Insurance Law Commons^™

The Coming Health Insurance Transition, Brendan S. Maher

Faculty Scholarship

For decades, the dominant form of private health insurance in the United States—by far—has been employment-based group health insurance. Somewhere in the range of 175 million employees and their families receive health care coverage through a system in which employers serve as financiers, procurers, administrators, and fiduciaries of the health insurance promise. An overwhelming percentage of those health insurance arrangements are governed by ERISA, with little room for state law.

That is going to change.

This Article explains—for the first time anywhere—why and how. Because of the tremendous and as-yet unrecognized power of an obscure-sounding funding arrangement called the Individual …

Avoiding Pandora’S Box: Why Federal Nondiscrimination Statutes Do Not Prohibit Health Insurance Coverage Exclusions Of Sex-Rejecting Procedures, Rachel N. Morrison

Catholic University Law Review

There is increasing litigation over whether employer-provided health insurance and state Medicaid plans can exclude coverage of procedures for “gender transitions.” Plaintiffs claim that gender-transition coverage exclusions violate the Equal Protection Clause of the Fourteenth Amendment and federal nondiscrimination statutes. While Fourteenth Amendment claims should be foreclosed by the Supreme Court’s holding in Geduldig v. Aiello, nondiscrimination claims require a separate analysis.

This article shows the proper analysis for whether coverage exclusions of transition procedures violate federal nondiscrimination statutes. Looking to the history of coverage exclusion claims, Part I traces sex and pregnancy discrimination claims challenging coverage exclusions of …

Unh Healthcare Vitals: Health Insurance Premiums Are Skyrocking For 2026-- Why?, Lucy Hodder

Law Faculty Scholarship

Health insurance premiums and out-of-pocket costs in New Hampshire are projected to rise sharply in 2026 due to expiring federal subsidies, escalating prescription drug prices, hospital consolidation, workforce shortages, and policy changes. Without intervention, affordability will worsen for individuals and employers, with significant impacts on coverage and access. The report outlines policy recommendations to help mitigate these challenges for Granite Staters.

Long-Term Care In The United States: History, Financing, And Directions For Reform, George A. (Sandy) Mackenzie

Upjohn Press

This book is a concise survey of the development of U.S. long-term care and its financing, with comparisons with other rich countries. It also includes a brief comparative account of the impact of the COVID-19 pandemic in the United States and several other countries. The study finds much that is amiss with American long-term care and proposes three sets of progressively more ambitious reforms.

The Reincorporation Of Prisoners Into The Body Politic: Eliminating The Medicaid Inmate Exclusion Policy, Mira K. Edmonds

Articles

Incarcerated people are excluded from Medicaid coverage due to a provision in the Social Security Act Amendments of 1965 known as the Medicaid Inmate Exclusion Policy (“MIEP”). This Article argues for the elimination of the MIEP as an anachronistic remnant of an earlier era prior to the massive growth of the U.S. incarcerated population and the expansion of Medicaid eligibility under the Patient Protection and Affordable Care Act of 2010. It explores three reasons for eliminating the MIEP. First, the inclusion of incarcerated populations in Medicaid coverage would signify the final erasure from the Medicaid regime of the istinction between …

Health Insurance And The Undocumented Immigrant, Anja Diercks

Honors Theses

The purpose of this thesis is to perform a comparative analysis on how seven different countries (USA, South Africa, Germany, England, Canada, France and Singapore) organize their healthcare system to cope with the issue of undocumented immigrants and whether or not these systems in place were “fair.” The thesis will also explore the possible ways the United States could change to be more inclusive and fairer in the world of healthcare and health insurance for the undocumented immigrant. A study on what fairness means both in ethical and economical terms is done to suggest a new basis of a fair …

Workplace Wellness Programs: Empirical Doubt, Legal Ambiguity, And Conceptual Confusion, Camila Strassle, Benjamin E. Berkman

William & Mary Law Review

Federal laws that protect workers from insurance discrimination and infringement of health privacy include exceptions for wellness programs that are “voluntary” and “reasonably designed” to improve health. Initially, these exceptions were intended to give employers the flexibility to create innovative wellness programs that would appeal to workers, increase productivity, and protect the workforce from preventable health conditions.

