By Todd Ruger, CQ Roll Call

June 25, 2015 -- The Supreme Court saved Obamacare from another critical legal challenge in a 6–3 decision that upholds health insurance subsidies for millions of low- and middle-income residents. President Barack Obama hailed the ruling.

Chief Justice John G. Roberts Jr., who wrote the ruling for King v. Burwell., joined the court's liberals in saving a signature piece of legislation for the president. Roberts was in the majority in 2012, when the court ruled that the law was constitutional. The decision focused on a narrower issue of the meaning of the statute.

The ruling upheld an IRS rule that allowed the federal government to help pay for individual health insurance in the 34 states that didn't set up their own health care marketplaces, or exchanges. The states instead rely on a federally run exchange.

"Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them," Roberts wrote for the majority. The court's role is to say what the law says, which is not always easy, he said.

"But in every case we must respect the role of the legislature, and take care not to undo what it has done," Roberts wrote. "A fair reading of the legislation demands a fair understanding of the legislative plan."

Obama said the law was "here to stay. The court upheld a critical part of this law: the part that made it easier for Americans to afford health insurance." The president said tens of millions of Americans are benefiting from the law. "This law is working and it is going to keep doing just that. This is healthcare in America."

House Speaker John A. Boehner, R-Ohio, and Senate Majority Leader Mitch McConnell, R-Ky., said Republicans would continue to try to repeal the law. Republicans have sought to repeal the legislation since they won control of the House in the 2010 elections.

"We will continue our efforts to repeal the law and replace it with patient-centered solutions that meet the needs of seniors, small business owners, and middle-class families," Boehner said. "ObamaCare is fundamentally broken, increasing health care costs for millions of Americans. Today's ruling doesn't change that fact. Republicans will continue to listen to American families and work to protect them from the consequences of ObamaCare."

McConnell said the "politicians who forced Obamacare on the American people now have a choice. They can crow about Obamacare's latest wobble towards the edge, or work with us to address the ongoing negative impact of a 2,000 page law that continues to make life literally miserable, miserable, for so many of the same people it purported to help."

But Republicans, who now control both chambers of Congress, are unlikely to have the votes for repeal. Senate Democrats would use procedural measures to block them and Obama would be expected to veto such a measure. In the days leading up to the high court's ruling, Republicans were searching for a replacement in the event the court decided against the law.

Hillary Clinton, a candidate for the Democratic nomination for president and a contender to succeed Obama in 2017, said the court affirmed what the law intended: "that health insurance should be affordable and available in every state."

She said Republicans should drop their criticism. "It's time for the Republican attacks to end." Clinton said the legislation "isn't perfect, but the evidence is clear: it's working."

The ruling avoids a debate in Congress and the White House over how to change the health care overhaul law had the Supreme Court decided a key provision did not allow the aide to 6.4 million people in the states which enrolled in individual health plans through the federal exchange.

Joining Roberts in the majority were associate justices Anthony M. Kennedy, Ruth Bader Ginsburg, Stephen G. Breyer, Sonia Sotomayor, and Elena Kagan.

The majority of justices rejected the argument of a cadre of libertarian lawyers who orchestrated and funded a legal challenge that was surgically precise, focused only on a six-word phrase buried in an important part of the 906-page law.

The Supreme Court decided the phrase—authorizing subsidies for "an exchange established by the state"—makes it possible for the federal government to help pay for individual health insurance in the states that didn't set up their own health care exchanges.

Justice Antonin Scalia wrote the dissent, which was joined by justices Clarence Thomas and Samuel A. Alito Jr.

"The terms of the law say quite plainly that tax credits are available only on an exchange established by the state," Scalia said in court announcing his dissent. "If Congress intended a different result, it should amend the law to conform to its intent. Until it does, we have no authority to ignore the law because we believe Congress must have intended something else."

"We really should start calling the law SCOTUSCare," Scalia said.

The case hinged on the justices's interpretation of what Congress meant with the law.

The law calls for a one-stop shopping spot for health insurance, called an exchange, to be set up by states. In states that decline to participate, the law says the federal government must establish and operate an exchange.

Section 36(B) authorizes subsidies for low- and middle-income residents enrolled in "an exchange established by the state." The challengers argued that the phrase would exclude residents who signed up on federal exchanges in states that did not set up exchanges and that the IRS interpretation was wrong.

