Research Roundup - December 2019-January 2020

California

Loopholes Limit California Law Protecting Patients from Lofty Air Ambulance Bills
By Michelle Andrews | Kaiser Health News | Jan. 14, 2020


A newly implemented California law limits what consumers owe if they’re transported by an out-of-network air ambulance to what they would pay an in-network provider, reports Kaiser Health News. However, the law won’t protect approximately 6 million consumers whose health plans aren’t regulated by the state, such as self-funded employer-sponsored plans regulated by the federal government. Additionally, federal law prohibits states from regulating the “rates, routes or services” of air carriers, including air ambulances. It is unclear whether California’s law, which doesn’t spell out a payment rate for a health plan, would be preempted by federal law if challenged in court.

California Could Become the First State to Sell Its Own Generic Drugs
Advisory Board | Jan. 13, 2020


California’s governor unveiled a proposal to make California the first state to sell its own generic prescription drugs to increase competition in the state's generic drug market, according to Advisory Board. The governor also proposed establishing a single market for drug pricing in California, among other strategies to lower costs. Health policy experts believe that California is ripe for testing these concepts at a government level, but California's Legislature will have to approve the proposals before the state can implement them.

Colorado

Expensive Healthcare? Blame the Hospitals, State Report Says
By John Daley | CPR News | Jan. 23, 2020


High prices at hospitals are driving up the cost of healthcare more dramatically in Colorado than elsewhere in the U.S., according to CPR News. Hospital profits increased by more than 280 percent between 2009 and 2018, a state report found, and profit per patient rose to more than $1,500 a patient. The report by the Department of Health Care Policy and Financing also found that uncompensated care in Colorado is at a historic low, and hospital spending on charity care and bad debt has dropped more than $385 million a year since Medicaid expansion in the state.

Connecticut

Governor Signs Executive Orders Reducing Healthcare Costs for Connecticut Residents
By Robert Wood Johnson State Network | Jan. 22, 2020


Connecticut’s Governor signed two executive orders to directly address healthcare costs, primary care spending and quality of care for individuals, businesses and the state government, according to Robert Wood Johnson’s State Network. The orders direct the Office of Health Strategy to establish statewide healthcare cost growth and quality benchmarks in addition to a primary care spending target, and direct the Department of Social Services to improve public transparency of Medicaid costs and quality.

 

Racial Disparities Persist in CT Healthcare, Two Groups Find
By Jenna Carlesso | The CT Mirror | Jan. 15, 2020

While Connecticut has led national efforts in public insurance reform, research shows that significant health disparities persist between the state’s residents of color and white residents, reports the CT Mirror. Specifically, Black and Latino residents are more likely than white residents to be uninsured, to die before reaching adulthood and to report being in poor health. Latino adults, in particular, were more than twice as likely as white residents to say they went without seeing a doctor in the past 12 months because of the cost.

Florida

Increases in Public Health Spending Lowered Maternal Mortality Rates for Black Mothers in Florida
By Patick Bernet, Gulcin Gumus and Sharmila Viswasrao | The Milbank Quarterly | Jan. 14, 2020


Researchers found that spending on public health significantly reduced the maternal mortality rate (MMR) among black mothers and narrowed black-white outcome disparities in Florida, according to Milbank Quarterly. U.S. MMRs reveal considerable racial disparities and exceed those of other developed countries. Moreover, while worldwide MMRs have dropped sharply since the 1990s, the U.S. MMR appears to be rising.

Idaho 

Idaho Develops a Medicaid Value-Based Payment Model for its FQHCs, Based on Cost and Quality
By Neva Kaye | NASHP | Dec. 9, 2019


Starting in early 2020, Idaho will launch a new value-based payment model that will compensate federally qualified health centers (FQHCs) and other providers based on how much they improve the cost and quality of care delivered to Medicaid enrollees, reports NASHP. Idaho Medicaid plans to sign contracts to implement the model in January, with implementation beginning July 1, 2020. Both FQHCs and other types of providers have expressed interest in participating in this value-based model.

Illinois

IL Governor Signs Law Capping Insulin Cost at $100 Per Month
By Melissa Espana | WGN9 | Jan. 24, 2020


A new Illinois law will cap out-of-pocket insulin costs at $100 for a 30-day supply, according to WGN9. The new legislation (SB 667) is expected to impact about 1.3 million people in the state who have diabetes and is considered an important step in lowering out-of-pocket costs for Illinois families.

