Highlights and updates
- Bright Health joining, will offer plans in Knoxville, Memphis, and Nashville
- Cigna and Oscar are expanding their coverage areas for 2019
- BCBSTN expects stable premiums in 2019, after finally turning a profit in 2017
- Three insurers for 2018, including newcomer Oscar
- Are Tennessee Farm Bureau plans causing market instability?
- Cost of CSR was added to silver plan premiums for 2018
- Majority of rate increase for 2018 was due to Trump/GOP-caused uncertainty
- BCBSTN re-entered Knoxville to prevent a bare spot
- Governor supported Graham-Cassidy legislation to repeal ACA
- Insurance Commissioner proposed reform, supports bipartisan approach
- Senator Alexander’s bipartisan effort abandoned by Senate leaders
Tennessee exchange overview
Tennessee has a federally-run exchange, so enrollees use Healthcare.gov to sign up for exchange plans. A 2016 HHS report indicates that 266,000 people in Tennessee gained insurance coverage — via the exchange and other avenues — from 2010 to 2015 as a result of the ACA.
228,646 people enrolled in private plans for 2018 through the Tennessee exchange during open enrollment. That was slightly lower than the 234,125 people who had enrolled the year before, but open enrollment was only half as long for 2018, ending in mid-December instead of continuing through January as it had for 2017 coverage. Enrollment was highest in Tennessee’s exchange for 2016, when 268,867 people enrolled.
For a few months in early 2017, it appeared that the Knoxville area would have no insurers offering exchange plans in 2018. But Blue Cross Blue Shield of Tennessee agreed to re-enter the Knoxville market (after leaving it at the end of 2016). In addition, Oscar Health Insurance Company entered the Tennessee exchange in the Nashville area
Premiums in the Tennessee exchange started out as some of the lowest in the country in 2014, but have increased rapidly since then. The premium increases appear to have caught up to claims costs, and Blue Cross Blue Shield of Tennessee is projecting that rates will remain relatively stable from 2018 to 2019.
Bright Health receives certification in Tennessee, will offer plans in Knoxville, Memphis, and Nashville
Bright Health is a newcomer to the insurance industry. They started in 2017 in Colorado, and expanded to Alabama in 2018. As of May 2018, Bright Health had job openings posted on their website for individual market broker managers in Arizona and Tennessee.
The Tennessee Department of Commerce and Insurance confirmed that Bright Health of Tennessee had received certification from the state as of April 1, 2018. And Bright has filed plans to offer 2019 coverage in 16 counties in the Knoxville area, nine counties in the Nashville area, and five counties in the Memphis area.
Oscar and Cigna expanding coverage area in 2019
In 2018, Oscar offers plans in nine Tennessee counties, all in the Nashville area. For 2019, Oscar has filed plans to expand into the Memphis area, and will have coverage available in a total of 23 Tennessee counties.
In 2018, Cigna’s plans are available in a total of 22 counties, in the Memphis area, the Nashville area, and the Tri-City area (the eight eastern-most counties in the state). This was the same coverage area they had in 2017. But for 2019, Cigna has filed plans to offer coverage in 30 counties, including the Knoxville area.
Blue Cross Blue Shield of Tennessee will continue to offer coverage everywhere except the Memphis and Nashville areas.
Form filings for 2019 coverage were due June 20 in Tennessee, but rate filings aren’t due until July 11. So while we know where insurers are planning to offer coverage in 2019 in Tennessee, we don’t yet know how much they’re planning to charge (as described below, BCBSTN has noted that premiums are not expected to change significantly in 2019). But the entry of Bright and the expansion of Cigna and Oscar is certain to provide residents in some areas of the state with more coverage options than they have in 2018
In 2018, Nashville and the Tri-City areas have two insurers offering plans in the exchange (BCBSTN and Cigna in the Tri-City area, and Oscar and Cigna in the Nashville area), and the rest of the state has just a single insurer available. But for 2019, some areas of the state will have three insurers:
- Nashville: Oscar, Cigna, Bright
- Knoxville: BCBSTN, Bright, and Cigna
- Memphis: Bright, Oscar, and Cigna
- Tri-City area: BCBSTN and Cigna
Blue Cross Blue Shield of Tennessee finally profitable in the individual market, rates expected to be stable in 2019
After losing $400 million in the individual market between 2014 and 2016, Blue Cross Blue Shield of Tennessee finally turned a profit in 2017. The insurer’s individual market segment generated $113 million in profit last year, putting the company on track for “relatively stable” premiums in 2019. Rates will be filed in Tennessee by July 11, but the expectation is that BCBSTN will propose only modest rate increases for 2019, if they increase premiums at all.
BCBSTN’s individual market plans increased in price by an average of 21 percent in 2018 (as described below, almost all of this increase was due to the Trump Administration’s decision to end funding for cost-sharing reductions, and uncertainty over whether the individual mandate would continue to be enforced), and the individual market continues to be a profitable segment for BCBSTN in 2018 (although claims costs tend to increase later in the year, after enrollees meet their deductibles).
Humana exited individual market, but BCBS of Tennessee agreed to offer coverage in Knoxville in 2018
In 2017, there were three insurers offering plans in Tennessee, including Humana. Humana offered exchange plans in 11 states in 2017, but is no longer offering individual market coverage in any states as of 2018. Before Oscar’s filing was announced, that left just BCBS of Tennessee and Cigna remaining in Tennessee’s exchange for 2018.
But Blue Cross Blue Shield of Tennessee pulled out of the metropolitan areas at the end of 2016, while remaining in the rural areas of the state. In 2017, Cigna offered coverage in the Memphis and Nashville areas; Humana offered coverage in the Memphis, Nashville, and Knoxville areas.
Humana’s exit meant that residents in the Knoxville area were facing the possibility of having no exchange insurers at all. Humana insured about 40,000 people in the Knoxville area, and about 79,000 people across all three metropolitan areas in the state.
For the 40,000 people in Knoxville, state regulators scrambled to reach a solution, and succeeded. In May 2017, Blue Cross Blue Shield of Tennessee agreed to once again offer coverage in 2018 in the Knoxville area in order to ensure that all areas of the state will have insurance plans available in the exchange. Their letter to Insurance Commissioner Mix McPeak indicated that rate increases were likely to be steep in order to guard against the significant market uncertainty that insurers are facing (including whether cost-sharing reductions will continue to be funded, and how well the individual mandate will be enforced).