The court used a two-step framework to analyze the IRS interpretation of Section 36B First, the court determined whether the statute is ambiguous. If the language is unambiguous, the court would enforce it as written. But the justices would have to determine whether the agency's interpretation of ambiguous language is reasonable.

The majority found "an exchange established by the state" to be ambiguous, particularly in the context of other provisions in the law.

"The phrase may be limited in its reach to state exchanges," Roberts wrote. "But it is also possible that the phrase refers to all exchanges—both state and federal—at least for the purposes of the tax credits."

The majority found the law as a whole was unambiguous, however, and rejected arguments from the challengers about the way the act works. In the challengers' view, Roberts wrote, "Congress made the viability of the entire Affordable Care Act turn on the ultimate ancillary provision: a sub-sub-sub section of the tax code. We doubt that is what Congress meant to do."

"Had Congress meant to limit tax credits to state exchanges, it likely would have done so in the definition of 'applicable taxpayer' or in some other prominent manner," Roberts wrote. "It would not have used such a winding path of connect-the-dots provisions about the amount of the credit."

The subsidies are necessary for federal exchanges to function like state exchanges, "and to avoid the type of calamitous result that Congress plainly meant to avoid," he wrote.
Scalia, in a scathing dissent that argues the phrase was unambiguous, said the majority decided that "exchange established by the state" means "exchange established by the state or federal government."

"That is of course quite absurd, and the court's 21-pages of explanation makes it no less so," Scalia wrote. "Words no longer have meaning if an exchange that is not established by a state is 'established by the state.'"

Scalia wrote that Congress knew how to equate two different types of exchanges when it wanted to do so, as it did in other parts of the law. He said the majority did "interpretive jiggery-pokery" with a particular end in mind.

Under all the usual rules of interpretation, in short, the government should lose this case," Scalia said. "But normal rules of interpretation seem always to yield to the overriding principle of the present court: The Affordable Care Act must be saved."

By Marissa Evans, CQ Roll Call

June 25, 2015 -- The Supreme Court's decision to uphold a key provision of 2010 health care law spared legislators in 34 states from what many of them might have seen as a Hobson's choice: Create a health insurance marketplace under the provisions of the law that some vociferously opposed, or leave an estimated 6.4 million low- and moderate-income constituents without access to affordable coverage.

The King v. Burwell case challenged whether under the law subsidies could be given to residents of states that didn't set up marketplaces for residents to buy private health insurance. About 87 percent of enrollees on the federal exchange—the vehicle for buying health insurance in states without marketplaces—received an average of $272 in tax credits nationwide. 

Last week's ruling preserved the status quo, whether lawmakers liked it or not.

Consider Texas Republican Gov. Greg Abbott's response to the ruling: 

"The Supreme Court abandoned the Constitution to resuscitate a failing health care law. Today's action underscores why it is now more important than ever to ensure we elect a President who will repeal Obamacare and enact real healthcare reforms."

With such sentiments lingering in many states, it appears unlikely that President Barack Obama's signature legislative achievement will be embraced nationwide in the near term. 

"You won't see more movement toward a state-based market because there won't be pressure to do so," said Heather Howard, director of Princeton University's State Health Reform Assistance Network.

Texas and Florida, which have two of the largest uninsured populations in the country, are examples. 

About 1.3 million Florida residents were receiving an average of $294 to help them buy coverage through the federal marketplace during the last open enrollment period. During the 2015 regular and special legislative sessions in Tallahassee, the closest state lawmakers came to authorizing a marketplace was a private one for low-income residents under Medicaid expansion. That bill failed. 

Republican Wisconsin Gov. Scott Walker, who is also a likely presidential candidate, has more than 166,000 residents keeping their subsidies, which averaged $315. Walker has said in prior speeches and interviews that he won't allow Wisconsin to have a state marketplace. 

Republican State Sen. Leah Vukmir, chairwoman of the Wisconsin Senate's Committee on Health and Human Services (HHS), said she and her colleagues "prefer states to be the laboratories of reform" when it comes to health care issues. She said while the decision allows consumers to keep their subsidies it's still not helping them afford the rising cost of insurance plans.

"It hasn't solved the problem it was supposed to," Vukmir said in an interview. "There was hope it would give states the ability to go back to the drawing board and basically continue to do things we had done in the past and now unfortunately unless there's a change with the next presidential election, those next reforms are much harder to do." 

Vukmir said there's no will in the Wisconsin legislature to create a state marketplace and that she will instead push for a bill to create more transparency about health care costs. 

