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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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.

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.

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.

Maternal Depression and Young Adult Mental Health: Key Policy Agenda for Systems that Support Mental Health and Wellness

February 13, 2018

Three million Americans living in poverty are either a mother who has experienced depression or a young adult who has experienced serious psychological distress during the past year. Untreated mental health needs have significant consequences for mothers and young adults as well as their families. This is especially true for low-income people. It is essential to create policy that better meets their mental health needs to ensure their healthy development and long-term success. This report makes the case for CLASP's new foundation-funded effort to strengthen Medicaid, mental health, and human services policy at the federal and state levels to improve outcomes for families and young adults living in poverty. The goals of this initiative are to: (a) develop frameworks for identifying and treating maternal depression among parents of young children as well as improved access to high-quality mental health supports for youth; and (b) help a small number of selected states implement important aspects of the two frameworks. CLASP is uniquely positioned to bridge diverse stakeholders, analyze and identify policy opportunities, and support states interested in advancing this policy agenda. Across numerous fields, policymakers and stakeholders must work together to foster equitable health and economic outcomes for low-income mothers and young adults living in poverty. This work is essential to building systems support all low-income people's mental health and wellness.

Addressing Barriers to Breast Cancer Care in California: The 2016 - 2017 Landscape for Policy Change

February 1, 2018

In 2018, over 29,000 women will be diagnosed with breast cancer in California and an estimated 4,500 will die of the disease. While the Affordable Care Act (ACA) has successfully expanded access to health insurance and breast cancer care, numerous population subgroups remain uninsured, and many others may lack adequate coverage for treatment and management of their breast cancer. Although insurance improves breast cancer outcomes compared to those with no insurance, challenges may remain even for the insured. Among those insured, there appear to be significant barriers to cancer care as health insurance premiums are increasing, networks are narrowing, and as the cost of breast cancer drugs is increasing.This report provides a comprehensive assessment of the significant barriers and challenges to accessing breast cancer care in California through the  completion of three key tasks: (1) a synthesis of the peer reviewed literature, news media, reports and policy briefs, (2) completion of a series of key informant/stakeholder interviews, and (3) an analysis of social media. The authors find five categories of barriers: (1) Health System Barriers, (2) Insurance Barriers, (3) High Costs, (4) Individual and Cultural Characteristics, and (5) Language.Although many barriers are shared across insurance types, where possible, this report provides insight on barriers unique to the insurance status of women, specifically for the uninsured, those covered by Medi-Cal, and those covered by commercial insurance. Findings from this report can be used to guide efforts of policymakers to improve timely access to breast cancer care among all women in California.

How to Increase Health-Insurance Coverage by Reducing ACA Crowd-Out

January 23, 2018

Public health-care entitlements in the U.S. have traditionally been designed to supplement rather than to supplant privately purchased health insurance. About 40% of the entitlement funds disbursed under the Affordable Care Act (ACA), however, have gone to individuals who already had private coverage. This displacement of private-sector spending by public-sector activity is called "crowd-out." While the ACA has reduced the share of the American population without health insurance, its spending has been poorly-targeted to fill gaps in care, and 28 million remain uninsured.This paper reviews estimates of ACA crowd-out and examines the potential for block grants to allow states to target assistance at individuals otherwise lacking coverage. Under such a reform, the same level of federal funding could do more to expand access to care and to provide protection from catastrophic medical costs for those who need help the most.

The Affordable Care Act’s 1332 Waiver: An Avenue for Short-run Adjustment, Innovative Change, or Political Acceptance?

January 19, 2018

Although the Congress repeatedly failed to repeal and replace the Affordable Care Act (ACA) in 2017, ACA policies have changed extensively over the past year. December's tax bill eliminated the financial penalties enforcing the individual mandate, starting in 2019. The Trump administration used its executive powers to slash ACA advertising spending and shrink the ACA enrollment period, and it ceased making cost-sharing reduction payments to insurers. These changes did not appear to have a big impact on ACA's 2018 enrollments, which were only slightly below the previous year's total, but there has been a decline in the number of participating insurers, and premiums increased in many rating areas.It is still too early to know the longer-term effects of these changes, much less anticipate future developments. They do, however, suggest that states are implementing the ACA in a dynamic, uncertain environment even after the act escaped wholesale replacement. To deal with these and future changes, or to modify policies that would make state ACA programs more effective, or more to their political liking, state governments may turn to the ACA's Section 1332 State Innovation Waivers. The 1332 waivers are not the only way in which states can modify ACA policies, and their role has been limited to date. But the waivers have potential as a means for widespread policy change, and that potential may grow. As of this writing, there are bipartisan proposals in the Congress to expand the authority under the ACA's section 1332 provision to foster even more state innovation.This paper discusses the 1332 waiver — its origins, powers and limitations, and uses thus far — and how it may be used to address major challenges facing the ACA. We note, for example, a shift in the purposes of planned 1332 applications before and after the 2016 elections, a shift that suggests a new and challenging function for waivers — not simply to allow states to adopt different pathways to common policy goals, but to respond effectively and quickly to rapid changes in healthcare markets. We discuss the practicality and implications of this shift along with ways in which 1332 waivers may be used to serve other purposes, including how they may be used in combination with other waivers and instruments to bring about comprehensive reforms in the delivery of healthcare. We also discuss the prospects for 1332 waivers in the coming years, their potential roles in adapting the ACA to changing and diverse circumstances, and ways in which the waiver process may be improved.

