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The Tortuous Journey of the Health Insurance Marketplace

Published online by Cambridge University Press:  01 January 2021

Abstract

This article examines the past, present, and future of individual market policies in the Affordable Care Act (ACA). It does so, first, by reviewing the law's goals, scope, and set of individual market policies, collectively called the Health Insurance Marketplace. The Marketplace, along with the ACA's Medicaid expansion, was designed to fill in gaps to provide all Americans with accessible, affordable coverage. Second, it reviews evidence on the law's impact to date, including changes under a new administration. Third, it discusses the three main policy options for the Marketplace: do nothing, build on it, or replace it. Lastly, it discusses the factors which could determine which pathway policy makers follow.

Type
Symposium Articles
Copyright
Copyright © American Society of Law, Medicine and Ethics 2018

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References

Obama, B., “United States Health Care Reform: Progress to Date and Next Steps,” JAMA 316, no. 5 (2016): 525532.Google Scholar
Congressional Budget Office, Budgetary and Economic Effects of Repealing the Affordable Care Act, Report, Congressional Budget Office (June 2015), available at <https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-effectsofacarepeal.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Iglehart, J.K., “Historic Passage — Reform at Last,” The New England Journal of Medicine 362, no. 14 (2010): e48.Google Scholar
Barnett, J.C. and Berchick, E.R., Health Insurance Coverage in the United States: 2016, Census Bureau Report Number: P60-260, (September 12, 2017).Google Scholar
Hushagen, E. and Fish-Parcham, C., Failing Grades: State Consumer Protections in the Individual Health Insurance Market, Families USA, (June 2008), available at <http://familiesusa.org/product/failing-grades-state-consumer-protections-individual-health-insurance-market> (last visited October 24, 2018).Google Scholar
ASPE Issue Brief, Essential Health Benefits: Individual Market Coverage, Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services (December, 16, 2011), available at <https://aspe.hhs.gov/basic-report/essential-health-benefits-individual-market-coverage> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Kirk, A.M., “Riding the Bull: Experience with Individual Market Reform in Washington, Kentucky, and Massachusetts,” Journal of Health Politics, Policy and Law 25, no. 1 (2000): 133173.Google Scholar
Oberlander, J., “Learning from Failures in Health Care Reform,” The New England Journal of Medicine 357, no. 17 (2007): 16771679.Google Scholar
Gabel, J., “Cancelled Non-Group Health Plans: What We Know Now that We Did Not Know in October, Health Affairs Blog, June 17, 2014, available at <https://www.healthaffairs.org/do/10.1377/hblog20140617.039634/full/> (last visited October 24, 2018); A.D. Holan, “Lies of the Year: If You Like Your Health Care Plan You Can Keep It,” PolitiFact, December 12, 2013, available at <http://www.politifact.com/truth-o-meter/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/> (last visited October 24, 2018).+(last+visited+October+24,+2018);+A.D.+Holan,+“Lies+of+the+Year:+If+You+Like+Your+Health+Care+Plan+You+Can+Keep+It,”+PolitiFact,+December+12,+2013,+available+at++(last+visited+October+24,+2018).>Google Scholar
Lambrew, J. and Montz, E., “The Next Big Thing in Health Reform: Where to Start?” The American Prospect 29, no. 2 (Winter 2018): 6769.Google Scholar
See Obama, supra note 1.Google Scholar
Sen, A.P. and DeLeire, T., The Effect of Medicaid Expansion on Marketplace Premiums, Issue Brief, Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services (September 6, 2016), available at <https://aspe.hhs.gov/system/files/pdf/206761/McaidExpMktplPrem.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Livingston, S., “Feds Owe Health Insurance $12.3 Billion in Unpaid Risk-Corridor Payments,” Modern Healthcare, November 14, 2017, available at <http://www.modernhealth-care.com/article/20171114/NEWS/171119935> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Weisman, J. and Peters, J., “Government Shuts Down in Budget Impasse,” The New York Times, September 30, 2013, on A1, available at <https://www.nytimes.com/2013/10/01/us/politics/congress-shutdown-debate.html> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Fabian, J., “Trump: Let ObamaCare Implode,” The Hill, July 28, 2017, available at <http://thehill.com/homenews/administration/344365-trump-let-obamacare-implode> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Pear, R., Haberman, M., and