State Efforts to Lower Cost-Sharing Barriers to Health Care for the Privately Insured

Overview

Sandy Ahn and Sabrina Corlette from the Center on Health Insurance Reforms at Georgetown University released a paper through the Urban Institute Research Hub analyzing the findings of state laws that lower consumers’ financial barriers to key health care services, primarily through regulation of health plan benefit design in the individual and small-group insurance markets. The research included a survey of laws and policies in all 50 states and D.C., and in-depth interviews of stakeholders in four states with such policies.

Findings

Six states and D.C. have policies aimed at lowering cost-sharing for key health care services in the individual and small-group markets through state-prescribed standardized plan designs: California, Connecticut, D.C. (only individual market), Massachusetts, New York, Oregon and Vermont. In most states, standardized benefit plans include requirements that insurers cover the following services before consumers must meet a deductible: doctor’s visits for non-preventive primary care, specialty care, mental health and substance use disorder (MH/SUD), urgent care and generic prescription drugs. Through stakeholder interviews, researchers found that these policies requiring standardized plans:

• were designed to create value for consumers by making high-value health care services more accessible and affordable, although data to assess the impact of pre-deductible coverage is not yet available;
• were developed and implemented in an open process with stakeholder input; and
• are challenging to develop within federal limits related to benefit design.

Implications for Policy and Practice

Some federal proposals to repeal and replace the Affordable Care Act are likely to result in more consumers purchasing high deductible health plans. State and federal policymakers can learn from the experiences of the six states and D.C. that enacted policies to minimize the deductible as a financial barrier to needed care. Policymakers may wish to consider requiring coverage of certain services pre-deductible or establishing cost-sharing limits for specific services in order to improve consumers’ access to necessary care.