 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.
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 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  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
Brigette Courtot, Stan Dorn, Vicki Chen 
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 
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  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
Linda J. Blumberg, Brigette Courtot, Ian Hill, John Holahan  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
John Holahan, Shanna Rifkin, Kevin Lucia, Katie Keith  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
Teresa A. Coughlin, Sabrina Corlette  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.
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