Public and Private Health Insurance Exchanges: Strategic ... · 26/04/2013 · • Individual exchanges will target uninsured and self-insured individuals • SHOP exchanges will

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COLORADO HOSPITAL ASSOCIATION

Public and Private Health Insurance Exchanges: Strategic and Financial

Considerations

Denver, Colorado

April 16, 2013



Agenda

• Introductions

• Public and Private Exchanges Overview

• Public Exchanges

• Private Exchanges

• Strategic and Financial Implications

• Questions and Discussion



Public and Private Exchanges Overview



Healthcare Exchanges Are Coming• “Exchanges” are marketplaces for individuals and businesses to comparison shop

and purchase healthcare coverage

• Seek to increase competition and/or consumer choice while providing benefit standardization, lower costs

• Public and private exchanges will co-exist in many areas

Public: Individual Public: SHOP Private

• Federally mandated for January 2014

• Individual exchanges will target uninsured and self-insured individuals

• SHOP exchanges will target small employers early on

• Community-rated premiums with limited risk-adjustment

• Small business tax credits and individual subsidies will make exchanges attractive

• Won’t exist in all states

• Targeted to large and mid-size employers

• Less regulated than public exchanges

• Will support defined contribution models



Public Exchanges: Overview



(as of 4/1/2013)

State Public Exchange Update

Source: Kaiser Family Foundation, statehealthfacts.org. State Decisions For Creating Health Insurance Exchanges as of April 2013.

www.statehealthfacts.kff.org.



Public Exchanges: Overview

• Available in all 50 states in October 2013 for January 2014 effectiveness

• Operated at state or federal levels (or shared)

• Standard benefit designs will be consistent across five levels

• Some public exchanges may have limited plan options based on amount of payer participation

• Individual and small group subsidies will be possible via tax credits



Public Exchanges: Insurer Implications

• Insurers will choose state exchange participation selectively

• Plans will be fully insured, filed, and approved prior to being offered

• Minimum (essential) benefit standards consistent across five benefit levels

• Plans will compete based on price not benefit coverage within any given level (price variance on age, geography, smoking)

• Individual premium rates may increase in many states due to increased taxes, benefit mandates, and underwriting reforms

• Small group premium rates may not be as significantly impacted due to less stringent underwriting reforms

• Guaranteed issue

• No lifetime/ annual caps

• No denials for pre-existing conditions



Public Exchanges: Consumer Implications• Individuals will evaluate and select plans via web, telephone, or paper

applications

• Benefit advisors or navigators will facilitate education and enrollment

• Older consumers cannot be charged more that 3X the rate younger consumers pay (3:1 rate band requirement)

• Premiums will have actuarial values between 60% and 90%

• Out-of-pocket expenses capped at $5,950 for individuals and $11,900 for families

• Subsidies will be available for those individuals and families whose income is between 133% and 400% of the FPL

• Subsidies in the form of refundable and advanceable tax credits will range from 2% to 9.5% of income based on FPL income level

• Non-subsidized individuals also can purchase insurance via exchanges



Public Exchanges: Enrollment



Public Exchange Enrollment Will Come From Both the Uninsured and Commercially-Insured Populations

Currently

Uninsured

Commercial

Currently

Uninsured

Commercial

(Group)

Commercial

(Non-Group)



Low Early Penalties May Slow Public Exchange Enrollment by the Uninsured

1.0%

2.0%

2.5%

2014 2015 2016

$95

$325

$695

2014 2015 2016

Penalty as a Percentage of Income Flat Dollar Penalty per Person1

1) Flat dollar penalty is indexed to inflation after 2016.

2) Some individuals may be exempt from penalties based on religion, citizenship, income, time noninsured, access to affordable coverage, etc.

Source: Kaiser Family Foundation: The Requirement to Buy Coverage Under the Affordable Care Act. www.healthreform.kff.org.

The penalty for not obtaining coverage will be the greater of a flat

dollar amount or a percentage of income unless certain

exemptions are met2



Public Exchange

Uptake DriverCommentary

Varies by

State?

