Key Proposals to Strengthen the Affordable Care Act

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Friday at the church. It is important for the Obama administration and its successor to reject waiver requests that would erode basic protections for Medicaid recipients. North York general hosp. Callwey, , p. Hatier, , 80 p.

Dr. Noah Forman

Katz (surname)

Monday at the church. A brief graveside service will be held at 2 p. Kenneth Gerike will officiate. Kueck was born Jan. He married Marian Schelp on June 15, His professional career was spent in the insurance industry.

He retired from Shelter Insurance Cos. He was president of the Missouri Association of Mutual Insurance Companies and served on the board of directors for many years. He also was a volunteer fire chief and active in civic and church endeavors. He was a long-time member of the board of directors of Concordia Bank.

He played high school and college basketball and was a referee certified with the Missouri State High School Athletic Association. He also was a softball player, a bowler, a tennis player, a water skier and a card player. He was an avid golfer and a member of the Columbia Country Club. He was preceded in death by a son, his parents and a brother. He was a lifelong active member of the Lutheran Church, Missouri Synod.

He served as president and elder of Trinity Lutheran Church and taught Bible class. In lieu of flowers, the family suggests a memorial donation to Good Shepherd Lutheran School, W. Published Wednesday, February 22, Floyd N.

A Masonic service will be performed at Friday by the Twilight Lodge No. Visitation will be from 10 a. Friday until the time of the service. They preceded him in death. His trade was as a plumber-pipe fitter. He served as past master at Twilight Lodge No. Andy also was a member of New Providence Baptist Church.

Andy is survived by his wife, Betty Jean; son, Bryan Kent; two grandchildren; several nieces and nephews; and a host of friends. He was preceded in death by a son, Reed Bradley. Services will be held at 3 p. Visitation will be from 2 to 3 p. Sunday at the church. Beulah was born Aug.

She married Charles Turner Sanders in , and he preceded her in death in She then married Tony S. Sapp in , and he also preceded her in death in She lived her entire life in Columbia. She was a nurse for over 20 years, working in all the local hospitals.

Beulah was a charter member of First Assembly of God Church, the longest continuous member, was active in the Ladies Ministry, drove the church van for five years and taught Sunday school.

Burge of Columbia; five grandchildren; and 11 great-grandchildren. She was preceded in death by her parents; two husbands; two sons; three brothers, Bud, Alvin and Roy Willis; and one sister, Grace Deason. Monday at the funeral home. Annette was born on Dec. She was married to Dean Hartmann and also to Phillip Keller, and they both preceded her in death. She was preceded in death by two sisters, Katherine Cameron and Mable Brewer. Services will be held at 10 a. Saturday, March 4, at Memorial Funeral Home.

Visitation will be held from 5 to 7 p. Friday at the funeral home. Barbara was born Dec. She was a lifelong resident of Columbia, where she was very involved with her family and she always had a smile for everyone. Barbara was preceded in death by her parents; husband; and one son, Michael Crane. Providence Road, Suite , Columbia, Mo. Services will be at 1: Saturday at the funeral home, with a Rebecca Lodge service at 6: Reynolds in Columbia, and he preceded her in death.

Edna was a talented seamstress, and she always filled everyone with laughter. Survivors include four children, James L. She was also preceded in death by her parents, a grandson, a son-in-law and a daughter-in-law. Memorial contributions are suggested to the American Cancer Society, N. Family memorial services will be held at Memorial Funeral Home.

William was born on Aug. Cuddy Thomure in St. Louis, and she survives. He owned Thomure Jewelers for several years and also was a mail courier for the University of Missouri-Columbia Athletic Department for many years. William enjoyed riding his motorcycles and shooting pistols and rifles, and he was an exceptional conversationalist. William was preceded in death by his parents. Memorial contributions are suggested to the American Heart Association, P.

Box , Columbia, Mo. Monday, March 6, at Memorial Funeral Home, with visitation from 5 to 7 p. Burial will take place at Memorial Park Cemetery. John was born Sept. John moved his family to Columbia in , and he worked for Shelter Insurance as a claims supervisor.

John was proud of his years of service with Shelter and the lasting memories and friends he made over the years. John always had a story to entertain an audience. Whether it was about working on the car ferry on Lake Michigan, putting raisins in Raisin Bran, describing his many adventures as a deputy sheriff in Michigan or replaying the latest Mizzou football game, he told it with enthusiasm. Those stories told time and time again will be remembered by loved ones for years to come.

As the patriarch of the Strom family, John ruled with a stern hand and a loving heart. Stubborn and generous, opinionated and protective, above all else a loyal friend, dedicated father and loving husband, John will be greatly missed. John will be greatly missed by his 10 grandchildren and three great-grandchildren.

Services will be at 2 p. Charles Road, with visitation from 1 to 2 p. He married Eula L. He was preceded in death by his parents; an infant brother, Madison; and sister Sondra Reynolds. Services will be at 10 a. Monday, March 13, at St. Thomas More Newman Center in Columbia. Visitation will be from 3 to 6 p. He married Elizabeth Plogsted on Aug. Ronald completed his residency at the University of Missouri-Columbia in and served a fellowship in diabetes and endocrinology at the University of Colorado-Denver from to He then joined the MU faculty in and later entered private practice in diabetes management for 12 years.

