The postelection efforts to repeal, replace, or modify the Affordable Care Act (ACA) suggest that the debate over healthcare coverage will remain contentious, particularly because of the high and rising cost of health care. Feasible, potentially bipartisan approaches to improving access to coverage should emphasize reforming health care to achieve higher quality at a lower cost. In the individual market, where many enrollees face limited options and rising premiums, a combination of high-risk pools, reinsurance, and risk adjustment could improve coverage options while encouraging innovations in care for the highest-risk patients. State Medicaid programs, which are increasingly important sources of coverage but are crowding out other important budget priorities that affect population health, could achieve better results through federal reforms that provide more flexibility for states alongside greater emphasis on achieving better outcomes. Accelerating payment reforms and other policy changes to encourage more innovative and efficient care delivery models, along with developing better evidence on successful models, can also improve the prospects for coverage reform.


Article metrics loading...

Loading full text...

Full text loading...


Literature Cited

  1. 1. US Department of Health and Human Services. 2017. Fiscal year 2017 budget in brief: strengthening health and opportunity for all Americans US Dep. Health Hum. Serv. Washington, DC: https://www.hhs.gov/sites/default/files/fy2017-budget-in-brief.pdf [Google Scholar]
  2. Cohen RA, Zammitti EP, Martinez ME. 2.  2017. Health insurance coverage: early release of estimates from the National Health Interview Survey, 2016 Natl. Cent. Health Stat. Washington, DC: https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201705.pdf [Google Scholar]
  3. Avery K, Finegold K, Whitman A. 3.  2016. Affordable Care Act has led to historic, widespread increase in health insurance coverage ASPE Iss. Brief, Sep. 29 Off. Assist. Sec. Plan. Eval., Dep. Health Hum. Serv. Washington, DC: https://aspe.hhs.gov/system/files/pdf/207946/ACAHistoricIncreaseCoverage.pdf [Google Scholar]
  4. 4. Kaiser Family Foundation. 2016. Medicaid expansion enrollment Kaiser Family Found. Washington, DC: Updated Sep. 30, 2016; accessed Oct. 12, 2017. https://www.kff.org/health-reform/state-indicator/medicaid-expansion-enrollment/ [Google Scholar]
  5. 5. United States Census. 2016. Uninsured rate by state Updated Sep. 15, 2016, accessed Oct. 12, 2017 US Census Bur. Washington, DC: https://www.census.gov/library/visualizations/2016/comm/cb16-158_hi_map.html [Google Scholar]
  6. 6. Office of the Assistant Secretary for Planning and Evaluation. 2015. Economic impact of the Medicaid expansion Mar. 23 Dep. Health Hum. Serv. Washington DC: https://aspe.hhs.gov/system/files/pdf/139231/ib_MedicaidExpansion.pdf [Google Scholar]
  7. 7. Commonwealth Fund. 2016. Americans’ experiences with ACA marketplace and Medicaid coverage: access to care and satisfaction. Findings from the Commonwealth Fund Affordable Care Act tracking survey, February–April 2016 May 25 Commonw. Fund New York, NY: http://www.commonwealthfund.org/publications/issue-briefs/2016/may/aca-tracking-survey-access-to-care-and-satisfaction [Google Scholar]
  8. 8. Office of the Assistant Secretary for Planning and Evaluation. 2016. Health plan choice and premiums in the 2017 health insurance marketplace ASPE Res. Brief, Oct. 24 Dep. Health Hum. Serv. Washington, DC: https://aspe.hhs.gov/system/files/pdf/212721/2017MarketplaceLandscapeBrief.pdf [Google Scholar]
  9. Hsu J, Overhage L, Price M. 9.  et al. 2016. Higher marketplace benchmark plan premiums could reduce post-subsidy premiums for many. Health Aff. Blog Nov. 16. http://www.healthaffairs.org/do/10.1377/hblog20161116.057578/full/ [Google Scholar]
