Posts About Private Insurance and Health Insurance Marketplaces

Thirty weeks. That’s how long we - concerned consumers, advocates and stakeholders - sustained a grassroots movement that forced Congressional Republicans to show us their cards before repealing the Affordable Care Act (ACA). Eight weeks. That’s how long it took Paul Ryan and House Republicans to pass a bill that would drastically reshape the American health care system by gutting Medicaid, striping more than 20 million people of their health insurance and dismantling the most important consumer protections in the ACA.

House Republicans might claim victory today, but we know that there’s nothing worth celebrating in a bill that would:

  • Cut Medicaid funding by $839 billion forcing states to raise taxes, lower payments to doctors and take away health coverage from children, seniors and people with disabilities.
  • Give the wealthiest Americans a tax break while throwing at least 24 million low- and moderate-income families off of their health coverage.
  • Allow insurance companies to charge older adults five times more for the same coverage as a young adult.
  • Undermine efforts to address the opioid crisis.
  • Reverses a long- standing commitment to protect low-income children by allowing states to cut benefits, roll back eligibility and deny children comprehensive preventive care needed to stay healthy.
  • Give states permission to get rid of the Essential Health Benefits that cover vital services like maternity care and mental health services.
  • Weaken the ACA’s protections against catastrophic costs for people with employer-sponsored coverage.
  • Gut the protections for people with preexisting conditions by sending us back to the days when insurance companies could charge people with preexisting conditions more for their coverage.

Paul Ryan and President Trump claimed they would repeal the ACA immediately after the inauguration. They didn’t. Next, they were certain it would be on the president’s desk by President’s Day. It wasn’t. Then, it was destined to pass the House on the ACA’s anniversary. It didn’t. Surely, by April recess it would be ready for the Senate. Never happened.

We’ve stopped it before, and we will stop it again. The AHCA is bad for the American people, and it’s time that the U.S. Senate hears this loud and clear.       

As we attempt to stave off the on-again, off-again House Republican repeal efforts, the Trump administration is also taking a quieter “wait for failure” approach that sets the stage for administrative and regulatory actions that could weaken the foundation of the law. One of these foundational provisions is the assurance that marketplace consumers have sufficient access to providers and care – or network adequacy. Therefore, it is more important than ever for states to step up to the plate to protect coverage and access to care for the millions of consumers who rely on marketplace plans.

Network Adequacy Advocacy Matters More than Ever in the Trump Era

Over the past few years, insurers have trended towards narrow network plans – especially those in the marketplace – in order to reduce premium costs for consumers. Although narrow networks are not inherently bad, consumers have little information on the tradeoff between lower premiums and network size, and are put at greater risk for surprise balance billing. Evidence has shown profound impacts of narrow networks on consumers, including inadequate coverage for some chronic health conditions, disruption in care and confusion over provider directories that can result in burdensome balance billing from out-of-network providers.

To a certain extent, consumers on the marketplace are protected by the ACA’s minimum network adequacy standards. However, in its first health care regulatory action, the Trump administration proposes to take a hands-off approach to enforcing network adequacy matters, punting responsibility to the states.

State Activity Around Network Adequacy Is Alive and Well

Fortunately, state activity around network adequacy is still active. During the current legislative session, initiatives to address surprise billing sprang up in several states – including Georgia, New Jersey, Texas, Oregon and Washington. Massachusetts is also working on improving provider directories. Success stories from the last couple years can guide continued advocacy efforts to strengthen state network adequacy protections where federal regulation and enforcement fall short. For instance, advocates played a pivotal role in helping pass laws in Georgia and Maryland that ensure updated and accurate provider directories, and helped put an end to surprise medical billing in California, Florida and New York.

We developed a case study highlighting how leadership from consumer advocacy groups like Georgians for a Healthy Future lead to a legislative win for one of the strongest provider directory laws in the country. One of the key advocacy strategies advocates in Georgia employed was strong engagement with state officials, policymakers and industry stakeholders. This strategy and more can be found in the case study as well as the strategic campaign template we developed specifically for network adequacy advocacy.

As the future of the ACA remains uncertain, insurers are likely to push for more narrow networks in order to deliver competitive low premiums for consumers. Moving forward, it is important that consumer health advocates work closely with policymakers and government officials in their states to shape policies that protect access to affordable and comprehensive coverage.

