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By Ralph Lindeman
In order for the health reform law to achieve its goal of expanding coverage to millions of uninsured Americans, the federal government—as well as the states—will need to engage in significant outreach efforts targeting people with low and moderate incomes, health policy experts said Jan. 6.
According to the Congressional Budget Office, more than 30 million people without health insurance will become eligible to obtain coverage beginning in 2014 as a result of the Patient Protection and Affordable Care Act, which expands Medicaid eligibility and mandates new state-based health insurance exchanges offering low-income subsidies.
However, expanded coverage will not occur automatically and policymakers need to heed previous examples of coverage expansion efforts that fell short of their goals, said Stan Dorn, a senior fellow in health policy at the Urban Institute, which sponsored the forum on “Enrolling the Uninsured under National Health Reform.”
Among the failures he cited was the expanded coverage offered to laid-off workers in the 2009 American Recovery and Reinvestment Act, which reached only about a quarter of those eligible.
“Not many people are wildly optimistic” that the new health reform law will succeed in reaching most of the uninsured, Dorn said, “but it is not Mission Impossible.”
Several “success stories” show how maximum enrollment can be achieved, he said, citing the implementation in 2006 of Medicare Part D drug benefits and the health reform law implemented in Massachusetts. Medicare Part D reached nearly three in four eligible beneficiaries less than six months after the new benefit became available, Dorn said, while in Massachusetts the percentage of uninsured dropped to the lowest level recorded in any state nine months after the new state health law went into effect.
Applying some of the lessons learned from these earlier examples, Dorn outlined three steps federal policymakers could take to maximize enrollment by the uninsured.
First, he recommended using federal income tax returns to help find the uninsured, noting that 86 percent of low-income people without health insurance file income tax returns in order to obtain federal tax credits. Information available on most income tax returns would enable federal officials to determine the eligibility of the uninsured for expanded health coverage options, Dorn said.
Second, a strong consumer assistance effort will be needed, one that includes public-private partnerships, to help those applying for coverage to navigate the new eligibility rules, Dorn said.
A third step would be to develop a “data matching machine” in each state that collects all available income data on individuals from state and federal agencies. The objective should be to enable those applying for health coverage to submit a single application that would determine their eligibility for a variety of programs, including Medicaid, federal low-income subsidies for coverage on the exchanges, or the Children's Health Insurance Program (CHIP), he said.
In sum, Dorn said, “It's not Mission Impossible, just Mission Really, Really Difficult.”
Taking a more optimistic view about PPACA reaching the uninsured was Penny Thompson, deputy director for Medicaid and CHIP services at the Centers for Medicare & Medicaid Services. The “confluence of advantages” aiding CMS she cited were past experience, new policies, and IT infrastructure.
In terms of experience, Thompson noted that in recent years many states have begun using such tools as “continuous eligibility” and “presumptive eligibility” for CHIP beneficiaries to avoid gaps in coverage during eligibility redeterminations. These kinds of techniques can be used in implementing PPACA‘s coverage expansion, she said.
New policies under PPACA starting in 2014 will provide for a single eligibility category for Medicaid, allowing people with incomes up to 133 percent of the poverty level to obtain coverage, she said. The new Medicaid eligibility rules, which will be based on an enrollee's modified adjusted gross income, will eliminate more complicated eligibility determinations that used a variety of “asset tests,” she said.
With respect to IT infrastructure, Thompson noted, “The good news is that there are a lot of IT innovators thinking about how to reach consumers and navigate through the system.” The goal will be to make the online application experience “delightful” to consumers, she said, adding it should be as easy as buying shoes on Zappos.com or books on Amazon.com.
Also appearing on the panel was Mark McClellan, former CMS administrator during the George W. Bush administration, who recounted the CMS efforts to implement the Medicare Part D drug benefit. He also emphasized the importance of outreach efforts, noting “It's not enough to send eligible people a letter.” CMS conducted follow-up phone calls and sponsored educational events across the country to inform people about the new benefits, he said.
Jason Levitis, a senior adviser with the Treasury Department's Office of Tax Policy, spoke about the premium tax credits available as subsidies to help the uninsured to obtain health coverage on health insurance exchanges.
In order to maximize coverage, he said, tax credits will be available to low-income uninsured individuals at the beginning of each tax year. As a result, even if a recipient's income increases during the year, coverage will continue, although there may be some reimbursement of the credit required at the end of the tax year.
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