HIX: Health Insurance Exchanges

Change is coming to the U.S. health insurance market and the road will be bumpy.

Nowhere is the change more apparent than the current debate surrounding the state-run

public health insurance exchanges. Our research underscores that the Affordable Care

Act of 2010 underestimated the cost and complexity of establishing public exchanges.

In spite of these issues, new and unforeseen opportunities are emerging relative to

health insurance distribution. The application of retail, product design and customer

service expertise could be transformational relative to the health insurance market for

individuals.

HIX: An assessment of the complexities and opportunities emanating from the ACA’s public health insurance exchange concept.

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EXECUTIVE SUMMARY 02

REVIEWING PROGRESS & ASSESSING RISKS 03

HIX COMPLEXITY: INTENSIFIED BY A MISALIGNMENT OF VISION & REALITY 04

COSTS: STATES THAT OVERLOOK SET-UP AND OPERATING COSTS DO SO

AT THEIR OWN PERIL 06

SUSTAINABILITY ISSUES COMPLICATED BY PRICING, RISK & POLITICS 07

ALTERNATIVES TO PUBLIC EXCHANGES EMERGE 09

LOOKING AHEAD 11

TRIPLE TREE RESEARCH 12

Table of Contents

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E X E C U T I V E S U M M A R Y

As the Affordable Care Act (ACA) marks its first anniversary, a number of key questions remain. One of the largest revolves around the costs and benefits for the federally mandated and state-run competitive marketplaces called Health Insurance Exchanges (HIX), where individuals will be able to shop for and purchase health insurance. The public (state-run) HIX is one of the cornerstones of the health reform legislation, and for individuals without healthcare coverage today – an estimated 34 million people – the public HIXs are the intended mechanism by which individuals will acquire health insurance.

The ACA requires1 that each state build and operate a multi-channel (i.e. online, phone, and paper-based) marketplace where any qualified individual can shop for and buy health insurance. The legislation provides some specifics as to what types of “essential health benefits” must be provided within the exchange, dictates guidelines and mandates as to how the states must run the HIX, and defines specific features the exchanges must possess. These include:

• A choice of certified and approved health plans from different carriers.

• Simple plan comparison tools that allow consumers to research and select the best policy for their needs.

• Enrollment assistance for those purchasing private insurance, and eligibility information for those qualified to receive government subsidies or Medicaid enrollment.

• A process for recouping operational costs of the HIX through surcharges in order to make them self-sustaining.

For these exchange-based insurance policies, federal and state law will closely regulate the products and benefits offered and the prices insurance companies can charge for their products. To keep the HIXs viable, insurance companies are forbidden from undercutting prices of products sold on a public exchange with competing products in the open market. They will also be required to pool risks across exchange and non-exchange participants. Further, the U.S. Department of Health and Human Services (HHS) will mandate a set of essential health benefits that must be provided under each policy, including coverage and deductible tiers for each plan offered.

While the public HIX concept seems simple and straight forward, TripleTree believes that implementation is fraught with costs, technical challenges, and sustainability issues that are neither recognized nor acknowledged, much less understood. Thus far, much of the debate about HIXs has focused on constitutional questions - and therefore political issues - related to the individual mandate which would compel citizens to purchase health insurance. As the states ramp their HIX implementation efforts in order to meet the 2014 deadline, we anticipate that several new challenges will come to the forefront. They will need to be addressed and will propel further change.

Healthcare reform and the resultant need for serving the individual market2 are propelling new approaches to capturing share in the insurance marketplace, and we expect that a range of new market entrants are just around the corner. Recognizing that it is still early in the progression of these alternative, free-market approaches, this report will review the concept of “private” insurance exchanges and reveal how they will likely serve a larger population than their public counterparts, and will provide more compelling insurance options and opportunities.

1 Each state must setup a not-for-profit health insurance exchange (HIX or Health Benefits Exchange) or join with a group of states into a regional HIX. Exchanges must be operational by January 1, 2014 for qualified individuals and by 2017 states can

open the exchanges to businesses with 100 or more employees.

