subject only to employee retirement income security act (erisa) and oversight by the u.s. department of labor, and most proposals would also allow for interstate plans." critics said that "exemptions would lead to market instability and higher premiums in the traditional small-group market. ahps exempt from state regulation and oversight would enable them to be more selective about who they cover. they will be less likely to cover higher-risk populations, which would cause an imbalance in the risk pool for other small business health plans that are part of the state small group risk pool. adverse selection would likely abound and association health plans would be selling an unregulated product alongside small group plans, which creates an unlevel playing field." according to the congressional budget office (cbo), "remiums would go up for those buying in the traditional small-group market." competing against ahps that offer less expensive and less comprehensive plans. the national association of insurance commissioners (naic), the national governors' association and "several insurance and consumer groups" opposed the ahp legislation. the naic issued a consumer alert regarding ahps, as proposed in developing the next generation of small businesses act of 2017. h.r. 1774. their statement said that ahp's "hreaten the stability of the small group market" and provide "inadequate benefits and insufficient protection to consumers." under ahps, "ewer consumers would have their rights protected, "ahps would also be exempt from state solvency requirements, putting consumers at serious risk of incurring medical claims that cannot be paid by their association health plan." in november 2017, president trump directed "the department of labor to investigate ways that would "allow more small businesses to avoid many of the costly requirements." under the aca, small-employer and individual markets had "gained important consumer protections under the aca and state health laws — including minimum benefit levels." in a december 28, 2017 interview with the new york times, trump explained that, "we've created associations, millions of people are joining associations. ...that were formerly in obamacare or didn't have insurance. or didn't have health care. ...it could be as high as 50 percent of the people. so now you have associations, and people don't even talk about the associations. that could be half the people are going to be joining up...so now you have associations and the individual mandate. i believe that because of the individual mandate and the association". final rules were released by the department of labor on june 19, 2018. prior to the effective date of april 1, 2019, a federal judge invalidated the rule. the court found that the dol had failed to set meaningful limits on ahps. the court of appeals for the district of columbia circuit granted the trump administration an expedited appeal. a three-judge panel heard oral arguments on november 14, 2019. individually purchased main article: individually purchased health insurance in the united states prior to the aca, effective in 2014, the individual market was often subject to medical underwriting which made it difficult for individuals with pre-existing conditions to purchase insurance. the aca prohibited medical underwriting in the individual market for health insurance marketplace plans. prior to the aca as of 2007, about 9% of americans were covered under health insurance purchased directly, with average out-of-pocket spending is higher in the individual market, with higher deductibles, co-payments and other cost-sharing provisions. while self-employed individuals receive a tax deduction for their health insurance and can buy health insurance with additional tax benefits, most consumers in the individual market do not receive any tax benefit. traditional indemnity or fee-for-service early hospital and medical plans offered by insurance companies paid either a fixed amount for specific diseases or medical procedures (schedule benefits) or a percentage of the provider's fee. the relationship between the patient and the medical provider was not changed. the patient received medical care and was responsible for paying the provider. if the service was covered by the policy, the insurance company was responsible for reimbursing or indemnifying the patient based on the provisions of the insurance contract ("reimbursement benefits"). health insurance plans that are not based on a network of contracted providers, or that base payments on a percentage of provider charges, are still described as indemnity or fee-for-service plans. blue cross blue shield association main article: blue cross blue shield association the blue cross blue shield association (bcbsa) is a federation of 38 separate health insurance organizations and companies in the united states. combined, they directly or indirectly provide health insurance to over 100 million americans. bcbsa insurance companies are franchisees, independent of the association (and traditionally each other), offering insurance plans within defined regions under one or both of the association's brands. blue cross blue shield insurers offer some form of health insurance coverage in every u.s. state, and also act as administrators of medicare in many states or regions of the united states, and provide coverage to state government employees as well as to federal government employees under a nationwide option of the federal employees health benefit plan. health maintenance organizations main article: health maintenance organization a health maintenance organization (hmo) is a type of managed care organization (mco) that provides a form of health care coverage that is fulfilled through hospitals, doctors, and other providers with which the hmo has a contract. the health maintenance organization act of 1973 required employers with 25 or more employees to offer federally certified hmo options. unlike traditional indemnity insurance, an hmo covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the hmo's guidelines and restrictions in exchange for a steady stream of customers. benefits are provided through a network of providers. providers may be employees of the hmo ("staff model"), employees of a provider group that has contracted with the hmo ("group model"), or members of an independent practice association ("ipa model"). hmos may also use a combination of these approaches ("network model"). managed care main article: managed care the term managed care is used to describe a variety of techniques intended to reduce the cost of health benefits and improve the quality of care. it is also used to describe organizations