SHADAC Staff

p 612.624.4802
e shadac@umn.edu

NHIS: Nationwide Uninsured Rate for January to September 2018 Unchanged from 2017

Nationwide, the uninsurance rate among non-elderly adults (ages 18-64) in the first three quarters of 2018 was 13.0%, statistically unchanged from 12.7% in the same period in 2017.

This finding is based on new health insurance coverage estimates for Q1-Q3 2018 from the National Health Interview Survey (NHIS). These estimates were released by the National Center for Health Statistics (NCHS) as part of the NHIS Early Release Program and are the first available coverage estimates for 2018 from a federal survey.

Uninsurance and Public and Private Coverage Rates Remained Stable for Nearly All Groups in 2018

The new NHIS estimates show that uninsurance rates, as well as rates of public and private coverage, were statistically unchanged across age, race/ethnicity, and most income groups between the first three quarters of 2017 and the first three quarters of 2018. Figure 1 shows levels of health insurance coverage by type among non-elderly adults overall across this time period.

Changes in Coverage Type among Some Subgroups

Among non-elderly adults with incomes below 100% of the federal poverty level (FPL), the rate of private coverage fell to 19.9% in the first three quarters of 2018 from 25.6% in the first three quarters of 2017 (Figure 2). The rates of uninsurance and public coverage among this group remained statistically unchanged over the same period.

Non-elderly adults with incomes between 100% and 138% FPL also saw a change in coverage type, with uninsurance among this group increasing from 68.7% in the first three quarters of 2017 to 73.6% in the first three quarters of 2018. The rates of private and public coverage among this group remained statistically unchanged over the same period.

Increase in Uninsurance in the Midwest Region

The rate of uninsurance among non-elderly adults in the Midwest^[1] increased from 9.5% in the first three quarters of 2017 to 11.0% in the first three quarters of 2018 (Figure 3). This change was larger among non-elderly adults in the East North Central^[2] region, a subset of the Midwest region, where uninsurance increased from 8.9 % to 10.6% over the same period. No other coverage changes occurred in the Midwest region over this period, and no other regions experienced a significant change in coverage type.

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Leveraging 1332 State Innovation Waivers to Stabilize Individual Health Insurance Markets: Experiences of Alaska, Minnesota, and Oregon

A new SHADAC analysis, prepared for the Robert Wood Johnson Foundation, examines the use of 1332 State Innovations Waivers to stabilize individual health insurance markets. SHADAC researchers compared the use of this strategy in Alaska, Minnesota, and Oregon, assessing how these states navigated the 1332 waiver process; identifying lessons learned about this process and about different reinsurance models; and discussing future concerns regarding the use of reinsurance programs.

To collect this information, SHADAC conducted an in-depth document review and qualitative inter­views with 31 individuals—including state agency and executive staff, legislators, actuarial analysts, health plan representatives, program administrators, and other stakeholders—across the three study states.

Alaska, Minnesota, and Oregon: Reinsurance Models

In 2017, Alaska, Minnesota, and Oregon became the first three states to receive federal approval to establish state reinsurance programs with federal funding via section 1332 State Innovation Waivers, which authorize states to waive key ACA requirements in order to experiment with dif­ferent policies in the individual and small group insurance market within certain guardrails.

• Alaska’s state reinsurance program is condition-based, paying 100% of claims from policyholders who have one of 33 possible specific medical conditions.
• The Minnesota Premium Security Plan (MPSP) is a traditional reinsurance model with an attachment point of $50,000 and a cap of $250,000 with payment of claims at an 80/20 coinsurance rate.
• The Oregon Reinsurance Program is a traditional reinsurance model with a 50/50 coinsurance rate, as well as an attachment point and cap to be determined at a later date.

Challenges and Facilitators of the 1332 Waiver Application Process
Interviewees across all stated noted numerous challenges during the 1332 waiver application process, including:

• Securing a state funding source
• Navigating rapid shifts in the political climate that affected the application process
• Being able to access timely data to support their applications
• Identifying a waivable requirement of the ACA

Respondents agreed, however, on common facilitators that aided the application process, which they listed as:

• Working hand-in-hand with insurance companies to keep them in the market
• Leveraging existing infrastructure and experience to support the state-based programs
• Using previously existing mechanisms to get analysis done quickly
• Engaging with the state’s congressional delegation

Lessons Learned about 1332 Waiver Application and Implementation Processes

Interview respondents also identified a number of lessons learned by the states as they navigated both the application and implementation stages for their 1332 waivers. A few key points are listed below.

