Did the Affordable Care Act Contain Costs?

While the Affordable Care Act (ACA) primarily focused on expanding coverage to many of the 46 million uninsured Americans at the time, it included various provisions that sought to slow the growth of health care spending. In an LDI Issue Brief two years ago, we looked at how the ACA provisions affected costs through 2015. We found little evidence that they had produced the changes necessary to “bend the cost curve,” although the double-digit growth rates of the 2000s had not returned. However, it is possible that the ACA’s changes have had more cumulative effects. This brief updates our earlier piece, and assesses the effects of the ACA on costs since its passage 10 years ago

Setting Standards for Affordable Health Care

In the run-up to the presidential election, the affordability of health care remains a top concern of the American voting public. But how do we know when health care is affordable? On a policy level, how do we set a standard for affordability that can be implemented in a reformed system? Sometimes policy debates about affordability focus only on whether insurance premiums are affordable, although consumers tend to be concerned about both premiums and out-of-pocket costs. At Penn LDI’s Medicare for All and Beyond conference, a panel of researchers, policy experts, and consumer advocates discussed and debated affordability in theory and practice. What emerged was a clearer understanding of the value judgments needed, friction points encountered, and principles that policymakers should apply to ensure that health coverage is affordable. This issue brief summarizes the panel’s insights

No-Trespass Policies in Public Housing

Increasingly, public housing authorities (PHAs) are implementing “no-trespass” policies designed to combat crime by non-residents in their developments. These policies allow PHAs to develop “ban lists” of unwanted non-residents who may be cited for criminal trespass if found on PHA property. Implementation of such policies may conflict with resident’s rights to have visitors, and invitees’ rights to visit. The effects of these policies on crime, perceptions of safety, and associational rights are unknown. Through legal analysis and case studies of three PHAs—Yonkers, NY; Chester, PA; and Annapolis, MD—I investigate the impact of these policies on residents, PHA officials, project managers, police, and people who are banned. My findings suggest that a no-trespass policy, narrowly targeted and as part of a larger security strategy, can promote perceptions of safety among public housing residents. Strong, stable PHA management and a collaborative relationship with residents are key to successful implementation. With due process protections and clear procedures for assuring that tenants’ rights to have visitors are not violated, it can pass constitutional muster. Whether it is an effective, or cost-effective, form of crime control is very much in debate. Implemented in isolation, however, a no-trespass policy is not likely to be effective in reducing crime and promoting perceptions of safety, and runs the risk of being used to police residents, rather than to protect them. If the policy is not narrowly tailored, it can divide families unnecessarily and discourage familial ties that create stability in a community. No-trespass policies can be blunt weapons against crime that cast very wide nets over a community, restrict movement, and interfere with family relationships. Applied arbitrarily and targeted indiscriminately, these policies are not likely to be constitutional. PHAs should consider whether no-trespass policies are worth the considerable resources needed to implement and maintain them, and reassess how these policies fit the larger objective of fostering safe places in which to live and raise a family. Longer-term safety may be better served by developing residents’ human and social capital, and by providing social supports and services, rather than on banning criminals from PHA property

Pennsylvania Scope of Practice Policy Brief

Pennsylvania is one of 28 states that has not expanded the scope of practice in its licensure laws for certified registered nurse practitioners (NPs), who must maintain formal collaborative agreements with physicians to practice. For many years, proposals to update licensure and adapt it to make it more compatible with current models of collaborative care could not overcome legislative logjams. Recognizing an opportunity to break the logjam, the University of Pennsylvania held a virtual workshop on November 20, 2020, bringing together researchers, health professionals, and consumers to chart a new path forward. This policy brief summarizes their recommendations to update scope of practice regulation to better meet the primary care needs of Pennsylvanians

