Making Sense of Delivery System Reform

The Affordable Care Act made a lot of changes – and improvements – to health insurance. But it was also meant to encourage changes in how health care is delivered – the care you get at the hospital, doctor’s office, pharmacy, and other places where people get health care.

Many people have frustrating experiences with health care that go beyond how it’s paid for. Maybe you can’t make an appointment without skipping work, or can’t get your prescription filled on time because of communication problems and end up skipping doses. Maybe you had to get a test done twice because re-doing it was easier than transferring your records to a new physician. Delivery system reform is meant to make the experience of getting health care better – in an ideal world, there would be seamless delivery system that lets doctors and patients focus on their health, not logistics.

HCFANY has produced a new issue brief to help consumers understand what is happening. Delivery system reform could be a great thing for everyone, but changing systems is always hard. A lot of stakeholders have learned to succeed under the status quo, and are afraid of changing how they do business. Consumers need to educate themselves about how delivery reform can benefit them and use their knowledge to encourage reform that benefits patients.

RWV Guest Blog Image UninsuredGuest blog by Lois Uttley, MPP, Director of Raising Women’s Voices-NY. Six years after the Affordable Care Act (ACA) was signed into law and three years after the ACA insurance marketplaces opened, the nation’s uninsured rate has dropped to the lowest level ever recorded. Between 2010 and 2016, the percentage of people without health insurance fell by nearly half, from 16 percent to 8.6 percent. The sharp decline is illustrated in this chart from Vox. The previous low of 9.1 percent was recorded in 2015.

The new numbers were released last week by the National Center for Health Statistics, and are based on the National Interview Survey conducted during the first quarter of 2016. The survey uncovered some important variations among population groups when it comes to health insurance. For example:

  • Only 5 percent of children 17 and younger are now uninsured. Of those, 42.1 percent had public coverage and 54.9 percent had private coverage.
  • Hispanic adults had the greatest decline in un-insurance, going from 40.6 percent in 2013 to 24.5 percent in 2016. But that reduced rate was still much higher than the 2016 rates for non-Hispanic Black (13 percent), white (8.4 percent) and Asian adults (6.7 percent).

States Fully Implementing the ACA Show Biggest Drop In Uninsured

The national survey data also reveal striking disparities between rates of un-insurance in states like New York that have fully implemented the ACA – by expanding their Medicaid programs and creating their own health insurance exchanges, or marketplaces – and those that have refused to do so because of conservative political opposition.

First, let’s look at the impact of a state’s decision to expand Medicaid. In the expansion states, the percentage of uninsured adults (ages 18 to 64) dropped by half — from 18.4 percent in 2013 to 9.2 percent in 2016. By contrast, in non-expansion states, the uninsured rate fell somewhat – from 22.7 percent in 2013 to 16.7 percent in 2016 — but still remained high.

Next, let’s look at the difference in uninsured rates between states that opened their own marketplace (or partnered with the federal government to create a marketplace) and those states that refused to do so, and instead defaulted to having a federally-run marketplace. There have been significant declines in uninsured rates in states with their own marketplaces (from 18.7 percent in 2013 to 9.1 percent in 2016) and in partnership marketplace states (from 17.9 percent in 2013 to 8.2 percent this year).

The survey found a different story in the states with federally-run marketplaces. Although even those states experience a drop in the uninsured rate (from 22 percent to 14.5 percent), the 2016 percentage of residents who remain uninsured is much higher than in the other states.






Yay BlogOnce again New York is leading the nation as one of only two states to implement a Basic Health Plan (BHP). As of January 31, 379,599 New Yorkers enrolled in comprehensive, affordable coverage through the New York’s BHP, branded the Essential Plan, which launched in 2016. A few weeks ago, the NY State of Health (NYSOH) released its report on the third open enrollment period, which ran from November 1, 2015 through January 31, 2016. HCFANY is excited to see so many consumers gaining access to health care through the EP in its first year.

The EP is meeting an important need for consumers in New York, particularly for those with incomes between 138 and 200 of the Federal Poverty Level (FPL). Before the implementation of the Essential Plan, individuals at this income level would only have been eligible to purchase Qualified Health Plans (QHP) with financial assistance, and many continued to face financial barriers to coverage. With the EP, low- and moderate income individuals can now receive coverage comparable to that of a QHP for a premium of $0 or $20 and no annual deductible. The average consumer saves over $1,100 compared to QHP coverage. This increased affordability has resulted in high enrollment levels for EP eligible individuals. According to NYSOH’s open enrollment report, 98 percent of individuals determined to be eligible for the Essential Plan enrolled compared to only 58 percent of individuals eligible for QHP.

Essential Plan coverage is also available to individuals under age 65 with incomes below 138 percent of the Federal Poverty Level (FPL) who are lawfully present in the United States, but have not met the five-year bar to qualify for Medicaid as well as lawfully present immigrants with incomes 138 to 200 percent of FPL.

Like Medicaid and Child Health Plus, individuals and families eligible for the EP can enroll throughout the year.

To enroll or learn more about the Essential Plan, contact NYSOH at (855)-355-5777 or can also get free one-on-one help from a Navigator or Certified Application Counselor, certified by NY State of Health, who serves your area at Or contact Community Health Advocates at (888)-614-5400 or

CID-NYGuest blog by Heidi Siegfried, Project Director at New Yorkers for Accessible Health Coverage (NYFAHC) and Health Policy Director, Center for Independence of the Disabled. A few days ago, Health Affairs published an article that highlighted how the non-discrimination provisions of the Affordable Care Act (ACA), Section 1557, can protect consumers against benefit designs that discriminate against people with chronic conditions or significant health needs.

New York has long prohibited denial of coverage or premium variation based on health status and the ACA now prohibits charging higher premiums or denying coverage for people with pre-existing conditions. Still, network and formulary designs can have the effect of discriminating against people with serious illnesses and disabilities.

People often overlook the fact that Section 1557 prohibits discrimination based on disability status as well as race, color, national origin, sex, and age.  HCFANY and NYFAHC submitted comments to the U.S. Department of Health and Human Services (HHS) on the proposed rules for Section 1557 in November 2015. In these comments, we asked HHS to specifically define discriminatory benefit design in the regulations implementing Section 1557 and to include all beneficiaries with chronic conditions or serious illnesses.  Although HHS did not provide a definition, they do consider benefit design discrimination on a case-by-case basis and will review complaints of disability-based discrimination. HHS also provides examples of potentially discriminatory benefit designs such as placing all HIV drugs on the highest tier.

The Health Affairs article points out that the Americans with Disabilities Act was amended to define disability as an impairment of major bodily functions such as immune system, normal cell growth, digestive, bladder, neurological, respiratory, and endocrine systems which would reach many people with chronic conditions.  Therefore, when consumers encounter discriminatory formularies, coverage limitations, or plans that exclude certain specialists, they can use Section 1557 to enforce their rights to non-discriminatory benefit design by filing complaints with the Office of Civil Rights at HHS or by challenging the plans in court.