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Health Insurance and States: NCSL Overview
STATE HEALTH INSURANCE MARKETS—HANGING IN THE BALANCE- NCSL Blog, Sept. 18, 2018
NCSL has tracked and evaluated activities in several project areas in health care, and has collaborated with or relied on a number of outside experts in this field. The list in the right-hand column includes links to current NCSL projects and publications. In addition, the resources listed below provide further details. Posted by Colleen Becker, NCSL.
2019 and 2018 Premium and Coverage Changes:
- *NEW* Analysis: The Marketing of Short-Term Health Plans: An Assessment of Industry Practices and State Regulatory Responses
This study assesses short-term limited-duration insurers’ marketing tactics in the wake of the new federal rules and, through interviews with insurance officials in Colorado, Florida, Idaho, Maine, Minnesota, Missouri, Texas, and Virginia, how regulators have evaluated and prepared for this new market. Full report by the Urban Institute and the Robert Wood Johnson Foundation, 9 pp. PDF
- Report: Americans with Employer Health Coverage Face Growing Cost Burdens
U.S. workers and their families, especially those living in the South, are spending a bigger share of their income on health care, a new Commonwealth Fund study finds. Average employee premium contributions for single and family plans consumed nearly 7 percent of U.S. median income in 2017, up from 5 percent in 2008. In Louisiana, premium contributions represented 10.2 percent of median income. For Americans whose incomes fall in the midrange of the income distribution, total spending on employer plan premiums and potential out-of-pocket costs to meet deductibles amounted to 11.7 percent of income last year, up from 7.8 percent a decade earlier. Full report by The Commonwealth Fund, 21 pp. PDF.
States retaining ACA preexisting condition coverage protections in state statutes - 2018
A pending federal lawsuit threatens Affordable Care Act preexisting condition protections but impact will depend on where coverage is purchased. New research published Aug. 29, 2018, illustrates 1) If the ACA’s preexisting condition protections are invalidated, consumers may be turned down for insurance, charged higher premiums, or have benefits for their health problems excluded from coverage. 2) States have the ability to enact and enforce their own laws to protect consumers, should ACA preexisting condition protections be removed.
• NCSL Summary and Link to Access-related state requirements.
• Also View 50-state Table and anslysis by The Commonwealth Fund. They report:
- "Four states (Colorado, Massachusetts, New York, and Virginia) have adopted all three ACA or equivalent protections.
- Fourteen states have partially adopted the suite of ACA preexisting condition protections, meaning that consumers in those states could face some gaps in coverage access and affordability. For example, Delaware law requires insurers to issue policies to consumers regardless of health status, but insurers would be permitted to impose preexisting condition exclusions if the ACA provision is struck down.
- Nine states and D.C. adopted one or more of the ACA’s preexisting condition protections but include provisions that render the state law protection void in the event the corresponding ACA provisions are repealed or invalidated.
- Twenty-nine states have not adopted any of the ACA consumer protections. Many of these states are also plaintiffs in the litigation."
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Tracking 2019 Premium Changes on ACA Exchanges - Update August 2018
A new tracker monitors preliminary 2019 premiums in the ACA's marketplaces as insurers file rate information with state regulators. Now with data more 20 states and the District of Columbia, the tracker shows preliminary premium information in nine major cities for the lowest-cost bronze plan and “benchmark” silver plan, which is used to determine the size of the premium tax credits available to low- and moderate-income enrollees. Kaiser Family Foundation. (News Release, Issue Brief)
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What States Doing to Affect Access to Health Insurance | An interactive map by The Commonwealth Fund
This new online tool provide statute data on eight categories of state regulation, including historical requirements from several decades, recent changes during the ACA implementation and examples in response to the 2018 proposed and final federal regulations.
- State Regulation of Short-Term Limited Duration Coverage
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State
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Does State Set Limits on the Sale of Short-Term Coverage that Are Stricter than the Federal Government's?
