Reports & Analysis

SHADAC’s Marketplace Enrollment Reports provide monthly updates of Marketplace enrollment by state using data included on the Assistant Secretary for Planning and Evaluation (ASPE) Marketplace enrollment reports. SHADAC focuses its reports on states running their own State-Based Marketplace and includes a map displaying which states are operating State-based; Federal-State Partnerships; and Federally-facilitated Marketplaces. This resource is updated regularly as additional state and ASPE enrollment reports are published and made available.

States, whether or not they have decided to operate their own health insurance marketplaces, must navigate rapidly changing health insurance markets in which the ACA’s reforms are affecting insurers, businesses, and consumers. Under the ACA, states are primarily responsible for implementing significant insurance reforms that went into effect on January 1, 2014. This paper explores the responses of eight states to the ACA’s new rules and the creation of the new health insurance marketplaces.

Many individuals receiving care for behavioral health conditions also have physical health conditions that require medical attention, and the inverse is also true. Unfortunately, our physical and behavioral health care systems tend to operate independently, without coordination between them, and gaps in care, inappropriate care, and increased costs can result. This brief examines five promising approaches currently underway in Medicaid to better integrate physical and behavioral health care. They can be arrayed along a continuum that ranges from relatively modest steps to coordinate care between the two systems, to more ambitious efforts to implement a single integrated system of care.

Concern about even modest disruption of existing health insurance coverage by the ACA regenerates the belief that "there's got to be a better way" to make coverage available, adequate and affordable. But this brief shows that disruption is inevitable in any health reform and that the ACA's disruption is remarkably limited—far less than single payer proposals on the left or market-based proposals on the right. Further, unlike even many narrowly targeted reform alternatives, the ACA improves the pooling of risk that is essential to effective insurance.

This analysis estimates the geographic concentration of the uninsured across U.S. counties. The estimates are from the 2011 Small Area Health Insurance Estimates (SAHIE) program at the U.S. Census Bureau. The SAHIE program models health insurance coverage by combining survey estimates with administrative records, population estimates, and the decennial census. This method produces annual estimates for all counties and includes a limited set of demographic features.  The advantage of using the SAHIE is that it is the only source for annual estimates uninsured for all counties.

Medicaid comprises a significant portion of state budgets and is expected to grow as states expand coverage under the Affordable Care Act (ACA). Given this projected growth, understanding Medicaid’s financing structure, its burden on taxpayers, and any unintended consequences of the federal matching grant is particularly important. The matching grant, in place since the enactment of Medicaid, uses the Federal Medical Assistance Percentage (FMAP) to reimburse states for the federal share of states’ Medicaid expenditures. This study snapshot presents an overview of the estimated federal and state Medicaid tax burdens per family.

This brief outlines key program design features of alternative Medicaid expansion models. It describes the premium assistance models Arkansas, Iowa, and Pennsylvania developed to use Medicaid funds to purchase private health insurance, as well as Michigan’s proposal to expand Medicaid using a health savings account model. Key themes emerging from these non-traditional proposals include: (1) a preference for solutions relying more on the private insurance market than on traditional Medicaid; and (2) an emphasis on higher enrollee cost-sharing, personal responsibility, and healthy behaviors.

The small-business exchanges, created under the law's Small Business Health Options Program (SHOP), offer group health plans to small companies. Employers with fewer than twenty-five employees must purchase coverage through a SHOP if they wish to take advantage of the small-business tax credit for health insurance established in the ACA. States had the option of creating these as separate exchanges or combining the individual and small-business insurance markets into one exchange. This Health Policy Brief focuses on issues that states have had to confront in designing and operating SHOP exchanges as well as challenges that these exchanges are likely to face in the future.

This brief explores ways that states are sharing the responsibility of consumer assistance with the federal marketplace in three key areas: marketing and advertising initiatives, the work of navigators and other in-person assisters, and the development of a system for eligibility decision appeals. It also provides specific examples of states utilizing the Federally Facilitated Marketplace (FFM) or those partnering with it (SPM) for consumer assistance, and illustrates some of the ways that FFM and SPM states can work with their existing consumer assistance structures and with the federal government to help consumers find their way in a new coverage landscape.

The participation of young adults in the health insurance marketplaces has received considerable attention. At issue is whether men and women ages 19 to 34—a group uninsured at disproportionately high rates but generally healthier than older adults—will enroll in marketplace health plans at a rate high enough to ensure the marketplaces' success. The conclusion of health insurance actuaries, health plan representatives, researchers, and federal officials invited to participate in a Commonwealth Fund meeting on the topic is that while young adult participation is important for the stability of the marketplaces and 2015 premiums, it was, and will continue to be, one of many factors that affect premiums.