Week in Washington: New Analysis on Private Markets

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Week in Washington: New Analysis on Private Markets


Kaiser Family Foundation has an outstanding analysis of the financial performance of the Medicare Advantage, Individual, and Group Health Markets for 2018. You can read the results here. A few highlights include:

  • Average medical expenses as a percentage of premiums was similar across the three markets (86% MA, 84% individual market, 84% group market).
  • For the first time, in 2018, total gross margins for the group and MA markets were approximately equal ($27 billion). Individual market gross margins were substantially less ($18 billion).
  • In 2018, average gross margins per member was highest in the MA market, followed by the individual market, followed by the group market.

Additionally, Modern Health Care reported on the claims to premium ratios for short-term health plans. On average these plans had loss ratios of 39%, with one insurer (Cambia) with a loss ratio of 9%. You can read more about short-term health plan financial performance here

Other news and notes


  • CMS released new guidance for states and Medicaid managed care companies that will influence how opioids are prescribed in this program. States will be required to have prospective and retrospective drug utilization reviews.
  • Wyoming released an interesting 1115 waiver in which the state would provide air ambulance coverage to all citizens. Essentially the state would treat air ambulance like a public utility and would provide the service to all Wyoming citizens. It’s unclear if CMS will approve.


  • CMS announced that Medicare will cover a new cancer treatment known as CAR T-cell therapy. The treatment is very expensive ($375,000+) but could effectively be a curative for some patients with advanced lymphoma or pediatric leukemia.
  • CMS released the final rule that sets the wage index which influences hospital Medicare payments. CMS shifted funds from urban hospitals to rural hospitals as the changes were budget neutral and adjusted to benefit rural hospitals.

Individual Market

  • At this stage, the majority of states have finalized their 2020 rates for the individual market. Overall the rates appear to be below trend. In fact, according to Charles Gabba’s calculations, currently, the individual market rates would be 0.5% higher in 2020 relative to 2019. You can check out each states increases here.

Keep an Eye Out For

  • Trump Health Plan Coming? – The Wall Street Journal reported that the White House was considering rolling out their own health plan idea in September in preparation for the upcoming 2020 election.
  • Public Charge Rule – Rumors are circulating that the White House will also release its public charge rule, which would reduce non-citizen access to Medicaid (and other programs). KFF has a good analysis and summary of the issue here.

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