I spent this morning at a briefing with top officials from Blue Cross Blue Shield Association, a federation of 39 state-based insurance plans. Collectively, they cover about 100 million Americans. They also have a number of ways they want to change what the health care law looks like. Here's a rundown:
More regulation! Yes, really. Shortly after the Affordable Care Act passed, BCBSA sent the Obama administration a list of its recommendations for implementation. Chief among them: Get all the major regulations done by January 2012 so that insurers have time to prepare for a hugely overhauled insurance market. It's November 2012 and BCBSA is still waiting on some key regulations, ones that will clarify what plans have to cover and how the new marketplaces will work. They're hoping to see those regulations ASAP and expecting some to come out before Thanksgiving.
Allow larger deductibles. As the name of the law implies, the Affordable Care Act aims to make health insurance more affordable. One way it does that is by limiting the out-of-pocket deductible on individual plans to $2,000. BCBSA wants to see that number increase, allowing insurers to set the deductibles at a higher level.
A bit of background on the reasoning: Under the law, insurers will sell plans that, on average, cover a certain amount of an individual's health care costs. This is known as "actuarial value;" a plan with an actuarial value of 70 percent, for example, would cover 70 percent of an average patient's medical costs.
The lowest actuarial value allowed on the new health insurance exchanges will be 60: These will be known as "bronze" plans, that can be expected to cover 60 percent of an average patient's costs.
BCBSA argues that the limit on the deductible could make it a challenge to develop bronze plans: If the government caps the deductible at $2,000, it essentially ties its hands in how it can create plans where the average consumer picks up 40 percent of the tab.
"When you think about building a bronze package, which many may look to for affordability purposes, having those out of pocket deductible limits makes it incredibly difficult," says Justine Handelman, BCBSA vice president for regulatory policy.
BCBSA says that the Obama administration has the authority to wave those deductible limits. It has been asking the White House to do just that, if the bronze plans can't be created.
Expand the age rating bands. The Affordable Care Act limits the premiums that insurers can charge older subscribers. A plan's oldest members can only pay three times as much as the youngest members - in health wonk parlance, that's known as a "3-to-1 age rating band." The idea is there is to ensure that insurance remains affordable for older Americans, who have tended to face higher premiums.
BCBSA argues this has a downside: It might make health insurance too expensive for the younger subscribers. And these tend to be the healthier people with lower medical costs - the exact ones you want to sign up and balance out the costs of older, less healthy subscribers.
To make premiums less expensive for young subscribers, BCBSA backs expanding the age rating band upward, allowing insurers to charge older subscribers five times as much as young members. The obvious downside here would be more expensive premiums for the older subscribers.
A national insurance plan, perhaps? The health care law mandates that the federal government contract with two insurers to set up "multi-state plans" to operate across the country. For these plans, the Office of Personnel Management will negotiate the “premiums and benefits” for this insurance coverage, which legislators included as a substitute for the public option.
BCBSA is interested in running one of those plans. "We're looking at that," Fox says. "There's an application process, we'll be looking at that. "