Health Plan Weekly

When President Joe Biden addressed a joint session of Congress late last month, he briefly exhorted lawmakers to “lower deductibles for working families” who get their health insurance on the Affordable Care Act exchanges. But Sen. Jeanne Shaheen (D-N.H.) in late February had answered that call by introducing legislation that would tie premium tax credits to gold-tier plans rather than silver, effectively making richer-benefit plans less expensive.

To find out how such a move would impact individual market consumers and insurers, AIS Health, a division of MMIT, spoke to health policy experts and actuaries who closely track the practical implications of ACA changes.

✦ Following on the heels of fellow startup insurers Alignment Healthcare, Inc., Clover Health Investments, Corp. and Oscar Health, Inc., Bright Health Group, Inc. on May 19 filed preliminary paperwork for an initial public offering (IPO) with the Securities and Exchange Commission. Bright Health has been rumored to be planning an IPO this year, and recently acquired telehealth platform Zipnosis, Inc. Founded in Minneapolis in 2015 by former UnitedHealth Group executives — including current Bright Health Executive Chairman Bob Sheehy — the insurer’s business model is based on close alignment with health care providers, a strategy that it says “provides consumers access to personalized care teams tailored to their individual needs.” It sells both individual market and Medicare Advantage plans and boasts “approximately 40 owned and managed advanced risk-bearing primary care clinics.”

✦ Anthem, Inc. said on May 19 that it is collaborating with the electronic medical record vendor Epic to “facilitate secure, bi-directional exchange of health information” between health care providers and Anthem’s affiliated health plans. By integrating Epic’s Payer Platform with Anthem’s operating system, Health OS, the initiative will allow payers and providers to seamlessly exchange clinical data as well as admissions, discharge and transfer data from patients’ hospital stays. Not only will that data exchange help close care gaps by providing point-of-care treatment decisions, it can also help streamline administrative processes like prior authorization, the companies said in a press release.

A recently reintroduced bipartisan bill would push health insurers to make “real-time” prior authorization determinations for Medicare Advantage (MA) beneficiaries. The bill, which was introduced by Rep. Suzan DelBene (D-Wash.) and co-sponsored by Reps. Mike Kelly (R-Pa.), Ami Bera (D-Calif.) and Larry Bucshon (R-Ind.), incorporates feedback from both payer and provider stakeholder groups.

“When seniors need critical medical care, doctors and other health care providers should be spending their time working with patients instead of going back and forth on requests that should be electronic, standardized, and eventually automated,” said DelBene in a May 13 press release. “The majority of the health care community agrees that prior authorization needs to be reformed. This bipartisan legislation creates sensible rules for the road and will offer transparency and oversight to the prior authorization process.”

Across the country, conservative state officials are going further than ever to thwart Medicaid expansion, taking steps to reverse successful ballot initiatives, reforming processes to block ballot measures before they reach voters — and erecting barriers to Medicaid enrollment for some residents who are already eligible. That’s all potentially bad news for Medicaid-focused insurers, experts say.

In Missouri, voters in August 2020 approved an amendment to the state constitution that expands Medicaid. However, the Republican-controlled state legislature refused to fund the new program. Though Republican Gov. Mike Parson had promised to implement the expansion program as recently as January, on May 13 he reversed his position and sent a letter to CMS withdrawing the State Plan Amendments required to launch the program. In response, a Missouri legal aid group filed a lawsuit against the state.

Three startup health insurers that became public companies this year — Oscar Health, Inc., Clover Health Investments, Corp. and Alignment Healthcare, Inc. — recently unveiled their first-quarter 2021 financial results, with all posting substantial net losses. While such results are not unexpected from still-growing companies, the details contained in the firms’ earnings reports suggest that they may not all be equally capable of eventually turning a profit, industry experts say.

“The overall takeaway from the quarter is that when you look across the board at all of the startup health plans, they all have materially underperformed the established, major health plans out there — the publicly traded ones that have reported their quarters so far. And the question is, what’s the degree of underperformance?” says Ari Gottlieb, a principal with the health care consulting firm A2 Strategy Group and a longtime critic of Oscar’s business model.