1. Challenges in Implementing Reforms for People with Income and Employment Changes Pamela Farley Short Penn State University

2. Acknowledgements Research support from The Commonwealth Fund Collaborators –Katherine Swartz, Harvard –Namrata Uberoi, Penn State –Deborah Graefe, Penn State

3. Reforms Offer Universal Access to Affordable Insurance Individual health insurance exchanges, with premium credits for some enrollees Lacking access to affordable employer plans Between 133% and 400% of poverty line Small employer exchanges –Separate or combined with individual (states decide) Medicaid for all children and adults < 133% of poverty line Childrens Health Insurance Program (CHIP) extended to 2019

4. Changes in income, employment, or family membership Could cause lots of people to gain or lose coverage from these sources each year Implementation Challenge: How to maintain –Coverage –Affordability –Shared responsibility when someones ability to pay for insurance is changing?

5. Year-to-Year Changes in Annual Income (2005 vs.2006) Source: Authors tabulations of 2004 Survey of Income and Program Participation 2006

6. Low-income Workers are Concentrated in Small Firms Source: Authors tabulations of 2004 Survey of Income and Program Participation Percent in firms with 100 or fewer employees

7. Coordinating Medicaid with premium credits to buy insurance from exchange is CRITICAL. Many new enrollees will be coming from the other program. Adds another large, federal bureaucracy (the Internal Revenue Service) to Medicaids federal-state mix History of special efforts needed to achieve high rates of participation in Medicaid Tax credits based on annual income, but Medicaid eligibility based on income at time of application

8. Policy suggestions Design eligibility and navigation systems to help people cope with changes in eligibility –Emphasize hand-offs between programs –Will need to answer what if questions involving income and employment changes in coming year Consider State Basic Health Plan to bring everyone below 200% of the poverty line under state umbrella

9. Policy suggestions (cont.) Extend Medicaid/CHIP eligibility through the next open season to the end of the year. Combine individual and small employer exchanges. Provide broad access to the same plans (or provider networks) through Medicaid and the exchange(s).