This report investigates what is motivating states to transition to full state-based marketplace status, assesses the benefits and risks of such a switch, and identifies considerations for other states considering a similar move.
This brief explores state variation in health insurance coverage changes during implementation of the primary health insurance coverage reforms of the Affordable Care Act (ACA) using data from the 2013 and 2017 American Community Survey.
This report updates previous analysis of the coverage and health spending implications of Healthy America and analyzes two additional options: one without an individual requirement and one that would lead to universal coverage for all legal residents of the US.
State policymakers have more flexibility than ever to advance health-promoting policies and programs, and showcase effective strategies from which other states—and the nation as a whole—might learn. RWJF helps inform these efforts through research and analysis, technical assistance and training, and advocacy.
This analysis examines some of the consequences should a case pending before the U.S. Court of Appeals for the Fifth Circuit be decided in favor of the plaintiffs, who argue that the entire Affordable Care Act (ACA) be eliminated.
This issue brief looks at progress made in using multi-payer claims databases for various strategic purposes, and offers considerations for states seeking to optimize claims databases to improve health care system performance improvement.
This article estimates the costs of implementing state-based reinsurance programs in four large states whose size provides a useful cost-projection base for other state policymakers considering reinsurance programs.
This commentary provides a brief background on the recent litigation surrounding cost sharing reductions, including executive actions, and state and insurer responses, as well as what could happen next.
This analysis examines the use of 1332 State Innovations Waivers to stabilize individual health insurance markets, comparing the use of this strategy in three states; assessing how they navigated the process; identifying lessons learned; and discussing future concerns.
This project encourages state, local, and national level organizations to include health considerations in policy decisions across multiple sectors, such as housing, transportation, and education. Research shows that the conditions in which people live, learn, work, and play influence their health, so the project also works to create cross-sector partnerships that include the expertise of health care and public health systems.
This tool helps identify policies and programs that are a good fit for community priorities. Analysts review and assess research to rate the effectiveness of a broad variety of strategies (i.e., policies, programs, systems & environmental changes) that can affect health through changes to: health behaviors, clinical care, social and economic factors, and the physical environment.
The Urban Institute conducted interviews with marketplace administrators and insurers selling marketplace coverage in ten states. They analyze marketplace insurer participation and pricing decisions, as well as several related topics.
This webinar discusses the implications of the proposed regulations easing the rules governing health reimbursement arrangements (HRA) and other account-based, tax-preferred health care benefits; and possible state responses.
Alaska, Minnesota and Oregon were the first to gain approval and federal funding to implement their own reinsurance programs under a 1332 waiver. This issue brief assesses their progress and lessons learned to date.
Using data from the American Community Survey and the Current Population Survey, this report assesses whether coverage gains from 2010 to 2016 were associated with changes in labor market outcomes across occupations.
This resource highlights articles published since January 2018 that report on the impact of Medicaid expansion in 33 states and DC, organized by health access and outcomes, economic impacts, and coverage impacts.
This report explores changes in coverage type between 2013 and 2016 overall and for key demographic and income subgroups. Between 2013 and 2016, the share of Americans ages 64 and younger without health insurance fell from 17 percent to 10 percent.
This report provides detailed estimates of changes in health insurance coverage types between 2013 and 2016 by demographic, socioeconomic, and geographic characteristics. In addition, state fact sheets detail coverage changes by income group in all 50 states and DC.
The Trump administration finalized regulations for short-term limited duration policies in early August 2018, which increase the maximum length of short-term, limited-duration insurance policies to just less than one year. This report provides updated tables taking these state legislative changes into account.
This report examines brokers’ evolving role in the individual market, consumer purchasing decisions, and brokers’ observations about how the market and consumers are responding to recent federal policy adjustments to the ACA.