But BCBS of Tennessee also noted that after three years of losses that totaled more than $400 million, their “2017 performance has improved.” Ultimately, BCBSTN ended up with an average rate increase of nearly 22 percent for 2018.
Humana had exited the off-exchange market nationwide at the end of 2016, but they continued to offer on-exchange plans in selected areas of 11 states in 2017, including Tennessee. But at the end of 2017, Humana exited the individual market altogether.
There were about 79,000 Tennessee residents with Humana plans in 2017 — about 39 percent of the state’s exchange population. Residents who had Humana coverage in 2017 and didn’t return to the exchange to pick a new plan for 2018 during open enrollment (November 1, 2017 to December 15, 2017), were auto-enrolled into a new plan by the exchnage. But they were also eligible for a special enrollment period triggered by loss of coverage, which continued until March 1, 2018.
Oscar Health joined the Tennessee exchange for 2018; residents of Tri-City and Nashville areas have choice of two insurers
Insurers that wished to offer individual market in Tennessee in 2018 had to file rates with the Tennessee Department of Commerce and Insurance by July 1, 2017, but form filings were due June 21.
Three insurers filed exchange plans for 2018. Cigna and BCBS of Tennessee both remained in the exchange, and Oscar Health, a New-York based company, joined them.
Cigna’s plans are available in Memphis, Nashville, and the Tri-City area (the eight eastern-most counties in the state), just as they were in 2017. Cigna’s plans are available in a total of 22 counties.
BCBS of Tennessee has plans available everywhere except Memphis and Nashville. They are continuing to offer coverage in the non-metro areas of the state where they offered plans in 2017, and have expanded back into the Knoxville area, which they had previously exited at the end of 2016.
Oscar Health has plans available in nine counties in the Nashville area.
Nashville and the Tri-City areas are the only parts of the state where enrollees have a choice between two insurers, with both BCBSTN and Cigna offering plans in the Tri-City area, and Oscar and Cigna offering plans in the Nashville area.
Tennessee Insurance Commissioner, Julie Mix McPeak, expressed satisfaction that all areas of the state are currently on track to have at least one insurer offering coverage in the exchange, but she reiterated in September how the uncertainty caused by the Trump Administration and Congress was damaging the individual health insurance market, noting that “the uncertainty about the future of the exchange, cost-sharing reduction payments, and enforcement of the individual mandate will likely increase carrier rate requests by 15 to 20 percent above what they would have otherwise filed. I share consumers’ frustrations about federal uncertainty and how that is impacting their ability to afford insurance.”
2018 rates: cost to cover CSRs was added to silver plan premiums
In September 2017, the Tennessee Department of Insurance and Commerce (TDIC) announced that the state had approved the rates that insurers had filed for 2018. However, the announcement indicated that Cigna’s approved average rate increase was 42.1 percent, which was based on the filing Cigna submitted in June 2017. An updated filing, with an average rate increase of 36.5 percent, was submitted in August, and TDIC confirmed by phone on September 21 that the updated filing was approved. The slightly smaller rate increase is due to Cigna’s decision to terminate some existing plans and replace them with new plans.
The following average rate increases were approved for 2018 individual market coverage:
42.1 percent36.5 percent (69,366 members)
- Blue Cross Blue Shield of Tennessee: 21.4 percent (78,000 members)
- Oscar Health: New to Tennessee for 2018, so no applicable rate increase
The weighted average rate increase was 28.5 percent. But those rate increases are averages, and the actual rate changes for each plan varied considerably. And it’s important to note that the approved rates are calculated before premium subsidies are applied (ie, these are “retail” rates, and most people pay far less than that as a result of premium subsidies).
88 percent of Tennessee exchange enrollees received premium subsidies in 2017, and those subsidies have increased to keep pace with the average cost of the second-lowest-cost silver plan in 2018. And silver plans are more expensive than usual in 2018 in Tennessee, as the Trump Administration is no longer funding cost-sharing reductions (CSRs) for 2018. Although the Trump Administration didn’t eliminate CSR funding until mid-October, TDCI confirmed in September that the additional premiums necessary to cover CSR in 2018 had already been added to silver plan rates for 2018 (pre-emptively, but presciently, since the funding was cut off by the federal government a few weeks later). The higher premiums for silver plans resulted in even larger premium subsidies for 2018. So although the federal government is no longer directly reimbursing insurers for the cost of CSR, they are indirectly continuing to fund CSR, via larger premium subsidies.
TDCI published a document showing average premiums for 35-year-olds and 55-year-olds in each rating area of the state, but again, those rates are pre-subsidy — most enrollees pay far lower premiums, as their premiums subsidies cover a large portion of the premiums.
2018 rate increases mostly caused by the Trump Administration
Blue Cross Blue Shield of Tennessee issued a press release in June 2017, going into great detail about their proposed rate increase for 2018. Their actuarial memo in their rate filing indicated that their average proposed rate increase was 21.4 percent, but that the majority of that was due to concerns that the Trump Administration wouldn’t continue to enforce the individual mandate, and the uncertainty surrounding ongoing funding for cost-sharing reductions (CSR).
[Note that GOP lawmakers subsequently repealed the individual mandate altogether in December 2017, but that repeal doesn’t take effect until 2019; people who are uninsured in 2018 will still face a penalty when they file their taxes in early 2019. And after threatening for months to cut off funding for CSR, the Trump Administration officially eliminated CSR funding in October 2017. But insurers are still on the hook to provide more robust coverage to low-income enrollees who select silver plans, even though the federal government is no longer directly reimbursing them for the cost — this is why TDCI allowed insurers to inflate the cost of silver plans for 2018, which turned out to be a wise decision.]
The press release from Blue Cross Blue Shield of Tennessee noted that of the 21.4 percent rate increase they proposed (which was later approved by TDCI), 14 percentage points were due to the possible lack of funding for cost-sharing subsidies, and 7 percentage points were due to concerns that the individual mandate wouldn’t be well enforced, resulting in a sicker risk pool (healthy people are the ones likely to drop coverage if the mandate isn’t enforced; sick people will maintain their coverage regardless).
So the rate increase for 2018 would apparently have been just 0.4 percent if it weren’t for the Trump Administration’s refusal to commit to funding cost-sharing reductions and enforcing the individual mandate. Instead, BCBSTN proposed an average rate increase of 21.4 percent, and state regulators had no choice but to approve it.
