Burgess COMMENTARY

Peter Burgess

Lack of Competition Might Hamper Health Exchanges

IMAGE A doctor checks a patient’s vital signs at a Detroit hospital. In Michigan and many other states, a single health insurer dominates the market, a situation that may endure even when health insurance exchanges launch in October. (AP)

Part One of Two Parts

The White House sums up the central idea behind the health care exchanges in the new federal health law with a simple motto: “more choices, greater competition.”

But even some stalwart supporters of the Affordable Care Act worry that in many states, people won’t have a lot of health insurance choices when the exchanges launch in October.

Health economists predict that in states that already have robust competition among insurance companies—states such as Colorado, Minnesota and Oregon—the exchanges are likely to stimulate more. But according to Linda Blumberg of the Urban Institute, “There are still going to be states with virtual monopolies.” Currently Alabama, Hawaii, Michigan, Delaware, Alaska, North Dakota, South Carolina, Rhode Island, Wyoming and Nebraska all are dominated by a single insurance company. The advent of the exchanges is unlikely to change that, according to Blumberg.

Competition aside, the exchanges face a number of technical and logistical problems. No less a figure than Montana Sen. Max Baucus, one of the chief Democratic authors of the ACA, said in a hearing earlier this month that he sees “a huge train wreck coming” when the exchanges open for business. Meanwhile, a March survey by the Kaiser Family Foundation indicates a majority of Americans still don’t know what a health insurance exchange is, and skeptics wonder how many eligible individuals will show up.

The exchanges were conceived as private marketplaces operating within federal guidelines. They are designed to give Americans who do not get health insurance from their employers the opportunity to choose from an array of private insurance plans, and to generate competition between insurers that will lead to lower premiums.

Individuals and businesses with up to 100 employees will be able to shop on the exchanges, and people who can’t afford coverage on their own will get government subsidies to help them. About 26 million Americans are expected to purchase health insurance through the exchanges.

But it is unclear how many insurance carriers will decide to seek approval for selling their products through these online marketplaces. Insurance companies have been mostly silent about their plans, with some citing uncertainty about federal and state rules as a reason for holding back.

Some fear that any uptick in competition will bypass those states where doctors are in short supply and the number of hospital systems is limited. A recent analysis by the American Medical Association found that a single insurance company held 50 percent or more of the market in nearly 38 percent of local markets nationwide.

On top of this lack of competition, some of the new federal regulations may push up premiums, at least in the short term. For example, under the health care law insurers will have to cover everyone, including people with pre-existing health conditions. Insurers are likely to raise their premiums to cover the cost of insuring these people who are less healthy.

The mandate that everybody must have insurance is intended to balance this new cost by adding a huge number of young, healthy people to the risk pool. Many of these people, figuring they wouldn’t need health care, have been taking their chances without coverage. But because the federal penalties for not having insurance are so small, especially before 2016, many of the healthiest people may continue to decline coverage.

The Society of Actuaries, which is aligned with the insurance industry, predicts that insurance rates for individuals may increase by as much as 32 percent over the first few years of the exchanges, according to a March report. The Obama administration argues, however, that while premiums may rise for certain people in the short term, in the long run the new federal rules will lead to lower premiums.

Cheryl Smith helped run an early exchange in Utah, and as a consultant she now helps other states develop their own marketplaces. But even though she is a strong believer in the concept, she doubts the exchanges will spur competition in the short term.

See big map and timelineSee The state of health insurance exchanges

“You can talk in theory about how competition will thrive in these exchanges, but the health plans don’t actually have a lot of time to get product on the shelf,” she said. “If you don’t have product on the shelf, where’s the competition?”

Will insurers come?

Under the federal health law, states had the choice of developing their own exchanges or letting the federal government do it for them. Even after the administration extended the deadline to early this year for states to declare what they would do, only 16 states and the District of Columbia chose to run their own exchanges. Seven others chose partnerships with the federal government. That left the federal government responsible for building exchanges in 27 states.

In addition, the U.S. Department of Health and Human Services is supposed to set up a “data hub” that all 50 exchanges will need to plug into to determine whether an individual or family is eligible for Medicaid or federal tax subsidies. U.S. Health and Human Services Secretary Kathleen Sebelius earlier this month assured Congress that the technology would be unveiled in time for the October launch of the exchanges, even though Republicans in Congress last year failed to approve the funding needed to complete the project.

Another cause for concern is the Obama administration’s recent proposal to scale back a requirement that small businesses offer their employees a menu of insurance policies. If the proposal is adopted, companies with fewer than 100 employees could offer a single policy to their workers, as they have in the past. Without employee choice, critics say, the small business exchange will do little to pressure insurers to develop lower-priced options.

