Key Proposals to Strengthen the Affordable Care Act

Expanding Access to Health Coverage for Moderate-Income Americans

Harold Urey
What a wonderfully interesting article. Editions universitaires, , p. Beginning, from Telos website: Later, I worked at the mill on the green chain and pulled the dry chain while continuing my education. This could be done by amendments to the ACA, but could be accomplished also by the administrative actions under existing authority and by state legislatures and insurance regulators. Jerzy Wiatr , "Herbert Marcuse: Wow… Loved the article… My shop is full or wood working machinery dating back to but this just puts everything into perspective.

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Awesome, do they do tours? I need to take my kids to see this awesome mill next time I am home. It looks like a green operation to me using their wood waste to heat the boiler. I toured this mill and took a number of photos. This mill is a throwback to the past and I love the history. After college, I worked in the Weyerhaeuser sawmill in Springfield, Oregon. They had a 10 foot bandmill for the large logs but everything was pretty much computerized at the time.

The smells, the flow through the mill, and skill sets required by the various machine operators will also be remembered. Thanks for sharing the Hull-Oakes story. Dad was a logger and pony-sawyer skilled labor. Nineteen sixty-seven, , Dad remarked how many people lost their jobs, how many families were no longer there. How he greived that year. Our town housed one of the largest sawmills in the British Commonwealth, owned at the time by B. These pictures bring back a lot of memories for me as my father was the chargehand electrician for many years and I worked part time in the mill while in high school and post secondary school.

This series of photos and descriptions of the mill workings is a treasure and should be in a museum for posterity. May I suggest sending it to the forestry museum in Duncan, B. It is very closely reminiscent of all that I remember in Youbou. Well done to those who developed it. My dad worked in the woods and then in sawmills and planer mills all his working life.

By the time I can remember he was working in a planer mill in Junction City, Oregon for his brother-in-law, Don Shelton. These pictures provoke wonderful memories of my childhood and visiting daddy at the mill! Thank you for the trip down memory lane and a more gentle time. Thanks to Grant Cunningham for the link. One of the last steam powered mills in the east was torn down to make way for the Georgia Dome in Atlanta about 20 years ago.

I used to go there to pick up bundles of survey stakes. I loved to stop by and watch the mill run. Thanks for a wonderful presentation. It brought back memories of my first job out of High School. With corked shoes I snagged the logs, pulled them into the mill, cut to length and split them to shingle bolt size. It was good exercise for an 18 year old and has stood me well and I feel I could still do it at I purchased the the old Car-Win cedar mill in Forks Wa.

It cut old growth cedar and exported it all over the world. Before I dismantled the mill I took hundreds of photos and of course recognize many of the same equipment as was in your presentation.

I restored the straddle buggy and take it for a short ride now and then. This mill was not steam operated but it took so much power that when it started all the light in Forks dimmed.

This mill also had planers and they sold a finished cedar product. Thanks again Respectfully Bill Sperry. I toured the mill last fall and still have short videos of the headrig cutting huge timbers on my cell phone. This was an absolute treat. Nice to have keepsakes around.

It is great to see a wonderful mill like this still in operation. I have a large circle saw 64inch in front of my house powered by a steam engine.. It has an atlas engine with a 10 inch bore and 14 inch stroke.. The headblocks are adjustable, so something a little larger could be set up for. The boiler is horizontal and has 92 3 inch flues 14 ft one inch long in it. The great area is five by nine feet.

We fire it on slabs and railroad ties. The engine is an Atlas manufactured in Indianapolis Indiana. The flywheel is about five feet in diameter and 14 inches wide.

It drives a 10 inch flat belt which goes to the husk and an edger. Sawdust is carried out by a drag chain. I have a machine shop next door in which all the lumber except the poles was sawed on this mill. Schwenk passed away a few years after setting up this mill. He had always wanted one. He also owned a horsepower Nichols Sheppard engine, a A. Baker engine and a Minneapolis engine,and his fathers engine a M.

Rumley engine built here in La Porte Indian. The baker engine was his favorite. Baker had invented a very modern valve gear for the engine, and was sought after by many railroads to put his steam efficient valve gear on their engines. I new have a two cylinder upright westinghouse single acting engine to be used for the swing cut off saw, and a two cylinder water pump engine.

