Reports & Analysis

Federal and state policymakers are faced with the challenge of integrating services to address both the physical and behavioral health needs of the population. This brief summarizes key lessons and opportunities for federal and state alignment that surfaced during a meeting supported by The Commonwealth Fund of high-level federal and state leaders. Several case studies are featured including Arizona, Missouri and Tennessee. Opportunities discussed spanned payment models, information and data sharing approaches, as well as operational strategies for achieving integration.
 

Whether they have health insurance through an employer or buy it on their own, Americans are paying more out-of-pocket for health care now than they did in the past decade. A Commonwealth Fund survey fielded in the fall of 2014 asked consumers about these costs. More than one in five 19-to-64-year old adults who were insured all year spent 5 percent or more of their income on out-of-pocket costs, not including premiums, and 13 percent spent 10 percent or more. Adults with low incomes had the highest rates of steep out-of-pocket costs. Two of five adults with private insurance who had high deductibles relative to their income said they had delayed needed care because of the deductible.
 

The ACA contains several provisions that may alter the scope and practice of public health. As a result, governmental health departments must evolve in order to accommodate the new health landscape and changing demands on the system. In the wake of these health systems changes, public health faces new opportunities and challenges. This recently-released Research Insights brief examines the role of public health following ACA implementation by looking at three innovative approaches to governmental public health – in Massachusetts, San Diego, and Vermont.

The ACA gives states the option to implement a Basic Health Program (BHP) that covers low-income residents through state-contracting plans outside the health insurance marketplace, rather than qualified health plans (QHPs). BHP offers the prospect of improved affordability for low-income residents, fiscal gains for some states, and reduced churning. However, it also poses financial risks for states and has implications for state marketplaces. This paper summarizes the federal policies on BHP, including the requirements for BHP as well as the methodology for determining federal BHP payments. It also analyzes the key trade-offs facing states as they decide whether and, if so, how to implement BHP, with a particular focus on the impact of BHP on state budgets and the size, stability, and risk level of state marketplaces.
 

This report analyzes the public education and application assistance strategies employed during the 2014 open enrollment period based primarily the Health Reform Monitoring Survey (HRMS) and interviews with diverse informants in 24 states.  In addition to describing general trends involving public education and application assistance, this analysis shares promising practices used by particular states as well as suggestions offered by stakeholders and researchers. Such practices and suggestions focus primarily on state-based and partnership marketplaces, but many could also apply to federally-facilitated marketplaces.
 

The end of the ACA’s first open enrollment period has seen better-than-expected participation and a significant drop in the number of uninsured, particularly in states that expanded Medicaid. However, many eligible uninsured have not yet signed up. This paper focuses on one factor that has emerged as a challenge to marketplace enrollment: namely, consumers’ perception that, even with federal subsidies, Qualified Health Plans are not affordable. The paper begins by analyzing how this factor played out during the open enrollment season for 2014, and then describes promising practices implemented by particular states to improve the affordability of coverage.
 

To achieve enrollment targets for 2015, the health insurance marketplaces must rely on millions of consumers renewing their current marketplace health plans. This is no small effort, and the marketplaces are constrained by information technology capacity, a short enrollment time frame, and limited resources for outreach and consumer assistance. This report examines the efforts of six state-based marketplaces (California, Colorado, Kentucky, Maryland, Rhode Island and Washington) to successfully renew health coverage for millions of marketplace enrollees.
 

The combination of fee-for-service payments and the US health care system’s standing commitment to treating existing illness discourages spending on the behavioral, social, and environmental (that is, the nonmedical) conditions that contribute most to long-term health. Pay-for-success, alternatively known as social impact bonds (SIBs), offers a possible solution. The pay-for-success model relies on an investor that is willing to fund a nonmedical intervention up front while bearing the risk that the intervention may fail to prevent disease in the future. Should the intervention succeed, however, the investor is repaid in full by a predetermined payer, such as a public health agency, and receives an additional return on its investment as a reward for taking on the risk. These efforts, supported by key policy reforms such as public agency data sharing and coordinated care, promise to increase the number of evidence-based nonmedical service providers and seed a new market that values health, not just health care.
 

Oregon has taken significant steps to transform its health care and early education systems. Recognizing that good health is a key component of ensuring children enter school ready to succeed, Oregon is now aligning the two systems with the ultimate goal of improving kindergarten readiness. This report describes Oregon’s approach to aligning its two innovative system transformations and highlights key strategies – including joint staffing, blended funding, and shared expectations – to elucidate lessons for policy makers seeking to bridge health care and early education.
 

The ACA’s employer mandate requires large firms to pay penalties unless they offer affordable health insurance coverage to full-time employees, raising concerns that employers might lay off workers or reduce hours. This brief estimates the number of workers potentially at risk of losing their jobs or having hours reduced. Fewer than 10 percent, less than 0.03 percent of the U.S. labor force, might see reductions in employment or hours in the short run. Over time, employment patterns might change, leading to fewer firm sizes and work schedules near the thresholds, potentially affecting up to 0.5 percent of the workforce.