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Issue Brief of the Commonwealth Fund

Joel Ario, Deborah Bachrach
Issue: The Affordable Care Act has expanded coverage to 20 million newly insured individuals, split between state Medicaid programs and commercially insured marketplaces, with limited integration between the two. The seamless continuum of coverage envisioned by the law is central to achieving the full potential of the Affordable Care Act, but it remains an elusive promise. Goals: To examine the historical and cultural differences between state Medicaid agencies and insurance departments that contribute to this lack of coordination...
2017: Issue Brief of the Commonwealth Fund
Justin Giovannelli, Emily Curran
Issue: Policymakers have sought to improve the shopping experience on the Affordable Care Act’s marketplaces by offering decision support tools that help consumers better understand and compare their health plan options. Cost estimators are one such tool. They are designed to provide consumers a personalized estimate of the total cost--premium, minus subsidy, plus cost-sharing--of their coverage options. Cost estimators were available in most states by the start of the fourth open enrollment period. Goal: To understand the experiences of marketplaces that offer a total cost estimator and the interests and concerns of policymakers from states that are not using them...
2017: Issue Brief of the Commonwealth Fund
Sara R Collins, Munira Z Gunja, Michelle M Doty, Sophie Beutel
Issue: Since 2001, long before the passage of the Affordable Care Act (ACA), the Commonwealth Fund Biennial Health Insurance Survey has examined health coverage and consumers’ experiences buying insurance and using health care. Goals: To examine long-term trends and to make comparisons before and after passage of health reform. Methods: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. Findings and Conclusions: There have been dramatic improvements in people’s ability to buy health plans on their own following the passage of the ACA...
2017: Issue Brief of the Commonwealth Fund
Sara Rosenbaum, Sara Rothenberg, Rachel Gunsalus, Sara Schmucker
Issue: Republicans in Congress are expected to repeal portions of the Affordable Care Act (ACA) using a fast-track process known as budget reconciliation. Goals: This issue brief examines how repeal legislation could affect Medicaid, the nation’s health care safety net, which insured 70 million people in 2016. Findings and Conclusions: Partial-repeal legislation that passed Congress but was vetoed by President Obama in 2016 offers some insight but new legislation could go further. It could repeal the ACA’s Medicaid eligibility expansions for adults and children but also roll back other provisions, such as simplified enrollment and improvements in long-term services and supports for beneficiaries with disabilities...
2017: Issue Brief of the Commonwealth Fund
Leighton Ku, Erika Steinmetz, Erin Brantley, Brian Bruen
Issue: The incoming Trump administration and Republicans in Congress are seeking to repeal the Affordable Care Act (ACA), likely beginning with the law’s insurance premium tax credits and expansion of Medicaid eligibility. Research shows that the loss of these two provisions would lead to a doubling of the number of uninsured, higher uncompensated care costs for providers, and higher taxes for low-income Americans. Goal: To determine the state-by-state effect of repeal on employment and economic activity...
2017: Issue Brief of the Commonwealth Fund
Amber Willink, Karen Davis, Cathy Schoen
Issue: Two-thirds of Medicare beneficiaries with physical and/or cognitive impairment (PCI) who live in the community have three or more chronic conditions and could benefit from integrated medical and social services. Over one-third of those with PCI have incomes under 200 percent of the federal poverty level but are not covered by Medicaid, exposing them to risk of financial burdens and nursing home placement. Goal: To analyze two policy options that expand financing for home- and community-based care for older adults with PCI...
October 2016: Issue Brief of the Commonwealth Fund
Amber Willink, Karen Davis, Cathy Schoen
Issue: More than half of individuals who age into Medicare will experience physical and/or cognitive impairment (PCI) at some point that hinders independent living and requires long-term services and supports. As a result of Medicare’s limits on covered services, Medicare beneficiaries with PCI experience financial burdens and reduced ability to live independently. Goal: Describe the characteristics and health spending of Medicare beneficiaries with PCI and estimate the likelihood of Medicaid entry and long-term nursing home placement...
