Counties at Risk of Having No Insurer on the Marketplace (Exchange) in 2018

This map shows the counties at risk of having no insurer on the marketplace (exchange), created by the Affordable Care Act, in 2018, based on a Kaiser Family Foundation analysis of insurer rate filings and news reports

Source: Counties at Risk of Having No Insurer on the Marketplace (Exchange) in 2018 | The Henry J. Kaiser Family Foundation

Our historical analysis of insurer participation on the marketplaces from 2014-2017 can be found here.

These data are preliminary and subject to change as more information becomes public. Insurer participation in 2018 will not be finalized until the fall of 2017. It is possible that another insurer will expand into the counties that currently appear bare, and it is also possible that insurers will exit from other counties not shown on this map.

If a county has no exchange insurer, consumers would not be able to purchase marketplace plans with federal subsidies, including advanced premium tax credits (APTCs) and cost-sharing reductions (CSR). Tax credits make coverage more affordable throughout the year by lowering consumers’ monthly premium costs; cost-sharing reductions help lower out-of-pocket costs. In 2017, 8.7 million people (84% of all marketplace enrollees) received tax credits to cover a share of their premium and 5.9 million people (57% of all marketplace enrollees) received cost-sharing reductions.

This map only shows participation by on-exchange insurers. It is possible that some people in counties with no exchange insurers in 2018 will be able to purchase individual plans off-exchange, though this coverage would not qualify for financial assistance. If no exchange insurer participates in their county, people that rely on these subsidies may be unable to afford insurance off-exchange.

Revised ACA Repeal and Replace Bill Likely to Increase the Uninsured Rate and Health Insurance Costs for Many

House Republicans are close to agreeing on an amended version of the American Health Care Act, their proposed repeal and replacement of the Affordable Care Act. David Blumenthal, M.D., and Sara Collins say that, based on the summaries circulated by the media, the revised bill will significantly increase the numbers of uninsured Americans while raising insurance costs for many of the nation’s most vulnerable citizens. At the same time, the bill’s restructuring of the Medicaid program is likely to hurt state economies and enrollees.

Source: Revised ACA Repeal and Replace Bill Likely to Increase the Uninsured Rate and Health Insurance Costs for Many – The Commonwealth Fund

News outlets report that House Republicans are close to agreeing on an amended version of the American Health Care Act (AHCA), their proposed repeal and replacement of the Affordable Care Act (ACA). The all-important legislative language for the revised bill is not yet available, nor are Congressional Budget Office (CBO) projections of its effects on coverage and the budget, so any analyses are necessarily tentative.

Nevertheless, the summaries leaked to the media offer insight on the amended bill. If accurate, those summaries suggest that the revised AHCA will significantly increase the numbers of uninsured Americans, raise the cost of insurance for many of the nation’s most vulnerable citizens, and, as originally proposed in the AHCA, cut and reconfigure the Medicaid program. The new amendment specifically allows states to weaken consumer protections by, for example, permitting insurers to charge people with preexisting conditions higher premiums.

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High Physician Turnover May Partly Explain ACOs’ Limited Success

Substantial Physician Turnover and Beneficiary “Churn” in a Large Medicare Pioneer ACO

Source: Physician Turnover Beneficiary Churn Medicare ACO – The Commonwealth Fund

Synopsis

A study of one of the nation’s largest Medicare accountable care organizations (ACOs) found that participating physicians see a relatively small number of patients who are actually part of the ACO population: less than 5 percent of a typical patient panel consists of ACO patients. The ACO also experiences substantial physician turnover. And when physicians leave the ACO, most of their attributed beneficiaries leave as well.

The Issue

“Physicians play a central role in the delivery of medical care and, not surprisingly, also are critical players in Medicare payment reform.”

To increase provider accountability for the cost and quality of patient care, health care systems, including the Medicare and Medicaid programs, have begun to move away from fee-for-service and toward ACOs and other alternative payment models that encourage more efficient and effective care delivery. With the ongoing implementation of the Medicare Access and CHIP Reauthorization Act of 2015, the numbers of physicians and provider organizations entering alternative payment models such as ACOs is likely to accelerate rapidly. Evidence to date, however, indicates that ACOs have achieved limited success in attaining their goals. Even though physicians play a decisive role in whether ACOs are able to deliver on their promise, there has been limited research on the physicians who work in ACOs and their experiences with patients. Commonwealth Fund–supported researchers studied a large Medicare Pioneer ACO to learn about the stability of physician participation and beneficiary enrollment.

