Category Archives: High Deductible Health Plans

Trial approaching in Sutter Health antitrust case

Posted on by • Posted in ACA, Antitrust, Competition, Federal Trade Commission (FTC), Health Policy, Health System, High Deductible Health Plans, High Premiums, High Prices, Hospital, Hospital Industry, Lawsuit, Market Consolidation, Market Power, Mergers & Acquisitions, Monopoly, Monopoly Behavior, Non-Profit Healthcare Industry, Operating Income, Operating Margin • Leave a comment

https://www.modernhealthcare.com/legal/trial-approaching-sutter-health-antitrust-case?utm_source=modern-healthcare-daily-finance&utm_medium=email&utm_campaign=20190923&utm_content=article1-readmore

Spurred in part by the Affordable Care Act, hospitals across the country have merged to form massive medical systems in the belief it would simplify the process for patients.

But a simpler bill doesn’t always guarantee a cheaper bill.

That’s a key issue in an antitrust lawsuit against one of California’s largest hospital systems set to begin Monday.

About 1,500 self-funded health plans have sued Sutter Health, a system that includes 24 hospitals across Northern California. The case has dragged on since 2014, but it picked up steam last year when Attorney General Xavier Becerra filed a similar lawsuit. The cases have been combined and jury selection begins Monday. Opening arguments are scheduled for October.

The lawsuit alleges Sutter Health gobbled up competing medical providers in the region and used its market dominance to set higher prices for insurance plans, which means more expensive insurance premiums for consumers.

Becerra points to a 2018 study that found unadjusted inpatient procedure prices are 70% higher in Northern California than Southern California. The lawsuit notes Sutter Health’s assets were $15.6 billion at the end of 2016, up from $6.4 billion in 2005.

“We never meant for folks to use integration to boost their profits at the expense of consumers,” Becerra said.

It’s rare for antitrust lawsuits of this size to go to trial because the law allows for triple damages — a prospect that often spooks companies into settling outside of court to avoid an unpredictable jury. Health plans in this case are asking for $900 million in damages, meaning Sutter Health could take a nearly $3 billion hit.

Atrium Health, a North Carolina-based hospital system, settled a similar anti-trust lawsuit with the federal government last year. And CHI Franciscan, a health system based in Washington state, also settled similar claims in March that had been brought by the state.

But Sutter Health is fighting the case. The company says the lawsuit is not about its prices, but about insurance companies who want to maximize their own profits. Sutter Health officials insist the company faces fierce competition, vowing to detail in court the expansion of other health systems in the San Francisco Bay Area and the Sacramento Valley.

Four Sutter Health hospitals had operating losses in 2018, totaling $49 million.

“The bottom line is that this lawsuit is designed to skew the healthcare system to the advantage of large insurance companies so they can market inadequate insurance plans to Californians,” said Sutter Health Director of Public Affairs Amy Thoma Tan.

At issue are several of Sutter Health’s contracting policies that Becerra says have allowed the company to “thoroughly immunize itself from price competition.”

One way insurance companies keep costs down is to steer patients to cheaper health care providers through a variety of incentives. Becerra says Sutter Health bans insurance companies from using these incentives, making it harder for patients to use their lower-priced competitors.

Becerra also says Sutter has an “all or nothing” approach to negotiating with insurance companies, requiring them to include all of the company’s hospitals in their provider networks even if it doesn’t make financial sense to do so.

The case was originally filed by a trust of Northern California’s largest unionized grocery companies in 2014. A representative for the trust said it was “unknowingly forced to pay Sutter’s artificially high prices.”

But the company says these contracting practices are designed to protect patients. People often are unable to pick which hospital they go to in a medical emergency, which can lead to surprise bills when they learn a hospital or doctor was not in their network.

Jackie Garman, lawyer for the California Hospital Association, said these contracting practices are standard at a lot of hospitals. If the lawsuit is successful, she said it could “disrupt contracting practices at a lot of other systems.”

But the consequences of not bringing the lawsuit could be greater, Becerra said.

“We are paying every time we allow an anti-competitive behavior to drive the market,” he said.

