Affordable Care Act Archives

Comparing Key Provisions: Affordable Care Act, American Health Care Act, and the Graham-Cassidy Proposal

In July 2017, the United States Senate rejected a series of proposals to repeal and replace the Affordable Care Act (ACA). On September 13, 2017, Senators Lindsey Graham and Bill Cassidy introduced a new proposal to repeal and replace the ACA.

The Graham-Cassidy proposal retains some similarities to the American Health Care Act, which passed the U.S. House of Representatives in May 2017, but includes some notable differences. This brief compares key provisions of the Affordable Care Act, American Health Care Act, and the Graham-Cassidy proposal.

The Senate has until September 30, 2017 to pass a repeal and replace package under the Fiscal Year 2017 budget reconciliation process, which requires a simple majority for passage. After the end of FY 2017, any repeal and replace legislation would most likely require 60 votes for passage. It is possible that budget reconciliation, requiring a simple majority for passage, could be used for repeal and replace legislation in FY 2018 if it is not used for other issues.

On Sept. 25, the U.S. Congressional Budget Office (CBO) issued a preliminary report on a version of the Graham-Cassidy proposal summarized in this brief. The CBO concluded that the bill would save at least $133 billion. However, it would result in millions of people losing health insurance. Additional, detailed analyses may be forthcoming.

READ THE BRIEF

The impact of the ACA on community mental health and substance abuse services: Experience in three Great Lakes states

The Affordable Care Act (ACA) allowed states to expand Medicaid coverage to low-income childless adults, many of whom receive specialty mental health and substance use services through community mental health systems. Leading up to the passage of the ACA, community mental health providers and their professional associations were generally supportive of expanding Medicaid under the ACA. Medicaid covers specialty services central to quality mental health and substance use care, as well as other physical health services that many in the serious mental illness (SMI) and substance use disorder (SUD) populations lacked before 2010. This brief examines the impact of the ACA Medicaid expansion on community mental health.

To date, 32 states have expanded Medicaid (including the District of Columbia), while the remaining 19 have not. This brief, which was developed with support from the Commonwealth Fund, examines the impact of the ACA on public mental health and substance use systems in three Midwestern states: Michigan and Indiana, both Medicaid expansion states, and Wisconsin, a non-expansion state.

The experience from these three states suggests that Medicaid expansion has had an important and overall beneficial effect in particular for the substance use population. The favorable impact is particularly important in light of the opioid epidemic.

Key findings include:

Prior to the Medicaid expansion, state and local funds paid for many services for the SMI/serious emotional disturbance (SED) and SUD populations. In Medicaid expansion states, most funding shifted to the federal government, providing both advantages and disadvantages: more people in need received insurance coverage, but that coverage was less flexible for SMI/SED populations than prior funding mechanisms.
Funding for substance use services improved substantially in Medicaid expansion states, serving a particularly important role in enabling states to provide more services in the wake of the opioid crisis. In these states, many more individuals had Medicaid SUD treatment benefits than before expansion and federal block grant funds were freed up to provide additional substance use services. As a result of the additional funding provided, Michigan was able to increase the numbers of those who received SUD care by 14%.

READ THE BRIEF

Decrease in Hospital Uncompensated Care in Michigan, 2015

The Affordable Care Act (ACA) expanded access to health insurance coverage for Michigan residents in 2014 through the creation of the Health Insurance Marketplace and the expansion of the Medicaid program. Since then, Michigan has experienced large decreases in the number of adults who lack health insurance, delay necessary care, and have trouble paying their medical bills.⁽¹⁾E. Austic, E. Lawton, M. Slowey, M. Riba, and M. Udow-Phillips, Changes in Health Care Cost Barriers under the Affordable Care Act in Michigan (Ann Arbor, MI: Center for Healthcare Research and Transformation, 2017). Hospitals also appear to have reaped the benefits of the ACA’s coverage expansions. Following the expansion of Michigan’s Medicaid program in April 2014, Michigan hospitals experienced a steep drop in uncompensated care costs. In 2015, uncompensated care costs continued to decline, and as uncompensated care’s share of hospital operating expenses decreased, the median hospital operating margin in Michigan improved for the second year in a row. As policymakers debate changes to the Affordable Care Act and Medicaid, it is important to assess the financial gains that Michigan hospitals have received in the first two years of ACA implementation and the potential losses they could incur with a repeal of the ACA.

For an analysis of uncompensated care costs nationwide and a comparison of these trends in several Midwestern states, please see CHRT’s companion piece, Hospital Uncompensated Care in the United States, 2015 – Comparison of Midwest States.

Hospital Uncompensated Care and Financial Trends

Recent studies have documented decreases in uncompensated care and the proportion of uninsured patients in Michigan hospitals after the ACA’s coverage expansion began in 2014. One study used Medicaid cost reports to find that uncompensated care costs for 88 Michigan hospitals⁽²⁾88 hospitals in the state of Michigan reported FY2015 data at the time of the study. decreased from $627 million in 2013 to $332.1 million in 2015.⁽³⁾T. Buchmueller, H. Levy, S. Nikpay, and J. Rhodes, Healthy Michigan Plan 2015 Report on Uncompensated Care and Insurance Rates, prepared for the Michigan Department of Health and Human Services, December 31, 2016 (accessed 6/12/17).

Another study examined shifts in payer mix in Michigan hospitals following the launch of the Healthy Michigan Plan in April 2014. This study found that the proportion of uninsured patients in Michigan hospitals from April-December 2014 decreased by four percentage points and the proportion of patients with Medicaid coverage increased by 6.5 percentage points compared to the same time periods in 2012 and 2013.⁽⁴⁾M. Davis, A. Gebremariam, and J. Ayanian, “Changes in Insurance Coverage Among Hospitalizeds Nonelderly Adults After Medicaid Expansion in Michigan,” Journal of the American Medical Association, June 21, 2016 (accessed 6/12/17).

In the present study, CHRT used Medicare cost reports to examine the financial characteristics of 104 hospitals in Michigan. Michigan expanded Medicaid eligibility with the launch of the Healthy Michigan Plan on April 1, 2014. By the end of the year Michigan experienced a sharp decline in uncompensated care, dropping from $903 million in 2013 to $677 million in 2014 (see Figure 1). This drop continued into 2015 as uncompensated care fell to $394 million, a decrease of 56 percent from 2013 levels.

