Tag Archives: affordable care act

Workers’ Comp in the Year 2030

At the WCRI Annual Issues & Research Conference, Dr. Richard Victor, former CEO of WCRI and currently a senior fellow with Sedgwick Institute, discussed his views of workers’ compensation in the future.

The workers’ compensation system was a compromise between labor and business designed to provide no-fault benefits in an environment that gave exclusive remedy protections to employers. Over the years, there have been ebbs and flows to the system in an effort to maintain balance. There is a constant struggle to balance benefits to workers with the costs of the system paid by employers.

In the past, when the workers’ compensation system got out of balance, it was due to actions from those within the system. That is something the system could correct with regulatory change. However, right now, there are things happening outside of the workers’ compensation system that could significantly affect it and cause a rethinking of the grand bargain.

Emerging labor shortages

Retiring baby boomers will cause labor shortages in healthcare and the insurance industry, which will delay claims and medical care. This will ultimately increase claims costs.

See also: The State of Workers’ Compensation  

In addition, a stronger economy is ultimately going to lead to a severe labor shortage. When you pair the aging workforce and people retiring with a growing job market, you end up with not enough qualified applicants to fill the positions. Employers have to relax their hiring standards. This leads to unqualified applicants being hired. These people will likely have higher accident rates.

Changes in the non-occupational health system

As workers see their out-of-pocket health insurance costs rise, it becomes more attractive to try to shift illness and injury episodes into the workers’ compensation system. Richard feels that this shifting will result in a 25% increase in workers’ compensation claims by 2030. With soft tissue injuries, it would be very easy for the worker to indicate the injury happened at work instead of at home. Disproving that would be very challenging for employers. Higher deductibles will greatly encourage workers to look for these cost-shifting possibilities.

Millions of workers losing health insurance

The number of uninsured workers is expected to decrease significantly as elements of the Affordable Care Act are repealed or weakened. These uninsured workers are also highly encouraged to shift their treatment into the workers’ compensation system. Richard estimates a 15% increase in workers’ compensation claims due to this.

Aging workforce

The injury rates for the older workers is higher than for younger workers. As the U.S. workforce ages, we will see higher injury rates across the employee population.

Federal immigration policies and practices

Limiting the flow of immigrants into the U.S. at a time there is a labor shortage will only compound the problem. The only way to grow our workforce to keep up with the demand is with immigrants. All of the growth in the labor force going forward is projected to come from immigrants.

Roughly 15% of all healthcare workers in the U.S. are foreign-born. If we discourage immigration into this country, Richard feels it could cause a labor shortage in the healthcare industry.

It does not even take a change in policy to see a change in immigration flow. After the Brexit vote there was a significant reduction in European nurses registering to work in the U.K. This is even though there had yet to be a policy change in the country.

See also: Healthcare Reform’s Effects on Workers’ Compensation

Conclusions

Taking all of the outside factors into consideration, Richard estimates a 55% increase in the number of workers’ compensation claims by the year 2030. When you add in medical inflation the costs of the workers’ compensation system could triple by 2030 with no change in indemnity benefit levels.

With this significant increase in costs, there will be questions about the continued viability of workers’ compensation. What is the solution? Are there viable options to traditional workers’ compensation? ERISA-style plans like the opt out in Texas have been widely criticized for providing inadequate protections for injured workers. Union carveout plans only apply to a very small sector of the workforce. Could we see workers’ compensation claims organizations become accountable to both employers and workers, with employees having the ability to choose which claims organization they want to use?

Gravity Is Real — You Can’t Ignore It!

For 10 years, I was an instructor of risk and insurance at LSU in Baton Rouge. I’d occasionally be invited to testify before legislative committees as an insurance expert. Often, some of the pending legislation was designed to solve real problems that were not fixable with insurance. In these cases, my testimony was simple. I’d explain:

“Ladies and gentlemen, today, this legislative body has the ability to outlaw the effects of gravity on all state-owned lands. If this legislation is approved, a citizen can jump off the observation deck on the 27th floor and will die EVEN THOUGH IT IS AGAINST THE LAW. Gravity is unforgiving like that.”

