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Payers’ biggest concerns for 2018, health insurance exchange participation plans, and how offerings could change.
Unresolved questions regarding the fate of the ACA and other policy issues are hitting managed care organizations hard as they attempt to plan for 2018. In late September, MCOs received a little more clarity when the Graham-Cassidy bill, a last-ditch attempt to repeal and replace Obamacare, failed to proceed to a vote.
Yet, policy experts say more attempts to chip away at the ACA will be made in 2018, even if a full repeal and replace doesn’t come to fruition.
Donna Zimmerman, senior vice president, government and community relations for HealthPartners, says the integrated payer/provider based in Bloomington, Minnesota is “working within the market rules that are part of the ACA” while federal policy discussions continue. “There’s a lot of uncertainty for the longer run, but for 2018 we had to move forward with the facts we have,” she says.
Marti Lolli, MBA, chief marketing officer, commercial markets, Priority Health, a health plan based in Grand Rapids, Michigan, says the company has a long history of being agile with changes to the healthcare market. “We continuously plan for different scenarios, so we’re ready to take advantage of opportunities to offer more affordable healthcare access to more people,” she says.
Alexis Miller, senior vice president, individual and small group business, Highmark Blue Cross Blue Shield in Pittsburgh, says the health plan is working closely with national trade associations and is routinely talking to elected officials from its core markets of Pennsylvania, Delaware, and West Virginia to advocate for sustainable healthcare reform. “There is a tremendous amount of uncertainty in the marketplace right now, which gives us great pause,” she says. “We need stability in the market with, at minimum, a continued commitment to uphold the intent of cost-share reduction subsidies and the individual mandate in 2018.”
L.A. Care Health Plan, based in Los Angeles, has led the formation of a coalition of nine other Medicaid plans to voice deep concerns to the Senate regarding proposed changes to the federal program. “We are advocating for meaningful Medicaid changes that focus on long-term reforms to improve care and reduce costs,” says John Baackes, chief executive officer.
A blanket ACA repeal without a replacement is among the greatest concerns of Ken Janda, JD, president and CEO, Community Health Choice, Inc., a managed care organization based in Houston offering Children's Medicaid, CHIP programs, and plans through the health insurance marketplace.
“This would be devastating to Americans and hurtful to our healthcare system, as a blanket repeal of the ACA would not only hurt the millions of Americans in the individual market, but it would also change the benefits and protections currently enjoyed under all plans, including employer-sponsored coverage,” he says.
Another primary concern is whether the Trump Administration will withhold funding for cost-sharing reduction payments, says Janda. The payments to insurers were authorized in September, but remain uncertain for future months.
“Without continued reimbursement, monthly premiums could rise across the board and nonprofit insurers like us could take a devastating loss-jeopardizing our future involvement in the individual marketplace. I continue to hope for bipartisan commonsense fixes like the legislation Senators Alexander and Murray have pursued.”
Janda says the lack of enforcement regarding the individual mandate is troubling, as is the fact that the Trump Administration appears to not support open enrollment for marketplace plans. “With the time period for enrollment cut in half, the advertising budget slashed by 90%, and fewer navigators this year, many Americans may not even know they can sign up for health insurance via the marketplace,” he says. “Additionally, the Trump administration has placed doubt and uncertainty in consumers’ minds about whether the individual mandate is being enforced,” he says. “A mechanism to encourage enrollment must exist to incentivize a healthy and robust risk pool-whether via the individual mandate, a premium surcharge, or a waiting period.”
As uncertainties about the future of healthcare legislation mount, Baackes is most concerned about the potential overhaul of the Medicaid financing structure. “For the first time in Medicaid’s history, the federal government is proposing to cap its share of payments to states, not only for those who gained coverage through Medicaid expansion under the ACA, but also for children, mothers, the developmentally disabled, and elderly in nursing homes-all of which have limited incomes and have been eligible since the program began in 1965,” he says. “We cannot ignore that these proposed changes would severely impact the most vulnerable populations.”
Lolli is working with the state of Michigan on creative solutions to keep insurance premiums affordable for the long term. “It’s a balancing act that requires smart and careful management of health risk,” she says.
