The price of health care in the United States is already high and continues to rise at unsustainable rates, driving affordability challenges and representing a major policy priority.1 The high price of health care is not evenly distributed: prices charged for care vary between insurance types, across geographic areas, and even between providers within a region.2 This report is the third in a series that explores how states that are seeking to lower the cost of care can also advance health equity as part of that effort through policy design and implementation, rather than as an afterthought.3 This report focuses on reference pricing: payers setting upper payment limits for health care services to normalize and lower health spending.4

This report begins by providing background on price variation in the health care system, as well as its impacts on equitable health care access and affordability. It then highlights the evidence that reference pricing can address this variation. It ends by describing several policy tools that states can use in implementing reference pricing to reduce health care costs for patients and states alike and promote health equity through the design, implementation, and execution of effective policies.

The Price of Health Care Varies Inequitably

Americans often find themselves paying exorbitant prices for health care services, with little correlation to quality or the actual cost of delivering those services.5 Contributing to this issue is the fact that prices for any given service can vary wildly. For example, the Health Care Cost Institute found that a commonly ordered blood test in Beaumont, Texas ($443) costs nearly twenty-five times more than the same test in Toledo, Ohio ($18).6 Similarly, a recent study in the Quarterly Journal of Economics found that annual spending for privately insured patients varied by as much as three times, ranging from $2,110 to $6,366, with half of this variation being driven solely by differences in prices, rather than differences in the quantity of care received or patient characteristics such as age or health.7 These inconsistencies in prices lead to significant inequities in access, affordability, and health outcomes.

A commonly ordered blood test in Beaumont, Texas ($443) costs nearly twenty-five times more than the same test in Toledo, Ohio ($18).

Variations in health care prices particularly burden rural residents, who as a result of higher prices charged tend to face higher health care expenditures, larger out-of-pocket burden, and higher marketplace premiums compared to their urban counterparts.8 As previously noted, there is no evidence suggesting that higher health care costs consistently translate to better quality care or improved health outcomes.9 Furthermore, despite higher prices and costs, rural health care actually often falls short in quality compared to suburban or urban settings, contributing to relatively poorer health outcomes and higher mortality rates for conditions ranging from chronic diseases such as diabetes to infectious diseases such as COVID-19.10 These poor health outcomes in rural communities create a vicious cycle of unmet need that leads to more intense and expansive care, driving much of the increased costs that these communities face.11

This urban–rural quality disparity is largely driven by limited access to health care in rural settings: due to lower demand in rural settings, providers tend to practice in urban settings, where there are more patients to support their practice.12 Specialists, in particular, may be more difficult to access in rural areas, leading to an overreliance on primary care providers for complex needs.13 These disparities in outcomes have real impacts on people’s lives. For example, the age-adjusted death rate in 2019 was more than 20 percent higher in rural areas than in urban areas.14

These disparities in outcomes have real impacts on people’s lives. For example, the age-adjusted death rate in 2019 was more than 20 percent higher in rural areas than in urban areas.

The impact of high and varying health care pricing and costs extends beyond health care access and usage. As health care costs continue to rise, they increasingly strain state budgets, limiting resources available for other programs aimed at promoting population health and addressing systemic inequities that impact health, such as food scarcity, inadequate or unaffordable housing, inadequate transportation infrastructure, or a lack of good jobs.15 And because the same systemic factors that drive high-cost, low-access health care in rural communities also impact their social determinants of health—low population density makes healthy food more expensive, internet access less likely, and job opportunities less frequent, for example16—rising health care costs can accelerate the downward spiral for these communities.

Government action is needed to address the harmful effects of this variance in health care pricing and the health inequities associated with it. In order to achieve true health equity, all communities need to be able to afford the health care they need, free of distortions in price or access.17 By reining in the variation in health care prices, states can advance health equity and ensure that all their residents can live their best lives.