The first three examples below are real and, unfortunately, not sustainable in a long-term insurance model because we can’t ignore adverse selection any more than we can ignore gravity. The fourth item is a “scientist” moving from the facts – and becoming (in my opinion) a social engineer acting on feelings.

Consider the brief notes below as an introduction to each issue, not a complete discussion.

1. The Affordable Care Act – I’ll remove the emotion of illness and fairness from this discussion and just look at the numbers. From a Jan. 13, 2017, Wall Street Journal article, see the following statistics:

  • The most expensive 5% of patients use 49% of health spending.
  • The most expensive 20% of patients use 82% of health spending.
  • The healthiest 50% of patients use only 3% of health spending.

Ours is a house divided. 50% of the market is perfect for an insurance model — the other 50% is not, because insurance works when there is a “chance of loss,” not when losses are certain. In a loss-certain model, the No. 1 need is funding — more and more money.

See also: U.S. Healthcare: No Simple Insurtech Fix

2. NFIP (National Flood Insurance Program) – From the Acadiana Advocate (Jan. 26, 2018) see the following headlines: “Hopes for flood insurance deal dim – Another short-term extension expected”

The future of NFIP is threatened by adverse selection. A disproportional number of high-risk buyers populate the pool, and an insufficient number of safe buyers (low-risk properties) exist to assure affordability and thus sustainability.

3. Auto insurance (issues of tort) – In the late 1970s in Louisiana, mandatory auto liability insurance became the law of the land. We can debate the wisdom or appropriateness of this, but it is the law. Today, ours is a house divided – those looking to sue and those fearful of being sued.

Often, our industry invites (and sometimes deserves) lawsuits by being inefficient or ineffective or unreasonable in claims handling. In other cases, lawyers are searching for incidents and accidents that can do more than indemnify a claimant for a loss by creating wealth or at least “over-indemnification” through the courtroom. Our industry is becoming a tort roulette wheel.

On a 140-mile trip from New Iberia to Baton Rouge, I counted 33 billboards for a specific attorney. There were many more for many others. Is this a cost the market is willing and able to pay? How many millions (billions) of dollars are taken out of the risk pool annually for over-litigation? Are we, the premium payers, willing to pay that cost?

4. Fairness in lieu of actuarial science – At its simplest, the insurance process includes four elements. Do these effectively, and you have a green and sustainable business model:

  • Identify the risk to be insured
  • Define the coverages
  • Establish a price (premium)
  • Pay the claims

On Saturday, Jan. 29, 2018, I was driving down a flooded Center Street in New Iberia concerned about the aforementioned flood article and the viability of the NFIP, when I heard a brief portion of a TED talk with Cathy O’Neil titled, “The Era of Blind Faith in Big Data Must End.” O’Neil, a data scientist with a PhD., talked about data being accurate but not being fair.

Actuarial science demands objective data, but our society is starting to demand “fair.” Can these co-exist? Should bad drivers pay more than good drivers? Should health conditions be considered in underwriting life and health policies?

See also: How Advisers Can Save Healthcare  

I believe insurance is a risk-sharing process requiring underwriting, but it is rapidly moving to a “social welfare” platform. The market will get what it wants or tolerates, but as shown above our traditional insurance model may be sacrificed in the process.

What does this mean in your world? Is it sustainable? What are we as an industry and a society going to do? Address the problems now or wait until these systems collapse or go bankrupt?

“A government that robs Peter to pay Paul can always count on the support of Paul.” — George Bernard Shaw

“We have met the enemy, and he is us” — Pogo comic strip

U.S. Healthcare: No Simple Insurtech Fix

I hadn’t worried much about U.S. health insurance in years, eight to be exact. I was interested, but not worried, because while I was living abroad I didn’t need it. Furthermore, I had a health insurance plan that covered me wherever I lived in the world. When I returned to the U.S. this past July, I was faced with buying an individual health insurance plan, which was something I’d never done (all my previous work experience in the U.S. gave me insurance as part of a group plan).

In August, I bought a policy with a carrier and used an agent.

As this is Open Enrollment season and I just purchased my first policy in the post-ACA world, I thought it would be a apt to talk a bit about the U.S. healthcare system and how I think insurtech can help. I will focus on three areas.

