This month, we're ringing within the new year with new health policy research. In our final roundup of 2022 publications, CHIR's Emma Walsh-Alker reviewed analyses about the impact of the ACA's Medicaid expansion on coverage status and use of maternal care, the way the Build Back Better Act (BBB) would change medical health insurance for low-income individuals and families, and consumer choice in health care.
Cynthia Cox et al., Build Back Better Would Alter the Ways Low-Income People get Medical health insurance, KFF, December 14, 2022. The authors examine how BBB, if passed, would create new pathways to health coverage for low-income individuals who reside in states which have not yet expanded Medicaid.
What it Finds
- The authors outlined multiple ways that BBB would improve the affordability and accessibility of marketplace coverage for low-income individuals residing in states that have not expanded Medicaid.
- Currently, in non-expansion states, adults with incomes underneath the FPL do not qualify for subsidized marketplace coverage. The BBB would provide a brand new option for consumers who fall in this “coverage gap” by providing $0 premium silver plans with low deductibles and reduced cost-sharing to adults below poverty in non-expansion states.
- Silver plans for people below 138 percent of poverty would also have to cover certain services with no cost-sharing in plan years 2024 and 2025, including non-emergency transportation and family planning supplies and services covered by Medicaid.
- In 2024 and 2025, new marketplace enrollees below 138 percent FPL wouldn't be necessary to reconcile premium tax credits on their tax returns.
- BBB proposes a significant change in industry enrollment process by allowing low-income individuals to enroll year-round, whereas enrollment is usually limited to the annual open enrollment period or special enrollment opportunities which are triggered by certain life events like loss of employer coverage.
- In addition, the BBB would allocate at least $175 million in funding for outreach to the people gaining eligibility for subsidized marketplace coverage, including funding for Navigator programs in non-expansion states, where the new coverage gap solution will take effect.
- The authors also discussed potential shortfalls of BBB's proposed changes that may result in higher costs for marketplace enrollees.
- Marketplace plans that customers in non-expansion states would access would not be necessary to cover care expenses from 3 months just before an enrollee's effective date of coverage, as Medicaid does.
- If Congress doesn't extend BBB's subsidies after they are going to expire in 2025, silver plan premiums would increase for marketplace-eligible individuals with incomes 100-138 percent FPL.
Why it Matters
The BBB has stalled in the Senate, but this introduction to potential reforms to the health insurance system reminds us why its passage is vital. There are other than Two million people who are uninsured as their state didn't expand Medicaid, and also the proposed legislation would provide these people with new use of comprehensive and affordable coverage. However, the House-passed BBB offers only a temporary fix (through 2025). As Congress is constantly on the debate the legislation, the coverage of millions hangs within the balance, and stakeholders should evaluate, suggest improvements, and work at a long-term solution to ensure low-income people have use of affordable coverage regardless of what state they reside in.
Erica L. Eliason, Jamie R. Daw, Heidi L. Allen, Association of Medicaid vs Marketplace Eligibility on Maternal Coverage and Access With Prenatal and Postpartum Care, JAMA Network Open, December 6, 2022. Researchers used data from the Pregnancy Risk Assessment Monitoring System to judge use of maternal health care for ladies with incomes between 100 and 138 percent from the federal poverty level (FPL). The authors compared differences in pregnancy-related care and coverage status according to residence of the cohort either in a Medicaid expansion state, where women were entitled to Medicaid coverage according to income, or non-expansion state, in which the women were eligible for coverage around the Affordable Care Act (ACA) marketplaces. Both groups were eligible for pregnancy-related Medicaid during pregnancy and as much as Two months after. The research looked at coverage status and receipt of care both prior to the ACA's coverage expansion was implemented (2011-2022) and after (2022-2022).
What it Finds
- Researchers found that following ACA implementation, residence in Medicaid expansion states was associated with increased Medicaid coverage and decreased uninsurance throughout the preconception period in addition to increased adequate prenatal care in accordance with the marketplace-eligible residing in non-expansion states.
- In the preconception period, residence in a Medicaid expansion state was of a 20.3 percentage point rise in preconception Medicaid coverage as well as an 8.7 percentage point decrease in uninsurance during preconception, when compared with residence in non-expansion states.
- Residence in an expansion state seemed to be associated with a 4.4 percentage point rise in adequate prenatal care in accordance with non-expansion states.