Cigna initially filed an average rate increase of 42.1 percent (with increases that ranged from 12.2 percent to 182.2 percent), and revised it in August to an average of 36.5 percent, after opting to eliminate — rather than renew — some plans. They noted that 14.1 percentage points of this was due to the fact that the Trump Administration had not committed to funding cost-sharing subsidies. Their initial proposed rate increase would have been 28 percent otherwise.
Oscar is new to the Tennessee market for 2018, so a rate increase is not applicable to them.
At ACA Signups, Charles Gaba calculated a weighted average proposed rate increase (for Cigna and BCBSTN) of 31.14 percent, based on initial filings. But he noted that without the Trump Administration’s sabotage of the individual health insurance markets, the proposed weighted average rate increase would have been just 13.5 percent.
Tennessee Insurance Commissioner’s reform proposals
Julie Mix McPeak is the Insurance Commissioner for Tennessee, and also serves as the President of the National Association of Insurance Commissioners. In February 2017, Mix McPeak spoke before the Senate Committee on Health, Education, Labor, & Pensions, presenting her recommendations for health care reform. Among her proposals were:
- Allowing states to define essential health benefits, rather than requiring all plans sold in every state to conform to the ACA’s essential health benefits (this has been part of most of the GOP proposals to repeal or change the ACA, although it has not been implemented. As of 2018, essential health benefits are still defined at the federal level).
- Relaxing the age band ratio from the 3:1 level set by the ACA, to a 5:1 or 6:1 cap. The ACA limits premiums for older enrollees to no more than three times those of younger enrollees. Mix McPeak suggested that insurers should be able to charge older enrollees five or six times as much as younger enrollees, in an effort to reduce premiums for younger enrollees and incentivize them to enroll (this is another provision that was included in most of the GOP efforts to repeal or change the ACA in 2017, but none of those efforts were successful. It’s worth noting that adjusting the age rating bands would result in lower premiums for younger people, but markedly higher premiums for older people. For those who receive premium subsidies, the subsidies would grow to offset the increase. But for those who don’t get subsidies, coverage could become unaffordable).
- Tighter restrictions and increased verification of eligibility for special enrollment periods (HHS finalized a market stabilization rule in April 2017 that includes increased eligibility verification, and restrictions such as limiting enrollees’ ability to use a special enrollment period to switch to a plan at a different metal level).
- Reducing the current 90-day grace period for people with premium subsidies down to a 30-day grace period (the market stabilization rule keeps the 90-day grace period, but allows insurers to apply new enrollment premiums to past-due balances from the previous 12 months if the person seeks to re-enroll after losing coverage for non-payment of premium).
Senator Alexander: 2017 legislation to protect bare counties, and a plea for CSR funding
The U.S. Senators from Tennessee, Lamar Alexander and Bob Corker, both Republicans, introduced legislation (S.761, the Health Care Options Act of 2017) in March 2017 that would allow people in counties without any participating exchange insurers to use ACA subsidies for off-exchange plans. At that point, there were 34,000 people in the Knoxville area who received subsidies to offset the cost of their Humana plans in 2017, and they were facing the possibility of having no exchange plans (and thus no subsidies) available for 2018. However, BCBS of Tennessee’s re-entry into the Knoxville area eliminated that concern for the time being, and S.761 did not advance in the Senate (there were several other states that were facing the prospect of “bare counties” in 2018, but insurers ultimately stepped up to fill in all of those areas, and every county in the US has exchange plans available in 2018).
Senator Alexander also, notably, stated in early 2017 that Congress or the Trump Administration should commit to funding cost-sharing reductions (CSRs) through 2019, in an effort to stabilize the individual health insurance market. CSRs lower out-of-pocket costs for low-income exchange enrollees who pick silver plans, and 57 percent of Tennessee exchange enrollees have plans that include CSRs in 2017.
CSR funding was ultimately eliminated by the Trump Administration in October 2017, but the uncertainty (during the rate filing season of spring/summer 2017) around whether or not the funding would continue resulted in premium proposals for 2018 that were higher than they would otherwise have been. Without a commitment to CSR funding, Tennessee Insurance Commissioner, Julie Mix McPeak estimated that premiums in Tennessee will be 15 to 20 percent higher than they would otherwise be in 2018 (this is in line with a national estimate from Kaiser Family Foundation), and as noted above, insurers in Tennessee (and around the country) added a considerable load to their 2018 silver plan rates to cover the cost of CSR.
Senator Alexander joined forces with Senator Patty Murray (D, Washington) in an effort to pass bipartisan legislation aimed at stabilizing the individual insurance markets nationwide, with a proposal that included CSR funding. However, Republican leadership in the Senate opted to push forward on their efforts to repeal the ACA (via the Graham-Cassidy legislation) and pulled the plug on Alexander and Murray’s bipartisan approach in September 2017.
In the announcement about the approved rates, Mix McPeak said “I’m disappointed by yesterday’s announcement out of Washington [about Alexander and Murray’s bipartisan approach being abandoned by Senate leadership]. While Tennessee is supportive of long-term strategies such as the Graham-Cassidy Amendment introduced in Congress, I appreciate the diligent efforts of Senators Lamar Alexander and Patty Murray to find common ground in providing more immediate stabilization in the marketplace. Instead, it appears more likely that Tennesseans must prepare themselves for a round of actuarially justified rates for 2018 that are far higher than could be necessary as a result of uncertainty in Washington.”
Tennessee Governor Haslam supported Graham-Cassidy, an ACA repeal bill
The Graham-Cassidy legislation was the GOP’s Hail-Mary attempt to pass ACA repeal before the clock ran out on 2017 budget reconciliation at the end of September (the measure was pulled in late September due to lack of support among Republican Senators, and never reached a vote). The legislation was opposed by America’s Health Insurance Plans (AHIP), AARP, the American Medical Association (because it failed the “do no harm” rule), and virtually all major patient advocacy organizations.
But Tennessee Governor Bill Haslam said that Graham-Cassidy would be “a home run for Tennessee” because the state would technically gain money under the legislation. But that’s only because Tennessee has been losing money hand over fist as a result of their refusal to accept federal funding to expand Medicaid.