Later he rejoined the faculty at MU and continued his work there. He initiated camps for diabetic children in Central Missouri and in the Republic of Georgia in the former Soviet Union. James wrote, "Diabetes has been a major inspiration and influence in my life. It prevented me from seeing my older sister who died of diabetic ketoacidosis at the age of 2, before I was born. I was diagnosed with diabetes at age 11 in January My childhood was very symptomatic but improved greatly when I was in medical school and learned how to manage it.

This influenced me to specialize in diabetology as a physician and to attempt to help diabetic children by helping operate camps for them here in Missouri and in the former Soviet Republic of Georgia. A major positive factor in this has been my wife, Betty, who did much to make it possible for me to be involved in the operation of the camps and who never stressed me by complaining about the manner in which I managed my diabetes. James; and his uncle, Travis James of Rolla. He was also preceded in death by a sister, Freda Louise James.

Services will be at 3 p. Monday, March 13, at Memorial Funeral Home. He married Phyllis Harrison on Feb. Billy Joe worked as a master bricklayer in Columbia.

He also raised tobacco and managed a commercial cattle herd. He loved his family and enjoyed fishing the Missouri River. He was born February 9, at Flat River, Missouri. Jere Watkins, Knoxville, Tennessee; also nieces, nephews, other relatives and friends. He was a member of Esther Baptist Chruch. Visitation will be at the Horton-Wampler Funeral Home after 5: Services for Dick Polk will be Saturday Burial will be at the St. Francois Memorial Park Cemetery. Nifong, with visitation at 11 a. Pfremmer was a veteran of the U.

Air Force and served in the Korean War, stationed there in as a forward weather observer. He returned to Chanute Air Force Base and studied to become a weather forecaster. While there, he founded Columbia Loan Co. He was a board member of the Missouri Capitol Society, a philanthropic organization for the arts in the Capitol in Jefferson City.

He was also a past member of the Columbia Chamber of Commerce. Eighth Street in Columbia. After a successful career in finance, Pfremmer entered the restaurant industry, opening several businesses with longtime friend and associate William Bratrud of Rochester, Minn. He created Phil E. Later in his hospitality career, he managed private golf and country clubs in Kansas and Missouri, including Sunset Country Club in St. After leaving the restaurant business and before retirement, he was a registered lobbyist in Jefferson City for the Missouri Liquor Retailer Association, founded with longtime friend and associate John Strecker of Columbia.

Pfremmer enjoyed golf and the outdoors in Surprise, Ariz. He was a mentor to many and an entrepreneur, always offering a firm handshake, a friendly smile and sound advice to those he loved. He is survived by sister Jeanne Jacobson of Scottsdale, Ariz. He has three stepchildren, six stepgrandchildren and many nieces, nephews, friends and extended family. Arrangements are by Buescher Memorial Home, Published Tuesday, March 14, Cletus M.

Friends may call from 6 to 8 p. Tuesday at the chapel. Burial will be at Forest Hill Cemetery. Cletus was born Oct. Local survivors include a daughter, Renee Koppenaal of Columbia. Published Tuesday, March 14, A. Funeral services will be held at 1 p. Unklesbay was born Feb. Unklesbay married Wanda Strauch of Byesville in Geological Survey in the strategic minerals branch and later the Iowa Geological Survey. After teaching at Colgate University, he moved to Columbia and was employed as professor of geology at the University of Missouri from to , serving as chairman of the geology department from to He was named vice president for administration of the University of Missouri system in and served in this position until his retirement from the university in Unklesbay held the position of executive director of the American Geological Institute in Washington, D.

Upon retiring for the second time, he returned to Columbia, where he continued to work with the geology department. Unklesbay was active in the community. He served on the Columbia Public Schools board from to and was a member of Kiwanis. Included in the many honors he received are an honorary doctor of science degree granted by Marietta College, Distinguished Service Award by the American Geological Institute, Distinguished Alumnus Award by the University of Iowa and the naming of the A.

Unklesbay Geological Sciences Library on the Columbia campus. Unklesbay was preceded in death by his parents; sister Martha; brothers Paul and Ray; Wanda, his wife of 31 years who died in ; and Mary Wheeler Mhyre, his wife of seven years. The family would like to acknowledge the kind compassionate care of the staff at Lenoir at the end of his life.

Memorial contributions are suggested to the A. Unklesbay Travel Award Fund or the A. A celebration of his life will be held at 11 a. Visitation will also be held from 5 to 8 p. Carl was a loving husband, father, grandfather, brother and friend.

He enjoyed hunting, fishing and spending time with his family and helping others. Carl became a resident of Columbia in , and over the years he donated his time and knowledge to too many people to mention. Carl was a member of Masonic Lodge No. He was preceded in death by his parents, Guy and Mossie Fritchey of Dixon; and infant brother and infant sister. Memorial contributions are suggested to the American Diabetes Association, P. Box , Fairfax, Va. Services were held at 1 p.