First is my experience with Open Enrollment this year (to, I hope, help some who are going through the same experience right now!). Second is areas that need to be considered when looking at U.S. health insurance. Third is a summary and ideas for insurtech startups.

Healthcare, especially U.S. healthcare, is very, very complex.  Hence, I will only dive into a few areas, and as usual, my recommendations at the end will be fundamental and principle-based.

While there are a lot of politics surrounding U.S. healthcare, I will endeavor to not touch on the political aspects (though through the reading you should understand my opinions on the current state of affairs).

Open Enrollment – How Open Is It?  

As of the writing of this article, I am in the final steps of selecting my plan for 2018.  If you are currently going through the Open Enrollment process yourself, I have included some links at the end of the article that are some great guides on the overall process (including one from Oscar for “solopreneurs”).

What follows, is my experience of preparing for Open Enrollment.

A few weeks ago, I received this in the mail:

And about a day later, an email from my agent that said this:

Well, neither one of these were very encouraging.

I started with the Covered CA website and PolicyGenius to do my search to see what carriers/plans were available.

As I went through both sites, I realized that I was going through a modified needs analysis (these questions were a combination of what I went through on both sites):

  1. How much am I willing to spend a month?
  2. How much of a deductible am I willing to have? (These two questions were followed by a lot of math playing between the variables of 1 and 2 on different scenarios.)
  3. Do I want to be able to book my own specialist, or do I care if I have a referral. Plus, do I want to have the ability to go out of network or not? (HMO or PPO?)
  4. Do I have any doctors whom I need to keep in my network? By the same token, which hospitals/doctors do I want in my network?

Regardless of the answers to 1, 2,  and 4, number 3 was the key: Do I want an HMO or PPO? Because I wanted a PPO, I had a whopping TWO carriers available to me.

See also: High-Performance Healthcare Solutions  

In addition to this, I think it’s worth it to mention that (I think) the US is the only developed country in the world that has a 2 month period of time in which one can purchase a health Insurance plan.

So much for ‘Open’ Enrollment…

As I was going through this process, I realized some of the biggest challenges with this whole thing

Some of the points that I mention below may seem like old news to many that have been dealing with US health Insurance since ACA came into effect.  Though, since this is my first time going through it, that is the case.

Hence, I will share what I think is wrong with US health Insurance and subsequently, how Insurtech may be able to help.   As mentioned earlier, this is not meant to be a political stance and I will focus on the fundamentals of Insurance as I go through this.

These are the a few key things wrong with the the current US health Insurance:

  1. It’s mandatory (if you’re not covered by a group plan)
  2. If one buys an individual plan – they may not choose the specific coverage that’s right for them (other than premium and deductible)
  3. There is no underwriting for it (it’s all guaranteed issuance)

While these things aren’t likely to change, it’s important to understand why these three pillars are here, because there are some guiding principles here which are meant to help individuals; namely 1) making it more affordable and 2) making it more accessible. There still may be some opportunities to shape US health Insurance within the current confines of the regulation, which will have to be adhered to as long as the current regulation is in form.

Aside from cost and access, what else needs to be looked at?

Some of the key areas to look at when it comes to health care are:

  1. Participants/Users – how to interact with them?
  2. Provider coverage – which doctors/hospitals will be ‘in network’/accessible to participants?
  3. Claims process – how can this be made easier?
  4. Treatment and monitoring – in addition to 2&3, how will ongoing monitoring be done?

This relates back to the triangle I had a few weeks ago and how all 3 parties needs need to be looked at when looking at the overall Insurance value chain (regardless of line of business):

Before I go into the summary, a quick note on Oscar.

I took a serious look at Oscar a consideration for my health Insurance.

Not only did I read through their policy and network coverages (as they were cheaper than every other network out there), but I did all the research on Oscar that I would do for any other start-up I would consider working with for my work outside of Daily Fintech.

I started with the Coverager Companies tab (especially the News tab, where I like to see to see their past reporting of the company which usually outlines the good, bad and ugly of the company itself).  I also read the Oscar Health Strategy teardown from CB Insights.  I read consumer reviews and even asked my doctors and their receptionists about dealing with Oscar.  I did not do this much research for any other company I was considering (even though there were only 2 PPO providers from my initial search, I still took a quick look at all 6 providers in California…).