It’s true that Tennessee would gain money under Graham-Cassidy, as opposed to the status quo (ie, keeping the ACA, and maintaining their refusal to accept federal funding to expand Medicaid). The Center on Budget and Policy Priorities estimates that Tennessee would gain about $1.6 billion in 2026 under Graham-Cassidy, making them among the biggest “winners” under the legislation (note that many states — especially those that expanded Medicaid under the ACA — would lose billions of dollars under the legislation, and overall federal funding would be $80 billion lower in 2026 if Graham-Cassidy were to be implemented).
But by refusing federal funding to expand Medicaid, Tennessee has missed out on $22.5 billion dollars over the 2013-2022 time frame. So although they would technically have “gained” money with Graham-Cassidy, it’s only because they haven’t implemented the ACA as intended, and have thus been missing out on billions in federal funding that would otherwise have gone towards health care in Tennessee.
As noted in the rate approval notification for 2018 premiums, Tennessee’s Insurance Commissioner also supported Graham-Cassidy, but expressed disappointment that the Senate’s bipartisan approach to market stabilization had been abandoned in favor of pursuing Graham-Cassidy (which was also ultimately abandoned).
2017 rates and carriers
Four carriers offered exchange plans in 2016, but UnitedHealthcare exited the exchange at the end of 2016. That left three carriers offering plans in the exchange for 2017, but Blue Cross Blue Shield of Tennessee is no longer offering coverage in the metro areas of Knoxville, Nashville, and Memphis, which are the three largest metropolitan areas in the state.
BCBST is not offering individual market plans (on or off-exchange) in 30 counties in those metro areas in 2017, although by remaining in some areas of the state, they’ve avoided a full market exit and left the door open for a possible return to state-wide coverage in 2018. For 2017 coverage, BCBSTN is not paying broker commissions for exchange enrollments in the Tennessee counties where they continued to offer plans, which means there are fewer enrollment assisters available to help consumers.
Blue Cross Blue Shield of Tennessee had the lion’s share of the Tennessee exchange market in 2016, covering almost 69 percent of the enrollees. The carrier says that from 2014 to 2016, they expect to incur half a billion dollars in individual market losses. In 2016, their medical loss ratio was 101.4 percent, meaning that for every dollar they collected in premiums, they spent $101.40 in claims. Although that’s lower than their medical loss ratios in 2014 and 2015, it’s unsustainable in the long run to be spending more on claims (before accounting for any administrative costs) than you’re collecting in premiums. Although Blue Cross Blue Shield of Tennessee has said they’ll consider re-entering the exchange statewide in 2018 or later, the market would have to stabilize first.
Because of BCBST’s exit from the three metropolitan areas, approximately 52,000 people in Nashville, 31,000 people in Knoxville, and 29,000 in Memphis had to switch to a different plan for 2017 (the exchange mapped them to a new plan via auto re-enrollment if they didn’t pick their own).
In 2016, United and BCBST both offered plans state-wide in Tennessee. United exited altogether at the end of 2016, and BCBST left the metropolitan areas. As a result, residents in 73 of Tennessee’s 95 counties only have one carrier option in the exchange.
For the three carriers that are offering coverage in the Tennessee exchange for 2017, approved rate increases were as follows:
- Blue Cross Blue Shield of Tennessee (68.9 percent of the exchange market share in 2016): 62 percent average rate increase
- Cigna (8.6 percent of the exchange market share): 46 percent average rate increase
- Humana (6.7 percent of the exchange market share): 44.3 percent average rate increase
UnitedHealthcare had the remaining 15.7 percent of the exchange market share in Tennessee in 2016, but their enrollees needed to select new plans for 2017 during open enrollment as they exited the individual market in Tennessee at the end of 2016 (more details below). Exchange enrollees with UnitedHealthcare coverage who didn’t return to the exchange to pick a new plan were auto re-enrolled by the exchange into the most similar plan available.
Cigna and Humana had originally filed average rate increases of 23 percent and 29 percent, respectively. But in early August 2016, regulators in Tennessee agreed to allow the carriers to refile new rates, after both carriers had told the state that the rates they had originally filed wouldn’t be adequate to cover claims costs.
In the eleventh hour, just three days before the start of open enrollment for 2017, Cigna signed a contract with Saint Thomas Health, allowing people in the Nashville Metropolitan area to have access to an exchange plan with Saint Thomas Health providers in the network (previously, Saint Thomas Health had been in-network for UnitedHealthcare and BCBST, but neither carrier is offering exchange plans in Nashville for 2017). But Vanderbilt University Medical Center is not in-network for any of the plans in the exchange in the Nashville area in 2017.
Several carriers across the country made headlines in August and September with announcements that they would exit the exchanges at the end of 2016, but UnitedHealthcare was the only insurer to exit the Tennessee exchange altogether. The fact that regulators in Tennessee allowed new rates to be filed helped to keep the carriers in the market, but it also resulted in more significant premium hikes for 2017. Carriers had asked to refile rates for 2016 during the summer of 2015, but state regulators would not allow them to do so; for 2017, regulators softened their stance in an effort to keep Cigna and Humana in the marketplace.
It’s notable that although BCBS of Tennessee’s rate proposal (62 percent average increase) was approved as filed in August, the carrier said at that point that they were “keeping all of [their] options open at this point about participating in the 2017 marketplace. [BCBST] anticipate[d] making a final decision in mid-September.” So the carrier’s decision to exit the state’s metropolitan areas didn’t come completely out of the blue.
Tennessee’s individual market rate increase (an average of 56 percent) was roughly tied with Minnesota’s for 2017, and both states trailed only Oklahoma, which had the highest weighted average increase for 2017. It’s helpful, however, to consider how the actual rates compare with the rest of the country. In 2014 and 2015, Tennessee had among the lowest overall average rates in the country. For 2016, the state’s relatively steep weighted average rate increase (driven mainly by BCBSTN’s 36.3 percent average increase) meant that rates in Tennessee caught up with the rest of the country.
In 2016, the average pre-subsidy premium for plans selected in the Tennessee exchange was $400 per month, which is very similar to the $396 per month average across all states that use Healthcare.gov. But Tennessee’s 56 percent weighted average rate hike for 2017 (versus about 25 percent nationwide) pushed Tennessee’s average well above the national average. The average pre-subsidy premium across all states that use the federally-run exchange is $476/month. In Tennessee, it’s $587/month.
But subsidies cover the lion’s share of the premiums for the 85 percent of Tennessee exchange enrollees who receive premium subsidies. The average after-subsidy premium is just $137/month (versus a $153/month average across all the states that use the federally-run exchange). When premiums increase, subsidies grow as well, to keep up with increasing benchmark plan premiums.
