Enactment of the Patient Protection and Affordable Care Act (ACA) in 2010 marked the most important accomplishment in U.S. health care reform in decades. Not since Medicare and Medicaid were passed in 1965 have so many Americans been given access to insurance coverage for their health care. Though the goal of universal health care was not achieved, ACA brought coverage to millions of uninsured Americans and provided assurance to the already-insured that if they lost their insurance through job loss or job change, they could turn to an expanded Medicaid program or a government-subsidized insurance policy for affordable coverage.
But while ACA has had a major impact on the U.S. health care system, its promise has been limited by its design. Rather than replacing the U.S. system with a more effective, less costly, and politically sustainable model, lawmakers decided to build on top of an inefficient, expensive, and politically insecure, existing model. A health care system that rested on a shaky foundation now has to carry more weight and that makes for an unstable future. Indeed, we are already starting to see some unraveling of ACA. For ACA to achieve its goals in a durable fashion, it should be replaced by a health care program that provides the same kind of health care coverage for all Americans rather than relying on a system that mixes employer-based insurance with individually-purchased private insurance and government-provided coverage.
We study the impact of deportation fear on the incomplete take-up of federal safety net programs in the United States. We exploit changes in deportation fear due to the roll-out and intensity of Secure Communities (SC), an immigration enforcement program administered by the Immigration and Customs Enforcement Agency (ICE) from 2008 to 2014. The SC program empowers the federal government to check the immigration status of anyone arrested by local law enforcement agencies and has led to the issuance of over two million detainers and the forcible removal of approximately 380,000 immigrants. We estimate the spillover effects of SC on Hispanic citizens, finding significant declines in ACA sign-ups and food stamp take-up, particularly among mixed-status households and areas where deportation fear is highest. In contrast, we find little response to SC among Hispanic households residing in sanctuary cities. Our results are most consistent with network effects that perpetuate fear rather than lack of benefit information or stigma.
An additional 24 million people had individually purchased guaranteed-renewable coverage (HIPAA required all non-short-term individual market plans to be guaranteed renewable). Such plans protected enrollees from premium spikes if they developed expensive conditions, were more secure than employer plans for patients with expensive conditions, and faced incentives to make plans attractive to the sick as well as not to renege on their commitments to the sick. Hundreds of millions of Americans once had the freedom to enroll in guaranteed-renewable plans but lost that choice when Obamacare outlawed them. A study by McKinsey and Company for the Department of Health and Human Services shows provider networks in individual-market plans have narrowed significantly since 2013, when the breadth of networks reflected actual consumer preferences.
It turns out that health care spending, at least in the underage-65 private markets for health insurance, has become less, not more, concentrated in recent decades. After a significant decline in spending concentration about two decades ago, it has stabilized
at that lower level. There is a significant decline in concentrated spending among individuals from one year to the next. That decline in the “persistence” of high spending continues in people’s later years, though at a less significant rate.
Nevertheless, the overall pattern remains that a majority of individuals below Medicare age, or people not redirected to other forms of public insurance coverage (primarily Medicaid) as a result of longer-term disabling and income-limiting health conditions, just don’t need to spend that much of their income on health care. Whether they still should be required to pay much more for their insurance under the ACA or some other government intervention is largely a matter of policymakers’ choice rather than economic necessity.
The unsurprising part is CBO’s expectation that if CSR subsidies are withdrawn, sponsors of silver plans will hike premiums substantially.
The surprising part is that CBO found that not only would this generally not hurt low-income participants, it would on balance benefit them – especially older Americans below 400 percent of the poverty line. The primary losers, under CBO’s analysis, would be federal taxpayers. Add it all up, and terminating the CSR subsidies would paradoxically lead to a substantial increase in progressive income redistribution.
Did the Affordable Care Act’s Medicaid Expansion Increase the Ability for Low-Income Households to Self-Insure? by Daeyong Lee :: SSRNJanuary 21, 2017
This article examines the effects of the Medicaid expansion on household financial income by focusing on the Affordable Care Act. The Affordable Care Act extended Medicaid program to childless adults and eliminated the asset-test for its eligibility from 2014. Using the March Current Population Survey Supplement Data, I find that households with no dependent children and income below the 100% federal poverty level living in Medicaid-expansion states significantly increased the annual dividend (interest) income by 63 (84) dollars after the Medicaid expansion. Meanwhile, the financial assistance these households received from relatives or friends was reduced by 159 dollars after the expansion.
Caught in the Gap Between Status and No-Status: Lawful Presence Then and Now by Sara N. Kominers :: SSRNNovember 24, 2016
Where the line is drawn between noncitizens who are incorporated into American society and those who are not has changed greatly over time, resulting in the creation of a gray area where certain immigrants fall between those with lawful immigration status and those with no status at all. These individuals are granted “lawful presence” which permits them to remain and work in the United States, but does not provide them with a path to citizenship. The number of people in this ambiguous category continues to grow and may dramatically expand again soon as President Obama recently exerted broad scale executive action in response to Congress’ refusal to reform immigration laws.
This article looks at the ways immigration law grants lawful presence and the changing responses of the legal system in dealing with this “gap” between status and no-status. The recent exclusion of Deferred Action for Childhood Arrivals from the Affordable Care Act and other essential health insurance programs serves as a case study to demonstrate how inconsistently laws handle this middle category of people today. The consequences of such a narrow division between who receives benefits and who does not is that the gap between status and no-status widens, encouraging state lawmakers to further discriminate against this group. I argue that the struggle over where the line should be drawn to decide which noncitizens should and should not have access to essential rights and benefits is exacerbated by the tension between a progressive President and a conservative Congress. In a system where the Executive branch may confer lawful presence but only Congress can confer lawful status, hundreds of thousands of people are caught in the gap. I conclude by arguing that as the number of people in this gray area continues to grow, courts should lean toward inclusion rather than exclusion of lawfully present noncitizens in resolving this tension in the law.