Accepted Manuscript

Title: Universal coverage reforms in the USA: From Obama

care through Trump

Authors: Thomas Rice, Lynn Y. Unruh, Ewout van Ginneken,

Pauline Rosenau, Andrew J. Barnes

PII: S0168-8510(18)30154-4
DOI: https://doi.org/10.1016/j.healthpol.2018.05.007
Reference: HEAP 3905

To appear in: Health Policy

Received date: 11-11-2017

Revised date: 9-3-2018
Accepted date: 15-5-2018

Please cite this article as: Rice Thomas, Unruh Lynn Y, van Ginneken Ewout, Rosenau
Pauline, Barnes Andrew J.Universal coverage reforms in the USA: From Obama care
through Trump.Health Policy (2018), https://doi.org/10.1016/j.healthpol.2018.05.007

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
Not Dead Yet: The ACA and the U.S. Search for Universal Healthcare under
the Trump Administration

Thomas Rice
UCLA Fielding School of Public Health, Los Angeles, CA, USA
trice@ucla.edu

PT
Lynn Y. Unruh
Department of Health Care Management and Informatics, Central Florida University,
Orlando, FL, USA

RI
Lynn.Unruh@ucf.edu

Ewout van Ginneken

SC
Berlin University of Technology and European Observatory on Health Systems and Policies
Berlin, Germany
ewout.vanginneken@tu-berlin.de

U
Pauline Rosenau
University of Texas School of Public Health, Houston, TX, USA
Pauline.Rosenau@uth.tmc.edu N
A
Andrew J. Barnes
School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
M

andrew.barnes@vcuhealth.org

Corresponding author: Thomas Rice, Professor, UCLA Fielding School of Public Health, 650 S.
D

Charles Young Drive, Los Angeles, CA 90095-1772, USA. Phone: 310-206-1824; Fax: 310-
825-3317; email: trice@ucla.edu
TE
EP

HIGHTLIGHTS

 President Trump’s administration is undoing some of the Affordable Care Act’s provisions
CC

 The individual mandate to purchase coverage has been repealed

 President Trump is using administrative authority to undo other ACA’s provisions

A

 Medicaid remains but premiums in insurance exchanges rose considerably in 2018

 Political compromise possible in short-run; long-run depends on upcoming elections

 In the meantime, prospects are that the number of uninsured will grow

1
ABSTRACT

Since the election of Donald Trump as President, momentum towards universal health care

coverage in the United States has stalled, although efforts to repeal the Affordable Care Act

(ACA) in its entirety failed. The ACA resulted in almost a halving of the percentage of the

PT
population under age 65 who are uninsured. In lieu of total repeal, the Republican-led Congress

repealed the individual mandate to purchase health insurance, beginning in 2019. Moreover, the

RI
Trump administration is using its administrative authority to undo many of the requirements in

SC
the health insurance exchanges. Partly as a result, premium increases for the most popular plans

will rise an average of 34% in 2018 and are likely to rise further after the mandate repeal goes

U
into effect. Moreover, the administration is proposing other changes that, in providing states
N
with more flexibility, may lead to the sale of cheaper and less comprehensive policies. In this
A
volatile environment it is difficult to anticipate what will occur next. In the short-term there is
M

proposed compromise legislation, where Republicans agree to provide funding for the cost-
D

sharing subsidies if the Democrats agree to increase state flexibility in some areas and provide
TE

relief to small employers. Much will depend on the 2018 and 2020 elections. In the meantime,

the prospects are that the number of uninsured will grow.

