Middle-income Americans paying more for health insurance

https://www.healthcaredive.com/news/middle-income-americans-paying-more-for-health-insurance/543903/

Dive Brief:

  • Middle-income families are spending more of their incomes on health insurance as average premiums skyrocketed in 2017 after modest rate increases earlier this decade, The Commonwealth Fund found in a new report.
  • Average employee contributions rose to nearly 7% of median income for single and family plans compared to 5.1% a decade ago. Premium contributions were 8% of median income or more in 11 states, including Louisiana, which had the highest percentage (10.2%).
  • The contributions and potential out-of-pocket spending for single and family policies was $7,240 in 2017. That was 11.7% of median income and an increase from 7.8% a decade ago.

Dive Insight:

Cost and price variations between areas aren’t anything new. A recent Network for Regional Healthcare Improvement found healthcare usage and pricing drive variation between states’ total healthcare costs. The report also found vast differences in costs between five states studied.

Overall, national health spending has slowed in recent years. The CMS Office of the Actuary reported this month that national health spending grew 3.9% ($10,739 per person) in 2017. It was the second consecutive year of slower healthcare spending growth. The slower cost growth is connected to fewer people receiving care.

The Commonwealth Fund found large differences between states. For instance, the average annual premium contributions for single-person plans ranged from $675 in Hawaii to $1,747 in Massachusetts. Michigan saw the cheapest premiums in family plans at $3,646 while Delaware had the highest at $6,533.

The average annual deductible for single-person policies increased to more than $1,800 in 2017. The gap was between $863 (Hawaii) and about $2,300 (Maine and New Hampshire). Three states (Florida, Mississippi and Tennessee) had average deductibles more than 6% of median income.

Premiums for employer health plans, which is how most Americans get coverage, increased 4.4% for single plans and 5.5% for family plans in 2017. All but five states saw higher single-person premiums with eight states averaging more than $7,000 (Alaska, Connecticut, Delaware, Massachusetts, New Jersey, New York, Rhode Island and Wyoming).

Meanwhile, family premiums increased in 44 states and were $20,000 or more in seven states (Alaska, Connecticut, Massachusetts, New Jersey, New York, West Virginia and Wyoming) and the District of Columbia.

The cost of health insurance is increasing faster than wage growth — and the Commonwealth Fund found that the added cost isn’t leading to higher-quality health insurance. The issue is especially a problem in southern states with lower median incomes, such as Mississippi.

The group suggested policymakers could tackle the problem of rising healthcare costs in a couple of ways.

Congress could provide more tax credits to people with employer-sponsored insurance, require businesses to improve plan benefit design to cover more services before employees reach their deductibles and offer refundable tax credits to offset out-of-pocket costs.

Other potential efforts include connecting provider payments to value and outcomes, addressing the concentration of payer and provider markets and slowing prescription drug cost growth. “Policymakers will need to recognize that the increasing economic strain of healthcare costs facing middle-income and poor Americans is driven by multiple interrelated factors and will require a comprehensive solution,” according to the report.

 

The Cost of Employer Insurance Is a Growing Burden for Middle-Income Families

https://www.commonwealthfund.org/publications/issue-briefs/2018/dec/cost-employer-insurance-growing-burden-middle-income-families

middle-income family shops for groceries

Recent national surveys show health care costs are a top concern in U.S. households.1 While the Affordable Care Act’s marketplaces receive a lot of media and political attention, the truth is that far more Americans get their coverage through employers. In 2017, more than half (56%) of people under age 65 — about 152 million people — had insurance through an employer, either their own or a family member’s.2 In contrast, only 9 percent had a plan purchased on the individual market, including the marketplaces.

In this brief, we use the latest data from the federal Medical Expenditure Panel Survey–Insurance Component (MEPS–IC) to examine trends in employer premiums at the state level to see how much workers and their families are paying for their employer coverage in terms of premium contributions and deductibles. We examine the size of these costs relative to income for those at the midrange of income distribution. The MEPS–IC is the most comprehensive national survey of U.S. employer health plans. It surveyed more than 40,000 business establishments in 2017, with an overall response rate of 65.8 percent.

