Affordable Care Act Archives

ACA Repeal and Replacement: Proposals and Action

Beginning last month, both U.S. President Donald Trump and the U.S. Congress began taking steps to repeal and replace the Affordable Care Act (ACA). However, a single replacement strategy has not yet emerged.

In a new one-page fact sheet, CHRT summarizes the most developed ACA repeal and replacement proposals offered to date and outlines the tentative replacement process.

You can also review CHRT’s companion piece, Select Affordable Care Act Replacement Plans and Implications, for a detailed table summarizing the key features and implications of the most developed full ACA repeal and replacement plans offered to date.

The face sheet summarizes three full replacements for the ACA: the House Republicans’ “A Better Way” proposal, Rep. Tom Price’s “Empowering Patients First Act”, and the Burr-Hatch-Upton “Patient Choice, Affordability, Responsibility, and Empowerment Act”. It also summarizes one partial replacement, the Cassidy-Collins “Patient Freedom Act”.

The fact sheet also details the process to repeal and replace the ACA. We summarize President Trump’s January 20 Executive Order and the 2017 Congressional Action. On January 3, the Senate Budget Committee created a budget resolution to provide framework for a partial ACA repeal using budget reconciliation. On January 12 the resolution received full Senate approval and on January 13 it received full House approval.

The House and Senate committees intended to have draft actual reconciliation legislation by January 27, but this has been delayed. April 15 is the prescribed deadline under current rules for the House and Senate to adopt annual budget resolutions, but this is generally not enforced. June 15 is the prescribed deadline to enact any reconciliation legislation, but this is also generally not enforced.

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Rate Analysis: Michigan’s 2017 Health Insurance Marketplace

While the results of the 2016 presidential election have sparked recent debates about options to repeal and replace the Affordable Care Act, the health insurance marketplaces created under the law continue to operate as usual. So although the future of the law remains unknown, Michigan consumers who enroll in the 2017 Health Insurance Marketplace can likely expect their coverage to remain uninterrupted for the 2017 plan year.

The changing dynamics of the health insurance marketplace are important for 2017 enrollees to understand. Under current federal policy, enrollees who do not actively apply and enroll in 2017 coverage are auto-renewed into their 2016 plan, if it continues to be offered. Beginning with the 2017 open enrollment period, individuals who were enrolled in a plan offered by an issuer that is no longer participating in the marketplace will automatically be enrolled into a plan offered in their area by a different carrier if they do not actively choose another plan.

In addition, changes to benchmark plans directly affect premium tax credit amounts, so many enrollees will need to balance potentially higher costs for renewing their 2016 plan with other important considerations, such as the breadth of available provider networks.

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Insurance Churning

The uninsured rate has declined substantially since provisions of the Patient Protection and Affordable Care Act (ACA) came into effect. Nevertheless, many individuals continue to experience instability in insurance coverage. Transitions between different insurance plans, as well as between insured and uninsured status, are often referred to as “insurance churning.”

The causes of insurance churning vary. Changes in job status may result in loss of coverage or transition to a new insurance plan. Eligibility for Medicaid or plans with Marketplace subsidies may change based on changes in family composition or fluctuations in income. Nationally, three to five percent of members are dropped each month by health plans offered on the Health Insurance Exchange due to non-payment of premiums.

Insurance churning can affect quality, cost, and continuity of care. Individuals may avoid seeking health care when they need it during gaps in insurance coverage. Even if consumers maintain continuous coverage while transitioning between different insurance plans, they may find that their regular health care providers do not accept their new insurance plan. In addition, when they change health plans, research shows that medication compliance is often disrupted. These and other churning-related problems tend to be exacerbated by uncertainty about what new co-pays or deductibles might be as well as by known increased costs associated with new insurance plans.

A recent study found no evidence of significant increases or decreases in broader indicators of insurance churning since the introduction of the ACA in three states (Texas, Kentucky, and Arkansas). Under the new administration, depending on which provisions of the ACA are repealed, replaced, defunded, or retained in the coming years and how these changes are implemented, rates of insurance churning could change dramatically.

Between 2013 and 2015, data from the Census Bureau show that the proportion of Michiganders who reported no source of health insurance declined by five percentage points—from 11 percent to 6 percent. Using data from the Center for Health and Research Transformation’s Cover Michigan Survey, this brief explores consumer experiences with insurance churning and access to care within the state of Michigan for approximately a one-year period in 2014–2015.