2 The individual market for health insurance is defined by consumers who buy insurance for themselves or their families directly from a health insurance company. The ACA allows the states flexibility to include “small groups” of under 100

members in the individual market by 2014.

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R E V I E W I N G P R O G R E S S & A S S E S S I N G R I S K S

Following the passage of the ACA in 2010, states began early planning toward establishing their required exchanges. Initial planning included identifying the appropriate governance structure and state agency to manage and operate the exchange. HHS awarded each of 48 states and the District of Columbia $1 million in grants to fund the initial planning. Two states, Alaska and Minnesota, abstained from accepting the grant (others are considering returning these funds). While several states have sued the federal government to suspend implementation of the ACA, most states are moving forward with their HIX implementation efforts while the constitutional questions are debated.

By late 2010, HHS began to publicly acknowledge the challenges and complexities of implementing the public exchanges. To address some of these issues, HHS awarded $241 million to seven states (Kansas, Maryland, New York, Oregon, Oklahoma, Wisconsin and a Massachusetts-led regional group) with “Early Innovator” grants. Under this grant program, each state has been asked to develop a prototype HIX and share the architecture and lessons learned for the benefit of other states.

While compelling on the surface, a review of the status of these Early Innovator grants is cause for concern, based on a few key observations:

• Organizational: States have not resolved the issues needed in resourcing each exchange.

• Politics: The state of affairs for participation in the HIX program has not been resolved; Oklahoma returned their Early Innovator grant money and projects in Kansas, Oregon, and Wisconsin are at risk.

• Technology: States must modernize adjacent systems including their Medicaid Management Information Systems (MMIS), tax and income reporting systems, and a host of other connected systems before they can support the HIX as mandated.

• Complexity: States are either underestimating the technical intricacies of establishing an HIX or are acknowledging after further study the tremendous amount of heavy lifting needed to implement the HIX.

• Funding: States are concerned with supporting the cost burdens for establishing the HIX beyond what federal grants will provide.

• Timing: Current schedules for bringing the Early Innovator HIXs online will make it nearly impossible for other states to adopt the reference models in order to meet the 2014 deadline.

Setting aside the political and policy issues relating to the exchange; the fundamental risks which range from technical complexity and cost to operational sustainability taken alone could result in the public exchanges falling short of their goal to create an efficient marketplace for health insurance acquisition.

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H I X C O M P L E X I T Y : I N T E N S I F I E D BY A M I S A L I G N M E N T O F V I S I O N A N D R E A L I T Y

When the ACA legislation was being debated, proponents argued that the exchanges will be straight forward to setup and simple to operate. Lost on the architects of the ACA, however, was the inherent complexity of configuring insurance products around variables such as plan design, specific benefits, exclusions, and deductibles.

The HIX was conceived on the vision of a comparison engine and shopping portal for health insurance. Parallels were drawn with popular web-based travel sites like Expedia. The public exchange supporters contended that, just as online travel shopping disaggregated the travel agent (broker) model and created new levels of market competition and shopping efficiency, public insurance exchanges would do the same for healthcare.

Exchanges are not drop-in products. Massive, and yet undetermined, effort will be required to make them function as intended. The interdependencies and required checks for income, qualification for alternate assistance programs (i.e. the Children’s Health Insurance Program/CHIP), citizenship verification, subsidy calculation, and other complexities are integral components of HIXs. It does not take long to realize that the technology requirements alone call for far more than “typical” off-the-shelf software deployments.

To help illustrate the complexity, a typical state HIX would require the following technical considerations and functions in order to fulfill the needs mandated by the ACA (a partial list of solution providers is also included).

Setting aside the political and

policy issues relating to the

exchange; the fundamental

risks which range from

technical complexity and cost

to operational sustainability

taken alone could result in

the public exchanges falling

short of their goal to create

an efficient marketplace for

health insurance acquisition.

