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BACKGROUND: In 2014, qualified health plans sold in the Affordable Care Act (ACA) marketplaces were accused of providing drug coverage that was too restrictive and costly. After the change in administration in 2016, efforts to repeal portions of the ACA led to increases in premiums, decreases in enrollment, and overall uncertainty. OBJECTIVE: To examine how the number of formulary tiers and medication cost sharing, as well as transparency around these aspects, in qualified bronze and silver health plans in California, Florida, and Illinois changed from 2014 to 2018. METHODS: A search of all bronze and silver qualified health plans in California, Florida, and Illinois was performed in 2014 and in 2018 through the marketplace and issuer websites. RESULTS: From 2014 to 2018, the total number of bronze and silver qualified health plans offered in California, Florida, and Illinois remained relatively stable (36 to 35, 123 to 122, and 60 to 74, respectively). Over the same time period, the median number of formulary tiers remained constant for California and Florida (four and five) and increased from five to seven for Illinois. Of note, most Illinois plans shifted from a formulary with five or fewer tiers (92% of plans) to seven tiers (73% of plans) between 2014 and 2018. There was also an increase in the use of coinsurance instead of copay for each of the four following formulary tiers: generic (19% to 27% of plans), preferred brand (21% to 38%), nonpreferred brand (33% to 52%), and specialty (76% to 91%). Additionally, there was an increase in the median coinsurance rates for each of the aforementioned tiers: 0% to 25%, 0% to 35%, 30% to 40%, and 30% to 40%, respectively. The proportion of plans that provided their formularies on the marketplace website increased from 82% to 97% from 2014 to 2018, with the increase mostly driven by California plans (0% to 80%). There was a small increase in the proportion of plans that reported medication cost sharing through the medical benefit from 2014 (19%) to 2018 (25%). CONCLUSIONS: Between 2014 and 2018, qualified health plans increased their use of formularies with greater numbers of tiers, the use of coinsurance for each tier, and higher coinsurance rates. Availability of formularies on marketplace websites increased, but cost sharing transparency for medications covered by the medical benefit could greatly improve. DISCLOSURES: No funding supported this study. Hung reports past employment by Blue Cross Blue Shield Association, CVS Health, and a grant from PhRMA outside of the submitted work. She was an intern at the Biotechnology Industry Organization when this work began. Sauvageau has no disclosures. This work was presented as a poster at the AMCP 2018 Managed Care & Specialty Pharmacy Annual Meeting; April 23-26, 2018; Boston, MA.

Background: Consumer directed health care proposes that patients will engage as informed consumers of health care services by sharing in more of their medical costs, often through deductibles. We examined knowledge of deductible plan details among new enrollees, as well as anticipated care-seeking changes in response to the deductible., Methods: In a large integrated delivery system with a range of deductible-based health plans which varied in services included or exempted from deductible, we conducted a mixed-method, cross-sectional telephone interview study., Results: Among 458 adults newly enrolled in a deductible plan (71% response rate), 51% knew they had a deductible, 26% knew the deductible amount, and 6% knew which medical services were included or exempted from their deductible. After adjusting for respondent characteristics, those with more deductible-applicable services and those with lower self-reported health status were significantly more likely to know they had a deductible. Among those who knew of their deductible, half anticipated that it would cause them to delay or avoid medical care, including avoiding doctor's office visits and medical tests, even services that they believed were medically necessary. Many expressed concern about their costs, anticipating the inability to afford care and expressing the desire to change plans., Conclusion: Early in their experience with a deductible, patients had limited awareness of the deductible and little knowledge of the details. Many who knew of the deductible reported that it would cause them to delay or avoid seeking care and were concerned about their healthcare costs.

This paper summarizes the results from a study of consumer decision making in California's individual health insurance market. We conclude that price subsidies will have only modest effects on participation and that efforts to reduce nonprice barriers might be just as effective. We also find that there is substantial pooling in the individual market and that it increases over time because people who become sick can continue coverage without new underwriting. Finally, we show that people prefer more-generous benefits and that it is difficult to induce people in poor health to enroll in high-deductible health plans.

Whether Medicare beneficiaries own private health insurance to supplement Medicare, and the characteristics of the policies they do own, are of interest both to public policy makers and to insurers. In this analysis of responses to a random survey of Medicare beneficiaries and of copies of the private insurance policies owned by these beneficiaries, the following variables were found to be important determinants of policy ownership: income, education, race, and self-perceived health status. It was also found that although most policies provide comprehensive coverage for Medicare copayments, few provide coverage for the many services and products needed by the elderly that are not covered by Medicare.

The nonmunicipal teaching hospital faces some special challenges in adapting to the increasingly austere fiscal environment in which all hospitals must operate. However, except in a few instances, such developments as constraints on Medicaid expenditures do not appear to be notably more serious for teaching hospitals than for their community counterparts. The teaching hospitals most closely connected with medical schools provide more charity care and carry more bad debt than community hospitals. But other teaching hospitals have about the same burden as their community counterparts. The most serious problem facing teaching hospitals results from new bases of prospective reimbursement, some of which do not adequately compensate hospitals that treat more "difficult" cases--that is, more expensive cases. Competitive providers of health care such as health maintenance organizations promise to reduce admissions at all types of hospitals; whether this reduction will selectively affect teaching hospitals is not yet clear. By contrast, the fiscal state of municipal teaching hospitals is far more precarious than that of their nonmunicipal counterparts. The ability of these institutions to maintain high-quality patient care and teaching programs is in considerable jeopardy.

A legislatively mandated copayment system for California state-funded family planning services was evaluated after the first six months of experience. Most clients reportedly could make their payments, but three times as many providers suggested lowering the fees as suggested raising them, and one-third reported a decrease in client donations. While the majority of providers did not report a decrease in clients, 22 per cent did so. For these drop-outs, it is estimated that the State would pay approximately $3 million in costs associated with unintended pregnancies, or one and a half times the amount cut from the Family Planning budget.