Around and after the time that the Affordable Care Act was enacted, many analysts identified problems with claims being made about the law, and we offered explanations of its likely actual effects. Too often these were brushed aside amid efforts to promote the ACA in the face of growing public opposition. But four years into the ACA, it is remarkable how well our predictions have been borne out.Below I will resurrect but five of my own specific predictions about the ACA, contrast them with what many advocates had said, and review what subsequent events have shown.
From California to Rhode Island, states are confronting new concerns that their Medicaid costs will rise as a result of the federal health care law.
That’s likely to revive the debate about how federal decisions can saddle states with unanticipated expenses.
Before President Obama’s law expanded Medicaid eligibility, millions of people who were already entitled to its safety-net coverage were not enrolled. Those same people are now signing up in unexpectedly high numbers, partly because of publicity about getting insured under the law.
Section 1332 of Title I of the Affordable Care Act offers to state governments the ability to waive significant portions of the ACA, including requirements related to qualified health plans, health benefit exchanges, cost sharing, and refundable tax credits. It permits state governments to obtain funding that otherwise would have gone to residents and businesses through the ACA and to use those funds to establish, beginning in 2017, an alternative health reform framework within statutory limitations. Section 1332 also permits states to apply in a coordinated fashion for waivers from Medicare, Medicaid, the Children’s Health Insurance Program, and “any other federal law relating to the provision of health care items or services.” This article reviews the statutory provisions and related regulations of this new and unprecedented state waiver authority, as well as the legislative history of section 1332. Finally, it reviews the limited activities thus far by states contemplating use of this provision and considers ways this authority may be considered for use by states in the future. Section 1332 has the potential to instigate a new, varied, and unprecedented array of state health sector innovations from both sides of the political divide over health care reform.
Today, Governor Mike Pence announced plans to implement ObamaCare’s Medicaid expansion using tenets of the Healthy Indiana Plan. Now in its seventh year of operation, the Healthy Indiana Plan currently extends health coverage to all Hoosiers earning up to 100% of the federal poverty level (FPL). Unlike traditional entitlement programs, enrollment in the Healthy Indiana Plan is capped, based on available funding.
Right-leaning health policy observers have long debated the merits of the Healthy Indiana Plan. Those who opposed the plan will certainly find flaws in Gov. Pence’s expansion proposal.
But for supporters, one glaring point remains. Any CMS-approved Medicaid expansion plan will likely gut the critical elements of the original Healthy Indiana Plan—relegating Gov. Pence’s proposal to Medicaid expansion by another name.
State Medicaid programs and other state health agencies need to monitor and evaluate changes in health insurance coverage, access to care, financing, and the quality of health care delivery. The availability of new financial resources through the Patient Protection and Affordable Care Act is accompanied by raised expectations for such accountability. While state agencies often contract with universities on an ad hoc basis for specific policy projects, fourteen states have established formal state-university partnerships so that their analytic and technical needs can be addressed more readily. After a brief overview of these partnerships, this article provides examples of their projects, which most often affect Medicaid policy, including work on program eligibility, provider payments, and optional benefits. State-university partnerships are working on policy-relevant projects that influence decision making. Like the variation in Medicaid programs across the country, no two partnerships are alike. They thrive in a mix of structures, using different means of contracting, and with varied degrees of data access. All partnerships are interested in building a national network to share innovative practices and projects, spawn comparative policy studies across states, and support the development of new state-university partnerships.
Freely available online through the Journal of Health Politics, Policy and Law open access option.
The Patient Protection and Affordable Care Act has fostered intense debate on the delivery of health care over the past five years. We are now five months into the six-month roll out of Obamacare, and fewer than one-quarter of Americans believe the President’s health care law will actually improve their family’s health care. Americans know there are problems in health care delivery, but they do not want Washington, D.C. to manage their personal health choices. Long wait times, inefficient systems, dysfunctional web sites, fewer choices and higher costs are all symptoms of the problem. But state legislatures have found a solution.
