Summer is finally here and it’s time to catch the wave of new health policy research. This June, researchers made a splash with policy studies and proposals on surprise medical bills, the affordability of coverage on the Affordable Care Act (ACA) marketplaces, and state-level health system performance.

Pollitz, K, et al. An Examination of Surprise Medical Bills and Proposals to Protect Consumers from Them. Kaiser Family Foundation; June 20, 2019. Researchers with the Kaiser Family Foundation analyzed large employer claims data to estimate the prevalence of out-of-network (OON) charges incurred from a health plan due to in-network hospital stays and emergency visits that could lead to a surprise bill.

What It Finds

• Among those covered by large employer plans, an estimated 18 percent of emergency visits and 16 percent of in-network hospital stays were associated with at least one OON charge in 2017.
• For people with large employer plans, 26 percent of emergency visits resulting in an inpatient admission led to an OON charge in 2017, versus 17 percent of outpatient-only emergency visits that same year. Researchers found this was in part due to a greater chance of OON emergency professional charges for inpatient admissions.
• Surprise bills vary across states:
  • For available data on in-network inpatient visits, the percentage of in-network inpatient hospital stays resulting in at least one OON charge ranged from 2 percent in South Dakota to 33 percent in New York.
  • For available data on care in emergency settings, surprise bills ranged from 3 percent in Minnesota to 38 percent in Texas.
• Twenty-seven states have laws on the books that protect consumers against balance billing with varying degrees of comprehensiveness; however, even the most comprehensive laws do not protect the 61 percent of covered workers in self-insured plans, the regulation of which is preempted under the federal Employee Retirement Income Security Act (ERISA).

Why It Matters

Surprise bills have been in both the media and Congressional spotlight recently due to the exorbitant medical bills patients are receiving for emergency care, surgeries, and other health services. Large employer plans are unique in that they are often self-insured and federally regulated, so their insurance plans are not subject to state law. Because of this, employees of insurance plans do not benefit from state protections, like New York’s 2014 law, that have substantially lowered surprise bills for consumers enrolled in state-regulated plans. The KFF research illustrates the breadth and depth of cracks in the system and highlights the need for federal action.

Blumberg, L, et al. A Targeted Affordability Improvement Proposal: The Potential Effects of Two Nongroup Insurance Reforms Designed to Increase Affordability and Reduce Costs. Urban Institute; June 14, 2019. After a failed attempt to come to agreement on a marketplace stability package to bring down premiums, Congress has largely stalled talks about ways to shore up the ACA’s marketplaces. New research from the Urban Institute may spark new conversations, with researchers using their Health Insurance Policy Simulation Model to analyze two policy proposals for the individual market aimed at making health insurance more affordable and decrease federal health outlays. The two proposals are:

• Capping provider reimbursement rates for both in- and out-of-network services for insurance coverage sold on the ACA-compliant individual market; or introducing a federal public option to the ACA-compliant individual market.
• Extending ACA premium tax credits (PTCs) to eligible individuals and families above the current income cutoff of 400 percent of the federal poverty level (FPL).

What it Finds

• Each policy implemented alone would increase comprehensive coverage and save households money.
• While capping provider payments would save the federal government $19.4 billion in 2020, extending PTCs above 400 percent FPL would increase federal spend by $8.2 billion in 2020.
• Implementing both policies together would:
  • Decrease federal spending on premium tax credits and Medicaid/CHIP acute care for the nonelderly by $12 billion in 2020, a 2.9 percent decrease compared to current spend.
  • Save households an aggregate of $9.2 billion on premiums and out-of-pocket spending for the nonelderly population in 2020, reducing average monthly premiums by 29 percent, or $200, for those with incomes above 400 percent of the FPL.
  • Decrease the number of people on non-ACA compliant short-term limited duration plans by 16.4 percent, or 401,000.
  • Increase the total number of people with comprehensive health insurance by 1.2 million people.

Why it Matters

The Trump Administration made a number of policy changes in 2017, shaking the foundation of the individual market and prompting the threat of bare counties, skyrocketing premiums, and coverage losses. Although states have been hard at work to shore up their markets through reinsurance programs and other state-based innovations, premiums and out-of-pocket costs remain a top concern for consumers. Individuals and families with incomes just over 400 percent of the FPL are particularly burdened because they are exposed to huge price increases. Policymakers should think about proposals like those modeled by the Urban Institute that work together to inject completion into the individual market and lower premiums for a population often priced out of marketplace plans.

Radley, D, et al. 2019 Scorecard on State Health System Performance: Deaths from Suicide, Alcohol, Drugs on the Rise; Progress Expanding Health Care Coverage Stalls; Health Costs Are a Growing Burden. Commonwealth Fund; June 12, 2019. Researchers with the Commonwealth Fund released a scorecard analyzing state-level health system performance on various measures such as quality of care, access to care, and income-based health care disparities.

What it Finds

• The growth in per capita spending in employer sponsored insurance (ESI) is outpacing the same measure in Medicare.
• While uninsured rates remain low, coverage gains have stalled or regressed, with 16 states seeing increases in their uninsured rate of 1 percent between 2016 and 2017.
• The percentage of adults ages 18 to 64 who didn’t get needed care due to cost rose 2 percentage points between 2016 and 2017.
• Hawaii, Massachusetts, Minnesota, Washington, and Connecticut were ranked the top five states based on a comprehensive score of 47 health care measures.
• Arkansas, Nevada, Texas, Oklahoma, and Mississippi were ranked the bottom five states based on the same health care criteria.

Why it Matters

States can be sources of health system innovation. The ACA set a federal floor for consumer protection and market reforms, but offered states additional opportunities to improve health outcomes through Medicaid expansion and options like state-based marketplaces and 1332 waivers. Evaluations like the Commonwealth Fund’s state scorecards shed light on what policies are working at the state level, and put health insurance in the larger health system context. Policymakers at the state and federal level can use this analysis and other measures of state progress to see best practices, common challenges, and areas still in need of state and federal reforms.