But supporters of the health law are confident that competition and lower prices will ultimately come. In the meantime, they say, consumers will be better off. Today many Americans pay high premiums if they are sick or old—if they can find coverage at all. They also run the risk of purchasing policies that don’t cover certain medical conditions or limit the total dollar amount of claims. In addition to the new pre-existing condition rule, the health law sets a minimum set of benefits; prohibits lifetime caps on claims; and mandates that insurance companies participating in the exchanges spend at least 85 percent of their revenue on health care.

Big New Market

Despite the federal rules, millions of potential customers will be a powerful draw for insurance companies to participate in the exchanges. Furthermore, the federal government is expected to provide about $350 billion in subsidies to people who can’t afford to purchase insurance on their own.

On top of that, if all states eventually choose to expand Medicaid, the federal government will pour another $952 billion into the health care market over the next 10 years, much of which will go to Medicaid managed-care companies and other private insurers.

Some predict that new insurance carriers, made up of hospitals and large physician practices, will emerge. As it becomes more difficult for traditional carriers to make a profit under the federal health law, the most successful new players may be provider organizations that can control medical costs by avoiding duplication and errors and more carefully coordinating the care they provide, said Rick Curtis, director of the Institute for Health Policy Solutions.

Furthermore, Medicaid managed-care companies, which are used to providing care to low-income people, may decide to offer commercial plans on the exchanges. According to Jeff Van Ness of the Association of Community Affiliated Plans, between one-quarter and one-third of the group’s 58 nonprofit safety net health plans are expected to offer products on the exchanges in 26 states the first year.

New Health Exchanges Unlikely to End Insurance Monopolies in Some States

IMAGE A doctor examines a patient at a clinic in Florence, Ala. Alabama is one of about a dozen states in which a single health insurance company has a virtual monopoly, a situation that may persist when new health insurance exchanges are launched in October. (AP)

Part Two of Two Parts

In Alabama, if you get your health insurance through your employer and you lose your job, you quickly realize there aren’t a lot options for purchasing coverage on your own. Blue Cross and Blue Shield of Alabama has had a virtual monopoly in the state since the Great Depression, and today it covers a whopping 89 percent of Alabamians.

In part, Blue Cross and Blue Shield is dominant in Alabama simply because it has been there for so long—it sold its first policy in 1936—and potential newcomers have found it difficult to convince hospitals and doctors to give them favorable prices so they can compete with the entrenched carrier. But it also has to do with Alabamians themselves: On average, residents of the state are poorer and less healthy than other Americans, making them more expensive to cover and thus less attractive customers.

The lack of competition in nearly a dozen states could present problems when the insurance exchanges that are part of the Affordable Care Act launch in October. The exchanges are supposed to give Americans who do not get health insurance from their employers the opportunity to choose from an array of private insurance plans. The idea is to generate competition between insurers that will lead to lower premiums.

Individuals and businesses with up to 100 employees will be able to shop on the exchanges, and people who can’t afford coverage on their own will get government subsidies to help them pay their premiums. About 26 million low-income Americans are expected to receive subsidies to purchase health insurance through the exchanges.

But in states with a dominant insurance carrier, competition and lower prices may not arrive for quite some time.

A recent analysis by the American Medical Association found that a single insurance company held 50 percent or more of the market in nearly 38 percent of local markets nationwide. And in 30 states, a single insurance company covers more than half the people who purchase insurance individually, according to the Robert Wood Johnson Foundation.

The dominance by a single insurance company is particularly pronounced in Alabama, Hawaii, Michigan, Delaware, Alaska, North Dakota, South Carolina, Rhode Island, Wyoming and Nebraska.

In general, multiple insurance companies are eager to compete in states that have a large number of health care providers and a lot of people who can afford to pay premiums. A relatively young and healthy population is also an attraction. In states that don’t have those characteristics, competition can be sparse.

Alabama ranks 45th in the nation in overall health status, and 46th in median household income, according to the United Health Foundation and the U.S. Census Bureau, respectively. Over the decades, a few major insurance carriers have tried to dip their toes into Alabama, but most pulled out after just a few years.

In other states, there are different reasons for the lack of competition. In Wyoming, for example, the problem is that the state has relatively few health care providers and people have to travel long distances to get care.

Wyoming has only 18.7 physicians per 10,000 people, ranking it 47th in the U.S., according to the Kaiser Family Foundation. By comparison, New York has 34.8 physicians per 10,000 people, Maryland has 35.3 and Massachusetts has 39.7. The national average is 25.7.

