Health Insurance

This Health Affairs brief provides an overview of accountable care organizations (ACOs), which are networks of physicians and other providers that agree to be held accountable for the cost and quality of the full continuum of care delivered to a group of patients. The brief covers the origins of the ACO concept, describes what makes ACOs different from existing health plans and provider arrangements, and summarizes the current status of adoption by Medicare and private health insurance plans. It also notes that based on the results of a five-year demonstration, ACOs will likely be able to improve clinical care quality but may have a harder time generating meaningful savings.

Many of the provisions to expand health coverage in the Affordable Care Act must be implemented by the states. With support from the Robert Wood Johnson Foundation, the Urban Institute is undertaking a comprehensive monitoring and tracking project to examine the implementation and effects of the ACA in ten of the states: Alabama, Colorado, Maryland, Michigan, Minnesota, New Mexico, New York, Oregon, Rhode Island and Virginia. This first report is a case study analysis of Oregon’s efforts to advance health care reform. Derived from a site visit and extensive interviews with state officials and state stakeholders, it documents Oregon's considerable progress in establishing an exchange, implementing insurance reforms, and preparing for an expansion of Medicaid, all within a challenging fiscal environment.

Five years after the enactment of Massachusetts health reform initiative, gains in insurance coverage and access to care have been sustained. This report provides an update on trends in the Bay State since fall 2006, just prior to the implementation of the state's health reform initiative, along with a more in-depth overview of the circumstances of working-age adults in 2010, as the state begins implementation of the Affordable Care Act.

Massachusetts is in its sixth year of a reform initiative that provided the template for the federal Affordable Care Act of 2010. This Health Affairs article reports on the status of health reform in Massachusetts as of 2010, providing an early indication of potential gains and challenges under national reform.

San Mateo County is one of a small number of innovative local jurisdictions that is expanding coverage for uninsured adults and at the same time undertaking a reform of its safety net primary care system. We evaluated the impact of the systems redesign by comparing outcomes for a group of people served at the largest county safety net clinic prior to systems redesign (2006) to those served at the clinic after systems redesign (2009). Use of any preventive care services in a year climbed from 25.9 percent to 33.3 percent. Continuity of care also rose significantly, and emergency room use declined. The county's experience provides an example for other communities to follow as they improve the efficiency of health care services for the most vulnerable members of society.

We use the Health Insurance Policy Simulation Model to explore the correlations between a state's progress toward implementing the Affordable Care Act and the anticipated benefits of the reform for state residents, as measured by the expected state gains in insurance coverage and federal subsidies. We group states in three categories based on the status of legislative action and the receipt of level 1 federal establishment grants. We find that states that have made the least progress in establishing health insurance exchanges are in general those that have the largest potential gains in coverage and federal subsidy dollars per capita.

The federal requirement for most Americans to have health insurance-the individual mandate-is an important part of how the ACA would reduce the number of uninsured. We use the Health Insurance Policy Simulation Model to estimate the effects of health reform with and without the mandate. With the mandate, the number of uninsured would decrease from 50 million to 26 million. Without a mandate, about 40 million would remain uninsured. Depending on the effectiveness of the health benefit exchanges in enrolling those eligible for subsidized coverage, exchange premiums would be 10 to 25 percent higher without a mandate.

John Holahan and Vicki Chen use the Current Population Survey to examine trends in health insurance coverage during the "Great Recession" of 2007-2010, as well as over the past decade. The uninsured have increased since 2000 with nonelderly adults shouldering the entire burden. Generous Medicaid coverage for children was able to offset falling ESI coverage, which caused the overall uninsured number of children to decrease. 2010 saw the continuation of many trends from 2007; ESI rates continued to fall, the share and number people who are low-income continued to grow, and unemployment continued to rise. Patterns of insurance coverage were similar across groups of all race/ethnicity, citizens and non-citizens, and all geographic areas. The one exception to recent trends in private coverage is coverage for young adults (ages 19-25). This group had an increase in private coverage while all other age groups experienced a decline in private coverage.