Yet a detailed look at the scientific literature reveals that wellness program efficacy is quite disputed, and even highly touted examples of program success have been shown to be unreliable. Meanwhile, the latest administrative regulations on wellness programs were vacated by a district …

Mhpaea & Marble Cake: Parity & The Forgotten Frame Of Federalism, Taleed El-Sabawi

Dickinson Law Review (2017-Present)

No abstract provided.

Executive Power And The Aca, Nicholas Bagley

Book Chapters

As with any law of its complexity and ambition, the Affordable Care Act (ACA) vests in the sitting president broad implementation discretion. The law is not a blank check: in many ways both large and small, the ACA shapes and constrains the exercise of executive power. But Congress has neither the institutional resources nor the attention span to micromanage the rollout of a massive health program. It has no choice but to delegate.

Naturally, both President Obama and President Trump have drawn on their authority to tailor the ACA to their policy preferences. Neither president, however, has been able to …

Seeking Insurance Parity During The Opioid Crisis, Valarie K. Blake

Scholarly Works

Too many privately insured face substantial barriers and delays to getting timely and affordable substance use disorder (SUD) care when they need it, sometimes with terrible and irreversible consequences. Historically, private insurers have been reluctant to cover such services and have been glad to leave this responsibility to public systems like Medicaid. Laws like the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Affordable Care Act (ACA) were meant to make private insurance more generous, but these laws are underenforced and too weak to fully address the challenges of the opioid epidemic. When patients and the …

Substance Use Disorder Insurance Benefits: A Survey Of State Benchmark Plans, Stacey A. Tovino

Faculty Articles

Professor Tovino presents the results of a survey of state benchmark health plan coverage of substance use disorder treatments and services, including treatments and services for opioid use disorder.

Reform At Risk — Mandating Participation In Alternative Payment Plans, Scott Levy, Nicholas Bagley, Rahul Rajkumar

Articles

In an ambitious effort to slow the growth of health care costs, the Affordable Care Act created the Center for Medicare and Medicaid Innovation (CMMI) and armed it with broad authority to test new approaches to reimbursement for health care (payment models) and delivery-system reforms. CMMI was meant to be the government’s innovation laboratory for health care: an entity with the independence to break with past practices and the power to experiment with bold new approaches. Over the past year, however, the Department of Health and Human Services (HHS) has quietly hobbled CMMI, imperiling its ability to generate meaningful data …

A Right To Care, Stacey A. Tovino

Faculty Articles

In this Article, Professor Stacey Tovino examines the right to care through a personal and historical lens, then attempts to fill a scholarly gap in legal literature surrounding the right to skilled care and rehabilitation for patients with group or commercial insurance. Professor Tovino first recounts the history of Medicare coverage for skilled care and rehabilitation, then she examines the limitations of group and commercial insurance, finally concluding by asserting a right to care.

Ideology Meets Reality: What Works And What Doesn't In Patient Exposure To Health Care Costs, Victor Laurion, Christopher Robertson

Faculty Scholarship

U.S. policymakers, scholars, and advocates have long displayed an ideological commitment to exposing insured patients to substantial out-of-pocket expenses. These commitments derive from both overt political ideologies, which favor individual responsibility and oppose redistribution of wealth and risks, as well as more-subtle ideological commitments of academic economists, which link observed patterns of consumption to value-claims about welfare. In this symposium contribution, we document those ideological commitments and juxtapose them with a review of the scientific evidence about the actual effects of patient cost-sharing. We find, as economic theory predicts, that patients exposed to healthcare costs consume less healthcare. However, a …

Key New Hampshire And Federal Statutes Regulating Health Care Delivery And Payment, Lucy Hodder

Law Faculty Scholarship

A summary of New Hampshire and federal regulations by subject matter, chart of New Hampshire state agency responsibilities, federal laws and regulation: An index

Erisa And Graham-Cassidy: A Disaster In Waiting For Employee Health Benefits And For Dependents Under 26 On Their Parents’ Plans, Leslie Francis

Utah Law Faculty Scholarship

Graham Cassidy § 105 would repeal the ACA “employer mandate”. Although its sponsors claim that the bill will give states a great deal of flexibility, it will do nothing to help states ensure that employers provide their employees with decent health insurance; quite the reverse. It will also give employers the freedom to ignore the popular ACA requirement that allows children up to age 26 to receive coverage through their parent’ plans, at least when their parents get health insurance from their employers. Here’s why.