We also have a twin cylinder pumping engine one injector,and a manual pump for water in the boiler. You just cant beat the smells and sounds of a saw mill running cutting oak and steaming steam cylinder oil in the air.

My hat goes off to you guys there for keeping your mill operating. I guess I am showing my age. I was lucky enough to run all the steam locomotives at Cedar Point in Sandusky Ohio for two summers. I pulled five cars four trips an hour and hauled three hundred and fifty passengers on every trip. The second year I not only ran the engines, but fired, took on water, and shovelled the coal into the tenders every morning by hand by myself. We had the old waste stuffed journals and I oiled them all every morning.

I also started the fires, blew out the flews with a steam hose to knock out the excess soot. My friend Don was one of the last to shock wheat and oats and corn here so he could thresh it with his old advance rumley separator. Come to Indiana in the fall to our threshing show.

I was one of the founders about 25 to 30 years ago. By the way the boiler on our mill formerly heated the New York Central track pan in Chesterton Indiana, and was hauled over to this area on a wagon drawn by horses.

Best Regards, Rich Lidke I have a video of our mill on here made by a friend. Thankyou for a wonderful journey through the operations of an old Steam driven sawmill. Thank you, and I hope the mill still keeps going for generations to come.

If at all possible, young children age should see this process to become aware of the hard ardous work necessary to obtain wood down to paper. We are honing in on becoming more green and appreciative of nature but a hands on visible look would be worth a thousand words. I am very impressed and enjoyed reading about the process of a tree. Later, my father and his brother took over the operation around In my cousin and myself both started working on the mill and in the woods of central PA cutting timber and running the backend of the mill.

We would take the lumber off the edger and stack it and cut all the slabs and edgings to either fire wood size or slabs for firing the brick yard kilms. We sold the sawdust also. This story really brought back the memories from that time.

We supplied a lot of ties to the railroad and prime oak for hardwood flooring. We also subblied ash blanks to be turned into handles and baseball bats. We also custom cut lumber for many special projects including homes and other buildings which required special timbers.

It was quite an experience. One of the stories my father told me about my grandfather was that when he was young, he lived in a logging camp. On Saturdays, the logging camps would get together and each camp would have a camp champion to box bare knuckle.

My grandfather was champion for a number of years and according to Dad, wan never defeated. A very enjoyable and informative presentation. I learned quite a bit with each picture. I love history information like this and hopefully it will stay around for many years for others to see and learn from. I sure am glad that I have taken the tour and being from California, plan on coming up north to take the physical tour so I can see, hear and smell the complete process.

I hope that will be o. I was sent this by a friend who knows my interest in steam power. But I found the whole mill operation absolutely fascinating. An operation like this is a one of a kind thing and deserves to be kept in use as long as possible. I noticed that they say the steam engines have less trouble than anything else they could use.

Unfortunately boilers are maintenance intensive by comparison. Thanks for all the work to put this together. I grew up with this mill. My dad worked there until he died in I spent my summers during high school with Hull family across the road from the mill. Field trip to San Francisco when in sixth grade spent the night on The C.

Thayer and did all the stuff that was done on the ship back when it was in operation. Great photos of mill. It should not be closed down. I graded lumber after it was dried in the kilns for a few years and then changed to the river crew, where I fed logs into the mill in a steel cable hoist, up to the head rig.

I sometimes worked as an off bearer behind the head rig, but finally transferred to the log dump. I ran the cantilever dump, lifting the entire loads off of the trucks and dumping them into the river where they were sorted and graded to be formed into rafts and stored until needed by the mill. Then the truck trailers were loaded back onto the trucks, so they could return to the woods for another load.

IP built a paper mill next to the saw mill and plywood plant, and used the slabs from squaring up the logs to chip into pieces to digest into paper pulp. The logs had to be barked before they could use them, so they were cold decked and not dumped into the river anymore. The old cantilever dump was sold to a shipyard across the river in Reedsport to lift boats onto the drydock.

IP cut all of their timber and shipped it to China. Leaving Gardiner like so many other lumber towns in the Pacific Northwest. I walked and sorted the logs before sending them into the mill. But, it sort of made me mad as I sat and thought about it. We live in a country where the ones who are rewarded most handsomely are those who produce absolutely nothing of value. Here, we have workers who actually work, yet more and more of their country is owned by the bankers, lawyers and speculators, those who have produced little of value for our country.

