1. 1 Review of Insurance Coverage Expansion Options James R. Tallon, Jr. United Hospital Fund December 12, 2005

2. 2 Current Profile of Eligibility, Enrollment, and Uninsured in New York

3. 3 % of Federal Poverty Level (FPL) Public Assistance Need Standard (varies by county) 200% 133% 250% ** 87% 100% 150% 250% ** 200% Infants Children Age 1-5 Pregnant Women Parents † Childless Adults †† New York State Eligibility Rules for Medicaid, Child Health Plus, Family Health Plus, and Healthy New York* Employed Individuals Small Business 208% No Ceiling Children Age 6-18 *** 100% 250% **

4. 4 *Medicaid and Child Health Plus A, and Healthy New York eligibility are expressed in net income while Child Health Plus B and Family Health Plus eligibility are expressed in gross income, as written in HCRA 2000 and Medicaid law. The 2005 Federal Poverty Level (FPL) is $9,570 for an individual. ** Children with gross family income above 160% FPL are charged an income-related premium. Premiums for children with gross family income between 160-222% FPL are $9/month/child up to $27; for children with gross family income between 223-250% FPL premiums are $15/month/child up to $45. ***Through March 2005, the Child Health Plus A eligibility level for children ages 6-19 was 133% FPL. Effective April 2005, the Child Health Plus A eligibility level for children ages 6-19 years was lowered to 100%FPL, at which time children in that age range with gross family income between 100%FPL and 133% FPL who were enrolled in Child Health Plus A were shifted into Child Health Plus B. † “Parent” is defined as a parent of a child under 21 years who lives in the household. Medicaid eligibility includes disabled adults and 19- and 20-year-olds up to 87% FPL. FHP eligibility includes 19- and 20- year-olds living with their parents up to 150% FPL. †† “Childless adult” is defined as a non-disabled adult aged 21 years and over who does not have a child living in the household. FHP eligibility includes 19- and 20-year-olds not living with their parents up to 100% FPL. Note: Low-income, uninsured women who are diagnosed with breast or cervical cancer through screenings in New York’s Healthy Women Partnerships program are eligible for Medicaid coverage. Women must have income levels below 250% FPL to qualify for the screenings. Females and males of childbearing age with income up to 200% FPL are eligible for Medicaid Family Planning Services. As of July 2003, disabled workers aged 16-64 with net income of up to 250%FPL and non-exempt resources up to $10,000 are eligible for Medicaid coverage through the Medicaid Buy-In for Working People with Disabilities program (MBIWPD); enrollees with incomes above 150% FPL will eventually be subject to an income-related premium. Notes to New York State Eligibility Chart

5. 5 ChildrenAdults Employed Individuals and Small Business Note: *Healthy New York enrollment includes both subscribers and their dependents. Categories may not sum to totals due to rounding. Source: United Hospital Fund analysis of NYS Department of Health enrollment report; New York State Insurance Department. New York State Program Enrollment, March 2005 Medicaid, Child Health Plus, Family Health Plus, and Healthy New York Elderly and Disabled 2,060,000 1,020,000 1,470,000 90,000 *

6. 6 A range of policies enacted by the state have simplified and streamlined enrollment in New York’s public health insurance programs.  Self-attestation of resources for Medicaid applications and renewals  Self-attestation of social security number for Medicaid applications and renewals  Self-attestation of income for Child Health Plus B renewals  Simplified renewal forms  Elimination of face to face interview for Medicaid renewal  Facilitated enrollment

7. 7 An estimated 1.3 million New York State residents are uninsured but eligible for public coverage. 450,000 880,000 Estimates of Uninsured Children Eligible for Child Health Plus A (Medicaid for Children) and Child Health Plus B and Adults Eligible for Medicaid/Family Health Plus, New York State, 2003 1,330,000 Note: Data are for 2003. Child Health Plus A (Medicaid for children) data include children aged 0-20 while Child Health Plus B data include children aged 0-18. Source: March 2004 Annual Social and Economic Supplement of the Current Population Survey. Tabulations prepared for the United Hospital Fund by the Urban Institute.