Highlights

  • After climbing modestly between 2011 and 2016, average premiums for employer health plans rose sharply in 2017. Annual single-person premiums climbed above $7,000 in eight states; family premiums were $20,000 or higher in seven states and D.C.
  • Rising overall employer premiums increased the amount that workers and their families contribute. Average annual premium contributions for single-person plans ranged from $675 in Hawaii to $1,747 in Massachusetts; family plans ranged from $3,646 in Michigan to $6,533 in Delaware.
  • Average employee premium contributions across single and family plans amounted to 6.9 percent of U.S. median income in 2017, up from 5.1 percent in 2008. In 11 states, premium contributions were 8 percent of median income or more, with a high of 10.2 percent in Louisiana.
  • The average annual deductible for single-person policies rose to $1,808 in 2017, ranging from a low of $863 in Hawaii to a high of about $2,300 in Maine and New Hampshire. Average deductibles across single and family plans amounted to 4.8 percent of median income in 2017, up from 2.7 percent in 2008. In three states (Florida, Mississippi, and Tennessee), average deductibles comprised more than 6 percent of median income.
  • Combined, average employee premium contributions and potential out-of-pocket spending to meet deductibles across single and family policies rose to $7,240 in 2017 and was $8,000 or more in eight states. Nationally, this potential spending amounted to 11.7 percent of median income in 2017, up from 7.8 percent a decade earlier. In Louisiana and Mississippi, these combined costs rose to 15 percent or more of median income.

 

 

 

 

Americans are still struggling with drug costs

https://www.axios.com/americans-struggling-drug-costs-goodrx-0b487b1b-a362-4776-8f43-8b118651d606.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Image result for Americans are still struggling with drug costs

 

More than 2 out of 5 Americans say paying for their prescription drugs in the past year was difficult, even though most have health insurance, according to a new survey from GoodRx, a consumer site that compares drug costs.

Why it matters: Drug prices are a top public concern because many people take medications every day and see the toll on their wallets. The survey shows people aren’t really feeling any relief amid the political promises to address the issue.

By the numbers: The GoodRx survey, which mirrors other public tracking polls, found:

  • A third of people have skipped filling a prescription in the last year due to the cost. Rising coinsurance rates and deductibles often are the culprits.
  • Almost 20% of Americans said they’ve had to use money from their savings to pay for their drugs. (Separately, another 12% said they didn’t have any savings to draw from.)
  • The survey got responses from more than 1,000 people, 70% of whom take at least one medication.

 

 

Doctors Are Fed Up With Being Turned Into Debt Collectors

https://www.bloomberg.com/news/articles/2018-11-15/doctors-are-fed-up-with-being-turned-into-debt-collectors

Highlighting a key implication of the rise in high-deductible health plans, both on the ACA exchanges and in employer-sponsored insurance, the article describes a question now commonly faced by doctors and hospitals—how best to collect their patients’ portion of the fees they charge? As one Texas doctor tells Bloomberg, reflecting the experience of the Maldonados from the other side of the equation, “If [patients] have to decide if they’re going to pay their rent or the rest of our bill, they’re definitely paying their rent.” He reports that the number of people dodging his calls to discuss payment has increased “tremendously” since the passage of the ACA. Another Texas doctor reports that his small practice had to add an additional full-time staff member just to collect money owed by patients, adding further overhead to his practice’s costs and making it more likely that he, like many other doctors, will eventually seek shelter by being employed by a larger delivery organization. That trend, as has been repeatedly shown, further increases the cost of care, exacerbating the increase in insurance costs for families like the Maldonados. This Gordian knot of increasing costs, rising deductibles, and growing premiums has left us with a healthcare system that’s forcing difficult decisions at every turn, for patients and providers.

Physicians, hospitals and medical labs are grappling with the rise in high-deductible insurance.

Doctors, hospitals and medical labs used to be concerned about patients who didn’t have insurance not paying their bills. Now they’re scrambling to get paid by the ones who do have insurance.

For more than a decade, insurers and employers have been shifting the cost of care onto their workers and customers, tamping down premiums by raising patients’ out-of-pocket costs. Last year, almost half of privately insured Americans under age 65 had annual deductibles ranging from $1,300 to as high as $6,550, government data show.

Now, instead of getting paid by insurance companies on a predictable schedule, health-care providers have to engage in an awkward dance. One moment they’re removing a pre-cancerous skin mole. The next, they’re haranguing patients to pay what’s become a growing portion of the total medical bill.

“It’s harder to collect from the patient than it is from the insurance,” said Amy Derick, a doctor who heads a dermatology practice outside Chicago. “If the plans change to a higher deductible, it’s harder to get the patients to pay.”

