Publications

Comparing Recent Health Care Proposals: From building on the ACA to Medicare for All

Yellow road sign reading "Health insurance changes ahead", referring to the changes to the Healthy Michigan Plan.

A yellow road sign reading, "Health insurance changes ahead," indicating changes due to the health care proposals the author is comparing.Democratic lawmakers in Congress have made a variety of proposals to strengthen or reform the United States health care system. These proposals range from building upon the Affordable Care Act (ACA) to fully transitioning the U.S. to a single-payer system. This fact sheet categorizes and compares the major provisions of these proposals, including possible implications for consumers, health care providers, and federal and state governments.

The proposals that the fact sheet compares are: ACA 2.0, which increases Marketplace financial assistance, restores outreach and assistance funding, and creates a reinsurance program; Public Option, which creates a publicly-administered health insurance plan offered for purchase on the Marketplace; Medicaid Buy-In, which provides certain individuals with the opportunity to purchase Medicaid coverage; Medicare Buy-In, which provides certain individuals with the opportunity to purchase Medicare coverage; Medicare for America, which provides an option and incentives for all US citizens to switch to Medicare coverage; and Medicare for All, which replaces the current health insurance system with universal Medicare coverage for all U.S. citizens.

For each health care proposal, the sheet considers who would be affected, what would be covered, what cost-sharing would look like, how it would impact other types of coverage, how it could impact health care providers, how it would be financed, and how much it could cost. The fact sheet also lists the specific bills and proposals for each health care option.

This fact sheet combines information on all the recent health care proposals in a straightforward, objective format so the proposals can easily be compared and considered. 

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Projected impacts of Medicaid work requirements: An overview of current state proposals

Several brown file tabs, with the center one reading "Requirements", referring to the new Michigan Medicaid work requirements.

A checklist with red checkmarks and "Requirements" written in red, indicating the Medicaid work requirements.As of January 2019, 14 states have submitted proposals to the federal government requesting permission to establish work requirements in their Medicaid programs. To date, the U.S. Centers for Medicare and Medicaid Services (CMS) has approved Medicaid work requirements for seven states, and two states (Arkansas and Indiana) have begun implementing these requirements for Medicaid beneficiaries. This overview examines the projected impacts of these Medicaid work requirements.

In June 2018, Michigan enacted work requirements for many enrollees in the Healthy Michigan Plan (HMP), Michigan’s expanded Medicaid program for low-income adults.

Beginning in January 2020, HMP enrollees under age 63 will be required to report 80 hours of work per month or obtain an exemption (see CHRT’s previous fact sheet, Proposed Medicaid Work Requirements in Michigan).

The Michigan House Fiscal Agency initially estimated that the impact of Medicaid work requirements would result in approximately 80 percent of enrollees subject to the requirements, while 20 percent would qualify for an exemption.  More recently, an independent analysis by Manatt Health projected that 39 percent of HMP enrollees would be automatically exempt (based on age, pregnancy, medically frail, or incarceration status; or because they are already meeting SNAP/TANF work requirements), while 61 percent would be required to report work hours or obtain an exemption. This analysis estimated that 9 to 27 percent of all HMP enrollees could lose coverage over a one-year period.

Most of the 14 states that have requested federal permission to establish Medicaid work requirements have projected that some current Medicaid enrollees will lose coverage as a result of these changes. While estimates vary, states have projected that anywhere from 5 percent to 50 percent of the populations subject to work requirements (i.e., those who are not currently working and do not qualify for an exemption) are estimated to lose coverage. The Kaiser Family Foundation has estimated that, if a work requirement were implemented at the national level, approximately 1.4 to 4 million enrollees (6-17 percent of non-elderly, non-disabled adult Medicaid enrollees) would lose coverage.

Early experience from Arkansas indicates that administrative or structural barriers may prevent individuals from complying with work requirements. According to a recent report from the Kaiser Family Foundation, many Medicaid enrollees were unaware of the new requirements and unable to navigate the state’s online-only reporting system. In addition, enrollees may face a lack of jobs (especially in rural areas), transportation, and/or internet access to obtain information about job and volunteer opportunities.

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Michigan at a crossroads: CHRT highlights key health policy issues for the incoming gubernatorial administration

Two feet standing on a road, with a red stripe going one direction and a yellow stripe going the other direction, showing how Michigan health policy issues are at a crossroads.The Michigan government has jurisdiction over a wide array of health policy issues. From the regulation of insurance products, to oversight of the state’s Medicaid program, to investing in local public health efforts, Michigan policymakers craft policies and budgets that impact the health of millions of Michiganders.

This brief provides an overview of four key and timely health policy topics:

  • Medicaid and the Healthy Michigan Plan;
  • the individual health insurance market and the federal Health Insurance Marketplace;
  • the opioid epidemic; and
  • the integration of services to address the social determinants of health.

