Category Archives: ACA

New spending from Build Back Better would outweigh cuts in DSH payments, finds Urban Institute

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https://www.healthcarefinancenews.com/news/new-spending-build-back-better-would-outweigh-cuts-dsh-payments-finds-urban-institute

Earlier this year, President Joe Biden proposed a framework called Build Back Better that would, among other things, expand Medicaid. If the BBB plan is implemented, a new Urban Institute analysis predicts that federal health subsidies would outweigh a projected increase in hospital spending by about 3-to-1.

The current draft of the Build Back Better Act (BBBA) includes provisions that would extend enhanced ACA subsidies to people below 100% of the federal poverty limit in the 12 states that have not expanded Medicaid. These provisions are intended to extend health insurance coverage to millions of people and to lower the cost of healthcare for many families.

Hospitals in non-expansion states would see more than $6.8 billion in new spending as a result of the BBBA’s closing of the Medicaid gap, which is about 15 times larger than the expected disproportionate share hospital allotment cuts of $444 million, the findings showed.

Overall, new federal health subsidies disbursed to non-expansion states for people in the coverage gap would be $19.6 billion. Florida, Texas, Georgia and North Carolina hospitals are among those that would have the most substantial increases in spending because of added coverage, the analysis found.

The Urban Institute also determined that the benefits of the changes would not necessarily go to the same hospitals that would sustain reductions in DSH allotments. If true, that means some hospitals may be worse off with the proposed changes.

Still, though only a portion of the total increased federal spending under the BBBA provisions would flow to hospitals, the researcher concludes that in the years during which additional subsidies would be provided, hospitals would be substantially better off overall than they are under current law, even after proposed Medicaid DSH cuts are taken into account.

WHAT’S THE IMPACT?

The effects of the new federal health subsidies would vary across states, largely because of differences in state populations, the Urban Institute showed. 

Florida hospitals, for instance, are projected to gain $1.7 billion in new spending because of added coverage, and to lose $33 million in DSH allotments, resulting in a net gain of $1.6 billion. Texas hospitals could gain $1.6 billion in new spending and lose $157 million in DSH allotments, gaining almost $1.5 billion. Georgia and North Carolina hospitals would also have substantial increases in spending because of added coverage that would exceed their reduced Medicaid DSH allotments by more than $750 million and almost $900 million, respectively. 

Meanwhile, because Wisconsin already covers adults up to the FPL under Medicaid, it would have a small net loss in payments to hospitals for the Medicaid gap population, but a net gain overall.

Hospitals serving a disproportionately high share of undocumented people would see less benefit from reform than other hospitals, and could see substantial DSH cuts. At the same time, the overall decline in the number of uninsured people could save spending on uncompensated care for the uninsured, data showed. If states and localities save on uncompensated care, the savings could be distributed to hospitals most in need after DSH cuts.

THE LARGER TREND

The BBBA’s increased subsidies are set to end after 2025, whereas the bill’s Medicaid DSH cuts would be permanent. More broadly, nationwide Medicaid DSH cuts specified under the Affordable Care Act have been repeatedly delayed, but they are now due to be implemented in fiscal year 2024. At $8 billion in that year, those cuts are much larger than the DSH cuts specified in the BBBA. 

Unless Congress intervenes, UI said, these ACA-related DSH reductions would be in addition to the DSH cuts in the BBBA for the 12 non-expansion states. 

The BBBA was slated to go to a vote the week of November 15, but that timetable may shift. According to CNN, the Congressional Budget office has yet to give a final cost estimate score for the bill; a group of moderate Democrats is waiting to see the CBO score before deciding whether to vote for the bill.

The Association Between Continuity of Marketplace Coverage During Pregnancy and Receipt of Prenatal Care

Posted on by • Posted in ACA, Health Insurance Coverage Adequacy, Health Policy, Open Enrollment, Pregnancy, Prenatal Care, Qualifying Life Event, Womens Health • Leave a comment
The Association Between Continuity of Marketplace Coverage During Pregnancy and Receipt of Prenatal Care
The Association Between Continuity of Marketplace Coverage During Pregnancy and Receipt of Prenatal Care | The Incidental Economist

Pregnancy is a significant life event, one that typically leads to substantially more interaction with the health care system than average. In the United States (US), pregnant people usually have about one health care visit per month of pregnancy, during which they receive a myriad of services. However, access to high quality prenatal care — and enough of it — is often limited by one’s health insurance coverage.