Thursday, March 16, at Memorial Funeral Home. Burial followed at Memorial Park Cemetery. Visitation was Wednesday at the funeral home. She married Sol Bryson on Jan. Mildred was also preceded in death by one sister and one brother. Monday, March 20, at Memorial Funeral Home. Funeral Mass will be held at 11 a. A light lunch will be served after Mass. Jean was a graduate of Stephens College. Jean was preceded in death by her husband, James Valentine Kelly, on May 1, As a young woman, Jean was known for her intelligence, wit and love of life.

Much of her later life was a struggle involving heartache seemingly too much for one soul to bear. Throughout it all, she proved her love for her children in innumerable ways. Your example taught us about perseverance, the power of imagination, undying love, amazing grace and the sweetness of protecting the underdog. We are your humbly grateful living legacy. Thank you and bless your soul. In lieu of flowers, the family requests contributions be sent to Columbia Art League, S.

Tributes may be left online at www. Services, conducted by the Rev. Kenneth Gerike and the Rev. Brian Thieme, will be at 6 p. Visitation will be two hours prior to the services at the church.

Burial will be at 10 a. Wednesday at Red Rock Cemetery. Cook and Gertie Forbis Cook. She married John Harpert on July 25, , in Columbia. Before retirement, she worked at Butternut Bakery and later at Wal-Mart. She was a member of Trinity Lutheran Church. She was preceded in death by her parents, five brothers and three sisters.

Arrangements are under the direction of Nilson Funeral Home. Burial will be at Mount Nebo Cemetery in Huntsdale. She was born Jan. She married Douglas Wilhite on Aug. Grace was a lifelong resident of Boone County and the Huntsdale-Rocheport area. She and Doug were farmers and members of Huntsdale Baptist Church. Survivors include a son, J.

Frank Wilhite and wife Carol of Lincoln, Ill. Hugh was born Sept. He was married to Ada Ilene Tucker, and she also preceded him in death. Denney was a member of First Christian Church in Columbia and an associate member of the Christian church in Boonville.

Hugh was in charge of state schools for the severely handicapped for 29 years. His hobbies included coin collecting, researching genealogy, traveling and participating in music. Louis; four grandchildren; and one great-grandchild. He also was preceded in death by one brother and one sister.

Memorial contributions are suggested to First Christian Church, N. Published Thursday, March 23, L. Graveside services will be at 1 p. Woody was born March 30, , to Bert M. Wade Alvis in Columbia. Griffin in Columbia, and she survives. Survivors include his wife, Ruby; two children, Bob Alvis and his wife, Donna, of Boonville and Glenda Nichols and her husband, Bob, of Columbia; six grandchildren; and 12 great-grandchildren.

He was preceded in death by his parents, two sisters and three brothers. Published Thursday, March 23, Tom E. Singer, 52, of Hartsburg passed away Wednesday, March 22, , at his home after a battle with cancer. Saturday, March 25, at Robinson Funeral Home, with visitation from 4 to 7 p. He married Patty L. Grant on March 3, , in Columbia, and she survives. He worked for 3M for 29 years. He then went to work for Creative Stone in the past year.

He loved his family, the farm, hunting and fishing. Survivors include his wife, Patty Singer; one son, Jeffrey S. Singer; one daughter and son-in-law, Wendy G. Published Wednesday, March 29, Peggy L. Dawson, 56, of Columbia died Tuesday, March 21, , at her home with her family by her side.

Services will be at 6 p. Peggy was born Jan. She married Bill Dawson on Jan. Peggy was on the faculty in the occupational therapy program at the University of Missouri from to and then worked at Boone Hospital Center in the mental health unit for 10 years. She was a member of Unity Center of Columbia. Peggy was preceded in death by her father. Memorials may be given for an MKT trail park bench in her memory, which may be forwarded to her husband, Bill.

Arrangements are by Kinney Crematory of Columbia. A Mass of Christian Burial will be held at 11 a. Saturday, April 1, at St. Eugene Catholic Church, with the Rev. Van Coutren was born Jan. In lieu of flowers, please make donations to your favorite charity. Visitation will be from 1 p.

Burial will be at Memorial Park Cemetery in Columbia. Elsie Afton Pat was born Aug. They moved to Columbia in She was a homemaker and longstanding member of Memorial Baptist Church in Columbia. She was also preceded in death by a brother and sister. Broadway in Columbia, with burial to follow at Memorial Park Cemetery. Leonard was born to Leonard O. His parents preceded him in death. They enjoyed a life of love together, and he will be dearly missed by all who knew him. Leonard taught school in Iowa for five years before entering the sales field.

His sales work with Family Record Plan brought him and his young family to Columbia. He later moved to the insurance field and represented Reserve National Insurance Co. After a few years of retirement, he was enjoying his most recent endeavor as a part-time distribution representative for Maximum Media. Since moving to Columbia in , Leonard was an active member of Community United Methodist Church, where he volunteered his many talents. He was also an active supporter of the VA Choral Ensemble, assisting them in their many activities and traveling with them for many years to their national concert each fall.

Among his other interests and activities, Leonard enjoyed cars, history, traveling, Mizzou athletics, a "goofy" sense of humor and supporting the many activities of his family. He is also survived by many nephews, nieces and cousins. Memorial tributes may be left online at www. Visitation will be held from 1 to 2 p. A funeral service will be at 2 p. Ken Watson will officiate.

