Plan Watch

ACA Means More Coverage of Diabetes for Blues


Frank Diamond

The Blues have participated in ACA exchanges more than any other health insurer for two reasons. It’s good business: The exchanges mean millions of new enrollees. And helping those who are uninsured or underinsured has always been the stated mission of the Blue Cross Blue Shield Association.

But a recent association report points out some of the challenges that come with jumping into the health care exchanges with both feet. Blues officials wanted to see what changed about their claims data in the individual market after the ACA exchanges took effect. The report also compares the post-ACA experience of those with individual Blues coverage with those who are covered by Blues plans through their employers.

2015 prevalence of select conditions

(Per 10,000)

Based on the first nine months of 2015 medical claims data.

The blue bar represents individuals who enrolled prior to 2014 and continued BCBS individual coverage into 2015.

Source: Blue Cross Blue Shield Association, “Newly Enrolled Members in the Individual Health Insurance Market After Health Care Reform: The Experience From 2014 and 2015,” March 2016

One finding that jumps out from the report is that the new buyers of Blues individual coverage in 2014 and 2015 were almost twice (94% higher) as likely to have diabetes as those who had bought individual Blues coverage prior to 2014 and continued with it through 2015.

And diabetes was not some oddball exception to the rule: The prevalence of HIV, hepatitis C, depression, coronary artery disease, and hypertension was also higher among new 2014 and 2015 individual coverage enrollees.

With the higher prevalence of expensive chronic disease, it’s not surprising that the Blues also saw an increase in medical spending. For the first nine months of 2014, the medical spending per member per month for those with individual Blues coverage was $501. For the first nine months of 2015, the medical spend per month jumped to $559, an increase of 12%.

Ideally, people with diabetes are engaged patients, mindful of their condition and conscientious about taking their medications. That is something the Blues want to facilitate, says Alissa Fox, senior vice president of the office of policy and representation for the Blue Cross Blue Shield Association. “Our plans are leading the health care industry in the development of patient-focused care programs that emphasize prevention, wellness, and coordinated care so that individuals get healthy faster and stay healthy longer,” Fox tells Managed Care. “We have documented reductions in emergency room visits, fewer hospital admissions and readmissions, and reduced hospital infection rates.”

She referred to the move to value-based care as well. “The programs today are centered on Blue companies’ ability to partner with medical professionals,” she said, ticking off some of the usual suspects of value-based care: data, analytical expertise, and delivering “the most appropriate care in the most appropriate setting.”

With UnitedHealthcare’s announcement in April that it will be exiting most ACA exchanges next year, the challenges that the Blues face in the individual market may only get steeper.