The following is the text of a Public Comment submitted on Feb. 1, 2019 by the State of Connecticut Office of the Healthcare Advocate regarding Proposed Rule 9926 from the federal Centers for Medicare & Medicaid Services. The original comment can be found here: https://www.regulations.gov/document?D=CMS-2019-0006-0026

Dear Administrator Verma,

For the record, I am Ted Doolittle, Healthcare Advocate for the State of Connecticut. The Connecticut Office of the Healthcare Advocate (“OHA”) is an independent state agency with a three-fold mission: assuring consumers have access to medically necessary healthcare; educating consumers about their rights and responsibilities under health plans, and assisting consumers in disputes with their health insurance carriers; and informing legislators and regulators regarding problems that consumers are facing in accessing care, and proposing solutions to those problems. I appreciate the opportunity to submit the enclosed comments regarding the Proposed Rule CMS-9926-P, as published in 84 Fed. Reg. 227.

I. The Verma Rate Hike will take away health insurance from 100,000 working families

First, your proposed changes to the method for calculating the premium adjustment measure under 45 C.F.R. §156.130(e) will result in a rate hike for healthcare consumers, and so will result in 100,000 people abandoning coverage; similarly, the proposed elimination of auto-enrollment for consumers who do not actively shop on the Marketplace will likewise reduce the number of consumers who have health insurance. These changes are 100% discretionary to you, and not required by any statute; therefore, the proposed unnecessary loss of health insurance by 100,000 American men, women and children is a deeply personal and optional choice of yours that if left in place will become an indelible part of your personal legacy at CMS.

Madam Administrator, this is a true gut-check moment for you. [1]

It is hard to see how any person of conscience could move forward with this part of the rule as drafted. Specifically, this Office strongly disagrees with CMS’s suggestion that premium hikes and other measures that force consumers to abandon their health coverage or otherwise reduce enrollment in the ACA is a positive good for the nation because forcing consumers to bear their own health care costs creates economic efficiencies and eliminates waste in that consumers will no longer seek out unneeded or recreational healthcare. [2] Followed to its logical conclusion, this approach would end all forms of health insurance, including employer-sponsored insurance, on the grounds that any system other than 100% patient responsibility creates economic distortions and inefficiency.

As we explain further below, academic research has long established that healthcare markets operate in a qualitatively different way from non-healthcare markets. Specifically, the view that forcing consumers to pay higher premiums or increased out-of-pocket fees (called “having skin in the game”) can lower costs by reducing waste, based on the thinking that good insurance causes consumers to become irresponsible or greedy and seek out unnecessary care, has been thoroughly and consistently disproven. The academic research shows that in this respect, healthcare is different from other economic markets for a variety of reasons. [3] This debunked position should not be promulgated by CMS, and should not be relied on as the justification for creating 100,000 more uninsured working Americans.

Turning to the specifics of how your proposal would raise prices for healthcare consumers, the changes you propose would both reduce the premium tax credit for all who receive it, and would also increase the allowable out-of-pocket maximum. Your own estimates show that these hidden rate hikes will be about $92/year for an individual, and $189/year for a family of four, in the form of decreased Premium Tax Credit assistance to working families across the country. Also, the out-of-pocket maximums are estimated to go up by $200/year for individuals, and $400/year for families; of course, for the sickest and most unfortunate families among us who consistently max out their out-of-pocket, this is an automatic, non-negotiable additional $400 annual bill from Administrator Verma. [4]

