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To clamp down on health care costs, a growing number of employers and insurers are putting limits on how much they'll pay for certain medical services such as knee replacements, lab tests and complex imaging.

A recent study found that savings from such moves may be modest, however, and some analysts question whether "reference pricing," as it's called, is good for consumers.

The California Public Employees' Retirement System (CalPERS), which administers the health insurance benefits for 1.4 million state workers, retirees and their families, has one of the more established reference pricing systems.

More than three years ago, CalPERS began using reference pricing for elective knee and hip replacements, two common procedures for which hospital prices varied widely without discernible differences in quality, says Ann Boynton, who helps set benefits policies at CalPERS.

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Working with Anthem Blue Cross, the CalPERS set $30,000 as the reference price for those two surgeries in its preferred provider organization plan.

Members who get surgery at one of the 52 hospitals that charge $30,000 or less pay only their plan's regular cost-sharing. If member choose to use an in-network hospital that charges more than the reference price, however, they're on the hook for the entire amount over $30,000, and the extra spending doesn't count toward their annual maximum out-of-pocket limit, Boynton says.

"We're not worried about people not getting the care they need," says Boynton. "They have access to good hospitals; they're just getting it at a reasonable price."

In two years, CalPERS saved nearly $6 million on those two procedures, and members saved $600,000 in lower cost sharing, according to research published last year by James C. Robinson, a professor of health economics at the University of California, Berkeley, and director of the Berkeley Center for Health Technology. Most of the savings came from price reductions at expensive hospitals.

The agency recently set caps on how much it would spend for cataract surgery, colonoscopies and arthroscopic surgery, Boynton says.

Those who have studied reference pricing say it is most appropriate for common, non-emergency procedures or tests that vary widely in price but are generally comparable in quality. Research has generally shown that higher prices for medical services don't mean their quality is higher. Setting a reference price steers consumers to high-quality doctors, hospitals, labs and imaging centers that perform well for the price, proponents say.

Others point out that reference pricing doesn't necessarily save employers a lot of money, however. A study released earlier this month by the National Institute for Health Care Reform examined the 2011 claims data for 528,000 autoworkers and their dependents, both active and retired. It analyzed roughly 350 high-volume and/or high-priced inpatient and ambulatory medical services that reference pricing might reasonably be applied to.

The overall potential savings was 5 percent, the study found.

"It was surprising that even with all that pricing variation, reference pricing doesn't have a more dramatic impact on spending," says Chapin White, a senior policy researcher at RAND and lead author of the study.

Even though the results may be modest, a growing number of very large companies are incorporating reference pricing, according to benefits consultant Mercer's annual employer health insurance survey. The percentage of employers with 10,000 or more employees that used reference pricing grew from 10 percent in 2012 to 15 percent in 2013, the survey found. Thirty percent said they were considering adding reference pricing, the survey found. Among employers with 500 or fewer workers, adoption was flat at 10 percent in 2013, compared with 11 percent in 2012.

This spring, the Obama administration said that large group and self-insured health plans could use reference pricing.

The health law sets limits on how much consumers have to pay out of pocket annually for in-network care before insurance picks up the whole tab — in 2015, it's $6,600 for an individual and $13,200 for a family plan. But if consumers choose providers whose prices are higher than a plan's reference price, those amounts don't count toward the out-of-pocket maximum, the administration guidance said.

Leaving consumers on the hook for amounts over the reference price needlessly drags them into the battle between providers and health plans over prices, says White.

"You expect the health plan to do a few things: negotiate reasonable prices with providers, and not to enter into network contracts with providers who provide bad quality care," White says. "Reference pricing is kind of an admission that health plans have failed on one or both of those fronts."

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Besides electing lawmakers Tuesday, voters settled ballot initiatives affecting everything from soda-pop taxes to fracking to marijuana sales.

The outcomes varied, but there was one economic issue that united voters. Overwhelmingly, they approved raises for minimum-wage workers.

In Alaska, Arkansas, Nebraska and South Dakota, voters passed binding referendums to raise state minimums above the $7.25 an hour wage level mandated by the federal government. In each of the conservative-leaning states, opposition to wage measures was muted, and victory margins were wide.

In Illinois, voters approved a non-binding advisory question that calls on the state legislature to approve a $10 minimum wage.

The federal minimum wage has been unchanged since the depths of the recession in July 2009. Democrats have proposed legislation raising it to $10.10 an hour. Republicans have blocked it.