Uncompensated care comprises both charity care costs and bad debt costs. The effect of the Medicaid expansion was larger for the charity care portion of uncompensated care compared to the bad debt portion. Charity care expenses for hospitals decreased by 70 percent from 2013 to 2015.

Figure 1: Hospital Uncompensated Care Costs in Michigan, by Bad Debt and Charity Care, 2011–2015

From 2013 to 2015, Michigan hospitals generally experienced improved overall financial outcomes as well as decreased uncompensated care burdens. Uncompensated care’s share of hospital expenses fell from 3.6 percent for the median hospital in 2013 to 1.7 percent in 2015 after increasing in the years prior to Medicaid expansion (see Figure 2). However, hospitals had different levels of uncompensated care burdens and the effects of coverage expansion varied by specific hospital characteristics (see Appendix).

Coinciding with the decline in uncompensated care costs, the median hospital operating margin (net profits from patient care services) increased from -4.3 percent in 2013 to -0.5 percent in 2015. The ACA includes several quality improvement programs, such as penalties for hospital readmissions, which affect Medicare reimbursement. While these types of penalties may have had a negative effect on the profitability of certain hospitals, many hospitals experienced substantial gains in profitability in 2015.

Figure 2: Median Hospital Financial Indicators in Michigan, 2011–2015

From 2011 to 2013 the number of inpatient days and outpatient visits at Michigan hospitals decreased from 4.68 million to 4.46 million (see Figure 3). In 2015, Medicaid volume increased by 16 percent to 1.13 million inpatient days and outpatient visits, while volume for other payers decreased by 4 percent. Overall volume has remained nearly unchanged from 2013 to 2015. Medicaid’s share of total patient volume increased from 21.7 percent in 2013 to 25.2 percent in 2015.

Figure 3: Hospital Inpatient Days and Outpatient Visits for Michigan Hospitals by Payer, 2011–2015

Conclusion

Hospital financial performance in Michigan has improved in the two years since the implementation of the ACA’s coverage expansions in 2014. Michigan continued to experience a decline in hospital uncompensated care costs in 2015 as hospitals saw fewer uninsured patients and a higher proportion of patients covered by Medicaid. Overall hospital operating margins also improved in 2015. Medicaid expansion appears to have had a positive effect on hospitals’ uncompensated care costs and overall margins since the launch of the Healthy Michigan Plan in 2014. With policymakers currently debating changes to Medicaid and the future of the Affordable Care Act, it will be important to monitor the connection between the coverage expansions created under the law and the financial performance of health care providers. Policy changes that reverse the ACA’s coverage gains could also affect hospitals’ financial status.

Data and Methodology

We extracted hospital data on uncompensated care and other facility characteristics from publicly available cost reports submitted by hospitals to the Centers for Medicare and Medicaid Services (CMS) via the Healthcare Cost Report Information System (HCRIS). Data include reports collected by December 31, 2016, which were released on January 19, 2017. For this analysis, we restricted the set of hospitals to short-term acute and critical access hospitals that submitted complete reports for each year from 2011 through 2015. This eliminated rehabilitation, long-term, psychiatric, children’s, and other specialty hospitals that have high nonresponse rates or are not largely affected the ACA’s Medicaid expansion. The resulting data set includes 3,474 hospitals nationwide and 104 in Michigan.

Hospitals submit worksheet S-10 as part of their cost report that breaks down their uncompensated care costs into their separate sources. In our analysis, we define uncompensated care as the sum of charity care (care delivered with no expectation of payment) and bad debt (care that is billed but no payment is received), but underpayments from public payers (Medicare, Medicaid, and the Children’s Health Insurance Program) were excluded. The use of cost report data for uncompensated care research is still relatively new, and not all responses from hospitals are audited by CMS. However, MedPAC has supported using worksheet S-10 to directly measure uncompensated care costs.⁽⁵⁾Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. March 2016. http://www.medpac.gov/docs/default-source/reports/march-2016-report-to-the-congress-medicare-payment-policy.pdf (accessed 3/17/16). Data for inpatient days and outpatient visits were extracted from worksheet S-3, part 1, and data on operating margins were extracted from worksheet G-3 of the cost reports.

Cost reports submitted to hospitals are based on individual hospitals’ fiscal years, which have varying beginning and end dates. To generate comparable time-series measures, we converted hospital fiscal year measures to calendar year estimates by combining the portion of each fiscal year that fell within a given calendar year. Uncompensated care amounts were converted from charges to costs using hospital-specific cost-to-charge ratios calculated in the cost reports, and all financial measures were adjusted for inflation to 2015 dollars. Facilities that reported outlier uncompensated care amounts compared to their historic trend were dropped from the study.

Hospitals were identified as for-profit, nonprofit, or government-owned based on control status data from the 2013 American Hospital Association annual survey.⁽⁶⁾American Hospital Association. Annual Survey Database: http://www.aha.org/research/rc/stat-studies/data-and-directories.shtml (accessed 3/17/16). Metropolitan status was determined based on the U.S. Department of Agriculture’s rural-urban continuum codes for 2013,⁽⁷⁾US Department of Agriculture, Economic Research Service, Rural-Urban Continuum Codes: http://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx (accessed 3/17/16). and hospitals were identified as teaching institutions if they indicated in their cost reports that they train residents as part of an approved graduate medical education program.

Appendix

Figure A-1: Median Financial Indicators for Michigan Hospitals by Select Characteristics, 2011–2015

References[+]

References
↑1	E. Austic, E. Lawton, M. Slowey, M. Riba, and M. Udow-Phillips, Changes in Health Care Cost Barriers under the Affordable Care Act in Michigan (Ann Arbor, MI: Center for Healthcare Research and Transformation, 2017).
↑2	88 hospitals in the state of Michigan reported FY2015 data at the time of the study.
↑3	T. Buchmueller, H. Levy, S. Nikpay, and J. Rhodes, Healthy Michigan Plan 2015 Report on Uncompensated Care and Insurance Rates, prepared for the Michigan Department of Health and Human Services, December 31, 2016 (accessed 6/12/17).
↑4	M. Davis, A. Gebremariam, and J. Ayanian, “Changes in Insurance Coverage Among Hospitalizeds Nonelderly Adults After Medicaid Expansion in Michigan,” Journal of the American Medical Association, June 21, 2016 (accessed 6/12/17).
↑5	Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. March 2016. http://www.medpac.gov/docs/default-source/reports/march-2016-report-to-the-congress-medicare-payment-policy.pdf (accessed 3/17/16).
↑6	American Hospital Association. Annual Survey Database: http://www.aha.org/research/rc/stat-studies/data-and-directories.shtml (accessed 3/17/16).
↑7	US Department of Agriculture, Economic Research Service, Rural-Urban Continuum Codes: http://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx (accessed 3/17/16).

