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Network Inadequacy and Administrative Complexity: Searching for in-network mental health care or diabetes care with marketplace insurance

Type: Report

Type: Report

Administrative professionals witness firsthand the challenges that people with marketplace insurance plans face when trying to access in-network health care providers. This brief report provides a perspective from administrative professionals on how narrow networks and complex benefits affect patients and shape their own work.

Based on in-depth interviews with twelve practice managers or office staff members from primary care, mental health care, and diabetes care practices, the scope and scale of this report are limited. All twelve interviewees reported that they were employed in offices that treat people covered by marketplace plans, including nine who reported that half or more of their patients were covered by marketplace plans. Interviewees were initially asked to reflect on their experiences with patients and plans in general, with selected follow-up questions focusing specifically on marketplace plans. These findings therefore do not pertain solely to marketplace plans. The methodology section provides details about this research. 

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Key Findings

  1. The administrative professionals interviewed discussed how difficult it can be for patients to keep up with changes in networks and insurance status. 
  2. Interviewees described how patients’ care can be delayed when plans require referrals and how the process of getting referrals authorized creates burdens for administrative staff.   
  3. Interviewees felt that prior authorization requirements for medical services negatively impact patients and make their own work unnecessarily complicated.

Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. 

Type: Report

Executive Summary:

In participatory budgeting (PB), members of the public vote on how public money should be spent. Equity goals have been central to PB processes in North America, but is money allocated through PB is spent equitably? Published in Local Development and Society, this peer-reviewed research examines whether PB-associated increases in public school investments have benefited students with higher economic needs. 

Co-authored by Carolin Hagelskamp, Berlin School of Economics and Law; Celina Su, Brooklyn College and CUNY Graduate Center; and David Schleifer, Public Agenda, the paper examines equity in project development, voting, and budget allocations in PB in New York City.

Using data on the proportion of students in schools whose families are eligible for public assistance, the research shows that PB-funded school projects in fiscal years 2016, 2017, and 2018 did not benefit either higher- or lower-needs students compared to school projects that city council members funded on their own discretion.

However, the research shows how two strategies with the potential to advance equity were used during PB project development. Equity descriptors—i.e. project descriptions on PB ballots that emphasize a school’s economic or other needs—were used in 7.2% of school-related ballot items. Bundling—i.e. combining projects across several schools into one PB ballot item—was used in 33.9% of school-related ballot items. 

The use of both equity descriptors and bundling were both found to be associated with winning PB votes. Interviews with PB volunteers and city council staff provide insight into how and why PB stakeholders in New York City use equity descriptors and bundling.

Findings are published in Carolin Hagelskamp, Celina Su, and David Schleifer (2023) “When Participatory Budgeting (PB) funds schools, who benefits? An equity analysis of PB-associated investments in NYC public schools,” Local Development & Society.

This research was supported in part by a grant to Public Agenda from the Democracy Fund. The findings are solely the responsibility of the authors and do not necessarily represent the official views of the Democracy Fund.

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Type: Report

How difficult is it for people with marketplace insurance to find in-network health care providers, and how do delays and challenges in accessing care affect people’s lives? This series of reports is based on in-depth qualitative research that followed people covered by insurance plans purchased on state and federal marketplaces as they tried to find in-network care providers for either mental health or diabetes care.

Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.

Use the navigation bar at the top to access reports for each respective topic.

Type: Report

7.13.23

Executive Summary

The prices charged by hospitals and other health care providers are major drivers of growth in health care spending. Most employers believe health care spending negatively impacts their competitiveness and limits their ability to increase employees’ compensation. Employers can try to address high provider prices by changing the design of employee benefits. But after decades of rising premium contributions and cost sharing, employees may see any such changes as shifting even more spending onto them. Employers can also advocate for state and federal regulation to address prices, but they may wonder whether their employees want them to play that role.

Public Agenda, with support from Arnold Ventures, set out to learn how employees understand health care costs and how they see employers’ roles in addressing providers’ pricing through benefit design and policy advocacy. In January and February 2023, Public Agenda conducted five focus groups with beneficiaries of employer-based insurance and conducted in-depth interviews with selected focus group participants.