Reference Pricing Can Address Inequitable Variation

Reference pricing (also known as reference-based pricing) is an option to address this variation in prices. Under reference pricing, payers—such as health insurers or government programs—set limits on what they will pay for a given service or health product, typically based on the Medicare rate for a service. Rather than allowing health providers to charge unjustified or arbitrary prices for needed services, purchasers set a lower, consistent price ceiling for a service. States such as California, Montana, and Oregon have been leaders on adopting this approach for hospital services.

California

The California Public Employees Retirement System (CalPERS) implemented reference pricing for knee and hip replacements in January 2011, because prices charged for these services varied by up to five times between hospitals without any relationship to quality. CalPERS set the reference price at $30,000–around 85 percent of the average price charged before implementing reference pricing.18 This price was the average of a subset of high-quality, geographically distributed providers before implementation.19

This approach resulted in significant reductions in patients choosing high-price hospitals for these procedures, and it resulted in these high-price hospitals lowering their prices to align with the reference price.20 Figures 1 and 2 show these changes over time.

Figure 1

Figure 2

CalPERS has since expanded its reference pricing program to include colonoscopies and cataract removal surgeries, which are two additional services with high variation. As with joint replacement surgeries, the application of the program to both colonoscopies and cataract removal surgeries showed significant reductions in price and meaningful increases in patients choosing lower-price facilities.21 None of the three reference pricing initiatives was associated with significant change in patient outcomes.

Montana

Another state that has led in its use of reference pricing for health care services is Montana. While Montana adopted the practice later than California, it did so for every service for all enrollees in its state employee health plan beginning in July 2016, rather than only a subset of more “shoppable” services.22 After negotiating with hospitals and analyzing payments across the state, the Montana Health Care and Benefits Division settled on 234 percent of the Medicare rate for all services. Described as “relatively generous,” this rate was still a meaningful reduction from previous prices, as the plan was paying between three and six times the Medicare rate for services beforehand.23

Montana’s experience highlighted one of the challenges of implementing reference pricing: five major hospital systems had not agreed to the reference rate in the months leading up to the start of the program, which could have left large gaps in the state’s hospital network. After threatening to go public with the names of the hospitals that were driving the variation in the prices Montana faced, four of the five hospitals agreed to the rate, leaving Benefis Health System in Great Falls as the only holdout.24 Benefis is the only major hospital within ninety miles of Great Falls, and it leveraged its market power to push for a more generous rate. After a public pressure campaign, led by public employee unions and other advocates, however, the hospital joined the network at the proposed 234 percent rate.

In 2021, an analysis commissioned by the National Academy for State Health Policy (NASHP) found that the state’s use of reference pricing saved as much as $47.8 million between state fiscal years 2017 and 2019.

As with California, Montana’s experience resulted in significant savings to the state. In 2021, an analysis commissioned by the National Academy for State Health Policy (NASHP) found that the state’s use of reference pricing saved as much as $47.8 million between state fiscal years 2017 and 2019.25 These savings represented an estimated savings of around 21 percent for inpatient services and around 11 percent for outpatient services.

Oregon

Oregon has also used reference pricing to lower its state employee health spending. The state’s legislature passed a law in 2017 setting an upper limit on hospital payments from the Oregon Educators Benefit Board (OEBB) and the Public Employees’ Benefit Board (PEBB) to 200 percent of Medicare’s rates for in-network providers and 185 percent of Medicare’s rates for out-of-network providers.26 The reference rates went into effect on July 1, 2019, and they did not apply to rural critical access hospitals, hospitals with fewer than fifty beds, or hospitals that receive at least 40 percent of their revenue via Medicare.27 Prior to the implementation of this law, the average payments by OEBB and PEBB’s insurers were around 215 percent of Medicare rates.

The implementation of Oregon’s reference pricing plan was not without hurdles. In its first plan year, the state realized its payments for maternity and newborn services were being paid at the maximum allowed of 200 percent of Medicare’s rates—much higher than they were prior to the implementation of the law. To address this, the state issued regulations clarifying that payments for these state employee plans should be the lesser of billed charges, contracted rates, or the reference price.