Small Change, Big Consequences — Partial Medicaid Expansions Under The Aca, Adrianna Mcintyre, Allan M. Joseph, Nicholas Bagley

Articles

Though congressional efforts to repeal and replace the Affordable Care Act (ACA) seem to have stalled, the Trump administration retains broad executive authority to reshape the health care landscape. Perhaps the most consequential choices that the administration will make pertain to Medicaid, which today covers more than 1 in 5 Americans. Much has been made of proposals to introduce work requirements or cost sharing to the program. But another decision of arguably greater long-term significance has been overlooked: whether to allow “partial expansions” pursuant to a state Medicaid waiver. Arkansas has already submitted a waiver request for a partial expansion, …

Covering The Care: Cost Sharing Reductions In Nh, Jo Porter, Lucy C. Hodder

Law Faculty Scholarship

This brief uses national data to describe the NH population who received Cost Sharing Reductions for coverage on the NH Marketplace.

Covering The Care: A Focus On The Nh Marketplace, Jo Porter, Lucy C. Hodder

Law Faculty Scholarship

The second brief uses national and state data to describe the NH population enrolled in the health insurance plans through the NH Marketplace.

Dinner For Two: Employer Mandate, Meet Erisa; How Dave & Buster’S Response To The Affordable Care Act’S Employer Mandate May Open The Door For Employees To Seek Erisa Relief, Kendall Victoria Dacey

Pepperdine Law Review

When the Affordable Care Act (ACA) became law in late March, 2010, Dave & Buster’s (D&B) had a choice: it could either comply and offer its full-time employees the minimum health insurance coverage required by the new “employer mandate” or it could ignore the new requirements and incur a penalty. Dissatisfied with either option, D&B made the drastic decision to circumvent the ACA entirely, and reduced its full-time staff below the ACA’s employee threshold so as to avoid triggering any penalty or having to pay increased health care costs. However, by dodging the employer mandate, D&B may have come in …

Disparities In Private Health Insurance Coverage Of Skilled Care, Stacey A. Tovino

Faculty Articles

This article compares and contrasts public and private health insurance coverage of skilled medical rehabilitation, including cognitive rehabilitation, physical therapy, occupational therapy, speech-language pathology, and skilled nursing services (collectively, skilled care). As background, prior scholars writing in this area have focused on Medicare coverage of skilled care and have challenged coverage determinations limiting Medicare coverage to beneficiaries who are able to demonstrate improvement in their conditions within a specific period of time (the Improvement Standard). By and large, these scholars have applauded the settlement agreement approved on 24 January 2013, by the U.S. District Court for the District of Vermont …

Changing The Tax Code To Create Consumer-Driven Health Insurance Competition, Regina Herzlinger, Barak D. Richman

Faculty Scholarship

Because current tax laws exclude employer-paid health insurance premiums from employees’ taxable wages and income, employer-sponsored insurance remains the primary source of health insurance for most employed Americans. Economists have long blamed the employer-based insurance tax exclusion for inflating health care costs, and, more recently, for constraining income growth and exacerbating income inequality.

We execute a simulation to test the effect of permitting employees to receive their employers’ premium contribution directly and then purchase health insurance themselves, using tax-free funds. Employees could deduct for income tax purposes the amount used for insurance and, if they spend less than the amount …

N.C. Medicaid Reform: A Bipartisan Path Forward, Barak D. Richman, Allison Rice

Faculty Scholarship

The North Carolina Medicaid program currently constitutes 32% of the state budget and provides insurance coverage to 18% of the state’s population. At the same time, 13% of North Carolinians remain uninsured, and even among the insured, significant health disparities persist across income, geography, education, and race.

The Duke University Bass Connections Medicaid Reform project gathered to consider how North Carolina could use its limited Medicaid dollars more effectively to reduce the incidence of poor health, improve access to healthcare, and reduce budgetary pressures on the state’s taxpayers.

