insurance

Preventive care stays free, for now

John McDonnell/AP

The Affordable Care Act survived yet another trip to the Supreme Court. The justices quibbled over just how powerful the members of the U.S. Preventive Services Task Force are, but the conclusion is this: Any preventive service that gets an A or B grade from the USPSTF must continue to be covered by health insurance companies at no cost for people. 

Bottom line: If you are insured, you still won’t owe a dime for several types of cancer screenings, like Cologuard, and medicines, like pre-exposure prophylaxis for HIV. But there’s a wrinkle: The USPSTF and its recommendations are constitutional only because they need to be signed off by the Health and Human Services Secretary, which is currently Robert F. Kennedy Jr. 

This potentially introduces political manipulation into what are supposed to be science-based determinations.

This isn’t just hypothetical. Federal law also requires insurers to cover vaccines at no cost for people if the vaccines are recommended by the Advisory Committee on Immunization Practices. And as I reported last week, Kennedy’s complete overhaul of ACIP with his own handpicked advisers clouds the future of vaccine coverage. 

This is America, so of course there are business implications to these developments. The stock price of Exact Sciences, which makes Cologuard, jumped by 4% Friday. The stock price of Gilead Sciences, which manufactures PrEP medications, went up 3%. Guaranteed insurance payment is a certainty unlike any other in health care. But with Kennedy holding the ultimate power over what preventive services must be covered, that certainty is very tenuous.

unitedhealth

UHC’s Medicare Advantage pullback

Earlier this month, UnitedHealth Group said it would stop paying commissions to brokers and agents, starting July 1, for new members enrolled in some of its UnitedHealthcare Medicare Advantage plans. The insurance company downplayed the move in a statement to STAT, saying it only affected a “small percentage” of its MA plans.

I obtained the full list of UnitedHealthcare’s MA plans that will no longer pay broker commissions, and cross-referenced it with federal data that shows enrollment for each MA plan contract. Those plans enrolled less than 10% of UnitedHealthcare’s 10.2 million MA enrollees, as of June. Most also appear to be enrolled in PPO plans, which have broader networks of doctors and hospitals. 

Importantly, UnitedHealthcare will not pay commissions on any of its “institutional special needs plans,” or I-SNPs. These are MA plans for very sick people who live in nursing homes — on average, MA plans get more than $35,000 per year for an I-SNP enrollee vs. $13,000 per year for a conventional MA enrollee. UnitedHealthcare controls roughly half of this market (60,000 of the roughly 122,000 I-SNP enrollees). 

Insurance companies halt commissions if they want to discourage enrollment, usually because medical costs are running higher than they expected. This has happened a lot lately in the MA market. UnitedHealth CEO Stephen Hemsley has made it clear the company will reverse “performance setbacks,” and now it’s surgically targeting MA plans that it believes have too many sick people. “They only want people in plans that are profitable,” a broker told me last week. 

More details may emerge July 29, when UnitedHealth is scheduled to report earnings, but do not be surprised if the company purposefully scales back more of its MA presence.