BITTER CHILL IN THE FALL AIR FOR OBAMACARE

by D. Kenton Henry, Editor, Agent, Broker

The Open Enrollment Period (OEP) when individuals and families can select and enroll in health insurance plans for the calendar year 2018 is, just around the corner, beginning, as usual, November 1. What is different this year is, the Department of Health and Human Services (DHS), which oversees Obamacare (the Patient Protection and Affordable Care Act ― ACA), has proposed ending it December 15th ― a period half as long as in all previous years. OEP historically ends January 31st. If this proposed change is effected, consumers, and agents and brokers on their behalf, will be under considerably more pressure to bind coverage during a period which has always been fraught with confusion and frustration. Expected to heighten the latter, are increasing premiums and less participation by insurance companies and providers. Increasing premiums (which have only accelerated during Obamacare) speak for themselves. Less participation by insurance companies means less competition and fewer plans from which consumers may choose. Less participation by providers means it will be even harder to find your doctor or hospital in the Health Maintenance Network (HMO) plans we Texans are forced to choose from since January 2016. Do not expect Preferred Provider Organization (PPO) plans to return for 2018. The reason behind this deliberate trend is the unstated agenda of the industry to accustom each of us to have our providers―and thereby our treatment―rationed. The stated agenda is an attempt to mitigate financial losses by the insurance companies. Those in office who would replace Obamacare, and our current insurance system, with a “Single-Payer” system have no problem, whatsoever, with this trend. This, because restrictions on providers and treatment will be inherent in any single-payer program.There are many in Washington who believe the solution to healthcare insurance is to add all of us to Medicare.Those who share in the belief the single-payer system is the solution should consider the reality that Medicare is 50 trillion is debt and predicted to be insolvent 12 years from now. (That is according to the Trump administration. Obama’s predicted it to be insolvent one year earlier, the Congressional Budget Office three years earlier) http://www.modernhealthcare.com/article/20170713/NEWS/170719951

And this is the reality with current members having paid into it their entire working careers. How do you think that is going to work when you add every other American, a great many of which are not contributing to Medicare and never have? In my mind, that will expedite the path to insolvency exponentially. Consider a true single-payer program which serves as an example: Veteran’s Administration Health Care. A beacon of mismanagement resulting in waiting lines, provider rationing, and, in many parts of the country, long travel distances for care.

To exacerbate the difficulty in predicting premiums, and budgeting accordingly, President Trump has stated he is considering withholding federal subsidies to insurance companies. Historically, these have bought down the retail premiums the consumer must pay. Here we are halfway through September, and we still do not know if Trump will do so. Now―here is the real wrench in the grist mill ― the insurance companies must submit their 2018 premiums to the State Insurance Regulators by September 30th!

“If there’s no deal on the subsidies within the next five weeks, states will have no choice but to approve rate increases that include surcharges and go with those rates for the start of open enrollment on Nov. 1. On average that would mean consumers would see an extra 20 percent price hike next year.” ― 20 August 2017, CNBC.COM

“In many ways, the die has already been cast… if nothing changes before the end of September, we’re pretty much looking at those rates being locked in for 2018,” said Wisconsin insurance commissioner Ted Nickel, who is also president of the National Association of Insurance Commissioners. ― 20 August 2017, CNBC.COM

That is 20 percent on top of general premium increases predicted to be in the 12 to 15% range.

Once again, whether you feel you need assistance in coping with these issues in electing your 2018 coverage and protecting yourself and family from the sky-rocketing cost of health care, please call me at 281.367.6565. I have been specializing in health insurance for 26 of my 31 years in insurance. I have assisted my clients in coping with Obamacare since its passage in March of 2010.

For those of you enrolled in Medicare ― Open Enrollment for election of your 2018 Part D Drug Plan begins, as usual, October 15th. Current clients should email me a list of your current drug regimen at allplanhealthinsurance.com@gmail.com. Upon receipt, I will provide you my recommendation your lowest out of pocket cost Part D plan in 2018. Those of you not currently my clients are encouraged to do the same.

http://thewoodlandstxhealthinsurance.com

https://healthandmedicareinsurance.com

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Featured articles:

Governors Tell Congress to Stabilize Individual Health Insurance Market

Michael Collins, USA TODAYPublished 1:25 p.m. ET Sept. 7, 2017 | Updated 5:45 p.m. ET Sept. 7, 2017

WASHINGTON — Governors from five states called Thursday on Congress to move quickly to stabilize the individual health insurance market and then embark on a serious effort to deal with skyrocketing health care costs.

“All of us — Republicans, Democrats and independents — should agree that our current path is not a sustainable one,” Tennessee Gov. Bill Haslam told a Senate panel.

The governors — three Republicans and two Democrats — testified during the second of four bipartisan hearings before the Senate Health, Education, Labor and Pensions Committee.

The panel is looking for a short-term fix to stabilize the individual market after the collapse of GOP efforts to repeal and replace the Affordable Care Act, or Obamacare.

The committee’s chairman, Sen. Lamar Alexander, R-Tenn., said he hopes senators can forge a bipartisan agreement by the end of next week and pass limited legislation by the end of the month to keep prices down and make it possible for everyone in the individual market to be able to afford insurance.

Congress must act quickly. New insurance rates for 2018 must be posted on the government’s website, healthcare.gov., by Sept. 27.

At Thursday’s hearing, the committee heard from Republican Govs. Haslam, Charlie Baker of Massachusetts and Gary Herbert of Utah and Democratic Govs. Steve Bullock of Montana and John Hickenlooper of Colorado.

A key issue is the future of federal cost-sharing payments to insurers that help them provide affordable coverage for low- and moderate-income families.

President Trump has threatened to end the payments, worth about $7 billion this year.

Read more:

With Obamacare in limbo, senators look for fix to stabilize health insurance market

Trump says GOP senators ‘look like fools’ on health care, warns of ‘imploding ObamaCare’

Congress has a crucial to-do list in September: Here’s what lawmakers must accomplish

All five governors testifying Thursday urged Congress to continue the payments, echoing the pleas of state insurance commissioners who appeared before the panel a day earlier.

The governors also called for creation of a reinsurance program that would limit losses to carriers that provide coverage in the marketplace and for the federal government to give states more flexibility to design and regulate insurance plans more suited to their own needs.

“It’s time for the federal government to work with us, not against us,” said Hickenlooper, arguing that state efforts to bring down premiums have been frequently undermined.

Without the federal government’s help, trying to keep insurance affordable is “like climbing one of Colorado’s famous 14,000-foot mountains in winter without crampons,” Hickenloopper said. “It can’t be done.”

Alexander said one option for giving states flexibility would be to allow the governor or state insurance commissioner to apply for a waiver from Obamacare’s rules, instead of waiting for the state legislature to act. He also suggested a “copycat” provision so that when one state wins federal approval for a program or initiative, other states could quickly follow suit.

Senators most likely will fashion a short-term stabilization plan that includes continuing cost-sharing for a limited period of time and gives states significantly more flexibility through Obamacare’s waiver process, Alexander said.

Once a short-term fix is enacted to stabilize the individual market, lawmakers can then move quickly to focus on how to make the market vibrant in the long run, Alexander said.

“I hope we can begin to spend most of our time on the larger issue of health care costs,” he said.

Two more hearings are planned next week. The committee will hear Tuesday from various health policy experts. Health care providers and other stakeholders will appear before the panel next Thursday.

Health Insurance

If Congress doesn’t fund Obamacare subsidies next month it could get pretty complicated

  • Insurers can’t wait past a Sept. 30 deadline to set key insurance rates for next year.
  • However, the fate of key subsidy payments under the Affordable Care Act is still unknown.
  • State health insurance regulators expect that subsidies could remain in limbo past key deadlines, and are making plans for that possibility.

Bertha Coombs | @BerthaCoombs

Published 8:01 AM ET Sun, 20 Aug 2017  | Updated 4 Hours Ago CNBC.com

https://www.cnbc.com/2017/08/19/if-congress-doesnt-fund-obamacare-subsidies-it-could-get-complicated.html

State health insurance regulators have been hoping for the best when it comes to 2018 exchange enrollment, but are now bracing for the worst-case scenario — that the fate of key health insurance subsidies will remain in limbo past key deadlines next month.

“We have a way to protect consumers, but it is complicated and will cause unnecessary confusion and anxiety,” said Diana Dooley, chair of Covered California, the state’s Obamacare exchange, in a statement Friday.

California officials say they will wait until the end of September to decide whether to let insurers impose a 12.8 percent surcharge on 2018 exchange premiums to account for the potential loss of cost-reduction subsidies that reduce out-of-pocket costs for low-income enrollees.

“We are extending our deadline to give Congress time to act when they return in September,” Dooley explained. “We are heartened by the bipartisan discussion that put consumers first, but we can’t wait past Sept. 30.”

Some Republican lawmakers have proposed passing a short-term funding bill next month to authorize 2018 reimbursements for cost-reduction subsidies insurers are required to make under the Affordable Care Act.

However, if there’s no deal on the subsidies within the next five weeks, states will have no choice but to approve rate increases that include surcharges and go with those rates for the start of open enrollment on Nov. 1. On average that would mean consumers would see an extra 20 percent price hike next year.

 

“In many ways the die has already been cast… if nothing changes before the end of September, we’re pretty much looking at those rates being locked in for 2018,” said Wisconsin insurance commissioner Ted Nickel, who is also president of the National Association of Insurance Commissioners.

Pressure to act fast

State insurance commissioners, insurers and most of the major health industry groups have been urging Congressional leaders to fund the so-called cost-reduction subsidies for months, but politically it puts Republicans in a difficult spot after their failure to repeal the Affordable Care Act.

A federal judge ruled in favor of House Republicans last year, after they sued the Obama administration arguing that funding for the subsidies was never authorized by Congress. That lawsuit has been put on hold three times since last fall, and is due back in court this week.

President Donald Trump has repeatedly threatened to pull the plug on the insurer reimbursements citing the ruling, though the administration has continued to make the payments on a month-to-month basis, and will make them for August.

