Prior to the ACA most states had little or no restrictions on insurance rates taking account of enrollees’ health risks. In the 1990s a small number of states imposed community rating and guaranteed issue in their health insurance markets, as the ACA has done, but without any subsidies, exactly the same situation that will result on the federal exchanges from a plaintiffs’ victory in King v. Burwell. It was widely predicted these states would experience an adverse selection death spiral. A 1999 National Bureau of Economic Research (NBER) paper by Thomas Buchmueller and John Dinardo compared New York, which had imposed community rating and guaranteed issue, with neighboring states. They “found no evidence for the conventional wisdom that the imposition of pure community rating tends to an adverse selection death spiral.” Similarly, another 2006 NBER paper by Bradley Herring and Mark V. Pauly compared states with community rating and guaranteed issue to states with no such regulations. They found a small increase in the number of uninsured, but did “not observe a strong positive relationship between risk status and the likelihood of being covered, that would be consistent with so-called death spirals.”
North Carolina Blues plan unloads price transparency surprise – Modern HealthcareVital Signs | The healthcare business blog from Modern HealthcareJanuary 13, 2015
There’s a fascinating story out of North Carolina about that state’s largest insurer unexpectedly publishing information on how much it pays healthcare providers for a wide range of elective, non-emergency services.
Providers were not pleased. More surprisingly, consumer advocates were sharply critical. But more such efforts are on the way and providers should stop complaining and get prepared.
Blue Cross and Blue Shield of North Carolina suddenly released its all-inclusive payment rates for services including kidney transplants, knee replacements, coronary bypass procedures, screening colonoscopies and other services. The insurer’s online look-up tool includes all payments for a service, including facility fees, doctor fees and pathology.
Commonwealth Fund: Implementing the Affordable Care Act: State Approaches to Premium Rate Reforms in the Individual Health Insurance MarketJanuary 3, 2015
The Affordable Care Act protects people from being charged more for insurance based on factors like medical history or gender and establishes new limits on how insurers can adjust premiums for age, tobacco use, and geography.
This brief examines how states have implemented these federal reforms in their individual health insurance markets. We identify state rating standards for the first year of full implementation of reform and explore critical considerations weighed by policymakers as they determined how to adopt the law’s requirements. Most states took the opportunity to customize at least some aspect of their rating standards. Interviews with state regulators reveal that many states pursued implementation strategies intended primarily to minimize market disruption and premium shock and therefore established standards as consistent as possible with existing rules or market practice. Meanwhile, some states used the transition period to strengthen consumer protections, particularly with respect to tobacco rating.
Proposition 45 doesn’t create a single payer system; it creates a single overseer system. By explicitly giving the Insurance Commissioner authority over rates and benefits, Proposition 45 gives this elected official implicit power over everything relating to health plans in California. This includes what treatments carriers cover—or don’t cover, what doctors and hospitals are in—or out—of a carrier’s network, what insurers spend on marketing and distribution, and virtually everything else but what colors are in the carrier’s logo. And a creative Commissioner could probably find a way to control that as well.The ability to leverage explicit powers to expand control over other items isn’t idle conjecture. I’ve seen it done in other contexts.
Indeed, it can be said that in no other country is as much oversight necessary—and performed—as it already is in the U.S. Here hospitals spend hundreds of millions, possibly billions, every year to be in compliance with government regulations, and government auditors and the Inspector General’s offices cost hundreds of millions more. Every U.S. hospital now has some executive vice president in charge of compliance, has a board subcommittee dealing with compliance and has a sizeable compliance department and confidential hotline for whistle blowers. There are a growing number of compliance consulting firms helping hospitals and clinics to remain in compliance with U.S. federal and state regulations, earning a fine living from the process—all at patients’ expense, of course. I have never encountered anything like it in other countries whose health systems I have studied.
The Political Roots of Health Insurance Benefit MandatesDouglas Webber, James Bailey | May 28, 2014
As of 2011, the average US state had 37 health insurance benefit mandates, laws requiring health insurance plans to cover a specific treatment, condition, provider, or person. This number is a massive increase from less than one mandate per state in 1965, and the topic takes on a new significance now, when the federal government is considering many new mandates as part of the “essential health benefits” required by the Affordable Care Act. A large body of literature has attempted to evaluate the effect of mandates on health, health insurance, and the labor market.
However, previous papers did not consider the political processes behind the passage of mandates. In fact, when they estimate the laws’ effect, almost all papers on the subject assume that mandates are passed at random. We use fixed effects estimation to determine why some states pass more mandates than others. We find that the political strength of health care providers is the strongest determinant of mandates. Our paper opens the way to estimating the causal effect of mandates on health insurance and the labor market using an instrumental variables strategy that incorporates political information about why mandates get passed.
As hospital, physician, and health insurance markets consolidate and change in response to health care reform, some commentators have called for vigorous enforcement of the federal antitrust laws to prevent the acquisition and exercise of market power. In health care, however, stricter antitrust enforcement will benefit consumers only if it accounts for the competitive distortions caused by the sector’s long history of government regulation. This article directs policy makers to a neglected dimension of health care competition that has been altered by regulation: the product. Competition may have failed to significantly lower costs, increase access, or improve quality in health care because we have been buying and selling the wrong things. Competition policy makers—meaning both antitrust enforcers and regulators—should force the health care industry to define and market products that can be assembled and warranted to consumers while keeping emerging sectors such as mHealth free from overregulation, wasteful subsidy, and appropriation by established insurer and provider interests.