Webinar: Health insurance auto-enrollment / HealthChoice

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you miss Berg from the brains institution like to welcome you to this webinar on auto enrollments sponsored jointly by Brookings and the American Enterprise Institute to begin persistent persistent impediments again in closer to universal coverage has been the reality that large numbers of people who are eligible for free who are highly subsidized coverage

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are not enrolled the Urban Institute is estimated that 25% of the uninsured are eligible for Medicaid and another 25% are eligible from marketplace coverage with financial assistance overall it's been estimated the 35 to 40 percent of the uninsured qualify for coverage that is absolutely free perspective that's been coming up perspective is that coming up with an approach to auto

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enrollment is critical to achieving universal coverage in a multi payor system and it's not surprising that policy thinkers on both the left and the right have been working on approaches to using an auto enrollment process this made it a good topic for Brookings and any item work together in sponsoring this webinar we're privileged to have five panelists to speak all of whom have been thinking working on this issue for some time each of them will make remarks

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reflecting their perspectives on how we can practically and effectively bring more auto enrollments into health insurance in each will comments on how their approaches navigate the political constraints that they perceive as well as the formidable administrative constraints after the panelists have completed their initial remarks I'll pose questions to the group as a whole and then turn to questions from the

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audience if you have questions send them either to events at Brookings don't need to you or use Twitter as the hashtag auto-enrollment so I think we'll turn to our first panelist Kristin blank young from the Brookings Institution hi everyone great um thank so much for being here today as Paul mentioned we we could cut

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the uninsured rate in half by enrolling those who are eligible for coverage into the program for which they are eligible either Medicaid or subsidized coverage in the individual market this insight is a big part of the reason that auto enrollment is such a powerful policy concept so what do we mean by that term the word auto enrollment tends to encompass two related ideas the first is what I call push the button Auto enrollment situations where the consumer

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becomes fully enrolled into health coverage with without having to take any action the phrase auto enrollment is also used to refer to strategies that require some sort of affirmative action by the consumer but make enrollment far more seamless and automatic than it is today and I think you'll hear me and other panelists today talking about auto enrollment in in both of those senses so why haven't we done Auto enrollment already there are four big challenges to auto enrollment first to auto enroll

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someone into coverage we need to know who they are and then we need to have enough information to truly know what form of cupboards they're eligible for not just have data that suggests their eligibility for a coverage program under current law getting that kind of determine of information ranges from hard to basically impossible so getting there will require changes to our eligibility rules generally to make eligibility more stable and predictable over a period of time the second big

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challenge is that we have to collect a premium some of the uninsured can qualify for zero premium of coverage which makes auto enrollment an easier task for that group but for others we need some source of payment which can make true automaticity Anna coverage program challenging third we need to figure out what plan we're going to enroll someone into in an auto enrollment program and then finally we need to understand that whatever auto enrollment system we build isn't going to be a hundred percent accurate and so we need to create something that is

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robust to those kinds of errors so those are big challenges but they're not insurmountable and I think there are two basic ways to get there to sort of put the pieces together and enable some sort of idle enrollment system both of which I'll talk about a little bit more the first is retroactive enrollment and the second is strategy is where you target a specific group and a specific moment in time in order to enroll them in coverage so retroactive enrollment is in my view the best way to get to truly

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population-wide auto enrollment the idea of this of this kind of type of program is that for anyone who is uninsured we would say that they were covered by a backstop health insurance plan that sort of operates in the background regardless of whether the consumer was even aware of it much less have taken any action to sign up the backstop will pay healthcare claims for any person who's otherwise uninsured who needs to access the healthcare healthcare system and in exchange everyone who is uninsured must retro actively pay a premium for the

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back-up plan typically when they file their taxes and the premium would be old regardless of whether or not the person you health care services in the year this is obviously a big change from the way we think about enrollment today and then it effectively makes enrollment as a coverage mandatory but I think it's actually less disruptive to our current system than it may sound largely because it operates within our current patchwork healthcare system and because it operates at a population level it's the path of the pack towards universal

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coverage that is that is in my view most feasible but we also have other options in this model of targeting specific populations or moments in time one area of particular interest is tax filing you're going to hear more about auto enrollment tax filing from others on that on a panel today but based on some simulations we've done here at Brookings we find that 31% of people who are uninsured at the time they file there as the time they file their taxes look like

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they are eligible for a zero premium option either the through enrollment in Medicaid or a $0 marketplace plan so if we had a way to auto enroll that group of people at the moment they filed their taxes we'd reduce the number of people who were uninsured in December several months later by about 25% so a small fraction of the group we auto-enrolled would gain employer coverage throughout the year so this is a powerful tool that can get a whole bunch of people enrolled and coverage it's not a pact to to truly universal coverage but it is nonetheless

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a really useful step another way to think about auto enrollment targets is to think about moments when people lose coverage for example prior to Coba 19 more than 400,000 people every month exited employer based coverage and became uninsurance a lot of those people interact with the unemployment insurance system so state UI agencies can play a role in facilitating enrollment state unemployment insurance websites can promote health coverage information to consumers as they apply for and recertify benefits within the

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unemployment insurance workflow or as UI agencies think about modernizing their technology they can also consider options to integrate health coverage within the unemployment insurance unemployment insurance application and recertification process so creating a really sort of truly streamlined and unified experience for consumers that that kind of model would also work in lots of other benefit programs where you would take consumers who were interacting with a state agency and integrate the health coverage

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application into the the other the other process so these are just a couple of examples and I look forward to our discussion about ideas like these I think it's over to you all right come get my slides up okay can you all see my slides I assume you can yes okay thank you very much for

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having me on the panel today this is a very important and good topic for us to discuss and people are about to lose their health insurance as also we hinted at in his introduction obviously what to do about that will dominate the conversation I think in the coming months and some of the ideas that were just presented and some more that are coming I think throughout the presentation they can be helpful as policymakers try to grapple with I think

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is going to be a pretty immense challenge of a spike in the uninsured rate in the coming months so just to bring a slightly different perspective into how to think about this I think the complaints that Kristin just made were very very good and relevant one other framework that might come in is of course that because of the complexity and the newness of auto enrollment perhaps we ought to begin initially with a state option that is that the federal government create a structure around

