HEALTH REFORM ARTICLES    |    FOLLOWING THE ACA BLOG POSTS



Health reform from Obamacare to Trumpcare is covered by Health Affairs in nonpartisan, peer-reviewed journal articles and Health Policy Briefs plus timely Health Affairs Blog posts from multiple points of view. Key health policy questions are explored for the Affordable Care Act (ACA), Medicare, Medicaid and payment reform. Health Affairs has informed health reform for 35 years.

Repeal and Replace or Amend?
Medicaid Block Grants
Premium Support
Private Insurance Regulation





March 10, 2017     AMERICAN HEALTH CARE ACT
Republicans Should Take The Time Necessary To Improve The American Health Care Act
The ACA repeal and replace plan, dubbed the American Health Care Act, has the major components needed for effective health reform. However, the plan falls short on several crucial details, details that can and should be changed before the bill clears Congress and goes to the president to become law.
Joseph Antos and James Capretta



Repeal and Replace or Amend?

March 13, 2017     HOUSE GOP BILLS
A Closer Look: House GOP Bills On Stop-Loss Coverage, Wellness Programs, And Association Health Plans
A House panel advanced three health care bills on March 8. The House may pass these bills in conjunction with the American Health Care Act, but they are not part of AHCA, which is moving through the House under budget reconciliation rules. They therefore cannot pass the Senate without 60 votes.
Timothy Jost

March 10, 2017     REPEAL AND REPLACE
ACA Round-Up: Repeal And Replace, Additional Legislation, And Risk-Corridor Litigation
As House GOP "repeal and replace" legislation moved through the chamber, a House Committee approved bills on stop-loss coverage, health information collection by wellness programs, and association health plans. Meanwhile, a court declined to dismiss an insurer's claim for risk corridor payments.
Timothy Jost

March 09, 2017     SELF-EMPLOYED COVERAGE
For Self-Employed Entrepreneurs, Losing The ACA Would Be An Enormous Setback
For many self-employed business owners, their firms would not exist without the ACA. Repealing the law is going to be a sizable setback for entrepreneurship.
John Arensmeyer

March 08, 2017     COST OF ACA
Reports Address Costs Of ACA, IRS Record In Processing Premium Tax Credits
CBO Director Hall stated that in 2017 the gross cost of the ACA's insurance coverage provisions was projected to be $214 billion in 2019, but that they are now projected to cost $148 billion. In addition, the Treasury Inspector General reported on IRS processing of premium tax credits.
Timothy Jost

March 07, 2017     REPEAL AND PUBLIC HEALTH
ACA Repeal Would Mean Massive Cuts To Public Health, Leaving Cities And States At Risk
It is well known that repealing the ACA could leave nearly 20 million Americans uninsured. An associated cost that has been less discussed, but no less relevant, is what repeal could mean for the nation's already-fragile governmental public health system.
Chrissie Juliano

March 07, 2017     HOUSE REPUBLICAN PLAN
Examining The House Republican ACA Repeal And Replace Legislation
On March 6, 2017, the House Republican leadership introduced Affordable Care Act repeal and replacement budget reconciliation bills in the Ways and Means and Energy and Commerce) committees. This post examines the bills, collectively titled the American Health Care Act,
Timothy Jost

March 06, 2017     MEDICAID EXPANSION
Myths About The Medicaid Expansion And The 'Able-Bodied'
A conservative critique of the ACA's expansion of Medicaid eligibility is that it may discourage "able-bodied" individuals from working. This false understanding of Medicaid recipients and their health insurance options has already influenced policymaking at the state level.
Leighton Ku and Erin Brantley

March 02, 2017     HIGH-RISK POOLS
Invisible High-Risk Pools: How Congress Can Lower Premiums And Deal With Pre-Existing Conditions
Maine's experience in creating an invisible high-risk pool and relaxing its premium rating bands can inform Congress and the Trump administration as they work to repeal and replace the ACA.
Joel Allumbaugh, Tarren Bragdon, and Josh Archambault

