December–January Research Roundup: What We’re Reading

By Kennah Watts

This winter, CHIR curled up with some good reads: the latest in health policy research. In December and January, we read studies on trends in employer-sponsored insurance (ESI), expanding insurance options for non-citizens, and state efforts to improve provider directory accuracy.

Mark Katz Meiselbach, Jeffrey Marr, and Yang Wang, Enrollment Trends in Self-Funded Employer-Sponsored Insurance, 2015 and 2021, Health Affairs, January 2024. Using data from the Clarivate Interstudy—which surveys insurers and third-party administrators (TPAs) and providing greater geographic detail than some other ESI enrollment sources—researchers at Johns Hopkins University examined trends in self-funded ESI enrollment between 2015 and 2021.

What it Finds

• Enrollment in ESI self-funded plans increased by approximately 5 percent between 2015 and 2021, equating to an additional 2.8 million enrollees in the ESI self-funded market.
  • Enrollment grew in nearly 80 percent of U.S. counties, increasing by more than 10 percentage points in almost a quarter (24.3 percent) of counties.
  • By 2021, a majority of ESI enrollment was in self-funded plans in 80.5 percent of U.S. counties. However, some states have lower rates of self-funded coverage—across North Dakota, for example, no counties had more than half of ESI enrollees in self-funded plans.
• Authors identified a lack of competition among insurers and TPAs in the self-funded market: in 2021, less than 5 percent of enrollees with self-funded ESI lived in a core-based statistical area with a “competitive” self-funded market, and 36.2 percent of self-funded ESI enrollees lived in a “highly concentrated” market.
• In 2021, the top insurers and TPAs in the self-funded market were Health Care Service Corporation, Cigna, CVS Health, UnitedHealth Group, and Elevance Health.
  • These five insurers and TPAs enrolled more than 71 percent of the self-funded market, and more than 60 percent of the total ESI population when accounting for self-funded and fully insured plans.
  • Elevance Health accounted for 17 million enrollees in self-funded plans (19 percent of the self-funded market).
• In contrast to the fully insured ESI market, which shifted from preferred provider plans (PPOs) to HMOs between 2015 and 2021, self-funded enrollment in PPOs increased during this timeframe, while self-funded HMO enrollment dropped. 

Why it Matters

Self-funded ESI is regulated under the Employee Retirement Income Security Act (ERISA), which preempts state regulation of these plans. Consequently, as self-funded ESI enrollment grows, states have regulatory authority over a smaller proportion of the commercial insurance market, which may have consequences for enrollees’ quality of and access to health care. Furthermore, state-run databases cannot require self-funded plans to submit claims data, limiting researchers’ and regulators’ ability to study pricing, spending, utilization, and outcomes, potentially hindering future reforms in the self-funded market. Finally, with less competition in the self-funded ESI market, insurers gain negotiating power while bearing less financial risk than employers; emerging evidence indicates that employers in self-funded plans may be paying higher provider prices than those in the fully insured market.

Dulce Gonzales, Jennifer M. Haley, and Sofia Hinojosa, State-Led Health Insurance Coverage Expansions for Noncitizens, Urban Institute, January 2024. To understand state expansions of public insurance coverage for noncitizens, researchers at the Urban Institute reviewed published reports, and then conducted interviews with national and state experts. Interviewees spoke about the conditions that drove expansion efforts and remaining gaps in research to inform policymakers and other stakeholders.