Kansas

Kansas Sees Shortage of Psychiatrists and Other Mental Health Providers
By Nomin Ujiyediin | KCUR | Dec. 27, 2019


Mental health centers in Kansas are forced to rely on out-of-state doctors willing to work remotely due to a shortage of mental health providers in certain areas of the state, according to KCUR. Like many states, Kansas is seeing an increase in patients seeking mental health treatment, but there aren’t enough doctors, nurses and therapists to treat them. Providers say the problem is worse in the state’s least-populated rural areas, where clinic jobs can stay open for years at a time. Only nine of 105 Kansas counties have enough psychiatrists and they are mostly in urban areas.

Maryland

Maryland's All-Payer Model Saves Medicare Nearly $1 Billion
By David Raths | Healthcare Innovation | Dec. 1, 2019


Maryland Medicare beneficiaries had 2.8 percent slower growth in total expenditures, relative to a comparison group, largely driven by a 4.1 percent slower growth in total hospital expenditures, reports Healthcare Innovation. The report, prepared by RTI International, examines the first five years of Maryland’s All-Payer annual, global hospital budget Model and finds that slower growth in emergency department expenditures (30.6 percent) and other hospital expenditures (17.2 percent) drove total Medicare hospital savings in Maryland. It's important to note that the model reduced both total expenditures and total hospital expenditures, indicating that costs were not shifted to other parts of the healthcare system outside of the global budgets.

Massachusetts

Rising Inpatient Acuity May Not Mean Patients Are Sicker, Mass. Commission Finds
By Alex Kacik | Modern Healthcare | Jan. 14, 2020


While higher inpatient spending in Massachusetts has been linked to rising prices and patient acuity levels, a recent report from the Massachusetts Health Policy Commission reinforces previous findings that state residents may not actually be getting sicker, according to Modern Healthcare. Indeed, the report shows that while inpatient acuity grew by over 10 percent from 2013 to 2018, the length of stay increased only 1.5 percent. The two largest health systems in the state and the state’s Health and Hospital Association stated that new or improved EHRs have increased the ability to document diagnostic information and are a major factor in rising acuity levels and risk scores.

Mississippi

Mississippi Workers are Hit Hardest by Rising Health Insurance Costs, Study Finds
By Luke Ramseth | Mississippi Clarion Ledger | Dec. 4, 2019


Residents of Mississippi spent nearly 17 percent of their annual wages on health insurance in 2018—the highest in the nation, according to a report from the Commonwealth Fund. Spending on premiums and deductibles outpaced wage growth in every state, with the average spending for a single person’s coverage reaching $749, states the Clarion Ledger. Mississippi’s median family income is among the lowest in the country and the percent of income residents contribute to insurance costs grew by nearly 6 percentage points since 2008. Moreover, Mississippians pay a larger share of the premium for their employer-sponsored coverage.

Nevada

Nevada Governor Appoints 11 Members and Executive Director to Patient Protection Commission
By Ryan McInerney | Office of the Governor | Dec. 19, 2019


The Nevada Governor announced the appointment of 11 members and an executive director to the Patient Protection Commission (PPC), according to the Governor’s office. The PPC, which was signed into law this past legislative session, will take a comprehensive look at the state of healthcare in Nevada and identify areas for improvement to ensure every Nevadan has access to affordable and quality healthcare.

Oregon 


Addressing Social Determinants of Health through Medicaid: Lessons from Oregon
By Jonah Kushner and K. John McConnell | Journal of Health Politics, Policy and Law | Dec. 1, 2019

As part of its 2012 Medicaid waiver, Oregon created 16 coordinated care organizations (CCOs) to manage care for Medicaid recipients with the ability to use “flexible services” to reduce the need for medical services--defined as low-cost, health-related services not covered by the state’s Medicaid program. A recent study in the Journal of Health Politics, Policy and Law looked at the use of these services and the challenges providers faced. A key finding was the need to provide managed care organizations (MCOs), such as CCOs, with detailed definitions and guidance up-front on health-related services they are expected to coordinate and pay for. While flexibility to pay for a variety of services may help MCOs respond to their patients’ unique health-related needs, many CCO informants described clarification and certainty provided by new rules as helpful. 