Before the court case, 16 states and the District of Columbia had set up their own marketplaces for residents to buy health insurance.

Some of the other states were moving toward establishing marketplaces as a precaution in case the court struck down the subsidies in non-marketplace states. Marketplace plans submitted by Arkansas, Delaware, and Pennsylvania were conditionally approved by the Centers for Medicare and Medicaid Services on June 15. 

But Democratic Pennsylvania Gov. Tom Wolf said yesterday that his state's plan would be dropped.

"I took steps to protect Pennsylvania's consumers by putting in place a contingency in the event the Supreme Court ruled people are not eligible for subsidies, but I am pleased to say that we will no longer need to rely on this plan," Wolf said in a news release. "My administration will be notifying the federal government that we will be withdrawing our plan to set up a state-based health insurance marketplace in Pennsylvania."

The state was on track to follow Nevada, New Mexico and Oregon by using federal technology to operate the backend of the exchange. Other states could still pursue that option—though they'll have to pay a fee for the support starting in 2017. States already using that arrangement are in talks with the Centers for Medicare and Medicaid Services over the fees. 

Arkansas won't back away from pursuing a state exchange just yet. Republican Gov. Asa Hutchinson's Legislative Taskforce on Healthcare Reform will be giving recommendations by the end of the year on whether the state should move forward with an exchange. The conditional waiver gives them time.

"I am convinced now more than ever that we need to proceed with caution to measure the costs to the taxpayers and the reliability of the outcome as we consider the potential of a state exchange," Hutchinson said in a news release. 

Trish Riley, executive director for the National Academy of State Health Policy, said that now the decision has come out it "gives states more certainty and more options" for how they move forward and think about coverage affordability and innovation. 

"A close eye will be kept on different state exchanges and how they grow and expand their reach," Riley said.

She also said it wouldn't be surprising to see states looking more closely at applying for state innovation waivers. Those waivers would allow states to finance entirely new approaches to providing affordable health care by using federal dollars that otherwise would have gone to pay for insurance premium subsidies in the state. 

"It's a heavy lift for states and it's not available until 2017 but it provides an opportunity for states to think of additional ways to reform health insurance," Riley said.

By Melissa Attias, CQ Roll Call

June 25, 2015 -- The Supreme Court ruling that the health law's subsidies should be available in all 50 states regardless of whether they set up their own insurance exchanges deprives Republicans of a prime opportunity to take swipes at the overhaul ahead of the 2016 presidential election. But it also saves them from the precarious political situation that they would have faced if the justices sided with the plaintiffs in King v. Burwell, prompting an estimated 6.4 million people in 34 states to lose their financial help.

While Republican leaders in both chambers have spent the past few months discussing contingency plans, it was unclear whether a caucus so anxious to scrap President Barack Obama's signature health care law (PL 111-148, PL 111-152) would have been able to rally around any solution that could be seen as prolonging it. The high court's recent decision allows GOP lawmakers to keep their focus on repeal without having to juggle the blame game that would have taken hold if the subsidies lapsed.

"The politicians who forced Obamacare on the American people now have a choice: crow about Obamacare's latest wobble towards the edge, or work with us to address the ongoing negative impact of a 2,000-page law that continues to make life miserable for too many of the same people it purported to help," Senate Majority Leader Mitch McConnell of Kentucky said in remarks for the floor.

Democrats, meanwhile, celebrated the decision as yet another validation of the overhaul after the high court in June 2012 upheld the requirement that most individuals maintain health coverage or pay a penalty. The ruling makes it unlikely that significant changes will be made to the overhaul before the 2016 elections, preserving the status quo for the remainder of the Obama White House.

"Today, for the second time, the Supreme Court has upheld the Affordable Care Act," House Minority Leader Nancy Pelosi of California said in a statement. "This is a victory for common sense and for all American families. It is long past time for Republicans to abandon their assault on the newfound health security that the Affordable Care Act is providing millions and millions of Americans across the country."

The Democratic Senatorial Campaign Committee quickly sent out a fundraising email cheering the decision. 

The decision will also come as a relief to hospitals and the insurance industry, which submitted friend-of-the-court briefs in support of the Obama administration's position. If the subsidies lapsed, the concern was healthier people would have stopped paying for coverage, skewing the risk pool toward the old and sick and raising premiums. Hospitals stocks, and shares of all health companies, surged after the ruling, reflecting investor relief that providers won't be at risk of taking a financial hit with the loss of newly-insured patients.