EP
CC

Keywords: Affordable Care Act, health care system, health insurance, health policy, health
reform
A

Since the election of Donald Trump as President, momentum towards universal health

care coverage in the United States has stalled. Most notable was the repeal of the individual

mandate to purchase health insurance in late December 2017. However, outright repeal of

2
President Obama’s signature piece of legislation -- the Affordable Care Act (ACA) -- has not yet

come to pass. Though the Republican Party controls the Presidency and both Houses of

Congress, attempts at wholesale repeal and replacement of the ACA during the summer and

early fall of 2017 failed. Congressional leaders could not muster enough votes in large measure

PT
because Congress’ own budget office reported that repeal would result in 23 million Americans

losing their coverage. 1 As a result, the ACA’s expansion of Medicaid remains fully intact and

RI
individuals continue to receive the same financial subsidies to purchase coverage from private

SC
insurers on the ACA’s insurance exchanges. Political developments, nevertheless, are taking

place at breakneck speed, making it difficult for the world community to know where things

U
stand. In this article, which constitutes an analysis of major legislative and policy changes

N
observed by the authors, we review past progress towards universal coverage in the U.S., present
A
the key issues under debate now, and outline possible future scenarios.
M

Health Insurance Coverage in the U.S. before the ACA

D

Until the major provisions of the ACA went into effect in January 2014, health insurance
TE

coverage was always voluntary. About 30% of the population was covered through the two
EP

major public programs enacted in 1965: Medicare for seniors (later extended to the disabled)

and Medicaid for poorer Americans. 2 Most others received coverage through their employment,
CC

either as employees or dependents, but such coverage was always voluntary: employers did not

have to provide it, and individuals were not required to buy it. Less than 10% purchased
A

coverage on their own.

As far back as the 1950s those with pre-existing illnesses generally found individual

insurance policies unaffordable because insurers could charge higher premiums to those with a

3
history of illness.” The ACA increased individual coverage by: prohibiting insurance companies

from excluding people or charging more for pre-existing conditions; mandating that all

individuals obtain insurance; and by helping individuals pay for this through income-based

premium subsidies.

PT
Nearly all other high-income countries provide coverage for those unable to afford it, but

this has not been true of the U.S. Until the ACA, only about half of poor adults were covered by

RI
Medicaid and almost 30% of both the poor and near-poor under age 65 lacked any coverage at

SC
all. 3,4 Coverage rates were higher for children in part because of the Children’s Health Insurance

Program (CHIP). Enacted in 1997, under CHIP the federal government matches state

U
contributions to provide coverage for children in families with incomes above Medicaid

N
thresholds, but who typically cannot afford private coverage. 5
A
Medicaid’s limited success in extending coverage to the poor was mainly because
M

program eligibility varied by state; states continue to have substantial powers in determining

eligibility, health benefits covered, and provider payment. Some established significant barriers
D

to eligibility such as requiring adults to have dependent children to be covered. Income

TE

requirements are also sometimes severe. For example, a parent with two dependent children in
EP

Texas, one of the most populous states, is ineligible for Medicaid if she earns just 18% (that is,
6
less than one-fifth) of the federal poverty line (FPL) -- only $3,700 per year. The ACA
CC

originally was designed so that all poor and some near-poor persons would receive Medicaid

coverage, but that intent was stymied by a ruling by the U.S. Supreme Court, as described next.
A

What the ACA Did – and Did Not – Do

4
 The ACA was passed in 2010 during a period in which the Democratic Party controlled

the Presidency and both Houses of Congress. Box 1 lists its major provisions.

Uninsurance rates among the under age 65 population have almost halved, from a peak of

18.2% in 2010 to 10.3% in 2017 (Figure 1). Researchers have estimated that average spending

PT
of adults (premiums plus out of pocket costs) fell by 12% during the first two years of full
7
implementation - and by over 20% for the poor and near-poor. The ACA did not achieve

RI
universal coverage, for several reasons: First, with the Supreme Court ruling, approximately 4.5

SC
million poor and near-poor people still do not receive Medicaid. 8 Generally, these people are

excluded from the individual mandate because they would have to spend more than 8% of their

U
income on premiums. Second, some people choose to pay the penalty rather than purchase

N
insurance; both penalties and enforcement of the mandate are far milder in the U.S. than in
A
Germany, the Netherlands, and Switzerland, all of which require that people purchase coverage. 9
M

Third, undocumented individuals are forbidden from purchasing on the exchanges and are not

eligible for subsidies - 42% are estimated to be uninsured. 10

D
TE

Policy Changes During the Trump Administration

EP

As noted, despite calls to repeal the ACA “on day one,” the President Trump, even with

the support of a Republican Congress, was not able to repeal the legislation -- although the vote
CC

in the U.S. Senate was very close. (Whether the House of Representatives would have passed

the Senate bill is conjectural.) Due to arcane rules in the U.S. Senate, repeal before the U.S.
A

National 2018 congressional elections will be extremely difficult because it would require 60

votes out of 100 – and Democrats and Democrat-leaning independents hold 48 seats.