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Key Findings in Brief

  1. Focus group participants were enthusiastic about government action to control providers’ prices but raised concerns about changes to benefit design. They wanted employers to advocate for government action but doubted they would or could do so.
    • Government regulation of providers’ prices and the limiting of hospital mergers both attracted strong support in these focus groups.
    • Participants saw price regulation as a way to make pricing more reasonable and predictable. They saw limiting mergers as a way both to control prices and protect quality by checking hospitals’ power.
    • In principle, participants supported employers’ advocating for government action to control providers’ prices. But they questioned whether small employers have enough power and whether large employers have enough incentive to do so.
  2. Of the three benefit designs participants considered, they favored reference pricing over adopting tiered networks or eliminating coverage for low-value providers, both of which, they believed, would adversely affect access. They did not trust insurers to measure quality.
    • Participants favored reference pricing, which they saw as a way to make pricing predictable with minimal impact on access. But they worried it could leave providers with less cash flow and fewer incentives to provide high-quality care.
    • Tiered networks sparked concern. Participants saw tiering as having the potential to maintain access, but they worried that it would make care more expensive for people who cannot travel to preferred providers.
    • Eliminating in-network coverage for low-value providers was not popular. Participants saw it as limiting access, especially for low-income people, people of color, and rural communities.
    • Participants did not trust insurers to decide which providers should be categorized as low- or high-quality in tiered or narrow networks.
  3. Participants underestimated how much providers’ prices drive growth in health care spending and how much employers contribute to premiums. When presented with data, they reasoned that providers’ steep price increases must be driven by greed.
    • Initially, focus group participants blamed inflation, insurers, and pharmaceutical companies for high health care costs more than they blamed providers.
    • When presented with data, participants were surprised to learn insurers and pharmaceutical companies account for relatively low proportions of health care spending. They were also surprised that providers account for a relatively large share of spending and that providers’ prices have increased so steeply. But these trends fit with their view of the health care system as greedy in general.
    • Participants initially believed employees pay the bulk of their own insurance premiums, but they understood that both employers and employees are affected by costly premiums.

This research is supported by Arnold Ventures.

Type: Report

6.15.23

Executive Summary

Americans widely agree on racial equality as a general principle, but Americans differ by political affiliation and by race and ethnicity in their views on racism, its impacts, and how to address it, according to a Public Agenda/USA TODAY Hidden Common Ground survey of 2,788 adults fielded in February and March 2023.

Because most Americans identify as either religious, or spiritual, or both, one goal of this research is to understand similarities and differences in views on racism and racial justice between people of varying degrees of religiosity and spirituality. This research finds that the 18 percent of Americans who identify as largely spiritual are consistently more likely to believe that racism negatively impacts people of color and to favor various approaches to address it. By comparison, the 6 percent of Americans who identify as largely religious are less likely to believe that racism has significant impacts or to support taking actions to address racism. The 42 percent who identify as both religious and spiritual and the 35 percent who are neither religious nor spiritual are less consistent in their views on racism, its impacts, and how to address it.

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This report also has a companion series of audio journals. You can find those here.

Key Findings in Brief

  • Americans agree on the principle of racial equality. But Democrats and Republicans differ in their views on racism, its impact on people of color, and the impact on white people of efforts to combat it. Differences of opinion by religiosity and spirituality also emerge in views on racism and its impacts.
  • Largely spiritual Americans as well as Democrats are especially supportive of actions to address racism and especially likely to see roles for various institutions in doing so. In a range of policy areas, Americans tend to favor equally distributing funding to all communities. But Democrats are somewhat more likely to favor providing additional funding to close gaps in communities of color.
  • Most Americans believe that religious and spiritual people, leaders, and communities should speak up about racism and advocate for policies to address it. Democrats are especially likely to believe so, as are largely spiritual people and people who are both religious and spiritual.