Despite this initial issue, Oregon has seen significant savings every year the program has been in practice. An evaluation of the first year of reference pricing by actuarial firm Willis Towers Watson found that, even with the increase in payments for maternity and newborn services, adopting reference pricing saved the state $59 million, or around 14 percent of the claims spending regulated by the law. The preliminary estimate for the program was around $81 million (23 percent of projected claims spending), and the firm attributed part of the underperformance to the COVID-19 pandemic changing utilization of health care services, as well as the initial maternity payment problem.

A more recent audit of 2021 claims data found even more striking results. . . . the state saved more than $112 million (one-third of the claims spending subject to the law).

A more recent audit of 2021 claims data found even more striking results. For 2021 claims, the same actuarial firm found that the state saved more than $112 million (one-third of the claims spending subject to the law). Comparison to other state spending further underscores the impact of this law. Over 2020 and 2021, the state limited cost growth in OEBB and PEBB plans to less than 2 percent, while Oregon’s commercial insurance spending over the same period grew by 6 to 8 percent. The average reimbursement by OEBB and PEBB plans in 2021 was 163 percent of Medicare’s rates.

How to Ensure Reference Pricing Is Done Equitably

While state experiences with reference pricing have reduced the dollar amount spent on care, the goal of advancing equity through this policy has been an afterthought. This report provides several strategies to ensure that policy solutions aimed at ensuring that reference pricing include advancing health equity as a central component. These strategies include:

  • collecting accurate, representative data to identify price variation;
  • establishing equitable reference rates;
  • ensuring provider participation;
  • minimizing patient cost-shifting; and
  • reinvesting savings to promote health equity.

Collecting Accurate, Representative Data to Identify Price Variation

The first step to effectively implementing reference pricing in an equitable manner is to ensure that regulators have an accurate understanding of health spending. Reference pricing is a tool intended to address high, varied prices; to do so, states need to know which services have high prices with significant levels of unjustified variation. There are multiple ways states can go about collecting these data.

First, they can use state employee and retiree health benefit programs as a baseline. As seen with California and Montana’s experiences, these data can provide significant insight into how spending may differ across a state without an associated increase in quality. Importantly, states would be able to use these data without enacting a new law or developing new databases.

Another option for a data source is to use or develop an all-payer claims database (APCD).28 APCDs are, as the name suggests, a collection of claims data from all payers within a state. Taking this approach is the most effective way to gather a significant amount of private payer data—especially important as slightly over half of the country has only private coverage whose claims are not captured by state payment systems.29 While such databases are generally voluntary, states can work to promote participation by ensuring that the data will not be shared among competitors, as well as only sharing any reference rates with APCD participants.

If states lack a robust, diverse data set, they run the risk of missing important variations in price that may exacerbate health inequities. For example, analysis of price variation should examine where there are patterns of unexplained high prices for communities known to experience health disparities. Additionally, sources of coverage vary significantly along racial and ethnic lines, and rural communities are more likely to be enrolled in Medicaid, as shown in Figures 3 and 4. Including Medicaid in reference pricing plans could address this disparity.

Figure 3

Figure 4

Establishing Equitable Reference Rates

After accurate, representative data are collected, the next decision point for state policy makers is the setting of the reference rates. This step has two major components, each of which are essential to an equitable, effective program: determining which services should be subject to referencing pricing and determining what the reference rate should be.

As discussed above, the central factors in deciding which services should be reference priced is the extent to which prices for a service vary without quality or patient differences, as well as how high the prices for a service are. A service could have low variation among payers or across a region, but still have an unsustainably high price, and policymakers should consider both aspects of a service’s price when developing reference rates. Lowering spending is a key goal of reference pricing, but it should not be the only one. In addition to examining the spending impact of a service, states should also consider the equity impacts of pricing policy.

For example, spending for a given service may not vary as widely as earlier examples in this report, but the higher-priced service could still disproportionately burden marginalized communities if it were charged by rural hospitals or hospitals that primarily serve Black patients, for example. By ensuring that reference pricing is targeted at both the services with the highest variance and the services whose variance has the most disparate impacts, states can advance health equity while also lowering health care spending.

By ensuring that reference pricing is targeted at both the services with the highest variance and the services whose variance has the most disparate impacts, states can advance health equity while also lowering health care spending.

