This article examines the past, present, and future of individual market policies in the Affordable Care Act. 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. (shrink)

This study examines the relative effects of three policy levers on health coverage and costs in plans aimed at covering all Americans. Specifically, using microsimulation analysis and hypothetical proposals, it assesses how the generosity of financial assistance, an employer mandate, and an individual mandate affect the level of uninsurance, distribution of coverage, and federal costs, holding delivery system and benefits constant. The results suggest that only an individual mandate would cover all the uninsured; neither an employer mandate nor generous subsidies (...) alone would be sufficient. The distribution of coverage would be least disrupted by an employer mandate, while 7.3% of people could lose employer coverage with generous subsidies and a voluntary purchasing pool. Federal costs would be highest under a combined individual and employer mandate since there would be costs to minimize disruption. Although less generous subsidies coupled with an individual mandate could yield universal coverage at a low federal cost, doing so would require large, new payments by individuals. Other key trade-offs are discussed. (shrink)

Health reform proposals tend to be rich with details and dimensions. The primary goal of health reform is typically to extend health coverage to people who lack it. Yet even the most similar of plans differ in terms of exactly who is targeted for assistance, the means by which assistance is delivered, and the type of health coverage promoted. Moreover, the Byzantine nature of the existing U.S. health system means that any reform plan can appear complex. The plan that aims (...) for a new, simple health system will require radical changes to achieve it, while the plan that strives to be the least disruptive will have extensive rules that target assistance while maintaining the existing sources of coverage. Indeed, some have argued that the complexity inherent in meaningful reform is an impediment to reform itself. Few involved in the 1993-94 health reform debate have forgotten the politically damaging chart created by Dick Armey and Newt Gingrich that described the “59 new federal programs, 79 new federal mandates” of the Clinton health reform plan. A similar chart could be made for almost any health reform plan. Despite this richness, health reform proposals are most often characterized by two numbers: how much they costs and how many people they assist. This article reviews these cost and coverage estimates through the prism of the health reform policy debate which has emerged in the 2004 election. Even at an early stage, when the focus on the major candidates’ policies has not yet sharpened, the importance of the numbers around health proposals is apparent. To gain insight into this phenomenon, the article examines why numbers matter, their meaning and sources, and their potential misuses. It concludes with a discussion of the powerful influence that numbers have in the current, past and probably future health reform debates. (shrink)

Health reform proposals tend to be rich with details and dimensions. The primary goal of health reform is typically to extend health coverage to people who lack it. Yet even the most similar of plans differ in terms of exactly who is targeted for assistance, the means by which assistance is delivered, and the type of health coverage promoted. Moreover, the Byzantine nature of the existing U.S. health system means that any reform plan can appear complex. The plan that aims (...) for a new, simple health system will require radical changes to achieve it, while the plan that strives to be the least disruptive will have extensive rules that target assistance while maintaining the existing sources of coverage. Indeed, some have argued that the complexity inherent in meaningful reform is an impediment to reform itself. (shrink)