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Does State Prohibit Underwritten Short-Term Coverage?*
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Does State Limit the Initial Contract Duration of Underwritten Short-Term Coverage to Less Than 364 Days?**
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Does State Limit the Total Length of Time a Consumer May Be Enrolled in Underwritten Short-Term Coverage to Less Than 364 Days?***
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Arizona
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Yes
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No
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Yes
(185 days)
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No
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California
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Yes
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No
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Yes
(185 days)
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No
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Colorado
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Yes
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No
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Yes
(6 months)
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Connecticut
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Yes
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No
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Yes
(6 months)†
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No
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Hawaii
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Yes
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No
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Yes
(90 days)
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Yes
(Coverage cannot exceed 90 days in a calendar year)††
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Indiana
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Yes
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No
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Yes
(6 months)
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No
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Maryland
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Yes
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No
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Yes
(3 months)
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No
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Massachusetts
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Yes
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Yes
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Michigan
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Yes
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No
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Yes
(185 days)
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Yes
(Coverage cannot exceed 185 days per insurer in a 365-day period)
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Minnesota
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Yes
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No
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Yes
(185 days)
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No
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Nevada
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Yes
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No
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Yes
(185 days)
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Yes
(Coverage cannot exceed 185 days in a 365-day period)
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New Hampshire
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Yes
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No
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Yes
(6 months)
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No
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New Jersey
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Yes
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Yes
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New York
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Yes
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Yes
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North Dakota
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Yes
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No
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Yes
(185 days)
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No
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Oklahoma
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Yes
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No
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Yes
(6 months)
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No
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Oregon
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Yes
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No
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Yes
(3 months)
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Yes
(Coverage cannot exceed 3 months per insurer in a 5-month period)
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South Carolina
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Yes
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No
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Yes
(11 months)
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No
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South Dakota
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Yes
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No
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Yes
(6 months)
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No
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Vermont
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Yes
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No
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Yes
(3 months)
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Yes
(Coverage cannot exceed 3 months in a 12-month period)
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Stripped-Down Insurance Plans Compete with Obamacare- Excerpts and links from Capitol Journal by LexisNexis, 8/28/2018.
“This is a really important new option for millions of Americans,” said Alex Azar, secretary of HHS, in an interview on Bloomberg TV. He conceded the plans “may not be right for everybody.” Defenders of the ACA see the stripped-down plans as the latest in a series of attempts by the Trump administration to undermine Obamacare. Other actions shortened the enrollment period and eliminated government payments to insurance companies to defray the cost of subsidies for low-income ACA recipients.
This separate research indicates that "insurers are banned or limited to three months by state regulation or legislative action in:
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• Hawaii, Maryland, Massachusetts, New Jersey, New York, Oregon, and Vermont.
• Connecticut requires that any short-term insurance include the benefits mandated by the ACA.
• California may soon join these eight if Gov. Jerry Brown (D) signs a bipartisan bill (SB 910) by state Sen. Ed Hernandez (D) that bans short-term plans. Hernandez termed them “junk insurance.”
Virginia, Gov. Ralph S. Northam (D) vetoed legislation (SB 844) in May that anticipated the Trump administration rule and would have extended short-term plans to a year. In Washington the state insurance commissioner has initiated a rule-making process to clarify standards for short-term plans.
The number of states that opt out of the federal rule could go significantly higher. Richard Cauchi, director of health programs for the National Conference of State Legislatures (NCSL), observes that most legislatures were out of session when the HHS rule was issued. Cauchi said he expects states to take “a fresh look” at health insurance plans when legislatures reconvene in 2019."
- Key Obamacare plan premiums will jump 15 percent next year, Congressional Budget Office Estimates
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The price of closely watched Health Exchange "benchmark silver-level" plans will rise 15 percent for 2019 the CBO projected in a new report, released May 23, 2018.
• Table: Gross and Net Premiums for Subsidized Enrollees in States Using Healthcare.gov.
Latest Insurance Information by the Numbers
“Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2017” Published by CDC's NCHS, 5/21/2018.
- In 2017, 29.3 million (9.1%) Americans of all ages were uninsured—not significantly different from 2016, but 19.3 million fewer than in 2010.
According to the most recent detailed U.S. census report (2015, published Sept. 15, 2016), these are latest official numbers on health insurance:
- In 2015, the health insurance coverage rate for the population living inside metropolitan areas was 90.7 percent, which is 2.3 percentage points higher than the rate in 2014.