A private family burial will follow the services. Wanda was born Feb. On June 15, , Wanda was united in marriage to Paul Keithley, who preceded her in death. Louis, Robert Keithley of St. Besides her husband, Wanda was preceded in death by her parents and a brother, Clyde McCollum. In lieu of flowers, the family suggests that memorials be made to First Christian Church.

Visitation with her family will be one hour before the services. Turner was born Aug. Published Monday, April 10, Robert L. There will be no services. McNamara was born March 23, , in Hazel, S. He received a doctorate in sociology from Ohio State University in His first appointment was to the faculty of Oklahoma State University.

He was appointed to the faculty of the University of Missouri in and served until He served as chairman of the departments of rural sociology and sociology. He had international assignments in Thailand, Colombia and Chile. He was awarded an honorary doctorate from South Dakota State in In lieu of flowers, the family suggests memorial contributions be made to the Dr. Woods of Columbia died Monday, April 10, , at home. The family will receive friends from 5 to 7 p.

Memorial services will be held at 11 a. Thursday at Calvary Episcopal Church, S. Following interment, a reception will be held at the home of Dr. William Woods, W. Jo was born Oct. Hatfield and Josephine Taylor Hatfield. She resided in Oak Ridge, Tenn. She moved to Columbia to attend Stephens College. After graduation, she married Larry M. Jo and Larry lived in Columbia until , when they retired to Tucson, Ariz.

They recently returned to be near their children and grandchildren. During her lifetime, Jo was an avid golfer and a certified rules official for the United States Golf Association. She was a member of the Episcopal church and involved in many civic activities and was devoted to raising her family. She was a great wife and mother, loved by her family, and will be missed. Graveside services will be at 10 a.

Survivors include a daughter, Carol Jones and husband William E. She was preceded in death by her parents, husband and one son, Jim Coleman. Broadway, with the Rev. Wednesday at Warren Funeral Chapel, 12 E. She was born Nov. She was married to Clarence Crum. Louis and Carrie Lou Patrick of Columbia; eight grandchildren; 15 great-grandchildren; and nine great-great-grandchildren.

She was preceded in death by her husband, her parents, one son and one sister. Gloria was born Sept. In , her junior year, it was "love at first sight" with a graduating medical student. Gloria married Jacob Sylvester Roden in In Midland, Texas, where her husband was in private practice, she served as president of the Doctors Wives Club and president of the League of Women Voters. She was actively involved in Democratic Party politics in Columbia.

No one who met her was ever surprised to discover that the first course Gloria developed for Stephens College was "Revolutions in The Modern World. In , she married Thomas Watkin Giller, who died in In , Gloria moved to Chapel Hill. Gloria was intellectual and honest, with a keen sense of personal style. Her family adored her beauty and courage. Published Friday, April 21, Charles B. Visitation will be at 3 p. Saturday, April 22, at Memorial Funeral Home, with memorial service following at 4: A private burial will take place at Locust Grove Baptist Cemetery.

Charles was born May 11, , on a farm near Sturgeon, the eighth of 12 children born to George and Mary Kent. He married Loretta Mathis in , and she passed away in He is survived by two brothers and by two children, Dennis Kent and Lisa Isaacson, both of Columbia; two grandchildren; and two great-grandchildren. Published Tuesday, April 25, Dorothy L. Wednesday, April 26, at St. Jude Thaddeus Catholic Church in Mokane.

Tuesday at Debo Funeral Home in Fulton. Burial will be at Mokane Cemetery. Published Friday, April 28, Mary M. McElroy, 83, of Columbia passed away Thursday, April 27, Visitation will be held from 2 p. Entombment will follow at Memorial Park Cemetery. Mary was born March 12, , to Thomas B. On May 13, , she married Glenn L.

Harold, you were really a pioneer in terms of what has now been called this bucketing concept for managing retirement income. Can you talk about the bucketing approach and why you think it makes sense for retirees who are managing their portfolios? The fact of the matter, it really makes sense for anyone.

I think we believe that the risk of investing in the market is the short-term volatility of the market. So we developed back in the early '80s I think we call our five-year mantra; "five years, five years, five years," simply means we don't believe anyone should invest money that they are going to need in the next five years.

So, we carve out for any lump sum, someone says, "Gee, I want to buy a second home three years from now," we will carve that out of the investment portfolio and put it in short-term bonds or cash. What that does is you can take that cash and set it up to pay your check once a month like a payroll check.

As you manage your investment portfolio, gets out of whack, you need to rebalance, you look over and say, "Gee, it's kind of down, let me move some money over. So you can be much more cost and tax efficient in managing that portfolio. You are not going to have to sell at the wrong time. You can sleep through volatile times. Access should be guaranteed to the full range of providers needed by plan enrollees, with an emphasis on primary care, mental health and substance abuse care, and care for children.

Failure to include providers necessary to address certain conditions should be treated as a discriminatory benefit design issue. Regulators should also ensure that formularies are adequate and non-discriminatory, and that an exceptions process is readily available. Regulations should also require insurers to enroll at least some providers that offer extended hours and weekend appointments. State regulators should pay special attention to access to essential community providers.

