Health Plan Weekly

Lobbying spending by the health care industry has increased steadily over the past decade, reaching $129.3 million in 2023, according to data compiled by OpenSecrets. Among the major health plans and industry organizations, Blue Cross Blue Shield plans, AHIP, The Cigna Group and UnitedHealth Group spent the most during the 2023-2024 period, with BCBS plans spending more than $43 million from 2023 through the second quarter of 2024.

Since 2016, the health services/HMOs industry, which traditionally gives more to Republicans, has shifted to distribute more campaign funds to Democratic lawmakers. With the 2024 presidential election around the corner, around 57.3% of funds were donated to Democrats in the 2023-2024 election cycle. Among the top 20 lawmakers who received the most contributions from the industry during this election cycle, 11 are Democrats. Kamala Harris, who is running for president after President Joe Biden dropped out and endorsed her, topped the list and received over $2,347,000. Former President Donald Trump, the Republican presidential nominee, received $638,421.

Five insurers received the highest scores in the latest National Committee for Quality Assurance (NCQA) Health Plan Ratings, which assess plans based on patient experience and clinical quality. Two of those health plans tell AIS Health that their early adoption of value-based care models and buy-in from physicians and members are the keys to achieving their highly rated status. 

The results of the annual NCQA report were published on Sept. 16 and included 1,019 commercial, Medicare and Medicaid health plans that reported Healthcare Effectiveness Data and Information Set (HEDIS) data to the NCQA, representing about 227 million people.  

In August, Highmark Inc. launched a new Medicaid managed care organization in West Virginia, becoming the Mountain State’s first Blue Cross Blue Shield-branded MCO. In doing so, the insurer will confront challenges that MCOs of all stripes are facing, such as building a comprehensive provider network and grappling with the financial pressures related to states resuming their routine eligibility checks after a multiyear pause.    

The West Virginia Dept. of Human Services approved Highmark Health Options’ application to be the state’s newest MCO in January, giving the not-for-profit organization a statewide contract that runs for four years. Highmark Health Options will compete against a trio of MCOs in West Virginia that include Elevance Health, Inc.’s Unicare Health Plan of West Virginia, Aetna Better Health of West Virginia, and The Health Plan’s Mountain Health Trust. As of September, Highmark Health Options West Virginia had attained roughly 1,800 members, according to AIS’s Directory of Health Plans (DHP). 

Three transgender women filed a lawsuit on Sept. 10 against CVS Health Corp.-owned Aetna alleging the insurer denied them coverage of gender-affirming facial reconstruction (GAFR) surgeries and procedures in violation of an Affordable Care Act statute. David Kaufman, a lawyer who is not involved in the case, tells AIS Health the plaintiffs made a “pretty persuasive argument” in the lawsuit, although he points out that court proceedings are “often a tedious, drawn-out process” and it remains to be seen whether a judge will certify the case as a class action. 

The plaintiffs — Binah Gordon, Kay Mayers and an individual identified as S.N. — alleged the surgeries and procedures they sought were medically necessary and that Aetna violated “the prohibition on discrimination on the basis of sex in federally funded health programs and activities under Section 1557” of the ACA. Gordon, a 42-year-old Nebraska resident who works as a language curriculum specialist at a community college, was covered under an Aetna plan in the federal employee health benefits program. Mayers, a 52-year-old Alaska resident who works in information technology, and S.N., a 48-year-old physical therapist from Pennsylvania, were enrolled in Aetna employer-sponsored plans.