Rhode Island 

Big Data, Small State, R.I Database Offers the Potential for Efficient, Improved Healthcare
By Brian E. Clark | Brown University | Dec. 18, 2019

A partnership between Brown University, the Rhode Island Department of Health and the federally funded Advance Clinical and Translational Research (Advance-CTR) now have access to the state’s all-payer claims database (APCD).. The primary goals of the APCD partnership is to use big data to benefit residents of Rhode Island, and the nation, by figuring out how to minimize waste, improve healthcare and train the next generation of healthcare scholars to be proficient in a data-driven world — all while properly safeguarding patients’ personal information.

Texas

What You Need to Know About Texas' New Surprise Medical Billing Law

By Edgar Walters | The Texas Tribune | Jan. 2, 2020

A Texas law that aims to protect patients from surprise medical bills has taken effect, according to The Texas Tribune. The legislation aims to remove patients from billing disputes between health insurance plans and healthcare providers. The protections apply to Texans with state-regulated health plans, which includes most state employees and public school teachers, people who purchase insurance through the ACA marketplace and some people who receive health insurance through their private employers. The new law bans balance billing for emergency care. In nonemergency situations, there is an exception that allows providers to charge balance bills to patients who intentionally seek out-of-network providers.  

Washington 


Transforming Systems to Improve Health Upstream: lessons from Washington's Accountable Communities of Health
By Amy Clary | NASHP | Jan. 17, 2020

Washington State launched a collaborative regional Accountable Communities of Health (ACH) model in 2015 to improve the health of communities across the state. These ACHs have evolved into independent organizations that are integral to the state’s health system transformation efforts. A 2019 evaluation by the Center for Community Health and Evaluation found this ACH model has largely succeeded in building robust regional coalitions to improve the health of their communities. This blog by NASHP highlights the ACHs’ diverse approaches to improving health.  

Washington Finished Five-Year Journey to Integrate Physical and Behavioral Health for Medicaid Clients
By Washington State Health Care Authority | Dec. 26, 2019

The Washington Health Care Authority (HCA) has finished a multi-year effort to integrate physical health, mental health and substance use disorder treatment services for nearly two million Apple Health (Washington Medicaid) recipients, according to a press release. Under the transformed system, managed care organizations are responsible for physical and behavioral health services for the Apple Health recipients they serve. Additionally, behavioral health administrative services organizations deliver crisis services that are available to all, and manage regional functions, such as employing an ombudsman and managing a community behavioral health advisory board. This effort is part of Washington’s value-based purchasing roadmap, in which HCA aims to shift 90 percent of state-financed healthcare to value-based payment by 2021.

Wisconsin

If More Wisconsin Doctors Provided Better Care, Key Medical Procedures Would cost 30 Percent Less
By Guy Boulton | Milwaukee Journal Sentinel | Dec. 5, 2019

In 2018, Texas had about 54 primary care physicians per 100,000 people—one of the lowest ratios in the country, far below the national ratio of 76 per 100,000. More than a quarter of Texans live in an underserved county, according to the Texas Observer. As a result, Texans often have to travel for hours to get care, which ultimately leads to poorer outcomes and higher mortality. 
 
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Recent Reports

January 2020 Health Sector Economic Indicators Briefs
By Altarum | January 2020

Healthcare price growth has accelerated, with drug prices spiking to 3 percent annual rise, according to analysis from Altarum. Moreover, in November 2019, year-over-year national health spending growth increased for the fourth consecutive month, from 4.2 percent in July to its current growth rate of 5.4 percent, the latter being the highest growth rate since March 2019.   
 

Culling Surprise Billing Would Save $40B Annually, Health Affairs Study Finds
By Shannon Muchmore | Healthcare Dive | Dec. 16, 2019

If specialties notorious for surprise billing were not allowed to bill out-of-network, physician payments for privately insured patients would drop 13.4 percent and total healthcare spending for people with employer-sponsored insurance would fall by 3.4 percent, or about $40 billion annually, according to research published in Health Affairs, reports Healthcare Dive. The study, which used 2015 claims data from a large, multi-state commercial insurer, found that claims involving pathologists were most likely to involve an out-of-network bill (12.3%), followed by anesthesiology (11.8%), assistant surgeons (11.3%) and radiologists (5.6%). The research also found that out-of-network billing was most common at for-profit hospitals and in areas with highly concentrated provider and payer markets.
 