Independent physicians cited reimbursement pressures as their biggest concern for staying in business, according to a report by Accenture Plc in 2015.

“If they have to decide if they’re going to pay their rent or the rest of our bill, they’re definitely paying their rent,” said Gerald “Ray” Callas, president of the Texas Society of Anesthesiologists, whose Beaumont, Texas, practice treats about 40,000 people annually. “We try to work with the patient, but on the other hand, we can’t do it for free because we still maintain a small business.”

Accenture

In 2016, Callas introduced payment options that allow patients with expensive plans to pay a portion of the bill upfront or on a monthly basis over several years. Even so, Callas said the number of people avoiding his calls after surgery has increased “tremendously” each year since the Affordable Care Act passed in 2010.

Derick instituted a “time-out” option a few years back that gives patients the billing codes before a procedure, allowing them to call their insurance companies for estimates. Even with the program, collection rates are slower, especially at the beginning of the year when insurance plan deductibles reset.

Even large medical companies with national operations are facing the problem. Quest Diagnostics Inc., the lab-testing giant, said 20 percent of services billed to patients in the third quarter of this year went unpaid, costing the company about $80 million in lost revenue.

“We certainly have a high bad-debt rate for the uninsured,” Chief Financial Officer Mark Guinan said in a telephone interview. “But really the biggest driver is people with insurance. It’s their coinsurance and their high deductibles, and they don’t always pay their bills.”

Another testing company, Laboratory Corp. of America Holdings, reported its first year-over-year uptick in unpaid bills in the first quarter of 2016. At the time, Chief Executive Officer David King said high-deductible plans, higher copays and greater incidences of non-covered services led to more dollars being shifted to patients. LabCorp declined requests for comment.

Northwell Healthcare Inc., a network of more than 700 hospitals and outpatient facilities, lost $106.9 million to unpaid services in 2015. Others have reported the same: Acute-care and critical-access hospitals reported$55.9 billion in bad debt for 2015, according to data compiled by the American Hospital Directory Inc. 

“High-deductible plans have had a very big impact,” said Richard Miller, Northwell’s chief business strategy officer.

Kaiser Family Foundation, American Hospital Association

When it comes to reimbursement, a common denominator across the health-care industry is the archaic process through which bills are processed — a web of medical records, billing systems, health insurers and contractors.

High deductibles only add to the red tape. Providers don’t have real-time, fully accurate information on patient deductibles, which fluctuate based on how much has already been paid. That forces providers to constantly reach out to insurance companies for estimates.

Tarek Fakhouri, a Texas surgeon specializing in skin cancer, had to hire an additional staff member just to reason through bills with patients and their insurers, a big expense for an office of six or seven employees. About 10 percent of Fakhouri’s patients need payment plans, delay their skin-cancer surgeries until they’ve met their deductibles, or have to choose an alternative treatment.

According to a study earlier this year by the Journal of American Medical Association, primary-care physicians at academic health-care systems lose about 15 percent of their revenue to billing activities like calling insurance companies for estimates.

“It’s an unnecessary added cost to the health-care system to have to hire staff just to sit there on hold with insurance companies to find out what a patient’s deductible status is,” said Fakhouri.

Callas, Derick, and Fakhouri said they all know physicians who have left private practice altogether, some for the sole purpose of ending their dual roles as bill collectors. According to a study by the American Medical Association, less than half of doctors were self-employed as of 2016 — the lowest total ever. Many left their own practices in favor of hospitals and large physician groups with more resources.

To cope with the challenge, labs and hospitals are investing millions in programs designed to help patients understand what they owe at the point of care. Northwell has been implementing call centers and facilities where patients can ask questions about their bills.

“There’s a burden on both sides,” said Callas. “But health-care providers get caught in the middle.”

 

When Hospitals Merge to Save Money, Patients Often Pay More

Image result for hospital mergers

 

 

Pre-existing conditions: Does any GOP proposal match the ACA?

https://www.politifact.com/truth-o-meter/article/2018/oct/17/pre-existing-conditions-does-any-gop-proposal-matc/?fbclid=IwAR2QXSwiwRryxaHWJVgO3evTUtJPk6QcV1HkxkaI2qq3iPWqsrXqGA0qPeY

From a routine visit to a critical exam, the stethoscope remains one of the most common physician tools. (Alex Proimos, via Flickr Creative Commons)

In race after race, Democrats have been pummeling Republicans on the most popular piece of Obamacare, protections for pre-existing conditions. No matter how sick someone might be, today’s law says insurance companies must cover them.