After determining the services that are most appropriate to reference price, states must then determine the actual reference rate. CalPERS’ approach offers lessons on adopting reference prices that do not have an adverse effect on patient access to care. The program examined spending across the state and associated quality measures, determining a rate that would maintain access to care across the state while still excluding higher-priced facilities from full reimbursement.30 Taking into account factors other than cost can advance equity. This approach is most reliant upon having a robust data set, however. If a state is limited to solely patients covered by the state, such as state employees and Medicaid enrollees, these rates may not meaningfully reduce spending for other patients.

In addition to CalPERS’ approach, states could also work to include patient perspectives in this stage of the process. States have taken similar approaches in their Medicaid Advisory Committees, and the Biden administration recently finalized a rule requiring greater patient involvement in these committees. A similar requirement exists for federally qualified health centers’ governing boards. Including patients, especially marginalized patients, in the process of establishing reference rates can ensure that policy change happens with participation by impacted communities, rather than to them.

Another option states can use is the approach adopted for Oregon’s OEBB and PEBB payments. Rather than determining rates for specific services, the state set upper limits in terms of percentages of Medicare’s rates for in-network (200 percent) and out-of-network providers (180 percent). This approach allowed the state to address all spending for patients enrolled in these programs, with the higher in-network limit incentivizing providers to participate in the OEBB and PEBB provider networks. Maintaining high levels of provider participation may leave some cost savings on the table, but it is essential to an equitably implemented reference pricing program, as discussed below.

Ensuring Provider Participation

Any effort to lower health care spending will have to develop a mechanism to ensure that health care providers continue to accept new, lower payments, and Montana’s experience demonstrates that reference pricing is no exception. While reference pricing has the capacity to meaningfully lower health spending, it can also result in significant gaps in health insurance networks via provider nonparticipation if states do not implement the reform carefully. There are ways that states can address this issue in an equitable manner.

In addition to the approach taken by Oregon’s public employee programs, states can tie acceptance of reference rates to existing, meaningful revenue streams for hospitals. States have used this approach for other regulations, such as promoting marketplace participation by insurers or participation with public option programs. For example, Nevada requires hospitals to contract with at least one public option plan to remain eligible for its Medicaid, state employee, and workers’ compensation programs.31 Taking a similar approach for reference pricing rates can help promote participation by providers with the new, more sustainable rates.

Another approach—which could be taken in tandem with the first option—is to establish varying rates depending on facility type. In addition to spending and quality, states could also include factors such as populations served and hospital type in determining the final reference-based price for a hospital’s services. This approach has been used to inform other health programs aimed at lowering spending: Washington State’s public option, for example, limits overall spending by participating plans to 160 percent of Medicare rates, but it establishes minimum reimbursement floors for rural hospitals and hospitals designated as Critical Access Hospitals.32 States could take similar approaches for other safety net hospitals, potentially driven by the patient participation in the reference process described above. Adopting a similar practice for reference pricing would help avoid unintentionally burdening these crucial sources of care, and it would help ensure greater participation by providers.

Minimizing Patient Cost-Shifting

Regardless of how a state implements its reference pricing program, there is a risk of patients facing unexpected new costs, especially early in the program’s implementation. Ideally, health care providers will continue to contract with states and other insurers using reference rates, but this may not be the case in all instances.

Failing to account for the potential increase in out-of-pocket costs for patients runs the risk of amplifying existing inequities in affording health care. For example, a 2023 survey of insured adults by KFF found that 23 percent of Black adults and 18 percent of Hispanic adults had problems paying a medical bill in the past year, compared to only 14 percent of white adults.33 If nonparticipating providers are those that disproportionately serve Black and Hispanic people, these disparities would increase.

CalPERS’ experience highlights the pitfalls of failing to protect patients throughout this process. When California implemented its reference pricing program for knee and hip replacements, patients paid an additional $700,000 in cost-sharing in the first year, despite the overall savings of around $2.8 million.34 This was largely driven by patients continuing to go to their preferred providers from before the implementation of the reference rate, even when those providers did not accept the new rate.35 As a result of CalPERS’ implementation, patients bore the burden of paying any difference between the reference rate and the charged amount.

