Linda J. Blumberg, Matthew Buettgens, and John Holahan
HEALTH POLICY CENTER, URBAN INSTITUTE
Gordon Mermin and Frank Sammartino
URBAN-BROOKINGS TAX POLICY CENTER
March 2017
In Brief
Congress is currently considering passage of the American Health Care Act (AHCA). This bill would
repeal large portions of the Affordable Care Act (ACA), including most of its sources of revenue, and it
would introduce significant changes to the Medicaid program and the private nongroup insurance
market. We use the Urban-Brookings Tax Policy Center Microsimulation Model and the Urban Institute
Health Policy Center’s Health Insurance Policy Simulation Model (HIPSM) to allocate changes in taxes
and federal health benefits across families grouped by income.
We find that the AHCA’s changes to federal taxes and health care benefits would be very
regressive: taking both tax reductions and benefit reductions into account, the average high-income
family would be significantly better off and the average low-income family would be significantly worse
off under the AHCA. The average family with less than $10,000 of income in 2022 would be $1,420
worse off, a net reduction of more than 30 percent of the family’s income. The average family with more
than $200,000 of income in 2022 would be $5,640 better off, a net increase of 1.1 percent of the
family’s income. Using a measure of family income as a percentage of the federal poverty level (FPL),
families with income below 200 percent of FPL would experience net tax and benefit losses and families
with income above 300 percent of FPL would experience net gains under the AHCA. The greatest net
gains would go to families with income exceeding 600 percent of the FPL.
HEALTH POLICY CENTER AND TAX POLICY CENTER
Who Gains and Who Loses
under the American Health Care Act
2
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
FIGURE 1
Distribution of Change in Average Net Transfers (Benefits less Taxes) under the AHCA, 2022
Sources: Urban-Brookings Tax Policy Center Microsimulation Model (version 0217-1) and Urban Institute Health Policy Center's
Health Insurance Policy Simulation Model (2017).
Notes:
a
Income is modified adjusted gross income (MAGI), defined as adjusted gross income plus nontaxable Social Security
benefits and tax-exempt interest. Income includes both filing and non-filing units but excludes dependents of other tax units. Tax
units with negative MAGI are excluded from the bottom income class but are included in the totals. Analysis includes AHCA
provisions as amended on March 21, 2017.
-$2,000
-$1,000
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
Income
a
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
3
Introduction
The version of the American Health Care Act
1
that was introduced in the House of Representatives on
March 6, 2017, would repeal and replace substantial portions of the Affordable Care Act. We analyze
the distributional effects of changes to federal taxes and health care spending that would result from
this bill (including the changes made to it on March 21, 2017), estimating net changes by income level
and by income relative to poverty categories.
The AHCA would eliminate almost all of the ACA’s revenue provisions starting in 2017. It would
eliminate the ACA’s cost-sharing subsidies (in 2020), income-related premium tax credits (modified in
2018 and eliminated in 2020), individual and employer mandate penalties (as of 2016), nongroup and
small-group insurance actuarial value standards (in 2020), 3:1 age rating limits (in 2020), funding for the
Prevention and Public Health Fund (at the end of 2018), and enhanced matching rate for people in the
Medicaid expansion population who do not maintain enrollment after 2019. Beginning in 2020, the bill
would introduce age-related tax credits for those purchasing insurance in the nongroup market, permit
states to adopt age rating at any ratios (with a presumption of 5:1 rating), impose late enrollment
penalties of 30 percent of premiums for those who do not stay continuously covered, provide nine years
of federal funding for a new State Innovation Grants and Stability Program that requires state matching
funds, increase tax benefits associated with health savings accounts, and convert Medicaid funding from
an open-ended federal matching entitlement to a program based on per capita allotments and limits on
annual growth.
We use the Urban-Brookings Tax Policy Center Microsimulation Model and the Urban Institute
Health Policy Center’s Health Insurance Policy Simulation Model to allocate changes in taxes and
federal health benefits across income groups.