8. 8 Nearly half the uninsured in New York State are eligible for public health insurance coverage. 2.9 million uninsured in 2003 Source: March 2004 Annual Social and Economic Supplement of the Current Population Survey. Tabulations prepared for the United Hospital Fund by the Urban Institute. 55% 15% 30%

9. 9 One-third of the uninsured in New York have income below 300% of the federal poverty level but are not eligible for existing public programs. 2.9 million uninsured in 2003 Source: March 2004 Annual Social and Economic Supplement of the Current Population Survey. Tabulations prepared for the United Hospital Fund by the Urban Institute. 45% 34% 21%

10. 10 Review of Insurance Coverage Expansion Options

11. 11 United Hospital Fund/Commonwealth Fund “Blueprint for Coverage in New York”  Strategies :  Further simplification of public program enrollment and renewal processes to enroll the eligible but uninsured.  Expansion of public program eligibility.  Increase affordability of coverage for persons with income below 300% FPL.  Explore mandatory options: employer and individual mandates.

12. 12 Simplification strategies that hold the most promise:  Passive renewal.  Eliminating the asset test in Medicaid and Family Health Plus.  Allowing self-declaration of income, with verification through existing databases and random audits.  “Express lane” eligibility strategies.

13. 13 Options for increasing affordability of coverage for persons with modest income:  Reinsurance  Subsidized buy-ins to public programs  Tax credits  High deductible health plans/health savings accounts

14. 14 Lessons learned about reinsurance:  Objective is to blunt insurers’ fear of adverse selection and thus reduce premiums.  The cost and impact of reinsurance depend upon design parameters chosen: reinsurance thresholds, amount of risk sharing, relevant expenses/benefits.

15. 15 Lessons learned about subsidized buy-ins to public programs:  Employer and/or individual buy-in options. Important to consider the different incentives of each, such as maintaining employer contributions toward coverage.  Importance of administrative simplicity: enrollment, disenrollment, seamless transitions as eligibility changes.  Subsidies can be more efficiently targeted to individuals.  Concerns include: selection bias, what program individuals or employers “buy in” to.  Experience in other states suggests that buy-ins do not attract a large number of previously uninsured persons.

16. 16 Lessons learned about tax credits:  Design options that hold the most promise:  Tax credit that is proportional to the cost of coverage and covers at least 75% of the premium.  Credits are better targeted to individuals, as opposed to firms which are heterogeneous.  It is more efficient to target credits to previously uninsured persons but fairer to target all persons at the same income level.  Eligible coverage can be group coverage, individual coverage, or both.  Credit should be advanceable and refundable.

17. 17 Lessons learned about high deductible health plans/health savings accounts:  Less than 1 million people are enrolled in these products nationally.  Out-of-pocket spending requirements are higher than traditional coverage, but cost sharing in traditional coverage is rising.  Incentives under HDHP/HSAs are the same for discretionary and non-discretionary spending.  HDHP/HSAs may not afford benefits to low-income persons because they do not face high marginal tax rates.  Unknown whether HDHP/HSAs attract a greater share of previously uninsured persons.  Experience is early.

18. 18 Lessons learned about employer mandates:  A “pay-or-play” approach whereby employers either pay a tax or provide benefits to employees is most likely to survive an ERISA challenge.  Also because of ERISA, a state cannot dictate a minimum employer share of premium or the scope of the benefits package.  “Employer-sponsored” insurance is paid for through reduced wages, increased prices, or reduced profits. It is difficult to take any of these actions in low-wage, small firms where the majority of the uninsured are found.  Consider what low-wage workers value: wages vs. benefits.  Pay-or-play approach can be seen as a defensive strategy to maintain employer contributions.

19. 19 Key points about individual mandates:  One way to approach universal coverage.  Importance of assuring that coverage is both available and affordable before imposing a mandate.  Simplified public program enrollment  Increase affordability of coverage  Determine what coverage satisfies the mandate.  Consider options for enforcing the mandate.