Medicare Advantage for Most.

Policy Points Fixing the ACA requires real cost containment in addition to better subsidies. Private Medicare (Medicare Advantage) plans are uniquely empowered to control costs and deliver good care. Medicare Advantage plans should serve as the public option on the ACA Marketplace. Medicare Advantage plans can also be deployed to voluntarily raise minimum employer-sponsored benefits and contain their costs.

The Better Care Plan: a blueprint for improving America's healthcare system.

The United States falls far short of its potential for delivering care that is effective, efficient, safe, timely, patient-centered, and equitable. We put forward the Better Care Plan, an overarching blueprint to address the flaws in our current system. The plan calls for continuously improving care, moving all payers to risk-adjusted prospective payment, and creating national entities for collecting, analyzing, and reporting patient safety and quality-of-care outcomes data. A number of recommendations are made to achieve these goals.

"Pick a Plan and Roll the Dice": A qualitative study of consumer experiences selecting a health plan in the non-group market.

Background: For consumers without access to employer-sponsored or public insurance, health plan choices in the non-group (individual) insurance market that do not meet consumer needs have the potential for negative downstream implications for health and financial well-being. Objective: This qualitative interview study sought to understand consumers' experiences and challenges with choosing a non-group health plan, among those who later had negative experiences with the plan they chose. Methods: We conducted semi-structured telephone interviews with a purposive sample of 36 participants from a large regional health insurance carrier in three states who enrolled in non-group plans in 2017 (21 in Affordable Care Act (ACA) Marketplace plans and 15 enrolled off-Marketplace). Participants were included if they reported negative experiences using their plan after enrollment, such as higher-than-expected medical costs. Interviews explored challenges choosing a plan; information needed for choosing; usefulness of available tools; and preferred format for interventions to improve plan choice experiences. We analyzed interview transcripts using thematic content analysis. Results: Study participants reported experiencing substantial challenges to choosing an insurance plan. Key barriers included understanding insurance terms, finding relevant information, and making comparisons across plans. Participants valued the ability to make comparisons across carriers when using the Marketplace websites but were less satisfied with customer service. Suggestions for improvement included greater standardization of plans and language and availability of customized one-on-one assistance. Conclusion: Findings from this study suggest that health plan selection in the non-group market presents challenges to consumers that may be addressed through enrollment assistance and improved presentation of information. Personalized assistance to find and choose coverage may lead to plan choices that better meet consumer needs and increase confidence choosing a plan in subsequent enrollment periods.

Understanding Consumer Experiences and Insurance Outcomes Following Plan Disenrollment in the Nongroup Insurance Market.

Disenrollment from health plans purchased on Affordable Care Act (ACA) Marketplaces is frequent; little is known whether disenrollment from off-Marketplace plans is as common or about the experiences and consequences of disenrollment. Using longitudinal administrative data on 2017-2018 nongroup plan enrollment linked with survey data, we analyze plan disenrollment in one regional insurance carrier servicing three states. Overall, 71% of enrollees disenrolled from their 2017 plan. Disenrollment was associated with purchasing through an ACA Marketplace, the carrier making significant changes to an enrollee's plan benefit design, being healthier, being younger, and paying a higher premium for their 2017 plan in 2018. Experiencing financial burden or poor access to preferred providers was not associated with disenrollment. Most disenrollees (93.2%) enrolled in other coverage, often at a lower premium, but lacked confidence that they could afford needed care. These results can inform policy to support enrollees through coverage transitions and foster stability in the nongroup market.

Affordability and Access Challenges Among US Subscribers to Nongroup Insurance Plans.

This cohort study assesses cost-related experiences in non-group plans purchased on or off Marketplace and variation by Marketplace enrollment, decision support use, and other characteristics.

In New England, Partisan Differences In ACA Marketplace Participation And Potential Financial Harm.

Political orientation can be a powerful motivator of certain health care decisions. This study examines how political orientation was associated with decisions to use the Affordable Care Act Marketplaces to enroll in nongroup health insurance plans and whether it was also associated with adverse financial consequences. We used administrative records and surveys of nongroup Marketplace enrollees from a large insurer in New England. Enrollees were categorized as Republican, Democrat, or independent through self-identification or were assigned to one of the political parties after responding to a political preference question. Republican enrollees were less likely than Democratic enrollees of comparable subsidy eligibility to enroll through the Marketplaces and receive subsidies. Among income-eligible enrollees, Republican subscribers received $66 per month less in premium subsidies than Democratic subscribers, equivalent to roughly $800 per year. However, this result varied by subgroups in the parties, and our results suggest that party effects on decision making may inversely relate to the magnitude of the financial consequence. Navigating the ongoing political polarization in the United States requires optimizing public policies, as well as the associated education and outreach, to ensure maximal efficacy regardless of political orientation.

Successes and failures with bundled payments in the commercial market.

