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The article offers information on the legal and operational challenges faced by the U.S. state and federal government in the development of health insurance exchanges under the U.S. Affordable Care Act. It informs that these exchanges help the small business firms and uninsured individuals in purchasing private health insurance. It discusses the U.S. Supreme Court case National Federation of Independent Business v. Sebelius (NFIB) focusing on the development of the U.S. health care system.

Beginning January 1, 2014, small businesses having no more than fifty full-time-equivalent workers will be able to obtain health insurance for their employees through Small Business Health Options Program (SHOP) exchanges in every state. Although the Affordable Care Act intended the exchanges to make the purchasing of insurance more attractive and affordable to small businesses, it is not yet known how they will respond to the exchanges. Based on a telephone survey of 604 randomly selected private firms having 3-50 employees, we found that both firms that offered health coverage and those that did not rated most features of SHOP exchanges highly but were also very price sensitive. More than 92 percent of nonoffering small firms said that if they were to offer coverage, it would be "very" or "somewhat" important to them that premium costs be less than they are today. Eighty percent of offering firms use brokers who commonly perform functions of benefit managers-functions that the SHOP exchanges may assume. Twenty-six percent of firms using brokers reported discussing self-insuring with their brokers. An increase in the number of self-insured small employers could pose a threat to SHOP exchanges and other small-group insurance reforms. [ABSTRACT FROM AUTHOR]

The 2010 Affordable Care Act (ACA) represents a milestone in U.S. health care policy. The ACA moves the American health care system away, in important respects, from market-driven health care, including imposing new regulations on health insurers. Yet the ACA also relies, in other respects, on market forces to achieve its aims, including its embrace of health plan competition and high-deductible insurance. This article explores how the ACA balances liberal aspirations and market principles, and the implications for health reform implementation and the future of U.S. health care. [ABSTRACT FROM AUTHOR]

The five largest US commercial health insurance companies together enroll 125 million members, or 43 percent of the country's insured population. Over the past decade these insurers have become increasingly dependent for growth and profitability on public programs, according to an analysis of corporate reports. In 2016 Medicare and Medicaid accounted for nearly 60 percent of the companies' health care revenues and 20 percent of their comprehensive plan membership. Although headlines have focused on losses in the state Marketplaces created by the Affordable Care Act (ACA), the Marketplaces represent only a small fraction of insurers' members. Overall, the five largest insurers have remained profitable since passage of the ACA as a result of profits in other market segments. Notably, companies with significant Medicare or Medicaid enrollment have continued to insure beneficiaries in states where the insurers do not participate in Marketplaces. Given the insurers' dependence on public programs, there is potential to improve access if federal or state governments, or both, required insurers that participate in Medicare or Medicaid to also participate in the Marketplaces in the same geographic area. Such requirements could ensure more viable and less volatile insurance, benefiting people insured within each market as well as those who cycle on and off public and private insurance. [ABSTRACT FROM AUTHOR]

Objectives We examine trends in prescription contraceptive sales following the Affordable Care Act's (ACA) zero-copayment contraceptive coverage mandate in areas more likely to be affected by the provision relative to areas less likely to be affected. Methods Before the ACA, several states had their own contraceptive insurance coverage mandates. Using a national prescription claims database combined with wholesaler institutional sales activity from January 2008 through June 2014, we compare sales of the intrauterine device (IUD), implant, injectable, pill, ring, and patch in states that had a state-level insurance coverage mandate before the ACA to states that did not. Results Overall, our results imply the ACA increased sales of prescription contraceptives, with stronger effects for some methods than others. Specifically, we find the ACA increased sales of injectable contraceptives, but had no significant impact on sales of the IUD, implant, pill, or patch in states without a state-level mandate before the ACA relative to states that had a state-level mandate. We also find suggestive evidence of a reduction in sales of the ring. Conclusions for Practice Demand responses to changes in out-of-pocket expenses for contraception vary across methods. Eliminating copays could promote the use of contraceptives, but is not the only approach to increasing contraceptive utilization. [ABSTRACT FROM AUTHOR]