October 2016: Issue Brief of the Commonwealth Fund
Jon Gabel, Heidi Whitmore, Matthew Green, Adrienne Call, Sam Stromberg, Rebecca Oran
Issue: Without the cost-sharing reductions (CSRs) made available by the Affordable Care Act, health plans sold in the marketplaces may be unaffordable for many low-income people. CSRs are available to households earning between 100 percent and 250 percent of the federal poverty level that choose a silver-level marketplace plan. In 2016, about 7 million people received cost-sharing reductions that substantially lowered their deductibles, copayments, coinsurance, and out-of-pocket limits. Goal: To examine variations in consumer cost-sharing reductions between silver-level plans with CSRs to traditional marketplace plans and to employer-based insurance...
October 2016: Issue Brief of the Commonwealth Fund
Sara R Collins, David C Radley, Munira Z Gunja, Sophie Beutel
Issue: Although predictions that the Affordable Care Act (ACA) would lead to reductions in employer-sponsored health coverage have not been realized, some of the law’s critics maintain the ACA is nevertheless driving higher premium and deductible costs for businesses and their workers. Goal: To compare cost growth in employer-sponsored health insurance before and after 2010, when the ACA was enacted, and to compare changes in these costs relative to changes in workers’ incomes. Methods: The authors analyzed federal Medical Expenditure Panel Survey data to compare cost trends over the 10-year period from 2006 to 2015...
October 2016: Issue Brief of the Commonwealth Fund
Sherry Glied, Claudia Solís-Román, Shivani Parikh
One important benefit gained by the millions of Americans with health insurance through the Affordable Care Act (ACA) is protection from high out-of-pocket health spending. While Medicaid unambiguously reduces out-of-pocket premium and medical costs for low-income people, it is less certain that marketplace coverage and other types of insurance purchased to comply with the law's individual mandate also protect from high health spending. Goal: To compare out-of-pocket spending in 2014 to spending in 2013; assess how this spending changed in states where many people enrolled in the marketplaces relative to states where few people enrolled; and project the decline in the percentage of people paying high amounts out-of-pocket...
September 2016: Issue Brief of the Commonwealth Fund
Claudia A Salzberg, Susan L Hayes, Douglas McCarthy, David C Radley, Melina K Abrams, Tanya Shah, Gerard F Anderson
Issue: Achieving a high-performing health system will require improving outcomes and reducing costs for high-need, high-cost patients--those who use the most health care services and account for a disproportionately large share of health care spending. Goal: To compare the health care experiences of adults with high needs--those with three or more chronic diseases and a functional limitation in the ability to care for themselves or perform routine daily tasks--to all adults and to those with multiple chronic diseases but no functional limitations...
August 2016: Issue Brief of the Commonwealth Fund
Susan L Hayes, Claudia A Salzberg, Douglas McCarthy, David C Radley, Melinda K Abrams, Tanya Shah, Gerard F Anderson
Issue: Finding ways to improve outcomes and reduce spending for patients with complex and costly care needs requires an understanding of their unique needs and characteristics. Goal: Examine demographics and health care spending and use of services among adults with high needs, defined as people who have three or more chronic diseases and a functional limitation in their ability to care for themselves or perform routine daily tasks. Methods: Analysis of data from the 2009–2011 Medical Expenditure Panel Survey...
August 2016: Issue Brief of the Commonwealth Fund
Sara R Collins, Munira Z Gunja, Michelle M Doty, Sophie Beutel
The number of uninsured people in the United States has declined by an estimated 20 million since the Affordable Care Act went into effect in 2010. Yet, an estimated 24 million people still lack health insurance. Goal: To examine the characteristics of the remaining uninsured adults and their reasons for not enrolling in marketplace plans or Medicaid. Methods: Analysis of the Commonwealth Fund ACA Tracking Survey, February--April 2016. Key findings and conclusions: There have been notable shifts in the demographic composition of the uninsured since the law's major coverage expansions went into effect in 2014...