In addition, Administrator Verma, I must reiterate my dismay that in discussing the 100,000 people whose insurance you are making the personal decision to take away, you state that this lack of insurance will result a benefit to the community, since when kids and grown-ups become uninsured, this reduces economic distortions and enhances economic efficiency because “these individuals will be bearing a larger share of the costs of their own health care consumption, potentially reducing spending on health care services that are personally only marginally valued ….” It is to some extent disturbing that a privileged senior official who is charged with protecting the most vulnerable among us, and charged specifically with insuring that working families have access to affordable healthcare, would discuss throwing 100,000 American workers and children off their healthcare in so cavalier a fashion; but the more disturbing aspect to your analysis, Administrator Verma, is that setting aside whether or not raising costs sufficiently to price 100,000 Americans out of health insurance can ever be good news from a policy perspective, your analysis elides the large and growing body of evidence that turning healthcare decision-making over to consumers results in less efficient — not more efficient — choices and outcomes, again because healthcare is different from other markets. So even from the perspective of economics, your proposed approach falls short. Perhaps in other economic arenas, it makes sense to assume that consumers will act more rationally and efficiently when they have more “skin in the game.” But academic studies consistently show that in the healthcare arena, consumers are particularly unsuited and unable to make rational decisions. Specifically, consumers spending their own money on healthcare turn out to be completely unable to distinguish which care they should purchase, and which they should bypass. In fact, we skip both needed and unneeded care in equal measure. [5] Uninsured Americans, which the proposed rule will create 100,000 more of, will be even more likely than underinsured people — e.g., high-deductible health plan consumers — to put off needed care until it is too late. [6]

Moreover, the evidence shows that gaining insurance results in better health, and that losing insurance conversely always results in degraded health, including unnecessary mortality. [7] For these reasons, I strongly urge you to abandon the analysis you put forth in the Proposed Rule actively welcoming the prospect of 100,000 people losing their insurance on the basis of economic efficiency and related principles drawn from non-healthcare economic theory. In economics, healthcare in fact is different. I urge you instead to follow the academic economic evidence from the healthcare field, which again to summarize shows that exposing consumers to added out-of-pocket costs consistently results in poorer decision-making, and that loss of insurance coverage causes bad health.

For many of the same reasons, I likewise cannot agree that ending auto-enrollment will assist consumers and the community by reducing ACA marketplace enrollment, thereby insuring that the newly uninsured are exposed to the full cost of their care. The academic research consistently shows that health insurance of any kind — including the often inadequate high-deductible policies that have become common on the ACA exchanges — results in improved health and in fact saves a certain number of lives every year. For better or worse, the United States has decided to rely on semi-privatized, semi-voluntary mechanisms to provide public goods like healthcare and retirement security (i.e., moving away from defined pensions to self-funded retirement plans like 401(k)’s, and providing health insurance to a great extent through private carriers including on the ACA exchanges). Setting aside the wisdom and economic efficiency of the American approach to providing such basic public goods, the research is clear that when such privatized and voluntary approaches are used, the community and the individuals get better results and deeper protection from “passive” strategies — i.e., opt-out oriented strategies that make participation or continuation the default. [8]

Thus, this Office strongly urges CMS to keep the Marketplace auto-enrollment default in place, which would keep CMS aligned with best practices and the standard benefits enrollment practices in other parts of the American economy, such as 401(k) contributions, mortgage and other billing auto-pay services, and employer-sponsored health insurance. [9] Passive enrollment “set it and forget it” is a powerful approach, especially when plan offerings are similar year-over-year. Consumers want convenience and continuity, and expect that the choices they have made will continue in place unless and until they subsequently make a different, affirmative choice. That is why passive opt-out (versus opt-in) strategies are the gold standard in the benefits area, and the proposed rule’s proposal to take this level of control, continuity, and convenience away not only goes against industry trends, but also will result in consumer confusion, dismay and frustration.

II. All-in Cost Transparency

To end on a more agreeable note, we strongly endorse and encourage CMS’s expressed intention to take the lead in developing and adopting innovative ways to get better and more usable healthcare cost and price data to consumers for comparison shopping. This Office for over a year has been advocating at the state level for this type of improvement, on and off the Exchange. One key innovation that CMS should adopt is to steer the exchanges away from comparison-shopping metrics and visualizations that focus on premiums, or perhaps even include only premiums. Premiums are only part of the consumer’s annual cost picture. It is important for consumers when comparing options to understand their all-in yearly costs, by which we mean premium plus all sources of patient responsibility. Ranking compared plans by premium alone, as is most commonly done, is at best not useful, and at worst borders on deceptive, since a beneficiary who signs up for a seemingly low-cost plan may not be aware of, or at least not sufficiently focused on, high deductibles or other forms of patient responsibility. [10] We therefore recommend that all marketplace plans be required to provide comparison-shopping consumers at the first comparison view with a likely range of actual total annual expenditure — encompassing premium information combined with information about all other possible costs. The information should be limited and simple — in fact there is a strong argument that annual all-in cost information should be presented essentially alone, and without any other information such as monthly premium or deductible amounts, which clearly confound consumers and lead to poor plan choices. [11]

