A Durable Path Forward on American Health Care

Reinsurance, Portable Coverage, Modernized Savings Accounts, and a More Efficient Role for Medicaid

Jun 22, 2026

Abstract: Federal health policy has alternated between expanding Affordable Care Act subsidies and restricting public assistance, without producing a durable settlement. This paper proposes four mutually reinforcing reforms: federal catastrophic reinsurance, portable employer contributions toward employee-owned Marketplace coverage, modernization of Health Savings Accounts and Flexible Spending Accounts, and broader use of Medicaid where it provides better protection at lower cost. Together, the reforms would lower underlying insurance costs, reduce job lock and coverage interruptions, protect household savings, and direct public assistance toward the financing mechanism best suited to each population. Because several provisions would reduce Premium Tax Credit, CHIP, or recession-related Medicaid costs, their net fiscal cost could be substantially lower than their gross cost.

Introduction

Since 2017, federal health policy has alternated between expansions of public assistance and efforts to deregulate insurance markets and restrain federal spending. The first Trump administration reduced the individual-mandate penalty to zero, supported Medicaid work requirements, and expanded the availability of short-term insurance. The Biden administration moved in the other direction by expanding Marketplace Premium Tax Credits, simplifying Medicaid enrollment, and restricting short-term plans. Following the 2024 election, the enhanced Premium Tax Credits expired at the end of 2025, while the 2025 budget reconciliation law imposed new Medicaid eligibility and work-related requirements and expanded Health Savings Account eligibility.^[1]

The result has been instability rather than a durable settlement. KFF estimates that average monthly effectuated Marketplace enrollment could fall from 22.3 million in 2025 to about 17.5 million in 2026 and could be as low as 16.5 million. Average Marketplace deductibles also rose from $2,759 in 2025 to $3,786 in 2026 even though more consumers shifted into less expensive bronze plans. Separately, the Congressional Budget Office estimates that the Medicaid provisions of the 2025 reconciliation law will increase the number of uninsured people by 7.5 million in 2034. CBO also estimates that permanently restoring the expanded Premium Tax Credits would increase insurance coverage by 3.8 million in 2035. Those estimates use different baselines and years and should not simply be added together, but both indicate that recent policy changes will materially reduce coverage.^[2]

Households that retain insurance increasingly confront a second problem: coverage that does not provide adequate financial protection. High deductibles, coinsurance, prescription costs, and narrow provider networks can leave insured families postponing treatment, accumulating medical debt, or reducing retirement contributions to pay current medical bills.

Progressive lawmakers have often responded by proposing Medicare for All. Current legislation includes a phased transition rather than an immediate overnight conversion, but the economic and administrative challenge would remain extraordinary. Hospitals, physicians, insurers, employers, workers, and households would all face major changes in payment, employment, taxation, and compensation. Concentrating most health-care financing and benefit decisions in a single federal program would also magnify the consequences of changes in national political control. Decisions involving reproductive care, gender-related treatment, medical necessity, and other contested services would become more directly dependent on federal regulation and appropriations.^[3]

The United States therefore needs an alternative to the recurring choice between dismantling the Affordable Care Act and replacing nearly the entire financing system with a single federal program. The objective should be a durable structure that preserves private contracting and individual choice while using public resources where markets perform poorly.

The Path Forward

The proposed framework consists of four mutually reinforcing reforms: catastrophic reinsurance to lower underlying premiums; portable employer contributions toward employee-owned coverage; modernized Health Savings Accounts and Flexible Spending Accounts; and expanded use of Medicaid where public coverage is less expensive and more protective than heavily subsidized private insurance.

The current system suffers from four broad structural problems. First, premiums remain unaffordable for many households, while income-based Premium Tax Credits impose high implicit marginal tax rates as assistance declines. These subsidies help people purchase coverage but do too little to reduce the underlying cost of insurance.

Second, insurers remain exposed to highly concentrated catastrophic claims. This raises premiums and strengthens incentives to avoid high-risk enrollment. It may also contribute to aggressive utilization controls and administrative disputes, although reinsurance alone would not eliminate the need for consumer-protection and claims-review standards.

Third, the tax preference for employer-sponsored insurance still ties most coverage to a particular job. Workers can lose or disrupt their insurance when they change employers, are laid off, retire before Medicare eligibility, or move into self-employment. Small businesses also bear the financial and administrative burden of operating firm-specific group plans.