Regulators should also ensure that health plans not only have network contracts with hospitals, but also with physicians within those hospitals, particularly with hospital-based physicians such as anesthesiologists, radiologist, pathologists, emergency room doctors, and hospitalists.

Insurers should be required to file access plans that describe in detail their networks, how those networks adequately address the needs of their enrollees, and how pertinent and timely information about their networks is clearly communicated to consumers.

The access plans should in particular address the criteria an insurer uses to select providers, including measures that address quality of care, and protocols for maintaining and updating network directories.

These access plans, and any changes to them, should be reviewed and approved by regulators before they go into effect. Regulators should regularly review compliance with network adequacy regulations, using such tools as secret shoppers and review of provider contracts to ensure adequacy.

Regulators should not passively rely on complaints to ensure insurer compliance. Regulators should also not simply rely on accreditation status to ensure network adequacy. Accreditation can provide an additional check on adequacy, but cannot substitute for public regulation.

Some enrollees will inevitably be unable to receive needed care in network plans. All network plans should thus be required to provide an exceptions process for enrollees who cannot find within-network providers, either because of their specialized needs or because of network capacity.

Requests for exceptions in urgent cases should be handled within twenty-four hours. Regulators should collect routinely data to monitor the frequency of use of out-of-network providers, the cost of out-of-network services, and the use of the exceptions process. If a provider and a plan terminate their contract or a provider is moved from one cost-sharing tier to a different tier, an enrollee who is pregnant, terminally ill, or under a course of treatment for a serious condition should be able to continue treatment at the same cost-sharing level for ninety days, or until a baby is delivered or the condition resolved.

The Centers for Medicare and Medicaid Services CMS has recently proposed regulations that would require federally facilitated marketplace qualified health plans to provide similar continuity of care protections.

Consumers should be protected from balance billing unless they have freely assumed the risk by knowingly seeking care from a non-network provider fully aware that they will receive a balance bill. Federal law now requires network plans to pay minimum provider rates and to not charge consumers higher coinsurance or copayments for out-of-network emergency care.

It does not, however, ban balance billing in emergency situations. A few states have laws requiring insurers to hold consumers harmless for emergency out-of-network care, but many states do not. Protections are also needed for consumers who have exercised reasonable caution to make sure that they are receiving treatment from in-network providers but nonetheless receive out-of-network services, for example from anesthesiologists, pathologists, or surgical consultants. CMS has recently proposed a rule under which a marketplace health plan could provide notice to an enrollee at least ten days in advance of the receipt of services from an in-network facility that there was a possibility that the enrollee might receive out-of-network services while at the facility.

This is a step in the right direction, but does not go far enough. When consumers schedule a procedure with an in-network provider in a nonemergency situation, they should be informed as to whether professionals that might be involved in the procedure are out-of-network and, if so, be offered the option of choosing in-network providers.

If consumers end up being treated by out-of-network providers despite reasonable efforts to receive only in-network care, an arbitration process should be provided to resolve the issue between the provider and insurer without involving the consumer. One goal of the ACA is to provide consumers with a range of health plan choices. Another is to encourage competition among insurers to constrain premium growth and improve quality and value. To accomplish both of these ends, the ACA created exchanges—now called marketplaces—where consumers can shop for individual and small group coverage and insurers can compete for their business.

The ACA constrains marketplace choices and competitions in several ways. Insurers are restricted from competing in the way they have traditionally—by avoiding high-risk enrollees or charging them higher premiums. Insurers also cannot compete in the individual and small group market by offering skinny benefit packages. All insurers in these markets must cover a reasonably comprehensive package of essential health benefits. Qualified health plans sold through the marketplaces must also meet other requirements, including inclusion of essential community providers that cover low-income and high-need enrollees, and accreditation by recognize accrediting entities.

Within these constraints, insurers are free to compete for consumer business, and consumers are free to choose the plan that they think best suits their own needs and resources. Although the extent of competition, and the ways in which insurers have competed, have varied from state to state, and from one region to another within a given state, competition has been robust throughout much of the country.

Consumers have, on average, five insurers and fifty health plans to choose from per county in the open enrollment period. Insurer competition has focused intensively on premiums. In a recent Commonwealth Fund survey, 41 percent of participants reported that low premiums were the most important factor in their selection of a qualified health plan see Figure Another 25 percent identified out-of-pocket payments as most important, with only 22 percent reporting that access to a preferred provider was most important.

Narrowing provider networks provides the most common approach used by insurers to lower both premiums and out-of-pocket payments. Fifty-four percent of consumers who report that they had the opportunity to save money by enrolling in a QHP with a narrower provider network chose to do so. Insurers also compete by offering a range of cost-sharing alternatives.

Although cost-sharing packages must meet actuarial value standards, there are many different ways in which plans can be designed to meet the same actuarial standard.

Different cost-sharing packages may be attractive to different consumer groups. Although, as we noted earlier, high cost-sharing may harm low-income populations, within limits, diversity and choice in cost-sharing alternatives is beneficial to consumers. Competition in this area, however, also imposes significant possibilities for confusion, imposing large responsibilities for processing information on individual consumers.

