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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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.

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.

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

State Health Compare

January 1, 2018

Analysis of healthcare access at the state level that goes beyond standard indicators of health insurance coverage.

Medicaid’s Role in Improving the Social Determinants of Health: Opportunities for States

June 19, 2017

In an environment of uncertainty surrounding the future of Medicaid policy and funding, addressing the social determinants of health to improve the health status of Medicaid beneficiaries could be dismissed as an unaffordable luxury. But there is a strong business case for state Medicaid programs to address the social determinants of health as a key strategy for providing cost-effective, efficient care. By partnering with state and local agencies to address the social determinants of health, state Medicaid leaders may enhance their ability to control costs and strengthen the program's financial sustainability over the long term.This policy brief explains how state Medicaid agencies and managed care organizations can address the social determinants of health (SDH). It reviews the evidence demonstrating a link between health status and SDH, summarizes the business case for Medicaid to support interventions aimed at addressing SDH, describes current opportunities—and limitations—for using Medicaid as a lever to address SDH, and discusses new prospects for state policymakers to tackle SDH in the current environment.

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.

How Accessible and Affordable Were Individual Market Health Plans Before the Affordable Care Act? Depends Where You Lived

January 24, 2017

Before the Affordable Care Act (ACA), the landscape of the individual market looked much different than it does today, particularly for those in less than perfect health. For the most part, what state you lived in determined how easily you could purchase a health plan, the price you would pay, and what the plan would cover. Rules for insurers in the individual market varied from state to state, but in most states, if you had a pre-existing condition, you could be denied coverage, pay more, or have coverage for your pre-existing condition excluded from your health plan. As Congress debates repeal of the ACA and its protections for people with pre-existing conditions, many policymakers have called for greater state flexibility in insurance regulation than currently exists under the ACA. It therefore is helpful to understand the range of consumer protections in the states before the ACA, and why the ACA included the insurance reforms it did. This issue brief summarizes state rules for the individual market on the eve of the Affordable Care Act.

Strengthening Medicaid as a Critical Lever in Building a Culture of Health

January 17, 2017

Strengthening Medicaid as a Critical Lever in Building a Culture of Health is a nonpartisan study panel report which offers a series of steps that would enable Medicaid to leverage its unique role as an insurer to increase its capacity for addressing the underlying social determinants of health. The study panel was convened to assess the current and possible future role of Medicaid in building a Culture of Health. The panel included state Medicaid program directors, public health and health policy experts, health researchers, medical and health professionals, and health plan representatives.The panel discussed strategies that could increase Medicaid's potential to help move the dial on individual and population health, while improving health care quality and program efficiency. The findings are divided into two categories: those that can be accomplished administratively (without any further legislative action) and those that would require legislative change.The report also recognizes key challenges that Medicaid faces, including the high cost states already bear for insuring vulnerable populations, the chronic insufficiency of funding for social service programs that could partner with Medicaid to foster health, and the complexities of implementing innovative care delivery models, among others.While the current political landscape signals new policy discussions about the future of the program and its funding, the analysis and options included in this report recognize that health care coverage is a critical underpinning for improving health. Whether and how Medicaid might be changed, its role as an insurer is foundational; this report assumes that Medicaid will continue to be central to the health care safety net as an insurer of low-income, vulnerable populations.

Institutionalizing Outreach: A Review of Enroll America's Get Covered Academy Training Program

September 16, 2016

Mathematica Policy Research examined the implementation of Enroll America's Get Covered Academy training program during the third open enrollment period to describe and assess the training and follow-up support delivered and to understand partners' ability to implement, use, and institutionalize Enroll America's strategies and tools. The findings in this report are based on interviews with Enroll America staff and a sample of Academy participants in spring 2016.

Evaluation of Outreach: Evaluation of Enroll America's Efforts to Support ACA Enrollment

November 20, 2015

Mathematica Policy Research examined the implementation of Enroll America's field outreach campaign during the second open enrollment period, to understand whether and how it adapted the campaign compared to its first year activities, to assess second-year performance, and to document Enroll America's expectations for their work in 2015 and beyond.

Making the Transition; The Uninsured

SHAP Enrollment and Eligibility Activities: Implications for Process and System Modernization Under National Health Reform

May 18, 2012

Shares five states' experiences and best practices in using State Health Access Program grants to expand public health coverage through community-based outreach and improved eligibility and enrollment processes, as well as implications for federal reform.

Lowering Costs of Care