By Kristen Ukeomah

Happy New Year! The holiday season may be over, but health policy researchers continue to bestow gifts onto our field. In December, we read about disruptions in health insurance coverage, the uninsured population, and gaps in provider network oversight. This roundup will highlight key findings of these articles, as well as their significance for our work.

James B. Kirby, Leticia M. Nogueira, Jingxuan Zhao, K. Robin Yabroff, and Stacey A. Fedewa, Past Disruptions in Health Insurance Coverage and Access to Care Among Insured Adults, American Journal of Preventive Medicine, December 2022. Authors used data from the Medical Expenditure Panel Survey and the National Health Insurance Survey to estimate the association between gaps in health insurance coverage and inadequate health care access, including any continued association after coverage is restored. The period of health insurance coverage observed predated the timeframe for reviewing health access outcome by roughly twelve months, allowing the authors to view some of the lasting impacts of coverage disruptions.

What it Finds

• Nearly 8 percent of non-elderly adults had at least one gap in coverage during the previous year
  • Only 2 percent were uninsured for the entire year, while the remainder experienced coverage gaps between one and eleven months.
  • Having a low household income, limited education, a less healthy lifestyle, and a negative outlook regarding the value of health insurance had particularly strong associations with past insurance coverage disruptions.
• Experiencing a gap in health insurance coverage during the survey period was associated with unmet medical needs and the absence of a usual source of care, even when controlling variables such as age, gender, race, ethnicity, income, and other demographic characteristics.
  • Compared to the group with continuous coverage, the share of individuals without a usual “usual source of care provider” in the years following the health insurance observation period was over 11 percentage points higher in the group with a coverage gap of over four months, and more than double in individuals who were uninsured for the entire insurance observation period.
  • Individuals with at least a four-month gap in coverage were nearly twice as likely to report unmet medical needs years after the disruption, and those with a gap of one to three months had a 47 percent higher risk of unmet medical needs.

Why it Matters

With the upcoming unwinding of continuous Medicaid coverage, millions of people are at risk of experiencing a gap in health insurance coverage. This study illustrates how such disruptions are associated with a lack of health care access that can persist for years—a phenomenon that—as the authors suggest—shows how loss of insurance can create more permanent barriers to accessing the health care system, such as lacking a usual source of care. These findings underscore the need for policies that mitigate the risk of coverage gaps during the transition between Medicaid and other coverage programs.

Jennifer Tolbert, Patrick Drake, and Anthony Damico, Key Facts about the Uninsured Population, KFF, December 2022. Researchers at KFF examine coverage trends and characteristics of the uninsured population in the second year of the COVID-19 pandemic (2021).

What it Finds

• In 2021, 27.5 million, or 10.2 percent of non-elderly individuals were uninsured, a decrease from 28.9 million, or 10.9 percent of non-elderly people in 2019.
  • Coverage gains were predominately driven by increases in Medicaid and non-group coverage during the pandemic, and were more prominent among Hispanic and Asian communities as well as low-income individuals.
• People of color made up 61.3 percent of the non-elderly uninsured population, despite accounting for only 45.1 percent of the general population in the U.S.
• Over 80 percent of nonelderly uninsured individuals had incomes under 400 percent of the federal poverty level (FPL); nearly half (48.2 percent) had incomes under 200 percent FPL.
• Nearly two-thirds (64.4 percent) of nonelderly individuals who were uninsured worked for an employer that did not offer them coverage.
• The majority of nonelderly uninsured individuals (64 percent) cited the cost of insurance as the reason they lack coverage.
• Twenty percent of uninsured nonelderly adults went without needed medical care due to cost, compared to 5 percent of adults covered by private insurance and 6.1 percent of adults covered by a public program.