Fourth, high deductibles and other out-of-pocket expenses leave many insured households unable to afford the care their policies technically cover. These costs increase medical debt, discourage necessary treatment, and reduce the liquid savings available for retirement and other long-term needs.

Each of the following reforms can be enacted independently. Their greatest value, however, comes from operating together: reinsurance lowers premiums, portable benefits make individual coverage more practical, modernized savings accounts protect households from unavoidable cost sharing, and Medicaid provides more appropriate coverage for families that cannot realistically absorb private-plan deductibles.

REFORM ONE: Shift Federal Assistance from Back-End Premium Tax Credits to Front-End Reinsurance

Premium Tax Credits have expanded coverage, but they do not directly reduce the underlying claims cost of insurance. Because the subsidy declines as income rises, the current system can also impose substantial implicit marginal tax rates on households that earn additional income. After the expiration of the enhanced credits, eligibility again ends abruptly at 400 percent of the Federal Poverty Level, recreating a sharp subsidy cliff.

A more efficient strategy would shift part of federal assistance from back-end premium subsidies to front-end catastrophic reinsurance. The federal government would reimburse insurers for a share of exceptionally high annual claims. An illustrative program might reimburse 50 percent of an enrollee’s annual claims above $50,000, subject to an annual cap. The attachment point, reimbursement percentage, cap, and treatment of prescription drugs would require actuarial modeling rather than being fixed by the example in this paper.

State reinsurance programs operating under Affordable Care Act Section 1332 waivers demonstrate the basic mechanism. By paying part of the highest-cost claims, reinsurance reduces the premiums insurers must collect from all enrollees. CMS has found substantial premium reductions across states operating these programs, although results vary with program size, market conditions, and design.^[4]

Reinsurance should also reduce some incentives to avoid high-risk enrollment. It may modestly reduce pressure for unusually aggressive utilization controls and could incentivize reduction in prior authorization and claim disputes.

Because reinsurance lowers benchmark premiums, it also lowers the amount of Premium Tax Credits required to make coverage affordable. That offset is central to the proposal: federal reinsurance is not free, but part of its gross cost would be recovered through lower premium subsidy payments.

The remaining Premium Tax Credits should be redesigned rather than eliminated. One illustrative target would limit household premium contributions to approximately six percent of income, with assistance declining through a smooth quadratic formula rather than through abrupt changes. The revised premium tax credit reduces the abrupt increase in premiums at 400 percent FPL under current law and would allow for elimination of the subsidy cliff because most subsidies will disappear because required household payments rise with income and the subsidy percent is a much lower percent of income.

REFORM TWO: Make Portable, Employee-Owned Coverage the Default Use of Employer Health Contributions

Most workers value employer contributions toward health insurance because those contributions receive favorable tax treatment. The problem is not the employer contribution itself; it is the connection between that contribution and a firm-specific insurance contract.

Federal regulations have permitted Individual Coverage Health Reimbursement Arrangements, or ICHRAs, since 2020. ICHRAs allow employers to reimburse workers on a tax-preferred basis for individually purchased insurance. Yet they remain a secondary and administratively constrained alternative rather than the normal structure of employer health benefits.^[5]

Reform should build on the ICHRA framework by placing portable individual coverage on equal footing with traditional group insurance for purposes of the employer mandate, tax exclusions, small-business assistance, and enrollment administration. The employer mandate should be revised—not eliminated—so that large employers remain responsible for helping finance employee coverage, while allowing a qualifying contribution toward an employee-owned Marketplace policy to satisfy the mandate when the resulting coverage meets applicable affordability and minimum-value standards. The long-run objective should be to make a portable contribution toward employee-owned coverage the default use of employer health benefits. A politically feasible transition could preserve traditional group plans as an alternative while the portable market develops sufficient scale.

Under this approach, an employee would choose and own a state Marketplace policy. The employer would make a tax-advantaged contribution toward its cost. The contribution could vary by lawful employee categories and family status, but the rules should be simpler and more standardized than the current ICHRA structure. Small employers would gain a practical alternative to administering a group plan, while larger employers could continue offering traditional coverage when workers prefer it.

Employer contributions and Premium Tax Credits would need to be coordinated through a single affordability formula. Employer payments should reduce the worker’s required contribution, while federal assistance supplements rather than unnecessarily displaces qualifying employer support. The rules must prevent both gaps in assistance and duplicate subsidies.