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which the states can explore various approaches to dealing with what is going to be a challenging and complex endeavor to start a new way of putting people into health insurance and so working with Stan and la nieve two of the other panelists today we thought through a couple of years ago what that might look like in terms of a state option and I think it does begin with a federal statute that the federal government try should try to put into place some kind

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of incentive program that brings both financial resources to bear on the question and also new authorities and tools that the states could use to build an auto enrolment program you know obviously the amount of money you know depends on exactly what would be intended in terms of start-up funds but I think we're talking about hundreds of millions of dollars maybe billions you know a billion but not that much certainly not in the context of money

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that's being spent right now on on the recovery program so in the scheme of things there should be a fairly small investment mainly aimed at helping the states build the systems that are necessary to do what Kristen described as sort of point of point in time enrollment efforts rather than the full retrospective approach okay so what could this look like I think it should be a grant to the HHS with funding to

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allow a state-administered program within a federal structure that funds would support us first of all building an IT program in programmatic infrastructure there's going to be a need at the outset to as you'll see from other conversation I think we're gonna have the day that to be able to do this right you're gonna have to have a lot of access to insurance registries to be

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able to cross-check who's enrolled in what well as well as their income to be able to get this right when states apply for this there should be some elements that they present to the federal government about exactly how they would go about this some sort of requirements for the application so to speak a little bit along the lines of when they apply for Medicaid waivers but basically they should be indicating how they will build an IT infrastructure to facilitate it

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how will the consumers be assigned to health plans and what rights and options do the consumers have both before and after assignment to a plan I think consumers auto-enrolled into insurance should be held harmless for income fluctuations during that year one of the big big complexities here is when somebody's Auto enrolled into a program what happens if their income changes sort of midstream and I think one of the

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things we have to understand about all this is that we built a multi-payer insurance system that is incredibly complex way too complicated really on a number of levels and one element of it is is to realize that people do have changes in the circumstances often good ones where their incomes go up but instead of penalizing people so you know repetitively and quickly this ought to be something where if they get auto and rolled into a program they're held harmless for a period of time and given

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the assurance that you're gonna be in this regardless of what happens for the next year or so and that allows them to I think have some more confidence that being auto enrolled into something isn't punitive but it will be helpful to them and then the big piece of this is really around what can the federal government do to make this easier for the states to explore this kind of program and I think the first one is related to what I just

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said which is to allow states to establish full-year eligibility for the Federal Premium tax credits and Medicaid based on prior state tax information so you just say if you're gonna do Auto enrollment based on last year's income level as you determine through your tax system we will use that and no other conditions are necessary for the next year or so and that can become the eligibility determination for premium tax credits for that period of time second thing I think is to provide you

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know data sources really that allow them to handle this in new responsibilities better this is actually number three on our list here what asset what data can the federal government provide federal employee coverage data Medicare coordination of coverage data health plan ACA section 605 five data that's data that has to be reported by the plans health self-insured coverage data through ERISA

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so you get rid of an ERISA exemption for this purpose and allow states to at least find out who's in the self-insured employer plans and you can add an element of our own health insurance the National directory of new hires which is something used for child support enforcement very regular rigorously by the states to include a health insurance component that would allow better cross-checking of who's already got insurance I think another element here is that states ought to be allowed to auto enroll anyone into a catastrophic plan right now the ACA limits that's two

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people thirty and under and then finally and I'll stop here encourage states to be creative about using other existence existing citizen touchpoints unemployment insurance DMV applications those seem to be two very good places where people are coming into contact with state government and could be reminded about options about health insurance and allowed to auto enroll into a program during that process

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thanks thanks very much I can come the next the next person up and it's really exciting to be here today with such amazing thought partners okay everybody see my screen let's see there we go let's share screen here we go all right terrific so we're gonna talk about that I'm going to talk about that using the tax filing moment as an

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opportunity to jumpstart eligibility enrollment into coverage whether automatically or in a streamlined fashion and we'll talk first about why that's a good context second some early results from Maryland's experiments in this area and there's some statements that are all policy implications so to begin with why income tax well let me try so the why use income tax filing as a place to start an enrollment well to paraphrase the famous saying associated

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with Willie Sutton cuz that's where the uninsured are a tremendous percentage of uninsured folks eligible for assistance file federal income tax returns either to claim earned income tax credits or other refunds or because they're legally required to do so there's really no other venue where you can reach as many uninsured as with tax filing and serendipitously tax filing also has all kinds of data associated with it from which eligibility can be determined so there's obviously the information on the form about income the previous year but there's also a social security number

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for many tax filers which agencies that run health programs can use to obtain other data needed to establish eligibility and there are other benefits as well there are limitations and for the purposes of this conversation the most important limitation is that you need to have proactive opt-in mechanisms for data sharing rather than opt-out mechanisms for our revenue collection as a country and states as well we depend on largely voluntary compliance with tax forms people need to feel comfortable knowing that even illegal income generating activities or unethical ones

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they don't want shared with their neighbors can be put safely on the tax return and if tax return data is scattered hither and yon people may be less willing to come forward and share that information and we lose revenue as a result so unlike other contexts here it's important for people to affirmatively consent to data sharing so it's inspired by some of these insights lawmakers in Maryland passed an easy enrollment bill in 2019 it garnered enormous bipartisan support a unanimous

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state Senate vote for example and the basic concept is when you file your state income tax return check a box if you're uninsured and you can say please revenue agency share my data with the health insurance exchange and have them see if we qualify for free or low-cost health insurance most people file electronically and that could potentially provide a venue where we have real-time eligibility determinations when somebody finds out right then and there you file your tax return you learn you're eligible for Medicaid you're automatically enrolled into Medicaid unless you opt out with

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exchange coverage we tried to push the idea of automatically enrolling people into free insurance insurance where the premium is completely paid by the premium tax credit but one of the main carriers in the individual market objected and so we're not going forward with that yet though some of us haven't given up hope of moving in that direction the bill was signed into law in the middle of 2019 and here in less than seven months later state agencies were involved implementing it unbelievable unbelievable cooperation and effort on their part it's a three phase approach