Rate increases, carrier exits — are Farm Bureau plans exacerbating the problem?
Tennessee has allowed transitional (grandmothered) plans to remain in force, but the Tennessee Department of Commerce and Insurance confirmed that they no longer have any grandmothered plans remaining in the individual market, as insurers have opted to end those plans and replace them with ACA-compliant plans instead.
But there are about 73,000 people in Tennessee who are covered under Farm Bureau plans that aren’t ACA-compliant. About 50,000 of those are grandfathered plans, but the rest are medically underwritten “traditional” plans that are still available for purchase. Medical underwriting means that the insurer uses the applicant’s medical history to determine whether to offer coverage and at what price. That practice is no longer allowed under the ACA — on or off-exchange — for any plans that are considered individual major medical health insurance.
But in Tennessee, the state doesn’t consider Farm Bureau to be a licensed health insurer. That’s been the case for more than two decades — Farm Bureau plans operate outside of the regulatory structure imposed by the state (and the ACA) on health insurers. As a result, Farm Bureau “traditional” plans, which are less expensive than regular health insurance but only available to healthy people, are being sold to healthy people in Tennessee, effectively removing them from the ACA-compliant risk pool.
People who enroll in Farm Bureau’s “traditional” plans are not in compliance with the ACA’s individual mandate, and are assessed a penalty for being uninsured unless they’re exempt from the individual mandate (this is the same as the rule that requires people with short-term health insurance to pay the individual mandate penalty; just like the Tennessee Farm Bureau “traditional” plans, short-term health insurance is not regulated by the ACA).
But some healthy people find that the combination of the lower premiums and the penalty is still less than the premiums for an ACA-compliant plan. The plans are not as robust as regular health insurance, and aren’t helpful for people with pre-existing conditions. But the fact that Tennessee has allowed them to continue to be sold outside the scope of the state’s insurance regulations could be part of the reason the state has a risk pool in the ACA-compliant market that’s sicker than most states.
Iowa has decided to follow Tennessee’s lead, enacting legislation in 2018 that allows Farm Bureau to partner with Wellmark to offer non-ACA-compliant plans in Iowa.
BCBSTN losses and rate hike request – some background
During open enrollment for 2016 coverage, 166,425 exchange enrollees (62 percent of the total) signed up with Blue Cross Blue Shield of Tennessee for 2016. This was an increase of 16 percent over BCBSTN’s exchange enrollment in 2015, despite the fact that the carrier raised its premiums by an average of 36 percent for 2016. The remaining 38 percent of the exchange enrollees selected plans from Humana, Cigna, and United Healthcare.
Blue Cross Blue Shield of Tennessee had the lowest priced plans in the Tennessee exchange – and the nation – in 2014. Although BCBSTN’s average rate increase was 19 percent for 2015 and 36 percent for 2016 (and their competitors had significantly smaller rate hikes), they still had among the lowest premiums in many areas of Tennessee in 2016. In the Memphis area, a search on Healthcare.gov indicated that the five least expensive bronze plans and the four least expensive silver plans were all offered by BCBSTN in 2016. Their lower premiums and brand-name recognition likely played a role in their outsized market share. But because enrollees have been sicker than expected, the carrier lost $300 million during 2014 and 2015, and projected total losses to reach $500 million by the end of 2016; losses of that magnitude are not sustainable.
In order to continue working towards long-term sustainability in the ACA-compliant individual market, BCBSTN had indicated earlier in 2016 that they were expecting to propose significant rate increases for 2017, although the expectation in early 2016 was that the proposed rate increases for 2017 would be comparable to the 36 percent average increase that the carrier implemented for 2016. Ultimately, BCBSTN requested a much higher average increase—62 percent—for 2017, and regulators approved it in order to keep the insurer in the marketplace.
Joe Sullivan of The Knoxville Mercury has tracked down some 2016 data that adds perspective to the proposed rate changes for 2017, particularly in the Memphis and Nashville metropolitan areas, where Humana, Cigna, and BCBS all offered plans in the exchange in 2016:
- BCBS has two networks, and offered 10 silver PPO plans in Nashville and in Memphis in 2016. The plans included out-of-network coverage. BCBST is not offering plans in either area in 2017.
- Humana had one silver PPO plan in Nashville and in Memphis.
- Cigna had three silver EPO plans in Nashville (no out-of-network coverage) and three silver PPO plans in Memphis.
- In Memphis, all three carriers offered silver PPO plans, and BCBS had the lowest prices (BCBST is not offering coverage in Memphis in 2017).
- In Nashville, Cigna’s silver prices were lower than BCBS, but the Cigna plans were EPOs, without coverage for out-of-network care (BCBST is not offering plans in Nashville in 2017).
UnitedHealthcare exited individual market
At the end of 2016, UnitedHealthcare exited the individual market in Tennessee. The Department of Commerce and Insurance confirmed that the exit applied to both the exchange (UnitedHealthcare Insurance Company) and off-exchange (UnitedHealthcare Life Insurance Company).
The state reported that 40,879 people needed to secure new coverage for 2017 as a result of United’s exit (the large majority of these enrollees had their United coverage through the exchange). They had an opportunity to pick a new plan during open enrollment for 2017 coverage, which began on November 1, 2016.
According to Kaiser Family Foundation’s analysis, UnitedHeathcare offered at least one of the two lowest-priced silver plans in the exchange in 73 of Tennessee’s 95 counties in 2016. If United had not participated in the exchange in 2016, the average benchmark (second-lowest-cost silver) plan would have been up to $25/month more expensive (pre-subsidy) for a 40-year-old in 43 of those counties, and between $25 and $100/month more expensive in the other 30. The vast majority—almost 88 percent—of Tennessee exchange enrollees qualified for premium subsidies in 2016, and those subsidies are larger in 2017 due to the increase in benchmark plan rates. But people who aren’t eligible for subsidies must bear the brunt of rate increases on their own.
Effectuated enrollment nearly 232k in 2016
During the 2016 open enrollment period, 268,867 people enrolled in private plans through the exchange in Tennessee. That’s about 16 percent more than the total who enrolled during the 2015 open enrollment period (231,440 people).
48 percent of the Tennessee residents who enrolled for 2016 were new to the exchange, and 85 percent were receiving premium subsidies to offset the cost of their coverage. Their average pre-subsidy premium is $400/month (right in line with the $396/month average across all 38 Healthcare.gov states), while their average after-subsidy premium is $104/month (again, very similar to the $106/month average for Healthcare.gov states).
