The five largest commercial health insurers, which enroll 43% of the nation’s insured population, have become increasingly dependent on public programs for growth and profit, according to a new analysis, and that connection may have implications for stabilizing the overall insurance market.
Cathy Schoen, a senior scholar at the New York Academy of Medicine, and Sara R. Collins, PhD, vice president for affordable health insurance at the Commonwealth Fund, both in New York City, found that last year, Medicare and Medicaid made up nearly 60% of the healthcare revenues for the top five: UnitedHealthcare, Anthem, Aetna, Cigna, and Humana. Those companies also hold 52% of the Medicare Advantage market.
Large growth in Medicare and Medicaid rolls and revenues from serving public beneficiaries have added to their profits and have offset losses encountered in the individual markets during the first years of the Affordable Care Act (ACA).
The findings were published online today in Health Affairs.
However, although the individual ACA markets were widely thought to be stabilizing in early 2017, the marketplace has become volatile, with national carriers, including UnitedHealthcare, Aetna, and Humana, pulling out or severely curtailing participation in the midst of uncertainty surrounding the ACA. But all have continued to participate in state Medicaid programs and Medicare Advantage markets.
The researchers say that gap presents an opportunity for reform and better access.
“[T]here is potential to improve access if federal or state governments, or both, required insurers that participate in Medicare or Medicaid to also participate in the Marketplaces in the same geographic area,” they write. “Such requirements could ensure more viable and less volatile insurance, benefiting people insured within each market as well as those who cycle on and off public and private insurance.”
This has been seen at the state level in Nevada and New York, where such requirements exist. The authors note that in 2012, Nevada rejected Medicaid bids if the plans did not offer silver- and gold-tier individual Marketplace plans.
Other Help May Be More Important
Eric T. Roberts, PhD, an assistant professor and health economist with the University of Pittsburgh Health Policy Institute in Pennsylvania, told Medscape Medical News he agrees that a key problem to solve involves low-income people who cycle on and off Medicaid and who lose access to other insurance. “The evidence is that about a third of adults will gain or lose Medicaid eligibility in a given year,” he said, and they become eligible for exchange coverage with subsidies. There is much concern about having comparable coverage when they move between programs.
He said that requiring participation in state and federal programs and the exchanges is not necessarily the solution.
He noted there are a number of policies that states and the Centers for Medicare & Medicaid Services (CMS) are considering to help align provider networks and carriers across Medicaid and the exchanges.
For instance, CMS and the ACA created the Basic Health Program, which entitles people to a Medicaid-like product and a provider network up to 200% of the federal poverty level for those who do not qualify for Medicaid or the Children’s Health Insurance Program.
CMS has also tried in certain markets to indicate on the exchange plans whether a carrier participates in Medicaid to help consumers understand which plan is appropriate, given that they may gain Medicaid eligibility at some point.
“None of [these efforts] have appeared to have had discernible impact on improving continuity of access to care or mitigating effects of transitions in coverage,” Dr Roberts told Medscape Medical News.
Low-income people, especially if they have not had insurance recently, need help understanding their options and getting in the right plan, help that the ACA’s healthcare navigator program provided, he said. However, the federal government has made steep cuts to the funding for that program.
“This is a complex market to enter,” he said. “Any number of well-intentioned policies can try to bridge different programs, but a well-informed individual guiding someone through this process is often the best solution. That requires investment from the federal government and states.”
Paying physicians fairly to care for Medicaid patients will also improve access, he added, noting that the rates differ widely by state.
“That ranges from almost 40% of Medicare’s fee schedule in states like New Jersey to 90% of Medicare’s fee schedule in states like Maryland,” he said. “We need to talk not just about the name of the carrier on the insurance card but about the amount that states are supporting physician fees.”
Analysis Spanned Periods Before and After ACA
The researchers used corporate filings with the Securities and Exchange Commission to study trends from 2010-2016, which captures the 3 years before and after major ACA reforms.
They found that over the study period, the five companies were making substantial gains.
“The membership increase from 2010 to 2016 for the five insurers combined was more than double the increase from 2005 to 2010 ― the five years leading up to passage of the ACA,” they write.
The authors found that the increase was driven largely by Medicare and Medicaid. Among the five companies combined, membership in the two programs doubled, from 12.8 million to 25.5 million.
There are risks with interdependence as well as potential benefits in an increasingly consolidated payer industry, the authors note. Multistate firms have shown that they will leave Medicare and Medicaid unless they can get large returns. That could put pressure on public programs to increase plan payments to keep them.
“[U]nless dominant insurance companies see themselves as public agents in for the long haul and willing to accept slim margins from publicly sponsored insurance programs in exchange for volume, the nation may face instability and volatility in both private markets and public insurance programs,” they conclude.
The Commonwealth Fund provided a grant to Cathy Schoen at the New York Academy of Medicine to support this analysis. Dr Roberts has disclosed no relevant financial relationships.
Health Aff. Published online December 4, 2017. Abstract
For more news, join us on Facebook and Twitter
Tidak ada komentar:
Posting Komentar