Priced out of the market

To market, to market, to buy a health care policy, the old nursery rhyme might say these days. But before you get home again, jiggety-jig, the premium for that coverage just might take most of the coins in your purse.

Five Indiana marketplace insurers-Anthem, UnitedHealthcare, - CareSource, Cigna and Coordinated Care Corp.-will hike premiums an average of 31.4% effective Jan. 1 under plans recently approved by the Indiana Department of Insurance. That's up sharply from an average 3.35% increase across four marketplace providers last year.

Nationally, the 312 insurers participating in the Affordable Care Act marketplaces from the 50 states and the District of Columbia will hike premiums about 18%, the highest increase since 2018, according to KFF, a nonpartisan health care research organization. Only four insurers have proposed decreasing premiums.

The steep increase is raising alarms with doctors, hospitals and patient advocates, who say the higher prices could throw tens of thousands of Hoosiers into the ranks of uninsured.

They may ignore or minimize their own symptoms for fear of what it may cost and end up letting a small problem go for far too long, said Dr. Ryan Singerman, a family practice physician with Parkview Physicians Group in Fort Wayne and president-elect of the Indiana State Medical Association. Then it may end up being something really tragic.

More than 359,000 Hoosiers are now enrolled in a marketplace plan, nearly triple the number from a decade ago.

The marketplace plans are 78° TE generally for people who dont have access to workplace health insurance, including students, the selfemployed, people between jobs and those who work for small businesses.

The insurers are blaming the higher cost and use of medical care, hospital services and prescription medications, which they say have climbed steeply in recent years.

But even as insurers plan to charge more, people enrolled in marketplace plans could soon get less help from the federal government for subsidies to help pay for plans.

Enhanced tax credits that have been in place since 2021 that help people pay for expensive plans are set to expire on Dec. 31, unless Congress extends them.

The tax credits were put in place under the American Rescue Plan Act of 2021 to ensure that millions of Americans could afford health insurance during the turmoil of the pandemic, when businesses were shutting down and millions of people were losing their jobs and health care coverage.

The tax credits increased the amount of financial assistance and expanded eligibility to marketplace plans.

About 97,000 Hoosiers-and 4.2 million Americans overall-could become uninsured if the enhanced tax credits are allowed to expire, according to San Francisco-based KFF. Other think tanks and experts, including the Congressional Budget Office, the Urban Institute and the Center for Budget and Policy Priorities, have published similar estimates.

Local experts agree that many people could lose coverage if premiums soar as expected, without enhanced tax credits to help people pay for them. That could just be the latest blow for low-income Hoosiers, who could also lose their Medicaid coverage under new Indiana legislation that created stricter requirements,

"I believe some people will be priced out of the program," said David Blish, director of health care consulting at Katz Sapper & Miller in Indianapolis. "Those unable to afford coverage are generally . those that need it the Bish UN most. And with Indiana Medicaid eligibility restrictions, they will likely fall through the cracks."

Hoosiers could pay hundreds

A patient advocacy group, Covering Kids & Families of Indiana, said it worries that many Hoosiers will go without health insurance rather than pay for costly premiums. The organization helps people enroll in health plans with the help of certified navigators and outreach campaigns.

"Without the enhanced subsidies that will soon expire, the marketplace is certainly not affordable for most Hoosiers," said Susan Jo Thomas, the group's executive director. "The catastrophic plans will be the only affordable choice for most people, yet those plans offer a risky option for the Those average Hoosier."

Catastrophic plans generally feature lower monthly premiums but usually have very high deductibles, meaning people can expect to pay large out-ofpocket amounts for medical care before the insurance kicks in.

The Indiana Hospital Association said the discontinuation of premium tax credits would affect patients' access to care and hospitals' ability to provide services. It predicted the move would significantly raise the amount of uncompensated care provided by hospitals.

"Not only will marketplace premiums drive up costs for patients, but private insurance premiums will likely go up as well to offset these cuts," said Scott Tittle, the organization's president. "It will take all of us- hospitals, insurance companies, policy leaders, employers and consumers-to come to the table to find workable solutions, so Hoosiers don't have to pay more for their health care."

Insurers, for their part, blame the rising cost and increased use of health care, including high-tech imaging and specialty medications. Indianapolis-based Anthem said the rate increase will affect 107,000 Hoosiers currently enrolled in the marketplace on one of its plans.

"Increases in the price of services are driven by technological advances, new specialty medications and a variety of other factors," Anthem wrote in its letter to the state insurance department.

Anthem plans to raise marketplace premiums an average of 21.3% in January, resulting in monthly premiums of $576.41.

But even at that price, Anthem will still have the cheapest average premiums on the Indiana marketplace next year. Four other insurers have received state permission to increase rates 27% to 30%. CareSource Indiana, with about 60,000 members currently enrolled in a marketplace plan, will have the highest average monthly premiums: $717.82.

In its filing to the state insurance department, CareSource said "costs for services and the number of services for both medical and pharmacy benefits have increased significantly and [are] the major contributor to this rate action."

Some benefits managers agree that hospital and medical costs are on the rise, with million-dollar claims becoming more prevalent, especially for treating cancer or for rare conditions that use specialty medications. When that happens, costs rise for almost everyone.

"For individuals with no access to group coverage and those losing - premium credits, their e coverage costs will definitely skyrocket," \ said Stan Jackson, chief innovation officer for Indianapolisbased Apex Benefits, - "Most likely, people will drop their coverage because of affordability."

Political uncertainty

So, with premiums on the rise, what is the chance that Congress will extend the enhanced tax credits to help people afford marketplace plans?

As of IBJs publication deadline, that scenario was playing out in Washington, D.C.

Congressional Democrats, led by Sen. Charles E. Schumer and Rep. Hakeem Jeffries, both of New York, have recently said their party will not vote to avert an Oct. 1 federal government shutdown unless Republicans agree to extend the enhanced subsidies, as well as undo President Trump's budget cuts to Medicaid and the National Institutes of Health.

"At a time when families are already being squeezed by higher costs, Republicans refuse to stop Americans from facing double-digit hikes in their health insurance premiums," Schumer and Jeffries said in a joint statement on Sept. 16.

But Republican leaders in the House and Senate said the following day they will reject Democratic demands for an immediate extension of health care subsidies.

Senate Majority Leader John Thune, R-South Dakota, said Democrats "have a choice to make" by Tuesday's deadline, according to The Associated Press. They can work with Republicans, Thune said, or "they can shut down the government with all that will mean for the American people."

The situation is fluid and could change at a moment's notice, like many political negotiations. But unless the two sides can come to an agreement that would include extending the enhanced tax credits, thousands of Hoosiers will be in for a sticker shock during the upcoming enrollment period, which runs from Nov. | to Dec. 15 for coverage that begins Jan. 1.

"People are gonna do what they can to ration their finances just like anyone else," said Singerman, the Fort Wayne family physician. "We are sitting in the middle of not exactly the most robust economy by many metrics, and to look at these tax credits going away, we're expecting insurance premiums to pretty much skyrocket.'