“What’s likely to happen is that Congress will pass some kind of interim funding, which negates the lawsuit,” said Julius Hobson, senior policy advisor at the Polsinelli law firm, adding that barring congressional authorization “it’s difficult to get a remedy that forces the government to spend the money.”

One thing that could help tip the balance for reaching a deal is the Congressional Budget Office’s report, which estimated that cutting the subsidies would increase the deficit by $194 billion over 10 years, in part because higher premium rates would result in more people qualifying for tax credits.

But Congress also has a number of key deals it has to reach next month, including raising the deficit and reaching an agreement to fund the government in order to avoid a shutdown.

What if the payments get funded after the rate hikes?

If funding for cost-reduction subsidies were approved after rates are locked in for open enrollment, consumers would not likely get relief from the price hikes right away.

“The Medical Loss Ratio that was instituted by the ACA will still be in place, meaning that consumers will be reimbursed [if] insures are not spending an 80% minimum on [health] care costs,” said Christina Cousart, senior policy associate at National Academy for State Health Policy, but she added those rebates would happen retroactively.

Some consumers might not be made whole for the premium surcharges. The higher rates would likely result in even fewer healthy unsubsidized consumers signing up for coverage. While the rate increases should be high enough to shield insurers from losses on sicker enrollees, they would not necessarily result in big rebates for consumers.

“There’s no way we can back out these higher rates that the companies put in… We’re going to have more expensive health insurance plans, we’re going to have fewer people enrolled,” said insurance industry consultant Robert Laszewski, president of Health Policy and Strategy associates.

What’s also unclear is whether consumers who receive larger tax credits would have to pay them back at tax time, if insurers do provide premium surcharge rebates.

“This is really hard to say at this point, without knowing how it will all play out — which is why we believe that the best solution is for Congress and the administration to resolve this issue now,” said Covered California spokesman James Scullary. “A resolution now eliminates the need for all of these workarounds to protect consumers.”

If Congress manages to come up with a funding deal to keep the subsidies in place, Wisconsin’s insurance commissioner says they should not stop there. He says the current problems underscore the need to give states more flexibility to stabilize their exchange markets than they have under current Obamacare rules.

“We have so little control now, so much of it is coming from the federal government through more of a central planning function rather than letting states engage in ways that best needs of their consumers,” said Nickel. “We do find ourselves in very difficult straights.”

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Changes Coming for Next Year’s Obamacare Open Enrollment Period

The Trump administration is working to make changes to the Affordable Care Act (ACA)

With the confirmation of Tom Price as Secretary of Health and Human Services, the Trump administration is already working to make changes to President Obama’s health reform law, the Affordable Care Act (ACA).

No, the promised “repeal and replace” of the ACA (also known as Obamacare) hasn’t happened yet, but Mr Price’s Department of Health and Human Services (DHS) has issued proposed guidelines that would affect consumers during 2018’s Obamacare open enrollment period.

The 2018 open enrollment period is not scheduled to begin until the fall of 2017. If the ACA is repealed, this next open enrollment period may be Obamacare’s last.

Let’s take a look at some of the proposed changes:

  • Shorter open enrollment period for 2018 – The 2018 Obamacare open enrollment period is currently scheduled to run from November 1, 2017 through January 31, 2018. DHS’s proposed change cut the duration of the the open enrollment period by half so that it runs from November 1 through December 15, 2017.
  • Some loosening of benefit requirements – The Obamacare law sets strict guidelines for “minimum essential coverage” that all major medical health insurance plans must provide. Though details are not yet available, DHS is proposing to loosen these rules somewhat, allowing insurers to offer plans with a broader range of coverage options.
  • More supporting documentation required for special enrollment periods – Outside of the nationwide open enrollment period, consumers can only purchase coverage on their own when they experience a major life change, such as marriage or divorce, or the birth or adoption of a baby, etc. A proposed revision of rules would tighten the requirements for applicants to provide documentation proving their eligibility for a special enrollment period.
  • Changes to doctor network rules – Under Obamacare, the federal government sets standards for what constitutes an adequate network of participating doctors and medical facilities for major medical plans. A proposed change from DHS would allow states to set these limits for themselves instead.
  • Collection of overdue premiums – In a move designed to discourage applicants from neglecting to pay their monthly premiums near year’s end and simply re-enrolling with the same plan for January, a proposed DHS rule would allow insurers to collect overdue premiums before extending coverage to such applicants in the next year.

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Trustees’ report says Medicare will be insolvent by 2029

Modern Healthcare

By Virgil Dickson  | July 13, 2017

The Medicare trust fund will be insolvent by 2029, the program’s trustees reported today.

 

The prediction is a year later than the 2028 date the Obama administration outlined in last year’s report. The Congressional Budget Office in January 2016 estimated the program would be solvent only until 2026.

 

Based on the new findings, the feared Independent Payment Advisory Board, which was designated by the Affordable Care Act to rein in Medicare costs if they grew faster than a set rate, will not be activated.

 

That’s likely good news as the board, called a death panel by ACA opponents, has never had to be formed. There hasn’t been the need, and some say, the willingness to expend the political capital. With midterm elections coming and possible fallout likely if Republicans repeal the ACA, this is one less possible political headache to worry about. Also of note, 2029 is 12 years longer than projected estimates before the Affordable Care Act become law.

 

However, trustees are worried doctors will exit the program anyway. The report contained new concerns about access to physicians in the coming years due to the Medicare Access and CHIP Reauthorization Act.

 

MACRA replaced the physician payment updates under the sustainable growth rate formula, which clinicians were paid under for years.

 

Under MACRA the annual physician payment update for 2017 through 2019 will be 0.5%. For 2020 through 2025, there will be no payment update, which alarmed the trustees.

 

“These amounts do not vary based on underlying economic conditions, nor are they expected to keep pace with the average rate of physician cost increases,” the report said. “Absent a change in the delivery system or level of update by subsequent legislation, access to Medicare-participating physicians may become a significant issue in the long term under current law.”

 

The new insolvency date does incorporate modest savings from the agency’s move to value-based care, including accountable care organizations. However, exact figures were not broken out.

 

“The innovations being tested under the ACA, such as bundled payments or accountable care organizations, could reduce incentives to adopt new cost-increasing technologies and could contribute to greater efforts to avoid services of limited or no value within the service bundle,” the report says.

 

Medicare Part D expenditures per enrollee are estimated to increase by an average of 6.4% annually over the next five years; that’s higher than the projected average annual rate of growth for the U.S. economy, which is 5.2 % during that period.

 

The report found that these costs are trending higher than previously predicted, particularly for specialty drugs.

 

In 2016, Medicare covered 56.8 million people and expenditures were $678.7 billion up from $647.6 billion and 55.3 million beneficiaries in 2015.

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THE FUTURE OF HEALTH INSURANCE IN 2018

Shortly after 1:30 a.m. Friday, July 28th, the U.S. Senate voted 49-51 to reject the Health Care Freedom Act (HCFA), a “skinny repeal” of the ACA. The pared-down version was attempted after previous efforts to pass a more sweeping repeal of the law have failed. Senate Majority Leader Mitch McConnell (R-KY) began floating the idea early in the week before ultimately releasing the text of the bill at 10 p.m. Thursday, just two hours before the vote. Republican Senators Susan Collins (ME), Lisa Murkowski (AK), and John McCain (AZ) joined all Democrats in voting no, while all other Republicans voted in favor. With the failure of this vote, congressional Republicans will no longer be able to use the budget reconciliation process to repeal provisions of the ACA until the next fiscal year and will instead have to move legislation under regular order that would require 60 votes for passage in the Senate. ― NAHU 7/28 (washingtonupdate@nahu.org)

Anyone who tells you they know what the next few months before health insurance OPEN ENROLLMENT  (OE)―the period during which individuals and families may apply for and obtain coverage for the coming calendar year―will produce definitively, is deluding themselves. OE is scheduled to begin November 1 and run through December 7th. At this point, the only safe prediction is the preservation of the status quo. In other words, premiums will increase another 15 to 25% minimum; there will be fewer options regarding carriers and plans and fewer in-network medical providers from which to choose. In some parts of the country, it will be even worse, with only one carrier to choose from and―in some cases ― none. Whether that will be the case in Texas remains to be seen.

Here is what we do know:

1) Premiums will increase significantly in most areas

2) In the area of Houston, one more carrier―Memorial Hermann Health Plan―has announced they are withdrawing from the market. All of their current policyholders must find replacement coverage for 2018.

3) Humana has canceled all their current individual and family plans effective July 1 and will not participate in the market in 2018. This is in addition to Aetna, Cigna’s and Unitedhealthcare’s withdrawal from the market in 2017.

4) Residents of Harris, Fort Bend, and Montgomery Counties will (hopefully) have only plans from BlueCross BlueShield of Texas, Community Health Choice, and Molina Healthcare from which to choose.

5) The only remaining network option available from the above-referenced carriers will be Health Maintenance Organization (HMO) plans where the insured individual must seek treatment within the network or have no coverage whatsoever.

Here is an important change this editor (who is also a health insurance broker) recently learned. Married couples who are small business owners seeking Preferred Provider Organization (PPO) coverage as a way of having access to providers and treatment―will no longer be eligible for coverage with most (if not all) small group carriers unless they had a minimum average of one W-2 employee in the previous calendar year. This new stipulation would have prevented many of my business owner clients from obtaining the group PPO health insurance they now have, had it been in effect before January 1 of 2017. A prospective client of mine whose family coverage was canceled by Humana, July 1―in the midst of cancer treatment―now finds himself denied covered access to his oncologist and hospital. It appears all ongoing medical treatment from those providers, at least through the remainder of the year, will be self-funded. If you are a small business owner considering moving to group insurance in 2108, bear this in mind and begin paying at least one employee W-2, full time, through the remainder of 2017.

Small business owners considering a move to small group coverage who can meet this eligibility requirement, please contact me for assistance in making the transition.