Blue Cross Blue Shield of Wyoming dominates the market. Do Wyoming consumers want more choices? “Sure they do,” said Tom Hirsig, Wyoming’s insurance commissioner. But Hirsig said it’s a huge challenge for new carriers to develop provider networks in Wyoming. “My sense right now is that the individual market inside the exchange is not going to be stacked with lots of competition.”

A shortage of hospitals is the problem in Rhode Island, where there are just 11 hospitals owned by two companies. Health Insurance Commissioner Christopher Koller said Rhode Islanders would like other options, but he isn’t sure they’ll have them when the state’s exchange launches in October.

RELATED: LACK OF COMPETITION MIGHT HAMPER HEALTH EXCHANGES

Big Changes

The vast majority of Americans get health insurance coverage through their employers. Millions of low-income Americans qualify for Medicaid, and seniors can sign up for Medicare. But for people outside of these groups, there are few good options when it comes to health insurance.

Many of these Americans pay high premiums if they are sick or middle-aged—if they can find coverage at all. They also run the risk of purchasing policies that don’t cover certain medical conditions or limit the total dollar amount of claims. That’s why so many of them go without insurance altogether.

The health insurance exchanges are designed to change that. The policies that are included on the menu will have a uniform set of benefits and pricing structures that will be easy for people to understand and compare.

In addition, the new health law will make it illegal to deny coverage to people who have pre-existing conditions. It also will mandate a minimum set of benefits; prohibit lifetime caps on claims; and require insurance companies participating in the exchanges to spend at least 85 percent of their revenue on health care.

The hope is that this new pool of previously uninsured people will attract insurers to enter new markets, creating competition where none exists now. Poor states across the South and West have the largest share of uninsured people, and thus hold the greatest potential for insurers to cash in on the $350 billion the federal government plans to spend over the next 10 years to help low-income people buy insurance.

Furthermore, the exchanges should allow smaller companies and non-profits to market their products more effectively, challenging entrenched incumbents. “When you go online, the Blue of Alabama won’t look so much bigger than the next plan,” said Andy Hyman of the Robert Wood Johnson Foundation. The exchange is meant to be an “equalizer,” Hyman said.

What’s Wrong With Monopolies?

Carriers that dominate a particular state often argue that they hold onto their position by keeping prices down. “There are lots of national carriers out there who would provide a product that is less expensive than what is in the market, if they could,” said Kim Holland, director of state affairs for the Blue Cross and Blue Shield Association. “We’re not so naïve as to think that if we don’t price our products correctly our customers won’t find another alternative.”

Some economists note that in some cases, a dominant carrier can use its heft to negotiate the best prices with hospitals and then pass along those savings to consumers. In some markets, dominant insurers are akin to utilities, explained Paul Ginsburg, director of the Center for Studying Health System Change. “You don’t necessarily need more than one,” he said.

Ginsburg said large carriers are likely to get better prices from hospitals and doctors, because providers can’t do without them. “I suspect that consumers have actually benefitted from high [market] concentration. It’s really a bigger problem for physicians,” he said.

Despite having the least competitive health insurance market in the country, Alabama’s individual premium prices compare favorably with neighboring states and are below average for the nation.

But the AMA, which represents doctors, disputes the idea that big insurers always secure the best prices for consumers. They point to national studies showing that when insurance companies merge and acquire smaller companies, their profits go up and so do their premiums.

Exchange Experience

Two states, Massachusetts and Vermont, already have exchanges, and offer a glimpse of what the future might hold.

When Massachusetts launched its exchange in 2007, new players did not immediately burst into the market. One new carrier, Centene Corporation, joined the exchange to offer a limited network of providers for Medicaid beneficiaries. Competition in the individual market remained relatively unchanged.

But Massachusetts already had a relatively competitive market, so existing carriers competed with each other to create new, lower-cost plans in response to market demand—and pressure from state officials to keep costs down. Despite the emergence of low-cost plans, however, average premium prices have continued to rise.

Earlier this month, Vermont became the first state in the nation to publish preliminary health insurance rates for its exchange. Not unexpectedly, the tiny state of only 626,000 residents did not attract any new insurance companies. And the price of the plans offered on the exchange? They cost about as much as what Vermonters were paying before.

Top 10 states with the least competitive commercial health insurance markets Alabama Hawaii Michigan Delaware Alaska North Dakota South Carolina Rhode Island Wyoming Nebraska Source: American Medical Association, 2012 market concentration analysis.