Ultimately, I think they are really on to something and I salute them for going after such a big and complex area (both in terms of product line and geographic area of that line!).  I would encourage everyone to read the teardown above to see what some of their strategies are.  Tackling US health Insurance is no easy feat, and they did take a long term view as described below:

While I do like them and some of the things they are doing, the reviews are not up to scratch yet.  My guess is that the long term view somewhat backfired on them, as customer expectation for a product that is so highly despised by many would have to have a real good experience very early on.

I have had real good experience with my current carrier and they are the most well known/biggest in my state.  As such, I’ll likely need to stick with them.  Health Insurance is too important to try something new on in my opinion.

I do think Oscar is very well positioned for the future, and they have outlined their strategy clearly above.  Building of an Insurance company takes time.  Health is a whole other animal.  Health in the US…well, that’s just going right for the gullet.  But, if done right, it can be a big prize (not only monetarily, but also for the sanity and health of US citizens!).  I’ll definitely be keeping en encouraging watchful eye on them.

Summary: It’s Complicated…

As I was preparing for this article, I read a few posts on Daily Fintech last year from Amy Radin, which I encourage you to read in conjunction with this post.  I have included them at the end for easy reference.

In her first post, she mentions four lenses to look at when it comes to US health Insurance: ‘the health of the American people, marketplace trends, the role of regulation, and the players’.

In her second post, she mentions that ‘Incumbent health insurers are pursuing legacy tactics to compete in the ACA world: M&A…; increasing premiums …; and reevaluating participation in the public exchanges…

As well as ‘the root of user pain points can influence how plans are selected and health care is consumed’:

# 1 People don’t see value because they don’t understand what they are buying.

# 2 People are being held accountable for health decisions that they are not equipped to handle.

# 3 People don’t always make rational decisions.

Fast forwarding 15 months since her last posts, other than some slight changes announced earlier this year and the recent subsidy cuts, not much has changed in terms of health of Americans, incumbent tactics and pain points for users.

See also: Healthcare: Need for Transparency  

Currently, CVS and Aetna are working on a merger.  It is rumored that Amazon is trying to expand into pharmaceutical sales as well (not to mention it’s other Insurance aspirations).  It’s also no secret that Apple has been preparing itself for a run at health care too.  Are all of these in the name of helping out the customer or just trying to get a slice of a pie that is so huge that everyone in the tech industry can taste it?

Recommendations for Insurtechs

Given that current regulation is both stringent and has an unknown future, it can be challenging for Insurtech start-ups to know where to start.  However, here are a few areas where I think can help the US health Insurance value chain, irrespective of regulation:

  • Education – I know this seems like something basic, but shopping for health Insurance was a nightmare.  Policy Genius was good, but it didn’t have it all.  Also, since health Insurance is so complex, there needs to be something that makes it really easy for people to understand.  Aside from how the subsidies work, which can be a challenge in it of itself, the specific clauses, terms and coverages for health Insurance is really complex and the majority of the population would likely not understand it.
  • Blockchain – With such a wide variety of illnesses, coverages and benefits, blockchain make a ton of sense for health care.
  • P2P – I wrote a couple weeks ago that I didn’t think P2P could be useful for health Insurance.  As I wrote this article, I do see some benefits, especially with a model like Inspeer, may be able to help.
  • Ecosystems – I’ve been reading more about ecosystems lately as it relates to Insurance/Insurtech, specifically with some of the things being some in China. When it comes to health, look at Ping An and Good Doctor (see below for infographic too). Talk about user experience.  The value proposition (image) below says it all..the more this can be integrated for the user, the better.  Though it doesn’t come without it’s challenges:
    1. Wearables – how much will people trust Insurance companies with all of their ongoing health information?  This is a big debate when it comes to information asymmetry.  Those that are healthy and live healthy lifestyles will be happy to, and others, may not be.
    2. Integration with hospitals/doctors – This will enhance the customer experience greatly, both for ongoing monitoring of the health from their doctors as well as with the claims process.  I recently had a few check ups at various doctors, having to fill out loads of paperwork that asked the same questions, bringing my images with me wherever I went, and having to re-explain my history over and again was a bit cumbersome.  It would be nice if the paperwork process was easier, if all doctors in my network had all the information on me (not just the ones in the same hospital) and the claim processed could be seamless after treatment received.  Integrating all of this is not easy when the infrastructure is not there and legacy systems exist for all parties.