This report explores options for states as they consider oversight of risk-bearing organizations (RBOs), with a focus on states that have elected to act to protect against provider insolvency. The State Health Policy Highlight reviews specific state considerations when overseeing RBOs; case studies examine approaches in California, Massachusetts, New York and Texas.
The ACA has made considerable gains in health insurance coverage, but many remain uninsured. This is an update to a 2015 analysis of the characteristics of the remaining uninsured, focusing on people uninsured in 2017 as well as how the characteristics of this population have changed.
This report examines the United States opioid epidemic at the state-level, analyzing trends in overdose deaths from heroin and other opioids. Using vital statistics data, it looks at which states have the highest rates of opioid-related deaths and which have experienced the largest increases in death rates.
To understand the marketplace enrollment gains and losses observed in 2018 relative to 2017, the Urban Institute interviewed key stakeholders in Rhode Island, Washington, and New York, which saw marketplace enrollment increases, and in West Virginia and Louisiana, which saw enrollment drops. This report explains the different features of the five states, presents cross-state findings, and discusses important factors in next year’s open enrollment period.
The Trump Administration is expanding the availability of alternatives to Affordable Care Act-compliant health insurance. Rules to expand association health plans and short-term limited duration health plans are imminent. This webinar explores what options states have to respond to these developments, featuring experts from Georgetown University’s Center for Health Insurance Reform.
States continue to identify and pursue strategies to further reduce the number of uninsured to make coverage more affordable for consumers and to improve access to care. This issue brief presents two possible models for a Medicaid buy-in program for states, and details the design considerations and authorities needed to implement each model.
This map tracks state Medicaid expansion decisions and approaches states are taking for expanding eligibility to 138 percent of the Federal Poverty Level. It also includes information on state legislative activity around Medicaid expansion, governors’ stances on the issue, and fiscal and demographic analyses from the state or other institutions. For states that are expanding Medicaid, but using an alternative to traditional expansion, the map also contains brief descriptions of these demonstration waivers.
This webinar untangles HHS's annual Notice of Benefit and Payment Parameters and its many implications for states. The rule is a collection of policies governing the ACA’s marketplaces, insurance reforms, and premium stabilization programs. Speakers include Sabrina Corlette and Justin Giovannelli from Georgetown’s Center on Health Insurance Reforms, Joel Ario from Manatt Health, and Jason Levitis.
The Affordable Care Act (ACA) made private nongroup health insurance more accessible to nonelderly adults with chronic conditions through the federal and state-based Marketplaces. As repeal of the ACA individual mandate takes effect in 2019, protecting coverage gains while stabilizing nongroup premiums may depend on state-level efforts to spread the risk of enrollees’ health care costs across a balanced insurance pool.
Although congressional efforts to repeal and replace the Affordable Care Act (ACA) did not succeed in 2017, the law continues to face an uncertain future. This brief examines insurers’ participation and pricing decisions for the 2018 and 2019 plan years through structured interviews with 10 insurance companies participating in the individual market in 28 states and the District of Columbia.
Many states continue to encounter challenges in stabilizing their individual health insurance markets, including large premium increases and declining insurer participation. One solution is a state-based reinsurance program similar to the federal program that reduced premiums by more than 10 percent per year from 2014 to 2016. The brief provides a roadmap of policy, program design, and financing considerations for states that are contemplating development of a state-based reinsurance program under 1332 waiver authority.
With effective repeal of the federal individual insurance mandate scheduled for 2019, many state policymakers are exploring ways to stabilize their insurance markets, including creating a state-based mandate similar to one in Massachusetts. This webinar includes a deep dive into Massachusetts’ mandate, and features a Maryland proposal to create an auto-enrollment process for individuals through its marketplace.
This report summarizes findings from the 2017 Minnesota Health Access Survey, focusing on trends in how Minnesotans obtained health insurance coverage, and provides an understanding of how the 2017 climate may have contributed to a contraction of coverage.