  10. Levitt L, Claxton G, Damico A. 11.  et al. 2016. Assessing ACA marketplace enrollment Iss. Brief, Mar. 4 Kaiser Family Found. Washington, DC: https://www.kff.org/health-reform/issue-brief/assessing-aca-marketplace-enrollment [Google Scholar]
  11. 12. Congressional Budget Office. 2016. Federal subsidies for health insurance coverage for people under age 65: 2016 to 2026 Congr. Budget Off. Washington, DC: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51385-healthinsurancebaseline.pdf [Google Scholar]
  12. Joffe MD. 13.  2015. Long-term trends in Medicaid spending by the states Mercatus Cent., George Mason Univ. Arlington, VA: https://www.mercatus.org/system/files/Joffe-State-Medicaid-Spending.pdf [Google Scholar]
  13. Palanker D, Volk J, Giovannelli J. 14.  2017. Eliminating essential health benefits will shift financial risk back to consumers. To the Point Blog Commonw. Fund, Mar. 24. http://www.commonwealthfund.org/publications/blog/2017/mar/eliminating-essential-health-benefits-financial-risk-consumers [Google Scholar]
  14. Kirzinger A, Wu B, Brodie M. 10.  2017. Kaiser health tracking poll: health care priorities for 2017 Jan. 6 Kaiser Family Found. Washington, DC: https://www.kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-health-care-priorities-for-2017 [Google Scholar]
  15. Riley T, Cardwell A. 15.  2017. High risk pools deja vu—lessons from states, questions for policymakers. State Health Policy Blog Natl. Acad. State Health Policy, Jan. 31. http://www.nashp.org/high-risk-pools-deja-vu-lessons-from-states-questions-for-policymakers [Google Scholar]
  16. Busch F, Houchens PR. 16.  2017. Reinsurance and high-risk pools: past, present, and future role in the individual health insurance market June 6 Milliman http://www.milliman.com/insight/2017/Reinsurance-and-high-risk-pools-Past–present–and-future-role-in-the-individual-health-insurance-market/ [Google Scholar]
  17. 17. American Academy of Actuaries. 2016. Drivers of 2017 health insurance premium changes Iss. Brief Am. Acad. Actuaries Washington, DC: http://www.actuary.org/files/publications/IB.Drivers5.15.pdf [Google Scholar]
  18. Walker B. 18.  2016. Alaska's proposal to waive certain provisions of the Patient Protection and Affordable Care Act per Section 1332, Waivers for State Innovation Dec. 29 Juneau, AK: https://www.commerce.alaska.gov/web/Portals/11/Pub/Alaska-1332-Waiver-Application-with-Attachments-Appendices.pdf?ver=2017–01–05–112938–193 [Google Scholar]
  19. Price T. 19.  2016. Letter to governors on 1332 state innovation waivers Mar. 13 Cent. Medicare Medicaid Serv., Dep. Health Hum. Serv., Washington, DC. https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Downloads/March-13-2017-letter_508.pdf [Google Scholar]
  20. Blewett L. 20.  2017. How Minnesota is stepping up to preserve its individual market. Health Aff. Blog Apr. 18. http://www.healthaffairs.org/do/10.1377/hblog20170418.059687/full/ [Google Scholar]
  21. Tolbert J, Pollitz K. 21.  2017. Section 1332 state innovation waivers: current status and potential changes Health Reform Iss. Brief., Kaiser Family Found. Washington, DC: http://www.kff.org/health-reform/issue-brief/section-1332-state-innovation-waivers-current-status-and-potential-changes [Google Scholar]
  22. 22. Medicare Payment and Advisory Commission. 2015. Sharing risk in Medicare Part D. Medicare and the Health Care Delivery System Rep. to Congr. Medicare Payment Advis. Comm. Washington, DC: http://www.medpac.gov/docs/default-source/reports/chapter-6-sharing-risk-in-medicare-part-d-june-2015-report-.pdf?sfvrsn=0 [Google Scholar]
  23. 23. Congressional Budget Office. 2016. Repeal the health insurance mandate. Health Option 5, Options for Reducing the Deficit: 2017 to 2026 Dec. 8 Congr. Budget Off. Washington, DC: https://www.cbo.gov/budget-options/2016/52232 [Google Scholar]
