Transcript National health reform proposals: Broad consensus but

The Affordable Care Act:
Opening the Door to 21st-Century
Public Benefits?
The Coalition to Promote Access & Opportunity
November 10, 2010 Webinar
Stan Dorn, Senior Fellow
The Urban Institute
Washington, DC
Overview
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Basic perspective
Affordable Care Act
Other public benefits
Part I
Basic perspective
Key 21st-century advances
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Computers
 Increasingly, the government has data showing who
qualifies for benefits
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Behavioral economics
 People are not entirely rational
 If consumers must do more to apply, fewer will claim
benefits
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Implication: whenever possible, use data
rather than application forms to qualify
people for benefits
 Why deny aid until the consumer tells the government
what it already knows?
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It’s not just low-income people and
public benefits
Percentage of eligible workers who participate in
tax-advantaged retirement accounts
90%
33%
10%
Independent enrollment in
IRA
Firms where new hires
enroll in 401(k) only after
completing a form
Firms where new hires go
into 401(k) UNLESS they
complete an opt-out form
Sources: Etheredge, 2003; EBRI, 2005; Laibson (NBER), 2005.
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Trade-offs
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The traditional trade-off with simplifying
applications—
 Simplification’s advantages
o Less red tape for consumers, hence more participation
o Lower administrative cost for government
 Simplification’s disadvantage: greater risk of error
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Data-based eligibility ends the trade-off
 All the advantages of simplification PLUS
 Greater protection of program integrity
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GAO agrees
“Improved information systems, sharing of data between programs, and
use of new technologies can help programs to better verify eligibility and
make the application process more efficient and less error prone. These
strategies can improve integrity not only by preventing outright abuse of
programs, but also by reducing chances for client or caseworker error or
misunderstanding. They can also help programs reach out to populations
who may face barriers. One strategy involves sharing verified eligibility
information about applicants across programs. Data sharing prevents
applicants from having to submit identical verification to multiple programs
for which they may be eligible, and it can also speed up the sometimeslengthy application process. In addition, data sharing allows programs to
check the veracity of information they receive from applicants with other
databases.”
Government Accountability Office, “Means-tested Programs: Information
on Program Access Can Be an Important Management Tool,” 3/05, GAO05-221
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Example: Medicare Part D LowIncome Subsidies
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1/2006, Part D coverage of prescription drugs
began
 Included low-income subsidies (LIS)
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By 6/16/06, 74% of eligible beneficiaries
received LIS
 Most qualified based on data matches with state
Medicaid programs or SSA
 People who received Medicaid last year automatically
get LIS this year
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Now, 81% of eligible beneficiaries receive LIS
Part II
The Patient Protection and
Affordable Care Act (ACA)
Health coverage subsidies in 2014
and beyond
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Medicaid and CHIP
 Medicaid up to 138% of the federal poverty level (FPL) for
children and adults
 CHIP continues at 2009 eligibility levels (for awhile)
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Health insurance exchanges in each state—places
where individuals and firms can enroll into health plans
 States run the exchange directly or contract with a non-profit
 The federal government runs the exchange if the state chooses
not to (or if HHS determines the state can’t do a decent job)
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Individuals covered in the exchange receive subsidies
up to 400% FPL
Eligibility determination and
enrollment
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1 application form for Medicaid, CHIP, and
subsidies in the exchange
 Disclosure authorization as an alternative
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Can file on-line, by mail, in person, by phone
Medicaid, CHIP, exchange work together behind
the scenes to determine eligibility seamlessly
“Modified adjusted gross income”
 Note: 75% of uninsured < 100% FPL file tax returns
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Data-matching with numerous sources
I.T. Infrastructure
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Federal reference software application model
 Consumers’ identifying information is input
 Software gathers data from multiple federal & state
sources, applies business rules to determine eligibility
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Common definition of core data elements
 Example: is DOB 1 field or 3?
 State eligibility systems need “translation” routines to
and from this common definition
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Funding sources for states
 90% FMAP for Medicaid
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 Exchange grants
Whither Medicaid?
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In exchange, the information superhighway:
 Eligibility criteria fit data from tax returns
 Year-end reconciliation addresses changing circumstances
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With Medicaid—muddy cow paths?
 Do eligibility criteria fit available data?
o Ambiguity around “point in time” eligibility: can states deny eligibility
until applicants produce pay stubs?
o “Newly eligible adults” – how to show an adult would have been
ineligible under 2009 rules? Add back asset tests for all applicants?
 At renewal, can states terminate Medicaid for people who fail
to return paperwork, even if data show continued eligibility?
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Part III
Other public benefits
Shorter-term strategies
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Ensure that Medicaid and the ACA succeed,
providing a model for other benefits
Give Medicaid enrollees a chance to obtain
other benefits
Connect other programs to the ACA’s IT system
 Explicit part of ACA Section 1561
 Potentially allow NGOs to gain access
 Key:
o Consumer authorization
o Data-sharing agreements and procedures to limit use and
protect confidentiality and data security
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Excerpts from ACA Sec. 1561
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HHS to “develop interoperable and secure standards and protocols that
facilitate enrollment of individuals in Federal and State health and human
services programs.”
Such standards and protocols “shall allow for”
 “Electronic matching against existing Federal and State data, including vital records,
employment history, enrollment systems, tax records, and other data determined
appropriate by the Secretary to serve as evidence of eligibility and in lieu of paperbased documentation”
 “Simplification and submission of electronic documentation, digitization of documents,
and systems verification of eligibility”
 “Capability for individuals to apply, recertify and manage their eligibility information
online, including … at points of service, and other community-based locations” etc.
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HHS “may require, as a condition of receiving Federal funds for the health
information technology investments, that States or other entities
incorporate such standards and protocols into such investments”
Longer-term: eligibility criteria that
fit available data
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If another program has already found someone to have
income below a certain level, why force another program
to reexamine that same issue?
 Express Lane Eligibility for child health;
 Categorical eligibility for SNAP;
 Direct Certification of eligibility for NSLP; etc.
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Base eligibility on prior-year tax data
 Medicare Part B means-tested premiums;
 College student aid; etc.
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Rosetta Stone income methodology?
Trade-off: eligibility rules less targeted to need
Conclusion
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The ACA’s IT infrastructure offers enormous
potential to streamline enrollment into multiple
public benefits
Directions for action
 Near-term: helping ACA succeed with Medicaid
 Near- and medium-term: connecting other benefits to
ACA’s IT infrastructure
 Longer-term: redefining public benefit eligibility in
terms that fit available data
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