The application of Reform One, exclusively to state exchange health insurance plans, makes this transition more practical. Reinsurance lowers the baseline cost of individual policies, allowing employer contributions and household payments to purchase more comprehensive coverage. A worker who changes jobs would keep the same policy and simply receive a contribution from a new employer, assuming the worker remains in the same service area.

A layoff would end the employer contribution, but it would not end the insurance policy. Loss of the contribution should trigger an automatic subsidy redetermination based on the worker’s expected annual income, together with temporary continuation assistance while the new Premium Tax Credit is calculated. Congress should also protect workers from unreasonable tax-reconciliation penalties when an unexpected layoff makes annual income difficult to predict.

Past proposals and temporary programs—including federal assistance with COBRA premiums and support connected to trade-adjustment programs—demonstrate that Congress can subsidize transitional coverage during periods of unemployment. Proposals to require large employers to help finance temporary COBRA coverage have also received attention, although debate over such mandates generally follows familiar partisan lines. These approaches are worth preserving as possible emergency tools, but they are not central to this reform. The principal advantage of employee-owned coverage is that a layoff would normally require only an automatic recalculation of the worker’s Premium Tax Credit, not enrollment in a new insurance policy. Reform One would make that response more affordable by lowering the underlying premium that federal assistance must support. During an unusually severe recession, Congress could supplement the recalculated tax credit with temporary premium assistance, but the existing individual policy would remain in place throughout the transition. By reducing coverage interruptions and job lock, portable benefits would allow workers to change jobs, start businesses, or retire early based more on economic opportunity and less on fear of losing insurance.

REFORM THREE: Modernize Health Savings Accounts and Flexible Spending Accounts

The substantial growth of deductibles has shifted more first-dollar medical costs onto households. In 2025, the average single deductible among covered workers with a general annual deductible was $1,886, and the average at firms with 10 to 199 workers was $2,631. In the individual Marketplace, the average deductible reached $3,786 in 2026. Cost exposure of this size can make insured families delay care or ration prescriptions.^[6]

Health Savings Accounts can help households prepare for these expenses, and the 2025 reconciliation law expanded HSA eligibility to bronze and catastrophic plans beginning in 2026. But the tax benefits are most valuable to households that already have enough disposable income to contribute. A deduction alone provides little help to a family that cannot spare the cash.^[7]

The federal government should therefore provide a refundable credit or direct matching contribution for moderate-income households enrolled in private high-deductible coverage. The match should be deposited directly into the HSA and should decline gradually with income. It should be concentrated above the Medicaid eligibility range proposed in Reform Four. For households eligible for comprehensive Medicaid with limited cost sharing, public coverage is generally more sensible than subsidizing a multi-thousand-dollar private deductible.

Flexible Spending Accounts present a different problem. Although employers may permit a limited carryover or grace period, many workers still forfeit unused balances. EBRI found that roughly half of FSA account holders forfeited money in 2023, with an average forfeiture of $436.^[8]

Congress should permit unused FSA balances to carry forward without an artificially low ceiling. As an alternative, balances above a reasonable health-care reserve could be transferred into a specially designated retirement account. Because FSA contributions are made with pre-tax dollars, the transfer rules must prevent a double tax benefit. Congress could treat transferred funds as pre-tax retirement money taxable upon withdrawal, impose an annual transfer limit, and restrict early nonmedical withdrawals.

This approach would end the unnecessary conflict between preparing for medical expenses and building retirement security. Workers would not have to spend balances merely to avoid forfeiture, nor would they need to reduce retirement contributions to maintain a health-care reserve. The objective is not to subsidize unlimited tax sheltering; it is to let households preserve savings that were set aside prudently but not needed immediately.

If policymakers must choose between these two proposals, FSA reform should take priority because high-deductible plans and HSAs are generally a poor vehicle for assisting lower-income households that lack both the disposable income to fund an account and the financial capacity to absorb a large deductible.

REFORM FOUR: Use Medicaid Where It Is Most Efficient While Preserving Private Choice Above Moderate Incomes

Health policy should match the financing mechanism to household resources rather than treating either public or private insurance as an end in itself. For many lower-income adults, Medicaid can provide more comprehensive financial protection at a lower total cost than purchasing private coverage through large Premium Tax Credits.

