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Publications by Judy Feder for Health Policy Center

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More about Judy Feder's areas of expertise can be found on this Urban Institute expert's page.


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The Inevitability of Disruption in Health Reform (Policy Briefs/Timely Analysis of Health Policy Issues)
Judy Feder

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.

Posted: February 18, 2014Availability: HTML | PDF

Health Homes in Medicaid: The Promise and the Challenge (Research Brief)
Barbara A. Ormond, Elizabeth Richardson, Brenda Spillman, Judy Feder

With the passage of the Affordable Care Act (ACA), health care providers and insurers are actively engaged in payment and delivery reform. Much of this reform focuses on integrating primary care and other aspects of health care. Medicaid Health homes, and option to states under the ACA, aims to improve the integration of physical health care needs with the broad range of mental health and social needs for high-cost, high-needs Medicaid beneficiaries. This brief draws on findings from Urban Institute's five-year evaluation of this new model of care, exploring the concept, as well as the challenges that must be overcome to achieve the desired results.

Posted: February 18, 2014Availability: HTML | PDF

Bundle with Care - Rethinking Medicare Incentives for Post-Acute Care Services (Commentary)
Judy Feder

Based on experience with payment for Medicare post-acute care services, Judy Feder argues that a shared-risk-and-savings approach to these services may be the best strategy for promoting Medicare's efficiency without undermining quality and access to care. Medicare already bundles skilled-nursing-facility (SNF) services into "days," and home-health-agency (HHA) services into "episodes." These bundles have generated high and varied profits that appear to have far more to do with skimping on care and avoiding costly patients than with efficiency in care delivery. In a service area with weak patient classification mechanisms and quality norms, a payment approach in which savings and risk are shared - a hybrid of a fee-for-service system and one providing rewards for spending reductions - will achieve a better balance of cost, quality, and access than a system of single bundled payments, at least until our capacity to measure patients' care needs and outcomes is sufficiently robust.

Posted: July 15, 2013Availability: HTML

Financing Medicare and Medicaid (Testimony)
Judy Feder, Paul Van de Water

Continuing to slow health cost growth is essential; but Medicare and Medicaid are not in crisis. Recent per beneficiary cost growth has slowed so significantly that CBO has dramatically reduced its spending projections for the coming decade. In Medicare, refinement of existing payment mechanisms alongside payment reform can produce additional savings. But as the elderly population doubles over the coming decades, a balanced deficit-reduction package must include new revenues The alternative, changing entitlement structures through vouchers or block grants (or adopting an overly ambitious savings target that could produce the same results), would undermine essential protections and shift or even increase health care costs.

Posted: March 27, 2013Availability: HTML | PDF

Implications of the Affordable Care Act for American Business (Policy Briefs)
Linda J. Blumberg, Matthew Buettgens, Judy Feder, John Holahan

Updated results from our Health Insurance Policy Simulation model show that, contrary to critics' claims, the law has a negligible impact on total employer-sponsored coverage and costs, leaves large business costs-per-person-insured largely untouched and makes small businesses-for whom coverage expands the most-financially better off, through tax credits and market efficiencies that lower premiums. Only among mid-size businesses does the ACA noticeably increase costs, largely due to increased enrollment. Our simulation does not reflect ACA cost containment provisions that may contain private as well as public cost growth-potentially slowing the decline of employer-sponsored health insurance that has been occurring for more than a decade.

Posted: October 05, 2012Availability: HTML | PDF

Why Premium Support? Restructure Medicare Advantage, Not Medicare (Policy Briefs)
Judy Feder, Stephen Zuckerman, Nicole Cafarella Lallemand, Brian Biles

Premium support proponents argue that replacing public insurance with vouchers to purchase private (or public) coverage will harness market forces to contain costs. But the debate often ignores traditional Medicare's administrative efficiency, purchasing power and the rewards to risk selection that accompany competition among plans. We show that despite Medicare Advantage (MA) plans' success in enrolling beneficiaries, they have been unsuccessful in lowering costs. Except in 15 percent of counties, MA costs per beneficiary exceed costs for traditional Medicare. Fiscal prudence warrants limiting MA payments to 100 percent of traditional Medicare costs, while keeping payments to MA plans below traditional Medicare in the highest cost counties.

Posted: September 26, 2012Availability: HTML | PDF

Protecting High-Risk, High-Cost Patients: "Essential Health Benefits," "Actuarial Value," and Other Tools in the Affordable Care Act (Policy Briefs/Timely Analysis of Health Policy Issues)
Lisa Clemans-Cope, Linda J. Blumberg, Judy Feder, Karen Pollitz

The Affordable Care Act (ACA) will dramatically improve the nongroup and small group health insurance markets for everyone in them, including the high-risk population. But insurance reforms, guided by requirements for minimum or "essential health benefits," insurance plan actuarial value and other tools provided by the ACA, are and will remain a work in progress. This analysis suggests the way these tools-working together and reevaluated over time-can most effectively ensure that ACA implementation progresses toward the goals of adequate and affordable insurance protection, especially for the highest-need, highest cost patients.

Posted: June 14, 2012Availability: HTML | PDF

The Individual Mandate in Perspective (Policy Briefs/Timely Analysis of Health Policy Issues)
Linda J. Blumberg, Matthew Buettgens, Judy Feder

The "individual mandate"-the requirement that individuals either have health insurance coverage or pay a fine-is both the best known and the least popular component of the Affordable Care Act (ACA). That people know about the mandate-and may even worry about it-is not surprising, given both the heated political controversy and the constitutional challenge surrounding this provision of the law. What may be surprising, however, is that if the ACA were in effect today, 94 percent of the total population would not have to newly purchase insurance or pay a fine. While a small number of people would be affected by the individual responsibility requirement, the overall benefit to the population would be large, in terms of reducing premiums and increasing stability of insurance markets.

Posted: March 27, 2012Availability: HTML | PDF

The Case Against Premium Support (Summary)
Judy Feder, Paul Van de Water, Henry J. Aaron

Proposals to replace traditional Medicare with "premium support"-or vouchers for the purchase of private insurance or, in some cases, Medicare-have once again emerged on the political agenda. This critical commentary on the Rivlin/Domenici proposal (markedly similar to the Ryan/Wyden proposal) finds much wanting in premium support—in particular, that Medicare already provides benefits more equitably and at lower cost than private insurance; that without "regulatory teeth", premium support would actually create coverage inequities and increase costs; and that implementation of the Affordable Care Act's payment and other Medicare reforms, not Medicare replacement, ought to be the nation's top priority in controlling overall health costs. These remarks were presented at a Brookings Institution forum on December 16, 2011.

Posted: December 22, 2011Availability: HTML | PDF

Why Employers Will Continue to Provide Health Insurance: The Impact of the Affordable Care Act (Policy Briefs/Timely Analysis of Health Policy Issues)
Linda J. Blumberg, Matthew Buettgens, Judy Feder, John Holahan

The Congressional Budget Office, the Rand Corporation, and the Urban Institute have estimated that the Affordable Care Act (ACA) will leave employer-sponsored coverage largely intact; in contrast, some economists and benefit consultants argue that the ACA encourages employers to drop coverage thereby making both their workers and their firms better off (a “win–win" situation). This brief's analysis shows that no such "win–win" situation exists and that employer-sponsored insurance will remain most workers' primary source of coverage. Analysis of three issues-the terms of the ACA, worker characteristics, and the fundamental economics of competitive markets-supports this conclusion.

Posted: October 26, 2011Availability: HTML | PDF

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