Key Findings

  • The ACO experienced substantial turnover among physicians: only 52 percent were affiliated over the entire three-year contract period.
  • Most (88%) physicians had at least some beneficiaries attributed to them, but these patients accounted for just a small part of their panels, which averaged 1,700 patients per panel. Half (50%) of physicians had just 70 or fewer attributed beneficiaries. ACO enrollees accounted for less than 5 percent of the median physician’s patient panel.
  • About half (49%) of beneficiaries who joined the ACO in contract year 2 or 3 did so because their physician had joined the ACO. When physicians left the ACO in year 2 or 3, 90 percent of their assigned beneficiaries also left.

The Big Picture

The study’s findings suggest that two factors can dampen an ACO’s potential to hit its financial targets: a relatively low number of enrollees attributed to participating physicians, and the loss of patients when physicians leave the ACO. To the extent that there is patient turnover, the ACO’s incentives also are dampened with respect to investments that require more than a few months to achieve any payoff. The authors conclude that the financial incentives provided by ACOs to provide better, more efficient care may not be sufficient to attract physicians, given the small numbers of ACO beneficiaries they tend to serve. Physicians, they say, might instead repond better to comparable incentives that are linked to having a larger number of patients on their panels. This, however, would require standardizing incentives across payers. Standardization also reduces the potential cacophony associated with having a large number of incentives. Health systems also could reconsider how they link beneficiaries to primary care physicians to concentrate care among a smaller number of physicians, creating a critical mass of patients that might encourage and facilitate practice pattern changes.

The authors also note that having the ability to select participating physicians each year creates a temptation for ACOs to improve their risk profile—and thereby increase their opportunity for shared savings—by dropping the small number of physicians whose patients have the most unfavorable risk mix (e.g., those with very high treatment costs). The Centers for Medicare and Medicaid Services could put policies in place that would reduce the incentive to game the risk pool.

About the Study

The researchers used the following data sources for their analysis: a list of beneficiaries aligned to Partners HealthCare’s ACO; a list of physicians affiliated with the ACO during that period; databases that captured the number of years a physician was affiliated with the ACO, physician specialty, and other factors; and Medicare claims data.

The Bottom Line

A low number of attributed enrollees per physician and substantial physician turnover may help explain the muted impact that accountable care organizations have had thus far.

The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review | The Henry J. Kaiser Family Foundation

Coverage: Studies show that Medicaid expansion results in significant coverage gains and reductions in uninsured rates, both among the low-income population broadly and within specific vulnerable populations.

Access to care, utilization, affordability, and health outcomes: Most research demonstrates that Medicaid expansion positively impacts access to care, utilization of services, the affordability of care, and financial security among the low-income population. Studies have also shown improved self-reported health following expansion, but additional research is needed to determine effects on health outcomes.

Economic measures: Analyses find positive effects of expansion on multiple economic outcomes, despite Medicaid enrollment growth initially exceeding projections in many states. Studies also show that Medicaid expansions result in reductions in uncompensated care costs for hospitals and clinics as well as positive or neutral effects on employment and the labor market.

As the Trump Administration and Congress debate ACA repeal and replacement, gains in coverage and access as well as economic benefits to states and providers are at stake if the Medicaid expansion is repealed.

Source: The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review | The Henry J. Kaiser Family Foundation

Research on the effects of Medicaid expansions under the Affordable Care Act (ACA) can help increase understanding of how the ACA has impacted coverage; access to care, utilization, affordability, and health outcomes; and various economic outcomes, including state budgets, the payer mix for hospitals and clinics, and the employment and labor market. Understanding these findings can help inform the debate over a repeal of the ACA (which would include the Medicaid expansion).

This summary reviews findings from 108 studies of the impact of state Medicaid expansions under the ACA published between January 2014 (when the coverage provisions of the ACA went into effect) and January 2017. (This is an update to an earlier issue brief, “The Effects of Medicaid Expansion under the ACA: Findings from a Literature Review,” that covered studies published through May 2016.) It includes peer-reviewed studies as well as free-standing reports, government reports, and white papers published by research and policy organizations, using data from 2014 or later. This brief only includes studies that examine impacts of the Medicaid expansion; it excludes studies on impacts of ACA coverage expansions generally (not specific to Medicaid expansion alone) and studies investigating potential effects of expansion in states that have not (or had not, at the time of the study) expanded Medicaid. In both the brief below and the tables, findings are separated into three broad categories: Medicaid expansion’s impact on coverage; access to care, utilization, affordability, and health outcomes; and economic outcomes for the expansion states.

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Disability Rights – National Health Law Program

Medicaid provides health coverage and protections for persons with physical, intellectual and developmental disabilities. NHeLP works with state health advocates and litigates when necessary to protect the rights of vulnerable persons, making sure persons with disabilities receive the care they need and are legally entitled to, as well as protecting their rights when care is denied, terminated or reduced without notice or a hearing.

