Earlier this month, Missouri legislators overrode Gov. Jay Nixon’s (D) veto to approve a bill that allow employers or health insurance providers to stop offering coverage for contraception, abortion, or sterilization if doing so violated their religious or moral convictions.

But before lawmakers passed the new law to push back against Obamacare, the state already had a decade-old law that “allows insurers to offer policies without contraception coverage to people or employers who say it violates their moral or religious beliefs,” according to the Associated Press.

Now, under the original contraception provision, the Missouri state department of insurance has issued a $1.5 million fine to insurance provider Aetna for failing to let employers opt out of contraception coverage. Additionally, Aetna provided insurance policies that covered abortion without an additional premium — in violation of a 1983 state law preventing abortion coverage in basic coverage. One official said Missouri’s settlement with Aetna is a reminder of the state’s current, restrictive laws:

“This settlement should be a reminder to all health benefit plans covering Missourians, that state law has stringent requirements honoring the religious and moral beliefs of insurance customers,” Missouri insurance director John Huff. “We will be enforcing Missouri’s decade-old contraception coverage law, as well as the new law on the subject, anywhere we see violations.” [...]

Under that newly enacted law, individuals, employers and insurers can cite religious or moral exemptions from mandatory insurance coverage for abortion, contraception and sterilization. It also changes a “may” to a “shall” when describing an insurer’s duty to provide policies without contraception coverage for those who request it.

It’s unclear what will happen to Missouri’s laws about contraception coverage because federal law invalidates them. The measures directly contradict with Obamacare’s regulation, which mandates that insurance plans cover contraception at no additional cost. The exemptions for religious organizations and accommodations for nonprofit religiously affiliated organizations do not include employers’ personal moral and religious views, making the Missouri regulations invalid under the Affordable Care Act. Under the Constitution, federal law “shall be the supreme law of the land,” and Missouri lawmakers cannot change that with a new or existing law to restrict women’s access to birth control.

Arijit Guha, a 31-year-old doctoral student at Arizona State University, hit his lifetime limit of $300,000 on his student insurance plan very quickly while fighting Stage 4 colon cancer. To pay for the remaining $118,000 in medical bills from his chemotherapy treatments, Guha started selling items on his website, Poop Strong, in February. He said a friend called his fundraiser “the world’s most important bake sale,” and he told Wonkblog’s Sarah Kliff that it “feels like this weird joke, that I’m selling T-shirts to pay for chemotherapy.”

In late July, Guha tried a faster way to address the unpaid bills: Twitter. He used the social media site to call out his insurance carrier, Aetna:

He sent a tweet to his insurance carrier, Aetna: “@Aetna’s 4th qtr profit up 73%: ‘it continued to benefit from low use of health care.’ Helps they can ensure low use.”

After he engaged in a back-and-forth with chief executive Mark Bertolini, the insurance company moved quickly to work out a solution. Within 24 hours, Guha’s 23-word tweet had done more than six straight months of fundraising ever could: It persuaded Aetna to cover all his outstanding medical bills, showcasing the power of social media to catalyze swift action from a major company. [...]

“Although he reached the limits of his plan, Aetna care managers have continued to provide support and we have worked to develop a solution,” the company said in a statement. [...]

Guha has come away with a similar conclusion. He was ecstatic about the result. But he also considers himself as an exception to the rule: Not every American struggling with medical debt gets into a Twitter exchange with a health insurance CEO and catches a lucky break.

Thanks to Obamacare, insurance providers will have to eliminate lifetime limits on health care plans. This regulation kicked in for student insurance plans in July 2012, so Guha will not have to worry about the $300,000 limit he passed long ago the next time he renews his insurance plan. And students who sign up for insurance plans through their universities will be guaranteed more comprehensive coverage.

As ThinkProgress reported in June, the plans some schools offer are mini-med plans that provide almost no protection when students actually get sick or injured. Upping the standards will lead to much better coverage for more students, and it is possible to avoid rising costs while improving benefits. In Massachusetts, for example, a number of schools joined together to buy coverage collectively for 12,000 students without dramatically increasing premiums.

According to the Government Accountability Office, 600,000 students — 7 percent of 18 to 23-year-olds in college — bought insurance through their school’s plans. By providing more comprehensive plans, like removing lifetime limits, future students faced with the same situation as Guha hopefully will not have to turn to T-shirt sales and Twitter to cover their cancer treatments.

A group of Aetna shareholders is challenging the health insurer for donating to the American Action Network and the U.S. Chamber of Commerce — two organizations dedicated to undermining Obamacare.

Aetna donated over $7 million to the two groups during the Democrats’ effort to enact health care reform, though the contributions did not become public until this year, when the company accidentally “made the disclosure in a year-end regulatory filing with the National Association of Insurance Commissioners.”

In a latter to Aetna on Monday, the shareholders claim that the company did not comply with disclosure policies or inform its investors about the donations:

“We believe Aetna is not in compliance with its corporate political and lobbying disclosure policy, a policy which we negotiated and expected would be met in spirit and in letter,” read the Monday letter to Aetna CEO and President Mark Bertolini from Mercy Investment Services Inc. and the Sisters of Charity of Saint Elizabeth, two Catholic groups with investments in Aetna. [...]

But in their recent complaint to Aetna, the Catholic investors point to a 2007 letter of agreement in which Aetna promised shareholders that it would disclose all expenditures for lobbying and political purposes, as well as trade association payments and grass-roots spending. The Aetna policy followed a 2006 shareholder resolution calling for the company to disclose its political spending.