This eLearning series will teach you about: Innovation and Public Health; Foundational Public Health Services: An Overview; Connecting the Dots of Emerging National Public Health Initiatives; and Policy, Systems, and Environmental Change to Drive Innovation in Public Health.
This report examines the issue that with no individual mandate and expanded non-comprehensive coverage, the divisions between states will deepen, and market conditions will deteriorate for unsubsidized farmers and others seeking coverage in states that don’t protect their risk pool.
Studies show that health disparities are often passed down from socially disadvantaged parents to their children and grandchildren. Poor children begin life on an uneven playing field; they face greater challenges than their healthier, more advantaged classmates; and they often struggle as adults to accumulate wealth to share with—and bequeath to—their children. State and federal health policymakers play a crucial role in breaking this cycle of poverty and inequity so that all can live healthy, prosperous lives.
Prior to the passage of the Affordable Care Act in 2010, Minnesota's health insurance market was relatively high-functioning across indicators of health insurance access and quality of care, although the state faced common challenges in the area of health care costs. This report considers Minnesota's health insurance market before and after the passage of the ACA and the outlook for the state's market given the current policy environment.
RWJF’s SHVS together with experts from Manatt Health, host this webinar that highlights and defines potential policy options, including the “Medicaid Buy-in,” that states may consider to leverage Medicaid to achieve their goals with respect to coverage availability and affordability. Conditions that make each option more or less favorable for a state, and implementation issues or other considerations in play for states are discussed.
Uncertainty about the future of health insurance options and concern about the ability of Affordable Care Act (ACA) marketplaces to offer adequate competition and choice have spurred states to look for new coverage approaches. Innovative strategies states are proposing include allowing consumers to buy into state Medicaid programs and developing state-specific coverage options within the ACA’s framework.
As Congress barrels toward the end of the year, several bills are in play that will have major and almost immediate ramifications for health insurance markets. They include: Tax Cuts and Jobs Act (H.R. 1); The Alexander-Murray insurance market stabilization bill; The Nelson-Collins reinsurance program bill; and the temporary elimination of the health insurance tax (H.R. 4620).
This report provides an overview of three areas of value-based innovation and then affords a deeper examination into specific examples of state employee purchaser activity in California, Connecticut, Massachusetts, Minnesota, Tennessee, and Washington.
More than 200 state health officials crowded into a NASHP annual conference session to learn about strategies to improve population health and reduce costs while simultaneously transforming their state’s health care finance and delivery models.
CMS released two informational bulletins detailing a new, streamlined approach for the review and management of Section 1115 demonstrations and state plan amendments and 1915 waivers. The streamlined approach may enhance states' ability to design innovative health care delivery initiatives in their Medicaid programs. These changes come at a critical time as states develop new approaches to reduce health care costs and stem the opioid epidemic.
HHS released proposed changes in its annual notice that governs standards for issuers and the health insurance marketplaces. The annual notice is one of the most significant tools the Administration wields in shaping the health insurance markets and this proposed notice carries significant implications for markets and states.
Understanding premium increases for individual market plans is more complicated this year. In many states, carriers attempted to recapture that lost revenue by increasing the premium of the silver plan relative to other metals. ‘Silver-loading’ gives subsidized non-cost-sharing reduction (CSR) consumers the opportunity to purchase a relatively more affordable bronze or gold plan.
With three states using Section 1332 waivers to help fund reinsurance programs for the 2018 plan year, many more state officials are considering the model for their state in future years. Having worked directly with the 2018 reinsurance states, State Health and Value Strategies presents a to-do list for states as they consider reinsurance for 2019.
The research included in this panel illustrates both the intended and unintended consequences of state policy decisions on a range of health systems outcomes and highlights the necessity of access to different types of federal surveys for the purposes of health policy evaluation. Federal survey data is especially critical when analyzing variation between states, as when comparing outcomes by Medicaid expansion status. As policy flexibility for states continues to grow, this ability to compare states to one another will continue to be essential.