One way to avoid this cost-shifting is to not contract with hospitals and other providers who do not accept the reference rate.

One way to avoid this cost-shifting is to not contract with hospitals and other providers who do not accept the reference rate. Patients overwhelmingly use in-network providers for medical care, so this approach may address most potential risk of cost-shifting to patients. Additionally, states can adopt Oregon’s approach and set limits on out-of-network reimbursement.36 Taking this approach would continue to incentivize providers to accept the reference rate while minimizing patient risk, as providers would still receive some amount of payment for their out-of-network services. States could also set limits on out-of-network cost sharing as the Affordable Care Act did for out-of-network emergency care.37

Reinvesting Savings to Promote Health Equity

Finally, states may be left with the decision of how to apply the savings achieved via reference pricing. Rather than purely banking such savings, states should consider the savings achieved as an opportunity to reinvest these funds into other programs that promote health coverage and advance health equity.

One option states could take here is to use these savings to fund standby capacity payments for rural hospitals, Critical Access Hospitals, and other at-risk facilities.38 Under this approach, hospitals would receive a baseline payment to ensure adequate staffing and capacity, regardless of patient volume in a given month. Doing so would ensure that these hospitals would be able to maintain adequate provider supply for the full scope of services patients need. This approach would also help avoid the vicious cycle of hospitals raising prices to make ends meet, putting care further out of reach for residents and requiring further price increases. Over time, this may even result in qualifying hospitals no longer needing a carveout from the overall reference rate.

Another option that could be applied is creating or expanding various subsidies to promote the affordability of coverage and care. This approach can also be targeted at specific, equity-focused goals. For example, several states have reduced cost-sharing for diabetes care.39 Black people are significantly more likely to have and suffer worse outcomes from diabetes, and research suggests that lowering cost-sharing can reduce racial disparities in access to care, even when applied to all members of a health plan.40

In addition to lower cost-sharing for a specific service, states could adopt a separate, lower deductible for a set of services, such as mental health services.41 Similar to prescription drug deductibles, out-of-pocket spending here would still count toward a patient’s overall deductible, but patients would have a lower threshold to meet for mental health care before insurance covers a greater portion of the cost. More than one in five U.S. adults have some form of mental illness, and LGBT people and people of color are more likely to struggle to access mental health care.42 Adopting this or another form of reduced cost-sharing for mental health services would help close these disparities in access, and it may also further contribute to lower overall spending, as untreated mental illness can often contribute to other costly health conditions.43

States can also go beyond direct health spending and use any savings that accrue to better fund other programs that promote health in their populations. Social determinants of health (SDOH, also called social drivers of health) can account for more than half of a person’s overall health outcomes, so investing in improving SDOH could eventually even lead to lower health spending overall. The Biden administration released guidance in November 2023 detailing how states can use 1115 waivers to address SDOH on a variety of needs, including housing and nutrition supports. Redirecting these savings to the state costs of SDOH programs could further lower health spending in the state, as well as improving population health. States could also recapture these savings to shore up other areas of their budget that affect costs and equity but have been historically strained by high health costs, such as education spending.

It is important to note, however, that these savings may not all accrue to states in a way that can be reinvested. For example, reductions in patient cost-sharing or premiums primarily accrue to individuals and families, and states will not be able to redirect it to other programs. Similarly, for expected reductions in state spending, there may be a delay in when these savings manifest. States should not expect to immediately be able to reinvest these funds into other programs, health-focused or otherwise.

Reference Pricing Can Lower Health Care Costs and Promote Health Equity

The cost of health care is unsustainably high, and part of this high cost is driven by unjustifiable differences in prices between providers that deliver comparable quality of care. Implementing a reference pricing system is a powerful tool for states to reduce high and variable provider prices within a state. States have tools to do so equitably.

