Allowing Health Insurance Products Governed by Different Rules and
Standards Would Further De-Stabilize the Individual Market and
Increase Costs for Those With Pre-Existing Conditions
Policies that increase uncertainty or threaten instability should be avoided
Background: Reports have surfaced that potential changes to the proposed Better
Care Reconciliation Act (BCRA) in the Senate are being considered that could permit
health insurers to sell non-compliant plans if the health insurer offered at least one plan
in a state’s federally-regulated Exchange Marketplaces (“Exchange”). Under this
proposal, the non-compliant policies would be exempt from consumer protections, such
as guaranteed access to coverage, community rating (e.g. no, premium surcharges
based on health-status), the ban on pre-existing condition exclusions, and the
requirement to offer comprehensive benefits with appropriate limits on patient costsharing.
Stable and well-functioning insurance markets require broad-based enrollment and a
stable regulatory environment that facilitates fair competition and a level playing
field. Unfortunately, this proposal would fracture and segment insurance markets into
separate risk pools and create an un-level playing field that would lead to widespread
adverse selection and unstable health insurance markets. This is particularly true for
patients with pre-existing conditions—who would be most affected and potentially lose
access to comprehensive coverage and/or have plans that were far more expensive, as
premiums in the Exchange market would rise much faster than under existing market
conditions and insurance options dwindle.
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Opening up non-compliant plans to new purchasers would create greater
instability in the marketplace, according to non-partisan experts such as
the American Academy of Actuaries. A key contributing factor to the current
risk pool instability in certain states was the transitional policy, which allowed
individuals to renew non-compliant plans. That is because it segments the
market—allowing healthier individuals to remain in their existing medicallyunderwritten plans while depriving the new Exchange markets of younger and/or
healthier individuals necessary for risk pool stability. Actuaries estimated that
states adopting the transitional policy experienced 10% higher rates for the
Exchange market than states that did not elect this policy. Proposals to reopen non-compliant plans would create even greater instability by driving
adverse selection and an acceleration of the downward spiral in the
Exchange markets of higher premiums and lower enrollment.

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The requirement that insurers also participate in the Exchange market
would not preserve protections for those with higher-than-average health
care costs. Such protections—such as guaranteed issue, community rating,
and banning pre-existing conditions—only work if there is broad participation to
assure stable markets and affordable premiums. By bifurcating risk pools and

 creating separate parallel market—where healthy individuals can select
underwritten plans at a preferred rate—this proposal would cause lower
enrollment in Exchange markets of the younger and heathier individuals
necessary for a stable insurance market. As a result, the Exchange markets
would basically function like a high-risk pool—with unaffordable premiums for
those with pre-existing conditions. As premiums rose, only those with the highest
health needs and expenses would remain thereby accelerating the decline in the
Exchange market.
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Including both “compliant” and “non-compliant” plans in a single risk pool
would be infeasible and not solve the problems of an unlevel playing field.
For a single risk pool to work, all health plans must provide coverage for the
same benefit categories – for example, under a common federal benefit “floor.”
However, if “skinnier” non-compliant plans could exclude coverage of certain
benefit categories (e.g., prescription drugs or maternity) while compliant plans
must cover all benefit categories, it would be very challenging to combine those
products into a single risk pool. Moreover, important premium stabilization
programs such as risk adjustment that compensate plans enrolling higher risk
individuals and protect against adverse selection would become unworkable and
unsustainable because of likely differences in the benefit categories, health
status and costs of enrollees in compliant versus non-compliant plans.

Conclusion: The individual market faces well-documented challenges to stability,
including higher premiums, lower-than-expected enrollment, fewer plan choices, and risk
pool problems in certain states and markets. Policy solutions exist to create more
stability in the market by reducing premiums and attracting enrollment of younger and
healthier individuals. In this context, it is important that policymakers avoid policies that
threaten to further increase uncertainty or threaten stability. Such policies include
opening up non-compliant plans to new enrollees, bifurcating the risk pool, or allowing
plans covered by different rules to compete in the same market.