Methods
Our estimates of federal Medicaid spending, AHCA tax credits, ACA premium tax credits, and ACA cost-
sharing reductions were produced by the Urban Institute’s Health Insurance Policy Simulation Model.
Estimates of Medicaid spending in 2022 were derived using the same methods as our recent report on
Medicaid per capita caps (Holahan et al. 2017). Estimates of ACA tax credits and cost-sharing
reductions were done in the same manner as the ACA estimates from our recent report on the impact of
ACA repeal (Buettgens et al. 2016).
The simulation of nongroup enrollment under the AHCA was new for this analysis. For each family,
we computed the premium tax credit amount as defined in the bill and applied them to premiums for a
60 percent actuarial value plan, a plan consistent with bronze-level plans currently offered in the ACA-
compliant nongroup markets. This plan level is appropriate for this analysis because the AHCA would
maintain the current nongroup insurance out-of-pocket maximums and essential health benefit
standards while eliminating the actuarial value standards. We accounted for other factors in addition to
income that disqualify people for the credit: employer coverage, eligibility for public coverage, and
4
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
documentation status. Total premiums were computed for each coverage state. Instead of using the
ACA’s individual mandate, we modeled the AHCA’s 30 percent premium surcharge for those who do not
maintain insurance coverage as a reduction in the value of being uninsured. Based on this reduction,
individuals and families in our model decided whether or not to enroll in private nongroup coverage,
considering factors such as premiums, tax credits, health needs, risk of high health costs, and family
income.
We assume that under the AHCA, states would eliminate Medicaid eligibility for the ACA expansion
population unless the state had expanded eligibility for childless adults up to 100 percent of FPL at the
traditional federal matching rate before the ACA. This differs from the assumption the Congressional
Budget Office used in its analysis of the bill, and as a consequence, our estimates of the AHCA’s impact
on the federal deficit are smaller (CBO 2017).
Our analysis accounts for changes to Medicaid per capita cap growth rates made in manager’s
amendments to the bill on March 21, 2017.
2
Though the amendments also include a provision increasing
subsidization of adults ages 50 to 64, the Senate will ultimately devise the structure of this additional
subsidy; thus, we do not include it in this analysis.
We simulated the proposal’s tax changes using the Urban-Brookings Tax Policy Center
Microsimulation Model. We simulated repeal of the following ACA tax provisions:
3
3.8 percent net investment income tax and 0.9 percent additional Medicare hospital insurance
tax for individuals with incomes exceeding $200,000 and couples with incomes exceeding
$250,000
Individual and employer mandate penalties for inadequate health insurance
Excise taxes on health insurance providers and pharmaceutical and medical device
manufacturers and importers
Additional limitations on the medical expense deduction
Premium tax credits for health insurance purchased through ACA Marketplaces
Additionally we simulated delaying the “Cadillac” tax on high-cost health plans until 2026. We also
simulated the new age-related health insurance credits, calibrating take-up to match projections from
HIPSM. To make the analyses consistent, we distributed HIPSM projections of Medicaid benefits and
cost-sharing subsidies to tax units in the TPC model in the same income groups.
Results
Table 1 shows the distribution of tax changes resulting from the AHCA in 2022 by tax unit income
group; we refer to tax units as families for convenience.
4
The tax changes include repeal of almost all of
the ACA’s revenue provisions and the individual and employer mandate penalties, elimination of the
ACA’s income-related tax credits, and implementation of the AHCA’s age-related tax credits. Table 2
shows the distribution of federal benefit changes that would result from the AHCA, including the new
Medicaid per capita caps, federal matching rate changes, and elimination of the ACA’s cost-sharing
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
5
subsidies. Table 3 combines the findings from tables 1 and 2 into net federal tax and benefit changes by
income group. Comparable distributional findings by income relative to the poverty level are found in
appendix tables A.1 through A.3. In each table, average tax changes and benefit changes are calculated
over the total number of families in each income group, not only those families that would actually
experience a change.
