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.

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 Individual Mandate Is Unnecessary and Unfair

October 25, 2017

The importance of the individual mandate to the Affordable Care Act's exchanges has been greatly exaggerated. It has done little to increase enrollment, to reduce insurance premiums, or to alleviate the burden of uncompensated care. Rather, the main effect of the provision has been to concentrate more of the expense of covering the chronically ill on the relatively small cohort of working Americans who lack employer-sponsored coverage. By doing so, the mandate has served to obscure the total cost of the entitlement.This issue brief examines the intent of the individual mandate, investigates why it was implemented in its present form, and demonstrates that its poorly distributed penalties have done little to enhance the affordability of health insurance or the stability of the individual market.

Rhetoric and Reality The Obamacare Evaluation Report: Access to Care and the Physician Shortage

July 9, 2013

President Barack Obama's first term was defined by the battle over, and the passage of, the Patient Protection and Affordable Care Act, the landmark health-reform legislation known popularly as Obamacare. Along the way, Obama, the law's supporters, and independent analysts such as the Congressional Budget Office (CBO) made specific claims or projections about how the law would affect consumers, patients, and businesses.Now, three years after Obamacare's passage, many key provisions of the legislation are beginning to be implemented. Whether implementation succeeds or fails will be strongly influenced by the reactions of states, providers, insurers, businesses, and consumers to the law's provisions and to the thousands of pages of new health-care regulations.Rhetoric and Reality is a project of the Manhattan Institute's Center for Medical Progress that is designed to offer an ongoing, objective, and accessible perspective on the law's performance in light of key claims or projections made about it. Our project will examine the law's effect on Americans in five overarching areas: health-care costs, insurance coverage, employment, access to care, and consumer-driven health plans. Additional topics may be added.Each evaluation will be based on the best available data and will be revised as new or more authoritative data become available.

Increasing Access to Care