May 16 2024 Section 1557 – Enabling Equity or Tool for Tyranny? Section 1557 of the Affordable Care Act prohibits health programs and activities receiving federal financial assistance (i.e., virtually every health plan, hospital, and provider) from discriminating on the basis of race, color, national origin, sex, age, and disability. 1 This discrimination prohibition is so straight-forward and plain, could it really be the source of controversy? Define “Sex” In the 14 years that have passed since Congress codified Section 1557, its seemingly plain text has unfolded in surprising ways. So much so that its terminology rings of “newspeak” from George Orwell’s dystopian 1984, in which “the Party” creates a truncated vocabulary called “newspeak” to eliminate even the possibility of objection. Can any sane person oppose anti-discrimination on the basis of sex? Well, it turns out that “discrimination on the basis of sex” means a lot more than one might initially expect. You Keep Using That Word. I Do Not Think It Means What You Think It Means. 14 years later, we are still unpacking exactly what “discrimination on the basis of sex” means. On May 6, 2024, the Biden Administration published new final rules interpreting Section 1557 and expanding the definition of “sex” to include “sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity; and sex stereotypes”. 2 The new rules largely restore Obama-era provisions, and pare back previous exemptions available to persons (particularly institutions) on the basis of religion and conscience, which begs the question: Are religious institutions actually turning away individuals on the basis of sex? And if not, is Section 1557’s discrimination prohibition really just “newspeak” for requiring providers, payors, and employers to provide and facilitate procedures they find to be morally objectionable? Hint: the Catholic Church has long promoted basic healthcare as an essential service and fundamental human right. 3 The patient received the surgery from a nearby hospital a few months later but argued that St. Joseph’s violated Section 1557, causing emotional distress. The Court did not find that St. Joseph’s was exempt from Section 1557, and the parties settled in 2021. In 2023, the U.S. District Court of Maryland ruled that the state-operated St. Joseph’s hospital in Baltimore violated Section 1557 by canceling a patient’s gender reassignment surgery, notwithstanding the fact that Catholic hospital was required to follow the Ethical and Religious Directives for Catholic Health Services (“ERDs”). 4 Also in 2023, a U.S. District Court in Washington ruled that Catholic Health Initiatives’ self-funded plan administered by Blue Cross Blue Shield of Illinois had to pay for a member’s gender reassignment surgery. 5 This case sets a particularly alarming precedent for self-funded religious employers, who typically rely on non-religious health plans to administer health insurance benefits. In these cases and others, Section 1557’s discrimination prohibition serves as pretext for requiring coverage for and provision of services that are morally illicit per the religion of certain providers and plan sponsors. Religious Exemption The new rules, promulgated by the Office for Civil Rights (“OCR”), pay lip service to existing federal religious protections generally available, and offer entities the opportunity to seek an exemption by submitting a request to OCR. OCR is also the office tasked with ensuring its anti-discrimination rules are enforced, making OCR the legislature, arbiter, and police. The rules’ reliance on existing federal religious protections injects a significant amount of uncertainty into its applicability. While there is likely strong precedent for religious providers to object on religious grounds, the applicability is much more attenuated for religious employers objecting to pay for morally objectionable services. For example, whereas federal protections such as the Religious Freedom Restoration Act (“RFRA”) protect free exercise of religion, it is unclear how religious employers offering fully-funded plans, or religious employers who self-fund and rely on non-religious health plans to administer their plans, will be protected (as typified in the Washington case described above). Conclusion The enforcement trends and new rule highlight the need for faith-based insurers to take advantage of religious liberties and safeguard individuals and employers from being hamstrung by dependence on non-religious health plans administering their benefits. This year, Presidio became the first company in American history to apply to form a religious insurer, which would extend the full scope of religious freedoms to individuals and employers seeking a health insurance option that aligns with their faith and values. 