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)
76% same category
<133% FPL
16% 7%
2006
2%
133-199% FPL
17%
51% same category
<133% FPL
30%
133-199% FPL
3%
200-399% FPL
9%
200-399% FPL
73% same category
15%
≥400% FPL
≥400% FPL
2005 Income
12%
87% same category
2006 Income
Source: Authors’ tabulations of 2004 Survey of Income and Program Participation
Low-income Workers are
Concentrated in Small Firms
Percent in firms with 100 or fewer employees
Source: Authors’ tabulations of 2004 Survey of Income and Program Participation
Coordinating Medicaid with premium credits
to 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).