Even though specific costs for a future year are not precisely predictable, it is possible to provide consumers with much useful information and context. Approaches that rely on ranges of possible outcomes are being employed successfully in other areas where consumers have to make important, life-changing selections between alternative offerings. For instance, the so-called “middle fifty” or “interquartile range” approach could help health insurance comparison shoppers who want to estimate their future experience. This technique, which provides consumers with a visual or table representation of where the middle 50% of experience will land during some future period, can give consumers a truly useful predictor of their likely future experience. The Middle-Fifty approach is operating with substantial success in another high-stakes arena — college admissions. In recent decades, the Middle-Fifty approach has become essentially universal for colleges and college admissions guidebooks displaying college admissions statistics.

In previous decades, colleges provided prospective applicants curious about their chances of admission with statistics such as average SAT, ACT and GPA scores for successful applicants (and sometimes for their applicant pool). While better than nothing (just as health insurance premium information is better than nothing), this did not give prospective applicants much of a feel for their personal likely experience. Colleges and college guides now have switched to displaying admissions statistics organized not around average scores and GPAs, but around the middle 50% — usually in a simple chart or table that gives the 25th and 75th percentile cutoff for each statistic, and often including the mean and/or median. Identifying the middle 50% instead of merely the average enables the prospective applicant to at a glance determine where she might falls on the continuum of admitted students. Knowing the middle 50% of experience (which of course simultaneously also provides understanding of who is in the lower and upper 25%) is far more powerful and actionable for the prospective applicant than knowing just the average. Likewise, the traditional healthcare insurance approach of providing just the monthly premium, combined perhaps with a look at the maximum deductible and/or out-of-pocket, gives the consumer little or no information about how he or she is actually likely to fare under the plan in terms of overall cost.

It is possible to bring this Middle-Fifty improvement into the health insurance shopping arena, with a focus on all-in cost. While it is not possible for a health plan to predict a specific individual or family’s all-in cost experience for a future year (just as there is no telling if a particular student will be admitted in the future), the plans in developing their premium rate requests have already created sophisticated actuarial analyses for the future plan year that necessarily includes detailed information about the expected range of all-in costs (i.e., premium plus all patient responsibility) for their expected risk pool. That is because as part of the actuarial process of calculating the premium they need to charge, the plans must forecast the total medical needs, and anticipated total claims costs, for the expected covered community or risk pool. The plans then titrate all the various sources of funds that will be used to pay these estimated costs, including insurance company payments from premium dollars collected, plus all forms of patient responsibility, such as co-pays, co-insurance, deductibles, etc., to achieve the desired balance between what the plans need to collect via premium dollars, versus what the plans expect patients to pay personally.

In short, the process of setting premiums and deductible levels accurately is impossible without a detailed estimated profile of the costs expected to be paid directly by the insured community — it is two sides of the same coin. Since this information is already being produced by the insurance companies for their own internal pricing and planning purposes, it should be possible for the plans to provide consumers with estimates of the 25th, 50th, 75th and 90th percentile of all-in costs, allowing prospective shoppers at a glance to predict the all-in cost range they should expect.

In summary, CMS should require or at the minimum encourage all marketplace plan cost comparison tools to default to all-in cost comparison data, and to in all ways feature and favor simplified all-in cost figures, while forgoing or at least de-emphasizing premium-only information. In addition, because of the impossibility of predicting with specificity any particular family’s actual cost experience in a future year, the default all-in cost information should be organized in some visually simple way, perhaps around the middle 50% of expected experience, though thought should be given to whether adding other reference points, such as the 90th percentile and the mean and/or median, would make the presentation even stronger, since insurance after all is about protecting against worst case scenarios.