Source: Disability Rights – National Health Law Program

 

Medicaid Work Requirements – Legally Suspect

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Source: Medicaid Work Requirements – Legally Suspect

Executive Summary

Legal Director Jane Perkins, and Policy Analyst Ian McDonald detail why adding a work requirement to Medicaid is “legally suspect.” They explain that currently the Medicaid Act has four requirements that an individual must meet that do not include a mandatory work requirement. “A number of courts,” Perkins and McDonald write, “have recognized that states may not ‘add additional requirements for Medicaid eligibility’ that are not set forth in the Medicaid Act.” They also note that the purpose of Medicaid is to “furnish medical assistance to low-income individuals who cannot afford the costs of medically necessary services and to furnish ‘rehabilitation and other services to help [such individuals] attain or retain capability for independence or self-care. A mandatory work requirement is not medical assistance; it is not a service provided to Medicaid beneficiaries.”

Medicaid Work Requirements – Not a Healthy Choice

Executive SummaryIn an effort to win conservative members’ support for the Affordable Care Care Act repeal bill, House Republicans have added a work requirement for Medicaid to the measure. In this issue brief, NHeLP Managing Attorney of the DC office Mara Youdelman,  Legal Director Jane Perkins, and Policy Analyst Ian McDonald detail why such work requirements “run counter to the purpose of Medicaid.” They conclude, “Work requirements would stand Medicaid’s purpose on its head by creating barriers to coverage and the pathway to health that the coverage represents.”DOWNLOAD PUBLICATION

Source: Medicaid Work Requirements – Not a Healthy Choice

Compare Proposals to Replace The Affordable Care Act | The Henry J. Kaiser Family Foundation

President Donald Trump and Republicans in Congress have committed to repealing and replacing the Affordable Care Act (ACA). How do their replacement proposals compare to the ACA? How do they compare to each other?Plans available for comparison:The American Health Care Act as introduced by the House Republican leadership, March 6, 2017 (PDF)The Affordable Care Act, 2010 (PDF)More plans for comparison:Rep. Tom Price’s Empowering Patients First Act, 2015 (PDF)House Speaker Paul Ryan’s A Better Way: Our Vision for a More Confident America, 2016 (PDF)Sen. Bill Cassidy’s Patient Freedom Act, 2017 (PDF)Sen. Rand Paul’s Obamacare Replacement Act, 2017 (PDF)House Discussion Draft, February 10, 2017 (PDF)Click the column header to view available plans to compare. You may compare up to 3 plans.

Source: Compare Proposals to Replace The Affordable Care Act | The Henry J. Kaiser Family Foundation

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Community Outreach Collaboratives | National Disability Navigator Resource Collaborative

Community Outreach Collaboratives The NDNRC has funded eighteen Community Outreach Collaboratives (COCs) for the third year of open enrollment – expanding on the eleven COCs who were funded in year two. The COCs will increase collaborations in the community, dissemination and outreach efforts and enrollment of people with disabilities in the ACA. The COCs have two primary tasks: 1) build cross-disability collaborations with other disability organizations; and 2) have the cross-disability collaboration work

Source: Community Outreach Collaboratives | National Disability Navigator Resource Collaborative

Outcomes of “Partnering to Transform Healthcare with People with Disabilities” (PATH-PWD) conference

Research Team Sarah H. Ailey Principal Investigator Rush CON Molly Bathje Co-Investigator Rush CHS Tamar Heller Co-Investigator University of Illinois Award Period 6/1/16 – 5/31/17 Funding Source Agency for Healthcare Research and Quality (AHRQ) R13 Conference grant

Source: Partnering to Transform Healthcare with People with Disabllities (PATH-PWD) – Improving Acute, Primary and Transitional Health care with People with Disabilities | | Rush University

On March 23 and 24, 2017, leaders on disability rights and disability health care from around the country gathered at Rush University for the Partnering to Transform Healthcare with People with Disabilities (PATH-PWD) conference sponsored by Rush University and the Rehabilitation Research and Training Center on Developmental Disabilities and Health, University of Illinois at Chicago. The conference was funded by grants from the Agency for Healthcare Research and Quality (AHRQ) and the Special Hope Foundation.

IASSIDD PowerPoint presentation of the “Tackling Health Disparities and Implementing a Best Practices Healthcare Model: Report from (PATH-PWD) Conference” presented at the American Academy on Developmental Medicine and Dentistry (June 5, 2017).
Sarah H Ailey PhD RN APHN-BC CDDN, Tamar Heller, PhD, & Molly Bathje, PhD, OTR/L

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