Health Care Cost Drivers and Options for Control

The growth of health care costs remains a serious concern in the United States. Slowing this growth involves understanding what drives health care costs and how to target those drivers effectively. In this brief, we review the relative importance of different health care cost drivers, including insurance benefits design, price inflation, provider incentives, technological growth, and inefficient system performance. We analyze the impact of these factors on the growth of health care spending in the last decade, which has been concentrated in hospitals and felt most acutely in the private market. We find that unit prices and technology remain the most important cost drivers of this recent growth. In reviewing public and private payer initiatives that target health care costs, we find that some have yielded modest results, but the evidence on most strategies is inconclusive or mixed. Designing and implementing effective interventions to slow cost growth remains a challenge, particularly in the privately insured market, where premiums have risen considerably in the last decade

Opportunities for Precision Cancer: Reflections from the Gant Consortium

There is substantial interest in targeted cancer therapies, spurred by recent biomedical research in genomics and oncology. Targeted cancer therapies, in which prevention and treatment of cancer are based on genomic and biologic analyses, hold promise for cancer care. However, the rising costs of such therapies may threaten that promise. In an effort to meet the future challenges of targeted cancer medicine head-on, the University of Pennsylvania convened the Gant Family Precision Cancer Medicine Consortium, a multidisciplinary work group of experts from health care economics, policy, law, regulation, cancer research and medicine, patient advocacy, and the pharmaceutical and insurance industry. The Gant Consortium sought answers to a central question: what approaches should stakeholders take to foster the economic viability and sustainability of targeted cancer drugs? The Consortium literature review was conducted from August through November 2016. The expert committee met regularly from October 2016 to May 2017 to identify points of contention and consensus, outline the issues at the core of sustainable targeted cancer medicine, and inform potential policy recommendations. The literature presented in this report does not include therapies developed afterwards, such as CAR-T. The views expressed in this White Paper reflect the discussions of the Gant Consortium but do not necessarily represent the views of either any individual member or of the Consortium as a whole

Essential Health Benefits: 50-State Variations on a Theme

All qualified health plans under the Affordable Care Act must cover a package of essential health benefits (EHBs) equal in scope to a typical employer plan. The law laid out 10 general categories of services that EHBs must cover, but did not itemize those services. Each state is allowed to identify an existing plan as a benchmark for these EHBs. The result of this policy is that EHBs vary from state to state, often because of a legacy of different state-mandated benefits (such as treatments for autism, infertility, or temporomandibular joint disorders). This Data Brief analyzes state variation in coverage and limits for these non-uniform benefits

The Skinny on Narrow Networks in Health Insurance Marketplace Plans

The Affordable Care Act (ACA) has prompted health plans to increase their use of “narrow networks” of providers as a cost containment strategy. The Leonard Davis Institute of Health Economics (LDI) has assembled the first integrated dataset of physician networks for the plans offered on the ACA marketplace. This data brief uses this new resource to describe the breadth of the physician networks in plans sold on the state and federal marketplaces. The percent of physician networks that were classified as small or x-small came to 41% overall, 55% for HMO networks, and 25% for PPO networks

Long-Term Care Financing In The United States

In the United States, people who need long-term care (LTC) face a system with large gaps in care, which they must rely on friends and family to fill. Medicaid finances the majority of paid LTC, but people must exhaust their resources to qualify. Medicare and private health insurance do not cover LTC, and the private market for long-term care insurance is failing. Unpaid family and friends provide most long-term services, but the value of their services is rarely reflected in debates about LTC financing and delivery. Beyond the value of the services, this system has costs to the economy, as spouses and adult children reduce paid work to care for their loved ones. As the population ages and families are less able to shoulder the burden of LTC, the current system may be unable to meet the growing need without an alternative, sustainable financing mechanism

State Variation in Narrow Networks on the ACA Marketplaces

In June, we presented national data from one of the first attempts to measure the size of provider networks in plans sold on the health insurance marketplaces. We used simple “T-shirt” sizes to categorize networks in a way that could help consumers quickly grasp the choices they were making. In this Data Brief, we present network sizes summarized up to the level of the state and the rating area. This analysis should help regulators and consumers assess and understand the trade-off between premiums and network size as we enter the next open enrollment period