Compelling research released March 30 by the Blue Cross Blue Shield Association (BCBSA) shows that individuals who enrolled in Blue Cross and Blue Shield (BCBS) health plans after the Affordable Care Act (ACA) took effect have higher rates of disease and received significantly more medical care, on average, than those who enrolled in BCBS individual plans prior to 2014. The report, “Newly Enrolled Members in the Individual Health Insurance Market After Health Care Reform: The Experience from 2014 and 2015,” represents a comprehensive, in-depth study of actual medical claims among those enrolled in individual coverage before and after the ACA took effect. The study also compares this group to those who receive insurance through their employers. Alissa Fox, senior vice president of the office of policy and representation for BCBSA, said the report was another signal that “better communication and coordination is needed so that everyone understands how to avoid unnecessary emergency room visits, make full use of primary care and preventive services, and learn how to properly adhere to their medications.” Building on what colleague Sam Glick talked about in a Wall Street Journal summary, Jim Fields, Oliver Wyman’s Global Head of Health Services, explains how the findings have potentially far-reaching business and policy implications for the Blues:
1) The characteristics of these new enrollees have driven the Blues’ very public losses on exchange business
- Between 2016 and 2017, pricing in most markets should reach a point that better reflects the utilization profile of the population.
- Some of the lower cost but financially unsound co-ops are leaving the market, which will bring more equilibrium to the pricing environment.
2) Policy makers and regulators will need to continue to refine the program to create a sustainable market
- In a number of states, many of the ACA individual enrollees are those beneficiaries that were previously covered by high risk pools. Subsidies and risk sharing mechanisms need to adequately cover the higher costs of this population in order to keep overall prices low enough to attract healthy individuals and achieve a balanced risk pool.
- Blues, and other plans committed to the ACA market, need to vocally push the Center for Consumer Information and Insurance Oversight (CCIIO) for these protections in order to ensure the insurance market remains viable so that vulnerable populations can continue to receive health coverage.
3) The report underscores the advocacy role of the Blues
- The Blues’ influence and importance in the communities that they serve is increasing as their membership represents more vulnerable populations.
- The results seem logical given improving unemployment and expanded Medicaid policies, both leading to more people moving across funding sources at the lower income levels.
- These economic shifts can exacerbate issues related to care coordination and where one seeks care as often patients lose their doctor during transitions or don’t have the employment flexibility to access care until they are symptomatic.
4) Simultaneous to working the pricing and policy agendas, plans need to aggressively manage care for the populations they have attracted
- Now that you have the membership, and you are getting your ‘price right’ for that membership, how can you manage cost on this population to remain viable?
- What are you doing to manage the unique care needs of this population?
- How are you designing your networks and benefits to encourage use of high quality and financially aligned providers?
- What types of experiences are you creating for members that attract them to preferred sites of care and encourage responsible health behaviors?
- Are you designing the product models and care models that will win on the future exchange market?