Over the weekend the National Association of Insurance Commissioners (NAIC) met in Denver, Colorado for their first meeting of 2017. Insurance commissioners and staff, industry representatives and consumer advocates gathered to discuss matters of insurance ranging from property and casualty issues like flood insurance to health insurance and the future of state implementation of the Affordable Care Act (ACA). On the health track, it was clear from the beginning that although attendees might be far from agreement on a range of issues, all would unite around one truth: uncertainty leads to instability, and instability breeds anxiety – especially in the health insurance market.

Chief among the causes of uncertainty – and most certainly the root of a lot of anxiety – is the future of the ACA’s cost-sharing reduction payments, which are the subject of a pending court case and ongoing debate between Congress and the Trump administration. While resolution to this issue remains mostly speculative, insurers worry about pricing products without knowing if they will receive these crucial payments, and regulators and consumer advocates worry this uncertainty will cause carriers to exit the ACA’s marketplaces leaving consumers with few coverage options in 2018.

Several other issues received attention from a range of stakeholders including the need for strong enrollment numbers in 2018 as well as how important enforcement of the individual mandate is to a stable individual market. The consumer representatives to the NAIC not only echoed many of these themes in their comments and presentations during committee meetings but also elevated how attempts to repeal and replace the ACA as well as pending administrative changes would negatively impact consumers.

In a newly released report, the health-focused consumer representatives highlight the ongoing need for consumer protections and stability amidst a time of federal uncertainty. At the meeting, they also stressed to state regulators the importance of finding ways to strengthen the individual market and the need to continue raising concerns to Congress and the administration as they introduce policies that could undermine coverage for consumers in their state. Commissioner Kreidler and the Association of Washington Healthcare Plans are leading the charge this week with a letter to HHS detailing their ideas for market stabilization as well as an important suggestion to explore ways to address affordability concerns for consumers. 

Time will tell if these messages make their way from Denver to D.C. However, when insurers, regulators and consumers all unite around one concern, reasonable minds should find that hard to ignore.

Movie sequels often fail to live up to the original, and Republicans' effort to repeal the ACA falls into this familiar pattern. As bad as the original was (and it was really bad), the sequel was even worse. Not content with taking health insurance away from 24 million people, increasing premiums and out-of-pocket costs for millions more, fundamentally undermining the Medicaid program, and shifting new costs onto states and providers, last week the Trump administration and House leaders continued to try to undermine health care coverage.

Fortunately, the revised proposal was quickly rejected and "pulled from the theatre." Republican lawmakers left town with nothing more to show for their flurry of activity than what appears to be a face-saving effort to get themselves out of the corner they painted themselves into when they attacked the idea of reinsurance as an "insurance industry bailout" by renaming it an "invisible high risk pool".

As much as this was a short-lived effort to bring the bill back to the floor, it contains two critical lessons:

First, if this was not already clear enough, President Trump's commitments on health care are meaningless. The huge gulf between his words and actions has been laid bare for everyone who doesn't have blinders on to see. Despite promising otherwise during the campaign, the original ACHA, which the Trump administration enthusiastically embraced, included a massive cut to Medicaid and even a cut to Medicare. It also undermined the insurance market reforms Trump promised to preserve by allowing states to waive Essential Health Benefits.

The EHB changes already in the AHCA would have undercut the ban on pre-existing condition exclusions by allowing the sale of insurance that excludes coverage for specific benefits or diseases while also exposing people to uncapped out-of-pocket charges. The proposed change in the rating rules would compound this by allowing insurers to charge people more based on their health status. These are devious proposals: while a guaranteed right to purchase would nominally remain, it would be virtually useless since insurers could charge sicker people such high premiums that coverage is priced out of reach.

Fortunately, the new deal collapsed for the same reason as the old one -- it was caught in a squeeze between the demands of the Freedom Caucus, which seeks an even more drastic rollback, and the outrage of an activated populace determined not to allow their health care to be stripped away.

Second, as in the typical horror flick, the monster can return from the dead multiple times. Despite the first failure, the House made a second effort, driven by the Trump administration, which again demanded they put a bill on the floor before April recess.

In a strange way, this abortive effort did us a favor. If anyone was feeling complacent after the collapse of the AHCA, the revived effort should have put people on notice. While the public outcry and GOP infighting have dealt ACA and Medicaid entitlement repeal a setback, the effort is far from dead. We should expect an effort to bring a bill back to the House floor in May, following the debate on spending for the remainder of 2017, which will occur in late April, and prepare accordingly. 

