Experts study all those powerful forces, and they don’t know how the consumer can get out of the middle.
“That’s sort of a question for the ages, isn’t it?” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation, a nonprofit health care research organization (and separate from Kaiser Permanente). “I don’t expect they have lobbyists. I think they get what they get.”
Supply and demand
Only Kaiser Permanente knows why it decided to price premiums in one county one way and in a separate county another way. But research shows the decision probably had something to do with competition.
In Rockdale County, Kaiser competes on the exchange only with Ambetter. Right next door in Henry County, it contends with two competitors.
In 2017, Blue Cross Blue Shield of Georgia made a dramatic decision to pull out of metro Atlanta. In 2018, it decided to come back, but not all the way: It returned to the entire metro region except for Clayton and Rockdale. It also stayed out of dozens of rural Georgia counties it initially proposed to enter after seeing competitors' proposals to do business there.
Blue Cross’ parent company, Anthem, describes the decision to omit Rockdale and Clayton as related to its health care provider networks that are farther away.
“After a thoughtful review of the marketplace in Georgia, (Blue Cross) modified the counties where we will offer health plans in 2019 to include the metro Atlanta area,” Anthem spokesman Colin Manning wrote. “We have a strong collaboration with Northside Hospital through our Pathway network. Because Northside does not have any facilities in proximity to Clayton and Rockdale counties, the decision was made to focus our efforts in areas where there is a strong Northside presence to provide greater affordability and access.”
In any case, that left Clayton and Rockdale with less competition for Insinger’s business. And when an insurance market falls from three companies to two, that’s when prices really go up, Pollitz said. “You tend to see much higher prices in areas where there’s less competition,” she said.
A spokeswoman for Kaiser Permanente in Georgia cited other reasons. “Multiple factors go into determining the rate for individual applicants,” Cheryl Brown said, “including the person’s age, the plan selected and county in which the individual lives. Just like our competitors, we file different products in different counties. The differences are around the configuration of the provider network, which means some products offer a slightly larger network of physicians.”
For patients such as Insinger, it all boils down to a bad day when they see the figure pop up on the computer screen.
“I was flabbergasted,” Insinger said. He only learned about the county-county difference later, and it was just one part of the increase that made for a total premium of $2,560.
“If you compare me to another equal person living in another county and they’re paying less than I am for the same insurance, that doesn’t make sense,” he said.
Great swaths of Georgia don’t even have two companies to choose from on the exchange, just one. Blue Cross this summer appeared set to return to most of the state but then pulled back and decided to offer plans in only 75 of the state’s 159 counties. The company pointed out it still is expanding the number of Georgians it will serve.
For consumers, the only option may be to get used to the shrinking options.
“There’s kind of a race going on between providers and insurers in terms of who can gain bargaining leverage,” said David Howard, a professor of health policy and management at Emory University. “Providers by getting bigger, insurers by adopting even narrower networks” that exclude health care providers they don’t have good deals with. “(Health care) is really expensive and consumers are being asked to bear a larger share of the costs. And that’s not going to go away.”
Insinger's solution was to give up on full insurance. He and his wife bought a "short-term" plan that doesn't offer the same coverage that an ACA plan would. It doesn't have to follow mandates under the ACA (also known as Obamacare) and excludes some pre-existing conditions, so it's rolling the dice a bit. But it's affordable.
Clayton County advocate Roberta Abdul-Salaam said every county deserves choices. “It’s not a one size fits all” for patients in Clayton any more than it is for patients in DeKalb County, she said. Moreover, she added, health care should be about more than markets and finance.
“I’m not going to pretend like I understand the economics,” she said. “But I do believe if you have a healthier community, a more productive community, then the whole community wins.”
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