There is evidence that premiums are lower in marketplaces in which many insurers actively compete. The challenge is to improve consumer choice while managing the accompanying cognitive and informational burdens.

In the run-up to the implementation of the ACA, proponents occasionally spoke of the process of buying marketplace coverage as something that could be done with the ease of selecting a book on Amazon. That vision was over-optimistic, given the complexity of insurance products.

The current consumer experience, in both the state and federal marketplaces, certainly does not approach that standard. The sheer volume of Americans who have used the marketplace accounts for much of the technical challenge. According to a recent Commonwealth Fund report, one-quarter of all U. Fifteen percent of visitors enrolled in Medicaid; 30 percent enrolled in a private plan.

Each of these individuals required extensive information processing, linking across multiple federal agencies and qualifying health plans, including identity verification, citizenship checks, and the computation of premium tax credits. These challenges crashed the initial launch of the federal healthcare. They still affect the consumer experience in many ways. With due allowance for inherent complexity, the human experience interacting with the new marketplaces remains mediocre.

Partly as a result of these shortcomings, consumers often err in choosing marketplace health plans. Survey data collected in —15 by the Commonwealth Fund underscores the challenge. The low response rate Yet the overall pattern is consistent with other data and media accounts. Consumers require significant help making sense of complex provider networks; premiums, deductibles, copayments, and coinsurance; and pharmaceutical formularies.

Improved decision aids could help consumers make better and more informed choices. This is a critical concern to ensure that individuals obtain affordable coverage, and to ensure that marketplace competition disciplines premium increases across plans. The dynamics of the open enrollment process underscored the importance of active consumer comparison-shopping.

An individual who purchased the cheapest silver plan and retained it in would experience an average 8. That same consumer, if she had chosen the cheapest silver plan, would have experienced only an average 1.

One-third of re-enrolling marketplace participants changed plan metal levels in The remaining two-thirds of metal plan participants retained their plan level. These likely will exhibit similar patterns. Some tools for improving consumer decision-making are emerging in the federal marketplace and across the states. This is a major advance over the initial open enrollment, which generally required individuals to establish personally identified marketplace accounts before gaining access to such information.

For the open enrollment period, healthcare. Materials recently released by CMS indicate important changes for the current marketplace. These include faster and improved browsing and account management, more user-friendly navigation, and simplified re-enrollment processes with comparisons to other local available plans. A new out-of-pocket cost calculator helps consumers estimate overall costs, beyond the monthly premium. This feature provides further information on premiums, deductibles, and co-pays for each plan, based on different anticipated levels of health care utilization.

New doctor and prescription drug lookup features will provide consumers with more readily searchable information about network and prescription-drug coverage in different plans. By , additional data will be incorporated, including plan quality ratings and the results of consumer satisfaction surveys.

A recent paper by economists Ben Handel and Jonathan Kolstad exemplifies how personalized decision supports and defaults could make marketplaces more transparent and competitive, and also less burdensome to individual consumers. These authors make several proposals to guide consumers towards plans most likely to match their projected health needs, network of providers, preferences about risk, and other factors. More should be done to integrate decision-making and consumer support tools with the predictable needs of Americans with chronic conditions.

Expert organizations such as the American Cancer Society could play a valuable role in preparing materials and automated decision aids that help consumers assess the quality of qualified health plans in treating specific conditions.

Although all of these tools will be helpful, they are not sufficient. Navigators and other types of enrollment assisters, including traditional agents and brokers, must help.

The most knowledgeable consumers may already have signed up for coverage, leaving many remaining uninsured who will need outreach and other services to obtain coverage and financial help.

According to one recent survey, half of uninsured adults who were potentially eligible for financial help had not heard about subsidies or looked for information on the new marketplaces. When the ACA first launched, the federal government financed much of this human help, funding many programs that help consumers with the mechanics of plan enrollment and marketplace subsidies. During the first open enrollment period, some 4, assister programs with more than 28, staffers and volunteers helped nearly 11 million consumers.

Some policymakers had hoped that the need for such supports would decline as the ACA became a permanent fixture and the new marketplaces enrolled increasing numbers of the previously uninsured.

Experience in Massachusetts and elsewhere suggests these hopes are misplaced. A particularly important challenge arises in reaching severely disadvantaged populations, such as individuals with substance use disorders or those under the supervision of the criminal justice system. The federal government can help to fill this gap. A large city such as Chicago might have additional specialists, who would be available to assist individuals with complicated health conditions or life circumstances, and to assist others such as Medicaid-eligible indigent individuals who would otherwise remain uninsured.

Such costs may be offset by the savings to states of increased Medicaid enrollment, and by savings to both individuals and the federal government if such enrollment assisters could help marketplace participants more effectively comparison-shop different plans. Private brokers and agents can also play a useful role. Some ACA supporters were initially skeptical that brokers could still play a valuable role once state marketplaces were implemented.

In part because of initial implementation difficulties, but also because of their specific expertise and experience in the insurance market, brokers and agents have played an important and continuing role.