For individuals and families who do not have a business, or employer sponsored health insurance, I will have whatever health insurance options are available to residents of your county and will soon begin testing and certifying (as I must each fall) to market these plans for the coming calendar year. I will be able to assist you whether you qualify for a subsidy of your health insurance premium or do not. If you do, I believe it will be much easier to obtain your subsidy and health insurance through me than by dealing with the marketplace, Healthcare.gov. If you do not qualify for a one, I have a strategy for minimizing your premium while giving you access to the provider of your choice. It is not appropriate for everyone, but it has worked for many of my clients.

Please contact me at 281-367-6565; text me at 713-907-7984, or email me at allplanhealthinsurance.com@gmail.com

Though I see little reason to be optimistic for a solution to the aforementioned problems until the Patient Protection and Affordable Care Act (Obamacare) implodes entirely, and Congress is forced to unite to provide a workable solution, let’s hope enough reasonable minds prevail before it comes to that. In the meantime, I am here to assist in acquiring the best available option, as I have for the past 26 years.

―D. Kenton Henry, editor, agent, broker

http://TheWoodlandsTXHealthInsurance.com

https://healthandmedicareinsurance.com

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FEATURED ARTICLE

GOP leaders say it’s time for Senate to move on from health care

(Jenny Starrs/The Washington Post)

By Sean Sullivan By Sean Sullivan July 31 at 9:24 PM

Senate Republican leaders signaled Monday that they intend to move on from health care to other legislative priorities, even as President Trump continued to pressure lawmakers to repeal and replace the Affordable Care Act.

The discord comes amid uncertainty in the insurance industry and on Capitol Hill about what will come next after last week’s dramatic collapse of the GOP’s effort to scrap the seven-year-old landmark law. Trump on Monday threatened to end subsidies to insurers and also took aim at coverage for members of ­Congress.

But the White House insistence appears to have done little to convince congressional GOP leaders to keep trying. One after another on Monday, top GOP senators said that with no evidence of a plan that could get 50 votes, they were looking for other victories.

“We’ve had our vote, and we’re moving on to tax reform,” said Sen. John Thune (S.D.), one of Senate Majority Leader Mitch McConnell’s top lieutenants, speaking of the next big GOP legislative priority.

Sen. Roy Blunt (Mo.), another member of the Republican Senate leadership, put it this way: “I think it’s time to move on to something else. Come back to health care when we’ve had more time to get beyond the moment we’re in — see if we can’t put some wins on the board.”

McConnell did not address health care in his remarks opening Senate business on Monday afternoon. His top deputy, Sen. John Cornyn (Tex.), brushed back comments White House budget director Mick Mulvaney made on CNN on Sunday urging Republicans not to vote on anything else until voting on health care again.

“I don’t think [Mulvaney’s] got much experience in the Senate, as I recall,” said Cornyn as he made his way into the Senate chamber. “And he’s got a big job. He ought to do that job and let us do our job.”

Mulvaney was echoing what Trump tweeted Saturday: “Unless the Republican Senators are total quitters, Repeal & Replace is not dead! Demand another vote before voting on any other bill!”

On Monday, Trump tweeted: “If Obamacare is hurting people, & it is, why shouldn’t it hurt the insurance companies & why should Congress not be paying what public pays?” He was referencing subsidies that members of Congress receive to help offset their coverage costs purchased through the District’s exchanges, as required under the Affordable Care Act.

Sen. Rand Paul (R-Ky.) said Monday that based on a conversation he had with Trump, the president is considering taking executive action on health care, Reuters reported. A Paul spokesman did not immediately respond to a request for comment, and it was not clear what such an action could be. Health and Human Services Secretary Tom Price indicated over the weekend that he was considering using his regulatory authority to waive the Affordable Care Act’s mandate that all Americans buy coverage or pay a tax.

Some rank-and-file Republican lawmakers have used the collapse of repeal-and-replace to offer new fixes and improvements to health care, but there was no sign their leaders were engaged. On Monday, Price met with fellow physician Sen. Bill Cassidy (R-La.), who has proposed restructuring how federal money is distributed under the Affordable Care Act. Separately, a bipartisan group of 43 House members released details of their own plan.

“We had a productive meeting. All involved want a path forward,” said Cassidy in a statement after his White House meeting, also attended by several governors. In addition to turning over federal funds to the states, Cassidy and Sens. Lindsey O. Graham (R-S.C.) and Dean Heller (R-Nev.) have proposed repealing key mandates and a tax under the law.

But there are no signs that plan will be put to a vote any time soon. It has not been scored by the nonpartisan Congressional Budget Office. It’s unclear how many Republicans would vote for it. And McConnell is working on confirming Trump’s nominees this week.

A growing number of Republican lawmakers have raised the prospect of working with Democrats on health care. The collection of centrist House Republicans and Democrats unveiled a proposal Monday calling for revisions they said would help stabilize the individual insurance ­market.

Rep. Tom Reed (R-N.Y.), a co-chair of the centrist Republican and Democratic “Problem Solvers Caucus,” which released the plan, said he and his colleagues have been working on a draft for about three weeks, as they saw “the writing on the wall” that the Senate bill was likely to fail.

House Speaker Paul D. Ryan (R-Wis.) did not champion the plan. AshLee Strong, his press secretary, said in an email: “While the speaker appreciates members coming together to promote ideas, he remains focused on repealing and replacing Obamacare.”

Strong did not respond to a follow-up question about how that ought to happen. The House passed a sweeping rewrite of the Affordable Care Act this year, with only Republicans voting for it.

The Senate tried to pass its own version but was unable to reach an accord, even on a more modest bill that was meant to keep the talks alive in both chambers. That bill was rejected Friday when Sen. John McCain (R-Ariz.) joined two other Republicans to sink the legislation in a tension-filled vote that happened while most of the country was asleep.

In their outline, Reed and his colleagues said federal cost-sharing subsidies should be placed under congressional oversight and that mandatory funding should be assured. Now such disbursements are up to the Trump administration, which has been paying them monthly but has threatened to withhold them.

Top Democrats and Republicans warned against that.

“Right now, as insurers prepare to lock in their rates and plans for 2018, the Trump administration is dangling a massive sword of Damocles over the heads of millions of Americans — threatening to end payments the administration is supposed to make that would lower deductibles and out-of-pocket costs for so many Americans,” said Senate Minority Leader Charles E. Schumer (D-N.Y.) on the Senate floor.

Thune said he was “hopeful” the administration would keep making the payments.

After Friday’s vote, some Democrats have felt more empowered to talk about changes to the Affordable Care Act. The centrist House lawmakers want to repeal the 2.3 percent tax on medical device manufacturers and loosen the employer mandate under the Affordable Care Act. The law says companies with 50 or more full-time employees must offer coverage. They want to raise the threshold to 500.

They also said they want to create a state stability fund to reduce premiums and spur more innovation at the state level.

Getting health-care legislation backed only by Republicans to Trump’s desk by the end of August is all but impossible, even if they suddenly put aside their disagreements. The House is in recess until September. The Senate is scheduled to be in session the first two weeks of August.

The prospects of a bipartisan deal were just as doubtful, amid fierce partisanship that has gripped the Capitol in the Trump era, which has shown no signs of abating. Even those pushing for one were tempering expectations.

“We’re not stupid,” Reed said. “Those partisan swords — they’re going to be out there.”

Paige Winfield Cunningham contributed to this report

SENATE ACA REPEAL AND REPLACE UP IN THE AIR

Senate’s ACA Repeal and Replace Bill Up In Air

― op-ed by D. Kenton Henry

The passage of the Senate’s Affordable Care Act repeal and replace bill, prior to their scheduled July 4th recess, is as up in the air as the fireworks will be coinciding with that illustrious date. With five Republican and additional Democrat senators currently opposed, its passage appears tenuous at best. This, in spite of President Trump’s expressed confidence it will happen.

As a medical insurance broker the past 30 years, I have certainly have an opinion on, and a vested interest in, the passage (or failure) of the bill. The reality is, the Democrats own the current Patient and Protection Affordable Care Act (PPACA). Not one Republican voted for it. Therefore (if repeal fails), come 2018, it will be the Democrat’s law which, I believe, will result in an even greater increase in health insurance premiums we have already seen skyrocket since the Act’s passage. And be certain―we will see an even greater exodus of insurance carriers from the marketplace, leaving some counties―and possibly states―with only one carrier. Or, possibly, none. In which case, Trump and the Republicans can continue to tell the Democrats, “We told you so!”.

The problem for the Republicans is, they were elected on a platform of repeal and replace. As such, there are two ways Republicans can fail the people. The first is by not fulfilling that promise. The second―and quite possibly the larger failure― is to pass something which turns out to be an equal or greater debacle than the PPACA itself. As much as I want to see the Act replaced with something better, upon analysis, I find myself largely in agreement with Senator Rand Paul. This bill almost resembles Obamacare more than it does not. Not only does it continue subsidies based on income, but it maintains ten of the twelve mandated “essential coverage items” which forced premiums up in the first place! The primary objectives of repeal and replace were to give people more control over the coverage they purchase and reject, and to bring premiums down. To acquire just what they need and reject what they don’t, all at a lower cost. As it stands today, the Senate bill cannot accomplish either because the remaining forced mandates will force insurance companies to keep premiums high while rationalizing the subsidies allow enough people to pay them using “other people’s money”. When all is said and done, if the bill passes as is, those who don’t qualify for a subsidy will feel angry and betrayed and our twenty trillion dollar budget deficit will grow at even faster than its current, virtually criminal, rate of escalation. Couple doing away with the individual mandate to purchase and maintain coverage with allowing people to purchase it anytime of the year―in spite of the state of their health―and you have a recipe for absolute failure. Many will refrain from purchasing until they receive a dread diagnosis, then purchase the insurance to force the loss of huge medical claims on someone else! I.e., the insurance companies and those responsible insured members who pay their own premiums. If passed without restrictions on when insurance may be purchased (Open vs. Closed Enrollment), I predict this replacement will fail more quickly than Obamacare has failed.