March 02, 2017     MEDICARE AND MARKETPLACE ENROLLEES
CMS Addresses Medicare-Eligible Marketplace Enrollees; Court Awards Risk Corridor Damages (Updated)
CMS has released a carrot and stick responding to insurer claims that people who could be in Medicare but remain in the marketplaces are driving up costs and premiums. The stick, however, appears inconsistent with its rules. Also, a court awarded damages to an insurer seeking risk corridor payments.
Timothy Jost

March 01, 2017     PRESIDENT'S SPEECH
Examining The President's Speech To Congress
What vision for health care reform did the president lay out in his speech to Congress, and what would the challenges be to achieving it?
Timothy Jost

February 25, 2017     HOUSE RECONCILIATION
A Look At Republican Intentions? Diving Into The Leaked ACA Replacement Bill
Yesterday a draft House reconciliation bill leaked. This post offers a summary of its major provisions.
Timothy Jost

February 23, 2017     REPLACEMENT AND STATES
Reading The Fine Print: Do ACA Replacement Proposals Give States More Flexibility And Authority?
A close examination of replacement proposals shows they would turn upside down a longstanding principle of federal-state regulation of insurance, which provides that the states should be the primary source of health insurance oversight and consumer protection.
Sabrina Corlette and Kevin Lucia

February 17, 2017     REPLACEMENT PRINCIPLES
ACA Round-Up: House Replacement Principles, New Bills, And Coverage Rate Updates
Recent health reform developments include a House Republican Leadership policy brief outlining its favored approach to replacing the Affordable Care Act; new legislation regarding pre-existing conditions, health savings accounts, and association health plans; and new coverage estimates.
Timothy Jost

February 14, 2017     BENEFITS
The Future Of Essential Health Benefits
The Essential Health Benefits requirement may be on the chopping block as the Administration and Congress seek to repeal and replace the ACA.
Ian Spatz and Michael Kolber

February 13, 2017     EYE ON HEALTH REFORM
First Steps Of Repeal, Replace, And Repair
Health Affairs launched a monthly series in the journal, "Eye On Health Reform," to provide a concise summary of recent developments concerning the ACA.
Timothy Stoltzfus Jost

February 10, 2017     PAYMENTS
Insurers Seeking Risk Corridor Payments Get First Courtroom Win; IRS Updates QAs
On February 9, Moda Health Plans won the first litigation victory for a health plan on the question of liability in a risk corridor challenge.
Timothy Jost

February 09, 2017     CALIFORNIA
How Californians Could Benefit From ACA 'Repeal And Replace'
There are at least two major areas where California could cooperate with the Trump Administration and the Republican Congress: improving coverage and access for the working poor, and controlling health care costs.
Timothy Jost

February 08, 2017     MARKET
ACA Round-Up: Market Stabilization, Fixed-Indemnity Plans, Cost-Sharing Reductions, And Penalty Updates
The administration sent to the Office of Management and Budget a proposed "market stabilization" rule, while the IRS addressed the tax treatment of benefits paid by fixed-indemnity health plans.
Timothy Jost

February 05, 2017     ENROLLMENT
Uncertainty, Headwinds Hurt Final Marketplace Enrollment Total
On February 3, CMS released its final snapshot of plan selections for the fourth Healthcare.gov open enrollment period, which ended on January 31, 2017.
Timothy Jost

February 01, 2017     ISSA PLAN
ACA Round-Up: Open Enrollment Ends, Issa Introduces FEHB-Based Replacement Plan
The second week of the Trump administration has proven to be relatively quiet for health reform as we await the confirmation of a new Health and Human Services Secretary.
Timothy Jost

January 30, 2017     OPIOIDS AND ACA
Repealing The ACA Could Worsen The Opioid Epidemic
The coverage expansions and protections under the ACA can help lessen the epidemic and save lives.
Lisa Clemans-Cope, Dania Palanker, and Jane Wishner

January 28, 2017     REPLACEMENT
Exchange Stabilization Bills Represent New GOP Approach To ACA
As January draws to a close, it appears that a new Republican strategy for dealing with the Affordable Care Act is coming to the fore: to adopt piecemeal replacement legislation even as repeal legislation proceeds through reconciliation.
Timothy Jost

