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States and the Affordable Care Act

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 states. Derived from site visits and extensive interviews with state officials and health care stakeholders, this series of reports documents each state’s progress in establishing an exchange, implementing insurance reforms, and preparing for an expansion of Medicaid. State reports are being produced on a rolling basis, and each will be posted here when available.

Federal and State Policy Toward Association Health Plans in Oregon
Kevin Lucia, Sandy Ahn, Sabrina Corlette

Under the ACA, health insurance sold through an Association Health Plan (AHP) to small employers must meet the same insurance standards of coverage sold in the small-group market. However, research indicates that some AHPs are now claiming single large-group health plan status under ERISA, thus sidestepping the ACA requirements for the small-group market. Through interviews with state regulatory officials, health benefit consultants, association representatives and insurers, this paper examines the experience of the AHP market in Oregon. It finds that the AHP market continues to exist for small employers in Oregon and may be positioned for growth.

Six-State Case Study on Network Adequacy
Implementation of the Affordable Care Act: Cross-Cutting Issues 

Sabrina Corlette, Kevin Lucia, Sandy Ahn

During the transition to new health insurance marketplaces, insurers revamped their approach to network design, and many now offer narrower provider networks. Researchers assessed network changes and efforts at regulatory oversight in six states. Researchers found that insurers made significant changes to the networks of their individual market plans. Insurers and state officials reported confusion about which plan networks included which providers, but most received few complaints about consumers' ability to obtain in-network services. While half these states have taken action to improve provider directories, it appears unlikely that states will dramatically change network standards, at least in the short-term.

Physician Network Transparency: How Easy Is it for Consumers to Know What They Are Buying?
Linda J. Blumberg, Rebecca Peters, Erik Wengle, Rachel Arnesen

Urban Institute researchers studied nine marketplace websites (California, Colorado, Connecticut, District of Columbia, Massachusetts, Minnesota, Oregon, Rhode Island and Washington) and healthcare.gov, and offer recommendations on how to improve the transparency of the marketplace sites. Recommendations include creating clear and accurate “hover over” definitions of plan and network types and sizes for consumers scrolling over specific plans, and creating fully functional physician directories for each plan within the marketplace website.

Marketplace Competition & Insurance Premiums in the First Year of the Affordable Care Act
John Holahan, Linda J. Blumberg

The Affordable Care Act has resulted in considerable competition. In a large number of markets, this has resulted in lower premiums than expected, though there is considerable variability within each metal tier. This analysis assesses the variation in premiums within markets and the effects of competition in 10 states: Alabama, Arkansas, Colorado, Maryland, Massachusetts, New York, Oregon, Rhode Island, Virginia, and West Virginia. Four of the states have fairly limited competition, while the other six were very competitive, especially in urban, more populated markets.

Early 2014 Stakeholder Experiences with Small-Business Marketplaces in Eight States
Linda J. Blumberg, Shanna Rifkin

Participation of employers in the small group Marketplaces, or Small Business Health Options Program (SHOP), has started very slowly.  The reasons for this are largely consistent across the states, and many of them lend themselves to reversal or improvement. Significant challenges remain, but it would be inappropriate to judge the long term prospects of SHOP merely on its first-year experiences. This analysis of early implementation experiences is based on case study interviews in eight states: Colorado, Illinois, Maryland, Minnesota, New Mexico, New York, Oregon, and Rhode Island. Interviews were conducted with a broad array of stakeholders in each state.

The Launch of Health Reform in Eight States: State Flexibility Is Leading to Very Different Outcomes
John Holahan, Linda J. Blumberg, Teresa Coughlin, Brigette Courtot, Ian Hill, Rebecca Peters, Shanna Rifkin, Margaret Wilkinson, Sabrina Corlette, and Kevin Lucia

This paper provides a review of a series of papers that examine early implementation of the Affordable Care Act in 8 states. These states – Alabama, Colorado, Maryland, Michigan, Minnesota, New York, Oregon, and Virginia – have made very different design choices in implementing the law. We examine coverage expansion; financial impacts; the development of information technology systems; outreach, education and enrollment assistance; insurer participation, competition and premiums in marketplaces; insurance market reforms; development of SHOP marketplaces; and issues of provider capacity. We conclude that different design choices made by states will lead to different results. The law will work very differently for residents in different states around the country and there will be different outcomes both in terms of coverage and economic impacts.