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phase one is underway right now where the state officials leveraged existing processes to enable quick implementation so the tax agency sends batch files to the health exchange the health exchange does a preliminary eligibility determination does a mail campaign sending out notices to everyone who check the box describing their their likely eligibility for assistance and then people who get the notices are told that they can sign up by using the standard procedures going online to the portal or calling the 1-800 number etc

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that's the initial phase later phases are gonna be more electronic we're starting with professionals with for-profit tax prep companies and then eventually moving to everyone people eval can get that automatic real-time eligibility determination followed by expedited or ideally automated enrollment but that's gonna be for the coming years now for year one the phase one approach we were not expecting huge numbers based on past experience several states had tried similar direct mail campaigns with children based on state income tax returns and gotten less than

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a 1% take-up rate the federal government did a major Direct Mail experiment which was incredibly important demonstrating the mortality effects of health insurance coverage but it increased participation it increased coverage levels by just one point three percentage points so we were not expecting much but what we got was really striking nearly 40,000 people check the box on their tax return and asked to have their information shared with the exchange to determine eligibility and nearly 3,000 have enrolled into coverage really an a

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strikingly high percentage for a direct mail campaign and it's also striking to see who has actually received coverage so most of the enrollees have been Medicaid folks 71% most have been low income fully twenty six percent are children most are young adults relatively few are in high in ranges so this suggests a lot of promise if this is representative of what broader efforts may bring in the future so there are a number of different state policy implications everybody wants to be one of the best states and Maryland's

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results suggest that other states could profitably follow along these similar lines including states that use the healthcare.gov portal those states could use this to help get Medicaid coverage for people who are eligible but not enrolled including children and the there are other lessons learned from the process through which this thing is implemented unbelievable involvement of all the state agencies in crafting legislation of stakeholders including plans providers consumer groups tax preparers have had a central role very important to take their concerns into

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account so it's really been a marvelous process that other states could learn from in terms of of federal changes I think Jim did a phenomenal job talking about the kinds of federal changes that could be needed giving additional flexibility to States to use data to determine coverage and uh having state pilots that are supported by the federal government the federal government itself could use individual income tax filing as a launchpad as Kristen talked about you'd have to revise eligibility criteria to a court

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with the available data Jim talked about that as well you might want to think about changing the enrollment cycle so the tax filing can be used as the time when people generally enroll into health coverage you'd need as a practical matter to give a lot of IT money to IRS IRS as information technology as we all have recently been reminded is under invested in its it needs modernization for this and for other purposes and you need to think about challenges to full automatic enrollment states may have concerns about repeat their caseload going up even though it's

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consist of eligible people and carriers may be concerned as well but is this the time to talk about it we're all dominated by COBIT 19 that's the topic of the day and Charlie Parker gave us the answer on half century though now is the time we have huge numbers of people who are losing employer based coverage most of them are eligible for some kind of help but we know historically most laid off workers do not enroll in coverage for which they qualify it's just overwhelming to be grappling with job loss and therefore it becomes imperative to make enrollment as

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easy seamless and automatic as possible tax time is one option as both Jim and Kristen noted unemployment insurance is another option and thinking about the pandemic now is the time we need people to get health insurance so that folks who come down with the illness quickly get care as soon as they start to feel sick that's good for their health it's good for their neighbors and family members health as well because it enables prompt or detection of the disease and in terms of the economy health care losses have been enormous and if we see torrential losses in

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health insurance coverage that means less revenue for hospitals doctors and clinics that means more job losses so if we want to fight both halves of the Cova crisis health app and you can onic have health insurance is critical and automatic enrollment is an important recipe to any successful approach to health insurance thanks very much great to be with this group of people I know all of them have worked very hard on on these important ideas and so what

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I thought I would do today is to share with you some thoughts about hopefully everyone can see this about kind of operationalizing auto-enrolment in thinking about some opportunities for using and deploying auto enrolment which I think Stan did a great job of outlining at the state level how they've done that in in Maryland and I just want to talk about a couple of thought experiments that I've done and concert with with a few others in thinking about

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about how to how to use auto enrollments so let me do this I'm gonna go to the presentation view hopefully this will work there we go so to start you know I think we've we've covered some of this which is the the challenge in operationalizing auto enrolment is is sort of multifaceted identifying a population figuring out who fits in actually enrolling them activating them effectuating coverage and reconciling

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whatever assistance they might get at the end of the day it does create a number of logistical challenges and so I think it's important to start with the premise and the question of who is it that we're trying to help what is a population group that might be useful sort of start in thinking about this and you know Jim Capretta and I have talked in the past about looking at at folks that might qualify for for example for

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some kind of zero premium or significantly reduced premium coverage ideally zero premium coverage and so I think focusing on that part of the uninsured population that falls into income categories where they would be able to look at a significant amount of assistance in effectuating coverage is a good place to start so in thinking about the analysis you can start by defining the problem a little bit so a lot of this is drawn for

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in my presentation from 2019 data and a lot of this comes with the assistance of the of the BlueCross and BlueShield Association if you look at the numbers carefully you begin with this sort of set of about 15 million people who are uninsured and this excludes those with access to affordable offers of coverage in the employer context those with access to public health coverage and those who are not lawfully present in the US which is obviously three relatively significant groups of people

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but let's just start with this group of people to begin with these numbers obviously are gonna look different with the Kovan crisis so let's just put that caveat aside for a moment and recognize that we're looking at a group of people before the crisis hit and and what you can see is that there's actually a relatively significant number of people about 4.2 million who fall into the category below 133 percent of FPL another million in that increment

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between 133 and 202 million in the 200 to 250 and then a relatively more sizable number over 250% of FPL so this just gives us a sense of the context that we're operating in okay if we look then at what percentage of the low-income uninsured can access free Bron's coverage under again 2019 data what we see is that the vast majority of rating areas in fact almost all rating

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areas across the country could offer $0 bronze coverage for people in the sixty-year-old category and then a little bit less in the forty five in the twenty one-year-old category but the the basic point is that almost all of the uninsured between 133 and 200 percent of FPL could have access to free bronze coverage again using 2019 data which i think is a really encouraging thing if you're trying to figure out where you start right because sometimes in thinking about the problem it can be so