National research has generally found that private coverage costs more than Medicaid for comparable lower-income adults, although the precise difference varies by population and state. More direct evidence comes from a matched study of Colorado adults immediately above and below the Medicaid eligibility boundary. Mean annual spending was $2,484 for Medicaid enrollees and $4,553 for Marketplace enrollees, while average out-of-pocket costs were $45 and $569, respectively. When Marketplace services were repriced at Medicaid payment rates, the remaining spending difference was not statistically significant. This suggests that Medicaid’s cost advantage arose primarily from lower provider-payment rates rather than substantially lower use of care.

These findings support enhanced federal assistance for states that extend Medicaid eligibility for adults toward 200 percent of the Federal Poverty Level. Families near this income level often lack the liquid assets needed to absorb large Marketplace deductibles and may be forced to borrow, sell assets, delay care, or miss other obligations when medical expenses arise.

A refundable HSA credit large enough to offset multi-thousand-dollar deductibles for millions of lower-income households would require substantial new spending and create another income-based benefit. It would help pay the deductible without addressing the higher underlying prices paid by private insurance. Medicaid instead combines limited cost sharing with lower administered or negotiated prices.

Medicaid nevertheless involves important tradeoffs. Lower provider-payment rates can reduce provider participation and make specialist appointments more difficult in some states or geographic areas. Any expansion should therefore monitor appointment availability, network adequacy, specialty access, and continuity of care. Targeted payment supplements may be necessary for primary care, behavioral health, obstetrics, rural providers, and pediatric specialties.

The federal budget effect would depend on the matching rate assigned to newly eligible beneficiaries. Medicaid may reduce total medical and public spending while reallocating costs between the federal government and the states. Legislative estimates should therefore report total medical spending, combined public spending, federal outlays, state costs, displaced Premium Tax Credits, and beneficiary out-of-pocket savings separately.

Reform One could also protect Medicaid managed-care programs from unusually high claims through a federal high-cost risk pool or reinsurance mechanism. The design would need to complement rather than duplicate existing capitation, risk-adjustment, and state risk-sharing arrangements. Properly structured, it could reduce the cost of rare and catastrophic cases while preserving incentives for effective care management.

Children require separate consideration. One option is to expand CHIP eligibility toward 300 percent of the Federal Poverty Level. Another is a pediatric reinsurance program that substantially lowers the private cost of rare diseases, complex disabilities, behavioral health treatment, developmental services, and other high-cost care. The appropriate balance may vary across states. Federal policy could permit states to choose among approved approaches subject to common standards for benefits, affordability, provider access, and continuity of care.[4]

Extending Medicaid toward 200 percent FPL would displace some heavily subsidized private Marketplace enrollment. In this setting, however, crowd-out need not be an economic loss. If Medicaid provides comparable or better financial protection at lower total public cost, shifting some enrollment from private plans to Medicaid can improve economic efficiency. The objective is not to maximize either public or private insurance; it is to use the financing system that provides the best combination of access, protection, and taxpayer value for each population.

Fiscal and Administrative Considerations

The numerical parameters in this paper are illustrative rather than final legislative specifications. The reinsurance attachment point, reimbursement percentage, Premium Tax Credit contribution schedule, Medicaid eligibility threshold, HSA match, pediatric coverage model, and federal Medicaid matching rate all require actuarial, distributional, and budgetary analysis.

Any legislation should separately report gross federal costs; savings from lower Premium Tax Credits; changes in federal and state Medicaid spending; beneficiary premium and out-of-pocket savings; employer effects; and administrative expenses. The reforms should be phased in with periodic evaluation and authority to adjust parameters as actual enrollment, premium, claims, and access data become available.

Several of the reforms could nevertheless be highly cost-effective because their direct costs would be partly offset by savings elsewhere in the health-financing system. General reinsurance would lower Marketplace premiums and therefore reduce the Premium Tax Credits required at every subsidized income level; sufficiently large premium reductions could also make a more limited subsidy eligibility ceiling or phaseout financially and politically sustainable. Pediatric reinsurance would lower the cost of family coverage, reduce related Premium Tax Credits, and lessen the need to move some children into publicly financed CHIP coverage. Portable state-exchange coverage supported by employer contributions would reduce coverage disruptions during job transitions and could limit some of the increase in Medicaid enrollment that ordinarily accompanies recessions. Finally, extending Medicaid to lower-income adults may cost less than providing those same households with especially generous Premium Tax Credits for private plans that pay higher provider prices. These offsets do not eliminate the need for formal budget estimates, but they mean that the gross cost of each reform would substantially overstate its likely net fiscal cost.