PenaltiesExemption prevalence (e.g., whether post-subsidy cost of

bronze plan exceeds 8% of income) will vary by market �

SubsidiesSubsidies taper off markedly at higher income levels;

income mix of uninsured varies by region �

Price ShockHigher premium increases will reduce uptake by those

not eligible for subsidies �

Exchange

Promotion

Growing concerns regarding limited marketing budget for

Federal Exchanges �

Political

Support

Key enabler of Massachusetts success; political

opposition could be barrier in many states �

Exchange

Readiness

Not all exchanges will be equally ready for open

enrollment on October 1, 2013 �

Public Exchange Uptake Among the Uninsured Likely to Vary Considerably by State

Note: Other key factors include the size of the illegal immigrant population and whether a state decides to expand Medicaid.

Source: 1. Gold J.: Worries Mount About Enrolling Consumers in Federally Run Insurance Exchanges. Kaiser Health News, April 7, 2013. 2. Citigroup Exchange

Conference Call. April 8, 2013.



Drivers That Could Impact Commercial Shift and Employer “Dumping” to Public Exchanges

Driver Influence FactorsShift

Impact

Firm SizeSmaller firms are more likely to chose SHOP exchanges or dump

to HIX ↑

Subsidy/Tax CreditsSubsidy and tax credit availability will stimulate exchange uptake

↑

Delivery CostFavorable insurer network contracts will increase plan

participation and pressure on employers to shift ↑

Wages/Part-Time WorkforceLow-wage geographies will have greater subsidy availability, part-

time employees more apt to shift ↑Exchange Implementation and

Promotion

Good communication, promotion, and receptivity will stimulate

enrollment ↔

TimingInitial uptake could be slow but 2015 /16 could see large

secondary uptake wave once market settles out ↔Exchange Plan Options and

Premiums

Fewer plan options and higher premiums will delay uptake↓

Penalties Low penalties to employers and individuals could delay uptake of

HIX or employer-sponsored insurance ↓



Significant Portion of Individual Market Commercial Lives Expected to Shift to Public Exchanges

16%

43%

42%

Category 1

< 138% FPL

138% FPL to

400% FPL

> 400% FPL

Commercial Individual Market

Income Levels - National

Source: Surveyed 2007 Population as reported in: Kaiser Family Foundation. A Profile of Health Insurance Exchange Enrollees. March 2011.

Portion may shift to exchanges; sensitive

to price shock given absence of subsidies

Lion’s share expected to move to

exchanges to access subsidies

Portion may shift to exchanges in

states not expanding Medicaid



81%

39%

-14%-20%

0%

20%

40%

60%

80%

100%

CO

32%National Average

OH

NY

Projected Individual Market Claims Cost Increases by 2017

Society of Actuaries, by State

Warnings of “Premium Shock” Are Growing More Prevalent

Note: Figure reflects gross Increases before subsidy offsets.

Source: Society of Actuaries . Cost of the Future Newly Insured under the Affordable Care Act. March 2013. www.soa.org/NewlyInsured.



Insurer Individual Small Group

As much as

116%+

As much as

25% to 50%

As much as

40% - 50%NA

Average:

55%

Average:

29%

Source: Mathews A and Radnofsky L. Health Insurers Warn on Premiums. The Wall Street Journal, March 22 2013.

Insurers Are Warning Brokers to Brace For Significant Rate Increases in the Individual and Small Group Markets

Insurer Rate Increase Guidance in Recent Broker Meetings



Uninsured

Rate-Shock

Impact

Public Exchange

Commercial Group

Public Exchange

CommercialIndividual

Public Exchange

Pre-

Reform

Post-

Reform

Lower

Uptake

Higher

Shift

Lower

Shift

Premium Shock Will Reduce Exchange Uptake by Uninsured and Have a Mixed Effect on Rotation to Exchanges from Commercial



More Exchange Enrollment Is Projected to Originate From Commercial Lives than the Uninsured in 2014

Currently

Uninsured

Commercial

(Group)

Commercial

(Non-Group)Note: Figures do not total 100% due to rounding. 5K enrollees from Medicaid excluded for

simplicity. High risk pool classified as individual. ESI shift includes SHOP (189K) and individual

exchange (72K) lives.

Source: Society of Actuaries . Cost of the Future Newly Insured under the Affordable Care Act. March

2013. www.soa.org/NewlyInsured.