The proposed rule also specifically asks for feedback about providing comparison shoppers with snapshots of the all-in financial outcomes for several different typical family health and utilization profiles. It seems that CMS is seeking feedback about the prospect of requiring each competing plan to provide all-in cost information for the same set of scenarios carefully chosen by CMS or the local marketplace, enabling a true apples-to-apples all-in cost comparison by consumers. [12] This also is a good idea that should be considered, in addition to the Middle-Fifty approach discussed above. The key is that the comparison metric needs to be focused on getting the consumers information about all-in costs, not just the inadequate premium-focused comparisons that predominated in earlier years. Based on personal participation and recollection of the undersigned, this selected-scenario based approach whereby a family could compare plans based on pre-defined health condition or utilization scenarios in fact was discussed internally within CMS at the most senior levels during the early ACA Marketplace design and stand-up period, at least in a limited way, and it is good that the discussion has resumed.

In the same vein of improving CMS’s and the plans’ provision of information that is actually valuable to the consumers, versus information that may technically be valid but in fact is not helpful or even harmful or deceptive, CMS would do well to reconsider the Actuarial Value metric (“AV”). AV is a needed and necessary metric — for the plans themselves; but in fact it is nearly useless and in fact misleading for consumers. The healthcare.gov website, for instance, defines AV as “The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. ” [13] The website goes on to note that “you could be responsible for a higher or lower percentage of the total costs,” and thus is certainly technically correct. But in fact, while it is true that overall a plan with an AV of 70% will pay 70% of the medical expenses for its entire covered population, the number of individual consumers who wind up with a personal AV of 70% — that is the number of actual individuals for whom the plan actually does pay 70% of expenses — is probably very close to zero. The vast majority of covered members will have personal AV’s much lower, perhaps 20% or lower for healthy families, while a relatively small slice of the population will experience personal AV’s of 70% or even higher for those with expensive conditions. For the vast majority of patients in a 70% AV plan, the plan in fact will pay much less than 70% of family medical expenses.

That is to say, the use of plan AV as a shorthand for which plans are “richer” is essentially useless for a comparison shopping consumer. (Though again, AV is completely necessary for the plans to use during plan design, and that is what the AV was designed to accomplish, and yes the metric does show which plans are richer from the plan perspective; it’s just not useful for consumers, and was never designed to be.) The raw, plan-level AV number could even be misleading, because different plan designs with the same overall plan-level AV could have dramatically different distributions of personal AV’s — a 70% AV can be accomplished by having the plan simply pay 70% of every single claim, but it could also be accomplished by having the plan pay every claim up until the 255th day of the plan year (September 12 — the day on which the year is 70% gone), or by the typical and much more complicated titration of deductible, copay, coinsurance and coverage levels for a range of different services. The point is that plan design will dramatically affect how many families wind up paying any given percentage of their all-in costs for the year, even among plans with an identical overall AV of 70%.

In the AV realm, of far more utility would be a scatterplot or other measure of the expected distribution of personal AV’s across the membership pool. In other words, the goal should be some type of graphic or metric that allows consumers to see what fraction of covered families are expected to pay any particular percentage of the family’s medical expenses. Again, as with the Middle-Fifty discussion above, the goal should be to give the consumer insight into the likelihood of various personal outcomes if they choose Plan A versus Plan B; consumers can and should have almost zero interest in the percentage of medical costs that the insurance company plans to pay at the population level, even though this AV number remains useful and indeed critical to the companies themselves and their regulators.

Thus, if CMS is proposing to develop metrics that are more useful and consumer-friendly, this Office is strongly supportive, and recommends that CMS take a close look at whether or not a consumer-centric AV measure or set of visualizations can be developed. That would be a true service to the insurance-shopping consumers of America.

To summarize, this Office strongly recommends: 1) that CMS move decisively away from premium-oriented data and towards simplified all-in cost data (premium plus all patient responsibility) for cost comparison purposes; 2) that CMS consider following the lead of the college admissions and many other sectors in moving toward simple bar chart data visualizations, or tables, emphasizing the middle 50% of all-in costs, which will provide health insurance comparison shoppers with much more actionable information than historically was available; and 3) that CMS

altogether end the presentation of raw plan-level AV information to consumers, and instead develop and encourage or require the use of entirely new and innovative consumer-centric AV metrics and/or visualizations.

