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.
 

The Affordable Care Act has resulted in considerable competition. In a large number of markets, this has resulted in lower premiums than expected, though there is considerable variability within each metal tier. This analysis assesses the variation in premiums within markets and the effects of competition in 10 states: Alabama, Arkansas, Colorado, Maryland, Massachusetts, New York, Oregon, Rhode Island, Virginia, and West Virginia. Four of the states have fairly limited competition, while the other six are very competitive, especially in urban, more populated markets.
 

This brief describes global and episodic bundling and outlines considerations for state Medicaid agencies when evaluating potential implementation, including the relevance of these strategies for Medicaid agencies employing managed care strategies.

The Affordable Care Act (ACA) created the Consumer Operated and Oriented Plan (CO-OP) Program to provide consumer-focused health insurance options. But the CO-OP experience to date reveals factors that limit market competition. This report considers the challenges that CO-OPs have faced through analysis of plan, pricing, and enrollment data for six CO-OPs. It describes how CO-OPs responded to the prohibition on using federal loans for marketing, problems associated with outsourcing health plan functions, CO-OP plan design and pricing strategies, dynamics of both high and low enrollment, and challenges related to the ACA’s premium stabilization programs. It includes a discussion of the role of federal and state policy decisions in adding to rather than reducing barriers to market entry for CO-OPs.

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.

On November 9, 2015, the Centers for Medicare & Medicaid Services released the final 2017 essential health benefits benchmark plan for each state. A summary of benchmark plan coverage and the supporting plan document, as well as a list of how many prescription drugs are covered in each United States Pharmacopeia (USP) category and class were posted. The final list includes feedback received during the 30-day comment period.

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.

This brief uses data submitted by insurers on medical loss ratios (MLRs) from 2010 to 2014 to assess how the Affordable Care Act’s (ACA’s) provisions impacted states’ individual health insurance markets. It compares average net MLRs by state and examines the distribution of net MLRs across insurers in each state. In the individual market, researchers found: average net MLRs rose because of rising net claims relative to net premiums, almost all states had average net MLRs higher than 80 percent by 2014, and average net MLRs varied from 83 percent at the 25th percentile to 99 percent at the 75th percentile.

Through reforms to cost containment and expanded access to health insurance plans, the Affordable Care Act (ACA) has begun to shape the delivery and cost of health care services to Americans. Many of these reforms are still taking hold, and it is too soon to completely know how they are affecting the health care system. But looking beyond these considerations, it appears that many enduring economic challenges persist in the markets that provide health care and health insurance to consumers. This paper offers six economic facts that highlight continuing challenges and complexities in health care and health insurance markets on which the policy debate should focus.
 

Large data sets that can be analyzed to determine patterns of behavior – popularly called “big data” – are being used in ever-expanding ways. State insurance regulators have adopted the use of big data to conduct oversight of certain kinds of insurance, such as workers’ compensation and life insurance. However, those agencies providing oversight of health insurers have undertaken only modest efforts to collect, analyze, and use large sets of claims, enrollment or sales data to understand market trends and how consumers are using their health insurance to access and pay for care. This issue brief discusses how insurance regulators and third parties are currently using data collection, and how it could change under yet-to-be-implemented provisions within the Affordable Care Act as means for improving health plan oversight and compliance.