The Launch of the Affordable Care Act in Selected States: Coverage Expansion and Uninsurance
John Holahan

This brief examines the impacts of the Affordable Care Act on health insurance coverage and the uninsured. The brief concludes that states will benefit from the establishment of marketplaces and income-related subsidies. Employer coverage is not expected to change significantly. States that are expanding Medicaid will have larger gains in insurance coverage than those states that do not and will see very large reductions in the number of uninsured. Those states that have not expanded Medicaid will see less impact on the uninsured. These states have more uninsured to begin with, thus current disparities in coverage will increase, at least in the early years.

The Launch of the Affordable Care Act in Selected States: The Financial Impact on States from the Affordable Care Act
John Holahan

This brief examines the financial impacts of the Affordable Care Act on (ACA) selected states. The brief concludes that states expanding Medicaid will receive significantly larger inflows of federal dollars than those that do. Medicaid expansion will bring in large amounts of federal dollars that will offset cuts in the ACA to Medicare provider payment rates and Medicaid and Medicare disproportionate share hospital payments. States that do not expand Medicaid will experience the ACA cuts but will have much smaller inflows of federal revenues. All states will experience some new spending but much can be offset by savings in other parts of state budgets.

The Launch of the Affordable Care Act in Selected States: Building ACA-Compliant Eligibility and Enrollment Systems
Brigette Courtot, Teresa A. Coughlin, Divvy Upadhyay

Arguably among the biggest tasks facing the health insurance marketplaces established by the Affordable Care Act (ACA) has been the creation of an information technology (IT) system (including a self-service enrollment web site) that determines eligibility for and facilitates enrollment into health coverage. This paper examines the development and performance of ACA-compliant eligibility and enrollment systems for health insurance marketplaces in eight states. Some of these states’ IT systems are operating smoothly while others have struggled to overcome technical glitches for months. These early successes and stumbles are reflected in marketplace-based enrollment numbers during the ACA’s first months of open enrollment.

The Launch of the Affordable Care Act in Eight States: Outreach, Education, and Enrollment Assistance
Ian Hill, Margaret Wilkinson, Brigette Courtot

The Affordable Care Act's success depends on whether eligible, uninsured persons can enroll in health coverage. Meeting enrollment goals partially hinges on the effectiveness of marketing campaigns to raise public awareness, and application assistance programs that help consumers enroll. This brief examines ACA-related marketing, outreach, and application assistance efforts in eight states: five that have aggressively participated in ACA implementation and three states that have taken a limited approach. Differences in the intensity of efforts across states are stark—with some launching multi-pronged marketing campaigns and funding community-based organizations and providers to lend hands-on assistance with enrollment, and others investing much less energy and resources in such efforts.  These differences may ultimately contribute to noticeably different enrollment experiences during early ACA implementation.

The Launch of the Affordable Care Act in Selected States: Insurer Participation, Competition, and Premiums
John Holahan, Rebecca Peters, and Kevin Lucia

This brief provides considerable data on insurer participation and premiums in several markets in 8 study states. The brief concludes that plan participation is less a function of whether states have state-based (SBM) or federally-facilitated (FFM) health insurance marketplaces and more a function of the pre-Affordable Care Act (ACA) insurance market, as well as the managed competition framework in the ACA. In both SBM and FFM states there are a large number of participants in most markets, including large and small commercial insurers and some new entrants such as Medicaid plans and Co-Ops. In most markets, premiums are lower than expected, although in markets with few plans and little competition, the ACA has had much less impact.