Thank you for your time and consideration as you undertake this extremely important review of the Department’s rules. If you have any questions concerning our position on these issues, please feel free to contact me at your convenience.

Regards,

Ted Doolittle

Healthcare Advocate for the State of Connecticut

P.O. Box 1543

Hartford, CT 06144

(860) 331–2441 — direct

(860) 331–2499 — facsimile

Ted.Doolittle@ct.gov

[1] “[D]octors and academics have tested whether a lack of health insurance increases the probability of death. Most have concluded that it does.” The Guardian, Will losing health insurance mean more US deaths? Experts say yes, https://www.theguardian.com/us-news/2017/jun/24/us-healthcare-republican-bill-no-coverage-death (2017). For a rigorous academic overview of the scholarship, see Annals of Internal Medicine, The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?, https://annals.org/aim/fullarticle/2635326/relationship-health-insurance-mortality-lack-insurance-deadly (2017) (“[t]he evidence strengthens confidence in the Institute of Medicine’s conclusion that health insurance saves lives”).

[2] For instance, see this portion of the proposed rule:

Either transition may result in greater exposure to health care costs, which previous research suggests reduces utilization of health care services. Economic distortions may be reduced, and economic efficiency and social benefits improved, because these individuals will be bearing a larger share of the costs of their own health care consumption, potentially reducing spending on health care services that are personally only marginally valued but that imposes costs on the federal government through subsidies.

(Footnote omitted.)

[3] It is worth noting in this regard that contrary to the healthcare policy shibboleth holding that American healthcare costs are high because of unnecessary care, recent scholarship has revealed that American patients receive fewer and less intensive services, and in many instances less technologically advanced services, than patients in other economically advanced nations — and the quality of healthcare received by American patients is middling at best. At the same time, almost every one of America’s most direct economic competitors is providing this somewhat superior care at half the cost, or less. This is not to say that there is no waste in the American system; clearly there is, though we are not aware of any evidence that the U.S. harbors more wasteful care than the other advanced economies. Rather, the point is all of the other advanced countries are in many respects providing more care (of similar quality) than the U.S., which exposes as myth the argument that the selfish U.S. consumer is at the root of the healthcare cost problem. See, e.g., Peter G. Peterson Foundation, Per Capita Healthcare Costs — International Comparison, https://www.pgpf.org/chart-archive/0006_health-care-oecd (2018) (chart showing U.S healthcare costs twice the OECD average); The Commonwealth Fund, U.S. Healthcare From a Global Perspective, https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective (2015) (including discussion of lower U.S. utilization, including lower physician visits and hospital admissions); Kaiser Family Foundation, How Do U.S. Healthcare Prices and Use Compare to Other Countries?, https://www.kff.org/slideshow/how-do-the-use-and-price-of-healthcare-in-the-u-s-compare-to-other-countries/ (2016) (“In general, people in the United States use the health system less than people in comparable countries, and services in the U.S. are consistently more expensive ….”). We understand that this is a difficult message for CMS to hear, given that the agency has for almost a decade heavily focused its systemic cost control efforts on Accountable Care Organizations, shared savings models, and other cost-containment approaches centered around the tenet that high healthcare costs are due mostly to unnecessary care — an approach that is often summarized as “wringing waste out of the system”; but the truth is that such utilization-centric tools, while possibly helpful if done right and with appropriate consumer protections, will in retrospect prove only ancillary to more direct cost and price control strategies of the sort that are operating successfully in not one, not two, but rather every single one of the OECD nations that today and every day are eating the lunch of U.S. employers and consumers on healthcare costs.

[4] Figures taken from Table 16 of the Proposed Rule. See also Center on Budget and Policy Priorities, Change to Insurance Payment Formulas Would Raise Costs for Millions With Marketplace or Employer Plans, https://www.cbpp.org/research/health/change-to-insurance-payment-formulas-would-raise-costs-for-millions-with-marketplace (2019).

