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.
Stabilizing Premiums Under the Affordable Care Act: State Efforts to Reduce Adverse Selection
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
New 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
This 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
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
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
With 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
In 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
With 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
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.