Merging Rural And Urban ACA Rating Areas Improved Choice, Premiums In Rural Texas.

Rural consumers often face a limited choice of carriers and plans and high premiums. To mitigate this issue, Texas recently adjusted its Affordable Care Act Marketplace rating areas to integrate rural areas into nearby urban markets for rating purposes. We found that rural consumers subsequently saw increases in carrier and plan choices, as well as decreases in overall plan premiums.

Race And Racial Perceptions Shape Burden Tolerance For Medicaid And The Supplemental Nutrition Assistance Program.

Safety-net programs do not reach all eligible Americans, partly because of administrative burden, or experiencing bureaucratic obstacles in obtaining and maintaining program benefits. This burden often disproportionately affects historically marginalized groups, adding concerns about equity. We used a national survey to examine public thinking about the acceptability of administrative burdens imposed by states when implementing Medicaid and the Supplemental Nutrition Assistance Program and the role of race in these considerations. We found that support for state actions associated with six types of burden was unchanged when respondents were informed about disparate effects by race. Neither racial identity nor prejudice toward other racial groups was associated with support for policies imposing higher burdens. However, non-Hispanic White respondents with higher levels of racial resentment were more supportive of policies that would create burden, whereas respondents who believed that burdens had disparate effects on historically disadvantaged groups favored less burdensome alternatives. Also associated with lower support for more burdensome policies were responses indicative of respondents' empathy, concerns about ability to manage burdens, Democratic party identification, and program experience.

State Efforts to Regulate Provider Networks and Directories: Lessons for the Future.

Managed care arrangements are the dominant form of insurance coverage in the United States today. These arrangements rely on a network of contracted providers to deliver services to their enrollees. After the managed care backlash, governments moved to ensure consumer access by issuing a number of requirements for carriers related to the composition and size of their networks and how this information is shared with consumers. The authors provide a comprehensive review of these state-based efforts to regulate provider network adequacy and provider directory accuracy for commercial insurance markets. In addition to common measures of adequacy, they also include requirements specifically targeted to underserved populations. Their assessment comes on the heels of recent empirical work that has raised significant questions about whether these efforts are effective, particularly considering the limited nature of enforcement. They also provide a brief overview and assessment of recent federal government efforts that replicate these state regulations with a focus on lessons learned from state regulations that may help improve their federal counterparts. Furthermore, they outline a future research agenda focused on a more comprehensive evaluation of efforts to ensure consumer access.

More Than Words? How Highlighting Target Populations Affects Public Opinion about the Medicaid Program.

CONTEXT: The Medicaid program provides health insurance coverage to a diverse set of demographics. We know little about how the policy community describes these populations (e.g., on Medicaid-related websites or in public opinion polls and policy writings) or whether and how these descriptions may affect perceptions of the program, its beneficiaries, and potential policy changes. METHODS: To investigate this issue, we developed and fielded a nationally representative survey of 2,680 Americans that included an experiment for priming respondents by highlighting different combinations of target populations of the Medicaid program as found in the Medicaid policy discourse. FINDINGS: Overall, we find that Americans view Medicaid and its beneficiaries rather favorably. However, there are marked differences based on partisanship and racial animosity. Emphasizing citizenship and residency requirements at times improved these perceptions. CONCLUSIONS: Racial perceptions and partisanship are important correlates in Americans' views about Medicaid and its beneficiaries. However, perceptions are not immutable. In general, the policy community should shift toward using more comprehensive descriptions of the Medicaid population that go beyond the focus on low income and that include citizenship and residency requirements. Future research should expand this work by studying descriptions in the broader public discourse.

Provider directory inaccuracy and timely access for mental health care.

OBJECTIVES: To evaluate the accuracy of provider directories for mental health providers and network adequacy, defined as timely access to urgent and general care appointments in California. STUDY DESIGN: We assessed provider directory accuracy and timely access using a novel, comprehensive, and representative data set of mental health providers for all plans regulated by the California Department of Managed Health Care with 1,146,954 observations (480,013 for 2018 and 666,941 for 2019). METHODS: We used descriptive statistics to assess provider directory accuracy and network adequacy assessed via access to timely appointments. We used t tests to make comparison across markets. RESULTS: We found that mental health provider directories are highly inaccurate. Commercial plans were consistently more accurate than both Covered California marketplace and Medi-Cal plans. Moreover, plans were highly limited in providing timely access to urgent care and general appointments, although Medi-Cal plans outperformed plans from both other markets when it came to timely access. CONCLUSIONS: These findings are concerning from both the consumer and regulatory perspectives and provide further evidence of the tremendous challenge that consumers face in accessing mental health care. Although California's laws and regulations are some of the strongest in the country, they are still falling short, indicating the need to further expand efforts to protect consumers.

