Reports & Analysis

As drug prices have been rising, insurers have been shifting the costs to consumers by creating specialty drug tiers that require patients to pay a large percentage of the total cost or very high copays. This blog post looks at how a number of states have already moved ahead with legislative and regulatory action to help consumers. The authors outline states’ approaches to addressing this issue, including caps on drug spending and, within state marketplaces, standardized insurance benefit designs that limit the number of drug tiers or have fixed copayments.

Research demonstrates that improving population health and achieving health equity will require broad approaches that address social, economic, and environmental factors that influence health. Reflecting the increased focus and new opportunities provided under the ACA, a growing number of initiatives are emerging at the national, state, and local level to bridge health care and community health. Given Medicaid’s longstanding role serving a diverse population with complex health, behavioral, and social needs, efforts to address social determinants of health are emerging through many Medicaid delivery and payment initiatives. This brief provides an overview of the broad factors that influence health and describes emerging efforts to address them, including initiatives within Medicaid.

There is widespread agreement that changes in healthcare payment systems are needed to achieve higher quality, more affordable healthcare. To date, however, most payment reform initiatives have had relatively little impact on either healthcare spending or quality.  This report describes seven different alternative payment models that can enable physicians in every specialty to redesign the way they deliver care in order to control spending and improve quality for their patients.

This report examines the ACA’s target population of consumers who were uninsured before the law’s main coverage provisions took effect in 2014. In every state, tax returns were filed for 56% or more of those who now qualify for Medicaid and 84% or more of those eligible for health insurance tax credits. The minority of tax preparers who help their clients apply for health coverage have developed several effective models. States could test the impact of measures to increase tax preparation services’ contribution to enrollment while guarding against unethical or incompetent conduct. Federal policy could also play an important role.

Prescription drug growth rates declined from 2000 to 2013, in part due to patent expiries and decreases in generic prices. This downward trend appears to be reversing; spending on prescriptions is estimated to have spiked upwards in 2014 and 2015 with grow rates of 11.6% and 6.8% respectively. This article explores the current trends in prescription drug spending.

The ACA created new opportunities for health centers and primary care associations (PCA) to play a leading role in supporting outreach and enrollment into new and expanded health coverage programs. Health centers and PCAs received new funding, sometimes from multiple state and federal entities, new training and tools, and a new mandate to find and enroll eligible individuals, both within their patient caseload and in the broader community. This case study examines the new roles of these entities in Kentucky and Montana, where the state PCA and health centers played an important role in their strong enrollment performance, and identifies promising strategies in their coordination with state Medicaid and insurance/exchange agencies.

This survey offers a window into the nation’s Medicaid programs at the 50th anniversary of the program. The survey results demonstrate the variety and coherence among the 56 Medicaid programs, and exemplify the changing job of “Medicaid Director” in the 50 states, the District of Colombia, and the 5 territories. The survey provides unique insight into how Medicaid Directors are managing increasingly sophisticated programs and driving system reform amid funding and staff constraints, and how they navigate the myriad stakeholders to build consensus and drive improvement.

To date, nine states have launched Accountable Care Organization (ACO) programs for all or part of their Medicaid population, and 10 more are actively pursuing ACOs. While state ACO models differ widely, all share the following core components: payment model, quality measurement approach, and data strategy. This brief summarizes these core ACO characteristics and profiles how nine states – CO, IL, IA, ME, MN, NJ, OR, UT, and VT – have incorporated these elements into their Medicaid ACOs. For each state, it outlines key ACO infrastructure; details unique payment, quality, and data approaches; and spotlights one of the state’s Medicaid ACOs.

As Marketplace enrollees begin to shop for coverage starting in 2016, the number of insurance choices available to them is changing in some parts of the country. Over the past year, some insurers have announced their exit or been required to withdraw from the Marketplaces, most notably a number of nonprofit Consumer Operated and Oriented Plans and some larger insurers like Blue Cross Blue Shield of New Mexico.  Despite these withdrawals, the Department of Health and Human Services recently announced that the average number of issuers per state is increasing slightly in 2016 and that about 9 out of 10 returning Healthcare.gov customers will have 3 or more insurers from which to choose in 2016. This Data Note highlights areas where insurer participation is changing in 2016, and where this may have an appreciable effect on market competition. It also examines insurer participation in rural areas, which have historically had low rates of insurer competition.

The Affordable Care Act’s (ACA) standards for essential health benefits are intended to ensure that health plans meet the coverage needs of individuals and small businesses. This blog post explains that most states are continuing to define their essential benefits much as they had originally—despite the opportunity to revisit this decision for 2017 and beyond. The authors explore how the states chose the health plan that would serve as the benchmark for essential benefits, and how the limited data available from insurers is making it challenging to assess whether the essential benefits policy is working.