As Senate Republicans struggle over their attempts to repeal Obamacare, one word describes the landscape for health insurers: uncertainty.
It's not clear whether repeated GOP efforts to undo much of the Affordable Care Act will ultimately succeed, and time is running short with the approach in a few months of open enrollment for 2018 health plans.
Nor has it been clear, with no hearings in Congress over a bill that affects one-sixth of the economy, what exactly would be in the newest version senators will vote on.
In New York, insurers who sell plans for individuals and small groups on the state insurance exchange have priced their coverage on the assumption that key pieces of Obamacare will remain in place. Major changes increase the risk they will seek even higher premium increases than proposed or stop selling those plans.
What do health insurers want to see happen? Most of all, they want stability.
"In any year, you want to know what the rules are, the benefits, the factors that contribute to the cost of premiums," said Donald Ingalls, vice president of state and federal relations at BlueCross BlueShield of Western New York.
"Things have been knocked around in so many different ways. It's really hard to figure out a path and understand the revenue coming in and the health of the population you are insuring," said Dr. Michael W. Cropp, president and chief executive officer of Independent Health.
Republican proposals have included reduced subsidies to help people buy private health plans and elimination of penalties for not having health insurance, as well as a rollback of the Medicaid expansion and an end to many of the taxes that paid for Obamacare.
A handful of issues stand out among Western New York's major companies, as well as those nationally.
· The Trump administration has threatened to disrupt the Affordable Care Act's insurance market by ending what are known as cost-sharing reduction payments to insurers as a tactic to compel Congress to pass a bill. Previous versions of the bill in the Senate have called for continuation of the payments but only until 2020.
Insurers use the payments to offer plans with lower deductibles and co-payments to consumers who shop for insurance in online exchanges. People also use the exchanges to determine if they are eligible for federal subsidies under Obamacare to help cover the cost of coverage or if they are eligible for Medicaid, the federal-state health insurance program for the poor, or, in New York, the Essential Plan.
The exchanges are used by individuals who don't get coverage through an employer, or who don't receive Medicare or use the VA.
"Without the payments, health plans will have to increase premium rates or stop selling those plans," Ingalls said. "Affordability is the biggest factor for buying coverage. As rates go up, you would see a decrease in enrollees."
· If Republicans intend to repeal the penalty for those who don't purchase insurance, insurers want alternative mechanisms strong enough to get healthy people to buy coverage.
Without everyone in the insurance pool – old and young, healthy and sick – insurers argue it's impossible to spread risk and maintain affordable premiums for people with costly medical care.
· Many insurers fear a proposal by Sen. Ted Cruz, R-Texas, that would allow insurers to sell plans that don't comply with Affordable Care Act regulations as long as they also sell plans that comply with Obamacare's rules.
Their argument: His amendment would disastrously splinter the insurance market, with healthy people flocking to plans with low premiums but skimpy benefits and high deductibles; and sick people concentrated in a pool that charges very high premiums for coverage.
· Maintain funding for the expansion of Medicaid, the state-federal insurance program for the poor and disabled. Obamacare allowed states to expand Medicaid eligibility to people whose household incomes were up to 138 percent of the federal poverty level.
In New York, the bill's cuts would force the state to either sharply reduce its Medicaid program or pick up the $2.3 billion annual share of the costs that counties now pay for it. That's significant because Medicaid also covers costs for the disabled and long-term care to the elderly. The bill also would eliminate federal funding for the state's Essential Health Plan, which serves lower-income people who don't qualify for Medicaid, in a move that will cost the state an estimated $3 billion a year.
"The Medicaid expansion has been a growth engine in New York. Just ask the hospitals," said Cropp. "Increased access to primary care is also the right thing to do. You are getting people engaged in care earlier, and to think that we're going to pull the rug out from millions of people who now have coverage is devastating."
Under the GOP bill, 50 million Americans would lack coverage by 2026, compared with 28 million if the Affordable Care Act stays in place, the Congressional Budget Office reported on July 20. Nearly 20 million people have gained health insurance since 2010 under Obamacare.
Republicans have split over the proposals, with some wanting the current law largely repealed and others worrying that the Senate bill will lead to health plans with skimpy benefits and higher costs.
Insurers are also increasing pressure on negotiations over the Senate bill.
The Blue Cross Blue Shield Association put it this way about the subsidies: “With open enrollment for 2018 only three months away, our members and all Americans need the certainty and security of knowing coverage will be available and affordable for them." Justine Handelman, senior vice president of policy and representation, said July 18 in a statement for the organization, which represents 36 Blues plans.
In a joint letter July 14 to Senate leaders, the Blues Association and America's Health Insurance Plans, the industry's largest lobbying group, made it clear they strongly oppose the Cruz amendment.
"It is simply unworkable in any form and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage for people currently enrolled in the individual market," the groups warned.
In Western New York, the future of insurance coverage for thousands of people is at stake. More than 26,480 individuals had enrolled in the Essential Plan at the end of 2016, and 15,181 bought private health plans, according to the state Health Department. Statewide, 3.6 million New Yorkers enrolled for some type of insurance coverage on the state's exchange, including 665,324 people with Essential plans and 242,880 individuals who purchased private qualified health plans.
In this region, five companies sell qualified private health plans on the exchange, and eight insurers enroll people in the state's Essential Plan. Fidelis Care has the largest slice of the market, with 14,573 enrollees in private or Essential plans at the start of 2017.
"Following recent events in Congress, we are hopeful that there will be a renewed focus on creating stability in the individual insurance markets and on preserving the critical safety net that has been established for millions of New Yorkers with the Medicaid expansion," Fidelis Care spokeswoman Allie Abbate said in a statement.
She said Fidelis Care is committed to participating in the marketplace in 2018.
Regardless of how the contentious debate over the health law ends, insurers are also focused on what's received little attention so far from Congress and the Trump administration — the cost of health care and prescription drugs.
"Premiums just reflect the costs of care," said Cropp, who expressed disappointment over the government's role so far to tackle the problem. "That's the real issue, with prescription prices at the top of the list."
BlueCross BlueShield of Western New York offered a more hopeful tone, stating: "Our hope is that any new federal health insurance reform also addresses the fundamental costs of health care in this country — specifically soaring prescription drug costs — without adding taxes, fees or other overreaching regulation. "