5
 The Republicans were able to make a major legislative dent, however, by repealing the

individual mandate. This was accomplished by including this provision in a major overhaul of

the federal income tax system that passed Congress and was signed into law just before the end

of 2017. Because Senate rules allow budget-related legislation to pass with a majority vote, the

PT
Republicans were able to succeed. The main reason was to fulfill, at least in part the promise

they made to voters to repeal the ACA, but another was more pragmatic. Repeal of the mandate

RI
will reduce the number of people purchasing coverage from the exchanges, which in turn will

SC
reduce federal outlays. This allowed the Republican party to increase the size of the tax cuts that

were included in the legislation.

U
One would expect an uptick in the number of uninsured for two reasons: (1) the financial

N
penalty for being uninsured will be removed beginning in 2019, and (2) premiums will rise due
A
to adverse selection, by an estimated 10%, although most people are protected through rising
M

financial subsidies. Estimates by the Congressional Budget Office project that by 2027, five

million Americans would lose individual coverage; another five million, Medicaid coverage; and
D

three million more, employer coverage. 11 Moreover, the Trump Administration has made
TE

various administrative decisions that will lead to fewer people choosing to purchase coverage,
EP

including: (1) occasionally stating that it would not have the Internal Revenue Service enforce

the tax penalties for those who choose to remain uninsured - this is relevant to 2018, when the
CC

individual mandate is still in force; (2) severely cutting funding for outreach during the annual

open enrollment period, as well as the length of the period; (3) providing negative public
A

statements about the ACA; and (4) choosing not to fund the so-called “cost-sharing subsidies.”

Where, then, do things now stand? The Medicaid expansion remains in place in 31

states; those eligible will continue to receive coverage, which typically has a broad benefit

6
package and little or no premiums or patient cost-sharing. However, because many physicians

do not accept Medicaid patients, due in large measure to low fees, access is often not the same as

for those with private insurance and Medicare. Regarding the exchanges, in spite of the efforts

of the Trump Administration, outlined above, enrollment during the 2018 open enrollment period

PT
was fairly stable. In 2018, an estimated 11.8 million million people enrolled through the federal

and various state exchanges, just 4% lower than the previous year. 12 Enrollment results are not

RI
yet in for the several states that have their own exchanges.

SC
In addition, the administration is proposing other changes that could to lead to the sale of

cheaper and less comprehensive policies at a cost of reducing consumer protections. States

U
would gain more flexibility in defining what constitutes essential health benefits. Individuals

N
would be allowed to purchase health insurance across state lines, which would give people in a
A
state with tougher regulations the ability to purchase from another state where regulations are
M

lower and insurance is cheaper. Regulations governing small employers that group together to

create their own plans (called “association health plans”) would be modified to permit less
D

comprehensive policies. And the sale of short-term policies would be permitted. 13,14 Such plans
TE

do not have to cover mandated “essential health benefits” under the ACA or comply with pre-
EP

existing condition regulations. They are currently limited to no more three months, but the
15
Trump Administration is discussing extending that time period, perhaps up to a full year.
CC

Overall the result would be a market containing some bare-bones plans, which are mostly

attractive to healthy people. By drawing these healthy individuals away from the exchanges,
A

premiums on the exchanges would likely increase.

The cost-sharing subsidies have been one of the most contentious issues – but also the

one on which prominent members of Congress are striving to reach a bipartisan solution. The

7
most common plan under the individual exchanges, called Silver, has annual deductibles that
16
average more than $3,000 for those with individual coverage. Since costs like these are

unaffordable to many people purchasing on the exchanges, the ACA also specified sharply

reduced cost sharing for those with incomes below 250% of the FPL. The insurer pays them and

PT
is reimbursed by the federal government. However, the ACA legislation did not include a

funding source for these subsidies, and thus, a federal court ruled them unconstitutional. The

RI
Obama administration was in the process of appealing the court ruling when President Trump

SC
was elected, and he chose not to continue with the appeal.