Who will be the major losers if this bill passes as is? Those individuals who must pay their own premiums; the American taxpayer; and―when the healthy drop coverage because they are no longer forced by law to purchase it―me. Who are the major winners? Employers who will see the mandate to provide coverage for groups of 50 plus dropped, creating an incentive to hire; Medical Device companies who will see taxes on their products repealed, encouraging innovation; those individuals and families who have someone else paying all, or the majority, of their premium; and the insurance companies who continue to be subsidized and receive even greater premiums (subsidized or not) for somewhat diminished coverage. And―in the case of where a broker’s compensation is based on a percentage of premium―me.

Who knows how this will ultimately shake out. All I know is, whatever the result, it will be a mixed bag depending on your position in the equation. Stay tuned and―regardless the result―contact me at 281-267-6565. Whatever your options, unless agents and brokers fall on the chopping block, I intend to be here to assist you identifying and obtaining the option most beneficial to your physical and financial health.

https://healthandmedicareinsurance.com

http://thewoodlandstxhealthinsurance.com

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FEATURED ARTICLE:

Senate health-care draft repeals Obamacare taxes, provides bigger subsidies for low-income Americans than House bill

By Paige Winfield Cunningham By Paige Winfield Cunningham June 21

Senate leaders on Wednesday were putting the final touches on legislation that would reshape a big piece of the U.S. health-care system by dramatically rolling back Medicaid while easing the impact on Americans who stand to lose coverage under a new bill.

A discussion draft circulating Wednesday afternoon among aides and lobbyists would roll back the Affordable Care Act’s taxes, phase down its Medicaid expansion, rejigger its subsidies, give states wider latitude in opting out of its regulations and eliminate federal funding for Planned Parenthood.

The bill largely mirrors the House measure that narrowly passed last month but with some significant changes aimed at pleasing moderates. While the House legislation tied federal insurance subsidies to age, the Senate bill would link them to income, as the ACA does. The Senate proposal cuts off Medicaid expansion more gradually than the House bill,\ but would enact deeper long-term cuts to the health-care program for low-income Americans. It also removes language restricting federally subsidized health plans from covering abortions, which may have run afoul of complex budget rules.

Senate Majority Leader Mitch McConnell (R-Ky.) intends to present the draft to wary GOP senators at a meeting Thursday morning. McConnell has vowed to hold a vote before senators go home for the July 4 recess, but he is still seeking the 50 votes necessary to pass the major legislation under arcane budget rules. A handful of senators, from conservatives to moderates, are by no means persuaded that they can vote for the emerging measure.

Aides stress that the GOP plan is likely to undergo more changes to garner the 50 votes Republicans need to pass it. Moderate senators are concerned about cutting off coverage too quickly for those who gained it under the ACA, also known as Obamacare, while conservatives don’t want to leave big parts of the ACA in place.

As a nod to conservatives, the Senate bill would give states more leeway in opting out of the ACA’s insurance regulations through expanding the use of so-called “1332” waivers already embedded within the law, according to the draft proposal. States could use the waivers to make federal subsidies available even off the marketplaces — but they couldn’t go so far as to lift ACA protections for patients with preexisting conditions.

But it may prove trickier to get moderates on board. Senate leaders are hoping the big draw for them lies in the bill’s more generous income-based approach to insurance subsidies, which closely mirror the subsidies offered under Obamacare.

Subsidies are available to Americans earning between 100 percent and 400 percent of the federal poverty level. Starting in 2020, under the Senate bill, this assistance would be capped for those earning up to 350 percent — but anyone below that line could get the subsidies if they’re not eligible for Medicaid.

The subsidies would also mirror the ACA in that they would be pegged to a benchmark insurance plan each year, ensuring that the assistance grows enough to keep coverage affordable for customers.

The Senate bill would also keep the ACA’s Medicaid expansion around for longer, gradually phasing it out over three years, starting in 2021.

Despite these shifts, moderates are likely to be turned off by how the bill cuts Medicaid more deeply than the House version. But the biggest cuts wouldn’t take effect for seven years, a time frame that could be more politically palatable for members like Sens. Rob Portman (R-Ohio) and Shelley Moore Capito (R-W.Va.).

Under the Senate draft, federal Medicaid spending would remain as is for three years. Then in 2021 it would be transformed from an open-ended entitlement to a system based on per capita enrollment. Starting in 2025, the measure would tie federal spending on the program to an even slower growth index, which in turn could prompt states to reduce the size of their Medicaid programs.

In a move that is likely to please conservatives, the draft also proposes repealing all of the ACA taxes except for its so-called “Cadillac tax” on high-cost health plans in language similar to the House version. Senators had previously toyed with the idea of keeping some of the ACA’s taxes.

The Senate bill would also provide funding in 2018 and 2019 for extra Obamacare subsidies to insurers to cover the cost-sharing discounts they’re required to give the lowest-income patients. Insurers have been deeply concerned over whether the subsidies will continue, as the Trump administration has refused to say whether it will keep funding them in the long run.

The House had a difficult time passing its own measure after a roller-coaster attempt, with the first version being pulled before reaching the floor after House Speaker Paul D. Ryan (R-Wis.) determined he did not have the votes. House Republicans went back to the drawing board and passed their own measure — which would more quickly kill Medicaid expansion and provide less-generous federal subsidies — on May 4.

Even if the Senate measure does pass the upper chamber, it will still have to pass muster with the more conservative House before any legislation could be enacted.

Juliet Eilperin and Amy Goldstein contributed to this report.

Health Insurance Plans and Premiums For 2017

health-insurance-premiums-2017

Well, here we are, two days from Obamacare Open Enrollment. Tuesday, November 1st, the starting gun goes off for Americans to shop for 2017 health insurance and we cross the finish line January 31st, at which point, our health insurance―barring a significant life change―will be locked in the remainder of the year. This month is my 30th year in the industry and it is my job to help you identify and elect your best health insurance option for 2017.

Here are the challenges ahead of us. As those of you who were in Under Age 65 health insurance market last year well know, you were forced off your PPO plan (assuming you were in one) and into HMO coverage. And you learned it was extremely difficult to find your doctors and hospitals in any HMO plan network. (In an HMO plan, you must utilize providers in your network or you have no coverage whatsoever.) Hence, you found your doctors, hospitals, and, effectively, your treatment rationed. Previews of the 2017 plans and premiums indicate most insurance companies have withdrawn from the market and those remaining are continuing to offer HMO coverage only. To add insult to injury, they are offering it at dramatically higher premiums. In Texas, premiums are 25% higher on average. And they are much higher in many other states.

As I write, plan and premium change notices are arriving in the mail and pushing the edge out of the sticker shock envelope. My own arrived, and while a 23% increase sounds good relative to what many of my clients are experiencing, the insurance company is also raising the deductible on my plan by a thousand dollars. A client left a message in my voicemail late Friday evening informing me his premium is increasing 58.9%. He went on to say, “That is unsustainable and I will pay the penalty before I pay that premium! We will have to find something else!” What he may not know yet―and what I will have to inform him―is that he will only have plans for two companies to choose from in his county. One is the company he is with. Regardless, all the options he will have are at significantly higher premiums than last year. Since 2014 (the first year Americans whose net income fell below a certain threshold were able to receive subsidies to offset a portion of their health insurance premium) I have said―if you qualify for a significant one―you may be happy with your health insurance premium. However, if you are one of the millions of hard working Americans making just above that threshold―in all likelihood―you are, like my client who left the voicemail, distraught over what is happening to your health insurance costs.

That being said, and as was already said, it is my job to help you identify your best option. And to do so without foregoing health insurance protection and paying the ensuing penalty for doing so. The strategy I employed for myself in 2016 is the same I will be utilizing in 2017. It is not what I would prefer, but what I would prefer is not an option. It is, however, the best option in light of the circumstances. Finances may not be your concern but access to your providers may be. Or, access to your providers may not be your concern but finances may be. Both may be your concern. My strategy may work for you or it may not. But I feel it provides the least compromise and is the best for adapting to this current state of affairs. At least until better options avail themselves in the individual and family health insurance market. Please contact me at 2813676565 to discuss it. If you feel it, or another approach, is the way you would like to proceed, I can make the application process go as quickly and smoothly as possible. And that is whether you qualify for a subsidy or not and without you having to personally deal with healthcare.gov.

ATTENTION SMALL BUSINESS OWNERS: You have possible recourse regarding the poor options in the individual and family health insurance market. If you are the owner of a legal business entity, e.g., LLC or corporation, you have an alternative. During the Small Business Open Enrollment Period (SBOEP)―from November 1 through December 15th―you may enroll your employer group and still have access to quality coverage and, more importantly, quality PPO provider networks where you are in control of who your providers are and, therefore, your treatment. During this SBOEP you will not have to meet the participation or contribution requirements which apply to small business group enrollment during the remainder of the year. In other words, you need only cover a minimum of two employees and you can require they pay 100% of their personal and family premium which will then be payroll deducted from their compensation. Please contact me if you have an interest in pursuing this strategy.

For those who are strictly in the market for individual and family health insurance, as of Tuesday, you may go to my website at http://TheWoodlandsTXHealthInsurance.com to review your options. While this site focuses on our hometown, it will provide quotes for residents of all 50 states. I can be the agent for residents of Texas, Indiana, Ohio and Michigan. Once there, you may apply online or call me to discuss the details of the options you see and I can submit your application for you. I the meantime (as of this moment), if you know―or believe―you qualify for a subsidy of your premium, you may go to my second quoting site where you may calculate the subsidy you qualify for or the penalty for not purchasing health insurance in 2017. You mag go on to obtain your quote and, if applying, log directly into healthcare.gov and apply. If doing so, when asked if you are working with anyone else on your coverage, select Agent or Broker and list my agent (legal) name, Donald Kenton Henry, and my National Producer Number (NPN) 387509. If you do this, I will be able to assist with any incomplete applications or outstanding requirements. If you become my client, in most cases, I can handle service related issues throughout the year without you having to deal with the personnel at healthcare.gov or an insurance company. The important thing I would like for you to appreciate is – you are charged not one penny more in premium by going through me for your health insurance than if you were to go directly through the front door of the insurance company whose product you wish to acquire and purchased it directly. And I charge no fee for my service. I only hope that, if I introduce you to a product you wish to utilize or a strategy, you wish to employ, you will acquire the product through me as your agent.

