1. 1 State Health Care Reform: Design Questions Danielle Holahan United Hospital Fund June 9, 2006

2. 2 Public Program Changes  Simplification of Public Program Enrollment and Renewal  Which simplification measures have had the greatest impact on enrollment in other states?  How have states balanced simplification reforms with program integrity?

3. 3 Public Program Changes (contd.)  Public Program Expansion  How can states limit crowd out of employer- sponsored insurance?  Would this be state-funded or eligible for federal match?

4. 4 Public Program Changes (contd.)  Public program buy-in  Allow residents of any income to buy-in?  Allow employers to buy-in?  How to structure subsidies?  Would the risk pool be separate from the existing public program?

5. 5 Employer mandate/assessment  ERISA constraints result in pay-or-play design.  How can a state ensure that workers of employers who “pay” get coverage?

6. 6 Employer mandate/assessment (contd.)  Setting the rate.  Should the employer assessment approach the cost of coverage? What about a “modest” employer assessment, as in Massachusetts?  It is not a simple decision. Employers provide coverage in order to attract and retain workers, because of the tax benefits of ESI, etc.  Not all workers will take up coverage without an individual mandate.  Determining which, if any, firms to exclude.

7. 7 Purchasing Pool  Public program buy-in and pay-or-play policies could necessitate the creation of a purchasing pool.  Create a new entity or build on an existing entity? What are the benefits and tradeoffs of each choice?  Determine eligibility rules, benchmark coverage, administrative issues.

8. 8 Individual mandate  Is an individual mandate necessary even with an employer mandate to achieve near- universal coverage?  What features are critical to the success of an individual mandate?  How would a state best ensure that coverage is available and affordable?  What coverage is mandated?  How would a state enforce the mandate?

9. 9 Subsidies  Scope of subsidies :  How high up the income scale?  What percent of income is considered “affordable”?  Do subsidies apply to premiums only or all out of pocket spending?