Abelson, R., “Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again,” The New York Times, October 12, 2017, available at <https://www.nytimes.com/2017/10/12/us/politics/trump-obamacare-executive-order-health-insurance.html> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Park, H., “We’re Tracking the Ways Trump Is Scaling Back Obamacare. Here are 12,” The New York Times, October 12, 2017, available at <https://www.nytimes.com/interactive/2017/10/12/us/trump-undermine-obamacare.html> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Jost, T., “Trump Executive Order Expands Opportunities for Healthier People to Exit ACA,” Health Affairs Blog, October 12, 2017, available at <https://www.healthaffairs.org/do/10.1377/hblog20171022.762005/full/> (last visited October 24, 2018); K. Keith and T. Jost, “The 2019 Proposed Payment Notice, Part 2: Consumer-Facing Provision,” Health Affairs Blog, October 28, 2017, available at <https://www.healthaffairs.org/do/10.1377/hblog20171028.887269/full/> (last visited October 24, 2018).+(last+visited+October+24,+2018);+K.+Keith+and+T.+Jost,+“The+2019+Proposed+Payment+Notice,+Part+2:+Consumer-Facing+Provision,”+Health+Affairs+Blog,+October+28,+2017,+available+at++(last+visited+October+24,+2018).>Google Scholar
Uberoi, N., Finegold, K., and Gee, E., Health Insurance Coverage and The Affordable Care Act, 2010-2016, Issue Brief, Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services, (March 3, 2016), available at <https://aspe.hhs.gov/system/files/pdf/187551/ACA2010-2016.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Karpman, M. and Long, S.K., 9.4 Million Fewer Families are Having Problems Paying Medical Bills, Urban Institute Report (May 21, 2015), available at <http://hrms.urban.org/briefs/9-4-Million-Fewer-Families-Are-Having-Problems-Paying-Medical-Bills.html> (last visited October 24, 2018).Google Scholar
Agency for Healthcare Research and Quality, “National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data from National Efforts to Make Health Care Safer,” U.S Department of Health and Human Services, December 2016, available at <https://www.ahrq.gov/professionals/quality-patient-safety/pfp/2015-interim.html> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Council of Economic Advisers, “Chapter 4 Reforming the Health Care System,” 2017 Economic Report of the President, Executive Office of the President (December 2016), available at <https://obamawhitehouse.archives.gov/sites/default/files/docs/chapter_4-reforming_health_care_system_2017.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Frean, M., Gruber, J., and Sommers, B.D., “Premium Subsidies, the Mandate, and Medicaid Expansion: Coverage Effects of the Affordable Care Act,” NBER Working Paper No. 22213 (2016): 7286.Google Scholar
Centers for Medicare and Medicaid Services, Health Insurance Marketplaces 2018 Open Enrollment Period Final Report, U.S. Department of Health and Human Services (April 3, 2017), available at <https://www.cms.gov/News-room/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-04-03.html> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
See Council of Economic Advisers, supra note 22.Google Scholar
Assistant Secretary for Planning and Evaluation, Health Insurance Coverage for Americans with Pre-Existing Conditions: The Impact of the Affordable Care Act, Issue Brief, U.S. Department of Health and Human Services (January, 5, 2017), available at <https://aspe.hhs.gov/system/files/pdf/255396/Pre-ExistingConditions.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Blumberg, L.J., Corlette, S., and Lucia, K., The Affordable Care Act: Improving Incentives for Entrepreneurship and Self-Employment, Timely Analysis of Immediate Health Policy Issues, Urban Institute, (May 2013), available at <https://www.urban.org/sites/default/files/publication/23661/412830-The-Affordable-Care-Act-Improving-Incentives-for-Entrepreneurship-and-Self-Employment.PDF> (last visited October 24, 2018).Google Scholar
Collins, S.R., Gunja, M.Z., Doty, M.M., and Beutel, S., How the Affordable Care Act has Improved Americans’ Ability to Buy Health Insurance on their Own, Issue Brief, Commonwealth Fund (February 1, 2017), available at <http://www.commonwealthfund.org/publications/issue-briefs/2017/feb/howthe-aca-has-improved-ability-to-buy-insurance> (last visited October 24, 2018).Google ScholarPubMed
Schmittdiel, J.A., Barrow, J.C., Wiley, D., Ma, L., Sam, D., Chau, C.V, and Shetterly, S.M., “Improvements in Access and Care Through the Affordable Care Act,” American Journal of Managed Care 23, no. 3 (2017): e95e97.Google Scholar
Deloitte, “2016 Survey of US Health Care Consumers: A Look at Exchange Consumers,” Presentation, Deloitte Development LLC, 2016, available at <https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-dchs-consumer-survey-hix.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