Hospital Uncompensated Care in the United States, 2015 – Comparison of Midwest States

Since the launch of health insurance coverage expansion in 2014 under the Affordable Care Act (ACA), Michigan and other states have experienced large decreases in the number of adults who lack health insurance, delay necessary care, and have trouble paying their medical bills.⁽¹⁾ Austic, E. Lawton, M. Slowey, M. Riba, and M. Udow-Phillips, Changes in Health Care Cost Barriers under the Affordable Care Act in Michigan (Ann Arbor, MI: Center for Healthcare Research and Transformation, March 2017). However, these effects have not been even nationwide, as 21 states had not adopted the ACA’s optional Medicaid expansion by the end of 2015.⁽²⁾ Dussault, M. Pinkovskiy, and B. Zafar, “Is Health Insurance Good for Your Financial Health?” Liberty Street Economics, June 6, 2016: http://libertystreeteconomics.newyorkfed.org/2016/06/is-health-insurance-good-for-your-financial-health.html (accessed 3/10/17). Hospitals are particularly affected by health insurance coverage expansions because many hospitals have traditionally provided free and/or reduced price services to low-income and uninsured patients as part of their social mission and community benefit requirements. Prior to the ACA coverage expansion, health care providers, including hospitals, provided approximately $1,000 of uncompensated care per uninsured individual.⁽³⁾T. A. Coughlin et al., “An Estimated $84.9 Billion in Uncompensated Care Was Provided in 2013; ACA Payment Cuts Could Challenge Providers,” Health Affairs, May 2014, 33(5): 807–14: http://content.healthaffairs.org/content/33/5/807.full (accessed 3/10/17).(accessed 3/10/17). This report examines the effect of health care expansion on hospital uncompensated care with a comparison of Midwest states.

Hospitals have two forms of uncompensated care: charity care and bad debt.⁽⁴⁾ Broader definitions of uncompensated care may include underpayments from Medicare and Medicaid, but underpayments were not included in this analysis. Charity care is delivered to indigent patients without the expectation of receiving payment, and bad debt occurs when a hospital bills for but is unable to collect the entire amount due from a patient.⁽⁵⁾ Hospitals have different procedures and qualifications for how patients can apply for charity care assistance, which limits the comparison of charity care and bad debt measures across hospitals.This report updates an earlier CHRT report⁽⁶⁾ Fangmeier and M. Udow-Phillips, “Hospital Uncompensated Care, 2014,” Cover Michigan 2016 (Ann Arbor, MI: Center for Healthcare Research and Transformation, 2016). to measure the effect of the ACA’s coverage expansion, particularly the optional Medicaid expansion, on hospital uncompensated care costs and other financial outcomes. In addition, this report compares trends in uncompensated care across eight selected Midwestern states.

Key Findings

Uncompensated care costs for hospitals decreased by about 23 percent nationwide from 2013 to 2015, but hospitals in Medicaid expansion states experienced much sharper deceases (39 percent) than those in non-expansion states (4 percent).
Almost all selected states in the Midwest experienced decreases in uncompensated care from 2011 to 2015, while Missouri, a non-expansion state, experienced an increase in uncompensated care during this time.
Compared to other selected Midwestern states, Michigan experienced the largest relative decline in uncompensated care costs from 2011 to 2015.

Health Insurance Coverage Expansions and Uncompensated Care

Several studies have examined the relationship between health insurance coverage expansions and the provision of uncompensated care by hospitals. As part of the Oregon Health Insurance Experiment—a randomized study of the effects of Medicaid coverage on adults—researchers found that a large share of the value of Medicaid spending for new enrollees went to external parties, including health care providers, who were previously providing care without payment.⁽⁷⁾A. Finkelstein, N. Hendren, and E. Luttmer, “The Value of Medicaid: Interpreting Results from the Oregon Health Insurance Experiment,” NBER Working Paper 21308 (Cambridge, MA: National Bureau of Economic Research, June 2015): http://www.nber.org/papers/w21308 (accessed 3/10/17).

Other researchers have found that every uninsured patient costs hospitals $900 and that hospital closures increase uncompensated care at nearby hospitals. They also found that increases in uninsured populations cut into profit margins, suggesting that hospitals cannot fully pass along the costs of uncompensated care to insurance companies.⁽⁸⁾C. Garthwaite, T. Gross, and M. Notowidigdo, “Hospitals as Insurers of Last Resort,” NBER Working Paper 21290 (Cambridge, MA: National Bureau of Economic Research, June 2015): http://www.nber.org/papers/w21290 (accessed 3/10/17).

Recent studies have documented the decline in hospital uncompensated care after the ACA’s coverage expansion began in 2014. One study found that state Medicaid expansion was associated with a $2.8 million decrease in uncompensated care per hospital and improved profit margins.⁽⁹⁾F. Blavin, “Association Between the 2014 Medicaid Expansion and US Hospital Finances,” Journal of the American Medical Association, Oct. 11, 2016, 316(14): 1475–83.2016: http://jamanetwork.com/journals/jama/fullarticle/2565750 (accessed 3/10/17). Another study found larger uncompensated care reductions for hospitals in Medicaid expansion states that had greater pre-ACA uncompensated care burdens or were located in regions with greater numbers of people who became newly eligible for Medicaid.⁽¹⁰⁾D. Dranove, C. Garthwaite, and C. Ody, “Uncompensated Care Decreased at Hospitals in Medicaid Expansion States But Not at Hospitals in Nonexpansion States,” Health Affairs, Aug. 2016, 35(8): 1471–9: http://content.healthaffairs.org/content/35/8/1471.abstract (accessed 3/10/17).