that use these techniques ("managed care organization"). many of these techniques were pioneered by hmos, but they are now used in a wide variety of private health insurance programs. through the 1990s, managed care grew from about 25% us employees with employer-sponsored coverage to the vast majority. rise of managed care in the us year conventionalplans hmos ppos posplans hdhp/sos 1998 14%27%35%24%— 1999 10%28%39%24%— 2000 8%29%42%21%— 2001 7%24%46%23%— 2002 4%27%52%18%— 2003 5%24%54%17%— 2004 5%25%55%15%— 2005 3%21%61%15%— 2006 3%20%60%13%4% 2007 3%21%57%15%5% 2008 2%20%58%12%8% 2009 1%20%60%10%8% 2010 1%19%58%8%13% 2011 1%17%55%10%17% 2012 <1%16%56%9%19% 2013 <1%14%57%9%20% 2014 <1%13%55%23%27% 2015 1%17%50%26%26% 2016 2%23%35%32%28% network-based managed care many managed care programs are based on a panel or network of contracted health care providers. such programs typically include: a set of selected providers that furnish a comprehensive array of health care services to enrollees; explicit standards for selecting providers; formal utilization review and quality improvement programs; an emphasis on preventive care; and financial incentives to encourage enrollees to use care efficiently. provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently. a survey issued in 2009 by america's health insurance plans found that patients going to out-of-network providers are sometimes charged extremely high fees. network-based plans may be either closed or open. with a closed network, enrollees' expenses are generally only covered when they go to network providers. only limited services are covered outside the network—typically only emergency and out-of-area care. most traditional hmos were closed network plans. open network plans provide some coverage when an enrollee uses non-network provider, generally at a lower benefit level to encourage the use of network providers. most preferred provider organization plans are open-network (those that are not are often described as exclusive provider organizations, or epos), as are point of service (pos) plans. the terms "open panel" and "closed panel" are sometimes used to describe which health care providers in a community have the opportunity to participate in a plan. in a "closed panel" hmo, the network providers are either hmo employees (staff model) or members of large group practices with which the hmo has a contract. in an "open panel" plan the hmo or ppo contracts with independent practitioners, opening participation in the network to any provider in the community that meets the plan's credential requirements and is willing to accept the terms of the plan's contract. other managed care techniques other managed care techniques include such elements as disease management, case management, wellness incentives, patient education, utilization management and utilization review. these techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. the use of managed care techniques without a provider network is sometimes described as "managed indemnity." blurring lines over time, the operations of many blue cross and blue shield operations have become more similar to those of commercial health insurance companies. however, some blue cross and blue shield plans continue to serve as insurers of last resort. similarly, the benefits offered by blues plans, commercial insurers, and hmos are converging in many respects because of market pressures. one example is the convergence of preferred provider organization (ppo) plans offered by blues and commercial insurers and the point of service plans offered by hmos. historically, commercial insurers, blue cross and blue shield plans, and hmos might be subject to different regulatory oversight in a state (e.g., the department of insurance for insurance companies, versus the department of health for hmos). today, it is common for commercial insurance companies to have hmos as subsidiaries, and for hmos to have insurers as subsidiaries (the state license for an hmo is typically different from that for an insurance company). at one time the distinctions between traditional indemnity insurance, hmos and ppos were very clear; today, it can be difficult to distinguish between the products offered by the various types of organization operating in the market. the blurring of distinctions between the different types of health care coverage can be seen in the history of the industry's trade associations. the two primary hmo trade associations were the group health association of america and the american managed care and review association. after merging, they were known as american association of health plans (aahp). the primary trade association for commercial health insurers was the health insurance association of america (hiaa). these two have now merged, and are known as america's health insurance plans (ahip). new types of medical plans in recent years, various new types of medical plans have been introduced. high-deductible health plan (hdhp) plans with much higher deductibles than traditional health plans—primarily providing coverage for catastrophic illness—have been introduced. because of the high deductible, these provide little coverage for everyday expenses—and thus have potentially high out-of-pocket expenses—but do cover major expenses. couple with these are various forms of savings plans. tax-preferenced health care spending account coupled with high-deductible plans are various tax-advantaged savings plans—funds (such as salary) can be placed in a savings plan, and then go to pay the out-of-pocket expenses. this approach to addressing increasing premiums is dubbed "consumer driven health care", and received a boost in 2003, when president george w. bush signed into law the medicare prescription drug, improvement, and modernization act. the law created tax-deductible health savings accounts (hsas), untaxed private bank accounts for medical expenses, which can be established by those who already have health insurance. withdrawals from hsas are only penalized if the money is spent on non-medical items or services. funds can be used to pay for qualified expenses, including doctor's fees, medicare parts a and b, and drugs, without being taxed. consumers wishing to deposit pre-tax funds in an hsa must be enrolled in a high-deductible insurance plan (hdhp) with a number of restrictions on benefit design; in 2007, qualifying plans must have a minimum deductible of us$1,050. currently, the minimum deductible has risen to $1.200 for individuals and $2,400 for families. hsas enable healthier individuals to pay less for insurance and deposit money for their own future health care, dental and vision expenses. hsas are one