Ever since the ACA went into effect in 2011 (3 years before newly-sold policies had to be ACA compliant), to help reduce price gouging, insurance carriers have been required to spend a minimum of 80% of their premium revenue (85% for the large group market) on actual medical claims.
Put another way, their gross margins are limited to no more than 20% (or 15% in the large group market). Remember, that's their gross margin, not net; all operational expenses must come out of that 20% (15%). The idea is that they should be spending as much of your premium dollars as possible on actual healthcare, as opposed to junkets to Tahiti or marble staircases in the corporate offices, etc. Anything over that 20% (15%) gross margin has to be rebated to the policyholder.
With all the controversy over the frighteningly quick expansion of Artificial Intelligence (AI) systems over the past year or so into every facet of our lives, I decided to run a quick experiment using ChatGPT. My request was pretty simple:
"Write a blog post in the style of Charles Gaba."
I didn't include anything about healthcare or the Affordable Care Act...just my name.
Here's what it came back with, verbatim. I'm putting the whole thing in quotes because while it was sophisticated enough to make the topic of the post the history of the ACA and the U.S. healthcare system in general, I sure as hell didn't write this:
Title: The Healthcare Odyssey: Navigating the Waves of Change
Subtitle: Charting a Course Through the Turbulent Sea of Healthcare Reform
To: State Department Directors and Autonomous Agency Heads
From: Governor Gretchen Whitmer
The federal Families First Coronavirus Response Act, passed to respond to the COVID-19 pandemic, required Medicaid programs to keep participants continuously enrolled and provided additional federal funding to do so. In December 2022, Congress passed a law ending the continuous enrollment and winding down the associated federal funding. As a result, more than 3 million Michiganders will need to undergo redeterminations for Medicaid coverage or find alternative health insurance if they no longer qualify.
During the COVID pandemic emergency, Congress passed legislation which, among other things, required states to provide "continuous coverage" of people who enrolled in Medicaid or the CHIP program.
Normally Medicaid/CHIP enrollees have their eligibility statuses "redetermined" every month (or quarter in some states, I believe) to make sure they were still eligible for the program, but the Families First Coronavirus Response Act (FFCRA) stated that in order to receive increased federal funding of their Medicaid/CHIP programs, states couldn't kick anyone off as long as the public health emergency was in place (unless they died, moved out of state or asked to be disenrolled).
This requirement ended effective April 1st, 2023 via an omnibus bill passed back in December.
Back in 2021 when I was posting weekly (and later, monthly) analysis of COVID vaccination rates at the county level, several counties in particular caught my eye for different reasons. One of these was Marin County, California. As I noted at the time:
Of counties with more than 100,000 residents, the top-vaxxed are Marin County, CA (76.9% vaxxed); Sumter County, FL (76.4%); and Montgomery County, MD (76.2% vaxxed).
New York's implementation of the ACA's Basic Health Plan provision (Section 1331 of the law) is called the Essential Plan. It currently serves over eleven times as many people as Minnesota's "MinnesotaCare" program does (around 1.1 million vs. 100K). Part of this is obviously due to New York having a larger population, but that's only part of it (NY has 19.84M residents, just 3.5x higher than MN's 5.71M).
Under the ACA, most states have expanded Medicaid to people with income up to 138 percent of the poverty level. But people with incomes very close to the Medicaid eligibility cutoff frequently experience changes in income that result in switching from Medicaid to ACA’s qualified health plans (QHPs) and back. This “churning” creates fluctuating healthcare costs and premiums, and increased administrative work for the insureds, the QHP carriers and Medicaid programs.
There's been another development in the long, winding saga of the Kelley / Braidwood v. Becerra federal lawsuit, which seeks to strike down the Affordable Care Act's preventative services provisions requiring health insurance providers to cover a long list of preventative healthcare services at no out of pocket cost to enrollees.
For the full backstory behind this case (and why a plaintiff win against the government here would be far more devastating than "just" the specific provisions being struck down), read my prior post (with many updates) on the case.
The most recent development prior to today came on March 30th, 2023:
Judge Reed O'Connor STRIKES DOWN a major provision of the Affordable Care Act requiring insurers to cover a vast amount of preventive care cost-free (contraception, cancer screening, PrEP, a ton of pregnancy-related care). The ruling applies nationwide. https://t.co/wL26vkIPsd
NEW YORK – New York Attorney General Letitia James and Acting Department of Health (DOH) Commissioner Dr. James McDonald today warned New Yorkers about a new scam targeting New Yorkers enrolled in public health insurance programs and provided important tips to protect consumers. For the first time since March 2020, people enrolled in Medicaid, Child Health Plus and the Essential Plan will have to renew their health insurance coverage. Attorney General James and Acting Commissioner Dr. McDonald are urging New Yorkers to be vigilant in light of reports of scammers deceptively calling people and asking them to pay hundreds of dollars to maintain their health insurance.
“It is despicable that scammers are trying to exploit New Yorkers’ need for quality health insurance and uncertainty over ongoing Medicaid coverage,” said Attorney General James. “The best tool consumers and families have to combat scams is knowledge, and that is why I am committed to raising this issue. I urge everyone to follow our important tips, and anyone impacted by this scam to contact my office immediately.”
The Massachusetts Health Connector Board of Directors voted on Thursday, May 11, to ensure that health insurance plans used by five million Commonwealth residents to meet the state’s individual mandate continue to deliver high-value preventive services at no cost to consumers. This vote follows a March 2023 decision by a federal District Court in Texas to limit the scope of preventive services covered under the Affordable Care Act.
The proposed regulation amendments guarantee that Massachusetts residents with health insurance plans meeting state Minimum Creditable Coverage (MCC) standards will continue to receive key preventive services like cancer screenings, HIV prevention, and cholesterol-lowering medication without cost-sharing. These proposed regulation amendments protect coverage standards that are current practice in the Commonwealth.