Why it Matters

The latest installment of KFF’s analysis of the uninsured shows that, despite progress, inequities in health insurance coverage persist. Cost remains the primary barrier to coverage, but characteristics of the 2021 uninsured population show that lack of coverage is not only a socioeconomic issue, but a racial issue; people of color are at higher risk of being uninsured. As stakeholders work to build on the Affordable Care Act’s (ACA) coverage gains, studies like this underscore the need for policies, outreach, and other data-driven efforts that tackle persistent coverage disparities.

Private Health Insurance: State and Federal Oversight of Provider Networks Varies, United States Government Accountability Office, December 2022. The Government Accountability Office (GAO) surveyed states, interviewed federal regulators, and reviewed literature as well as federal guidance and reports regarding provider network adequacy. The GAO describes findings related to state and federal network adequacy oversight.

What it Finds

• Between 2019–2021, officials from 45 states (including the District of Columbia) conducted regulatory oversight of the adequacy of individual and group health plans’ provider networks; five states did not take steps to oversee network adequacy.
  • Thirty-two states reported reviewing provider networks prior to approving plans for sale, while 23 states initiated reviews based on changes to plan networks.
  • Almost all of the 45 respondent states (44) used a qualitative or quantitative standard to evaluate network adequacy
    • Thirty states used both qualitative and quantitative standards
      • The most common quantitative standard was a maximum time or distance requirement (26 states); maximum appointment wait times were less frequently used (10 states).
    • Nine states used only qualitative standards.
    • Five states used only quantitative standards.
  • Officials from 18 responding states found provider networks that failed to comply with applicable network adequacy standards.
    • Some states reported that common areas of noncompliance included failure to meet quantitative standards, including time and distance standards, provider-to-enrollee ratios, appointment wait times, and required participation by certain specialists.
  • State respondents identified a variety of oversight challenges, including insufficient data, a lack of staff or software to evaluate network adequacy data, and challenges incorporating telehealth into network adequacy reviews.
• The Centers for Medicare & Medicaid Services (CMS) found that, as of August 2022. 243 out of 375 health plan issuers did not comply with network adequacy standards for Plan Year 2023 (though regulators indicated some compliance issues may stem from incorrect paperwork).
  • As of September 2022, CMS reported that all issuers selling certified marketplace plans had come into compliance with applicable network adequacy requirements.
  • CMS identified its own challenges to effective network adequacy oversight, including the dynamic nature of provider networks (which can change over time) and the lack of capacity to conduct ongoing monitoring efforts.
• Monitoring by state and federal regulators has identified several issues with provider directories
  • Twelve state respondents systematically reviewed provider directories; some of these states cold called a sample of providers to confirm a consumer’s ability to make an appointment with the provider.
  • For Plan Year 2020, CMS selected seven marketplace plan insurers for an annual compliance review, and found that all seven had at least one provider directory issue, such as incorrect contact information or improperly denoting a provider as accepting new patients.
  • For Plan Years 2017–2021, CMS consistently discovered discrepancies between provider network data and secret shopper studies, including a finding that less than half (47 percent) of a selection of listed providers had accurate and complete information.

Why it Matters

Establishing standards for and providing oversight of network adequacy is critical to ensuring enrollees’ access to covered services. When insurers fail to offer adequate networks, enrollees can face significant bills from out-of-network providers or be unable to obtain necessary care due to cost or the inability to travel long distances. Gaps in provider networks have a disproportionate impact on marginalized communities, especially rural areas that have limited health care options. Yet there is evidence that provider networks have been growing more and more narrow, particularly in the health insurance Marketplaces, as insurers compete fiercely to offer the lowest premiums. The GAO report illustrates that monitoring plans’ network adequacy and holding insurers accountable can be challenging for state and federal regulators. Recently, the Biden administration instituted quantitative network adequacy standards for the federally facilitated marketplace and has stepped up its oversight of Marketplace plans. While it remains to be seen whether these recent efforts will significantly improve the adequacy of Marketplace plan networks, they could help stem the “race to the network bottom” that has been occurring in many markets.