As of March 31, effectuated enrollment stood at 231,705, and 87.7 percent of those enrollees were receiving premium subsidies that averaged $299 per month. Attrition is a normal part of the individual market; some enrollees never pay their initial premiums, while others end up cancelling their coverage before the end of the year.
Open enrollment ended on January 31. Open enrollment for 2017 coverage will begin on November 1, for coverage effective January 2017. Between now and November, you can enroll in a plan (on or off-exchange) only if you experience a qualifying event (Native Americans can enroll year-round without a qualifying event, as can anyone eligible for Medicaid or CHIP).
2016 rates and carriers
Tennessee had among the highest rate average rate increases in the country for 2015, yet still ended up with among the lowest overall rates (see below). And Tennessee once again made headlines with rate filings for 2016.
Of the five carriers that offered plans in the Tennessee exchange in 2015, four filed proposed rates for 2016. The fifth carrier, Assurant, announced they would exit the health insurance market nationwide, and are no longer offering plans.
Then, just two weeks before the start of open enrollment for 2016 coverage began, regulators in Tennessee announced that Community Health Alliance (the state’s ACA-created CO-OP) would cease operations by the end of 2015, and their plans would not be for sale during open enrollment (more details below).
But UnitedHealthcare joined the Tennessee exchange for 2016, so there are four carriers from which to choose (United’s tenure on the exchange will be just one year, as they’re exiting the individual market in Tennessee at the end of 2016). Rates were finalized by the Tennessee Department of Commerce and Insurance in late August:
- Blue Cross Blue Shield of Tennessee: 36.3 percent average rate increase. BCBS is the dominant carrier in the state, with 72 percent of the individual market share in 2014, and 70 percent in 2015. Their proposed 36.3 percent average rate increase was approved as requested. They have 62 percent of the exchange enrollees in 2016.
- Humana: 5.8 percent average rate increase. Initially, Humana requested a 15.8 percent rate increase, and state regulators approved it. But Humana subsequently decided to stop offering their platinum plans, resulting in an average rate increase of just 5.8 percent for their remaining plans.
- Cigna: 0.4 percent average rate increase. State regulators approved Cigna’s proposed 0.4 percent average rate hike.
- UnitedHealthcare: Monthly premiums range from about $94 to $1,123; 2016 was UHC’s first – and only – year offering plans in the exchange, so a rate increase was not applicable.
In terms of market share in the exchange, BCBS of Tennessee had 164,896 enrollees in 2015, while Community Health Alliance had 35,761 members in May 2015, but that had dropped to around 27,000 by October. The other 30,783 exchange enrollees were spread among the three remaining carriers.
The exit of Community Health Alliance from the marketplace actually served to reduce the weighted average rate increase, since CHA had the highest rate increases of any of the carriers (44.7 percent). But all of CHA’s enrollees needed to switch to a plan offered by one of the other carriers in order to continue to have coverage in 2016.
The rate changes described above were for pre-subsidy premiums; subsidies cushioned the impact of rate increases for the majority of the exchange enrollees in Tennessee (nearly 88 percent of private plan enrollees in the Tennessee exchange are receiving premium subsidies in 2016). Subsidies limit benchmark plan premiums to a set percentage of an enrollee’s income, as long as the enrollee doesn’t earn more than 400 percent of the federal poverty level.
Carriers noted that the proposed rate changes for 2016 were much more fact-based than the rates we saw in 2014 and 2015. For 2014, carriers could do little more than make educated guesses. Even for 2015, the rates were filed in the spring of 2014, within weeks of the end of the first open enrollment period. That meant there was very little in the way of actual claims data for actuaries to use when creating rates for the coming year. But the rates that carriers proposed for 2016 were based on more than a year of claims data (all of 2014 plus the early part of 2015). And industry experts point out that there shouldn’t be as much price variation from one carrier to another as we go forward, since they’re all able to base premiums on actual claims experience now.
Although Tennessee’s rate hikes were considerable in 2016, these changes have to be viewed against the backdrop of Tennessee having lower-than-average rates in 2014 and 2015. And as always, it was vitally important that enrollees shop around during open enrollment to make sure they ended up with the plan that represents the best value for their needs in 2016.
Community Health Alliance shut down
On October 14, 2015, the Tennessee Department of Commerce and Insurance announced that Community Health Alliance, the state’s ACA-created CO-OP, would wind down its operations by the end of the year. Regulators noted that the shut-down at the end of 2015 was based on the fact that “the risk of CHA’s potential failure in 2016 was too great and would have caused substantial detrimental effects on the market as a whole if it were to collapse.”
Community Health Alliance was the sixth CO-OP to shut down at that point, and the fifth since July (by the end of 2015, 12 CO-OPs had closed and 11 remained operational). As was the case with Kentucky‘s CO-OP earlier in October, Community Health Alliance’s demise was at least partially triggered by the fact that HHS announced on October 1 that risk corridor payments to insurers in December (based on 2014 losses) would end up being only 12.6 percent of what was owed.
Community Health Alliance had the lowest prices in the exchange for 2015, but proposed an average rate increase of 32.6 percent for 2016 (and regulators had increased the rate hike to 44.7 percent in an effort to keep the carrier sustainable). The CO-OP stopped selling 2015 plans as of January 15, 2015, noting that they had already met their enrollment goal for the year. Community Health Alliance had planned to begin selling plans again during the 2016 open enrollment, but instead they ceased operations altogether at the end of 2015.
No new enrollees joined the CO-OP since January 2015, but there were still 27,000 enrollees who needed to select new coverage for 2016 from a different carrier. They had until the end of February to enroll in a new plan, since they had a 60 day special enrollment period following the loss of coverage.
In January 2017, Tennessee Insurance Commissioner, Julie Mix McPeak indicated that Community Health Alliance “should be able to repay the federal government a portion of the monies allocated for its startup and solvency purposes” despite the fact that the CO-OP failed.
Humana ended grandfathered individual plans
Grandfathered plans are those that were already in effect when the ACA was signed into law on March 23, 2010. They can remain in force without complying with most of the ACA’s provisions, but carriers can choose to discontinue them instead (just as insureds can choose to drop their grandfathered coverage). Humana had fewer than 3,500 people with grandfathered individual plans in Tennessee in 2015, but they all had to enroll in new coverage as of their renewal date in 2016.