Click on this link to calculate penalties, subsidies and preview the plans available Tuesday, November 1: https://allplanhealthinsurance.insxcloud.com/my-quote/individual-info

I look forward to working with you and to, if becoming your agent, providing you the best of insurance service throughout the year. Again, please call me at 2813676565.

(Donald) Kenton Henry ― editor, broker

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FEATURE ARTICLE

The New York Times

Health Law Tax Penalty? I’ll Take It, Millions Say

By ROBERT PEAR OCT. 26, 2016

The decision by many healthy people not to sign up under the Affordable Care Act, even if it means a tax penalty, is undermining the plan. CreditKaren Bleier/Agence France-Presse — Getty Images

WASHINGTON — The architects of the Affordable Care Act thought they had a blunt instrument to force people — even young and healthy ones — to buy insurance through the law’s online marketplaces: a tax penalty for those who remain uninsured.

It has not worked all that well, and that is at least partly to blame for soaring premiums next year on some of the health law’s insurance exchanges.

The full weight of the penalty will not be felt until April, when those who have avoided buying insurance will face penalties of around $700 a person or more. But even then that might not be enough: For the young and healthy who are badly needed to make the exchanges work, it is sometimes cheaper to pay the Internal Revenue Service than an insurance company charging large premiums, with huge deductibles.

“In my experience, the penalty has not been large enough to motivate people to sign up for insurance,” said Christine Speidel, a tax lawyer at Vermont Legal Aid.

Some people do sign up, especially those with low incomes who receive the most generous subsidies, Ms. Speidel said. But others, she said, find that they cannot afford insurance, even with subsidies, so “they grudgingly take the penalty.”

The I.R.S. says that 8.1 million returns included penalty payments for people who went without insurance in 2014, the first year in which most people were required to have coverage. A preliminary report on the latest tax-filing season, tabulating data through April, said that 5.6 million returns included penalties averaging $442 a return for people uninsured in 2015.

With the health law’s fourth open-enrollment season beginning Tuesday, consumers are anxiously weighing their options.

William H. Weber, 51, a business consultant in Atlanta, said he paid $1,400 a month this year for a Humana health plan that covered him and his wife and two children. Premiums will increase 60 percent next year, Mr. Weber said, and he does not see alternative policies that would be less expensive. So he said he was seriously considering dropping insurance and paying the penalty.

“We may roll the dice next year, go without insurance and hope we have no major medical emergencies,” Mr. Weber said. “The penalty would be less than two months of premiums.” (He said that he did not qualify for a subsidy because his income was too high, but that his son, a 20-year-old barista in New York City, had a great plan with a subsidy.)

Iris I. Burnell, the manager of a Jackson Hewitt Tax Service office on Capitol Hill, said she met this week with a client in his late 50s who has several part-time jobs and wants to buy insurance on the exchanges. But, she said, “he’s finding that the costs are prohibitive on a monthly basis, so he has resigned himself to the fact that he will have to suffer the penalty.”

When Congress was writing the Affordable Care Act in 2009 and 2010, lawmakers tried to balance carrots and sticks: subsidies to induce people to buy insurance and tax penalties “to ensure compliance,” in the words of the Senate Finance Committee.

But the requirement for people to carry insurance is one of the most unpopular provisions of the health law, and the Obama administration has been cautious in enforcing it. The I.R.S. portrays the decision to go without insurance as a permissible option, not as a violation of federal law.

The law “requires you and each member of your family to have qualifying health care coverage (called minimum essential coverage), qualify for a coverage exemption, or make an individual shared responsibility payment when you file your federal income tax return,” the tax agency says on its website.

Some consumers who buy insurance on the exchanges still feel vulnerable. Deductibles are so high, they say, that the insurance seems useless. So some think that whether they send hundreds of dollars to the I.R.S. or thousands to an insurance company, they are essentially paying something for nothing.

Obama administration officials say that perception is wrong. Even people with high deductibles have protection against catastrophic costs, they say, and many insurance plans cover common health care services before consumers meet their deductibles. In addition, even when consumers pay most or all of a hospital bill, they often get the benefit of discounts negotiated by their insurers.

The health law authorized certain exemptions from the coverage requirement, and the Obama administration has expanded that list through rules and policy directives. More than 12 million taxpayers claimed one or more coverage exemptions last year because, for instance, they were homeless, had received a shut-off notice from a utility company or were experiencing other hardships.

“The penalty for violating the individual mandate has not been very effective,” said Joseph J. Thorndike, the director of the tax history project at Tax Analysts, a nonprofit publisher of tax information. “If it were effective, we would have higher enrollment, and the population buying policies in the insurance exchange would be healthier and younger.”

Americans have decades of experience with tax deductions and other tax breaks aimed at encouraging various types of behavior, as well as “sin taxes” intended to discourage other kinds of behavior, Mr. Thorndike said. But, he said: “It is highly unusual for the federal government to use tax penalties to encourage affirmative behavior. That’s a hard sell.”

The maximum penalty has been increasing gradually since 2014. Federal officials and insurance counselors who advise consumers have been speaking more explicitly about the penalties, so they could still prove effective.

Many health policy experts say the penalties would be more effective if they were tougher. That argument alarms consumer advocates.

“If you make the penalties tougher, you need to make financial assistance broader and deeper,” said Michael Miller, the policy director of Community Catalyst, a consumer group seeking health care for all.

http://www.nytimes.com/2016/10/27/us/obamacare-affordable-care-act-tax-penalties.html?smid=fb-share&_r=0

http://thewoodlandstxhealthinsurance.com

http://allplanhealthinsurance.com

https://allplanhealthinsurance.insxcloud.com/my-quote/individual-info

 

ON THE STATE OF OBAMACARE EXCHANGES AS 2017 OPEN ENROLLMENT APPROACHES

By D. Kenton Henry

As a health insurance broker the last thirty years, I have a vested interest in the state of the industry, and especially so since the Affordable Care Act (ACA) , commonly referred to as Obamacare, was passed in March of 2010. It has been a turbulent ride as I and my clients have struggled to adapt to each phase of the law’s implementation. This has been especially true, the previous three years, as I prepared―and now prepare again―for “Open Enrollment” (OE). OE is the period during which the Department of Health and Human Services allows people to acquire individual and family health insurance for the coming year. This year, it is scheduled to run from November the 1st through January 31st. I say “scheduled”, because they typically extend it in an effort to give people more time to enroll. And, apparently, the Department needs to give people as much time as possible because the latest numbers indicate Obamacare enrollment has fallen significantly short of expectations. (Refer to our feature article from The Washington Post below.)  As it explains, enrollment in the exchanges is less than half initially predicted. The success of the exchanges was predicated on the young and healthy enrolling in numbers sufficient to offset the sick and elderly who would naturally submit more and higher claims to the insuring companies. The young and healthy have largely declined enrolling―presumably and primarily because, well―they’re young and healthy. Had they enrolled, the theory was they would have diluted the claims (losses) with positive (no losses) premium dollars. Additional factors are that, unless someone qualifies for a subsidy, the premiums are high and, for the most part, going higher. The only cases where premiums seem to have gone down are where the insured members are forced into Health Maintenance Organization (HMO) plans where they find their providers and treatment rationed. Furthermore, the penalties (“Shared Responsibility Tax”) for not having insurance, relative to the premiums for having it, are so small as to be largely ignored. Yes, the penalties are increasing but not in proportion to the premiums. And word is, the premiums are only going higher in 2017.

*(CLICK ON THE GRAPHIC TO ENLARGE STATE BY STATE PROJECTED 2017 PREMIUM INCREASES.)

PREMIUM STATS 2017

As our feature article from the Wall Street Journal ( posted below) describes ―another factor detrimental to the success of the Act and the exchanges is decreasing competition among carriers. In spite of the high premiums they charge, insurers are experiencing losses too great to allow them to remain in the marketplace. As a result, they are dropping out in ever increasing numbers. These losses result, in part, because the government itself has cut the subsidies they originally promised insurance companies in order to offset the losses they anticipated. Obviously, companies have less money to pay the higher than expected claims they are experiencing. A Kaiser Family Foundation study, cited in the WSJ article, indicates exchange shoppers may have only one insurance company to choose from in 31% of the nation’s counties and the possibility of only two in another 31%. While many are quick to blame the “greedy” insurance companies, this editor feels the need to point out the reality that insurance companies are not charities. And even charities must operate in the black if they are to remain in existence. It is my opinion that only the government feels it is entitled to operate at a loss and, additionally, that, that is acceptable. Of course, when your are operating entirely with other people’s money―that is a much easier thing to do.

I will now put down my keyboard and go back to studying, testing and certifying to offer and provide the new Obamacare and Medicare related plans to both my clients and prospective clients for 2017. It amounts to an investment of many hours in order to remain informed and credible in an extremely complicated market. As in 2016, one key hurdle for those purchasing 2017 individual and family coverage will be to deal with the inability to find their doctors, and even their hospitals, in the HMO networks. I have developed a strategy for coping with this which I have utilized for myself. While it does not entirely eliminate the inconvenience of the aforementioned problem, it does soften the blow and in some cases―from a purely monetary standpoint―offset the loss in dollars a total and ideal solution would have cost.  Please call me at 281.367.6565 to discuss this and other strategies designed to minimize the difficulties and accompanying stress of identifying and acquiring 2017 health insurance.

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FEATURE ARTICLES

Wall Street Journal

Health Insurers’ Pullback Threatens to Create Monopolies

Analysis suggests ACA exchanges are likely to offer just one coverage option in 31% of U.S. counties

By Anna Wilde Mathews and Stephanie Armour

Updated Aug. 28, 2016 7:47 p.m. ET

Nearly a third of the nation’s counties look likely to have just a single insurer offering health plans on the Affordable Care Act’s exchanges next year, according to a new analysis, an industry pullback that adds to the challenges facing the law.

