Interview with Matt Eyles, President and Chief Executive Officer at America's Health Insurance Plans (AHIP)

KW: Since the COVID-19 pandemic is still front-page news for so many reasons, how do you see this event changing “healthcare” … the access to, delivery of and payment for healthcare?

ME: The COVID-19 crisis has challenged every American. And throughout this crisis, people have become much aware of how important our healthcare heroes on the front lines are as they continue to fight this virus. Their unwavering commitment is an inspiration, and health insurance providers continue to support them in numerous ways as they continue their work.

It’s also made people much more aware of the importance and value of their private market health insurance coverage. From day one, we took swift and decisive action to ensure that cost was not a barrier to people needing a diagnosis or treatment for the disease. We have collaborated with doctors and healthcare systems in all our communities to ensure the right resources are directed to where they are needed most. And we’re continuing to work with patients and doctors to ensure that people are safely getting the essential preventive health services and other care they may have been putting off.

Telehealth has played a surprisingly important role in those solutions – and it’s pretty clear that telehealth will be a big part of our healthcare system well beyond COVID-19.

KW: What regulatory and/or legislative changes at the federal and state levels do you see being a legacy of the pandemic?

ME: Most of the proposals we focused on to help overcome the COVID-19 crisis were timely, targeted, and temporary solutions to help Americans keep their coverage, and ensure that coverage was able to deliver the access and services that Americans have come to expect. They included support for COBRA, additional subsidies to help hardworking families afford their premiums, and an enhanced Federal Medical Assistance Percentage (FMAP) for Medicaid.

But more broadly, it looks like we are seeing some positive movement from the Centers for Medicare & Medicaid Services (CMS) to ensure that telehealth can play a bigger role in healthcare delivery.

KW: The pandemic response – the lockdowns, the cost shifting, the issues related to the lack of care being provided other than that related to COVID – this has actually helped the managed care industry financially in the short term. First, how do you see the industry preparing for the risk of significant expenses when the flood gates open post-vaccine; and second, what has the industry been doing to help members and providers survive the crisis – both health and financial?

ME: As we head into the fall, our industry is well aware that we could see a lot more care and higher costs than we saw in the first half of the year, and we’re ready. We’re already hearing reports that hospitals are getting back to their pre-COVID treatment levels.

As the country continues to reopen, health insurance providers have been working with doctors, hospitals, and local community organizations to ensure that care environments are safe, and we’ve been encouraging Americans to see their doctors for routine health screenings, treatments, and procedures that have been deferred due to the COVID-19 crisis. If care continues to be delayed, it could end up becoming more complex, and more costly.

As to the second question, I’ve never been more proud of our industry than I have been as I have watched them take direct, swift action to help Americans overcome the crisis. Since COVID-19 began impacting the country, health insurance providers have eliminated patient cost-sharing for COVID-19 diagnostic testing and treatment, and expanded and waived cost sharing for telehealth. We’ve also launched virtual mental and behavioral health services to support our members in these uncertain times.

And health insurance providers are helping as many people as possible stay covered by offering grace periods and premium discounts.

We’ve also supported our front-line healthcare heroes through accelerated claims payments and have boosted our local communities through a variety of donations and grants.

KW: The Trump Administration was very active both before and during the pandemic related to CMS regulations. Are there any specific rules or regulations that you feel are helpful or harmful to the healthcare sector as a whole or the managed care industry?

ME: The Trump Administration has been very focused on lowering drug prices, and we applaud it for its commitment. But we are very concerned that the Administration’s revival of the “rebate rule” would directly harm America’s seniors.

The rule would limit the ability of health insurance providers to negotiate discounts with drug makers under Medicare Part D, and the end result would be higher premiums.

We already know this is a bad rule. Actuaries from CMS itself have said it would raise Medicare premiums by 25 percent, increase Medicare drug spending by $196 billion, and give drug manufacturers a $100 billion bailout. And recent polling has shown that voters do not approve.

KW: Can you address the impact on the industry of the new price transparency rules in place for hospitals and the proposed rule for managed care plans?

ME: Patients and consumers deserve better access to personalized healthcare information, which can empower them to make better, more informed decisions.

But the Trump Administration’s proposal to force disclosure of privately and competitively negotiated rates would not provide information that is helpful to consumers. It would only drive up healthcare costs and raise privacy concerns.

The proposal is overly broad and would not provide consumers with user-friendly, personalized, and actionable information.

KW: In the 1980s – and I know you are not that old – we had the anti-HMO or managed care argument that having “bean counters” control health was very bad and that the HMO industry was a sham designed to make some rich while ruining the healthcare system. Without pointing fingers at where those tactics came from, and despite them, managed care has grown and grown. It has helped retard the growth in healthcare spending and it has had an impact on quality of care – but it has been far from perfect. What do you see as the best and worst of the industry? Where has it excelled, where has it failed? What can it do better?

ME: First let’s recognize that the health insurance provider of today is a far cry from the health insurance provider of the 1980s. Back in the 1980s insurance providers primarily served the HR department of American businesses, and was focused first and foremost on costs and risk mitigation.

