What does 2016 hold for the health insurance industry? In a recent article at Modern Healthcare magazine, contributor Bob Herman identified three major questions. Let’s see what’s brewing for this year.

1. Will antitrust regulators approve the big health insurance mergers?

The U.S. Justice Department is reviewing a few recent purchases you might have heard about: last year, Aetna bought Humana for $37 billion, and Anthem bought Cigna Corp for $54 billion. Meanwhile, Centene Corp is currently buying Health Net for $7 billion in a merger that would consolidate Medicaid plans.

The question here is whether the Obama administration will respond to calls from consumers and providers to halt the mergers – or, on the other hand, will it leverage its approval as a bargaining chip to gain cooperation from insurers on other fronts? We should have their decision by this summer.

2. Will the Affordable Care Act health insurance exchanges achieve sustainability?

The future of the ACA is unclear, but we can be fairly sure of one thing: it’s in for some changes.

What those changes prove to be depends on who gets elected in 2016. The least-disruptive scenario would involve targeted adjustments aimed at making the ACA more effective. On the other end of the spectrum, there’s talk of completely dismantling the ACA in order to replace it with an alternative approach to health reform.

Either way, certain issues with the ACA must be addressed. While the uninsured rate is now at its lowest in 50 years, there’s some concern that young customers aren’t signing up fast enough. This year, the penalty for going without insurance will rise from 2 to 2.5 percent. Will this compel uninsureds to join?

In other news, non-compliant plans that were grandfathered in will sunset by the end of this year, along with two out of three ACA risk-mitigation programs (risk corridors and reinsurance) which currently protect plans against adverse selection. How this affects the healthcare picture remains to be seen.

3. Will states adopt new regulations for health insurance provider network adequacy?

Consumers are getting increasingly upset about unexpected out-of-network medical bills, in a phenomenon that Forbes called “financial roulette.”

It works like this. A patient checks into an in-network hospital or clinic, but while there, they receive care from an out-of-network specialist. The bill for out-of-network services is much higher than they had expected (there is no ACA cap on out-of-network costs), and to make things worse, these higher costs are entirely unexpected: the patient thought they were receiving in-network care.

The problem is due in part to a narrowing of networks, which providers initiated to help control their costs. But the combination of narrow networks and unexpected costs could be addressed by implementing broader networks and higher premiums. Whether with this or some other solution, the ACA must evolve to address the situation.

Keep in touch as 2016 unfolds: subscribe to our blog for continued updates on health insurance developments.

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