• Established “health exchanges” or “marketplaces” on a statewide basis that sold community-rated individual and family insurance policies that were required to cover ten sets of “essential health benefits.” Policies could be sold in four “metal tiers”, Bronze, Silver, Gold, and Platinum, which cover 60%, 70%, 80%, and 90%, respectively, of typical health expenses. The tiers with the more comprehensive coverage generally have higher premiums.•Provided income-based subsidies to purchase insurance policies on the exchanges. Families earning up to four times the FPL were eligible for at least some financial assistance to pay for insurance. Various restrictions applied; for example, people…
Medicaid Expansion Under the ACA
"Since January 1, 2014, states have had the option to extend Medicaid coverage to most non-elderly, nonpregnant adults with income up to 133% of FPL. Twenty-four states and the District of Columbia implemented the ACA Medicaid expansion at that time. Since then, the following seven states have implemented the expansion: Michigan (April 1, 2014), New Hampshire (July 1, 2014), Pennsylvania (January 1, 2015), Indiana (February 1, 2015), Alaska (September 1, 2015), Montana (January 1, 2016), and Louisiana (July 1, 2016). (See Figure 1.)"Virginia is expected to begin coverage of the ACA Medicaid expansion on January 1, 2019. Maine adopted the…
Affordable Care Act and “Shared Responsibility”
"The Affordable Care Act (ACA), enacted in 2010, established “shared responsibility” between the government, employers, and individuals for ensuring that all Americans have access to affordable and good-quality health insurance. However, health coverage remains fragmented, with numerous private and public sources, as well as wide gaps in insured rates across the U.S. population. The Centers for Medicare and Medicaid Services (CMS) administers Medicare, a federal program for adults 65 and older and some people with disabilities, and works in partnership with state governments to administer both Medicaid and the Children’s Health Insurance Program (CHIP), a conglomeration of federal–state programs for…
Health Insurance Coverage In the US Before the ACA
"Until the major provisions of the ACA went into effect in January 2014, health insurance coverage was always voluntary. About 30% of the population was covered through the two major public programs enacted in 1965: Medicare for seniors (later extended to the disabled) and Medicaid for poorer Americans [2]. Most others received coverage through their employment, either as employees or dependents, but such coverage was always voluntary: employers did not have to provide it, and individuals were not required to buy it. Less than 10% purchased coverage on their own."As far back as the 1950s those with pre-existing illnesses generally found…
Problems That Hampered Implementation of ACA’s Coverage Provisions
"Several major problems have hampered the implementation of the coverage provisions of the ACA. First was the troubled debut of the federally run insurance marketplaces and a number of state-run programs. The federal marketplaces now seem to be functioning adequately, and most states with problems have either fixed them or imported solutions from other states or the federal government. Second, a number of insured Americans were upset and surprised when companies canceled policies that did not meet minimum standards under the ACA. The numbers of canceled policies have declined over time, and cancellations have become less troublesome as better-functioning marketplaces…
ACA Hampered By Financial Vulnerabilities From the Start
"The ACA is vulnerable to the availability of resources at many other levels. The United States has a large national deficit for which the federal government must account. The states find themselves with inadequate financial resources. Many states cannot legally run a deficit and this limits their ability to participate in many of the ACA programmes that require their funding (Weissert & Weissert, 2006)."The federal budget compromise enacted by Congress in March 2011 reduced funding for many programmes as part of a package of budget cuts required to ensure that the federal government could continue to function in the face…
ACA’s Medicaid Expansion and NFIB v Sebelius
"As enacted, the ACA Medicaid expansion was a mandatory expansion of Medicaid eligibility to non-elderly adults with incomes up to 133% of the federal poverty level (FPL). However, on June 28, 2012, in National Federation of Independent Business v. Sebelius, the U.S. Supreme Court found that the federal government could not withhold payment for a state’s entire Medicaid program for failure to implement the ACA Medicaid expansion. Instead, the federal government could withhold only funding for the ACA Medicaid expansion if a state did not implement the expansion, which effectively made the expansion optional."After the Supreme Court ruling, the Centers…
Impact on Coverage of Administrative Changes and Repeal of the ACA’s Individual Mandate
"One would expect to see an uptick in the number of uninsured for two reasons: (1) the financial penalty for being uninsured will be removed beginning in 2019, and (2) premiums will rise due to adverse selection, by an estimated 10%, although most people are protected through rising financial subsidies. Estimates by the Congressional Budget Office project that by 2027, five million Americans would lose individual coverage; another five million, Medicaid coverage; and three million more, employer coverage [11]. Moreover, the Trump Administration has made various administrative decisions that will lead to fewer people choosing to purchase coverage, including: (1) occasionally…
ACA Policy Changes 2017-2018
"As noted, despite calls to repeal the ACA 'on day one,' the President Trump, even with the support of a Republican Congress, was not able to repeal the legislation – although the vote in the U.S. Senate was very close. (Whether the House of Representatives would have passed the Senate bill is conjectural.) Due to arcane rules in the U.S. Senate, repeal before the U.S. National 2018 congressional elections will be extremely difficult because it would require 60 votes out of 100 – and Democrats and Democrat-leaning independents hold 48 seats."The Republicans were able to make a major legislative dent,…
Impact of Other Proposed Changes to ACA
"In addition, the administration is proposing other changes that could to lead to the sale of cheaper and less comprehensive policies at a cost of reducing consumer protections. States would gain more flexibility in defining what constitutes essential health benefits. Individuals would be allowed to purchase health insurance across state lines, which would give people in a state with tougher regulations the ability to purchase from another state where regulations are lower and insurance is cheaper. Regulations governing small employers that group together to create their own plans (called “association health plans”) would be modified to permit less comprehensive policies. And the…