Reports & Analysis

Ever since the Supreme Court effectively ruled in June 2012 that states could choose whether or not to expand Medicaid to nonelderly adults under the ACA, that choice has been one of the most prominent and often one of the most contentious issues for states. This report describes the six states (Arkansas, New Hampshire, Indiana, Iowa, Michigan and Pennsylvania) that requested and received approval from the federal government to experiment with coverage approaches that are modelled on private insurance concepts and not permitted in a standard Medicaid expansion.

Since implementation of the ACA, the 30 states that have expanded Medicaid have enrolled more than 10 million people in Medicaid or the Children’s Health Insurance Program and the collective rate of uninsured individuals in these states has fallen from 18 percent to less than 11 percent. This paper examines early data on expansion-related decreases in uncompensated care costs and related state budget implications, including impending reductions in federal support for Medicaid Disproportionate Share (DSH) payments and waiver pools made available to support hospital uncompensated care costs prior to the Medicaid expansion authorized and funded under the ACA.

This report reveals significant collaboration between Arkansas's public and private sectors to expand health care coverage through the Health Care Independence Program (commonly known as the "private option") and the federally facilitated marketplace partnership. The political environment in Arkansas that led to decisions related to the ACA are detailed in the report, along with the fluid status of the state’s pioneering decisions in light of recent leadership transitions and uncertainty at the federal level.

The Supreme Court is expected to issue a ruling by the end of June in King v. Burwell, a case challenging the legality of health insurance subsidies provided to low- and middle-income people in the 34 states where the federal government is operating the insurance Marketplace under the Affordable Care Act. This map and table show for each state: the number of people now receiving premium subsidies who would lose them if the Court finds for the challengers; the total amount of federal subsidy dollars; the average premium tax credit that subsidized enrollees have qualified for; and the average increase in premiums that subsidized enrollees would face if the subsidies are disallowed.

Introduced by the Affordable Care Act (ACA), the Essential Health Benefits (EHBs) are a set of ten health care service categories that non-grandfathered health plans in the individual and small group markets must cover. States are in the process of making important decisions about the EHBs, therefore this is a key time to influence and shape the next phase of EHBs across states. This brief highlights steps that California has taken to update the EHBs, and continued advocacy efforts.

In the five years since the ACA was passed, the nation's attention has shifted from the law's insurance market reforms and the bumpy rollout of healthcare.gov to the success of the marketplaces in covering millions of previously uninsured Americans. Far less attention has been paid to the parts of "Obamacare" that target problems with how health care is delivered and paid for, many of which become apparent when people receive their insurance card and seek out care.

Dollars spent on health care are dollars not available for other uses. Understanding the rate at which costs are growing—and the growth rate the economy can bear—is important for the financial health of any state. This report looks at total cost of care measurement activities in four states and the policy priorities in each state that are driving the activity. It examines the questions these states had to ask and in determining total cost of care measurement—where data come from, what to count, how to count—and how they answered them.

New estimates from the Commonwealth Fund Biennial Health Insurance Survey, 2014, indicate that 23 percent of 19-to-64-year-old adults who were insured all year—or 31 million people—had such high out-of-pocket costs or deductibles relative to their incomes that they were underinsured. These estimates are nearly double those found in 2003 when the measure was first introduced in the survey. The share of continuously insured adults with high deductibles has tripled, rising from 3 percent in 2003 to 11 percent in 2014. Half of underinsured adults reported problems with medical bills or debt and more than two of five reported not getting needed care because of cost.

In the short time since states have been able to expand Medicaid to low-income adults under health reform, a clear divide has emerged between states that have expanded Medicaid and those that have not. Since the major coverage provisions of the ACA took effect in 2014, insurance coverage rates have improved across the country, but the gains are far greater in the states that have expanded Medicaid. As a result, hospitals in expansion states are treating fewer uninsured patients, and the amount of uncompensated care they are providing is declining steeply. Moreover, contrary to critics' claims that Medicaid expansion is financially unsustainable for states, there is increasing evidence that expansion has saved states money, and these savings are expected to grow over time.

Approximately 14.1 million previously uninsured Americans gained health insurance between the beginning of open enrollment in October 2013 and March 4, 2015. Some of the greatest declines in uninsured rates were for lower- and middle-income consumers, including those eligible for tax credits to help pay their premiums for plans in the health insurance marketplaces. But simply having health insurance is no guarantee that consumers can afford to pay for health care. Unfortunately, this study shows that, for many Americans with non-group coverage, deductibles and other out-of-pocket costs are prohibitively high, and are associated with many of these insured consumers forgoing needed health care.