Provider directory accuracy and timely access to mammograms in California.

Provider directory accuracy and access to timely appointments are crucial determinants of health outcomes. However, to our knowledge, no studies have analyzed provider directory accuracies or network adequacy for mammograms, an important preventive service. We fill that gap using large-scale, random, and representative surveys of provider directories and timely access for all managed care plans in California for mammogram providers, obtained from the Department of Managed Health Care for 2018 and 2019 for commercial, ACA marketplace, and Medicaid plans with more than 33,000 observations. Directory inaccuracies ranged from a low of 23 percent to a high of 38 percent. Consumers were able to schedule appointments with specific providers within 15 days in between 59 percent to 73 percent of cases. Comparisons of accuracy and adequacy between the three markets (commercial, ACA, Medicaid) were inconsistent. Even with one of the nation's strictest and most well-resourced regulatory regimes for provider networks, our findings show substantial inaccuracies and inadequacies exist.

Directory Accuracy and Timely Access in Maryland's Medicaid Managed Care Program.

We assessed provider directory accuracy and timely access in Maryland's Medicaid managed care program, using annual surveys from the annual random and representative provider surveys conducted on behalf of the Maryland Department of Health for 2018 and 2019. Based on 3,262 calls to 2,002 providers in 2018 and 2,739 calls to 2,033 providers in 2019, we found that provider directories are highly inaccurate. Insurance coverage could only be verified for 46% of the listed providers in 2018 and 56% of the listed providers in 2019. Among providers whose insurance participation was verified, beneficiaries were able to schedule timely general care appointments in 90% of verified providers in 2018 and 85% of verified providers in 2019; slightly more than 70% of appointments were scheduled on the first call. The success rate for urgent care appointments was lower but improved substantially once alternative providers were accounted for. Even for verified providers, timely access standards were often not met, particularly for general care. We also note the substantial variation across managed care organizations and across years. Our findings raise concerns from both an enrollee as well as a broader policy perspective. More oversight and enforcement are necessary to guarantee access to care.

Potemkin Protections: Assessing Provider Directory Accuracy and Timely Access for Four Specialties in California.

CONTEXT: The accuracy of provider directories and whether consumers can schedule timely appointments are crucial determinants of health access and outcomes. METHODS: We evaluated accuracy and timely access data obtained from the California Department of Managed Health Care, consisting of responses to large, random, representative surveys of primary care providers, cardiologists, endocrinologists, and gastroenterologists for 2018 and 2019 for all managed care plans in California. FINDINGS: Surveys were able to verify provider directory entries for the four specialties for 59% to 76% of listings or 78% to 88% of providers reached. We found that consumers were able to schedule urgent care appointments for 28% to 54% of listings or 44% to 72% of accurately listed providers. For general care appointments, the percentages ranged from 35% to 64% of listed providers or 51% to 87% of accurately listed providers. Differences across markets related to accuracy were generally small. Medi-Cal plans outperformed other markets with regard to timely access. Primary care consistently outperformed all other specialties. Timely access rates were higher for general appointments than for urgent care appointments. CONCLUSIONS: Our finding raise questions about the regulatory regime as well as consumer access and health outcomes.

Lingering Legacies: Public Attitudes about Medicaid Beneficiaries and Work Requirements.

CONTEXT: This article provides a detailed picture of the mindset of Americans about Medicaid work requirements and the important roles that perception of deservingness and racial bias play in public attitudes. METHODS: The authors conducted a large original survey to investigate public attitudes toward work requirements. They analyzed the predictors of overall support for work requirements, correlates of who should be exempt from them, and attitudes toward work supports that make compliance with work requirements easier. FINDINGS: The authors found that public opinion is split relatively evenly when it comes to Medicaid work requirements in the abstract. When Americans are confronted with the complexities of the issue, important nuances emerge. The authors also found consistent evidence that support for work requirements is higher among conservatives, those who see Medicaid as a short-term program, and racially resentful non-Hispanic whites. They show that groups that have historically been framed as deserving see high levels of support for their exemption (e.g., the disabled and senior citizens). Finally, the authors found that Americans are supportive of policies that provide individuals with help when transitioning into the workforce. CONCLUSIONS: Americans' views of Medicaid and the populations it serves are complex and continue to be influenced by perceptions of deservingness and race.