Key findings include:

Medicaid recipients had the most instability in their coverage status of all respondents to the survey. Medicaid recipients were also seven times more likely to have experienced a temporary uninsured period in the past year compared to respondents with employer-sponsored or individual coverage.
Those with individually purchased coverage in 2014 were the most likely to switch to a different type of coverage in 2015. Among respondents with an individually purchased plan in 2014, less than half reenrolled in the same plan in 2015, and nearly a third transitioned to Medicare or to an employer-sponsored plan in 2015.
Those with employer-sponsored coverage experienced the least amount of churning compared to respondents with other coverage. Ninety-four percent of respondents with employer-sponsored coverage remained continuously insured from 2014 to 2015.

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Potential GOP Approaches to the Affordable Care Act

A focus on changes to the Affordable Care Act is one of President-elect Donald Trump’s top priorities, and he will enter office with a Republican-controlled Congress eager for a repeal and replace. What are the potential GOP approaches to the Affordable Care Act? In a new one-page summary, CHRT explains:

What the GOP repeal and replacement plans could include
What could be included in a budget reconciliation package
Some of the complexities of changes to the ACA

President-elect Donald Trump and Republicans’ proposals to replace the ACA have not been fully detailed. Republicans have made multiple repeal attempts, but have not yet coalesced around a single replacement proposal.

Trump’s plan to repeal the Affordable Care Act could:

Allow insurance to be sold across state lines
Make premiums tax deductible
Establish high risk pools
Reduce Medicaid funding and use block grants
Allow the importation of drugs

Repealing the entire ACA would be extremely complex because the law is sweeping and includes many provisions that go beyond health insurance coverage issues.

Repeal would require 60 votes in the Senate to overcome a likely Democratic filibuster. Republicans will retain the majority in the Senate, but will not gain enough seats to pass that 60-vote threshold. Regulations and guidance would need to be changed if a full repeal is pursued.

Repeal of parts of the law could take place through the budget reconciliation process only to the extent that the provisions have budgetary impact. Reconciliation requires a simple majority in both chambers and cannot be filibustered.

Editor’s note: This summary was updated to correct a typo. The document now identifies an increase in Medicare (instead of Medicaid) payroll taxes for households making over $200,000/year as one of several parts of the ACA that can be repealed through the budget reconciliation process.

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The Effects of the Affordable Care Act on Federally Qualified Health Centers in Michigan

Federally Qualified Health Centers (FQHCs) form a critical part of the health care safety net, providing essential primary care services to people with limited health care access. The Affordable Care Act (ACA) increased FQHC funding from 2010 through 2015 and significantly expanded the insured population beginning in 2014.

The purpose of this brief is to describe how the overall experience of Michigan FQHCs has changed with ACA implementation, based on analysis of 2008–2015 Uniform Data System data, 2016 Health Resources and Services Administration (HRSA) Delivery Site data, as well as data from interviews with FQHC leaders across the state.

Key findings include:

Many health centers have used increased grant funding to provide new services and expand existing ones, such as dental and mental health services.
Coverage expansion, particularly through the Healthy Michigan Plan (Michigan’s Medicaid expansion program), has substantially decreased the number of uninsured patients. Overall, the uninsured share of the Michigan FQHC population dropped by nearly 50 percent between 2013 and 2015, falling from 31 percent to 16 percent.
Although specialty referrals are easier for insured patients, such referrals remain a major challenge in some regions and specialties, especially for Medicaid patients. Some of the more difficult services to find include those in psychiatry, rheumatology, orthopedics, and neurology.
FQHCs have been developing new partnerships and strategies to help address the remaining needs of their patients. This includes partnerships with hospitals and community mental health organizations as well as partnerships with specialists outside their geographic area to provide telehealth services.
FQHCs still experience many barriers to growth, including challenges with hiring necessary providers, such as psychiatrists, as well as adequate funding for particular types of services, such as oral surgery, or for personnel, such as community health workers.

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Advance Care Planning: Tying a Community Perspective to the National Conversation

Advance care planning (ACP) is a process where people talk with family members and doctors about their end-of-life care preferences and designate someone to carry out their wishes. ACP helps people plan for future medical treatment in the event of a serious illness. Controversies associated with ACP—perhaps most famously the accusations of “death panels” that demonized the Affordable Care Act—have sometimes overshadowed substantial research on the ACP’s benefits. Research shows that the preferences of patients who engage in ACP are more likely to be known and followed, and ACP reduces the burden of medical decision-making among family members. Even with these benefits, few Americans, including older adults, have engaged in advance care planning.

