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“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 Issue
ACEP Now: Vol 35 – No 11 – November 2016Since 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.)
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One Response to “Opinion: Affordable Care Act Consolidation Increases Health Plans’ Market Power”
November 21, 2016
Joseph Mooney MD, MBA, FACEPAt this point in time the bad actors in all of this are the CMS and the Insurances. We in the EM field are really sharp end of this inequity in health care coverage. Due to present legislation we see all comers, obviously the more insured the better ( as they say in the business, ‘self pay’ equals ‘no pay’). However, it would seem that although the ACA may have been well intentioned, it was still a bandaid to a already mortally wounded creature. Maybe our efforts should be toward a restorative solution to healthcare, both in cost and scope. I am not opposed the a single payer system ( although I doubt that it would be single, as seen in several countries that have a national systems) but I am only one and this is a nationwide issue. Present remedies to healthcare have been presidential decrees, politically motivated incomplete fixes that have been applied, however seem only to shift the holes in care. I am also not sure that the present patrician mandates that the government have in place and keeps expounding, are anything but propaganda as none tackle the issues to definitively repair of the problem. When I last looked at the cost of healthcare, a few years ago it, was up to 2 trillion dollars annually and the governments healthcare safety net, The Medicare Trust, had been in warning for a couple of years as the principle had been breached each year. At this cost, this is a national issue, and corrective measures may need a more defined approach. To that end, why not an amendment to the Bill of Rights to include healthcare. Although not specifically mentioned and unlikely to have been included as such in this document,( health care wasn’t something anyone wanted at that time as, well..it wasn’t of good or of value) and support an amendment specifically for health care. I believe such a move would be warranted as nationally we could clearly say how we want tax dollars to be spent towards our healthcare. I think that it would be beneficial to the citizenry to cut the cost of care. Either way, I believe that the costs would be greatly improved. With a national system, there would less gray area and cost and services would be more inline with a market economy where users and payers directly interact. The non-payers would vanish, as either it is all covered or if you can’t afford it, you don’t get it. I am not saying that physicians would be better off, as I don’t see that going forward in any of the present scenarios. I think that this is a downward slide for us, from our independence in the past to our earning potential, whatever course is chosen. However it turns out, it would be the people who decide and a mandate for a definitive plan would be made clear, not the present minimalist approach by the political machinery that only makes it appears that they care about the issue!