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THE WASHINGTON POST

Business

Health-care exchange sign-ups fall far short of forecasts

By Carolyn Y. Johnson

Business

August 27 at 8:10 p.m.

Enrollment in the insurance exchanges for President Obama’s signature health-care law is less than half the initial forecast, pushing several major insurance companies to stop offering health plans in certain markets because of significant financial losses.

As a result, the administration’s promise of a menu of health-plan choices has been replaced by a grim, though preliminary, forecast: Next year, more than 1 in 4 counties are at risk of having a single insurer on its exchange, said Cynthia Cox, who studies health reform for the Kaiser Family Foundation.

The debate over how perilous the predicament is for the Affordable Care Act, commonly called Obamacare, is nearly as partisan as the divide over the law itself. But at the root of the problem is this: The success of the law depends fundamentally on the exchanges being profitable for insurers — and that requires more people to sign up.

In February 2013, the Congressional Budget Office predicted that 24 million people would buy health coverage through the federally and state-operated online exchanges by this year. Just 11.1 million people were signed up as of late March.

Exchanges are marketplaces where people who do not receive health benefits through a job can buy private insurance, often with government subsidies.

Aetna, the nation’s third-largest health insurer, announced that it will pull back from Obamacare exchanges citing losses of more than $430 million since January 2014. (Daron Taylor/The Washington Post)

Aetna, the nation’s third-largest health insurer, announced that it will pull back from Obamacare exchanges citing losses of more than $430 million since January 2014. Aetna, the nation’s third-largest health insurer, announced that it will pull back from Obamacare exchanges citing losses of more than $430 million since 2014. (Daron Taylor/The Washington Post)

“Enrollment is key, first and foremost,” said Sara R. Collins, a vice president at the Commonwealth Fund, a nonpartisan foundation that funds health-care research. “They have to have this critical mass of people so that, by the law of averages, you’re going to get a mix of healthy and less healthy people.”

A big reason the CBO projections were so far off is that the agency overestimated how many people would lose insurance through their employers, which would force them into the exchanges. But there have been challenges getting the uninsured to sign up, too.

The law requires every American to get health coverage or pay a penalty, but the penalty hasn’t been high enough to persuade many Americans to buy into the health plans. Even those who qualify for subsidized premiums sometimes balk at the high deductibles on some plans.

And people who do outreach to the uninsured say the enrollment process itself has been more complex and confusing than Obama’s initial comparison to buying a plane ticket.

“This exchange will allow you to ‘one-stop’ shop for a health-care plan, compare benefits and prices, and choose a plan that’s best for you and your family,” Obama said in a speech in 2009. “You will have your choice of a number of plans that offer a few different packages, but every plan would offer an affordable, basic package.”

In some markets, a shortfall in enrollment is testing insurers’ ability to balance the medical claims they pay out with income from premiums. In an announcement curtailing its involvement in the exchanges this month, Aetna cited financial losses traced to too many sick people signing up for care and not enough healthy ones.

The health-care law has been a political lightning rod from the beginning, and Republican legislators have used insurance companies’ withdrawals from the exchanges to reignite calls for the law’s repeal.

Kaiser tracks public data on insurer participation in the exchanges to project how many options counties will have, but the numbers are not final. This year, exchanges in about 7 percent of counties had just one insurer. Earlier this month, Aetna announced that it will pull out of 11 of the 15 states where it offers coverage on the health-care exchanges. Humana made a similar decision weeks earlier, planning to exit several states. And last spring, UnitedHealth Group said it would remain in three or fewer exchanges next year.

Obama has used the health-care law’s challenges to issue a new call for a public insurance option.

“Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited,” he wrote in an essay published in the Journal of the American Medical Association. “Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government.”

Chicago resident Eva Saur, 32, is exactly the kind of healthy person insurers would like to have on their rolls. Saur hasn’t had coverage in nearly a decade, but she takes good care of her health. For the handful of times she’s been sick, a walk-in clinic at a pharmacy has been sufficient.

“I was raised — not against the system — but we had a doctor who would prescribe us herbs before a prescription” medication, Saur said. “For me, monetarily, it makes way more sense to do this.”

Saur’s tax penalty for being uninsured was a bit more than $600 last year, while the cheapest health plan she examined cost about as much for three months in premiums — and came with a $7,000 deductible.

The penalty for not signing up is increasing. Still, some policy experts insist it is not enough motivation to buy insurance.

“It was basically no stick at all. This is the classic case of where Johnny marked crayon on the wall, his mother said, ‘Don’t do that,’ and then slapped his hand a day later,” said Joseph Antos, a resident fellow at the American Enterprise Institute. “The connection between the offense and the penalty is a little remote.”

The health-care law has had unequivocal successes. In some areas, lots of insurers compete on the exchanges, which helps keep premiums low. In Cleveland and Los Angeles, the average premium for a benchmark health plan actually declined in 2016. The number of uninsured Americans continues to shrink, hitting 9.1 percent last year — the lowest level ever.

The average premium for the people who receive tax credits – 85 percent of the people signed up through the exchanges — is just $106 per month. People who qualify for the income-based tax credits are largely sheltered from premium increases.

The first people to sign up for insurance through the exchanges were expected to be those with chronic diseases and high medical costs. Because insurers could no longer discriminate against those people, the law built in three mechanisms for the government to redistribute money from plans with healthier patients to those with sicker ones. Two of those programs expire at the end of the year. The third, called the “risk adjustment” program, transferred $4.6 billion between insurers in 2014.

Critics say there’s a fundamental problem with the system, and the risk-adjustment program needs to be fixed. But supporters of the law argue that the problem is temporary, the natural evolution of a nascent free-market system. Some of the first companies to enter the market made bad bets on how healthy customers would be, resulting in unprofitable health plans. Proponents say it’s natural for new entrants to replace them, with better information and more competitive plans.

Cigna, for example, has said it has filed to enter exchanges in three new states next year.

“There’s no bottleneck, this is just the natural growth pains of a new market,” said Jonathan Gruber, an economist at the Massachusetts Institute of Technology. “What happened is they set up this new market where insurers didn’t have experience; insurers made an estimate as to what people would cost and their estimate turned out to be too low.”

Supporters point to a recent government analysis that suggests the “risk pool” — the number of high-cost sick customers relative to healthy ones — is not worsening and could even be improving. Medical costs per enrollee in the marketplaces fell by 0.1 percent in 2015, while medical costs for people in the broader health-insurance market grew by at least 3 percent. In states with strong enrollment growth, there were greater reductions in members’ costs.

Everyone agrees that more healthy people need to sign up.

In June, the Obama administration unveiled its plan to target younger and healthier adults, including direct outreach to individuals and families who paid the penalty. It also released new guidance, encouraging insurance companies to communicate more with young adults being kicked off their family’s plan when they turn 26 years old.

Even older adults are taking their chances without health-care coverage.

Donte Fitzhugh, 55, of Charlotte was laid off last year from a job as a call-center operations manager. COBRA, which allows former workers to extend their employer-provided health insurance if they pay the full premium, was expensive, and Fitzhugh didn’t sign up for the exchanges for very human reasons: He figured he’d find a job faster than he did. He thought every penny counted when he was unemployed. He didn’t have major health problems, and he got a coupon to help cover the costs of his hypertension medicine.

As the window to sign up for health insurance passed without a new job, he kept procrastinating. Although health insurance from a new job will begin in October, he faces a penalty that will cost him hundreds of dollars.

“I believe in Obamacare. As an American, it’s my responsibility to have health insurance,” Fitzhugh said. “Since I didn’t have it, it’s going to impact me financially.”

Such are the barriers to insurance: Remaining uninsured can be more attractive or just easier than signing up to pay hundreds of dollars a month for something that many people don’t think they need.

Judy Robinson, a health insurance support specialist at the Charlottesville Free Clinic, has counseled hundreds of patients who are eligible for subsidized insurance on the exchanges but ultimately decide not to sign up. She said the subsidized insurance on the marketplace tends to be a good deal for those who make between 100 and 150 percent of the poverty level. But those who make more often are faced with large deductibles that don’t seem like a good deal to many people.

Beyond the sticker price, she said it can require a lot of paperwork to demonstrate the annual income required to qualify for tax credits if people are juggling multiple part-time jobs. And sometimes, people are simply mistrustful.

“There’s a lot of people that live sort of off the grid, sort of semi-off the grid and they just don’t go to the doctor,” Robinson said. “The hospital is the place where you go to die, and doctors are just going to try and make you do procedures and get money out of you. That’s how they think.”

There are also those who want insurance but are struggling — and find themselves trapped by the high cost of health care.

Donna Privigyi, 49, of Charlottesville has looked into insurance through the exchanges a few times. But over the past few years, much of her modest child-care salary and effort went toward trying to help support her adult son, Mark, who hadn’t been the same since the death of his younger brother. Donna was focused on trying to support her son. Health insurance — even rent — was an afterthought.

“With supporting my son, it didn’t matter,” Privigyi said. “I was just like, I can barely get by, just juggling the bills and taking care of him.”

Late last year, Mark died of a drug overdose, and Privigyi — consumed by grief — wasn’t thinking about insurance when the window to sign up opened and closed.

Then, in June, she got appendicitis. Her bills from two hospitals were $33,000.

The argument for having health insurance is the pile of bills she has been collecting — now with late fees added. The obstacle to getting health insurance is that same stack of bills.

“It’s such a gamble, you know, until I figure out what to do with these medical bills,” Privigyi said. “They’re just adding on late fees. How can I even afford to sign up?”

Juliet Eilperin contributed to this report.

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Medicare Part B Premiums Projected To Go Up For 2017 ― Insurance Companies Participating In Obamacare Going Down

By Kenton Henry, editor

A double whammy is expected to impact the medical insurance market for 2017. There is bad news for the consumer on both the Medicare and the Under Age 65 ends of the medical insurance spectrum.