So unions and community groups have shifted focus from pushing Congress to act, and instead have turned to state initiatives. Those referendums have been enormously popular with voters. For example, in Alaska, the wage hike won 69 percent of the vote.

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As of January, when higher wages also take effect in Hawaii, Maryland and West Virginia, workers in the majority of states will have hourly earnings above the federal floor.

Alaska's minimum wage will ratchet up to $9.75 by 2016. Arkansas' minimum wage will rise to $8.50 by 2017, Nebraska's to $9 by 2016, and South Dakota's to $8.50 by 2015. An estimated 680,000 minimum-wage workers would get raises if Illinois were to join those four states in increasing minimum pay levels.

In addition, a number of cities and counties in California and Wisconsin also had wage-hike referendums. Those passed too.

"People understand that $7.25 is not nearly enough to make ends meet," Christine Owens, director of the National Employment Project Action Fund, said in a statement. "This is a clear mandate for minimum and living wage proponents to soldier on until we have fair wages throughout the country."

The Employment Policies Institute, a group that opposes wage-hike legislation, said the results showed conservative candidates could win in states where wage hikes passed. Michael Saltsman, research director for the organization, said in a statement that candidates "who bucked labor union pressure and expressed skepticism of a higher minimum wage still won last night, which means that acknowledging the economic realities of wage hikes is not a political loser."

Voters also weighed in on other economic matters, including:

Berkeley, Calif., approved a 1-cent-per-ounce tax on soda in an effort to discourage consumption of sugar. But a soda tax failed in San Francisco, leaving the beverage industry with a split decision in the pair of high-profile votes.

In Colorado, voters rejected a push to require packaged foods to be so labeled if they contained genetically modified organisms, or GMOs. Food and beverage companies say such labeling would drive up grocery costs. A similar outcome is expected is Oregon, but votes are still being counted and it remains too close to call.

The marijuana industry was lifted higher in Alaska, Oregon and the District of Columbia. In Oregon and Alaska, voters agreed to legalize recreational use of pot. In the District of Columbia, possession of up to two ounces of pot was made legal.

Fracking bans had mixed results. A number of cities and counties tried to prohibit the use of hydraulic fracturing, or fracking, for recovering natural gas or oil. In Northern California's San Benito County, voters approved a fracking ban, but a similar measure failed in Santa Barbara County. In Denton, Texas, voters banned fracking, but in Youngstown, Ohio, they rejected a ban for the fourth time.

In Massachusetts, voters rejected an effort to keep out resort casinos.

The Department of Justice released more than 64,000 pages of documents related to its Operation Fast and Furious Monday night, in a move Republicans are calling both a data dump and a victory. The Obama administration had withheld the records, citing executive privilege.

The documents were redacted by several agencies, including the Bureau of Alcohol, Tobacco, Firearms and Explosives and the State Department. But several details already have become the center of conversations, including one email in which Attorney General Eric Holder criticizes House Oversight and Government Reform Committee Chairman Darrell Issa, R-Calif.

In an email Holder sent on April 15, 2011, he wrote:

"Issa and his idiot cronies never gave a damn about this when all that was happening was that thousands of Mexicans were being killed with guns from our country. All they want to do — in reality — is cripple ATF and suck up to the gun lobby. Politics at its worst — maybe the media will get it."

Those thoughts came in an email thread in which Holder and members of his staff discussed efforts by Issa to subpoena a witness to testify about the failed ATF operation along the U.S.-Mexico border. The program has been blamed for providing a weapon that was used to kill U.S. Border Patrol agent Brian Terry.

Holder and Republicans in the House have been fighting over the documents since at least the summer of 2012, when the House cited the attorney general for contempt.

In the court case regarding the fight, U.S. District Court Judge Amy Berman decided not to hold Holder in contempt — even as she denied Holder's request that she allow him to withhold the documents, as Politico reported last month.

On his Facebook page today, Issa wrote, "Judge's order compelled the production of 64,280 pages of Operation Fast and Furious documents that President Obama and the Justice Department illegally withheld from Congress."

That message was echoed on the Facebook feeds of several Republicans in Congress on Election Day; Issa's House Oversight Committee also released a statement, saying that the release of so many documents shows that the Obama administration tried to overextend the rights of executive privilege "to avoid disclosing documents that embarrass or otherwise implicate" officials.

