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Can Newer Entrants In The Individual Healthcare Market Beat Out Long-Standing Incumbents

By News Creatives Authors , in Small Business , at September 8, 2021

Vijay Murugappan is the CEO of First Quadrant Advisory (FQA), a healthcare consulting firm with deep operational expertise. 

Over the past few years, an attractive individual health insurance market has led many payers to consider expansion. While opportunities certainly exist, insurers looking to expand their reach in the individual market should take into consideration the following factors:

1. Insurer participation is predicted to increase due to the stable market outlook, making it more challenging to capture and retain market share.

2. Established insurers must be aware of new disruptors entering their markets with differentiated products and aggressive pricing to attempt to build a member base.

3. Policy issues like Medicaid expansion, a lowered age of eligibility for Medicare, and a public option may pose challenges in the future, and payers will need to adapt.

As the individual marketplace becomes more crowded, it may become more difficult to maintain profitability.

The current attractiveness of the individual market has led to a notable increase in competition.

A stabilizing market has led to significant payer expansion efforts. The average number of marketplace insurers per state has been increasing steadily since 2018. In 2020, 45% of insurers noted an intent to increase the number of ACA plans provided to consumers. In 2021, Anthem, United and Oscar entered regions they previously exited.

Counties with only one insurer have reached their lowest levels since the beginning of the exchange, with 10% of counties having a sole insurer. Only 11 counties in the United States saw a decrease in the number of insurers in 2021, per available data. In Texas, for example, it is likely there will be several new competitors entering the exchange in 2022 and beyond as the five-year lockout period comes to an end for all those who left the exchange due to instability in 2016 and 2017.

Industry disruptors pose competitive threats to traditional, entrenched insurers and may affect short-term results.

Traditional payers should expect industry disruptors to enter new markets and offer low price points with more virtual care options. As consumer habits have become more accustomed to virtual care during the Covid-19 pandemic, these disruptors will likely no longer appeal to only younger or healthier consumers. This poses a serious threat to the profitability of entrenched competitors, or new entrants unable to compete with such low prices, and will require enhanced network options, digital health incentives and other creative product design.

New disruptors may also have the advantage of more agile processes and systems, along with more integrated analytics. Whether or not low prices offered by disruptors will be sustainable in the long-term, they nonetheless have the ability to disrupt the short-term results of more established payers.

Medicaid expansion could reduce the number of eligible individual marketplace consumers.

There are 12 states that have not opted to expand Medicaid. With the Covid-19 pandemic, improved public opinion toward ACA and additional monetary incentives in the American Rescue Plan (ARP) Act, it is likely that some remaining states will expand Medicaid in the coming years. When this occurs, lower-income individuals who currently purchase individual subsidized plans may move onto Medicaid plans.

Increased Medicare eligibility would reduce the number of individual market consumers and could lead to changes in provider reimbursement.

There is currently an increased push to lower the age of eligibility for Medicare to age 60. High utilizers of individual health plans in this age group would likely transition to Medicare. In addition to the loss of membership in the individual market under this scenario, payers could also expect providers to try to recoup potential losses from shifting more care to Medicare plans by negotiating rates more aggressively for individual plans.

A public option is unlikely before 2024.

An additional hurdle for insurers would be the passage of a public option requirement. While there have been varying public option bills introduced in Congress, from my perspective, the current administration is unlikely to pass a public option in the short term.

The main concern a public option presents for insurers is that the public option’s cost advantage could eventually crowd out private plans in the marketplace. The failure of a public option in Connecticut may serve as a harbinger for what is to come in the near term for current public option legislation — private insurers investing significant dollars in preventing the passage of a public option. Positive public opinion has been steadily increasing regarding a public option, however, and insurers would be wise to begin planning for how they would maintain profitability under such a system.

Payers should prepare for a complex, competitive market.

Insurers must thoroughly explore regulatory hurdles and competitive threats, and how they are evolving. Unique conditions in the individual market make understanding current, pending and future regulatory legislation essential for successful performance. There are many complex state regulatory laws and unique state benefit designs (e.g., Essential Plans in NY, ConnectorCare in MA, Value Plans in MD, etc.) that require significant planning and strategic positioning. To prepare, payers should:

Properly evaluate the ROI of infrastructure investments needed for expansion. An in-depth analysis is necessary to assess the cost of entering a new market, the cost of staying in that market and whether there are infrastructure investments that can be leveraged across states, increasing their return on investment.

Develop a differentiated how-to-win plan for each target geography. Planning for individual market expansion is regularly occurring several years out, and it will be essential to have a well-considered plan in place that considers all competitive, regulatory and operational avenues to determine an insurer’s optimal path forward.

Each one of the state exchanges poses unique regulatory and competitive challenges. Experience has shown that insurers maximize profitability when they tailor a how-to-win plan to individual states and, in some cases, to individual MSAs. Despite significant hurdles, insurers can definitely be profitable in the individual market, but it won’t be easy.


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