The passage of the Affordable Care Act represents an historic change in the way health insurance has been handled in the United States. With political discourse about the act continuing to occupy public policy debates and the news media, this collection attempts to shed light on the impact of the policy on citizens and providers as well as examine how the ACA is affecting quality, access, and costs of care.

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How the Affordable Care Act Has Improved Americans' Ability to Buy Health Insurance on Their Own: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016

February 2, 2017

Issue: Since 2001, long before the passage of the Affordable Care Act (ACA), the Commonwealth Fund Biennial Health Insurance Survey has examined health coverage and consumers' experiences buying insurance and using health care. Goals: To examine long-term trends and to make comparisons before and after passage of health reform. Methods: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. Findings and Conclusions: There have been dramatic improvements in people's ability to buy health plans on their own following the passage of the ACA. For adults with family incomes less than $48,500, uninsured rates dropped about 17 percentage points below their 2010 peak. Lower-income whites, blacks, and Latinos have experienced drops this large, though Latinos are uninsured at higher rates. Among working-age adults who had shopped for plans in the individual market and ACA marketplaces over the prior three years, the percentage who reported it was very difficult to find affordable plans fell by nearly half from 2010, prior to the ACA reforms, to 2016. Coverage gains are helping working-age Americans get the care they need: the number of adults who reported problems getting needed health care and filling prescriptions because of costs fell from a high of 80 million in 2012 to an estimated 63 million in 2016.

Increasing Access to Care; Lowering Costs of Care

The Children’s Health Insurance Program: Why CHIP is Still the Best Deal for Kids

April 18, 2018

CHIP covers those who earn too much to qualify for Medicaid but not enough to be able to purchase health insurance coverage on their own. CHIP's supporters recognized the value of investing in children's coverage to make sure that all children have access to the medical care they need to grow up to become healthy and productive adults.CHIP has a long history of bipartisan support from lawmakers on both sides of the aisle who recognize that providing health coverage for our nation's children is a critical investment in America and its future. If funding for CHIP is not extended beyond FY 2017, the remarkable trend toward universal coverage for children would most certainly be reversed and significant numbers of children would become uninsured.

Can U.S. Health Care Escape MACRA's Bureaucratic Briar Patch?

March 28, 2018

Congress has struggled for decades to reform Medicare's fee-for-service payment system, which has driven up the cost of American health care by reimbursing medical providers for services, regardless of their value or quality. The most recent attempt at reform, the 2015 Medicare and CHIP Reauthorization Act (MACRA), seeks to quantify the value of care delivered and to get medical practices to bear some responsibility for the aggregate costs associated with a course of treatment.To do so, the law provides higher payments to clinicians who participate in Alternative Payment Models (APMs), in which practices are penalized for excessive aggregate costs associated with the delivery of a full course of treatment. Most medical practices have balked at APMs, which require them to bear substantial financial risks. These practices, however, will become subject to a complex grading mechanism, the Merit-based Incentive Payment System (MIPS), which will adjust Medicare payments to clinicians in line with their performance relative to peers on a vast array of performance metrics. Yet the federal agency tasked with overseeing this scoring system has publicly declared MIPS to be unworkable and called for its repeal.The fact that Medicare has inadvertently encouraged the proliferation of low-value services does not mean that it is capable of transforming health care for good by identifying and rewarding high-value care. It would be enough to avoid doing harm. That goal can be accomplished if APMs were to give clinicians full credit for treating patients enrolled in Medicare Advantage—which would eliminate the risk to taxpayers of inflated volumes of low-value services, while freeing medical practitioners from arbitrary and counterproductive regulations.

The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review

March 28, 2018

A substantial body of research has investigated effects of the Medicaid expansion under the Affordable Care Act (ACA) on coverage; access to care, utilization, affordability, and health outcomes; and various economic measures. This issue brief summarizes findings from 202 studies of the impact of state Medicaid expansions under the ACA published beginning in January 2014 (when the coverage provisions of the ACA went into effect) and updates earlier versions of this brief with studies through February 2018.1 More recent studies continue to support earlier findings but provide additional findings in key areas, including expansion's effects on health outcomes, access to services and medications for behavioral health and other needs, and providers' financial stability.

