This month, we’re ringing in the new year with new health policy research. In our final roundup of 2021 publications, CHIR’s Emma Walsh-Alker reviewed analyses about the impact of the ACA’s Medicaid expansion on coverage status and access to maternal care, how the Build Back Better Act (BBB) would change health insurance for low-income individuals and families, and consumer choice in health care.

Cynthia Cox et al., Build Back Better Would Change the Ways Low-Income People get Health Insurance, KFF, December 14, 2021. The authors examine how BBB, if passed, would create new pathways to health coverage for low-income people who live in states that 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 living in states that have not expanded Medicaid.
  • Currently, in non-expansion states, adults with incomes below the FPL are not eligible for subsidized marketplace coverage. The BBB would provide a new option for consumers who fall in this “coverage gap” by offering $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 would not be required to reconcile premium tax credits on their tax returns.
  • BBB proposes a major change in the marketplace enrollment process by allowing low-income individuals to enroll year-round, whereas enrollment is typically restricted to the annual open enrollment period or special enrollment opportunities that 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 individuals 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 could lead to higher costs for marketplace enrollees.
  • Marketplace plans that consumers in non-expansion states would gain access to would not be required to cover care expenses from three months prior to an enrollee’s effective date of coverage, as Medicaid does.
  • If Congress does not extend BBB’s subsidies after they are set 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 breakdown of potential reforms to our health insurance system reminds us why its passage is crucial. There are more than 2 million people who are uninsured because their state did not expand Medicaid, and the proposed legislation would provide these individuals with new access to comprehensive and affordable coverage. However, the House-passed BBB offers only a temporary fix (through 2025). As Congress continues to debate the legislation, the health coverage of millions hangs in the balance, and stakeholders should evaluate, suggest improvements, and work towards a long-term solution to ensure low-income people have access to affordable coverage regardless of what state they live 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, 2021. Researchers used data from the Pregnancy Risk Assessment Monitoring System to evaluate access to maternal health care for women with incomes between 100 and 138 percent of the federal poverty level (FPL). The authors compared differences in pregnancy-related care and coverage status based on residence of the cohort in either a Medicaid expansion state, where women were eligible for Medicaid coverage based on income, or non-expansion state, where the women were eligible for coverage on the Affordable Care Act (ACA) marketplaces. Both groups were eligible for pregnancy-related Medicaid during pregnancy and up to 60 days after. The study looked at coverage status and receipt of care both before the ACA’s coverage expansion was implemented (2011-2013) and after (2015-2018).

What it Finds

• Researchers found that following ACA implementation, residence in Medicaid expansion states was associated with increased Medicaid coverage and decreased uninsurance during the preconception period as well as increased adequate prenatal care relative to the marketplace-eligible living in non-expansion states.
  • In the preconception period, residence in a Medicaid expansion state was associated with a 20.3 percentage point increase in preconception Medicaid coverage and an 8.7 percentage point decrease in uninsurance during preconception, compared to residence in non-expansion states.
  • Residence in an expansion state was also associated with a 4.4 percentage point increase in adequate prenatal care relative to non-expansion states.
  • However, the study identified no significant differences among those in expansion versus non-expansion states in early prenatal care or postpartum checkups and contraception, which are also important measures of pregnancy-related health outcomes.
  • Researchers did not find any differences between the two groups at childbirth, citing the availability of pregnancy-related Medicaid for women with incomes between 100-138 percent FPL in all states.
  • Researchers found similar results when controlling for variables that could affect this data, such as excluding women aged 18-26 who may have been covered through a parent’s health insurance plan after ACA implementation.
• Researchers conclude that the higher levels of uninsurance among marketplace-eligible women before and after pregnancy indicate barriers to enrollment in marketplace coverage, perhaps due to affordability concerns and/or more limited enrollment windows.

Why it Matters
Poor maternal health outcomes remain a challenge in the United States, especially because of racial disparities; women of color and their children are at higher risk of pregnancy-related mortality and other negative health outcomes. Previous research suggests that preconception coverage status can affect access to health care during pregnancy, underscoring the importance of improving coverage rates for marketplace-eligible women. As policymakers consider ways to reduce uninsurance and increase care access, they should keep in mind the current obstacles to continuous coverage identified in this study, such as the limited enrollment opportunities and affordability issues that limited access to marketplace coverage prior to ARPA subsidy enhancements. Policies such as extending the American Rescue Plan Act (ARPA) enhanced subsidies or the Medicaid “coverage gap” solution in 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 Inform the Way Forward, Commonwealth Fund, November 30, 2021. The authors reviewed evidence from 82 papers published between 1990-2020 on why and how consumers make decisions about health care 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 health care coverage and services.

What it Finds

• The “consumer choice” model has been touted as a way to improve the quality and lower the cost of healthcare. It stems from the notion that with access to accurate information about their plan options and appropriate decision-making tools, consumers will choose insurance based on either price or quality, creating an incentive for providers to compete on these measures.
• The authors find that consumers follow this model sometimes, but not all the time—for instance, they may not switch health plans when a better option becomes available.
• The authors also found that even patients with high-deductible health plans (HDHP), who have greater exposure to out-of-pocket costs than those with lower or no deductibles, were not more likely to choose lower-cost providers. Instead, HDHP enrollees limited their consumption of both high- and low-value services, demonstrating that higher cost sharing does not lead consumers 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 can have unintended consequences, such as 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 utilize the transparency tools that are intended to promote easy comparison between different health care options, such as quality report cards and price 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 more widely available to spur creative policies that foster higher-value consumer choices, but authors warned regulation may be required in markets with a few dominant health systems.
  • The authors expressed some optimism about newer price transparency tools, such as 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 consumer decision-making process. In a health care system that currently leaves many overwhelmed when seeking health coverage and care, developing tools that help consumers make better decisions must be paired with improving consumer awareness and evidence-based approaches. Policymakers should work to improve consumer education and outreach as they build upon regulations, such as the 2020 price transparency rule, that advance consumer access to quality information about their health care options. Moreover, this study shows that the “blunt instrument” of high deductibles has led consumers to forgo all types of care rather than choosing higher-value services, suggesting that stakeholders—including payers—need to reconsider the notion of consumer “skin in the game” if their goal is to improve clinical outcomes in addition to lowering costs.