More Dragons on the Road Ahead

The AHCA, in whatever metastasized form, is not the only threat. Even if Republicans in Congress abandon a straight repeal effort, there are several other critical danger points. If, and when, Congress turns its attention to taxes, they are likely to need spending offsets to pay for (wait for it…) tax cuts for the rich. That could lead lawmakers back to looking at Medicaid (or the ACA) as a pay-for. Similarly, an effort to increase military spending might also create a hunt for spending offsets and put Medicaid and/or the ACA back on the chopping block. CHIP refinancing presents another "opportunity" for lawmakers predisposed to undermining the Medicaid financing structure.

Perhaps even more dangerous than these various legislative threats is the damage Congress and the Trump administration could inflict upon the ACA through both harmful actions and "malign neglect.” By creating a climate of uncertainty about the "rules of the road," including whether they will finance cost-sharing reductions and enforce the individual mandate, we can expect more insurance carriers to drop out of the Marketplace. This could leave more counties with only one option - and others with none at all (at least temporarily). Coupled with this uncertainty, and in the absence of action to improve the risk pool or a commitment to a robust enrollment push, we expect many insurers that stay in the Marketplace could seek another year of large rate increases. This could reverse the surge in popular support for the ACA and fuel the "ACA is broken" narrative.

To be very clear, ACA defenders are in a much stronger position after the defeat of the AHCA in the House, and there are plenty of things Congress or the states could do to lower premiums and cost-sharing and expand coverage, if they are so inclined. However, the bottom line is attacks on our health security are not going to subside any time soon. If people want to keep their health care, they are going to have to keep fighting to defend it. In other words, the only way to make sure this zombie stays in the ground is to keep shoveling dirt on the grave.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.

As Republicans struggle to come to agreement on how far to go with ACA repeal and what to put in its place, they are confronted with three interlocking math problems: first, how to make their budget numbers add up; second, how to put together a proposal that can command a majority in both the House and the Senate; and third, how to avoid running afoul of public opinion.

Where to Start?

Let's start with the budget problem. The budget reconciliation instruction only requires Congress to save $2 billion over 10 years, which is barely even rounding error in the context of overall federal health spending. It should be easy, right? But the complications begin immediately with the Republican commitment to repeal the taxes that helped pay for the expanded benefits in the ACA.

How to plug that hole? In the good old days of "repeal and delay" (about a month ago), you simply wiped out all of the ACA spending – including both the tax credits for marketplace coverage and all of the Medicaid expansion funds – and made some vague promises about fixing it later, someday, maybe (not!). But “repeal and delay” ran aground on the other two problems – public opinion, which is strongly against it (only 18 percent support this course), and that constituents have not been shy about making their objections known to their members of Congress.

As a result, there aren't enough votes to pass repeal and delay, so GOP leadership is in need of some kind of replacement plan. That replacement plan has to make good on Republican commitments to preserve access to coverage for people with pre-existing conditions and also has to avoid yanking Medicaid coverage (and funding) away from states. But preserving funding for the Medicaid expansion (even if the federal matching rate phases down over time) and creating a substitute for the ACA tax credits, even at reduced levels, eats up some of your savings, so you are still left with a budget hole.

How big a hole depends on how much of the expansion funding is preserved and how adequate are the new tax credits. The greater the funding preserved, the bigger the budget hole. But proposals to shrink the funding have fueled opposition in states that have benefited from the Medicaid expansion, including 16 states with Republican governors. It would also cause the number of uninsured to spike and do little to allay the public's fear that people with pre-existing conditions will again be locked out of the insurance market. 

A notable feature of the recently leaked draft House repeal-and-replace plan is that it tries to address these problems by providing more funding for the Medicaid expansion and for subsidizing private insurance than did previous proposals, such as the one authored by now-HHS Secretary Tom Price. But because at least a portion of the ACA funding is preserved, a sizable budget hole remains, although we don't know how big because no CBO score has yet been made available.

Fixing a Hole?

How is this hole to be plugged? Again according to the leaked plan, there are two additional revenue sources. One, involves cuts to the core Medicaid program; the other involves changes to the tax exclusion for employer-sponsored insurance, in the sphere of the ACA's "Cadillac tax" that places an excise tax on the most expensive health plans. But both of these revenue sources immediately run into trouble with respect to math problems two and three, above. The "Cadillac tax" is wildly unpopular with both the public and in Congress, across party lines. It is not at all clear that a majority of members will repeal the Cadillac tax only to turn around and support replacing it with something that essentially does the same thing.

