1. The Future of Health Reform: What’s Next?
The future of private health insurance
Patrick Cahill
Vice President, Massachusetts Market
March 27, 2019

2. Health Reform: Almost A Decade After Passage of the ACA is Constantly Evolving
Uninsured levels are at historic lows; around 14% nationally
Coverage for pre-existing conditions and dependents up to age 26 have become core tenants of the health care lexicon
Risk stabilization, uniform rating rules, and essential health benefits have fundamentally altered and brought consistency to plan offerings
37 states have expanded Medicaid coverage to ACA limits

3. After Initial Growth Individual Market Enrollments Shrinking Nationally
Subsidized market driving exchange enrollments
Unsubsidized market shrinking nationally both on and off exchange

4. Employer Based Insurance Market Health Care Financing Disrupting the Risk Pool
Small employers/ Individuals:
Short-term limited duration plans
Association health plans
HRA rule
Self-funding alternatives
Large employers:
Captives
Purchasing coalitions
Private exchanges
Pharmacy carve-outs

5. Health Plan Focus On Improving Population Health
Medical Management Initiatives
Pharmacy Management
Innovation in Provider & Pharmacy Contracting, concierge Medicine, etc.

6. Key 2019 trends Employers are playing an activist role
Emotional health is moving to the forefront
Very high new treatment costs, especially with specialty pharmacy
Employers Playing Activist Role —Health care costs continue to put economic pressure on employers and employees. The pace of meaningful and sustained change is slower than needed. More employers are driving transformation in health care delivery by either directly contracting, partnering with their health plans, or working with other third parties to promote value-based care. Nearly half of the employers surveyed (49%) by NBGH are pursuing one or more of these strategies that focus on improving access and convenience in addition to better quality and lower cost.
Meeting the Needs of Today’s “On Demand Consumer”—Employers are rethinking consumerism. Today’s consumer places a premium on simplicity, convenience, and personalization. Navigators, concierge services and virtual resources are expanding to help consumers take some of the complexity out of accessing care and to better anticipate and address their unique needs. For the first time, the NBBH survey shows a 9% decline in the number of employers offering only consumer-directed health plans and this percentage is expected to grow in future years reflecting a movement towards increased choice.
Fast Approaching Tipping Point on Prescription Drugs—The push for more straightforward, simple, and streamlined supply-chain pricing and contracting models is reaching a tipping point may well be the year the paradigm shifts. Over 90% of employers responding to the survey would welcome an alternative to the rebate-driven approach to managing drug costs.
Emotional Health Moves to the Forefront - From stress and anxiety to addiction, depression and serious mental illness, the full continuum of emotional, behavioral and mental health is front and center. Employers are addressing the access challenge through onsite and virtual counseling, network expansion where feasible and the integration of EAP and mental health benefits. Successful approaches remove stigma and consider brain health on par with other medical conditions.
Disruption Is the “New Normal”—Incumbents are evolving while new entrants will continue to make a splash and shake up the existing players. Artificial intelligence, wearables, voice recognition, genomics, blockchain, bioprinting and other advancements will play an increasingly larger role in disrupting health care delivery and access. 
Consumers demanding the latest and greatest
New entrants are driving competition and changing the landscape
Medical trend continues it’s upward movement
Ranging between 7-9% in New England 2018
Source: National Business Group on Health (NBGH) survey

7. Tracking disintermediation and new disruptors that could bring significant change
Increase in insurers buying physician groups
Vertical integrations could significantly change the industry landscape
New disruptors are figuring out how to compete in this highly regulated industry
UnitedHealth’s acquisition of DaVita’s physician network
Humana acquiring Kindred Healthcare and Curo Health
Anthem’s acquisition of Aspire Health
CVS – Aetna
Cigna – Express Scripts
Walmart – Humana (rumored)
Magellan – Senior Whole Health
Horizontal integration
Large horizontal mergers such as Anthem-Cigna and Aetna-Humana were blocked by regulators. Smaller ones have succeeded such as Centene-Health Net
Vertical includes insurers buying physician groups, for example:
UnitedHealth’s acquisition of DaVita’s physician network;
Humana acquiring Kindred Healthcare and Curo Health (which will make Humana the largest hospice provider in the U.S.),
Anthem’s acquisition of Aspire Health, a community palliative care provider.
Examples of other vertical integrations include:
CVS – Aetna
Cigna – Express Scripts
Walmart – Humana (rumored to be happening)
Magellan – Senior Whole Health
Payer Consolidation will impact New England