“We, investors, withdrew the resolution in good faith expecting that the resolution establishing oversight and transparency would be followed, revised as best practices evolved and in place for reference by the members of the committee preparing the annual reports,” read the letter. In an interview, Sister Valerie Heinonen, one of the letter’s authors, said investors were “dismayed” that the agreed-on policy had not been followed.

Aetna maintains that it intended the funds to be use for educational purposes, yet both the American Action Network and the Chamber are still fighting reform. Just days after the Supreme Court’s decision upholding the constitutionality of the law, AAN announced a $1.2 million advertising campaign urging Republicans to repeal the Affordable Care Act.

Aetna CEO, Chairman and President Mark Bertolini praised the Affordable Care Act during the HIMSS12 Conference in Las Vegas this week, arguing that while the new law and its regulations have “pulled [the insurance industry] through the crucible” and “reshaped” the health care market, “For most of what has already been implemented, it has been a pretty good thing”:

So what will the health insurers look like in the future? Bertolini offered a strong endorsement of the accountable health organization model, positioning health insurers as uniquely suited to usher in an era of coordinated care. “We need to move the system from underwriting risk to managing populations,” he said. “We want to have a different relationship with the providers, physicians and the hospitals we do business with.” [...]

Pondering the future of the health care exchanges, Bertolini foresees the brands of health systems superceding those of health insurers. “We want to leverage or technologies and capabilities to allow you to be the face in marketplace,” he said.

Indeed, Bertolini says this new arrangement makes great sense from the perspective of the customer. The lack of coordination inherent in the current system stems largely from the various stakeholders acting rationally in their own self-interest. “For the patient it’s a nightmare. Think of a hockey game where everybody has their own puck.”

The Aetna chief also “discounted the prospect that the results of the 2012 presidential election or a Supreme Court decision striking down aspects of the ACA would deter the change,” noting, “Reform is not going to stop. It won’t go away.”

Insurers have generally accepted the inevitability of the ACA and have worked to shape its implementation to meet their needs. For instance, health lobbyists are pressuring Congress to repeal taxes on the industry, and have urged the Department of Health and Human Services to adopt exchange regulations that would allow almost all private insurers to participate in the new marketplaces and provide greater leeway for plans to design the standard essential health benefits package that will be offered in 2014. Insurers have also lobbied conservative governors to establish health care exchanges.

At the same time, the industry is preparing for the expansion of new customers. Last September, Cigna — one of the nation’s largest health insurers — kicked off a $25 million ad campaign designed to attract the individual consumers who will begin shopping for their own policies and the industry joined forces with health care and consumer groups to form the “Enroll America” campaign, an effort to “encourage states to make it easy for people to sign up for coverage, by providing model regulations” and “get the word out among the uninsured, through advertising and community outreach.”

Sam Stein reports that “[h]ealth insurance giant Aetna is planning to force up to 650,000 clients to drop their coverage next year as it seeks to raise additional revenue to meet profit expectations.” One industry analyst told Stein, “[t]hey were surprised by an acceleration in medical costs in 2009 which pressured their earnings.” “In an effort to get back to a more profitable level, they are raising their prices to match cost trends. When you raise rates, you run the risk of losing your membership. Health insurance is a very competitive marketplace“:

“The pricing we put in place for 2009 turned out to not really be what we needed to achieve the results and margins that we had historically been delivering,” said chairman and CEO Ron Williams. “We view 2010 as a repositioning year, a year that does not fully reflect the earnings potential of our business. Our pricing actions should have a noticeable effect beginning in the first quarter of 2010, with additional financial impact realized during the remaining three quarters of the year.”

The customers Aetna is targeting could have sicker profiles, but they could also be located in areas of the country where Aetna doesn’t have the market clout to negotiate cheaper rates with dominant providers. For Aetna, the customers may be more expensive because the insurer has to pay doctors and hospitals more than its competitors, not because they are significantly sicker than the average beneficiary.

As Princeton health economist Uwe Reinhardt explains it:

REINHARDT: It depends on the market power. If you face, as a hospital, a huge insurance company, they will bargain for a steep discount. But if you’re an uninsured, middle-class individual, you have no market power, and they will charge you often twice the price that would be charged to an insurance company.

NPR: So if I’m – sorry, so if I’m a massive insurance company, I can say I’m going to bring you 75,000 MRIs this year, you’d better charge me very little for them, whereas if I’m one uninsured person, I’ve got no bargaining power. Is that what you’re saying?

REINHARDT: That’s what it is. The insurance company will say look, we lower the price, but you can make it up on the volume, we bring you big volume, while the individual says I bring you one appendix. That’s not a volume. And so they can jack up the price and take what they want from you.

In 2001, Aetna felt like providers in certain areas were doing just that — charging the company too much for medical services. “Aetna completely overhauled its business between 2000 and 2003, going from 21 million members in 1999 down to 13 million in 2003, but boosting its profit margin from about 4% to higher than 7%.” The company pushed out almost 8 million enrollees by increasing their premiums and then pulled out of those insurance markets. “The most important characteristic…is that they were in markets in which we did not have very significant presence. So that the contracts that we had with the doctors and the hospitals were not as favorable as that of our competitors,” Jack Rowe, Aetna’s former CEO told PRI’s This American Life.

A recent analysis of the Massachusetts health care market concluded that “insurance companies pay some hospitals and doctors twice as much money as others for essentially the same patient care.” The report found that “payments were most closely tied to market leverage, with the largest hospitals and physician groups, those with brand-name recognition, and those that are geographically isolated able to demand the most money.”