On the Medicaid front, the House proposal is to continue to provide states with enhanced matching funds through 2019, but only for those beneficiaries who are currently enrolled. New enrollees would receive only the regular match rate. Starting in 2020, states would receive a capped amount for each beneficiary. The proposal calls for this capped payment to grow at the rate of medical CPI plus one percentage point. It's not clear that this adjustment factor saves a lot of money. If not, it then doesn't do much to fill the budget hole (running into math problem one).

The House Medicaid proposal differs significantly from another leaked proposal, this one developed by a number of Republican governors. In particular, the governors do not want to be forced to assume increased risk for the cost of care for beneficiaries who are jointly eligible for Medicare and Medicaid. (The "dual eligibles" account for over one-third of all Medicaid spending.) At the same time, at least some Republican governors seem perfectly comfortable with substantial Medicaid funding cuts as long as they have increased freedom to cut people off of Medicaid and reduce benefits for those who remain. Of course, this would just shift costs onto providers and beneficiaries. In essence, perhaps in an effort to keep senior citizens, people with disabilities and the providers who serve them on the sidelines, the governors' plan boils down to massive eligibility and benefit cuts for non-disabled adults and children.

Especially if the votes aren't there for tackling the tax-exclusion, then the Medicaid cuts would have to be deeper – much deeper – than what is laid out in either of the leaked draft proposals.  And benefits would likely be even skimpier both for Medicaid beneficiaries and in the private market. An analysis of the replacement plan based on documents released by Speaker Ryan suggests that millions would lose coverage. Such draconian cuts in health coverage would spark even more public outcry and could erode support in both the House and Senate, even though one House leader called a decline in coverage "a good thing" (again, see math problems two and three, above).

All in all, once the "original sin" of repealing the ACA taxes is committed, solving all three "math problems" – i.e., finding a way to make the budget numbers work while keeping a majority of support lined up in both the House and the Senate and not enraging the voters – adds up to a monstrous headache for Speaker Ryan and Leader McConnell. (Sad!)  Perhaps that's why former House Speaker Boehner predicts that the Republican effort to repeal most of the ACA will ultimately fail.

Let's hope he is right.

Transitioning between Medicaid and Marketplace coverage can create health care potholes for consumers, placing them in harm’s way. Transitioning coverage can be further complicated by challenges with health literacy and health insurance literacy – or understanding how to use health information to make informed health care decisions. Case in point: Connecticut.

July 31st marked the expiration of Connecticut’s Transitional Medicaid Assistance (TMA) option for parents whose Medicaid eligibility was reduced in the 2015 state budget. The transitional Medicaid program assists low-income families’ transition from Medicaid over one year. This experience shines light on two key issues facing consumers who transition between Medicaid and Marketplace coverage—understanding how to select and use health insurance and how to fit health insurance into family budget.

Why were these parents on TMA? In 2015, Connecticut reduced the Medicaid eligibility limit of parents from 201 to 155 percent Federal Poverty Level ($31,140 for a family of three). This resulted in “rollbacks” of parents from Medicaid to Marketplace eligibility. Affected were a small number of parents who were eligible for Medicaid through a category other than income, and the remaining parents who had become ineligible for Medicaid based on income and were poised to lose their coverage—about 14,000 parents. Connecticut Voices for Children led a successful advocacy campaign in 2015 to protect this group of parents from being dropped from Medicaid by highlighting parent’s legal access to Transitional Medicaid Assistance (TMA).

So how did it go? About 41 percent of those eligible enrolled in Marketplace plans, leaving over 8,000 uninsured. It also exposed a more complex set of issues.  Lingering problems remain for low-income consumers—health literacy and plan affordability. These are two longstanding pre-ACA factors that influence the success of a consumer-focused health agenda—not just in Connecticut, but in all states.   


Meeting consumers where they are….and sticking with them.

Connecticut’s effort to transition this group of parents from Medicaid to Marketplace coverage reveals the need for ongoing health literacy support. The literacy required to move from a public to private platform for health coverage is significant and can create confusion—even for veteran enrollment assistance workers. Health literacy is beyond understanding basic health insurance terminology—it is empowering consumers to be active partners in their health decision making, resulting in better health. In Connecticut, advocates supported this initial translation work through the development of their own flyers with clear, plain language instructions for low-income consumers. Advocates shared these resources broadly through their networks as a way to augment those of the Marketplace. Access Health CT also directed its energy and resources toward holding enrollment fairs.