Rather than being dis-intermediated by the new marketplaces, brokers are accounting for a surprisingly high proportion of enrollment in California, Kentucky, and other states. Such collaboration also requires regulation of potential conflicts of interest and new training regarding low-income consumers and other populations likely to participate in state marketplaces, who have rarely interacted with agents or brokers before.

Improved network and formulary transparency would greatly improve the consumer shopping experience. Federal regulations and the laws in some states require health plans to make their network directories and drug formularies available online and to update them regularly. Comprehensive federal regulations, however, apply only to qualified health plans sold through the ACA marketplaces and to Medicare Advantage and Medicaid managed care plans , and state laws and regulations do not apply to self-insured group health plans, which cover the majority of employees covered through employee benefit plans.

ERISA, which does cover employer plans, imposes less rigorous network disclosure requirements. Transparent network coverage is necessary to ensure that consumers who enroll in narrow network plans understand the constraints they are accepting and can determine whether the providers they want or need are in-network. For example, McKinsey in its analysis of networks defines broad networks as those with 70 percent of all hospitals in the rating area participating, narrow networks with 31 percent to 70 percent of all hospitals, and ultra-narrow networks with 30 percent or less of all hospitals participating.

Plans should also describe the criteria used for determining network participation, the cost differentials for enrollees who use in- or out-of-network providers, and how balance bills are handled. Provider directories should be readily available online and in paper form. These must be easily searchable and understood by the general public. Consumers should be able to determine whether specific providers with whom they have established relationships, specific types of specialties that they need, providers in their geographic location, or providers who speak their language or are accepting patients, are available in a network before they sign up for it.

Directories for individual and small group plans should be available to the public online without the need to log-in or to provide a password. Directories for all individual market plans should also be provided by insurers in machine-readable form to permit private companies to create search tools.

Directories should include, and be searchable by, information on providers including name, contact information, location, specialty, languages spoken, and whether or not the provider is accepting patients. The recently launched federally facilitated marketplace doctor lookup tool should be supplemented by private marketplace search tools.

If a network is tiered, providers should be identified and be searchable by tier. The directory should clearly define the ramifications of tiered status in terms comprehensible to ordinary consumers. Consumers should also be able to trust the accuracy of provider directories. Directories should be updated monthly. Only a handful of states currently require this, although CMS now require monthly updates from QHPs in the federally facilitated marketplaces.

Network directory updates should be filed with state insurance regulators, who should make reviewing network directories part of their regular market conduct analysis, as well as respond to complaints about directories. Trusted consumer organizations such as Consumers Union or Consumer Checkbook could also rate plan networks for their comprehensiveness and quality.

Formularies should be available online and in machine-readable form and regularly updated. Insurers and group health plans should not be allowed to remove drugs from a formulary or change its tier status within a plan year unless the drug is determined to not be safe or effective, a generic form of a previously brand-name only drug becomes available, or an over-the-counter equivalent of the drug becomes available. Nevada has recently considered a formulary regulation that takes this approach.

Consumer shopping in the non-group market could also be improved through greater standardization. While it is important for consumers to have options in insurance markets and while product innovation can be beneficial to consumers, consumers do not benefit from having available many plans with minimal and confusing differences. Several state marketplaces have developed standardized designs for marketplace plans. The California marketplace requires insurers to offer plans in each of the four metal tiers and to offer a standardized plans in each tier.

Marketplaces should develop a limited number of standard product designs and require insurers that want to offer products in the market to offer those products. Insurers could also be allowed to offer a limited number of nonstandard products, but would have to justify why the product is valuable for some specific group of consumers and that offering such a product would not aggravate risk-segmentation or deter high-cost consumers.

Seventy-two million Americans are enrolled in Medicaid, At this writing, twenty states have chosen to opt out. This process should continue. Indeed, ongoing dialogue between conservative state officials and the Obama administration may be the most effective bipartisan negotiation now occurring in health policy.

And states could be offered additional incentives to expand Medicaid. Finally, several steps, outlined below, could be taken to make Medicaid more beneficial to Medicaid beneficiaries. The Congressional Budget Office estimated that the federal government will pay 93 percent of the costs of the Medicaid expansion between and The additional cost to states represents a 2. Economic analyses indicate that the local economic impact of Medicaid expansion is highly favorable to state government and to state economies.

One simple response to these concerns would be for the federal government to assume all remaining costs of the Medicaid expansion in all states. Section of the Social Security Act has long authorized research and demonstration projects in Social Security Act programs, including Medicaid.

Medicaid research and demonstration projects have been used for decades to waive or vary program requirements, often for many years, without meaningful research purpose or oversight and with little transparency. After the NFIB decision, conservative states began demanding that program requirements be waived under section as a condition of the states expanding Medicaid.

It has allowed genuine bipartisan negotiations between Republican state office-holders and the Obama administration, in which each side has strong incentives to expand health coverage. The resulting negotiation provided a politically palatable pathway for some states to implement Medicaid expansion despite deep-seated political opposition to the ACA itself.

States might also design innovative and constructive waivers that improve the terms of the Medicaid expansion. For example, a state might explore better mechanisms to reduce churn between the Medicaid and marketplace plans, or to better coordinate care for individuals and families who move from one program to the other.

Caution is warranted, however, in reviewing waivers, as some states have submitted waiver requests that serve no research or demonstration purpose and are contrary to the goals of Medicaid itself.

