There is an increasing need for policies that will persuade insurers to enter the Patient Protection and Affordable Care Act (ACA) marketplace, particularly in regions of the country that have few insurers participating in the marketplace, according to an article published in the New England Journal of Medicine.

As the United States Congress continues to debate the ACA, there is a rising public demand for bipartisan strategies regarding health care. High enrollee costs, expiration of reinsurance and risk corridors, and doubts surrounding the federal government’s cost-sharing reduction payments currently dissuade many insurers from participating in the ACA marketplace.

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According to the investigators, the ACA debate is missing essential proposals dedicated to improving care affordability for marketplace enrollees. Currently, when prices increase, so do the insurers’ premiums. In turn, this can cause disproportionate coverage among patients enrolled in marketplace coverage vs those who are traditional beneficiaries of Medicare.

Creating equality among commercial and Medicare prices may mean the implementation of laws necessitating payment to providers of “traditional Medicare prices for out-of-network services” for marketplace enrollees. This proposed legislation may reduce the likelihood of insurers exiting the marketplace or prevent raised premiums.

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Additionally, the reduction of out-of-network markups may help retain providers in networks where more patients can have access to their services. In order to make this attractive for providers, it is suggested that policy be phased in or initially applied only to certain services.

Because a health insurance market needs competition to maintain good standing, the investigators suggest that reducing or eliminating “the disparity between commercial and Medicare prices could enhance competition in the marketplace as well as help improve equity and, ultimately, affordability.”


Song Z. Using Medicare prices — toward equity and affordability in the ACA marketplace [published online October 18, 2017]. N Engl J Med. doi: 10.1056/NEJMp1710020