Assessing the Promise and Risks of Income-Based Third-Party Payment Programs.

Issue: Consumers' concerns about affordability limit participation in ACA marketplaces. Funded by local hospital systems and run by independent nonprofits, third-party payment (TPP) programs improve affordability for low-income consumers by paying premium costs not covered by tax credits. Goal: To assess the potential of TPP to make marketplace coverage more affordable, without harming insurance risk pools. Methods: Interviews in May and June 2016 with program administrators, hospital systems, carriers, and consumer groups in five localities and the Washington State marketplace. Key Findings: The most effective local program reached 1,148 people, or 25 percent of all eligible marketplace enrollees. Other local programs served between 202 and 934 consumers; the Washington State program reached 1,133. Findings suggest that without TPP, numerous beneficiaries would have remained uninsured. Hospitals funding these programs reported net financial benefits, with declines in uncompensated care exceeding program costs. Carriers reported no adverse selection in these carefully designed programs. Conclusions: Widespread adoption of TPP could help additional low-income consumers obtain marketplace coverage. Hospitals' financial gains from TPP programs make replication more feasible. However, broader policies, such as increased premium tax credits and cost-sharing reductions, are likely needed for major nationwide improvements to affordability.

New Risk-Adjustment Policies Reduce But Do Not Eliminate Special Enrollment Period Underpayment.

Millions of uninsured Americans do not sign up for available coverage despite job loss or other factors that would make them eligible for special enrollment periods (SEPs). Such periods let people enroll in nongroup insurance outside the usual open enrollment period for Marketplace coverage. Concerned that risk adjustment results in underpayment for the health risks associated with SEP enrollees, carriers rarely market their products to consumers eligible for SEPs, and many do not pay agents and brokers to enroll such consumers. To address the apparent underpayments, federal officials added enrollment duration factors that, starting in 2017, increased risk scores for SEP enrollees and other part-year members. Using individual-market claims data for 2015 from two large carriers, we found that risk adjustment did, in fact, undercompensate plans for part-year members. However, underpayment was much larger for SEP enrollees than for part-year members who joined during open enrollment periods. Short-term, urgent health problems appeared to drive enrollment more for SEP enrollees than for part-year members who signed up during open enrollment. We also found that the federal government's enrollment duration factors will remedy underpayment for part-year members whose coverage begins during open enrollment but leave carriers significantly underpaid for SEP enrollees. For carriers to recruit rather than avoid SEP enrollees, further increases to risk adjustment for such enrollees are likely needed.

"Canaries in the mine..." the impact of Affordable Care Act implementation on people with disabilities: Evidence from interviews with disability advocates.

BACKGROUND: The Affordable Care Act (ACA) has many provisions that could improve health care for people with disabilities, including Medicaid expansion and the ability to purchase qualified health plans (QHPs). OBJECTIVE: To explore how ACA provisions affected people with disabilities' health care experiences during the first enrollment period and to suggest hypotheses for future research. METHOD: We conducted semi-structured interviews with disability community leaders (N = 16) from a maximum variation sample of 10 U.S. states between March and April 2015. Our interdisciplinary team used qualitative description and a series of immersion-crystallization cycles to identify themes. RESULTS: Four themes for people with disability emerged. (1) State-based climate influenced ACA implementation decisions (e.g., Medicaid expansion) and thus individual experiences. (2) Medicaid coverage was viewed as more relevant, affordable and comprehensive than QHPs. (3) Despite expanded coverage, pre-enrollment challenges included accessing enrollment resources (e.g., website, helpline) and obtaining detailed plan information and post-enrollment barriers to needed care due to inadequate provider networks, high co-pays, or visit/service limitations. (4) Navigators with prior experience working with people with disabilities attenuated the identified barriers. CONCLUSION: Our results depict a complex interplay between the ACA, state efforts and community outreach that influenced people with disabilities' experience. While coverage gains were generally positive, challenges emerged in plan selection and accessing care following enrollment. Attending to contextual factors like state climate and navigator experience as part of ACA implementation may determine health care access, and, ultimately, the health status, of people with disabilities and other population groups.

Spurring enrollment in Medicare savings programs through a substitute for the asset test focused on investment income.

Fewer than one-third of eligible Medicare beneficiaries enroll in Medicare savings programs, which pay premiums and, in some cases, eliminate out-of-pocket cost sharing for poor and near-poor enrollees. Many beneficiaries don't participate in savings programs because they must complete a cumbersome application process, including a burdensome asset test. We demonstrate that a streamlined alternative to the asset test-allowing seniors to qualify for Medicare savings programs by providing evidence of limited assets or showing a lack of investment income-would permit 78 percent of currently eligible seniors to bypass the asset test entirely. This simplified approach would increase the number of beneficiaries who qualify for Medicare savings programs from the current 3.6 million seniors to 4.6 million. Such an alternative would keep benefits targeted to people with low assets, eliminate costly administrative expenses and obstacles to enrollment associated with the asset test, and avoid the much larger influx of seniors that would occur if the asset test were eliminated entirely.

COBRA subsidies for laid-off workers: an initial report card.

Initial reports about the new COBRA premium subsidy program for recently laid-off workers indicate that enrollment in COBRA continuation coverage has increased substantially, with a healthier mix of individuals enrolling than before. Moreover, implementation has gone smoothly, and most eligible people have heard about the subsidy. Still, many of those who are eligible cannot afford to purchase COBRA coverage, even with the 65 percent premium subsidy. Very high subsidies and very easy enrollment are likely needed to enroll all, or nearly all, newly unemployed people who lack another source of affordable coverage. If the subsidies are extended beyond February 2010, Congress should provide new assistance in ways that are consistent with the existing administrative infrastructure and rules for both COBRA and the ARRA subsidies

Administrative costs for advance payment of health coverage tax credits: an initial analysis.

Health Coverage Tax Credits (HCTCs), created under the Trade Act of 2002, pay 65 percent of health insurance premiums for certain workers displaced by international trade and early retirees. These credits can be paid directly to insurers when monthly premiums are due, in advance of annual tax return filing. While HCTC administrative costs have fallen significantly since program start-ups, they still comprise approximately 34 percent of total spending. Changes to the HCTC program could lower administrative costs, but the size of the resulting savings is unknown. These findings have important implications for any future tax credit plan intended to cover the uninsured.

Limited take-up of health coverage tax credits: a challenge to future tax credit design.

The Trade Act of 2002 created federal tax credits to subsidize health coverage for certain early retirees and workers displaced by international trade. Though small, this program offers the opportunity to learn how to design future tax credits for larger groups of uninsured. During September 2004, the most recent month for which there are data about all forms of Trade Act credits, roughly 22 percent of eligible individuals received credits. The authors find that health insurance tax credits are more likely to reach their target populations if such credits: 1) limit premium costs for the low-income uninsured and do not require full premium payments while applications are pending; 2) provide access to coverage that beneficiaries value, including care for preexisting conditions; 3) are combined with outreach that uses easily understandable, multilingual materials and proactive enrollment efforts; and 4) feature a simple application process involving one form filed with one agency.