Private Health Insurance Premiums and Rate Reviews

[Excerpt] In general, the premiums charged by health insurance companies represent actuarial estimates of the amount that would be required to cover three main components: (1) the expected cost of the health benefits covered under the plan, (2) the business administrative costs of operating the plan, and (3) a profit. The final premium calculation often is adjusted upward or downward to reflect several factors, such as making up for a previous financial loss. Health insurance premiums have been trending up, while the value of coverage has trended down. Available data indicate that both administrative and medical costs continue to rise, but the rate of growth in these expenses slowed between 2008 and 2009. The data also suggest that the rise in medical costs is primarily attributable to the price of services, not increased utilization. The rise in the cost of health insurance has received considerable attention by Congress and resulted in calls for more regulation. The regulation of private health insurance has traditionally been under the jurisdiction of the states. Most states have used their regulatory authority over the business of insurance to require the filing of health insurance documents containing rate information for one or more insurance market segments or plan types. With the enactment of the Patient Protection and Affordable Care Act (P.L. 111-148, PPACA) on March 23,2010, and subsequent amendments, the federal government will assume a role in private health insurance rate reviews by providing grants to states and requiring health insurance companies to provide justifications for proposed rate increases determined to be unreasonable. This report provides an overview of the concepts, regulation, and available public data regarding private health insurance premiums. This report will be updated to reflect relevant legislative activity and the availability of new public data

Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study.

OBJECTIVE:To examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17). DESIGN:Quasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions. SETTING:United States. PARTICIPANTS:A nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey. MAIN OUTCOMES AND MEASURES:Four annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons. RESULTS:37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change -28.0% (95% confidence interval -38.4% to -15.8%); adjusted absolute change -122 (£93; €110); adjusted P<0.001), lower out-of-pocket plus premium spending (-29.0% (-40.5% to -15.3%); -442; adjusted P&lt;0.001), and lower probability of experiencing a catastrophic financial burden (adjusted percentage point change -4.7 (-7.9 to -1.4); adjusted P=0.01) in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions. CONCLUSION:Medicaid expansions under the Affordable Care Act were associated with lower out-of-pocket spending and a lower likelihood of catastrophic financial burden for low income adults in the third and fourth years of the act's implementation. These findings suggest that the act has been successful nationally in improving financial risk protection against medical bills among low income adults

The Economics of Healthcare Rationing

This article examines the economics of healthcare rationing. We begin with an overview of the various dimensions across which healthcare rationing operates, or at least has the potential to operate, in the first place. We then describe the types of economic analyses used in healthcare rationing decision-making, with particular reference to cost-benefit analysis and cost-effectiveness analysis. We also discuss healthcare rationing in practice, such as how economic analyses inform decisions regarding which services to cover, and conclude by discussing various practical and conceptual challenges that may arise with economic analyses and that span both economics and ethics

Health Insurance Exchanges Under the Patient Protection and Affordable Care Act (ACA)