Type: Report

5.30.23

Public Agenda’s research team conducted 18 in-depth confidential online interviews across all six teams, with state-based grantees, community-based partner organizations, and community members who served on steering committees. Interviews were designed and conducted to allow for reflection on the work completed, identify best practices, and consider improvements. The goal of this report is to inform the efforts of people working to strengthen health policy in communities through community engagement and community-engaged research and those who support that work.

Lessons learned include:

  • Trust is essential for a successful initiative; building and maintaining it is time-consuming but necessary.
  • Thoughtful and deliberate partnership composition is important; attention to the inclusion of diverse perspectives and approaches to achieving the same goal adds value.
  • Sustaining an initiative requires community buy-in and authentic ownership.
  • Initiatives need to be flexible to address community needs. Time to evaluate, reflect, and adjust is valuable.
  • Diversity alone is not enough: People recognize when they are invited but not heard.
  • Policy change takes years, but engaging lawmakers from the start may help the process.
  • Technical assistance is valuable: more is welcomed, especially how to find additional funding.

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Type: Report

2.20.23

Executive Summary

Online degree programs were common even before the COVID-19 pandemic. In the fall of 2019, about 18 percent of undergraduates were enrolled in what the U.S. Department of Education calls exclusively distance education courses. A disproportionate share of students studying online were enrolled in for-profit colleges. For-profit college students represented only 5 percent of all undergraduates that semester but nearly 63 percent of them were enrolled in exclusively distance education, compared to 13 percent of undergraduates at public nonprofit colleges and 21 percent of those at private nonprofit colleges.

Students will continue to choose online programs even as COVID-19 abates, raising the possibility that more people may enroll in for-profit colleges. To help understand whether nonprofit public and private colleges better serve online learners than for-profit colleges do, and to inform efforts to protect all students, this research compares the perspectives of alumni of online degree programs at nonprofit colleges versus alumni of online degree programs at for-profits. Findings are based on a representative survey of 217 nonprofit online alumni and 169 for-profit online alumni fielded March 17 to May 31, 2022.

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Key Findings in Brief

More nonprofit than for-profit online alumni are satisfied with their colleges. Most online alumni of nonprofits were very satisfied (70 percent) with their college, while just 48 percent of for-profit online alumni were very satisfied. When asked about specific attributes of their college—such as providing effective guidance, making tutors available, and having good instructors—more for-profit than nonprofit online alumni counterparts say their college fell short. The only attribute of their schools that more nonprofit than for-profit online alumni say their college fell short on was helping with financial aid. 

Half of for-profit online alumni believe that their school prioritized profits. Two-thirds of nonprofit online alumni believe that their school prioritized students. Sixty-nine percent of nonprofit online alumni say their school prioritized educating students while 31 percent say it prioritized making money. By comparison, 50 percent of for-profit online program alumni say their school prioritized students and 50 percent say it prioritized money. 

More nonprofit than for-profit online alumni think their degree has paid off. More for-profit online alumni with loans say that making payments is difficult. Majorities of both nonprofit and for-profit alumni say they were confident before enrolling that their degree would improve their job prospects. But that majority was stronger among nonprofit online alumni (78 percent) than among their for-profit counterparts (61 percent). Just 39 percent of for-profit online alumni believe that getting their degree was worth it compared to 57 percent of nonprofit online alumni. Among those with loans, more for-profit online alumni (62 percent) say that making payments is difficult, compared to 44 percent of nonprofit online alumni. 

When deciding where to enroll, more nonprofit than for-profit online alumni paid attention to affordability, accreditation, and transfer policies. Eighty-three percent each of nonprofit online alumni and for-profit online alumni say they only applied to or seriously considered one college. When considering college, 75 percent of nonprofit online alumni paid a great deal of attention to affordability, compared to 60 percent of for-profit online alumni. More nonprofit than for-profit online alumni also paid attention to both accreditation and the ease of transferring credits.