I know the motto of many entrepreneurs/founders out there revolves around solving challenging problems, so, despite my feelings at the moment about US health Insurance, I am confident about the future of it!!

This article was originally published on Daily Fintech.

The Deception Behind In-Network ‘Discounts’

Here’s a strange paradox: Healthcare costs have increased by an unsustainable rate of about 8.5% each year over the past decade, according to PwC’s Health Research Institute. Already, the average employer-based family health insurance plans costs more than $18,000 annually.

But Medicare spending has been relatively stable. Over the past three years, the program’s payouts to hospitals have increased by only 1% to 3% a year, roughly even with inflation. The prices paid for some core services, such as ambulance transportation, have actually gone down.

See also: ‘High-Performance’ Health Innovators 

To see what’s happening, we can start by pulling back the curtain on how preferred provider organizations do business. A PPO is a network of preferred health-care providers such as doctors and hospitals, typically assembled by an insurance carrier. In theory, the insurer can save money for its customers by persuading providers in the network to discount their services in exchange for driving volume to their facilities.

UnitedHealthcare Choice Plus, for instance, boasts that its PPO—a network of more than 780,000 professionals—cuts the cost of typical doctor visits by 52%, while saving 69% on MRIs. Pull back the curtain, and you’ll see these discounts are an accounting trick. To allow PPOs to advertise big discounts, providers simply inflate their billed charges on a whole range of services and treatments.

Don’t insurers have a natural incentive to keep provider prices down, even if they don’t end up paying the list price?

In fact, no—at least not since the Affordable Care Act took effect. That law established a “medical loss ratio,” which requires insurers covering individuals and small businesses to spend at least 80 cents of every premium dollar on medical expenses. Only 20 cents can go toward administrative costs and profit. (For insurers offering large group plans, the MLR rises to 85%.)

If a provider raises the cost of a blood test or medical procedure, insurers can charge higher premiums, while also boosting the value of their 20% share. Insurers can make more money only if they lower their administrative expenses or charge higher premiums.

In this way, the MLR rule encourages insurers to ignore providers’ artificial price hikes. Insurers can continue to attract customers with the promise of steep discounts through their PPO plans—and providers can continue to ratchet up their prices. By hoodwinking their customers, both insurers and providers make more money. Since insurance costs are merely a derivative of health-care costs, the result has been a steady rise in insurance costs for millions of working families.

For employers caught in this price spiral, there is a way out: partial or full self- insurance. When businesses self-insure, they pay employee health claims directly. That creates an incentive for businesses to question—and push back on—providers’ price increases. Self-insuring businesses can strengthen their leverage by using “reference- based pricing,” which caps payments for “shoppable”—nonemergency—services at the average price in a local market. Members who use providers with prices below the limit receive full coverage. If they use a provider that charges more than the limit, they pay the difference out-of-pocket.

This setup creates a strong incentive to control costs: Patients have a reason to shop around for the best value, while providers are pressured to keep their prices below the cap. The most expensive doctor is not always the doctor with the best outcomes.

See also: High-Performance Healthcare Solutions  

That’s what happened when the California Public Employees’ Retirement System adopted a reference-pricing approach a few years ago. The agency had noticed that provider charges for hip and knee replacements varied from $15,000 to $110,000. In 2010, Calpers established a reference price of $30,000 for the procedures. Predictably, patients flocked to providers charging that price or less and shunned higher-cost facilities. Over the next couple of years, the number of California hospitals charging below $30,000 for a hip replacement jumped by more than 50%. In the first year Calpers saved an estimated $2.8 million on joint replacements.

What worked for Calpers can work just as effectively for small and midsize businesses. Today’s medical inflation is exactly what one would expect from health policies that reward insurers and providers for raising prices. Employers shouldn’t accept this status quo. By self-insuring and setting their own reference-based reimbursement, businesses can sidestep the traditional insurance model that continues to bleed them dry.

