November 17, 2020 Paul Shafer, PhD1; Austin B. Frakt, PhD1,2
Author
Affiliations Article Information JAMA. 2020;324(19):1931-1932. doi:10.1001/jama.2020.21609
Once
former Vice President Biden clinched the Democratic Party presidential
nomination in early June, it was clear that the chances of a
Medicare-for-all–type system in the near future had all but disappeared. Yet, frustration with the
fragmented health insurance system crystallized support of progressives for a
fundamental rethinking of how US residents pay for health care. Although many
progressives will not be satisfied with incremental changes to health care
financing, such an approach is considered likely if
Biden is elected. Below are several possible concrete steps his administration
could take to fulfill his pledge to improve access to and
affordability of health care coverage.
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Automatic
Enrollment
One
of the biggest problems with the social safety net—including Medicaid and the
Affordable Care Act (ACA) marketplace—is getting and keeping people enrolled.
Administrative burdens on consumers are substantial and have become amplified during the coronavirus disease
2019 (COVID-19) pandemic. People unable to fight through a daunting process requiring documentation
and certifications are left out of programs for which they are eligible.
The
Biden plan would help US residents with low incomes get health insurance
coverage by making a free public option available everywhere, including in
states without Medicaid expansion. Moreover, it would automatically enroll
individuals “when they interact with certain institutions…or other programs,”
including, the plan notes, the Supplemental Nutrition Assistance Program,
popularly known as food stamps.
But
the plan lacks detail on how this would actually work. One mechanism it could
leverage already exists in 14 states, though you have probably never
heard of express lane eligibility (ELE). Created
with reauthorization of the Children’s Health Insurance Program (CHIP) in 2009,
ELE allows states to use data collected by other agencies to make Medicaid and
CHIP eligibility decisions automatically. For example, Louisiana, which
implemented ELE in 2010, automatically enrolled 20 000 people in
Medicaid that year. It cost the state less to do this than an outreach campaign
that enrolled just 329 children.
One
reason states have underinvested in ELE is because it
could strain state budgets if it is too
successful in enrolling people in public programs, such as Medicaid, for which
the state pays some of the cost. In addition, though the Medicaid and CHIP
Payment Advisory Commission has recommended making ELE permanent, the authority that ELE
relies on remains temporary, perhaps deterring states from committing to it.
Although
some issues would need to be worked out to take ELE nationwide, it is
a platform that the Biden administration could build on to bring this promise
of automatic enrollment in Medicaid or a free marketplace public option to
life.
Getting
Employers out of the Insurance Game
Because
of World War II–era tax breaks that remain in place today, the vast majority of
working-aged adults and their families (163 million US residents) are covered
through employer-sponsored insurance. Despite the reliance on it in the US,
work-based coverage comes with problems that the country is
now in a good position to solve.
During
economic downturns, such as the COVID-19–induced one the US is experiencing
now, the loss of a job can mean the loss of access to affordable coverage. Even
for those employed with good health insurance, the arrangement can keep
people locked into jobs they would prefer to
leave. If the tax break for employer-sponsored coverage ended, the marketplace
would become the largest health insurance market in the country overnight.
Given the technical problems that plagued the
marketplace in the early days, that might be worrying to some. But those
problems are long gone. And, with a massive expansion of the market, insurers
would be eager to participate. Concerns about bare counties without individual market
insurers and shallow risk pools would instantly
disappear.
Yet,
it may not be wise to implement a massive change to the health system
overnight. There are incremental ways to ease out of employer-sponsored
coverage. One of them is part of a rule that the Trump administration finalized last year. It allows employers to
help their employees buy coverage in the marketplace using health reimbursement
arrangements. The administration projected that more than 11 million
workers will be covered this way by 2029.
With
this as a first step, Biden has a plan to take
another. He wants to allow all those who can obtain more affordable
coverage with marketplace subsidies than through their workplace to be able to
do so. The ACA created an obstacle to this by making most people with available
job-based coverage ineligible for financial help in the
marketplace.
The
next administration could also work with Congress to reform the tax break conferred on
employer-sponsored plans with the ACA’s Cadillac tax (a substantial tax on the
most generous employer-provided health insurance plans) having been delayed and
then repealed. With these ideas, reliance on
employer-sponsored coverage would gradually diminish, thereby reducing the
problems it creates.
Change
is slow and hard, particularly in health care. There are many other proposals
in the Biden plan to improve access and affordability, but also many ideas that
will not, such as all-payer rate setting or price transparency. Inching closer to
universal coverage and improving the affordability of care without
fundamentally rethinking the health care system is going to require some experimentation, even if change will not
always be popular.
Corresponding
Author: Paul R. Shafer,
PhD, Department of Health Law, Policy, and Management, Boston University, 715
Albany St, Talbot 340 W, Boston, MA 02118 (pshafer@bu.edu).
Conflict
of Interest Disclosures: None
reported.
Previous
Publication: This article was
previously published in JAMA Health Forum at
jamahealthforum.com.
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