State-based Exchanges Research Articles

Trends in State-Level Opinions toward the Affordable Care Act.

This article argues that the devolution of the Affordable Care Act (ACA) to the states contributed to the slow progression of national public support for health care reform. Using small-area estimation techniques, the authors measured quarterly state ACA attitudes on five topics from 2009 to the start of the 2016 presidential election. Public support for the ACA increased after gubernatorial announcement of state-based exchanges. However, the adoption of federal or partnership marketplaces had virtually no effect on public opinion of the ACA and, in some cases, even decreased positive perceptions. The authors' analyses point to the complexities in mass preferences toward the ACA and policy feedback more generally. The slow movement of national ACA support was due partly to state-level variations in policy making. The findings suggest that, as time progresses, attitudes in Republican-leaning states with state-based marketplaces will become more positive toward the ACA, presumably as residents begin to experience the positive effects of the law. More broadly, this work highlights the importance of looking at state-level variations in opinions and policies.

Coverage of Medications That Treat Opioid Use Disorder and Opioids for Pain Management in Marketplace Plans, 2017.

Efficacious medications to treat opioid use disorders (OUDs) have been slow to diffuse into practice, and insurance coverage limits may be one important barrier. To compare coverage for medications used to treat OUDs and opioids commonly prescribed for pain management in plans offered on the 2017 Health Insurance Marketplace exchanges. We identified a sample of 100 plans offered in urban and in rural counties on the 2017 Marketplaces, weighting by population. We accessed publicly available plan coverage information on healthcare.gov for states with a federally facilitated exchange, the state exchange website for state-based exchanges, and insurer websites. About 14% of plans do not cover any formulations of buprenorphine/naloxone. Plans were more likely to require prior authorization for any of the covered office-based buprenorphine or naltrexone formulations preferred for maintenance OUD treatment (ie, buprenorphine/naloxone, buprenorphine implants, injectable long-acting naltrexone) than of short-acting opioid pain medications (63.6% vs. 19.4%; P<0.0001). Only 10.6% of plans cover implantable buprenorphine, 26.1% cover injectable naltrexone, and 73.4% cover at least 1 abuse-deterrent opioid pain medication. Many Marketplace plans either do not cover or require prior authorization for coverage of OUD medications, and these restrictions are often more common for OUD medications than for short-acting opioid pain medications. Regulators tasked with enforcement of the Mental Health Parity and Addiction Equity Act, which requires that standards for formulary design for mental health and substance use disorder drugs be comparable to those for other medications, should focus attention on formulary coverage of OUD medications.

Consumer Health Insurance Shopping Behavior and Challenges: Lessons From Two State-Based Marketplaces.

Selecting a health plan in a health insurance exchange is a critical decision, yet consumers are known to face challenges with health plan choice. We surveyed new enrollees in two state-based exchanges in 2015 to investigate how a nonelderly, primarily low-income population chose their health plans and the implications of shopping behavior for early experiences in their plans. Financial considerations were most important to enrollees. Prior Medicaid enrollees and the uninsured were more likely to have multiple shopping challenges (e.g., difficulty identifying the best or most affordable plan, fair/poor experience, unmet need for help) than enrollees with prior employer coverage (42.9% vs. 32.5% vs. 16.4%, respectively, p < .01). Shopping challenges were associated with difficulty finding a doctor, understanding coverage, and getting questions answered. Assistance targeting enrollees who previously had Medicaid or lacked insurance could improve both shopping experiences and downstream outcomes in plans.

Assessing Individual Health Insurance Coverage and Utilization Before and After the Patient Protection and Affordable Care Act

The adoption of the Patient Protection and Affordable Care Act (PPACA) in 2010 with the intent to improve the U.S. health care delivery system by expanding health insurance coverage and controlling health care costs has generated intense debate regarding its implementation. Marketplaces known as insurance exchanges have been established to provide coverage for Americans who otherwise could not get affordable health care benefits. These exchanges have been plagued with financial losses and other challenges leading to several large insurance providers discontinuing participation in the program. There are many possible remedies under consideration to make the program work better. This research seeks to support program evaluation as well as potential modifications to the law by providing baseline data to compare access and costs in states with state-based exchanges compared to states with federal exchanges. The authors perform an analysis by state for the years 2012 and 2013 (pre-PPACA implementation) using data from the Current Population Survey (U.S. Census) as well as de-identified claims data from Inovalon, Inc.

