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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.

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.

Building a Better "Cadillac"

January 4, 2017

The excise tax on premiums paid for high-cost employer-sponsored plans, also known as the Cadillac tax, is an important provision of the Affordable Care Act (ACA) and should be retained even if the larger law is repealed because it will not only help control the growth of health care spending but also will provide revenues needed to pay for any potential ACA replacement, according to a new paper (PDF) by experts at the Urban Institute and the Center for Health Policy at Brookings. However, the tax should be improved to increase political acceptability and to correct genuine shortcomings in the current law.

Financial Burden of Medical Spending by State and the Implications of the 2014 Medicaid Expansions

April 3, 2013

This study is the first to offer a detailed look at medical spending burden levels, defined as total family medical out-of-pocket spending as a proportion of income, for each state. It further investigates which states have greater shares of individuals with high burden levels and no Medicaid coverage, but would be Medicaid eligible under the 2014 rules of the Affordable Care Act should their state choose to participate in the expansion. This work suggests which states have the largest populations likely to benefit, in terms of lowering medical spending burden, from participating in the 2014 adult Medicaid expansions.

The Individual Mandate in Perspective

March 27, 2012

Estimates the number and percentage of Americans who are exempt from the healthcare reform law's requirement to have insurance coverage; those who are subject to it but already have coverage; and those who are required to purchase coverage or pay a fine.

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.

The Effects of Health Reform on Small Businesses and Their Workers

June 21, 2011

Synthesizes research findings about how the 2010 healthcare reform will affect small business owners and employees, including savings in healthcare costs and premium contributions, coverage for workers and dependents, offer rates, and number of uninsured.

Multi-State Health Insurance Exchanges

April 1, 2011

Considers possible advantages of creating multi-state exchanges: administrative economies of scale, ability to serve multi-state metropolitan areas, pooling across state lines, and a critical mass of insured persons to establish stable risk pools.

How Will the Patient Protection and Affordable Care Act Affect Small, Medium, and Large Businesses?

August 1, 2010

Outlines how the 2010 healthcare reform's insurance mandates, state exchanges, and tax credits will affect businesses in each category and according to whether they currently offer insurance, including new options and financial obligations or assistance.

How Will the Patient Protection and Affordable Care Act of 2010 Affect Young Adults?

July 6, 2010

Summarizes how healthcare reform provisions including the expansion of dependent coverage, subsidies for insurance premiums, and penalties for opting out of coverage will affect young adults ages 19-29 by income level and gender.

How Will the PPACA Impact Individual and Small Group Premiums in the Short and Long Term?

July 6, 2010

Outlines the changes to non- and small group premiums to be implemented in 2010 and 2014 and their potential effects on out-of-pocket costs, pre-existing condition exclusions, and premiums, as well as determining factors such as provider payment rates.