This report is submitted to North Carolina’s policymakers and citizens. It assesses …

Redefining Medical Care, Lauren R. Roth

Scholarly Works

President Donald J. Trump has said he will replace the Affordable Care Act (ACA) with health savings accounts (HSAs). Conservatives have long preferred individual accounts to meet social welfare needs instead of more traditional entitlement programs. The types of “medical care” that can be reimbursed through an HSA are listed in § 213(d) of the Internal Revenue Code (Code) and include expenses “for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body.”

In spite of the broad language, regulations and court interpretations have narrowed this definition substantially. …

Health Insurance Mandates, Mammography, And Breast Cancer Diagnoses, Christopher K. Carpenter, Marianne P. Bitler

Vanderbilt Law School Faculty Publications

We examine the effects of state health insurance mandates requiring coverage of screening mammograms. We find evidence that mammography mandates significantly increased mammography screenings by 4.5-25 percent. Effects are larger for women with less than a high school degree in states that ban deductibles, a policy similar to a provision of federal health reform that eliminates cost-sharing for preventive care. We also find that mandates increased detection of early stage in-situ precancers. Finally, we find a substantial proportion of the increased screenings were attributable to mandates that are not consistent with 2014 recommendations of the American Cancer Society.

Nfib V. Sebelius And The Individual Mandate: Thoughts On The Tax/Regulation Distinction, Kyle D. Logue

Michigan Business & Entrepreneurial Law Review

When Chief Justice John Roberts wrote the opinion of the Court in National Federation of Independent Businesses v. Sebelius (NFIB) explaining the constitutionality of the Affordable Care Act’s (ACA) minimum essential coverage provision (sometimes referred to as the individual mandate), he reasoned that the mandate—or, more precisely, the enforcement provision that accompanied the mandate (the Shared Responsibility Payment or SRP)—could be understood as a tax on the failure to purchase health insurance. According to this view, the enactment of the mandate and its accompanying enforcement provisions fell within Congress’s virtually unlimited power to “lay and collect taxes.” This tax-based interpretation …

Hospital Chargemaster Insanity: Heeling The Healers, George A. Nation Iii

Pepperdine Law Review

Hospital list prices, contained in something called a chargemaster are insanely high, often running 10 times the amount that hospitals routinely accept as full payment from insurers. Moreover, the relative level of a particular hospital’s chargemaster prices bears no relationship to either the quality of the services the hospital provides or, to the cost of the services provided. The purpose of these fictitious list prices is to serve as a starting point or anchoring point, for negotiations with third-party payers regarding the amount that they will actually pay the hospital for it’s goods and services. Ironically, there is widespread agreement, …

The Affordable Care Act, Experience Rating, And The Problem Of Non-Vaccination, Eric Esshaki

University of Michigan Journal of Law Reform Caveat

Polio, the whooping cough, and the mumps, among many other communicable diseases, were once prevalent in communities within the developed world and killed millions of people.1 The advent of vaccinations contained or eradicated several of these diseases.2 However, these diseases still exist in the environment3 and are making a comeback in the United States.4 Their persistence is directly attributable to the rising trend among parents refusing to vaccinate their children.5 One proposed solution to this problem is to hold parents liable in tort when others are harmed by their failure to vaccinate. Another proposed solution argues that parents should pay …

The Ownership Of Health Insurers, Peter Molk

UF Law Faculty Publications

Spending by private health insurers exceeds $800 billion and is expected to rise. The Affordable Care Act provides $2 billion in subsidies to jump-start health insurers owned by their policyholders in an attempt to bring these costs under control. Firms with this corporate ownership structure have succeeded in other insurance markets, where Nationwide, Northwestern Mutual, and State Farm are just a few prominent examples. However, the potential of policyholder ownership in health insurance, which is dominated by investor and nonprofit ownership, is poorly understood. This Article applies theories of corporate ownership and control to analyze the strengths and weaknesses of …

Dying Fast: Suicide In Individuals With Gambling Disorder, Stacey A. Tovino

Faculty Articles

These published remarks carefully document the history of health insurance coverage of gambling disorder. They begin by providing examples of gambling disorder insurance benefit disparities in the contexts of public health care programs and private health plans. They proceed by reviewing the effect of three pieces of legislation, including the Mental Health Parity Act of 1996, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, and the Affordable Care Act of 2010, on public and private insurance coverage of gambling disorder. They highlight the partial victory that will occur in some states beginning in …