insurers is increased, and most critically, lower-income Americans are provided with affordable health insurance. Put simply, there's no downside for states.
The Trump administration is prevented from restricting silver loading through 2021. However, a forthcoming Supreme Court case, Texas v. Azar, may yet repeal the entire ACA. If the court's conservative majority rules in favor of the GOP plaintiffs, they will put affordable health insurance out of reach for the 11.4 million Americans that purchased health insurance in the marketplaces. They will also eliminate Medicaid coverage for an additional 16.9 million Americans.
If the case succeeds, the uninsured rate could easily surpass levels not seen since the height of the Great Recession. And for millions of Americans, access to health insurance – desperately needed, particularly during the COVID-19 pandemic – will be eliminated.
Coleman Drake is Assistant Professor, Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, University of Pittsburgh
David Anderson is Health policy research scientist, Duke University
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Why do some folks use social media but don't engage?
Psychologist says people who never comment on social media share these 5 positive traits
For over 20 years, social media has developed into a staple in many people’s day-to-day lives. Whether it’s to keep in communication with friends and family, following the thoughts of celebrities, or watching cat videos while sipping your morning coffee, there seem to be two types of social media users: commenters and lurkers.
The term “lurker” sounds equally mysterious and insidious, with some social media users writing them off as non-participants at best or voyeurs at worst. However, mindfulness expert Lachlan Brown believes these non-commenters have some very psychologically positive and healthy traits. Let’s take a look at how each one of these traits could be beneficial and see how fruitful lurking might be even though it can drive content creators crazy.
1. Cautious about vulnerability
Consciously or not, making a post online or commenting on one puts you and your words out there. It’s a statement that everyone can see, even if it’s as simple as clicking “like.” Doing so opens yourself up to judgment, with all the good, bad, and potential misinterpretation that comes with it. Non-commenters would rather not open themselves up to that.
These silent users are connected to a concept of self-protection by simply not engaging. By just scrolling past posts or just reading/watching them without commentary, they’re preventing themselves from any downsides of sharing an opinion such as rejection, misunderstanding, or embarrassment. They also have more control on how much of themselves they’re willing to reveal to the general public, and tend to be more open face-to-face or during one-on-one/one-on-few private chats or DMs. This can be seen as a healthy boundary and prevents unnecessary exposure.
Considering many comment sections, especially involving political topics, are meant to stir negative emotional responses to increase engagement, being extra mindful about where, when, and what you comment might not be a bad idea. They might not even take the engagement bait at all. Or if they see a friend of theirs post something vulnerable, they feel more motivated to engage with them personally one-on-one rather than use social media to publicly check in on them.
2. Analytical and reflective mindset
How many times have you gone onto Reddit, YouTube, or any other site and just skimmed past comments that are just different versions of “yes, and,” “no, but,” or “yes, but”? Or the ever insightful, formerly popular comment “First!” in a thread? These silent browsers lean against adding to such noise unless they have some valid and thoughtful contribution (if they bother to comment period).
These non-posters are likely wired on reflective thinking rather than their initial intuition. Not to say that all those who comment aren’t thoughtful, but many tend to react quickly and comment based on their initial feelings rather than absorbing the information, thinking it over, researching or testing their belief, and then posting it. For "lurkers," it could by their very nature to just do all of that and not post it at all, or share their thoughts and findings privately with a friend. All in all, it’s a preference of substance over speed.
3. High sense of self-awareness
Carried over from the first two listed traits, these silent social media users incorporate their concern over their vulnerability and their reflective mindset into digital self-awareness. They know what triggers responses out of them and what causes them to engage in impulsive behavior. It could be that they have engaged with a troll in the past and felt foolish. Or that they just felt sad after a post or got into an unnecessary argument that impacted them offline. By knowing themselves and seeing what’s being discussed, they choose to weigh their words carefully or just not participate at all. It’s a form of self-preservation through restraint.
4. Prefer to observe rather than perform
Some folks treat social media as information, entertainment, or a mix of both, and commenting can feel like they’re yelling at the TV, clapping alone in a movie theater when the credits roll, or yelling “That’s not true!” to a news anchor that will never hear them. But contrary to that, social media is a place where those yells, claps, and accusations can be seen and get a response. By its design, social media is considered by experts and the media as performative, regardless of whether it is positive or negative. Taking all of the previously mentioned traits into account, one can see why they would prefer to “observe the play” rather than get up on the stage of Facebook or X.
On top of that, these non-commenters could be using social media differently than those who choose to fully engage with it. Using this type of navigation, there may be nothing for them to comment about. Some commenters are even vying for this for their mental health. There are articles about how to better curate your social media feeds and manipulate algorithms to create a better social media experience to avoid unnecessary conflict or mentally tiring debate.
If you go on a blocking spree on all of your accounts and just follow the posters that boost you, it could turn your social media into a nice part of your routine as you mainly engage with others face-to-face or privately. In terms of commenting, if your curated Instagram is just following cute dogs and all you have to offer for a comment is “cute dog,” you might just enjoy the picture and then move on with your day rather than join in the noise. These non-commenters aren’t in the show and they’re fine with it.
5. Less motivated by social validation
The last trait that Brown showcases is that social media users who browse without posting tend to be independent from external validation, at least online. Social media is built to grow through feedback loops such as awarding likes, shares, and reposts of your content along with notifications letting you know that a new person follows you or wants to connect. This can lead many people to connect their activity on social media with their sense of self worth, especially with adolescents who are still figuring out their place in the world and have still-developing brains.
Engaging in social media via likes, shares, comments, and posts rewards our brains by having them release dopamine, which makes us feel good and can easily become addictive. For whatever reason, non-commenters don’t rely on social media as a means to gauge their social capital or self worth. This doesn’t make them better than those who do. While some non-commenters could have healthier ways to boost their self worth or release dopamine into their systems, many get that validation from equally unhealthy sources offline. That said, many non-commenters’ silence could be a display of independence and self confidence.
Whether you frequently comment online or don’t, it’s good to understand why you do or don’t. Analyzing your habits can help you determine whether your online engagement is healthy, or needs to be tweaked. With that information, you can then create a healthy social media experience that works for you.