Consumer Operated and Oriented Plans (CO-OPs)

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What are CO-OPs and how are they different?

Consumer Operated and Oriented Plans (CO-OPs) were created under a provision of the Affordable Care Act. CO-OP plans were proposed by Senator Kent Conrad (D-ND) when the original public plan option was jettisoned during the health care reform debate. Lawmakers added the CO-OP provision to the Affordable Care Act to placate Democrats who had pushed for a government-run, Medicare-for-all type of health insurance program.

At the time, progressives who preferred a public option derided CO-OPs as a poor alternative because they can’t utilize the efficiencies of scale that would come with Medicare For All, nor do they have the market clout that a single payer system would have when negotiating reimbursement rates with providers.

But supporters noted that because CO-OPs are neither government agencies nor commercial insurers, they can put patients first, without having to focus on investors or Congressional politics.

Instead of paying shareholders, CO-OP profits are reinvested in the plan to lower premiums or improve benefits (in 2014, only one CO-OP, Maine Community Health Options, had revenue that exceeded claims and administrative expenses – but the reinvestment of profits is the plan for all CO-OPs, once they become profitable). And customers’ health insurance needs and concerns become a top priority because the CO-OP’s customers/members elect their own board of directors. And a majority of these directors must themselves be members of the CO-OP.

CO-OPs are private, nonprofit, state-licensed health insurance carriers. Their plans can be sold both inside and outside the health insurance exchanges, depending on the state, and can offer individual, small group, and large group plans. But they’re are limited to having no more than a third of their policies in the large group market (a more lucrative market than individual or small group).

Lawmakers had originally planned to provide $10 billion in grants to get the CO-OPs up and running in every state. But insurance industry lobbyists and fiscal conservatives in Congress succeeded in reducing the total to $6 billion, and turning it into loans – with relatively short repayment schedules – instead of grants (and CO-OPs are not permitted to use federal loan money for marketing purposes). Then, during budget negotiations in 2011, those loans were cut by another $2.2 billion. And in 2012, during the fiscal cliff negotiations, CO-OP funding was reduced even further – and applications from 40 prospective CO-OPs were rejected.

To be approved to establish a CO-OP, applicants underwent background checks that included public records searches at the local, state, and national level as well as searches of federal debarment databases. Loan recipients are subject to strict monitoring, audits, and reporting requirements for the length of the loan repayment period plus 10 years.

Ultimately, the Centers for Medicare and Medicaid (CMS) awarded about $2.4 billion in loans to 23 CO-OPs across the country (there were 24 CO-OPs, but Vermont Health CO-OP never became operational. CMS retracted their loan in September 2013 – before the exchanges opened for the first open enrollment – because there were doubts that the program could be viable with Vermont’s impending switch to single-payer healthcare in 2017; ironically, Vermont pulled the plug on their single payer vision in late 2014).

Focus on cost savings and reinvested profits

How do CO-OPs increase cost efficiencies?

* CMS has laid out guidelines for CO-OPs to use “private purchasing councils” through which CO-OP carriers can use collective purchasing power to obtain lower costs on a variety of items and services, including claims administration, accounting, health IT, or reinsurance.
* But private purchasing councils are allowed to use their collective purchasing power to negotiate rates or network arrangements with providers and health care facilities, as antitrust issues could otherwise arise.
* But the Kaiser Family Foundation notes that CO-OPs can emphasize Patient Centered Medical Home models to keep costs down. (the PCMH model allows physicians to use health information technology and care managers to provide a full spectrum of care that’s coordinated among each patient’s various providers. The goal is to keep patients healthy – and out of the hospital – by using best practices and evidence based medicine. If PCMH doctors are successful, they qualify for
* CO-OPs generally emphasize preventive care in an effort to keep their members healthy.
* A challenge for CO-OPs has been developing their provider networks. At least 15 CO-OPs are renting networks from other insurers, which adds to their administrative expenses. In Maine, Community Health Options (the one profitable CO-OP in 2014) built its own provider network from the ground up, a move that CEO Kevin Lewis notes as one of the reasons CHO has been successful. CO-OPs also have the option to hire doctors directly, rather than contract with them through provider networks (the upside for the doctors is that the CO-OP then handles the administrative details, and the doctor can focus on healthcare instead).

Will the remaining CO-OPs survive?

It’s too soon to tell. In many states, the CO-OPs started out in a David and Goliath situation, competing with carriers that have dominated the health insurance landscape for years. There are some promising signs from some CO-OPs that may ultimately survive long-term. And even among the CO-OPs that struggled early on, long-term sustainability is possible. Premiums that carriers – including CO-OPs – set for 2014 and 2015 were little more than educated guesses from actuaries, since there was very little in the way of actual claims data on which to rely (there was no data at all when the 2014 rates were being set, and only a couple months of early data available when 2015 rates were being set). Once the CO-OPs had more than a year of claims history in the books, they were able to be more accurate in pricing their policies for 2016, and that will again be the case for 2017.

CO-OP supporters had hoped that the new carriers would disrupt existing markets, driving down premiums and shaking up the market share among commercial insurers. Although CO-OPs struggled financially in their first year, average premiums market-wide were lower in both 2014 and 2015 in states that have CO-OPs than in states without CO-OPs. A GAO report found that average CO-OP premiums in 2014 and 2015 in most states tended to be lower than the average premiums across all carriers in those states. And enrollment in CO-OPs increased at a much faster pace than overall enrollment growth (across all carriers) from 2014 to 2015.

CMS acknowledged from the start that not all of the CO-OPs would be likely to succeed – just as a crop of new for-profit health insurance carriers wouldn’t all be expected to succeed. But over the next few years, CO-OPs will have an opportunity to refine their business models, reinvest any profits they make, and grow their enrollment – especially as grandmothered plans cease to exist by the end of 2017, increasing the number of people who need to purchase ACA-compliant plans.

The retention of grandmothered plans has benefited health plans that were already in place prior to 2014, since enrollees on grandmothered plans had to go through underwriting to obtain their coverage; on the other hand, new insurers like CO-OPs have had to contend with a population that’s less healthy than expected, partly because people with grandmothered plans have not yet all transitioned to ACA-compliant plans. In short, it’s too soon to know how the CO-OPs will fare. Will more of them collapse over the next few years? Probably. But some of them are likely to succeed and become integral parts of the health insurance landscape.

Source: https://www.healthinsurance.org/obamaca ... sts-first/