Too many coincidences

Are they coincidences or is something behind them? For example early May:

·       Military personnel may become eligible for Medicare Advantage plans under a provision of national security authorization legislation in Congress.[1]

·       Health plans filed their 2019 Affordable Care Act plan proposed premiums in Virginia and Maryland. They’re up. A lot.[2]

·       National Nurses Week takes place May 6-12, 2018, concluding on Florence Nightingale’s 198th birthday.

What’s behind them is this: after decades of debates and reforms, primary drivers behind health policy change and practice in the United States remain the trifecta of care costs, quality and access.

Any wag can describe the Pentagon as a huge health plan with a fighting force subsidiary. Its worldwide military health system delivers direct care.  Tricare, its health plan, serves some 9.1 million military personnel, certain retirees and their dependents.[3] With a $50 billion budget, defense health spends one in 12 U.S. defense dollars, twice what the Navy spends on ships.[4] It’s three-quarters the size of the Veterans Administration.

Meanwhile, Medicare Advantage (MA) contracts with health plans to provide Medicare benefits to beneficiaries for a capitated payment. While significant legislation and policy is replacing fee-for-service care with alternative payment models, by far the largest such experiment running is MA. Its plans covered one in three Medicare beneficiaries in 2017, 19 million people, nearly four times what it did 15 years ago, totaling 33% market share.[5] People like what they’re getting. They like its lower out-of-pocket costs[6] and modern plan innovations that promote wellness and target chronic disease prevention and management.  Maybe people in uniform in an MA pilot plan, if it’s enacted, will agree.

Commercial plans filed their proposed 2019 ACA marketplace premiums earliest in Virginia and Maryland and the word is ouch. Maryland increases average 30% year over year. Virginia Blues HMOs are up 18%. Its lightly subscribed PPO hikes 91%.

The plans blame federal policy changes. They say repeal of the individual mandate will drive healthier beneficiaries to short-term limited duration plans and association health plans (STLD and AHP, their revised final rules await publication[7]). Healthy people without employer coverage may also go without coverage, leaving ACA plans with sicker, costlier beneficiaries. People with lower incomes remain eligible for subsidies that take the sting out of their premium increases. Who gets hit hardest? The most frequent users of the unsubsidized individual market are middle-income households whose work does not offer health benefits[8] – that is, small businesspeople and their employees. Left unmentioned: other factors increasing health care costs.

Which brings me to National Nurses Week, overlapping in 2018 with National Hospital Week. The U.S. is home to more than 4 million nurses. Nursing is the most respected profession overall,[9] the largest workforce in the health care sector and one that anticipates deeper shortages the more our population ages. At the same time, schools of nursing are turning away qualified applicants. They say faculty and clinical practice educational sites are short. Roles of nurses and advanced practice nurses are varied and growing, thanks in no small part to a National Academies of Science report that has been its most viewed nearly a decade running.[10]  But major coverage of nurses and their use as news sources has remained minuscule for 20 years.[11]

Three major developments: military health, ACA rates and the recognition of nurses. What they have in common is they all contribute mightily to the availability, affordability and quality of health and care – and of quality and security of life in America. Without their innovation, without their competition in the market, without recognition of policy barriers that impair choice without improving quality, we’ll keep getting what we get.

It’s not enough. Industry, professional and consumer organizations in the health sector can and do press for better. Even in an election year, even or maybe especially in a time of policy uncertainty, leaders can and should press for better upon state capitals and Washington.

Are you a leader? What’s your plan?


Frank Talk is a product of Cardinal Waypoint LLC, a new consultancy for health policy and leadership. You can have Cardinal Waypoint at work for you. Contact Cardinal Waypoint here.


[1] HR 5755, Chairman’s Mark National Defense Authorization Act for 2019. Title VII, Subtitle A, Sec. 701, Tricare Medicare Advantage demonstration program. May 3, 2018. p. 100 et seq., retrieved 5/9/2018.

[2] Livingston R. Health insurers seek big rate hikes for 2019. Modern Healthcare, May 7, 2018., retrieved 5/9/2018.

[3] A useful summary of the military health system may be found at: Congress of the United States. Approaches to changing military health care. Congressional Budget Office, October 2017, p. 7 et seq., retrieved 5/9/2018.

[4] Larter D. U.S. Navy wants more sailors, jets, and an extra ship in 2019. Defense News, Feb. 12, 2018., retrieved 5/9/2018.

[5] Henry J. Kaiser Family Foundation. Medicare Advantage. KFF, Oct. 10, 2017., retrieved 5/9/2018.

[6] Starc A. Who benefits from Medicare Advantage? Penn Wharton Public Policy Initiative Issue Brief 2(5), May 2014., retrieved 5/9/2018. Starc argues in favor of ACA policy reducing government payments to MA plans. Her point that lower payments would reduce plan profitability but not impair beneficiaries is unpersuasive. Nonetheless the most recent Part C rule authorized a 3.40% increase for 2019.

[7] The AHP proposed rule appears at 83 Fed. Reg. 614, 1/5/2018, The STLD proposed rule appears at 81 Fed. Reg. 7437, 2/21/2018, Comment periods are closed.

[8] Jost T. How will state and federal actions affect individual health insurance coverage for middle-income Americans? The Commonwealth Fund, Apr. 10, 2018., retrieved 5/9/2018.

[9] Brenan M. Nurses keep healthy lead as most honest, ethical profession. The Gallup Organization, Dec. 26, 2017., retrieved 5/9/2018. Lowest rankings go to members of Congress, lobbyists and car salespeople.

[10] Shalala D et al. The future of nursing, leading change, advancing health. The National Academies, Oct. 5, 2010., retrieved 5/9/2018.

[11] Mason D and Glickstein B. Underrepresentation of nurses in health care coverage continues to be a concern. Covering Health, Association of Health Care Journalists, May 8, 2018., retrieved 5/9/2018.