Humana discontinued grandfathered individual plans in 11 states, including Tennessee. Impacted insureds qualified for a special enrollment period beginning 60 days in advance of the loss of coverage, and continuing for 60 days afterwards (the same as the special enrollment period that applied to former Community Health Alliance members). People losing coverage under a grandfathered plan from Humana were able to enroll in a plan through the exchange, or outside the exchange, but subsidies are only available in the exchange.
The exchange carriers are also selling plans outside the exchange in Tennessee. In addition, four other carriers sold plans only outside the exchange in 2016: Tennessee Rural Health, UnitedHealthcare Life Insurance Company, Aetna, and Freedom Life Insurance Company of America.
For 2017, UnitedHealthcare Insurance Company and UnitedHealthcare Life Insurance Company are not offering plans in the individual market in Tennessee, or or off-exchange.
King v. Burwell – subsidies are safe
In June 2015, the Supreme Court ruled that subsidies are legal in every state, regardless of whether the exchange is run by the state or federal government.
The Tennessee Department of Insurance confirmed that if the Supreme Court had eliminated subsidies in Tennessee (and other states that use Healthcare.gov), carriers in Tennessee would have been required to submit revised rates for 2016. There is no doubt those rates would have been considerably higher than the initially-proposed rates, so everyone who purchases individual insurance in Tennessee is certainly better off with the Court’s ruling against the King plaintiffs.
In addition to sharply higher rates market-wide, nearly 150,000 people in Tennessee would have lost their subsidies – and in most cases, their health insurance – if the subsidies had been struck down.
But some lawmakers in Tennessee supported the King plaintiffs, and tried to eliminate subsidies in states like Tennessee that use the federally facilitated marketplace. In December 2014, 19 Tennessee lawmakers (some current, some former) signed an amicus brief that was delivered to the Supreme Court, asking the Court to rule that subsidies are not legal in states with HHS-run exchanges.
2015 enrollment data
231,440 people enrolled in private plans through the exchange during the 2015 open enrollment (November 15 to February 22, including the week-long extension). 53 percent of Tennessee’s enrollees were new to the exchange for 2015, and 83 percent were eligible for premium subsidies.
HHS had projected that Tennessee’s exchange would enroll 195,000 people during the 2015 open enrollment period (up from the 151 thousand who enrolled during the 2014 open enrollment period). Ultimately, the exchange far surpassed that target – unsurprisingly, given that it was already at 99 percent of the projected enrollment in January.
But by the end of June, attrition had resulted in the effectuated (paid-up) enrollment falling to 177,453 people. Nearly 85 percent of them were receiving premium subsidies, and 63 percent were receiving cost-sharing subsidies.
In addition to the private plan enrollees, 40,373 Tennessee exchange enrollees were eligible for Medicaid or CHIP between November 15 and February 22, despite the fact that the state has not yet expanded Medicaid and is continuing to use the old eligibility guidelines.
According to Gallup data, the uninsured rate in Tennessee in 2013 was 16.8 percent, and fell to 12.9 percent by the first half of 2015. It would be considerably lower if Tennessee had expanded Medicaid, but even still, the state is making progress.
In mid-2014, Blue Cross Blue Shield of Tennessee filed rate proposals with an average increase of 19 percent for 2015 (they were approved with very little modification). Cigna was proposing a rate increase of 7.5 percent, while Humana’s came in at 14.4 percent. Once rates were approved, the average rate increase in Tennessee across all eight carriers in the individual market (including on and off-exchange plans) came in at 12.5 percent, making it one of eight states in the PricewaterhouseCooper analysis with double digit average rate increases.
But that’s only part of the story. Because Tennessee had rates so much lower than the national average in 2014, their rates are still much lower than most states in 2015, even after the rate hikes. A Kaiser Family Foundation analysis of benchmark plan (second lowest-cost silver plan) premium changes in major metropolitan areas in all 50 states found that the Nashville area still has the fifth lowest average benchmark premium in the country in 2015, even after an increase of nearly 8 percent.
Tennessee’s rate changes are a perfect example of why it’s so important for enrollees to go back to the marketplace and double check their options for the coming year, rather than simply letting their plan auto-renew. In virtually every area of Tennessee, people who enrolled in the benchmark plan in 2014 and opted to renew that plan for 2015 were subject to rate increases that averaged at least 15 percent. But people who shopped around and switched to the new benchmark saw much more modest rate changes in most areas – even a decrease in the western part of the state.
Across all metal levels and plans sold in the exchange, a Commonwealth Fund analysis found an average 2015 rate increase of 9 percent in the Tennessee exchange, for a 40 year-old non-smoker.
Outreach and education
Blue Cross Blue Shield of Tennessee – by far the dominant carrier in the exchange in 2014, began conducting outreach to target Latino and Millennial populations during the second open enrollment period, as both demographics were under-represented during the first round of enrollments.
Blue Cross Blue Shield of Tennessee has also focused on general education and enrollment assistance state-wide, after a survey found that 80 percent of the 2014 enrollees signed up without any help, just using HealthCare.gov on their own. Many of them didn’t understand all of the details of their coverage as a result, and BCBSTN has been working to make sure that people receive help with the renewal and enrollment process.
The Tennessee Health Care Campaign is also working to provide education and enrollment outreach in Tennessee.
Get Covered America-Tennessee announced in June 2014 that Jacob Flowers would be their new director. Flowers’ job initially was to educate and enroll as many people as possible during the 2015 Obamacare open enrollment period, utilizing resources that have already been allocated to Tennessee. In September 2015, Flowers announced that Get Covered Tennessee had been awarded $1.65 million to fund outreach activities for 2015. In announcing the award, CMS noted that Get Covered Tennessee “is a statewide network of agencies that will provide a physical ACA presence in all 95 TN counties—a first for TN.”
During the 2016 open enrollment period, the mayors of Tennessee’s four largest cities have reached out to their constituents to urge them to visit Healthcare.gov or GetCoveredTenn.org to seek assistance with the enrollment process. Chattanooga Mayor Andy Berke, Knoxville Mayor Madeline Rogero, Memphis Mayor AC Wharton, and Nashville/Davidson County Mayor Megan Barry joined together with Get Covered Tennessee and Enroll America “to make it as easy as possible for every resident of our great cities to get access to the information they need to get covered.”