Long live sawmill workers. I just called them up and asked if I could visit and they said yes. While I was there, one of the employees took me on a tour. Same thing the second time I went. You should make a video and get this on a program like This Old House. What a great story and my hat is off to those that have spent their life working at this mill. I moved from N. Last year they closed the mill at Frenchtown and the Lumber mill at Bonner,Mt.

It is appalling that we now send our logs over to China to get made into different products and when they are finished they are shipped back to the U.

I have seen this when I drove Truck picking up loads from the docks in Ca. Ironically I have even been sent to deliver loads and pick them up at the papermill plant in Frenchtown,Mt.. I can remember everything coming from Japan when I was growing up and now our country is suffering from loss of jobs because our politicians,bankers and government has sold us short. Now we know that these groups have been lying about what is really going on and they did this so they could get government-taxpayer money over all these years for their special programs.

Our government and politicians are letting this happen. Forest fires destroy more trees than a logger can cut in a hundred years.

Trees can be grown and harvested just like crops of wheat,barley etc. Maybe we can turn this around and start producing in our own country again soon. The woods, the mill, made boxes, doors and the town. The mill saws could handle giant sugar pine logs cut from the slopes of Mt. One never forgets the smell and whistles of a company owned lumber town. And a previous comment was true: Blessed to have followed my Dad into forest products, and to have spent some time in old sawmills both as a laborer, and as a safety professional.

The sounds, the feel of the wood, the aroma of freshly sawn timber, and the satisfaction of surviving yet another damn difficult day hard-at-it, are unforgetable memories. But the best part of it all — and the single most endearing aspect of Hull-Oakes, is the folks who work there and live that life-style as close as you can find to how it was. All that old technology, and the effort they put into maintaining their historic designation is impressive to say the least.

It is by Green Frog Productions, Ltd. It is very well done, tracking a log through the process just as your photo essay does. This was on the Menominee Indian Reservation in NE Wisconsin which had some of the last remaining old-growth timber left of the great forests that once covered most of that state.

The mill was unusual in that it was built by the US government to provide an industry for the tribe, so the main mill building was of cast concrete, sturdy enough that it still operates today. Back then, it was still powered by a big steam engine, and the sights, sounds, smells and overall action of all the saw carriage, jacks, moving chains and workers was immensely fascinating for a 7 year old.

And still is for a 68 year old! I lived near Placerville, CA. Not many had bandsaws, most used circular saws, one mounted above the other which permitted them to cut large logs. The circular saw blades had removable teeth, occasionaly a tooth would come off and go through the roof of the mill. Most lumber was not planned, homes were built with rough lumber. A two by four was acually that size and had lots of splinters, must have been tough being a carpenter in those days.

I worked as a log setter in a small mill in Riddle Or. I was a timber faller for some time. All the logs shown in these pictures are douglas fir. I fell thousands of them, some even larger than any pictured. I got out of the woods in I worked as a furniture salesman for 30 years. I met Mrs hull at Blackledge furniture in Corvallis Or. I was out to her home several times and sold her a lot of things over the years. The family was all wonderful.

She had a large log house built over by Bend Or. One of the store decorators furnished it for her. Barker would to me imply to place the bark onto the log. Other areas may use different terms. I think you have the time of Mr. Hulls death wrong, it must have been ,it was some time before I retired in I worked in sawmills Bandsaw mill such as the sawmill Pictured located in Hilis, CA from age 18 years of age until I was The teeth on the back of the bandsaw also served to cut pieces of the log that may spring out after the sawyer went through the cut.

We referred to the teeth as splinter teeth. I was the person that rode the carriage and was called a ratchett setter. Pictures bring back many memories from into My dad work for the Kerr Lumber co. He not only worked in the saw mill but was the engineer of the train that hauled the logs out of the forest.

I was born at that time but he used to tell us about it. My mother would talk about it also. He died in I have part of one of the boards found in an old barn that was torn down several years ago. Nothing like the smell of fresh cut wood and the beauty of a finished object made of wood. What a great, great presentation, but just as interesting have been all the follow up comments, so many by people in my age bracket, i.