Republican efforts to repeal and replace Obamacare have all aimed to retain the guarantee that past health would be no bar to new coverage.

Democrats aren’t buying it.

In campaign ads in NevadaIndianaFloridaNorth Dakota, and more, Democrats charged their opponents with either nixing guaranteed coverage outright or putting those with pre-existing conditions at risk. The claims might exaggerate, but they all have had a dose of truth.

Republican proposals are not as air tight as Obamacare.

We’ll walk you through why.

The current guarantee

In the old days, insurance companies had ways to avoid selling policies to people who were likely to cost more than insurers wanted to spend. They might deny them coverage outright, or exclude coverage for a known condition, or charge so much that insurance became unaffordable.

The Affordable Care Act boxes out the old insurance practices with a package of legal moves. First, it says point-blank that carriers “may not impose any preexisting condition exclusion.” It backs that up with another section that says they “may not establish rules for eligibility” based on health status, medical condition, claims experience or medical history.

Those two provisions apply to all plans. The third –– community rating –– targets insurance sold to individuals and small groups (about 7 percent of the total) and limits the factors that go into setting prices. In particular, while insurers can charge older people more, they can’t charge them more than three times what they charge a 21-year-old policy holder.

Wrapped around all that is a fourth measure that lists the essential health benefits that every plan, except grandfathered ones, must offer. A trip to the emergency room, surgery, maternity care and more all fall under this provision. This prevents insurers from discouraging people who might need expensive services by crafting plans that don’t offer them.

At rally after rally for Republicans, President Donald Trump has been telling voters “pre-existing conditions will always be taken care of by us.” At an event in Mississippi, he faulted Democrats, saying, they have no plan,” which ignores that Democrats already voted for the Obamacare guarantees.

At different times last year, Trump voiced support for Republican bills to replace Obamacare. The White House said the House’s American Health Care Act “protects the most vulnerable Americans, including those with pre-existing conditions.” A fact sheet cited $120 billion for states to keep plans affordable, along with other facets in the bill.

But the protections in the GOP plans are not as strong as Obamacare. One independent analysis found that the bill left over 6 million people exposed to much higher premiums for at least one year. We’ll get to the congressional action next, but as things stand, the latest official move by the administration has been to agree that the guarantees in the Affordable Care Act should go. It said that in a Texas lawsuit tied to the individual mandate.

The individual mandate is the evil twin of guaranteed coverage. If companies were forced to cover everyone, the government would force everyone (with some exceptions) to have insurance, in order to balance out the sick with the healthy. In the 2017 tax cut law, Congress zeroed out the penalty for not having coverage. A few months later, a group of 20 states looked at that change and sued to overturn the entire law.

In particular, they argued that with a toothless mandate, the judge should terminate protections for pre-existing conditions.

The U.S. Justice Department agreed, writing in its filing “the individual mandate is not severable from the ACA’s guaranteed-issue and community-rating requirements.”

So, if the mandate goes, so does guaranteed-issue.

The judge has yet to rule.

Latest Republican plan has holes

In August, a group of 10 Republican senators introduced a bill with a title designed to neutralize criticism that Republicans don’t care about this issue. It’s called Ensuring Coverage for Patients with Pre-Existing Conditions. (A House Republican later introduced a similar bill.)

The legislation borrows words directly from the Affordable Care Act, saying insurers “may not establish rules for eligibility” based on health status, medical condition, claims experience or medical history.

But there’s an out.

The bill adds an option for companies to deny certain coverage if “it will not have the capacity to deliver services adequately.”

To Allison Hoffman, a law professor at the University of Pennsylvania, that’s a big loophole.

“Insurers could exclude someone’s preexisting conditions from coverage, even if they offered her a policy,” Hoffman said. “That fact alone sinks any claims that this law offers pre-existing condition protection.”

The limit here is that insurers must apply such a rule across the board to every employer and individual plan. They couldn’t cherry pick.

But the bill also gives companies broad leeway in setting premiums. While they can’t set rates based on health status, there’s no limit on how much premiums could vary based on other factors.

The Affordable Care Act had an outside limit of 3 to 1 based on age. That’s not in this bill. And Hoffman told us the flexibility doesn’t stop there.