When the Affordable Care Act was enacted, it established the individual Marketplaces from which those who are ineligible for Medicaid, Medicare, and/or employer-sponsored insurance can purchase coverage. However, pregnancy is not considered a qualifying life event, so an individual cannot just sign up for coverage once they find out they’re pregnant; they must wait until the next open enrollment period or the birth of their child, whichever comes first. Thus, they may be stuck without coverage during pregnancy. This can have a significant impact on access to appropriate prenatal care.

New Research

A recent study in Health Affairs looked at Marketplace enrollment patterns for pregnant people and the impact of Marketplace insurance coverage on their health and care utilization.

The authors are Sarah Gordon and Melissa Garrido from Boston University School of Public Health (BUSPH) Health, Law, Policy, and Management Department (HLPM) and VA Boston Healthcare System; Charlotte Alger from BUSPH HLPM; and Eugene Declercq from BUSPH Community Health Sciences Department.

The authors used data from the Pregnancy Risk Surveillance and Monitoring System (PRAMS) from 2016 to 2018. Developed by the Centers for Disease Control and Prevention, PRAMS is a self-reported survey within 40 states and New York City and is representative of 83 percent of all US births. State health departments pull a representative sample of recent births from birth certificate registries and reach out via mail and telephone to the selected mothers. The survey asks respondents about health status and behaviors, health care use, and insurance coverage.

With these data, they studied two questions. First, they assessed how likely pregnant people were to be enrolled in Marketplace insurance coverage preconception, during pregnancy, and/or postpartum. Sample size for this question was 6491 and the authors used simple descriptive analysis techniques.

Second, they studied how Marketplace enrollment impacted individuals’ receipt of prenatal care, such as the number of prenatal visits, receipt of care within the first trimester, and receipt of specific health care services like flu shots and screenings for intimate partner violence and depression. The sample size for this question was 3443, limited to individuals who reported Marketplace coverage during pregnancy. The authors used logistic regression models and inverse probability of treatment weights to conduct these analyses.

Findings

For enrollment, the authors found that about one third of respondents had continual Marketplace coverage, from preconception to postpartum. Of those who were only enrolled in the Marketplace preconception, over 70 percent reported Medicaid coverage during pregnancy. Of those who were only enrolled in the Marketplace postpartum, almost 50 percent reported Medicaid coverage and one third reported employer-sponsored insurance coverage during pregnancy.

For impact of enrollment during pregnancy, the authors compared those with continuous coverage (preconception to postpartum) to those who only enrolled in the Marketplace during pregnancy. Those with continuous Marketplace coverage were more likely to have “adequate” or “more than adequate” prenatal care use. (The authors defined these classifications using the Adequacy of Prenatal Care Utilization Index which measures timing and quantity of care.) Those with continuous coverage were also more likely to initiate prenatal care in the first trimester, though over 80 percent of respondents in both groups did so. The authors did not find any significant differences in the likelihood of receipt of particular prenatal services, such as flu shots or social/mental health screenings.

Limitations

There were several limitations to this study due to the nature of the PRAMS data set. For example, PRAMS is self-reported, subject to both recall bias and response bias. Plus, the survey is not conducted in all states and, thus, assumptions must be made about generalizability. Lastly, PRAMS simply includes a finite set of questions; this is certainly understandable but does limit researchers’ analyses.

Discussion

With the connection between insurance coverage and access to care clear, several notable policy questions arise from this study. Classifying pregnancy as a qualifying life event is perhaps the most obvious. As mentioned previously, pregnancy is not a qualifying life event, though the birth of a child is. (Only two states have implemented policies to the contrary.) Allowing an individual to sign up for health insurance coverage once pregnant, rather than waiting until birth or the next open enrollment period, could improve access to prenatal care and even improve maternal and child health outcomes.

Another related policy implication is determining what type of insurance is ideal for pregnant individuals. The authors found that individuals without Marketplace coverage often have other types of coverage, at least temporarily. What type of insurance is best or most cost-effective for pregnant people — and the benefits of coverage continuity regardless of type — could be studied further.

The study did not touch on the quality of prenatal care but that is also worth discussion. In the US, pregnant people tend to receive far more prenatal care than other countries but that doesn’t mean the quality is better, nor do maternal health outcomes suggest that’s true. In fact, the US’ maternal health outcomes are some of the worst in the industrial world.

Pregnancy is full of changes, expenses, and challenges. Determining how Marketplace insurance coverage — which has been around for a decade — access to care, and maternal and child health outcomes all interact from preconception to postpartum warrants more study.