Many of these trends continued into 2015. The American Hospital Association (AHA) found that uncompensated care costs for hospitals nationwide decreased from $42.8 billion in 2014 to $35.7 billion in 2015. The ratio of uncompensated care to total expenses also fell substantially and is now the lowest it has been since the AHA began reporting in 1990.⁽¹¹⁾American Hospital Association, Uncompensated Hospital Care Cost Fact Sheet, December 2016: http://www.aha.org/content/16/uncompensatedcarefactsheet.pdf (accessed 3/10/2017).

With the reduction in uninsured patients, some hospital systems expanded their qualification rules for charity care to provide assistance to patients with high deductibles and other out-of-pocket costs. In 2016, Ascension Health began waiving unpaid bills for patients with an income below 250 percent of the federal poverty level (FPL) and experienced a 12 percent increase in charity care costs in 2016.⁽¹²⁾Ascension. Management’s Discussion and Analysis of Financial Condition and Results of Operations for Ascension, n.d.: http://ascension.org/~/media/files/ascension/about/community-investor-relations/2017/management-discussion-q2-2017.pdf?la=en (accessed 3/10/2017).

Hospital Uncompensated Care and Financial Trends

In the present study, CHRT used Medicare cost reports to examine the financial characteristics of 3,474 hospitals across the United States. Based on this data, we found that hospitals provided $28.8 billion in uncompensated care in 2013, prior to the ACA’s coverage expansion (see Figure 1). Beginning in 2013, Medicaid expansion states experienced sharp decreases in uncompensated care, declining by 39 percent by 2015. By comparison, non-expansion states showed a 4 percent decrease, and some states experienced increases in uncompensated care (see Appendix).

Figure 1: Hospital Uncompensated Care Costs for Medicaid Expansion and Non-Expansion States, 2011–2015

Regional Comparison of Uncompensated Care Trends

To better understand the connection between coverage expansion and hospital uncompensated care, CHRT compared eight Midwestern states with varying market and policy characteristics. For example, hospitals in Michigan, Ohio, and Illinois were more likely to have a teaching program for the graduate medical education of residents (see Figure 2). Hospitals in Iowa, Minnesota, and Wisconsin were more likely to have a critical access designation as a rural provider and have fewer hospital beds. Missouri and Indiana hospitals were more likely to be part of investor-owned, for-profit companies compared to the other Midwestern states.

Figure 2: Characteristics of Hospitals in Selected Midwestern States

States across the Midwest have taken different approaches to setting Medicaid eligibility for low-income adults. Minnesota took advantage of the ACA’s option for states to expand coverage prior to 2014 and allowed adults with an income less than 75 percent of the FPL to enroll in 2011.⁽¹³⁾Sommers, G. Kenney and A. Epstein, “New Evidence On The Affordable Care Act: Coverage Impacts Of Early Medicaid Expansions”, Health Affairs, Jan. 2014, 33(1):78–87: http://content.healthaffairs.org/content/33/1/78.full (accessed 3/10/17).

Illinois, Iowa, Minnesota, and Ohio then adopted the full Medicaid expansion on January 1, 2014. Indiana and Michigan expanded enrollment on April 1, 2014, and February 1, 2015, respectively (see Figure 3). Illinois, Michigan, and Ohio all experienced a decrease in their uninsured population of over 40 percent from 2013 to 2015.

Neither Missouri nor Wisconsin has expanded Medicaid. However, Wisconsin is the only non-expansion state in the country that does not have a coverage gap for financial assistance.⁽¹⁴⁾Adults with incomes below 100 percent FPL in all other non-expansion states fall into a coverage gap because they are ineligible for Medicaid coverage, and tax credits to purchase coverage on the health insurance marketplace are only available to those with incomes above 100 percent FPL.Wisconsin’s Medicaid program covers adults with income up to 100 percent FPL, and adults whose income is above the poverty line are eligible for financial assistance through the health insurance marketplace. In contrast, childless non-disabled adults in Missouri are not eligible for Medicaid, regardless of income level.

Figure 3: Characteristics of Medicaid and Health Insurance Coverage in Selected Midwestern States

⁽¹⁵⁾Kaiser Family Foundation, Medicaid Income Eligibility Limits for Other Non-Disabled Adults, 2011–2017, http://kff.org/data-collection/trends-in-medicaid-income-eligibility-limits/ (accessed 3/10/17) ⁽¹⁶⁾Gates, R. Rudowitz, and S. Artiga, Two Year Trends in Medicaid and CHIP Enrollment Data: Findings from the CMS Performance Indicator Project (Menlo Park, CA: Henry J. Kaiser Family Foundation, June 2016): http://files.kff.org/attachment/Issue-Brief-Two-Year-Trends-in-Medicaid-and-CHIP-Enrollment-Data (accessed 3/10/17). ⁽¹⁷⁾Kaiser Family Foundation. State Health Facts: Health Insurance Coverage of the Total Population, 2015: http://kff.org/other/state-indicator/total-population/ (accessed 3/10/17). ⁽¹⁸⁾Indiana uses a state-specific income disregard that results in a slightly greater eligibility threshold for the group.

From 2011 to 2015, nearly all of the selected Midwestern states experienced a decrease in hospital uncompensated care costs (see Figure 4). Minnesota, with its early Medicaid expansion, saw uncompensated care decline immediately after 2011. States that expanded in 2014 experienced sharp declines from 2013 to 2014. Indiana, which expanded in early 2015, saw a drop in uncompensated care in 2015 after experiencing rising levels for three straight years from 2011 to 2014. Uncompensated care in Missouri, which did not expand Medicaid, is still above 2011 levels.

Overall, Michigan experienced the largest relative decrease in uncompensated care among the selected Midwestern states, dropping to 49 percent of 2011 levels in 2015. Wisconsin, which did not expand Medicaid but does not have a coverage gap, saw uncompensated care drop to 64 percent of 2011 levels. A study by the Wisconsin Hospital Association found similar declines in uncompensated care, especially from 2013 to 2015.⁽¹⁹⁾Wisconsin Hospital Association, Uncompensated Health Care Report,. Fiscal Year 2015 (Madison, WI: WHA Information Center, Sept. 2016): http://www.whainfocenter.com/uploads/PDFs/Publications/Uncompensated/Uncompensated_2015.pdf (accessed 3/10/17)

Figure 4: Uncompensated Care Costs Compared to 2011 Levels, by State

Conclusion

Medicaid expansion states have continued to experience large declines in hospital uncompensated care costs since 2014. As debate among state and federal policymakers about the future of the Affordable Care Act continues, it will be important to examine the connection between health insurance coverage expansions and financial outcomes for health care providers. Not all hospitals experienced the same effects of coverage expansion on uncompensated care, and it is not clear how hospitals would respond to policy changes that reduce the coverage gains under the ACA or the value of coverage to those who became newly insured.

