GOP senators in close races mislead on preexisting conditions

https://www.washingtonpost.com/politics/2020/07/15/gop-senators-close-races-mislead-preexisting-conditions/?utm_campaign=wp_main&utm_medium=social&utm_source=facebook&fbclid=IwAR3XOi91b1jsLf-grP_iIXALJiIvlZNItPE1ZDO0_ql4Wlw8m3GicyoHIH8

2018 midterms: Republicans mislead voters about preexisting ...

“Steve Daines will protect Montanans with preexisting conditions.”

“Of course I will always protect those with preexisting conditions. Always.”

“What I look forward to working on is a plan that protects people with preexisting conditions.”

— Sen. Cory Gardner (R-Colo.), in an interview with Colorado Public Radio, July 1, 2020

 

Sound familiar? Just like President Trump, these Republican senators say they support coverage guarantees for patients with preexisting health conditions. And just like Trump, their records show the opposite.

The president’s doublespeak — voicing support for these protections while asking the Supreme Court to strike them down — is spreading into some battleground Senate races this year.

 

It’s a classic case of buyer beware: Look under the hood of what Daines, Gardner and McSally are selling, and you’ll find a car without an engine.

THE FACTS

Republicans for a decade have tried to repeal the Affordable Care Act, President Barack Obama’s signature health-care legislation. The Supreme Court has upheld the law twice in the face of challenges from conservative groups. As coronavirus cases reached a new high in the United States, the Trump administration filed a legal brief on June 25 asking the Supreme Court to strike down the entire law, joining with a group of GOP state attorneys general who argue that the ACA is unconstitutional.

Before the ACA, insurance companies could factor in a person’s health status while setting premiums, a practice that sometimes made coverage unaffordable or unavailable for those in need of expensive treatment or facing a serious illness such as cancer.

 

The ACA PROHIBITED THIS PRACTICE through two provisions: “guaranteed issue,” which means insurance companies must sell insurance to anyone who wants it, and “community rating,” which means people in the same age group and geographic area who buy similar insurance pay similar prices. The changes made insurance affordable for people with serious diseases or even those with minor health problems, who also could have been denied coverage before the law’s passage.

Now, about 20 million people covered through the ACA could lose their health insurance if the Supreme Court strikes down the law, among many other consequences bearing directly on the U.S. response to the coronavirus pandemic.

In addition to the coverage guarantee, the ACA established online health insurance marketplaces and subsidies for participating buyers. The law also directs billions of dollars a year in federal funding to states that have chosen to expand their Medicaid programs under the Obamacare law. Millions of Americans have gained coverage through those provisions.

We asked the Daines, Gardner and McSally campaigns whether the senators support or oppose the GOP lawsuit at the Supreme Court and how they would address affordability issues for patients with preexisting conditions if the ACA falls. None of their campaigns responded to our questions.

 

“Steve Daines will protect Montanans with preexisting conditions.”

Daines voted to repeal the ACA in 2013 and has supported efforts to repeal and replace the law more recently during the Trump administration.

Regarding the GOP lawsuit, a Daines spokesperson was quoted in the Billings Gazette saying the senator “supports whatever mechanism will protect Montanans from this failed law, lower health care costs, protect those with preexisting conditions and expand access to health care for Montanans.”

 

“What I look forward to working on is a plan that protects people with preexisting conditions.” (Gardner)

Gardner has been voting to repeal, defund or replace the ACA since 2011, the year after its passage. This year, his campaign website says nothing about the law, but his official Senate website says, “Fixing our healthcare system will require repealing the Affordable Care Act and replacing it with patient-centered solutions, which empower Americans and their doctors.”

Asked by the Hill whether he supported the GOP lawsuit, Gardner said: “That’s the court’s decision. If the Democrats want to stand for an unconstitutional law, I guess that’s their choice.” In an interview with Colorado Public Radio, Gardner evaded the question six times in a row.

“Of course I will always protect those with preexisting conditions. Always.” (McSally)

In 2015, McSally voted to repeal the ACA when she served in the House. In 2017, she voted to replace the ACA with the American Health Care Act, which would have allowed insurers to charge higher premiums to patients with complicated medical histories.

McSally, now in the Senate, has declined to comment on the GOP lawsuit pending before the Supreme Court. When asked by PolitiFact, “the campaign didn’t specifically answer, but pointed to her general disapproval of the ACA.”

WHAT HAPPENS IF  THE GOP LAWSUIT SUCCEEDS?