2014 Exchange Lives:

616K

228K

(37%)

262K

(42%)

127K

(20%)

Projected 2014 Colorado Public Exchange Enrollment by Source

Society of Actuaries



Public Exchanges: Provider Contracting Terms



Hospital in

South Carolina

System in

Ohio

System in

Texas

Hospital in

Kentucky

System in

Florida

Medicare Medicare (+) Commercial (-) CommercialMedicaid

• Reimbursement rates will be driven by a variety of factors including provider competition, payer competition, and current contract rates

• Payers are carefully evaluating and selecting a limited number of markets for exchange participation (i.e., UnitedHealthcare selecting between 10-25, BC/BS: 15-25)

• Initial contracts will mirror current commercial contracts but may shift to value-based reimbursement over time

A Broad Range of Public Exchange Contract Rates Is Emerging

Note: Rate examples listed are not meant to be representative of a given state’s exchange contract rates across all providers/ markets.

Source: Mathews A and Kamp J, Another Big Step in Reshaping Healthcare, The Wall Street Journal, 28 Feb. 2013 and UnitedHealth Weighs In on New

Exchange Option, The Wall Street Journal, 17 Jan, 2013



• A variety of network configurations will be seen across markets

• Tiered and narrow networks are beginning to form in many markets

• FFS reimbursement likely for early network configurations

• Value-based reimbursement likely to follow based on reduced pricing/ cost pressure

• Providers will need to demonstrate the ability to provide high-quality, cost-effective care under a variety of contract designs

Public Exchange Network Design



"We believe the exchange

is going to be driven by

price, and therefore we're

looking for a lower-price

option.” - Chief Executive

Patrick J. Geraghty

"The need for a smaller network with lower

pricing was critical,“ indicating they hope to offer

a PPO plan built around a provider network

around 40%-45% of its traditional PPO scope

- Juan Davila, EVP

Source: Mathews A.W. and Kamp J. Another Big Step In Reshaping Health Care. The Wall Street Journal, Feb 28, 2013.

Public Commentary from Key Players Suggests… Has recently signed three

BC/BS narrow or "tiered"

network exchange contracts at

less than 10% discount from

existing commercial rates

“Premiums are the most

important factor in consumers'

choices, with more than half

typically opting for a narrow-

network product if it cost them

at least 10% less than an

equivalent with broader choice”

Aiming to pay providers

somewhere between

Medicaid and Medicare

rates, and sees talks

trending toward rates

close to Medicare



Private Exchanges



Private Exchanges – What Are They?As the commercial insurance market continues to move from defined benefit to

defined contribution, employers will seek new benefit models to maximize or cap the value of their healthcare benefit subsidies

Private Exchange Sponsors

Defined ContributionDefined Benefit

Private exchanges will support this market shift by offering a broader choice of plan and coverage options sponsored by a variety of organizations



Private Exchanges – Why Are They Attractive?• Targeted to large employers for active employees and retirees

• Large employers have used retiree private exchanges for 5+ years

• Allow for better benefits cost management and administrative expense reduction

• Employers can continue employee subsidies via defined contribution

• Used to improve coverage choice and potentially offer lower-cost options

• Can be based on “single-carrier” or “multi-carrier” models

• May not be available in all states and areas

• Offer greater flexibility and broader scope of services than public exchanges

• 100+ private exchanges already operating across the country



1) Percentage of employers who are “extremely” or “very” confident.Source: 1. Employers Held Health Benefit Cost Growth to 4.1% in 2012, the Smallest Increase in 15 Years. Mercer, Nov 14, 2012. www.mercer.com/press-releases/1491670. 2. Nixon A. Western Pa. Employers Explore Private Insurance Marketplaces to Lower Costs. TribLive, March 15, 2013. www.tribline.com. 3. Morrison I. The Impact of Private and Public Health Insurance Exchanges. Hospitals and Health Networks, Jan 8, 2013. www.hhnmag.com.

Surveys Suggest Growing Interest Among Employers in Private Exchanges

18%

56%

2011 2012

Percentage of Employers Who Would

Consider Private Exchange for Active or

Retired Employees

Mercer

23%28%

Public

Exchange

Private

Exchange

Percentage of Employers Who Are

Confident1 Exchanges Would Provide a

Viable Alternative in the Next Few Years

Harris Interactive, 2012



Drivers That Could Impact Commercial Shift to Private Exchanges

Driver Influence FactorsShift

Impact

“Me Too” Effect Initial wave of employers moving to private exchanges

will result in larger secondary wave in subsequent years ↑Rising Administrative Costs Employers continue to look for ways to lower admin.