If Economists Chose the Health Care System

Posted on by • Posted in ACA, Adverse Selection, Economist, Employer-Based Health Insurance, Health Insurance Industry, Health Policy, High Drug Prices, Medicaid, Medicaid Block Grants, Medicaid Work Requirements, Medical Loss Ratio (MLR), Medicare, Medicare Age Eligibility, Medicare Based on Income, Pharmaceutical Industry, Preexisting Conditions, Sin Tax, Social Determinants of Health, Voucher Based Health Insurance System • Leave a comment
If Economists Chose the Health Care System
If Economists Chose the Health Care System - YouTube

Health economists study the economic determinants of health. They also analyze how health care resources are utilized and allocated, and how health care policies and quality of care can be improved. In this episode, we discuss what exactly a healthcare system would look like if these professionals were calling all the shots.

Drug pricing, most Medicare expansions are out of Biden’s economic bill

Posted on by • Posted in ACA, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, High Drug Prices, Medicaid, Medicaid Expansion, Medicare, Medicare Drug Price Negotiation, Medicare Expansion • Leave a comment

https://www.washingtonpost.com/politics/2021/10/28/drug-pricing-most-medicare-expansions-are-out-biden-economic-bill/

The FDA could greenlight a vaccine for kids as soon as Friday and more workers now have vaccine mandates. But first: 

Democrats are ditching progressives’ health priorities in their economic bill

The White House says Democrats have clinched a deal. 

The $1.75 trillion framework for Biden’s massive social spending bill temporarily funds several of the party’s health care ambitions. But it includes big misses on health care, such as significantly paring back progressives’ goal of adding new benefits to Medicare — instead including only coverage for hearing services — and excluding Democrats’ plan aimed at lowering the sky-high prices of prescription drugs. 

Will all Democrats get on board? Senior administration officials projected confidence that they would, and characterized the framework as the biggest expansion of health care in a decade. Yet, it includes major defeats for the party’s more liberal members, who have been reticent to draw red lines on what they would or wouldn’t support.

It’s a critical day. President Biden is heading to huddle privately with House Democrats this morning. House Speaker Nancy Pelosi announced plans for the chamber’s Rules Committee to hold a hearing, although legislative text hasn’t yet been released. And before leaving for his trip overseas, Biden will speak publicly about the path forward for his legislative agenda, per a White House official. 

Early this morning, senior administration officials spoke to reporters on the condition of anonymity to detail the framework. 

What’s in and what’s out

Prescription drug negotiation: OUT

Democrats campaigned on reducing prices of prescription drugs — and letting Medicare directly force lower prices is a key plank of that effort. But the party couldn’t overcome fierce divisions amid a lobbying storm.

  •  “At the end of the day, there are not yet enough votes to get something across the line to deliver what the American people need and expect on prescription drugs,” a senior administration official said. “We’re going to keep fighting to get this done and deliver lower drug prices.”

The House’s signature drug proposal faced resistance from a trio of House moderates who instead backed more limited drug negotiation. On the other side of the Capitol, Sen. Kyrsten Sinema had raised objections and other senators had concerns with a bill as sweeping as the one the House passed in 2019. The industry’s main trade group has been working furiously to keep the proposal out of Democrats’ economic package.

  • Of note: The framework includes fully repealing a Trump-era ban on prescription drug rebates as a way to offset the cost of the package. The administration anticipates that would save $145 billion.

Medicare expansion: mostly OUT

Sen. Bernie Sanders (I-Vt.) and the House Congressional Progressive Caucus have been bullish on two main health policies: allowing the federal government to negotiate drug prices, and using those savings to expand Medicare to cover dental, vision and hearing.

The framework only creates a new Medicare benefit for hearing. 

  • Rep. Pramila Jayapal (D-Wash.), the chair of the CPC, has repeatedly said her 96 members aren’t drawing red lines. But here’s how she characterized the CPC’s thoughts yesterday: “For a lot of members, it’s like what are we doing for seniors? How do we make sure we get some benefits for seniors in here?”
  • Sanders is the person to watch here. He’s long championed expanding Medicare, and has already come down on his ambitions for a wide-ranging $6 trillion bill.

Closing the Medicaid coverage gap: IN 

The framework extends coverage for 2.2 million adults in the dozen, mostly GOP-led states that have refused Obamacare’s Medicaid expansion. They’ll get tax credits to receive premium-free health coverage on the Obamacare health exchanges through 2025. 

Earlier this week, Manchin raised concerns with allowing the federal government to pay for health coverage for 2.2 million adults in the dozen, mostly GOP-led states refusing Obamacare’s Medicaid expansion. His own colleagues — such as Georgia Sens. Raphael Warnock and Jon Ossoff — lobbied heavily to change his mind.