Data and Methodology

We extracted hospital data on uncompensated care and other facility characteristics from publicly available cost reports submitted by hospitals to the Centers for Medicare and Medicaid Services (CMS) via the Healthcare Cost Report Information System (HCRIS). Data include reports collected by December 31, 2016, which were released on January 19, 2017. For this analysis, we restricted the set of hospitals to short-term acute and critical access hospitals that submitted complete reports for each year from 2011 through 2014. This eliminated rehabilitation, long-term, psychiatric, children’s, and other specialty hospitals that have high nonresponse rates or are not largely affected the ACA’s Medicaid expansion. The resulting data set includes 3,474 hospitals nationwide.

Hospitals submit worksheet S-10 as part of their cost report that breaks down their uncompensated care costs into their separate sources. In our analysis, we define uncompensated care as the sum of charity care (care delivered with no expectation of payment) and bad debt (care that is billed but no payment is received), but underpayments from public payers (Medicare, Medicaid, and the Children’s Health Insurance Program) were excluded. The use of cost report data for uncompensated care research is still relatively new, and not all responses from hospitals are audited by CMS. However, MedPAC has supported using worksheet S-10 to directly measure uncompensated care costs.⁽²⁰⁾

Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. March 2016. http://www.medpac.gov/docs/default-source/reports/march-2016-report-to-the-congress-medicare-payment-policy.pdf services.pdf?sfvrsn=0 (accessed 6/6/17). Data for inpatient days and outpatient visits were extracted from worksheet S-3, part 1, and data on operating margins were extracted from worksheet G-3 of the cost reports.

Cost reports submitted to hospitals are based on individual hospitals’ fiscal years, which have varying beginning and end dates. To generate comparable time-series measures, we converted hospital fiscal year measures to calendar year estimates by combining the portion of each fiscal year that fell within a given calendar year. Uncompensated care amounts were converted from charges to costs using hospital-specific cost-to-charge ratios calculated in the cost reports, and all financial measures were adjusted for inflation to 2014 dollars. Facilities that reported outlier uncompensated care amounts compared to their historic trend were dropped from the study.

Hospitals were identified as for-profit, nonprofit, or government-owned based on control status data from the 2013 American Hospital Association annual survey.⁽²¹⁾American Hospital Association, Annual Survey Database: http://www.aha.org/research/rc/stat-studies/data-and-directories.shtml (accessed 3/17/16). Metropolitan status was determined based on the U.S. Department of Agriculture’s rural-urban continuum codes for 2013,⁽²²⁾U.S. Department of Agriculture,Economic Research Service, Rural-Urban Continuum Codes: http://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx (accessed 3/17/16). and hospitals were identified as teaching institutions if they indicated in their cost reports that they train residents as part of an approved graduate medical education program.

Appendix

Figure A-1: Uncompensated Care Trends in the United States, 2011–2015

Figure A-2: Uncompensated Care Trends by State, Medicaid Expansion States, 2011–2015

Figure A-3: Uncompensated Care Trends by State, Non-Expansion States, 2011–2015

References[+]

References
↑1	Austic, E. Lawton, M. Slowey, M. Riba, and M. Udow-Phillips, Changes in Health Care Cost Barriers under the Affordable Care Act in Michigan (Ann Arbor, MI: Center for Healthcare Research and Transformation, March 2017).
↑2	Dussault, M. Pinkovskiy, and B. Zafar, “Is Health Insurance Good for Your Financial Health?” Liberty Street Economics, June 6, 2016: http://libertystreeteconomics.newyorkfed.org/2016/06/is-health-insurance-good-for-your-financial-health.html (accessed 3/10/17).
↑3	T. A. Coughlin et al., “An Estimated $84.9 Billion in Uncompensated Care Was Provided in 2013; ACA Payment Cuts Could Challenge Providers,” Health Affairs, May 2014, 33(5): 807–14: http://content.healthaffairs.org/content/33/5/807.full (accessed 3/10/17).(accessed 3/10/17).
↑4	Broader definitions of uncompensated care may include underpayments from Medicare and Medicaid, but underpayments were not included in this analysis.
↑5	Hospitals have different procedures and qualifications for how patients can apply for charity care assistance, which limits the comparison of charity care and bad debt measures across hospitals.
↑6	Fangmeier and M. Udow-Phillips, “Hospital Uncompensated Care, 2014,” Cover Michigan 2016 (Ann Arbor, MI: Center for Healthcare Research and Transformation, 2016).
↑7	A. Finkelstein, N. Hendren, and E. Luttmer, “The Value of Medicaid: Interpreting Results from the Oregon Health Insurance Experiment,” NBER Working Paper 21308 (Cambridge, MA: National Bureau of Economic Research, June 2015): http://www.nber.org/papers/w21308 (accessed 3/10/17).
↑8	C. Garthwaite, T. Gross, and M. Notowidigdo, “Hospitals as Insurers of Last Resort,” NBER Working Paper 21290 (Cambridge, MA: National Bureau of Economic Research, June 2015): http://www.nber.org/papers/w21290 (accessed 3/10/17).
↑9	F. Blavin, “Association Between the 2014 Medicaid Expansion and US Hospital Finances,” Journal of the American Medical Association, Oct. 11, 2016, 316(14): 1475–83.2016: http://jamanetwork.com/journals/jama/fullarticle/2565750 (accessed 3/10/17).
↑10	D. Dranove, C. Garthwaite, and C. Ody, “Uncompensated Care Decreased at Hospitals in Medicaid Expansion States But Not at Hospitals in Nonexpansion States,” Health Affairs, Aug. 2016, 35(8): 1471–9: http://content.healthaffairs.org/content/35/8/1471.abstract (accessed 3/10/17).
↑11	American Hospital Association, Uncompensated Hospital Care Cost Fact Sheet, December 2016: http://www.aha.org/content/16/uncompensatedcarefactsheet.pdf (accessed 3/10/2017).
↑12	Ascension. Management’s Discussion and Analysis of Financial Condition and Results of Operations for Ascension, n.d.: http://ascension.org/~/media/files/ascension/about/community-investor-relations/2017/management-discussion-q2-2017.pdf?la=en (accessed 3/10/2017).
↑13	Sommers, G. Kenney and A. Epstein, “New Evidence On The Affordable Care Act: Coverage Impacts Of Early Medicaid Expansions”, Health Affairs, Jan. 2014, 33(1):78–87: http://content.healthaffairs.org/content/33/1/78.full (accessed 3/10/17).
↑14	Adults with incomes below 100 percent FPL in all other non-expansion states fall into a coverage gap because they are ineligible for Medicaid coverage, and tax credits to purchase coverage on the health insurance marketplace are only available to those with incomes above 100 percent FPL.
↑15	Kaiser Family Foundation, Medicaid Income Eligibility Limits for Other Non-Disabled Adults, 2011–2017, http://kff.org/data-collection/trends-in-medicaid-income-eligibility-limits/ (accessed 3/10/17)
↑16	Gates, R. Rudowitz, and S. Artiga, Two Year Trends in Medicaid and CHIP Enrollment Data: Findings from the CMS Performance Indicator Project (Menlo Park, CA: Henry J. Kaiser Family Foundation, June 2016): http://files.kff.org/attachment/Issue-Brief-Two-Year-Trends-in-Medicaid-and-CHIP-Enrollment-Data (accessed 3/10/17).
↑17	Kaiser Family Foundation. State Health Facts: Health Insurance Coverage of the Total Population, 2015: http://kff.org/other/state-indicator/total-population/ (accessed 3/10/17).
↑18	Indiana uses a state-specific income disregard that results in a slightly greater eligibility threshold for the group.
↑19	Wisconsin Hospital Association, Uncompensated Health Care Report,. Fiscal Year 2015 (Madison, WI: WHA Information Center, Sept. 2016): http://www.whainfocenter.com/uploads/PDFs/Publications/Uncompensated/Uncompensated_2015.pdf (accessed 3/10/17)
↑20	Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. March 2016. http://www.medpac.gov/docs/default-source/reports/march-2016-report-to-the-congress-medicare-payment-policy.pdf services.pdf?sfvrsn=0 (accessed 6/6/17).
↑21	American Hospital Association, Annual Survey Database: http://www.aha.org/research/rc/stat-studies/data-and-directories.shtml (accessed 3/17/16).
↑22	U.S. Department of Agriculture,Economic Research Service, Rural-Urban Continuum Codes: http://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx (accessed 3/17/16).

