Highmark pulls out of ACA marketplace in 27 Pennsylvania counties for 2017
Highmark Inc. is canceling individual health plans in more than half of the Pennsylvania counties in which it has sold the plans on the Affordable Care Act's marketplace, reducing the competition that some experts say is necessary to make the market sustainable.
The Pittsburgh-based insurer is no longer selling the plans in 27 of the 49 counties in which it sold them for 2016, according to a Tribune-Review analysis of federal marketplace data. About 70 percent of the insurer's individual marketplace members in Pennsylvania will lose their plans, according to a Highmark spokesman.
The plans expire at the end of the year. Those with canceled plans will have to choose another plan if they want to stay insured and might have to find new doctors.
The 70 percent includes people who still may be able to buy other Highmark plans on the marketplace or directly from the insurer, depending on where they live. Cost-lowering federal subsidies are available on the marketplace at healthcare.gov, but not when people buy plans directly from the insurer.
The insurer's withdrawal from the counties contributes to a reduction in competition across Pennsylvania after insurers Aetna and UnitedHealthcare withdrew completely from the 2017 market in the state. Eleven Western Pennsylvania counties will have only one insurer on the marketplace for 2017, leaving consumers less protected from rate increases and limited plan choices.
Insurance Commissioner Teresa Miller said she approved rate hikes averaging 50 percent for Highmark's marketplace plans to prevent the insurer from abandoning the marketplace altogether. The exit of the state's largest insurer could have had a cascading effect as other insurers would have had to enroll Highmark's former members, who have proven difficult to treat profitably.
“They were saying, ‘if Highmark is out, we don't want to be here. We certainly don't want to be the last carrier in the market,' ” Miller said Thursday of the other four insurers selling plans in the marketplace.
In a typical market, insurers would want the new customers, Miller said, but the ACA market has been difficult.
“I don't think most of our carriers are hopeful that they're going to get additional enrollment, because this has been an expensive market for them,” she said.
Highmark's losses in the market have topped $800 million since 2014, which the insurer blames on sicker-than-expected people signing up for its plans. Miller has said she hopes the 2017 rate hikes will be a one-time correction to underpriced plans that will help stabilize the market.
Highmark is selling marketplace plans for 2017 only in counties where at least one other insurer is selling the plans.
“Wherever they're selling this, they're hedging their bets,” said Stephen Foreman, an associate professor of health care administration at Robert Morris University. “They don't want to be the only insurer in the county, because then they get all the bad risk.”
Highmark spokesman Aaron Billger said in an email that other insurers' participation has “very little impact” on the company's decisions about where to sell marketplace plans.
The insurer made its decisions, Billger said, based on where it was able to “develop provider partnerships focused on our products.”
In Western Pennsylvania, 13 percent of people with Highmark marketplace coverage will lose their plans, he said.
Miller said she thought Highmark initially filed for rate increases in counties where the insurer later decided not to sell plans. Highmark would have been able to view other insurers' requested rate increases for the counties in their rate filings, she said.
Highmark is leaving 17 Western Pennsylvania counties in 2017. UPMC Health Plan will be the only insurer selling marketplace plans in 11 of them — Greene, Fayette, Indiana, Armstrong, Lawrence, Mercer, Crawford, Warren, Forest, Clarion and Elk.
UPMC officials have said the health system has broken even on its Affordable Care Act line of business. Still, UPMC Health Plan is increasing premiums by up to 26.5 percent for 2017. UPMC Chief Financial Officer Rob DeMichiei said revenue from treating UPMC Health Plan patients at UPMC hospitals helps offset the health plan's costs.
UPMC Health Plan models its ACA business after government lines of insurance such as Medicaid managed care plans and Medicare Advantage plans. Analyses have shown that insurers with more experience with those populations have performed better with the ACA patients nationally.
Miller said federal changes are needed to make the state's ACA marketplace sustainable.
Highmark has sued the federal government in the Court of Federal Claims over a risk program meant to protect insurers from runaway losses, saying the government owes the insurer $223 million for 2014 and more for subsequent years. Miller has requested the court's permission to file an amicus brief supporting Highmark in the lawsuit, and encourages federal lawmakers to improve the marketplace.
“At the end of the day, what we heard from the carriers is we really need the federal government to help us in the stabilization process,” she said.
Wes Venteicher is a Tribune-Review staff writer. Reach him at 412-380-5676 or firstname.lastname@example.org.