In reviewing the chart, it is worth noting that no vendor offers a “turnkey” solution for a complete public HIX. Creating a fully functional HIX, at least today, would require stitching together a collection of bits and pieces to form a comprehensive solution. States will have to rely on multiple vendors to provide functionality in assembling their respective exchanges, a much larger effort than is being planned for by some of the Early Innovator grantees. Also, the chart reveals that there are functional requirements where no solution, or even partial solution, exists today. These gaps can be met, but they will be difficult to develop and integrate. We believe that many states and HHS are underestimating the complexities of assembling the exchange as mandated in the ACA, and this poses a tremendous risk – both economic and operational.

C O N S U M E R

E N G A G E M E N T /

D E C I S I O N S U P P O R T

C R M / S Y S T E M O F

R E C O R D

C A L L C E N T E R

B E N E F I T S

A G G R E G AT I O N

I N T E G R AT I O N

PAY M E N T

A D M I N I S T R AT I O N

F U N C T I O N A L

R E Q U I R E M E N T S

Consumer ecommerce front-end: Supports self-service, product configuration wizard and multi-carrier price quoting, plan comparison, documentation creation, multi-channel support

Master customer/ subscriber catalog (name/record matching) and product catalog (with ties to multiple carriers). Sales and service oriented capabilities

Support for insourced or outsourced call center with healthcare/ insurance specific workflow; multi-channel interaction (web, call, and paper-based)

Automated checks for eligibility, subsidy, and verification (income, citizenship, etc.) and determination if other programs (i.e. Medicaid, CHIP) are appropriate

Systems, data, workflow integration to interconnect systems (CMS, States, Medicaid, Carriers, Employers), insurance catalogs, underwriting, and various state/fed repositories

Individual market: Direct billing or support for carrier billing. Group billing (individual breakout but bill aggregation), collection, reconciliation, premium consolidation, and commissions

S E R V I C E

P R O V I D E R

L A N D S C A P E

Large vendors have portal tools but not purpose built healthcare commerce platforms. Specialized vendors may be more relevant

Potential scalability issues with smaller vendors, limited healthcare specific functionality for larger platforms, with specialized solutions offering limited CRM integration

Health insurance vendors support either an insourced model or generic horizontal call center capabilities

No out-of-the-box support among competitive landscape. Heavy integrator involvement required

Third-party professional services prevalent but with limited healthcare domain expertise

No group has built a productized solution for public HIX and multiple requirements remain unanswered. Vendors represented here may have some of the capabilities required

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Source: TripleTree

PUBLIC HIX FUNCTIONAL REQUIREMENTS

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D O S O AT T H E I R P E R I L

HHS is committed to funding the exchanges regardless of cost, and based on our assessment of several state HIX plans, these will be significant. One year after the passage of the ACA, and $300 million later, little HIX progress has been made on any front (organizational, planning, implementation), and the ongoing costs of operating and maintaining an HIX are far from known.

One example is Oregon, which has estimated its two year cost of building its exchange at $100 million. Other states have put forth larger and smaller estimates. Extrapolating this out over 50 states could push the pricing for just setting up the exchanges at $3 to 5 billion or more. This is an investment level never considered in the accounting figures of the ACA.

Compounding this cost is the reality that each state-run HIX will need to add a surcharge for every individual buying a policy through the exchange in order to be “self-sustaining” by 2015. While information is somewhat limited as to how large this charge will be, some states are speculating the surcharge could run into the hundreds of dollars per policy per year. Unfortunately, a meaningful data point for anticipating this cost is unknown, the number of people who will actually use a public HIX. That key data point will undergo significant scrutiny in the next several quarters, and likely be made even more uncertain as political debate shifts cost equations and value measurements.

