(Image: iStock)

In theory, most of the U.S. health care delivery system and most of the health care finance system could work about the same way in 2018 as they’ve worked in 2017.

Medicare and group health plans look as if they’ll continue on something like the same path.

Even the 2018 individual major medical market could go through some bumps and then settle down into looking like a creakier version of the 2017 market.

(Related: Market Makers Reveal Real 2018 Individual Health Rates)

At press time, however, the future of the U.S. health care delivery and finance systems was up in the air.

Most of the Affordable Care Act was still in place. The Trump administration was administering the ACA system, including HealthCare.gov, about as well as possible, in some ways, but appeared to be working to block it in other ways.

The administration appeared to be close to working out a settlement with health insurers on billions of dollars in ACA cost-sharing reduction subsidy payments, but, whatever happens to the subsidy payments, the administration has made the point that it could change health insurance system administration procedures quickly, without much apparent concern for how the changes might affect health insurers.

Many nonprofit health insurers seem to be hunkering down and trying to stand up to the administration: they have elected chief executives from two of the most enthusiastic insurance company players in the ACA system to lead both America’s Health Insurance Plans and the Blue Cross and Blue Shield Association.

But some of the biggest, publicly traded health insurers seem to be coping by doing when they can to retreat from the individual major medical insurance market, and avoid talking too much about their role in the fully insured employer-sponsored health plan market.

UnitedHealth Group Inc., for example, is calling itself a health care company.

Aetna Inc. is trying to become a division of a drug store chain.

If the individual major medical market stays as unpredictable in 2018 as it’s been in 2017, and some of that upheaval spills over into other health insurance sectors, what then?

Trying to make anything as firm as a “prediction” for the health insurance system seems foolhardy, but here are some questions that might shape our coverage of health insurance in the coming year.

1. Will more companies could try to disguise more major medical insurance products as something else?

One symptom of a regulatory-driven market breakdown is participants’ efforts to escape from the official market, into black market or gray market alternatives.

Many insurers, agents and consumers have already been trying to sidestep the challenges plaguing the individual major medical market by focusing more on partial individual major medical substitutes, such as short-term health insurance or hospital indemnity insurance.

Up till now, fear of patients’ facing serious gaps in coverage, and lawsuits, have held down many agents’ sales of major medical substitutes.

The more the individual major medical market deteriorates, the less squeamish market players may be about trying to work around it. 

2. Will everyone get religion?

The Affordable Care Act includes a provision officially allowing the sale of a kind of arrangement that could, in theory, provide something like true individual major medical insurance: health care cost-sharing ministry memberships.

Ministries in effect when the ACA came along can continue to sell memberships without facing ACA mandates, or any other federal regulations or oversights whatsoever.

Rapid expansion of health care cost-sharing ministries could be another symptom of individual major medical market breakdown.


3. Will hospitals collapse?

Health insurers see hospitals as the biggest components in large sophisticated health care systems that tend to have much higher profit margins than health insurers.

S&P Global Ratings are predicting, in a look at top industry trends for 2018, that the big hospitals S&P rates should do reasonably well in 2018.

“We expect hospitals to see very low single-digit organic growth (consisting of near-zero volume growth and low-single-digit blended reimbursement rate increases), while companies providing outsourced services to hospitals and outpatient providers should grow slightly faster,” the S&P analysts write. “We expect industry participants to see modestly higher bad debt expense in 2018 (reflecting slightly lower insurance coverage levels and the increasing prevalence of high-deductible health plans, given difficulty in collecting amounts owed by consumers).”

But many small hospitals, especially those that treat many uninsured patients, and many patients who have Medicaid coverage, operate on thin margins.

If the individual major medical market goes through severe problems, or the Congress or the administration somehow impose sharp reductions in Medicare or Medicaid reimbursement rates, that could push some hospitals over the edge.

A wave of hospital failures could affect patients with group health coverage or Medicare coverage as well as those with individual major medical coverage and Medicaid.

4. Will doctors go fishing?

Consumers in many communities already see that psychologists have, in effect, dropped out of the market for insurance-paid behavioral health services.

Mental health care providers in those communities often refuse to provide care for the rates health plans are willing to pay them.

The S&P analysts say they expect to payers to continue to focus on containing costs.

If health plans try to cut costs too much, it’s possible that large numbers of medical doctors could follow mental health care providers out of the health plan provider network door. 

5. Will health savings accounts shine?

President Donald Trump promoted health savings accounts (HSAs) while he was on the campaign trail.

Most Republicans in Congress, and Trump’s nominees at the U.S. Department of Health and Human Services and other federal agencies, like HSAs.

The tax bill would leave the HSA intact.

If the Trump administration and Congress start to move past major budget reconciliation bill battles, efforts to promote and expand the HSA program could heat up.

—Read 5 2018 Health Care Regulatory Worlds That Could Make You More Popular on ThinkAdvisor.

— Connect with ThinkAdvisor Life/Health on
Facebook and Twitter.