Trump told The Washington Post days before his inauguration in 2017 that he was nearly done with his plan to replace the ACA. Three and a half years later, no replacement plan has emerged from the administration and Republicans in Congress hardly agree on what it would look like — or how to preserve the protections for preexisting health conditions.

Sen. Thom Tillis (R-N.C.), who is also running for reelection this year, has introduced a 24-page bill called the Protect Act that includes language guaranteeing coverage for preexisting conditions. Daines signed on as a co-sponsor on June 24, the day before the Justice Department filed its brief in the Supreme Court. McSally signed on in April 2019. Gardner is not listed as a co-sponsor.

Experts say the Tillis proposal does not offer the same level of protection for preexisting conditions as the ACA, and they warn that millions of Americans could lose their health coverage if the ACA falls and the Protect Act is the only replacement.

“Insurers before the Affordable Care Act had multiple and redundant ways that they could avoid people who had preexisting conditions,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. The Protect Act prevents some of those practices, but it “leaves enough other loopholes that it would make it very possible and likely for insurers to be able to avoid paying benefits for the conditions they most worry about,” she said.

 

Before the ACA, an insurance company could reject an application outright, say, after reviewing a patient’s medical history. The Protect Act has language barring that practice.

“The second thing they could do is, they could sell you coverage, but they could exclude your preexisting condition. ‘Oh, you have diabetes? I’m not going to pay for any of those benefits,’” Pollitz said. “The Tillis bill says you can’t do that, so that’s good.”

In the days before the ACA, insurers were allowed to charge higher premiums based on a patient’s health status. To prevent this, the Protect Act takes language from the Health Insurance Portability and Accountability Act (HIPAA), rather than the newer ACA.

“The Protect Act inserts old HIPAA nondiscrimination language that prevents employers from varying worker premium contributions based on health status,” Pollitz said. “But the Protect Act also includes the old rule of construction that says nothing limits what the insurance company can charge the employer or individual.”

Pollitz said the “community rating” language in the ACA provides clearer protections in this area. The Protect Act says “nothing … shall be construed to restrict the amount that an employer or individual may be charged for coverage under a group health plan.”

“The bill would reinstate three protections at risk in the Texas case — prohibiting insurers from denying applicants based on pre-existing conditions, charging higher premiums due to a person’s health status, and excluding pre-existing conditions from coverage,” Sarah Lueck, a senior policy analyst at the left-leaning Center on Budget and Policy Priorities, wrote in an analysis.

“But it would leave many others on the cutting room floor,” she wrote, because insurers would be able to exclude coverage of benefits such as maternity care, mental health and substance-use treatment; set annual and lifetime limits on insurance payouts; and charge older patients more than younger patients at greater levels than the ACA allows, among other changes.

It’s important to keep in mind that the Protect Act would not replace other parts of Obamacare, such as the online marketplaces and subsidies. Neither would it continue the ACA’s Medicaid expansion, which 37 states and D.C. have now adopted. That includes Arizona, Colorado and Montana.

 

The Pinocchio Test

Voters deserve straight answers when their health care is on the line, especially in the middle of a deadly pandemic.

Daines, Gardner and McSally have voted to end the Affordable Care Act. People with preexisting conditions would have been left exposed because of those votes; insurers could have denied coverage or jacked up prices for sick patients.

The three senators’ comments about the GOP lawsuit are woefully vague, but they can all be interpreted as tacit support. Asked about the case, a Daines spokesperson said “whatever mechanism” to get rid of the ACA would do. McSally’s campaign “didn’t specifically answer, but pointed to her general disapproval of the ACA.” Gardner avoided the question six times in one interview, but in another, he said: “That’s the court’s decision. If the Democrats want to stand for an unconstitutional law, I guess that’s their choice.”

Four Pinocchios all around.

 

 

 

 

UnitedHealth Group posts $6.6B in Q2 profit amid COVID-19 care deferrals

https://www.fiercehealthcare.com/payer/unitedhealth-group-posts-6-6b-q2-profit-amid-covid-19-care-deferrals?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiTldOaVpEUTJOMk0yTWpNNSIsInQiOiJJcFROOCtmWDU4TEhnT0FkTFFCTHZmRHpVWHBJV015M0QzQSswV3llT2liQzFsXC9wM1VYXC8yT2xsREdQVVh1WnhvNHk3TEdHNEtrTlZcL2s5WXlWZXZVMjR1TUdPZEgrNnVPOTVuYUNJSVo5VmFhT05XQlZYYmlJTHE2ekhwZENDdCJ9

The outside of UnitedHealth Group's headquarters

UnitedHealth Group reported $6.6 billion in profit for the second quarter, beating Wall Street projections.