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large and so significant that you don't necessarily know okay where do we get started what I've encouraged policymakers to do in my conversations with them is you know it's okay to start small or it's okay to start with a portion of the population or part of the population who could benefit from from coverage or could benefit from an auto enrollment style approach if you look at the number of uninsured who could access free or low-cost silver you actually see that a significant number of silver

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plans could be accessed for relatively low premium not zero premium in in many cases although for sixty year olds you will see on the far right my far right that I'm looking at now that there are a number of rating areas where the premium would be zero even for a silver plan but even at that twenty one-year-old level at one hundred and thirty three percent of FPL what you see is that the vast majority of the country offers access to silver plans for a relatively low

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premium and so I saw it so I do think that these last two these last two charts sort of demonstrate the degree to which you might be able to gain access to either bronze or silver coverage across the different age strata for people who are pretty low income and could really benefit from automatic enrollment so you know another way to think about this is is there some way to start with a smaller group of people even than those group of people that we

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were talking about and that is could you auto enroll young people who are aging off their parents plans whose incomes fall into 133 to 200 percent of FPL level again the goal here being for policy makers to be able to define a population with which to pilot auto enrollment and as you will be able to see in a minute a large percentage of this population in particular according to analysis it's been done can access zero premium bronze coverage with with with an apt see with the tax credits

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available through the ACA I think the big question that we often get is you know how scalable is this and I think it's a fair point to stan's analysis I really do think that the state level is that is the key place the key locus of activity because that's really where I think in some states you could see this being the core of an experiment that then radiates outwards with other sort of people other populations potentially being included based on the needs and the situations

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found in those particular states and so this next chart that I'm gonna show demonstrates the percentage of 21 year olds at a hundred and thirty-three percent of FPL who could have access to free bronze coverage after their apt see after their premium tax credit and and what you see first of all III will readily admit this is a and not that significant percentage of people right we're talking about 50,000 individuals

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nationwide who are estimated to be uninsured who are 27 years old and who fall into this income category so we've we've now taken the overall pie and we've shrunk it down into an inch maybe an interesting thought experiment pilot group and what you see is sure enough 95 percent of rating regions across the country including a hundred percent in many states big states - like like Texas what you find is that the vast majority

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of the this sort of pilot population we're talking about could qualify for $0 bronze coverage after applying the a PTC and so there is so sense that for this population Auto enrollment might be a good solution to get people covered and it might be a good way of thinking about how you can take a concept that I think the other speakers on the panel have really elegantly outlined and try and put it into effect for a small group of people who could potentially really

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benefit from it and as you can see for many many people in this population they would be able to access zero premium coverage and be enrolled into coverage that would would certainly help them prevent serious economic calamity in the event that we have a crisis strike such as the one that we've seen so so I probably end my remarks there but I'll just briefly point out I know David's going to get it a lot more in today there are some political considerations to think about namely that you know a

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lot of Republicans that I've been in contact with this have expressed the need for strong opt-out concerns they clearly have what I would characterize as Liberty concerns as well as concerns about being involved in more widespread implementation of the ACA and then I would say the other side Democrats have generally been pretty enthusiastic although I think the challenge there is maybe a little too enthusiastic in the sense that they have they have said for example well why don't we start with auto enrollment of Medicaid populations which obviously gets gets conservatives

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many conservatives somewhat concerned and then and then the last thing which we've touched on is sort of the state versus federal issue which is how much of this belongs to the state level how much of it belongs to the federal level I think those are open questions certainly the federal level could be involved in in providing some funding in providing some guidelines but ultimately I do think this is this is going to be a state-based endeavor fundamentally and it's gonna require that coordination from from the from the federal government with the state governments

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together and with that I will I will conclude right now is to bring it back up to the 10,000 foot level and sort of talk about the political appeal and you've heard a lot of great analysis and it's taking of the benefits and making them so what I want to do is is

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basically talk about why first of all why I like the which is you know simple a lot of health care policy is complicated and as we know and you know Ruhlman makes control much easier to get coverage for people it creates a safe default choice for consumers so they can't go too far astray from when it comes to their health care coverage if somebody forgets to enroll or gets

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overwhelmed by the choices they still get coverage and today's discussions I think has made it clear that as we're grappling with auto enrollment for people who forget we're also going to make it easier for people who enroll themselves so right now I want to cover three topics there the first is the appeal of auto enrollment across the political spectrum we talked about examples about our moment in current law and then some of the political challenges that despite the appeal heard

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from so first let's look at some key pieces of legislation that include perhaps the most automatic of all is the make care Medicare for all Act which has automatic enrollment because everybody is automatically entitled coverage and then automatically Medicare for America Act is contains two kinds of auto moment the first is a default enrollment for a public plan for the uninsured and the second is automatic enrollment at birth

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and then in the patient freedom act senators Casting Collins composed enabling States to do a woman is long Ian and Jim have talked about next to amongst various think-tank rapunzel's we see a lot of ideological diversity as Brookings and admit it already clear they're on the vanguard of making automatic a woman a part of their proposals Christians just Kristen just discussed how the Brookings proposed

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proposal was is retrospective so you get automatic and grow and retrospectively in coverage yeah I proposed a clause for as much automatic enrollment as possible doing it in America no way and then we also have the Urban Institute plan which includes auto a moment for the low-income individuals as well as automatic enrollment for people and receiving food stamps or welfare and then in Medicare for extra for all caps plan it's a basis for the dalaran Schakowsky though which concludes the

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automatic enrollment to be assured in default public and automatic enrollment at birth our third way couples a clap costs cost caps and covers for all we kind of combine the bookings and I approaches we have as much upfront automatic enrollment as possible in a private plan and then a retrospective enrollment in a public plan for anybody who's locked as a backstop and lastly we all remember finally when her father was at the Heritage Foundation he proposed automatic enrollment as an alternative

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to the individual mandate so the popularity of auto auto MIT has already become embodied in why let me give you a few examples not a comprehensive list Medicare Part A it's automatically enroll it's actually hard to kind of get out of it but you can Medicare Part D has a low income automatic enrollment floor to subsidies for Part D drug coverage we also have kind of forms of automatic enrollment through auto enroll