Surprise Bills Vary by Diagnosis and Type of Admission
By Karen Pollitz, et al. | Peterson Kaiser Family Foundation Health System Tracker | Dec. 9, 2019

Compared to all admissions, admissions for surgery are more likely to lead to an out-of-network charge (21 percent), according to new data analyzing insurance claims from large employer plans from the Kaiser Family Foundation. Additionally, the incidence of out-of-network charges was 50 percent higher for heart attacks compared to the incidence rate of all diagnoses for both emergency services (27% vs. 18%) and for inpatient admission at in-network facilities (23% vs. 16%), respectively. Authors note that the higher likelihood of surprise out-of-network medical bills increases a patient’s financial exposure and some health conditions (like giving birth) allow more time for patients to prepare and presumably plan to us an in-network provider (unlike heart attacks and other urgent medical conditions).
 

Hospital Mergers Don't Improve Readmissions, Mortality or Experience, Study Finds
By Maria Castellucci | Modern Healthcare | Jan. 2, 2020

Hospitals acquired by health systems experienced a modest decline in patient experience scores, while performance on 30-day readmissions and mortality rates stayed largely flat, according to a study published by researchers at Harvard University looking at all hospital acquisitions from 2009 to 2013. Other studies have shown that mergers and acquisitions raise prices and can hinder quality, but hospitals have been steadfast in their defense of the deals. The American Hospital Association took issue with the use of CMS’ patient experience survey to examine the quality of care—pointing to low completion rates, states Modern Healthcare.
 

Self-Insured Companies Do No Better on Cost Control
By Drew Altman | Axios | Jan. 27, 2020

Despite conventional wisdom that big, self-insured companies do a better job of controlling healthcare costs, studies show there is no meaningful difference between premiums in fully insured and self-insured firms, according to a new analysis from Kaiser Family Foundation. Though self-insured firms can cut out the middleman, have the ability to implement the newest payment reforms and contract directly with providers in their network, large fully insured firms tend to buy insurance from the same companies that administer self-insured plans.
 

Value-Based Reimbursements Hit 53 Percent in 2017, Reform Slows
By Kelsey Waddill | Health Payer Intelligence | Dec. 9, 2019

Although nearly half of commercial payers were involved in value-based reimbursement in 2017, the growth in payment reform is stagnating, reports Health Payer Intelligence. According to the Catalyst for Payment Reform Scorecard, the percentage of the patient population in value-based care rose from 2 percent to 24 percent between 2012 and 2016, payment reform decelerated between 2016 and 2017—with less than five percent growth. Experts assert that real payment reform should address prices—the major driver of rising healthcare costs. 
 

ACOs Have Saved Medicare $3.53B from 2013 to 2017, New Analysis Finds
By Rajiv Leventhal | HealthCare Innovation | Dec. 3, 2019

A new, independent evaluation has found that accountable care organizations (ACOs), Medicare’s dominant value-based care initiative serving nearly 11 million seniors, lowered spending by $3.53 billion from 2013 to 2017 and saved $755 million after paying providers shared savings, reports Healthcare Innovation. The research is the latest in a series of analyses that has demonstrated ACOs’ value to Medicare, particularly during a time when there’s been significant debate over the results these organizations have delivered to date.
 

Bundles Cut Spending on Join Replacements, But Not for Other Conditions
By Harris Meter | Modern Healthcare | Jan. 6, 2020

Medicare's voluntary bundled-payment program for hip and knee replacements reduced spending by 1.6 percent from 2013 to 2016 — less than previously estimated — with no overall change in quality, according to a study in Health Affairs. Another meta-analysis found that lower extremity joint replacement was the only type of clinical episode in the Medicare bundled-payment program that produced savings so far. Under the Bundled Payment for Care Improvement Advanced demonstration program, providers make money if they keep total costs below the target price, which the CMS has discounted by 3 percent and are at risk for up to 20 percent of costs that exceed the target price, states Modern Healthcare.
 

Cost-Sharing Payments for Out-of-Network Care in Commercially Insured Adults
By Wendy Yi Xu, et al. | American Journal of Managed Care | Dec. 12, 2019

Although balance billing has received attention from policymakers lately, there has been less attention to cost sharing for covered out-of-network (OON) care and the differences between in-network and OON care. A recent study in the American Journal of Managed Care looked at variations in out-of-network cost sharing at the state level and by care settings, and the pattern of OON care use and cost sharing associated with OON care over time. Results show that slowly decreasing rates of OON care over time occurred in different care settings and at different urgency levels, with cost-sharing amounts for OON care rising rapidly from 2012 through 2016 before slowing in 2017. While the amount enrollees spend on OON care grew in most states, there were substantial variations. State policies, such as closely monitoring plan network adequacies, would also help alleviate financial burdens. 
 