  24. Verma S, Price T. 24.  2017. Letter to governors on 1115 waivers Dep. Health Hum. Serv. Washington, DC: https://www.hhs.gov/sites/default/files/sec-price-admin-verma-ltr.pdf [Google Scholar]
  25. Kasich J, Snyder R, Sandoval B, Hutchinson A. 25.  2017. Republican governors letter to congressional leaders on Medicaid reform Mar. 16. http://healthtransformation.ohio.gov/Portals/0/Governors%20letter%203-16-2017.pdf?ver=2017-03-17-083220-263 [Google Scholar]
  26. Kasich J. 26.  2017. The way forward on health care. N. Y. Times Opinion, July 18. https://www.nytimes.com/2017/07/18/opinion/john-kasich-the-way-forward-on-health-care.html [Google Scholar]
  27. 27. The Kaiser Commission on Medicaid and the Uninsured. 2015. Medicaid expansion in Indiana Feb. 3 Kaiser Family Found. Washington, DC: http://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-indiana [Google Scholar]
  28. 28. The Lewin Group, Inc. 2016. Indiana Healthy Indiana Plan 2.0: interim evaluation report Prepared for Indiana Family Soc. Serv. Admin, July 6. https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/1115/downloads/in/healthy-indiana-plan-2/in-healthy-indiana-plan-support-20-interim-evl-rpt-07062016.pdf [Google Scholar]
  29. Pradhan R. 29.  2017. Pence's Medicaid experiment confounds expectations on the left and right. Politico Apr. 15. http://www.politico.com/story/2017/04/mike-pence-medicaid-indiana-237241 [Google Scholar]
  30. Verma S, Neale B. 30.  2016. Healthy Indiana 2.0 is challenging Medicaid norms. Health Aff. Blog Aug. 29. http://www.healthaffairs.org/do/10.1377/hblog20160829.056228/full/ [Google Scholar]
  31. Solomon J. 31.  2016. Indiana Medicaid waiver evaluation shows why Kentucky's Medicaid proposal shouldn't be approved Aug. 1 Cent. Budget Policy Priorities Washington, DC: https://www.cbpp.org/research/health/indiana-medicaid-waiver-evaluation-shows-why-kentuckys-medicaid-proposal-shouldnt-be [Google Scholar]
  32. McClellan M. 32.  2013. Moving forward on Medicaid reform: shared savings in Medicaid, and how to do it. Health Aff. Blog Sep. 5. http://www.healthaffairs.org/do/10.1377/hblog20130905.034038/full/ [Google Scholar]
  33. Vardaman K. 33.  2015. Money Follows the Person (MFP) demonstration Oct. 27 Medicaid and CHIP Payment and Access Comm. Washington, DC: https://www.macpac.gov/wp-content/uploads/2016/10/Money-Follows-the-Person-Demonstration-Program-Progress-to-Date-and-Questions-for-the-Future.pdf [Google Scholar]
  34. 34. Medicare-Medicaid Coordination Office. 2017. People enrolled in Medicare and Medicaid Fact Sheet, Mar., Cent. Medicare Medicaid Serv., Dep. Health Hum. Serv. Washington, DC: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf [Google Scholar]
  35. Shatto JD. 35.  2016. Center for Medicare and Medicaid Innovation's methodology and calculations for the 2016 estimate of fee-for-service payments to alternative payment models Memo to R Rajkumar, Cent. Medicare Medicaid Innov., Mar. 3 Cent. Medicare Medicaid Serv. Off. Actuary Washington, DC: https://innovation.cms.gov/Files/x/ffs-apm-goalmemo.pdf [Google Scholar]
  36. Findlay S. 36.  2016. Medicare's new physician payment system. Health Policy Brief, Health Aff., Apr. 21. Robert Wood Johnson Found., Washington, DC. http://www.healthaffairs.org/do/10.1377/hpb20160421.151319/full/
  37. 37. Health Care Payment Learning and Action Network. 2017. Alternative payment model APM framework Mitre Corp White Pap. http://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf [Google Scholar]
  38. Muhlestein D, Saunders R, McClellan M. 38.  2017. Growth of ACOs and alternative payment models in 2017. Health Aff. Blog June 28. http://www.healthaffairs.org/do/10.1377/hblog20170628.060719/full/ [Google Scholar]