Working in small businesses has been identified as a key factor for low coverage rates in immigrant communities. In this study, we identify specific cultural and socioeconomic predictors of Asian Americans who work in small businesses to identify subgroups at a greater disadvantage than others in obtaining health insurance. Logistic regression models were fitted using a sample of 3,819 Asian American small business owners and employers extracted from pooled 2005-2012 California Health Interview Survey data. We found that individuals with low income levels, Korean Americans, U.S.-born South Asian and Southeast Asian (other than Vietnamese) Americans, immigrants without citizenship (particularly those lacking a green card), and individuals with limited English proficiency had higher odds of lacking coverage. The odds of being uninsured did not differ between small business owners and employees. Based upon these key findings, we propose several strategies to expand coverage for Asian Americans working in small businesses and their most vulnerable subgroups. [ABSTRACT FROM AUTHOR]

The Affordable Care Act gives states the option to create health insurance exchanges from which individuals and small employers can purchase health insurance. States have considerable flexibility in how they design and implement these exchanges. We analyze several key design options being considered, using the Urban Institute's Health Insurance Policy Simulation Model: creating separate versus merged small-group and nongroup markets, eliminating age rating in these markets, removing the small-employer credit, and setting the maximum number of employees for firms in the small-group market at 50 versus 100 workers. Among our findings are that merging the small-group and nongroup markets would result in 1.7 million more people nationwide participating in the exchanges and, because of greater affordability of nongroup coverage, approximately 1.0 million more people being insured than if the risk pools were not merged. The various options generate relatively small differences in overall coverage and cost, although some, such as reducing age rating bands, would result in higher costs for some people while lowering costs for others. These cost effects would be most apparent among people who purchase coverage without federal subsidies. On the whole, we conclude that states can make these design choices based on local support and preferences without dramatic repercussions for overall coverage and cost outcomes. [ABSTRACT FROM AUTHOR]

Since the passage of the Affordable Care Act, there has been much speculation about how many employers will stop offering health insurance once the act's major coverage provisions take effect. Some observers predict little aggregate effect, but others believe that 2014 will mark the beginning of the end for our current system of employer- sponsored insurance. We use theoretical and empirical evidence to address the question, "How will employers' offerings of health insurance change under health reform?" First, we describe the economic reasons why employers offer insurance. Second, we recap the relevant provisions of health reform and use our economic framework to consider how they may affect employers' offerings. Third, we review the various predictions that have been made about those offerings under health reform. Finally, we offer some observations on interpreting early data from 2014. [ABSTRACT FROM AUTHOR]

The Affordable Care Act calls on states to create health insurance exchanges serving small businesses by 2014. These exchanges will allow small-business owners to pool their buying power, have more choices of health plans, and buy affordable health insurance. However, creating an exchange that appeals to small-business owners poses several challenges. Past and current exchanges provide valuable insights into the role exchanges can play, services they can offer, and design features that can make them successful. For example, states should allow insurance brokers to provide employers with advice and analysis regarding plans offered in the exchanges. Exchanges should also provide services to ease enrollment, such as a single application for all of the plans they offer, and make additional benefits, such as wellness programs, available on a stand-alone basis or within insurance plans. [ABSTRACT FROM AUTHOR]

The boundaries of what constitutes "sufficient" health have always been open and, as such, health care has proven to be an opportune area for profit growth. In the United States, the allure of health as a market commodity has proven very strong, but even here it cannot be a mere spontaneous product of the market. It requires government to foster and develop public policy that effectively promotes and maintains health care delivery across the population. Historically, U.S. public policy has veered away from anything akin to universal care, and it has typically been understood as an outlier among advanced industrial states. But, simultaneously, it is also the largest health care market in the world, soon to engulf a full fifth of its GDP. In this paper, I argue that the complicated dynamic between a growing market in health delivery and a patchwork of political reforms has encouraged "adaptive accumulation," a process whereby capital secures optimized accumulation outcomes from enhanced government intervention, deriving extra-market benefits along the way. To make this argument, I explore critical components of the health system, including Medicare Advantage, Medicare Part D, as well as the Affordable Care Act and its aftermath. [ABSTRACT FROM AUTHOR]