Comparing Key Provisions: Affordable Care Act, American Health Care Act, and Better Care Reconciliation Act

Editor’s Note: CHRT revised the following table (originally published June 27, 2017) to reflect both the U.S. Senate’s July 13 revision of its Better Care Reconciliation Act (BCRA) and the Congressional Budget Office’s score of the revised BCRA.

On June 22, 2017, Senate Republicans released a discussion draft of the Better Care Reconciliation Act, their proposal to repeal and replace the Affordable Care Act (ACA). The Senate draft retains a similar overall structure as the American Health Care Act, which passed the U.S. House of Representatives in May 2017, but includes some notable differences. The following table compares key provisions of the ACA, American Health Care Act, and Better Care Reconciliation Act. It compares them across several categories: Ensuring Continuous Coverage, Tax Credits for Individual Market Coverage, Cost-Sharing Reductions, Medicaid Expansion, Medicaid Funding Structure, Health Savings Accounts, Private Insurance Market Regulations, Market Stability and Risk Pool, Taxes and Fees, Impacts on Coverage and Premiums, and Impacts on Federal Budget.

For example, for the category of Ensuring Continuous Coverage, the ACA requires an individual with a lapse in coverage to pay an individual mandate penalty of $695 or 2.5% of income above $10,000. The American Health Care Act repeals the ACA’s individual mandate penalty and instead requires individuals with a lapse in coverage to pay 30% higher premiums for one year upon re-enrolling in individual coverage. The Better Care Reconciliation Act also repeals the ACA’s individual mandate penalty, and subjects individuals with a lapse in coverage to a six-month waiting period before re-enrolling.

This document reflects the revised Better Care Reconciliation Act as of July 13, 2017. CHRT will update this table if the Senate votes to approve the motion to proceed.

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American Health Care Act: Key Provisions and Implications, May 2017 Update

In March 2017, House Republicans unveiled the American Health Care Act (AHCA), their proposal to replace the Affordable Care Act (ACA). On May 4, the U.S. House of Representatives passed AHCA by a vote of 217-213. On March 13, the U.S. Congressional Budget Office projected that under AHCA (as introduced), 14 million Americans would lose their health insurance in 2018, with the number of uninsured rising to 24 million by 2026. The Congressional Budget Office will be updating their score of this legislation to account for several amendments that were adopted in the House-passed version of the bill.

The following table summarizes key AHCA provisions. It lists the provision, the details of the American Health Care Act, and who is primarily affected. The provisions reviewed are:

Replace the ACA’s individual mandate with a continuous coverage requirements
Change Tax Credits from those based on income and premium cost in the ACA to based on age and allow tax credits to be used on or off Exchange
Repeal Cost-Sharing Reduction Subsidies
Widen Age Rating Bands
Freeze Medicaid Expansion
Shift Medicaid f rom funding based on the cost of coverage to Per-Capita limit or block grant
State Waivers
Patient and State Stability Fund

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April 2017 HHS Rule and Other Proposals to Stabilize the Health Insurance Marketplaces

Health plans are now determining whether to offer coverage in the Marketplace this fall and if so, which products and rates to offer. While there is continuing discussion about repealing and replacing the Affordable Care Act (ACA), legislative action does not appear imminent. To assure a robust ACA market, many have advocated for “repairs” to the ACA. These potential repairs to the ACA range from the addition of a “public option” in areas with low competition, to fixing the “family glitch,” to eliminating the Cadillac Tax.

In this fact sheet, we highlight some of the potential repairs to ACA that are currently in discussion and are particularly relevant to health plans as they decide whether or not to participate in the 2018 Marketplace.