Loss of the cost-sharing subsidies alone means that premiums will rise by an estimated

U
19% in 2018, varying from 7% to 38% by state17 - and by far more (between 35% and 90%) over

a three-year period. 18 N
This is on top of other premium increases resulting from higher than
A
anticipated service utilization. (Premium increases from repeal of the individual mandate will
M

not occur until 2019.) While the size of premium increases varies a great deal by state, they were

substantial during the 2018 open enrollment period (which ended on 15 December 2017 in the
D

19
federal marketplace) - an average increase of 34% for Silver plans. Elimination of the
TE

subsidies, however, may have unintended consequences. This is because insurers raised
EP

premiums in Silver plans the most to offset anticipated cuts to cost-sharing subsidies, which only

apply to those plans in the 4-tier exchange plans (Bronze, Silver, Gold, Platinum). Premium
CC

subsidies to those below 400% of the FPL, which are required by law and are not affected by this

executive order, are calculated using the price of the second cheapest Silver plan. Thus, subsidies
A

will increase for many consumers, allowing them to afford more generous Gold-tier plans,

should they choose to purchase them. Interestingly, it is estimated that the net effect of

elimination of the cost-sharing subsidies will be to increase federal spending by an average of $3

8
billion a year over the next ten years. This is because the increase in premium subsidies resulting

from higher premiums for Silver plans will exceed the reduction in cost-sharing payments made

by the federal government to health insurers. 20

PT
Next Steps - and Beyond

In such a volatile and fast-paced environment it is difficult to anticipate how things will

RI
turn out. One thing is nearly certain: the push towards universal coverage is stalled, if not

SC
reversing course. The individual mandate expires after 2018, and all signs from both the Trump

Administration and Congress are that they want to undo as many other federal rules brought

U
about through the ACA as they can. By doing so, many Republicans expect to make the ACA

N
untenable and redistribute the federal spending back to the states to spend as they wish. This, in
A
fact, was explicit in a recent proposal, dubbed Graham-Cassidy, that, while approved by the
M

House of Representatives, failed Senate approval by a single vote in September 2017.

21
There is talk of political compromise, as well as a bipartisan bill, whereby the
D

Republicans agree to provide funding for the cost-sharing subsidies if the Democrats agree to
TE

increase state flexibility through “innovation waivers” and provide relief to small employers.
EP

Such compromise is likely to be difficult to achieve, with many Republicans balking at

increasing the price tag of the ACA, and many Democrats being reluctant to support any
CC

proposals that allow insurers to sell policies in which those with pre-existing conditions are

charged more. At time of writing, the most recent development was a letter from the federal
A

Centers for Medicare & Medicaid Services (CMS), which administers the Medicare and

Medicare programs, that would give states the flexibility to establish a work or community

9
engagement requirement as a condition of Medicaid eligibility. Such a requirement has already

been approved for Kentucky, and nine other states have made similar requests. 22,23

Moving further into the future, much depends on upcoming November 2018 mid-term

election. All members of the House of Representatives, and about one-third of the Senate, are up

PT
for election. If Republicans retain control of both, they will have two more years to make major

alterations to the ACA or even repeal it. Presidential elections follow in 2020. In the meantime,

RI
the prospects are that the number of uninsured will grow and some of the insurance policies that

SC
are purchased will provide less comprehensive coverage.

Because the political future of the country is so uncertain, it is not possible to know even

U
the rough direction of future major health policy reforms. Box 2 lists some of the options being

N
discussed; it is divided into left-leaning and right-leaning proposals. Proposals on the left
A
include the recently-released “Medicare Extra for All” and single-payer. The former, proposed
M

by the Center for American Progress, may be viewed as “single payer light,” in that employers

can choose to continue providing coverage if they wish. On the right, up till now most emphasis
D

has been on repealing the ACA, so there are few proposals that propose reforming the health care
TE

system from scratch. We provide information about Republican plans to channel far more
EP

monies to states through block grants, as well as expanding health savings accounts (HSAs).