Percent of Children Covered by Medicaid/CHIP by County, 2012-2016

March 26, 2018

Notes: Children are defined as under 18 years of age. Children with two or more types of coverage are not included in the map. A dash indicates that the percent of children with Medicaid/CHIP coverage in the county are unreported on the map because there are fewer than 10 children residing in the county. Source: Georgetown University Center for Children and Families analysis of the five-year estimates of summary data from the 2016 American Community Survey (ACS). The U.S. Census Bureau publishes ACS summary data on American Fact Finder. Percent estimates were computed.

Abortion Coverage in the Bipartisan Health Care Stabilization Act of 2018 ( S.1771 )

March 22, 2018

The role of government in regulating abortion coverage began to be debated shortly after the landmark Supreme Court ruling in Roe v Wade. Since 1976, the Hyde Amendment has blocked federal funds under Medicaid and other federal programs from being used to pay for abortion, allowing exceptions only for pregnancies that endanger a woman's life, or that result from rape or incest. The Affordable Care Act (ACA) interpreted the federal abortion-funding ban to include the federal tax credits that functioned as premium subsidies to help individuals afford Marketplace plans. This issue brief reviews current federal and state policies on private insurance coverage of abortion services, and how the Bipartisan Health Care Stabilization Act of 2018 would affect abortion coverage for women enrolled in the individual market.

Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2018: Findings from a 50-State Survey

March 20, 2018

This 16th annual 50-state survey provides data on Medicaid and the Children's Health Insurance Program (CHIP) eligibility, enrollment, renewal and cost sharing policies as of January 2018. It takes stock of how the programs have evolved as the fifth year of implementation of the Affordable Care Act (ACA) begins, discusses policy changes made during 2017, and looks ahead to issues that may affect state policies moving forward. It is based on a survey of state Medicaid and CHIP officials conducted by the Kaiser Family Foundation and the Georgetown University Center for Children and Families.Key FindingsMedicaid and CHIP provide a robust base of coverage for low-income children. All but two states cover children with incomes up to at least 200% of the federal poverty level (FPL, $41,560 per year for a family of three in 2018), including 19 states that cover children with incomes at or above 300% FPL. The ten-year extension of federal funding for CHIP approved by Congress provides states stable funding to maintain children's coverage and continues protections for children's coverage moving forward.There have been major gains in Medicaid eligibility for parents and other adults under the Affordable Care Act (ACA) Medicaid expansion, but eligibility remains limited in the 19 states that have not implemented the expansion. Among non-expansion states, the median eligibility level for parents is 43% FPL ($8,935 for a family of three in 2018) and other adults generally are ineligible. Alabama and Texas have the lowest parent eligibility limits at 18% FPL or $3,740 per year for a family of three. Additional states may expand Medicaid for adults in the coming year, which would reduce the number of poor uninsured adults who fall into the coverage gap. States moving forward with expansion may seek waivers to add requirements or restrictions for adults as a condition of expanding.Through significant investments of time and resources, most states have transformed their Medicaid and CHIP enrollment and renewal processes to provide a modernized, streamlined experience as outlined in the ACA. With these processes, a growing number of states are processing real-time eligibility determinations and automated renewals through electronic data matches with trusted data sources. Looking ahead, waivers and other proposed changes for adults, including premiums and cost sharing, work requirements, and lockout periods, require complex documentation and costly administrative processes that run counter to the simplified enrollment and renewal processes states have implemented under the ACA.

Insurers Remaining in Affordable Care Act Markets Prepare for Continued Uncertainty in 2018, 2019

March 19, 2018

A new report, supported by the Robert Wood Johnson Foundation and authored by Georgetown CHIR and Urban Institute researchers, examines how uncertainty over the long-term future of the ACA have affected insurers' participation and premium setting decisions for the 2018 and 2019 plan years. We interviewed 10 insurance companies participating in the individual market in 28 states and D.C. and a few key takeaways include:The rollback of the ACA's individual mandate led insurers to implement higher premiums in 2018 and will likely drive premiums even higher in 2019. However, insurers' views differed on the impact of repealing the individual mandate. Some felt it would ultimately lead to a collapse of the market and are considering further retrenchment; others felt confident that a market for highly subsidized, low-income consumers would continue.The midyear loss of the ACA's cost-sharing reduction plan reimbursements drove 2018 premium increases ranging from 10 percent to 20 percent. However, several insurers noted that proposed federal legislation to restore cost-sharing reduction funding could result in significant disruption and sticker shock for consumers receiving premium tax credits.All insurers had concerns regarding an expansion of short-term and association health plans under the President's October 12, 2017 executive order. Insurers worry that an expansion of these plans could siphon healthy people away from the individual market, leaving a sicker, costlier population.Insurers with narrow provider networks reported concerns about the potential exit of competing insurers, noting that their network providers lacked capacity to take an influx of new, often sicker enrollees. They further noted that unexpected insurer exits can produce considerable disruption, particularly if remaining insurers lack sufficient time or ability to readjust their pricing.A worsening of the risk pool will likely cause many insurers to reduce their market presence, will cause all insurers to raise their premiums, and may lead to more exits.