2014 enrollment stats
151,352 Tennessee residents had completed their Obamacare enrollment in private plans through the exchange by April 19, 2014. The final total was 23% more than the original projected target for Tennessee.
Although Tennessee had a strong 2014 open enrollment period, there was still a long way to go. Prior to the first open enrollment period, the Kaiser Family Foundation estimated that 645,000 Tennessee residents would be eligible to purchase policies in the exchange, and 387,000 of them would qualify for subsidies to do so.
But as in all states, the realities of getting people enrolled – especially people who have never had insurance before and are entirely unfamiliar with the system – have proved challenging in Tennessee.
Governor pursued Medicaid expansion
Although the state’s Medicaid enrollment system has been plagued with difficulties, an additional 83,591 exchange enrollees were eligible for Medicaid under the state’s existing rules, despite the fact that Tennessee has not expanded Medicaid. In November 2013, TennCare requested an additional $180 million for its budget as a result of the influx of new applications.
In March 2014, Tennessee Democrats called on their state and their governor to move forward with Medicaid expansion, or at the very least, Governor Bill Haslam’s “Tennessee Plan,” noting that anything would be better than nothing for the 161,000 residents who are currently in the “coverage gap” – not eligible for Medicaid, and not eligible for exchange subsidies.
Haslam spent much of 2014 discussing options with the federal government and TennCare. Although public approval for the ACA overall is relatively low in Tennessee, the majority of the state’s voters – 56 percent according to a November 2014 Vanderbilt poll – support Medicaid expansion.
Then in December 2014, Haslam unveiled his Insure Tennessee plan that would include two options: one would involve privatized TennCare participation, and the other would involve vouchers that would allow workers access to previously unaffordable employer-sponsored coverage. Enrollees with incomes between 100 percent and 138 percent of poverty level would be required to pay modest premiums for their coverage.
A study conducted by the University of Tennessee’s Center for Business and Economic Research determined that Haslam’s Insure Tennessee plan would bring about 50,000 jobs to the state, along with $1.14 billion in new spending to drive the economy. But the legislature still had to agree to Haslam’s plan…
but Senate committee rejected expansion
A special legislative session to address Governor Haslam’s Insure Tennessee plan convened on February 2, 2015. But ultimately, just two days later, the Senate Committee for Health and Welfare rejected the proposal by a 7 to 4 vote. That means it will not proceed to the Senate floor for debate, and Medicaid expansion is likely off the table in Tennessee for this year.
But there is certainly some support within the legislative body for Medicaid expansion. In fact, US Rep. Steve Cohen has called out Gov. Haslam on his opposition to straight Medicaid expansion (Haslam’s plan involves private insurance for the Medicaid-eligible population), and wants Tennessee to move forward with Medicaid expansion – including accepting $1 billion in federal funds – as outlined under Obamacare.
And after the Supreme Court’s King v. Burwell ruling kept subsidies available in the Tennessee exchange, supporters of Medicaid expansion renewed their push for expanded access to healthcare, rallying in Nashville on June 29, 2015 for a news conference to call attention to the fact that millions of Americans – including 161,000 in Tennessee – are essentially locked out of health coverage altogether, since they have incomes below the poverty level and they’re in states that haven’t expanded Medicaid.
Supporters of Insure Tennessee continue to advocate for the expansion of Medicaid, and are touring the state raising awareness of the need to accept federal funds to expand the state’s Medicaid program.
Heading into the 2016 legislative session that began on January 12, Insure Tennessee supporters were pushing for the issue to be resurrected, but Lt. Gov. Ron Ramsey (R – Blountville) said that there was no way the legislature would pass the Insure Tennessee proposal in 2016. He noted instead that a new president would be elected in November, and his plan appeared to hinge on getting a block grant for Medicaid, assuming a Republican in the White House and Congressional approval of a major overhaul of the ACA (note that the AHCA, passed by the House in May 2017, would switch all Medicaid funding to block grants or per-capita allotments).
As the 2016 legislative session wore on, Citizens for Insure TN paid for billboards urging House Speaker Beth Harwell to take action to bring Insure TN to the floor of the House for a full vote. Haslam continues to support Insure TN, but reminded constituents that “The thought that somehow the speaker is going to reach down there and pull that bill to the floor, that’s not how that works.” And in March 2017, when the AHCA had been pulled from the floor of the House during its first go-round (it was ultimately passed in May), Haslam indicated that the was not planning to call a special session of the legislature to reconsider the Insure Tennessee plan.
Legislation was also introduced in January 2016 to have the issue of Medicaid expansion placed on the November 2016 ballot in Tennessee, but the bill did not make it out of committee.
Tennessee ACA legislation and regulations
Although the ACA is obviously popular with the hundreds of thousands of Tennessee residents who have new coverage in place, GOP lawmakers in the state moved forward in mid-January 2014 with a bill that would prevent state and local government entities – and state contractors – from participating in the HHS-run exchange. Ultimately, SB1888 did not advance out of committee.
The Tennessee Department of Commerce and Insurance drew attention for emergency rules issued shortly before the Oct. 2013 launch of the new marketplace. The emergency rules require individuals who will help others use the new health insurance marketplace be fingerprinted and undergo background checks, and would have forbidden lay people from assisting their friends and neighbors with health insurance applications.
Religious and community groups questioned the motivation behind the rules and sued to block the rules. A judge didn’t block the emergency rules, but did agree they were too broad and could be interpreted to apply to those giving informal advice, and a temporary restraining order against the rules was issued. Two lawsuits were brought against the emergency rules, and by mid-October 2013, the state government had backed off of the rules, making it easier for people to assist others in Tennessee, both formally and informally.
History of the Tennessee exchange
In December 2012, Gov. Haslam announced Tennessee would not develop its own health insurance exchange, citing a lack of information from the federal government.
Prior to his 2012 announcement, Haslam had leaned toward a state-run exchange. He believed local state control was preferable and that the state could run the exchange more cost-effectively that the federal government.
However, Republican legislators opposed the exchange, Tea Party supporters staged repeated protests, and Tennessee eventually ended up with an exchange run by HHS.
Tennessee health insurance exchange links
Health Assist Tennessee
Helps connect Tennesseans with public and private programs to meet health care needs and assists TennCare members with access to medical care.
State Exchange Profile: Tennessee
The Henry J. Kaiser Family Foundation overview of Tennessee’s progress toward creating a state health insurance exchange.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.