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Aligning Maternal Health Policies with Birthing People’s Preferences and Experiences

October 2, 2023

The US's maternal mortality and morbidity rates are strikingly high, especially amongBlack and Indigenous individuals. Documenting the birthing experiences andpreferences of Black, Indigenous, and Latinx pregnant and parenting women and otherswho can become pregnant is critical to informing and shaping policy conversationsaround initiatives and programs designed to improve outcomes and mitigate maternaland infant health inequities. Our team conducted in-depth phone interviews with 19women and focus groups with 26 women nationwide to understand their experiencesand preferences for care throughout pregnancy, delivery, and postpartum. We focusedour recruitment on Black, Latinx, and Native American/Indigenous pregnant andpostpartum individuals. Important takeaways include ensuring that those who arepregnant/postpartum are provided with full, relevant information needed to makeinformed decisions and feel they have bodily autonomy. Participants shared frustrationwith the lack of pregnancy and delivery care options and feelings of coercion andpowerlessness regarding decisions about their bodies during pregnancy. These findingsreinforce the need to align the birthing preferences and lived experiences of women ofcolor and other pregnant/postpartum individuals of color and center their voices in thepolicy conversation.

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff

April 6, 2022

Nursing homes play a unique dual role in the long-term care continuum, serving as a place where people receive needed health care and a place they call home. Ineffective responses to the complex challenges of nursing home care have resulted in a system that often fails to ensure the well-being and safety of nursing home residents. The devastating impact of the COVID-19 pandemic on nursing home residents and staff has renewed attention to the long-standing weaknesses that impede the provision of high-quality nursing home care.With support from a coalition of sponsors, the National Academies of Sciences, Engineering, and Medicine formed the Committee on the Quality of Care in Nursing Homes to examine how the United States delivers, finances, regulates, and measures the quality of nursing home care. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff identifies seven broad goals and supporting recommendations which provide the overarching framework for a comprehensive approach to improving the quality of care in nursing homes.

A Framework for Assessing the Racial Equity Impact of the American Rescue Plan Act

October 1, 2021

The issue brief, "A Framework for Assessing the Racial Equity Impact of the American Rescue Plan Act," translates the framework for assessing the equity impact of ACHs to the new funding available under ARPA, and other investments in communities going forward.

How Would State-Based Individual Mandates Affect Health Insurance Coverage and Premium Costs?

July 20, 2018

Issue: The Tax Cuts and Jobs Act of 2017 eliminated the financial penalty of the Affordable Care Act's individual mandate. States could reinstate a similar penalty to encourage health insurance enrollment, ensuring broad sharing of health care costs across healthy and sick populations to stabilize the marketplaces.Goal: To provide state-by-state estimates of the impact on insurance coverage, premiums, and mandate penalty revenues if the state were to adopt an individual mandate.Methods: Urban Institute's Health Insurance Policy Simulation Model (HIPSM) is used to estimate the coverage and cost impacts of state-specific individual mandates. We assume each state adopts an individual mandate similar to the ACA's.Findings and Conclusion: If all states implemented individual mandates, the number of uninsured would be lower by 3.9 million in 2019 and 7.5 million in 2022. On average, marketplace premiums would be 11.8 percent lower in 2019. State mandate penalty revenues would amount to $7.4 billion and demand for uncompensated care would be $11.4 billion lower. The impact on coverage and on premiums varies in significant ways across states. For example, in 2019, the number of people uninsured would be 19 percent lower in Colorado and 10 percent lower in California if they implemented their own mandates. With mandates in place, average premiums would be 4 percent lower in Alaska and 15 percent lower in Washington.

2018 Scorecard on State Health System Performance

May 3, 2018

Hawaii, Massachusetts, Minnesota, Vermont, and Utah are the top-ranked states according to the Commonwealth Fund's 2018 Scorecard on State Health System Performance, which assesses all 50 states and the District of Columbia on more than 40 measures of access to health care, quality of care, efficiency in care delivery, health outcomes, and income-based health care disparities.The 2018 Scorecard reveals that states are losing ground on key measures related to life expectancy. On most other measures, performance continues to vary widely across states; even within individual states, large disparities are common.Still, on balance, the Scorecard finds more improvement than decline between 2013 and 2016 in the functioning of state health care systems. This represents a reversal of sorts from the first decade of the century, when stagnating or worsening performance was the norm.

State Regulation of Coverage Options Outside of the Affordable Care Act: Limiting the Risk to the Individual Market

March 29, 2018

ABSTRACTIssue: Certain forms of individual health coverage are not required to comply with the consumer protections of the Affordable Care Act (ACA). These "alternative coverage arrangements" — including transitional policies, short-term plans, health care sharing ministries, and association health plans — tend to have lower upfront costs and offer far fewer benefits than ACA-compliant insurance. While appealing to some healthy individuals, they are often unattractive, or unavailable, to people in less-than-perfect health. By leveraging their regulatory advantages to enroll healthy individuals, these alternatives to marketplace coverage may contribute to a smaller, sicker, and less stable ACA-compliant market. The Trump administration recently has acted to reduce federal barriers to these arrangements.Goal: To understand how states regulate coverage arrangements that do not comply with the ACA's individual health insurance market reforms.Methods: Analysis of the applicable laws, regulations, and guidance of the 50 states and the District of Columbia.Findings and Conclusions: No state's regulatory framework fully protects the individual market from adverse selection by the alternative coverage arrangements studied. However, states have the authority to ensure a level playing field among coverage options to promote market stability.