TABLE 1
Distribution of Federal Tax Change under the AHCA, 2022
Income
a
Number of
tax units
(thousands)
Share of all
tax units (%)
Average tax
change per
Average tax
change as
percentage of
income (%)
Share of total
tax change
(%)
< $10,000
17,630
9.8
-4.8
4.3
$10,000–$20,000
23,370
12.9
0.1
-0.5
$20,000–$30,000
25,600
14.2
0.8
-5.9
$30,000–$40,000
18,410
10.2
0.5
-3.8
$40,000–$50,000
13,310
7.4
0.1
-0.6
$50,000–$75,000
26,520
14.7
-0.4
7.3
$75,000–$100,000
16,850
9.3
-0.5
9.1
$100,000–$200,000
27,250
15.1
-0.5
20.4
> $200,000
10,780
6.0
-1.1
70.6
All
180,680
100.0
-0.6
100.0
Addendum
> $1,000,000
780
0.4
-1.6
46.2
Sources: Urban-Brookings Tax Policy Center Microsimulation Model (version 0217-1) and Urban Institute Health Policy Center's
Health Insurance Policy Simulation Model (2017).
Notes: The AHCA would repeal the following ACA taxes: 3.8 percent net investment income tax; 0.9 percent additional Medicare
hospital insurance tax; excise tax on employers offering inadequate health insurance coverage; excise tax on individuals without
adequate health insurance; increase in the threshold for medical expense deductions; excise taxes on health insurance providers,
pharmaceutical manufacturers and importers, and medical device manufacturers and importers; and the premium tax credit. The
bill would delay the Cadillac tax until 2026 and enact a new health insurance tax credit. Analysis excludes changes to health
savings accounts and medical flexible spending accounts. Analysis captures change in taxes and credits but does not include the
impact of changes in premiums or the welfare impact of changes in health insurance coverage or coverage generosity.
a
Income is modified adjusted gross income (MAGI), defined as adjusted gross income plus nontaxable Social Security benefits and
tax-exempt interest. Income includes both filing and non-filing units but excludes dependents of other tax units. Tax units with
negative MAGI are excluded from the bottom income class but are included in the totals.
Taxes would decrease for families with incomes of $50,000 or more and, in general, increase for
families with lower incomes (table 1). Those with incomes below $10,000 would experience a tax
decrease on average because they would become eligible for age-related premium tax credits; however,
as shown in table 2, simultaneous Medicaid benefit losses for this income group would be much larger
than the decrease in taxes. For families with incomes above $50,000 per year, the average tax reduction
increases markedly as income increases. The average family with more than $200,000 of income would
receive a $5,680 tax reduction, and this high-income group would account for 70.6 percent of the net
tax decrease under the AHCA. Families with income exceeding $1,000,000 would see a tax decrease of
6
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
$51,410 on average, accounting for 46.2 percent of the net tax decrease for the whole population. This
decrease would amount to 1.6 percent of their income on average.
TABLE 2
Distribution of Change in Federal Medicaid and Cost-Sharing Benefits under the AHCA, 2022
Income
a
Number of
tax units
(thousands)
Share of all
tax units (%)
Average
benefit change
per tax unit ($)
Average
benefit change
as percentage
of income (%)
Share of total
benefit change
(%)
< $10,000
17,630
9.8
-1,630
-37.4
33.1
$10,000–$20,000
23,370
12.9
-1,050
-6.9
28.3
$20,000–$30,000
25,600
14.2
-520
-2.1
15.3
$30,000–$40,000
18,410
10.2
-400
-1.2
8.5
$40,000–$50,000
13,310
7.4
-310
-0.7
4.8
$50,000–$75,000
26,520
14.7
-180
-0.3
5.5
$75,000–$100,000
16,850
9.3
-100
-0.1
1.9
$100,000–$200,000
27,250
15.1
-50
0.0
1.6
> $200,000
10,780
6.0
-40
0.0
0.5
All
180,680
100.0
-480
-0.6
100.0
Sources: Urban-Brookings Tax Policy Center Microsimulation Model (version 0217-1) and Urban Institute Health Policy Center's
Health Insurance Policy Simulation Model (2017).