A Look Under the Hood: Regulatory Policy Making and the Affordable Care Act.

The Affordable Care Act (ACA) was signed into law a decade ago. Partisanship has limited the number of statutory changes, leaving the law mostly unchanged across the past 10 years. However, the ACA delegated vast powers to the executive branch, which opened the door for significant regulatory policy-making activities (also called "rulemaking"). We collected data on all regulatory actions related to the Affordable Care Act that have been taken since its passage to provide the first exploratory analyses of both the public law itself and the ensuing rulemaking activities. We also provide illustrative examples of two controversial issues: short-term limited-duration insurance plans and contraceptive coverage for women. Despite relative statutory stasis, regulatory actions have continued to shape the implementation of the Affordable Care Act. Both the Obama and Trump administrations have taken advantage of a vast delegation of policy-making power. Importantly, regulatory policy making holds the potential to yield significant changes depending on the policy goals of the presidential administration. Scholars, policy makers, and the public are well-advised to pay attention to ACA-related rulemaking activities. Moreover, "quasi-rulemaking" (i.e., the use of agency guidance as a policy tool) remains largely unexplored but could indicate an even greater regulatory enterprise than illustrated here.

Going the Extra Mile? How Provider Network Design Increases Consumer Travel Distance, Particularly for Rural Consumers.

CONTEXT: The practical accessibility to medical care facilitated by health insurance plans depends not just on the number of providers within their networks but also on distances consumers must travel to reach the providers. Long travel distances inconvenience almost all consumers and may substantially reduce choice and access to providers for some. METHODS: The authors assess mean and median travel distances to cardiac surgeons and pediatricians for participants in (1) plans offered through Covered California, (2) comparable commercial plans, and (3) unrestricted open-network plans. The authors repeat the analysis for higher-quality providers. FINDINGS: The authors find that in all areas, but especially in rural areas, Covered California plan subscribers must travel longer than subscribers in the comparable commercial plan; subscribers to either plan must travel substantially longer than consumers in open networks. Analysis of access to higher-quality providers show somewhat larger travel distances. Differences between ACA and commercial plans are generally substantively small. CONCLUSIONS: While network design adds travel distance for all consumers, this may be particularly challenging for transportation-disadvantaged populations. As distance is relevant to both health outcomes and the cost of obtaining care, this analysis provides the basis for more appropriate measures of network adequacy than those currently in use.

A Consumer-Centric Approach To Network Adequacy: Access To Four Specialties In California's Marketplace.

We assessed the effect of provider networks on access to four medical specialties for Affordable Care Act Marketplace enrollees in California. Our approach incorporated a crucial consumer-focused attribute, travel distance, and identified the restrictions on provider access resulting from network design. Our analysis indicated that Marketplace plan networks are narrower than their commercial plan counterparts and feature just over half as many providers. However, there is much diversity in network breadth, depending on consumers' choice of plans and geographic region. Furthermore, network designs often create important access issues for consumers because of what we call "artificial local provider deserts"-geographic areas within networks devoid of providers by design. Consumers in large metropolitan areas are generally guaranteed a significant degree of access and choice, but network design exacerbates limited access for rural areas in which few providers are available to any consumer.

A Knotty Problem: Consumer Access and the Regulation of Provider Networks.

In order to increase access to medical services, expanding coverage has long been the preferred solution of policy makers and advocates alike. The calculus appeared straightforward: provide individuals with insurance, and they will be able to see a provider when needed. However, this line of thinking overlooks a crucial intermediary step: provider networks. As provider networks offered by health insurers link available medical services to insurance coverage, their breadth mediates access to health care. Yet the regulation of provider networks is technically, logistically, and normatively complex. What does network regulation currently look like and what should it look like in the future? We take inventory of the ways private and public entities regulate provider networks. Variation across insurance programs and products is truly remarkable, not grounded in empirical justification, and at times inherently absurd. We argue that regulators should be pragmatic and focus on plausible policy levers. These include assuring network accuracy, transparency for consumers, and consumer protections from grievous inadequacies. Ultimately, government regulation provides an important foundation for ensuring minimum levels of access and providing consumers with meaningful information. Yet, information is only truly empowering if consumers can exercise at least some choice in balancing costs, access, and quality.

How Intense Policy Demanders Shape Postreform Politics: Evidence from the Affordable Care Act.