42 U.S.C. § 18116 [↩]89 Fed. Reg. 37,522 (May 6, 2024) (to be codified at 42 C.F.R. § 92.101). [↩]See, United States Catholic Conference of Bishops, Health and Healthcare, Pastoral Letter, November 19, 1981 (“health care is so important for full human dignity and so necessary for the proper development of life that it is a fundamental right of every human being”); and Pontifical Council of Justice and Peace, Compendium of the Social Doctrine of the Church, para. 166 (“The demands of the common good are . . . strictly connected to respect for and the integral promotion of the person and his fundamental rights. These demands concern above all . . . the provision of essential services to all, some of which are St. Joseph’s Regional Medical Center in New Jersey was sued in 2017 for refusing to perform a gender reassignment surgery. ((Conforti v. St. Joseph’s Healthcare System, Inc. et al., U.S. District Court for the District of New Jersey, No. 2:17-cv-00050-CCC-CLW. [↩]Hammons v. University of Maryland Medical System Corporation, et al., U.S. District Court for the District of Maryland, No. DKC 20-2088. In a quirky fact patter, St. Joseph was acquired by the University of Maryland Medical System Corporation – a public entity – in 2012, and the asset purchase agreement contained covenants requiring the hospital to be operated consistent with Catholic values and principles, including the ERDs. [↩]Pritchard v. Blue Cross Blue Shield of Illinois, U.S. District Court for the District of Washington, No. 3:20-cv-06145. The ruling in this case is far-reaching for two reasons: first, it applies Section 1557 to Blue Cross’ third-party administrator services by virtue of Blue Cross’ receipt of federal funding for insurance operations, and second, it extends Blue Cross’ Section 1557 obligations to its Catholic employer client without consideration of the Catholic employer’s religious protections. At the time of this article’s publication, the Court’s order granting plaintiffs’ motion for classwide relief and nominal damages is being appealed to the Ninth Circuit. [↩]
Sep 28 2023 ACA Scorecard: Half the Enrollment at 3x the Cost Presidio cofounder Daniel Cruz coauthors National Review article based on his published white paper detailing ACA enrollment trends and costs. The paper is expected to be used to promote policy reforms promoting more efficient means to increase health insurance enrollment. Read the full Paragon white paper here. Read the National Review article here. Presidio HealthCare cofounder Daniel Cruz recently coauthored a white paper in collaboration with Paragon Health Institute that puts a reality check on the “record high” enrollment in ACA markets. Americans were told that the individual market would have 40 million enrollees by 2021…in reality there were only 20 million. Further, the subsidies were artificially boosted by over 45% compared to the original design to get half the expected enrollment…all while employer coverage has dropped, resulting in only 1.6 million more people with private insurance, costing American taxpayers over $36,000 per additional private market enrollee. Instead of increasing coverage, the ACA exchanges have effectively fostered a winners-and-losers demographic shift that attracts a different group of people — primarily older, sicker, and lower-income households eligible for large subsidies. Meanwhile, the negative impact of higher premiums has hurt Americans who do not qualify for subsidies and are increasingly unwilling to purchase health insurance in the individual market. Only 21 percent of individual-market enrollees in 2022 paid the premium without taxpayer help. In 2013, the individual market was entirely unsubsidized. Improved federal and state policies to expand more options at affordable prices can help more Americans get access to better coverage. Here at Presidio, we are building products that can react quickly to current and future policy environments to help families purchase better plans that also promote the culture of life!
Sep 11 2023 What is Pro-Life Health Insurance? In the wake of the Affordable Care Act, many Americans are stuck with health insurance coverage that pays for services that violate their consciences. Presidio HealthCare is launching the first faith-based, pro-life health insurance company, with a vision of breathing new life into the health insurance markets as a catalyst for building a culture of life and promoting human flourishing. Why a pro-life option is needed The Affordable Care Act (“ACA”) continues to shape the health insurance landscape, and requires virtually all health insurance policies to provide certain preventive services for women – including contraceptive services and abortifacients – free of cost.1 That means virtually every comprehensive, fully-insured health insurance policy pays for contraceptive services and abortifacients.2 Some states even require private insurance plans to pay for abortions,3 and many large private insurers electively cover abortions with or without state mandates. 