Markets or Monopolies? Considerations for Addressing Health Care Consolidation in California

Over the past three decades, markets for health insurers and providers have gone through waves of consolidation. As of 2018, 95% of metropolitan areas in the United States had highly concentrated hospital markets. Markets for health insurers are also highly concentrated. Between 2006 and 2014, the combined market share of the top four insurers climbed from 74% to 83%. The coronavirus pandemic appears to be fueling another round of consolidation — especially acquisition of providers by private equity firms.Markets or Monopolies? Considerations for Addressing Health Care Consolidation in California compiles the latest research and data on California's health care systems and shows that consolidation is not limited to any one system, market segment, or geographic region in the state: Most markets across California are highly concentrated. Hospital markets, in particular, are now approaching "monopoly levels" in many California counties. In addition, there is mounting evidence that mergers of health care companies are resulting in increased prices for health care services, with little or no improvement in quality for consumers.The report highlights several actions policymakers could consider, given significant consolidation. For example, California's attorney general has the authority to block transactions that transfer a "material amount of the assets" only for nonprofit health facilities. To increase scrutiny of provider mergers in California, policymakers could require all health care providers — not just nonprofit ones — to provide written notice to, and obtain the written consent of, the attorney general.  Policymakers could also expand the authority of state regulatory agencies to include "affordability standards" when they review health insurance plans for sale in California

Increasing the Net Charge and Decreasing the Hydrophobicity of Bovine Carbonic Anhydrase Decreases the Rate of Denaturation with Sodium Dodecyl Sulfate

AbstractThis study compares the rate of denaturation with sodium dodecyl sulfate (SDS) of the individual rungs of protein charge ladders generated by acylation of the lysine ε−NH3+ groups of bovine carbonic anhydrase II (BCA). Each acylation decreases the number of positively charged groups, increases the net negative charge, and increases the hydrophobic surface area of BCA. This study reports the kinetics of denaturation in solutions containing SDS of the protein charge ladders generated with acetic and hexanoic anhydrides; plotting these rates of denaturation as a function of the number of modifications yields a U-shaped curve. The proteins with an intermediate number of modifications are the most stable to denaturation by SDS. There are four competing interactions—two resulting from the change in electrostatics and two resulting from the change in exposed hydrophobic surface area—that determine how a modification affects the stability of a rung of a charge ladder of BCA to denaturation with SDS. A model based on assumptions about how these interactions affect the folded and transition states has been developed and fits the experimental results. Modeling indicates that for each additional acylation, the magnitude of the change in the activation energy of denaturation (ΔΔG‡) due to changes in the electrostatics is much larger than the change in ΔΔG‡ due to changes in the hydrophobicity, but the intermolecular and intramolecular electrostatic effects are opposite in sign. At the high numbers of acylations, hydrophobic interactions cause the hexanoyl-modified BCA to denature nearly three orders of magnitude more rapidly than the acetyl-modified BCA

Are State Public Option Health Plans Worth It?

The COVID-19 pandemic exposed the weaknesses of the U.S. health care system\u27s reliance on private, employer-based health insurance. The crisis in health care access and affordability has increased support for a public option--the choice to purchase a state-initiated health plan with publicly determined rates. Congressional gridlock, however, may dim the chances for a federal public option. States have stepped into the policy vacuum, proposing forty-nine bills to establish state public options since 2010, including three that became law. This article provides a comprehensive survey and taxonomy of state public option proposals from 2010-2021, identifying three main models: (1) Medicaid Buy-In Public Options; (2) Marketplace-Based Public Options; and (3) Comprehensive Public Options. Though each model serves different policy goals and varies in scope, the defining aim of all public option plans is to improve access to affordable health coverage by applying public payment rates to the private insurance market. We seek to answer whether state public option plans are legally viable and “worth it” for states to pursue. The answer is yes to both, but, surprisingly, the degree of legal difficulty is inversely related to the scope of the plan\u27s reach--the broadest plans have fewer legal hurdles than narrower plans. Moreover, the policy effects increase with the scope of the plan and the robustness of the controls on provider payment rates. Public options with modest provider rate controls may have too little impact on affordability and costs, falling short of their defining goal of improving affordability. As a result, the legal and political difficulty of enacting such plans may not be worth it. State public option plans may be most effective when they cover a broad swath of the population and pursue robust provider rate controls. In short, for state public option plans to be worth it, bigger is better

Are State Public Option Health Plans Worth It?

The COVID-19 pandemic exposed the weaknesses of the U.S. health care system\u27s reliance on private, employer-based health insurance. The crisis in health care access and affordability has increased support for a public option--the choice to purchase a state-initiated health plan with publicly determined rates. Congressional gridlock, however, may dim the chances for a federal public option. States have stepped into the policy vacuum, proposing forty-nine bills to establish state public options since 2010, including three that became law. This article provides a comprehensive survey and taxonomy of state public option proposals from 2010-2021, identifying three main models: (1) Medicaid Buy-In Public Options; (2) Marketplace-Based Public Options; and (3) Comprehensive Public Options. Though each model serves different policy goals and varies in scope, the defining aim of all public option plans is to improve access to affordable health coverage by applying public payment rates to the private insurance market. We seek to answer whether state public option plans are legally viable and “worth it” for states to pursue. The answer is yes to both, but, surprisingly, the degree of legal difficulty is inversely related to the scope of the plan\u27s reach--the broadest plans have fewer legal hurdles than narrower plans. Moreover, the policy effects increase with the scope of the plan and the robustness of the controls on provider payment rates. Public options with modest provider rate controls may have too little impact on affordability and costs, falling short of their defining goal of improving affordability. As a result, the legal and political difficulty of enacting such plans may not be worth it. State public option plans may be most effective when they cover a broad swath of the population and pursue robust provider rate controls. In short, for state public option plans to be worth it, bigger is better