 

 

 

On same day of hospital concentration study, AMA says payers are the ones with less competition

Posted on by • Posted in Antitrust, Health Insurance Industry, Health Plan, Health Policy, High Deductible Health Plans, High Premiums, High Prices, Market Consolidation, Market Power, Out of Network, Out of Pocket Expenses, Out-of-Network • Leave a comment

https://www.beckershospitalreview.com/payer-issues/on-same-day-of-hospital-concentration-study-ama-says-payers-are-the-ones-with-less-competition.html?oly_enc_id=2893H2397267F7G

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In 2018, 75 percent of commercial health insurance markets were highly concentrated, according to a study published by the American Medical Association.

For its study, AMA analyzed market concentration in 382 metropolitan areas across the nation. AMA estimated that 73 million Americans with commercial health plans live in highly concentrated markets and don’t have many health plans to choose from. 

“Americans in three-quarters of commercial health insurance markets have a limited number of health insurers from which to choose,” AMA President Patrice Harris, MD, said in a prepared statement. “In almost half of metropolitan areas, a single health insurer has 50 percent or more of the market, and patients are not benefiting from this degree of market power. While health insurers grow corporate profits, networks are too narrow, premiums are too high, and benefits are too watered down.”

The study was published the same day the Health Care Cost Institute published an analysis finding a growing number of metropolitan areas have highly concentrated hospital markets. HCCI found that by 2016, hospital markets in the majority (72 percent) of 112 metro areas the institute studied were highly concentrated. HCCI said this “reflects the fact that most metros became increasingly concentrated over time.”

Read the full AMA study here.

 

Federal Reserve announces 2nd consecutive rate cut

Posted on by • Posted in Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Hospital, Hospital Industry, Interest Rates, Key Performance Indicators, Leadership, Market Uncertainty, Non-Profit Healthcare Industry, Performance Management, Pharmaceutical Industry, Physician Practice Management, Population Health, Strategy • Leave a comment

https://www.axios.com/federal-reserve-rate-cut-77c504c1-1bed-4336-9c37-490a3452a54f.html?stream=top&utm_source=alert&utm_medium=email&utm_campaign=alerts_all

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The Federal Reserve cut interest rates by a quarter point on Wednesday, bringing the target range for the benchmark Fed Funds rate to 1.75%–2%.

Why it matters: The Fed’s 2nd consecutive rate cut reflects worries about the U.S. economy. The trade war and slowing growth around the world have made corporate executives more worried than they’ve been in years.

  • The move prompted a near-immediate response from President Trump, who called chair Powell a “terrible communicator.” The president has demanded in a series of tweets that the Fed cut interest rates more aggressively.

The big picture: Speaking at a press conference, Powell again cited the trade war as a key risk to the economic outlook. “Our business contacts around the country have been telling us that uncertainty about trade policy has discouraged them from investing in their businesses,” Powell said.

  • Still, new projections showed a division among Fed officials about whether more rate cuts are warranted this year.
  • Powell did note that if “the economy does turn down, then a more extensive sequence of rate cuts could be appropriate.”

Powell also acknowledged the liquidity shortfall in money markets that has forced the Fed to intervene — something that before this week hadn’t happened since the financial crisis.

  • In response to the drama in the short-term funding markets, Powell suggested that the Fed may increase the size of its balance sheet through “organic growth” earlier than expected.

 

 

 

 

Report: 3 in 4 hospital markets are now ‘highly concentrated’

Posted on by • Posted in American Hospital Association (AHA), Antitrust, Harvard Global Health Institute, Health Policy, Health System, Herfindahl-Hirschman Index, High Deductible Health Plans, High Premiums, High Prices, Hospital, Hospital Industry, Market Consolidation, Market Power, Out of Pocket Expenses, Out-of-Network, Robert Wood Johnson Foundation, The Urban Institute • Leave a comment

https://www.fiercehealthcare.com/hospitals-health-systems/report-three-four-hospital-markets-are-now-highly-concentrated?mkt_tok=eyJpIjoiT1dJNE5tUTFZV0k1TVdRNCIsInQiOiJMakFtS1IzZmxaRDlQNUtjdFdMUHVYUFdBd1wvXC9EZFR3ekhHU3ZsYVNib2t3bTlEb0Z2bklLZndEZXFOTjZ1RVZ0bURYMXI5dGFNcW92SXFYV25HTVh4d01tNEY4YkVCUnBMamhpbllXSytVTW5ybGJ1OTh0UjJmVDRmSWJ6c1wveCJ9&mrkid=959610

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Nearly 3 in 4 hospital markets around the U.S. are “highly concentrated,” according to a new Healthy Marketplace Index report by the Health Care Cost Institute (HCCI).