- Between 2014 and 2015, the percentage of people covered by health insurance increased in all 25 of the most populous 25 metropolitan areas. The change in the rate of coverage ranged from 0.8 percentage points to 5.2 percentage points.
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Map: Uninsured Rate by State [PDF] Sept. 2017
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Map: 2016 Uninsured Rate by State [PDF] - Census Bureau, Sept. 2016
Recent actions on Health Care
NCSL Reports and Resources: A Table of Contents
State-Initiated Health Alternatives
Pre-ACA ideas re-emerge in 2017-2018 Discussions. For the past 10 to 20 years, individual states have enacted or considered less known health insurance strategies and programs. Since the 2016 election, several of these ideas have made headlines again, as core items for 2018. NCSL has tracked and recorded these pre-ACA state actions in several such areas. Is your state one of those with such a law, or a bill that did not pass?
- Out-of-State Purchase of Health Insurance, being redifined as Association Health Plans. A growing number of state legislators have been interested in whether can states allow or facilitate the purchase of health insurance across state boundaries or from out-of-state regulated companies. At least 23 states considered legislation and six have some language enacted. No state has actually hosted such sales. Review the 10-year history across the states and the latest Trump Administration plan for nationwide Association Health Plans that can operate without state regulation. Read or download Out-of-State Health Insurance. Updated for 2018.
- Adult Dependent health coverage using parent and family health plans; more than 20 states enacted this consumer-based insurance choice before the passage of the federal ACA. Read NCSL's full report here; updated 2018
- High Risk Pools: To provide coverage for previously uninsurable individuals with pre-existing health conditions, 35 states took independent action. Between 1976 and 2010 each established high-risk health insurance pools. Enrollment totaled just 222,000 by 2010. The 2010 federal reform law provided $5 billion among all 50 states, for newly created or add-on expanded programs, almost all of which are now closed. Review the history for your state and region. Updated 2017.
- HSAs (Health Savings Accounts): HSAs were established in federal law in 2003, as tax-free financial accounts that are designed to help individuals save for future health care expenses. HSAs also are an expansion and evolution of Medical Savings Accounts (MSAs), which were launched in over 20 states and in a federal pilot program in the mid-1990s. Overview of HSA State Actions and Policies. Updated Jan. 2017.
- Make health care a right-Oregon state lawmakers vote. Amending the constitution to establish health care as a right would be unprecedented in the United States, according to Richard Cauchi of the National Conference of State Legislatures. ABC News/AP, Feb. 13, 2018.
Top 10 Examples of NCSL Reports
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Health Insurance: Premiums and Increases- Read a Comparison of Individual and Family Premiums Nationally and by State. Compiled by NCSL; Updated July 2018. (314,000 visitors in 2017)
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Section 1332 Innovation Waivers: NCSL report on State Roles and Legislation for 2015-2018 shows 35 states with filed bills and 19 states with signed laws; and eight states with fully approved or operational waivers - November 2018
- Health News on Costs and Insurance - NCSL web feature with links to recent articles and reports. Updated periodically for 2018.
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The State of Health Insurance - 2017. NCSL hosted this Webinar on Jan. 6, 2017 to provide a federal and state-oriented look at the private health insurance market. Hear three national experts discuss developments and policy scenarios. Click Here for slides.
- Rate Review and Approval for Health Insurance - NCSL's report describes current state roles and the recent federally authorized review process for the 50 states.
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Small and Large Employer Health Insurance: An Overview - NCSL report. Updated 2016.
- Mandates and EHB on Health Insurance: Report on Mandates on State Insurance and the ACA Essential Health Benefits Provisions - Summer 2018
- State and Public Employee Health Insurance:
- State Employee Health Benefits - NCSL report- updated 2018.
- ACA Requirements for Medium and Large Employers to Offer Health Coverage - NCSL explains public employer coverage in a 2016 report applicable to states, state legislatures and local governments as employers [download full report; 6 pages, PDF]
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State Health Systems Innovations – NCSL resource page featuring the range of projects and products completed by NCSL for the Commonwealth Fund, 2014-2018. Includes direct links to publications, meetings, blogs and more.
Other NCSL reports
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