• There are both pros and cons to condition-based vs. traditional reinsurance models.
  States noted that they chose reinsurance models that would be easy to implement in a short timeframe. Traditional models were less complex, but condition-based models maximized cost of care options.
• Robust communication efforts with multiple stakeholders were needed.
  Respondents consistently emphasized the need for dedicated communication between state agencies, legislators, health insurers, congressional delegations, CMS officials, and community stakeholders in order to put together a successful waiver application. 
• Microsimulation models allowed states to be responsive to rapidly shifting policies.
  States were required to submit actuarial and economic analyses as part of their waiver applications, and the microsimulation models used by Alaska and Oregon allowed them to respond to several real-time policy changes (such as the repeal of the individual mandate).

Future Concerns

Though respondents in all three states felt that state-based reinsurance was necessary to help stabilize the markets, they did report a number of concerns for the future of these programs.

• It is difficult to measure the impact of reinsurance programs beyond premium rates.
  All three states reported a reduction in premium costs in the individual market as a result of implementing a reinsurance program, but other evaluations of program impacts have not been clear, often due to lack of data.
• No accountability measures were included.
  Due to the short turnaround time to both apply for and implement their 1332 waivers, none of the study states included accountability measures within their reinsurance programs for the individual market.
• Reinsurance is only a short-term fix and does not address the underlying problem of health care costs.
  Although interviewees from Alaska, Minnesota, and Oregon felt that state-based reinsurance was an important tool to stabilize the individual market, all questioned the viability of such programs as a long-term solution, commenting that individual marketplaces were only part of the whole, and only when the larger picture is addressed can the root of the issue of high health care cost be properly addressed.

Related Readings and Resources

Modeling State-based Reinsurance: One option for Stabilization of the Individual Market

Minnesota’s 13332 Reinsurance Waiver Dilemma

Resource: 1332 State Innovation Waivers for State-Based Reinsurance

Leveraging 1332 State Innovation Waivers to Stabilize Individual Health Insurance Markets: Experiences of Alaska, Minnesota, and Oregon (Final Report)

In 2017, Alaska, Minnesota, and Oregon became the first three states to receive federal approval to establish state reinsurance programs with federal funding via section 1332 State Innovation Waivers, which authorize states to waive key requirements under the law in order to experiment with dif­ferent policies in the individual and small group insurance market within certain guardrails. A new SHADAC analysis, prepared for the Robert Wood Johnson Foundation, examines the use of 1332 State Innovations Waivers to stabilize individual health insurance markets within these states. SHADAC researchers compared the use of this strategy in Alaska, Minnesota, and Oregon, assessing how the 1332 waiver process was navigated; identifying lessons learned about this process and about different reinsurance models; and pinpointing future concerns about the use of reinsurance programs. 

SHADAC conducted an in-depth document review and qualitative inter­views with individuals - including state agency and executive staff, legislators, actuarial analysts, health plan representatives, program administrators, and other stakeholders - across the three study states who were involved in the design and/or implementation of state reinsurance programs and the 1332 waiver application process. Each of the states faced numerous challenges in their individual health insurance markets (high costs, increasing premiums, shifting marketplace makeup and plan availability, etc.) that led them to establish state-based reinsurance programs. However, as the report details, state policymakers found unique ways to facilitate both the waiver application and implementation processes, including working hand-in-hand with insurance companies, leveraging existing infrastructure and experience within their own agencies, having mechanisms in place to get analysis done quickly, and engaging with the state’s congressional delegation.

Alaska, Minnesota, and Oregon: Reinsurance Models
In 2017, Alaska, Minnesota, and Oregon became the first three states to receive federal approval to establish state reinsurance programs with federal funding via section 1332 State Innovation Waivers, which authorize states to waive key ACA requirements in order to experiment with dif­ferent policies in the individual and small group insurance market within certain guardrails.

• Alaska’s state reinsurance program is condition-based, paying 100% of claims from policyholders who have one of 33 possible specific medical conditions.
• The Minnesota Premium Security Plan (MPSP) is a traditional reinsurance model with an attachment point of $50,000 and a cap of $250,000 with payment of claims at an 80/20 coinsurance rate.
• The Oregon Reinsurance Program is a traditional reinsurance model with a 50/50 coinsurance rate, as well as an attachment point and cap to be determined at a later date.

Challenges and Facilitators of the 1332 Waiver Application Process
Interviewees across all stated noted numerous challenges during the 1332 waiver application process, including:

• Securing a state funding source
• Navigating rapid shifts in the political climate that affected the application process
• Being able to access timely data to support their applications
• Identifying a waivable requirement of the ACA

Respondents agreed, however, on common facilitators that aided the application process, which they listed as:

• Working hand-in-hand with insurance companies to keep them in the market
• Leveraging existing infrastructure and experience to support the state-based programs
• Using previously existing mechanisms to get analysis done quickly
• Engaging with the state’s congressional delegation

Lessons Learned about 1332 Waiver Application and Implementation Processes
Interview respondents also identified a number of lessons learned by the states as they navigated both the application and implementation stages for their 1332 waivers. A few key points are listed below.