Maryland Department of Health Master Agreement Annual Report of Activities and Accomplishments: FY 2017

October 1, 2017

This report describes the services The Hilltop Institute provided to the Maryland Department of Health (MDH) under the Master Agreement between Hilltop and MDH. The report covers fiscal year (FY) 2017 (July 1, 2016, through June 30, 2017). Hilltop's interdisciplinary staff provided a wide range of services, including: Medicaid program development and policy analysis; HealthChoice program support, evaluation, and financial analysis; long-term services and supports program development, policy analysis, and financial analytics; and data management and web-accessible database development.

Medicaid Is Vital for Women’s Jobs in Every Community

June 26, 2017

Medicaid is primarily known as the government program that provides health insurance coverage to individuals struggling to make ends meet. Women make up the majority of Medicaid enrollees, and the program covers a range of services – birth control, maternity care, prescription drugs, hospitalization, long-term care, and more – that address many of women's major health needs throughout their lives.At the same time, Medicaid plays a critically important role in advancing women's economic security through directly supporting women's jobs and by providing health insurance coverage that enables women to work.Proposals to fundamentally change how Medicaid is financed and create barriers to enrollment threaten the livelihood of millions of women.

Double the Trouble: Health Care Access Without the Affordable Care Act or Planned Parenthood

June 23, 2017

Access to high quality, affordable health care, including reproductive health care, is critical to an individual's health, economic security, and dignity. But access to health care requires more than just an empty promise—the existence of health care services means nothing if a person can't afford them or if there are no quality health care providers in their area to deliver the services they need.In light of relentless attacks on both the ACA and Planned Parenthood by Congress and the Trump Administration, this report paints a picture of what health care access would look like if the ACA is dismantled and Planned Parenthood is defunded. This analysis contains five example scenarios of the obstacles that potential patients could face in getting the health care they need.

Healthcare Workforce Transformation: Preparing the Workforce for a Healthy Rhode Island

May 11, 2017

Rhode Island is changing the way it delivers and pays for healthcare. In Rhode Island, healthcare doesn't stop at the doctor's office or the hospital bed—It extends to where people live, work, play, and learn. It rewards quality outcomes rather than quantity—the number of patient visits. This approach to care is data-driven and evidence-based—tracking patient populations to identify risks and measure results. To achieve its goals, Rhode Island has mounted a number of initiatives to change healthcare payment policies and service delivery.None of these changes in healthcare are possible without a transformed workforce—with the right workers, with the right skills and tools, in the right place at the right time. To determine what this workforce looks like and how to prepare for it, the Rhode Island Executive Office of Health and Human Services, in partnership with the State Innovation Model Test Grant, convened a cross-section of stakeholders from the state's healthcare providers, education and training organizations, and policymakers in health and workforce. This group—the Rhode Island Healthcare Workforce Transformation Committee—gathered to establish workforce priorities and weigh potential strategies. Topics analyzed included primary care, behavioral health practice and integration, social determinants of health, health information technology, oral health, chronic disease, and home and community-based care. This report, prepared by Jobs for the Future (JFF), provides background research to support Rhode Island's development of a healthcare workforce transformation strategy. To determine workforce needs in a changing healthcare environment, this study asks not just how many new workers are needed in particular occupations, but how to renew the skills of the existing workforce to assume new and evolving healthcare roles in new settings.

How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data

April 1, 2017

The American Health Care Act, which was considered by Congress, would have repealed the state option to expand Medicaid under the ACA. However, with the ACA remaining intact, states that did not expand Medicaid now have the chance to reconsider.Key FindingsUsing data through fiscal year 2015:In states that expanded Medicaid through the ACA, hospitals had $5.0 million in increased Medicaid revenue and $3.2 million decreased uncompensated care costs, on average per hospital. Hospitals in states that expanded Medicaid through the ACA improved average operating margins by 2.5 percentage points.Small hospitals, for-profit and non-federal-government-operated hospitals, and those in non-metropolitan areas saw the strongest gains in profit margins.ConclusionFor states still considering Medicaid expansion, experts say that expansion likely would improve hospitals' payer mix and overall financial outlook, particularly for hospitals in non-metro areas.