Reports & Analysis

Social determinants of health have taken center stage in recent discussions of health policy in the wake of the ACA. Health care providers are being asked to extend the models' impact beyond costs and quality of health care into what has traditionally been beyond the providers' sphere of influence: the health outcomes of the population they serve. Although health policy makers have traditionally considered nonmedical influences on health to be the domain of other state agencies and nonprofit actors, a reconsideration of how the social determinants of health can be addressed within the current health policy landscape is underway. This report summarizes and synthesizes existing evidence about the impact of investing in social services and partnerships between health care and social services, paying special attention to the innovative models for improving health outcomes and reducing health care costs.

As of Spring 2015, states had completed the second open enrollment period for the new health insurance marketplaces established by the ACA and most of the 30 states that have adopted the Medicaid expansion to low-income adults were well into their second year of implementation. This brief provides an on-the-ground view of ACA implementation after completion of the second open enrollment period based on 40 in-person interviews conducted in five states – Colorado, Kentucky, Utah, Virginia, and Washington. The report presents key findings related to enrollment systems; enrollment and renewal; outreach, marketing, and enrollment assistance; and access to and utilization of care. It concludes with key priorities identified by stakeholders looking ahead.

Because eligibility for Medicaid is determined by current monthly income, many beneficiaries temporarily lose coverage when their seasonal employment or overtime pay increases, and later requalify when their income dips. This churning can result in disruptions in care for the beneficiaries, and places administrative burdens on states and Medicaid managed care plans. This study reviews four policy options for addressing the problem and simulated their impact on churning and enrollment. The options include: 1) extending coverage to the end of the calendar year; 2) granting coverage for 12 continuous months, regardless of changes in income or life circumstances; 3) basing eligibility on an estimate of annual income; and 4) extending coverage by three months when a change in income or life circumstances causes a loss of eligibility.

The State Health Access Data Assistance Center monitors enrollment in the fifteen state-based marketplaces and posts monthly reports from the states on the SHADAC website. This document provides an overview of the information states are reporting and, where data allow, shows changes between open enrollment period one (OEP1; October 1, 2013 - March 31, 2014) and open enrollment period two (OEP2; November 15, 2014 - February 15, 2015).

As consumers gain familiarity with their health coverage, they are increasingly looking for help selecting plans that align with their financial circumstances and health care needs. In response, policymakers are working to improve the accessibility and transparency of information on key plan features and to develop consumer-friendly tools that make it easier to compare and select health plans. In light of growing interest in how best to support consumer decision-making in the marketplace, this qualitative analysis offers recommendations for improving plan comparison and selection processes. This new report is based on interviews with national consumer assistance experts and navigators in California, Colorado, Florida and Illinois.

The ACA has prompted health plans to increase their use of "narrow networks" of providers as a cost containment strategy. These plans have proven popular on the ACA marketplace because they carry lower premiums. Yet consumers have little information to guide them on the tradeoff between lower premiums and network size when shopping among the various plans offered on the ACA marketplace. Regulators and policymakers also have little information on these networks. New federal requirements for updated, accurate provider directories create an opportunity to significantly improve consumers' ability to make more informed health plan choices. This data brief describes the breadth of the physician networks in plans sold on the state and federal marketplaces.

State action to prevent discriminatory benefit designs has been prompted, in part, by vital input from consumer advocacy organizations. This resource, which resulted from invitations sent to health-related consumer groups that signed the 2014 "We are (Still) Essential" letter to U.S. Department of Health and Human Services Secretary Burwell, provides a compilation of organizations that are willing to assist state insurance regulators with identifying discriminatory benefit designs or for other regulatory tasks that require expertise related to a certain disease group or consumer concern.

Prior to the Affordable Care Act (ACA), most states' individual health insurance markets were dominated by one or two insurance carriers that had little incentive to compete by providing efficient services. Instead, they competed mainly by screening and selecting people based on their risk of incurring high medical costs. One of the ACA's goals is to encourage carriers to participate in the health insurance marketplaces and to shift the focus from competing based on risk selection to processes that increase consumer value, like improving efficiency of services and quality of care. This brief looks at how carriers are competing in the new marketplaces in six states, namely through cost-sharing and composition of provider networks.

Delivery system and payment reform are dynamic and ever-evolving policy areas of state Medicaid programs; virtually every state has initiatives underway. This interactive map is designed to provide users with an environmental scan of the activity, to help introduce these complex concepts and also dive deeper. It allows users to explore specific initiatives more in depth, and it also provides related briefs that elucidate these concepts.

This paper presents findings from a study that surveyed nearly 3,000 low-income adults in late 2014 to compare experiences in three states with markedly different policies regarding the ACA: Kentucky, which expanded Medicaid, created a successful state Marketplace, and supported outreach efforts; Arkansas, which enacted the private option and a federal-state partnership Marketplace, but with legislative limitations on outreach; and Texas, which did not expand Medicaid and passed restrictions on navigators. It found that application rates, successful enrollment, and positive experiences with the ACA were highest in Kentucky, followed by Arkansas, with Texas performing worst. The paper explores these findings and the factors that most greatly contributed to successful enrollment.