Cost-sharing reduction payments are also critical to keeping health coverage affordable and accessible for low- and moderate-income individuals and families, she says. “Without these subsidies, it’s difficult for health plans to stay competitive in the individual market.”
Miller says Highmark Blue Cross Blue Shield has long advocated for policies to stabilize the individual market, including insurance parameters that encourage the alignment of premium and risk, distinct funding for individuals with high medical costs, appropriate subsidies to support affordability, and strong incentives to obtain and maintain health insurance coverage. “We are urging leaders in Washington to continue to focus on these and other policies that moderate premiums and promote choice and competition in a stable, private insurance market,” she says.
For Zimmerman, the initial focus was on working to obtain federal approval for a reinsurance program. “Minnesota lawmakers voted to approve this program earlier this year; it was critical for helping to ensure the most affordable rates possible,” she says.
Like others, in the longer term, Zimmerman supports the continuation of cost-sharing reduction payments and policies that keep people in the market. “First and foremost, we believe that a private market is preferable and possible, and having everyone in is ideal,” she says. “We prefer a requirement that people must have insurance so we can keep the pool as large as possible.”
At this point, despite the uncertainties, Baackes says L.A. Care Health Plan is committed to participating in California’s exchange marketplace. “This is an extension of our mission to serve people who transition from Medicaid to our commercial plan, as it ensures the continuity of their care-allowing them to keep seeing the doctors they have come to know and trust,” he says.
Janda says the ACA remains the law of land and Community Health Choice cannot act on hypotheticals regarding possible regulatory changes that may never come to fruition; therefore, the organization plans to continue participating in the exchanges.
Lolli reports that Priority Health will also remain in the exchanges. “We’ve worked hard to develop health plans with narrow network options designed to lower costs with a focus on our members’ needs-consumers are asking for more control over their healthcare costs; narrow networks offer 20% lower rates on average,” she says.
Rhonda Mims, senior vice president and chief public affairs officer, WellCare Health Plans, Inc., based in Tampa, Florida, on the other hand, reports that the provider of Medicare and Medicaid managed care plans will not be in the exchange, as it ceased involvement in state-based exchanges in Kentucky and New York on December 31, 2016. “We are focused on providing quality, cost-effective healthcare solutions for our Medicaid and Medicare Advantage beneficiaries across the country,” she says.
As rising costs continue to impact members, Janda says Community Health Choice is developing plans that are less costly to consumers without sacrificing access to preventative care and other highly valued services. Two examples are developing a health savings account-compatible high-deductible health plan and encouraging use of generic drugs.
Priority Health will continue to offer individual plans to families who want better control of their healthcare spending. “Our individual health plans deliver affordable access to the services people use most, so they pay less for routine care and still have peace of mind knowing they’re protected if something catastrophic happens,” Lolli says. “We have also developed tools such as a cost estimator that empowers members to make informed healthcare decisions with their family and budget in mind.”
Highmark Blue Cross Blue Shield continues to launch integrated care models and clinical programs designed to engage with the complex clinical and social needs of its ACA members. “We have also developed new ACA networks for some of our markets that improve quality and better manage costs for ACA members,” Miller says. “We will be offering members in certain regions either a health maintenance organization (HMO) or an exclusive provider organization (EPO) plan, with multiple options for deductibles, cost sharing, and out-of-pocket maximums, as well as plans designed for use with tax-advantaged health savings accounts.”
WellCare recently attained an accountable care organization line of business when it acquired Universal American. “As we explore this offering, we expect this model to expand our network of providers and complement WellCare’s Medicare Advantage business,” Mims says.
HealthPartners is offering small employer products in the market for 2018. “Affordability remains an issue for the small employer market,” Zimmerman says. “The Minnesota reinsurance program does not apply to the small employer market. We are committed to ensuring that the small group market remains stable and viable.”
The bottom line, says Miller, is that whether or not Washington leaders drive for immediate action to address the way Americans pay for healthcare, Congress must address the longer-term issues of medical care cost drivers and work toward high-quality, value-based care.
Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.