Massachusetts, ACA and Health Care Reform

What are the three dimensions of the Triple Aim framework?

Health of a population, individual experience, per capita cost.

What does the Quadruple Aim add to the Triple Aim?

Health care team well-being.

What does the Quintuple Aim add to the Quadruple Aim?

Health equity.

What is considered the bottom line in evaluating health care interventions?

Health outcomes.

What quote summarizes the test of health system quality according to the IOM?

“The ultimate test of the quality of a health care system is whether it helps the people it intends to help.”

How was care funded in Massachusetts prior to the 2006 reform?

Free care pool, Medicaid waivers, disproportionate share hospital payments.

What was the uninsured rate among working-age adults in MA before 2006 reform?

About 14%.

What law enacted MA health reform in 2006?

Chapter 58 of the Acts of 2006.

What is the Health Connector in MA?

An exchange marketplace to purchase individual insurance.

What two types of plans are offered through the Health Connector?

Commonwealth Care (subsidized) and Commonwealth Choice (non-subsidized).

What percentage of FPL qualifies someone for subsidized insurance in MA?

Below 300% of the Federal Poverty Level.

What insurance reforms were implemented in MA in 2006?

Community rating, guaranteed issue, merged risk pools, defined creditable coverage.

What changes were made to MassHealth in the 2006 reform?

Expanded eligibility for children to 300% FPL and raised adult enrollment caps.

What requirement was placed on MA employers with ≥11 employees?

Provide health insurance or contribute to Fair Share fund.

What was the MA individual mandate?

Adults must have insurance or pay a penalty unless exempt.

What is the penalty for not having insurance under the MA mandate?

50% of the lowest premium unless exempt.

What are examples of MassHealth plan names?

MassHealth Standard, CommonHealth, CarePlus, Family Assistance, Small Business Employee, Premium Assistance, Limited.

What is the Health Safety Net in MA?

Pays for some hospital and community health center care for low-income patients.

When was the Affordable Care Act (ACA) signed into law?

March 23, 2010.

Was the ACA a single-payer health system?

No, it was not.

What were the four main pillars of the ACA?

Employer mandate, individual mandate, Medicaid expansion, insurance regulation.

Who was required to have health insurance under the ACA individual mandate?

All U.S. citizens and legal residents.

What was the penalty for not having coverage under the ACA (before repeal)?

Greater of $695 per year (max $2,085 per family) or 2.5% of household income.

What income range qualified for premium and cost-sharing assistance?

100–400% of the federal poverty level (FPL).

What are the ACA’s two main types of Exchanges?

American Health Benefit Exchanges and Small Business Health Options Program (SHOP).

Who could purchase coverage through SHOP Exchanges?

Small businesses with ≤100 employees (states could expand in 2017).

What were states allowed to do with Exchanges?

Form regional Exchanges or operate multiple within a state.

What is the Bronze tier plan under the ACA?

Covers 60% of costs with essential benefits and capped out-of-pocket limits.

What is the Silver tier plan under the ACA?

Covers 70% of costs with essential benefits and capped out-of-pocket limits.

What is the Gold tier plan under the ACA?

Covers 80% of costs with essential benefits and capped out-of-pocket limits.

What is the Platinum tier plan under the ACA?

Covers 90% of costs with essential benefits and capped out-of-pocket limits.

What did the ACA require for insurance market rules?

Guaranteed issue and renewability, rating limits, dependent coverage up to 26.

What factors can be used for premium rating under ACA rules?

Age, geography, family composition, tobacco use.

What was the purpose of the ACA’s high-risk pool?

To insure people with pre-existing conditions before full ACA implementation.

What were insurers required to justify under the ACA?

Premium increases.

What limits were removed by the ACA?

Lifetime and annual limits on coverage.

What was the waiting period cap under the ACA?

No waiting period longer than 90 days.

When can coverage be rescinded under the ACA?

Only in cases of fraud.

What is the employer mandate under the ACA for employers with <50 employees?

They are exempt.

What is the ACA penalty for large employers (≥50 FTEs) not offering coverage?

$2,000 per employee (excluding first 30) if any employee receives a subsidy.

What is the penalty for large employers offering coverage but still having employees get subsidies?