expenses of employee benefits ↑Delivery Cost Favorable insurer network contracts will increase plan

participation and pressure on employers to shift ↑Exchange Plan Options and

Premiums

Plan designs and premiums must be as good or better

than current group coverage ↔Paternalism Large employers can be paternalistic and are resistant

to significant changes in employee benefit design ↓Union and Public Sector Collectively bargained cohorts and public sector

employers typically are slower to change ↓



Source: 1. Based on interview with Liazon Corporation (a defined contribution benefit company) documented in Singhal S, Stueland J, and

Ungerman D, How US Health Care Reform Will Affect Employee Benefits. McKinsey & Company, June 2011.

Chose Less

Expensive Plan

Primary Options for Private Exchange

Employees Seeking to “Trade Down”

�

High

Deductible

Narrow/ Tiered

Network

Impact on Plan Choice of Shift From

Defined Benefit to Defined Contribution

Liazon Corporation1

Attacking Moral Hazard: Private Exchanges Are Likely to Lead Some Employees to Trade Down to Less Expensive Options

70%



Source: 1. Enrollment Results Show Aon Hewitt’s Corporate Exchange Empowers Employees to Become More Astute Health Care Consumers. Aon Hewitt,

March 18, 2013. www.aon.com. 2. Mathews A.W. Big Firms Overhaul Health Coverage. The Wall Street Journal, Sept 26, 2012. online.wsj.com.

Sears and Darden Private Exchange

• Sears and Darden chose a defined benefit/ private exchange healthcare benefit model

for 2013

• More than 100,000 Sears and Darden employees were given a company credit to

purchase benefits via an exchange sponsored by Aon Hewitt

• Aon Hewitt decision support tools and benefits advisors facilitated employee plan

decisions

Sears and Darden Among the First Major Employers to Pioneer the Private Exchange Concept for Active Employees



Sears and Darden found that choice of plans changed when employees were presented with expanded plan options and control over employer subsidy

Source: Mathews A.W. To Save, Workers Take on Health-Cost Risk. The Wall Street Journal, Mar 17 2013. online.wsj.com.

70%

47%

18%

14%

12%

39%

2012 2013

Consumer-Directed

Health Plan

HMO

PPO

Distribution of Sears and Darden Employee Health Benefits

by Type of Plan

Many Participants Shifted to Consumer-Directed Plans in the First Year of the Sears and Darden Private Exchange



Private Exchanges Likely to Be a Catalyst for the Shift to Narrow Networks Over the Longer TermProviders and health systems may have limited or no access to existing and new managed care populations under private exchange plans

��

��

��

��

Current State

Open Access

Provider Network

Employee Populations

Enrolled in Traditional

Group Plan

Seek Care Across Broad

Network

Employer groups have traditionally chosen open

access PPO plans with large provider networks

where patients are free to choose any network

provider

Future State

Private exchanges will offer a variety of new plans

which may have narrow or limited networks and

require PCP referrals

�

�

�

�

�

�

�

�

�

�

�

�

Exchange Product

Provider Networks

Employee

Populations

Enrolled in Private

Exchange Plans

Seek Care Across

Limited or Narrow

Networks



Private Exchanges Will Break Apart Employee Populations, Leading to New Contracting and Strategic Considerations

Employee populations

will break apart

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

��

Lives will be broken up across multiple carriers and networks, resulting in

increased fragmentation of the market, risk of share and revenue loss



Public and Private Exchange Summary Outlook



13%

7%

16%

36%

65%

27%

20%

3%

5%

30%

25%

5%

8%

25%

10%

65%

62%

53%

29%

17%

Projected Shift of Commercial Lives to Public and Private Exchanges 2018 Illustrative National Midpoint Scenario

Estimated Commercial Lives

Distribution by Segment

ESI - Public

ESI - Private

>100

ESI - Private

50-99

ESI - Private

<50

Individual

17%

53%

8%

9%

2018 % Shift to Public and

Private Exchanges - by Segment

2018 % Shift to Public and

Private Exchanges - Total

13%

Note: See appendix for sources and methodology/limitations.

2%

1%



29%

11%

26%

66%

7%

3%

7%

17%

13%

7%

16%

36%

2018 % Shift to Public

and Private Exchanges

Low Scenario



Midpoint Scenario



High Scenario

Note: See appendix for sources and methodology/limitations.

