Boy, #12 on my "If I Ran the Zoo" compilation of ACA fixes seems to be taking off!

Earlier this year, in response to popular demand, I put together an extensive list of serious proposals to actually repair, improve and strengthen the ACA itself, as opposed to a) tearing it apart and replacing it with the GOP's Godawful pile of crap or b) tearing it apart and attempting to replace it with a total single payer system (which simply is not going to happen in the near future no matter what).

I came up with some of these ideas on my own (though I'm sure others have made similar suggestions), but most of them have been widely discussed by various heatlhcare wonks over the past few years. Some would require additional funding, but others are simply regulatory and wouldn't cost a single state or federal dime.

One of these seems to be catching on pretty quickly...number 12:

12. LEGALLY TIE MEDICARE ADVANTAGE/MANAGED MEDICAID CONTRACTS TO EXCHANGE PARTICIPATION.

Andrew Sprung, Michael Hiltzik and I have all written about this before. I have no idea whether it's even legally feasible/practical or not, but if so, it makes a lot of sense to me: Remember, many of the same carriers whning about losing hundreds of millions of dollars on the individual market are simultaneously making billions of dollars in profit off of their other divisions...which include fat federal and state contracts to manage Medicare and/or Medicaid plans. If they want to play in the managed care sandbox, make exchange participation a requirement as well. I'm not saying they should have to treat it as a loss leader--they'd still be able to raise their premiums at an actuarially responsible rate as appropriate--but they should have to at least participate.

Unfortunately, Medicare Advantage contracts are apparently done at the federal level (makes sense since it's a federal program), so that's not likely to happen anytime soon. Managed Medicaid contracts, on the other hand, are handled at the state level (MCOs = Managed Care Organizations), and that's a different story:

• First, I later found out that Nevada already had exactly this policy in place for several years. They actually backed off of it halfway this year, instead using a "point-based incentive" to strongly encourage carriers to participate in their exchange (any carrier which does so gets an extra 5 points towards their MCO contract preference scoring...call it "extra credit" towards winning the contract).

This is working beautifully for Nevada: Centene is expanding into NV's exchange next year, and even Aetna--which previously said they were bailing the indy market in every state--has agreed to participate next year specifically citing NV's MCO incentive as the reason.

• Then, New York Governor Andrew Cuomo announced that as part of a series of executive orders he's using to protect the NY insurance market in the event that the GOP's Trumpcare bill is signed into law, he's following my original advice and stating that any carrier which wants a shot at an MCO contract will indeed have to participate in the NY exchange. There seems to be some potential legal issues with this under NY state law, but assuming it's kosher, good for him; this is exactly what I was recommending.

• Finally, a couple of weeks ago, Colorado Governor John Hickenlooper tentatively hopped on board the MCO tie-in train:

Colorado Gov. John Hickenlooper said he's considering blocking insurance giant Anthem from state health care insurance contracts if it leaves the state's Affordable Care Act exchange.

Anthem Blue Cross Blue Shield is weighing whether to pull out of Connect for Health Colorado.

Hickenlooper, a Democrat, told Colorado Matters on Wednesday that barring Anthem from the state's lucrative Medicaid contracts is one of many options he's considering.

"We've certainly talked about that," Hickenlooper said, "... as a way to try to provide motivation that more insurers cover all parts of the state — or at least a number of parts of the state."

...If Anthem exits, 14 Colorado counties would be without an insurer on the exchange. The deadline for insurers to submit their 2018 plans to Colorado is June 19, 2017.

Well, it looks like just the threat of tying MCO contracts to exchange participation may have been enough:

Anthem BCBS says it has filed preliminary rates in CO today and is not commenting until state releases specific info #cohealth #copolitics pic.twitter.com/HLWMj1IIwq

— John Daley (@CODaleyNews) June 20, 2017

I wouldn't be surprised if other states make similar announcements (or at least threats) in the near future. Medicaid contracts are lucrative, and it's a perfectly reasonable bargaining chip for the states to hold over the carriers' heads. Remember, no one's saying the carriers have to underprice...if they genuinely need their rates to go up a certain amount to break even or make a reasonable profit, fine; this is just about requiring them to at least participate.

Anyway, stay tuned...if the Trumpcare bill goes through, all bets are off anyway.