The aggregate economics of a public HIX are troubling. At the high end of the range, federally funded start-up and first year operating costs are likely to exceed $6 billion, and our research shows that another $2 billion or more of annual premium surcharge will be needed to support annual operations. This is on top of approximately $100 billion subsidies that will be pushed through the exchanges. These unpredictable figures will challenge the value proposition of the entire initiative and the concept of enhancing the affordability of healthcare in America. Economic expenditure as a driving force in healthcare is not a new concept in this country (often the hoped for “solution” somehow lies within the strategy of throwing money at the problem) and in this instance, we may very well be pursuing an initiative for the effort itself, rather than because of any fundamental goal it realizes.

The aggregate economics of

a public HIX are troubling.

At the high end of the range,

federally funded start-up and

first year operating costs are

likely to exceed $6 billion,

and our research shows that

another $2 billion or more of

annual premium surcharge

will be needed to support

annual operations.

S U S TA I N A B I L I T Y I S S U E S A R E C O M P L I C AT E D BY P R I C I N G , R I S K , & P O L I T I C S

If one were to assume that the technology and cost issues are successfully addressed, the long term viability of each state’s HIX will be subject to numerous market pressures that threaten their sustainability. These include:

• Alternative approaches to the public HIX, which could attract more individuals seeking insurance and thus lower volumes needed to support the process.

• The ability to attract a cross section of consumers critical to having a viable health insurance risk pool in a competitive marketplace where multiple options for procuring health coverage exist.

• Ongoing political and legal challenges that will be disruptive and inturn costly.

The state-run HIXs will be the only marketplace where federal subsidies will be provided to make insurance affordable to low-income individuals – those between 125% and 400% of the Federal Poverty Level (FPL). The Congressional Budget Office (CBO) estimates this population is approximately 19 million3 individuals. While 19 million seems to be a large number, this population is not evenly distributed across states. As a result, the smaller states could experience relatively limited HIX usage which may adversely impact the costs and efficiency surrounding the HIX.

Competition: Depending on how creative the pricing, packaging, partnerships and customer service options from the insurance companies become, competition could cause state exchanges to fall short of operating membership projections and result in an inadequate member base to support annual operating costs. As noted earlier, the ACA legislation mandates that the health insurance companies cannot undercut public HIX pricing with comparable plans in the open market. While it is reasonable to expect state regulators to use their authority in enforcing this provision, it is not difficult to envision commercial insurers aggressively promoting a compelling suite of insurance alternatives.

Risk Pools: The fiscal assumptions of reform and the economics of the HIX are based on risk pools unencumbered by adverse selection and include healthy individuals (with lower medical expenses) entering the system along with those who have known illness or higher risks. An unbalanced ratio of sick-to-healthy individuals invariably leads to adverse economic results. This can also occur if a disproportionate population of healthy individuals opts out of mandatory coverage and simply choose to pay fines as dictated by the ACA provisions. The cost burden of covering the less healthy population within a HIX, subject to such adverse selection could doom the public exchanges or, at the very best demand greater financial support than originally envisioned.

3 CBO estimates that the exchanges will service between 24-30 million individuals by 2019 but only 19 million will be eligible for a subsidy.

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The Kaiser Family Foundation (KFF) published an analysis in March 20114 which indicates the risk of adverse selection is a very real threat to the viability of the HIXs. Kaiser concluded that individuals entering the exchange will be in poorer physical and mental health and it can be implied that they may potentially have more chronic conditions than the general population. This implies greater need for medical services, and produces a different risk profile. If the Kaiser analysis is directionally true, it may be impossible to avoid adverse selection within the public HIX, thus creating tremendous concerns regarding their sustainability.

The Politics of Healthcare: Presently, over half of the states in the U.S. object to the ACA’s exchange requirement. Governors and state Attorneys General have sued to stop the federal requirement to establish health insurance exchanges, arguing that the exchanges create unfunded liabilities, are far too burdensome in their regulation, and that the individual mandate exceeds the Constitutional authority of the federal government. A range of legal arguments and appeal processes will ultimately be brought before the Supreme Court, meaning a final decision on the constitutionality of healthcare reform will remain unsettled at least through 2012.