That’s also a significant increase in profit compared to the second quarter of 2019, where the healthcare giant brought in $3.3 billion, according to its earnings report (PDF) issued Wednesday.

UnitedHealth’s mid-year profits sit at $10 billion, compared to $6.8 billion in the first half of 2019.

The insurer also reported $62.1 billion in revenue for the quarter, an increase year-over-year but a number that fell short of analysts’ expectations. UnitedHealth brought in $60.6 billion in revenue in the second quarter of 2019.

Through the first half of 2020, UnitedHealth has earned $126.6 billion in revenue, up from $120.9 billion in the first six months of 2019.

The insurer attributes the unexpectedly high profit to large amounts of care deferral due to the coronavirus pandemic and said it’s likely to see that offset in future quarters as elective procedures and other services resume.

In the earnings release, CEO David Wichmann touted the company’s efforts to combat the pandemic in the second quarter.

“Our 325,000 dedicated team members, including the 120,000 clinicians serving on the front lines of care, have tirelessly responded to COVID-19 with agility, innovation and compassion,” Wichmann said in a statement.

“We moved swiftly to assist the people we serve and their care providers, including the provision of $3.5 billion in proactive voluntary customer assistance and accelerated care provider funding. We remain committed to taking further actions to address any future imbalances as a result of the pandemic,” he said.

Though COVID-19’s full impact on finances remains unclear, UnitedHealth maintained its full-year earnings guidance of between $15.45 and $15.75 per share.

 

 

 

 

Trump admin seeks relaxed grandfathered ACA health plan rules that up out-of-pocket costs

https://www.healthcaredive.com/news/trump-admin-seeks-relaxed-grandfathered-aca-health-plan-rules-that-up-out-o/581463/

Paying for Health Insurance Out of Pocket Maximum, OOP Health ...

Dive Brief:

  • The Trump administration proposed a rule Friday to allow some group health plans grandfathered under the Affordable Care Act to raise out-of-pocket costs for enrollees but still allow them to have health savings accounts. Such plans must not discriminate against enrollees with pre-existing conditions, but are exempt from many other ACA regulations. If they violate any rules regarding costs or structure they lose their grandfathered status and are required to follow all the mandates of the landmark 2010 law.
  • The proposed rule, issued by the U.S. Department of Labor, would relax some of the complex inflation and pricing calculations grandfathered plans must follow. The department admitted that the change could lead to higher deductibles and other out-of-pocket costs for the estimated 23.1 million enrollees in such grandfathered plans.
  • The rule stems from a 2017 executive order issued by President Donald Trump that allows regulatory changes to be made in response to perceived economic burdens imposed by the ACA. However, the Labor Department conceded in its Federal Register publication of the proposed rule that the current rules for grandfathered health plans probably weren’t that burdensome.

Dive Insight:

The administration has made no secret of its ire for the ACA and is actively trying to overturn it at the U.S. Supreme Court. A release explaining the changes notes fixed cost-sharing for high-deductible health plans would be raised, and “an alternative method of measuring permitted increases in fixed-amount cost sharing” has been introduced that “would allow plans and issuers to better account for changes in the costs of health coverage over time.”

The formal 76-page proposal, published in the Federal Register on Sunday, said premiums might go down as a result of the changes, but there were no estimates provided or circumstances where that might occur.

Moreover, the proposed rule also noted that the change could lead to more people foregoing healthcare because their out-of-pocket costs might become unaffordable.

The Labor Department also noted that there have been so few fluctuations in the state of grandfathered health plans in recent years that it was likely the current regulations were not overly burdensome in the first place.

Public comments will be solicited until mid-August before a final rule is issued.

Sen. Patty Murray, D-Wash., and ranking member of the Senate Health, Education, Labor, and Pensions Committee, wasted little time late last week blasting the proposal.

“Regardless of what the president wants to believe, we’re in the middle of a pandemic that is devastating families’ health and finances,” Murray said in a statement.

 

 

 

 

American patients can’t shop their way to a low cost healthcare system

American patients can’t shop their way to a low cost healthcare system

Hospital price transparency is a distraction from policies that could reduce costs without burdening patients, say Jamie Daw and Adam Sacarny.

 

The prices that hospitals charge privately insured patients in the US have long been shrouded in secrecy. These prices—which are negotiated between hospitals and private insurers—vary widely: the price for the same blood test could vary 39-fold within Tampa, Florida and the cost of a cesarean delivery varies by up to $24 000 in San Francisco, California.