Incredible memories, and I saw most of the large mills in CA when I was a woods rat cruising timber. I am surprised to see that there is still at least one log pond around. Once the big handling equipment that LeTourneau, Cat and Euclid built came on the scene, most mills turned to log yards, sorting on land instead of water.

Beyond the head rig the conveyor system could handle only small dimension stuff. If they were cutting an RR tie or a large square, once it was to dimension the sawyer would bring back the carriage at full speed, the dogs would be lifted, and when the carriage came to a stop the timber would shoot back out of the mill, fall some 20 feet, and land in the pond with a gigantic splash. Could give you quite a start if you were driving by and not expecting it.

I used to work in a lumber yard back in Ames, Iowa for several years. I received your presentation from friends in Central Oregon this morning and how great it is. I have read every one of the comments and much to my suprise there are none from Anacortes, WA, where we had two huge sawmills, a pulp mill, a plywood mill, and a dozen shingle mills, plus numerous individual shake cutters. Wood and fish was our life blood on this island. I grew up hanging out at our local shinglemill on Similk bay at Summit Park, and knew every hand there.

IT was all steam, as all our mills were. My dad worked in the logging industry before me. Years later as an engineer and business owner, I converted two steam mills to Hydraulic. The first at Johnsondale, CA a complete company owned town and mill and the second was a smaller mill at Davenport, CA. I did live in the Bloedel-Donovon Owners house in Bellingham, Washington in that over looked their mill.

Thanks for sharing this wonderful piece of history. I have driven by this mill you showcased many times. The lovely old log trucks were out though and made for great photographs. The sawmill is going to be open to the public for a tour on May 18, as a part of Historic Preservation Month.

I grew up in the Wauconda Area Graduated from Republic High schoo in , As a kid I used to help a friend of the family cut railroad ties I used to use a sort of knife like article and cut the bark off of the ties that he cut. Made a dollar a day then after a stint in the Army after being discharged in I worked in a steam powered saw mill in Tonasket, Washington for quite some time so I really enjoyed this article Thanks again for bringing back fond memories Bill Fischer.

I visited Hull Oakes a few years ago and found it fascinating. Now I am involved in a writing project involving specific elements of Oregon history and would like to use this story as a resource, with permission.

When I got out of the Navy in 79 my new bride lived in Corvallis. We moved from Georgia to Philomath Oregon where there was I believe 5 sawmills within the city limits or very close to it. I went for a millwright position at Pedee lumber company, which had already been filled.

The owner did me a favor since we were both navy men from the black gang boiler rooms he put me on as the off bearer by the big bandmill. I soon began to wonder if he really did me a favor or not, when you work in one of these old mills where most all of the work was manually done, there was know slowing down and you generally had more than one job at a time.

If you worked in one of these mills and lasted, you were a real man. Thanks for the memories. I am in the process of setting up a small mill in the back of my place, not to really make money but to enjoy the sounds and smells of logs being milled. Some guys want bass boats, I prefer a sawmill.

Sawmill in Monroe, Oregon. There also has been one book written about the mill, its processes and history. Here is the citation:. A Case Study in Industrial Archaeology. Keep up the good work. What an excellent documentary of the mill and the timber industry.

It brings back a flood of memories as my entire family has been involved in the industry in one way or another for over years. The company would later become Publishers Paper Co.

Sadly, the mill was recently forced into bankruptcy when it was unable to compete with the Chinese for raw materials. My Grandfather started a career in the woods in Alsea maintaining a steam donkey for the logging operations. He later moved to the Hull-Oaks mill in maintenance to work on the steam engines there. To know the toughness of these folks, my Grandfather talked of the times that he would walk from Alsea to Corvallis for food provisions for the family.

That is an uphill walk back of some 22 miles carrying a load of groceries! During the depression, another group took the risks and constructed a plywood mill in Albany. This mill used steam power for the lathe while the balance of the machinery was electric. The electric power came from two steam turbine generators that had sufficient generation capacity to run the entire city of Albany in an emergency. The steam was also used in the dryers to dry the veneer. At times the peeler blocks were so large in diameter that they would be chucked off center and rocked back and forth to cut down one side and then re-chucked to clear the floor.

During World War II, these thick panels of plywood were used for the carrier decks on our aircraft carriers. I started my career in wood products at this mill; learning to run every machine station there was while going to college, studying in the field of accounting. Later, as a CPA working for a national accounting firm in Portland, I would return to this mill to audit the books as an independent accountant. Sadly, this mill too is gone; lost to the Spotted Owl controversy that closed down logging operations for so many mills.

