January 10, 2024

Oscar Says It Can Be Profitable in 2024 And May Expand To Other Products

Insurtech Oscar says its enrollment will hit 1.3 million members in the Exchanges once open enrollment concludes, a 31% increase year-over-year. It also could see positive margins in 2024, as much as 5%. It could expand into individual coverage health reimbursement arrangements (ICHRA) and Medicare Advantage (MA) in the future.

Both Oscar CEO Mark Bertolini (former Aetna CEO) and Centene CEO Sarah London are right that the Affordable Care Act (ACA) is here to stay with over 20 million enrollees.  

ICHRA is a good Trump-era rule that allows employers to make tax-free contributions toward employees’ individual coverage.  Oscar would be well-placed to offer a total ICHRA administrative solution coupled with enrollment in individual Exchange enrollment. Bertolini is a genius on this issue.

In other news, Alignment Healthcare touted its Star scores.

Additional articles:




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#oscar #exchanges #alighnmenthealthcare #medicareadvantage #ichra

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Premiums and Paperwork Discourage Enrollment in Healthcare

I don’t doubt what is found in this recent study published in Health Affairs – that even small premium contributions and paperwork lead to less uptake on insurance coverage.  As a Republican, I am a bit unique in that I advocate for affordable universal access. I believe healthcare should be affordable to all and contributions should be scaled based on income. What I find objectionable, though, is that some Americans care so little about their healthcare that they are unwilling to pay even a de minimis contribution or are too bothered to put in a little sweat equity to get covered.  You won’t get sympathy from me. I do not oppose some extension or permanency to the premium subsidy enhancements in the Exchanges.  But while some advocates will argue that we should dispense with small investments from the consumer for healthcare, I would argue otherwise. Skin in the game is important.  Everyone should appreciate what they are getting.

The Health Affairs study is here:


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#coverage #healthcare #healthinsurance

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Docs Push For Partial Or Full Restoration of Medicare Physician Pay Cut

Many may not see me as someone who is provider-friendly, but I do have sympathy for physicians with regard to Medicare payments.  They are constantly on a treadmill.  The funding scheme needs to be overhauled and a permanent fix applied.  The annual fights make no sense.  And I do believe they have impact on access.

#physicians #providers #medicare

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Dysfunction Junction: The Government Funding Deal That May Not Be A Deal

Rightist House Republicans ganged up with Democrats in a committee to sink a procedural vote on a government funding rule. It was meant to send a signal to House Speaker Mike Johnson, one of their own, that they are unhappy with the budget funding parameters.  The question is now will the procedural blocs continue in the House? As well, would Democrats ever jump off the budget deal and sink the overall compromise and shut down government?  There is a lot more to play out, including some so-called “poison pill” policies that could make their way into bills.

#governmentshutdown #spending #crs

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Exchange Enrollment Will Be Over 20 Million in 2024

The Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) announced that enrollment for 2024 in the various federal and state Exchanges under the Affordable Care Act (ACA) have hit over 20 million enrollees with another week to go.  I predicted in my blog and podcast that enrollment would jump from 16.3 million in 2023 to between 19 and 20 million.  I was right and wrong.  So happy!  Huge kudos to the Biden administration for driving enrollment in the Exchange via premium subsidy enhancements and reversing some very ugly Trump-era open enrollment and outreach/marketing restrictions.

CMS press release: https://www.cms.gov/newsroom/press-releases/under-biden-harris-administration-over-20-million-selected-affordable-health-coverage-aca

Additional article: https://thehill.com/homenews/4400342-obamacare-enrollment-breaks-record-for-third-consecutive-year/

#exchanges #aca #obamacare #coverage #healthcare

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KFF’s Great Public Service On Medicaid Redeterminations Research

The Kaiser Family Foundation (KFF) has done a huge public service with all its tracking and surveys on the Medicaid redeterminations that commenced again in April 2023 after suspension during the COVID pandemic.  In its latest installments of compelling material, KFF finds that 14.4 million have been disenrolled since redeterminations began again. Most lost coverage due to procedural reasons. 

Some key findings from the latest survey data show the following:

  • Despite some outreach, more than a third of people did not understand that redeterminations would occur again.
  • Some states have instituted best practices with regard to outreach and communication along with streamlining and administrative reform of eligibility processes.  But many have not.
  • States have been overwhelmed with the redetermination process and had inadequate staffing.
  • The eligibility process is complex and many simply do not understand it.  As a former state official constantly involved in eligibility processes, it is complex and I do not know how citizens deal with it.  Imagine if you have social determinant impacts, like many enrollees do.
  • Some are regaining coverage but not enough.
  • Some are moving to other coverage, such as state children’s coverage, but again not enough.
  • Affordability of other coverage is an issue, even in the Exchanges.

I hope that every lawmaker reads KFF’s material and takes it to heart.  After all, we are dealing with families’ healthcare and wellbeing here. Government has a duty to protect them.

Disenrollment tracker from KFF: https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-unwinding-tracker/

KFF: press release: https://www.kff.org/medicaid/press-release/with-more-than-half-of-medicaid-enrollees-awaiting-their-renewal-process-new-report-highlights-lessons-learned-that-can-inform-state-efforts-and-reduce-disenrollments-for-procedural/

#medicaid #redeterminations #coverage #kff

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Should Medicare Star Adherence Measures Go Away?

Interesting Health Affairs Forefront blog arguing Medicare Advantage and Part D Star measures for medication adherence should go away. The article raises some important points, including:

  • The measures are many years old and may have outlived their usefulness.
  • The measures are not sensitive to appropriate vs. inappropriate medication use.
  • Measures are not sensitive to clinical changes.
  • Measures do not capture self-pay drugs (some generics are so cheap it could be less to self-pay compared to copays in a Part D drug plan) because measures are calculated based on Part D claims only. Others get meds from other government programs, such as the VA.
  • There is an emerging conflict between good clinical practice and exceling on the adherence measures. In essence, these measures can be gamed.
  • The measures prioritize purchase rather than use.
  • There may be technology that better ascertains disease state maintenance than medication adherence calculations.

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#medicationadherence #medicareadvantage #partd #pdp

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— Marc S. Ryan

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