With the expansion of Medicaid and the launch of the Affordable Care Act’s individual Health Insurance Marketplace, the numbers of uninsured Michiganders have been considerably reduced since 2013. Yet Michigan policy makers will still face numerous policy issues and decisions related to health care coverage, health disparities, and access to care in the years to come. Our state will continue to struggle with complex health issues such as substance use and access to mental health services.

Michigan policy leaders, local public health agencies, and the private sector are engaged in many innovative initiatives to address these issues and improve the health of communities. In particular, the state has committed to programs that are intended to improve health equity and focus on the social determinants of health.

All of this work is being conducted at a time of great political change and considerable turmoil at the federal level. The new governor and the 100th Legislature will be faced with both tremendous responsibility and opportunity to shape the health policy landscape for years to come.

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Proposed work requirements for Medicaid in Michigan: June 7, 2018

A white sheet of paper with writing. A green highlighter is highlighting the word "legislation", referring to new Michigan Medicaid work requirements.

At the start of 2018, the U.S. Centers for Medicare and Medicaid Services (CMS) announced a major shift in federal policy that would allow states to request permission to establish, and test the impact of, work and community engagement requirements for able-bodied adults receiving Medicaid health insurance coverage. In the last five months, work requirement proposals have been approved in four states; formal applications have been submitted by seven more, and a number of others are preparing proposals. Michigan is among the states proposing Medicaid work requirements.

In April, the Michigan State Senate took the first step toward establishing work requirements by passing Senate Bill 897. The Michigan House of Representatives passed an updated version of the bill on June 6. And on the morning of June 7, the Michigan Senate approved the revisions and sent the bill to the Governor’s office for signature.

In this fact sheet, we compare the characteristics and projected impact of Michigan’s most recent Medicaid work requirement proposal against the characteristics and projected impact of approved work requirement proposals in Kentucky, Indiana, Arkansas, and New Hampshire. We also describe new requirements for Healthy Michigan Plan enrollees who wish to maintain coverage after four years, and a series of triggers that would terminate the Healthy Michigan Plan if CMS fails to approve these requirements.

To learn more, read our Consumer’s Guide to the Medicaid work requirements.

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Proposed work requirements for Medicaid in Michigan: April 20, 2018

A stack of red and yellow files and notebooks. On the top notebook, "Proposal A-2136" is written in black marker, referencing Michigan's proposed Medicaid work requirements.

A stack of red and yellow files and notebooks. On the top notebook, "Proposal A-2136" is written in black marker, referencing Michigan's proposed Medicaid work requirements.At the start of 2018, the U.S. Centers for Medicare and Medicaid Services announced a major shift in federal policy that would allow states to request permission to establish, and test the impact of, work and community engagement requirements for able-bodied adults receiving Medicaid health insurance coverage. In early March, Michigan state senators took the first step toward preparing a Medicaid work requirement proposal of their own by introducing Senate Bill 897. The bill passed the Michigan State Senate on April 19.

In the last three months, work requirement proposals have been approved in three states; formal applications have been submitted by seven more; and a number of others are preparing proposals.

In this fact sheet, we compare the characteristics and projected impact of Michigan’s Medicaid work requirement proposal against the characteristics and projected impact of approved work requirement proposals in Kentucky, Indiana, and Arkansas.

The characteristics we compare include: target Medicaid populations, Medicaid enrollment, populations exempt from the new work requirements, the hours of work required, activities counted as work, and loss of coverage rules. It is difficult to project the impact of work requirements on the Medicaid population because there is no precedent program, but we discuss some possibilities.

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For updated information, read our article from June 7.

Bipartisan Budget Act adds $3B for substance abuse, mental health, more

A handshake between a red hand and a blue hand, indicating the bipartisanism of the Bipartisan Budget Act.

A handshake between a red hand and a blue hand, indicating the bipartisanism of the Bipartisan Budget Act.The Bipartisan Budget Act was signed into law on February 9, 2018. While the main purpose of the legislation is to temporarily fund the federal government through March 23, 2018, it also includes an agreement to raise the caps on domestic and military spending for the next two years.

The legislation includes many health care policies, as well. The health care policies in the Bipartisan Budget Act include:

  • New funding for the National Institutes of Health (NIH) and for substance abuse and mental health programs related to the opioid epidemic.
  • Extenders and reauthorizations for the Children’s Health Insurance Program (CHIP); Community Health Centers; the Maternal, Infant and Early Childhood Home Visiting Program; Medicare Extenders; a Medicare Therapy Caps Repeal; the National Health Service Corps; and the Teaching Health Center Graduate Medical Education Program.
  • Policy changes relating to the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act; the “Doughnut Hole” Closure; the Independent Payment Advisory Board (IPAB); Medicaid Disproportionate Share Hospital (DSH) Cuts; and Medicare Home Health Reforms.
  • Key offsets for Medicare Parts B & D Premiums, Physician Fee Schedules, and the Prevention and Public Health Fund (PPHF).

To learn the details of the health care policies included in the Bipartisan Budget Act, read the full brief.

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