The Launch of the Affordable Care Act in Eight States: Reforming Insurance Markets and Protecting Consumers
Sabrina Corlette and Kevin Lucia

States, whether or not they have decided to operate their own health insurance marketplaces, must navigate rapidly changing health insurance markets in which the ACA's reforms are affecting insurers, businesses, and consumers. Under the ACA, states are primarily responsible for implementing significant insurance reforms that went into effect on January 1, 2014. This paper explores the responses of eight states to the ACA's new rules and the creation of the new health insurance marketplaces.

The Launch of the Affordable Care Act in Selected States: Small Group Marketplaces
Linda J. Blumberg, Shanna Rifkin, and Erik Wengle

This is one of a series of 9 briefs comparing the early implementation experiences of the Affordable Care Act (ACA) in eight states: five that have chosen to aggressively participate in all aspects of the ACA (Colorado, Maryland, Minnesota, New York, and Oregon) and three that have taken only a limited or no participation approach (Alabama, Michigan, and Virginia). This brief focuses on the implementation of the Small Business Health Options Program (SHOP) Marketplaces, which are new structured markets for the employer purchase of small group insurance for their workers. 

The Launch of the Affordable Care Act in Eight States: The Problem of Provider Capacity
Ian Hill and Margaret Wilkinson

Much of the success of the Affordable Care Act (ACA) will hinge on issues surrounding access to care, particularly as millions of individuals become newly-insured and strain the capacity of provider systems. New service delivery reforms in state Medicaid programs and the private sector, as well as provisions in the ACA focused on increasing primary care reimbursement and provider supply, and increasing funding for Community Health Centers, hold promise to improve access to quality care. This brief describes the efforts taken by eight states—five that have aggressively participated in ACA implementation and three states that have taken a limited approach—in addressing provider capacity issues.

Stabilizing Premiums Under the Affordable Care Act: State Efforts to Reduce Adverse Selection
Linda J. Blumberg, Shanna Rifkin, Sabrina Corlette, Sarah J. Dash

As a consequence of the ACA’s reformed nongroup insurance market, some have raised concerns about short-term “rate shock”—an increase in premiums as a result of enhanced consumer protections and more risk-sharing compared with the pre-reform market – as well as longer-term instability due to adverse selection -- the phenomenon by which particular insurance plans or markets attract an enrollment with higher than average health care risks. While the ACA includes strategies intended to mitigate these effects, some states are introducing additional strategies to strengthen the protections.  This paper explores policies designed to address these concerns being implemented in 11 states.

Reaching and Enrolling the Uninsured: Early Efforts to Implement the Affordable Care Act
Ian Hill, Brigette Courtot, Margaret Wilkinson

The Affordable Care Act's success depends on whether eligible, uninsured persons can enroll in health coverage. Meeting enrollment goals partially hinges on the effectiveness of marketing campaigns to raise public awareness, and application assistance programs that help consumers enroll. This brief describes early state efforts, and finds that government officials have taken many positive steps including launching multi-pronged campaigns that combine broad marketing with grass-roots outreach, and funding community-based organizations and providers to provide hands-on assistance. Differences in the intensity of these efforts across states are stark, however, and may contribute to noticeably different enrollment experiences during early ACA implementation.

Moving to High Quality, Adequate Coverage: State Implementation of New Essential Health Benefits Requirements
Sabrina Corlette, Christine Monahan, Kevin Lucia

The Affordable Care Act attempts to improve the adequacy of health insurance by establishing a minimum standard for "essential health benefits" (EHB). This paper documents challenges faced by insurance companies and state officials in the development and oversight of new plans that meet the new EHB requirements. We find that most people will see little change in the number of benefits covered by plans, but some will gain benefits, such as maternity care, mental health, and prescription drugs, that have often not been covered. The study also finds that insurers are taking limited advantage of their flexibility to add and subtract benefits through substitution.

Insurer Participation and Competition in Health Insurance Exchanges: Early Indications from Selected States
John Holahan, Kevin Lucia, Rebecca Peters, Christine Monahan

One of the key goals of the Affordable Care Act (ACA) is to make health insurance coverage more affordable and consumer-friendly by managing competition among health insurers through the creation of health insurance exchanges. This paper explores state actions to encourage or require participation in exchanges, and preliminary responses from health insurers in six study states. Our central conclusion is that there will be robust competition in many states and this will lead to reasonably priced premiums, with lower premiums for unsubsidized enrollees and lower subsidy costs to the federal government. Our review of initial rate filings from three states reflects this finding.

