Reforming Private Health Insurance

Between 1987 and 1991, the portion of Americans covered by individually purchased health insurance dropped 40per cent. Assuming the US will continue to rely on private financing for health care, the author clarifies benefits to society from an efficient health insurance market.

The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. This report analyzes health care utilizations as they relate to impairment severity and SSA's definition of disability. Health Care Utilization as a Proxy in Disability Determination identifies types of utilizations that might be good proxies for "listing-level" severity; that is, what represents an impairment, or combination of impairments, that are severe enough to prevent a person from doing any gainful activity, regardless of age, education, or work experience.

This book establishes a framework for assessing health care reform proposals and their implementation. It helps clarify objectives, identifies issues to be addressed in proposals, distinguishes between short- and long-term expectations and achievements, and directs attention to important but sometimes neglected questions about the organization and provision of health care services. In addition, the volume presents a discussion and analysis of issues essential to achieving fundamental goals of health care reform: to maintain and improve health and well-being, to make basic health coverage universal, and to encourage the efficient use of limited resources. The book is a useful resource for anyone developing or assessing options for reform.

The private health insurance provisions in the Patient Protection and Affordable Care Act (P.L. 111-148, ACA, as amended) include market reforms that impose requirements on private health insurance plans. Such reforms relate to the offer, issuance, generosity, and pricing of health plans, among other requirements. ACA's market reforms largely focus on the individual and small group health insurance markets, and in this report the reforms have been grouped by effective dates: “immediate” market reforms that become effective prior to the full implementation date of ACA, and reforms that become effective on the full implementation date (January 1, 2014). ACA requires implementation of a number of reforms prior to its full implementation date (i.e., prior to plan years beginning on or after January 1, 2014). “Immediate” reforms include a process to review unreasonable rate increases; an Internet portal to assist consumers in identifying coverage options; prohibition on lifetime limits and restriction of annual limits; the prohibition on rescissions; coverage of preventive health services with no cost-sharing; extension of dependent coverage; prohibition of discrimination based on salary; standards related to medical loss ratios and rebates to plan participants; appeals process; coverage of preexisting health conditions for children; patient protections; uniform explanation of coverage documents; and reporting requirements regarding quality of care. Market reforms effective beginning in 2014 include nondiscrimination based on health status; guaranteed issue and guaranteed renewability; coverage of preexisting health conditions (regardless of age); nondiscrimination regarding clinical trial participation; rating restrictions; waiting period limitation; and nondiscrimination regarding health care providers. This report provides background information about the private health insurance market, including market segments and regulation. It describes each ACA market reform and notes any major implementation activity that has occurred (e.g., issuance of final rule from a department such as Health and Human Services). The appendices of the report provide additional information about the status of regulations relating to each reform and how the reforms apply to the different market segments and health plans.

1. Israel : partial health care reform as laboratory of ongoing change / David Chinitz and Rachel Meislin -- 2. Change and continuity in Dutch health care : origins and consequences of the 2006 health insurance reforms / Kieke G.H. Okma and Hans Maarse -- 3. Reform and re-reform of the New Zealand system / Toni Ashton and Tim Tenbensel -- 4. Health care reforms in Singapore / Meng-Kin Lim -- 5. Consumer-driven versus regulated health insurance in Switzerland / Luca Crivelli and Iva Bolgiani -- 6. Taiwan's national health insurance system : high value for the dollar / Tsung-Mei Cheng -- Conclusions : debates, reforms, and policy adjustments / Kieke G.H. Okma and Luca Crivelli