The potential repairs we review are:

Fully fund cost-sharing reduction
Extend and fully fund the reinsurance program
extend and increase funding for risk corridors program
Require pre-enrollment verification by HHS to verify eligibility for special enrollment periods
Limit grace period for premium payments
Shorten open enrollment period
Allow increased variation in actuarial value requirements

The fact sheet also presents a timeline for insurer Qualified Health Plan (QHP) filings. On Feb. 17, 2017, the Centers for Medicare and Medicaid Services (CMS) announced plans to revise its schedule for the 2018 Qualified Health Plan (QHP) filing and rate review process for insurers offering coverage on the federally-facilitated Health Insurance Marketplaces created under the Affordable Care Act (ACA). This change is intended to give insurers more time to determine their participation and prepare their 2018 filings.

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Changes in Health Care Cost Barriers under the Affordable Care Act in Michigan

The Affordable Care Act (ACA) not only significantly expanded access coverage starting in 2014, but also sought to improve access to services by reducing cost barriers to care and requiring coverage of certain “essential benefits”. For example, the ACA established patient annual out-of-pocket cost maximums; eliminated patient cost sharing for certain preventive care services; and prohibited annual and lifetime limits on benefits. The ACA expanded access to coverage primarily in the individual market through the Health Insurance Marketplace and by expanding Medicaid based on household income.

The Medicaid expansion allowed states to offer federal subsidies covering 90 to 100 percent of costs for Medicaid coverage to adults whose household income was below 138% of the federal poverty level (FPL).⁽¹⁾Status of State Action on the Medicaid Expansion Decision (Henry J. Kaiser Family Foundation. March, 2016): http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0 (accessed 01/28/2017) By the end of the second year of ACA implementation in Michigan (2015), nearly 2.37 million of Michigan’s 9.92 million residents (about 24 percent of Michiganders) were enrolled in Medicaid⁽²⁾Green Book Report of Key Program Statistics (State of Michigan Department of Human Services, Dec. 2015). http://www.michigan.gov/mdhhs/0,5885,7-339-73970_61179_10830—Y_2015,00.html (accessed 01/28/2017) — up from 1.93 million in April of 2014 (around 20 percent of Michiganders), when the Medicaid expansion program was first launched in Michigan.⁽³⁾Green Book Report of Key Program Statistics (State of Michigan Department of Human Services, Dec. 2014). http://www.michigan.gov/mdhhs/0,5885,7-339-73970_61179_10830—Y_2014,00.html (accessed 01/28/2017) This represents a net increase of around 440,000 Michigan Medicaid enrollees between 2012 and 2015.⁽⁴⁾Green Book Report of Key Program Statistics (State of Michigan Department of Human Services, Dec. 2012). http://www.michigan.gov/mdhhs/0,5885,7-339-73970_61179_10830—Y_2012,00.html (accessed 01/28/2017)

Federal marketplace subsidies were also made available to consumers with incomes between 100% and 400% of the FPL who were not eligible for Medicaid or affordable employer-based coverage (i.e., coverage costing more than about 9.5% of the employee’s household income). Around 272,000⁽⁵⁾Health Insurance Marketplace Summary Enrollment Report for the Initial Annual Open Enrollment Period (State of Michigan Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, May 1, 2014). https://aspe.hhs.gov/pdf-report/health-insurance-marketplace-summary-enrollment-report-initial-annual-open-enrollment-period (accessed 01/28/2017) Michigan adults signed up for federal marketplace plans during the first 2014 open-enrollment period, while 341,000⁽⁶⁾Health Insurance Marketplace Summary Enrollment Report for the Initial Annual Open
Enrollment Period (State of Michigan Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, March 10, 2015). https://aspe.hhs.gov/pdf-report/health-insurance-marketplace-2015-open-enrollment-period-march-enrollment-report (accessed 01/28/2017) signed up during the first 2015 open-enrollment period.

Our findings show that since insurance has been expanded in Michigan under the ACA, cost-related barriers to care and delaying care have been reduced significantly. Thus, the ACA seems to have succeeded in reducing some barriers to accessing and affording health care. Now that changes in the Affordable Care Act are all but certain, it will be important to assess proposed approaches to coverage and care with the experience of the Affordable Care Act in mind so that the progress we see evidenced with these data is not erased. This brief presents findings on how health care access changed in Michigan with ACA implementation, using the Center for Healthcare Research & Transformation’s 2010, 2012, 2014, and 2015 Cover Michigan Surveys.

Key Findings

During the first two years of ACA implementation, there was a significant and sustained drop in the proportion of Michigan adults who reported having trouble paying their medical bills.
Fewer Michigan adults delayed seeking necessary medical care after ACA implementation.
Prior to ACA implementation, among Michigan adults who delayed seeking necessary medical care in the previous six months, more than half cited cost concerns as reasons for delaying care. By the second year of ACA implementation, cost concerns had become less prominent, and convenience concerns (such as being too busy or not having time to go) were cited just as often as cost concerns among all Michigan adults, and more often than cost concerns among those with coverage.

Changes in Medical Financial Burden

The proportion of Michiganders who reported having problems paying medical bills decreased significantly after the introduction of the ACA. In the second year of open enrollment, 19 percent of respondents reported problems paying medical bills during the previous twelve months, compared to 20 percent during the first year of open enrollment, and 27 percent two years prior to the implementation of the ACA. Figure 1 This represents an 8-percentage-point drop in the proportion of all Michigan adults having problems paying medical bills.

Both before and after the ACA implementation, around one in six respondents had a household income below — or within a few thousand dollars of being below — 138% of the Federal Poverty Line (FPL) (adjusted by year and household size). The proportion of low-income Michigan adults did not significantly decrease over time, but there was a statistically significant 15-percentage-point drop in the proportion of low-income Michigan adults who reported having problems paying or being unable to pay medical bills. This reduction in medical financial burden is likely the result of more people gaining coverage, as well as increased financial protections for insured patients under the ACA, such as elimination of insurer lifetime and annual limits on benefits, and establishment of patient annual out-of-pocket cost maximums.

