The increase in undocumented immigration between 1999 and 2007 contributed to an increase in the number of uninsured people in the United States. During this period, the number of undocumented immigrants increased from an estimated 8.5 million to 11.8 million, leading to an estimated additional 1.8 million uninsured. These uninsured and undocumented immigrants were estimated to represent 27 percent of the overall increase of 6.9 million uninsured people during this period. Undocumented immigrants accounted for one in seven of the uninsured in 2007, up from one in eight in 1999. These undocumented immigrants will not be eligible for public insurance or any type of private coverage obtained through exchanges under the Affordable Care Act of 2010. As a result, members of this group will eventually constitute a larger percentage of the uninsured population, unless other policy actions are taken to provide for their coverage, or their immigration status is changed.

The policy community generally has assumed Medicare Advantage (MA) plans negotiate hospital payment rates similar to those for commercial insurance products and well above those in traditional Medicare. After surveying senior hospital and health plan executives, we found, however, that MA plans nominally pay only 100-105 percent of traditional Medicare rates and, in real economic terms, possibly less. Respondents broadly identified three primary reasons for near-payment equivalence: statutory and regulatory provisions that limit out-of-network payments to traditional Medicare rates, de facto budget constraints that MA plans face because of the need to compete with traditional Medicare and other MA plans, and a market equilibrium that permits relatively lower MA rates as long as commercial rates remain well above the traditional Medicare rates. We explored a number of policy implications not only for the MA program but also for the problem of high and variable hospital prices in commercial insurance markets.

Despite expectations that Medicare accountable care organizations (ACOs) would curb healthcare spending, their effect has been modest. One possible explanation is that ACOs cannot prohibit outof-network care, limiting control over spending. To examine this possibility, we examined the association between out-of-network care and per beneficiary spending using national Medicare data, 2012-2015. While there was no association between out-of-network specialty care and ACO spending, each percentage point increase in receipt of out-of-network primary care was associated with a $10.79 increase in quarterly ACO per beneficiary total spending. When we broke down total spending by place of service, we found that out-of-network primary care was associated with higher spending in outpatient, skilled nursing, and emergency settings, but not inpatient settings. Our findings suggest an opportunity for the Medicare program to realize substantial savings, if policymakers developed explicit incentives for beneficiaries to seek more of their primary care within network.

Hospital-acquired conditions (HACs) are pervasive and expensive, and they cause unnecessary morbidity and mortality. As of 2017, 9 HACs still occurred for every 100 discharges. 1 The Hospital-Acquired Conditions Reduction Program (HACRP) was created to reduce this rate.Despite the critical need to improve safety, research indicates the HACRP has not been effective. While improvement on claims data-based measures accelerated after HACRP implementation, the program did not improve patient outcomes. 2 Risk adjustment is inadequate, leading to disproportionate penalties for teaching hospitals and hospitals caring for more patients with socioeconomic disadvantages. 3 Penalization has not improved safety. 4 In addition, the HACRP has not been associated with improvement on included measures based on data other than claims 5 or high-quality registry data. 6These dismal results highlight 2 HACRP problems: (1) inaccurate, unreliable HAC assessment 7 and (2) penalties disproportionately and unfairly affecting certain hospitals. However, crucial modifications could be made through rulemaking. Rulemaking entails the executive branch specifying Congressional policy and regulation details. After public comment and the revision of Federal Register-published proposed rules, a final rule is published creating binding regulations. For Medicare policies, the Department of Health and Human Services (DHHS) plays a leading role.The HACRP legislation (Affordable Care Act section 3008) 8 requires that hospitals in the worstperforming quartile by HAC rate receive a 1% Medicare inpatient payment penalty. However, specific measures, performance determination, auditing, and other details are not described. Given this lack of specificity, DHHS has considerable degrees of freedom to improve the HACRP through rulemaking.

IMPORTANCE Under the Patient Protection and Affordable Care Act (ACA), US hospitals were exposed to a number of reforms intended to reduce spending, many of which, beginning in 2012, targeted acute care hospitals and often focused on specific diagnoses (eg, acute myocardial infarction, heart failure, and pneumonia) for Medicare patients. Other provisions enacted in the ACA and under budget sequestration (beginning in 2013) mandated Medicare fee cuts. OBJECTIVE To evaluate the association between the enactment of ACA reforms and 30-day pricestandardized hospital episode spending. DESIGN, SETTING, AND PARTICIPANTS This policy evaluation included index discharges between