44% of American adults identify as “pro-life”,4 and large religious communities – such as the Catholic Church – morally object to the use of contraception. Yet the vast majority of individuals and employers are stuck with health insurance plans that pay for services that violate their consciences. What does “pro-life” mean? We started Presidio because we think Americans deserve a better option – one that does not violate the consciences of those who object to services like abortion and contraception. But “pro-life” means a lot more than just anti-abortion. Our vision for Presidio is to provide insurance products that promote human flourishing. That vision is guided by a Christian anthropology, which includes the following beliefs: Human beings are a body-soul composite – care for the body and soul needs to be considered holistically; Human beings are created “in the image and likeness” of God5 – this inherent dignity emphasizes the need for patient autonomy as opposed to paternalism in medicine; Human beings are endowed with everlasting souls, and our bodies will be resurrected – the lens of eternity shapes our understanding of life and death; Fertility is a gift and invitation to participate in the divine act of pro-creation – care surrounding fertility and pro-creation should align with God’s creative order; Jesus Christ assumed our mortal flesh, and redeemed us by his suffering and death – this dignifies our suffering, even giving it redemptive power; God is the sovereign author of life – healthcare technologies should be developed and leveraged to promote health and wellness, while appropriately revering the mystery and divinity of the source of life. As we build insurance products, we envision these policies as more than just standard health insurance policies with mere carve-outs for things like abortion, contraceptive services, “gender-affirming” care, etc. Rather, we want Presidio policies to build the culture of life by covering things like: Fertility awareness and holistic procreative technologies – while fertility awareness can be leveraged to avoid or achieve pregnancy, it can also help identify underlying health issues, and can be combined with new technologies and procedures that are clinically proven to be as effective as artificial reproductive technologies for treating infertility;((NaProTECHNOLOGY and Conscientious OB/GYN Medicine (AMA Journal of Ethics))) Mental health benefits – this specialty is particularly vulnerable to ideological influence, so connecting members with values-aligned mental health professionals is a top priority; Marriage and family therapy – we believe families are the fabric of society, and we are exploring policies that encourage family flourishing; Holistic, patient-centered care – services like homebirths can be cost-effective alternatives to hospital births, but are often not covered because they require care teams to revolve around the mother and baby rather than the other way around. Is Presidio religious? Presidio is religious, but does not require its members to subscribe to a religion or set of moral beliefs. Think of Presidio like a faithful Catholic hospital – it is grounded in religious principles and provides services to individuals of all faith backgrounds precisely because of its religious principles. Presidio coverage determinations will be consistent with the Ethical and Religious Directives for Catholic Health Care Services (“ERDs”).6 The ERDs are the most succinct and baseline articulation of Christian healthcare ethics, and are consistent with Presidio’s Catholic identity. That does not mean Presidio members need to subscribe to the ERDs – it just means services inconsistent with the ERDs will not be covered under Presidio insurance policies. Conclusion At Presidio, we view religion as more than a set of rules to follow, but principles to promote human flourishing. This is precisely why Christian communities, and the Catholic Church in particular, have pioneered healthcare services((See, e.g., Catholic Hospitals in American Healthcare (Grand Valley State University))) in response to Christ’s command to heal the sick and proclaim the kingdom of God.((Luke 10:9)) Religious communities have historically focused on delivering healthcare services to those in need. The ACA has ushered in an era that calls for new focus on building faith-based health insurance options that exclude services that violate many Americans’ consciences, and that promote human flourishing. The time is ripe for faith-based communities to meet the demand for pro-life health insurance options, and Presidio seeks to offer products that align with Christian values to promote a culture of life. 42 U.S.C. § 300gg-13(a)(4); A Statement by U.S. Department of Health and Human Services Secretary Kathleen Sebelius, January 20, 2012 [↩]We discussed the scope of the religious exemption in more detail in our article, “The Un-Utilized Religious Insurer Exemption” [↩]California, Illinois, Maine, Maryland, Massachusetts, New York, Oregon and Washington require insurance plans to cover abortion. See Regulating Insurance Coverage of Abortion (Guttmacher Institute) [↩] ‘Pro-Choice’ or ‘Pro-Life’ Demographic Table (Gallup) [↩]See Gen 1:26 [↩]Ethical and Religious Directives for Catholic Health Care Services (United States Conference of Catholic Bishops) [↩]
