Private Insurance:
Improving the Market
Improving the Market provides more technical information for advocates and policymakers about tools used to regulate and improve the private market for consumers.
From Families USA
Help Wanted: Preparing Navigators and Other Assisters to Meet New Consumer Needs explains the requirements for navigator programs and answers seven key questions that states will face as they seek to establish effective navigator programs. It is available as an online tool kit and as a PDF. (Updated January 2013)
Filling in Gaps in Consumer Assistance: How Exchanges Can Use Assisters explains the key differences between navigator and assister programs and how in-person assistance can function in the different types of exchanges. It also recommends actions advocates can take. (Updated January 2013)
Consumer-Friendly Standards for Qualified Health Plans in Exchanges: Examples from the States outlines the minimum standards for qualified health plans as set out in the Affordable Care Act. It then provides examples from eight state-based exchanges and one partnership exchange state on how to implement those standards in consumer-friendly ways. (January 2013)
The District of Columbia Health Benefits Exchange Proposal provides answers to questions about how the exchange will work and how it will help District residents and small businesses obtain affordable health coverage. (October 2012)
Exchange Implementation: To Partner or Not to Partner? lists questions to consider in determining whether a partnership exchange would be in the best interest of consumers and small businesses in states that are unlikely to establish state-based exchanges. (October 2012)
State Responsibilities in a Partnership Exchange explains the options for states that choose to implement a partnership exchange, and it describes the functions that partner states will need to perform. (October 2012)
Worry No More: Americans with Pre-Existing Conditions Are Protected by the Health Care Law provides estimates of how many people will be protected from discrimination based on their health status thanks to the health care law. For the first time, the state reports include county-level data, and they include state-level data that are broken down by age, income, and racial or ethnic group. (July 2012)
Good Business Sense: The Small Business Health Care Tax Credit in the Affordable Care Act provides national and state-level estimates of the number of small businesses that will be eligible for this tax credit and of how much the credits will be worth. It also includes data on how many workers could benefit as a result, broken down according to racial and ethnic group. (Done in collaboration with Small Business Majority, May 2012)
Decoding Your Health Insurance: The New Summary of Benefits and Coverage provides national and state-level data on the nearly 173.5 million people with private insurance who will be helped by these plain-language summaries that are required by the health care law. (May 2012)
Implementing the Patient Protection and Affordable Care Act: A 2012 State To-Do List for Exchanges, Private Coverage, and Medicaid gives state advocates an in-depth blueprint for action in 2012, outlining issues to start thinking about and tasks that deserve immediate attention. (February 2012)
Designing Consumer-Friendly Beneficiary Assignment and Notification Processes for Accountable Care Organizations discusses the challenges advocates will face when developing these processes, and it recommends certain notification requirements and beneficiary protections. (January 2012)
Putting the Accountability in Accountable Care Organizations: Payment and Quality Measurements examines some of the challenges that advocates will face when working with policy makers, insurers, and providers to develop mechanisms that ensure that beneficiaries receive high-quality care at a lower cost. | Determining Shared Savings or Losses (January 2012)
States Making Progress on Rate Review highlights state efforts to protect consumers from unreasonable increases in insurance premiums. It also explains provisions of the Affordable Care Act that encourage improvements to states' rate review processes. (October 2011)
Why We Need a Health Insurance Exchange is a one-page handout that cites several reasons why consumers will benefit from the new exchanges, including competition, affordability, and quality. Advocates can modify this version to fit their needs. (June 2011)
Obtaining Exchange Funding and Achieving Consumer-Friendly Outcomes: A State "To Do" List outlines tasks states need to complete to obtain federal exchange grants and move ahead with implementation of an exchange. (May 2011)
The Affordable Care Act: Patients' Bill of Rights and Other Protections is a compilation of all of our fact sheets to date on consumer rights and protections. (April 2011)
Implementing Health Insurance Exchanges: Options for Governance and Oversight highlights key issues to consider in the creation of a successful, consumer-friendly governance structure, including where the exchange should be housed, good governance, and duties of a board. (April 2011)
Selecting Plans to Participate in an Exchange: A State Guide is designed to help stakeholders understand what's involved and how the process can be structured in the best interest of state residents. It reviews the federal minimum standards, discusses additional elements to consider, and offers specific state examples. (February 2011)
Building an Effective State Exchange offers 15 benchmarks to guide advocates and legislators as they develop the new health care exchanges that are required by the Affordable Care Act. Advocates are free to take this document and adapt it to the needs of their states. 3 pp. (December 2010)
Buyer Beware: Unlicensed Insurance Plans Prey on Health Care Consumers reports on actions that states have taken against American Trade Association, Serve America Assurance, and Smart Data Solutions. It also discusses the sale of phony insurance more generally, weaknesses in oversight of association health plans, and new protections under the Affordable Care Act. (October 2010)
How States Are Making Sure Coverage Is Available to Children notes that, under health reform, insurers are required to accept children regardless of any pre-existing conditions in all group plans and in newly sold individual plans, and it examines what several states are doing to make sure that child-only policies are still available. (October 2010)
Implementing Health Insurance Exchanges: A Guide to State Activities and Choices describes the requirements in the Affordable Care Act that exchanges must meet and outlines key questions that states and consumer advocates will need to consider as the exchanges are designed. (October 2010)
Families USA had prepared a series of fact sheets on the Patients' Bill of Rights and other consumer protections in the Affordable Care Act that took effect on September 23. (September 2010)
Rate Review: Holding Health Plans Accountable for Your Premium Dollars discusses common problems with the process of reviewing health insurance premium rates, the lessons learned from state rate review procedures, and how health reform will address these problems. (March 2010)
Medical Loss Ratios: Making Sure Premium Dollars Go to Health Care—Not Profits discusses medical loss ratios, state requirements regarding medical loss ratios, and why medical loss ratio requirements are so important for protecting consumers. (February 2010)
Fighting Revocations and Limitations of Health Insurance Policies addresses the insurance company practice of revoking an individual's health insurance or suddenly eliminating coverage for health services long after the person has enrolled (known as "post-claims underwriting"). It also discusses what consumers and advocates can do about the practice. (July 2008)
Failing Grades: State Consumer Protections in the Individual Health Insurance Market. Laws protecting consumers purchasing health coverage in the individual market vary across the country. In many states, insurance companies can deny coverage, raise premiums significantly, refuse to cover treatment for certain conditions, and even revoke the coverage of policyholders who have been paying premiums for years. (June 2008)
Medical Loss Ratios: Evidence from the States presents the results of a 50-state survey we conducted in March and April 2008 that determined which states have laws or regulations that establish a minimum "medical loss ratio" (a percentage of premium dollars that must be spent on medical care). (June 2008)
The Facts about Prior Approval of Health Insurance Premium Rates discusses several insurance industry myths about the consequences of prior approval. The prior approval process is used by most states to make sure that insurance companies' proposed premium increases are not excessive. (June 2008)
Reinsurance: A Primer aims to help policymakers and advocates better understand what reinsurance is and how it can make coverage easier to obtain and more affordable. It also identifies some of the benefits of reinsurance to aid lawmakers as they design reinsurance programs to meet the needs of their states. (April 2008)
A Pound of Flesh: Hospital Billing, Debt Collection, and Patients' Rights provides an overview of some of the progressive reform measures that state policymakers have implemented to help families struggling with medical debt. (March 2007)
Families USA and Community Catalyst Consumer Guide to State Health Reform provides advocates with an array of policy options that can improve the private insurance market for health care consumers.
