The Challenges of Migrating the Previously Uninsured into New Insurance Venues
Tampa—Managing the movement of the estimated 47 million to 50 million uninsured Americans into new insurance venues was the topic of a roundtable discussion led by Joe deSimone, research director, Health Strategies Group, during a session at the AMCP meeting. Among the challenges included are the changing landscape created by the Medicaid expansion alternatives; barriers to continuity of care because of issues such as churning and chronic conditions that the newly insured have; administrative risks caused by the combining of Medicaid and marketplace benefits in alternative benefit plans, as these plans will not cover all of the uninsured; and changes brought about by small employers as they seek to hire fewer full-time employees and look for private exchanges to emerge.
The Patient Protection and Affordable Care Act provides coverage with a “no wrong door” policy, a system by which consumers may apply through different agencies but are seamlessly routed to the program that best meets their needs; however, discerning new eligibility for Medicaid and Medicaid re-enrollment are not yet clear, according to Mr. deSimone. Most applicants (60%) appear eligible for the health insurance marketplace, and 30% of applicants appear eligible for Medicaid/Children’s Health Insurance Program.
More than half of the uninsured population (52%) will access the marketplace. There are >5 million marketplace enrollees, most of whom are ≥35 years of age. The majority of individuals eligible for the marketplace are also eligible for tax subsidies. Approximately one-third of the uninsured population (33%) are eligible for Medicaid or newly eligible for Medicaid, with non-US citizens comprising the remaining 15% of the uninsured. Individuals eligible for Medicaid are more likely to be childless men <44 years of age who did not graduate from high school, have an income at 138% below the federal poverty level, and had no prior insurance.
One issue the newly insured will likely have in common is the existence of chronic conditions, largely in the areas of behavioral health, asthma, diabetes, cancer, and HIV, according to the presentation.
The expansion of Medicaid, which is being implemented in 26 states and the District of Columbia, will cover close to 10 million lives, Mr. deSimone noted. A total of 25 states are not moving forward. Some, including Arkansas, are expanding into the health insurance marketplace. States that do not expand are creating a coverage gap, with close to 5 million uninsured individuals living at 100% below the federal poverty level who still require coverage. These states are seeking alternatives via means such as Section 1115 expansion waivers to leverage the health insurance marketplace. Those following the Arkansas model will result in approximately 8 million individuals able to access the marketplace.
Churning, the process of cycling between coverage levels due to income variability, will be common, particularly this year, and will affect approximately 1 in 3 adults, Mr. deSimone said. Nearly 6.9 million individuals <65 years of age have an income of 138% below the federal poverty level, making them eligible for subsidies or Medicaid; about 19.5 million have an income level of 138% above the federal poverty level and are eligible for subsidies but ineligible for Medicaid; and about 3 million have an income of 400% above the federal poverty level and are ineligible for subsidies.
To combat churning, states can undertake a number of options, including streamlining eligibility to provide continuous enrollment and ensure continuity; alternative benefit plans, which are designed exclusively for the newly-eligible Medicaid population and include the 10 essential health benefits available in the health insurance marketplace; and a new basic health plan (to come in 2015), which will provide a low income benefit alternative to Medicaid or the marketplace.
These new programs, Mr. deSimone concluded, will not be without unintended consequences. Streamlining eligibility requires means testing, and ethical issues exist at the margins of eligibility. Alternative benefit plan waivers that pay marketplace premiums with Medicaid dollars create a new administrative burden (eg, coupon programs that may trigger the antikickback statute). Finally, he said, Medicaid expansion, along with the health insurance marketplace, exacerbates existing physician shortages, with high pressure to leverage emerging care models.