States should work to include as robust a data set and analysis of it as possible to ensure that regulators can best address harmful prices, whether those are the highest prices, the prices with the most severe variation, or the prices with the most inequitable variation. States should also factor equity impacts into the process of identifying services to be referenced and what the reference should be, ensuring that crucial health care providers and the patients they serve are helped and not harmed in the process. Working to minimize cost-shifting to patients and reinvesting the savings achieved into other health programs can build on the lower prices that reference pricing delivers and further promote health equity.

Notes

  1. “Why Are Americans Paying More for Healthcare?,” Peter G. Peterson Foundation, January 3, 2024, https://www.pgpf.org/blog/2024/01/why-are-americans-paying-more-for-healthcare; Audrey Kearney et al., “KFF Health Tracking Poll February 2024: Voters on Two Key Health Care Issues: Affordability and ACA,” KFF, February 21, 2024, https://www.kff.org/affordable-care-act/poll-finding/kff-health-tracking-poll-february-2024-voters-on-two-key-health-care-issues-affordability-and-aca/.
  2. Zack Cooper et al., “Geographical Variation in Health Spending across the US among Privately Insured Individuals and Enrollees in Medicaid and Medicare,” JAMA Network Open 5, no. 7 (July 20, 2022), https://doi.org/10.1001/jamanetworkopen.2022.22138.
  3. For the first reports in the series, see Tara Oakman and Thomas Waldrop, “Cost-Growth Benchmarks Can Make Health Care More Affordable and Equitable,” The Century Foundation, December 3, 2023, https://tcf.org/content/report/cost-growth-benchmarks-can-make-health-care-more-affordable-and-equitable/ and Tara Oakman, Thomas Waldrop, and Lex Brierley, “How States Can Advance Equity When Addressing Health Care Consolidation,” The Century Foundation, March 6, 2023, https://tcf.org/content/report/how-states-can-advance-equity-when-addressing-health-care-consolidation/.
  4. Adrienne Smith, “Healthcare 101: What Is Reference-Based Pricing (RBP)?” Sana Benefits, July 12, 2021, https://www.sanabenefits.com/blog/what-is-reference-based-pricing/.
  5. “Health Care Affordability in New York,” Altarum Healthcare Value Hub, July 2023, https://www.healthcarevaluehub.org/application/files/4716/9506/6144/New_York_Deep_Dive_2023.pdf.
  6.  Kevin Kennedy et al., “Past the Price Index: Exploring Actual Prices Paid for Specific Services by Metro Area,” Health Care Cost Institute, April 30, 2019, https://healthcostinstitute.org/hcci-originals-dropdown/all-hcci-reports/hmi-2019-service-prices.
  7. Zack Cooper et al., “The Price Ain’t Right? Hospital Prices and Health Spending on the Privately Insured,” The Quarterly Journal of Economics 134, no. 1 (September 4, 2018): 51–107, https://doi.org/10.1093/qje/qjy020.
  8. Dunc Williams and Mark Holmes, “Rural Health Care Costs,” North Carolina Medical Journal 79, no. 1 (January 2018): 51–55, https://doi.org/10.18043/ncm.79.1.51; “Rural and Urban Health,” Georgetown University Center on an Aging Society, accessed April 25, 2024, https://hpi.georgetown.edu/rural/; Erik Wengle, Linda J. Blumberg, and John Holahan, “Are Marketplace Premiums Higher in Rural than in Urban Areas?” Robert Wood Johnson Foundation, November 2018, https://www.rwjf.org/en/insights/our-research/2018/11/are-marketplace-premiums-higher-in-rural-than-in-urban-areas.html.
  9. Peter S. Hussey, Samuel Wertheimer, and Ateev Mehrotra, “The Association between Health Care Quality and Cost,” Annals of Internal Medicine 158, no. 1 (January 1, 2013): 27, https://doi.org/10.7326/0003-4819-158-1-201301010-00006.