Projected Shift of Commercial Lives to Public and Private Exchanges 2018 Illustrative National Scenario Summary



Strategic and Financial Implications



Already Second-Guessing? Timing of Public Exchange Participation Can Cause Uncertainty

• Large Texas health system with exclusivity, strong market position, and favorable contract rates (180% of Medicare)

• Offered rates between Medicaid and Medicare for public exchange product participation

• Opted not to participate for 2014

• Other providers in the market accepted contract and rates

Texas Health System Case Study

“Initially we thought this was a no-brainer, but now we’re wondering if

we made the right choice not to participate and what impact it may have

on our existing revenue and growth”

Texas Health System CFO



Exchanges Will Accelerate Transition to Emerging Payment Models and Create New Strategic/Financial Challenges

Today’s Model Emerging Models

Open Access PPO High Deductible Narrow/ Tiered

Public ExchangesDeployed in some

markets

Catastrophic plans

for enrollees <30

Common payer strategy absent

regulatory/market restrictions

Private ExchangesExpected to decline

over time

Likely near-term

model of choice

Expected to increase over time as

narrow/tiered networks mature

Implications

Risk of Share Loss Limited threatRisk of OP share loss to lower cost/

freestanding competition

Risk of IP/OP loss

if not in-network

Price Pressure Limited threatSignificant for OP services with

cheaper freestanding competition

Threat of steerage increases payer

leverage for IP/OP prices

Bad Debt Limited threat ChallengeLow actuarial value exchange

plans may create challenges



Transparency Tools Are a Key Catalyst for High Deductible Impact

• Growth in high deductible health plans has prompted payers and employers to develop price transparency tools revealing cost and quality data to members

• Informed patients are likely to choose the “low-cost/high-quality” providers when faced with increased cost sharing

• Providers in competitive markets are at risk of revenue and market share erosion as payers and patients become aware of reimbursement variance

• Improving cost structure and competing on value is the only viable long-term option

Select Companies Offering Transparency Tools



Exchange Participation Timing Implications

• Current market position should drive participation timing

• First and second mover options present unique costs and benefits

2014 2015 2016 2017

Enter

Exchange

Market

Enter

Exchange

Market

Health System A

Non dominant

market position and

low rates

“Second Mover” Advantage

• Rate/ revenue preservation

• Market settling

• Access more favorable contracts

Enter

Exchange

Market

Enter

Exchange

Market

“First Mover” Advantage

• Increase market share via initial wave

• Narrow network priority access

• Revenue growth

Health System B

Strong market

position and high

rates



• Current market position should drive participation timing

• First and second mover options present unique costs and benefits

2014 2015 2016 2017

Enter

Exchange

Market

Enter

Exchange

Market

Health System A

Non dominant

market position and

low rates

“Second Mover” Dis-Advantage

• Carved out of narrow networks

• Revenue and share loss

• Less favorable contract options

Enter

Exchange

Market

Enter

Exchange

Market

“First Mover” Dis-Advantage

• May lock-in unsustainable low rates

• Increased bad-debt exposure

• Slow exchange uptake could delay benefits

Health System B

Strong market

position and high

rates

Exchange Participation Timing Implications (continued)



What is the optimal way to balance these threats and opportunities?

Balancing New Revenue Opportunities and Cannibalizing the Existing Commercial Business

Uninsured

�

Exchange

Commercial

�

Exchange

New Rev. Lost Rev.



