Challenges in Implementing Reforms for People with Income
and Employment Changes
Pamela Farley Short
Penn State University
Acknowledgements
• Research support from The Commonwealth Fund
• Collaborators– Katherine Swartz, Harvard – Namrata Uberoi, Penn State– Deborah Graefe, Penn State
Reforms Offer Universal Access to Affordable Insurance
• Individual health insurance exchanges, with premium credits for some enrollees
• Lacking access to affordable employer plans
• Between 133% and 400% of poverty line
• Small employer exchanges – Separate or combined with individual (states decide)
• Medicaid for all children and adults < 133% of poverty line
• Children’s Health Insurance Program (CHIP) extended to 2019
Changes in income, employment, or family membership
• Could cause lots of people to gain or lose coverage from these sources each year
• Implementation Challenge: How to maintain – Coverage– Affordability– Shared responsibility
when someone’s ability to pay for insurance is changing?
Year-to-Year Changes in Annual Income (2005 vs.2006)
Source: Authors’ tabulations of 2004 Survey of Income and Program Participation
2006
Low-income Workers are Concentrated in Small Firms
Source: Authors’ tabulations of 2004 Survey of Income and Program Participation
Percent in firms with 100 or fewer employees
Coordinating Medicaid with premium creditsto buy insurance from exchange is CRITICAL.
• Many new enrollees will be coming from the other program.
• Adds another large, federal bureaucracy (the Internal Revenue Service) to Medicaid’s federal-state mix
• History of special efforts needed to achieve high rates of participation in Medicaid
• Tax credits based on annual income, but Medicaid eligibility based on income at “time of application”
Policy suggestions
• Design eligibility and navigation systems to help people cope with changes in eligibility– Emphasize hand-offs between programs– Will need to answer “what if” questions involving
income and employment changes in coming year
• Consider State Basic Health Plan to bring everyone below 200% of the poverty line under state umbrella
Policy suggestions (cont.)
• Extend Medicaid/CHIP eligibility through the next open season to the end of the year.
• Combine individual and small employer exchanges.
• Provide broad access to the same plans (or provider networks) through Medicaid and the exchange(s).