Obamacare subsidies: IN

The framework would extend more generous financial help to Obamacare consumers through 2025, building on an effort that began in Biden’s coronavirus relief bill passed this spring. 

In-home care: IN 

Biden has pushed for a $400 billion investment in home care for seniors and the disabled. It’s been clear for weeks that his ask will be significantly pared back. Administration officials said funding for home and community-based services is included in the framework, but didn’t detail how much money would go toward the program helping keep seniors and those with disabilities out of institutional settings.   

Democrats’ risky health care play

Posted on by • Posted in ACA, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, High Drug Prices, Medicaid, Medicaid Expansion, Medicare, Medicare Drug Price Negotiation, Medicare Expansion • Leave a comment

https://www.axios.com/democrats-health-care-coverage-medicaid-affordable-care-act-4758a48b-fc65-4ca4-8c1e-888c882e759f.html

Some Democrats say it’s possible that pieces of their social policy agenda end up being enacted or extended for only a year or two, including major Affordable Care Act and Medicaid provisions.

Why it matters: Limited terms may be the only way Democrats can strike a deal within their budget. But the risk is that Republicans will be able to undo these temporary programs if they’re able to regain control of Congress through next year’s midterms.

  • There also aren’t many policy areas that Republicans are less excited about than the ACA and Medicaid expansion.

What they’re saying: Extending programs for only a year or two is a “possibility,” Senate Majority Whip Dick Durbin (D-Ill.) told Axios.

  • Extending enhanced ACA subsidies and closing the Medicaid coverage gap were measures that “we wanted … to be permanent,” said Sen. Ben Cardin D-Md.). “Clearly there’s a lot of pressure to get as much in as we can, [which] means shorter periods.”
  • “I think all of the programs are being considered for shorter periods. There are some that are of greater importance to get as long as possible,” Cardin added. He said it’s also possible that an extension of the child tax credit would also last only a year.

The big picture: Political, budgetary and practical factors are all at play as Democrats try to figure out what’s in and what’s out of their reconciliation bill.

  • But one giant consideration when it comes to the health care provisions — particularly the ACA and Medicaid ones — is that Republicans may not feel compelled to extend these programs should they gain power.
  • “I expect Republicans would be glad to take back the mantle of the child tax credit but Democrats should not fool themselves into thinking Republicans will feel any real pressure to extend these health care policies,” said Brendan Buck, a longtime aide to former Republican House Speaker Paul Ryan.

The other side: Republicans may encounter political pressures similar to the ones they did in 2017, when they struggled — and ultimately failed — to repeal and replace the ACA.

  • Declining to extend Democrat-enacted coverage policies in the next couple of years would be somewhat similar, in that the result would be millions of low-income people would lose their health coverage or see its cost skyrocket.
  • Also, most of the states that haven’t expanded Medicaid are ruby-red.
  • “Remember what happened with the Affordable Care Act — they said that they didn’t like these things, but then they couldn’t repeal them because they didn’t have another option,” said Sen. Tina Smith, (D-Minn.)

Yes, but: But inaction is different from voting to end a benefit, Buck said.

  • Some Democrats are skeptical, too.
  • “The modern Republican party isn’t for much other than the destruction of government. So the idea that Republicans are going to want to hold onto programs even if they benefit the middle class runs a bit contrary to the recent history of the party,” said Sen. Chris Murphy (D-Conn.).

The bottom line: At this point, Democrats will take any party-wide agreement they can get. And temporary health coverage expansions may have their upside.

  • “It’s an easy way to slim costs,” said one Democratic strategist, adding that it allows both Sen. Bernie Sanders (I-Vt.) and Sen. Joe Manchin (D-W.Va.) to claim victory.
  • “If I’m [Majority Leader] Chuck Schumer, I do it for a year and make Republicans vote on it in October,” right before the midterm elections, the strategist added.

Democrats’ prescription drug collapse

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https://www.axios.com/democrats-prescription-drug-congress-collapse-692c3cfd-036f-4024-a1ca-150b9055d84c.html?stream=health-care&utm_source=alert&utm_medium=email&utm_campaign=alerts_healthcare

After campaigning on health care one election cycle after another, Democrats have put forward a social policy framework that does nothing to lower prescription drug prices, expands Medicare benefits to only include hearing coverage, and temporarily builds on the Affordable Care Act.