While there are other initiatives to support health literacy underway in Connecticut, in some communities, the outreach and literacy work is largely unfunded. Over the long term, health literacy support and the advancement of broader goals around health improvement cannot be attained without dedicated resources.

Connecticut’s experience is an important reminder that if we really want to reach and improve the health of the “hard-to-reach,” we need assets inside communities to communicate an authentic message that inspires folks to enroll—and use their insurance coverage to improve their health. But is that enough? Even when community partners are heavily involved in outreach and enrollment efforts to aid with the transition, challenges still arise with helping consumers switch coverage in ways to allow them to continue accessing needed care.

Rhode Island illustrates that when you roll back the parent population from Medicaid to Marketplace coverage as they did in 2014, it is challenging to enroll consumers in coverage even with robust outreach and enrollment efforts. For parents, Marketplace plans are unfamiliar and have a more limited benefit package that lacks important supports like transportation and access to in-network clinics or providers.  Further, plans and networks are not aligned across platforms. Consumers’ knowledge of cost-sharing structures and risk-based insurance products offered in Marketplaces is limited. Additional support is needed to help consumers integrate private coverage into their household budget and access additional social service programs that address their financial stability beyond health care coverage. Community partners can play a key role in supporting consumers in this process, connecting them to existing networks of social service partners and working to ensure consumers have ongoing access to affordable, robust coverage.

The road ahead.

The long-term success in Connecticut will be measured during the next enrollment period when enrolled parents are asked to renew their Marketplace plans. Access Health CT understands the importance of assessing consumer experience. Over the coming months, it will conduct focus groups to learn what outreach strategies worked well and whether or not parents are utilizing their new plans. This will be important data to share with community partners so that all stakeholders can work together to improve consumer experience and support consumers in their effort to reach optimal health.

We have much work to do in protecting low-income consumers from high-cost coverage. High on the list are designing Marketplace products that meet the unique needs of low-income consumers and continuing to push for investment in outreach and enrollment and ongoing interactions between enrollers and consumers to promote increased health literacy for all.  As health system stakeholders pave the road for healthy communities, advocates can play a key role in ensuring consumers avoid health care potholes and have seamless access to needed services and supports to keep themselves and their families financially secure and healthy over the long run.

The Affordable Care Act’s (ACA) Essential Health Benefits (EHB) completely changed health coverage by requiring health plans on the individual and small-group market to cover the same ten benefits without discrimination. These 10 essential categories of benefits range from general—office visits and hospital care – to more specific population focused requirements, including pediatric care, mental health and substance use disorder services. However, CMS, health plans and state regulators have experienced challenges bringing this robust standard to life resulting in inconsistent implementation across states.

A recent report by the American Occupational Therapy Association (AOTA) found some concerning issues with the coverage of the rehabilitation and habilitation services and devices EHB found in the marketplace. While the report finds that only a minimal percentage of plans were counted as discriminatory, about a third of plans combined their rehabilitation benefit with their habilitation benefit. Combining rehabilitation with habilitation coverage can restrict consumers with disabilities who utilize this benefit and who are inherently at risk of discriminatory benefit design, health treatment and health disparities. CMS has recognized this issue and has required plans to keep the benefit limits of rehabilitation and habilitation services separate starting January 2017.

Beyond the benefits analyzed in the AOTA report, the recently finalized Section 1557 rule gives examples of other benefit design practices that CMS has recognized as discrimination, including arbitrary age limits and placing medications on the highest cost-sharing tiers. Nonetheless, Section 1557 still leaves a lot of room to determine discriminatory benefit design on a case-by-case basis. Therefore, robust monitoring and enforcement of EHB standards (and other relevant federal rules) plays an important protective role to ensure that consumers get the full benefits promised to them.

Making the health coverage feedback loop work better

AOTA’s report can be a handy resource to check states’ marketplace plan coverage of rehabilitation and habilitation services and devices. On a broader level, its findings suggest a need for a more systematic way to monitor benefit design and take corrective action – such as strengthening the feedback loop between consumer assisters, consumers, advocates, state departments of insurance and the Office of Civil Rights (when the issue is based on discrimination); improving the consumer complaints process; and, sharing findings of discriminatory benefit design.