[Excerpt] A health insurance exchange is a structured marketplace for the sale and purchase of health insurance. “Customers” can include individuals and businesses. The insurance companies (“issuers”) that choose to sell their products through an exchange may be required to comply with consumer protections, such as offering insurance to every qualified applicant. Exchanges, however, are not issuers; rather, exchanges contract with issuers who will make insurance products available for purchase through exchanges. Essentially, exchanges are designed to bring together buyers and sellers of insurance, with the goal of increasing access to coverage. This rather broad definition allows for a great deal of latitude, and therefore variance, in the number and scope of responsibilities covered in a particular exchange. For example, the role of an exchange may be more or less administrative: facilitating the sale and purchase of health insurance. An administrative-only exchange may function similar to websites that allow individuals to find airline travel options and purchase tickets (e.g., Kayak). Such an approach does not necessarily change or establish standards for the products being sold (whether they are health plans or airline tickets), or limit the types of buyers and sellers participating in the exchange, beyond what already exists in the private market. An example of a minimalist health insurance exchange is the Utah Health Exchange. Essentially, Utah’s exchange is an Internet portal that is “designed to connect consumers to the information they need to make informed health care choices, and in the case of health insurance, to execute that choice electronically.” At the other end of the spectrum, an exchange may have multiple functions beyond the role of insurance marketplace. For instance, an exchange may be responsible for implementing regulatory standards, such as requiring standardization of all products offered through it or imposing requirements on exchange participants. An exchange may be responsible for determining eligibility for exchange plans and government-provided subsidies. An example of a more regulatory-oriented exchange is the Health Connector (“Connector”) in Massachusetts. Similar to Utah’s exchange, the Connector provides an online tool to allow consumers and others to find commercial health insurance options available to them. In addition, the Connector also manages a publicly subsidized coverage program for low-income state residents, and offers certificates to exempt individuals from the state’s individual mandate, among other duties. An exchange may occupy a physical location and/or be virtual (i.e., performing its functions on the Internet). It may be governed by a public agency, a private entity, or a hybrid organization. The insurance options offered through an exchange may also vary across insurance markets and plan types. Nonetheless, while the authority and responsibilities of an exchange may vary, its fundamental purpose is to provide a venue where insurance companies may sell their insurance products and purchasers can compare and choose from multiple options available to them. Thus an exchange allows for “one-stop shopping” with respect to health insurance. The exchange concept was included in the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended), as a means to increase access to health insurance. While ACA places many restrictions on the design and function of exchanges, the law also leaves many operational decisions to the states. Such flexibility will likely lead to variation in exchange models across the states. For example, a state may decide to operate an exchange by itself, establish an exchange in partnership with the federal government, or leave this work entirely to the federal government. States had to declare whether they will have a state exchange by December 14, 2012. By February 15, 2013, states must declare whether they will operate an exchange in partnership with the federal government. The initial open enrollment period for all exchanges will begin on October 1, 2013, and all exchanges are to be operational and offering coverage on January 1, 2014. This report looks at the requirements for exchanges established in ACA and provides information on the requirements and choices available to states for the establishment, functions, financial responsibilities, and coverage of the ACA exchanges. It also includes a brief discussion of the interactions between exchanges and other provisions in the law

Community-based health insurance and social protection policy

Of all the risks facing poor households, health risks pose the greatest threat to their lives and livelihoods. A health shock adds health expenditures to the burden of the poor precisely at the time when they can afford it the least.One of the ways that poor communities manage health risks, in combination with publicly financed health care services, are community-based health insurance schemes (CBHIs). These are small scale, voluntary health insurance programs, organized and managed in a participatory manner. They are designed to be simple and affordable, and to draw on resources of social solidarity and cohesion to overcome problems of small risk pools, moral hazard, fraud, exclusion and cost-escalation. Less than 10 percent of the informal sector population in the developing nations has health coverage from a CBHI, but the number of such schemes is growing rapidly. On average, CBHIs recover between a quarter to a half of health service costs. As a social protection device, they have been shown to be effective in reducing out-of-pocket payments of their members, and in improving access to health services. Many schemes do fail. Problems, such as weak management, poor quality government health services, and the limited resources that local population can mobilize to finance health care, can impede success.Health Economics&Finance,Health Monitoring&Evaluation,Poverty Assessment,Safety Nets and Transfers,Insurance&Risk Mitigation

Health Care Coverage: Job Lock and the Potential Impact of the Patient Protection and Affordable Care Act

[Excerpt] The majority of Americans—about 55 percent in 2010—rely on employer-sponsored health care coverage, which is largely subsidized by most employers and thus less costly to employees than coverage purchased by individuals on their own. Although a valued employee benefit, many believe that having health coverage tied to employment can influence workers to stay in jobs they might otherwise leave, a phenomenon generally known as “job lock.” The Patient Protection and Affordable Care Act (PPACA), enacted in 2010, includes provisions that are designed to increase the accessibility and affordability of health coverage, particularly for individuals with preexisting health conditions. PPACA implementation is phased; though some provisions went into effect during the year of enactment, many provisions are scheduled to take effect in 2014. Some suggest that one benefit of PPACA may be a decrease in the occurrence of job lock. You asked us to examine job lock and the specific ways PPACA may affect it. Accordingly, we examined two key questions: 1. What has research shown about whether and the extent to which workers stay in jobs they might otherwise leave out of fear of losing health care coverage and the impact of those decisions on the labor market? 2. What are expert views on the ability of PPACA to mitigate job lock

Plan Management: Issues for State, Partnership and Federally Facilitated Health Insurance Exchanges

Examines the state's plan management function of insurance exchanges under federal healthcare reform, including overseeing the licensing and solvency of plans, network adequacy, benefit and rate review, marketing and regulation, quality improvement

The Affordable Care Act and Beyond: Opportunities for Advancing Health Equity and Social Justice