Leaders in geriatrics have argued for national- and community-level policy change to create an environment conducive to ACP. In order to improve the environment for ACP, however, it is essential to understand the current obstacles. To that end, the Washtenaw Health Initiative (WHI), a volunteer collaborative in Washtenaw County, Michigan, examined community barriers and their relationship to nationally identified barriers. In early 2016, the WHI conducted a series of focus groups and interviews with over 80 Washtenaw County community members and physicians to understand the community’s experiences and challenges with ACP. This brief summarizes key findings and policy recommendations related to challenges to ACP, based on the focus groups and interviews and a review of relevant literature.

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Effects of the Affordable Care Act on the Health Care Safety Net in Detroit

Since its passage in 2010, the Affordable Care Act (ACA) has introduced a series of health care financing and delivery reforms to expand coverage, invest in health care infrastructure, and implement changes to improve quality and costs. In 2014, the ACA’s coverage expansion began in Michigan through the launches of the health insurance marketplaces on January 1 and the Healthy Michigan Plan (Michigan’s Medicaid expansion program) on April 1. These programs have contributed to sharp reductions in the number of uninsured Michigan residents.

The ACA coverage expansion has also had outsized effects on the health care safety net, particularly for federally qualified health centers (FQHCs). These centers are supported through federal grants to deliver services in impoverished and high-need areas, and have traditionally been a major source of medical services for the uninsured. FQHCs have been expected to financially benefit under the ACA from serving more patients with health insurance. In addition, the ACA supported grants to local organizations to bolster the safety net, the health care workforce, public health infrastructure, and other quality improvement programs. This brief will describe the effects of the ACA on the safety net in Detroit, with a focus on the experiences of the city’s FQHC providers.

Key findings include:

Detroit-based organizations have received more than $100 million in federal grant funding supported by the ACA and subsequent legislation to expand delivery capacity, train new health care workers, and develop other programs.
The number of patients and patient visits at FQHCs in Detroit increased by over 6% from 2013 to 2014, and the number of uninsured patients decreased by over 30% as the ACA’s coverage expansion took effect.
Detroit FQHC patients tend to be poorer and are more likely to be racial minorities than other FQHC patients in Michigan. The characteristics of FQHC patients in Detroit were relatively stable from 2013 to 2014.
The number of health care providers (physicians, nurses, physician assistants, etc.) employed directly by FQHCs grew by over 21% from 2013 to 2014 as FQHCs prepared to serve more patients. As FQHCs adjust to the new environment under the ACA, many are working to develop new strategies to serve unmet patient needs, particularly in areas related to behavioral health, oral health, substance use, and transportation.

These CHRT reports were produced for the Altarum Institute’s Center for Sustainable Health Spending, which received funding from the National Institute for Health Care Reform to examine strategies for improving the health of the people of Detroit, and the related economic consequences.

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Effects of the Affordable Care Act on Health Insurance Coverage in Southeast Michigan

Combined with a decreasing unemployment rate, the Affordable Care Act’s (ACA) coverage expansion contributed to a sharp decrease in Michigan’s uninsured rate in 2014. However, effects of the coverage expansion have been uneven, and socioeconomic and geographic disparities in coverage remain across the state.

Since the launch of the ACA coverage expansion in 2014, millions of previously uninsured Americans have enrolled in health insurance. The ACA coverage expansion has two primary components: expansion of Medicaid eligibility to low-income adults and financial assistance to help individuals purchase private coverage through the health insurance marketplaces. Expanded health insurance coverage under the ACA has coincided with improved access to medical care and reductions in problems paying medical bills for many families. In addition, providers have seen a reduction in uncompensated care costs since the ACA coverage expansion began.

This brief describes the ACA coverage expansion for southeast Michigan (Livingston, Macomb, Monroe, Oakland, Washtenaw, and Wayne counties) and the reductions in the uninsured population. It also examines the remaining uninsured population and the potential for further gains in health insurance coverage.