Delaying Care

By the second year of implementation of the ACA (2015), 5 percent of respondents were uninsured, compared to 14 percent before the ACA implementation (2012). In 2015, 23 percent of Michigan adults reported that they had delayed seeking necessary medical care in the prior 6 months, which was a reduction from 29 percent in 2012 (p = 0.053). Figure 2

Before the roll-out of the ACA in Michigan, cost concerns were cited by more than half of those delaying necessary care — even among the insured. Figure 3 Cost concerns included the perceived expense of seeking care or concern about the amount of copays and/or deductibles. When respondents were asked why they had delayed care during the first two years of ACA implementation, reasons related to cost decreased dramatically, with only about one in three citing them. By the second year of ACA implementation, when respondents were asked why they had delayed care, approximately twice as many insured Michigan adults reported doing so due to convenience concerns as did before the ACA was introduced. Convenience concerns included not feeling like going, being too busy to go, and thinking one could get better on one’s own because the problem was not severe.

Although fewer respondents reported delaying seeking necessary care due to cost concerns in more recent years, cost issues — such as having trouble paying medical bills — remained a challenge for about one in five Michigan adults, as shown in Figure 1.

Conclusion

Since the implementation of the ACA, far fewer Michigan adults are having trouble paying medical bills, and fewer are delaying seeking necessary medical care due to cost concerns. As the federal government looks to make what may be significant changes to this law, emphasis should be placed on continuing to reduce cost-related barriers to health care.

Methodology

The survey data presented in this brief were produced from a series of survey questions added to the Michigan State University Institute for Public Policy and Social Research (IPPSR) quarterly State of the State Survey. A full report of the IPPSR State of the State Survey methodology can be found at: http://ippsr.msu.edu/soss/.

Demographic and socio-economic characteristics of the Cover Michigan Survey samples can be found at: https://chrt.org/demographic-socio-economic-characteristics-cover-michigan-survey-samples/ . A description of methods used for CHRT’s Cover Michigan briefs can be found at: https://chrt.org/cover-michigan-survey-methods/

Acknowledgments: The staff at the Center for Healthcare Research & Transformation would like to thank Robert Goodman, Helen Levy, Sanjay Saint, Renuka Tipirneni, and the staff at the Institute for Public Policy and Social Research (IPPSR) at Michigan State University for their assistance with the design and analysis of the survey.

References[+]

References
↑1	Status of State Action on the Medicaid Expansion Decision (Henry J. Kaiser Family Foundation. March, 2016): http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0 (accessed 01/28/2017)
↑2	Green Book Report of Key Program Statistics (State of Michigan Department of Human Services, Dec. 2015). http://www.michigan.gov/mdhhs/0,5885,7-339-73970_61179_10830—Y_2015,00.html (accessed 01/28/2017)
↑3	Green Book Report of Key Program Statistics (State of Michigan Department of Human Services, Dec. 2014). http://www.michigan.gov/mdhhs/0,5885,7-339-73970_61179_10830—Y_2014,00.html (accessed 01/28/2017)
↑4	Green Book Report of Key Program Statistics (State of Michigan Department of Human Services, Dec. 2012). http://www.michigan.gov/mdhhs/0,5885,7-339-73970_61179_10830—Y_2012,00.html (accessed 01/28/2017)
↑5	Health Insurance Marketplace Summary Enrollment Report for the Initial Annual Open Enrollment Period (State of Michigan Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, May 1, 2014). https://aspe.hhs.gov/pdf-report/health-insurance-marketplace-summary-enrollment-report-initial-annual-open-enrollment-period (accessed 01/28/2017)
↑6	Health Insurance Marketplace Summary Enrollment Report for the Initial Annual Open Enrollment Period (State of Michigan Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, March 10, 2015). https://aspe.hhs.gov/pdf-report/health-insurance-marketplace-2015-open-enrollment-period-march-enrollment-report (accessed 01/28/2017)

Michigander’s satisfaction with health care coverage has increased since ACA implementation

Data from the Center for Healthcare Research and Transformation’s (CHRT) Cover Michigan Survey describes the rate of satisfaction with health care coverage before and after implementation of the Patient Protection and Affordable Care Act (ACA).

Satisfaction with health care coverage in the state of Michigan has increased since the implementation of the ACA. In 2015, 57 percent of Michiganders reported that they were satisfied with their health coverage, which is in alignment with national rates of satisfaction with health care. This represents a significant increase from the 51 percent of respondents who reported they were satisfied with their health care coverage in 2012 before the ACA took effect. In 2014, 52% of Michigan residents reported that they were satisfied with their health care coverage.

The Cover Michigan Survey data presented in this brief were produced from a series of survey questions added to the Michigan State University Institute for Public Policy and Social Research quarterly State of the State Survey. Further methodology detail can be found on CHRT’s website. In 2015, the survey was fielded between October and December 2015 and included a sample of 972 Michigan adults, with a 17.0 percent response rate. In 2014, the survey was fielded between September and November 2014 and included a sample of 1,002 Michigan adults with a 20.2 percent response rate. In 2012, the survey was fielded between August and October 2012 and included a sample of 1,018 Michigan adults, with a 31.6 percent response rate.

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Select Affordable Care Act replacement plans and implications

No single replacement for the Affordable Care Act (ACA) has yet emerged. However, there are several ideas that seem to have considerable support among those in health care leadership roles in President Trump’s Administration and Congress.

This brief, Select Affordable Care Act Replacement Plans and Implications, summarizes the key features of the most developed full repeal and replacement plans offered to date.

The provisions that are summarized include:

Replace the individual mandate with a continuous coverage requirement
Change tax subsidies
Expand Health Savings Accounts (HSAs)
Allow adult dependents up to age 26 to stay on their parents’ plan
Replace the ACA’s “Cadillac Tax” with a cap on the tax exclusion for employer-sponsored insurance
Medicaid block grants per capita cost limits
Implement high-risk pools
Loosen benefit design requirements
Widen age bands
Permit association health plans
Permit interstate insurance sales
Reform medical liability

The brief summarizes Representative Paul Ryan’s A Better Way proposal, Representative Tom Price’s Empower Patients First Act, and Senator Richard Burr, Senator Orrin Hatch, and Representative Fred Upton’s The Patient Choice, Affordability, Responsibility, and Empowerment Act. It also details who is primarily affected by each provision and the implications.

You can also see CHRT’s companion piece, ACA Repeal and Replacement: Proposals and Action, for a one-page summary of the plans and tentative process.

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