Notes:
a
Income is modified adjusted gross income (MAGI), defined as adjusted gross income plus nontaxable Social Security
benefits and tax-exempt interest. Income includes both filing and non-filing units but excludes dependents of other tax units. Tax
units with negative MAGI are excluded from the bottom income class but are included in the totals.
Table 2 shows the change in federal health care spending resulting from Medicaid funding
reductions and elimination of the ACA’s federal cost-sharing reductions. The average reduction in
federal health care benefits would increase quickly as income decreases, reflecting the fact that these
benefits accrue largely to low-and middle-income populations under the ACA. Almost 77 percent of the
federal funding losses under the AHCA would come from families earning less than $30,000 per year.
Most of the rest of the funding reductions would come from families with incomes between $30,000
and $50,000 per year. The federal benefit losses to families with incomes below $10,000 would amount
to 37.4 percent of their income on average. As table 2 shows, federal funding losses as a share of income
decrease dramatically as income increases.
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
7
TABLE 3
Distribution of Change in Net Transfers (Benefits less Taxes) under the AHCA, 2022
Income
a
Number of
tax units
(thousands)
Share of all
tax units (%)
Average net transfer
change per tax unit
($)
Average net transfer
change as percentage
of income (%)
< $10,000
17,630
9.8
-1,420
-32.6
$10,000–$20,000
23,370
12.9
-1,070
-7.1
$20,000–$30,000
25,600
14.2
-720
-2.9
$30,000–$40,000
18,410
10.2
-580
-1.7
$40,000–$50,000
13,310
7.4
-350
-0.8
$50,000–$75,000
26,520
14.7
60
0.1
$75,000–$100,000
16,850
9.3
370
0.4
$100,000–$200,000
27,250
15.1
600
0.4
> $200,000
10,780
6.0
5,640
1.1
All
180,680
100.0
0
0.0
Sources: Urban-Brookings Tax Policy Center Microsimulation Model (version 0217-1) and Urban Institute Health Policy Center's
Health Insurance Policy Simulation Model (2017).
Notes:
a
Income is modified adjusted gross income (MAGI), defined as adjusted gross income plus nontaxable Social Security
benefits and tax-exempt interest. Income includes both filing and non-filing units but excludes dependents of other tax units. Tax
units with negative MAGI are excluded from the bottom income class but are included in the totals.
Table 3 shows the net effect of the AHCA’s federal tax and health benefit changes. On average,
families with incomes below $50,000 would be worse off, and the average amount of the loss in both
absolute dollars and as a share of income would increase as income falls. For example, the average net
loss for those with incomes below $10,000 would amount to 32.6 percent of income, but the net loss for
families with income between $30,000 and $40,000 would amount to 1.7 percent of income. Families
with incomes over $50,000 in 2022 would see net gains under the AHCA, but the gains would constitute
a small percentage of income (less than 0.5 percent) for those with incomes below $200,000. Families
with incomes above $200,000 would receive the largest net gains in absolute dollars ($5,640 on
average) and as a share of income (1.1 percent). Similarly, appendix table A.3 shows that families with
incomes below 200 percent of FPL would experience measurable net losses, but those with incomes
exceeding 600 percent of FPL would gain the most, $2,250 on average.
Conclusion
Upper-income families would receive net benefits from the tax and spending changes proposed in the
AHCA, and lower-income families would experience net losses. Higher-income families benefit the most
from the tax cut, with 70.6 percent of the tax reductions in 2022 received by those with incomes over
$200,000 and 46.2 percent of the tax reductions received by those with incomes over $1,000,000.
