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."

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)
What States Doing to Affect Access to Health Insurance | A n 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.
- The new rule allows states to override HHS on the stripped-down plans, as eight states have already done. This Table excerpt reflects existing practices over the past decades.
State Regulation of Short-Term Limited Duration Coverage

State	Does State Set Limits on the Sale of Short-Term Coverage that Are Stricter than the Federal Government's?	Does State Prohibit Underwritten Short-Term Coverage?*	Does State Limit the Initial Contract Duration of Underwritten Short-Term Coverage to Less Than 364 Days?**	Does State Limit the Total Length of Time a Consumer May Be Enrolled in Underwritten Short-Term Coverage to Less Than 364 Days?***
Arizona	Yes	No	Yes (185 days)	No
California	Yes	No	Yes (185 days)	No
Colorado	Yes	No	Yes (6 months)	-----
Connecticut	Yes	No	Yes (6 months)†	No
Hawaii	Yes	No	Yes (90 days)	Yes (Coverage cannot exceed 90 days in a calendar year)††
Indiana	Yes	No	Yes (6 months)	No
Maryland	Yes	No	Yes (3 months)	No
Massachusetts	Yes	Yes	-----	-----
Michigan	Yes	No	Yes (185 days)	Yes (Coverage cannot exceed 185 days per insurer in a 365-day period)
Minnesota	Yes	No	Yes (185 days)	No
Nevada	Yes	No	Yes (185 days)	Yes (Coverage cannot exceed 185 days in a 365-day period)
New Hampshire	Yes	No	Yes (6 months)	No
New Jersey	Yes	Yes	-----	-----
New York	Yes	Yes	-----	-----
North Dakota	Yes	No	Yes (185 days)	No
Oklahoma	Yes	No	Yes (6 months)	No
Oregon	Yes	No	Yes (3 months)	Yes (Coverage cannot exceed 3 months per insurer in a 5-month period)
South Carolina	Yes	No	Yes (11 months)	No
South Dakota	Yes	No	Yes (6 months)	No
Vermont	Yes	No	Yes (3 months)	Yes (Coverage cannot exceed 3 months in a 12-month period)

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:
• 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
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.
Map: Uninsured Rate by State [PDF] Sept. 2017
Map: 2016 Uninsured Rate by State [PDF] - Census Bureau, Sept. 2016

^{Sources: New American Community Survey Statistics for States and Local Areas,September 14, 2017;}^{compare to Health Insurance Coverage in the United States: 2015 - Census.gov}

Recent actions on Health Care

Exchanges: State Actions to Address Health Insurance Exchanges - Report on State activities 2010-2018.
- COOP: Health Insurance Purchasing Cooperatives: State and Federal Roles - NCSL report covering 1990's to 2016
- Creative Marketing and Enrollment by Exchanges - NCSL presentation to Exchange Oversight Comm. of Colorado 7/28/2016

CBO cost estimate report on Repeal of ACA legislation, released 7/19/2017

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

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)
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.
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.
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
- Autism and Insurance Coverage State Laws 2015 |
- Diabetes Drug Insurance Coverage - Read the survey report An NCSL survey of 2016 Insurance Plans in 50 states, examining 1) patient access to the scores of diabetes drug treatments and 2) results in the 46 states with laws mandating or offering diabetes coverage. NCSL original research, published summer 2016
- Dependent Health Coverage and Age for Healthcare Benefits - 2016
- Mental Health Benefits: State Laws Mandating or Regulating - material added 2016
- Obesity Health Mandates - March 2016
- Preventive Services Health Insurance Coverage under the ACA - 2018
- State Mandated Health Insurance Benefits - Overview and list of individual NCSL reports - updated 2016
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]
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

Cafeteria Plans Used by States to Provide Health Insurance - NCSL report. Updated 2014
Individual Health Insurance - read Individual Health Insurance in the States - Updated 2015
Employer Tax Incentives to Offer Health Insurance- NCSL report by Fiscal Program & Health Program, 4/2011
Managed Care, Market Reports and the States - latest reports on Illinois, Michigan and Minnesota - Updated 2016; including archives 2008-2013
Massachusetts Insurance: Massachusetts Health Initiatives: 25+ Years of Change. Updated Dec. 2016
Network Adequacy in Health Plans - Read about state laws and policies by NCSL
State Laws and Actions Challenging Certain Health Reforms - NCSL comprehensive list of Laws and Actions Challenging Health Reforms actions from 2010 to 2016 to opt-out of individual and employer mandates and other strategies; includes summaries and links for court decisions. Updated 2016
Transparency and Disclosure of Costs and Prices - Read the state actions report. Updated March 2017
Expedited Partner Therapy - 2017 50-state description and map. Updated July 2017

Federal Health Reform/"Obamacare": Major Effects on State Health Insurance

The 2010 federal health reform laws made major changes in the way private health insurance is handled and regulated. Several of these changes were made in 2010 and 2011, with full effect by 2014-2017: NOTE: 2017 congressional proposals to repeal or replace the ACA have had no effect on these provisiosn as of 10/18/2017