This brief puts a state lens on emerging proposals in the ACA repeal and replace debate. Over the last decade, 21 states introduced legislation to sell across state lines, only five states enacted such laws, but no insurer has yet to offer.
Sens. Lamar Alexander (TN) and Patty Murray (WA) released a bipartisan bill designed to bring short-term stability to the health insurance market. While there are indications that Alexander and Murray secured the 60 votes needed for passage in the Senate, it faces an uncertain fate in the House and with the President.
The prospects for these new players reflect tensions for the market as a whole. Clearly the massive number of net exits signals a retrenchment by many market participants in 2018, resulting in shrinking of territorial footprints and outright withdrawal by large parts of the industry. For a variety of reasons, including attempts to repeal the ACA, the potential of the individual market has not yet been fully realized. Yet, it still remains the source of coverage for millions of people.
This report provides an annual update to comparisons of uninsurance estimates from four federal surveys:
-The American Community Survey (ACS)
-The Current Population Survey (CPS)
-The Medical Expenditure Panel Survey - Household Component (MEPS-HC)
-The National Health Interview Survey (NHIS)
This SHADAC chartbook uses data from the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC) to highlight the experiences of private-sector workers with employer-sponsored insurance (ESI) from 2012 through 2016 at the national level and in the states. The ESI chartbook is accompanied by state-level fact sheets summarizing key ESI characteristics from 2012 to 2016.
While there are risks to the stability of their markets that states cannot well control, one important route to adverse market outcomes may be state policy decisions. There are frequent calls for more state flexibility, but these data suggest that the exercise of existing state flexibility is one way that states have visited a considerable amount of trouble upon their markets. Yet there is a hopeful note here as well, since this suggests that there are steps that states can take to improve their situation.
This chart summarizes major provisions included in the 2010 Affordable Care Act, provisions included in the American Health Care Act passed by the House on May 4, 2017, as well as preliminary analysis of the Senate Better Care Reconciliation Act (BCRA) discussion draft as amended on June 26, 2017, and then revised on July 13, 2017 and July 20, 2017.
The Senate released two bills as part of its efforts to repeal the Affordable Care Act (ACA): A revision to the Better Care Reconciliation Act (BCRA) eliminating the “Ted Cruz Amendment,” which provided funding to create coverage alternatives for high-risk individuals, and the Obamacare Repeal Reconciliation Act (ORRA), which would repeal many of the major provisions of the ACA within a two-year period, but does not offer plans to replace those provisions.
This blog examines three potential changes to state public health programs, based on insights in the proposed White House budget for FY 2018. The budget is expected to change in Congress; however, it is important for states to consider what the administration’s priorities could mean for public health. It proposes some targeted infrastructure investments and proposes to reduce funding for public health infrastructure and services.
State health policymakers are increasingly acknowledging housing as a key component of health and are weaving housing strategies into their broader health system transformations. States have powerful levers at their disposal and a range of funding streams that they can bring to bear to support integrated health and housing, while local public housing authorities also play a large role in community efforts to house vulnerable, low-income households.
This report examines the United States opioid epidemic at the state-level, analyzing trends in overdose deaths from heroin and other opioids, such as prescription painkillers. Using vital statistics data, it looks at which states have the highest rates of opioid-related deaths and which have experienced the largest increases in death rates.
This report explores Louisiana’s permanent supportive housing program. The program, administered jointly by the state’s Medicaid agency and housing authority, is a cross-agency partnership that braids funding to serve vulnerable cross-disability populations, address homelessness, reduce institutionalizations, and save money for the state.
The AHCA, which proposes to repeal and replace the ACA, would dismantle the Prevention and Public Health Fund (PPHF). States received over $625 million from the PPHF in fiscal year 2016, and stand to lose more than $3 billion over five years if it is repealed. The bill would repeal all new appropriations for the PPHF starting in fiscal year 2019, and rescind any funds left over at the end of 2018.