Multiple Interdependencies Warrant Careful Consideration

New Exchange Revenue from

Uninsured

Commercial Rotation to Exchange

Uptake Rates

Market Share

Contract Rates

Degree of Shift

Market Share

Contract Rates

Financial

Impact



Strategic Dynamics Will Vary by Market

Driver Commentary

Commercial Price

Levels

Higher prices relative to Medicare create more “room” for

undercutting and amplify the potential for material financial impacts

Capacity Utilization

Narrow/tiered networks less impactful if capacity constraints

preclude meaningful steerage; some spare capacity needed for

tiered/narrow networks to be effective

Market Willingness to Give

Up Choice

The price discount required to give up choice will vary by market,

leading to different tradeoffs between price and volume

Urban vs. Rural

Competition is required for narrow/tiered contracts to be

practical/effective; rural markets with sole community providers will

be less dynamic



Impact Area Commentary Imperative

Rates

Accepting lower rates for exchange

products could negatively impact existing

commercial rates (“spillover effect”) via

employer and payer pressure

Careful evaluation of current

commercial book to determine

financial risks/opportunities of

accepting new rates

Contract Terms

Terms and conditions of exchange

contracts could impact existing commercial

products

Use caution developing contract

strategies and conducting

negotiations. Ensure reasonable

termination periods

Reimbursement

Methodologies

Initial methodologies will most likely not

differ from current commercial contracts

but future models will be value-based

Must possess or develop key skills

and competencies for increased risk

and value-based contract success

Price

Transparency

Transparency will drive consumer selection

towards low-cost/high-quality providers

Cost reduction and management

are critical for long-term

sustainability

Market ShareShort-term growth may result in long-term

loss based on changing market conditions

Population segmentation analysis

necessary to understand full market

opportunity

Implications of Exchange Participation on Current Contracts and Contracted Rates



• No risk

FFSIncentive

-Based FFS

P4PCase Rates

Partial Risk

Full Risk

Health Plan

• VBP• Bonuses• Withholds

• Episodic• Bundled

payments

• Limited scope

• Gain-share• MSSP

• PMPM• Percent of

premium

• Full integration• Health plan and

delivery system

• Quality and cost payments

• PQRS

• Continued reductions in FFS rates are not sustainable

• Health systems will need to compete on value to maintain and grow market share

• Markets will likely offer a variety of choices based on payers, providers, costs, and sophistication

Upon determination of the appropriate value-based model, specific skills and capabilities must be in place to produce optimal results

Notes: FFS = fee for service; P4P = pay for performance; PMPM = per member, per month; PQRS = Physician Quality and Reporting System.

The Long View: Value-Based Reimbursement Must Be Considered



How Do You Prepare for Healthcare Exchanges?Kaufman Hall believes that operational and financial success with healthcare exchanges requires an integrated planning framework

• Strategic Planning: A Healthcare Exchange Strategy will be necessary to compete in the changing market environment. New reimbursement and contract models, in addition to FFS, will be used for exchange-based products, most likely requiring providers to assess and acquire new strategies and tactics

• Financial Planning: Many health systems and providers are in the early stages or have not yet begun to plan for how healthcare exchanges will impact their current and future patient populations and revenue base. A thorough analysis and plan to quantify the implications and potential financial impact should be completed

• Tactical Planning: New skills and capabilities will certainly be required for financial and operational success when working with healthcare exchanges. Developing the right tactical plan, resources, and investments while taking into consideration specific opportunities, priorities, risks, and benefits will be necessary



Questions and Discussion



Appendix



• Distribution of lives by segment were estimated using national data on employees by segment (Census, BLS), insurance uptake by segment (Kaiser/HRET survey), and individual market size estimates (Urban Institute)

• Key limitations to distribution estimates

• Linear interpolation applied to the 20-99 segment to estimate <50 and 50-99 segments

• Public firms assumed to have the same coverage rates as large national private firms

• High scenario definition reflects adapted 2011 McKinsey survey results1

• ESI shift to public exchange of 37% (<50 EE), 31% (50-499 EE), and 22% (500+ EE)

• ESI shift to SHOP of 45% (<50 EE) and 44% (50-99 EE)

Projected Shift of Commercial Lives to Public and Private Exchanges 2018 Illustrative National Scenarios – Methodology Notes

1) McKinsey survey results represent portion of employers who would “definitely or probably” shift assuming exchanges become an “easy and affordable” way to obtain coverage.

Source: 1. Historical Data Tabulations by Enterprise Size 2009. U.S. Census. www.census.gov/econ/susb. 2. Employment, Hours, and Earnings. Bureau of Labor Statistics. www.bls.gov/data. 3.

Employer Health Benefits Survey. Kaiser Family Foundation and Health Research & Educational Trust, 2012. 4. Blavin F., Buettgens M, and Roth J. State Progress Toward Health Reform

Implementation: Slower Moving States Have Much to Gain. The Urban Institute, Jan 2012. 5. Singhal S, Stueland J, and Ungerman D, How US Health Care Reform Will Affect Employee Benefits.

McKinsey & Company, June 2011.



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Documents

Public and Private Health Insurance Exchanges: Strategic ... · 26/04/2013 · • Individual exchanges will target uninsured and self-insured individuals • SHOP exchanges will