  39. Backus E, Gobeille A, Hogan C. 39.  et al. 2016. The all-payer accountable care organization model: an opportunity for Vermont and an exemplar for the nation. Health Aff. Blog Nov. 22. http://www.healthaffairs.org/do/10.1377/hblog20161122.057616/full/ [Google Scholar]
  40. McConnell KJ, Renfro S, Meath THA. 40.  et al. 2017. Early performance in Medicaid accountable care organizations: a comparison of Oregon and Colorado. JAMA Intern. Med. 177:4538–45 [Google Scholar]
  41. 41. Centers for Medicare and Medicaid Innovation. 2017. Comprehensive Primary Care Plus Cent. Medicare Medicaid Serv. Baltimore, MD: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus [Google Scholar]
  42. 42. Tenncare. 2017. Episodes of care State of Tennessee Nashville, TN: https://www.tn.gov/tenncare/topic/episodes-of-care [Google Scholar]
  43. 43. Health Care Transformation Task Force. 2017. State innovation spotlight: implementing multi-payer bundled payment modelswebinar and resources July 24 Health Care Transform. Task Force Washington, DC: http://hcttf.org/s/State-Innovation-Bundled-Payment.pdf [Google Scholar]
  44. Navathe AS, Troxel AB, Liao JM. 44.  et al. 2017. Cost of joint replacement using bundled payment models. JAMA Intern. Med. 177:2214–22 [Google Scholar]
  45. McWilliams JM, Hatfield LA, Chernew ME. 45.  et al. 2016. Early performance of accountable care organizations in Medicare. N. Engl. J. Med. 374:2357–66 [Google Scholar]
  46. Leavitt MO, McClellan M, DeVore SD. 46.  et al. 2016. Competencies and tools to shift payments from volume to value Sep. 19, Disc. Pap. Vital Dir. Health and Health Care Initiative, Natl. Acad. Med. Washington, DC: https://nam.edu/wp-content/uploads/2016/09/Competencies-and-Tools-to-Shift-Payments-from-Volume-to-Value.pdf [Google Scholar]
  47. 47. Population-Based Payment Work Group. 2016. Accelerating and aligning population-based payment models: data sharing White paper Health Care Payment Learning & Action Network Washington, DC: http://hcp-lan.org/workproducts/ds-whitepaper-final.pdf [Google Scholar]
  48. 48. Population-Based Payment Work Group. 2016. Accelerating and aligning population-based payment models: performance measurement White paper Health Care Payment Learning & Action Network Washington, DC: http://hcp-lan.org/workproducts/pm-whitepaper-final.pdf [Google Scholar]
  49. Friedberg MW, Chen PG, White C. 49.  et al. 2015. Effects of health care payment models on physician practice in the United States. RAND Health Q 5:18 https://www.rand.org/pubs/periodicals/health-quarterly/issues/v5/n1/08.html [Google Scholar]
  50. Patel K, Presser E, George M. 50.  et al. 2016. Shifting away from fee-for-service: alternative approaches to payment in gastroenterology. Clin. Gastroenterol. Hepatol. 14:4497–506 [Google Scholar]
  51. Garfield SS, Armstrong SO. 51.  2014. Risk sharing for medical devices: Has the time come?. ISPOR Connect 20:34 https://www.ispor.org/News/Connections-economic-medical-devices.pdf [Google Scholar]
  52. Spencer A, Freda B. 52.  2016. Advancing state innovation model goals through accountable communities for health Brief, Cent. Health Care Strat. New York, NY: https://www.chcs.org/media/SIM-ACH-Brief_101316_final.pdf [Google Scholar]
  53. Mehrotra A, Dean KM, Sinaiko AD. 53.  et al. 2017. Americans support price shopping for health care, but few actually seek out price information. Health Aff 36:81392–400 [Google Scholar]
  54. McClellan M, Richards R, Japinga M. 2017. 54.  Evidence on payment reform: Where are the gaps?. Health Aff. Blog Apr. 25. http://www.healthaffairs.org/do/10.1377/hblog20170425.059789/full/ [Google Scholar]
  55. Shrank WH, Saunders RS, McClellan. 55.  2017. Better evidence to guide payment reforms: recognizing the importance of perspective. JAMA 317:8805–6 [Google Scholar]
  • Article Type: Review Article
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error