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June 2013 St@teside

Health Reform Resources

SCI keeps its Federal Reform Resources web page up-to-date with the most recent information from the states, the federal government, and health policy organizations in an effort to guide our readers through the health reform implementation process. We know there are several places to go for the latest health reform resources, and we thank you for using SCI as one of your trusted sources. Here are some of the most recent resources that can be found on our Federal Reform page:

Insurance Market Reform
State Health Reform Assistance Network
One of the objectives of the Affordable Care Act (ACA) reform of the nongroup insurance market, including new market and rating rules and reliance on public health insurance exchanges, is to enhance competition. More competing health plans increases consumer choice, as well as the market pressure on health plans to manage administrative costs, improve their service and contract with clinical providers at optimal rates. Especially in the context of health plans contracting selectively with providers in order to hold down payment rates, a choice of more health plans serves consumers well and signals a vibrant market. This brief, prepared by Wakely Consulting Group, provides an early indicator of the level of competition among health insurers that market reforms and state-based exchanges are generating.
Insurance Exchanges
Congressional Research Service
This report outlines the required minimum functions of exchanges, and explains how exchanges are expected to be established and administered under ACA. The coverage offered through exchanges is discussed, and it provides detail on how individuals will qualify for federal tax credits. The report concludes with a discussion of how exchanges will interact with selected other ACA provisions.
Urban Institute
This paper focuses on states’ roles in implementation of FFEs. It provides an overview of recent regulations issued by CCIIO that describe the possible roles both for states and the federal government in the FFEs. It then provides in-depth descriptions of each of the specific FFE options as implemented in three states—Alabama, Michigan, and Virginia—with an eye to each state’s role in developing mechanisms to carry out their new responsibilities and progress in creating relationships with the federal government in order to ensure successful implementation of the three types of federally facilitated exchanges.
Health Affairs
The ACA will have important impacts on state Medicaid programs, likely increasing participation among populations that are currently eligible but not enrolled. The size of this “welcome-mat” effect is of concern for two reasons. First, the eligible but uninsured constitute a substantial share of the uninsured population in some states. Second, the newly eligible population will affect states’ Medicaid caseloads and budgets. Using the Massachusetts 2006 health reforms as a case study and controlling for other factors, researchers at the State Health Access Data Assistance Center (SHADAC) found that among low-income parents who were previously eligible for Medicaid in Massachusetts, Medicaid enrollment increased by 16.3 percentage points, and Medicaid participation by those without private coverage increased by 19.4 percentage points, in comparison to a group of control states. Their analysis has potentially important implications for other states attempting to predict the impact of this effect on their budgets.
Urban Institute
This brief explores how state officials and stakeholders are analyzing the fiscal and macroeconomic implications of their choice about whether to expand Medicaid. It focuses on 10 of the 11 states that are participating in the Robert Wood Johnson Foundation’s (RWJF) health reform monitoring and tracking project. The discussion is divided into four sections: the legal and policy context in which states are deciding whether to expand Medicaid; the status of decision-making around Medicaid expansion in our 10 RWJF states; how the fiscal effects of Medicaid expansion are being analyzed; and how the macroeconomic effects of Medicaid expansion are being analyzed.
Kaiser Family Foundation
One of the major vehicles in the ACA to increase health insurance coverage is an expansion of Medicaid to adults with incomes at or below 138% of the federal poverty level (FPL). While the expansion was intended to be implemented in all states, as a result of the Supreme Court decision on the ACA, it is now effectively a state choice. Based on an analysis of 2011 American Community Survey data, this brief examines the implications of current state Medicaid expansion decisions on coverage by race and ethnicity. In sum, it finds that people of color will be disproportionately impacted by state decisions to expand Medicaid; the impact of current state Medicaid expansion decisions varies widely by race and ethnicity, with Blacks being at highest risk of continuing to face coverage gaps due to state decisions not to expand at this time; and expansion decisions by a few key states have significant implications for coverage across races and ethnicities.
Strategic Planning
Enroll America
Enroll America recently released an interactive mapping tool using Google Maps to demonstrate where the uninsured are in communities. The map shows the distribution of the nonelderly uninsured in any given state by Public-Use Microdata Area (PUMA; an area within a state that contains at least 100,000 residents).  Clicking on any PUMA in a state provides details about the number of uninsured and their distribution by income, age, and race/ethnicity. The estimates used for the tool were produced by the Centers for Medicare and Medicaid Services (CMS) and the Assistant Secretary for Planning and Evaluation (ASPE) using the 2011 American Community Survey (ACS).   
National Academy for State Health Policy
Several of the Affordable Care Act’s (ACA) key provisions are aimed specifically at children, but much of the law focuses on covering the larger uninsured population of adults without dependent children. As states focus on implementing these ACA coverage programs and other systemic changes by January 1, 2014, it will be important that children’s coverage remains a priority as well. This report explains some challenges and opportunities for making health care reform work for children. The report, developed with the support of The Atlantic Philanthropies, draws upon lessons learned from state Medicaid and Children’s Health Insurance Programs (CHIP), federal policy, and relevant research. 
Center for Studying Health System Change and California HealthCare Foundation
This issue brief examines the status of community safety-net systems in six regions in California. Under the federal Patient Protection and Affordable Care Act (ACA), large numbers of Californians will become eligible for Medi-Cal in 2014. Even with federal resources to help safety-net providers prepare, however, communities with weaker safety-net systems are lagging in reform preparations. As a result, low-income people in those communities may be left without health coverage and timely access to health care services. Even well-prepared regions will need time and assistance to help people gain health care coverage.
Delivery System Redesign
Harvey L. Neiman Health Policy Institute
Many initiatives are underway to redesign health care delivery and payment systems to curb rising costs while maintaining, and ideally improving, the overall quality of care. Whether in the form of Accountable Care Organizations, Patient-Centered Medical Homes, or various other models for payment reductions coupled with shared-savings incentives, the common feature of these systems is an increased shift of risk—for both cost and quality—to providers. Although most early efforts have focused on integrated care delivery models, with primary care providers at the center serving as gatekeepers to manage service utilization, powerful opportunities exist for physician specialists as well. This Neiman Report highlights two of several emerging models being developed by the Harvey L. Neiman Health Policy Institute designed to align provision and payment of specialty care with efforts to ensure a sustainable, high quality health care system.
Aligning Forces for Quality
While fee-for-service remains the dominant approach to paying for health care in the United States, multiple local and regional initiatives have sought to demonstrate that other payment schemes can do better—that they can achieve higher quality and better overall outcomes, greater efficiency, and lower or at least controlled costs. Bundled payment (BP) is one such alternative. Bundled payment is the concept of paying a fixed dollar amount to cover a set of services, as an episode of care over a defined period. Because of the fixed price, providers are encouraged to hold variable costs down; yet BP programs usually require providers to satisfy a minimum set of quality metrics in order to receive payment, thus ensuring providers do not skimp on care. This paper examines issues confronted by two AF4Q communities that are considering or implementing BP initiatives.