August 2016: Issue Brief of the Commonwealth Fund
Dania Palanker, Karen Davenport
Issue: Since enactment of the Affordable Care Act (ACA), many more women have health insurance than before the law, in part because it prohibits insurer practices that discriminate against women. However, gaps in women's health coverage persist. Insurers often exclude health services that women are likely to need, leaving women vulnerable to higher costs and denied claims that threaten their economic security and physical health. Goal: To uncover the types and incidence of insurer exclusions that may disproportionately affect women's coverage...
August 2016: Issue Brief of the Commonwealth Fund
Justin Giovannelli, Emily Curran
Issue: Nearly 12.7 million individuals signed up for coverage in the Affordable Care Act's (ACA) health insurance marketplaces during the third open enrollment period, and by the end of March there were 11.1 million consumers with active coverage. States that operate their own marketplaces posted a year-to-year enrollment gain of 8.8 percent. To maintain membership and attract new consumers, the state-based marketplaces must sponsor enrollment assistance programs and conduct consumer outreach. These marketplaces relied heavily on such efforts during the third enrollment period, despite declining funding...
July 2016: Issue Brief of the Commonwealth Fund
Mark A Hall, Michael J McCue
Starting in 2014, the Affordable Care Act transformed the market for individual health insurance by changing how insurance is sold and by subsidizing coverage for millions of new purchasers. Insurers, who had no previous experience under these market conditions, competed actively but faced uncertainty in how to price their products. This issue brief uses newly available data to understand how health insurers fared financially during the ACA's first year of full reforms. Overall, health insurers' financial performance began to show some strain in 2014, but the ACA's reinsurance program substantially buffered the negative effects for most insurers...
July 2016: Issue Brief of the Commonwealth Fund
Munira Z Gunja, Sara R Collins, Michelle M Doty, Sophie Beutel
For people with low and moderate incomes, the Affordable Care Act's tax credits have made premium costs roughly comparable to those paid by people with job-based health insurance. For those with higher incomes, the tax credits phase out, meaning that adults in marketplace plans on average have higher premium costs than those in employer plans. The law's cost-sharing reductions are reducing deductibles. Lower-income adults in marketplace plans were less likely than higher-income adults to report having deductibles of $1,000 or more...
July 2016: Issue Brief of the Commonwealth Fund
Sophie Beutel, Munira Gunja, Sara R Collins
The Affordable Care Act's premium subsidies and cost-sharing reductions have helped to reduce out-of-pocket costs for low-income people enrolled in marketplace plans. This financial protection has been particularly important for people with incomes above 100 percent of poverty who live in states that have not expanded Medicaid. However, a key question for policymakers is how this protection compares to Medicaid. This brief analyzes a sample of silver plans offered in the largest markets in 18 states that use the federal website for marketplace enrollment and have not expanded Medicaid eligibility...
June 2016: Issue Brief of the Commonwealth Fund
Sherry Glied, Adam Striar
One effect of the Affordable Care Act's "Cadillac tax" (now delayed until 2020) is to undo part of the existing federal tax preference for employer-sponsored insurance. The specific features of this tax on high-cost health plans--notably, the inclusion of tax-favored savings vehicles such as health savings accounts (HSAs) in the formula for determining who is subject to the tax--are designed primarily to maximize revenue and minimize coverage disruptions, not to reduce health spending. Thus, at least initially, these savings accounts, rather than enrollee cost-sharing or other plan features, are likely to be affected most by the tax as employers act to limit their HSA contributions...
June 2016: Issue Brief of the Commonwealth Fund
Michael J McCue, Mark A Hall
The new health insurance exchanges are the core of the Affordable Care Act's (ACA) insurance reforms, but insurance markets beyond the exchanges also are affected by the reforms. This issue brief compares the markets for individual coverage on and off of the exchanges, using insurers' most recent projections for ACA-compliant policies. In 2016, insurers expect that less than one-fifth of ACA-compliant coverage will be sold outside of the exchanges. Insurers that sell mostly through exchanges devote a greater portion of their premium dollars to medical care than do insurers selling only off of the exchanges, because exchange insurers project lower administrative costs and lower profit margins...
June 2016: Issue Brief of the Commonwealth Fund
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