Table 3.

Healthcare Reform Strategies and Impacts.

Reform strategy	Advantages	Disadvantages	Impact on marginalized groups	References
Institute state-specific mandates	Prevent adverse selection (withdrawal of healthy people from the insurance Marketplace)	Can drive up health care costs; Loss of individual autonomy	Reduce overall cost of insurance for low-income individuals	Levitis 2018 [22]; eHealth 2019 [25]; Gasteier 2018 [99]
Increase opportunity to purchase and hold short-term insurance	Increased availability and affordability of insurance; Greater freedom of choice	Could divert healthy individuals away from the insurance Marketplace; Coverage of ten essential benefit categories no longer guaranteed	Costs of BRCA1/2 genetic testing, colonoscopy and polyp removal increased; Denial of insurance to individuals with preexisting conditions	Palanker et al. 2017 [100]
Engage more states in Medicaid expansion	Decreased rate of uninsured; Earlier cancer detection	Greater federal and state healthcare costs; Reduced quality of care, e.g., in appointment availability and wait time	Reduced number of low-income and racial-ethnic minority uninsured	Artiga et al. 2019 [46]
Enact Medicare for All	Decreased rate of uninsured, aided by unrestricted or lowered age of enrollment	Sizable increase in federal budget; Increased insurance premiums or payroll taxes depending on strategy used	BRCA1/2 counseling and genetic testing and colonoscopy covered; increased availability to low income and racial-ethnic minority groups	Oberlander 2019 [56]; Committee for a Responsible Federal Budget 2019 [60]
Enact Medicare for All variations (e.g., a public option)	Decreased rate of uninsured; Allowing a public option would be nondisruptive to current insurance Marketplace	Disparity between public and private insurance payment rates; Possible employer “dumping” of sickest into public plans	Supports individuals at high-risk, e.g., those with a family history of breast or colorectal cancer; increased availability to low-income and racial-ethnic minority groups	Hellmann 2019 [61]; Glied 2019 [62]
Permit state-specific benchmarking of benefits plans	States can select benefit plans according to their particular population’s needs	Conservative states could select least generous benefits	Increased flexibility could work either way – increase benefits (e.g., Lynch syndrome genetic testing) or reduce benefits (e.g., pre-cancer screening) for those in need	Gibson et al. 2018 [101]
Federal agency revised guidance on or legislative amendment of ACA	Provide changes to ACA benefits that apply nationally	Incremental increases to insurance costs; Value of changes depends on rigor of evidence	Introduce changes that increase covered services (e.g., Lynch syndrome testing, BRCA genetic testing) for groups in need	CMS 2018 [102]; Mach and Kinzer 2018 [103]