Understanding How Health Insurance Premiums Are Regulated discusses the state and federal regulation of health insurance premiums. (September 2006)
High-Risk Health Insurance Pools provides answers to key questions about high-risk pools, including who they help and how they are financed. The report also includes a list of questions consumers should ask if they are considering joining a high-risk pool, as well as a checklist for advocates. (May 2006)
Protecting Consumers from Unfair Rate Hikes: The Need for Regulation of Health Insurance Renewal Premium Increases This Issue Brief examines the insurance industry practice of re-underwriting at renewal and discusses current efforts to regulate the practice at the federal and state levels. (February 2003)
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From Other Organizations
Insurers’ Responses to Regulation of Medical Loss Ratios finds that, although insurers reduced administrative costs in response to the medical loss ratio rule in the Affordable Care Act, these reduced costs were offset by increased profits for insurance companies. (Commonwealth Fund, December 2012)
Jobs without Benefits: The Health Insurance Crisis Faced by Small Businesses and Their Workers explains how the Affordable Care Act will help small business employees, who are more likely to be uninsured than workers in large firms, with new coverage options, tax credits, the medical loss ratio rule, and protection from coverage denials for pre-existing conditions. (Commonwealth Fund, November 2012)
State Profiles provides information on each state’s exchange implementation status, including the amount of federal funding the state has received to create an exchange, the decisions it has made related to outreach and enrollment, and links to other state-specific resources. The profiles will be regularly updated to reflect progress in creating exchanges. (Enroll America, November 2012)
Quantifying the Effects of Health Insurance Rate Review compares the average rate changes that insurers requested to the rates that were ultimately implemented. It finds that, on average, approved rate increases were 1.4 percentage points lower than what insurers initially requested. It also includes an overview of the rate review information that is available for each state and links to view rate information online. (Kaiser Family Foundation, October 2012)
Federal Health Reform Is Largely Market-Based, Despite Contrary Assertions explains that the Affordable Care Act creates a more effective insurance market by encouraging consumers to seek the best value in health coverage and enabling them to do so with better information and more affordable options. (Urban Institute, October 2012)
Selling Health Insurance across State Lines: An Assessment of State Laws and Implications for Improving Choice and Affordability of Coverage analyzes the implementation of laws in six states (GA, KY, ME, RI, WA, and WY) that allow the sale of insurance across state lines. Although these laws were designed to enhance consumer choice, to increase competition, and to make insurance more affordable, the complexities of how insurance is sold and regulated have deterred insurance companies from entering new markets, thereby undermining the laws’ goals. (Center on Health Insurance Reforms, October 2012)
Designing Navigator Programs to Meet the Needs of Consumers: Duties and Competencies elaborates on the minimum requirements for navigators and discusses how states can expand the role of navigators to better serve consumers. It also includes a table with examples of activities that navigators can engage in to fulfill their required responsibilities. (Center for Children and Families, September 2012)
2012 Annual Rate Review Report: Rate Review Saves Estimated $1 Billion for Consumers discusses the benefits of rate review, which is the provision in the Affordable Care Act that requires insurance companies to justify premium increases of 10 percent or more. Since its implementation in September 2011, rate review has saved consumers money, and it has increased transparency in the insurance market. (HealthCare.gov, September 2012)
Plan Participation in Health Insurance Exchanges: Implications for Competition and Choice considers how competition among insurance plans is likely to play out in 10 states: AL, CO, MD, MI, MN, NM, NY, OR, RI, and VA. It finds that states are more likely to experience effective competition in their exchange if they have multiple insurers with a significant market share and the ability to negotiate with providers. (Robert Wood Johnson Foundation and the Urban Institute, September 2012)
State Progress in Implementing Health Insurance Exchanges: Results from 10 State Analyses describes the status of exchange development in 10 states: AL, CO, MD, MI, MN, NM, NY, OR, RI, and VA. Because the Affordable Care Act allows for a great deal of flexibility in exchange design, states are developing exchanges with a variety of goals and characteristics. The report includes a table that outlines key differences among the 10 featured states. (Robert Wood Johnson Foundation and the Urban Institute, September 2012)
Establishing Health Insurance Exchanges: An Overview of State Efforts provides an overview of what states have done so far to set up exchanges. It includes a table that lays out key characteristics of established exchanges, such as structure, contracting type, and governance. (Kaiser Family Foundation, August 2012)
Consumer Assistance in the Digital Age: New Tools to Help People Enroll in Medicaid, CHIP, and Exchanges focuses on how states can help the millions of Americans who will be eligible for more affordable coverage through Medicaid or the exchanges and how current consumer assistance efforts will change as new technology transforms the enrollment process. (National Academy for State Health Policy and the Robert Wood Johnson Foundation, July 2012)
Health Insurance Exchanges: Can States and the Federal Government Meet the Deadline? is a briefing that answered the following questions: What do states need to do between now and January 2014 to successfully implement exchanges? What are the options for states that fail to meet the November deadline to declare their exchange plans? And what are the potential challenges of implementing the federal exchange, especially in states that oppose the law? (Alliance for Health Reform, July 2012)
State Action to Establish Health Insurance Exchanges is an interactive map that shows the status of state action on exchanges. In states that have begun to establish exchanges, the map explains key aspects of existing exchanges, state legislation, and executive orders. (Commonwealth Fund, July 2012)
Health Care after the Supreme Court Decision: What’s Next? answers the following questions: How many states will be ready to run exchanges? Is the federal government prepared to administer exchanges in states without one? What does the court’s ruling mean for people without insurance? And will some states continue to delay implementation efforts until after the November elections? (Alliance for Health Reform, July 2012)
Massachusetts Health Care Reform: Six Years Later examines implementation efforts in Massachusetts and looks to what lies ahead under the Affordable Care Act. It finds that the state has succeeded in expanding coverage to nearly all residents, and people have experienced increased access to coverage, but the state still struggles with rising health care costs. (Kaiser Family Foundation, May 2012)
