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How Auto-Enrollment Can Achieve Near-Universal Coverage: Policy and Implementation Issues

June 10, 2021

Issue: Automatic enrollment is receiving increased policy attention as a means of achieving universal coverage. Auto-enrollment also could have eliminated insurance gaps that occurred during the COVID-19 pandemic. However, it could face resistance from some Americans who would newly be expected to pay premiums. The approach also raises difficult design and implementation issues.Goal: Explore how two auto-enrollment strategies, one affecting all legal residents and another affecting a narrower low-income population, might work.Methods: Based on lessons learned from the Affordable Care Act and understanding of subsidized insurance programs, we explore design and implementation issues, such as how to deem enrollment, how to collect premiums, and which exemptions to permit. We also use the Urban Institute's Health Insurance Policy Simulation Model (HIPSM) to estimate coverage and cost implications of each approach.Key Findings and Conclusions: Both the comprehensive and limited approach to auto-enrollment would require the development of new administrative systems and enhanced marketplace subsidies to improve coverage affordability. Each approach would operate more simply if accompanied by a public insurance option. We conclude that the administrative and financing challenges related to auto-enrollment can be addressed and that a balance between public costs and sufficient political support could be identified.

How Would State-Based Individual Mandates Affect Health Insurance Coverage and Premium Costs?

July 20, 2018

Issue: The Tax Cuts and Jobs Act of 2017 eliminated the financial penalty of the Affordable Care Act's individual mandate. States could reinstate a similar penalty to encourage health insurance enrollment, ensuring broad sharing of health care costs across healthy and sick populations to stabilize the marketplaces.Goal: To provide state-by-state estimates of the impact on insurance coverage, premiums, and mandate penalty revenues if the state were to adopt an individual mandate.Methods: Urban Institute's Health Insurance Policy Simulation Model (HIPSM) is used to estimate the coverage and cost impacts of state-specific individual mandates. We assume each state adopts an individual mandate similar to the ACA's.Findings and Conclusion: If all states implemented individual mandates, the number of uninsured would be lower by 3.9 million in 2019 and 7.5 million in 2022. On average, marketplace premiums would be 11.8 percent lower in 2019. State mandate penalty revenues would amount to $7.4 billion and demand for uncompensated care would be $11.4 billion lower. The impact on coverage and on premiums varies in significant ways across states. For example, in 2019, the number of people uninsured would be 19 percent lower in Colorado and 10 percent lower in California if they implemented their own mandates. With mandates in place, average premiums would be 4 percent lower in Alaska and 15 percent lower in Washington.

Insurers Remaining in Affordable Care Act Markets Prepare for Continued Uncertainty in 2018, 2019

March 19, 2018

A new report, supported by the Robert Wood Johnson Foundation and authored by Georgetown CHIR and Urban Institute researchers, examines how uncertainty over the long-term future of the ACA have affected insurers' participation and premium setting decisions for the 2018 and 2019 plan years. We interviewed 10 insurance companies participating in the individual market in 28 states and D.C. and a few key takeaways include:The rollback of the ACA's individual mandate led insurers to implement higher premiums in 2018 and will likely drive premiums even higher in 2019. However, insurers' views differed on the impact of repealing the individual mandate. Some felt it would ultimately lead to a collapse of the market and are considering further retrenchment; others felt confident that a market for highly subsidized, low-income consumers would continue.The midyear loss of the ACA's cost-sharing reduction plan reimbursements drove 2018 premium increases ranging from 10 percent to 20 percent. However, several insurers noted that proposed federal legislation to restore cost-sharing reduction funding could result in significant disruption and sticker shock for consumers receiving premium tax credits.All insurers had concerns regarding an expansion of short-term and association health plans under the President's October 12, 2017 executive order. Insurers worry that an expansion of these plans could siphon healthy people away from the individual market, leaving a sicker, costlier population.Insurers with narrow provider networks reported concerns about the potential exit of competing insurers, noting that their network providers lacked capacity to take an influx of new, often sicker enrollees. They further noted that unexpected insurer exits can produce considerable disruption, particularly if remaining insurers lack sufficient time or ability to readjust their pricing.A worsening of the risk pool will likely cause many insurers to reduce their market presence, will cause all insurers to raise their premiums, and may lead to more exits.

Why Does Medicare Advantage Work Better Than Marketplaces?

January 30, 2018

Medicare Advantage (MA) markets are significantly more robust, with higher private insurer participation and lower average premium growth than the Affordable Care Act (ACA) marketplaces. The programs differ in insurer participation, the risk-adjustment system, and provider payments.Key FindingsBased on MA's success relative to the ACA marketplaces in terms of marketplace strength and long-term stability, there are five policies that could be useful for the ACA marketplaces:Raise enrollment in marketplace plans by increasing premium and cost-sharing subsidies and eliminating short-term plans;Cap provider payment rates at Medicare rates or a fixed percentage above them;Standardize cost-sharing within metal tiers, or limit the number of plan designs available;Lift the budget neutrality requirement for risk adjustment in the marketplaces; andUse a higher benchmark than the second-lowest-cost silver plan for calculating premium tax credits. ConclusionMA's success lays out a possible model for the ACA marketplaces. By adopting policies geared towards increasing enrollment in marketplace plans as well as insurer participation, the ACA marketplaces could become stronger and more stable.

Russians Back Protests, Political Freedoms and Putin, Too

May 23, 2012

Presents survey findings about Russians' reaction to the December 2011 parliamentary and March 2012 presidential elections and subsequent protests, attitudes toward democracy, and views of leaders, nationalism, and Russia?s global image.

ACA Implementation Monitoring and Tracking: Declining Health Insurance in Low-Income Working Families and Small Businesses

May 19, 2012

Examines falling employer-sponsored insurance rates among low-wage employees of large firms and high-wage employees of small firms and how provisions of federal healthcare reform address coverage for these groups.

Medicare, Medicaid and the Deficit Debate

May 19, 2012

Examines 2000-10 Medicare and Medicaid expenditures; projections for 2011-20 from the Centers for Medicare and Medicaid Services and the Congressional Budget Office; contributing factors, including enrollment growth; and proposals for curbing spending.

A Decade of Coverage Losses: Implications for the Affordable Care Act

February 24, 2012

Examines 2000-10 trends in employer-sponsored health insurance and Medicaid/CHIP coverage by income group; contributing factors, including a growing low-income population; and projected coverage among low-income adults under the 2010 healthcare reform.

ACA Implementation Monitoring and Tracking: Maryland Site Visit Report

February 20, 2012

Assesses Maryland's progress in implementing the 2010 federal healthcare reform, including legislation to establish an insurance exchange, information technology development to facilitate enrollment and eligibility determinations, and insurance reforms.

ACA Implementation Monitoring and Tracking: Rhode Island Site Visit Report

February 13, 2012

Assesses Rhode Island's progress in implementing the 2010 federal healthcare reform, including earlier reforms that facilitate Medicaid expansion, advances in establishing a health insurance exchange, and efforts to pass private market reform legislation.

Changes in Health Insurance Coverage in the Great Recession, 2007-2010

December 15, 2011

Examines trends in the number of uninsured by age, race/ethnicity, work status, citizenship status, and region; contributing factors such as the decline in employer-sponsored coverage and real incomes; and mitigating factors such as Medicaid provisions.

Refocusing Responsibility for Dual Eligibles: Why Medicare Should Take the Lead

October 5, 2011

Examines the federal share of costs for those eligible for both Medicare and Medicaid, potential savings from better management of Medicare-funded care, and risks of greater state responsibility for spending. Calls for federally led efforts to cut costs.