Health Plan Weekly

Under the Biden administration’s new regulations — which will allow Deferred Action for Childhood Arrivals recipients to receive federal health care coverage — more than 100,000 uninsured DACA recipients are expected to enroll in Affordable Care Act (ACA) marketplace plans next year, according to CMS.

As of Dec. 31, 2022, there were 580,000 active DACA recipients and almost 28% of them resided in California. A KFF survey showed that most people who were likely eligible for DACA lived in a family with at least one full-time worker and over half of them worked full time themselves. However, they were much less likely than U.S.-born individuals in their age group to receive health care coverage.

Hospital and outpatient service prices paid by commercial health plans grew in 2022, reaching a national average of 254% of Medicare’s compensation rate that year, according to RAND Corp. researchers. Experts tell AIS Health that they agree with the study’s conclusions that market consolidation is a key contributor to high prices and that higher costs are not correlated with higher quality. But they also say payers aren’t powerless to stem the tide of rising costs. 

According to the May 13 RAND research, which is based primarily off an analysis of commercial claims data from all 50 states and all-payer claims database data in states where it is available, hospital and outpatient prices have grown substantially since earlier versions of the same research was published that studied the 2010s. (For a more detailed look at the RAND data, see this infographic.) In addition, the study concluded that there is a strong correlation between market consolidation and high prices. 

Although insurers have bet big — and cashed in — on privatized Medicare and Medicaid plans, recently those business lines have shown some signs of distress.  

For example, Humana Inc. and CVS Health Corp.’s Aetna this week put concrete numbers behind the Medicare Advantage membership losses that they expect to sustain next year due to significant headwinds facing the MA industry. And heightened medical loss ratios in managed Medicaid dinged the otherwise solid first-quarter 2024 financial results recently reported by Centene Corp. and Molina Healthcare, Inc. 

Although first-quarter performance was decidedly mixed for the country’s largest publicly traded health insurers, three startup “insurtechs” — Oscar Health, Inc., Alignment Healthcare, Inc. and Clover Health Investments Corp. — largely impressed industry analysts with their financial results.  

Oscar had a particularly outstanding showing, as the Affordable Care Act marketplace-focused insurer recorded its first quarterly profit since its founding in 2012 (the firm went public in 2021). Its adjusted earnings before interest, taxes, depreciation and amortization (EBITDA) were $219 million, which was approximately $100 million ahead of the Wall Street consensus estimate. The firm reported diluted earnings per share of 62 cents, compared to an 18-cent loss in the first quarter of 2023.