Implementation of Small Business Exchanges in Six States
Linda J. Blumberg, Shanna Rifkin

The Affordable Care Act includes Small Business Health Options Programs (SHOP) exchanges, intended to provide administrative relief and affordable coverage options to small employers across the country. This paper provides an overview of SHOP exchange development in six states. The six state based exchanges studied are all intending to offer employee choice in 2014 and report an encouraging amount of carrier interest. Specific policy decisions in design tend to reflect prior state differences in small group markets. State contacts note that employer education is one of the major challenges they face, and outreach efforts to small businesses are just beginning.

State Level Progress in Implementation of Federally Facilitated Exchanges: Findings in Three Case Study States
Linda J. Blumberg, Shanna Rifkin

This paper focuses on states' roles in implementation of FFEs. We start by providing an overview of recent regulations issued by CCIIO that describes the possible roles both for states and the federal government in the FFEs. We then provide in-depth descriptions of each of the specific FFE options as implemented in three states-Alabama, Michigan, and Virginia-with an eye to each state's role in developing mechanisms to carry out their new responsibilities and progress in creating relationships with the federal government in order to ensure successful implementation of the three types of federally facilitated exchanges.

Medicaid Expansion Under the ACA: How States Analyze the Fiscal and Economic Trade-Offs
Stan Dorn, John Holahan, Caitlin Carroll, Megan McGrath

In 2014, many states will expand Medicaid to cover their poor and near-poor residents, but others will not. As the final undecided states make up their minds, a new report shows that in 10 diverse states, very different approaches were taken to analyzing impacts. Those states that conducted comprehensive analyses found that Medicaid expansion will: (a) provide state savings and revenues that exceed increased costs, yielding net state budget gains and (b) result in increased employment because of the influx of federal dollars.

Are State Medicaid Managed Care Programs Ready for 2014? A Review of Eight States
Teresa A. Coughlin, Brigette Courtot, Rebecca Peters

The Medicaid expansion authorized by the Affordable Care Act (ACA) will result in significant enrollment increases for state Medicaid programs. A majority of these new enrollees will receive care through a Medicaid managed care plan. This brief describes how eight states are preparing to provide Medicaid coverage to these new enrollees and, more generally, altering their managed care programs. While some challenges were noted, state officials in each of the eight states felt their Medicaid managed care programs were well positioned to handle ACA-related Medicaid enrollees. Moreover, health plan capacity was described as sufficient, although there was some concern about provider capacity.

Factors Affecting Self-Funding by Small Employers: Views from the Market
Kevin Lucia, Christine Monahan, Sabrina Corlette

Policy experts predict that small employers, especially those with younger and healthier employees, will increasingly establish “self-funded” health plans, leaving the traditional fully insured market to obtain lower premiums and avoid market reforms under the Affordable Care Act. Through interviews with stakeholders in 10 study states, this paper describes factors that may influence whether and how extensively this change occurs. It also shows that states have minimal data on this potentially growing market, but they would be well served to improve their monitoring efforts so they can identify any increases in small group self-funding and resulting adverse selection, and respond appropriately

Will There Be Enough Providers to Meet the Need? Provider Capacity and the ACA
Ian Hill

Much of the success of the Affordable Care Act (ACA) will hinge on issues surrounding access to care, particularly as millions of individuals become newly-insured and strain the capacity of provider systems. New service delivery reforms in state Medicaid programs and the private sector, as well as provisions in the ACA focused on increasing primary care reimbursement and provider supply, and increasing funding for Community Health Centers, hold promise to improve access to quality care. Drawing on the experiences of ten study states participating in the Robert Wood Johnson Foundation’s health reform monitoring and implementation project, this brief examines how states are addressing the complex issues of provider capacity and access to care. 