Estimating the Impact of the Medical Loss Ratio Rule: A State-by-State Analysis estimates that consumers would have received almost $2 billion in rebates this year if the medical loss ratio rules had been in effect in 2010. It also breaks down the rebates consumers would have received by state and by insurance market. (Commonwealth Fund, April 2012)
Gaps in Health Insurance: Why So Many Americans Experience Breaks in Coverage and How the Affordable Care Act Will Help finds that one-quarter of adults aged 19 to 64 experienced a gap in their health insurance in 2011, with a majority remaining uninsured for one year or more. It also explains how the Affordable Care Act’s Medicaid expansion and exchanges will help people maintain coverage. (Commonwealth Fund, April 2012)
Insurer Rebates under the Medical Loss Ratio: 2012 Estimates finds that consumers and businesses are expected to receive an estimated $1.3 billion in rebates from health insurers who spent more on advertising, administrative expenses, and profits than allowed by the Affordable Care Act. (Kaiser Family Foundation, April 2012)
States and the Affordable Care Act is a series of state reports that analyze the effects of the Affordable Care Act on coverage, health expenditures, affordability, access, and premiums. It also assesses state’s progress with implementation of the law. The reports examine the following states: CO, MD, NY, OR, and RI. (Urban Institute, April 2012)
Implementing the Affordable Care Act: State Action on Early Market Reforms explains that 49 states and the District of Columbia have worked to implement certain consumer protections that took effect in 2010. It also suggests that, even if legislative action is difficult, states can still make progress with implementation by issuing sub-regulatory guidance and verifying insurers’ compliance with the law. (Commonwealth Fund, March 2012)
Implementing Health Reform in the States discusses key elements of the Affordable Care Act that states must address and offers an update on the status of implementation. It also discusses the issues of whether states will aggressively promote the Medicaid expansion to those who will be eligible and what will happen if the Supreme Court rules the expansion unconstitutional. (Alliance for Health Reform, March 2012)
Turning to Fairness: Insurance Discrimination against Women Today and the Affordable Care Act discusses the practice of gender rating, in which insurance companies charge women different premiums than men. Gender rating costs women about $1 billion a year, but the Affordable Care Act will outlaw this practice in 2014. (National Women's Law Center, March 2012)
Under the Affordable Care Act, 105 Million Americans No Longer Face Lifetime Limits on Health Benefits breaks down the number of Americans who are enjoying improved coverage without lifetime limits by age group, state, and race or ethnicity. (Department of Health and Human Services (HHS), March 2012)
Achieving Equity by Building a Bridge from Eligible to Enrolled explains the importance of doing culturally and linguistically appropriate outreach and education to facilitate enrollment in health coverage. Without effective multilingual efforts in California, language barriers may mean that 110,000 fewer people with limited English proficiency enroll in coverage through the state’s exchange. (California Pan-Ethnic Health Network, the UCLA Center for Health Policy Research, and the UC Berkeley Labor Center, February 2012)
Fifty-Four Million Additional Americans Are Receiving Preventive Services Coverage without Cost-Sharing under the Affordable Care Act breaks down the number of Americans who are receiving preventive services with no cost-sharing by age group, state, and race or ethnicity. (Department of Health and Human Services (HHS), February 2012)
Frequently Asked Questions on Essential Health Benefits Bulletin answers questions for advocates and policy makers who are working to define the Essential Health Benefits package in their state. Topics include funding of state-mandated benefits, selection of benchmark plans, and coverage of preventive health services. (Centers for Medicare and Medicaid Services (CMS), February 2012)
Health-Insurance Coverage for Low-Wage Workers, 1979-2012 and Beyond discusses the steady decline in coverage for low-wage workers over the past three decades, but it also explains that the experience with health reform in Massachusetts suggests that the Affordable Care Act may reverse this trend. (Center for Economic and Policy Research and Georgetown University, February 2012)
Small Business Insurance Exchanges examines issues that states have to address in designing Small Business Health Option Program (SHOP) exchanges and the challenges advocates and policy makers? are likely to face. Although exchanges for individuals and small businesses will have similar functions, they will have unique attributes reflecting the populations they serve. (Health Affairs and the Robert Wood Johnson Foundation, February 2012)
ACA Implementation in Oregon—Monitoring and Tracking is the first of 10 state reports that analyze the effects of the Affordable Care Act on coverage, health expenditures, affordability, access, and premiums. It also assesses Oregon’s progress with implementation of the law. The remaining nine reports will examine the following states: AL, CO, MD, MI, MN, NM, NY, RI, and VA. (Robert Wood Johnson Foundation and the Urban Institute, February 2012)
Employers and the Exchanges under the Small Business Health Options Program: Examining the Potential and the Pitfalls introduces a collection of articles in the February issue of “Health Affairs” that discuss the need for small business exchanges and how they will function. It also examines the difficulties that exchanges will face and the opportunities they will offer to states, employers, and individuals. (Health Affairs, February 2012)
Essential Health Benefits: Balancing Affordability and Adequacy answers the following questions: How do states select and design “benchmark” plans that are both comprehensive and affordable? How will states and HHS ensure that benefits are sufficiently standardized so that consumers and employers can choose plans based on differences in premiums and cost-sharing? And are there opportunities for using the essential health benefits to lower health spending? (Alliance for Health Reform, February 2012)
The Income Divide in Health Care: How the Affordable Care Act Will Help Restore Fairness to the U.S. Health System explains that the law will narrow the income divide in health coverage and access through expanded Medicaid eligibility, state insurance exchanges, premium tax credits, cost-sharing protections, and the individual mandate. (Commonwealth Fund, February 2012)
Building a Relationship between Medicaid, the Exchange, and the Individual Insurance Market focuses on the following key areas where states can focus their efforts to promote continuity of coverage: establishing a joint strategy to align health plan policies across markets, aligning the eligibility determination and redetermination process, and coordinating benefit design across multiple markets. (National Academy of Social Insurance and the Robert Wood Johnson Foundation, January 2012)
Explaining Health Care Reform: How Will the Affordable Care Act Affect Small Businesses and Their Employees? explains the provisions of the law that relate specifically to small businesses, including exchanges, penalties for not providing affordable coverage, and tax credits to assist with insurance costs. (Kaiser Family Foundation, January 2012)
