Issue Brief of the Commonwealth Fund

Issue: When discussing universal health insurance coverage in the United States, policymakers often draw a contrast between the U.S. and high-income nations that have achieved universal coverage. Some will refer to these countries having "single payer" systems, often implying they are all alike. Yet such a label can be misleading, as considerable differences exist among universal health care systems. Goal: To compare universal coverage systems across three areas: distribution of responsibilities and resources between levels of government; breadth of benefits covered and extent of cost-sharing in public insurance; and role of private insurance...

ISSUE: Pharmacy benefit managers (PBMs) are responsible for negotiating payment rates for a large share of prescription drugs distributed in the U.S. Recently, policymakers have expressed concern that certain PBMs' business practices may not be consistent with public policy goals to improve the value of pharmaceutical spending. GOAL: We sought to explain key controversies related to PBM practices and their roles in driving value in the pharmaceutical market. METHODS: Literature review and feedback from top experts on PBM business practices and potential policy solutions...

Issue: Serving Medicare beneficiaries with complex health care needs requires understanding both the medical and social factors that may affect their health. Goal: Describe the prevalence and characteristics of high-need individuals enrolled in the Medicare Advantage program. Methods: Analysis of the 2015 Medicare Health Outcomes Survey. Key Findings: Thirty-seven percent of enrollees in large Medicare Advantage plans have high needs, requiring both medical and social services...

Issue: Medicare Advantage (MA), the private option to traditional Medicare, now serves roughly 37 percent of beneficiaries. Congress intended MA plans to achieve efficiencies in the provision of health care that lead to savings for Medicare through managed competition among private health plans. Goal: Two elements are needed for savings to accrue: a sound payment policy and effective competition among the private plans. This brief examines the latter. Methods: We use data from 2009–17 to describe market structure in MA, including the insurers offering plans and enrollment in each U...

Issue: The German health care system resembles that of the United States in important ways — it is financed by multiple private payers and relies principally on negotiation rather than regulation to establish prices. New drugs that offer minimal benefits compared with existing alternatives within a therapeutic class are subject to reference pricing; those with incremental benefits are subject to price negotiations. Together, the reference and negotiated pricing systems have held German prices substantially below U...

Issue: Republicans and Democrats agree on prioritizing choice in health insurance, but disagree on what it entails and how to achieve it. Choice and competition can create negative consequences, including adverse selection and consumer confusion. Goals: Examine the experiences of the Affordable Care Act’s marketplaces and recommend ways policymakers can harness choice and competition to improve coverage, satisfaction, and affordability. Methods: Review of existing evidence...

Issue: In addition to medical care, individuals with functional or cognitive impairment often require long-term services and supports (LTSS), which Medicare does not cover. Little is known about the additional out-of-pocket expenses that individuals and their families incur to meet these needs. Goal: To analyze medical and LTSS spending among older Medicare beneficiaries, particularly the costs of assistive devices and personal care and the ways those costs are met...

Issue: Older adults' needs have evolved and are no longer met by the Medicare program. With the recent passage of the Bipartisan Budget Act of 2018 (BBA), Medicare Advantage (MA) plans can now provide beneficiaries with nonmedical benefits, such as long-term services and supports (LTSS), which Medicare does not cover. Goal: To examine the use of LTSS among Medicare beneficiaries age 65 and older living in the community and explore differences by age, income, and other variables...

Issue: With many states expanding Medicaid eligibility, individuals leaving jail or prison are now often able to enroll in health coverage upon release. It is increasingly clear, however, that coverage alone is insufficient to address the often complex health and social needs of people who cycle between costly hospital and jail stays. Goals: To identify emerging trends in the care delivery models that state Medicaid programs use for former inmates. Methods: Literature review and interviews with state officials, plans, and providers...

Issue: New payment and care delivery models such as accountable care organizations (ACOs) have prompted health care delivery systems to better meet the requirements of their high-need, high-cost (HNHC) patients. Goal: To explore how a group of mature ACOs are seeking to match patients with appropriate interventions by segmenting HNHC populations with similar needs into smaller subgroups. Methods: Semistructured telephone interviews with 34 leaders from 18 mature ACOs and 10 national experts knowledgeable about risk stratification and segmentation...