Reductions in federal funding for health benefits would hurt lower-income families the most; families
with incomes below $30,000 would sustain more than three-quarters of the losses in benefits. Taking
both tax and benefit changes into account, the largest average gains under the AHCA would go to those
with the highest incomes ($5,640 on average for those with incomes over $200,000), and the largest
average losses from the AHCA would go those with the lowest incomes.
8
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
APPENDIX TABLE A.1
Distribution of Federal Tax Change under the AHCA, 2022
Income relative
to FPL
a
Number of
tax units
(thousands)
Share of all
tax units
(%)
Average tax
change per
tax unit ($)
Average tax change
as percentage of
income (%)
Share of total
tax change
(%)
< 50% of FPL
13,470
7.5
-210
-6.4
3.3
50–100% of FPL
18,730
10.4
-250
-1.8
5.4
100–138% of FPL
15,180
8.4
510
2.4
-8.9
138–200% of FPL
24,320
13.5
540
1.9
-15.1
200–300% of FPL
28,350
15.7
-190
-0.4
6.2
300–400% of FPL
20,330
11.3
-440
-0.7
10.3
400–500% of FPL
16,000
8.9
-470
-0.6
8.7
500–600% of FPL
11,530
6.4
-540
-0.5
7.2
> 600% of FPL
31,780
17.6
-2,280
-0.8
83.5
All
180,680
100.0
-480
-0.6
100.0
Sources: Urban-Brookings Tax Policy Center Microsimulation Model (version 0217-1) and Urban Institute Health Policy Center's
Health Insurance Policy Simulation Model (2017).
Notes: FPL = federal poverty level. The AHCA would repeal the following ACA taxes: 3.8 percent net investment income tax; 0.9
percent additional Medicare hospital insurance tax; excise tax on employers offering inadequate health insurance coverage;
excise tax on individuals without adequate health insurance; increase in the threshold for medical expense deductions; excise
taxes on health insurance providers, pharmaceutical manufacturers and importers, and medical device manufacturers and
importers; and the premium tax credit. The bill would delay the Cadillac tax until 2026 and enact a new health insurance tax
credit. Analysis excludes changes to health savings accounts and medical flexible spending accounts. Simulation of health
insurance credits calibrated to match HIPSM. Analysis captures change in taxes and credits but does not include the impact of
changes in premiums or the welfare impact of changes in health insurance coverage or coverage generosity.
a
Income is modified adjusted gross income (MAGI), defined as adjusted gross income plus nontaxable Social Security benefits and
tax-exempt interest. Income includes both filing and non-filing units but excludes dependents of other tax units. Tax units with
negative MAGI are excluded from the bottom income class but are included in the totals.
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
9
APPENDIX TABLE A.2
Distribution of Change in Federal Medicaid and Cost-Sharing Benefits under the AHCA, 2022
Income relative
to FPL
a
Number of
tax units
(thousands)
Share of
all tax
units (%)
Average
benefit change
per tax unit ($)
Average benefit
change as percentage
of income (%)
Share of total
benefit
change (%)
< 50% of FPL
13,470
7.5
-1,770
-53.8
27.5
50–100% of FPL
18,730
10.4
-1,160
-8.4
25.1
100–138% of FPL
15,180
8.4
-1,240
-5.8
21.7
138–200% of FPL
24,320
13.5
-470
-1.6
13.2
200–300% of FPL
28,350
15.7
-200
-0.5
6.5
300–400% of FPL
20,330
11.3
-110
-0.2
2.6
400–500% of FPL
16,000
8.9
-70
-0.1
1.3
500–600% of FPL
11,530
6.4
-50
0.0
0.7
> 600% of FPL
31,780
17.6
-30
0.0
1.1
All
180,680
100.0
-480
-0.6
100.0
Sources: Urban-Brookings Tax Policy Center Microsimulation Model (version 0217-1) and Urban Institute Health Policy Center's
Health Insurance Policy Simulation Model (2017).