The Justice Department says the documents show that Holder hadn't known about the doomed program before early in 2011.

Thanks to NPR's Carrie Johnson for sending some of the documents our way.

operation fast and furious

Eric Holder

In 2010, President Obama lost six seats in the Senate and 63 in the House and he called it "a shellacking." Four years before that, President George W. Bush lost six seats in the Senate and 30 in the House and called it a "thumpin.' "

We need a new term for the midterm mojo that once again struck the president and his party last night. This time, it was a derecho — sudden and destructive, blowing down the vulnerable and blasting through some incumbents' fortifications.

The White House had braced for the loss of half a dozen seats or more in the Senate, implying the loss of the majority in that chamber and the last of Obama's leverage on Capitol Hill. There also was resignation about the probable loss of another dozen or so seats in the House, pushing the GOP to its biggest majority since the 1940s and making it look all but impregnable.

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No one was really prepared for the carnage that ensued. Early in the evening, when pivotal Democratic incumbent Jeanne Shaheen was surviving in New Hampshire, it seemed there might still be a silver lining. But she scraped by just barely, and it turned out to be the briefest of breaks in the clouds. Eight other Democratic Senate seats went to the GOP, and a ninth is likely to turn over in a month when Louisiana holds a runoff between incumbent Democrat Mary Landrieu and her Republican challenger, Rep. Bill Cassidy.

Yet the most striking damage was done where it was least expected — and where Democratic hopes had been relatively high: in the races for governor.

Republicans began the night with 29 of the 50 governorships. Democrats expected to whittle that number a bit, targeting controversial GOP incumbents in Maine, Pennsylvania, Georgia, Florida, Ohio, Michigan and Wisconsin. In the end, only Republican Tom Corbett of Pennsylvania went down. Meanwhile, the Democrats watched in horror as their seats in Massachusetts, Maryland and Arkansas were captured, and as incumbent Pat Quinn was ousted in Obama's home state of Illinois. Dannel Malloy in Connecticut and John Hickenlooper in Colorado also were endangered in races too close to call in the wee hours of Wednesday morning.

No doubt the same dynamic that drove the Senate and House results was at work in the gubernatorial contests. People who came out to register their distress with Obama or congressional Democrats — or with any aspect of current reality – were more likely to vote Republican for governor, as well. The anti-incumbent element of the nation's indigestion was often trumped by the desire to punish Democrats, whether in office or not.

And the unpopularity of Congress, an institution that has an approval rating below 20 percent – half that of "the unpopular president" — once again seemed hard to reconcile with high rates of re-election. Most members of both parties who were on the ballot won. Those who lost were overwhelmingly Democrats.

What does all this portend for the days ahead? It surely undercuts the message of the Democratic Party. It calls into question Democrats' ability to mobilize voters or to win close races with a big majority among women, young voters and non-Anglo communities. Just as clearly, it invigorates all those whose faith is in an alternative, conservative vision.

But the actual working out of divided government will be a work in progress for the next two years, so let's take its problems in phases.

The Lame Duck. In the weeks ahead, the Democrats will have a chance to confirm as many Obama appointees to executive branch jobs and judicial vacancies as time will allow. The Senate GOP will object and drag its feet and seek to minimize the number. There also will be negotiations for a longer-term budget deal, and there could be action on fronts such as immigration, Ebola and the military response to ISIS. All the old players from the 113th Congress will be back, many making a final curtain call. But the dynamic will be different in anticipation of the new power arrangements that take effect in January.

The First Half of 2015. There is a window for the two parties and the two chambers to work together and demonstrate their willingness to cooperate, but it will be closing soon. If Mitch McConnell truly wishes to be a transformational leader in the Senate, he will need to unite his own party's dealmakers and its ideologues. Then he will need to negotiate a deal with his chamber's Democrats and another with the House's Republicans. Ultimately, it will all have to pass muster with the president, who will still have his veto pen and the knowledge his veto will not be overridden.

The 2016 Cycle. The new election cycle begins the day after Election Day. That is especially true when there will be a White House vacancy to fill in the next round of voting. Candidates are already preparing and flocking to early primary states. So even if the GOP manages to delay its first TV debates and reduce the number of these bruising affairs, the gloves will come off and the competition for primary votes will commence. At this point, any cooperation with the Democrats or the president will be much more difficult.

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2014 elections

Battle for the Senate 2014

President Barack Obama