Reports & Analysis

This fact sheet details state and hospital roles and responsibilities in implementing HPE programs. It outlines components necessary for HPE programs as well as requirements for state plan amendment submission.  It also includes a hypothetical example to illustrate how the HPE determination process can help an uninsured individual during a hospital visit.

Many states have worked tirelessly over the past two years to develop health insurance exchanges and prepare for the expansion of their Medicaid programs in order to meet the requirements of the ACA. Programs to expand coverage, however, do not necessarily ensure seamlessness for many individuals who are likely to experience shifts in program eligibility due to changing circumstances (e.g., income fluctuations, family composition changes, etc.). A number of states are actively working to limit the impact of changes in program eligibility by developing policies that limit either the incidence of program eligibility changes and/or the impact those changes have on individual consumers. Various emerging state approaches take into account program history, the desire for state flexibility, and the political and operational challenges states face in developing coverage expansions that work for consumers, stakeholders, and policy makers.

This issue brief focuses on the key purchasing strategies that state Medicaid agencies and state employee health benefit purchasers can implement in order to reduce the overuse and misuse of health care services, and improve the quality and reduce the cost of care. This brief primarily focuses on actions state purchasers can take with contracted plans, providers, and other engaged purchasers to reduce overused and misused services. The research and recommendations in this issue brief were originally provided as technical assistance to a state as part of the Robert Wood Johnson Foundation’s State Health and Value Strategies project.

This report presents data on the population targeted for coverage expansions under the ACA, and aims to help policymakers target early efforts and evaluate the ACA’s longer-term effects. The report is based on a new series of comprehensive surveys of the low and moderate income population that provides data on these groups’ experience with health coverage, current patterns of care, and family situation. This report, based on the baseline 2013 Kaiser Survey of Low-Income Americans and the ACA, provides a snapshot of health insurance coverage, health care use and barriers to care, and financial security among insured and uninsured adults across the income spectrum at the starting line of ACA implementation.

The ACA is designed to improve access to coverage for millions of Americans. Because states are the primary implementers of these requirements, this report examines the status of state action on the three major components of health reform—the market reforms, the establishment of health insurance marketplaces, and Medicaid expansion. The analysis finds that nearly all states will require or encourage compliance with the market reforms, every state will have a marketplace, and more than half the states will expand their Medicaid programs. The analysis also shows that federal regulators have stepped in where states have been unable or unwilling to take action.

The ACA has created new health insurance coverage opportunities for millions of low-income Americans. Many of these individuals, however, are likely to "churn" in and out of eligibility for Medicaid and marketplace coverage due to fluctuating income and changing family circumstances. Adults who change health insurance coverage are less likely to have a usual source of care and may delay care during coverage transitions. This brief outlines key steps that states can take to reduce the potential gaps in coverage caused by churn. It includes examples from states that have begun to address this issue and outlines concrete strategies for states to mitigate the impact of coverage transitions.

The ACA allows hospitals to use preliminary information to enroll people who appear eligible for Medicaid into coverage on a temporary basis. The goal of this “presumptive eligibility” (PE) option for hospitals is to quickly and efficiently enroll eligible people into Medicaid while insuring immediate health care costs are covered. While presumptive eligibility is not a new concept in Medicaid, the ACA for the first time gives hospitals – rather than states – the authority to decide whether to participate in PE. This issue brief, prepared by Manatt Health Solutions, describes the flexibility available to states to establish training and performance standards for hospitals conducting PE determinations, and discusses approaches states may want to consider as they develop standards.

Prior to the ACA, one key reason a number of states used Section 1115 waiver authority was to expand Medicaid coverage to low-income adults who could not otherwise be covered under federal rules. The ACA’s Medicaid expansion to nearly all low-income adults at or below 138% FPL, and the significant federal funding provided to states for this expansion, fundamentally alters the role of Section 1115 waivers in expanding coverage to adults. Through guidance and recent waiver approvals in three states, CMS has identified some of the parameters related to the use of waivers to expand coverage to adults in light of the ACA’s Medicaid expansion. This brief provides an overview of the potential role of Section 1115 waivers to expand coverage since the enactment of the ACA and key themes in recently approved and proposed coverage expansion waivers.

In recent months, there has been considerable focus on cancellations of nongroup health insurance policies. It is difficult to directly obtain data on premiums that individuals were paying prior to the ACA, but this brief provides data on the premium cost to enrollees for the lowest cost bronze plans and the second lowest cost silver plans by age and income group in each state. The authors conclude that it would be difficult for the majority of individuals, particularly those qualifying for subsidies, to obtain coverage for a lower premium than those available in the Marketplaces today. Unsubsidized individuals, particularly those in older age groups, are more likely to face higher premiums.

As part of the Agency for Healthcare Research and Quality's Infrastructure for Maintaining Primary Care Transformation initiative, NASHP worked with four states (Idaho, Maryland, Montana, and West Virginia) that sought to adapt aspects of North Carolina’s nationally recognized model of primary care practice transformation. This report summarizes the value of primary care transformation for the states, describes the North Carolina model, and outlines states' successes, challenges and lessons learned.