In addition, the ruling preserves the pillars of the law that the supporters of the lawsuit said would have given way in federal exchange states. The challengers said that the absence of subsidies would have exempted many people from the mandate that they purchase coverage or face penalties because buying insurance would have been a financial hardship. And they maintained that businesses would have no longer had to comply with the mandate that they provide coverage of pay penalties because that requirement is linked to the availability of subsidies.

House Ways and Means Health Care Subcommittee Chairman Kevin Brady, R-Tex., said the ruling would speed up, rather than slow down GOP attempts to use budget reconciliation rules to repeal the law.

"It is accelerated now because of the ruling. I think we will move sooner rather than later. It's now clear reconciliation won't be used to free individuals and states from the law. It will be used to put full repeal on the president's desk," Brady said.

At a press conference following the decision, Speaker John A. Boehner, R-Ohio, said Republicans haven't made a decision on how to use the reconciliation process. He also wouldn't commit to having a House vote this year on a GOP alternative to the health law, noting that while the issue has been discussed, most of the focus was on what to do if the Obama administration lost in King v. Burwell.

If the court has sided with the plaintiffs, Boehner said House Republicans were prepared to move forward with a proposal and praised bicameral work on finding a unified response. "Now it's not necessary," he said.

By Rebecca Adams, CQ Staff

June 22, 2015 -- The mood at a White House Rose Garden reception with President Barack Obama on April 22 was jovial. Advocates celebrated the signing a week earlier of a Medicare law that included two years of continued federal funding for the Children's Health Insurance Program (CHIP) along with a little-discussed but dramatic boost in aid to states.

Starting in October, states will get a 23-percentage-point increase in the share of the coverage costs that the federal government will pick up. As a result, no state in the country will have to pay more than 12 percent of CHIP costs for the next two years. Eleven states and the District of Columbia will no longer have to contribute a cent.

Children's advocates hadn't been sure that fiscally conservative Republicans would allow the increase, which was originally part of Obama's 2010 health care overhaul, to take effect this fall. It was a big victory for the program, which since 1997 has provided medical coverage for low-income families who are not poor enough for Medicaid.

But worries persist. Some of the most ardent supporters of children's health coverage are uneasy about the unintended consequences of letting states off the hook for so much of the program's costs. They fear that state officials will no longer have an incentive to scrutinize spending and will fail to plan for the day when their states have to pick up their contributions after the two-year authorization runs out.

Most of all, the advocates say that the $5.6 billion net increase for CHIP for the next 11 years won't do much to expand coverage for kids. That's largely because states are free to use the money they save as they see fit. In Pennsylvania, for instance, a Democratic governor is using some of the funds to plug the state's budget gap.

"Is the money staying in health care, or something for kids? Where is the money going?" asks Bruce Lesley, a former Democratic congressional staffer who is president of First Focus, an advocacy group for families. "Don't be under the illusion that you're helping kids."

State Decisions

Children's advocates would like states to spend the money that they ordinarily would spend on CHIP on greater efforts to find and enroll children who qualify for health insurance but are not covered, or other programs that help poor children. But the law enacted in April is silent on what states do with the money they would have spent on CHIP.

"It relieves some of the pressure on overall state budgets but we can't track really what states will do with that relieved pressure," says Robin Rudowitz, a former Congressional Budget Office expert and associate director for the nonpartisan Kaiser Commission on Medicaid and the Uninsured.

It's a state and local decision, says Wayne Turnage, director of the District of Columbia Department of Health Care. "They may give tax cuts to taxpayers, or they may use it to relieve budgetary pressures elsewhere."

Governors in 12 states, led by Texas and Florida, proposed net tax cuts in fiscal 2016, according to a June 16 report of data compiled through April by the National Association of State Budget Officers. Governors in another 16 states, led by Pennsylvania, proposed tax increases to fill budget holes.

Pennsylvania Gov. Tom Wolf is taking a broad view of the $63 million the state will save this year from the federal CHIP aid. He "took great care in his budget to address the fact that the commonwealth is facing a significant structural budget deficit and costs continue to increase year-to-year in other human services areas," spokesman Jeffrey Sheridan said in an email.

Matt Salo, executive director of the National Association of Medicaid Directors, believes that many states will consider using the extra money in the state budget for health care needs, such as potentially expanding Medicaid.

In the District of Columbia, where the local contribution to children's health insurance costs is declining this fall from 21 percent of costs to nothing, officials will use much of the money to offset rising costs in Medicaid, Turnage says. "We are certainly not cutting health care costs," says Turnage.