HSAs generally are not considered a model for national health systems, with the key exception
CC

of Singapore.

Universal health coverage through universal health insurance remains an elusive goal for
A

the U.S. The country started late but it has come a long way. Nevertheless, it may never catch up

with other industrialized countries because the concept remains controversial even though 60%

say that “it is the federal government’s responsibility to make sure all Americans have healthcare

10
coverage.” 24
Those who disagree hold strong opinions on this topic and the American

Constitution was written to protect minorities with intense opinions. And so it still does today.

PT
None of the authors declare any conflicts of interest. The research did not receive any specific
grant from funding agencies in the public, commercial, or not-for-profit sectors.

RI
BOX 1

SC
Major Provisions of the Affordable Care Act

 Established “health exchanges” or “marketplaces” on a statewide basis that sold

U
community-rated individual and family insurance policies that were required to cover ten
N
sets of “essential health benefits.” Policies could be sold in four “metal tiers”, Bronze,
A
Silver, Gold, and Platinum, which cover 60%, 70%, 80%, and 90%, respectively, of
M

typical health expenses. The tiers with the more comprehensive coverage generally have
D

higher premiums.


TE

Provided income-based subsidies to purchase insurance policies on the exchanges.

Families earning up to four times the FPL were eligible for at least some financial
EP

assistance to pay for insurance. Various restrictions applied; for example, people with

access to employer-sponsored health insurance, and those with incomes below the U.S.
CC

poverty level, could not purchase on the exchanges.


A

Provided coverage free of cost-sharing requirements for specific services (e.g., annual

physicals, some screenings) and for poorer Americans.

 Required that insurers sell coverage to applicants regardless of health status (called

“guarantee issue”)

11
 Liberalized Medicaid coverage so that (as passed originally) everyone up to 138% of the

FPL (except legal immigrants, who may have to wait five years before obtaining

coverage) 25 would be eligible for Medicaid, regardless of their family circumstances. In

2012 the U.S. Supreme Court ruled that requiring states to expand their Medicaid was

PT
unconstitutional. Nineteen states have chosen not to expand Medicaid even though 90%

of costs were to be paid for by the federal government.

RI
 Required that most people have health insurance or pay a penalty, a provision called the

SC
“individual mandate.” Employers with more than 50 employees were also required to

provide coverage or pay a penalty although implementation of this provision was

U
delayed.

 N
Required that employers that provide family coverage to workers cover workers’ children
A
until the reach the age of 26.
M
D
TE
EP
CC
A

12
BOX 2
Selected Proposals to Reform the U.S. Health Care System
LEFT-LEANING PROPOSALS
“Medicare Extra for All”
Example: Proposal by Center for American
Progress, “Medicare Extra for All. 26 Provides
universal coverage in part by expanding the
Medicare program to anyone who chooses to
join, as well as all newborns and individuals
turning age 65 - who are automatically
enrolled. Employers have the choice of
continuing to provide coverage, or enrolling
their employees into Medicare Extra. Has
broad benefits package including dental,
vision, and hearing services. Cost sharing
requirements and premiums are income-related
A
and free for those below 150% of the poverty
level. Provider payment rates are the same
M
irrespective of the source of patient insurance
coverage, and are based on current Medicare
fee levels. Government would negotiate
D
prescription drug prices. It is to be financed
through employer contributions, income-
TE
related premiums, and taxes on high-income
individuals.
EP
CC
Single Payer
Example: Proposal by Senator and 2016
A
Democrat presidential candidate Bernie
Sanders. 29 Provides universal coverage by
creating a single, public insurance system.
Care would be free at point of service, and
cover “the entire continuum of health care.”
Likely to be financed through employer
premium payments, income-based household
premium payments, and federal income taxes.
13
RIGHT-LEANING PROPOSALS
State-Based Block Grants and Spending Caps
PT
Example: Graham-Cassidy, H.R. 1628. 27
Proposal to repeal and replace the Affordable
RI
Care Act. It was not passed by the U.S.
Congress. The bill contained many provisions,
including allowing insurers to sell plans not
SC
compliant with the ACA’s mandatory benefit
package, and allowing insurers to sell across
state lines. A key component of the proposal
U
calls for block grants to states, replacing ACA
premium subsidies and funds allotted to the
N
Medicaid expansion. It allows states to devise
alternative ways of subsidizing and regulating
coverage. States can use the grants “to expand
their Medicaid programs …, establish high-risk
pools, provide premium and cost-sharing
assistance to insurance enrollees, make direct
payments to insurers, and pay health care
providers…”28 It would also cap growth in
Medicaid based on an annual per capita federal
contribution. Contribution increases are
limited to the growth in medical inflation for
children and adults, and CPI + 1% for the
disabled and seniors until 2025; thereafter
annual increases for the two groups would be
limited to general inflation and medical
inflation rates, respectively.
Health Savings Accounts (HSAs)
Various modifications to U.S. laws regarding
HSAs have been proposed as part of
Republican legislative bills to reform health
care. Examples include: (a) doubling annual
contribution caps; (b) allowing spouses age 50
and older to make additional “catch up”
contributions; (c) allow HSAs be used to pay
for over-the-counter medications; (c) reducing
penalties for HSA distributions made before
 the age of 65; and (e) allowing HSA funds to
be used for medical expenses incurred up to 60
days before establishment of the HSA. 30