Millions of Americans may be eligible for Marketplace coverage outside open enrollment as a result of qualifying life events.

Federal regulations establish special enrollment periods--times outside of open enrollment periods--during which people may enroll in or change their health insurance plans offered through the federal and state-based exchanges, or Marketplaces. To be eligible, a person must experience a shift in income or another "qualifying life event," such as a change in marital status or the number of dependents, or the loss of minimum essential health coverage. We produced an upper-bound estimate that 3.7 million nonelderly adults with coverage through a federal or state Marketplace could have experienced a qualifying life event and become eligible for a special enrollment period because of income shifts. In addition, more than 8.4 million nonelderly adults who did not have Marketplace coverage--three-quarters of whom had no insurance--became eligible for a special enrollment period as a result of other qualifying life events. Many if not most of these people may be unaware of their eligibility. In states that did not expand Medicaid eligibility, we estimated that 1.9 million people experienced income shifts outside of the open enrollment period that would make them eligible for Marketplace subsidies. However, because they were uninsured or had nongroup coverage (instead of Medicaid) during the most recent open enrollment period, they had to wait until the next period to enroll in a Marketplace plan.

Republican States Bolstered Their Health Insurance Rate Review Programs Using Incentives From the Affordable Care Act.

The Affordable Care Act (ACA) included financial and regulatory incentives and goals for states to bolster their health insurance rate review programs, increase their anticipated loss ratio requirements, expand Medicaid, and establish state-based exchanges. We grouped states by political party control and compared their reactions across these policy goals. To identify changes in states’ rate review programs and anticipated loss ratio requirements in the individual and small group markets since the ACA’s enactment, we conducted legal research and contacted each state’s insurance regulator. We linked rate review program changes to the Centers for Medicare and Medicaid Services’ (CMS) criteria for an effective rate review program. We found, of states that did not meet CMS’s criteria when the ACA was enacted, most made changes to meet those criteria, including Republican-controlled states, which generally oppose the ACA. This finding is likely the result of the relatively low administrative burden associated with reviewing health insurance rates and the fact that doing so prevents federal intervention in rate review. However, Republican-controlled states were less likely than non-Republican-controlled states to increase their anticipated loss ratio requirements to align with the federal retrospective medical loss ratio requirement, expand Medicaid, and establish state-based exchanges, because of their general opposition to the ACA. We conclude that federal incentives for states to strengthen their health insurance rate review programs were more effective than the incentives for states to adopt other insurance-related policy goals of the ACA.

Federal Health Insurance Reform and “Exchanges”: Recent History

The major national innovation of the Affordable Care Act (ACA) is the insurance exchange or health insurance marketplace (HIM). We begin by briefly reviewing the ACA's chief features and detailing its HIM provisions. Section two explores the policy history of exchanges, beginning with Clinton's proposals and Massachusetts' Connector and concluding by contrasting the House-passed bill with one national exchange and the Senate bill with state-based exchanges. The Senate bill became the ACA. The evolution of policy ideas about exchanges suggests three critical conditions for a successful exchange: commodification (of insurance products), competition (between insurers), and communication (to potential buyers and the public about insurance). The penultimate section compares the rollout of the state-run Kentucky exchange and the federally facilitated exchange in North Carolina in light of what we will call the 3 Cs. The conclusion reflects more widely upon the unique form that the pro-competition or deregulatory strategy has taken in health policy.

Patient care opportunities under ACA in 2014

Patient care opportunities under ACA in 2014

More Than Half Of Individual Health Plans Offer Coverage That Falls Short Of What Can Be Sold Through Exchanges As Of 2014

The Affordable Care Act creates state-based health exchanges that will begin acting as a market place for health insurance plans and consumers in 2014. This paper compares the financial protection offered by today's group and individual plans with the standards that will apply to insurance sold in state-based exchanges. Some states may apply these standards to all health insurance sold within the state. More than half of Americans who had individual insurance in 2010 were enrolled in plans that would not qualify as providing essential coverage under the rules of the exchanges in 2014. These people were enrolled in plans with an actuarial value below 60 percent, which means that the plans covered less than that proportion of the enrollees' health expenses. Many of today's individual health plans are below the "bronze" level, the lowest level of plan that can be sold through exchanges. In contrast, most group plans in 2010 had an actuarial benefit of 80-89 percent and would qualify as highly rated "gold" plans in the exchanges. To sell to ten million new buyers on the exchanges, insurers will need to redesign benefit packages. Combined with a ban on medical underwriting, the individual insurance market in a post-health reform world will sharply contrast with the market of past decades.