A recent federal court decision stands to shine a light on opaque hospital pricing in the US. In a lawsuit brought forward by the American Hospital Association, a federal judge upheld a regulation issued by the Trump administration that will soon require hospitals to post a wealth of information on payment rates online.

This policy seems intuitive: in other sectors of the economy, consumers usually know the price of a service or product before they purchase it. By comparing prices, consumers can shop around and save money. In turn, sellers anticipate that behavior and are incentivized to keep prices low. Who wouldn’t want a virtuous circle like that in healthcare? 

The Trump administration argues that hospital price transparency will encourage value in healthcare by helping patients and employers find lower prices, while pressuring hospitals to cut them further. However, the potential effects—and who stands to benefit—are not so straightforward.

 

Firstly, giving consumers information on prices doesn’t necessarily mean that they will respond by seeking lower cost services. Studies have consistently found that patients tend not to use price transparency tools, and their effects on healthcare spending are small or nonexistent. Why? Shopping for healthcare services is often complicated or impossible. 

 

Many of the most expensive services are for emergencies where there is little scope for patients to shop.

Even when a patient has time to compare prices for non-urgent procedures or tests, the complexity of healthcare payment systems and insurance products makes it next to impossible for a patient to preemptively calculate what they would personally pay for an encounter. Establishing that amount requires patients to know the cost-sharing parameters of their insurance plan, the set of services they will use during the encounter, and how aggressively the hospital will bill for those services.

Insurance also obscures patients’ incentives to shop by insulating them from healthcare prices.

While patients can be given strong incentives to shop—and an increasing number of American workers are enrolled in high deductible health plans with this aim—these incentives are created by hoisting financial risk on patients. This financially burdens American families and can result in patients forgoing appropriate care.

 

Beyond the challenges posed by patient shopping, the empirical evidence supporting price transparency is weak.

It could even backfire. Economists have pointed out that in sectors with low competition, price transparency can facilitate collusion and lead to higher prices. This fear was borne out in Denmark when authorities began publishing the prices of ready-mixed cement. Prices proceeded to converge and rise, and the authorities eventually abandoned the idea. The most hopeful evidence in the US healthcare system comes from New Hampshire, where prices for medical imaging fell by 3% after the state established a price transparency website. But even effects of this magnitude, while beneficial, would only make a tiny dent in lowering US healthcare costs. 

 

Price transparency efforts reflect a broad trend for American policy makers to turn to consumer-driven strategies to reduce healthcare costs.

These strategies are built on the assumption that patients ought to be responsible for navigating their way to high quality, low cost healthcare. However, the challenges faced by patients in assessing the complex cost-quality tradeoffs in healthcare limit the potential for price transparency to have the impact that the administration advertises.

Perhaps more troubling is that these efforts could distract policy makers from addressing the main drivers of US healthcare prices, such as rapid and ongoing consolidation. Concentrated hospital markets are becoming the norm in the US and are strongly associated with higher prices. Antitrust actions, such as preventing hospital mergers, could reduce and reverse consolidation, likely leading to lower prices.

Another option for policy makers is to assume a greater regulatory role over healthcare prices, including introducing price caps and an all-payer rate setting. A Supreme Court decision made it much more difficult for state governments to collect the data that would undergird these efforts. As a result, the information released under the transparency rule may end up being more useful for states considering new price regulations than for patients shopping for healthcare services.

 

If we want to reduce prices without burdening patients with financial risk, then policy makers need to address the emerging causes of rising healthcare costs directly. Efforts to control costs are most likely to succeed when policy makers tackle the structural drivers behind the most expensive health system in the world.

 

 

 

 

Walmart confirms a new avatar — it’s also a health insurance agency

https://medcitynews.com/2020/07/walmart-confirms-a-new-avatar-its-also-a-health-insurance-broker/?utm_campaign=MCN%20Daily%20Top%20Stories&utm_medium=email&_hsmi=90973681&_hsenc=p2ANqtz-81Jwk3CVNhJLTDzB0d_5dxRASKqJQULhnQYEg1uxEGxr-l_EbrHhNlSq7UcPZ103ku0wBylrpCk8Y0i1vrK7rRE5rJuA&utm_content=90973681&utm_source=hs_email

Should I buy health insurance from Walmart? - Castaline Insurance ...

Walmart quietly launched a new health insurance business. The company, called Walmart Insurance, was filed with the Arkansas Secretary of State last month.

Walmart is making clear what an executive declared in a virtual conference: that it is firmly in the healthcare business, not just in retail healthcare.