More nonprofit than for-profit online alumni had support from employers in learning about colleges and paying tuition. About half of nonprofit online alumni (52 percent) enrolled in college in order to get ahead in their current job, compared to 25 percent of for-profit online alumni. Instead, a 43 percent plurality of for-profit online alumni enrolled in order to change jobs entirely. More nonprofit online alumni (18 percent) learned about colleges and programs from an employer than did for-profit online alumni (8 percent). While student loans were the most common way that both groups paid for college, more nonprofit online alumni (25 percent) relied at least in part on employers to pay their tuition, compared to 10 percent of for-profit online alumni. 

Most online alumni from both for-profits and nonprofits express concern about student debt, while fewer are concerned about low graduation rates or low job placement rates. But rather than favoring penalties for underperforming colleges, more alumni favor efforts to support students at those colleges. When asked to consider a range of problems in higher education, far more online alumni from both for-profits and nonprofits are concerned about high debt loads than about any other issue, such as low completion rates or low job placement rates. When asked how to hold colleges with poor track records accountable, more online alumni support requiring colleges to make plans to improve and to support students with financial, academic, or career counseling. Few support withholding colleges’ federal financial aid dollars, revoking accreditation, or closures.

Education

Type: Report

2.20.23

We asked leaders of California’s civic and community-based organizations about their views on the state of public participation in local governance. The following report explores what these civic leaders say is working, what’s not, and how public engagement can be improved. Traditional models for including the public in local decision making, these leaders say, fail to meet the needs of both residents and local officials. Most see significant value and potential in more inclusive and deliberative forms of engagement, and many agree local officials are making increasing efforts to include residents more meaningfully. Overall, this research suggests civic and community-based organizations are looking for newer and more effective ways to engage the public and may be ready for stronger collaborations with local government.

The report also includes more concrete recommendations for local officials and their institutions, civic leaders and their organizations, and foundations and other funders. The recommendations can help improve public engagement in local governance throughout California and, we hope, beyond.

Public Agenda conducted this research in partnership with the Institute of Local Government and The Davenport Institute at Pepperdine University. The work was commissioned by The James Irvine Foundation.

Data for this research was collected through a state-wide, representative survey of 462 leaders of civic and community-based organizations that as part of their mission seek to improve local decision making by working with residents and/or local officials on issues that affect their communities (“civic leaders”). The survey was conducted between July 10 and August 22, 2012. Additional data was collected through focus groups and individual interviews with civic leaders across the state.

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Type: Report

1.7.15

Overview

The U.S. Department of Education has renewed its focus on ensuring that all students, especially those in under-resourced communities, have access to excellent educators. By June of 2015, all states must engage education stakeholders on locally-developed solutions to ensure every student has effective educators.

This discussion starter is designed to help educators, administrators and other school and district employees work through how their school, community, district and state can best tackle equal access to excellent educators. This guide can be used in dialogue and focus groups, and insights from these discussions can be used to inform state and federal policy.

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Education

Type: Report

7.11.22

Executive Summary

Americans think higher education can help people economically, particularly in their home states, according to this Public Agenda/USA TODAY Hidden Common Ground (HCG) research. But by a variety of measures, Americans question whether the benefits of college are worth the cost. Young people without degrees are especially skeptical. Based on a nationally representative survey fielded in May 2022 and focus groups conducted in January 2022, the research finds that Americans across partisan lines worry about high tuition and student debt in an economy that most think is rigged to benefit the wealthy. Most see college education as time-consuming and see colleges as stuck in the past. Although most Americans recognize that higher education helps people become informed, engaged citizens, fewer think it benefits democracy overall.

However, there is strong agreement across the political spectrum that all Americans should have the opportunity to get a college education if they want one. There is also very strong support, across partisan lines, for state investments in specific initiatives to make public higher education more affordable, accessible, and responsive to today’s students, including working adults. Although few Republicans view racism as making it more difficult for Black and Latino Americans to get a college education, there is nonetheless majority cross-partisan and cross-racial support for state investments in initiatives to support Black and Latino students and the institutions that serve them.

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Key Findings

1.  Strong cross-partisan, cross-racial majorities believe that higher education can benefit working adults. The consensus is weaker on how much it benefits the economy overall or our democracy. But when people focus on their states, more are confident about the economic benefits of higher education.

