Republican states bolstered their health insurance rate review programs using incentives from the Affordable Care Act

Brent D. Fulton, Ann Hollingshead, Pinar Karaca-Mandic, Richard M. Scheffler

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


The Affordable Care Act (ACA) included financial and regulatory incentives and goals for states to bolster their health insurance rate review programs, increase their anticipated loss ratio requirements, expand Medicaid, and establish statebased exchanges. We grouped states by political party control and compared their reactions across these policy goals. To identify changes in states' rate review programs and anticipated loss ratio requirements in the individual and small group markets since the ACA's enactment, we conducted legal research and contacted each state's insurance regulator. We linked rate review program changes to the Centers for Medicare and Medicaid Services' (CMS) criteria for an effective rate review program. We found, of states that did not meet CMS's criteria when the ACA was enacted, most made changes to meet those criteria, including Republican-controlled states, which generally oppose the ACA. This finding is likely the result of the relatively low administrative burden associated with reviewing health insurance rates and the fact that doing so prevents federal intervention in rate review. However, Republican-controlled states were less likely than non-Republicancontrolled states to increase their anticipated loss ratio requirements to align with the federal retrospective medical loss ratio requirement, expand Medicaid, and establish state-based exchanges, because of their general opposition to the ACA. We conclude that federal incentives for states to strengthen their health insurance rate review programs were more effective than the incentives for states to adopt other insurance-related policy goals of the ACA.

Original languageEnglish (US)
JournalInquiry (United States)
StatePublished - 2015

Bibliographical note

Funding Information:
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors are thankful for funding provided by Robert Wood Johnson Foundation through its Changes in Health Care Financing and Organization Program (grant 69906). Pinar Karaca-Mandic also acknowledges funding from the National Institute on Aging (grant K01AG036740).


  • Affordable Care Act
  • Federalism
  • Health care reform
  • Health insurance rate review
  • Policy implementation
  • Politics

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