PT
RI
SC
U
N
A
M
D
TE
EP
CC
A

14
References
1
Congressional Budget Office. H.R. 1628, American Health Care Act of 2017. 24 May 2017.
https://www.cbo.gov/publication/52752 [Accessed 4 November 2017]
2
Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human
Services. Overview of the uninsured in the United States: A summary of the 2011 Current
Population Survey. 13 September 2011.

PT
https://aspe.hhs.gov/basic-report/overview-uninsured-united-states-summary-2011-current-
population-survey [Accessed 4 November 2017]
3
Ibid.

RI
4
Kaiser Commission on Medicaid and the Uninsured. Medicaid: A primer. 2013.

SC
https://www.kff.org/medicaid/issue-brief/medicaid-a-primer/ [Accessed 4 November 2017]
5
Medicaid.gov: Program History
https://www.medicaid.gov/about-us/program-history/index.html. [Accessed 12 February 2018]

U
6
Kaiser Family Foundation. Medicaid income eligibility limits for adults as a percent of the
N
federal poverty level. 1 January 2017. https://www.kff.org/health-reform/state-
indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-
A
level/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%2
2asc%22%7D
M

[Accessed 4 November 2017]

7
Goldman AL, Woolhandler S, Himmelstein DU, Bor DH, McCormick D. Out-of-pocket
D

spending and premium contributions among implementation of the Affordable Care Act. JAMA
Internal Medicine 2018;178(3):347-355.
TE

8
Vox.com. We asked 18 states if they’re expanding Medicaid now that Obamacare is here to
stay. 29 March 2017. https://www.vox.com/policy-and-politics/2017/3/29/15072636/medicaid-
EP

expansion-florida-texas-ahca-obamacare-repeal [Accessed 4 November 2017]

9
Van Ginneken E, Rice T. Enforcing enrollment in health insurance exchanges: Evidence from
the Netherlands, Switzerland, and Germany. Medical Care Research and Review 2015;72(4):
CC

496-509.
10
Kaiser Family Foundation. Health coverage and care for immigrants. 11 July 2017.
A

https://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-immigrants/
[Accessed 4 November 2017]
11
Jost, T. Mandate repeal provision ends health care calm. Health Affairs 2018;37(1):1-2.
12
Kaiser Family Foundation. Marketplace enrollment, 2014 - 2018.