Researchers examined more than 4 million commercial inpatient hospital claims between 2012 and 2016 and found 81 out of 112 (72%) were considered “highly concentrated” using the Department of Justice’s Herfindahl-Hirschman Index (HHI). That’s up from 67% in 2012. 

“Increasingly concentrated hospital markets have been linked to the rising cost of hospital care by nearly every expert in the field,” said Niall Brennan, president and CEO of HCCI, in a statement.

Funded by the Robert Wood Johnson Foundation, the report found:

  • 69% of markets studied experienced an increase in concentration.
  • Metro areas with smaller populations tended to have higher concentration levels. For instance, Springfield, Missouri; Peoria, Illinois; Cape Coral, Florida; and both Durham and Greensboro, North Carolina, had the most concentrated markets in the U.S.
  • Larger metropolitan areas including New York City, Philadelphia and Chicago had the lowest levels of concentration.
  • Some of the less concentrated metros in 2012 like Trenton, New Jersey, experienced larger increases in concentration over time.

“Our findings add to the growing consensus that most localities have highly concentrated hospital markets, and this is becoming increasingly true over time,” Bill Johnson, Ph.D., a senior researcher at HCCI and an author of the report, said in a statement. “The increased concentration we observed can be driven by many factors such as hospital closures, mergers, and acquisitions, changes in hospital capacity, patient preference, or changes in patients’ insurance networks.”

Previous, HCCI reports found inpatient hospital prices were rising in nearly every metro area studied. This new study found a positive relationship—but not a causal relationship—between price increases and increases in hospital market concentration. Those findings align with similar findings correlating consolidation with rising healthcare prices including from the Harvard Global Health Institute and the Robert Wood Johnson Foundation and The Urban Institute.

However, the American Hospital Association recently released its defense of consolidation in a report that argues mergers can improve costs by increasing scale, improving care coordination, reducing capital costs and improving clinical standardization.

 

 

 

Rate of uninsured people increases for first time since ACA rolled out

Posted on by • Posted in 2020 Election Issues, ACA, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Plan, Health Policy, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Medicaid, Medicaid Expansion, Out of Pocket Expenses, Short Term Health Insurance, Skinny Health Plans, Underinsured, Uninsured • Leave a comment

https://www.axios.com/uninsured-rate-increases-first-time-since-obamacare-ec6dbd6d-fffc-446d-be4c-02bed0d3ea3e.html

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Roughly 27.5 million people, or 8.5% of the U.S. population, had no health insurance at some point in 2018, according to new figures from the Census Bureau.

Why it matters: Last year’s uninsured rate increased from 7.9% in 2017 — the first time the uninsured rate has gone up since the Affordable Care Act has been in effect.

Between the lines: The uninsured population does not include the “underinsured,” or people who have medical coverage but face prohibitively high deductibles and out-of-pocket costs.

  • The figure also does not include people who have short-term plans, association plans and religious-based sharing ministries — policies the Trump administration has promoted, but that have holes in coverage that could leave people on the hook for high costs.

The intrigue: The type of coverage that witnessed the largest decline in 2018 was Medicaid, which fell 0.7 percentage points.

  • 4 states where the uninsured rate had a statistically significant increase were Alabama, Idaho, Tennessee and Texas, all of which have not fully expanded Medicaid under the ACA.

The bottom line: The uninsured rate is still markedly lower before the ACA became law, but it’s an odd paradox to see more people lose health coverage even though the economy created more jobs.