Lesser of $3,000 per subsidized employee or $2,000 per full-time employee (excluding first 30).

What requirement applies to employers with >200 employees under the ACA?

Must auto-enroll employees into plans (opt-out allowed).

What income level qualified for ACA Medicaid expansion?

Up to 133% FPL (effectively 138% due to 5% income disregard).

Who was eligible under ACA Medicaid expansion?

All non-Medicare-eligible individuals under age 65 within the income threshold.

What benefits were guaranteed to newly eligible Medicaid adults?

Benchmark benefit package matching essential benefits in Exchanges.

How was ACA Medicaid expansion initially funded?

100% federal funding (2014–2016), then phased down to 90% by 2020+.

What payment increase did ACA provide for Medicaid primary care services?

100% of Medicare payment rates for 2013 and 2014.

Who financed the primary care Medicaid payment increase?

Fully funded by the federal government.

What program did the ACA expand alongside Medicaid?

CHIP (Children’s Health Insurance Program).

What tax-related provisions were included in the ACA?

Fees on drug/insurance companies, limits on HSA OTC purchases, small business tax credits.

How did the ACA aim to improve Medicare and Medicaid?

Through coordinated care models like ACOs.

What transparency requirements were added by the ACA?

Disclosure of financial relationships among providers.

What new data collection was mandated by the ACA?

Race, ethnicity, sex, language, disability, rural/underserved populations.

What prevention/wellness initiative did the ACA fund?

USPSTF level A & B services fully covered with no cost-sharing.

What food labeling rules were introduced by the ACA?

Nutrition labeling on chain restaurant and vending machine items.

What were some additional ACA initiatives?

Long-term care, workforce development, trauma care, disaster preparedness, community needs assessments.

What did the 2012 Supreme Court decision rule about the ACA?:It upheld the individual mandate as a tax and made Medicaid expansion optional for states.

What did the 2015 Supreme Court decision (King v. Burwell) determine?:It allowed continued subsidies for insurance purchased on both federal and state exchanges.

What major ACA provision was eliminated by the 2017 Tax Cuts and Jobs Act?:The individual mandate penalty was eliminated starting in 2019.

What did the 2018 Texas court rule regarding the ACA?:That the ACA was unconstitutional without the individual mandate.

What was the outcome of the Supreme Court case California v. Texas in 2021?:The challenge to the ACA was rejected 7–2, and the ACA remained in place.

What did Braidwood v. Becerra challenge in 2023?:The constitutionality of requiring preventive services coverage based on USPSTF recommendations.

What was the 2025 Supreme Court decision in Kennedy v. Braidwood?:USPSTF recommendations remained valid; HHS Secretary has authority to appoint/remove task force members.

Which states were initially required to expand Medicaid under the ACA?:All states were required, but the 2012 Supreme Court ruling made it optional.

What is the ACA Medicaid expansion criteria?:It covers individuals up to 138% of the Federal Poverty Level (FPL).

What are the financial terms for states that expand Medicaid?:The federal government covers 90% of the expansion cost.

As of 2024, how many states have not expanded Medicaid?:Ten states have not expanded Medicaid.

What is the coverage gap?:A situation where individuals earn too much for Medicaid but not enough for marketplace subsidies in non-expansion states.

What are the outcomes of Medicaid expansion?:Increased insurance coverage, improved access to care, and better financial security.

What did the ACA aim to reduce in terms of insurance coverage?:The number of uninsured individuals.

How did the ACA affect young adults?:Allowed them to remain on a parent’s plan until age 26.

How did the ACA address preexisting conditions?:It prohibited insurers from denying coverage or charging more due to preexisting conditions.

What was the ACA’s impact on racial and ethnic disparities in insurance?:It reduced disparities in coverage, particularly among Black and Latinx populations.

What was the ACA’s effect on underinsurance?:It helped but did not eliminate underinsurance, as cost-sharing (e.g., deductibles) remains high.

What was the ACA’s effect on medical bankruptcies?:It reduced medical bankruptcies but did not eliminate them.

Why does the U.S. continue to face health care cost challenges despite the ACA?:Because the ACA focused more on expanding coverage than controlling costs.