It is important for the Obama administration and its successor to reject waiver requests that would erode basic protections for Medicaid recipients. Some waiver requests, seek to enroll Medicaid recipients into mandatory wellness programs or charge copayments for selected forms of emergency department care or other services.

The RAND Health Insurance Experiment and subsequent research indicate that even modest copayments and deductibles deter use of valuable care and can harm individuals facing the dual challenge of low-income and significant injury or illness. Efforts to impose cost-sharing on low-income or chronically ill populations thus deserve particular scrutiny.

Some of the most concerning waiver requests would require families with incomes below the federal poverty line to pay monthly premiums, or to satisfy a work requirement. These policies limit Medicaid access by making the program unaffordable for precisely the low-income population that needs the greatest help. If necessary, Congress should amend the Medicaid statute or section to prohibit such waivers. The Medicaid statute allows states to recover program expenditures from the estates of certain Medicaid beneficiaries.

This program is primarily targeted at elderly individuals who receive expensive long-term care and who may have a home or other assets that could be sold to repay the Medicaid program for the cost of these services at their death.

The Medicaid statute, however, gives states the option of recovering Medicaid expenditures from the estates of any Medicaid beneficiary aged 55 or older. This includes beneficiaries in the expansion population. Ten states have indicated that they may try to recover Medicaid expenditures from the estates of expansion population enrollees aged 55 or over.

The possibility of an estate claim may tend to discourage individuals who are aware of it from enrolling in Medicaid, regardless of their need for health care.

In fact, Medicaid beneficiaries who fall within the expansion population are likely to account for low health care expenditures compared to the elderly long-term residents against whom the estate recovery program is directed.

They are also likely to live for a considerable period, during which the state will have to keep track of these individuals and the expenditures it has incurred before it can finally make a claim against the estate.

Medicaid estate recovery raises serious concerns in every beneficiary population. Enforcement of the estate claims against the expansion population is especially unwise, imposing high administrative costs for minimum recoveries and deterring appropriate take-up of the Medicaid program.

Congress should amend the statute to bar estate recoveries against the expansion population. Alternatively, states can amend their statutes or regulations to eschew estate recoveries against members of the expansion population. At the very least, research should be undertaken to determine what the costs and benefits would be of eliminating these requirement. It is vitally important that Medicaid beneficiaries not only possess Medicaid coverage but are actually able to use that coverage to obtain care.

Indeed, the ACA amended the Medicaid statute to clarify that states were obligated under the program not just to pay for care, but also to ensure that care was actually available. In many states, Medicaid reimbursement rates have fallen below the levels required to ensure practical access to needed services.

Indeed, six states—Rhode Island, Florida, New Jersey, California, Michigan, and New York—impose Medicaid reimbursements for primary care that are 50 percent or less of what Medicare pays for primary care services.

The ACA provided a temporary increase, covering and , in selected Medicaid reimbursement rates to achieve parity with Medicare rates. Fifteen states have continued to provide such enhanced reimbursement after these provisions expired. Interestingly, some of these states, such as Mississippi, Alabama, and South Carolina, are among those most adamantly opposed to Medicaid expansion and other more politically prominent provisions of the ACA.

CMS has recently issued a final rule for ensuring access to care in state Medicaid fee-for-service programs. These plans must address the extent to which beneficiary needs are met, availability of care and providers, changes in beneficiary service utilization, and comparisons between Medicaid rates and rates paid by Medicare and commercial insurers.

States must use these tools to review proposals for reducing or restructuring provider payments before submitting those proposals to CMS. States must also consider input from beneficiaries and providers prior to submitting such proposals. States will be required to monitor the effect of changes reducing or restructuring provider payments on access for at least three years after the changes are effective.

States must additionally review every three years access to a core set of services—primary care including dental , physician specialists, behavioral health, pre- and post-natal obstetrics including labor and delivery , and home health services. States may review additional services at their discretion and must also review services for which the states or CMS receive a high level of complaints.

States are required to implement ongoing mechanisms for receiving provider and beneficiary feedback on access to care. States must develop remediation plans within ninety days of discovering an access deficiency that would correct the problem within twelve months.

The final rule is a step forward in ensuring access to care for Medicaid beneficiaries, but more needs to be done. First, the final rule does not provide beneficiaries or providers a mechanism for initiating CMS review of the adequacy of Medicaid access to care in a state.

With access to the federal courts further limited by the Armstrong case discussed below , beneficiaries and providers need some means for initiating an independent review of state limits on access to care. This rule does not provide it. Second, the rule does not provide any concrete metrics for determining whether access is sufficient.

CMS has requested further information on what metrics might be appropriate, but for now leaves the states to develop their own metrics. Once a state submits a proposed amendment it can proceed to implement it, subject to later disapproval.

CMS approval should be a prerequisite for implementation. This reform would provide states with concrete incentives to raise provider rates. It may also alter Medicaid politics by calling specific attention to these concerns at the state level.

One template policy would be to raise federal matching rates five percentage points for each service in which the state reimburses providers some minimum rate. The threshold could, for example, be set at 70 percent of the corresponding Medicare rate.

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