High-Deductible Plans Jeopardize Financial Health of Patients and Rural Hospitals
By Markian Hawryluk | Kaiser Health News | Jan. 10, 2020

In rural areas, where high-deductible plans are even more prevalent and incomes tend to be lower, patients often struggle to pay their deductibles, reports Kaiser Health News. The result is financial struggles for patients and a substantial rise in the amount of uncollectible “bad debt” written off by hospitals. According to the Healthcare Financial Management Association, hospital bad debt increased by $617 million to nearly $56.5 billion between 2015 and 2018. More hospitals, especially those in rural areas, are left teetering financially. At least 120 rural hospitals nationwide have shut down in the past decade.   


The Evidence for Value-Based Insurance Designs: The Full Potential of V-BID for Employers Is Yet to Be Realized
By Suzanne Delbanco and Julianne McGarry | American Journal of Managed Care | Dec. 31, 2019

Researchers assessed the impact of V-BID for public purchasers, commercial health plans and private employers and saw varying results. While evidence demonstrates that V-BID has the potential to reduce healthcare costs and use of low-value services among programs implemented by public purchasers, a National Bureau of Economic Research study found that the Oregon Public Employee Benefit Board’s program did not have a significant effect on total health expenditures or emergency department use, despite a small decrease in in-patient admissions. On the other hand, Pitney Bowes, a private employer, implemented a V-BID program that reduced the average amount spent on prescription drugs and emergency department visits for asthma and diabetes patients.
 

How Can U.S. Healthcare Save More than $600B? Switch to a Single-Payer System
By Joanne Finnegan | FierceHealthcare | Jan. 7, 2020

The U.S.’s current multi-payer system cost the country $812 billion in administrative costs in 2017—four times more than Canada, which has a single-payer system—mostly due to the increasing overhead of private insurers, according to a study in the Annals of Internal Medicine, as reported in FierceHealthcare. Researchers concluded that cutting U.S. administrative costs to Canadian levels by adopting single-payer health financing would have saved more than $600 billion. 
 

Healthcare Hotspotting - A Randomized, Controlled Trial
By Amy Finkelstein, et al. | The New England Journal of Medicine | Jan. 9, 2020

A study assessing the Camden Coalition of Healthcare Providers’ care-transition program found that readmission rates were not lower among patients randomly assigned to the Coalition’s program than among those who received usual care. The Coalition’s Camden Core Model uses real-time data on hospital admissions to identify patients who are “superutilizers,” or patients with very high use of healthcare services,” an approach referred to as “hotspotting,” and then engages them using a face-to-face care model to connect them with appropriate medical care. Prior to this study, the only evidence of the program’s effectiveness was an analysis of the healthcare spending of 36 patients before and after the intervention, instead of comparison to a control group. The authors stipulated that regression to the mean may have been responsible for earlier results showing large declines in readmissions.
 

Using Applied Machine Learning to Predict the Use of Healthcare Based on Socioeconomic Determinants of Care
By Soy Chen, et al. | American Journal of Managed Care | Jan. 15, 2020

A decision tree-based machine learning approach was able to predict inpatient and emergency department use with a high degree of discrimination using only purchasable and publicly available data on social determinants of health, according to a study in the American Journal of Managed Care. Using more than 130,000 patients across three health systems in the U.S., researchers used only socioeconomic features – age group, gender, and race – in the prediction of a patient’s risk of admission. This study indicated that it’s possible to risk-stratify patients’ risk of utilization without interacting with the patient and that this approach could positively affect health systems by creating individualized interventions to tackle detrimental social determinants of health.

Visit the Hub website for more on surprise medical bills, ACOs, value-based insurance design, high-deductible health plans, administrative spending, single-payer and more!