January 27, 2017     PAUL PLAN
ACA Round-Up: Rand Paul's Replacement Plan, Non-Discrimination Litigation, And New CBO Projections
The most original contribution in Senator Paul's plan is allowing individuals to choose between a tax deduction and credit.
Timothy Jost

January 26, 2017     ESRD CASE
Reasoning In ESRD Case Could Pose Obstacle To Speedy Changes Under Trump
Among other health reform developments, a judge has blocked a rule on third-party payment of premiums for ESRD patients because of a lack of notice and comment rulemaking, suggesting that the new administration may have to jump through administrative hoops before making ACA-related changes.
Timothy Jost

January 26, 2017     EXECUTIVE ORDER
Trump's Obamacare Executive Order: Much Ado About Very Little
Despite the Administration's hype and the headline hullabaloo about the executive order, that order constitutes much ado about very little. Indeed, the executive order is vacuous.
Ron Pollack

January 24, 2017     REPLACEMENT
ACA Replacement Bill From Cassidy And Colleagues Offers State Options, Roth HSAs
A new ACA replacement plan from Senators Cassidy, Collins, Isakson, and Capito gives states three choices.
Timothy Jost

January 24, 2017     PRICE PLAN
Would Confirmation Pave The Way For A Price Replacement Starting Point?
Unlike other plans, the Price plan is not a comprehensive alternative vision for overall health care market reform, but instead, is largely limited to replacing the individual and small group reforms.
S. Lawrence Kocot, Tracey McCutcheon, and Ross White

January 20, 2017     EXECUTIVE ORDER
Trump Executive Order On ACA: What It Won't Do, What It Might Do, And When
On his first day in office, President Trump issued an executive order addressing the Affordable Care Act. It may not be, however, all that his supporters expected.
Timothy Jost

January 20, 2017     REPLACEMENT
Universal Access And Delegation To States: Examining Two Currents In ACA Replacement Plans
Two ideas are surfacing in Republican plans to replace the Affordable Care Act that should be examined-setting a goal of "universal access" rather than "universal coverage" and shifting responsibility for ACA replacement to the states.
Timothy Jost

January 18, 2017     ACCESS TO INSURANCE
How We Can Repeal The ACA And Still Insure The Uninsured
Even if the ACA stays in place, there will still be almost 30 million people without health insurance. The initial goal of reform should be: making sure everyone has access to health insurance that is affordable and that gives them dependable access to medical care.
Pete Sessions, Bill Cassidy, and John Goodman

January 17, 2017     REPEAL
CBO Releases Report On Effects Of ACA Repeal
On January 17, the Congressional Budget Office released a report on how reconciliation legislation to repeal the Affordable Care Act would affect health insurance coverage and premiums.
Timothy Jost

January 17, 2017     HHS SECRETARY
First, Do No Harm: A Physician Secretary Of HHS And The Reach Of Hippocrates
If the U.S. Senate confirms the nomination of Representative Tom Price to serve as the 23rd U.S. Secretary of Health and Human Services (HHS) he will be only the third physician to lead that department since its formation in 1953.
Louis W. Sullivan

January 13, 2017     ACA AND ORAL HEALTH
Obamacare, Trumpcare, And Your Mouth
Though the ACA reinforced the status quo approach of maintaining separate medical and dental care financing and delivery systems, there have been some interesting lessons worth highlighting.
Marko Vujicic

January 12, 2017     EXECUTIVE ORDER
What Could President Trump Do Through Executive Order To Dismantle The ACA?
What can the executive do to unwind a law without congressional action?
Timothy Jost

January 11, 2017     REPEAL
ACA Round-Up: Enrollment Report, Repeal Efforts, And More (Updated)
The budget reconciliation process to replace Obamacare is underway, although President-elect Trump said today that repeal and replace would take place "essentially simultaneously."
Timothy Jost

