Reports & Analysis

The ACA presented new challenges for states to develop models for health system and payment reform, implement health insurance marketplaces, and expand Medicaid. This created a need for states to fully understand and utilize data sources in order to effectively implement, monitor, and evaluate health care reform. To assist states in this effort, SHADAC, with support from the Office of the Assistant Secretary for Planning and Evaluation, developed a series of white papers that are focused on innovative uses of data resources and analytic approaches that states can apply to monitor and evaluate health care reform efforts. The series provides an overview of data sources available to state policymakers, such as state-level administrative data, health insurer filings, marketplace enrollment data, and survey data. The series also highlights key analytic questions that states could use the data sources to address.
 

Financial incentives offer a new tool for Medicaid programs to encourage beneficiaries to choose healthy behaviors. Programs serving non-Medicaid populations have demonstrated that financial incentives can help influence healthy behaviors, enhance long-term health outcomes, and reduce health care costs. Several states are considering incentive strategies within new Medicaid expansion programs. This brief explores how financial incentives can be used to influence healthy behaviors. It reports on findings from past Medicaid healthy behavior incentive programs; highlights current Medicaid incentive approaches, including New Mexico’s model; and offers recommendations for states that are establishing or modifying programs to encourage healthy behaviors in Medicaid.
 

To increase support for physicians providing primary care for Medicaid beneficiaries, and to improve access to primary care as Medicaid coverage expands, the ACA increased Medicaid payment rates for many primary care services to Medicare fee levels in 2013 and 2014. The rate increase applies only to physicians serving Medicaid beneficiaries in both fee-for-service and managed care. The federal government funded 100% of the primary care fee increase relative to the rates states were paying as of July 1, 2009. This report assesses states’ plans to extend the primary care rate increase beyond December 31, 2014.
 

All qualified health plans under the ACA must cover a package of essential health benefits (EHBs) equal in scope to a typical employer plan. The law laid out 10 general categories of services that EHBs must cover, but did not itemize those services. As an interim policy for 2014 and 2015, the Department of Health and Human Services allowed each state to identify an existing plan as a benchmark for these EHBs. The result of this policy is that EHBs vary from state to state, often because of a legacy of different state-mandated benefits (such as treatments for autism, infertility, or temporomandibular joint disorders). This brief analyzes state variation in coverage and limits for these non-uniform benefits.
 

This guide is focused solely on the private insurance reforms of the ACA, including the health insurance marketplaces, rating, benefit and cost structures, and premium tax credits. It is intended to supplement the Navigator training available from the U.S. Department of Health and Human Services. It is not intended to be a comprehensive, stand-alone resource for all the reforms of the ACA. This resource is organized into sections that address how individuals may present themselves to Navigators based on their insurance status and coverage options. It includes questions and answers developed in collaboration with the staff at the Center on Budget and Policy Priorities, the Georgetown University Center for Children and Families, and the Kaiser Family Foundation.
 

One objective of the health insurance Marketplaces created through the Affordable Care Act (ACA) is to encourage competition among insurers with the goal of lower premiums for consumers and lower subsidy costs for the federal government. One strategy insurers have used to offer lower premiums and capture market share has been the creation of “narrow networks” of providers and facilities. The ACA includes network adequacy requirements, but there remains considerable variation in the breadth of acceptable hospital networks and the options available in each. This brief investigates which hospitals are included in Marketplace plans in major cities in six states, and examines how hospital networks vary across plans within a single insurer and across all insurers.
 

The new National Scorecard on Payment Reform shows commercial health plans have dramatically shifted how they pay physicians and hospitals, with 40 percent of their payments now designed to encourage health care providers to deliver higher-quality and, in some cases, more affordable care. It also shows a 29 percentage point increase over 2013, when just 11 percent of payments were value-oriented. However, 60 percent of payments remain largely in traditional fee-for-service. While the Scorecard findings are not wholly representative of all health plans nationally, they offer a baseline against which to measure progress toward value-oriented payment in the commercial sector.
 

Spending on specialty medications is growing by more than 15 percent annually, and it is expected to account for approximately half ($235 billion) of total annual pharmacy spending by 2018. Among the numerous reasons for the high cost of this heterogeneous group of medications are the increasing size of target patient populations, the high cost of drug development, and a complex and uncoordinated delivery system. This article describes the evolution of the specialty market, characterize the current state of specialty medication use, and articulate key challenges and potential solutions.
 

Under the 2010 Affordable Care Act, millions of Americans gained health coverage in 2014. Coverage is key to accessing affordable, high-quality care, but consumers who struggle to understand how health insurance works and how to estimate out-of-pocket costs are at risk of going without needed care even if they are covered. This brief outlines what health insurance aspects pose the greatest problems for consumers, which groups need more assistance to enroll and use benefits, and what topics and skills consumer-counseling efforts should focus on.
 

For more than a decade, economic conditions, including two major recessions, were the primary driver of changes in Medicaid spending and enrollment. In FY 2014 and in budgets adopted for FY 2015, enrollment and spending have grown with implementation of the major coverage provisions in the ACA, including the federally financed Medicaid expansion. This report provides an overview of Medicaid spending and enrollment growth with a focus on state fiscal years 2014 and 2015 (FY 2014 and FY 2015) and an overview of Medicaid financing. Findings examine changes in overall enrollment and spending growth and compare expansion and non-expansion states.