“They could charge people in less healthy communities or occupations way more than others,” Hoffman said. “Just guaranteeing that everyone can get a policy has no meaning if the premiums are unaffordable for people more likely to need medical care.”

Rodney Whitlock, a health policy expert who worked for Republicans in Congress, told us those criticisms are valid.

“Insurers will use the rules available to them to take in more in premiums than they pay out in claims,” Whitlock said. “If you see a loophole and think insurers will use it, that’s probably true.”

Past Republican plans also had holes

Whitlock said more broadly that Republicans have struggled at every point to say they are providing the same level of protection as in the Affordable Care Act.

“And they are not,” Whitlock said. “It is 100 percent true that Republicans are not meeting the Affordable Care Act standard. And they are not trying to.”

The House American Health Care Act and the Senate Better Care Reconciliation Act allowed premiums to vary five fold, compared to the three fold limit in the Affordable Care Act. Both bills, and then later the Graham-Cassidy bill, included waivers or block grants that offered states wide latitude over rates.

Graham-Cassidy also gave states leeway to redefine the core benefits that every plan had to provide. Health law professor Wendy Netter Epstein at DePaul University said that could play out badly.

“It means that insurers could sell very bare-bones plans with low premiums that will be attractive to healthy people, and then the plans that provide the coverage that sicker people need will become very expensive,” Epstein said.

Insurance is always about sharing risk. Whether through premiums or taxes, healthy people cover the costs of taking care of sick people. Right now, Whitlock said, the political process is doing a poor job of resolving how that applies to the people most likely to need care.

“The Affordable Care Act set up a system where people without pre-existing conditions pay more to protect people who have them,” Whitlock said. “Somewhere between the Affordable Care Act standard and no protections at all is a legitimate debate about the right tradeoff. We are not engaged in that debate.”

 

 

IN SEARCH OF INSURANCE SAVINGS, CONSUMERS CAN GET UNWITTINGLY WEDGED INTO NARROW-NETWORK PLANS

https://www.healthleadersmedia.com/search-insurance-savings-consumers-can-get-unwittingly-wedged-narrow-network-plans?utm_source=silverpop&utm_medium=email&utm_campaign=ENL_181101_LDR_BRIEFING%20(1)&spMailingID=14541829&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1520057837&spReportId=MTUyMDA1NzgzNwS2

Wedged Into Narrow-Network Plans

Despite federal rules requiring plans to keep up-to-date directories, consumers may lack access to clear information about which health plans have ‘narrow networks’ of providers or which hospitals and doctors are in or out of an insurer’s network.

As a breast cancer survivor, Donna Catanuchi said she knows she can’t go without health insurance. But her monthly premium of $855 was too high to afford.

“It was my biggest expense and killing me,” said Catanuchi, 58, of Mullica Hill, N.J.

A “navigator” who helps people find coverage through the Affordable Care Act found a solution. But it required Catanuchi, who works part time cleaning offices, to switch to a less comprehensive plan, change doctors, drive farther to her appointments and pay $110 a visit out-of-pocket — or about three times what she was paying for her follow-up cancer care.

She now pays $40 a month for coverage, after she qualified for a substantial government subsidy.

Catanuchi’s switch to a more affordable but restrictive plan reflects a broad trend in insurance plan design over the past few years. The cheaper plans offer far narrower networks of doctors and hospitals and less coverage of out-of-network care. But many consumers are overwhelmed or unaware of the trade-offs they entail, insurance commissioners and policy experts say.

With enrollment for ACA health plans beginning Nov. 1, they worry that consumers too often lack access to clear information about which health plans have “narrow networks” of medical providers or which hospitals and doctors are in or out of an insurer’s network, despite federal rules requiring plans to keep up-to-date directories.

“It’s very frustrating for consumers,” said Betsy Imholz, who represents the advocacy group Consumers Union at the National Association of Insurance Commissioners. “Health plan provider directories are often inaccurate, and doctors are dropping in and out all the time.”

These more restrictive plans expose people to larger out-of-pocket costs, less access to out-of-network specialists and hospitals, and “surprise” medical bills from unforeseen out-of-network care.

More than 14 million people buy health insurance on the individual market — largely through the ACA exchanges, and they will be shopping anew this coming month.