Should States Integrate Health Insurance Exchanges and Medicaid? discusses the benefits of integration for both states and consumers, such as reduced costs and continuity of coverage. (Robert Wood Johnson Foundation, January 2012)
Federally-Facilitated Exchanges and the Continuum of State Options reviews how the core functions of an exchange will work depending on where it falls on the continuum from entirely state-based to entirely federally operated. It also discusses the implications for states as they choose exchange formats as interim or permanent solutions. (National Academy of Social Insurance and the Robert Wood Johnson Foundation, December 2011)
New CMS Estimates of State-by-State Health Expenditures examines trends in spending and their implications for several efforts to constrain health care costs, including provisions of the Affordable Care Act and various state initiatives. A video and podcast are available. (The Kaiser Family Foundation, December 2011)
Promoting Healthy Competition in Health Insurance Exchanges: Options and Trade-Offs examines decisions that state governments will face regarding standardization of premiums and benefits in their exchanges. States must find the right balance between simplicity and flexibility to promote competition among insurers, maximize the quality of health care, and minimize costs. (The National Institute for Health Care Reform, November 2011)
Addressing Barriers to Online Applications: Can Public Enrollment Stations Increase Access to Health Coverage? discusses the use of computers or kiosk stations in public places to make online applications more accessible. It identifies challenges and opportunities that policy makers need to understand as they design effective online application systems. (Consumers Union, November 2011)
Accountable Care Organizations in Medicare and the Private Sector: A Status Update provides an overview of ACOs, their origins, and the current status of Medicare and private health plans adopting this model. (The Robert Wood Johnson Foundation and the Urban Institute, November 2011)
Making the Grade: A Scorecard for State Health Insurance Exchanges assesses the progress that states have made in establishing exchanges. For those states that have not begun to set up their exchange, the report evaluates whether they will ultimately be successful in improving their insurance markets. (U.S. PIRG Education Fund, October 2011)
How Competitive Are State Insurance Markets? assesses state health insurance markets in order to establish a baseline and provide context for policy decisions about exchanges and rate review. (The Kaiser Family Foundation, October 2011)
Employer-Sponsored Health Insurance: Down but Not Out explains that, while it is convenient to refer to job-based coverage as a single concept, the needs of employers differ dramatically. Similarly, the impact of the Affordable Care Act will vary substantially depending on differences in state approaches to reform implementation and local labor market conditions. (The Center for Studying Health System Change, October 2011)
Implementing Health Insurance Exchanges: State Profiles examines each state’s progress in setting up the exchanges that were mandated by the Affordable Care Act. The state-specific briefs cover where states are in the legislative process, whether states have received federal funding, and their next steps. (The Kaiser Family Foundation, October 2011)
The Role of Exchanges in Quality Improvement: An Analysis of the Options explains that, because an exchange can aggregate the purchasing power of individuals and small groups, it could improve health care quality as well as payment and delivery. The piece describes options that states could pursue to use their exchanges to drive these improvements. (The Robert Wood Johnson Foundation and the Georgetown University Health Policy Institute, September 2011)
State Action towards Creating a Health Insurance Exchange is an easy-to-read table that includes regularly updated information on the status of states’ work on implementing exchanges. The chart also notes the structure and type of exchange that each state seeks to enact. (statehealthfacts.org, August 2011)
Health Insurance Exchange Development: Innovation in the States is a video of panel discussions with state leaders and stakeholders that explores states’ progress on implementing the exchanges; it also identifies next steps. A podcast is also available. (Kaiser Family Foundation, July 2011)
Will Health Insurance Ever Get Cheaper? addresses the problems with rate review, noting that too many states lack or fail to exercise the authority to guarantee that health insurance premiums are affordable. Under the health care law, the federal government offered most states a $1 million grant to improve their rate review capabilities. (Stateline, July 2011)
The Evolution of State Health Insurance Exchanges looks at the impact of exchanges on the health care industry, states, and health reform efforts. The forum also discusses the political climate surrounding health reform and how it might affect the law and its implementation. (Health Industry Forum, July 2011)
Improving Health Care Access for Low-Income People: Lessons from Ascension Health’s Community Collaboratives examines seven communities where Ascension Health, the largest nonprofit health system, collaborated with other safety net providers to improve health care. While some challenges remain, the lessons from these communities can be valuable to policy makers as they implement the health care law. Log in required. (Health Affairs, July 2011)
Active Purchasing for Health Insurance Exchanges: An Analysis of Options discusses whether active purchasing or a broader approach—similar to Travelocity.com—would be preferable for states. While there is no one-size-fits-all plan for every state, it concludes that, even in the states that are most resistant to active purchasing, there will be at least some activities that exchanges can undertake on behalf of beneficiaries. (Georgetown University Health Policy Institute and the National Academy of Social Insurance (NASI, June 2011)
States Should Take Additional Steps to Limit Adverse Selection among Health Plans in an Exchange explains how the health care law seeks to minimize adverse selection in the exchanges and recommends additional steps that states can take to do so, such as requiring insurers that sell in the exchanges to offer plans in every coverage level. (Center on Budget and Policy Priorities, June 2011)
Keeping Coverage Continuous: Smoothing the Path between Medicaid and the Exchange looks at the approaches states and the federal government are taking to minimize the disruption for people who will be moving between public coverage and the exchanges as their incomes fluctuate. (Alliance for Health Reform, May 2011)
Maintaining Coverage, Affordability, and Shared Responsibility When Income and Employment Change offers recommendations on how states and the federal government can coordinate eligibility for premium credits, Medicaid, and the Children’s Health Insurance Program (CHIP); facilitate continuous coverage as incomes change; and minimize transitions between the individual and small business exchanges as they implement the health care law. (Commonwealth Fund, May 2011)
Women at Risk: Why Increasing Numbers of Women Are Failing to Get the Health Care They Need and How the Affordable Care Act Will Help finds that rising health care costs, combined with slow income growth, have contributed to the decrease in health insurance among women. The health care law will help make coverage more affordable by requiring that plans offer free preventive care, banning gender rating, and offering premium subsidies. (Commonwealth Fund, May 2011)