Issue: Over the past decade, traditional Medicare’s per-beneficiary spending grew at historically low levels. To understand this phenomenon, it is important to examine trends in postacute care, which experienced exceptionally high spending growth in prior decades. Goal: Describe per-beneficiary spending trends between 2007 and 2015 for postacute care services among traditional Medicare beneficiaries age 65 and older. Methods: Trend analysis of individual-level Medicare administrative data to generate per-beneficiary spending and utilization estimates for postacute care, including skilled nursing facilities, home health, and inpatient rehabilitation facilities...

Issue: With thousands in Arkansas losing their Medicaid benefits under the state’s work-requirement demonstration, the importance of evaluating such experiments could not be clearer. In Stewart v. Azar, the court concluded that the purpose of Section 1115 demonstrations such as Arkansas’s is to promote Medicaid’s objective of insuring the poor; evaluations of these demonstrations, as required by law, inform policymakers whether this objective is being achieved. Goal: To examine the quality of evaluation designs for demonstrations that test Medicaid eligibility and coverage restrictions...

Issue: The Affordable Care Act (ACA) made it easier for older adults and those with medical conditions to enroll in individual-market coverage by eliminating risk rating and limiting age rating. While the ACA also encourages young and healthy people to enroll through subsidies and the individual mandate, it’s not clear whether these incentives have been sufficient to prevent the risk pool from becoming disproportionately old and sick. Goal: To assess whether patterns in individual-market participation changed following ACA implementation...

Issue: Immigrant women of reproductive age in the U.S. face significant challenges obtaining comprehensive and affordable health insurance coverage and care--including sexual and reproductive health services--compared with U.S.-born women, because of myriad policy and systemic factors. Goals: Synthesize recent evidence on immigrant women’s access to sexual and reproductive health coverage and care and provide recommendations for policymaking and research. Methods: A rapid literature review to identify and summarize evidence from peer-reviewed and select grey literature published since 2011 on health insurance coverage and sexual and reproductive health care services use among immigrant women in the U...

Issue: Delivery system reform has been a focus of regulatory and legislative policy to date, but it is unclear how policymakers will integrate reforms into their plans for 2020 and beyond. Goal: To present and evaluate options for integrating delivery system reform into upcoming legislative proposals. Methods: Literature review. Findings and Conclusions: Policymakers should integrate delivery system reform into their 2020 plans to continue driving value in the health care system...

Issue: In 2017, health insurance marketplaces in some states were thriving, while those in other states were struggling. What explains these differences? Goal: Identify factors that explain differences in issuers’ participation levels in state insurance marketplaces. Methods: Analysis of the Robert Wood Johnson Foundation’s HIX Compare dataset, and the National Association of Insurance Commissioners’ 2010 Supplemental Health Care Exhibit Report...

Issue: The Centers for Medicare and Medicaid Services approved Medicaid work requirement demonstration projects in four states, and other states also have applied. However, the future of these projects has been clouded by legal and policy challenges. Goal: To assess whether state Medicaid work requirement projects are designed for success in promoting employment among unemployed Medicaid beneficiaries. Methods: To examine the design of new work requirement projects, we reviewed the evidence, analyzed the overlap of Medicaid and Supplemental Nutrition Assistance Program (SNAP) work requirements, and convened a roundtable of seven experts who have research or implementation experience with work programs for Medicaid and public assistance recipients...

Issue: A current Republican legislative proposal would permit insurers to offer plans that exclude coverage of treatment for preexisting health conditions, even while the bill would maintain the Affordable Care Act’s rule prohibiting denial of coverage to people with a preexisting condition. Goal: Estimate patients’ out-of-pocket costs for five common preexisting conditions if the bill were to become law and assess any additional impact on out-of-pocket expenditures if spending on care for preexisting conditions no longer counted against plan deductibles...

Issue: There has been relatively little discussion about the small-group employer insurance market since the implementation of reforms under the Affordable Care Act. It is important to understand the condition of this market before the impact of recent regulatory changes from the Trump administration. Goal: To understand how the ACA’s market reforms have affected prices, enrollment, and competition in the small-group market. Methods: Analysis of financial data filed by small-group insurers with the federal government, along with relevant published literature...

Issue: Out-of-pocket expenses are capped for enrollees in Medicare Advantage (MA) plans but not for beneficiaries in traditional Medicare, which also requires a high deductible for hospital care. The need for supplemental Medigap coverage adds to traditional Medicare’s complexity and administrative costs. Shortfalls in financial protection also make it difficult to offer traditional Medicare as a choice for people under age 65, as some have proposed. Goals: Describe alternative benefit designs that would limit out-of-pocket costs for traditional Medicare’s core services, assess their cost, and illustrate financing mechanisms...