TREND APPEARS TO BE SLOWING

For 2018, 73 percent of plans offered through the exchanges were either health maintenance organizations (HMOs) or exclusive provider organizations (EPOs), up from 54 percent in 2015.

Both have more restrictive networks and offer less out-of-network coverage compared with preferred provider organizations (PPOs), which represented 21 percent of health plans offered through the ACA exchanges in 2018, according to Avalere, a health research firm in Washington, D.C.

PPOs typically provide easier access to out-of-network specialists and facilities, and partial — sometimes even generous — payment for such services.

Measured another way, the number of ACA plans offering any out-of-network coverage declined to 29 percent in 2018 from 58 percent in 2015, according to a recent analysis by the Robert Wood Johnson Foundation.

For example, in California, HMO and EPO enrollment through Covered California, the state’s exchange, grew from 46 percent in 2016 to 70 percent in 2018, officials there said. Over the same period, PPO enrollment declined from 54 percent to 30 percent.

In contrast, PPOs have long been and remain the dominant type of health plan offered by employers nationwide. Forty-nine percent of the 152 million people and their dependents who were covered through work in 2018 were enrolled in a PPO-type plan. Only 16 percent were in HMOs, according to the Kaiser Family Foundation’s annual survey of employment-based health insurance.

The good news for people buying health insurance on their own is that the trend toward narrow networks appears to be slowing.

“When premiums shot up over the past few years, insurers shifted to more restrictive plans with smaller provider networks to try and lower costs and premiums,” said Chris Sloan, a director at Avalere. “With premium increases slowing, at least for now, that could stabilize.”

Some research supports this prediction. Daniel Polsky, a health economist at the University of Pennsylvania, found that the number of ACA plans nationwide with narrow physician networks declined from 25 percent in 2016 to 21 percent in 2017.

Polsky is completing an analysis of 2018 plans and expects the percent of narrow network plans to remain “relatively constant” for this year and into 2019.

“Fewer insurers are exiting the marketplace, and there’s less churn in the plans being offered,” said Polsky. “That’s good news for consumers.”

Insurers may still be contracting with fewer hospitals, however, to constrain costs in that expensive arena of care, according to a report by the consulting firm McKinsey & Co. It found that 53 percent of plans had narrow hospital networks in 2017, up from 48 percent in 2014.

“Narrow networks are a trade-off,” said Paul Ginsburg, a health care economist at the Brookings Institution. “They can be successful when done well. At a time when we need to find ways to control rising health care costs, narrow networks are one legitimate strategy.”

Ginsburg also notes that there’s no evidence to date that the quality of care is any less in narrow versus broader networks, or that people are being denied access to needed care.

Mike Kreidler, Washington state’s insurance commissioner, said ACA insurers in that state “are figuring out they can’t get away with provider networks that are inadequate to meet people’s needs.”

“People have voted with their feet, moving to more affordable choices like HMOs but they won’t tolerate draconian restrictions,” Kreidler said.

The state is stepping in, too. In December 2017, Kreidler fined one insurer — Coordinated Care — $1.5 million for failing to maintain an adequate network of doctors. The state suspended $1 million of the fine if the insurer had no further violations. In March 2018, the plan was docked another $100,000 for similar gaps, especially a paucity of specialists in immunology, dermatology and rheumatology. The $900,000 in potential fines continues to hang over the company’s head.

Centene Corp, which owns Coordinated Care, has pledged to improve its network.

Pennsylvania Insurance Commissioner Jessica Altman said she expects residents buying insurance in the individual marketplace for 2019 to have a wider choice of providers in their networks.

“We think and hope insurers are gradually building more stable networks of providers,” said Altman.

NEW STATE LAWS

Bad publicity and recent state laws are pushing insurers to modify their practices and shore up their networks.

About 20 states now have laws restricting surprise bills or balance billing, or which mandate mediation over disputed medical bills, especially those stemming from emergency care.

Even more have rules on maintaining accurate, up-to-date provider directories.

The problem is the laws vary widely in the degree to which they “truly protect consumers,” said Claire McAndrew, a health policy analyst at Families USA, a consumer advocacy group in Washington, D.C. “It’s a patchwork system with some strong consumer protections and a lot of weaker ones.”

“Some states don’t have the resources to enforce rules in this area,” said Justin Giovannelli, a researcher at the Center on Health Insurance Reforms at Georgetown University. “That takes us backward in assuring consumers get coverage that meets their needs.”