One positive note ― more than 60 million Medicare recipients are projected to receive a cost of living adjustment in their Social Security Benefit! But if you’re part of this group … don’t spend all your new found increase in one place. It’s projected to be a minuscule 0.2 percent! What the government giveth . . .  (well, you can see this coming!) The flip side is, their monthly Part B premiums would go to $107.60 in 2017 ― a $2.70 increase.

On the other hand, 30% of recipients, which includes those new to Medicare in 2017; those who do not have their Part B premiums deducted from their Social Security Income Account in 2016; and those with higher incomes may see increases in premium to $149.00 for the lowest tax bracket; from $166.30 ― to $204.40 per month for the next; and from $380.20 to $467.20 in the highest bracket. Whether these projections―which amount to as much as a 22% increase for the highest income earners―are realized will not be known until October.

Part B premiums are extremely relevant when one has the option of remaining on one’s (or one’s spouse’s) company group health insurance beyond age 65 and into retirement and is weighing the cost of such against the cost of transitioning fully to Medicare Part A and B.

For guidance in this consideration please feel free to consult with the author / editor. *(see featured article from the Wall Street Journal below)

And for those still not age 65, or otherwise eligible for Medicare―and not covered by an employer’s group health insurance plan―your options for coverage are scheduled to diminish along with competition in the individual and family Affordable Care Act (ACA) compliant insurance market. If realized, the  proposed mergers between Anthem and Cigna and between Aetna and Humana would reduce your options. This on top of Unitedhealthcare’s (America’s largest insurer) announcement it is pulling out of 90% of its current markets in 2017. Furthermore, BlueCross BlueShield Association announced they may also decline or diminish  participation in the marketplace. Lastly (until our next episode), to cast further doubts on what options will remain for the consumer, both Aetna and Humana have announced they may pull out of the majority of their individual and family markets regardless of whether their proposed merger is approved. Humana issued a statement just last week to the effect they would be limiting coverage to 156 counties this month compared the 1,351 they participate in currently. **(please refer to feature article on Humana below)

For these reasons, and because the majority of my individual and family clients have been forced to migrate to Health Maintenance Organization plans (where their providers and treatment are rationed) I have been advising those who are business owners to transition to group health insurance where they not only have more options relative to benefits but can still benefit from Preferred Provider Organization (PPO) coverage. With the PPO plans, they have the final say on their providers and, thereby, better control the quality of their treatment. Small Business (less than 50 employees) owners should take note that if they enroll during the Small Business Open Enrollment Period (November 15th ― December 15th) they will not have to meet the 75% full-time employee participation rate or the 50% of employee premium contribution requirement. The only requirement is that a minimum of 2 full time, W-2 employees be covered on the plan. This is an excellent opportunity for small, closely held companies who want to improve their family’s health insurance but cannot afford coverage for all employees.

Again, please feel free to contact our office for further insight and guidance on this issue.

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Feature Article #1

WALL STREET JOURNAL

By Anne Tergesen

Updated June 22, 2016 5:12 p.m. ET    

Nearly a third of all Medicare beneficiaries face a steep increase in their premiums next year, the result of a policy that in certain circumstances requires some beneficiaries, including higher earners, to shoulder the burden of rising costs.

The government health-care plan’s trustees projected in a report Wednesday that premiums would rise by as much as 22% for wealthier beneficiaries of Medicare Part B, which covers doctor visits and other types of outpatient care.

The projected increase results from an intersection of the rules governing Medicare and Social Security, said Tricia Neuman, senior vice president and an expert on Medicare at the Kaiser Family Foundation.

Under the Social Security Act’s “hold harmless” provision, Medicare can’t pass along premium increases greater than what most participants would receive through Social Security’s annual cost-of-living adjustment. That adjustment is expected to be just 0.2% in 2017 thanks to low inflation. As a result, Medicare couldn’t pass along any premium increase greater than the dollar increase in Social Security payments to the estimated 70% of beneficiaries who will qualify for hold harmless treatment in 2017, Ms. Neuman said.

Instead, Medicare must spread much of the projected increase in its costs across the remaining 30%. Those who are paying the standard $121.80 a month for Medicare Part B this year would be charged $149 a month in 2017 if the trustees’ predictions come to pass.

Higher earners would pay more. The trustees project individuals earning between $85,001 and $107,000 and couples earning between $170,001 and $214,000 would have their 2016 monthly premiums rise from $170.50 a person this year to about $204.40 in 2017. For those earning more than $214,000, or $428,000 for couples, the projected increase is to about $467.20 a month, from $389.00 in 2016.

This isn’t the first time there has been such a disparity in Part B premiums between Medicare recipients.

Last year, Congress staved off a 52% premium increase for Medicare beneficiaries not covered by the hold harmless provision via a deal in the budget agreement that raised premiums by 16% for them instead. Those covered by the hold harmless provision, in contrast, pay $104.90 a month—the same amount they paid in 2014 due to the fact that there was no Social Security cost-of-living increase in 2016.

The projected increase in Part B premiums affects several other groups of Medicare beneficiaries, including those who receive Medicare but have deferred or aren’t eligible for Social Security benefits. It also would apply to those who are new to Medicare in 2017 and lower-income Medicare beneficiaries whose premiums are paid by state Medicaid programs.

In the latter case, the increase would be paid by Medicaid, Ms. Neuman said.

Paul Van de Water, senior fellow at the nonprofit Center on Budget and Policy Priorities, said the final Social Security cost-of-living adjustment won’t be known until October. If inflation rises by more than the trustees expect between now and then, it could “reduce the spike in the premium” for those who aren’t held harmless, he said.

Acting Administrator for the Centers for Medicare and Medicaid Services Andy Slavitt said at a news conference Wednesday, “We will continue to monitor the data and explore administrative options as needed.”

The Medicare trustees are projecting that the base Medicare Part B premium will reset for everyone at $124.40 a month in 2018, because they expect higher Social Security cost-of-living increases.

Medicare covered 55 million people last year, according to the trustees’ report. Part B covered nearly 51 million. In 2017 Medicare is expected to have 58.7 million total participants and 53.5 million in Part B.

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Feature Article # 2

Humana beats 2Q forecasts, details ACA-related scale back

Tom Murphy, AP Health Writer

Published 9:09 am, Wednesday, August 3, 2016

Humana beat second-quarter earnings expectations and reaffirmed its forecast for 2016, even as the health insurer set aside an additional $208 million to cover expenses in its individual, commercial coverage.

The company also said Wednesday it was scaling back that individual business for next year and would only offer it in 156 counties, compared to 1,351 this year. The insurer also said it will sell coverage on Affordable Care Act individual exchanges in 11 states next year, down from 15 this year.

Humana, based in Louisville, Kentucky, provides individual coverage for nearly 500,000 people through the exchanges. It covers an additional 200,000 individual customers off the exchanges, a small slice of its total medical membership of 14.2 million.

Other major insurers like UnitedHealth Group and Anthem also have recently detailed struggles with coverage they sell on the ACA’s state-based exchanges, which have helped millions of consumers gain insurance since they opened for enrollment in the fall of 2013. Aetna, which is trying to buy Humana, said Tuesday that it cancelled its exchange expansion plans for 2017 and was taking a hard look at the markets in which it is currently participating.

Insurers have been struggling with higher-than-expected claims on the exchanges and lower-than-expected support from government programs, among other issues.

Humana also is one of the nation’s largest providers of Medicare Advantage plans, which are privately run versions of the government’s Medicare program for people over age 65 or disabled. The company said Wednesday that its core businesses remained strong in the second quarter.

Overall, Humana earnings plunged 28 percent to $311 million compared to last year’s quarter, when it booked a $267 million gain from a business sale.

Earnings, adjusted for non-recurring costs and amortization costs, came to $2.30 per share.

Analysts expected, on average, earnings of $2.22 per share, according to Zacks Investment Research.

The health insurer posted revenue of $14.01 billion in the period, which topped the average Wall Street forecast for $13.63 billion.

The company also said Wednesday that it still expects full-year earnings to total at least $9.25 per share.

Shares of Humana edged up 52 cents to $170.09 Wednesday morning while broader indexes were flat.

Humana shares have decreased 5 percent since the beginning of the year, while the Standard & Poor’s 500 index has climbed 5.5 percent.

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The State of Health Insurance for 2017 (or “If It Weren’t For Bad News . . .)

HEALTH BLOG PIC 1

By D. Kenton Henry, editor

 

We are more than half-way through 2016 and three months away from the scheduled beginning of the 2017 Affordable Care Act (ACA) individual and family health insurance Open Enrollment Period (OEP). All of which finds this broker and many of his clients still reeling from the this year’s OEP which ended in February.

By last September, the rumor was health insurance premiums would not be inflating. That was quite encouraging to myself and to my clients who inquired as to such. However, what was unsaid―and to our shock―was what we learned with the commencement of OEP, November 1. Specifically, all carriers in southeast Texas (my major market) were eliminating Preferred Provider Organization (PPO) plans and forcing all new policyholders to accept Health Maintenance Organization (HMO) plans in their place. Anyone who knows anything about the latter knows that, with this type of plan, the patient must obtain treatment within the network or have no coverage whatsoever. For the young and bulletproof this seemed no great compromise. But to the middle-aged and older, whose health problems are moderate to very serious, it was a huge one. My existing PPO plan clients who were not grandfathered, including myself, were forced by the state’s largest insurance carrier (among others) to accept HMO coverage as a substitute or lose coverage altogether effective January 1, 2016. I scrambled to find acceptable replacement coverage for over 150 of my clients from the 2017 HMO plan options. This endeavor materialized into a “Mission Impossible” style nightmare as the HMO networks made available to them had nothing approaching the larger number of provider doctors and hospitals to which the employees and dependents of large employer plans had access. My clients learned they would be unable to utilize the providers in their current (and now former) PPO plans. It was mostly an exercise in futility attempting to find all of a person’s providers in any one network and, even if that person were so lucky, the inconvenience of getting their Primary Care Physician to refer them to a specialist was another cumbersome hurdle most considered an unwanted liability. After first enrolling in a higher cost Silver Plan offering doctor’s office copays, I myself, before the close of OEP, switched to a lower cost Bronze (non-copay plan) with another company. This after realizing it was virtually impossible for my physician to successfully maneuver the referral process.  I made the decision it was best to take the premium savings involved in the benefit downgrade and have it for the occasional doctor’s visit which I have found to average $150. I save much more than this by having gone with a Bronze plan and―so far―it has worked out for me.