Multi-State Health Insurance Exchanges explains why states may want to pursue regional exchanges, including to promote pooling across state lines and to establish more stable risk pools by combining markets in small population states. The brief also cautions lawmakers about possible drawbacks, such as adverse selection and political and administrative issues that may arise. (Robert Wood Johnson Foundation and the Urban Institute, April 2011)
How People Get Health Coverage under the Affordable Care Act Beginning in 2014 is an easy-to-use flow chart that explains how different people will get coverage under the health reform law based on their income level and job status. (Kaiser Family Foundation, March 2011)
A Profile of Health Insurance Exchange Enrollees highlights key characteristics of people who will enroll in the exchanges. This piece is designed to help federal and state policy makers make informed decisions about how to structure the exchanges to best meet the health needs of these groups. (Kaiser Family Foundation, March 2011)
The Massachusetts and Utah Health Insurance Exchanges: Lessons Learned examines the quality and choice of plans, affordability of coverage, and ease of enrollment for each plan and outlines the most important lessons from each state. (Georgetown University Health Policy Institute Center for Children and Families, March 2011)
Help on the Horizon: How the Recession Has Left Millions of Workers without Health Insurance, and How Health Reform Will Bring Relief examines the effect of the recession on the health coverage of adults between the ages of 19 and 64 and the implications for both their finances and their access to health care. The Affordable Care Act will greatly reduce the impact on health coverage and will protect workers from becoming uninsured. (Commonwealth Fund, March 2011)
Making Health Insurance Cost-Sharing Clear to Consumers: Challenges in Implementing Health Reform’s Insurance Disclosure Requirements reports on findings from a Consumers Union study that examined consumers’ initial reactions to the proposed Summary of Benefits and Coverage form, which uses standard language and formatting to explain what different health plans offer so that consumers can easily compare options for coverage. The findings revealed that, while consumers were able to use the form to compare coverage, they lacked confidence in the listed cost-sharing rates. (Commonwealth Fund, February 2011)
Health Care Reform without the Individual Mandate discusses what will happen to the health reform law if the mandate is repealed and explores alternatives to the mandate. The brief considers the two most popular alternatives and estimates their impact on insurance coverage, public-sector costs, and insurance prices. (Center for American Progress, February 2011)
Designing an Exchange: A Toolkit for State Policymakers builds on the National Association of Insurance Commissioners’ (NAIC) model exchange act in order to provide technical assistance to state policy makers who are interested in a broader range of policy options for designing an exchange. The toolkit includes legislative language with alternatives and additions to the NAIC model act, as well as explanations of key issues and concerns in designing an exchange. (National Academy of Social Insurance, January 2011)
Governance Issues for Health Insurance Exchanges discusses the options that are available to states to structure their exchanges: through a state government agency (either existing or newly created), a nonprofit entity established by the state, a multi-state exchange, or a federally operated exchange. The brief also outlines the issues and challenges that states are likely to face in developing their exchanges. (National Academy of Social Insurance, January 2011)
Opinion Survey: Small Business Owners’ Views on Key Provisions of the Patient Protection and Affordable Care Act looks at how small business owners view the small business tax credits and health insurance exchanges. Roughly one-third of employers who don’t currently offer insurance said they would be more likely to do so because of the tax credits. However, less than 50 percent of respondents were familiar with either provision. (Small Business Majority, January 2011)
Adults Ages 50-64 and the Affordable Care Act of 2010 describes the provisions that adults in this age group will benefit from the most, including the pre-existing condition insurance plan, the expansion of Medicaid eligibility, and the creation of exchanges and premium subsidies for people with low and moderate incomes. (Commonwealth Fund, December 2010)
Preventive Services without Cost Sharing examines the importance of preventive services, the expansion of access to those services that is required by the Affordable Care Act, and the pros and cons of expanding access to screenings and other tests. The law not only protects preventive services in private insurance, but it also gives state Medicaid programs financial incentives to cover preventive services, and it eliminates cost-sharing for preventive services in Medicare. (Health Affairs, December 2010)
Rate Review: Spotlight on State Efforts to Make Health Insurance More Affordable provides the results of a survey of 50 state rate review statutes and follow-up interviews with insurance regulators in 10 states (AK, CT, CO, ID, LA, ME, OH, PA, SC, and WI) to find out how rate regulation works in practice. (Kaiser Family Foundation, December 2010)
State Trends in Premiums and Deductibles, 2003-2009: How Building on the Affordable Care Act Will Help Stem the Tide of Rising Costs and Eroding Benefits finds that family premiums for job-based coverage increased by 52 percent, while per-person deductibles rose by 77 percent. Without the Affordable Care Act, average family premiums would rise to more than $23,000 by 2020. (Commonwealth Fund, December 2010)
Employer-Based Health Coverage Declined Sharply over Past Decade discusses how the health reform law will reverse this trend by giving tax credits to small businesses to help them provide coverage, fining large employers that do not offer affordable coverage to their employees, and encouraging workers to take up employer coverage through the individual responsibility provision. (Center on Budget and Policy Priorities, December 2010)
Early Retiree Insurance describes the temporary Early Retiree Reinsurance Program, which reimburses retiree health plans for high-cost medical claims. The program is intended to slow the decline in job-based coverage for retirees until the health insurance exchanges are up and running in 2014. (Health Affairs, November 2010)
Medical Loss Ratios describes what a medical loss ratio is, and it explains that how the federal regulations eventually define what constitutes a medical cost versus an administrative cost is important to how effective those regulations will be. (Health Affairs, November 2010)
Designing a Marketplace that Works: Steps to Affordable Coverage discusses the key issues for state and federal officials to consider when designing an exchange, including the timeline for developing an exchange, whether states should design their own exchanges, and the key challenges for states in implementing the new law. (Alliance for Health Reform and the Commonwealth Fund, October 2010)