Aug 28 2023 Why Healthcare Sharing Ministry Costs Keep Rising Many families are concerned with upcoming increases in their healthcare sharing ministry (“HCSM”) monthly share pricing – this year many HCSMs will nearly double their monthly shares from just a few years ago! These seemingly unpredictable increases have led many to wonder if there is an end in sight. But these shock increases are in fact predictable, based on well-established actuarial principles, and would typically be far less dramatic in a traditional health insurance environment. The trifecta behind these increases is comprised of 1) stabilizing HCSM growth, 2) no HCSM risk-assumption, and 3) pre-existing conditions exclusion, each of which we explain in this post. Growth To understand HCSM’s growth pattern, it is important to consider their history. HCSMs exploded in popularity in the wake of the Affordable Care Act (“ACA”). HCSMs provided an avenue of escape from the ACA’s double-whammy of increased premium rates and mandated coverage.((Premiums rose 121% for the first five years of the ACA (Rate Review Data (cms.gov)); coverage was mandated per § 500A of Pub. Law 111-148 (11th Congress) )) The exponential growth trend continued for several years as displayed in Figure 1, which charts the enrollment of two major HCSMs from 2010 to 2021. Figure 1 1 But recent enrollment seems to be stabilizing. For example, Medi-Share self-reported enrollment dropped 4% from 2021 to 2022 – new enrollment comprised 20.2% of overall enrollment in 2021, but just 10.7% in 2022.2 While the market for Christian values-aligned products remains largely untapped, this narrower market – i.e. families willing to stomach the inherent risk that comes with HCSMs – may be saturated. Additional headwinds to enrollment growth in 2022 and 2023 include the temporary increase in federal subsidies to purchase on-exchange ACA plans, improving the affordability of ACA coverage for some Americans. This stabilizing growth pattern is the first key to understanding pricing increases. No Risk Assumption HCSMs do not assume risk – here, it is important to understand what HCSMs are (and are not). HCSMs are unlicensed, largely unregulated organizations that facilitate payment for participants’ healthcare costs, usually through monthly “sharing” costs. Typically, participants submit their medical bills to the HCSM, and the HCSM matches participants who have medical bills with other participants to facilitate bill payment. HCSMs are sometimes viewed as a health insurance alternative. But unlike insurers, HCSMS 1) have no legal obligation to pay medical bills, 2) are not subject to insurance regulator oversight, and 3) do not assume risk.((There is a lot to unpack in differentiating HCSMs from insurers, which is important in its own right and will be the subject of a future blog post. )) This third feature means HCSMs typically do not accumulate reserves for future changes in needs. In the HCSM world, “perfect” pricing means matching annual revenues (i.e., participants’ monthly share contributions) with annual expenses (i.e., medical and administrative expenses) – without generating reserves necessary for future unexpected medical costs. Setting the monthly share price without accounting for reserves accumulation is the second key to understanding pricing increases. Pre-Existing Conditions Exclusion HCSMs typically exclude pre-existing conditions, which means certain illnesses and conditions are not eligible for “sharing” in the first year or so. This makes the initial risk pool very healthy, and the associated medical costs of first-year enrollees remain artificially low. But as participants stick with the product, they eventually develop new illnesses and conditions that incur expenses that start to add up. For so long as the HCSM is enrolling new participants each year, the new enrollees’ low and predictable healthcare costs can offset the relatively higher costs of second, third, and fourth-year participants. The exponential growth pattern prior to 2022 allowed HCSMs to keep monthly sharing costs very affordable. But as new enrollment stabilizes, the risk pool normalizes to reflect actual lifetime illnesses and associated medical expenses. Reality sets in, and HCSMs must increase monthly sharing costs to keep up with growing claims submissions. Perfect Storm and Death Spiral This explains why healthcare sharing ministry costs keep rising. HCSMs were initially extremely affordable – in 2017, a family of 5 could purchase a HCSM product for roughly $400 per month. More recently, those monthly costs have nearly doubled across the major HCSMs (see Figure 2). Figure 2 3 These increases are a predictable effect of the volatile combination of 1) lack of policy reserves and 2) pre-existing conditions exclusion. These two features can only co-exist in equilibrium when a third element – enrollment growth – is strong. When enrollment growth stabilizes, imbalance ensues, and price increases are inevitable to keep up with increasing medical expenses. Worse yet, the inevitable price increases can result in a “death spiral”. In this scenario, large premium increases further depress new enrollment and cause healthy participants to drop their coverage, leading to an even unhealthier risk pool, which in turn leads to further price increases. How Insurers Avoid Death Spirals To be sure, health insurers increase premiums for a variety of reasons, including inflation, medical costs, and changes in coverage or health status. But insurance premium pricing increases tend to be more predictable and stable compared to the HCSM world. This is because insurance companies assume risk, and therefore calculate lifetime expected costs as part of the underwriting process that determines policy premiums. In other words, insurance companies predict that new members will eventually become sick, and price for