Insurance Market Reform

Prior to the Affordable Care Act (ACA), most states' individual health insurance markets were dominated by one or two insurance carriers that had little incentive to compete by providing efficient services. Instead, they competed mainly by screening and selecting people based on their risk of incurring high medical costs. One of the ACA's goals is to encourage carriers to participate in the health insurance marketplaces and to shift the focus from competing based on risk selection to processes that increase consumer value, like improving efficiency of services and quality of care. This brief looks at how carriers are competing in the new marketplaces in six states, namely through cost-sharing and composition of provider networks.

State action to prevent discriminatory benefit designs has been prompted, in part, by vital input from consumer advocacy organizations. This resource, which resulted from invitations sent to health-related consumer groups that signed the 2014 "We are (Still) Essential" letter to U.S. Department of Health and Human Services Secretary Burwell, provides a compilation of organizations that are willing to assist state insurance regulators with identifying discriminatory benefit designs or for other regulatory tasks that require expertise related to a certain disease group or consumer concern.

This document contains final regulations regarding the summary of benefits and coverage (SBC) and the uniform glossary for group health plans and health insurance coverage in the group and individual markets under the Affordable Care Act (ACA). It finalizes changes to the regulations that implement the disclosure requirements to help plans and individuals better understand their health coverage, as well as to gain a better understanding of other coverage options for comparison.

Employees of small businesses have much lower rates of insurance coverage and less generous benefits than their peers at bigger companies, owing largely to challenges unique to the small group market. The ACA introduced significant reforms aimed squarely at these problems, but implementation has moved slowly and the ultimate impact of these changes is unclear. This essay takes a look at developments in the small group market since the passage of the ACA and highlights several issues that could threaten the long-term viability of this market as implementation moves forward.

Introduced by the Affordable Care Act (ACA), the Essential Health Benefits (EHBs) are a set of ten health care service categories that non-grandfathered health plans in the individual and small group markets must cover. States are in the process of making important decisions about the EHBs, therefore this is a key time to influence and shape the next phase of EHBs across states. This brief highlights steps that California has taken to update the EHBs, and continued advocacy efforts.