[5] National Bureau of Economic Research, What Does a Deductible Do? The Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics, https://www.nber.org/papers/w21632 (2015) (“We find no evidence of consumers learning to price shop after two years in high-deductible coverage. Consumers reduce quantities across the spectrum of health care services, including potentially valuable care (e.g., preventive services) and potentially wasteful care ….”); The New York Times, The Big Problem With High Health Care Deductibles (Feb. 5, 2016) (“There was no evidence that workers were comparing prices or making wise choices on where to cut, even after two years in the new plan. They visited the same doctors and hospitals they always had. They reduced low-value medical services and medically important ones at about the same rate ….”).

[6] In this regard, it is well to remember that consumers weighing costly healthcare expenditures by definition are under great physical and emotional stress due to personal or family illness, and thus not at the top of their rational decision-making game — these consumers, facing financial pressure during times of often great illness and emotional turmoil, are the families that this Office sees and assists every day, and my case managers and I can tell you that any structure that by design places a frightened young couple with a sick baby in the role of foundational economic decision-maker … is built on sand.

[7] See supra, n.1; see also The New England Journal of Medicine, Health Insurance Coverage and Health — What the Recent Evidence Tells Us, https://www.nejm.org/doi/full/10.1056/NEJMsb1706645 (2017) (“[I]nsurance coverage increases access to care and improves health”).

[8] See, e.g., RAND Corp., Opting out of Retirement Plan Default Settings, https://www.rand.org/pubs/working_papers/WR1162.html (2017) (“automatic enrollment (AE) … has greatly increased retirement plan participation”).

[9] As of 2011, 71% of U.S. employers utilized passive auto-enrollment strategies. See Society for Human Resource Management, Most U.S. Employers Opt for ‘Passive’ Open Enrollment, https://www.shrm.org/ResourcesAndTools/hr-topics/benefits/pages/passiveenrollment.aspx (2011).

[10] There is burgeoning scholarship on the inability of health insurance consumers to pick out the best financial option See National Bureau of Economic Research, Dominated Options in Health-Insurance Plans, https://www.nber.org/papers/w24392.pdf (2018); Quarterly Journal of Economics, Choose to Lose: Health Plan Choices from a Menu With Dominated Options, https://www.cmu.edu/dietrich/sds/docs/loewenstein/ChoseLose.pdf (2017); National Bureau of Economic Research, Do Individuals Make Sensible Health Insurance Decisions? Evidence from a Menu With Dominated Options, https://www.nber.org/papers/w21160.pdf (2015).

[11] There is work on strategies to present all-in cost information in manners that lead to better selections, and this work is directly relevant to the improvements contemplated by CMS’s Proposed Rule. Behavioral Science & Policy, The Costs of Poor Health (Plan Choices) & Prescriptions for Reform, https://www.cmu.edu/dietrich/sds/docs/bhargava/BLB_BSP%202017.pdf (2017) (“policymakers should reconsider the benefits of restricted health plan menus or personalized defaults that do not lead consumers into costly and persistent errors in enrollment”). See also UConn Health Disparities Institute, Health Insurance Simplification Seminar Series 2017 — Seminar 2, https://health.uconn.edu/health-disparities/health-insurance-simplification-seminar-series-2017-seminar-2/ (2017).

[12] Better still would be a system that ingests the comparison-shopping family’s entire real-life claims history from a recent year, and produces a firm, real-life projection of what that same year of experience would cost under each compared plan. In other words, produce an all-in cost estimate utilizing the family’s actual claims, actual providers, and actual network pricing for the future year. This may be aspirational, based on still-existing systems and data-sharing limitations, but this type of true individual experience comparison tool is getting closer by the year, and should be the goal.

[13] https://www.healthcare.gov/glossary/actuarial-value/

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The Office of the Healthcare Advocate is an independent state agency in Connecticut charged with representing the interests of healthcare consumers.

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Ted Doolittle -- Office of the Healthcare Advocate

Ted Doolittle -- Office of the Healthcare Advocate

The Office of the Healthcare Advocate is an independent state agency in Connecticut charged with representing the interests of healthcare consumers.

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