News emerged today that the company is planning to throw its weight around in another healthcare segment in need of an overhaul: insurance. A spokeswoman from the Bentonville, Arkansas retail behemoth confirmed that the company has created “Walmart Insurance Services LLC” to sell insurance policies. The business entity’s name was first filed with the Arkansas Secretary of State in late June.

“We currently offer access to insurance information in our Walmart Health locations, and we have a long-standing education program called Healthcare Begins Here to help people find the right insurance plan for them,” spokeswoman Marilee McInnis wrote in an email. “We’re expanding our current insurance services to now include the sale of insurance policies to our customers.”

A handful of job postings at a call center in the Dallas metro also match up with Walmart Insurance Services, as first pointed out by Talk Business & Politics. Walmart has listings for licensed insurance agents and Medicare sales supervisors.

“Yes, you read that right, Walmart now has an insurance agency,” the listings read.

It looks like the new subsidiary will be focused on selling Medicare Advantage plans, though the company was mum when asked for additional details. The spokeswoman’s statement about the “sale of insurance policies to our customers” also leaves open the possibility of Walmart expanding its services beyond senior shoppers in the future.

Medicare Advantage plans have been experiencing rapid growth in the past decade, with more than a third of all beneficiaries enrolled in a plan managed by a private insurer. That figure is expected to increase in the future.

 

Deeper into the pharmacy space

Separately, on Tuesday, Walmart announced that it had struck a partnership with  PBM startup Capital Rx, which provides health plans real-time information on prescription drug prices.

Walmart has been a big player in the pharmacy space for several years, and the company appears to be deepening that through this partnership

“‘Everyday low price’ has been a guiding principle at Walmart. We take pride in providing affordable prices to more than 160 million customers who shop Walmart each week,” Walmart Health and Wellness Vice President Luke Kleyn said in a news release. “Working with Capital Rx will allow us to do the same for prescription drugs,”

Capital Rx was founded just over two years ago by AJ Loiacono, a former insurance auditor, with the idea of providing drug prices as part of pharmacy benefit plans.

Loiacono started his career in the pharmaceutical manufacturing industry, where “everything that comes out of that plant has a price.”

When he moved over to the auditing and procurement side, working with payers and self-insured companies, he was shocked to find out that none of their contracts included drug prices. To solve this, the company uses Medicaid’s National Average Drug Acquisition Cost, rather than the average wholesale price, to calculate costs.

As a standalone company, Capital Rx was able to provide price information for retail drugs, but they weren’t able to do the same for mail and specialty drugs. The partnership with Walmart will “complete the model,” with Walmart providing mail and specialty drug fulfillment.

With the partnership, Capital Rx was able to quickly sign on some payers, though it hasn’t yet disclosed which ones.

“Walmart is a diversified company. We liked the fact that they were independent. They’re not part of a PBM or a health system today,” Loiacono said. “The other part of it is, they have scale.”

Loiacono also pointed to similar goals in price transparency — something Walmart emphasized when it shared the cash pay prices for its new health clinics.

“This is what we’re seeing a little bit more of as the future in the roadmap,” Loiacono said. “They’re making a serious investment in healthcare.”

 

 

 

 

Short-term ‘junk’ plans widely discriminate against those with pre-existing conditions, House probe finds

https://www.healthcaredive.com/news/short-term-junk-plans-widely-discriminate-against-those-with-pre-existing/580556/

U.S. Rep. Castor's Statement Following a Federal Judge's Ruling on ...

Dive Brief:

  • A yearlong probe by the House Committee on Energy and Commerce into bare-bones insurance plans encouraged by the Trump administration found widespread discrimination against people with pre-existing conditions, even as a growing number are enrolled.
  • Top congressional Democrats investigated eight insurers selling short-term, limited duration plans, finding they all denied medical care claims if they found a consumer had a pre-existing condition. Some refused to pay for medical claims for no discernable reason, processing them only after consumers sued or complained to state regulators. Most rescinded coverage if they determined a member had a pre-existing condition or developed one later.
  • An HHS spokesperson defended the coverage as an affordable option to pricier Affordable Care Act plans, telling Healthcare Dive, “We’ve been abundantly clear that these plans aren’t for everyone.” America’s Health Insurance Plans made similar points, with spokesperson David Allen noting: “For Americans with pre-existing conditions, they may not be protected at all.”

 

Dive Insight:

The investigation looked at 14 companies that sell or market the plans, including eight insurers such as market giants Anthem and UnitedHealth Group, and six brokers.

It found insurers frequently turned down consumers with pre-existing conditions and discriminated against women, turning down applicants who were pregnant or planning to become pregnant and charging women more than men for the same coverage.