Background: Reductions in health insurance enrollment outreach could have negative effects on the individual health insurance market. Specifically, consumers may not be informed about the availability of coverage, and if some healthier consumers fail to enroll, there could be a worse risk pool for insurers. Kentucky created its own Marketplace, known as kynect, and adopted Medicaid expansion under the Affordable Care Act, which yielded the largest decline in adult uninsured rate in the United States from 2013 to 2016. The state sponsored an award-winning media campaign, yet after the election of a new governor in 2015, it declined to renew the television advertising contract for kynect and canceled all pending television ads with over a month remaining in the 2016 open enrollment period.Objective: The objective of this study is to examine the stark variation in television advertising across multiple open enrollment periods in Kentucky and use this variation to estimate the dose-response effect of state-sponsored television advertising on consumer engagement with the Marketplace. In addition, we assess to what extent private insurers can potentially help fill the void when governments reduce or eliminate television advertising.Methods: We obtained television advertising (Kantar Media/Campaign Media Analysis Group) and Marketplace data (Kentucky Health Benefit Exchange) for the period of October 1, 2013, through January 31, 2016, for Kentucky. Advertising data at the spot level were collapsed to state-week counts by sponsor type. Similarly, a state-week series of Marketplace engagement and enrollment measures were derived from state reports to Centers for Medicare and Medicaid Services. We used linear regression models to estimate associations between health insurance television advertising volume and measures of information-seeking (calls to call center; page views, visits, and unique visitors to the website) and enrollment (Web-based and total applications, Marketplace enrollment).Results: We found significant dose-response effects of weekly state-sponsored television advertising volume during open enrollment on information-seeking behavior (marginal effects of an additional ad airing per week for website page views: 7973, visits: 390, and unique visitors: 388) and enrollment activity (applications, Web-based: 61 and total: 56).Conclusions: State-sponsored television advertising was associated with nearly 40% of unique visitors and Web-based applications. Insurance company television advertising was not a significant driver of engagement, an important consideration if cuts to government-sponsored advertising persist. [ABSTRACT FROM AUTHOR]

Context: State governments have been powerful sites of Republican resistance to the implementation of the Affordable Care Act (ACA), the Democratic Party's signature 2010 law. By influencing how citizens experience the ACA, state-level implementation can affect the nationallevel political implications of the law. Methods: I examine three largely unstudied areas of marketplace implementation: navigator laws, transidonal plan termination, and rating area configurations. For each policy area, I use linear probability models to investigate the determinants of state lawmakers bolstering or eroding marketplaces. Findings: In each case. Democrat-controlled states were more likely to bolster marketplaces than Republican-controlled states were, with decisions more polarized in those policy areas-navigator laws and transitional plan termination-and with greater potential for national-level feedback. For navigator laws, where Republican state lawmakers were most cross-pressured by national party interests and local interests, marketplace eroding policy was highly associated with strength of conservative networks. Conclusion: Crafters of federal legislation cannot expect state lawmakers to universally implement federal law to maximize the direct benefits to their constituents. Rather, we should expect state lawmakers to, in many instances, implement federal law in ways that benefit their parties. [ABSTRACT FROM AUTHOR]

A summary of the Affordable Care Act of 2010 in Colorado is presented.

The Affordable Care Act changed the regulations governing small firms' health insurance premiums. However, small businesses can avoid many of the new regulations by self-insuring or maintaining grandfathered plans. If small firms with healthy and lower-cost enrollees avoid the regulations, premiums for coverage sold through insurance exchanges could be unaffordable. In this analysis we used the RAND Comprehensive Assessment of Reform Efforts microsimulation model to predict the effects of self-insurance and grandfathering exemptions on coverage and premiums available through the exchanges. We estimate that Affordable Care Act regulations restricting employers' ability to offer grandfathered plans will result in lower premiums on plans available through the exchanges and will have small negative effects on enrollment in the exchanges. Our results suggest that these regulations are essential to keeping premiums on the Small Business Health Options Program (SHOP) exchanges affordable. Our analysis also found that Affordable Care Act regulations limiting self-insurance will reduce enrollment in the exchanges somewhat, without substantially affecting exchange premiums. [ABSTRACT FROM AUTHOR]

As implementation of the Affordable Care Act reshapes the US health insurance market, state policy makers should be prepared to revisit regulation of stop-loss coverage--a form of reinsurance--for small businesses. Aspects of the reform law could motivate small businesses to self-insure, rather than participate in state-regulated markets either inside or outside the new health insurance exchanges. If younger or healthier groups self-insure, premiums for insured plans might rise to an extent that could seriously impair the regulated market. States can influence small businesses to participate in the regulated market by making it more difficult or costly to obtain stop-loss coverage, which self-funded employers rely on to protect their businesses from catastrophic medical costs incurred by one or more insured workers. States can limit the comprehensiveness of stop-loss coverage, ban stop-loss coverage outright, or regulate it as they do primary coverage. But states need federal guidance about how to exercise this authority if they are to promote, or prevent the undermining of, important aspects of federal health care reform. [ABSTRACT FROM AUTHOR]