The relatively few examples of commercially funded condition-specific bundled payments provide insights into how to spread this alternative payment model further in the private insurance market.

Consumer Health Insurance Shopping Behavior and Challenges: Lessons From Two State-Based Marketplaces.

Selecting a health plan in a health insurance exchange is a critical decision, yet consumers are known to face challenges with health plan choice. We surveyed new enrollees in two state-based exchanges in 2015 to investigate how a nonelderly, primarily low-income population chose their health plans and the implications of shopping behavior for early experiences in their plans. Financial considerations were most important to enrollees. Prior Medicaid enrollees and the uninsured were more likely to have multiple shopping challenges (e.g., difficulty identifying the best or most affordable plan, fair/poor experience, unmet need for help) than enrollees with prior employer coverage (42.9% vs. 32.5% vs. 16.4%, respectively, p < .01). Shopping challenges were associated with difficulty finding a doctor, understanding coverage, and getting questions answered. Assistance targeting enrollees who previously had Medicaid or lacked insurance could improve both shopping experiences and downstream outcomes in plans.

Decision-Making Experiences Of Consumers Choosing Individual-Market Health Insurance Plans.

The health insurance Marketplaces established by the Affordable Care Act include features designed to simplify the process of choosing a health plan in the individual, or nongroup, insurance market. While most individual health insurance enrollees purchase plans through the federal and state-based Marketplaces, millions also purchase plans directly from an insurance carrier (off Marketplace). This study was a descriptive comparison of the decision-making processes and shopping experiences of consumers in two states who purchased a health insurance plan from the same large insurer in 2017, either through the federal Marketplaces or off Marketplace. In a survey, those who selected plans through the Marketplaces reported less difficulty finding the best or most affordable plan than did those enrolling off Marketplace. Respondents in families with chronic health conditions who enrolled through the Marketplaces reported better overall experiences than those who enrolled off Marketplace. Respondents with low health insurance literacy reported poor experiences in enrolling both through the Marketplaces and off Marketplace. Access to consumer assistance in the individual health insurance market should target off-Marketplace populations as well as all populations with low health insurance literacy.

Nudging Leads Consumers In Colorado To Shop But Not Switch ACA Marketplace Plans.

The Affordable Care Act (ACA) dramatically expanded the use of regulated marketplaces in health insurance, but consumers often fail to shop for plans during open enrollment periods. Typically these consumers are automatically reenrolled in their old plans, which potentially exposes them to unexpected increases in their insurance premiums and cost sharing. We conducted a randomized intervention to encourage enrollees in an ACA Marketplace to shop for plans. We tested the effect of letters and e-mails with personalized information about the savings on insurance premiums that they could realize from switching plans and the effect of generic communications that simply emphasized the possibility of saving. The personalized and generic messages both increased shopping on the Marketplace's website by 23 percent, but neither type of message had a significant effect on plan switching. These findings show that simple "nudges" with even generic information can promote shopping in health insurance marketplaces, but whether they can lead to switching remains an open question.

How small business health exchanges can offer value to their future customers--and why they must.

The success of the Small Business Health Options Program (SHOP)-health insurance exchanges targeted at the small-group market and opening for business in January 2014-will depend in large part on persuading small employers and qualified health plans to participate. The most important objective will be offering employers lower-cost health plans than they have now. Other critical objectives will be offering small firms administrative efficiencies and access to choices among high-value plans that are not offered elsewhere. This article frames the challenges that exchanges will encounter in meeting these objectives. In particular, it discusses the advisability of small-business exchanges' offering an "employee choice" model (which the article describes in detail); of combining the small-business and individual exchanges to broaden product offerings and gain operational efficiencies; and of encouraging low-cost plans to enter the exchange market, perhaps by enabling Medicaid managed care plans to offer comparable commercial products, and in turn affording health plans access to a uniquely motivated market of small firms and their workers who want affordable coverage.

Insurance exchanges under health reform: six design issues for the states.

The Patient Protection and Affordable Care Act depends on new, state-based exchanges to make health insurance readily available to certain segments of the population. One such segment is the lower-income uninsured, who can qualify for subsidized coverage only through an exchange. Other segments are unsubsidized individuals and small employers, who may choose to buy coverage inside or outside of an exchange. Although the law provides some guidance in structuring these new exchanges, it leaves many key decisions to the states. Successfully implementing exchanges will require public-private partnerships, expertise in insurance operations and marketing, and a series of strategic decisions. We review the half-dozen most important design issues.

Implementing health care reform in Massachusetts: strategic lessons learned.

Massachusetts has been in continuous campaign mode on health reform since 2004, when then Gov. Mitt Romney (R) and advocacy groups from both parties began to promote universal coverage. The state has already enacted two sets of reforms (in 2006 and 2008), and it may soon consider an all-payer proposal aimed at containing costs. Much remains to be done, but the political strategy of enacting reform in stages has already produced big gains and momentum to do more.