Enabling Sustainable Investment in Social Interventions: A Review of Medicaid Managed Care Rate-Setting Tools

January 1, 2018

This report explores practical strategies that states can deploy to support Medicaid managed care plans and their network providers in addressing social issues. It is widely recognized that social factors, such as unstable housing and lack of healthy food, have a substantial impact on health outcomes and spending, particularly with respect to lower-income populations. For Medicaid, now dominated by managed care, this raises the question of how states can establish managed care rates to sustain investments in social supports.

Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients

January 1, 2018

The U.S. health care and social services delivery systems are not well-equipped to effectively manage patients with multiple chronic diseases and complex social needs such as food, housing, or substance abuse services. Community-level efforts have emerged across the nation to integrate the activities of disparate social service organizations with local health care delivery systems. Evidence on the experiences and outcomes of these programs is emerging, and there is much to learn about their approaches and challenges.

How Medicare Could Provide Dental, Vision, and Hearing Care for Beneficiaries

January 1, 2018

The Medicare program specifically excludes coverage of dental, vision, and hearing services. As a result, many beneficiaries do not receive necessary care. Those that do are subject to high out-of-pocket costs. This report examines gaps in access to dental, vision, and hearing services for Medicare beneficiaries and design a voluntary dental, vision, and hearing benefit plan with cost estimates.

Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage? Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March–June 2017

September 7, 2017

Issue: After Congress's failure to repeal and replace the Affordable Care Act, some policy leaders are calling for bipartisan approaches to address weaknesses in the law's coverage expansions. To do this, policymakers will need data about trends in insurance coverage, reasons why people remain uninsured, and consumer perceptions of affordability.Goal: To examine U.S. trends in insurance coverage and the demographics of the remaining uninsured population, as well as affordability and satisfaction among adults with marketplace and Medicaid coverage.Methods: Analysis of the Commonwealth Fund Affordable Care Act Tracking Survey, March–June 2017.Findings and Conclusions: The uninsured rate among 19-to-64-year-old adults was 14 percent in 2017, or an estimated 27 million people, statistically unchanged from one year earlier. Uninsured rates ticked up significantly in three subgroups: 35-to-49-year-olds, adults with incomes of 400 percent of poverty or more (about $48,000 for an individual), and adults living in states that had not expanded Medicaid. Half of uninsured adults, or an estimated 13 million, are likely eligible for marketplace subsidies or the Medicaid expansion in their state. Four of 10 uninsured adults are unaware of the marketplaces. Adults in marketplace plans with incomes below 250 percent of poverty are much more likely to view their premiums as easy to afford compared with people with higher incomes. Policies to improve coverage include a federal commitment to supporting the marketplaces and the 2018 open enrollment period, expansion of Medicaid in 19 remaining states, and enhanced subsidies for people with incomes of 250 percent of poverty or more.

Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

August 24, 2017

Issue: Prior to the Affordable Care Act (ACA), blacks and Hispanics were more likely than whites to face barriers in access to health care.Goal: Assess the effect of the ACA's major coverage expansions on disparities in access to care among adults.Methods: Analysis of nationally representative data from the American Community Survey and the Behavioral Risk Factor Surveillance System.Findings and Conclusions: Between 2013 and 2015, disparities with whites narrowed for blacks and Hispanics on three key access indicators: the percentage of uninsured working-age adults, the percentage who skipped care because of costs, and the percentage who lacked a usual care provider. Disparities were narrower, and the average rate on each of the three indicators for whites, blacks, and Hispanics was lower in both 2013 and 2015 in states that expanded Medicaid under the ACA than in states that did not expand. Among Hispanics, disparities tended to narrow more between 2013 and 2015 in expansion states than nonexpansion states. The ACA's coverage expansions were associated with increased access to care and reduced racial and ethnic disparities in access to care, with generally greater improvements in Medicaid expansion states.

How the Affordable Care Act Has Helped Women Gain Insurance and Improved Their Ability to Get Health Care

August 10, 2017

Issue: Prior to the Affordable Care Act (ACA), one-third of women who tried to buy a health plan on their own were either turned down, charged a higher premium because of their health, or had specific health problems excluded from their plans. Beginning in 2010, ACA consumer protections, particularly coverage for preventive care screenings with no cost-sharing and a ban on plan benefit limits, improved the quality of health insurance for women. In 2014, the law's major insurance reforms helped millions of women who did not have employer insurance to gain coverage through the ACA's marketplaces or through Medicaid.Goals: To examine the effects of ACA health reforms on women's coverage and access to care.Method: Analysis of the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2016.Findings and Conclusions: Women ages 19 to 64 who shopped for new coverage on their own found it significantly easier to find affordable plans in 2016 compared to 2010. The percentage of women who reported delaying or skipping needed care because of costs fell to an all-time low. Insured women were more likely than uninsured women to receive preventive screenings, including Pap tests and mammograms.