  10. Meena Seshamani et al., “Addressing Rural Health Inequities in Medicare,” Centers for Medicare & Medicaid Services, February 10, 2023, https://www.cms.gov/blog/addressing-rural-health-inequities-medicare; Jane Bolin and Alva Ferdinand, “The Burden of Diabetes in Rural America: Rural Health Research Project,” The Burden of Diabetes in Rural America: Rural Health Research Project, March 2018, https://www.ruralhealthresearch.org/projects/811; Eugenio Paglino et al., “Monthly Excess Mortality across Counties in the United States during the COVID-19 Pandemic, March 2020 to February 2022,” Science Advances 9, no. 25 (June 23, 2023), https://doi.org/10.1126/sciadv.adf9742.
  11. Williams and Holmes, “Rural Health Care Costs.”
  12.  Michael Meit et al., “The 2014 Update of the Rural-Urban Chartbook,” Rural Health Reform Policy Research Center, October 2014, https://ruralhealth.und.edu/projects/health-reform-policy-research-center/pdf/2014-rural-urban-chartbook-update.pdf.
  13. “Healthcare Access in Rural Communities,” Rural Health Information Hub, April 19, 2024, https://www.ruralhealthinfo.org/topics/healthcare-access.
  14. Sally C. Curtin and Merianne Rose Spencer, “Trends in Death Rates in Urban and Rural Areas: United States, 1999–2019,” Centers for Disease Control and Prevention, September 2021, https://www.cdc.gov/nchs/products/databriefs/db417.htm.
  15. William C. Johnson and Jean Fuglesten Biniek, “Sources of Geographic Variation in Health Care Spending among Individuals with Employer Sponsored Insurance,” Medical Care Research and Review 78, no. 5 (July 6, 2020): 548–60, https://doi.org/10.1177/1077558720926095; Tara Oakman and Thomas Waldrop, “Cost-Growth Benchmarks Can Make Health Care More Affordable and Equitable,” The Century Foundation, December 5, 2023, https://tcf.org/content/report/cost-growth-benchmarks-can-make-health-care-more-affordable-and-equitable/.
  16. “Rural Hunger and Access to Healthy Food Overview – Rural Health Information Hub,” Overview—Rural Health Information Hub, January 3, 2024, https://www.ruralhealthinfo.org/topics/food-and-hunger; “Broadband,” U.S. Department of Agriculture, accessed April 25, 2024, https://www.usda.gov/broadband.
  17. Jamila Taylor and Thomas Waldrop, “Health Equity in Practice: A Framework to Assess Meaningful Implementation in Health Insurance Reforms,” The Century Foundation, September 21, 2022, https://tcf.org/content/report/health-equity-in-practice-a-framework-to-assess-meaningful-implementation-in-health-insurance-reforms/.
  18. “Hips and Knees Reference Based Pricing,” California Public Employees’ Retirement System, June 18, 2013, https://www.calpers.ca.gov/docs/board-agendas/201306/pension/item-7.pdf.
  19. Ibid.
  20. James C. Robinson and Timothy T. Brown, “Increases in Consumer Cost Sharing Redirect Patient Volumes and Reduce Hospital Prices for Orthopedic Surgery,” Health Affairs 32, no. 8 (August 2013): 1392–97, https://doi.org/10.1377/hlthaff.2013.0188.
  21. James C. Robinson et al., “Association of Reference Payment for Colonoscopy with Consumer Choices, Insurer Spending, and Procedural Complications,” JAMA Internal Medicine 175, no. 11 (November 1, 2015): 1783, https://doi.org/10.1001/jamainternmed.2015.4588; James C. Robinson, Timothy Brown, and Christopher Whaley, “Reference-Based Benefit Design Changes Consumers’ Choices and Employers’ Payments for Ambulatory Surgery,” Health Affairs 34, no. 3 (March 2015): 415–22, https://doi.org/10.1377/hlthaff.2014.1198.
  22. Julie Appleby, “Holy Cow’ Moment Changes How Montana’s State Health Plan Does Business,” KFF Health News, June 20, 2018, https://kffhealthnews.org/news/holy-cow-moment-changes-how-montanas-state-health-plan-does-business/.
  23. Ibid.
  24. Marshall Allen, “In Montana, a Tough Negotiator Proved Employers Don’t Have to Pay so Much for Health Care,” ProPublica, October 2, 2018, https://www.propublica.org/article/in-montana-a-tough-negotiator-proved-employers-do-not-have-to-pay-so-much-for-health-care.
