Uninsured/Uncompensated Care

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.

This Robert Wood Johnson Foundation-funded paper by Robert Berenson and Nicole Cafarella provides a status report on the Innovation Center's activities to date—including delineating the goals envisioned by Congress, detailing the new tools it was given, and emphasizing how the enhanced authority compares with CMS’s traditional demonstration programs. The paper describes the Center's major initiatives to date, including those that address primary care redesign, bundled payments, ACOs, dual-eligible beneficiaries, and the health care system's capacity for spreading innovative ideas. The authors note that some observers have expressed concern that the Innovation Center's fast-paced approach may be overwhelming to smaller delivery systems.

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.

Low-income Medicare beneficiaries are eligible for subsidies to help them pay premiums and cost sharing. However, these subsidies fall short of those contained in the Patient Protection and Affordable Care Act (ACA) that help low-income families afford adequate health coverage. In this report we consider policy options to reform Medicare's low-income subsidies to better align with ACA provisions. We estimate that a significant simplification in low-income protection and cost-sharing rules could greatly reduce burdens on the poorest and sickest beneficiaries. Depending on how they are implemented, these reforms could either reduce or only modestly increase total public spending.

To help pay for expanded health insurance coverage, the health reform legislation enacted in 2010 included a new 3.8 percent tax on the net investment income of high-income taxpayers. When it goes into effect in 2013, it will increase the top tax rate on capital gains, dividends, and other investment income, regardless of whether the 2001 and 2003 tax cuts are allowed to expire. Almost all the burden will be borne by taxpayers with extremely high incomes. More than half the burden, for example, falls on taxpayers in the top 0.1 percent of the income distribution.

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.