Notes: FPL = federal poverty level.
a
Income is modified adjusted gross income (MAGI), defined as adjusted gross income plus nontaxable Social Security benefits and
tax-exempt interest. Income includes both filing and non-filing units but excludes dependents of other tax units. Tax units with
negative MAGI are excluded from the bottom income class but are included in the totals.
APPENDIX TABLE A.3
Distribution of Change in Net Transfers (Benefits less Taxes) under the AHCA, 2022
Income relative
to FPL
a
Number of
tax units
(thousands)
Share of all
tax units (%)
Average net transfer
change per tax unit ($)
Average net transfer
change as percentage
of income (%)
< 50% of FPL
13,470
7.5
-1,770
-53.8
50–100% of FPL
18,730
10.4
-1,160
-8.4
100–138% of FPL
15,180
8.4
-1,240
-5.8
138–200% of FPL
24,320
13.5
-470
-1.6
200–300% of FPL
28,350
15.7
-200
-0.5
300–400% of FPL
20,330
11.3
-110
-0.2
400–500% of FPL
16,000
8.9
-70
-0.1
500–600% of FPL
11,530
6.4
-50
0.0
> 600% of FPL
31,780
17.6
-30
0.0
All
180,680
100.0
-480
-0.6
Sources: Urban-Brookings Tax Policy Center Microsimulation Model (version 0217-1) and Urban Institute Health Policy Center's
Health Insurance Policy Simulation Model (2017).
Notes: FPL = federal poverty level.
a
Income is modified adjusted gross income (MAGI), defined as adjusted gross income plus nontaxable Social Security benefits and
tax-exempt interest. Income includes both filing and non-filing units but excludes dependents of other tax units. Tax units with
negative MAGI are excluded from the bottom income class but are included in the totals.
10
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
Notes
1. The AHCA consists of two separate bills, one from the House Ways and Means Committee
(https://waysandmeans.house.gov/wp-content/uploads/2017/03/AmericanHealthCareAct_WM.pdf) and one
from the House Energy and Commerce Committee
(http://energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/documents/American
HealthCareAct.pdf).
2. American Health Care Act of 2017, H.R. 1628, 115th Cong. (2017).
3. For description and analysis of the distribution of ACA taxes, see Mermin (2017). We exclude AHCA provisions
that enhance health savings accounts and reduce limits on medical flexible spending accounts.
4. A tax unit is an individual or a married couple who files a tax return or would file a tax return if their income
were high enough, along with all dependents of that individual or married couple. A tax unit can differ from a
family in certain situations.
References
Buettgens, Matthew, Linda J. Blumberg, John Holahan, and Siyabonga Ndwandwe. 2016. The Cost of ACA Repeal.
Washington, DC: Urban Institute.
CBO (Congressional Budget Office). 2017. Cost Estimate: American Health Care Act. Washington, DC: CBO.
Holahan, John, Matthew Buettgens, Clare Wang Pan, and Linda J. Blumberg. 2017. The Impact of Per Capita Caps on
Federal and State Medicaid Spending. Washington, DC: Urban Institute.
Mermin, Gordon. 2017. Affordable Care Act Taxes. Washington, DC: Urban Institute.
About the Authors
Linda J. Blumberg is a senior fellow in the Health Policy Center at the Urban Institute,
having joined in 1992. She is an expert on private health insurance (employer and
nongroup), health care financing, and health system reform. Her recent work includes
extensive research related to the Affordable Care Act (ACA); in particular, providing
technical assistance to states, tracking policy decisionmaking and implementation
efforts at the state level, and interpreting and analyzing the implications of particular
policies. She codirects a large multiyear project using qualitative and quantitative
methods to monitor and evaluate ACA implementation in states and nationally.