Commentary/News

Race and Medicine: The Harm That Comes from Mistrust
By Austin Frakt | The New York Times | Jan. 13, 2020

People of color (POC) receive less care—and often worse care—than White Americans, according to a new piece from the New York Times. As a result of systematic disparities (e.g., communication barriers and racial stereotyping), POC have poorer health outcomes. Part of the problem may be distrust caused by harmful studies like the Tuskegee experiments, which most likely led to the one-third Black-White gap in male life expectancy in the immediate aftermath of the study. The author cites other examples of harm that have caused mistrust among POC including forced sterilizations and less attention paid to sickle cell disease. Reinforcing the fact of racial bias in healthcare, a recent study found that care for Black patients is better when they see Black doctors. Moreover, a systematic review found that racially matched pairs of patients and doctors achieved better communication.
 

New Vertical Merger Guidelines Disappoint Antitrust Experts
By Harris Meyer | Modern Healthcare | Jan. 21, 2020

Much to the dismay of antitrust experts, new proposed vertical merger guidelines from the federal government give little detail on how the government will analyze deals between organizations across the delivery system, such as hospitals and physician groups, according to Modern Healthcare. Vertical mergers create some specific competitive risks including preventing rivals from accessing products from the downstream merger partner, sharing sensitive business information about competitors and enabling coordinated interaction that hobbles rival firms. The federal government has rarely challenged vertical mergers in any industry, in contrast to its more aggressive policy toward horizontal mergers between firms competing head to head.
 

Envisioning a Better U.S. Healthcare System for All: A Call to Action by the American College of Physicians
By Robert Doherty, et al. | Annals of Internal Medicine | Jan. 21, 2020

In Envisioning a Better Health Care System for All: Coverage and Cost of Care, the American College of Physicians (ACP) recommends transitioning to a system of universal coverage through either a single-payer system, or a public choice to be offered alongside regulated private insurance. The ACP proposes that costs be controlled by lowering excessive prices, increasing adoption of global budgets and all-payer rate setting, prioritizing spending and resources, increasing investment in primary care, reducing administrative costs, promoting high-value care, and incorporating comparative effectiveness and cost into clinical guidelines and coverage decisions.
 

Pharma's Take on the Pelosi Drug-Pricing Bill: Fair Warning or Fearmongering?
By Shefali Luthra| PolitiFact | Dec. 5, 2019

A bill that would allow Medicare to negotiate prices for a limited number of drugs, cap what seniors pay out-of-pocket at $2,000 and force companies that have raised prices beyond inflation since 2016 to either reverse the price or rebate the amount of the increase to the federal government has been criticized by the pharmaceutical industry for its potential to harm innovation. However, the Congressional Budget Office’s preliminary estimates project that similar legislation could result in 5 percent fewer drugs coming to market. Moreover, the riskiest portion of drug development is taken on by government-funded labs. In partnership with Kaiser Health News, PolitiFact gives PhRMA’s statement a “mostly false” rating.
 

Hospitals Sue HHS, Warning Price Transparency Rule Would Chill Competition, Crash Computers
By Samantha Liss | Healthcare Dive | Dec. 4, 2019

Hospital groups filed a lawsuit against HHS over a final rule that would force hospitals to reveal the secret rates they negotiate with insurers for services, reports Healthcare Dive. The lawsuit, filed by the American Hospital Association, along with other industry groups and health systems, said the administration's push on prices exceeds the government's authority and violates the First Amendment because it compels hospitals to reveal confidential and proprietary information. An HHS spokeswoman told Healthcare Dive the administration will continue to push price transparency to help patients make informed decisions. "Hospitals should be ashamed that they aren't willing to provide American patients the cost of a service before they purchase it," said Caitlin Oakley, spokeswoman for HHS. The plaintiffs argued that revealing negotiated rates will confuse patients, overwhelm hospitals and thwart competition and said it does nothing to help people understand their actual out-of-pocket costs and what they will owe a provider. 
 

Healthy Investments: Leveraging Health Plan Capital for Affordable Housing and Community Development
By Renee Markus Hodin and Nancy Turnbull | Community Catalyst, Center for Consumer Engagement in Health Innovation and the Kresge Foundation | Dec. 17, 2019

A new issue brief highlights health plan resources that can be invested in increasing the availability of safe and affordable housing and community development, given growing support for addressing non-medical drivers of health. The authors note that health plans have enough capital to make these investments—the five largest health insurers in the country were highly profitable in 2018 and the first three quarters of 2019, and together total nearly $150 billion in net worth. The brief goes on to describe investment vehicles that involve direct ownership of housing, indirect ownership through a variety of investment vehicles, and direct contributions.

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