The District expanded Medicaid coverage for adults earlier than most states and has more generous eligibility requirements than many states. "We have a very ambitious program," Turnage says, "and any extra dollars help."

Some states led by Democrats are using at least some of the money for other priorities.

In California, advocacy groups were angry that Gov. Jerry Brown planned to use some of the $381 million the state is saving in its children's coverage costs for other programs not connected to health care for children.

"The diversion of the CHIP dollars to backfill the general fund is unacceptable," wrote Anda Kuo, associate clinical professor at the University of California-San Francisco, and Kelly Hardy, senior managing director of health policy for Children Now, in a May 30 op-ed. "It's like stealing from a child's piggy bank."

Brown countered that he wants to devote part of the funds to additional Medicaid coverage for low-income adults and children. He also proposed an earned income tax credit to benefit lower-income families.

"If you look at the overall budget, some programs receiving increased funding will have a benefit to kids' health," says California Department of Finance Deputy Director for External Affairs H.D. Palmer.

Advocates were less upset after a budget deal added about $40 million in Medicaid funds for undocumented children.

In Alabama, the money is going into the general treasury fund. That means it could be spent on anything that the state funds except for education, which is financed through a separate account, says CHIP Director Cathy Caldwell. The federal government will pay all of Alabama's CHIP costs through fiscal 2017, so that the state no longer has to put in its annual share of about $47 million, Caldwell says.

"There are huge deficits so I have no doubt that legislators trying to pass the budget were thankful there was a little less of a request" from the CHIP program, she says. "I really doubt that money will go to expand coverage. It should provide a little bit of general fund relief."

Questioning Incentives

Alabama is one of the 11 states that will pay nothing for children's health coverage through fiscal 2017, along with Arizona, Arkansas, Georgia, Idaho, Kentucky, Mississippi, New Mexico, South Carolina, Utah and West Virginia. Neither will the District of Columbia.

Seven states will have 98 percent or more of costs paid by the federal government: Indiana, Michigan, Montana, Nevada, North Carolina, Oregon and Tennessee.

That could lead to a lack of accountability and scrutiny or the potential for misuse of funds, some advocates say. If a health insurer asks a state for a large increase in payment rates, will the state have an incentive to say no if the federal government is picking up almost all of the costs?

Similarly, a possible scandal involving CHIP funds could undermine support for the entire program when it comes up for reauthorization in 2017.

"There has never been an argument before that CHIP is not effective or efficient," says Ed Walz, a spokesman for First Focus. "If all of a sudden, we're having a Las Vegas vacation paid for out of CHIP funds, that'll be a very different reauthorization discussion than what we've had so far."

First Focus supported increasing the federal matching rate for CHIP this year somewhat above the normal levels, but preferred that all states keep sharing some costs.

Other children's advocates say that the increases are important. The program is credited with keeping the uninsured rate among children far lower than that of adults during recent difficult economic times.

"I don't see any downside to additional federal investments in a proven coverage program that has only helped kids," says Elisabeth Wright Burak, senior program director for the Georgetown Center for Children and Families. "At a time when we see the federal government passing many costs to states, it's refreshing to see additional federal investments in CHIP, giving states more ability to invest state dollars in other ways that can benefit kids. It may also mean preventing harmful cuts."

Before the law passed, officials in 18 states needed the money so much that they counted on the 23-percentage-point influx in planning for the state budget, according to a January survey by the National Academy for State Health Policy. At the time the survey was conducted, it wasn't clear when Congress would even extend the regular matching rate funds for CHIP, much less add support. Burak notes that since the law's passage, some states, including Nebraska and Ohio, are backing away from some Medicaid cuts that they initially proposed. That could be because they are saving money on CHIP.

After the law passed, a children's health coalition ran ads applauding lawmakers for providing extra money for CHIP. But just as pleased were the nation's governors and state legislators, who will control the state budget savings.

"This legislation provides much-needed certainty for states," the National Governors Association said in a statement when the House passed the bill.

By Kerry Young, CQ Roll Call

June 23, 2016 -- The nation's cancer specialists are stepping into an intensifying debate over the cost of treatment, with the American Society of Clinical Oncology (ASCO) recently announcing a plan to help patients better assess the value of different options.

The framework is meant to help build user-friendly, standardized tools to help doctors in their talks with patients.

