Reports & Analysis

Medicaid health homes, made possible through the ACA, provide states with a mechanism to support better care management for people with complex health needs with the goal of improving health outcomes and curbing costs. As of March 2014, 15 states have 22 approved state plan amendments to implement Medicaid health homes. Six "early adopter" states – Iowa, Missouri, New York, North Carolina, Oregon, and Rhode Island – have collectively enrolled more than 875,000 Medicaid beneficiaries in health homes.  This brief draws from the experiences of early health home adopter states to outline elements critical to implementation and sustainability of this new model.
 

This brief compares ACA Marketplace enrollment as of March 1, 2014 (the most recent state-specific data) to projected enrollment for 2014 and 2016, and estimates of the number of people eligible for subsidies. Nationally, by March 1, the Marketplaces had enrolled 61 percent of projected 2014 enrollment of subsidized and unsubsidized individuals. They had enrolled 63 percent of the subsidized population expected to enroll in 2014. Collectively, State-Based Marketplaces (SBMs) have been more successful in reaching projected enrollment than the Federally Facilitated Marketplaces (FFMs), with SBMs overall also having significantly higher rates of subsidized enrollment than FFMs.
 

This brief reviews the literature on the impact of premiums and cost sharing on enrollment, service utilization, and health status. It focuses particularly on how the research consensus fits with the flexibility Medicaid law gives states to establish premiums and cost sharing. It also highlights changes brought about by new cost sharing regulations and discusses the legal and policy ramifications of proposals by some states to charge Medicaid beneficiaries even higher cost sharing and premiums.
 

This study is the first to offer a detailed look at medical spending burden levels, defined as total family medical out-of-pocket spending as a proportion of income, for each state. It further investigates which states have greater shares of individuals with high burden levels and no Medicaid coverage, but would be Medicaid eligible under the 2014 rules of the Affordable Care Act should their state choose to participate in the expansion. This work suggests which states have the largest populations likely to benefit, in terms of lowering medical spending burden, from participating in the 2014 adult Medicaid expansions.
 

The ACA has dramatically increased the number of low-income nonelderly adults eligible for Medicaid. Starting in 2014, states can elect to cover individuals and families with modified adjusted gross incomes below a threshold of 133 percent of federal poverty guidelines, with a 5 percent income disregard. This study uses simulation methods and data from the Medical Expenditure Panel Survey to compare nondisabled adults enrolled in Medicaid prior to the ACA with two other groups: adults who were eligible for Medicaid but not enrolled in it, and adults who were in the income range for the ACA’s Medicaid expansion and thus newly eligible for coverage. Although differences in health across the groups were not large, both the newly eligible and those eligible before the ACA but not enrolled were healthier on several measures than pre-ACA enrollees.
 

The ACA gave states a number of choices in how to implement the broad coverage changes it required. As such, health reform looks different from state to state, and the impact of the ACA may or may not differ because of these state decisions. This brief examines a number of choices related to the establishment and running of the new health insurance marketplaces, and their potential impact on enrollment rates to date.

Stemming from training at insurance departments in various State Network states, Georgetown University Health Policy Institute (Georgetown) has released updated form review checklists. These resources are designed to help insurance regulators effectively implement Affordable Care Act (ACA) provisions, regulations, and other guidance by ensuring that insurance forms submitted by carriers meet all the ACA requirements. They are in writable Microsoft Word document form, allowing insurance regulators to simply download and modify to their state’s specifications.

Public payers are moving to implement payment strategies that reward value in the health care system by linking payment to quality. This report—the third in a series supported by The Commonwealth Fund to explore opportunities for improvement in federal and state policy— highlights quality measurement strategies underpinning value-based purchasing initiatives at the federal and state level. It also describes opportunities for federal-state alignment identified during a Commonwealth Fund-supported discourse among high-level state and federal officials hosted by NASHP.
 

Before the implementation of the major ACA insurance reforms, data from U.S. census surveys indicated nearly 32 million insured people under age 65 were in households spending a high share of their income on medical care. Adding these “underinsured” people to the estimated 47.3 million uninsured, the state share of the population at risk for not being able to afford care ranged from 14 percent in Massachusetts to 36 percent to 38 percent in Idaho, Florida, Nevada, New Mexico, and Texas. The report provides state baselines to assess changes in coverage and affordability and compare states as insurance expansions and market reforms are implemented.
 

This is the first in a series of regional reports examining ACA implementation, focusing on the start of the initial six-month ACA open enrollment period beginning October 1, 2013. The first report examines the Western region where the state governments have generally embraced the ACA, and includes reports on Arizona, California, Colorado, Idaho, Oregon, New Mexico, Nevada and Washington. An overview report that describes the policy setting and goal alignment of these western states is also available.