The passage of the Affordable Care Act represents an historic change in the way health insurance has been handled in the United States. With political discourse about the act continuing to occupy public policy debates and the news media, this collection attempts to shed light on the impact of the policy on citizens and providers as well as examine how the ACA is affecting quality, access, and costs of care.

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Insurers Remaining in Affordable Care Act Markets Prepare for Continued Uncertainty in 2018, 2019

March 19, 2018

A new report, supported by the Robert Wood Johnson Foundation and authored by Georgetown CHIR and Urban Institute researchers, examines how uncertainty over the long-term future of the ACA have affected insurers' participation and premium setting decisions for the 2018 and 2019 plan years. We interviewed 10 insurance companies participating in the individual market in 28 states and D.C. and a few key takeaways include:The rollback of the ACA's individual mandate led insurers to implement higher premiums in 2018 and will likely drive premiums even higher in 2019. However, insurers' views differed on the impact of repealing the individual mandate. Some felt it would ultimately lead to a collapse of the market and are considering further retrenchment; others felt confident that a market for highly subsidized, low-income consumers would continue.The midyear loss of the ACA's cost-sharing reduction plan reimbursements drove 2018 premium increases ranging from 10 percent to 20 percent. However, several insurers noted that proposed federal legislation to restore cost-sharing reduction funding could result in significant disruption and sticker shock for consumers receiving premium tax credits.All insurers had concerns regarding an expansion of short-term and association health plans under the President's October 12, 2017 executive order. Insurers worry that an expansion of these plans could siphon healthy people away from the individual market, leaving a sicker, costlier population.Insurers with narrow provider networks reported concerns about the potential exit of competing insurers, noting that their network providers lacked capacity to take an influx of new, often sicker enrollees. They further noted that unexpected insurer exits can produce considerable disruption, particularly if remaining insurers lack sufficient time or ability to readjust their pricing.A worsening of the risk pool will likely cause many insurers to reduce their market presence, will cause all insurers to raise their premiums, and may lead to more exits.

Regulation of Health Plan Provider Networks: Narrow Networks Have Changed Considerably under the Affordable Care Act, but the Trajectory of Regulation Remains Unclear

July 28, 2016

Health insurance plans with limited networks of providers are common on the Affordable Care Act's (ACA's) health insurance Marketplaces. Recent studies have found that these "narrow network" plans constituted nearly half of all Marketplace offerings in the first two years of coverage, with one analysis concluding that about 90 percent of all consumers had the option of buying such a plan if they chose.Plans with limited networks are not new and are not confined to the Marketplaces. Yet there is reason to believe that they have grown in prevalence partly because of the ACA. Many of the health law's consumer protections--prohibitions on health status underwriting, increased standardization of benefits, a maximum limit on out-of-pocket spending, and the elimination of annual and lifetime limits on benefits, for example--have foreclosed traditional strategies used by insurers to keep costs in check. Meanwhile, other elements of reform, including online Marketplaces that make it easier for consumers to compare plans based on premiums and a financial assistance framework that links the amount of a person's premium tax credit to the cost of the second cheapest plan available to them at the silver metal tier, explicitly encourage insurers to compete on price. These developments appear to have led many insurers to design Marketplace health plans that combined a comparatively low premium with a more restricted choice of providers.Limited network plans might offer value to consumers. Coverage that pairs a low premium with a network that provides meaningful access to health care might meet the needs of many enrollees, no matter the network's overall size. Negotiations between insurers and providers over network participation might encourage more efficient delivery of care. And the power to contract selectively might allow insurers to create networks comprising a subset of providers who meet raised standards of quality, potentially resulting in higher-value care.But these plans also pose risks. A network can be too narrow, jeopardizing the ability of consumers to obtain needed services in a timely manner. This can happen if the network contains an inadequate mix of provider types. For example, a recent examination by Harvard researchers of the network composition of health plans offered on the federal Marketplace during 2015 found that nearly 15 percent of the sampled plans lacked in-network physicians for at least one specialty. Or a network might have an insufficient number of providers: There might be too few physicians who are taking new patients, who are available for an appointment within a reasonable time, or who speak the same language as the enrollee. Certain network limitations also might have the effect of discouraging enrollment by sicker consumers, potentially skewing the risk pool. Plans that provide limited or inadequate access to in-network providers make it more likely that enrollees will obtain care from out-of-network sources, exposing them to significant expenses and the possibility of surprise medical bills.Surveys show that many consumers are open to trading network breadth for a lower premium. They also suggest that, in practice, large numbers of consumers do not find network designs to be transparent. If the features of a plan's network are inadequately explained or its list of participating providers is inaccurate, it might be impossible for consumers to make an informed decision about whether the plan's combination of network and price is right for them.Consumers' experiences with narrow network plans since the ACA's implementation have defied easy characterization. Surveys of the insured, including those with Marketplace coverage, suggest that the vast majority are satisfied with their plan's choice of doctors. Yet anecdotal complaints about networks have proliferated, and the exclusion by some health plans of high-profile hospitals and care facilities has generated media headlines.In light of these developments, and as part of a larger effort to keep pace with changes to the health insurance markets since passage of the ACA, lawmakers and regulators have devoted significant attention to determining how networks should be regulated to ensure they are adequate and transparent. This work has involved efforts to establish or update standards for evaluating the sufficiency of a plan's network, improve the accuracy of provider directories, and protect enrollees from surprise bills from out-of-network providers. This brief offers an overview of state and federal actions that address the first two categories--network standards and provider directories--with a focus on rules that govern plans sold on the ACA's health insurance Marketplaces.

ACA Implementation Monitoring and Tracking: New York Site Visit Report

April 19, 2012

Examines New York's progress in implementing the 2010 federal healthcare reform, including an executive order to establish a health insurance exchange, legislation to enact insurance reforms, and the debate over implementing the Basic Health Program.

Making the Transition

Premium Incentives to Drive Wellness in the Workplace: A Review of the Issues and Recommendations for Policymakers

February 27, 2012

Outlines trends in workplace wellness programs; healthcare reform law provisions allowing greater financial incentives for employees; policy considerations for vulnerable populations, privacy issues, and affordability of coverage; and recommendations.

Lowering Costs of Care

ACA Implementation Monitoring and Tracking: Oregon Site Visit Report

February 7, 2012

Assesses Oregon's progress in implementing the 2010 federal healthcare reform, including establishing a health insurance exchange, amending the state insurance code, and planning for seamless eligibility and enrollment processes across state programs.

Making the Transition

The Role of Exchanges in Quality Improvement

September 28, 2011

Explores state options and considerations for driving healthcare quality improvement and delivery system reform at the plan and provider levels through insurance exchanges, including the need to involve all stakeholders in developing and executing policy.

Improving Quality of Care

The Massachusetts and Utah Health Insurance Exchanges: Lessons Learned

March 30, 2011

Examines the quality and choice of plans, affordability, and ease of enrollment in existing state-run exchanges. Outlines lessons learned, including the need for ongoing refinement, consideration of broader market interactions, and public outreach.

Making the Transition