Exchanges and Health Marketplaces
States have the option of playing a variety of legislative roles with Affordable Care Act authorized health exchanges or marketplaces. This includes state authorizing, funding, structure and regulation of state and federally facilitated exchanges; also activity related to private exchanges and the small employer market.
Free Market; Challenges and Alternatives
Legislatures may include provisions emphasizing free-market and state-initiated innovations: expanded use of health savings accounts; cross-state insurance sales and purchases; health interstate compacts; noncompliance with penalties for lacking individual health insurance; or employers choosing not to offer insurance.
Cost containment includes measures intended to moderate or slow health cost increases, inefficiencies, duplication and waste.
Legislative efforts to define or expand enrollment, consumer rights and assistance, establish limits on deductibles and copayments, assure coverage for adult dependents and use of public-private program coordination. These include the approach known as "no wrong door."
Health provider delivery reforms include medical homes, accountable care organizations (ACOs), and use of primary care networks.
Market—Health Insurance Reforms
State insurance laws include health regulations and ACA-related reforms and responses, also covering premium rate review, defined medical loss ratios and ombudsman-style consumer rights and assistance.
Market—Mandates and Essential Health Benefits
State laws that define health insurance mandates and affect federally created essential health benefits, including requirements, restrictions and flexibility as enacted by states.
Policymakers can require health insurers to include larger numbers or variety of providers. Alternatively states can authorize the availability of more limited provider networks at lower premium costs.
New and emerging innovations that do not fit typical or widespread policies may be listed here.
Commercial and private market payment reforms can include incentives or requirements for value-based purchasing, pay-for-performance, accountable care organizations, and bundled and global payments.
Price disclosure and transparency initiatives include all-payer-claims databases, requirements to publish or publicly post charges and rates, and related privacy issues.
Payment reform is a promising tool for controlling health care spending and often supports changes in the delivery system. Traditionally, Medicaid providers have been reimbursed on a fee-for-service (FFS) basis, which compensates for every service, test or procedure provided. Rather than reward volume, payment reform models seek to reward value and create financial incentives for health care providers to focus on primary and preventive care, improve access, and adopt more effective, efficient models of care delivery to improve quality and reduce costs.
Provisions of the Affordable Care Act expanded Medicaid to all Americans under age 65 whose family income is at or below 133 percent of federal poverty guidelines by Jan. 1, 2014. On June 28, 2012, the U.S. Supreme Court ruled that Congress may not make a state’s entire existing Medicaid funds contingent upon the state’s compliance with the ACA Medicaid expansion. In practice, this ruling makes the Medicaid expansion a voluntary action by states.
These laws amend or change state Medicaid in ways other than expansion and payment reform. (Users may check all three Medicaid search options to view program changes from a broader perspective) See NCSL's Medicaid online resource.
This category allows users to examine a range of new state laws that implement or respond to provisions in the Affordable Care Act, including insurance protections, exchanges, Medicaid, 1332 waivers for alternative designs, and other pilot programs or grants provided for in the 2010 federal law.
While Americans as a group are healthier and living longer, disparities persist. For a number of racial and ethnic minorities in the U.S., good health is more difficult to attain because appropriate care is often associated with an individual's economic status, race and gender. Policymakers are responding to these issues by introducing legislation aimed at eliminating health disparities. Also see NCSL's online resource on Health Disparities.
State-run programs include state and local public employee benefits, single payer proposals, state-funded public-private partnerships and other measures not tied to federal structures.
Telehealth and telemedicine programs include encouraging, regulating and reimbursing electronic and remote health services, both video and audio, and out-of state. These measures are now tracked above, for sessions starting in 2016 and seprately for earlier years via NCSL's Telehealth webpage.
Database Project staff: Richard Cauchi, Colleen Becker, Kate Blackman, Samantha Scotti, and Lisa Waugh. Previously: Ashley Noble (2015-17), Laura Tobler and former health staff Melissa Hansen contributed to this project, 2015. NCSL Health Program, Denver.