  • Most Americans (86 percent) across political affiliations agree that a college education can help working adults advance their careers. Fewer (64 percent) believe that people with a high school diploma would make a better living if they got a college education. Only half (52 percent) believe higher education strengthens the economy overall.
  • Most Americans (71 percent) think a college education helps people become informed, engaged citizens. But only 51 percent think our democracy would be stronger if more people had college educations. Some focus group participants objected to the idea that people without degrees are less capable, responsible citizens than those with degrees.
  • At the state level, Americans are confident in higher education’s shared economic benefits: 75 percent believe that there would be positive impacts on people’s ability to earn a good living if more people in their state had a college education, and 71 percent believe that there would be positive impacts on their state’s capacity to attract employers—including majorities across the political spectrum.

2.  While recognizing its potential benefits, many Americans question whether a college education is worth it. In an economy that most see as fundamentally unfair, Americans view college as expensive and time-consuming, and they see colleges as stuck in the past.

  • Only half of Americans (49 percent) think the economic benefits of a college education outweigh the costs. Young people without degrees are particularly skeptical.
  • Most Americans (83 percent) see college costs as prohibitive to low-income students. Most think both debt and inadequate financial aid are serious problems. Two-thirds (66 percent) see colleges as stuck in the past, not meeting the needs of today’s students.
  • Meanwhile, most Americans (72 percent) think the economy is rigged to advantage the rich and powerful. This view is shared by majorities across the political spectrum and across racial/ethnic identities.
  • Among different types of public higher education institutions, more people view community colleges as offering good value for students and taxpayers.
  • The largest share of Americans think the primary goals of their state’s public higher education institutions should be career readiness and providing a well-rounded education.

3.  Very strong cross-partisan and cross-racial majorities agree on a broad range of approaches to making public higher education more affordable.

  • Americans’ top priorities for their state’s public higher education institutions are affordability, access, and teaching career-relevant skills.
  • Most Americans (67 percent) believe that there are many qualified people who do not have the opportunity to attend college.
  • Substantial majorities of Americans across the political spectrum and across racial/ethnic identities support many approaches to making public higher education more affordable. For example, two-thirds or more Democrats, Independents, and Republicans support tax incentives for employers to pay employees’ tuition; state governments offering interest-free loans; students paying back loans based on post-graduation earnings; and requiring public higher education institutions to be transparent about student debt.
  • Half or more Democrats, Independents, and Republicans support increasing taxes on the wealthy to make public higher education more affordable and making public community colleges free.

4.  There is surprising cross-partisan and cross-racial agreement on state investments to support Black and Latino students as well as low-income students.

  • Substantially fewer Republicans (24 percent) than Democrats (72 percent) or Independents (49 percent) believe that racial discrimination makes it more difficult for people of color to get a college education.
  • Yet majorities of Republicans, Democrats, and Independents, and majorities across racial/ethnic identities, support various state investments to improve college access, affordability, and degree completion for Black and Latino students.
  • These include providing additional resources for public higher education institutions that are doing an especially good job of helping Black and Latino students complete their degrees, increased oversight of institutions that are not, and providing effective advising and financial aid to Black and Latino students.
  • Stronger majorities favor such investments to support low-income students.

5.  When people know what they’re paying for, substantially more are willing to invest in public higher education.

  • Across political affiliations, Americans largely think that public higher education should either be funded mostly by government with some student contribution or equally by government and students.
  • When asked about state investment in general, 61 percent of Americans overall support increased funding for public higher education, including 75 percent of Democrats but less than half (46 percent) of Republicans.
  • But strong majorities across the political spectrum support investing in specific public higher education initiatives to help students succeed in college and beyond.
  • This includes strong support for state investments in flexible short-term credential programs; providing students with job experience while they learn; partnerships with K-12 systems so students graduate from high school with college credits; hiring more faculty so students can take the classes they need to graduate on time; and colleges tailoring curricula to meet employers’ needs.
  • Cross-partisan majorities believe that states should maintain funding for public higher education institutions during hard economic times. Support is even stronger when people learn that the vast majority of college students attend public institutions.

Education Hidden Common Ground

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