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and minute renewal and Medicare Advantage and exchange plans there's also this thing called express lane eligibility for chip and Medicaid where you don't have to you just have one apple set of information from one application for multiple programs and lastly in employer-based plans we saw retirement really get this whole movement started one study showed that when you have automatic enrollment and retirement plans participation rates are

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about 86 percent compared to 46 percent so with automatic coverage having such strong support across the ideological divide and such strong legal precedents you might be wondering why hasn't Congress already in evidence well you know as I said health care is complicated you've heard that and I see three key challenges we actually four so the first is what are we rolling people in is this gonna be just another version of an individual mandate see the truth is we don't have a political agreement

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on what the standard for default carbons is it a health plan with essential benefits as defined of the ACA or a short-term plan that doesn't near productions or is the plan that the states get to determine that's a big problem we kind of touched on that today the second problem is the fiscal impacts you know we would be increasing coverage quite a bit that's gonna have a big impact now I know right now we're not supposed to be worrying about you know cost because of you call the crisis and that's appropriate but eventually we're gonna have to start thinking about our

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long-term sustainability of budgets and you know relates to the third problem which is that you know as long as there's an unorganized group of people out there it's gonna make it hard to get a big push in Congress to get this done you know just make a little bit of fun but there's no organized consistency for people who forget to do things and get on the lawn by their choices now they're great advocates for consumers like Nancy would say but it's going to be hard to organize you're on automatic enrollment and would love to do but it's gonna have

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to be really coupled with broader coverage in push for universal coverage and the last challenge is implementation as we kind of touched on already some consumers will definitely be confused about and even if they can opt out which they certainly should be able to they may you know experience some some dissonance over that and they may be confused about not switch to another planet they don't like the planet so ultimately the political challenges are significant it comes down ultimately to

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doing the right thing worth the risk that the appreciation will come later so and I think that's kind of what happens with health policy you may remember our lifetime Republican from Wisconsin who wrote President Obama thanking him for the Affordable Care Act which saved his life this is what he wrote to my president I have a pre-existing condition so could never purchase health insurance only after the ACA came into being could I be covered quit simply to not take up

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too much of your time if you are in fact taking the time to read this I would not be alive today without access to care I receive due to your law the President did read that he posted it online and I can easily imagine the next president receiving such a letter after our enrollment is enacted and Americans that it has given them the protection that they ended up eating okay thanks I'm muted want to thank you all for really thoughtful presentations and I've got some questions supposed to you as the group I think you're gonna

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have to unmute yourselves unless the baby wants to unmute you all now see who has something to say good first I want to talk about doing auto enrollments on the state or federal level and it's not surprising that we're focusing on States today because we've always seen States as the laboratories for experimentation in public policy and that's certainly happening and of course

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by doing things in the state level we get her away from some of the hostility and gridlock associated with the a ACA but I wonder what your thoughts are about you know if auto enrollment really turns out to be something that works well people supports is this something that's ultimately better as a state activity with federal government supporting all the states and doing it or is this something that would work

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better as a federal activity well I guess since I did the state presentation let me let me jump in here and I'm sure the others laughs applause - I think actually this is something where let's imagine we wanted to write a federal statute I think unless we did the retroactive enrollment option sort of the the big one you know we just sort of placed everybody into a plan of some sort it's not entirely clear to me that

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we all would agree on or even know exactly what did to put into a federal statute to do auto enrollment easily at the moment it's a pretty complex endeavor and I think there's such differentiation across the states in terms of how they're thinking about their insurance markets that also frankly levels of capacity to [Music] engage in this that maybe that's an

48:07

argument for the federal level but I think what I'm trying to say is that I'm not even sure we'd be ready to write a federal statute that would make this easily done at least I was I wouldn't sure I would know how to do it so this seems to be one of those things where and also let me just say one other thing about the framing of this the United States after the ACA you know we got to 90 91 92 percent of coverage at this point after the pandemic it obviously seems like the uninsured rates going to

48:38

go up but there is a structure now in place to try to get at least in a normal environment to 90 plus percent coverage and let's say you ask the country at that point what do you want to do to take care of the last 10% there's a lot of people proposing various programs to do that but when you tell them as long he slides indicates and everybody's information is indicated then the majority of people who are uninsured are actually eligible for something and I

49:10

think it really changes the conversation quite a bit and people say well why don't we try to make what we already have worked better and they get into what they're already eligible for before we create another program and I think there I think that means that you know we're gonna maybe a little bit of a long slog you know let's imagine the federal government did do what I recommend it I'll create some kind of federal structure some seed money to the states they start experimenting I think it could take five or ten years to figure it out how to go from 90% coverage to

49:43

you know 98 and maybe California would get there first but I think that's the that's maybe the the recipe the United States might have to follow yeah I was slightly different perspective my answer is both and that states really are where a lot of the action is right now and obviously we're doing work in Maryland we've done work talk we've had conversations with people in other states to try to follow on Maryland's lead so that that's the immediate

50:14

challenge and I think Jim is completely right that we will learn a lot hopefully from what states do and there's a tradition in the country of health care innovations beginning at the state level and then eventually becoming ash from a whether that's what the children's health insurance program or Medicare Part D or the ACA which was piloted in significant part in Massachusetts so hugely there's definitely role for states and I think that the idea is that Jim and outlined in terms of things that the federal government can do to give a boost the state efforts are absolutely

50:45

right on the money on the other hand if we do in fact see in the coming months an opportunity for a major federal coverage expansion auto enrollment should be a part of the design it's not enough just to have say if you build it they will come you need to think about how exactly do they come how do they enter and how do we make it as seamless and simple as possible for people to get coverage so if we have a major federal effort in in the coming months this will be a part of the conversation also if we have the existing coverage system in

51:16

place I definitely could see an opportunity for some middle-level tweaks making a huge difference so if we were to say sort of picking up on Kristin's idea about changed eligibility criteria and also you know that Jim talked about this as well saying that prior and I think Lonnie did as well saying that prior year tax records can determine current eligibility for subsidies that would let lots of people be enrolled in the coverage and filing when they file their income taxes whether into Medicaid or into your premium marketplace coverage so I could see some