As more and more people gain coverage through the marketplaces, it is critical that they, especially the most prone to discrimination, get the care they need. Fulfilling the promise of the ACA’s 10 EHBs not only ensures that people with health conditions and disabilities have access to coverage, but also that they are no longer excluded from necessary and effective treatments on the basis of their health status. While Section 1557 provides the regulatory framework to protect consumers, consumer advocacy is still a key ingredient to truly make non-discriminatory benefit design a reality.

Amidst the noise of insurance companies deciding whether or not to sell on the Affordable Care Act’s (ACA) marketplaces and proposed rates “doom,” the Commonwealth Fund released a new report that paints a brighter picture of the ACA and its marketplaces. Using insurer’s filings for the 2016 plan year, the report compares ACA-compliant plans on and off the marketplaces to better understand how effectively the marketplaces promote value for consumers.

The good news: Enrollment in marketplace plans continues to increase, and the report suggests plans offered on the marketplace have lower overhead costs and a slower rate of premium increases as compared to those outside of the marketplace.

The less good news: Premium savings on the marketplaces are likely attributable to the rise in enrollment in plans with closed or very narrow networks.

Insurers selling marketplace plans spend 2.5 percent less on administrative costs.

The ACA requires insurers selling ACA-compliant plans to use a certain portion of premium payments for paying medical claims and advancing quality – known as the medical loss ratio (MLR). The remaining funds from premium payments may be allocated to profits and overhead costs (i.e. salaries, marketing and broker and agent commissions). One benefit of the MLR is quite tangible – insurance companies must issue rebate checks to consumers if they fail to comply with the rule. While it is not entirely clear why marketplace plan administrative costs are lower, the report suggests that the marketplace structure itself might be the key, perhaps due to increased competition and sales efficiency.

2016 premium increases were lower for marketplace plans, but at what cost?

Certainly news of keeping premiums at bay is notable. However, as the report indicates, a closer look at the data suggests that the ability of marketplace plans to keep premiums lower is linked to increased enrollment in narrow-network plans. While plans providing out-of-network care both on and off the marketplaces were more expensive and experienced a decrease in enrollment, only the marketplace plans experienced an enrollment spike in narrow or closed network plans (37 percent in 2016). At face value this might indicate that price-sensitive consumers are simply choosing a plan that is the most affordable. However, until state and federal regulators figure out how to systematically protect consumers from falling prey to inaccurate provider directories and surprise out-of-network bills, the tradeoff for lower premiums might prove more costly in the end.


As we near November, the ACA and its marketplaces will undoubtedly be under a microscope. Certain findings in this report should give ACA proponents a little relief – marketplace enrollment continues to grow, threats of adverse selection between the individual markets remain unrealized, and we’re continuing to make progress on realizing the ACA’s goals of increasing coverage and lowering costs.

The ACA is here to stay, and the forecasters of doom are wrong again. That doesn’t mean the law is perfect. It’s time to turn toward building the foundation to make coverage and care more affordable for more people.  

Despite political opposition to the Affordable Care Act at the highest levels of state government, Florida led the nation as the state with the most people gaining new health insurance through the Affordable Care Act. However, for Floridians with coverage, being insured has not completely provided assurance against exorbitant and unfair surprise medical bills. Stories in Florida newspapers and national media have highlighted the problem of “balance billing” for out-of-network services to people who thought they were covered. Fixing this problem for consumers became a focus of both opponents and advocates of the Affordable Care Act, resulting in Florida’s enactment of one of the strongest consumer protections against unfair out-of-network balance bills in the nation. The law exempts consumers from being held responsible for out-of-network rates in emergency and non-emergency situations if they’re denied opportunities to receive treatment by in-network providers.

As a statewide consumer health advocacy organization, Florida CHAIN is advocating to improve health insurance through state regulation and oversight of carriers. CHAIN has a seat, appointed by the Insurance Commissioner, on the Florida Health Insurance Advisory Board (FHIAB). For the past two years the CHAIN representative has recommended to the Board that the Insurance Commissioner propose and support legislation that protects consumers from out-of-network balance billing.

Despite the optics, the political will in Florida this year was strong to address high-health care prices. The Florida House and Governor remain unyielding in opposition to expanding Medicaid in conflict with the Florida Senate, which seeks to cover the expansion population with a waiver approach. This intra-legislature disagreement led to myriad health care-related bills in 2016 designed by the House in a charade that lowering costs, mostly through deregulation, would fix the health care access problem for more than three million uninsured Floridians. The bills to prevent out-of-network balance billing were a part of the pretense.