One of my major clients turned out to be Publishers Paper Co. Later, I would leave public accounting and take various accounting positions with Publishers. I later moved on to other wood produicts companies finally retiring. I still build from wood and will until I die. In my early years I would pass through the mill many times on my way to hunt for deer in the hills west of the mill and later on, to ride motorcycles all over those hills.

If you knew the old dirt log roads well enough you could ride all the way to the Oregon Coast. The guys at the mill were always friendly and would wave as you went by or stop you on your way out from hunting to inquire of your luck.

The sound of the screaming saws, the steam engine, debarker and the mill overall was a symphony of pure pleasure. Finally, being politically incorrect, as most timber folks are, I will note that the favored term for the articulated arm on the carriage that turns the log is the Nigger.

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HSAs can, however, be of value to marketplace enrollees. While it would be preferable to increase APTC and cost-sharing reduction eligibility levels and generosity, if this is not politically possible, HSA investments can provide some relief for individuals with moderate incomes or individuals who underestimate their income and are faced with high APTC repayments at tax filing time.

Some legislative changes could make HSAs even more helpful for those who actually use them to cover health care costs. First, the out-of-pocket limits under the ACA could be amended to align them with out-of-pocket maximums for HSA-linked high-deductible health plans.

Although the limits were initially aligned, they increase under different inflation adjustment rules, making it possible that ACA compliant plans would not be HSA eligible. These rules could be easily aligned. Modest direct federal contributions to HSAs for moderate-income Americans could also be considered.

These could be paid as a refundable tax credit at the time of tax filing based on actual taxable income, avoiding the need for reconciliation. As with retirement accounts, modest subsidies could be implemented with a well-designed choice architecture that could overcome behavioral inertia to encourage greater savings. Government or private plans could also assist consumers with the logistical practicalities of establishing such accounts. Consideration should also be given to allowing small employers to fund health reimbursement accounts HRAs that could be drawn upon by employees to purchase health insurance in the individual market.

This is currently illegal under administration interpretations of the ACA and preexisting tax law. Provision would also have to be made to ensure that the offer of an HRA did not disqualify employees from receiving marketplace premium subsidies unless the HRA contribution made coverage genuinely affordable. But with these protections, found in current legislative proposals HR , a program that allowed small employer contributions for coverage through HRAs could encourage some employers who would not otherwise offer traditional small group coverage to make coverage more affordable for their employees.

Even if the ACA is not amended to increase cost-sharing support, health insurers could make health care more affordable. Some marketplace plans currently offer some services—coverage of generic drugs for example—that are not subject to the deductible. In fact, in , 80 percent of marketplace silver plan enrollees selected a plan with a primary care visit covered before the deductible while 82 percent selected a plan with generic drugs covered below the deductible. Such plan designs carry some danger of risk selection.

If these plans impose lower cost-sharing on individuals with minimum medical demands, they must make up for it by imposing higher cost-sharing elsewhere, presumably on higher-cost individuals.

On the other hand, if offering some covered services to individuals with low medical needs attracts those individuals into the marketplace, this might have the effect of lowering the cost of coverage for all marketplace participants. As noted above, accumulating evidence confirms that greater patient cost-sharing leads to reduced utilization.

But there is little evidence that consumers respond to cost-sharing by effectively comparing prices for costly services, or by focusing on the highest-value care. Annual medical spending quickly dropped, with total firm-wide medical spending declining by more than 10 percent. Brot-Goldberg and colleagues found little evidence that workers effectively distinguished wasteful from valuable care. Given a financially generous high-deductible health plan with an accompanying HSA, even this group of relatively high-income, highly educated workers markedly reduced its receipt of clinical preventive services and other valuable care.

There was also little evidence that this relatively advantaged consumer group used available tools to identify cheaper services and providers, or even that consumers strategically responded to the actual economic incentives created by their insurance plan.

Researchers found especially concerning utilization declines among people with health problems, who may have foregone important forms of care.

Almost half of the spending reduction also occurred among predictably sick individuals likely to exceed their annual deductibles, for whom the true marginal cost of specific services was often quite low. This overall pattern of findings casts doubt on the power of calibrated consumer incentives to safely and effectively improve the cost-effectiveness of medical care.