Cost, complexity, and sustainability questions may be overcome by the 2014 deadline, but a year into the legislation more questions and uncertainty than ever before exists as to whether the states will in fact implement the mandated public health insurance exchanges. At present, it is very difficult to handicap the probability of success for the state HIX. There certainly is a large market need and a tremendous opportunity for vendors to fill state capability gaps in building the exchanges, but by 2014 the true question will relate to the survivability of the exchanges – a system forced upon the states by federal dictat.

4 A Profile of Health Insurance Enrollees http://www.kff.org/health reform/8168.cfm

Presently, over half of the

states in the U.S. object to the

ACA’s exchange requirement.

A LT E R N AT I V E S T O P U B L I C E X C H A N G E S E M E R G E

Even if the states are able to overcome the challenges previously identified and successfully launch their respective exchanges, direct competition to the public HIX is emerging. An estimated 45-60 million individuals will purchase insurance either directly from an insurance company, though a broker, or through other channels by 2019.

The CBO estimate of public HIX participation (24 million individuals by 2019) is dissected by the previously mentioned Kaiser Family Foundation (KFF) study into two groups:

• 18 million who will be net new users of a HIX. These are currently uninsured individuals.

• 6 million who will migrate into a HIX from alternative channels. These individuals either purchase directly from an insurance carrier today or will enter the public exchange when their employer discontinues company coverage.

Assuming the CBO and KFF estimates are reasonably accurate, we estimate that there could be up to 36 million individuals who will purchase the mandated health insurance from sources other than the public HIX. For those 36 million, options for purchasing health insurance will abound. Several insurance carriers are now looking at how they can establish their own exchange (either singularly or through competitive consortia), or how they can work with partners to create multiple private health insurance exchanges. Most carriers realize that they lack a strong direct-to-consumer presence and it’s generally acknowledged they lack world-class customer service skills. Partnerships with retailers and financial institutions for other service oriented industry partners could help address their skills gap.

In this vein, retailers like Walgreens and Wal-Mart, and trusted employer organizations (including some unions and trade groups), are considering establishing themselves as leaders in a new category of private insurance exchanges. Using uniquely branded online sites, retailers are likely to begin selling insurance products in their own multi-carrier marketplace. Their benefits would obviously include a new array of products for customer up-sell and cross-sell, discounts, and new opportunities to build customer loyalty and long-term relationships. For health insurers, the unique opportunity for strategic retail-oriented partnerships and new distribution channels are similarly very compelling.

Because the ACA prohibits insurers selling products to individuals in a public HIX from undercutting prices of like-for-like products in the private marketplace, the private exchanges will need to excel in competitive areas including product innovation, brand awareness, trust, customer service and ancillary offerings.

The private exchanges will have a time-to-market advantage in building their member bases because the public exchanges won’t come online until 2014. Also, they aren’t burdened by the same coverage mandates or technical complexities inherent in the state-based systems, nor will they be required to integrate with state Medicaid Management Information Systems infrastructure, provide a complex system of eligibility verification (i.e. income and citizenship), calculate subsidies, build multi-lingual portals, or adhere to all the compliance mandates within the ACA legislation.

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The private exchanges won’t have “essential benefits” mandates that HHS will impose on the public exchanges, and so the private exchanges will have much more flexibility in aligning coverage, deductibles, and costs with the market need.

Finally, if a private exchange is aligned alongside a strong consumer brand, built-in consumer loyalty could help them integrate ancillary products like wealth planning, retail discount cards, or bundled insurance packages including life, property and auto. Further, the products in the private exchange might be better aligned with individual’s needs.

Estimating the size of the private exchange “marketplace” opportunity is difficult, but as offered earlier and as illustrated below, the business opportunity for private exchanges could be significantly larger than that for the public HIXs in terms of insurable populations and revenues.

It is premature to know if and how the private exchanges will compete for subsidy-eligible individuals, but many commercial enterprises understand that the public HIX will condition consumers to change how they shop for insurance; it will also likely cause employers to re-evaluate their need to offer group benefit policies. These changes could open up a huge opportunity for competitive, open-market insurance shopping. Commercial interests are accordingly now working to align their capabilities with market needs.