We took advantage of the unique political climate that positioned consumer advocates alongside our anti-ACA ‘surprise bedfellows’ in support of protections from unfair surprise medical bills. Using our proposal to the FHIAB, the Insurance Commissioner recommended legislation that prohibited balance billing and helped increase our visibility with other state agencies. When the Florida Insurance Consumer Advocate (ICA) convened a Balance Billing Forum, she invited CHAIN to present the consumer perspective along with industry speakers.

As a consumer advocacy organization, we stood firm on our goal to hold consumers harmless when they have no opportunity to choose an in-network provider. Our one-page brief for stakeholder groups and legislators highlighted that the consumer should not be party to any dispute resolution process. Despite a wide chasm in the design and definitions of a payment resolution process between providers and payers with no middle ground in sight, we successfully advocated for a “clean bill” that only addressed the consumer protections.

Our allies at Consumers Union worked to mobilize a groundswell of email and phone action from Florida constituents urging their legislators to “pass a bill – clean.” State media reported on the bills and the advocacy by highlighting consumer stories we referred to them as the bills made their way to the finish line.

Advocating through our seat on the state advisory board, working with close allies and key stakeholders, and taking advantage of the media’s interest in the issue helped move this legislation from a bill into a law that will protect 11.5 million Floridians with private insurance from the financial distress of unfair surprise medical bills.

Laura Brennaman PhD RN, Policy and Research Director at Florida CHAIN

Recently, UnitedHealth Group signaled they will be exiting Affordable Care Act (ACA) marketplaces in several states following losses they sustained because too many sick people are buying their plans and using their insurance.

UnitedHealth seems to have learned what many people at the bottom of the health care delivery system have known all along: Those who haven’t had insurance often need it the most. UnitedHealth is in good company, though, as many players selling plans in the marketplace seem to have underestimated the pent-up demand for medical services. Thus, they priced themselves a little too competitively, while also ending up with significantly sicker enrollees than they had anticipated. The attitude coming from UnitedHealth seems to be to cut their losses (insured people) and maybe come back in when the market’s more palatable and they have plans that stand to make them more revenue.

UnitedHealth seems to be a victim of the law’s success. It turns out that the people who had been locked out of access to affordable insurance prior to implementation of the ACA, perhaps due to a pre-existing medical condition, lack of steady income or working for an employer who doesn’t offer it, haven’t been getting the regular (now free, thanks to the ACA) preventive maintenance their bodies need. As a result, they need a little – or in some cases, a lot – more of a tune-up now that they can actually afford to purchase and use insurance. 

These sick Americans have posed a problem for a company like UnitedHealth, the nation’s largest health insurer, who cited losses in the markets of $720 million last year, or 0.46 percent of their annual revenue.

At this point, it feels like UnitedHealth is trying to signal three horn blasts from the Wall. Unfortunately, the threat they face is not an undead army threatening peace throughout the world, but actually a chronically ill, severely underserved population whose threat seems to mainly consist of making a very minor dent in United’s $157.1 billion in 2015 revenue

I can only imagine that insurers like United were salivating at the pool of 12.7 million new potential customers who purchased health insurance through marketplaces. After all, economic theory tends to hold that a bunch of new customers = $$$$$$. And while I’m not sure that’s exactly how it’s spelled out in “The Wealth of Nations,” it does hold that this great new economic market created by the ACA is taking its time in getting settled as insurers get accustomed to who marketplace consumers are, what they need and how companies can best provide it while still making significant amounts of money.

It has certainly not been smooth sailing, but it turns out the ACA isn’t going anywhere. The positive things it has done – covering people with pre-existing conditions, allowing young people to stay on their parents’ plans longer and capping out-of-pocket expenses – are too darn common-sensical and liked(!) for even critics of the law to propose abolishing.

And while debating topics like the Congressional undermining of “risk corridor adjustment” payments speaks to the wonk in all of us, it speaks to the practicality of none – especially the thousands of affected patients and their families impacted by UnitedHealth leaving the market who may, once again, be looking for good insurance. 

Martin Luther King, Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Thankfully, he was a little more optimistic in saying, “The arc of the moral universe is long, but it bends towards justice.” I hope that the arc of history is long enough for UnitedHealth to regret not offering insurance to hardworking families.

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