Today, 10 years after the Affordable Care Act (ACA) was passed, healthcare coverage looks very different, with more personal control and choice than ever before – from the individual market, to choices among plans at some large employers, to Medicare Advantage, to choices among Medicaid plans under a managed care model.

America has also embraced the notion that the best way to control healthcare costs long term is to help people stay healthy, and to ensure people swiftly and consistently get the care they need when they need it. That’s a fundamental shift in how you build your business strategies. It’s less about risk mitigation, and more about strategies to address healthy lifestyles, reimbursement models based on healthy populations, and health equity – to give just a few examples.

KW: What about the ACA? It’s before SCOTUS again with the Texas vs California case once again, putting the constitutionality of the ACA in the judicial crosshairs.  Without asking you to be clairvoyant regarding the ultimate outcome, what would be the impact to the managed care industry if the ACA is found unconstitutional?

ME: Let’s be clear: invalidating the ACA would wreak havoc on the entire healthcare system. 

It would undo so many of the reforms Americans have come to count on, including guaranteed coverage for individual preexisting conditions, allowing children to stay on their parents’ healthcare plan until they’re 26, and prohibiting lifetime benefit limits.

And it would cut off billions of dollars for states that have expanded their Medicaid programs, jeopardizing the healthcare of millions of newly covered individuals.

The COVID-19 crisis has further highlighted the importance of the ACA. Both the federally facilitated marketplace and the Medicaid expansion have provided Americans who have lost their jobs with affordable, high quality healthcare.  

No industry has been more directly impacted by the ACA than ours has. We firmly believe that the ACA has shifted the paradigm for healthcare coverage, extending quality, affordable coverage to tens of millions of American families, regardless of health status. And we firmly believe the Court should not permit this unwarranted attempt to sweep all that progress away.

We need to build on the success of the ACA, not tear it down.

KW: We all know that growth in any industry is essential to its health. With commercial employer plan participation at its limit in terms of penetration, and the ACA having never delivered the 30 million insureds promised, how can the industry sustainably grow via Medicaid managed care and Medicare Advantage?

ME: We still have nearly 30 million Americans who are not protected by health insurance coverage today. We have a responsibility to work together to get them covered – whether that is coverage through their job, through the individual market, or through Medicaid expansion in the states that haven’t yet expanded. Working together across the public sector and free market, there is a lot we can do to make coverage more affordable and available to everyone.

Take Medicaid managed care.

Medicaid managed care plans consistently control prescription drug costs more effectively than traditional Medicaid. For example, they yielded $6.5 billion in net savings for states and taxpayers during fiscal year 2018, according to a report from the Menges Group done on behalf of AHIP.

States are recognizing the value of Medicaid managed care. Medicaid enrollment in managed care plans more than doubled from 25.6 million people in 2010 (51 percent of Medicaid enrollees) to 56.5 million people (77 percent of enrollees) in 2018, and this trend is expected to continue.

And more than 70 percent of all Medicaid prescriptions nationwide were delivered through Medicaid managed care plans in 2018, compared to only 28 percent in 2011.

Medicare Advantage (MA) has also never been more popular. More than 24 million Americans - over a third of all Americans eligible for Medicare - are enrolled in an MA plan, and they’re enrolling because MA is delivering better value, better services, and better access to care.

MA is growing, and as it continues to represent an ever-growing percentage of the Medicare program, every American has a vested interest in ensuring that it continues to deliver quality, affordability, and value.

KW: What do you think is the best way to combat “surprise” or out of network billing? Congress has failed to deliver a solution and to be frank, I feel that would be best left to the states …. But what do you think in terms of responsibility to address the issue and how?

ME: No one should have to face a surprise medical bill that potentially leads to financial ruin. Any real solution to the problem has to protect patients, and the best way to do that is by establishing a fair, market-based benchmark price based on locally negotiated rates.

Arbitration has been touted by some as a way to end surprise medical billing, but it’s not a workable solution. It would boost patient premiums and drive up the cost of healthcare for everyone.

Private equity has increasingly become the driving force in surprise medical billing, and out-of-network providers backed by private equity firms are exploiting loopholes to gouge patients.

KW: I know we have covered a number of topics, is there anything else you feel we should address – that the ABA Health Law Section should hear from a leader in the managed care industry?

ME: We are very focused on the issue of health equity.

For several years, health insurance providers have been studying disparities in healthcare and providing solutions to help address them. With COVID-19, many more Americans have had their eyes opened to the growing healthcare disparity.

Disadvantaged and minority communities have been experiencing higher rates of infection and death from the disease, and have also felt a greater economic impact because the social factors that are challenging in normal times are only amplified by a global health crisis.

Our industry will continue to address the socioeconomic needs of our members, during the COVID-19 crisis and beyond. Health insurance providers will continue to create innovative programs focused on improving food security, employment, and housing.

KW: Thank you Matt for your time and helping to enlighten us related to issues related to managed care, healthcare policy, reimbursement, costs, and how AHIP sees the future of the industry. This has been most insightful and I wish to express our gratitude for your time in responding to these questions.

This interview has been edited for length and clarity.