"Our goal is to help oncologists and their patients weigh potential treatment options based on high-quality scientific evidence and a thoughtful assessment of each patient's needs and goals," said Julie M. Vose, the president of ASCO and a University of Nebraska doctor, in a statement. "In publishing this initial version of the framework, just the beginning of the process, we hope to drive discussion and debate about a critically important issue."

Newly approved cancer drugs can cost more than an average of $10,000 a month, with some exceeding $30,000 per month, according to ASCO. The expenses are difficult for consumers. Many insurance plans are shifting an increasingly large share of payments for medicine directly to their customers through higher co-pays.
"Even well-insured patients are often unprepared for the high out-of-pocket cost of some cancer therapies. Too often, that leads to severe financial strain and even bankruptcy," said Lowell E. Schnipper, chair of ASCO's Value in Cancer Care Task Force, in a statement.

The trade group for drugmakers, Pharmaceutical Research and Manufacturers of America (PhRMA), said it intends to work with ASCO.

"Judgments about treatment value are highly individualized and vary over time as new research and new treatment options emerge," said Lori Reilly, executive vice president, policy and research at PhRMA, in a statement.

In recent weeks, there have been several high-profile calls for a re-examination of how cancer drugs are priced and sold.

The Medicare Payment Advisory Commission last week told Congress to consider overhauling the Part B outpatient program of the federal health plan for the elderly and disabled, which covers much of the cancer treatment provided in the United States. Medicare now pays a premium of roughly 4 percent on the cost of medicine that doctors purchase to administer to patients in their office, an approach that generates profits when more expensive products are used and when more treatment is given.

A "60 Minutes" news program on June 21 featured interviews with doctors who are leaders in efforts to curb rising cancer drug costs, including Memorial Sloan Kettering Cancer Centers physicians Leonard Saltz and Peter Bach. Saltz last month questioned the rising costs in a widely reported speech at ASCO's annual meeting. Bach is a frequent speaker on this topic and appeared an April briefing for congressional staff.

By Rebecca Adams, CQ Roll Call

June 23, 2015 -- The differences between big health insurers and the industry's trade association, America's Health Insurance Plans (AHIP), spilled into the open last week when the nation's largest insurer announced it was quitting AHIP.

UnitedHealth Group said that it will no longer be a member by June 30.

"UnitedHealth Group believes the interest of our company and the customers we serve are no longer best represented by AHIP and accordingly are ending our membership effective June 30," said the company in a statement. "AHIP has set forth a strategy and direction it feels best serves a membership profile and need that does not fit UnitedHealth Group and our diversified portfolio. AHIP has to respond to its needs and interest of many members, which understandably resulted in a more limited and complicated advocacy focus."

United is one of the founding members of the Better Medicare Alliance, a group that was created in December to advocate for higher payments to private Medicare Advantage plans. Former Democratic congresswoman Allyson Y. Schwartz was recently named president and CEO. The other major funders of the alliance are Humana and Aetna Inc.

The move came a month after Karen Ignagni, who had been a top lobbyist for the industry for 22 years, left AHIP to take the helm at EmblemHealth in New York. AHIP Interim CEO Dan Durham is currently leading the trade association.

"AHIP has a strong and demonstrated track record of successful advocacy on behalf of the health insurance industry. Our board has focused us on the critical issues facing health insurers and the customers we serve, including affordability, high cost drugs, and Medicare Advantage," said Durham in a statement.

United spokesman Matt Stearns said that the change in AHIP leadership and United's departure were unrelated.

AHIP spokeswoman Clare Krusing said that no other member companies are leaving AHIP and that no other AHIP staff members are expected to leave the association. Ignagni chose to leave AHIP because she had been interested in the idea of leading a health plan for some time, Krusing said.

"She was presented with an opportunity she couldn't pass up," said Krusing. "She really could have retired but she always wants to take the next big challenge and opportunity." Krusing added that the AHIP team "is a family."

United has sent a letter to AHIP announcing its plans to leave the trade association.

Tensions between the larger, for-profit insurers and some other members of AHIP—such as smaller, regional insurers or some nonprofits—have grown over the years. United has the clout and lobbying muscle to leave the association without fear that its viewpoint will be overlooked in Washington.

In 2012, United led a group of five other large insurers in Wisconsin that abandoned the Wisconsin Association of Health Plans, which worked closely with AHIP but was not an affiliate.

Before AHIP was created in 2003, the insurance industry was represented by two major associations, the Health Insurance Association of America and the American Association of Health Plans, which Ignagni led.