What it Finds

• The rate of uninsurance for nonelderly noncitizens is four times greater than the national uninsurance rate; without restrictions based on citizenship status, 25 percent uninsured nonelderly noncitizens would be eligible for Medicaid or CHIP and 41 percent would be eligible for ACA premium assistance.
• As of January 2024, a dozen states have expanded funded coverage expansions to provide affordable health insurance to noncitizens.
  • In 12 states—California, Connecticut, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington—and the District of Columbia (DC), low-income children can receive state-funded, Medicaid-like coverage or primary and preventive care.
  • California, Illinois, New York, Oregon, and DC have expanded Medicaid-like coverage to either some or all income-eligible adults.
  • Noncitizens residing in Colorado and Washington can receive income-based subsidies for private insurance.
• While further research is needed, preliminary findings indicate that coverage expansions for noncitizens reduce the uninsured population, increase care utilization, improve health outcomes, and drive down unmet health needs.
  • Expanding prenatal care access for noncitizens in Oregon led to higher utilization and lower infant mortality.
  • In states that expanded coverage for noncitizens, children in immigrant families were less likely to be uninsured and forgo care than children in states without such an expansion.
• Across states, the catalyst for proceeding with coverage expansion varied, such as the inequities exposed by the COVID-19 pandemic or a public health argument for improving health care access across the population. Small expansions often built momentum, leading to further expansion.
• Stakeholders noted that additional research is needed to understand the implementation and maintenance of these coverage expansions, ranging from budgets and financing options to the short- and long-term impacts on individuals and families as well as risk pools and health care costs.
  • However, stakeholders warned that some research may reinforce negative stereotypes and/or risk individual confidentiality, emphasizing the importance of nuance and context to minimize potential harm to noncitizens.

Why it Matters

Noncitizens are an underserved population, particularly in the realm of health insurance. Restrictions and exclusions in federal coverage programs leave noncitizens with few, if any, affordable options to protect their health and financial wellbeing. This study shows that state-funded expansions are working to reduce inequities in health access and outcomes for noncitizens, but more work is needed to reduce their uninsured rate. Stakeholders interviewed by the Urban Institute also commented that further research could help pave the way to more policy action. And while expansion is a necessary first step, researchers and policymakers should remain mindful of other barriers to coverage and care, such as language, administrative burdens, and fear concerning citizenship applications.

Stephanie Kissam, Michele Dorsainvil, Keegan Barnes, and John Feher, State Efforts to Coordinate Provider Directory Accuracy: Final Report, Office of the Assistant Secretary for Planning and Evaluation (ASPE), December 2023. Provider directories identify doctors and other health care professionals participating in a plan’s network. Challenges for plans and providers updating information can lead to delays, outdated information, and other inaccuracies. To streamline this process, some states have explored a new option: a centralized provider directory. ASPE funded the Research Triangle Institute to assess state efforts to create such a resource.

What it Finds

• Provider directory errors are relatively common.
  • A study on directory accuracy found that phone numbers could only be verified for about half of psychiatrist directory listings for a DC-based commercial insurer.
  • A California insurer’s directory had more than a quarter of providers listed (26.2 percent) no longer practicing at the listed location.
• California is the only state to have developed and implemented a centralized provider directory that standardizes health plan information for all users (i.e., enrollees, providers, plans, plan vendors, and oversight entities).
  • Michigan, Rhode Island, and Oregon have attempted similar systems, but faced implementation and technical challenges such as high costs for implementation; a lack of interest across health agencies, plans, and providers; and insufficient incentives for providers and plans to participate.
• Symphony, California’s centralized provider directory, compiles information from plans and providers, verifies the information by checking it against other data sources, and distributes the validated information to plans to inform patient-facing directories.
• Despite continued hopes that Symphony will improve provider directory accuracy, there is not yet evidence that centralized directories can lead to fewer errors.
  • An AHIP pilot study before California implemented Symphony identified some obstacles to success, including providers failing to verify information.
• While a centralized provider directory could aid state regulators in monitoring both directories and provider networks, this potential has not yet been realized.
  • Research has not yet shown if state coordination of a centralized directory could help monitor and ensure adequacy of behavioral health provider networks.
  • The California agency that regulates health plans does not rely on Symphony’s data to monitor directory accuracy.
• Implementation requires significant costs to cover technology, provider participation incentives, and administration.

Why it Matters

Provider directories are a crucial tool for plan enrollees. They can also offer valuable information about the adequacy of provider networks. Outdated and inaccurate provider directories create difficulties for patients seeking care and can result in higher out-of-pocket costs if an enrollee visits an out-of-network provider based on inaccurate directory data. These inaccuracies hurt consumers as well as warp regulators’ understanding of plan quality and network adequacy; without accurate information on a plan’s provider network, regulators cannot identify and fill gaps in the plan’s care. Although centralized provider directories may hold promise, more evidence is needed to determine if the cost of establishing and maintaining one is worth the effort. States that aim to improve directory accuracy may also consider other policy options, such as mandated accuracy benchmarks and data standards paired with increased enforcement, oversight, and incentives for plans.