Value-based insurance design VBID attempts to balance the competing goals of greater economy and cost-effectiveness with greater financial protection and improved health. Consumers require the most generous coverage and most minimal cost-sharing for high-value services likely to improve health, with less generous cost-sharing for lower-value services such as name-brand drugs for which cheaper generic substitutes are readily available.

Preventive Services Task Force based on rigorous clinical trials. Equivalent bodies could develop an evidence-based list of secondary prevention and chronic disease management services that would similarly be covered without patient out-of-pocket cost or with minimal cost.

The Center for Medicare and Medicaid Innovation recently announced an initiative to deploy VBID principles to align cost-sharing more carefully with high-value services in Medicare Advantage. Beginning in January , these programs will test the utility of structuring patient cost-sharing and other health plan design elements to promote high-value clinical services in seven states.

This effort provides a promising platform to design more innovative marketplace plans, which the federal and state marketplaces should encourage. Further steps should be taken to improve the adequacy of provider networks and formularies. Consumers also need to be protected from surprise balance billing when they unintentionally use the services of out-of-network providers. This could be done by amendments to the ACA, but could be accomplished also by the administrative actions under existing authority and by state legislatures and insurance regulators.

Narrow provider networks are a familiar feature in American health care. These have become only more common and narrower in recent years, due largely to the concurrent effects of rising costs and competitive pressure on insurers to reduce premiums. With proper transparency, narrow networks can benefit consumers. Narrow networks provide insurers and thus their customers greater leverage to constrain prices and to maintain quality. But narrow networks can leave consumers without necessary access to providers.

If providers are too far away, if delay times to obtain appointments or the times in the waiting room after arriving for an appointment are too great, the enrollee can effectively be denied coverage. If an enrollee has special needs—pediatric oncology or HIV therapy, for example—and a network lacks providers that can provide specialized care, the enrollee may lack practical access to the most essential benefits of their insurance coverage. Moreover, some insurers might intentionally restrict networks to deter high-cost patients from enrolling.

A particular concern is that insurers may restrict drug formularies to discourage individuals who need access to high-cost specialty drugs from enrolling in their plans. Recent analysis of plans available in six cities found that most marketplace plans include at least one marquis hospital or academic medical center. But physician network adequacy is more complex and less readily observed by consumers. Proper regulation is therefore essential to ensure access and to avoid risk selection across plans.

QHP networks must, under the federal rules, include a sufficient number and variety of types of providers, including mental health and substance abuse providers, to ensure that all services are available without unreasonable delay. QHP plans must also include essential community providers that serve low-income and medically underserved individuals.

QHP insurers must make provider directories available online and in hard copy and must update their online directories monthly. If necessary in-network care is unavailable, plans should be required to pay for out-of-network care with in-network cost-sharing.

QHPs must also cover at least one drug from each U. QHPs must provide an exceptions process for enrollees who need drug not on the formulary and cannot discriminate through the use of their formulary, for example, by excluding HIV drugs. The Department of Health and Human Services also regulates network and formulary adequacy for Medicare Advantage and Medicaid managed care plans. Regulation of Medicare Advantage plans has become quite sophisticated, with a focus on geographic accessibility of providers, 89 while regulation of Medicaid plans will be tightened up under recently proposed regulations.

Regulation of network adequacy is, therefore, primarily the responsibility of state insurance regulators. State regulation, however, varies widely, while advocates and the news media are more focused on Washington, D. Therefore, progress on this front will require improving state regulatory efforts directed at network adequacy.

Although the National Association of Insurance Commissioners NAIC has had a managed care plan network adequacy model act since , fewer than one-quarter of states had adopted the model, as of a recent survey. Only about half the states imposed quantitative standards in place for evaluating time and distance to providers Only about one-fifth limited how long enrollees must wait for an appointment with providers or require minimum ratios of enrollees to providers.

Many states did not affirmatively monitor ongoing network adequacy for non-HMO plans unless they received a complaint. A program for regulation of network adequacy has been proposed by the consumer representatives to the NAIC. Under the program proposed by the consumer representatives, states should have to adopt network adequacy regulations governing all insured plans that use networks—that is, virtually all insurance plans. 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.

Executive Summary