They are increasingly adopting the Health Care Compact, a way for states to take control of health care regulations locally. Eight states currently belong to the HCC, because local control would improve the delivery of health care while improving medical innovation, reducing fraud and providing more health care options for people within their states. Additional states are also considering the HCC and for good reason; local control works better. For example, during the disastrous healthcare.gov website roll out we were told that the problems were mostly with the federal website and that state web sites were working much better. This fact reflects the larger point of the HCC; that states can manage problems better on behalf of their citizens.
Legislation to continue Arkansas’ compromise Medicaid expansion has failed in the state House.
The plan would have reauthorized funding for the “private option” that was approved last year as an alternative to expanding Medicaid’s enrollment under the federal health law. The measure fell five votes shy of the 75 needed for passage in the 100-member House.
Under the private option, Arkansas is using federal Medicaid funds to purchase private insurance for thousands of low-income residents.
Supporters of the measure are expected to try again. House Speaker Davy Carter has said he would try multiple times if the funding measure failed.
That Oregon ended up with the most disastrous of all the Obamacare exchanges—an impressive achievement, considering how bad the law’s rollout has been—has stunned America’s growing herd of health care wonks. Twenty-five years ago—long before Massachusetts created the template for Obamacare—Oregon began trying to implement universal health care coverage. The state should know more about its uninsured population and how to reach them than any other. But no one who’s watched developments over that quarter-century should be surprised that, once again, Oregon’s attempt to provide health care coverage to everyone in the state has culminated in a nationally embarrassing failure.
Vermont’s CGI Federal-built website didn’t work on October 1, and today, the state still does not have a fully functioning marketplace. There is no way for small businesses, the heart of Vermont’s economy, to purchase coverage online; instead, they have to buy insurance directly from one of two state-approved insurers. Payments for premiums still cannot be processed online – people have to snail-mail checks to a CGI processor in Nebraska. And individuals who registered online but then got divorced, changed jobs or had either pay cuts or increases cannot alter their information online.
A review of the state’s race to build a health insurance website is more than a fresh look at how CGI Federal, the Fairfax, Va.-based arm of Montreal-based CGI Group, bungled its attempt to cobble together a highly complex piece of technology on a very tight deadline. It is also a tale of how many Republican and Democrat state officials, the latter ardent supporters of Obamacare and in control of the state, glossed over ominous warning signs and Keystone Cops-like planning to chase a bigger prize: bragging rights to an exchange that Vermont hopes will underpin the nation’s first system in which the state foots health-care bills for all residents – what conservatives call “socialized medicine,” some call “single-payer” and liberals, including Peter Shumlin, Vermont’s Democratic governor, call “universal financing.”
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“It was all just way too ambitious,” says Amy Lischko, associate professor of public health and community medicine at Tufts University medical school and a member of an advisory board to Vermont exchange officials. “Did CGI overpromise? Yes, but everybody had a can-do attitude, and there was a lot of money floating around.”
Under the scheme, a provision of Obamacare requires that staff members of every hospital in Massachusetts be paid at least as much as the members of the staff of the state’s rural hospitals, with the federal government paying for the extra cost of compliance.
As it conveniently happens, the only “rural hospital” in Massachusetts serves the rich and famous on the fashionable island of Nantucket, summer enclave of the rich and beautiful people, mostly Democrats.
The hospitals in bucolic Western Massachusetts must pay the same wages as the well-appointed medical “cottage” that caters to Nantucket’s 1 percenters, including Mr. Kerry. It’s a $257 million Medicare reimbursement bonus for Massachusetts.
It’s beyond outrageous. According to the Centers for Medicare and Medicaid Services, this scam will cost Arkansas hospitals $5.2 million, Louisiana will lose $6.7 million and North Carolina $12.6 million. The 2014ers are desperate to correct this imbalance before the autumn campaigns.