15
https://www.kff.org/health-reform/state-indicator/marketplace-enrollment-2014-
2017/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%2
2asc%22%7D [Accessed 2 March 2017]
13
Morning Consult. Higher demand seen for short-term insurance as ACA mandate set for
repeal. 21 December 2017.
https://morningconsult.com/2017/12/21/higher-demand-seen-for-short-term-insurance-as-aca-
mandate-set-for-repeal/ [Accessed13 February 2018]

PT
14
Vox.com. Trump’s executive order to undermine Obamacare, explained. 12 October 2017.
https://www.vox.com/policy-and-politics/2017/10/12/16458184/trump-obamacare-executive-
order-association-health-plans-short-term-insurance [Accessed 4 November 2017]

RI
15
CNN Money. Obamacare. 20 February 2018.
http://money.cnn.com/2018/02/20/news/economy/trump-obamacare-short-term-health-

SC
insurance/index.html [Accessed 2 March 2018]
16
Kaiser Family Foundation. Impact of cost sharing reductions on deductibles and out-of-pocket
limits. 22 March 2017. https://www.kff.org/health-reform/issue-brief/impact-of-cost-sharing-

U
reductions-on-deductibles-and-out-of-pocket-limits/ [Accessed 4 November 2017]
17 N
Kaiser Family Foundation. How the loss of cost-sharing subsidy payments is affecting 2018
premiums. 27 October 2017. https://www.kff.org/health-reform/issue-brief/how-the-loss-of-
A
cost-sharing-subsidy-payments-is-affecting-2018-premiums/ [Accessed 4 November 2017]
M

18
Covered California. Individual markets nationally face high premium increases in coming
years absent federal or state action, with wide variation among states. 8 March 2018.
http://hbex.coveredca.com/data-research/library/CoveredCA_High_Premium_Increases_3-8-
D

18.pdf
TE

19
National Conference of State Legislatures. Health insurance: Premiums and increases. 10
October 2017. http://www.ncsl.org/research/health/health-insurance-premiums.aspx [Accessed 4
November 2017]
EP

20
Kaiser Family Foundation. The effects of ending the Affordable Care Act’s cost-sharing
reduction payments. April 2017. http://files.kff.org/attachment/Issue-Brief-The-Effects-of-
CC

Ending-the-Affordable-Care-Acts-Cost-Sharing-Reduction-Payments [Accessed 4 November

2017]
21
Congress.gov. Bipartisan Market Stabilization and Innovation Act of w2017. 22 December
A

2017.
https://www.congress.gov/bill/115th-congress/house-bill/4695/text?format=txt Accessed 13
February 2018].
22
Centers for Medicare & Medicaid Services. Opportunities to promote work and community
engagement among Medicaid beneficiaries. 11 January 2018.
https://www.medicaid.gov/federal-policy-guidance/downloads/smd18002.pdf [Accessed13
February 2018].

16
23
Kaiser Family Foundation. Medicaid and work requirements: New guidance, state waiver
details and key issues. 16 January 2018.
https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements-new-guidance-state-
waiver-details-and-key-issues/ [Accessed 13February 2013]
24
Ibid.
25
Kaiser Family Foundation. Health Coverage of Immigrants.
https://www.kff.org/disparities-policy/fact-sheet/health-coverage-of-immigrants/ [Accessed 12
February 2018]

PT
26
Center for American Progress. Medicare Extra for All. 22 February 2018.
https://www.americanprogress.org/issues/healthcare/reports/2018/02/22/447095/medicare-extra-for-all/
[Accessed 2 March 2018]

RI
27
https://www.cassidy.senate.gov/imo/media/doc/LYN17709.pdf [Accessed 2 March 2018]
28
Antos, J, Capretta, J. The Graham-Cassidy plan: Sweeping changes in a compressed time frame. Health Affairs
Blog. 22 September 2017.

SC
https://www.healthaffairs.org/do/10.1377/hblog20170922.062134/full/ [Accessed 2 March 2018]
29
Medicare for All: Leaving No One Behind.
https://berniesanders.com/issues/medicare-for-all/ [Accessed 2 March 2018]
30
International Foundation on Employee Benefit Plans. Five proposed health savings account (HSA) changes. 22

U
August 2017.
https://blog.ifebp.org/index.php/five-proposed-health-savings-account-hsa-changes [Accessed 2 March
2018]
N
A
M
D
TE
EP
CC
A

17
 A FIGURE 1

CC
EP
TE
D
M

18
A
N
U
SC
RI
PT