January 11, 2017     EMPLOYER-SPONSORED INSURANCE
Get Health Insurance Through Your Employer? ACA Repeal Will Affect You, Too
Job-based plans offered to employees and their families cover 150 million people in the United States. If the ACA is repealed, they stand to lose critical consumer protections that many have come to expect of their employer plan.
JoAnn Volk

January 11, 2017     MARKETPLACES
ACA 'Repeal And Delay' Would Leave A Narrow Window To Stabilize Exchanges
This post describes the deadlines facing health plans as they make decisions about whether to continue participating in the Exchanges in 2018. We then offer options that Congress and the executive branch could use to stabilize the Exchanges and encourage continued health plan participation.
Joel Michaels and Jeremy Earl

January 10, 2017     MEDICARE
To Get Dems On Board With ACA Replacement, Republicans Should Take Medicare Off The Table
With two relatively straightforward acknowledgements, Republicans could create a pathway for bipartisan reconsideration of health care coverage in America.
Rodney Whitlock

January 05, 2017     THE HOUSE
The Republican Study Committee's ACA Replacement Proposal
On January 4, 2017, the House Republican Study Committee, a caucus of conservative Republican House members, introduced the American Health Care Reform Act, their replacement proposal.
Timothy Jost

January 05, 2017     HEALTH LAW
The Best-Laid Plans For Health Care
Tremendous uncertainty awaits, though I expect that we will see a slowing down of the repeal and replace process, with even the individual mandate persisting for some time; unmaking the Affordable Care Act without leaving millions stranded will be harder than the campaign may have suggested.
I. Glenn Cohen

January 04, 2017     THE COURTS
Judge Certifies Insurer's Risk Corridor Case As A Class Action
This is one of more than a dozen cases that have been brought by insurers in the Court of Claims challenging the failure of the government to pay marketplace insurers amounts that they claim were due to them under the ACA's risk corridor program.
Timothy Jost

January 04, 2017     MEDICAID
The ACA Transformed Medicaid Enrollment Processes. Rolling Them Back Would Wreak Havoc.
Implementing the ACA's Modified Adjusted Gross Income (MAGI) rules and systems were a heavy lift for states. Reversing them would wreak havoc for states and low-income families who depend on Medicaid.
Tricia Brooks

January 03, 2016     LEGISLATION
The Problems With 'Repeal And Delay'
The most likely end result of "repeal and delay" would be less secure insurance for many Americans, procrastination by political leaders, and ultimately no discernible movement toward a real marketplace for either insurance or medical services.
Joseph Antos and James Capretta
January 03, 2017     BUDGET RESOLUTION
ACA Repeal Process Begins In Congress
On January 3, 2017, Senator Mike Enzi, Chair of the Senate Budget Committee, introduced a concurrent budget resolution in the Senate to begin the process of repealing the Affordable Care Act.
Tim Jost

January 02, 2017     NONDISCRIMINATION
ACA Pregnancy Termination, Gender Identity Protections Blocked; Wellness Program Incentives Survive (Updated)
A judge has preliminarily enjoined protections regarding pregnancy termination and gender identity in an ACA nondiscrimination rule. Another judge refused to block regulations allowing employers to offer incentives for employees to disclose medical information in connection with wellness programs.
Tim Jost

December 06, 2016     HEALTH REFORM
Health Reform: Where We've Been, Where We're Going
What are the ACA's successes and failures? How might the new administration and Congress proceed with repealing and replacing it? What provisions might be adopted to replace the ACA and how might these provisions improve on, or undermine, the law's accomplishments?
Tim Jost

December 22, 2016     COVERAGE
ACA Round-Up: Robust Marketplace Enrollment, CBO On Defining Health Insurance, And More
As of December 19, the deadline for enrolling in coverage for January 1, 2017, 6,356,488 consumers were covered by plans selected on HealthCare.gov, HHS announced. Other developments included CBO blog posts discussing how that agency would evaluate coverage effects of ACA replacement proposals.
Timothy Jost

