Insurance Market Reform

Having health insurance is a key step to obtaining health care. But insurance alone does not guarantee that consumers will have meaningful access to care. People of color, in particular, may continue to face barriers to health care, including access to health providers that can meet their needs. To help address these obstacles, the provider networks created by private health insurers should be adequate—ensuring that consumers of color can get the right care, at the right time, in a language they understand, without having to travel unreasonably far. This brief reviews: the ideal components of a health insurance provider network that meets the needs of people of color; examples of policies from states to help ensure that private insurance networks are adequate for communities of color; and strategies for advocates to use to put these policies in place.
 

As rate filings for 2015 Affordable Care Act (ACA) health plans become public, virtually all media attention has focused on premium changes. What have been ignored are the changes in the plans’ out-of-pocket expenses. Inasmuch as deductibles and physician fees have the potential to add thousands of dollars in annual healthcare expenses, media disregard of health plan cost-sharing is especially unhelpful to the portion of the public who uses healthcare services regularly. This report examines major out-of-pocket cost categories within public rate filings for 2015 Affordable Care Act plans in 9 states.
 

To better understand the nature of coverage available to consumers through the Exchanges, Breakaway Policy Strategies partnered with the Robert Wood Johnson Foundation to collect detailed information on premiums, network composition, deductibles, out-of-pocket limits, and cost-sharing for every 2014 Silver Exchange plan in all 50 states and the District of Columbia. This report takes a closer look at cost-sharing for primary care physician (PCP) and specialist visits, including application of plan deductibles, copayment and coinsurance amounts, and the unique plan design features that may lead some enrollees to think twice before scheduling their next appointment with a doctor.
 

All-payer claims databases (APCDs) collect and compile medical, pharmacy, and sometimes dental claims, eligibility, and provider files from public and private payers. APCDs are currently being used for a variety of functions, including population health analysis, comparative analysis of provider and facility quality, cost management for Medicaid and other public programs, support for provider payment reform initiatives, and consumer transparency tools. This issue brief explains the potential uses of APCDs for rate review and other regulatory functions. It includes descriptions of possible uses for APCDs and ranks the level of effort necessary to use an APCD for those purposes, along with the relative value of doing so.

The Affordable Care Act (ACA) contains numerous consumer protections designed to remedy shortcomings in the availability, affordability, adequacy, and transparency of individual market insurance. However, because states remain the primary regulators of health insurance and have considerable flexibility over implementation of the law, consumers are likely to experience some of the new protections differently, depending on where they live. This brief explores how federal reforms are shaping standards for individual insurance and examines specific areas in which states have flexibility when implementing the new protections