it up front. This results in a “smoothing out” of premium prices that are largely immune from stagnating enrollment growth. Figure 3 shows that the average year-to-year rate changes for HCSMs have consistently outpaced (and often doubled!) that of employer sponsored health insurance. While not a perfect proxy for off-exchange individual marketplace products, pricing actuaries in both insurance markets are trained to maintain stable premium increases through adequate reserving and pricing calculations. This allows for significantly more stability in health insurance pricing compared to HCSMs – this is part of the stability families seek when shopping for health insurance. Figure 34 Conclusion Rigorous actuarial pricing and regulatory oversight are unique features of the insurance industry that protect consumers from unexpected pricing increases and death spirals. This is just one of the many reasons we believe Christians need a faith-based insurance alternative to HCSMs and are launching Presidio to serve as the financially secure option families deserve. Author’s calculations based on Health Care Sharing Plans and Arrangements in Colorado (Colorado Department of Regulatory Agencies Division of Insurance) (hereinafter, the “Colorado Report”); The State of the Ministry, 2017 (Samaritan Ministries); and Health Care Sharing Ministries: an Uncommon Bond (Charlotte Lozier Institute). Note that enrollment numbers in this unregulated industry are notoriously difficult to ascertain. More consistent data is anticipated October 2023, when the Colorado Department of Regulatory Agencies Division of Insurance publishes its 2022 report. For purposes of the Colorado Report “Medi-Share” is reported as Christian Care Ministries dba Medi-Share and may be broader than just the Medi-Share product offered by Christian Care Ministries. [↩]See 2022 Annual Report (Christian Care Ministry) and 2021 Annual Report (Christian Care Ministry) archived from the original. Again we note that HCSM enrollment numbers are difficult to ascertain, and Christian Care Ministry’s self-reported annual numbers differ from the numbers reported to the Colorado Department of Regulatory Agencies Division of Insurance (neither report details, e.g., exact time period, how members are calculated, or which products are included or excluded). Nonetheless, Christian Care Ministries’ annual reports note decreases in total members (356,352 as of 6/30/22, down from 369,500 as of 6/30/21) and total new members (34,455 in 2022, down from 74,747 in 2021). [↩]Monthly costs for average family of 5 using historic advertised costs of highest tier plan without add-ons or additional protections. All 2023 prices are based on respective HCSM websites as of August 25, 2023. Medi-Share historic pricing is based on historic MedishareReviews.com archives accessed through http://web.archive.org/. All other historic pricing was derived from the respective HCSM’s historic websites using archived websites accessed through http://web.archive.org/. Medi-Share pricing could not be located prior to 2017. Note that Solidarity launched in 2016. [↩]See footnote 5. 2023 employer health insurance change represents author’s estimate based on 5-year trend. 2022 employer health insurance data from Employer Health Benefits 2022 Summary of Findings (KFF). All other employer health insurance data adapted from 2021 Employer Health Benefits Survey (KFF). [↩]
Aug 14 2023 Freaky Friday Health care spending comprises almost 20% of our national gross domestic product1 and everyone is 100% confident that health care is “broken”. The health care system is ripe for disruption, yet multiple entries into the health insurance landscape by venture backed start-ups have resulted in catastrophically high losses and liquidations in multiple states. While there is great opportunity in this $4T industry, the pareto principle (aka the “80/20 rule”) should be kept top of mind when assessing the prospects of new health insurance companies, particularly in assessing which cost centers yield competitive advantages. What Happened to Oscar, Bright and Friday? In the Affordable Care Act (“ACA”) individual market alone, Oscar, Bright and Friday (collectively “OBF”), the three most well-known health insurance start-ups, have collectively lost $1.3B from 2014 to 2021.((See Medical Loss Ratio Data and System Resources (CMS))) Exhibit 1 To understand why, you must understand how a standard health insurance company spends its premium dollars in a post-ACA world. The following table shows the percentage of premium dollars spent in the listed categories with a comparison between all individual market carriers combined versus OBF-specific results for 2014-2021. Exhibit 2 2 The first thing to note is that, on average in the ACA markets, 80% of premium dollars are spent on medical expenses. Medical expenses are directly related to a health plan’s ability to negotiate favorable contractual reimbursement rates with physicians and hospitals. A plan with more members has more leverage to negotiate favorable reimbursement rates. Start-ups begin with zero members, so the baseline assumption should be that they will not be able to compete on medical costs immediately out of the gates. Most start-up insurers focus on tech-based