• There are both pros and cons to condition-based vs. traditional reinsurance models.
  States noted that they chose reinsurance models that would be easy to implement in a short timeframe. Traditional models were less complex, but condition-based models maximized cost of care options.
• Robust communication efforts with multiple stakeholders were needed.
  Respondents consistently emphasized the need for dedicated communication between state agencies, legislators, health insurers, congressional delegations, CMS officials, and community stakeholders in order to put together a successful waiver application. 
• Microsimulation models allowed states to be responsive to rapidly shifting policies.
  States were required to submit actuarial and economic analyses as part of their waiver applications, and the microsimulation models used by Alaska and Oregon allowed them to respond to several real-time policy changes (such as the repeal of the individual mandate).

Future Concerns
Though respondents in all three states felt that state-based reinsurance was necessary to help stabilize the markets, they did report a number of concerns for the future of these programs.

• It is difficult to measure the impact of reinsurance programs beyond premium rates.
  All three states reported a reduction in premium costs in the individual market as a result of implementing a reinsurance program, but other evaluations of program impacts have not been clear, often due to lack of data.
• No accountability measures were included.
  Due to the short turnaround time to both apply for and implement their 1332 waivers, none of the study states included accountability measures within their reinsurance programs for the individual market.
• Reinsurance is only a short-term fix and does not address the underlying problem of health care costs.
  Although interviewees from Alaska, Minnesota, and Oregon felt that state-based reinsurance was an important tool to stabilize the individual market, all questioned the viability of such programs as a long-term solution, commenting that individual marketplaces were only part of the whole, and only when the larger picture is addressed can the root of the issue of high health care cost be properly addressed.

Download a PDF of the report.

Related Readings and Resources

Modeling State-based Reinsurance: One option for Stabilization of the Individual Market

Minnesota’s 13332 Reinsurance Waiver Dilemma

Resource: 1332 State Innovation Waivers for State-Based Reinsurance

 

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

MACStats from MACPAC: 2018 Medicaid and CHIP Data Book Now Available

The Medicaid and CHIP Payment and Access Commission (MACPAC) recently released the 2018 version of its Medicaid and CHIP Data Book. This data book is a collection of federal and state statistics regarding the Medicaid and CHIP programs that are compiled by MACPAC from multiple data sources on key topic areas including Medicaid and CHIP eligibility, enrollment, and expenditures, as well as beneficiary health, service use, and access to care. An excellent resource, the data book draws on a wide variety of data sources including Medicaid administrative data (e.g., CMS-64 data, MSIS data, Medicaid Managed Care enrollment reports, etc.) as well as federal survey data in order to compile policy relevant, but difficult to access, information about the Medicaid and CHIP programs into one comprehensive tool.

SHADAC is excited to be among the contractors that contributed to this product, providing MACPAC with estimates from the National Health Insurance Survey (NHIS) and the Medical Expenditure Panel Survey (MEPS) that highlight individual enrollment, primary source of insurance coverage, and service use and access to care with breakdowns available by age, demographics, and health characteristics. SHADAC produced these estimates using data for years 2016 and 2017, which are the latest available respectively for each survey.

Access the new MACStats: Medicaid and CHIP Data Book to read more and to download specific tables and figures from the data book.

For additional information on data methods and sources used in the data book, see MACPAC’s Technical Guide to MACStats, which provides supplementary information to help readers interpret the exhibits in the MACStats tables and figures as well as to understand the data sources and methods used.

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Register Now: February 6th Webinar - Exploring Disparities Using SHADAC's State Health Compare

Exploring Disparities Using New and Updated Measures on SHADAC’s State Health Compare: State-Level Highlights for Unaffordable Rents, Unhealthy Days, and More
Date: February 6, 2019
Time: 1:00 p.m. – 2:00 p.m. Central
Register now.

Join us on Wednesday, February 6^th at 1:00 PM Central for a webinar introducing two new measures of health outcomes and social determinants of health on SHADAC’s State Health Compare—Unhealthy Days and Unaffordable Rents. This presentation, hosted by SHADAC researchers Brett Fried and Robert Hest, will examine these new measures and highlight how the estimates can be used to explore disparities between states and among sub-populations.

The webinar will also provide a virtual tour of some of the more than 40 state-level measures currently available on State Health Compare, highlighting recently updated data in particular. Mr. Fried and Mr. Hest will demonstrate how users can employ State Health Compare to easily create compelling maps, charts, and graphs, as well as download the raw estimates to perform deeper analyses and statistical testing.