Success of Health Exchanges Hinges on Cost Considerations

Success of Health Exchanges Hinges on Cost Considerations

Reality check for American dream

There's a lot of confusion out there; says Janet Witt, from the National Committee to Preserve Social Security and Medicare, the scheme that provides insurance to people aged over 65. Witt has been trying to explain what President Obama's health-reform legislation means. It has not been easy. are a lot of rumours; says Witt. The legislation itself is nearly a thousand pages long and will take years to implement. Its impact will depend partly on how individual states--many of them hostile to change--put it into effect. The law extends insurance coverage to 32 million previously uninsured Americans. This extension will be paid for by increasing premiums, imposing new taxes and making cuts to Medicare. Almost all Americans will be obliged to get coverage by 2014 or face being fined. From 2013, individuals earning more than US$ 200 000 a year and households earning more than US$ 250 000 will pay higher contributions, while high-income taxpayers will start paying a 3.8% tax on income such as dividends and interest. There will also be a 40% tax on so-called Cadillac plans--those with an annual cost exceeding US$10 200 for individuals or US$ 27 500 for families (not including optical and dental benefits). The self-employed and those working in small business will be among the main beneficiaries of the reforms. Other immediate changes to include free preventive services, such as screenings for colon, prostate and breast cancer. Senior citizens caught in a funding gap for prescription drugs (referred to as the doughnut hole) will receive a one-off rebate of US$ 250 and, from 2011, they will be eligible for a 50% discount on brandname pharmaceuticals. A notable change will be reductions in subsidies to Advantage, a scheme introduced in 1997 to promote the use of private insurers within the main programme. Offered by private health insurance companies, plans are funded partially by and partially by charging members an additional monthly premium r to cover extra items such as prescription drugs, dental and optical care. Currently 24% of beneficiaries participate in plans. However, average payments to private insurers under this scheme are estimated at between 9-13% more than what would have been paid in the traditional programme. The reform will reduce these excess subsidies to the private insurers while concurrently offering bonus payments to insurers that score well in a quality rating system. Patricia Nemore, a senior policy attorney at the Center for Advocacy in Washington DC, welcomes these changes. Medicare was unfair to the taxpayers because part of it was funded by general revenues, and it was unfair to every single beneficiary because they were paying their premiums but were not all enrolled in Advantage she says. [ILLUSTRATION OMITTED] Revenue from these changes will allow the government to increase participation in Medicaid, a means-tested programme serving people on low-incomes or with certain disabilities. This will increase coverage to an extra 20 million people and increase Medicaid eligibility in some states by 50% or more. But Professor Randy Ellis, a health economist at Boston University and supporter of the reforms, warns: We have now increased the number of people eligible for Medicaid without changing the number of doctors or beds. However, Dr Robert Wachter, at the University of California San Francisco Medical Center, says increased Medicaid enrolment will not necessarily pose a problem. If the reform encourages people to use primary care, hospital use may not be significantly increased. Just as dramatic as the extension of coverage is the change to how health insurance will be sold. From 2014, private insurance will be sold in state-based exchanges. Insurers will be unable to reject applicants based on health status or increase premiums beyond regulated levels. …

Insurance Exchanges Under Health Reform: Six Design Issues For The States

The Patient Protection and Affordable Care Act depends on new, state-based exchanges to make health insurance readily available to certain segments of the population. One such segment is the lower-income uninsured, who can qualify for subsidized coverage only through an exchange. Other segments are unsubsidized individuals and small employers, who may choose to buy coverage inside or outside of an exchange. Although the law provides some guidance in structuring these new exchanges, it leaves many key decisions to the states. Successfully implementing exchanges will require public-private partnerships, expertise in insurance operations and marketing, and a series of strategic decisions. We review the half-dozen most important design issues.