Stabilizing Health Insurance Markets

ACP Chapter Action Tool Kit

Prepared by ACP’s Division of Governmental Affairs and Public Policy

February 21, 2019

Call to Action

ACP urges chapters to advance policies at the state level that will help ensure continued health coverage and essential benefits, strengthen and expand Medicaid, and stabilize the health insurance market.  Specifically, and as applicable based on your states circumstances, chapters should urge state legislatures/governors to:

  • Withdraw their support for overturning the Affordable Care Act (Texas v. United States), if your state is one of the 20 states serving as plaintiffs in the case. 
  • Reject efforts to implement work requirement rules as a condition for those receiving Medicaid.  Seven states have imposed such work requirements.  Eight other states are awaiting approval by CMS to implement such work requirements.
  • Limit the expansion and promotion of short-term limited duration health plans as they are not required to comply with the ACA’s insurance market regulations, or cover essential health benefits like the pre-existing condition exclusion prohibition, coverage of essential health benefits without annual or lifetime dollar limits, preventive care, maternity and prescription drug coverage, rating restrictions, and guaranteed renewability. 

ACP has developed a tool kit of materials designed to help chapters advocate on these issues at the state level, complete with the necessary background information and resources to understand these policies and a sample letter to state lawmakers/governors that chapters can customize to fit their circumstances.  We urge you to join in this campaign to the greatest extent practicable.

Where Do Things Stand with the Affordable Care Act (ACA)?

The ACA established marketplaces (also called exchanges) where certain individuals can, during an annual open enrollment period, purchase one of four levels of coverage as well as receive progressive income-based premium subsidies (meaning the lower one’s income, the higher the subsidy) if their incomes fall between 100 and 400 percent of the federal poverty level (FPL), and cost-sharing subsidies for persons with income up to 250 percent of the FPL.  The ACA also established basic consumer protections including: no lifetime or annual dollar limits on coverage; prohibits insurers from denying, canceling or charging higher premiums to people with pre-existing conditions;  requires all health plans to cover 10 categories of essential health benefits; and prohibits insurers from charging higher premiums to women based solely on their gender.  

The ACA, which instituted comprehensive health care coverage and benefits for millions, continues to be the law of the land but efforts by the federal government and the states to strike down the law or chip away at its reforms continue, as outlined in detail below.

*Texas v. United States

On December 14, 2018, a federal judge in Texas ruled that the entire Affordable Care Act (ACA) is unconstitutional.  The judge’s ruling stated that since the ACA’s “individual mandate” – a requirement that most Americans maintain “minimum essential” coverage or face a tax penalty -- is unconstitutional, the rest of the law cannot stand without it. The ACA will remain in place pending appeal.  This ruling from a Texas judge is putting the health of millions of patients at risk.  If this ruling stands, patients could once again be turned down or charged more for pre-existing conditions, and insurers would no longer be required to cover essential benefits like prescription drugs, maternity care, doctor visits, and mental health and substance use disorder treatment. The latter benefit is especially crucial as our nation confronts an opioid overdose epidemic that takes 130 lives every day. Additionally, premium subsidies to make coverage affordable would end; high-quality preventive services would be subject to cost-sharing; and annual and lifetime limits on coverage would return. Federal funding for Medicaid expansion would also be terminated, and seniors would no longer have access to no-cost preventive services.  ACP has urged the courts on appeal to consider the legal and patient protection arguments made by ACP, together with the American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry, in an amicus curiae brief filed in this case. 

The Texas Attorney General is leading a group of 18 Republican attorneys general, two Governors (TX, WI, AL, AR, AZ, FL, GA, IN, KS, LA, ME, MO, MS, NE, ND, SC, SD, TN, UT, WV) and two individual plaintiffs in challenging the Affordable Care Act.

*Imposing Work Requirements under Medicaid

In 2018, CMS issued new guidance that allowed states to seek federal approval to include work and community engagement requirements for non-elderly, non-pregnant adults who are not eligible for Medicaid due to a disability. This new policy makes it easier for states to implement work requirement rules as a condition for receiving Medicaid.  As of February 2019, according to a Kaiser Family Foundation report, the federal government has approved waivers for seven states (AZ, AR, IN, KY, MI, NH, WI), which include work requirements. Eight other states (AL, MS, OH, OK, SD, TN, UT, VA) are awaiting approval from CMS to implement their work requirements.  

A recent analysis by the Kaiser Family Foundation found that 80 percent of Medicaid enrollees are in working families and 60 percent are themselves working.  Among adult Medicaid enrollees who were not working, most reported major impediments to their ability to work. The analysis noted that, More than one-third of those not working reported that illness or disability was the primary reason for not working, nearly nine in ten (88 percent) non-SSI Medicaid adults who report not working due to illness or disability has a functional limitation, and more than two-thirds (67 percent) have two or more chronic conditions such as arthritis or asthma.

ACP is strongly opposed to making access to health care coverage through Medicaid conditional on an individual’s employment status.  In ACP’s paper, Medicaid Expansion: Premium Assistance and Other Options, ACP argues that assistance in obtaining employment, such as through voluntary enrollment in skills- and interview-training programs, can appropriately be made available however it should not be a requirement for Medicaid eligibility. In addition, ACP, along with other leading medical organizations, signed on to an amicus brief in the Stewart v. Azar case that challenges U.S. Secretary of Health and Human Services (HHS) Alex Azar’s approval of Kentucky’s Medicaid waiver program which, among other things, imposed work requirements on new enrollees.  Early in 2018, ACP launched a chapter action campaign on state Medicaid waivers, which you may also find helpful.

*Incentivizing Sub-standard Health Plans

Those with pre-existing conditions face a real threat in the wake of the administration’s 2018 guidance to allow Short-Term, Limited-Duration Insurance Plans to be sold as full-year substitute coverage for Affordable Care Act plans.  ACP expressed its opposition to this proposal in April of last year. Short-term insurance plans are intended to provide temporary insurance during gaps in coverage, such as when a person is between jobs and does not have access to employer-based health insurance. Since they are not required to comply with the ACA’s insurance market regulations, they may not include coverage typical of comprehensive, major medical insurance. As noted in the administration’s proposal, these policies “would be unlikely to include all the elements of PPACA-compliant plans, such as pre-existing condition exclusion prohibition, coverage of essential health benefits without annual or lifetime dollar limits, preventive care, maternity and prescription drug coverage, rating restrictions, and guaranteed renewability.”  See if your state has limited the sale of these Short-Term, Limited-Duration Insurance Plans.



Chapters interested in advocating for policies designed to ensure continued health coverage and essential benefits, strengthen and expand Medicaid, and stabilize the health insurance market as noted above should contact their state governor/legislators/attorney general. A sample letter that chapters can customize is available here.

Additional Suggested Chapter Actions

  • The above sample letter could be customized for all chapter members to send to their elected state lawmakers (changing the introduction and closing so it is coming from the individual member rather than the chapter and its governor) and distributed with your membership to urge them to take action.
  • A news release could be drafted and sent to local media when your chapter letter is sent to lawmakers and your state’s governor.  If you would like to do this, ACP’s communications staff can help.
  • You can promote your efforts using social media, by posting content to your chapter’s Facebook or Twitter pages.  If you post on twitter, we encourage you to include @ACPinternists so we are aware of, and can retweet, your tweets.
  • Please let Shuan Tomlinson know what you are doing.  She can also address any questions you may have or put you in touch with one of our policy experts.