Why it matters: The framework may be the best the party can do with razor-thin vote margins in Congress. But some health care advocates say it’s unacceptable — and voters may not be thrilled either.

The big picture: Democrats can certainly claim some health care victories.

  • The framework would extend the enhanced ACA subsidies that the party enacted earlier this year, although only through 2025. This has been plenty of moderate Democrats’ primary health care goal.
  • The framework also makes ACA subsidies available to people in the Medicaid coverage gap in states that have chosen not to expand, another major priority for many Democrats. This would also last through 2025.

The other side: Progressives have a much tougher pill to swallow. And when it comes to drug prices, nearly the entire party has campaigned on lowering them.

  • Progressives, championed by Sen. Bernie Sanders, have been pushing for Medicare to cover dental and vision benefits, as well as hearing. And that’s a far cry from what they actually want, which is Medicare to be offered to more or all Americans.
  • Lowering drug costs and expanding Medicare benefits are also very popular with voters — particularly seniors, who vote in large numbers.

What they’re saying: “We are outraged that the initial framework does not lower prescription drug prices,” said AARP in a statement. “Americans are fed up with promises that have not been kept.”

  • “The president and Democratic leaders are on the record fiercely supporting drug price negotiations and Medicare dental benefits. These are wildly popular benefits that almost all families across this nation want. Unfortunately, this small number of intransigent Democrats, who are schilling for lobbyists and drug companies, are standing in the way,” Families USA wrote in a statement.

What we’re watching: What’s out today is just a framework, and some key Democrats are vowing to keep fighting.

  • Energy and Commerce Chairman Frank Pallone and Senate Finance Chairman Ron Wyden both told reporters that drug prices are still being discussed.
  • And plenty of other Democrats, especially those in vulnerable seats, may be very sensitive to the prospect of failing to follow through on the party’s commitment.

Democrats’ moral Medicaid dilemma

Posted on by • Posted in ACA, Access, Access & Quality of Healthcare, Dilemma, Health Equity, Health Inequity, Health Insurance Coverage Adequacy, Health Policy, Medicaid, Medicaid Expansion, Medicare, Medicare Expansion • Leave a comment
https://www.axios.com/democrats-medicaid-medicare-dilemma-68bfff7e-48f9-41ff-8664-a923d7f5280b.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Democrats’ push to extend health coverage to millions of very low-income people in red states has a lot working against it: It’s expensive, it’s complicated, it may invite legal challenges, and few national Democrats stand to gain politically from it.

Yes, but: The policy is being framed as a test not only of Democrats’ commitment to universal health coverage, but also their commitment to racial equity.

The big picture: Democrats are still figuring out how much money they have to spend in their massive social policy legislation, but there’s already intense competition among policies — including between health care measures.

  • Progressives are adamant about expanding Medicare to cover dental, vision and hearing benefits. But a handful of prominent Democrats are making the case that closing the Medicaid coverage gap is equally, if not more, important.
  • The gap exists in 12 Republican-controlled states that have refused to accept the Affordable Care Act’s Medicaid expansion, the majority of which are in the South.

What they’re saying: Closing the coverage gap is “very, very important to people of color. The majority of Black people in this country still live in the South,” said Rep. Jim Clyburn, one of the leading proponents of the measure.

  • More than 2 million adults are in the coverage gap, and 60% of them are people of color, according to the Center on Budget and Policy Priorities.
  • “What is the life expectancy of Black people compared to white people? I could make the argument all day that expanding Medicare at the expense of Medicaid is a racial issue, because Black people do not live as long as white people,” Clyburn added. “If we took care of Medicaid, maybe Black people would live longer.”

Between the lines: In terms of raw politics, it’s pretty easy to see why many Democrats would prioritize Medicare expansion over closing the Medicaid gap: Seniors live in every district and state in the U.S.

  • Only three Democratic senators represent non-expansion states, and in 2020, only ine of the 41 battleground House seats identified by Ballotpedia were in non-expansion states.

Yes, but: Sens. Jon Ossoff and Raphael Warnock, both from Georgia, are the reason that Democrats are able to consider their social policy legislation at all. Warnock is up for re-election next year.

  • “This is about people in this country, and I wish we’d stop this red state and blue state stuff,” Clyburn said. “Warnock and Ossoff won a runoff that nobody gave them a chance to win by promising they would close this gap.”

The catch: States that have already expanded Medicaid are covering a small portion of those costs themselves, and may question the fairness full federal funding for the holdout states.

