Letter from the Editor

This issue of RAND Health Quarterly covers a variety of topics, with a particular focus on work related to health care reform in the United States under the Affordable Care Act (ACA). A set of five articles analyzes the effects of the major coverage provisions of the ACA on five individual states: California, Connecticut, Illinois, Montana, and Texas. The proportion of the population that is uninsured in each state (from 11 percent in Connecticut to 28 percent in Texas) is projected to decrease dramatically, to no more than 6 percent in any state after ACA implementation. The added costs that states will face vary widely, but they stem mainly from increased Medicaid enrollment. Connecticut, unlike the other states, is expected to have lower costs under the ACA; this is because the federal government will assume payment responsibility under the Medicaid expansion for many individuals for whom the state voluntarily provides coverage today.

A separate study explores whether small firms with healthy, low-cost enrollees might avoid new rating regulations imposed by the ACA by self-insuring (that is, paying for enrollees’ health care costs directly and bearing the associated risk). Because self-insurance is risky for small employers, the authors predict that few small firms will self-insure unless generous reinsurance policies, known as stop-loss policies, become widely available after the ACA takes full effect. The current lack of nationally representative data on stop-loss insurance, however, makes it difficult to predict how the stop-loss market will respond to the ACA. Finally, we share details from a report that includes content for a toolkit that will prepare community and faith-based organizations to take advantage of community health-promotion opportunities encouraged by the ACA.

Among the several articles included in this issue related to military health, one reviews RAND research on how deployment to Iraq and Afghanistan is affecting U.S. service members and their families. Another suggests that along with the consolidation of military medical education and training that has already occurred as a result of the 2005 Base Realignment and Closure Commission at Fort Sam Houston, Texas, there is a clear need for an office of institutional research to help the Sam Houston campus attain its organizational goals. A third study in this area reviews the general psychology literature on evidence-informed factors for promoting psychological resilience, with the goal of identifying lessons learned for military programs to help service members and their families cope with multiple deployments and stress.

In other health research, we include a study that examines a 2007 amendment requiring that insurers and self-insured entities report to Medicare awards they receive from claims settlements in which Medicare is the secondary payer—so that Medicare may receive a share of the payments. The authors find that Medicare is unlikely to reap large benefits, on net, from smaller awards, which are a large portion of all such awards.

This issue includes two studies from RAND Europe. The first explores the early development and management issues surrounding health technology cooperatives—entities being developed to help influence the development of medical devices and other innovations in the private sector and in academia. The second focuses on the UK’s National Health Service, investigating the use of prizes to support the objectives of the Department of Health Research and Development Directorate, and concludes that there is indeed merit in developing incentives to support excellence in health research in addition to “standard” performance management and routine inspection.

David I. Auerbach, Ph.D., Guest Editor

Robin M. Weinick, Ph.D., Editor