The four reforms also require coordination across the tax code, the Affordable Care Act, Medicaid, CHIP, ERISA, employer-mandate rules, and state insurance regulation. The framework is modular, but each module needs a complete statutory architecture rather than relying on broad administrative discretion.

Conclusion

The United States does not need to choose between dismantling the Affordable Care Act and replacing nearly the entire health insurance system with Medicare for All. A more durable strategy would preserve what works, correct identifiable market failures, and direct public resources toward the places where they produce the greatest benefit for patients and taxpayers.

The four reforms reinforce one another. Reinsurance lowers the underlying cost of individual coverage and reduces the amount required for Premium Tax Credits. Lower premiums make portable employer contributions more practical. Modernized HSAs and FSAs help moderate-income families manage unavoidable cost sharing without sacrificing retirement security. Medicaid provides a more efficient and protective alternative for households that cannot realistically absorb private-plan deductibles.

Each reform could be enacted independently, but together they offer an alternative to the recurring cycle of partisan expansion and retrenchment. The objective is neither to maximize government insurance nor to preserve private insurance for its own sake. It is to provide affordable and continuous coverage, encourage work and mobility, protect household savings, preserve meaningful choice, and obtain better value from every public dollar.

Health care reform should not require Americans to surrender the coverage they value, remain trapped in jobs they would otherwise leave, or risk financial ruin when illness strikes. A well-designed system can provide security without imposing uniformity, support markets without ignoring their failures, and expand coverage without abandoning fiscal discipline. That is the practical path forward.

Appendix: Notes

Technical Notes for “A Durable Path Forward on American Health Care”

These notes provide additional evidence and explain legal, budgetary, and administrative considerations underlying the four reforms. They supplement the main discussion without interrupting its flow.

Note 1. Trump Administration Health Policy Changes and Coverage Effects

During the first Trump administration, the 2017 tax legislation reduced the Affordable Care Act’s individual-mandate penalty to zero, the administration approved Medicaid work-requirement demonstrations under Section 1115 waivers, and federal rules expanded the availability of short-term limited-duration insurance. The Biden administration later reversed or limited several of those policies, expanded Premium Tax Credits through the end of 2025, streamlined Medicaid enrollment, and again restricted short-term plans.

Federal policy shifted again after President Trump’s return to office. The enhanced Premium Tax Credits expired after December 31, 2025. Public Law 119-21, signed on July 4, 2025, requires certain Medicaid expansion adults to document work or other qualifying activities, requires eligibility redeterminations every six months, shortens retroactive coverage, imposes cost sharing on some expansion adults, constrains several state Medicaid financing mechanisms, and tightens Marketplace subsidy eligibility, verification, and repayment rules. The law also expands Health Savings Account eligibility by treating bronze and catastrophic Marketplace plans as HSA-compatible beginning in 2026.

Early 2026 data indicate substantial coverage and affordability effects. KFF estimates that average monthly effectuated Marketplace enrollment could decline from 22.3 million in 2025 to approximately 17.5 million in 2026 and could be as low as 16.5 million. Average enrollee premium payments increased from $113 to $178 per month, while average Marketplace deductibles increased from $2,759 to $3,786 as many consumers shifted toward lower-premium, higher-deductible plans. These figures remain preliminary because complete effectuated-enrollment data for 2026 are not yet available.

The Congressional Budget Office separately estimates that the Medicaid provisions of Public Law 119-21 will increase the number of uninsured people by 7.5 million in 2034 relative to its January 2025 baseline. That estimate should not be mechanically added to separate estimates of the effects of the Premium Tax Credit expiration because the estimates use different policy comparisons and may use different projection years.

Sources: KFF, Health Provisions in the 2025 Federal Budget Reconciliation Law; KFF, What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles; Congressional Budget Office, Supplemental Cost Estimate for Public Law 119-21; Internal Revenue Service, One Big Beautiful Bill Provisions.

Note 2. ICHRAs and Portable Employer Benefits

Individual Coverage Health Reimbursement Arrangements have allowed employers to reimburse employees for individual-market insurance on a tax-preferred basis since 2020. The portable-benefit proposal would build on this framework by placing employee-owned coverage on equal footing with traditional group insurance, simplifying employee-class rules, coordinating employer contributions with Premium Tax Credits, and standardizing treatment under the employer mandate and small-business tax rules.