- However, the research identified no significant differences the type of in expansion versus non-expansion states in early prenatal care or postpartum checkups and contraception, that are also important measures of pregnancy-related health outcomes.
- Researchers did not find any differences between the two groups at childbirth, citing the supply of pregnancy-related Medicaid for ladies with incomes between 100-138 percent FPL in most states.
- Researchers found similar results when controlling for variables that may affect this data, such as excluding women aged 18-26 and also require been covered through a parent's medical health insurance plan after ACA implementation.
- Researchers conclude that the further levels of uninsurance among marketplace-eligible women before and after pregnancy indicate barriers to enrollment in marketplace coverage, perhaps because of affordability concerns and/or more limited enrollment windows.
Why it Matters
Poor maternal health outcomes remain challenging in the usa, especially because of racial disparities; women of color and their youngsters are at higher risk of pregnancy-related mortality along with other negative health outcomes. Previous research suggests that preconception coverage status can impact access to health care during pregnancy, underscoring the significance of improving coverage rates for marketplace-eligible women. As policymakers consider ways to reduce uninsurance and increase care access, they ought to keep in mind the present obstacles to continuous coverage identified within this study, such as the limited enrollment opportunities and affordability issues that limited access to marketplace coverage just before ARPA subsidy enhancements. Policies such as extending the American Rescue Plan Act (ARPA) enhanced subsidies or even the Medicaid “coverage gap” solution within the BBB may help to lower some of these barriers.
Anna D. Sinaiko, Elizabeth Bambury, Alyna T. Chien. Consumer Choice in U.S. Health Care: Using Insights from the Past to see the Way Forward, Commonwealth Fund, November 30, 2022. The authors reviewed evidence from 82 papers published between 1990-2022 on why and how consumers decide about healthcare and coverage. Drawing from past trends in consumer experiences with price transparency, financial incentives, and provider communication, the authors make recommendations on further empowering consumers to make informed choices about healthcare coverage and services.
What it Finds
- The “consumer choice” model has been touted as a way to enhance the quality and lower the cost of healthcare. It stems from the concept with use of accurate details about their plan options and appropriate decision-making tools, consumers will choose insurance according to either price or quality, creating an incentive for providers to compete on these measures.
- The authors discover that consumers follow this model sometimes, but not all the time-for instance, they may not switch health plans whenever a better option opens up.
- The authors also discovered that even patients with high-deductible health plans (HDHP), who've greater exposure to out-of-pocket costs compared to those with lower or no deductibles, were not more prone to choose lower-cost providers. Instead, HDHP enrollees limited their use of both high- and low-value services, demonstrating that more expensive sharing does not lead customers to choose higher-value care.
- On the other hand, benefit design that incentivized higher-value care through cost-sharing structures, such as tiered provider networks and value-based insurance design, showed some promise when the design led to predictable and clear prices. However, these programs might have unintended consequences, for example tiered prescription drug formularies resulting in lower medication adherence.
- Surveys show that consumers increasingly value price transparency regarding medical services and providers. However, few consumers actually make use of the transparency tools that are meant to promote easy comparison between different health care options, such as quality report cards and value transparency websites, and availability has not resulted in patients switching to lower-priced providers or less spending.
- Large purchasers may be able to play a role in making prices and quality metrics extensively available to spur creative policies that foster higher-value consumer choices, but authors warned regulation may be required in markets with some dominant health systems.
- The authors expressed some optimism about newer price transparency tools, for example real-time benefit tools (RTBT) that allow patients and providers to see and discuss out-of-pocket drug costs during appointments.
Why it Matters
This study's findings highlight the need for simplifying the customer decision-making process. In a health care system that currently leaves many overwhelmed when seeking coverage of health and care, developing tools that help consumers make better decisions must be paired with improving consumer awareness and evidence-based approaches. Policymakers should try to improve consumer education and outreach because they build upon regulations, such as the 2022 price transparency rule, that advance consumer use of quality details about their own health care options. Moreover, this study shows that the “blunt instrument” of high deductibles has led consumers to forgo all kinds of care rather than choosing higher-value services, suggesting that stakeholders-including payers-need to reconsider the idea of consumer “skin in the game” if clients meet to enhance clinical outcomes along with lowering costs.
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