Most insurance marketplaces set up under the ACA, including the federally-run marketplace, accept insurers who clear a bare-bones threshold of participation regulations.
Covered California, the largest ACA marketplace or “exchange”(now serving around 1.2 million enrollees), is a rare exception. From the outset, it was set up as an “active purchaser,” meaning that it bargains directly with insurers to develop affordable products that are aimed at improving the health of their enrollees.
Unique among ACA exchanges, Covered California requires all insurers to offer a standard patient-centered benefit design for each level of coverage. This requirement encourages greater use of preventive care and discourages overuse of services. For instance, outpatient care in higher tiers is not subject to a deductible, and prescription drug costs are capped.
Health plans participating in Covered California must monitor rates of use of preventive services among enrollees, collect information about their health status, and participate in health disparity workgroups. They must also ensure that participating providers meet diabetes control measures.
These standards have teeth: Covered California has declined to accept insurers who fail to meet them. The marketplace also participates in Choosing Wisely, the consortium of medical organizations dedicated to reducing unnecessary care.
While ACA marketplaces face an uncertain future under the incoming administration, Covered California is the most likely to survive. Under any circumstances, it offers a model for what any insurance marketplace can do to promote health.
This study is based on dozens of interviews with employees of Covered California, including the executive director and medical directors, as well as personal participation in scores of planning meetings during the creation of the marketplace.
The author wrote the first academic study of the exchange and has consulted to numerous groups that work closely with it, including the California Association of Health Plans and health insurance brokers.
Shared decision making and patient-reported outcomes , Oversupply of providers (e.g. hospitals, physicians, etc) and technologies (e.g. imaging, , Organizational factors (such as structure and culture) that drive overuse