  • That could create an incentive for existing expansion states to drop the ACA’s Medicaid expansion and pick up the new program instead. And any effort Congress makes to stop them could invite legal challenges.
  • “The case law in this domain is a bit of a moving target, and as we’ve seen over the past decade, there’s an awful lot of litigation over things pertaining to health reform,” said Nick Bagley, a professor at the University of Michigan Law School.

The bottom line: Like Democrats’ other proposed health policies, filling the coverage gap could cost hundreds of billions of dollars.

  • But “if your goals are relieving health care cost burdens or expanding access to care, then it’s hard to do better on a dollar-for-dollar basis than buying coverage for uninsured people below the poverty line,” said Brookings’ Matt Fiedler.

What we’re watching: “I don’t see Medicaid as being on the radar of some of my friends in the caucus who seem to feel it’s more important to do Medicare,” Clyburn said. “I’m trying to get Medicaid on their agenda.”

  • “I’m tired of my party perpetuating … inequity,” he added. “Treating people according to their needs is what breaks the cycle.”

AMA report: U.S. has “highly concentrated” payer markets that stifle competition  

Posted on by • Posted in ACA, America's Health Insurance Plans (AHIP), American Medical Association (AMA), Competition, Federal Trade Commission (FTC), Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Market Consolidation, Market Failure, Market Power, Market Share, Market Trends, Mergers & Acquisitions, Monopoly, Monopoly Behavior, Out of Network, Out of Pocket Expenses, Surprise Bills • Leave a comment

https://medcitynews.com/2021/10/ama-report-u-s-has-highly-concentrated-payer-markets-that-stifle-competition/?utm_campaign=MCN%20Daily%20Top%20Stories&utm_medium=email&hsmi=166812730&_hsenc=p2ANqtz–Z_7y9-ZOPkhC7HI4RXSwuM5xDzd2B0uZi9sApeW1J89hQBktG-rqujxpBFiXmxEEnaK77vlq-7vHhr-qK8mxRgBmwA&utm_content=166812730&utm_source=hs_email

About 73% of health insurance markets are highly concentrated, and in 46% of markets, one insurer had a share of 50% or more, a new report from the American Medical Association shows. The report comes a few months after President Joe Biden directed federal agencies to ramp up oversight of healthcare consolidation.

The majority of health insurance markets in the U.S. are highly concentrated, curbing competition, according to a report released by the American Medical Association.

For the report, researchers reviewed market share and market concentration data for the 50 states and District of Columbia, and each of the 384 metropolitan statistical areas in the country.

They found that 73% of the metropolitan statistical area-level payer markets were highly concentrated in 2020. In 91% of markets, at least one insurer had a market share of 30%, and in 46% of markets, one insurer had a share of 50% or more.

Further, the share of markets that are highly concentrated rose from 71% in 2014 to 73% last year. Of those markets that were not highly concentrated in 2014, 26% experienced an increase large enough to enter the category by 2020.

In terms of national-level market shares of the 10 largest U.S. health insurers, UnitedHealth Group comes out on top with the largest market share in both 2014 and 2020, reporting 16% and 15% market share, respectively. Anthem comes in second with shares of 13% in 2014 and 12% in 2020.

But the picture looks different when it comes to the market share of health insurers participating in the Affordable Care Act individual exchanges. In 2014, Anthem held the largest market share among the top 10 insurers on the exchanges, with a share of 14%. By 2020, Centene had taken the top spot, with a share of 18%, while Anthem had slipped to fifth place, with a share of just 4%.

Another key entrant into the top 10 list in 2020 was insurance technology company Oscar Health, with 3% of the market share in the exchanges at the national level.

“These [concentrated] markets are ripe for the exercise of health insurer market power, which harms consumers and providers of care,” the report authors wrote. “Our findings should prompt federal and state antitrust authorities to vigorously examine the competitive effects of proposed mergers involving health insurers.”

The payer industry hit back. In a statement provided to MedCity News, America’s Health Insurance Plans, a national payer association, said that Americans have many affordable choices for their coverage, pointing to the fact that CMS announced average premiums for Medicare Advantage plans will drop to $19 per month in 2022 from $21.22 this year.

“Health insurance providers are an advocate for Americans, fighting for lower prices and more choices for them,” said Kristine Grow, senior vice president of communications at America’s Health Insurance Plans, in an email. “We negotiate lower prices with doctors, hospitals and drug companies, and consumers benefit from lower premiums as a result.”

Further, the report does not mention the provider consolidation that also contributes to higher healthcare prices. Mergers and acquisitions among hospitals and health systems have continued steadily over the past decade, remaining relatively impervious to even the Covid-19 pandemic.

