HEALTH INSURANCE EXCHANGES - University Of Iowa
HEALTH INSURANCE EXCHANGES: WHAT LESSONS CAN BE LEARNED FROM THE CONCENTRATION OR COMPETITION IN FEDERAL EMPLOYEE HEALTH BENEFIT PLANS? Timothy D. McBride Professor and Associate Dean for Public Health Washington University in St. Louis Co-Authors: Yolonda Campbell, Leah Kemper, Keith Mueller, Lisa Pollack, Fred Ullrich, Sidney Watson Washington University, University of Iowa, St. Louis University, RUPRI Center for Health Policy Analysis
Just Monday, the proposed rule for “Affordable Insurance Exchanges” was announced “ These proposed rules are a major step forward in implementing the Exchanges. Starting in 2014, individuals and small businesses will have the same affordable insurance choices as Members of Congress and will be able to purchase private health insurance through the Exchanges.” From “Obama Administration Rolls Out Standards for Health Insurance Marketplaces,” Robert Pear, New York Times, 7/11/11: “Trumpeting the advent of the exchanges, the administration said Monday that they would ‘give Americans the same insurance choices as members of Congress.’ However, in response to questions after a news conference on Monday, health officials acknowledged that this claim was not necessarily correct.” 2
Affordable Care Act and Health Insurance Exchanges By January 1, 2014, states will establish Affordable Insurance Exchanges for individuals and for small business employees Exchanges are entities for If not, the DHHS Secretary will establish and operate an Exchange in the state purchasing health insurance in a structured and competitive market, emphasizing choice of health plans, rules for offering and pricing of insurance, and transparency – providing information to help consumers better understand and navigate through options available to them. Eligibility: U.S. citizens, Legal immigrants, Small business employees Legal Obligations: Certify qualified health plans (QHP), Transparency, Communicate with beneficiaries, Administrative Tasks, Consult with stakeholders 3
Health Reform, Exchanges and Multi-state Plans, §1334 Per the rule: ”Section 1334(a) of the Affordable Care Act establishes multi-State plans; the Office of Personnel Management (OPM) will enter into contracts with health insurance issuers to offer at least two multi-State QHPs through each Exchange in each State.” Directs OPM to administer and negotiate with plans as they do with FEHBP contracts Uniform benefit package nationwide that meets ACA requirements for “qualified health plans” Must be licensed in every state and in compliance with all state laws not inconsistent with ACA §1334 For individuals and small groups A least one must be with a non-profit entity 4
FEHBP has been seen as a model for Exchanges for years “The HIE concept is broadly similar to the popular and successful Federal Employees Health Benefits Program (FEHBP), the consumer-driven system that covers Members of Congress, federal workers and retirees, and their families The FEHBP is the only large group insurance system in the nation in which individuals can choose the plans and benefits that they want at prices they wish to pay. As state officials work to reform their health insurance markets, they should take the best features of the FEHBP and apply them to their own markets ” Robert Moffitt, “State-Based Health Reform: A Comparison of Health Insurance Exchanges and the Federal Employees Health Benefits Program,” Heritage Foundation, June 2007. 5
FEHBP Plans Nationwide Fee-For-Service Open to All Blue Cross/Blue Shield Service Benefit Plans Standard Option PPO Basic Option Closed Network PPPO PPO Plans sponsored by unions, employee associations GEHA (various insurers provide network) NALC (Cigna Network) APWU (Cigna Network) SAMBA Nationwide (Cigna Network) Mail Handlers (Coventry Network in all states except NJ and OH) Nationwide Fee-For-Service for Specific Groups Rural Carrier Benefit Plan 3 others (Foreign Service, Panama Canal, Compass Ross State Specific HMOs, HDHPs and CDHPs 6
Question: What lessons can we learn from FEHBP program? Why? FEHBP program is: Nationwide Offers private plans Broad choice of plans and benefits Not as heavily regulated as other models (e.g. Medicare Advantage) Provision of consumer information Offered to a mixed set of enrollees (individuals, families) Key differences? FEHBP not as bound by state benefit mandates FEHBP is group purchasing agent FEHBP does restrict entry of plans Federal employees: not much exposure to low-income population SOURCE: Robert Moffitt, “State-Based Health Reform: A Comparison of Health Insurance Exchanges and the Federal Employees Health Benefits Program,” Heritage Foundation, June 2007 . 7