Access to insurance for people with preexisting conditions through federally-funded high risk pools. (beginning July 1, 2010)
No preexisting condition restrictions for children;
Restrictions on certain insurance practices;
Reporting requirements;
A small-business tax credit;
Expanded dependent coverage;
Coverage and access provisions;
Expanding access to information on health insurance;
Retirees’ access to health insurance
Self-Insured Group Health Plans: Report (U.S. Dept. of Labor)
- Appendix A | Appendix B (Deloitte analysis)
Student Health Coverage - Report: Student Health Coverage: Application of the Market Reforms and Provisions of the ACA (U.S. Dept. of Labor) 2/5/2016

Additional Recent Reports on Costs and Premiums

Employer-Sponsored Health at the State Level, 2017: Premiums and Deductibles Continue to Rise
While costs related to the Affordable Care Act marketplaces, the majority of non-elderly Americans (51.6%) continue to get their health insurance coverage from an employer.[1] A new analysis from University of Minnesota highlights the experiences of private sector workers with employer-sponsored insurance (ESI) from 2013 through 2017 at the national level and within the states. Their report includes a Two-page fact sheet on ESI for each state; separate 50-state interactive map showing premiums for in 2017, with links to state profile pages, and 50-state comparison tables. Posted 10/1/2018 *UPDATED *
What’s the Difference Between Reinsurance and a High-Risk Pool? Two approaches to insuring those with pre-existing conditions. Report Posted on March 6, 2017 by CHIR Faculty. Georgetown Uinv.
Employer Tax Exemption: The Hidden federal Subsidy That Helps Pay for Health Insurance. Read analysis by
Trends in Total Out-of-Pocket Spending in Metro Areas: 2012-2015
A new report from HCCI examines health care spending trends in 40 metro areas across the country, focusing in particular on the out-of-pocket burden for consumers. The research highlights the geographic variations in spending across local health care markets. For example, in Augusta, GA, more than 20 percent of total health spending was paid out out-of-pocket by consumers versus 14 percent in New York City. The study also finds that out-of-pocket per capita spending was 61 percent higher in the highest spending metro areas than the lowest in 2015. HCCI, released 8/31/2017.
2017: CBO Report on the House-passed American Health Care Act (AHCA).Text of CBO updated estimates | Exrernal analysis: Commonwealth Fund, May 25, 2017.

2017 Milliman Medical Index. In 2017, the cost of healthcare for a typical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $26,944 (see Figure 1), according to the Milliman Medical Index (MMI). ¹Download the report » By Milliman | 16 May 2017.
• Rate of increase is 4.3%. This is the lowest rate since they began tracking the MMI in 2001.Of the $26,944 spent by a family of four, $11,685 is paid by the employee, through a combination of $7,151 in payroll deductions for premium, and $4,534 in out-of-pocket costs incurred at time of care.
• Prescription drug trends were lower, but still high. For the first time since 2013 and 2014, the family of four’s prescription drug trends have decreased in two consecutive years. Still, the 2017 prescription drug cost increase of 8% is more than double the medical increase of 3.6%.
The Milliman Medical Index for 2016 indicates the costs for a typical American family of four will increase by 4.7%--the lowest rate of increase in the history of their study--though the total dollar increase of $1,115 marks the 11th consecutive year that the total dollar increase has exceeded $1,100. The employer pays $14,793 of the total healthcare costs and the employee--through payroll deductions and cost sharing at the time of service--pays $11,033. Source: Milliman; published May 2016
Drivers of Health Insurance Premium Changes for 2017 - A new issue brief produced by the American Academy of Actuaries’ Individual and Small Group Markets Committee, “Drivers of 2017 Health Insurance Premium Changes.”
“There are both upward and downward pressures on premiums for 2017, but for the individual and small group markets as a whole, the factors driving premium increases dominate,” said Academy Senior Health Fellow Cori Uccello. “Increased health care costs and the end of the ACA’s transitional reinsurance program are two of the biggest factors pressuring rates higher. The one-year moratorium of the health insurance provider fee will partially offset these increases.” Released 5/6/2016.
2107 Employer Health Benefits Survey. Annual premiums for employer-sponsored family health coverage.rose an average of 3 percent to $18,764 this year, with workers on average paying $5,714 towards the cost of their coverage, continuing a six-year run of relatively modest increases, according to the Kaiser Family Foundation/ HRET 2017 Employer Health Benefits Survey. Kaiser/HRET survey, published 9/19/2017.
- For comparison, the 2016 Employer Health Benefits Survey showed annual premiums for employer-sponsored family health coverage reached $18,142 year, up 3 percent from 2015 with workers on average paying $5,277 towards the cost of their coverage. Summary | Full Report. Kaiser/HRET survey, published 9/2016.

Compiled by Richard Cauchi, NCSL Health Program, Denver.

STATE HEALTH INSURANCE MARKETS—HANGING IN THE BALANCE

What can states do to ready themselves for federal changes to health insurance markets because of laws, regulations and executive orders? Will the cost of health insurance premiums level off? Where can states innovate to help consumers?