Cost-Sharing Reductions, Technocrat Tinkering, and Market-Based Health Policy

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The Trump Administration has exposed both the durability and vulnerability of the Patient Protection and Affordable Care Act’s insurance reforms. One of the Administration’s first strikes at “Obamacare” was to discontinue federal government payment of cost-sharing reductions, which insurers pay to low-income enrollees on the exchanges to reduce their out-of-pocket share of medical spending. The states struck back with a clever solution that could hold insurers and enrollees harmless. This Article examines this strategy and why, while impressive, it reaffirms larger problems with the ACA’s market-based approach to health reform and the need for new pathways forward.


Health law & policy, insurance regulation, Patient Protection & Affordable Care Act, PPACA, ACA, insurance exchanges, Obamacare, cost-sharing reduction payments, CSRs, premium subsidies, market-based reform, bureaucracy

Publication Title

Journal of Law, Medicine & Ethics

Publication Citation

46 J. L. Med. & Ethics 873 (2018)