Scrutiny around consolidation in the healthcare industry may grow. In July, President Joe Biden issued an executive order urging federal agencies to review and revise their merger guidelines through the lens of preventing patient harm.

The Federal Trade Commission has already said that healthcare businesses will be one of its priority targets for antitrust enforcement actions.

Democrats’ competing health care priorities

Posted on by • Posted in ACA, Competing Priorities, Health Equity, Health Inequity, Health Insurance Coverage Adequacy, Health Policy, Home Care, Home-Based Care, Medicaid, Medicare, Medicare Drug Price Negotiation, Priorities • Leave a comment
https://www.axios.com/democrats-health-care-congress-medicare-politics-95831a8b-1bf5-4f5c-b277-e0e38f40b809.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

The Democrats’ reconciliation bill includes several major health care pieces backed by different lawmakers and advocates, setting up a precarious game of policy Jenga if the massive measure needs to be scaled back.

Between the lines: Health care may be a priority for Democrats. But that doesn’t mean each member values every issue equally.

Why it matters: As the party continues to hash out the overall price tag of its giant reconciliation bill, it’s worth gaming out which policies are on the chopping block — and which could potentially take the entire reconciliation bill down with them.

There are clear winners of each pillar of Democrat’s health plan:

  • Seniors benefit from expanding Medicare to cover dental, vision and hearing benefits.
  • Low-income people — primarily in the South and disproportionately people of color — in non-expansion states benefit if the Medicaid gap is closed, giving them access to health coverage.
  • Affordable Care Act marketplace enrollees benefit if the increased subsidy assistance that Democrats enacted earlier this year is extended or made permanent.
  • Elderly and Americans with disabilities benefit from an expansion of their home-based care options, and their caretakers benefit from a pay bump.
  • Seniors — and potentially anyone facing high drug costs — benefit if Medicare is given the authority to negotiate drug prices, although the drug industry argues it will lead to fewer new drugs.

Yes, but: Each of these groups face real problems with health care access and affordability. But when there’s a limited amount of money on the table — which there is — even sympathetic groups can get left in the dust.

Each policy measure, however, also has powerful political advocates. And when Democrats have a razor-thin margin in both the House and the Senate, every member has a lot of power.

  • Seniors are disproportionately powerful on their own, due to their voting patterns. But expanding what Medicare covers is extremely important to progressives — including Sen. Bernie Sanders.
  • Closing the Medicaid gap is being framed as a racial justice issue, given that it disproportionately benefits people of color. And although many Democrats hail from expansion states — particularly in the Senate — some very powerful ones represent non-expansion states.
  • These members include Sen. Raphael Warnock, who represents Georgia and is up for re-election next year in an extremely competitive seat, and Rep. Jim Clyburn, who arguably is responsible for President Biden winning the 2020 primary.
  • The enhanced ACA subsidies are scheduled to expire right before next years’ midterm elections. Democrats’ hold on the House is incredibly shaky already, making extending the extra help a political no-brainer.
  • Expanding home-based care options was one of the only health care components of Biden’s original framework for this package. But aside from the president’s interest in the issue, unions care a lot about it as their members stand to gain a pay raise — and Democrats care a lot about what unions care about.
  • And finally, giving Medicare the power to negotiate drug prices has the most powerful opponents, theoretically making it vulnerable to the chopping block. But it also polls very highly, and perhaps even more importantly, produces enough government savings to help pay for these other health care policies.

The bottom line: “From a political perspective, none of these health care proposals seem very expendable,” said KFF’s Larry Levitt.

  • Most — if not all of them — can be scaled to save money.
  • But there are also powerful constituencies for the other components of the bill that address issues like child care and climate change, meaning these health care measures aren’t only competing against one another.
  • And, Levitt points out, “there’s always a difference between members of Congress staking out positions and being willing to go to nuclear war over them.”

The next attack on the Affordable Care Act may cost you free preventive health care

Posted on by • Posted in ACA, Health Insurance Coverage Adequacy, Kelley v. Becerra, Preventable Disease, Preventative Care, Residual Costs, Roe v. Wade, Supreme Court • Leave a comment
The next attack on the Affordable Care Act may cost you free preventive health care
The next attack on the Affordable Care Act may cost you free preventive health care

Many Americans breathed a sigh of relief when the Supreme Court left the Affordable Care Act (ACA) in place following its third major legal challenge in June 2021. This decision left widely supported policies in place, like ensuring coverage regardless of preexisting conditions, coverage for dependents up to age 26 on their parents’ plan and removal of annual and lifetime benefit limits.