 

 

Biden, Sanders, Warren clash over Medicare for All in Houston

Posted on by • Posted in 2020 Election Issues, ACA, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Medicare, Medicare for All, Out of Pocket Expenses, Politics, Preexisting Conditions, Uncertainty, Underinsured, Uninsured, Universal Healthcare System, Value-Based Healthcare, Vote • Leave a comment

Biden, Sanders, Warren clash over Medicare for All in Houston

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The battle over health care that has dominated the Democratic race for the White House took center stage in Houston, where for the first time the top three candidates tangled over whether the nation is ready for sweeping reforms.

Former Vice President Joe Biden went back and forth at the opening of Thursday’s debate with the two progressives who are his leading challengers atop the polls, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.).

Arguing that the “Medicare for All” proposal championed by Sanders would cost people their insurance, Biden called out the Vermont senator as a socialist and said his proposals would be too costly.

At one point in the debate, Biden said of Warren and Sanders that “nobody’s yet said how much it’s gonna cost for the taxpayer.”

He also pointed to the taxes that would have to increase for middle class people to pay for Medicare for All.

“There will be deductible in your paycheck,” Biden said, referencing the chunk that taxes would take out of people’s pay.

Sanders said most Americans were getting a raw deal in terms of their present health care costs compared with countries that have systems more similar to his Medicare for All approach.

“Let us be clear, Joe, in the United States of America we are spending twice as much per capita on health care as the Canadians or any other major country on earth,” Sanders said. 

“This is America,” Biden retorted. 

“Yeah, but Americans don’t want to pay twice as much as other countries and they guarantee health care to all people,” Sanders responded. 

Health care is a top issue in the race according to polls, and Democrats believe they can win the White House if the general election against President Trump is focused on the issue.

But it is also the issue that divides the Democratic candidates the most, with Biden and other centrists proposing more modest steps, such as reforms to ObamaCare.

The battle over health care is intertwined with the debate Democrats are having over which of their candidates is best positioned to defeat President Trump, with some in the party worried that Warren and Sanders are too liberal to win a general election. Others say their bold ideas are what is needed for the party to defeat Trump.

Biden argues Medicare for All means scrapping former President Obama’s signature achievement, the Affordable Care Act, instead of building on it.

While Sanders touted that everyone would have coverage under his plan and that it would be more generous, with no premiums or deductibles, Biden countered with the cost of the proposal, which estimates put at around $32 trillion over 10 years.

In the debate’s first hour, Biden was already hitting Sanders and Warren over the cost of the plan.

“The senator says she’s for Bernie,” Biden said of Warren’s support for Sanders’s Medicare for All plan. “Well I’m for Barack.”

Warren, pressed by host George Stephanopolous on whether middle class taxes would rise from Medicare for All, did not directly answer, pivoting to argue that overall costs for the middle class would go down once the abolition of premiums and deductibles is taken into account.

“What families have to deal with is cost, total cost,” Warren said, adding: “The richest individuals and the biggest corporations are going to pay more, and middle class families are going to pay less.”

Other candidates were also in the middle of the Medicare for All exchanges.

Sen. Kamala Harris (D-Calif.), who drew flak in the early months of the campaign for seeming to change her position on health care several times, touted the plan she eventually developed, to allow some private insurance to remain under Medicare for All by allowing private companies to administer some plans in a tightly regulated way.

“I want to give credit to Bernie. Take credit, Bernie,” Harris said, while adding, “I wanted to make the plan better, which I did.”

At another point in the debate, Biden dismissed the idea that employers would raise workers’ wages if employers no longer had to provide health insurance under a Medicare for All system. 

“My friend from Vermont thinks the employer’s going to give you back what you’ve negotiated as a union all these years … they’re going to give back that money to the employee?” Biden said.

“As a matter of fact they will,” Sanders interjected.

“Let me tell you something, for a Socialist you’ve got a lot more confidence in corporate America than I do,” Biden responded. 

While all of the Democrats advocate large additional government spending to expand health insurance coverage, the debates over whether private insurance should remain as an option has proven to be a particularly fierce source of debate.

Republicans have sensed an opening on that point as well, eagerly bashing Democrats for wanting to take away employer-sponsored coverage that millions of Americans have. Sanders and Warren counter that Medicare for All coverage would be better insurance, with no deductibles at all, so people would not miss it.

“I’ve actually never met anybody who likes their health insurance company,” Warren said, noting people like their doctors, which they would be able to keep. 