Under current law, an offer of an affordable ICHRA generally affects an employee’s eligibility for Premium Tax Credits. A broader portable-benefit system would therefore require an integrated affordability formula under which employer assistance and federal subsidies complement one another without leaving coverage gaps or providing duplicate benefits.

Source: U.S. Department of Labor, Individual Coverage Health Reimbursement Arrangements Final Rule and Model Notice materials.

Note 3. Deductibles, HSAs, and FSAs

KFF reports that the average 2025 single deductible among workers enrolled in plans with a general annual deductible was $1,886. At firms with 10 to 199 workers, the average was $2,631. Public Law 119-21 broadened HSA eligibility, but broader eligibility alone does not provide the cash needed by households that cannot afford to contribute.

The Employee Benefit Research Institute reports that roughly half of FSA account holders forfeited funds in 2023 and that the average forfeiture was $436. Current law permits, but does not require, an employer to offer a limited carryover or grace period.

Allowing unused FSA balances to move into retirement accounts would require a specific tax rule because FSA contributions were excluded from taxable income when contributed. One possible structure would treat transferred balances as pre-tax retirement funds that are taxable when withdrawn. Other structures could achieve the same objective, provided they prevent both forfeiture and a double tax benefit.

Sources: KFF, 2025 Employer Health Benefits Survey; EBRI, Updates from EBRI’s Flexible Spending Account Database; IRS Publication 969; IRS, One Big Beautiful Bill Provisions.

Note 4. Medicaid Cost, Access, Financing, and Pediatric Coverage

Two often-cited 2018 Congressional Budget Office figures provide historical context. CBO estimated average federal Marketplace and Basic Health Program subsidies of $6,300 per subsidized enrollee and average federal Medicaid benefit spending of $4,230 per adult enrollee. Because the figures cover different populations and categories of expenditure, they do not establish a fixed percentage saving from moving a particular enrollee from Marketplace coverage to Medicaid.

More direct evidence comes from a matched Colorado study of adults near the Medicaid eligibility threshold. Average annual spending was $2,484 under Medicaid and $4,553 under Marketplace coverage, while average out-of-pocket spending was $45 and $569, respectively. When the researchers repriced, services using Medicaid payment rates, the statistically significant total-cost difference disappeared, indicating that lower provider prices explained much of Medicaid’s cost advantage. Earlier national studies estimated that private coverage would cost approximately 18 to 26 percent more for comparable low-income adults. The evidence therefore supports a Medicaid cost advantage, but not a single national savings percentage applicable in every state or population.

Lower Medicaid spending partly reflects lower payments to hospitals, physicians, and other providers. These payment levels can affect physician participation, specialist access, and appointment availability, although the magnitude varies across states and services. Any expansion above the current Affordable Care Act eligibility threshold should include network-adequacy standards, reporting on appointment wait times, and authority for targeted payment supplements where access is inadequate, particularly in behavioral health, obstetrics, rural care, primary care, and pediatric specialties.

The budgetary effects of expansion would depend heavily on the federal matching rate. A complete estimate should separately report total medical spending, federal outlays, state outlays, displaced Premium Tax Credits, beneficiary premiums and cost sharing, and administrative expenses. Medicaid may reduce total medical spending while shifting costs differently between the federal government and the states.

For children above current Medicaid eligibility limits, policymakers could use broader CHIP eligibility, pediatric reinsurance, or a combination of the two. The most efficient approach may vary by state because Marketplace premiums, CHIP thresholds, provider networks, and family cost-sharing rules differ. Any approved model should cover essential pediatric services and protect continuity of care for children with complex medical, developmental, behavioral, or disability-related needs.

Sources: JAMA Network Open, Comparison of Utilization, Costs, and Quality of Medicaid vs. Subsidized Private Health Insurance for Low-Income Adults; KFF, Medicaid Spending Growth Compared to Other Payers; Urban Institute and Robert Wood Johnson Foundation, Is It Still Less Expensive to Serve Low-Income People in Medicaid Than Private Coverage?; Medicaid and CHIP Payment and Access Commission, Provider Payment and Delivery Systems; MACPAC, Evaluating the Effects of Medicaid Payment Changes on Access to Physician Services.