Health Insurance Exchanges and the Affordable Care Act: Eight Difficult Issues analyzes and responds to eight of the most difficult issues that states and the federal government face in implementing the exchanges, including who should run the exchanges, how exchanges should avoid adverse selection, and what exchanges can do to reduce administrative costs. (Commonwealth Fund and Washington and Lee University Law School, September 2010)
Health Insurance Exchanges: Key Issues for State Implementation highlights several issues, including risk selection (both inside and outside of the exchanges), the rules governing carrier participation, how exchanges will interact with existing public programs, and whether states should establish their own exchanges or defer to the federal government. (Academy Health and State Coverage Initiatives from the Robert Wood Johnson Foundation, September 2010)
Realizing Health Reform’s Potential: Small Businesses and the Affordable Care Act of 2010 discusses the provisions designed to help small businesses pay for and maintain health coverage for their workers. The provisions include a tax credit to make coverage more affordable, exchanges to lower administrative costs and pool risk more broadly, and new market rules and benefit standards to protect smaller firms from second-rate health plans. (Commonwealth Fund, September 2010)
How Will the Patient Protection and Affordable Care Act Affect Small, Medium, and Large Businesses?provides an overview of the requirements and options for businesses under the new law, including the new Small Business Health Options Program (SHOP) exchanges that will be available to small (
Does the Patient Protection and Affordable Care Act Permit the Purchase of Health Insurance across State Lines? finds that, while the law does allow some cross-state sales of insurance, there are important differences between provisions in the Affordable Care Act and earlier proposals. Two important differences are that the law requires all states to meet a minimum standard of insurance regulation, and cross-state sales will not be allowed unless states join together to form a compact. (Robert Wood Johnson Foundation and the Urban Institute, August 2010)
States Should Structure Insurance Exchanges to Minimize Adverse Selection recommends four steps that states should take when setting up their exchanges to provide protection from adverse selection. These optional steps include making the market rules outside the exchange consistent with those that apply inside the exchange, and requiring insurers to offer the same products both inside and outside the exchange. (Center on Budget and Policy Priorities, August 2010)
How Much Is Too Much: Have Nonprofit Blue Cross Blue Shield Plans Amassed Excessive Amounts of Surplus? reports that out of the 10 plans sampled, seven held more than three times the minimum amount needed for solvency protection. In addition, many of these plans with large surpluses continued to raise premiums. The report recommends that states take surpluses into consideration when reviewing rate increases and establish better standards for what is an appropriate surplus for a nonprofit plan. (Consumers Union, July 2010)
How Will the Patient Protection and Affordable Care Act of 2010 Affect Young Adults? describes how different elements of health reform will help young adults, specifically the Medicaid expansion, subsidies for private insurance, the expansion of dependent coverage, and insurance market reforms. (Urban Institute and the Robert Wood Johnson Foundation, July 2010)
Realizing Health Reform’s Potential: Women and the Affordable Care Act of 2010 looks at how women will benefit from provisions that improve coverage and reduce premiums, eliminate pre-existing condition exclusions, eliminate gender rating, and others. Given that women, on average, use more health services over their lifetimes, the new law is likely to greatly improve women’s experience with the health care system. (The Commonwealth Fund, July 2010)
Delivering on the Promise: A State Guide to the Next Steps for Health Care Reform describes the issues and opportunities that states will face when implementing the law, such as the state exchanges, consumer protections, provisions focused on lowering costs and improving quality, and ways that states can continue improving health care beyond the new law. The guide is a useful tool for policy makers and advocates alike. (U.S. PIRG, June 2010)
Patients' Bill of Rights: President Obama has released new rules to implement key consumer protections that were part of the new Patient Protection and Affordable Care Act. (The White House, June 2010) | Families USA Press Release
What Women Need to Know about Health Reform: Insurance Reforms explains how women will benefit from these reforms given that plans have routinely discriminated against women by using gender rating, treating domestic violence as a pre-existing condition, and denying coverage because they’ve had a c-section or breast cancer. New insurance reforms and the “exchanges” will make it easier for women to get coverage in a private market that treats everyone fairly. (National Women's Law Center, June 2010)
Financial Incentives for Health Care Providers and Consumers looks at health reform’s efforts to employ financial incentives to promote the use of effective health services and discourage the use of marginally effective services. Under reform, HHS will study the effectiveness of wellness programs, the impact of incentives on consumer behavior, and the effectiveness of different types of rewards to ensure that these incentives not only control costs, but also improve the quality of care. (Mathematica, May 2010)
Key Health Insurance Market Reforms Not Achievable without an Individual Mandate explains that passing important insurance reforms without a mandate would encourage people to wait until they are sick to buy coverage. The insurance pool would then have primarily older, sicker people, which would raise premiums for everyone. The individual mandate will help get healthy people into the health insurance market, which would keep premiums at a more reasonable level. (The Center on Budget and Policy Priorities, April 2010)
Near-Term Changes in Health Insurance: Newly Enacted Health Reform Legislation Mandates Dozens of Health Insurance Changes details the provisions that go into effect during the first two years. Some of the early changes include requiring new health plans to eliminate cost-sharing for preventive services, create internal and external appeals processes, and ban pre-authorization requirements for emergency services. (Health Affairs, April 2010)
Health Insurance Exchanges in Health Care Reform: Legal and Policy Issues explains the nature and function of an exchange, including six roles that exchanges are intended to play in health reform. The report concludes that, given our past experience, the effectiveness of any new exchange will depend entirely on the institutions that are established to administer it, highlighting the importance of how Congress designs the exchanges in its health reform legislation. (The Commonwealth Fund and Washington and Lee University School of Law, December 2009)
Considering a Health Insurance Exchange: Lessons from the Rhode Island Experience highlights the importance of clearly defining the goals of an exchange, and getting major stakeholders to participate, during the health reform process. Rhode Island’s public reform process gave participants a greater understanding of which policy goals could be achieved by the various components of the exchange. States looking to Rhode Island as an example should note the basic steps to be followed when analyzing any exchange model. (The Robert Wood Johnson Foundation, June 2009)