In 2010, the most monumental health care legislation in forty-five years was enacted. The Patient Protection and Affordable Care Act ( ACA ) makes changes great and small in virtually every important component of the American health care system. The new law\u27s implications will not be known fully for many years because state governments and federal agencies are in the process of interpreting key provisions, drafting rules and devising general implementation strategies. And, uncertainty exists about the scope of the ACA because of the recent Supreme Court ruling in National Federal of Independent Business v. Sebelius. The court upheld nearly all of the provisions in the ACA, but it ruled that the federal government cannot withhold Medicaid funds from states that refuse to expand their Medicaid programs to cover individuals with incomes of as much as 133 percent of the federal poverty level. This article seeks to analyze the most significant changes that affect communities of color and to examine the resulting health equity and social justice implications. Part I explains the moral and economic case for eliminating racial and ethnic health care disparities. Part II analyzes provisions in the new law designed to expand access to health insurance. Part III focuses on the special access challenges communities of color face and how the ACA provisions attempt to address these. Part IV examines key ACA provisions that are explicitly intended to reduce health disparities and improve the health of racially and ethnically diverse populations. Part V argues that achieving health equity for racial and ethnic minority groups will require policy strategies focused outside of the health care arena. This article concludes with recommendations on how to leverage federal spending to advance racial and ethnic equality

Restoring Health to Health Reform: Integrating Medicine and Public Health to Advance the Population\u27s Wellbeing

The Patient Protection and Affordable Care Act is a major achievement in improving access to health care services. However, evidence indicates that the nation could achieve greater improvements in health outcomes, at a lower cost, by shifting its focus to public health. By focusing nearly exclusively on health care, policy makers have chronically starved public health of adequate and stable funding and political support. The lack of support for public health is exacerbated by the fact that health care and public health are generally conceptualized, organized, and funded as two separate systems. In order to maximize gains in health status and to spend scarce health resources most effectively, health care and public health should be treated as two interactive parts of a single, unified health system. The core purpose of health reform ought to be the improvement of the population’s health. We propose five criteria that would significantly advance this goal: prevention and wellness, human resources, a strong and sustainable health infrastructure, robust performance measurement, and reduction of health disparities. Although the Patient Protection and Affordable Care Act includes provisions addressing these criteria, population health is not a central focus of the reform. In order to guide health reform implementation and to inform future health reform efforts, we offer three major policy reforms: changing the environment to incentivize healthy behavioral choices, strengthening the public health infrastructure at the state and local levels, and developing a health-in-all policies strategy that would engage multiple agencies in improving health incomes. Adopting these reforms would facilitate integration and dramatically improve the population’s health, particularly when compared to the health gains likely to be realized from a continued focus on access to health care services

The Design of an Instrument to Assess Clinical Laboratories Efficacy Post Implementation of the Patient Protection Affordable Care Act

The healthcare system in the United States has undergone substantial changes in support of the Patient Protection and Affordable Care Act (PPACA). On March 23, 2010, the implementation of the new healthcare law brought universal healthcare access to all Americans, while attempting to increase quality and decrease medical costs. The new law promotes more of a quality-focused, outcome-based model rather than a pay-for-fee service model; thus, moving the paradigm from infrequent to preemptive healthcare. The PPACA postulates as the only way to achieve cost savings while increasing quality and access. Never before has there been such an extensive change to the healthcare system since the inception of the Medicare system in 1965. In 2014, approximately 49 million uninsured Americans entered the healthcare system prompting increased demands of providers in navigating the new law; therefore, encouraging institutions to adopt best practices regarding health care reform. The purpose of this study is to begin assessing those best practices in clinical laboratories, by creating an accurate instrument, based on the theory of the iron triangle of health care. William Kissick first proposed the theoretical framework in 1994, when he conceptualized that healthcare 1) as a tightly linked, self-equilibrating system of three constructs: cost, quality, and access 2) when the increase occurs in one or two of the constructs, an effect to the third construct will occur. As a reformer to healthcare in the laboratory, the PPACA maybe a disrupter to the theory, therefore this study addresses the effects of PPACA. One-Hundredth Sixty Clinical Laboratory Improvement Amendment (CLIA) affiliated laboratory managers from 50 states provided data to validate the Clinical Laboratory Manager Inventory survey (CLMI). The data from the survey were analyzed using IBM SPSS 23 and AMOS 23 software with the statistical methodology Structural Equation Modeling (SEM). The results of the study showed the CLMI explained 75% of the variance associated with PPACA effects on the laboratory, indicating that it is an accurate instrument and that PPACA acts as a disrupter to theory. This finding allows the laboratory community to have a plausible instrument to assess the impact of PPACA on subsequent research