Progress in Implementing Selected Medicaid Provisions of the Affordable Care Act: A Ten-State Analysis
Brigette Courtot, Teresa A. Coughlin

Even in the wake of the Supreme Court ruling that made the Affordable Care Act’s (ACA) Medicaid expansion voluntary, Medicaid remains a centerpiece in the law’s effort to expand coverage and reform the nation’s health care system. States are working diligently on many different fronts to prepare for the 2014 coverage expansions, while also taking advantage of various opportunities to save costs and improve their Medicaid programs. This brief describes ten states’ experiences with selected ACA Medicaid provisions, including (among others) the requirement to modernize eligibility and enrollment systems and testing of new delivery systems.

Monitoring State Implementation of the Affordable Care Act in 10 States: Early Market Reforms
Kevin Lucia, Sabrina Corlette, Katie Keith

The ten states participating in the Robert Wood Johnson Foundation’s monitoring and tracking project have taken significant steps to implement the early market reforms of the ACA. Each state took action to require or encourage insurers to comply with these reforms. Although some challenges were noted, insurers are generally complying with them; regulators are hearing few consumer concerns, and premiums have not risen substantially because of these reforms.  Compliance was largely facilitated through the efforts of state regulators, insurers, and consumer advocates. The actions taken by these states reflect the diversity of approaches that exist among states nationwide.

State Progress in Implementing Health Insurance Exchanges: Results from 10 State Analyses
Linda J. Blumberg, Shanna Riffkin

This paper describes the status of health insurance exchange development and design choices in the 10 states participating in the Robert Wood Johnson Foundation health reform implementation monitoring and tracking project.  We found state policy-makers, their staffs, stakeholders, and consumer advocates to be highly engaged in exchange policy discussions and  development processes. By all accounts, each state was making concerted efforts to engage with a broad-swath of stakeholder and consumer interests and allowing all perspectives to be heard.  However, many state policy environments remain politically contentious, and progress in exchange development has been slow for some as a result.

Monitoring State Implementation of the Affordable Care Act in 10 States: Rate Review
Sabrina Corlette, Kevin Lucia, Katie Keith

The ten states participating in the Robert Wood Johnson Foundation’s monitoring and tracking project have enhanced their health insurance rate review programs in response to the Affordable Care Act. Although there has been significant variation among the states, all have taken steps to improve their processes to ensure that health insurance rates are justified. They have also increased transparency and expanded efforts to educate consumers about the factors underlying rate increases and involve them in the process. To a large extent, the actions taken by these states reflect the diversity of approaches to rate review that exist among states nationwide.

Plan Participation in Health Insurance Exchanges: Implications for Competition and Choice
John Holahan

This brief examines the conditions under which competition in health insurance exchanges is likely to be effective in placing downward pressure on insurance premiums. We conclude that areas with a single dominant insurer or a dominant hospital system are less likely to experience effective competition. In markets in which there are several insurers with significant market share and no dominant hospital system, the result could be limited or tiered network products that could successfully constrain the cost of premiums. Participation of existing Medicaid plans may also increase effective competition in health insurance exchanges.

ACA Implementation—Monitoring and Tracking: New Mexico Site Visit Report
Teresa A. Coughlin, Kevin Lucia, Katie Keith

New Mexico_MapNew Mexico has taken several important steps to implement the ACA by, for example, designating a central state office of health reform to coordinate its efforts across agencies as well as working with federal officials and state health care stakeholders.  Although it has yet to pass legislation or otherwise establish the legal authority to authorize an exchange, New Mexico has signaled that it intends to move forward in implementing an exchange.  In addition, the state is pursuing some of the ACA Medicaid demonstration opportunities including health homes and the capitated integrated model for dual eligibles as well as using federal funds to help overhaul its Medicaid eligibility and enrollment processes.  While New Mexico is engaged in several health reform activities, the state faces many challenges ahead in implementing reform on time.

