Expanding Coverage Through the Health Insurance Marketplaces

Expanding Coverage Through the Health Insurance Marketplaces

Ideas from the Closing Penn HIX Conference Panel

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As the just-promulgated American Rescue Plan Act provides new infusions of funding and support to the ACA health insurance exchange (HIX) system, a session of the annual Penn HIX Conference focused on potential policy changes and adjustments to further expand and improve the insurance marketplaces.

The final March 19 session of the annual University of Pennsylvania Health Insurance Exchange Conference focused on the need to address equity issues through smarter benefit design; the potential use of IRS records-based auto-enrollment of low-income people into free exchange plans; and the expansion of the Affordable Care Act marketplace subsidies to make free plans available to more people.

Co-sponsored by Penn's Leonard Davis Institute of Health Economics (LDI), Penn's Carey Law School, and the Princeton Center for Health and Well-Being, the event was supported by the Robert Wood Johnson Foundation. The annual Penn HIX conference was established in 2013 as an outgrowth of the LDI Health Insurance Exchanges Working Group headed by LDI Senior Fellow and Penn Carey Law School professor, Tom Baker, JD.


Allison Hoffman, JD

Not enrolled
LDI Senior Fellow, Penn Carey Law School Professor and panel moderator Allison Hoffman, JD, opened the session by noting that while the new American Rescue Plan Act signed into law by President Biden on March 12 will expand participation in the ACA insurance marketplaces, "it also still leaves a large number of people who are eligible but who are not choosing to enroll." She asked panelists what policy changes are needed to address that.

Panelist James Capretta, MA, former Associate Director of the White House Office of Management and Budget, advised that "before we start creating new things, let's try to do a better job trying to get as many people who are already eligible for something into the program they're already eligible for in a very frictionless manner."


James Capretta, MA

Capretta suggested creating "an automatic enrollment system using tax data as much as possible for people who are already eligible for coverage through the Affordable Care Act premium subsidy system. That will be even more people [as a result of] the new American Rescue Plan Act. Put them into the free coverage and then allow them to opt out if they like."

Auto enroll vs. mandate
Panelist Jonathan Gruber, PhD, a former White House health care consultant, agreed with Capretta, but warned of any effort to auto enroll people beyond low-income individuals eligible for the premium subsidies that make their coverage free. He noted some officials involved in the Obama-era ACA creation process championed the idea of having auto enrollment in the exchanges instead of a universal mandate."


Jonathan Gruber, PhD

"Back then," Gruber said, "I argued that 'if you think the politics of mandates are ugly, the politics of auto enrolling someone into something that will cost them thousands of dollars a year is even uglier.' We do need to think about auto enrollment for the free stuff as Capretta suggests, but I would also bump up the bottom so the free-coverage category is available up to two times the poverty income rate."

Politically sensitive discussions
Held virtually this year, the annual Penn HIX conference brings together top academics, government officials, and insurance industry executives from across the country to discuss the latest trends and developments in the state health insurance markets created by the Affordable Care Act. Most portions of the two-day conference are closed to the public to facilitate frank discussions of what is and is not working in the politically sensitive insurance marketplaces.

The March 19 panel session, "Prospects for Reform of Individual Health Insurance and the ACA's Exchanges," was open to the public and featured four top authorities in the field. Participating were Capretta, MA, a resident Fellow at the American Enterprise Institute; Gruber, PhD, a MIT Economics Professor; Katie Keith, JD, MPH, an Associate Professor at the Georgetown University Center on Health Insurance Reforms; and Hoffman, JD, Penn Care Law School Professor and panel moderator.


Katie Keith, JD, MPH

Exchanges' health equity issues
A need for new levels of policy sensitivity to ACA health equity issues was emphasized by panelist Katie Keith, a principal at Keith Policy Solutions, LLC, a boutique consulting firm advising nonprofits and foundations on the ACA and other policy issues-related federal programs. She is also frequent contributor to the Health Affairs "Following the ACA" blog.

"We have to have this as part of the safety net. The pandemic underscores why we need to keep up this marketplace, ensure that it remains healthy, and make it easier for people who need it to land there," said Keith. "For instance, I think there's a real equity component to how we design plans' cost sharing, whether it's exclusions, higher out-of-pocket costs allowances, or drug tiering. At this moment, we have a stated commitment to equity from insurance companies and the health care industry. We should be looking to standardize plans in ways that help communities of color better manage and control diseases they are more predominantly affected by, like diabetes."

"I want to punch on the point that we have the opportunity to make sure the folks who need benefits the most are actually getting them. We need to be designing plans in a really smart and thoughtful way," Keith said.


For more about the future of health care reform, please join Penn LDI on May 7, 2021 for a half-day virtual conference, The Promise of Health Reform and a Public Option in a Biden Administration.