December 20, 2016     THE COURTS
Two Recipients Of ACA Cost-Sharing Subsidies Seek Voice In Litigation
Two of the 5.9 million people who benefit from ACA cost-reduction payments have asked to intervene in House v. Burwell to protect their interests in continuing to receive the CSRs.
Timothy Jost

December 15, 2016     COUNCIL OF ECONOMIC ADVISORS
Obama Administration Lays Out Its Case For ACA's Success
A new Obama administration report and accompanying material argue that by many measures the ACA has been an outstanding success in addressing the key issues of our health care system-expanding access, lowering costs, and improving quality.
Timothy Jost

December 12, 2016     DELIVERY SYSTEM REFORM
Building A System That Works: The Future Of Health Care
As the Obama Administration comes to a close, Secretary Burwell lays out a vision for the future of health care.
Sylvia Mathews Burwell

December 08, 2016     HSAs
Trump Plan To Increase Health Savings Accounts Should Ensure That They Do Not Only Benefit The Wealthy And Healthy
New approaches will be needed if HSAs are to be used more widely and improve health outcomes for the broader population.
Kathryn Phillips

December 07, 2016     REPEAL
Five Reasons The ACA Won't Be Repealed
The repeal and replace "two step" is fraught with difficulty, bolder than the ACA itself, and far from certain to succeed.
Billy Wynne

December 01, 2016     PRESIDENTIAL NOMINEES
Previewing Potential HHS Leadership
Tim Jost profiles the records of Rep. Tom Price (R-GA) and Seema Verma, Donald Trump's designated HHS Secretary and CMS Administrator.
Tim Jost

November 09, 2016     DAY ONE AND BEYOND
What Trump's Election Means for the ACA
On the day following the election, Health Affairs Blog regular and legal expert Timothy Jost offered a first pass at what Donald Trump’s election may mean for the ACA, popularly known as Obamacare.
Timothy Jost

August 29, 2016     MEDICAID WAIVERS
Healthy Indiana 2.0 Is Challenging Medicaid Norms
Seema Verma is President-elect Trump's pick to head CMS. Here she describes how Indiana launched the most significant departure from Medicaid to date, achieved with a series of waivers sought by Vice President-elect Mike Pence (then governor of Indiana).
Seema Verma and Brian Neale

December 09, 2015     ACA ALTERNATIVE
An Alternative Framework for Reform
Scott Gottlieb recently joined President-elect Trump's health transition team. In this post, he joins with a group of conservative coauthors to propose a plan to replace the ACA and to enact major reforms to the tax treatment of employer-sponsored health care, Medicaid, Medicare, Health Savings Accounts, and other areas.
Joseph Antos, James Capretta, Lanhee Chen, Scott Gottlieb, Yuval Levin, Thomas Miller, Ramesh Ponnuru, Avik Roy, Gail R. Wilensky, and David Wilson

November 07, 2016     VIEWS ON HEALTH CARE
The 2016 Election: Differences Are Deeper than Ever
John McDonough

June 22, 2016     ACA ALTERNATIVE
The House Republican's Health Plan
Joseph Antos and James Capretta

June 16, 2016     SESSIONS-CASSIDY BILL
The World's Greatest Health Care Plan
John Goodman

June 01, 2016     SESSIONS-CASSIDY BILL
Sessions-Cassidy: An ACA Alternative
Timothy Jost

September 18, 2015     REPUBLICAN PLAN
What Would Republicans Do Instead of the ACA?
John McDonough and Max Fletcher

April 14, 2015     REPEAL AND REPLACE
If the ACA Were Repealed, What Would Replace It?
Timothy Jost

JULY 10, 2015     REFORM ALTERNATIVE
A Health Reform Framework: Breaking Out of the Medicaid Model
Joseph Antos and James Capretta

September 20, 2011     CONTROLLING COSTS
Medicare Is More Efficient Than Private Insurance
Diane Archer

November 2008     Health Reform
The McCain Plan to Restructure Health Insurance
Thomas Buchmueller, Sherry A. Glied, Anne Royalty and Katherine Swartz



Medicaid Block Grants

APRIL 18, 2013     HEALTH POLICY BRIEF
Per Capita Caps in Medicaid
This policy brief examines the issues surrounding per capita caps in Medicaid and explores other policy options for states and the federal government.