Since the close of OEP my phone rings throughout the week with people pleading with me to get them out of their HMO plan and into PPO coverage so they may see the doctor of their choice. I have only one PPO medical plan I can refer them to. This plan made itself available after the close of OEP but it is a hospital system plan which requires the patient remain in the system or face high out-of-network expenses. Furthermore, if the prospect has not had what the Department of Health and Human Services and ACA call a “Life Changing Event” they cannot change to a new plan at this time and must wait until October to enroll for a January 1 effective date. To add personal insult to injury, the plan does not even allow brokers and agents to be appointed with them for the purpose of doing business. Any business we refer or submit to them is done strictly on a “pro bono” basis. The only good news to be had for the consumer is that premiums not only stabilized but, in the case of those forced to migrate to HMO coverage, may have even gone down. Of course. Why shouldn’t they? The forced migration took client/patients from a position of having the final say on who their provider was to a position of having their providers, and therefore, treatment rationed. Most do not consider the trade off a worthy one. I know I do not. Of all my clients on individual and family PPO plans, forced to exchange such, some were small business owners. Those that had the minimum two W2 employees were able to switch to “Group” (employer based coverage) and maintain a PPO plan and provider network. If you fit this profile, please contact me. I can assist you in acquiring group coverage at any time throughout the calendar year.

My clients ask me if I expect PPO plans to re-enter the individual and family market in 2017. I tell them we will have to wait until the beginning of the OEP October 15th. But I advise them not to bet the ranch on it. If insurance companies do reintroduce PPOs, it will be only to entice policyholders to make a plan switch which would require a new contract (policy) in which brokers and agents would be excluded from compensation. This would be done in an effort to wipe the insurance companies books clean of the liability for our compensation. Their rationale is they can now put a great deal of the cost of enrolling people on the American taxpayer by directing prospective enrollees to the state and federal health insurance exchanges. The lion’s share will be directed to Healthcare.gov.

But what of the financial health and solvency of the insurance companies and their plans? Today’s feature article, from the New York Times (below) describes the push to ration provider access and treatment. Of course, they do not use those words, choosing instead to describe it as a move to “curb” cost in an effort to stabilize premiums. In spite of such, the insurers, for the most part, still struggle for solvency. The article explains that companies overestimated the number of ultimate enrollees and underestimated the cost of providing all the mandated care. To exacerbate their generally thin to negative profit margin, they did not receive all the government subsidies originally promised. Like so many programs, it would appear they cannot approach solvency without tax-payer funded subsidies.

Given all this, most of the insurance co-ops have failed and even major carriers are announcing withdrawal from the market. UnitedHealthcare, the nation’s largest health insurance carrier, has announced it will be pulling out of 90% of its current market in 2017. Anthem seeks to buy Cigna and Aetna seeks to merge with Humana. All this results in far less competition and . . . less competition means higher premiums for the consumer.

Stay tuned to see what the market offers us during this fall’s OEP. I will be focusing more and more on my “Medicare” clients who, much to my regret, were somewhat neglected during last fall’s scramble on my part to find new policies for 150 plus under-age 65 health insurance clients. Medicare recipients will be a priority this fall during their own OEP for Medicare Advantage and Part D Prescription Drug Plans. I hope the market allows me to play an active role in assisting families in obtaining health insurance.  . . . We shall see. Predicting what is going to happen next in terms of what the general public refers to as “Obamacare” is a lot like walking into a swamp. You’re not quite certain if your next step will land in quicksand or on top of an alligator. Terra firma would be a welcome and unexpected change for the consumer and this agent / broker.

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*FEATURED ARTICLE

New York Times

Business Day

Health Insurer Hoped to Disrupt the Industry, but Struggles in State Marketplaces

By REED ABELSON JUNE 19, 2016

Oscar Health was going to be a new kind of insurance company. Started in 2012, just in time to offer plans to people buying insurance under the new federal health care law, the business promised to use technology to push less costly care and more consumer-friendly coverage.

“We’re trying to build something that’s going to turn the industry on its head,” Joshua Kushner, one of the company’s founders, said in 2014, as Oscar began to enroll its first customers.

These days, though, Oscar is more of a case study in how brutally tough it is to keep a business above water in the state marketplaces created under the Affordable Care Act. And its struggles highlight a critical question about the act: Can insurance companies run a viable business in the individual market?

Oscar has attracted 135,000 customers, about half of them in New York State. And some of its efforts with technology have been successful. But for every dollar of premium Oscar collects in New York, the company is losing 15 cents. It lost $92 million in the state last year and another $39 million in the first three months of 2016.

“That’s not a sustainable position,” said Mario Schlosser, chief executive at Oscar.

Companies like Oscar were initially attracted by the potential of millions of new customers added to the individual market by the health law. But the reality has been far messier.

In an effort to attract customers, insurers put prices on their plans that have turned out to be too low to make a profit. The companies also assumed they could offer the same sort of plans as they do through employer-based coverage, including broad networks of doctors and hospitals.

But the market has turned out to be smaller than they hoped, with 12 million signed up for coverage in 2016. Fewer employers have dropped health insurance than expected, for example, keeping many healthy adults out of the individual market.

And among the remaining population, the insurers cannot pick and choose their customers. The law forces them to insure people with pre-existing conditions, no matter how expensive those conditions may be.

As a result, most insurers are still trying to develop a successful business model. Last year, only a quarter of the insurers appear to have made money selling individual policies, according to a preliminary analysis from McKinsey, the consulting firm. Giant insurers like UnitedHealth Group have stopped offering individual coverage through the public exchanges in some states. And most of the new insurance co-ops, which were founded to create more competition, have failed.

A few times a week, Oscar Health serves a catered lunch for employees. The company has attracted 135,000 customers, but it is losing money. Credit Richard Perry/The New York Times

The heavy losses do not necessarily mean that the individual market is ready to implode. Some insurers, including large companies like Anthem, say they remain committed to the market, and some insurers have made money.

But the turbulence is certainly greater than expected. And it may well lead many insurers to seek double-digit percentage rate increases and tighten their networks.

“There was tremendous uncertainty that even the very established companies were flummoxed by,” said Larry Levitt, an executive with the Kaiser Family Foundation, which has been closely following the insurers’ progress.

Over all, insurance companies continue to make profits. The dearth of profits from the individual markets, though, show how challenging it is to make insurance affordable when it is not subsidized by the government or an employer.

The troubles in the individual market also underscore how some of the law’s provisions meant to protect the insurers have not worked as well as desired. Insurers did not receive all the payments they were due under one of the law’s provisions, and another provision, meant to even out the risk among companies to protect those that enroll sicker individuals, has been described as flawed by many health care experts. Federal officials have said they would tweak those formulas.

The companies that have fared best so far are those that have kept the tightest control over their costs, by working closely with low-cost providers or a limited group of hospitals and doctors. Many have abandoned the idea of offering the kind of access available through many employer plans. The successful companies have also avoided the very low prices found in some of the co-ops.

For most of the insurers, though, the math has just not added up, which is the case with Oscar.

In New York State, where Oscar is based, the company recently filed eye-catching requests to raise rates by a weighted average of nearly 20 percent for 2017. Regulators will make a decision in August.

“The market is over all too low in price,” Mr. Schlosser said. “We, like everybody else, have priced in a very aggressive way.”

Many of the big insurers, like Anthem, can rely on their other businesses to generate profits while they wait for this market to stabilize. Oscar does not have that luxury; it is focused on individual marketplaces. (In addition to New York, Oscar operates in California, New Jersey and Texas.)

Other new insurers that sell plans to employers or under government programs like Medicare have been a little more insulated. When Northwell Health, the system in New York previously known as North Shore-LIJ Health System, entered the insurance market, it created a new company. That company, CareConnect, has 100,000 customers, most of them individuals insured through both large and small employers.

“If we only had the individual market, we would have taken undue risk because we would not have understood that market,” said Alan J. Murray, CareConnect’s chief executive. He said the company is close to turning a profit.

Oscar says it plans to begin offering coverage to small businesses, but Mr. Schlosser was adamant that individuals will eventually be buying their own coverage, rather than relying on employers. The company is also racing to incorporate plans with smaller networks.

Bright Health, another start-up, also plans to work closely with health systems to offer consumer-friendly plans.

While Oscar has had to use another insurer’s network in New York, the company’s goal is to form partnerships with systems to create networks that specialize in managing care. The company began experimenting with these networks this year in Texas and California.

“Oscar talks about narrow networks like no one has seen one before,” said Dr. Sanjay B. Saxena, who works with insurers and health systems at the Boston Consulting Group.

Oscar has received $750 million from its investors, and Mr. Schlosser insists that the company understood how long it would take for the new insurance marketplaces to develop, calling these “very, very early days.”

Oscar points to its technological edge as a way to manage patients’ health better than the established insurers. It has created teams, including nurses, who are assigned to groups of patients and can intervene when its data flags a potentially worrisome condition like a high blood sugar level.

Promoting itself as a consumer-friendly alternative to the other insurers also has its risks. While Oscar has loyal customers, others say they are disappointed to find the insurer behaving like everyone else. Cosmin Bita, a real estate broker in New York, switched to Oscar from an insurer that had given him the runaround about whether it would pay for blood tests as part of his annual physical. Although Oscar said when he enrolled that the tests would be covered, he said, he found himself fighting with the company over whether everything was covered.

“The exact same thing happened,” Mr. Bita said.

Oscar executives said the company works hard to keep customers satisfied.

But so far, it has not proved that it has created a better model than the rest of the industry.

As Darren Walsh, a principal at Power & Walsh Insurance Advisors, said: “They haven’t invented a new mousetrap.”

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