See Centers for Medicare and Medicaid Services, supra note 24.Google Scholar
Assistant Secretary for Planning and Evaluation, Health Plan Choice and Premiums in the 2018 Federal Health Insurance Exchange, Issue Brief, U.S. Department of Health and Human Services (October 30, 2017), available at <https://aspe.hhs.gov/system/files/pdf/258456/Landscape_Master2018_1.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
See Deloitte, supra note 30.Google Scholar
Sheingold, S., Nyguyen, N., and Chappel, A., Competition and Choice in the Health Insurance Marketplaces, 2014-2015: Impact on Premiums, Issue Brief, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services (July 30, 2015), available at <https://aspe.hhs.gov/basic-report/competition-and-choice-health-insurance-marketplaces-2014-2015-impact-premiums> (last visited October 24, 2018).Google Scholar
Glied, S., Arora, A., and Solís-Román, C., The CBO's Crystal Ball: How Well Did it Forecast the Effects of the Affordable Care Act, Issue Brief, Commonwealth Fund (December 15, 2015), available at <http://www.commonwealthfund.org/publications/issue-briefs/2015/dec/cbo-crystal-ball-forecast-aca> (last visited October 24, 2018).Google ScholarPubMed
See Assistant Secretary for Planning and Evaluation, supra note 32.Google Scholar
Blumberg, L.J, Holahan, J., and Wengle, E., Are Nongroup Marketplace Premiums Really High? Not In Comparison with Employer Insurance, Issue Brief, Urban Institute (September 19, 2016), available at <https://www.urban.org/sites/default/files/publication/84256/2000931-Are-Nongroup-Marketplace-Premiums-Really-High-Not-in-Comparison-with-Employer-Insurance.pdf> (last visited October 24, 2018).Google Scholar
See Assistant Secretary for Planning and Evaluation, supra note 32.Google Scholar
American Academy of Actuaries, Drivers of 2017 Health Insurance Premium Changes, Issue Brief (May 2016), available at <https://www.actuary.org/content/drivers-2017-health-insurance-premium-changes-0> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Council of Economic Advisers, Understanding Recent Developments in the Individual Health Insurance Market, Issue Brief, Executive Office of the President (January 2017), available at <https://obamawhitehouse.archives.gov/sites/default/files/page/files/201701_individual_health_insurance_market_cea_issue_brief.pdf> (last accessed October 24, 2018); Council of Economic Advisers, The Profitability of Health Insurance Companies, Issue Brief, Executive Office of the President (March 2018), available at <https://www.white-house.gov/wp-content/uploads/2018/03/The-Profitability-of-Health-Insurance-Companies.pdf> (last visited October 24, 2018).+(last+accessed+October+24,+2018);+Council+of+Economic+Advisers,+The+Profitability+of+Health+Insurance+Companies,+Issue+Brief,+Executive+Office+of+the+President+(March+2018),+available+at++(last+visited+October+24,+2018).>Google Scholar
Fiedler, M., Taking Stock of Insurer Financial Performance in the Individual Health Insurance Market Through 2017, Report, Brookings Institution (October 27, 2017), available at <https://www.brookings.edu/research/taking-stock-of-insurer-financial-performance-in-the-individual-health-insurance-market-through-2017/> (last visited October 24, 2018).Google Scholar
See Centers for Medicare and Medicaid Services, supra note 24.Google Scholar
See Assistant Secretary for Planning and Evaluation, supra note 32.Google Scholar
Levitt, L., Cox, C., and Claxton, G., The Effects of Ending the Affordable Care Act's Cost-Sharing Reduction Payments, Issue Brief, Kaiser Family Foundation (April 25, 2017), available at <http://files.kff.org/attachment/Issue-Brief-The-Effects-of-Ending-the-Affordable-Care-Acts-Cost-Sharing-Reduction-Payments> (last visited October 24, 2018).Google Scholar
Congressional Budget Office, Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2018 to 2028, Report, Congressional Budget Office (May 23, 2018), available at <https://www.cbo.gov/system/files?file=2018-06/53826-healthinsurancecoverage.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Blumberg, L.J, Buettgens, M., and Wang, R., Updated: The Potential Impact of Short-Term Limited Duration Policies on Insurance Coverage, Premiums, and Federal Spending, Issue Brief, Urban Institute (March, 2018), available at <https://www.urban.org/sites/default/files/publication/96781/2001727_updated_finalized.pdf> (last visited October 24, 2018).Google Scholar