What to Know About ACA Open Enrollment

Open enrollment for individual health insurance policies is coming up. It is important to be aware of significant changes that will affect those applying for new coverage or changing coverage. Being familiar with these changes will help you successfully keep your health insurance and enroll. Since January, there have been multiple attempts to formally repeal the Affordable Care Act, which all ultimately failed in the Senate. Unfortunately, there is a clear trend that steps are being taken to weaken the ACA.

The Affordable Care Act remains in place.

Any claims that the ACA or Obamacare are failing or dead are not true. Due to the hard work of multiple state insurance commissioners, as 2018 Obamacare deadline nears, U.S. states believe every county is covered.

There is no further pretense: It is Trump vs. the Affordable Care Act. Failing to work with Congress, Trump has through executive actions and the announcement to terminate the payment of cost-sharing subsidies, thrown the entire health insurance ecosystem into greater chaos. The termination of the cost-sharing subsidies is a short-term issue while the executive actions are slightly longer-term.

These actions will cause further instability in the health insurance marketplace as it is almost certain that fewer people will enroll in health insurance plans this year. The reduction will mostly come from younger, healthier people, which will lead to a pool of people who have health issues and will have higher claims. Higher claims mean higher premiums. And higher premiums will lead to fewer enrollees leading to a tougher, but not failing market.

Michael Che of Saturday Live summed it up accurately with the comparison of Trump tweeting: “The Democrats ObamaCare is imploding. Dems should call me to fix” to Godzilla tweeting: “Tokyo is totally imploding right now. I alone can solve!”

Here’s what you need to know about the termination of the cost-sharing subsidies:

Insurance companies must continue to offer policies with subsidized premiums to those who qualify (58% of the 11.1 million Americans enrolled in ACA plans). The ACA requires insurers to charge lower out-of-pocket costs to low-income consumers, and the CSR payments compensate insurance companies for doing so. So, CSR payments are not a bail-out for insurance companies. And insurance companies are suing the government to make these legally obligated payments.

Insurers have already filed their premium rates for 2018. Insurance companies can still attempt to raise rates or even pull out of some markets. The loss of the CSRs is a huge cost for any insurance company that didn’t price in the possibility of the CSRs being eliminated. However, given that Trump has consistently threatened to not make the CSR payments, insurance companies have for the most part taken this into account; in other words, they were not surprised. Insurance companies can terminate their contact with the federal exchange if cost-sharing reductions are terminated. However, they are still subject to state laws on withdrawing from the marketplace. They can only terminate their exchange enrollees if they fail to pay their premiums, which many people would likely do if an insurance company left the exchange and they no longer received the advance premium tax credit (APTC).

A number of states allowed insurance companies to file dual rates, with one set assuming CSRs and the other set assuming no CSRs. Some states had already ordered insurance companies to add a surcharge to cover the potential loss of CSRs. For example, California required an additional 12.4% surcharge on silver plans. To find out how your state is allowing insurance companies to deal with the uncertainty over cost sharing reductions, check out this compilation of data.

In fact, Trump’s action would lead to an increase in enrollments in ACA plans in many states, including California, where about 90% of enrollees pay subsidized premiums. Covered California, the state’s Obamacare exchange, calculated in January that the reduction in net, or after-subsidy, premiums in gold, platinum and bronze plans resulting from the higher subsidies would lead to an enrollment increase of 20,000 people, or 1.4%, in subsidized plans. That’s good. What’s not so good is that the change would batter the unsubsidized population — those with income higher than 400% of the poverty level.

Bottom line, insurance companies will get less money from the government for helping low-income people with out-of-pocket costs on silver plans, causing silver plan premiums to increase to compensate. That will then trigger the federal government to increase all APTC-based subsidies to make sure people can still afford insurance. And to take advantage of the ATPC and avoid the higher-priced silver plans, people will move to bronze, gold and platinum plans. In fact, Trump’s health subsidy shutdown could lead to free insurance.

See also: How to Save Individual ACA Market  

According to a report by the Congressional Budget Office released in August, “The Effects of Terminating Payments for Cost-Sharing Reductions,” this will result in about 1 million fewer people covered in 2018. However, by 2020, the effect on coverage would stem primarily from the increases in premium tax credits, which would make purchasing non-group insurance more attractive for some people. As a result, a larger number of people would purchase insurance through the marketplaces, and a smaller number of people would purchase employment-based health insurance. The CBO report does not take into account the other changes made by Trump and his administration.

