Federal Efforts to Stabilize ACA Individual Markets through State Innovation

Prior to full implementation of the Affordable Care Act (ACA) in 2014, states had taken the leading role in regulating individual health insurance markets. The ACA’s regime of subsidies, penalties, and federal regulations made individual coverage more accessible to those with moderate incomes and those with preexisting medical conditions. Premiums for such coverage, however, doubled between 2013 and 2017, leading to turmoil in individual markets. Both Congress and the Centers for Medicare and Medicaid Services (CMS) sought to grant states more authority to stabilize their markets through a waiver process established by section 1332 of the ACA. These efforts fell short. Congress did not enact significant changes to the ACA, and few states obtained CMS approval for section 1332 waivers to stabilize their markets. This paper offers several recommendations for streamlining and improving that waiver process that would provide states with more tools to stabilize individual markets.