Infographics

The Congressional Budget Office estimated that in 2023, 248 million people who are younger than 65 will have health insurance coverage, with over 57% covered through employment-based health plans. As COVID-era policies expire over the next decade, employment-based coverage will grow to 159 million and remain the largest source of insurance.

The coverage patterns vary significantly by income. People with income less than 150% of the federal poverty level are more likely to be uninsured or covered through Medicaid or the Children’s Health Insurance Program, while those with higher income are predominantly insured through employer-sponsored coverage.

Since the FDA’s approval of the first biosimilar in 2015, the agency has approved almost 40 more agents. However, their adoption in the U.S. market has been slow. A recent study, published in the journal BioDrugs, found that biosimilars were covered more restrictively than their reference biologics in 19.4% of coverage decisions made by select commercial health plans.

The study examined 1,181 coverage decisions made by 17 commercial health plans as of August 2021 from the Tufts Medical Center Specialty Drug Evidence and Coverage database, which included 19 commercially available biosimilars for seven biologic reference products used in treating 28 conditions.

Medicare Advantage enrollment grew by more than 507,000 lives during the 2023 Open Enrollment Period (OEP), according to CMS’s May data release and AIS’s Directory of Health Plans. That’s a significant increase from last year’s OEP, when plans added about 230,000 new members from February to May 2022. The news comes just weeks after a KFF analysis found that the number of seniors enrolled in MA vs. original Medicare officially crossed the 50% threshold.

More than 1 in 5 adults without access to a vehicle or public transportation missed or skipped a health care visit in the previous year, according to a recent Urban Institute study.

Using June 2022 data from the Urban Institute’s Health Reform Monitoring Survey, the researchers found that overall, about 5% of non-elderly adults reported forgoing medical care due to transportation barriers in the previous year. The experience was more common among Black and Hispanic/Latinx adults, individuals from low-income families, people with disabilities and those using public insurance.

Since the FDA’s approval of the first biosimilar in 2015, the agency has approved almost 40 more agents. However, their adoption in the U.S. market has been slow. A recent study, published in the journal BioDrugs, found that biosimilars were covered more restrictively than their reference biologics in 19.4% of coverage decisions made by select commercial health plans.

The study examined 1,181 coverage decisions made by 17 commercial health plans as of August 2021 from the Tufts Medical Center Specialty Drug Evidence and Coverage database, which included 19 commercially available biosimilars for seven biologic reference products used in treating 28 conditions.

The higher the market share of the leading insurer in a state, the lower the negotiated prices were that the insurer paid to hospitals, according to a new study published in Health Affairs, which used market concentration data from 2019 and payer-specific negotiated prices from 1,446 acute care hospitals as of the end of 2021.

The level of insurer market concentration varied significantly across the nation. In states like Alabama and Alaska, the dominant insurers held a near-monopoly position with market share over 71%, while the leading health plans in states like New York and Wisconsin faced a more competitive environment. The study found that market leaders in the most concentrated markets paid 15% less to hospitals than those in the least concentrated markets.

In February 2023, the Help Ensure Lower Patient (HELP) Copays Act (H.R. 830), bipartisan federal legislation that would prohibit the use of copay accumulator programs, was reintroduced to Congress. The bill would require health plans and PBMs to count the value of copay assistance that patients receive toward their cost-sharing requirements, and it would apply to individual, small-group and employer-sponsored health plans.

Copay accumulators work by preventing any monetary assistance that pharmaceutical companies o­ffer commercially insured patients from counting toward their deductible or out-of-pocket maximum. Another common practice, copay maximizers, takes the total amount of a manufacturer’s copay offset program and divides­ it by 12, making that amount the new monthly copayment on any given drug over the course of a year.

A spate of deals and new initiatives from Kaiser Permanente, CareSource and Blue Cross Blue Shield of Michigan highlight the race for nonprofit insurers to expand and diversify in increasingly competitive markets, as well as the rise of value-based care.

Perhaps the most significant deal is Kaiser’s planned acquisition of Geisinger Health, a nonprofit health system of 10 hospitals in Pennsylvania that also operates the ninth-largest insurer in the state. If the deal gains regulatory approval, Geisinger will be the first member of Kaiser’s new Risant Health, a nonprofit alliance of health systems focused on value-based care. “Risant Health’s vision is to improve the health of millions of people by increasing access to value-based care and coverage and raising the bar for value-based approaches that prioritize patient quality outcomes,” Kaiser said in an April 26 press release. Kaiser aims to add “like-minded” regional or community-based health systems to Risant, which will operate “separately and distinctly” from Kaiser as a whole.

As more employers shifted to self-funded health plans, the stop-loss insurance segment expanded to $26 billion in 2021, with a growth rate exceeding 10% in each of the past five years, according to an A.M. Best report. There has been a notable uptick in employers with fewer than 1,000 employees choosing stop-loss insurance since 2018. Although the medical loss ratio for stop-loss has been lower than for group commercial coverage over recent years, it rose from 81.5% in 2020 to 85.0% in 2021, largely due to a year-over-year increase in stop-loss claims from major insurers and several other insurers that had claims for the first time in 2021.

Here’s how major health insurers’ stock performed in April 2023. UnitedHealth Group had the highest closing stock price among major commercial insurers as of April 28, 2023, at $492.09. Humana Inc. had the highest closing stock price among major Medicare insurers at $530.49.