HHS Secretary Tom Price issued a letter to governors encouraging them to take advantage of Sec. 1332 State Innovation Waivers under the Affordable Care Act and cited Alaska‘s request as an example. Alaska’s waiver seeks federal funds to support a reinsurance plan to stabilize its individual insurance market.
This chart summarizes how the American Health Care Act, passed out of House committees the day before, differed from the Affordable Care Act. State leaders, representing the diversity of states and breadth of state health policy agencies and officials, met at a summit to discuss those changes and how they might affect states.
Congressional action to repeal and replace the ACA is on the fast track. The administration and GOP leaders have outlined a three-pronged effort to reform healthcare beginning with passage of the American Health Care Act (AHCA). Congress released Manager’s Amendments to the AHCA, inclusive of a series of policy and technical changes to the bill. Here is a full statutory text of policy and technical amendments.
Recent state waivers can inform the question of whether and how low-income individuals could benefit from health savings accounts (HSAs) with high-deductible health plans. State experiences incorporating health savings accounts into Medicaid can be instructive, as policymakers consider the role of HSAs in proposed health care reforms. This brief looks at health savings and similar accounts in Michigan and Indiana.
Congress began its ACA repeal effort and evolving replacement options are receiving considerable attention. NASHP is tracking issues that appear in multiple proposals and will provide state perspectives, including: How might they impact states? What might they cost? Have they been tried before in states and what did we learn from past initiatives?
This chart provides an overview of ACA provisions and snapshot of the implications for states if the ACA is repealed. States are the primary regulator of insurance and as such had laws in place prior to the enactment of ACA. Some states repealed those laws and replaced them with ACA provisions, while other states revised their laws but left other old, preempted laws on the books.
This report describes six potential integration strategies that state agencies might employ to better integrate social services and health care delivery. For each, the report contains examples from several states that have utilized these strategies in their own efforts to increase integration.
Leaders from across state governments, in both the executive and legislative branches, convened to help identify cross-cutting issues that provide opportunities to advance health reform and transform our health system to one that lowers cost, rewards value, and improves health. This brief presents key opportunities before the new administration that could maintain and accelerate state-based reforms.
Health coverage transitions—sometimes referred to as churn—have always existed to some degree, but with the Affordable Care Act there are additional possibilities for churning to occur across multiple coverage sources. This report examines current efforts in some states to measure these coverage transitions and provides broader context on the issue of churn.
PHAB is the nonprofit accrediting body for Tribal, state, local, and territorial public health departments. In 2015, PHAB launched PHNCI, a new division established to identify, implement, and spread innovations in public health practice to help meet the health challenges of the 21st century in communities nationwide. This report explains the alignment between version 1.5 of the accreditation standards and measures and version 1.0 of the foundational capabilities as part of the foundational public health services framework.
In this brief, we explore two revenue sources states may deploy to fund the non-federal share of expansion: provider assessments and provider donations. Both are authorized by federal law and both have been used by states in connection with expansion.
This issue brief examines seven safety-net ACOs across five states to understand their origins, organization, characteristics and functions and to identify federal and state policy questions associated with their emergence. The issue brief identifies both challenges facing safety-net provider ACO aspirants and state strategies to support safety-net provider development of ACOs.
This report identifies key lessons from ACO activities across the country to date. It examines how ACOs can build upon these initial successes and informs policymakers, researchers, and foundations about key considerations to further the development of effective ACO approaches across the health care market.
As state Medicaid programs increase their focus on value-based payment, it is important to consider how FQHCs may participate in payment reform strategies. Through their focus on improved health outcomes, patient satisfaction, and access to appropriate care, alternative payment methodologies can benefit FQHCs, the state purchaser, and most importantly Medicaid beneficiaries. This brief describes a number of state-level payment reform strategies that include FQHCs and offers strategies and considerations for states and FQHCs alike.