Now let’s look at the dynamics from the larger perspective of the United States as a whole. According to a report from Aug. 19, 2016, in The New York Times and an analysis that the Times commissioned, there is exactly one ACA health plan selling policies in the exchanges in Alaska, Arkansas, Kansas, Oklahoma, South Carolina, and Wyoming. While small portions of these states have more than one plan, Missouri, North Carolina, Tennessee, Utah, and West Virginia have largely one ACA health plan per state.2 In contrast, in 2016, Wyoming and most of Utah had only one ACA plan. So what does that mean for the future of the ACA and the future of the broader health plan agenda?
Explore This IssueACEP Now: Vol 35 – No 11 – November 2016
The health plans can and will leverage their positioning in the exchanges on future federal and state administrations in an attempt to make OON balance billing prohibited by federal fiat (a legal, authoritative decision that has absolute sanction), as the Obama administration threatened to do in November 2015.
Much of it depends on the outcome of the presidential election. Hillary Clinton seeks to expand and defend the ACA, according to her policy papers on her website and her public statements. According to independent analyst Charles Gaba, the national average year-over-year (YOY) requested ACA premium increase is 23.9 percent for 2017.3 What would occur in the future if the health plans remaining in the exchanges didn’t receive their YOY premium increase requests from the Centers for Medicare & Medicaid Services (CMS) and state insurance officials?
The answer is that the health insurance exchanges would collapse, barring federal intervention—and isn’t that begging the question for the future of a single-payer system? The cynic would say that this was the goal all along: Make it look like a market-based solution for a few years and then sweep in with the “Medicare for all” proposal.
Finally, the dynamics of the ever-growing leverage a small number of health plans has over political leaders has major impact on the OON issues. The health plans can and will leverage their positioning in the exchanges on future federal and state administrations in an attempt to make OON balance billing prohibited by federal fiat (a legal, authoritative decision that has absolute sanction), as the Obama administration threatened to do in November 2015.4 Aetna proved this summer that it wasn’t below “leveraging” (threatening) the administration. Aetna has also been one of the loudest voices to drive OON reimbursement to at or about 125 percent of the Medicare fee schedule in states considering OON restrictions.