Transforming Health Care Through Evidence and Collaboration
Transforming Health Care Through Evidence and Collaboration
The NIHCM Foundation is a nonprofit, nonpartisan organization dedicated to improving the effectiveness, efficiency and quality of America's health care system.
  • Awards

    NIHCM Foundation is pleased to welcome Dr. Karen DeSalvo, Dr. Aaron E. Carroll and Eliza Barclay to the independent judges panel of the NIHCM Awards. All three bring considerable expertise to the prestigious panel.

    Press Release Judges Panels The NIHCM Awards
  • Data Insights

    Mental illness has become more common over the last decade, particularly among 18- to 25-year-olds. This Data Insights looks at trends in mental health and their implications for the future.

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  • Briefing

    NIHCM Foundation led a briefing on Capitol Hill to discuss social determinants of health and the opioid crisis with Founding President and CEO Nancy Chockley, former CMS Administrator Don Berwick, Curtis Barnett of Arkansas Blue Cross Blue Shield, Craig Samitt of Blue Cross and Blue Shield of Minnesota, and Grant Baldwin from the CDC.

    Press Release Watch the Video
  • Data Insights

    As urbanization increases, an older, sicker and poorer population remains in rural America. Despite the health care challenges posed by these changes, promising initiatives can improve rural health.

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  • Advisory Board

    NIHCM Foundation is pleased to welcome Dr. Scott Gottlieb, Sherry Glied, PhD, and Katherine Baicker, PhD, to its distinguished Advisory Board. Their ideas and insights will advance NIHCM's mission to improve health care for millions of Americans.

    Press Release Advisory Board
  • News

    NIHCM welcomed Secretary Azar to a meeting in March to discuss efforts by the Department of Health and Human Services to transform health care by lowering costs and improving value for patients.

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Events

January 27, 2020
SDOH-webinar-graphic-012720

This webinar will explore public and private sector efforts to improve health outcomes by addressing social determinants of health.

December 19, 2019
shutterstock_560761723_1

Part of the Beyond the Beltway: Health Policy Webinars for Journalists series, this rapid response webinar explained the December 18th ruling from the Fifth Circuit on the Affordable Care Act.

Watch the Recording

In the News

January 2020
Population Health Spotlight
newsletter-loneliness-kas_10

What to Expect for 2015 ACA Premiums: An Actuary Opens the Black Box

John Bertko, FSA, Retired Senior Actuary, Center for Consumer Information and Insurance Oversight, CMS
John Bertko
John Bertko

The Affordable Care Act (ACA) greatly changed how health insurers set premiums in the individual market starting in 2014. In spite of the uncertainty introduced by these changes, premiums for this year generally emerged better than expected, and CBO and JCT have lowered their estimate of average 2014 premiums in the exchanges by about 15 percent.1 Time will tell whether these premiums end up being too low, too high, or right on the mark for the population enrolled. While early enrollment snags in many exchanges fueled concerns about adverse selection and a possible spike in premiums for 2015, the late enrollment surge seems to have mitigated some of this concern.2

Well before the full 2014 experience is known, however, insurers must set their prices for 2015. Initial rate filings are already underway, and negotiations with regulators and exchange managers over the summer will determine final rates. In this essay, I describe the myriad factors that will be on the minds of health plan actuaries as they develop premiums, highlighting factors that will be more – or less – predictable and assessing their likely influence on future rates. This assessment is from a national perspective; individual state experiences will differ significantly based on whether they allowed insurers to extend non-ACA compliant policies beyond 2013 and their overall success in enrolling a large and balanced risk pool in exchange plans. Pricing updates also will vary across markets within a state and even within markets, depending on the characteristics of the local market and the insurers offering products.

Remember the Single Risk Pool

Under ACA rules an insurer must price for the individual market using a single risk pool that includes all of its enrollees in ACA-compliant policies, whether purchased on or off the exchange. Enrollees in catastrophic plans are excluded, as are those remaining in pre-2014 non-compliant products via grandfathering, early renewal or the extension of these products first permitted in November 2013. It is the exclusion of this latter group, largely expected to be better risks, that leads to concerns about worsening risk pools in states allowing such transitions. However, many off-exchange enrollees will be healthier people who were previously underwritten and “retained” by their insurer, offsetting some of the pressure for higher premiums based on exchange enrollment alone.

Knowable Factors

Some factors affecting insurers’ 2015 premiums can be projected with a fair amount of certainty. As always, actuaries will begin by using prior-period adjudicated claims to compute “trend” – that is, the rates at which cost per service, service use per enrollee, and intensity of service use have been changing for all of their privately insured enrollees. This factor will point to increasing premiums. They must then project this trend forward to the 2015 rating period by assessing whether utilization patterns of the 2014 enrollees differ from those underlying the trend (such as due to the new, very expensive drug for Hepatitis C) and developing expectations about whether the 2015 enrollees will look like the 2014 pool.

Insurers now assessing their 2014 enrollees will face data shortcomings but will not be completely in the dark. Many carriers will have claims for their pre-ACA enrollees who stayed with them in 2014 by moving into ACA-compliant products on or off the exchange. Actuaries at several insurers have told me they expect these enrollees to comprise up to three-quarters of their single risk pool – providing very significant insights for future pricing as well as a large share of enrollees expected to be healthier, on average. Similarly, insurers will know the risk profile of any enrollees continuing in their non-compliant plans and can estimate the impact of excluding them from the pricing pool.

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Events

January 27, 2020
SDOH-webinar-graphic-012720

This webinar will explore public and private sector efforts to improve health outcomes by addressing social determinants of health.

December 19, 2019
shutterstock_560761723_1

Part of the Beyond the Beltway: Health Policy Webinars for Journalists series, this rapid response webinar explained the December 18th ruling from the Fifth Circuit on the Affordable Care Act.

Watch the Recording

In the News

January 2020
Population Health Spotlight
newsletter-loneliness-kas_10

Grants

Journalism GrantsJournalism Grant Program

We are no longer accepting letters of inquiry for the 2019-2020 round of grantmaking. NIHCM will notify grant winners in November 2019.

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Investigator-Initiated Research Grant Program

Nine new grantees for the 2019-2020 funding cycle have been announced! We will begin accepting Letters of Inquiry for the 2020-2021 funding cycle in late spring 2020.

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Awards

Now Accepting Entries for the 26th Annual Research and Journalism Awards

Winners Announcment 2018 1

Submit your research or reporting published in 2019 by February 3, 2020 for a chance to win up to $20,000. Winners and finalists will be recognized at a dinner in Washington, D.C., in May 2020.

Learn More and Apply