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Health Affairs’ October Issue: Insurance, The ACA, Care In India & More

Bethesda, MD - The October issue of Health Affairs, a variety issue, includes several reports detailing aspects of the implementation of the Affordable Care Act (ACA) at a time when the latest census data shows the smallest-ever share of the US population without health insurance. The issue also features a cluster of articles about the quality of health care in India.

Marketplace premiums lower with narrower physician networks.
The introduction of health insurance Marketplaces under the Affordable Care Act (ACA) has been linked to the growth of restricted provider networks. While researchers have identified a correlation between narrower hospital networks and lower consumer costs, the association between breadth of physician networks and plan pricing has not been established. In the first study to explore that connection, Daniel Polsky of the University of Pennsylvania and coauthors examined data on 2014 silver plans in all US health insurance exchanges and found that the premiums of plans with a small network were 6.7 percent lower than premiums for otherwise equivalent plans with a large network. According to the authors, in markets with average-price plans, this translates to annual savings of $212–339 per person for an individual plan (depending on the consumer’s age) and up to $692 for a young family of four. Since the cost of health insurance premiums remains the main reason many Americans remain uninsured, the authors conclude that the use of narrow networks, with lower premium prices, could hold the key to reducing the number of uninsured people. 

Another ACA-related study in the issue:

Wide variation in state oversight of freestanding emergency departments. 
Freestanding emergency departments (EDs), introduced in the 1970s, are proliferating, with 400 being operated in thirty-two states as of December 2015. Some are hospital-affiliated, while others are independent. Texas and Ohio have the greatest numbers of freestanding EDs (see map below). Catherine Gutierrez of Harvard Medical School and coauthors evaluated state regulations of freestanding EDs and found that twenty-one states had policies for freestanding EDs, either incorporated into hospital regulations or listed independently. According to the authors, twenty-nine states had no regulations, with New York and Washington regulating freestanding EDs on a case-by-case basis, and California indirectly barring them in its hospital regulations. The authors conclude that consistent state regulation of freestanding EDs is needed so patients can better understand the EDs’ capabilities and costs, enabling patients to choose the most appropriate site for emergency care.

In North Carolina, Medicaid enrollees circumvent a controlled substance lock-in program.
Controlled substance lock-in programs, which require high-risk patients to visit a single prescriber and pharmacy for coverage of opioid and benzodiazepine prescriptions, are attracting interest from payers and policy makers. At least forty-six states operate one of these programs in Medicaid. The programs contain a loophole: It is possible for participants to obtain additional drugs by paying full price out of pocket to fill a controlled substance prescription at a pharmacy to which they are not locked in. To find out how often this happens, Andrew Roberts of Creighton University and coauthors conducted a retrospective cohort study of the North Carolina program from October 2009 through September 2012, using a data set that linked that state’s Medicaid claims data with records from the state’s prescription drug monitoring program. According to the authors, the estimated probability that enrollees would circumvent their Medicaid coverage at least once in a given month to purchase an opioid or benzodiazepine prescription out of pocket was 55 percent following lock-in enrollment, compared to 16 percent in the months before the lock-in program’s restrictions took effect. The authors believe that this finding highlights the need for further scrutiny of the appropriate role and design of the program for combatting opioid abuse as well as its potential unintended consequences.

A related study about state laws and opioids:

Lessons from India: Delivering high-quality, efficient cataract surgery.
In India, cataracts—which can be successfully treated with surgery—are a leading cause of reversible blindness. Hong-Gam Le of the University of Michigan Medical School and coauthors evaluated the Aravind Eye Care System, a network of eleven specialty eye hospitals in southern India that annually provides care to over 3.8 million patients and performs more than 400,000 ocular procedures—two-thirds of which are cataract surgeries. The authors analyzed data on a sample of the 10,954 patients who visited the Aravind Eye Hospital in the city of Madurai during July 2013 and found that total costs per operation were, on average, only US $120, or $195 per quality-adjusted life-year gained, which indicates that cataract surgery there is highly cost-effective. They say that factors contributing to the highly cost-effective care include the domestic manufacturing of supplies, the use of a specialized workforce and standardized protocols (including operating rooms with more than one operating table per surgeon, which allows for fast transitions between operations), and the presence of few regulatory hurdles to be overcome. The authors conclude that the Aravind model could help improve the delivery of cataract surgery elsewhere in India and abroad. These lessons are further detailed in the issue’s People & Places report, “Lessons From Low-Cost, High-Quality Eye Care,” authored by Margaret Saunders, Health Affairs’ deputy editor for global health.

There are six other papers in the issue about the quality of care in India.

Also of interest: the issue’s Narrative Matters essay:

About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print and online, with additional Web First papers and health policy briefs published regularly at You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download monthly Narrative Matters podcasts. Tap into Health Affairs content with the iPad app.