NCSL's Health Systems Digest

NCSL's 2019 Legislative Summit Features Health Insurance, Medicaid and More!

NCSL's 2019 Legislative Summit, which runs from Aug. 5 through Aug. 8 in Nashville, Tenn., features multiple health-related sessions on topics such as consumer health care costs, behavioral health and Medicaid. Please visit the NCSL website for registration and agenda details.

Innovations in Health Care: A Toolkit for State Legislators

For decades, state legislatures have been faced with the increasingly difficult task of figuring out how to increase access to high-quality, low-cost health care for their constituencies. No area of policy demonstrates this more than in the realms of health insurance and Medicaid. NCSL's new toolkit provides an overview of the opportunities and challenges confronting lawmakers when considering health coverage in their states. The toolkit features Medicaid topics such as payment reform, managing high-need, high-cost populations, and practice transformation models that integrate physical and behavioral health. For the private or commercial markets, topics covered include health insurance exchanges, alternative coverage options, and state 1332 innovation waivers.

New State Scorecard: Trends in Opioid Deaths, Insurance Coverage, and Costs

Rising death rates from suicide, alcohol and drug overdose, growth in health care spending and continued rates of uninsured individuals are among the trends highlighted in the Commonwealth Fund's new 2019 Scorecard on State Health System Performance. The scorecard assesses all 50 states and the District of Columbia on a wide range of health care measures, covering access to care, costs, health outcomes, income-based disparities, and more. In addition, the new data center allows users to explore and compare state health system performance and policy changes through custom tables, graphs, and maps.

The Underlying Causes of Surprise Medical Bills

High health costs are keeping Americans up at night — nearly half of working-age adults say they could not pay an unexpected $1,000 medical bill within 30 days, according to a 2018 Commonwealth Fund survey. Several estimates suggest one of five inpatient emergency department visits may lead to surprise bills. The problem has captured the interest of lawmakers on both sides of the political aisle because the outsized impact on consumers. In the a recent post on the Commonwealth Fund's blog, To the Point, Dr. David Blumenthal and Shanoor Seervai discuss what policymakers can do to address the problem.

New York's 2014 Law to Protect Consumers from Surprise Out-of-network Bills Mostly Working as Intended: Results of a Case Study

In 2014, the New York legislature passed the Emergency Services and Balance Billing Law. The law protects consumers from charges for out-of-network services not paid by an insurance plan, in cases of emergency or circumstances in which the patient did not have a reasonable choice between an in-network and out-of-network provider. New York's law has been touted as a model for other states as well as potential federal legislation because of its unique "baseball-style" arbitration approach to settling payment disputes, which generated broad buy-in among a set of stakeholders that typically have strongly opposing views. Five years post-enactment, a study published by the Robert Wood Johnson Foundation assesses the implementation of New York's law and how it is working for consumers, providers, and insurance company stakeholders today.

'Medicare for All'? How About 'Medicaid for More'?

Colorado and Washington state both passed legislation this year that could offer a new health insurance option to people who make too much money to qualify for Medicaid but not enough to afford private health coverage. Most Medicaid recipients pay no premiums, but the idea of letting some people buy a form of Medicaid is gaining steam. Learn more in NCSL's recent blog post and the article in Governing.

Individual Insurance Market Performance in 2018

An analysis published in Kaiser Family Foundation found that individual market insurers saw better financial performance in 2018 than in all the earlier years of the ACA and returned to, or even exceeded, pre-ACA levels of profitability. Premiums fell slightly on average for 2019, as it became clear that some insurers had raised 2018 rates more than necessary. Now, insurers are expecting to pay a record total of about $800 million in rebates to individual market consumers for not meeting the ACA medical loss ratio threshold, which requires them to spend at least 80% of premium revenues on health care claims or quality improvement activities. These new data from 2018 offer further evidence that insurers in the individual market are regaining profitability, though more recent policy and legislative changes taking effect in 2019 – the repeal of the individual mandate penalty and the interest in short-term insurance plans – contribute to cloudy expectations for the future.

States Step Up to Protect Insurance Markets and Consumers From Short-Term Health Plans

Short-term health insurance plans have potential to siphon healthy individuals away from the ACA-compliant insurance market, which could cause higher premium rates in the individual market and leaving millions enrolled in coverage that excludes key services and financial protections. Researchers at the Commonwealth Fund took a comprehensive look at state regulation of short-term plans to better understand emerging trends in regulation of the short-term market, and glean lessons learned in the policymaking process.

Litigation, Legislation Leave Association Health Plan Guidance in Flux

New legislation in Congress seeks to preserve the substance of Department of Labor final rules that made it easier for small businesses and the self-employed to form association health plans (AHPs) after a federal court struck them down in March. The ruling eliminated one of two pathways to AHP formation. While the legislation faces uncertain prospects, DOL will appeal the court's decision and has issued guidance to clarify the ruling's impact. Meanwhile, AHPs formed under the new rules will need to make some quick decisions. This post offers background on the final rules and discusses the implications of the court's decision and the pending legislation.

How Much U.S. Households with Employer Insurance Spend on Premiums and Out-of-Pocket Costs: A State-by-State Look

Millions of Americans with employer health coverage are spending large shares of their income on health care costs, according to a new Commonwealth Fund report. The analysis looks at what people in every state report spending on premiums and out-of-pocket costs for medications, copays, and dental and vision care. It is a complement to an earlier report that looked at employer-reported premiums and deductibles.

Plans Emerge For New Jersey Health Insurance Marketplace, New Protections

The New Jersey Spotlight reports that three months after Gov. Phil Murphy announced New Jersey would take the reins for the state's health insurance marketplace from the federal government, the details are starting to appear. Lawmakers introduced a dozen bills late last week to create the infrastructure, funding and regulatory structure for a state-based system that would enable New Jersey officials to create, market and sell health insurance policies to low-income individuals and small businesses with fewer than 50 employees.

Medicaid and CHIP Enrollment Decline Suggests the Child Uninsured Rate May Rise Again

In 2018, enrollment in Medicaid and CHIP declined by 912,000 children in 38 states while only 13 states experienced gains in enrollment. Despite a strong economy, there is little evidence that any significant economic factors have substantially increased access to affordable private or employer-sponsored insurance. It appears that both national and state-specific factors played a role in the decline. This paper from the Gerogetown University Health Policy Institute Center for Children and Families examines the significant decline in children's combined enrollment in Medicaid and CHIP during 2018 reported in federal and state administrative data; what may be happening to coverage for these children; and why it occurred.


The Commonwealth Fund is a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the presenters and not necessarily those of NCSL or of The Commonwealth Fund, its directors, officers, or staff. Unless noted, NCSL takes no position on state legislation or laws mentioned in linked material.