Health Reform and Changes in Health Insurance Coverage in 2017

March 19, 2018

More than 20 percent of the gains in health insurance under the Affordable Care Act (ACA) disappeared by the end of 2017. The uninsured rate for nonelderly adults increased by 1.3 percentage points in 2017, after decreasing by 6.3 percentage points between 2013-2016, after the full implementation of the ACA. Key FindingsResearchers pointed to factors that could be contributing to fewer people with insurance:Fewer federal resources devoted to raising awareness of coverage options and signing-up individuals;Increasing premiums in the individual marketplace;Recent regulatory changes.ConclusionThe ACA is associated with large gains in coverage and access to care. As the partial loss of these gains over 2017 shows, this increased coverage isn't necessarily permanent, and ongoing policy debates will have an impact on health insurance coverage. Continued monitoring of changes in coverage levels, utilization of health care services, and population health are needed to fully understand the effects of policy changes on the ACA's impact.

Do Medicare Advantage Plans Respond to Payment Changes? A Look at the Data from 2009 to 2014

March 14, 2018

Issue: Medicare Advantage (MA) enrollment has grown significantly since 2009, despite legislation that reduced what Medicare pays these plans to provide care to enrollees. MA payments, on average, now approach parity with costs in traditional Medicare.Goal: Examine changes in per enrollee costs between 2009 and 2014 to better understand how MA plans have continued to thrive even as payments decreased.Methods: Analysis of Medicare data on MA plan bids, net of rebates.Findings: While spending per beneficiary in traditional Medicare rose 5.0 percent between 2009 and 2014, MA payment benchmarks rose 1.5 percent and payment to plans decreased by 0.7 percent. Plans' expected per enrollee costs grew 2.6 percent. Plans where payment rates decreased generally had slower growth in their expected costs. HMOs, which saw their payments decline the most, had the slowest expected cost growth.Conclusions: In general, MA plans responded to lower payment by containing costs. By preserving most of the margin between Medicare payments and their bids in the form of rebates, they could continue to offer additional benefits to attract enrollees. The magnitude of this response varied by geographic area and plan type. Despite this slower growth in expected per enrollee costs, greater efficiencies by MA plans may still be achievable.

Women’s Connections to the Healthcare Delivery System: Key Findings from the 2017 Kaiser Women’s Health Survey

March 13, 2018

Women's ability to access the care they need depends greatly on the availability of high quality providers in their communities as well as their own knowledge about maintaining their health through routine checkups, screenings, and provider counseling. This brief presents findings from the 2017 Kaiser Women's Health Survey, a nationally representative survey of women ages 18 to 64 on their health status, relationships to regular providers and sites of care, and the frequency at which they receive routine preventive care. The Kaiser Family Foundation has conducted surveys on women's health care in 2001, 2004, 2008, and 2013. This brief focuses on findings from the newest 2017 survey and presents some findings compared to earlier years.

Kaiser Health  Tracking Poll – February 2018 : Health Care  and the 2018 Midterms, Attitudes Towards Proposed  Changes to Medicaid

February 27, 2018

With still a few months until the midterm elections are in full swing, the latest Kaiser Health Tracking Poll finds health care costs as the top health care issue mentioned by voters when asked what they want to hear 2018 candidates discuss. When asked to say in their own words what health care issue they most want to hear the candidates talk about during their upcoming campaigns, one-fifth (22 percent) of registered voters mention health care costs. This is followed by a series of other health care issues, such as Medicare/senior concerns (8 percent), repealing or opposition to the Affordable Care Act (7 percent), improve how health care is delivered (7 percent), increasing access/decreasing the number of uninsured (6 percent), or a single-payer system (5 percent). Health care costs is the top issue mentioned by Democratic voters (16 percent) and independent voters (25 percent), as well as one of the top issues mentioned by Republican voters (22 percent), followed by repealing or opposing the ACA (17 percent).