Examples of her research include several analyses of competition in nongroup
Marketplaces, estimation of the implications of ACA repeal through the reconciliation
process, strategies for improving the ACA, an array of studies on the implications of the
King v. Burwell Supreme Court case, analysis of the remaining uninsured, and
codirecting 22 state case studies of stakeholder perspectives on ACA implementation.
She also led the quantitative analysis supporting the development of a “Roadmap to
Universal Coverage” in Massachusetts, a project with her Urban colleagues that
informed the 2006 comprehensive reforms in that state. She received her PhD in
economics from the University of Michigan.
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
11
Matthew Buettgens is a senior research analyst in the Health Policy Center at the
Urban Institute, where he is the mathematician leading the development of Urban’s
Health Insurance Policy Simulation Model (HIPSM). The model is currently being used
to provide technical assistance for health reform implementation in Massachusetts,
Missouri, New York, Virginia, and Washington as well as to the federal government. His
recent work includes a number of research papers analyzing various aspects of national
health insurance reform, both nationally and state-by-state. Research topics have
included the costs and coverage implications of Medicaid expansion for both federal
and state governments; small firm self-insurance under the Affordable Care Act and its
effect on the fully insured market; state-by-state analysis of changes in health
insurance coverage and the remaining uninsured; the effect of reform on employers;
the affordability of coverage under health insurance exchanges; and the implications of
age rating for the affordability of coverage.
John Holahan is an Institute fellow in the Health Policy Center at Urban, where he
previously served as center director for over 30 years. His recent work focuses on
health reform, the uninsured, and health expenditure growth. He has developed
proposals for health system reform, most recently in Massachusetts. He has examined
the coverage, costs, and economic impact of the Affordable Care Act (ACA), including
the costs of Medicaid expansion as well as the macroeconomic effects of the law. He
has also analyzed the health status of Medicaid and exchange enrollees, and the
implications for costs and exchange premiums. Holahan has written on competition in
insurer and provider markets and implications for premiums and government subsidy
costs as well as on the cost-containment provisions of the ACA.
Gordon Mermin is a senior research associate in the Urban-Brookings Tax Policy
Center at the Urban Institute, where he focuses on the tax treatment of retirement
saving, higher education, and health insurance. Mermin develops and maintains the Tax
Policy Center’s microsimulation model of the federal tax system and is part of the
effort to extend the model to state-level analysis. He has written extensively on
retirement policy and work at older ages.
Frank Sammartino is a senior fellow at the Urban-Brookings Tax Policy Center and an
affiliate of Urban’s State and Local Finance Initiative. His current work focuses on the
interaction among federal, state, and local tax policies and on the influence of tax and
transfer policies on income inequality. Sammartino has written extensively about
federal tax and retirement policy issues. In an earlier stint at Urban, he designed and
developed the initial version of the Tax Policy Center microsimulation model, which
researchers use to analyze how federal tax policies affect federal revenues and families
at different income levels. He also led a team of researchers in developing a new
version of the Dynamic Simulation of Income Model, which Urban researchers use to
analyze how public policies and economic and demographic forces shape retirement
income security.
12
WHO GAINS AND WHO LOSES UNDER THE AMERICAN HEALTH CARE ACT
Acknowledgments
Support for this research was provided by the Robert Wood Johnson Foundation through the Health
Policy Center. The views expressed here do not necessarily reflect the views of the Foundation. We are
grateful to them and to all our funders, who make it possible for Urban to advance its mission.
The views expressed are those of the authors and should not be attributed to the Urban Institute,
its trustees, or its funders. Funders do not determine research findings or the insights and
recommendations of Urban experts. Further information on the Urban Institute’s funding principles is
available at www.urban.org/support.
The authors are grateful for comments and suggestions from Eric Toder and for copyediting by
Vicky Gan.
ABOUT THE URBAN INST
ITUTE
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