51:48

opportunities for federal action as well so we're we're out produce opportunistic and Families USA whatever opportunities we see for coverage gains we're going to see is them and do the best we can and I just want to underscore that that last point that that Stan made there is absolutely a role for state experimentations here but you do need some federal policy infrastructure to enable that state experimentation every single one of us talked about what can see what uninsured consumers are eligible for but in fact none of the

52:19

data sources that we are using demonstrate what people are eligible for under existing law when it comes to the the private insurance market under current law eligibility is a is a calculation that's made at the end of the year based on sort of what happened during the 12 months and and and consumers make a projection themselves based on their own private knowledge during the year and so no automatic system can replicate eligibility the way it works under current law so to enable the the kind of

52:50

experimentation that we're talking about you do need federal policy changes that that tweak the structure of eligibility so that that a tax entity or an employer who sees people turning 27 and aging out of the employer plan or whoever it is someone can sort of take existing information and treat that as authoritative to put them in coverage and so that's going to be a federal policy change that's that's necessary for any of these ideas to move forward but just to add one set one sentence on that I think that's a very important

53:21

point and ought to be considered you know part of our health insurance system is way too complicated and allowing prior year tax or prior income information to determine what you're eligible for and the following calendar year there's an eminently reasonable thing to do it's something so complicated and you don't want so much churn and uncertainty and honestly you know they ought to just make it easier for people to stay in that coverage for some period of time stability and the

53:52

coverage is important and maybe this can be part of the conversation that goes a little bit beyond auto enroll which is what information should would be using to determine eligibility and does it really make sense for this complicated premium tax credit retroactive reconciliation process which honestly they're not doing that well anyway and probably are missing all kinds of all kinds of things that are supposedly reconciled so I think simplification using last year's information making it easier to use the tax system to put people into coverage federal and state

54:24

stand I'd be willing to look at both I think that's the way to go and let me just add to that you know we are there is lots of other areas of our policy the federal policy which we used retrospective qualifications like student loans me all that is done on prior taxes so that's a good point to make as well let me also have an echo you know both the political motivation here is going to be you know

54:56

the biggest thing that people worried about our costs and running for president say it's going to come up and say we're gonna protect everybody from high costs well part of that has to be coverage you can't protect people from high costs unless they have carbon so so I see this you know fitting nicely into a federal debate about where we go next with coverage now of course Tony okay also and that the states are going to be where the action takes place so we've

55:27

really got to do both but it's Christmas that it's got to be you know I just thought of something that's you know so much of the work we've done on ottoman elements has happened during a period of strong economy economic stability and now you know the the issue of the urgency of the moment is what about all this massively a massive amount of

55:58

unemployment are a lot of people going to lose coverage and how can that what can the federal government do either through the states or its own to reduce that impact and you start thinking about you know like prior tax data you know will not help fast enough to deal with some things I almost wonder if there we need to have a you know more than one approach to at least be available during

56:28

our current challenge and I think that the the FAFSA analogy that that they brought up is a great one so our student loan system which reaches high into the the income spectrum I think it is analogous to health coverage in that way and that it is not just a very low-income group but you know large segment of the middle class as well the the FAFSA process is based on your prior your family's prior year tax return but you also have the option to get additional assistance if you have had a

57:01

major change in circumstances and there's additional documentation requirements if if you are this category of seeking additional assistance but we sort of start with the idea of letting the tax return to you the work and then people who have had a significant change can can get additional assistance without as Jim mentioned penalizing people who have sort of an improvement in their circumstances so when I think about these kinds of policy changes that's the model I'm imagining where we sort of reduced the complexity for for most people and enable auto enrolment to

57:31

to function at scale whether that's in the state or whatever you know what a pilot program but it's actually functional across a group of people but you also preserve some some complexity therefore for the people who really need it because of they've had a massive change in circumstances or something like that and I would just add sorry Stan I would just add that the that the current condition the current economic condition where we know a lot of people are probably going to be displaced from employer coverage to the extent that for

58:02

example they work at a smaller business and smaller business offer coverage which is more limited to start with I recognize but this would seem to be one of those scenarios that would be ideally suited to auto enrollment now having spent a little bit of time over the last you know two weeks kind of thinking about how you would operationalize it it is a challenge there any number of different challenges but you could imagine some states trying to take up the mantle here and figuring out okay we've got a group of people that's no longer on employer coverage could they

58:33

easily be bridged into a marketplace plan that would offer a similar or substantially similar coverage that would also be available at a at a cost point of them that's similar to what their premium contributions may have been under employer sponsored plan so that's just the theoretical framework you apply it's obviously much more difficult in this situation because people are churning between jobs potentially hopefully when the economy begins to recover they might get an offer of coverage again you know there are issues involved there but certainly for this period of time I do think it

59:05

bears thinking about whether in fact there is some way of content people from their their employer coverage into an affordable marketplace plan I mean I think certainly that would be a more affordable route than for example subsidizing COBRA continuation coverage which you know maybe the the the the best available option out of very few options at this point but still I would think I don't a moment would be an interesting and potentially attractive alternative you know London

59:35

do you think it's feasible to that this could actually show up in a federal Kovac relief bill and the sense be one more example of how responding to the pandemic you know was changes policy more dramatically in areas then we would have any right to envision otherwise I you know I would say Paul in in just the conversations I've had I think it's only gonna be feasible if you can identify a

01:00:05

group of people to start with and it can't just be you know everybody who's lost employer-sponsored coverage in the last three months although we would want in an ideal world to help those folks transition to to marketplace coverage I think it's got to be more narrow than that so this is why I've been kind of racking my brain trying to figure out is there a subset of people who's been economically displaced and displaced from coverage who could you know who

01:00:37

could find their way into a good marketplace plan I mean one sort of basis of inspiration for this is there's actually a few carriers in a few states as I understand it and it totally who have offered to essentially transfer the deductible the spending toward deductible and an employer plan to a marketplace plan so in other words if you've spent 200 out of your $500 deductible you would get credit for that spend against your deductible in a marketplace plan as if it were your