Research and Policy Questions What is the range of choice of plans offered in FEHBP in states and counties? How much competition and concentration do we see in plans, in terms of how individuals enroll in the plans? What is the variation in plan premiums and benefits, across the country, and in relation to plan characteristics? 8
Data sources and methods Data sources Federal Employees Health Benefits Program (FEHBP) County level data: Enrollment data obtained from U.S. Office of Personnel Management (OPM) in response to a FOIA request FEHBP premium and benefits data obtained from OPM website and participating plan brochures Area Resources File (ARF) US Department of HHS, Health Resources and Services Administration Methods Files merged at county level Descriptive analysis shown here today Leading towards multivariate analysis 9
Concentration in FEHBP, by Type of Plan FEHBP Enrollment by Type of Plan Total Enrollment 7.942 million 1% BCBS National Plans Other National Plans State Specific Plans 21% 15% 63% National Plans Limited Enrollment 10
FEHBP Enrollment, By Region and Plan Type Midwest 1% Northeast 20% 2% National Plans 15% State Specific Plans 79% South 1% 83% National PlansLimited Enrollment 1% West 15% 38% 61% 84% 11
Concentration, by Rural/Urban Urban Rural Enrollment 6,869,000 (86%) Enrollment 1,072,000 (14%) 1% BCBS Plans 3% 6% 23% Other National Plans 19% 15% State Specific Plans 61% 72% National Limited Enrollment Plans 12
Why so much concentration? Limited Availability of State-Specific Offerings While consumer-directed health plans and highdeductible health plans are offered in all states 11 States have no HMO offered AK, AL, 12 MS, NE, NC, SC, CT, RI, VT, NH, ME states have only one HMO offered OR, NV, MT, WY, CO, OK, AR, LA, TN, WV, DE, MA 13
14
15
99% of enrollees in counties with no state-specific plans are in nationwide plans. Most counties have few choices of state-specific plans available. About 30 counties have no state-specific HMO plans available. 74% of enrollees in counties with statespecific plans are in nationwide plans. Not shown are nationwide plans, one highdeductible plan (Aetna) available in most counties in the state, and one consumer16 directed plan available in 10 counties.
Level of Competition in FEHBP Market, by County Extremely Low ( .55) Extremely Low 7% (.45 - .55) 14% High ( 0.15) High 1% (.15-.25) 15% Low (.35 - .45) 31% Moderate (.25 - .35) 32% **Competition levels derived from Herfindahl index values, which measure concentration of firms. "High competition" refers to low-to-moderate Herfindahl indices (under 0.25), while "Moderate", “Low", and "Extremely Low" categories correspond to high Herfindahl indices of 0.250.35, 0.35-0.45, and above 0.45, respectively. 17
Level of Competition by Urban and Rural Counties 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Rural Urban High 0.15 High Moderate Low Extremely Extremely (.15-.25) (.25 - .35) (.35 - .45) Low Low (.45 - .55) ( .55) **Competition levels derived from Herfindahl index values, which measure concentration of firms. "High competition" refers to low-to-moderate Herfindahl indices (under 0.25), while "Moderate", “Low", and "Extremely Low" categories correspond to high Herfindahl indices of 0.25-0.35, 0.35-0.45, and above 0.45, respectively. 18
State-by-State Comparison State Comparisons Herfindahl Index* Premium Utah .25 43.10 Wyoming .45 45.20 North Carolina .38 41.00 South Carolina .40 42.10 Iowa .34 40.00 Nebraska .39 42.10 Louisiana .35 42.70 Alabama .59 45.20 National plans include the nationwide FFS open to all and nationwide FFS open only to specific groups. *A lower Herfindahl index equals a higher level of competition. 19
FEHBP Plan Attributes by Level of Competition Level of Competition (Based on Herfindahl Index) Premium (individual’s share) Copayments for: Primary Visits Specialist Visits Inpatient Hospital High ( .15) 57.27 18.90 27.78 348 High (.15-.25) 62.50 19.66 29.19 317 Moderate (.25-.35) 60.72 20.55 30.74 381 Low (.35-.45) 61.94 21.20 31.12 389 Extremely Low (.45-.55) 65.24 21.04 31.10 355 Extremely Low ( .55) 60.24 18.90 29.36 325 **Competition levels derived from Herfindahl index values, which measure concentration of firms. "High competition" refers to lowto-moderate Herfindahl indices (under 0.25), while "Moderate", “Low", and "Extremely Low" categories correspond to high Herfindahl indices of 0.25-0.35, 0.35-0.45, and above 0.45, respectively. Source of data: U.S. Office of Personnel Management (OPM) 2010 data. Produced by: RUPRI Center for Rural Health Policy Analysis, 2011 20