The implementation of the Affordable Care Act (ACA) has been a politically volatile process. The ACA's institutional design and delayed feedback effects created a window of opportunity for its partisan opponents to launch challenges at both the federal and state level. Yet as recent research suggests, postreform politics depends on more than policy feedback alone; rather, it is shaped by the partisan and interest-group environment. We argue that "intense policy demanders" played an important role in defining the policy alternatives that comprised congressional Republicans' efforts to repeal and replace the ACA. To test this argument, we drew on an original data set of bill introductions in the House of Representatives between 2011 and 2016. Our analysis suggests that business contributions and political ideology affected the likelihood that House Republicans would introduce measures repealing significant portions of the ACA. A secondary analysis shows that intense policy demanders also shaped the vote on House Republicans' initial ACA replacement plan. These findings highlight the role intense policy demanders can play in shaping the postreform political agenda.

Secret Shoppers Find Access To Providers And Network Accuracy Lacking For Those In Marketplace And Commercial Plans.

The adequacy of provider networks for plans sold through insurance Marketplaces established under the Affordable Care Act has received much scrutiny recently. Various studies have established that networks are generally narrow. To learn more about network adequacy and access to care, we investigated two questions. First, no matter the nominal size of a network, can patients gain access to primary care services from providers of their choice in a timely manner? Second, how does access compare to plans sold outside insurance Marketplaces? We conducted a "secret shopper" survey of 743 primary care providers from five of California's nineteen insurance Marketplace pricing regions in the summer of 2015. Our findings indicate that obtaining access to primary care providers was generally equally challenging both inside and outside insurance Marketplaces. In less than 30 percent of cases were consumers able to schedule an appointment with an initially selected physician provider. Information about provider networks was often inaccurate. Problems accessing services for patients with acute conditions were particularly troubling. Effectively addressing issues of network adequacy requires more accurate provider information.

California hospital networks are narrower in Marketplace than in commercial plans, but access and quality are similar.

Do insurance plans offered through the Marketplace implemented by the State of California under the Affordable Care Act restrict consumers' access to hospitals relative to plans offered on the commercial market? And are the hospitals included in Marketplace networks of lower quality compared to those included in the commercial plans? To answer these questions, we analyzed differences in hospital networks across similar plan types offered both in the Marketplace and commercially, by region and insurer. We found that the common belief that Marketplace plans have narrower networks than their commercial counterparts appears empirically valid. However, there does not appear to be a substantive difference in geographic access as measured by the percentage of people residing in at least one hospital market area. More surprisingly, depending on the measure of hospital quality employed, the Marketplace plans have networks with comparable or even higher average quality than the networks of their commercial counterparts.

You Can't Make Me Do It, but I Could Be Persuaded: A Federalism Perspective on the Affordable Care Act.

The Affordable Care Act (ACA) seeks to change fundamentally the US health care system. The responses of states have been diverse and changing. What explains these diverse and dynamic responses? We examine the decision making of states concerning the creation of Pre-existing Condition Insurance Plan programs and insurance marketplaces and the expansion of Medicaid in historical context. This frames our analysis and its implications for future health reform in broader perspective by identifying a number of characteristics of state-federal grants programs: (1) slow and uneven implementation; (2) wide variation across states; (3) accommodation by the federal government; (4) ideological conflict; (5) state response to incentives; (6) incomplete take-up rates of eligible individuals; and (7) programs as stepping-stones and wedges. Assessing the implementation of the three main components of the ACA, we find that partisanship exerts significant influence, yet less so in the case of Medicaid expansion. Moreover, factors specific to the insurance market also play an important role. Finally, we conclude by applying the themes to the ACA and offer an outlook for its continuing implementation. Specifically, we expect a gradual move toward universal state participation in the ACA, especially with respect to Medicaid expansion.

Balancing adequacy and affordability?: Essential Health Benefits under the Affordable Care Act.

The Essential Health Benefits provisions under the Affordable Care Act require that eligible plans provide coverage for certain broadly defined service categories, limit consumer cost-sharing, and meet certain actuarial value requirements. Although the Department of Health and Human Services (HHS) was tasked with the regulatory development of these EHB under the ACA, the department quickly devolved this task to the states. Not surprisingly, states fully exploited the leeway provided by HHS, and state decision processes and outcomes differed widely. However, none of the states took advantage of the opportunity to restructure fundamentally their health insurance markets, and only a very limited number of states actually included sophisticated policy expertise in their decisionmaking processes. As a result, and despite a major expansion of coverage, the status quo ex ante in state insurance markets was largely perpetuated. Decisionmaking for the 2016 revisions should be transparent, included a wide variety of stakeholders and policy experts, and focus on balancing adequacy and affordability. However, the 2016 revisions provide an opportunity to address these previous shortcomings.