features as a competitive advantage. The problem is that tech only drives a portion of that 17% administrative expense noted in Exhibit 2. So even if they could produce 10% greater efficiencies than the Blues, 10% of 17% of the premium results in only 1.7% improvement on the premium. If the Blues are 5% better on medical reimbursement (which they are at least), they beat that 1.7% with a 4.1% advantage (81.5% x 5%). So how did OBF grow to 1.3 million members by 2021? The simple strategy of “buying enrollment” or pricing at a loss. OBF could have priced products that were 10% more expensive than established health plans but that would have resulted in minimal growth. Instead, they priced their products at intentional losses, resulting in a -9.0% profit margin. The following is an example of Friday Health Plans’ pricing in the Dallas, Texas marketplace – in 2021 and 2022 Friday Health Plans’ product was approximately 10% – 15% cheaper than Blue Cross, Blue Shield of Texas in this marketplace.3 Exhibit 3 What Strategies Can Help Start-Ups? Start-up health insurance companies need to understand their strengths and weaknesses. As an actuarial consultant, I had a few principles when considering a new product launch: Maximize Margins – Never leave money on the table. There may be geographic areas, benefit levels or markets where you have a competitive advantage on cost, and if there is, find ways to maximize those margins to supplement the rest of your business. This seems obvious, but surprisingly a lot of organizations leave money on the table or fail to identify the right areas of opportunity. Land the Plane – Better to land the plane than to sink the boat! Rather than growing enrollment rapidly through risky underpricing, grow at the right rate with appropriately priced premiums. Building a cost-effective network may take some time for a start-up health insurer. It is always better to aim a little high on first year premium rates and work on calibrating them in years 2, 3 and beyond than to put yourself in a hole through underpricing. Focus On Your Greatest Strength – It is hard to gain enrollment, but being focused on the greatest area of differentiation is the best bet to grow. This could mean a certain regional presence, ability to control costs, relationships with medical groups and hospitals, filling a market gap, etc. Don’t Lie to Yourself – The simple fact is that people typically buy insurance based on premium cost, network and plan designs – in that order . . . anything else (like customer service or shiny apps) are likely bonus items that can be tiebreakers but will not drive sales by themselves. Focus on strategies to compete on cost while also building brand and differentiating tech-solutions. Other Marketplace Opportunities? Since 2014, there has existed an alternative marketplace with a variety of product options not subject to the ACA. This includes 1) Health Sharing Ministry products which have grown 10-fold since 2014 to 1.7 million enrollees, and 2) short-term, limited-duration (STLD) products which have 3 million enrollees nationwide. There are additional innovative products in this landscape that share a similar cost-structure with STLD plans and which have favorable margins that can allow for start-up products to compete on day one. An example is shown below: Exhibit 4 From a start-up perspective, the key benefit of the non-ACA marketplace is that the margin (15%) that is built into the competitive landscape allows for new carriers to price a product that is both competitive and profitable. The non-ACA landscape provides a great opportunity for a faith-based health insurer to fill a market gap by offering a product that is cost-effective in relationship to the ACA, values-aligned with pro-life benefits, and competitively priced compared to similar products. The large group, fully insured market may also allow for start-ups to target employers with younger and healthier employees, since the large group market is not subject to risk adjustment. In other words, if a plan gets the healthier members, it can charge competitive premiums based on the better risk, rather than paying other carriers through a risk-adjustment mechanism (which is what happens in the individual and small group ACA markets). Conclusion The health insurance industry has many areas that are ripe for disruption. However, you cannot ignore simple realities of how health plans compete, one of which is that more established health plans have a greater ability to negotiate favorable contractual rates with providers. Entering markets takes an understanding of how you will compete on premium rates and network offerings and choosing select areas that allow you to focus on your strengths and maximize your margins. One area that has not been taken advantage of is establishing a pro-life, faith-based health insurance carrier. Presidio is positioning itself to be the first carrier to do so by targeting markets where it has the greatest strengths, and focusing on building a path to launching in more traditional markets when ready to compete on cost without pricing at a loss. Healthcare Spending in the United States Remains High (Peter G. Peterson Foundation) [↩]See id. [↩]2022 QHP landscape data (healthcare.gov) [↩]