ACA Implementation—Monitoring and Tracking: Virginia Site Visit Report
Linda J. Blumberg, John Holahan, Vicki Chen

virginiaThis report is one in a series of 10 on state implementation of the Affordable Care Act, and covers reform activity in Virginia.  The state has not indicated at this date how it will respond to the now optional expansion of Medicaid coverage or whether it will establish an exchange. But at the same time, the state has created a highly regarded process for debate on the exchange which has produced a recommended framework for development.

ACA Implementation—Monitoring and Tracking: Minnesota Site Visit Report
Brigette Courtot, Stan Dorn, Vicki Chen

Minnesota_Map

A longstanding leader in private- and public-sector health reform, Minnesota is making remarkable progress implementing the Patient Protection and Affordable Care Act (ACA), despite a challenging political environment. The state’s ability to accomplish as much as it has - including the creation of two task forces, securing multiple grants to support different pieces of ACA implementation, adopting the early Medicaid expansion, implementing early insurance reforms, and taking vigorous steps toward building an effective Exchange in time to meet challenging federal deadlines - testifies to remarkable collaboration between state agencies and stakeholders in transforming the state’s health system.

 ACA Implementation-Monitoring and Tracking: New York Site Visit Report
Teresa A. Coughlin, Randall Bovbjerg, Shanna Rifkin, Sabrina Corlette

New York map

In this fifth of a series of ten briefs on state implementation efforts of the Affordable Care Act, researchers from the Urban Institute and Georgetown University provide a recap of their findings from a New York site visit conducted in December 2011.  The findings in the report are based off of extensive interviews with state government officials, health care stakeholders and policy experts. New York's ACA implementation successes and challenges thus far relating to the health insurance exchange, Medicaid expansion, and private insurance market reforms, are discussed throughout the report.  Current political difficulties and the state's history of involvement in insurance regulation and Medicaid eligibility expansion are also considered as New York moves ahead in implementing national health reform. 

ACA Implementation-Monitoring and Tracking: Colorado Site Visit Report
Ian Hill, Brigette Courtot, Randall R. Bovbjerg, Fiona Adams

Colorado mapWith less than two years to go before the Affordable Care Act is fully implemented, the State of Colorado is reasonably well positioned. A bipartisan foundation was built before the ACA became law, and stakeholders have largely worked collaboratively to begin putting various required policies and structures in place. Adopting a “Colorado-specific” version of health reform has been critical for state policymakers in responding to the ACA, and was a key factor in the successful passage of exchange legislation. Strong leadership, bipartisan political support, and continued aggressive action will be needed for Colorado to succeed in implementing reform on time.

ACA Implementation-Monitoring and Tracking:  Maryland Site Visit Report
Linda J. Blumberg, Brigette Courtot, Ian Hill, John Holahan

MD mapIn this third of a series of ten briefs on states’ implementation of the Affordable Care Act, Urban Institute researchers summarize their findings from a site visit and extensive interviews with Maryland state officials and health care stakeholders.  The analysis of the state’s progress to date highlights successes and challenges related to insurance exchange planning and information technology development, private insurance market reforms, Medicaid, and provider and insurance markets.  Gubernatorial leadership, stakeholder involvement, legislative progress, the state’s prior experience in health system reform, and the importance of the state’s all-payer hospital rate-setting system are all discussed.

ACA Implementation - Monitoring and Tracking: Rhode Island Site Visit Report
John Holahan, Shanna Rifkin, Kevin Lucia, Katie Keith

RIWith financial support from the Robert Wood Johnson Foundation, the Urban Institute is undertaking a comprehensive monitoring and tracking project to examine the implementation efforts and effects of the Affordable Care Act on 10 states—Alabama, Colorado, Maryland, Michigan, Minnesota, New Mexico, New York, Oregon, Rhode Island, and Virginia. The second case study report draws on a site visit and key informant interviews, to provide an in-depth description of Rhode Island's efforts to implement health reform. The report chronicles Rhode Island's successes thus far, with a special look at exchange establishment, private market reforms, and preparations for Medicaid expansion.

ACA Implementation - Monitoring and Tracking: Oregon Site Visit Report
Teresa A. Coughlin, Sabrina Corlette

OregonMany 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.

 



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