But the hits keep coming. One of the most popular benefits offered by the ACA, free preventive care through many employer-based and marketplace insurance plans, is under attack by another legal domino, Kelley v. Becerra. As University of Michigan law professor Nicholas Bagley sees it, “[t]his time, the law’s opponents stand a good chance of succeeding.”

We are public health and economics researchers at Boston University who have been studying how preventive care is covered by the ACA and what this means for patients. With this policy now in jeopardy, health care in the U.S. stands to take a big step backward.

What did the ACA do for preventive health?

The Affordable Care Act tried to achieve the twin ideals of making health care more accessible while reducing health care spending. It created marketplaces for individuals to purchase health insurance and expanded Medicaid to increase coverage for more low-income people.

One way it has tried to reach both goals is to prioritize preventive services that maximize patient health and minimize cost, like cancer screenings, vaccinations and access to contraception. Eliminating financial barriers to health screenings increases the likelihood that common but costly chronic conditions, such as heart disease, will be diagnosed early on.

Section 2713 of the ACA requires insurers to offer full coverage of preventive services that are endorsed by three federal groups: the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices and the Health Resources and Services Administration. This means that eligible preventive services ordered by your doctor won’t cost you anything out of pocket. For example, the CARES Act used this provision to ensure COVID-19 vaccines would be free for many Americans.

Removing the financial barrier has drastically reduced the average cost of a range of preventive services. Our study found that the costs of well-child visits and mammograms were reduced by 56% and 74%, respectively, from 2006 to 2018. We also found that the ACA reduced the share of children’s preventive checkups that included out-of-pocket costs from over 50% in 2010 to under 15% in 2018.

Residual costs for preventive services remain

Despite these reductions in costs, there are limitations to this benefit. For example, it doesn’t cover follow-up tests or treatments. This means that if a routine mammogram or colonoscopy reveals something that requires further care, patients may have to pay for the initial screening test, too. And some patients still receive unexpected bills for preventive care that should have been covered. This can happen, for example, when providers submit incorrect billing codes to insurers, which have specific and often idiosyncratic preventive care guidelines.

We also studied the residual out-of-pocket costs that privately insured Americans had after using eligible preventive services in 2018. We found that these patients paid between $75 million to $219 million per year combined for services that should have been free for them. Unexpected preventive care bills were most likely to hit patients living in rural areas or the South, as well as those seeking women’s services such as contraception and other reproductive health care. Among patients attempting to get a free wellness visit from their doctor, nearly 1 in 5 were later asked to pay for it.

Nevertheless, the preventive health provision of the ACA has resulted in significant reductions in patient costs for many essential and popular services. And removing financial barriers is a key way to encourage patients to use preventive services intended to protect their health.

The threat of Kelley v. Becerra

The plaintiffs who brought the latest legal challenge to the ACA, Kelley v. Becerra, object to covering contraception and preexposure prophylaxis (PrEP) for HIV on religious and moral grounds. The case is currently awaiting decision in a district court in Texas, but seems to be headed to the Supreme Court.

The case rests on two legal issues: 1) violation of the nondelegation doctrine, and 2) the appointments clause of the Constitution. The nondelegation doctrine is a rarely used legal argument that requires Congress to specify how their powers should be used. It essentially argues that Congress was too vague by not specifying which preventive services would be included in Section 2713 up front. The appointments clause specifies that the people using government powers must be “officers of the United States.” In this case, it is unclear whether those in the federal groups that determine eligible preventive care services qualify.

Texas District Judge Reed O’Connor has indicated so far that he takes a kind view toward the plaintiff’s case. He could rule that this provision of the ACA is unconstitutional and put the case on a path to the Supreme Court.

Patients stand to lose more than just money

If Section 2713 were repealed, insurers would have the freedom to reimpose patient cost-sharing for preventive care. In the short run, this could increase the financial strain that patients face when seeking preventive care and discourage them from doing so. In the long run, this could result in increased rates of preventable and expensive-to-treat chronic conditions. And because Section 2713 is what allows free COVID-19 vaccines for those with private health insurance, some patients may have to pay for their vaccines and future boosters if the provision is axed.

The ACA has been instrumental in expanding access to preventive care for millions of Americans. While the ACA’s preventive health coverage provision isn’t perfect, a lot of progress that has been made toward lower-cost, higher-value care may be erased if Section 2713 is repealed.

Lower-income patients will stand to lose the most. And it could make ending the COVID-19 pandemic that much harder.