Fork in the Road: Alternative Paths to a High Performance U.S. Health System compares three different health reform scenarios: 1) one that includes a public plan option in which health care providers would be paid at rates midway between Medicare rates and private plan rates, 2) one that includes a public plan option that links payments more closely to Medicare rates, and 3) one that includes no public plan (instead relying exclusively on private plans). Cumulative health system savings would range from $3 trillion under option 1 to $2 trillion for option 2 to $1.2 trillion for a purely private plan approach under option 3. (The Commonwealth Fund, June 2009)
How to Structure a “Play-or-Pay” Requirement on Employers examines not only how to structure an employer coverage mandate, but also the economic and political impacts of such a mandate, as part of health reform. In addition, it offers recommendations for navigating the political issues raised by such a requirement. The authors conclude that the potential negative effects of instituting a mandate are modest and would be outweighed by the benefits. (The Campaign for America’s Future, June 2009)
Setting a National Minimum Standard for Health Benefits: How Do State Benefit Mandates Compare with Benefits in Large-Group Plans? compares state-mandated benefits with the services and providers covered under the Federal Employees Health Benefits Program (FEHBP) Blue Cross and Blue Shield standard benefit package. With few exceptions, the FEHBP plan either meets or exceeds the benefits that state mandates require. Under a national standard, states would still have the option of providing other benefits above the national standard. (The Commonwealth Fund, June 2009)
Coverage When It Counts: What Does Health Insurance in Massachusetts Cover and How Can Consumers Know? details the complex challenges consumers face when making choices about which health insurance plan to purchase. The authors use Massachusetts as an example to suggest a new method for evaluating health insurance plans and make recommendations for states that are working to increase transparency in health insurance pricing. (The Robert Wood Johnson Foundation, May 2009)
Designing Benefit Standards for a Health Insurance Exchange explains that, in any exchange that is created as part of health reform, it is crucial to establish benefit standards so that all plans cover a comprehensive range of services, thereby ensuring that individuals and small businesses have a choice of affordable, comprehensive plans. These benefit standards would protect people with particular medical conditions from facing excessive costs, and they would better enable consumers to compare plans based on price and quality. (The Center on Budget and Policy Priorities, May 2009)
Ensuring Affordable Health Coverage and Health Care Services in an Insurance Exchange finds that any health reform proposal that requires everyone to obtain health insurance must establish mechanisms to make health coverage and health care affordable. It also identifies four key components that any successful exchange should have: minimum standards for benefit packages, limits on the degree of variation in different benefit packages, limits on the number of different plan choices, and a requirement that insurers in the exchange offer the full range of benefit packages. (The Center on Budget and Policy Priorities, May 2009)
Health Insurance Exchanges: See How They Run is a webcast that looks at insurance exchanges and examines the following questions: What is meant by a health insurance exchange, and how might it work? Who would be allowed to seek coverage through the exchange? What rules would govern the conduct of plans offering coverage? What’s in it for the consumer? (The Alliance for Health Reform, May 2009)
Rules of the Road: How an Insurance Exchange Can Pool Risk and Protect Enrollees finds that a strong exchange can greatly reduce the problems many people currently face when they must obtain coverage on their own without the help of an employer. It then lays out four key components of an efficient insurance exchange, including minimum standards for the benefits packages offered and a limit on the number of different benefit packages. (The Center on Budget and Policy Priorities, April 2009)
Retiree Health VEBAs: A New Twist on an Old Paradigm – Implications for Retirees, Unions, and Employers provides an overview of stand-alone VEBA trusts, vehicles through which employers have rid themselves of future obligations to pay retiree health benefits in exchange for making a payment that approximates the projected cost of these benefits. The brief looks at three case studies, including the Big Three VEBAs, and highlights some of the pros and cons of such arrangements for employees, unions, and employers. (Kaiser Family Foundation, March 2009)
Expanding Coverage for Dependents finds that young adults are one of the fastest-growing groups without health insurance. The report proposes changing state laws to allow young people to remain on their parents’ health insurance plans beyond age 18. However, most states continue to place restrictions on which dependents are eligible for coverage by limiting it to those who are students, who live with their parents, or who do not have access to other forms of insurance. (Community Catalyst, February 2009)
How Have Employers Responded to Health Reform in Massachusetts? Employees’ Views at the End of One Year reveals that employers have neither dropped coverage nor restricted eligibility for coverage in the state’s first year of health reform. Despite initial concern from critics, researchers have found that employers made no changes to the scope of benefits, range of provider choices, or quality of care available under their plans. (The Commonwealth Fund, October 2008)
Using Section 125 Premium-Only Plans to Expand Health Coverage discusses how Section 125, or "cafeteria" plans, may be able to expand coverage, or at least make employer-based coverage more affordable for those who already have it, by allowing employees to pay their premiums with pre-tax dollars. This brief also examines policies that states are using to encourage greater adoption of cafeteria plans. (Mathematica Policy Research, October 2008)
Health Insurance for Low-Income Working Families proposes comprehensive reforms that are designed to provide coverage for everyone at every income level, while still encouraging work. According to the study, in 2005, only 37 percent of adults in low-income working families had employer-based health insurance, and 42 percent had no health coverage. The proposals include state purchasing pools, individual mandates, and strategies for reducing health care costs. (The Urban Institute, July 2008)
On the Road to Universal Coverage: Impacts of Reform in Massachusetts at One Year found that in the first year, the rate of the uninsured working-age adults in the state dropped by almost half, from 13 percent to 7 percent. In addition, the study found improvements in access to care, particularly among low-income adults, and fewer adults with high out-of-pocket costs and medical bill problems. (The Commonwealth Fund, June 2008)