Semanskee, A., Claxton, G., and Levitt, L., How Premiums Are Changing in 2018, Issue Brief, Kaiser Family Foundation (November 29, 2017), available at <https://www.kff.org/health-reform/issue-brief/how-premiums-are-changing-in-2018/> (last visited October 24, 2018); see Assistant Secretary for Planning and Evaluation, supra note 32.Google Scholar
Congressional Budget Office, Re: Appropriation of Cost-Sharing Reduction Subsidies, Letter, Senator Lamar Alexander, Congressional Budget Office (March 19, 2018), available at <https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53664-costsharingreduction.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Hall, M.A. and McCue, M.J., Health Insurance Markets Perform Better in States That Run Their Own Marketplaces, Issue Brief, Commonwealth Fund (March 7, 2018), available at <http://www.commonwealthfund.org/publications/blog/2018/mar/health-insurance-markets-states> (last visited October 24, 2018).Google Scholar
Lucia, K., Giovannelli, J., Corlette, S., Volk, J., Palanker, D., Kona, M., and Curran, E., State Regulation of Coverage Options Outside of the Affordable Care Act: Limiting the Risk to the Individual Market, Report, Commonwealth Fund (March 2018), available at <https://www.commonwealthfund.org/publications/fund-reports/2018/mar/state-regulation-coverage-options-outside-affordable-care-act> (last visited October 24, 2018).Google Scholar
Goldstein, A., “Iowa Tries Another End Run Around the Affordable Care Act,” The Washington Post, April 2, 2018, available at <https://www.washingtonpost.com/national/health-science/iowa-tries-another-end-run-around-the-affordable-care-act/2018/04/01/cd25baec-3429-11e8-94fa-32d48460b955_story.html?utm_term=.af54a626c8a1> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Semanskee, A., Cox, C., and Levitt, L., Individual Insurance Market Performance in Early 2018, Issue Brief, Kaiser Family Foundation (June 26, 2018), available at <https://www.kff.org/private-insurance/issue-brief/individual-insurance-market-performance-in-early-2018/> (last visited October 24, 2018).Google Scholar
See Council of Economic Advisers, supra note 40.Google Scholar
Keith, K., “ACA Update: Analyses Show Insurer Profits, Reversal of Coverage Gains, and Wealth Transfers,” Health Affairs Blog, March 23, 2018, available at <https://www.healthaf-fairs.org/do/10.1377/hblog20180323.989982/full/> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Luhby, T., “Insurers Aren’t Running Scared from Obamacare Anymore,” CNN, July 6, 2018, available at <https://www.cnn.com/2018/07/06/politics/obamacare-insurers/index.html> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Alexander, L. and Murray, P., Bipartisan Health Care Stabilization Act of 2017, undated, available at <https://www.help.senate.gov/imo/media/doc/THE%20BIPARTISAN%20HEALTH%20CARE%20STABILIZATION%20ACT%20OF%202017-%20TEXT.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
See Congressional Budget Office, supra note 48.Google Scholar
Congressional Budget Office, H.R. 1628: American Health Care Act of 2017, Cost Estimate, Congressional Budget Office (May 24, 2017), available at <https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628aspassed.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Congressional Budget Office, Preliminary Analysis of Legislation that Would Replace Subsidies for Health Care With Block Grants, Report, Congressional Budget Office (September 2017), available at <https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/53126-health.pdf> (last visited October 24, 2017).+(last+visited+October+24,+2017).>Google Scholar
Lambrew, J.M., Getting Ready for Health Reform 2020: What Past Presidential Campaigns Can Teach Us, The Commonwealth Fund (June 26, 2018), available at <https://www.commonwealthfund.org/publications/fund-reports/2018/jun/getting-ready-health-reform-2020-presidential> (last visited October 24, 2018).Google Scholar
Congressional Budget Office, Bipartisan Health Care Stabilization Act of 2018, Cost Estimate, Congressional Budget Office (March 19, 2018), available at <https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/bipartisanhealthcarestabilizationact.pdf> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
Cunningham, P.W., “The Health 202: This Abortion Fight Derailed a Bipartisan Obamacare Fix in Spending Bill,” The Washington Post, PowerPost, March 22, 2018, available at <https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/03/22/the-health-202-this-abortion-fight-derailed-a-bipartisan-obamacare-fix-in-spending-bill/5ab2c18230fb045e48d05b41/?utm_term=.c949b68a2f81> (last visited October 24, 2018).+(last+visited+October+24,+2018).>Google Scholar
See Congressional Budget Office, supra note 45.Google Scholar
Lambrew, J.M., “Lessons from the Latest ACA Battle,” New England Journal of Medicine 377, no. 22 (November 30, 2017): 21072109.Google Scholar