The plans had significant coverage limitations. Some excluded routine care like basic preventive visits and pelvic exams. Some plans had hard coverage cutoffs that left consumers with massive medical bills.

In one case, a consumer was billed a whopping $280,000 and lost coverage after being treated for an infection. The insurer said the patient previously had gotten an ultrasound that was “suspicious for deep venous thrombosis.”

AHIP spokesman Allen said it is not surprising given the plans are not intended to replace comprehensive coverage.

“They often do not cover the care and treatments that patients need throughout the year — preventive care, prescription drugs, mental health care or treatments for chronic health conditions — or if they do, they may limit or cap the benefits,” he acknowledged.

On average, short-term plans spend less than half of premium dollars collected from consumers on medical care: only 48%, the investigation found. That’s in stark contrast to plans in the ACA’s individual market, which are required to shell out at least 80% of all premium dollars on claims and benefits.

Short-term insurance represents a significant and growing share of the individual healthcare market. Roughly 3 million consumers bought the plans in 2019, a 27% growth from 2018, the investigation launched in March last year found.

The growth came after the Trump administration, in a controversial move, extended the maximum duration of the plans. The skimpy coverage, which isn’t required to cover the 10 essential benefits under the ACA, was originally designed as cheap safety net coverage for three months.

But in August 2018, HHS expanded the plans to 12 months, with a three year renewal period, and opened them up to all consumers, not just for those who can’t afford other coverage.

ACA supporters and patient advocates blasted the move, which sparked an ongoing legal challenge from safety net providers. Reports of consumers purchasing the coverage, believing it was comprehensive, then being shocked by balance bills prompted the House investigation.

The report also found brokers are paid up to 10 times more compensation for peddling short-term plans than ACA-compliant coverage. The average commission rate for short-term plans compared to ACA plans was 23% versus 2%, respectively.

Currently, 24 states ban or restrict the sale of short-term plans. Some states, including California, Massachusetts, New Jersey and New York, prohibit their sale entirely, while others like Colorado, Connecticut, New Mexico and Rhode Island have such strict regulations that no plans are sold.

Democratic leaders unveiled a bill on Wednesday to bolster the ACA and rescind the administration’s expansion of the plans and expand subsidies, allowing more people to qualify for coverage.

The effort has zero chance of moving this year with Republicans in control of the Senate, but both it and the probe are likely to play into the looming 2020 presidential and congressional elections.

“The heavy-handed tactics uncovered in this investigation demonstrate why Congress must reverse the Trump Administration’s expansion of these junk plans,” E&C Chairman Frank Pallone, D-N.J., Health Subcommittee Chairwoman Anna Eshoo, D-Calif., and Oversight and Investigations Subcommittee Chair Diana DeGette, D-Colo., wrote in a joint statement. “It also shows how dangerous a post-ACA world would be if Republican Attorneys General and the Trump Administration are successful in striking down the law and its protections.”

That lawsuit, led by 18 red states, argues the ACA, which expanded insurance to some 20 million people, is unconstitutional because a tax bill passed in 2017 zeroed out the penalty for its individual mandate. It’s currently pending before the U.S. Supreme Court.

President Donald Trump and his health officials have repeatedly promised people with pre-existing conditions will be protected if the ACA is struck down, but neither the administration nor Republicans in Congress have said specifically how.

 

 

 

 

 

White House set to ask Supreme Court this week to overturn ACA: 4 things to know

https://www.beckershospitalreview.com/hospital-management-administration/white-house-to-ask-supreme-court-this-week-to-overturn-aca-4-things-to-know.html?utm_medium=email

New rules for Supreme Court justices as they plan their first-ever ...

The White House is expected to file legal briefs with the Supreme Court this week that will ask the justices to end the ACA, according to The New York Times

Four things to know:

1. The filings are in relation to Texas v. United States, the latest legal challenge to the ACA. Arguments around the case center on whether the ACA’s individual mandate was rendered unconstitutional when the penalty associated with it was erased by the 2017 tax law. Whether that decision invalidates the entire law or only certain parts of it is at question.

2. The White House is set to ask the Supreme Court June 25 to invalidate the law. The filings come at a time when the COVID-19 pandemic has caused millions of Americans to lose their jobs and their employer-based health coverage.

3. Republicans have said they want to “repeal and replace” the ACA, but there is no agreed upon alternative, according to The New York Times. Party strategists told the publication that Republicans will be in a tricky spot if they try to overturn the ACA ahead of the November elections and amid a pandemic. 