Key findings include:

The number of residents in southeast Michigan who selected a marketplace plan during open enrollment increased from about 141,000 in 2014 to 164,000 in 2015. However, the number of plan selectors was virtually unchanged in Wayne County.
Total Medicaid enrollment, including both traditional Medicaid and Healthy Michigan Plan (Michigan’s Medicaid expansion program) enrollment, grew in each county in southeast Michigan, increasing from about 877,000 prior to launch of the Healthy Michigan Plan in April 2014 to 1.12 million in August 2015. In Wayne County, more than 36% of residents were enrolled in Medicaid by December 2015.
Every county in southeast Michigan experienced a decrease in the number of uninsured residents from 2013 to 2014, with Wayne County experiencing the sharpest decrease, from 16.4 to 12.5%.
Within the City of Detroit, the uninsured rate fell from 22.5 to 17.1% in 2014 as both public and private coverage increased.
Areas within the City of Detroit experienced the largest coverage gains in the region in 2014, but the magnitude of coverage gains varied across the region.
Across southeast Michigan in 2014, more than three out of four uninsured residents were eligible
for financial assistance under the ACA, either through Medicaid, the Children’s Health Insurance
Program (CHIP), or subsidies through the health insurance marketplace.

This CHRT report was produced for the Altarum Institute’s Center for Sustainable Health Spending, which received funding from the National Institute for Health Care Reform to examine strategies for improving the health of the people of Detroit, and the related economic consequences.

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Changes in Health Insurance Coverage in the United States, 2014

These figures describe the health insurance coverage changes that occurred during the 2014 calendar year, the first year of the Affordable Care Act’s (ACA) coverage expansion provisions. These provisions included the launch of the health insurance marketplaces in all states and the optional Medicaid expansion adopted by 26 states and the District of Columbia in 2014.

Overall, the number of uninsured Americans declined considerably over the course of 2014. However, many Americans continued to experience short spells of uninsurance or other changes in their coverage situation over the course of the year. Compared to Medicaid and individual market coverage, employer-sponsored insurance continued to be the most stable form of coverage in 2014.

To determine the changes in health insurance coverage in the first year of the ACA, CHRT analyzed data from the household component of the Medical Expenditure Panel Survey (MEPS). MEPS is a federal survey that measures the cost and use of health care and asks respondents to identify the type(s) of health insurance coverage they had each month, if any.

Figures in this infographic include:

Number of non-elderly Americans by coverage category from January to December 2014
Percentage of non-elderly Americans by number of uninsured months during year
Percentage of non-elderly Americans who started with an maintained the same coverage all year
Number of uninsured non-elderly Americans by month in 2014

CHRT has also published a brief examining the effects of the ACA on health insurance coverage in Southeast Michigan.

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Cover Michigan Survey: The Uninsured in Michigan

This brief examines the characteristics of those in Michigan who reported being uninsured, approximately two years after the ACA’s major coverage provisions went into effect beginning in 2014.

A major goal of the Affordable Care Act was to reduce the number of Americans who are uninsured. The main provisions of the law that were intended to help achieve that reduction include: 1) the individual mandate, 2) the expansion of Medicaid, 3) the creation of the health insurance marketplaces and the introduction of subsidies for individuals purchasing coverage, 4) the extension of coverage to adult children up to age 26, and 5) requirements that certain employers offer affordable health insurance coverage or pay a penalty.

Requirements that insurers cover those with preexisting conditions and prohibitions on rescission of coverage were also intended to further expand the number of Americans with access to affordable coverage. Because of these policies, estimates show that 16 million Americans gained insurance between 2010 and 2015. Nevertheless, an estimated 29 million Americans remained uninsured in 2015.

Our study of the uninsured in Michigan in 2014 and 2015 is based on data from the Center for Healthcare Research & Transformation’s (CHRT) 2015 Cover Michigan Survey of Michigan adults, fielded between October and December 2015. Comparison data is drawn from the 2009, 2011, 2012, and 2014 Cover Michigan Surveys.

Key findings include:

Since 2009, Michigan’s uninsured rate has declined dramatically. Specifically:

5 percent of respondents reported being uninsured at the time of the survey. By comparison, in 2012, 14 percent of respondents reported being uninsured.
More than twice as many respondents reported having been uninsured at some point during the year before the survey than were uninsured at the time of the survey, indicating that many of the uninsured gained or regained coverage relatively quickly.
41 percent of the uninsured reported annual household incomes below $30,000, and 54 percent reported incomes between $30,000 and $59,999.
Half of uninsured respondents worked full time.
64 percent of the uninsured were male.
39 percent of uninsured respondents were between the ages of 18 and 30.
Half of uninsured respondents lived in small cities or towns.

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