Private exchanges will cause

employers to reevaluate their

need to offer group benefit

policies.

Traditional direct sales model supported by either inbound or outbound marketing programs.

Heavy emphasis on seniors market but expanding to multiple market segments.

Licensed brokers/agencies or newer web-based brokers that specialize in health insurance products.

May represent multiple carriers.

Retailers, employee groups, and financial services companies are partnering with carriers to offer insurance distribution marketplace private exchanges.

ACA requires all states (and DC) to establish exchanges for the individual market (2014) and the small group market (2016). Channel for federal subsidies.

Each exchange must offer a minimum set of benefits and policy choice of at least 2 carriers.

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• Strong brand awareness

• More ways to engage consumer using consumer-friendly tools

• Carrier relationships

• Connectivity to automate information exchange

• Ability to manage new realities of MLR commissions

• Favorable consumer-oriented brand

• Robust distribution systems to support specialized sales

• Customer services expertise

• Advanced marketplace e-commerce architecture

• Easy way for carriers to offer plans and enroll new customers

• Heavy compliance mandates

27-36M INDIVIDUALS 18-24M INDIVIDUALS

CARRIER DIRECT BROKER NETWORKPRIVATE / COMMERCIAL

EXCHANGEPUBLIC / STATE

EXCHANGE

4 5 - 6 0 M I N D I V I D U A L S BY 2 0 1 9

Source: TripleTree

L O O K I N G A H E A D

The Affordable Care Act (ACA) was drafted and passed to facilitate market competition by forcing insurers to sell within a highly regulated, controlled state-run health insurance exchange. It was envisioned that heavy subsidies would enable the millions of uninsured Americans to afford health insurance, while a centralized marketplace would help break dependency and portability issues that individuals have on employers to provide an insurance benefit.

While HHS and the states are working to establish the mandated public health insurance exchanges, multiple roadblocks around cost, technology, and sustainability must be overcome. In fact, it’s questionable whether all of the states can successfully establish a HIX in the manner envisioned by health reform legislation. The realities are that the costs and risks associated with establishing a HIX in each state are profound, and they will likely serve a much smaller population than intended.

Paradoxically, the recent health reform legislation, even if it fails in its goals of creating public exchanges, may succeed in its goal of creating an environment that benefits the consumer. As the 2014 deadline approaches, commercial interests are working in earnest to build consumer-friendly options for purchasing affordable health insurance. The potential of health insurers aligning with partners who understand consumer retailing, pricing and online marketing will benefit the goals of the ACA. The marketplace and the commercial exchanges may ultimately be responsible for making health insurance a better value.

Regardless of which type of insurance exchange (public or private) is ultimately deemed successful, the ACA legislation will be viewed as the catalyst that drove the health insurance industry to change how insurance products are distributed and how the consumers can be better served.

Financial and governmental pressures on the health insurance market are profound, and have brought the importance of consumerism to the forefront of discussions around insurance product design, marketing, distribution and customer service. It is yet another example of where the economics and healthcare delivery and supply chains will be disrupted – and where innovation is needed. The effort is underway and a variety of stresses, challenges, and responses will shape the ultimate outcome and the hope for a more efficient and affordable healthcare system.

As a strategic advisor and investment

bank for emerging and global

companies, TripleTree remains

committed to continuing our assessment

of these factors and welcome your

feedback and reactions.

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This report was published in a collaborative effort by our research team.

Since our founding, TripleTree research has created a unique mechanism by which we share information and insight with an ecosystem of three distinctive yet interrelated groups – disruptive, high growth businesses, financial sponsors, and global aggregators. We have aligned this approach with a collective 250 years of healthcare operating experience and strive to be one of the most highly regarded strategic advisors in North America.

To learn more, contact us at www.triple-tree.com or 952-253-5300.

Copyright © 2011 by TripleTree, LLC. All rights reserved.

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