Shortly before the U.S. Supreme Court adjourned for its annual summer vacation, the high court dropped a major decision that affected the health insurance and employee benefits marketplace directly: Subsidies remain available for insurance customers who access state-based exchanges.
Opponents of the Affordable Care Act charged that because the ACA stated that financial assistance was only available to people who used the federal marketplaces, people who use those organized by states could not take advantage of financial assistance in order to help pay for coverage. In a 5-to-4 decision, though, a slight majority of the Court found in favor of the government, meaning that those who got subsidies from the government despite using state-run exchanges could keep them.
Including the District of Columbia, there are 15 entirely state-based marketplaces, including New York, California and Rhode Island among them. In the wake of the King v. Burwell decision, all the state-run exchanges – as well as those operated jointly by the state and the federal government – have tried to shore up these marketplaces in order to make them more advantageous for the consumer and business owner who provides employee health benefits through the exchanges.
However, as the National Health Council notes, all these efforts have not been equal in terms of recognizable proactive measures, specifically for patients with chronic diseases and disabilities.
Delaware, Montana and California making strides
In Montana, for example – which doesn't have a state-run exchange but rather one that's organized by the federal government – insurance providers now must ensure all "metal" plan types – i.e. silver, gold and platinum – enables consumers to uses co-payments instead of co-insurance. Additionally, all prescription drugs have to fall under the co-payment rubric.
In Delaware, the exchange that's jointly operated by the federal government and the state, the local marketplace has established a transition period for health insurance users, according to NHC. This enables consumer who may be changing plans to still access their prescriptions medicines even though they're in between plan types.
And in California, one of the first state-run exchanges that opened soon after the ACA was signed into law in 2010, the Golden State allows has a standardized benefit design. This means that whatever type of ACA plan consumers have – i.e. gold, silver, platinum – the cost sharing benefits are all uniform.
"We learned that regardless of the type of exchange established by the state, there are effective ways to improve the health insurance marketplace," said Marc Boutin, NHC chief executive officer. "While some states have emerged as leaders in implementing patient-centered standards and reforms, there is still more work left to do."
Transparency, state oversight, uniformity and care continuity were among the five key principles the NHC report identified as areas in which the exchanges could stand to improve.
Exchanges have fewer choices
Another area where there's plenty of room for improvement is the plan options that ACA-based exchanges make available to consumers, based on recent analysis from health care advisory services company Avalere. According to recent analysis of the health insurance exchanges, consumers who use them have 34 percent fewer plan provider choices than what's typical for the average commercially run insurance organization. Additionally, exchange plan networks have 42 percent fewer oncology and cardiology specialists, 32 percent fewer mental health and primary care providers and 24 percent fewer general practice hospitals.
Elizabeth Carpenter, Avalere vice president, indicated that patients should be sure to research how many providers are within an exchange network before signing up.
"Out-of-network care does not accrue toward out-of-pocket maximums, leaving consumers vulnerable to high costs if they seek care from a provider not included in their plan's network," Carpenter explained.
She added that if consumers choose a health facility that's not in their network, everything they spend out of pocket won't go toward their deductible. In other words, they're all on their own in terms of medical payments.