Sen. Amy Klobuchar (D-Minn.), who has staked out a more moderate ground, tore into Sanders, though, over his plan’s elimination of private insurance.

“While Bernie wrote the bill, I read the bill, and on page eight of the bill it says that we will no longer have private insurance as we know it,” Klobuchar said.

“I don’t think that’s a bold idea, I think it’s a bad idea,” she added. 

Amid the division, Harris tried to strike a unifying note.

“I think this discussion is giving the American people a headache,” she said. “What they want to know is that they’re going to have health care and cost will not be a barrier to getting it.” 

 

Another round of debate over hospital consolidation

Posted on by • Posted in 2020 Election Issues, Antitrust, Health Policy, Health System, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Hospital, Hospital Industry, Market Consolidation, Market Power, Mergers & Acquisitions, Monopoly, Monopoly Behavior, Out of Pocket Expenses, Quality, Quality of Care • Leave a comment

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Are hospital mergers a good thing or a bad thing?

Much of the answer to that question depends on what happens after the merger—does the combined organization provide better, more efficient care, or does it use its increased leverage to raise prices? Yet another round of back and forth on this issue took place this week, as the American Hospital Association (AHA) released the results of a study it commissioned from economic analysis firm Charles River Associates (CRA), while a group of academic antitrust specialists countered with their own briefing in response.

The AHA study, based on interviews with select health system leaders and econometric analysis by CRA, shows (surprise, surprise) that consolidation decreases hospital expenses by 2.3 percent, reduces mortality and readmissions, and reduces revenue per admission by 3.5 percent—indicating that the “savings” from consolidation are being passed along to purchasers. The economists, including Martin Gaynor at Carnegie Mellon, Zack Cooper at Yale, and Leemore Dafny at Harvard, countered in their briefing (surprise, surprise) that CRA’s research was biased in favor of hospitals, and cited numerous academic studies that indicate that hospital consolidation drives overall healthcare costs higher.

Beyond the predictable debate, our view is that consolidation can and should lead to better quality and lower prices—but that it largely hasn’t delivered on that promise. The prospect of “integrated care” that’s often touted by consolidation advocates hasn’t materialized in most places, both because hospital executives haven’t pushed hard enough on strategies to produce it, and because the market lacks sufficient incentives to encourage it.

Many Americans clueless about out-of-pocket medical costs, study finds

Posted on by • Posted in 2020 Election Issues, ACA, Bad Debt Expense, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Out of Pocket Expenses, Underinsured, Uninsured • Leave a comment

https://www.beckershospitalreview.com/finance/many-americans-clueless-about-out-of-pocket-medical-costs-study-finds.html?origin=cfoe&utm_source=cfoe

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When it comes to out-of-pocket medical costs, many people are unaware of their potential financial burden, according to a new study released by Discover Personal Loans, a provider of banking tools and resources across various financing options.

For the study, researchers examined the average cost of certain medical procedures and compared them to perceptions of costs from 969 surveyed U.S. residents.

Four takeaways from the study:

1. Researchers found that a three-day hospitalization, knee replacement surgery and an appendectomy had the greatest variation of average actual costs compared to average perceived costs.

2. For example, surveyed Americans perceived the average cost of a three-day hospitalization to be $11,013, while the actual average cost posted on Healthcare.gov is about $30,000. That’s a variation of 63 percent.

3. The variation between average actual cost and average perceived cost for a knee replacement surgery and an appendectomy were 34 percent and 32 percent, respectively.

4. Surveyed Americans anticipate spending $2,016 for an emergency room visit, up 5 percent from the average actual cost from the Health Care Cost Institute and cited by CNN, $1,917.

Read more about the study here.

 

 

 

The plight of America’s rural health care

Posted on by • Posted in 2020 Election Issues, ACA, Bankruptcy, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Out of Pocket Expenses, Patient Safety, Rural Health, Rural Hospital, Safety Net Hospitals, Safety-Net Providers, Underinsured, Uninsured • Leave a comment

https://www.axios.com/the-plight-of-americas-rural-health-care-a34b6c66-7674-4f78-abdc-33f8e711a601.html

Illustration of a tractor plowing a field in the shape of a heart monitor that is petering out

Rural America is stuck in a cycle of increasingly vulnerable patients with declining access to health care.