Here’s what you need to know about open enrollment:

Increased tax credits for those who qualify (84% of enrolled): The ACA includes an additional subsidy that is designed to reduce the cost of premiums, ensuring that family budgets are largely unaffected — it’s called the Advance Premium Tax Credit. CSR payments are applied only to silver plans. Insurance companies will add a premium surcharge, then, to the silver plans. Silver plans are the basis for the amount of the APTC that consumers receive. So, for most consumers, an increase in the silver premium will be offset by an increase in the APTC. Because of the application of the CSR linked premium surcharge to silver-tier plans, nearly four of five consumers will actually see their premiums remain the same or decrease as the amount of premium assistance they receive will rise.

To qualify for the APTC, your income must be between 133% and 400% of the federal poverty level. The premium increase impact will be heaviest on those who do not qualify for Advanced Premium Tax Credits. Because more people qualify for APTCs, the net cost to the federal government will actually rise. Find out if you qualify for the APTC here.

If you are in one of 19 states that did not expand Medicare, your premiums will be higher because there will be a larger number of enrolled who qualified for the CSRs. This will be offset by higher Advanced Premium Tax Credits.

Increased premiums for those in silver plans in 2018: Silver plans are the only plans that qualify for cost-sharing subsidies. Without the CSRs, silver plans may no longer be the best choice for many people.

The individual mandate remains in place, and there is a minimum penalty ($695 for adults and of $347.60 for children under age 18) for not having health insurance. The maximum tax penalty is $2,085 per household. The IRS has announced that it will not accept a return that does not have the health coverage question completed.

There will be a shorter open-enrollment period of six weeks, rather than the 12 weeks in previous years. Open enrollment starts on November 2017 and ends on December 15, 2017. It is important to act quickly and to be aware of this much-earlier deadline. Open enrollment is the only time when you are able to change to a completely new plan on the public marketplace or switch cover tiers, with changes taking effect on January 1. There are special enrollment periods for those who meet certain criteria, such as losing group health insurance coverage.

Certain state exchanges have longer open enrollment periods:

  • California: runs through January 15, 2018
  • Colorado: runs through January 12, 2018
  • District of Columbia: runs through January 31, 2018
  • Massachusetts: runs through January 23, 2018
  • Minnesota: runs through January 14, 2018
  • Rhode Island: runs through December 31, 2018
  • Washington: runs through January 15, 2018

Note: Insurance companies were in favor of this because the hope is it will encourage healthier people to enter the risk pool. This was also a recommendation in my Health Insurance Roadmap in conjunction with limiting special enrollment periods, which encourages people to keep their policies throughout the year (and keep their paying premiums) rather than hopping in and out of the risk pool.

Reduced access to healthcare.gov: HHS has announced it will shut down the federal exchange site for 12 hours for all but one Sunday during the open-enrollment season (December 10) as well as on the first day of open enrollment (November 1). More than 36 states use healthcare.gov for their marketplace.

  • HHS has reconfigured its website to make enrollment information harder to access.
  • This limited access could have a secondary impact because of additional website outages with greater numbers of people using the site at one time, compounded by the shorter enrollment period.
  • Website key point: More than 12 million people enrolled on the state and federal marketplaces for 2017 coverage — with nine million of those enrollments being on the federal exchange.

Marketplace outreach funds have been significantly reduced by 90% (from $100 million to 10 million). Budgets have been restricted to mostly being online — so no television, radio or print ads.

So don’t wait for any advertising for healthcare.gov .

  • Earlier this year, the administration pulled paid advertising for sign-ups on HealthCare.gov.
  • HHS has, instead, produced videos designed to undermine public support for “Obamacare” with funds that were intended to help promote enrollment in the ACA. These “testimonial videos” feature individuals claiming to have been harmed by the ACA.
  • These actions have prompted an inquiry by a federal inspector general into these decisions and regarding whether they have had a negative impact on sign-ups.