01:01:08

employer plan now this is not happening widely I've just heard that it habits happened in a few cases in a few states but that's an example of the kind of thing that would make a transition into marketplace coverage much more seamless during a time when people clearly could could use it so I think we have to we have to start thinking creatively and by we I really mean everyone on this call and everyone who's listening about are there specific target populations that we might be able to propose as a demo for example that could make it in very well could make it

01:01:39

in to some kind of relief package later this year thank you you're waiting no that's okay okay good let me go on to another question how do other advanced economies of countries with multi payer systems for example Germany Switzerland Netherlands how do they use auto enrollments to achieve universal coverage I think I'll jump in here because actually Paul and I talked about this in advance and but I'm sure those

01:02:10

might have some information here as well it's interesting to look at these countries because particularly the Netherlands that they do have multi payer systems private insurance and they have all of them has an individual mandate and it's actually much more rigorously enforced than anything we were thinking about doing before the tax penalty was repealed in this country they're pretty tough about it and the auto enrolment feature is really tied to

01:02:42

their systems of tracking down people who are not insured and then going through a series of coops with them trying to get them into a plan and then the ultimate step is just to put them into a plan and then start trying to make sure they pay for it so for instance in the Netherlands they a few years ago they set up a special data registry to try to kind of collect it sorted a little bit the same kind of

01:03:14

thing we're trying to do with the state level through that legislative structure I was proposing earlier is to give they set up a essentially a matching system of registries to figure out who is uninsured in their country using the insurance plans that are regulated by the country in the state and if someone is sort of rakal such not signing up they actually Bend this place them into the competing plans in the country on a proportional basis

01:03:43

based on market share and then they assign the premiums that are owed to that person and have a number of collection authorities that they can then implement over time to try to extract the money out of the person so in some sense our task should be a lot easier than it is in the Netherlands right because what we're trying to say essentially is hey we're already giving you the money to pay for a premium as long he said please take it and we'll sign you up for a plan so the amount of coercion of trying to extract some money

01:04:15

out of the folks will be a lot less I think in our auto enrollment system then they even are in these other countries where they're really tied a little bit to enforcement of an individual mandate Switzerland has a you know a continent can tunnel system where the Canton's enforce their mandate and it varies a little bit across them basically they have at the end of the day when they they always start with a number of other things where the person voluntarily signs up but if the person doesn't sign

01:04:46

up they then assign them to a plan and again they go through a collection process to get the premiums Germany has a very small private insurance alternative to the sickness funds and you know I can't quite tell but I don't think they have that much auto enrolment in the plans it's much more of a enforcement of the individual mandate okay any other comments on this question should I go on you know why don't we learn from

01:05:19

initiatives by employers that use auto enrolment for retirement plans are any employers using such an approach for their health benefit plans I know a little bit about the employer retirement system I gotta say I don't know for sure if they're any doing employee health but I'm the employer retirement site which is obviously a lot easier the basic story there is that it has

01:05:49

boosted enrollment into 401ks quite substantially there's some question about whether or not there because they're putting them into a certain tier of contributions whether or not if the person did it on their own they would have contributed more but in general I think the body of evidence would indicate that this is worked fairly well to boost coverage and the really important point is that once people are in they don't ever opt out again they're

01:06:21

given plenty of opportunity to get out if they want or to change the selection so this has long he indicated earlier there was a lot of inertia that drives non enrollment and I think some Americans may think or say on the conservative side of the political spectrum there could be some some point of view that sort of says well you know we ought to give people the option to not participate because that's their constitutional right you know maybe perhaps so but honestly most people aren't invoking a constitutional right

01:06:52

not to see you know sign up with health insurance what they're doing is they just are busy with other things in life and they're not signing up and so I think the reaction would be like it has been in 401 k's if we did a lot more auto enroll even through employers I think most of the response from the people who get auto enroll will be Oh golly thank you I'm glad I got this idea you know it's one last thing I have to worry about now rather than you violated my rights you know I think I do think

01:07:22

they're there I think there's sort of two dynamics that make auto enrollment of health insurance different in the employer context then then into into a retirement benefit and the first is when an employer Auto enrolls you into a 401 K the employer is is largely spending your money sometimes there's a matching contribution but they are primarily spending you money in enrolling in the 401k when they're enrolling into a health insurance plan they're primarily spending their own money because of

01:07:53

course employers offering employer sponsored health insurance pay between 70 and 85 percent of the premium and so so the sort of financial incentive for the employer is a little bit different the other I think important dynamic here is poor is that is affecting employees eligibility for premium assistance in the individual market so of course under current law people who are offered employer coverage but for whom that coverage is very expensive are able to

01:08:25

receive a premium tax credit if they decide to forgo their employer coverage and opt for marketplace coverage instead and so there's some concern that employers by Auto enrolling employees may be firewalling individuals from sort of better more affordable coverage for their low-wage workers in the marketplace and so and so I think there has that has sometimes been a concern I think that has perhaps been sort of overblown at times on the

01:08:57

other hand the employer can manipulate its own liability under the employer responsibility requirement potentially in this way which which could could be a cause for concern so employers have tread had generally tread lightly here one thing that has come up and Stan uses this word a lot is employers do more commonly use sort of a forced choice they don't in a lot of employer health plans it's not possible to just not answer the question you your HR office is going to keep hounding you until you tell them yes or no to to the health

01:09:28

coverage that they're offering and they don't you're allowed to opt out but they're not they're not gonna let you be quiet they will they will keep bugging you until you until you tell them yes or no which is not quite the same as auto enrollment but may achieve some of the same benefits the other big difference with health coverage in the employer context is that you might be turning down the employer plan because you're covered through your spouse's plan for for auto enrollment to work you need to know that the benefit that you're enrolling people in is going to be something that folks buy

01:09:59

value and if you have a large percentage of people who don't because they're enrolled in their spouses plan that's a that's a problem as a challenge but then I want to underline the point that underscore the point that Jim made which is the success of auto enrollment and the employer retirement savings accounts really shows that it can offer enormous potential with health coverage too and I'm thinking about when in Louisiana when they did the closest thing we've come and Medicaid to automatic enrollment with the express lane eligibility program where they essentially they mailed families cards