Why it matters: Rural patients often can’t afford care, are being hounded by hospitals and collection agencies over their unpaid bills, and are facing the reality of life in communities where the last hospital has closed.

Rural Americans tend to be older, sicker and lower-income than urban Americans. They suffer from higher rates of obesity, mental health issues, diabetes, cancer and opioid addiction, as my colleagues Stef Kight and Juliet Bartz reported.

  • They’re also more likely to be uninsured or covered by Medicare or Medicaid, which pay doctors and hospitals less than private insurance does.
  • A small and shrinking population, mostly covered by insurance plans that don’t pay very much, many of whom need a lot of care, puts more financial pressure on providers, especially hospitals. Physician shortages are common.

What they’re saying: “Rural hospitals have long been right there on the edge on average, and we’re seeing more and more of them flip over to red,” said Mark Holmes, a professor at UNC-Chapel Hill and director of the Cecil G. Sheps Center for Health Services Research.

And hospital closures often exacerbate the problems communities were already facing.

  • Hospitals are often the largest or second-largest employer in a rural community.
  • 113 rural hospitals have closed since 2010, according to the Sheps Center.
  • These are disproportionately located in the South — the region with the nation’s worst health outcomes, and where most states haven’t expanded Medicaid — leaving hospitals with more uninsured patients.
  • A 2018 study in Health Affairs found that Medicaid expansion is “associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets.”

The bottom line: “What we have here is not one root cause; there’s multiple things going on here,” Holmes said. “All these sort of modest kind of trends are adding up to something that’s quite considerable.”

Go deeper:

  • Bloomberg Businessweek reported on eastern Montana’s sole psychiatrist, despite being the state with the nation’s highest suicide rate.
  • The Washington Post detailed a hospital in Missouri’s practice of suing its patients for payment — money that the hospital needed but patients generally don’t have.
  • Kaiser Health News and NPR have profiled the fallout in a rural community in Kansas after its sole remaining hospital closed, which included a 2-week lapse in nearby emergency care.

 

 

 

 

Rates for Affordable Care Act plans aren’t going up much

Posted on by • Posted in 2020 Election Issues, ACA, Health Insurance Industry, Health Policy, High Deductible Health Plans, High Premiums, Out of Pocket Expenses, Underinsured, Uninsured • Leave a comment

https://www.axios.com/affordable-care-act-plans-premiums-arent-going-up-much-1bfabbbe-5b97-400b-8c19-023bd7e4e545.html

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Premiums for Affordable Care Act coverage are going down in some places, and barely rising in others.

The big picture: Health insurers raised ACA rates dramatically over the past few years, largely due to political chaos. But their plans have still proven to be extremely profitable. Now many companies are lowering premiums as they expect to send money back to their customers.

Driving the news: Blue Cross Blue Shield of North Carolina is reducing the average premium for ACA plans by 5.5% in 2020.

  • Nationally, average ACA premiums are basically flat for next year and are going down in a handful of states, according to an analysis by ACA tracker Charles Gaba.

Between the lines: Insurers jacked up ACA premiums after the Trump administration cut off cost-sharing subsidies and nullified the individual mandate, and as Republicans threatened to eradicate the entire law, among other things. Now, they’re correcting for that overpricing.

  • BCBS of North Carolina CEO Patrick Conway said in an interview premiums are falling because the plan cut some providers from its already narrow network and changed the way it pays some hospitals. But he also said the company has “more expertise in the market than when we started.”
  • BCBS of North Carolina’s ACA plans have been extremely lucrative — in fact, too lucrative. The ACA requires insurers to spend at least 80% of their premiums on medical care, or rebate the difference back to their customers.
  • In the first quarter of this year, BCBS of North Carolina spent just 67 cents of every premium dollar on care for most of its ACA plans, according to financial documents.
  • Many other insurers are in the same boat.

The bottom line: ACA plans for many middle-class people remain prohibitively expensive — often around $600 a month for individuals who get no subsidies. But for those who get financial help, “this is a stable, functional, mature market,” said David Anderson, a health policy researcher at Duke University.