“The opportunity to secure ourselves against defeat lies in our own hands, but the opportunity of defeating the enemy is provided by the enemy himself.”—Sun Tzu
Explore This IssueACEP Now: Vol 35 – No 11 – November 2016
Since the enactment of the Affordable Care Act (ACA) on March 23, 2010, and the creation of commercial health exchanges, there has been a growing stream (that has now become a torrent) of health plans leaving the exchanges. The insurance exchanges are where health plans like Blue Cross Blue Shield, Aetna, and UnitedHealthcare (UHC) have sold subsidized health care policies to individuals pursuant to the insurance mandates of the ACA. Citizens between 138 and 400 percent of federal poverty level (FPL) receive premium subsidies, and there are cost-sharing subsidies for folks who are at or below 250 percent of FPL. (Premium subsidies continue for folks from 250 percent of FPL up to a maximum of 400 percent of FPL, while the cost sharing [eg, coinsurance and deductible] subsidies phase out at above 250 percent of FPL.)
Also consider as an overall environmental assessment the full frontal assault by these same health plans at the federal and state level to ban or severely restrict out-of-network (OON) balance billing by hospital- and clinic-based physicians and in some cases specifically targeting emergency physicians.
You might be tempted to ask, how are the health plans’ participation (or lack thereof) in the ACA exchanges and the largely state-level efforts to ban and/or restrict OON balance billing related? Although it may seem that we’re talking about two different subjects, they’re more closely interwoven than you might think.
Staying “In Network”
Let’s take one case in point: Aetna’s announcement on Aug. 15, 2016, that it will withdraw from 11 of 15 states where it participates in the ACA exchanges.
In July 2015, Aetna announced that it would purchase Humana in a $37 billion cash and stock deal. In April 2016 while on a quarterly earnings conference call with analysts, Aetna CEO Mark Bertolini said of the ACA exchanges, “We see this as a good investment.” In May, Bertolini reiterated that Aetna planned to stay in the exchanges in response to questions regarding UHC’s decision to leave the exchanges in 2017.
After being asked to respond, however, Bertolini wrote to the US Department of Justice (DOJ) on July 5, 2016, saying, “If the DOJ sues to enjoin the transaction [with Humana], we will immediately take action to reduce our 2017 exchange footprint.”1 (Under the federal antitrust laws, the DOJ and the Federal Trade Commission have jurisdiction to review, revise, and/or legally oppose mergers and acquisitions.)