4. In addition to the filings, Democratic House speaker Nancy Pelosi is expected to reveal a bill this week that would boost the ACA. Proposals include more subsidies for healthcare premiums, expanding Medicaid coverage for uninsured pregnant women and offering states incentives to expand Medicaid.

Read the full report here

 

 

Health insurance marketplace GoHealth files to go public

https://www.fiercehealthcare.com/tech/health-insurance-marketplace-gohealth-files-to-go-public?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiWmpjeVlXVTRZV0l5T1RndyIsInQiOiJLWWxjamNKK2lkZmNjcXV4dm0rdjZNS2lOanZtYTFoenViQjMzWnF0RGNlY1pkcjVGcFwvZFY4VjFaUUlZaFRBT1NRMGE5eWhGK1ZmR01ZSWVZWGMxOHRzTkptZVZXZmc5UnNvM3pVM2VIWDh6VllldFc3OGNZTTMxTDJrXC8wbzN1In0%3D

GoHealth files for $100M IPO

GoHealth, an online health insurance marketplace, is looking to raise up to $100 million in an initial public offering, according to a filing with the U.S. Securities and Exchange Commission (SEC) Friday.

The Chicago company, launched in 2001, said its stock will trade on the Nasdaq Global Market under the symbol “GHTH,” according to an S-1 filing.

The company didn’t list specific share price or the number of shares it’s selling in the filing.

GoHealth operates a health insurance portal offering a variety of plans that allows customers to compare numerous insurance plans such as family health plans and self-employed insurance.

The company works with more than 300 health insurance carriers and has enrolled more than 5 million people into health plans.

Goldman Sachs, BofA Securities and Morgan Stanley are acting as the managing book runners for the proposed offering. Barclays, Credit Suisse, Evercore ISI, RBC Capital Markets and William Blair are acting as book runners for the proposed offering. Cantor and SunTrust Robinson Humphrey are acting as co-managers for the proposed offering, according to a GoHealth press release.

GoHealth will join a growing list of technology-enabled healthcare companies that are testing the public markets, including One Medical, Livongo, Phreesia, Health Catalyst, Change Healthcare and Progyny.

The company has shifted its focus toward Medicare products over the past four years, positioning itself to capitalize on strong demographic trends and an aging population.

Medicare enrollment is expected to grow from approximately 61 million individuals in 2019 to approximately 77 million individuals by 2028, the company said in its SEC filing.

At the same time, an increasing proportion of the Medicare-eligible population is choosing commercial insurance solutions, with 38% of Medicare beneficiaries, or approximately 23 million people, enrolled in Medicare Advantage plans in 2019, an increase of approximately 1.5 million people from 2018 to 2019, the company said.

The market is “ripe for disruption” by digitally enabled and technology-driven marketplaces like the GoHealth platform, according to the company.

GoHealth estimates a total addressable market of $28 billion for Medicare Advantage and Medicare Supplement products.

“We believe that these trends will drive a larger market in the coming years that, when taken together with our other product and plan offerings, will result in an even larger addressable market. We also believe that we are poised to benefit from market share gains in what has traditionally been a highly fragmented market,” the company said in the S-1 filing.

The company uses machine-learning algorithms and insurance behavioral data to match customers with the health insurance plan that meets their specific needs.

In 2019, the company generated over 42.2 million consumer interactions.

In September 2019, Centerbridge acquired a majority stake of GoHealth in a deal that reportedly valued the company at $1.5 billion, the Chicago Tribune reported.

Net revenues grew to $141 million for the first quarter of this year, compared to $69.1 million last year. The company reported 2019 pro forma net revenues of $540 million, up 139% from 2018’s revenue of $226 million, the company reported in its SEC filing.

The company reported a net loss of $937,000 for the first quarter of 2020 compared to a net income of $5 million for the same period in 2019, according to its IPO.

Demographic, consumer preference and regulatory factors are driving growth in the individual health insurance market, according to the company. Medicare enrollment is expected to grow significantly over the next 10 years as 10,000-plus individuals turn 65 each day and become Medicare-eligible.

At the same time, the growth in plan choices makes education and assistance with plan selection more important for consumers, GoHealth said.

“Marketplaces such as ours help educate consumers, and assist them in making informed plan choices,” the company said.

The company also faces significant risks that may impede its growth. Currently, a large portion of GoHealth’s revenue is derived from a limited number of carriers. Carriers owned by Humana and Anthem accounted for approximately 42% and 32%, respectively, of the company’s net revenues for the first three months of 2020, the company said in its IPO paperwork.

The COVID-19 pandemic also creates uncertainty in the healthcare market, and future developments in the outbreak could impact the company’s financial performance, GoHealth said.