The Affordable Care Act did not start the consolidation rapidly occurring with hospitals/health systems and medical groups, but it most definitely accelerated the movement to combine. In the last five years, the number and size of consolidations have been at an all-time high. This comment reviews the degree to which consolidation has occurred and explores the key reasons behind these consolidations. It then posits that consolidations should be evaluated in light of the Triple Aim goals of enhancing access to care, reducing cost, and strengthening quality, and looks at the evidence to date in light of these goals. [ABSTRACT FROM AUTHOR]

The article focuses on the U.S. Patient's Protection and Affordable Care Act (ACA) and discusses its economic aspects for health care industry of the U.S. It analyzes the role of the U.S. Supreme Court's judgment regarding Commerce Clause in the legislation in mandating commercial power for the U.S. Congress. It informs that individual mandate of ACA exceeds commercial liability of the Congress in purchasing health care products.

The article focuses on the Affordable Care Act (ACA) in the U.S. Topics mentioned include the management of the U.S. health care system, the importance of healthcare insurance, and the private insurance exchanges. Also mentioned are the public health management, the Employee Retirement Income Security Act (ERISA), and the employee fringe benefits.

An introduction is presented in which the editor discusses various reports within the issue on topics including multi-share health plans to help small businesses provide health insurance for employees, role of leadership in patient-centered care, and a successful process improvement program.

Healthcare transparency is gaining public support, but still faces multiple obstacles to becoming a broad reality across the industry. Some surgery centers are leading the way in making costs and outcomes transparent through their websites. [ABSTRACT FROM AUTHOR]

Enrollment in the Marketplaces of the Affordable Care Act (ACA) has fallen short of original expectations, because the ACA's regulatory changes made coverage costlier for many Americans with incomes above 150 percent of the federal poverty level. There are ways to strengthen and expand the role of the individual market in providing affordable, personalized options to all nonelderly Americans. These include insured people in costly group plans, uninsured people in good health but without affordable options, those with preexisting conditions, and those who live in states that did not expand eligibility for Medicaid. A more robust individual market could expand coverage so that it would be more sustainable than the status quo. Much as the authors of the Affordable Care Act drew on Massachusetts reforms signed into law by Gov. Mitt Romney (R), market-oriented health reformers should learn from the ACA and Medicare's private insurance programs in order to build a personalized, consumer-driven path toward universal coverage. [ABSTRACT FROM AUTHOR]

The Affordable Care Act created the Small Business Health Options Program (SHOP) Marketplaces to help small businesses provide health insurance to their employees. To attract the participation of substantial numbers of small employers, SHOP Marketplaces must demonstrate value-added features unavailable in the traditional small-group market. Such features could include lower premiums than those for plans offered outside the Marketplace and more extensive choices of carriers and plans. More choices are necessary for SHOP Marketplaces to offer the "employee choice model," in which employees may choose from many carriers and plans. This study compared the numbers of carriers and plans and premium levels in 2014 for plans offered through SHOP Marketplaces with those of plans offered only outside of the Marketplaces. An average of 4.3 carriers participated in each state's Marketplace, offering a total of forty-seven plans. Premiums for plans offered through SHOP Marketplaces were, on average, 7 percent less than those in the same metal tier offered only outside of the Marketplaces. Lower premiums and the participation of multiple carriers in most states are a source of optimism for future enrollment growth in SHOP Marketplaces. Lack of broker buy-in in many states and burdensome enrollment processes are major impediments to success. [ABSTRACT FROM AUTHOR]

The health insurance exchange is the centerpiece of the insurance reforms created by the Affordable Care Act. The Small Business Health Options Program (SHOP) is intended to create a marketplace for small, and perhaps eventually large, employers to purchase health insurance for their employees. This paper introduces a collection of articles that illuminate the need for small-business exchanges and discuss how they will function. The paper also describes the difficulties these exchanges will face, as well as the opportunities they will offer to states, employers, and individuals. The success or failure of small-business exchanges may well hinge on how states choose to address these challenges. [ABSTRACT FROM AUTHOR]