January 12, 2012     HEALTH POLICY BRIEF
Medicaid Reform
This policy brief explores some of the major ideas being discussed to restructure Medicaid and outlines the competing arguments.

July 2015     MEDICAID AT 50
Remarkable Growth Fueled by Unexpected Politics
Michael Sparer

JANUARY 2003     HEALTH AFFAIRS THEME ISSUE
Medicaid Comes of Age
This thematic issue of the journal on the growth of Medicaid explores questions about how to finance the program.

JANUARY 2003     MEDICAID FINANCING
The Flexibility Factor: Finding the Right Balance
Cindy Mann

JANUARY 2003     MEDICAID AND STATES
There's Something about Medicaid
Alan Weil



Premium Support

February 08, 2017     PREMIUM INCREASES
The Marketplace Premiums Increase: Underwriting Cycle Or Death Spiral?
In this post, we aim to illuminate the underlying forces that led to dramatic increases in premiums so as to clarify the historical record and provide lessons for policymakers who aim to replace the ACA.
Jon Gabel and Heidi Whitmore

March 22, 2012     PROS AND CONS OF PREMIUM SUPPORT
Premium Support In Medicare
This Health Policy Brief explains the concept of premium support and examines the debate between proponents and critics.

April 06, 2012     DEFINING PREMIUM SUPPORT
Vouchers or Premium Support: What's in a Name?
The term "premium support" was introduced by Henry Aaron and Robert Reischauer in a 1995 Health Affairs article. Aaron and Reischauer's ideas drew heavily on Alain Enthoven's theory of managed competition, which are definitively explained in a 1993 Health Affairs article.
Henry Aaron

JANUARY 2015     MEDICARE COSTS
Variations in Medicare Costs Have Implications for Premium Support
By Brian Biles, Giselle Casillas, and Stuart Guterman

MAY 2012     MEDICARE REFORM
Three Large-Scale Changes to Medicare
Christine Eibner, Dana P. Goldman, Jeffrey Sullivan, and Alan M. Garber

SEPTEMBER 2000     PREMIUM SUPPORT
Is Premium Support the Right Medicine for Medicare?
Jonathan Oberlander



Private Insurance Regulation


High-Risk Pools:


February 16, 2017     INSURANCE MARKETS
Unpacking The Trump Administration's Market Stabilization Proposed Rule
On February 15, HHS released its first notice of proposed rulemaking of the Tom Price era, intended to shore up the individual health insurance markets. What's in the proposed rule, what might its effects be, and what else must be done to stabilize the markets?
Timothy Jost

March 15, 2016     COVERAGE
It's All About The Risk Pool
Linda Blumberg and John Holahan

March 2011     ENROLLMENT
The Preexisting Condition Insurance Plan
Joann Kenen

June 2010     ENROLLMENT
Temporary Insurance for High-Risk Individuals
Deborah J. Chollet

May 2007     INSURANCE MARKET
Risk Pooling And Regulation: Policy and Reality
Mark V. Pauly and Bradley Herring

October 2002     INSURANCE MARKET
Competitive Markets for Individual Health Insurance
Scott Harrington and Tom Miller

October 2002     COVERAGE
Expanding Individual Health Insurance Coverage: Are High-Risk Pools the Answer?
Deborah Chollet

October 2002     INSURANCE MARKET
The Nongroup Insurance Market: Short on Facts, Long on Opinions and Policy Disputes
Mark V. Pauly and Len Nichols

October 2002     COVERAGE
Using Tax Credits and State High-Risk Pools to Expand Coverage
Bruce Abbe

Selling Across State Lines:


February 24, 2010     COVERAGE
Should We Be Able to Buy Insurance Across State Lines?
John Goodman

October 27, 2010     INSURANCE SALES
Interstate Insurance Sales: Questioning the 'Race to the Bottom'
John Goodman