  25. Steve Schramm and Zachary Aters, “Estimating the Impact of Reference-Based Hospital Pricing in the Montana State Employee Plan,” Optumas, April 6, 2021, https://www.nashp.org/wp-content/uploads/2021/04/MT-Eval-Analysis-Final-4-2-2021.pdf.
  26. Oregon State Legislature, “SB 1067,” July 18, 2017, https://olis.oregonlegislature.gov/liz/2017R1/Measures/Overview/SB1067.
  27. Ibid.
  28. “All-Payer Claims Databases,” Agency for Healthcare Research and Quality, February 2018, https://www.ahrq.gov/data/apcd/index.html.
  29. “Health Insurance Coverage of the Total Population, Multiple Sources of Coverage,” KFF, accessed April 25, 2024, https://www.kff.org/other/state-indicator/health-insurance-coverage-of-the-total-population-multiple-sources-of-coverage/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D.
  30. “Hips and Knees Reference Based Pricing,” California Public Employees’ Retirement System.
  31. Jamila Taylor and Thomas Waldrop, “States Must Prioritize Health Equity as They Expand Coverage through Public Options,” The Century Foundation, September 8, 2022, https://tcf.org/content/report/states-must-prioritize-health-equity-as-they-expand-coverage-through-public-options/.
  32. Lanhee J. Chen, “Early Lessons from State-Based Public Option Plans,” JAMA Health Forum 5, no. 3 (March 28, 2024), https://doi.org/10.1001/jamahealthforum.2024.0973.
  33. Karen Politz et al., “KFF Survey of Consumer Experiences with Health Insurance,” KFF, June 15, 2023, https://www.kff.org/mental-health/poll-finding/kff-survey-of-consumer-experiences-with-health-insurance/.
  34. Robinson and Brown, “Increases in Consumer Cost Sharing Redirect Patient Volumes and Reduce Hospital Prices for Orthopedic Surgery.”
  35. Ibid.
  36. Oregon State Legislature, “SB 1067.”
  37. “Know Your Rights with Insurance,” Centers for Medicare & Medicaid Services, October 12, 2023, https://www.cms.gov/medical-bill-rights/know-your-rights/using-insurance.
  38. Caroline Hoover, “How a New Funding Model Would Help Rural Hospitals Avoid Closure,” The Century Foundation, August 30, 2023, https://tcf.org/content/commentary/how-a-new-funding-model-would-help-rural-hospitals-avoid-closure/.
  39. Christine Monahan and Jalisa Clark, “Using Health Insurance Reform to Reduce Disparities in Diabetes Care,” Using Health Insurance Reform to Reduce Disparities Diabetes Care | Commonwealth Fund, August 18, 2022, https://www.commonwealthfund.org/blog/2022/using-health-insurance-reform-reduce-disparities-diabetes-care.
  40. “Diabetes and African Americans,” Office of Minority Health, November 10, 2022, https://minorityhealth.hhs.gov/diabetes-and-african-americans; “V-Bid in Action: The Role of Cost-Sharing in Health Disparities,” University of Michigan V-BID Center, August 26, 2016, https://vbidcenter.org/v-bid-in-action-the-role-of-cost-sharing-in-health-disparities/.
  41. Nicole Rapfogel, “The Behavioral Health Care Affordability Problem,” Center for American Progress, May 26, 2022, https://www.americanprogress.org/article/the-behavioral-health-care-affordability-problem/.
  42. “About Mental Health,” Centers for Disease Control and Prevention, April 16, 2024, https://www.cdc.gov/mentalhealth/learn/index.htm.
  43. Caroline Medina, Thee Santos, and Lindsay Mahowald, “Protecting and Advancing Health Care for Transgender Adult Communities,” Center for American Progress, August 18, 2021, https://www.americanprogress.org/article/protecting-advancing-health-care-transgender-adult-communities/; “Mental Health by the Numbers,” National Alliance on Mental Illness, April 2023, https://www.nami.org/about-mental-illness/mental-health-by-the-numbers/.

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