 

 

 

COVID-19 Implications for pharma: US payer insights

https://www.healtheconomics.com/resource/covid-19-implications-for-pharma-us-payer-insights

What are the implications for pharma as COVID-19 forces fundamental change in US payer practice and policy?

The COVID-19 pandemic has created a unique set of challenges for US payers. In the short-term emergency healthcare packages have included increasing patient access to medicines, waiving co-pays, relaxing prior approval requirements and increasing telemedicine services. But longer term? The commercial healthcare market is likely to contract and demand for Medicare/Medicaid will increase. Payers are looking at a very different post-COVID-19 world and the impact on drug prices, formulary coverage, generic use and plan coverage will present significant hurdles to drug manufacturers.

Pharma needs to plan for a new long-term reality. To explore current thinking we interviewed, in COVID-19 implications for pharma: US payer insights, experienced US payers to give you a clear perspective of the immediate actions being taken and the emerging issues and trends that will shape pharma/payer relations.

Payers explore key issues

  • What emergency measures are in place to ensure the health plans address customers’ medical needs and will these need to be reconsidered on an ongoing basis?
  • What precautions are currently being taken to negate the impact of costs directly related to COVID-19 such as screening, hospital admissions and long-term treatment of COVID-related health issues?
  • What impact could COVID-19 have on private healthcare plans and Medicare/Medicaid and their formulary coverage, market access to medicines and the role of telemedicine services in the future?
  • How might COVID-19 impact policy on co-payments, premiums and patient selection criteria for treatments in the future?
  • What impact could COVID-19 have on pricing and reimbursement of drugs and the role of value-based contracting?

Click here for more information about this report.

 

 

 

 

Navigating a Post-Covid Path to the New Normal with Gist Healthcare CEO, Chas Roades

https://www.lrvhealth.com/podcast/?single_podcast=2203

Covid-19, Regulatory Changes and Election Implications: An Inside ...Chas Roades (@ChasRoades) | Twitter

Healthcare is Hard: A Podcast for Insiders; June 11, 2020

Over the course of nearly 20 years as Chief Research Officer at The Advisory Board Company, Chas Roades became a trusted advisor for CEOs, leadership teams and boards of directors at health systems across the country. When The Advisory Board was acquired by Optum in 2017, Chas left the company with Chief Medical Officer, Lisa Bielamowicz. Together they founded Gist Healthcare, where they play a similar role, but take an even deeper and more focused look at the issues health systems are facing.

As Chas explains, Gist Healthcare has members from Allentown, Pennsylvania to Beverly Hills, California and everywhere in between. Most of the organizations Gist works with are regional health systems in the $2 to $5 billion range, where Chas and his colleagues become adjunct members of the executive team and board. In this role, Chas is typically hopscotching the country for in-person meetings and strategy sessions, but Covid-19 has brought many changes.

“Almost overnight, Chas went from in-depth sessions about long-term five-year strategy, to discussions about how health systems will make it through the next six weeks and after that, adapt to the new normal. He spoke to Keith Figlioli about many of the issues impacting these discussions including:

  • Corporate Governance. The decisions health systems will be forced to make over the next two to five years are staggeringly big, according to Chas. As a result, Gist is spending a lot of time thinking about governance right now and how to help health systems supercharge governance processes to lay a foundation for the making these difficult choices.
  • Health Systems Acting Like Systems. As health systems struggle to maintain revenue and margins, they’ll be forced to streamline operations in a way that finally takes advantage of system value. As providers consolidated in recent years, they successfully met the goal of gaining size and negotiating leverage, but paid much less attention to the harder part – controlling cost and creating value. That’s about to change. It will be a lasting impact of Covid-19, and an opportunity for innovators.
  • The Telehealth Land Grab. Providers have quickly ramped-up telehealth services as a necessity to survive during lockdowns. But as telehealth plays a larger role in the new standard of care, payers will not sit idly by and are preparing to double-down on their own virtual care capabilities. They’re looking to take over the virtual space and own the digital front door in an effort to gain coveted customer loyalty. Chas talks about how it would be foolish for providers to expect that payers will continue reimburse at high rates or at parity for physical visits.
  • The Battleground Over Physicians. This is the other area to watch as payers and providers clash over the hearts and minds of consumers. The years-long trend of physician practices being acquired and rolled-up into larger organizations will significantly accelerate due to Covid-19. The financial pain the pandemic has caused will force some practices out of business and many others looking for an exit. And as health systems deal with their own financial hardships, payers with deep pockets are the more likely suitor.”