Summary and Policy Implications Findings FEHBP has a wide array of plan choices ostensibly offered, but most enroll in just the nationwide plans This likely is result of choices facing many enrollees or networks in their areas; but a historical connection of BC/BS organization with FEHBP Policy Implications ACA assures at least two national plans in every area FEHBP offers a cautionary tale: is this enough competition? State and federal policymakers may need to assure that the regulations are written to assure choice and competition 21
A potential limitation? FEHBP enrollees includes a good number of “annuitants”, that is retirees Thinking forward, the uninsured population entering Exchanges will not include retirees 2.8 million out of 7.9 million FEHBP enrollees are retirees Only 676,000 out of the 50.7 million uninsured are over age 65. However, note that we still have a large number (5.1 million of non-retirees in the FEHBP data) And 7.6 million outside of the D.C. area, and 4.9 million non-retirees. 22
Acknowledgements Funded by: Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services, Grant #U1C RH20419 RUPRI Center for Rural Health Policy Analysis, University of Iowa College of Public Health, Department of Health Management and Policy http://www.public-health.uiowa.edu/rupri Washington University, Brown School http://gwbweb.wustl.edu/Pages/Home.aspx Saint Louis University, Center for Health Law Studies http://law.slu.edu/healthlaw/index.html 23
3 Affordable Care Act and Health Insurance Exchanges By January 1, 2014, states will establish Affordable Insurance Exchanges for individuals and for small business employees If not, the DHHS Secretary will establish and operate an Exchange in the state Exchanges are entities for purchasing health insurance in a structured and competitive market,
The ACA required health insurance exchanges to be established in all states and the District of Columbia.3 In general, the health insurance exchanges began operating in October 2013 to allow consumers to shop for health insurance plans that began as soon as January 1, 2014.
STORED PROGRAM CONTROLLED TELEPHONE EXCHANGES. STORED PROGRAM CONTROLLED TELEPHONE EXCHANGES. A. Boesveld Rapporteurs: Mr. R.H. Campbell Dr. D.M. Russell This talk covers the historical development of telephone techniques, leading to the application of computer controlled exchanges. The structure and function of the programs used is described. 1 Introduction A telephone engineer, who talks on an international seminar in Computing Science, has to face a serious risk of .
The king's insurance options 5 Things you need to know 7 The stuff you need to do 14 How to claim 16 Our commitment to you 20 Car insurance 22 Car warranty 37 Shortfall cover 45 Scratch and dent 46 Tyre and rim 48 Motorbike insurance 53 Trailer and caravan insurance 64 Watercraft insurance 68 Home contents insurance 77 Buildings insurance 89
into stock exchange IPO and ongoing listing requirements. Stock exchanges can require companies to include provisions for Annual General Meeting (AGM) proxy voting and shareholder resolutions. The 2010 UN Sustainable Stock Exchanges event in China will focus on how stock exchanges and key stakeholders can improve ESG disclosure and
countries a new need for price discovery and even physical trading mechanisms, a need that can often be met by commodity exchanges. Hence, recent years have seen the rapid creation and growth of new commodity exchanges in developing countries. Exchanges in Asia have enjoyed the greatest success in the advancement of
What are WaSH marketing exchanges? Marketing exchanges describe the ways in which people gain access to water, sanitation and hygiene products and services. They involve a transfer of value among individuals and groups. Sometimes, this is interpreted narrowly as the transfer of 'money', but WaSH marketing exchanges can go beyond that.
of affordable health insurance to individuals, and give small businesses the same purchasing clout as large businesses. The Exchanges are scheduled to start open enrollments in October 2013, for insurance effective dates beginning January 1, 2014. They will allow individuals and small employers to compare private health
IGCSE – Accounting 0452 9 reputation of the firm which equal the difference between the net assets and selling price of the firm. 16. Direct expense of manufacturing There are any expenses which a manufacturer can directly link with the product begin manufactured 17. Appropriation account That account which shows how the profit for the year has been used 18. Collection period for trade .
