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 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.

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.

The Impact of Alabama’s Proposed Medicaid Work Requirement on  Low-Income Families with Children

March 19, 2018

Alabama is seeking federal permission through a Section 1115 Medicaid demonstration waiver to require parents and caregivers who rely on Medicaid to work 20 to 35 hours a week, prove they are looking or training for a job or do community service before receiving Medicaid. This proposal targets the very poorest and most vulnerable families with children in Alabama – many of whom will lose their health coverage.If approved, according to the state's own projections, this work requirement would result in as many as 8,700 of Alabama's poorest residents losing their Medicaid coverage in the first year alone.Alabama is not the first state to seek a work requirement, but it is one of the first to do so without accepting the Medicaid expansion provided under the Affordable Care Act. That expansion allows adults with incomes slightly above the poverty line (138 percent of the federal poverty level) to receive Medicaid. In Alabama, only the poorest parents and caregivers, those making 18 percent of the poverty level or less—$3,740 a year for a family of three or about $312 a month—now qualify. That is the strictest eligibility requirement in the nation (along with Texas). Because Alabama has not expanded Medicaid, the work requirement would apply only to these extremely poor parents.The new requirement would also affect workers using Transitional Medical Assistance (TMA) by cutting TMA benefits from 12 to six months despite eligibility rules, which ensure that these beneficiaries, by definition, are working more. This contradicts the stated goals of the state's Section 1115 proposal and suggests that this aspect of the proposal is not about encouraging work but rather about cutting enrollment and Medicaid spending.In addition, the proposal creates more red-tape and barriers to health coverage without any guarantee of new resources to help families overcome barriers to employment such as job training, transportation or childcare assistance so that very low-income mothers can fulfill their parental responsibilities while meeting the new restrictions on Medicaid coverage.

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.

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.

Key Healthcare Proposals in Governors’ Proposed Budgets for SFY 2019 from a Preliminary Look at 32 States

February 15, 2018

Key Healthcare Proposals in Governors' Proposed Budgets for SFY 2019 from a Preliminary Look at 32 States.

Why Does Medicare Advantage Work Better Than Marketplaces?

January 30, 2018

Medicare Advantage (MA) markets are significantly more robust, with higher private insurer participation and lower average premium growth than the Affordable Care Act (ACA) marketplaces. The programs differ in insurer participation, the risk-adjustment system, and provider payments.Key FindingsBased on MA's success relative to the ACA marketplaces in terms of marketplace strength and long-term stability, there are five policies that could be useful for the ACA marketplaces:Raise enrollment in marketplace plans by increasing premium and cost-sharing subsidies and eliminating short-term plans;Cap provider payment rates at Medicare rates or a fixed percentage above them;Standardize cost-sharing within metal tiers, or limit the number of plan designs available;Lift the budget neutrality requirement for risk adjustment in the marketplaces; andUse a higher benchmark than the second-lowest-cost silver plan for calculating premium tax credits. ConclusionMA's success lays out a possible model for the ACA marketplaces. By adopting policies geared towards increasing enrollment in marketplace plans as well as insurer participation, the ACA marketplaces could become stronger and more stable.

What Is the "CHIP Cliff" and How Can Congress Fix It?

January 29, 2018

On January 22, 2018, Congress included a six-year extension of the Children's Health Insurance Program (CHIP) as part of a continuing resolution (CR) to keep the federal government funded on a temporary basis. Funding for CHIP had expired 114 days before, at the close of September 2017. States were continuing to operate their programs with unspent funding from FY 2016 and FY 2017 and a $2.85 billion appropriation from Congress in the CR passed in late December.However, by this past week, states were rapidly running out of any funding. A report by Georgetown's Center for Children and Families had estimated, "If Congress fails to approve long-term funding for CHIP in January, nearly 1.7 million children in separate CHIP programs in 21 states with shortfalls in March 2018 could lose coverage by the end of February 2018."The latest CR is critically important in providing the funding necessary for the next six years to protect the health and well-being of the 9 million children and pregnant women who rely on CHIP for their health coverage, but leaves in place concerns among advocates and states about the long term fiscal health of the program, due to what advocates refer to as a "CHIP cliff."

Association Health Plan Proposed Rule: Summary and Implications for States

January 19, 2018

The U.S. Department of Labor (DOL) received over 900 comments on its proposed rule, which aims to promote the growth of Association Health Plans (AHPs) by making it easier for self-employed individuals and small employers to buy coverage through professional and trade associations. The proposed rule suggests relaxing the definition of AHPs so that eligible members can join together to act as a single, large group under the Employee Retirement Income Security Act (ERISA). In doing do, members would be regulated as large-group coverage, and therefore, would be exempt from many of the Affordable Care Act's (ACA) critical standards, including the provision of essential health benefits and compliance with the risk adjustment program

Medicaid Works: No Work Requirement Necessary

December 1, 2017

Several states have submitted proposals for Medicaid waivers to the Centers for Medicare and Medicaid Services that include work requirements. While work requirements are new to health programs, we have decades of experience with such requirements in other safety net programs, specifically cash assistance under Temporary Assistance for Needy Families and the Supplemental Nutrition Assistance Program. Ideas and language put forth by states in their Medicaid waivers are clearly drawn from these programs. We know from these programs that the main effect of work requirements is to discourage enrollment, with little effect on employment outcomes. This document translates many of the lessons learned from TANF and SNAP to Medicaid.