Less help with open enrollment, cuts of 90% to navigators — this reduces the ability to get advice to review different plans. For the most recent open enrollment period at the end of 2016, navigators received over $62.5 million in federal grants while enrolling 81,426 individuals for an approximate cost per enrollee of $768. For this open enrollment period, CMS plans to spend $10 million on education activities. (Source: CMS Policies Related to the Navigator Program and Enrollment Education for the Upcoming Enrollment Period.)

Funding for in-person outreach has also been cut in half, from $62.5 million to $36 million. The Trump administration has ended contracts with firms that have provided in-person assistance to states using healthcare.gov.

Regional representatives from the HHS will not be participating in open enrollment events in states and with health advocacy groups as it had done in the past so to reach uninsured populations by helping with sign-ups in terms of explaining, enrolling and shopping. Here’s what HHS press secretary Caitlin Oakley had to say last month: “Marketplace enrollment events are organized and implemented by outside groups with their own agendas, not HHS. These events may continue regardless of HHS participation.” She went on to say, “As Obamacare continues to collapse, HHS is carefully evaluating how we can best serve the American people who continue to be harmed by Obamacare’s failures.”

Navigators from multiple states are reporting issues with the online training certification videos.

See also: 10 Ideas That Could Fix Healthcare  

According to Sheila Quenga, director of the Palmetto Project, software programs are occurring more frequently than in the past, and it can take weeks before CMS resolves an issue. This is the Latest Snag In ACA Sign-Ups: Those Who Guide Consumers Are Hitting Roadblocks.

What to consider when reviewing your options:

  • If you are getting a subsidy, it is recommended that you review alternatives on healthcare.gov or your state health insurance exchange.
  • Find out if you qualify for the APTC here.
  • Review the total costs of premiums and deductibles and estimate co-payments and coinsurance.
  • Make sure the plan covers your medical providers and medications.
  • Use the optimal insurance deductible calculator to find the deductible that provides the most value to you.

Here are some resources to help you with open enrollment:

  • healthcare.gov — Check it out before open enrollment to review your options so you can be prepared.
  • State insurance departments. Find a link your state insurance department here.
  • Private groups, consumer advocacy groups and insurance companies. For example, a new campaign, “Get America Covered,” is going to run digital advertising and will partner with employers, community organizations and other entities. Its staff and co-chairs draw heavily from people who worked on ACA enrollment in the Obama administration’s HHS. The campaign draws on a mix of health-policy wonks, celebrities and political figures: Democratic activist Van Jones, actress Alyssa Milano, actor Bradley Whitford, ousted health insurance CEO Mario Molina and former Obama health care official Andy Slavitt. Other advocacy groups include Out2Enroll, Young Invincibles, Community Catalyst and the Get Covered Coalition. Unfortunately, HHS is the only entity that has access to records of who’s insured, so the lack of data will lessen the impact.
  • PolicyGenius has put together the comprehensive “Your state-by-state guide to the 2018 health insurance open enrollment period.”

If you have group health insurance through your employer, be aware of your open enrollment period and options.

What’s next?

The best outcome is that this might finally spur a true bipartisan effort. Trump’s actions can be remedied by Congress acting to guarantee funding the cost-sharing subsidies. And while a bipartisan deal, the “Bipartisan Health Care Stabilization Act,” has been reached by Senators Lamar Alexander and Patty Murray, President Trump has repeatedly switched from supporting it to not supporting it. The other question is whether Senate Majority Leader Mitch McConnell will do the right thing and put this deal up for a Senate vote, with the speculation being that he won’t. Currently, the bill has 22 additional co-sponsors (11 Republicans and 11 Democrats), so it seems feasible that it could actually pass in the Senate.

Then the question becomes getting the bill through the House, where Speaker Paul Ryan has come out against it and may not let it be put to a vote. House members have already approved an Affordable Care Act change bill, H.R. 1628, that would continue funding for the cost-sharing reduction subsidy program for two years. The other likely scenario is that with budget talks coming up, an Obamacare fix could end up in year-end package. Either way, this would not remedy any cost-sharing subsidies not paid and may come too late for insurance companies to change their 2018 premiums.

So, please start early and be prepared. As you should always do with any type of insurance, it’s important to understand what your health insurance options are and obtain coverage accordingly. To get the best plan at the optimal price, shop and compare the different tiers.

The bottom line to get the best plan at the best price: shop and compare all plans, even if you currently have a policy.