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ERISA Pre-emption: Implications for Health Reform and Coverage provides an overview of state and local attempts at comprehensive health insurance reform and finds that ERISA limits states’ ability to carry out these reforms. For example, ERISA prevents states from establishing minimum levels of coverage for employer-based plans and limits their ability to fund health insurance subsidies for low-income adults through a tax. (EBRI, February 2008)
Increasing Health Insurance Coverage of Workers in Small Firms: Challenges and Strategies: Testimony before the Finance Committee United States Senate calls for a reduction of small business owners that are uninsured. It suggests income-related subsidization of insurance coverage. (The Urban Institute, October 2007)
Health Insurance Connectors & Exchanges: A Primer for State Officials examines a crucial component of the 2006 Massachusetts health care reform law known as “the Commonwealth Health Insurance Connector Authority,” or simply, “The Connector.” The Connector is presented as a prototype that other states can adapt when seeking to expand health coverage, depending on the specific characteristics in those states. (State Coverage Initiatives, September 2007)
The Illusion of Coverage: How Health Insurance Fails People when They Get Sick describes how private insurance fails to protect people from financial hardship when they become ill or are injured. The report discusses the aspects of insurance that lead to medical debt and that hamper people's ability to make meaningful choices when purchasing health plans, as well as the consequences of medical debt. It also provides recommendations on how to provide people with access to comprehensive and affordable insurance products. (The Access Project, March 2007)
Americans between the ages of 19 and 29 represent the largest and fastest-growing segment of the population without health coverage. Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help argues that there are several ways to extend coverage to young adults—and prevent others from losing it. These include extending eligibility for Medicaid and SCHIP beyond age 18; extending eligibility for dependents beyond age 18 or 19 regardless of student status; and ensuring that colleges and universities require full- and part-time students to have insurance. (The Commonwealth Fund, May 2006)
Massachusetts has enacted a health care plan designed to offer virtually universal health coverage. Massachusetts Health Care Reform Plan summarizes the new plan and its implications for individuals, who must obtain insurance or face tax penalties, as well as employers, who must provide insurance or contribute to the government’s “Fair Share” program. (The Kaiser Family Foundation, April 2006)
Fundamentals of Underwriting in the Nongroup Health Insurance Market: Access to Coverage and Options for Reform Although the majority of Americans with health insurance obtain coverage through their employers, many individuals must negotiate the nongroup insurance market alone. Insurers use a process called medical underwriting to identify applicants with current or recent medical problems. Because these applicants are likely to cost the insurer more in claims than a healthier person, insurers may charge them higher premiums or restrict or deny coverage. This report reviews the practice of underwriting, state and federal regulation of insurers that offer nongroup health coverage, and several proposed options for improving access to coverage for applicants who are in poor health. (National Health Policy Forum, April 2005)
Changing Health Care Marketplace Project, a Kaiser Family Foundation project, conducts research and analysis on trends in the marketplace, particularly as they affect vulnerable groups like the poor and the elderly, and on policy proposals that involve the private health care system. There have been striking changes in the health care marketplace in the last few years. Some of these changes build on historic trends; others depart, sometimes dramatically, from prior expectations about how the marketplace would evolve. (Kaiser Family Foundation, February 2005)
The Health Care for All Californians Act: Cost and Economic Impact Analysis l Summary The Health Care for All Californians Act (SB 291, introduced in February 2003) would have provided health insurance coverage for all Californians through a single health plan funded by the state. This report looks at what implementing the Act would have cost and the broader economic impact it would have had. In the first year of the plan alone, $8 billion would have been saved statewide. Businesses would have saved 16 percent over what they pay today, and families would have saved an average of $340 per year. (The Lewin Group, January 2005)
Designing Maine's DirigoChoice Benefit Plan DirigoChoice is Maine's innovative private-public partnership that offers health insurance to employees of small businesses, the self-employed, and the uninsured. This report discusses the process that Maine went through in developing a plan for DirigoChoice and outlining the health care benefit package that would be provided. (National Academy of State Health Policy and the Commonwealth Fund, December 2004)
Stretching State Health Dollars: Building on Employer-Based Coverage Spurred on by tough financial times, many states have begun to develop creative ways to expand coverage by building on employer-sponsored health insurance. This report looks at the approaches that 14 states have taken in an attempt to expand coverage, including premium assistance, reinsurance, state subsidized health care programs for the low-income workers, small business expansions, and "pay-or-play" employer mandates. (The Commonwealth Fund, October 2004)
The Role of Reinsurance in State Efforts to Expand Coverage In order to spread the risk of health insurance, many states have implemented various models of reinsurance—in which the state takes over a portion of high-cost claims. This report discusses how six states have used models of reinsurance to assist in the expansion of coverage. (State Coverage Initiatives, October 2004)
Dirigo Health Reform Act: Addressing Health Care Costs, Quality and Access in Maine In June 2003, Maine Governor John Baldacci signed the Dirigo Health Reform Act into law. The Act was designed to ensure that every Mainer has access to quality, affordable health care within five years. This report discusses the three major elements of the Dirigo Health Reform Act: cost, quality, and access. It also provides a bit of background on the development of the DirigoChoice Health plan. (National Academy of State Health Policy and the Commonwealth Fund, June 2004)
Reinsurance is when a state opts to cover a portion of private insurer's claims. This "stop-loss" mechanism may cover catastrophic claims above a certain dollar amount, or it may cover claims within a designated corridor. It is an indirect way of reducing premium prices, thereby providing a more affordable option for uninsured workers, and it remains a popular strategy for states that wish to maintain or increase health coverage. More Answers on Reinsurance is designed to serve as a technical guide for states that are interested in building a reinsurance program. (State Coverage Initiatives, June 2004)
Assessing State External Review Programs and the Effects of Pending Federal Patients' Rights Legislation examines key features of state external review programs and how they very across states. It also compares features of those state programs with the external review provisions in the patients' rights bills passed by the House and Senate. (Kaiser Family Foundation, March 2002)
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