All States Need to Improve ACA Plans, Patient Group Says

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By Sara Hansard

July 14 — While all states and the District of Columbia have taken steps to improve access to care in Affordable Care Act marketplaces, there is a lot of room for improvement throughout the country, a group representing patients with chronic conditions said in a report July 14.

Following the U.S. Supreme Court decision in King v. Burwell affirming the ability of enrollees in federally run exchanges to receive health insurance subsidies, “We think it's incredibly important that all states continue to evaluate what is happening in their own marketplaces, whether they run them or whether they're federally facilitated,” Marc Boutin, chief executive officer of the National Health Council (NHC), said in a press call. The NHC describes itself as “the united voice for the more than 133 million Americans with chronic conditions and their family caregivers.”

Boutin said the report will be used as a benchmark for state progress concerning issues such as nondiscrimination against enrollees with health problems and transparency of plan information to make comparisons easier. The NHC will be active in pushing for reforms when the Department of Health and Human Services issues its annual requirements for plans, the notice of benefit and payment parameters rule and the letter to issuers guidance, he said.

Five Priorities

The report, “Enhancing the State Health Insurance Markets: State Progress Reports,” was prepared by health-care advisory firm Avalere Health LLC and was based on marketplace plans in effect Jan. 1, 2015. The report outlined five principles for evaluating ACA marketplaces, including nondiscrimination, transparency, oversight of exchange plans, uniformity of plan benefit standards and continuity of care to protect patients whose eligibility changes between marketplace plans and the ACA's expanded Medicaid program.

Alabama, which has a federally facilitated exchange, ranked the lowest based on 15 enhancements the NHC said were important to patients and on the five core principles, while California, which has a state-based exchange, received the highest ranking using both measures.

“There is no state that has met all of the criteria,” Boutin said. But he said examples were found in all three exchange types—federally facilitated exchanges, state based exchanges and state partnership exchanges—“where you've seen significant progress in making enhancements that are patient-centered.”

Nondiscrimination, Transparency, Uniformity

Washington, which operates a state-based exchange, was cited as a state that has “gone above and beyond” minimum requirements in protecting patients from discrimination based on health status, Avalere Health Director Kelly Brantley said on the press call. The state's insurance commissioner has broad authority to reject plans with discriminatory benefits, she said.

Montana, a federally facilitated exchange state, also led in nondiscriminatory marketplace policies by requiring issuers to offer at least one silver-, gold- and platinum-tier plan using copayments rather than coinsurance. Coinsurance payments are based on a percentage of costs, which can be high for expensive charges, while copayments are generally lower flat-dollar amounts. In addition, no drugs, including high-cost specialty tier drugs, are subjected to annual deductibles, Brantley said.

Maryland, which operates a state-based exchange, is a “real trailblazer” for requiring transparency for drug formularies for exchange plans to include not only the tier placement that determines the level of coverage, but also the cost sharing for each medication covered, Brantley said.

In the area of uniformity, actions taken by California's state-based exchange to standardize benefits and cost sharing across the state make it easier to compare coverage, Brantley said. The state's exchange, Covered California, doesn't allow any nonstandardized plans, she said.

Addressing Costs

“The floor is going to continue to rise,” Boutin said, referring to exchange standards. Addressing costs will have a “huge” impact in reducing discrimination against people with chronic conditions, he said.

“Many people with chronic conditions experience the maximum out-of-pocket costs in the first couple of months of enrollment, and for those people and their families it often means that they go without seeing their doctors or receiving their medicines,” Boutin said.

He suggested that the maximum out-of-pocket costs could be spread over 12 months, or limits could be placed on how costs can accrue in the early months of a year. “You do not want that person not to see their specialist or take their medicines because their condition will be debilitating and it's irreversible and it will cost the health-care system much more money,” he said.

To contact the reporter on this story: Sara Hansard in Washington at

To contact the editor responsible for this story: Janey Cohen at