01:10:32

this is under Bobby Jindal help Medicaid cards to families and said your child is eligible for Medicaid based on snap you can consent to enroll by using the card by the end of the year more than eighty percent of the families had used the card we did some focus group studies when I was at the Urban Institute and we talked to these families and they loved it people who would not use the card set it is just such a source of peace of mind to know that if anything happens to my child I can go to the doctor and it's gonna be covered there was like not the kind of pushback we were concerned about

01:11:03

it people just loved it so I think Jim is right if we design it right people may like it a lot now one of the reasons that carrier that the one carrier in Maryland push back against automatic enrollment was the you know the arguments well a lot of people who are enrolled they won't like it they're gonna call us up they're gonna complain I'm hopeful that we could see our way to at least towards testing it for its pilot testing it in part of the state and and my hope would be that the carriers would see that in fact people are happy to be enrolled in coverage that doesn't cost them anything and that provides them with some access to

01:11:33

coverage and care so so I think Jim it's really good point there as usual okay actually I just wanted to ask that I think you know almost you know profound change in thinking in economics you know has come in the last couple of decades as far as behavioral economics the notion that people sometimes can make better decisions with ELQ and the notion that I guess the Nobel laureate Baylor came up with it was a nudge that and

01:12:05

then I think it probably some of the intellectual basis of auto enrollments that you know most people would actually be very pleased could this happen to that and we ought to help them but you know with the gentle enough nudge that we're not taking their greeting away you go to another question I think we've done a

01:12:36

good job yeah any comments on the political needs to avoid what turns would turn out to be overpayments and underpayments and subsidizing coverage so I can start on this one I think an overpayment in an underpayment is what you what the law defines as an overpayment or or an underpayment and so in my view the way we should be

01:13:09

approaching this is to define eligibility in a way that makes overpayments and underpayments there's not the same problem that they are today rather than considering it an overpayment if last year's tax returns and your income was 178 percent of poverty but now your income is 201 percent of poverty and so you know that that's an overpayment we can just say last year's tax return was was sort of good enough for us I do think we have to acknowledge that that I said this at the

01:13:40

beginning but our system is not going to be perfect we'll put people in Medicaid when they should have been in the private market or vice versa or whatever and so we just need to to build a system that that doesn't treat those those those things as a as an error or failure but rather as going to be the inevitable inevitable impact of running something across a large population and so so cost is important but I would would want to avoid this language of overpayments and

01:14:12

underpayments because an overpayment is what you define an overpayment to be which brings me do I want to raise one issue here which is related to all of this and very much agree with that point which is if you if you did a state-based experimentation program I could imagine the state like Maryland or another state saying wouldn't it make sense for us to use prior year tax information to do all this and also shift our regular enrollment for the exchange process into the spring and not a habit in the fall

01:14:42

so maybe the federal structure should allow this is sort of a waiver idea and go July 1 to July 1 and so everybody's income from the prior year will count for eligibility for Medicaid and premium tax credits July 1 going to the following July 1 based on the prior calendar your tax information and honestly you know you just make it a lot easier for everybody if you just did it that way and you know I can see a state kind of coming to that conclusion once

01:15:12

this federal structure put all this in place gave them the information gave them the authority to do it and we can see what happened I think it might actually work a little bit better than the process we have now where we're trying to you know put them into eligibility based on everybody trying to you know guess what their income is going to be in the following county yeah I see two panelists nodding heads and blacks giving the opportunity to follow up on what Jim said just to say I agree yeah but Stan don't you have a problem

01:15:43

with July 1st don't you want to do a little earlier yeah those are small details as I agree I just want to make sure the states had time to you know process all that tax data good I some questions have come in the two ways I mentioned remember events at Brookings do you or Twitter auto enrollments and

01:16:12

just keep coming in so I move my screen several states do not have broad-based income tax how would auto enrollment if it all work in those states from Chris peril Stan do you want to take that one so a couple possibilities one is particularly in the current environment State Workforce agencies which run unemployment insurance programs I think are too critical important place to look as I mentioned earlier you know we've tried many times

01:16:43

in the country's history to enroll laid off workers into health coverage whether with the healthcare health coverage tax credit program passed in 2002 Cobra subsidies in past 2009 now the ACA we've generally failed to reach this population because people are just overwhelmed and struggling with the challenges both emotionally and practically I've I've lost my job with this that I mean Who I am as a person how do I get unemployment insurance do I get snap people do not have the bandwidth generally speaking to deal with health coverage so this is a really

01:17:14

important opportunity to figure out how can we make it as light a lift as possible for people so what we're suggesting to folks is and the unemployment insurance agencies themselves are overloaded right now so they don't have much space to do huge innovation one possibility would be the state health agency either the exchange in the state-based marketplace state or the Medicaid agency writes an email for the UI agency to send all of its UI applicants this seems to me like the lowest lowest hanging fruit and let the unemployment insurance recipient our

01:17:44

applicant just you know click the link go to a webpage maintained by the health agency and just provide contact information and social security number and say please reach it out to me in the following way you know email text cell phone call and sign me up for coverage and walk me through the process that now that would require the health agency to invest resources in doing the individualized follow-up but that's the kind of thing that actually got people enrolled into coverage that's one option the other place to look it seems to me

01:18:16

is driver's licenses particularly now that we're doing Real ID you know good better and different no matter how you feel about Real ID it means that states have a lot more data about us in important ways and that may be a useful place to go in states that don't have their own income tax systems doesn't have income tax it's a really good question because it really shows the importance of doing both federal and state policy at the same time that's the without a federal without a state income tax could have access to the federal

01:18:48

income tax data when I fell off the student cases for my kids for you know college you know there was an automatic download that I agree to from the from the IRS to my FAFSA application st. we could do the same thing for states who don't have any anyone could speak to besides Maryland's which states have been most active in pursuing our

01:19:21

enrollments experiments well Massachusetts has done some interesting things they've got these a lot of great academics who've been working with the exchange there and figuring out what kinds of nudges work most effectively with people and what sort of auto and long instruction strategies work um we've gotten inquiries from states like Colorado New Mexico Virginia Maine Pennsylvania but a

01:19:54

lot of that interest went away when Koli hit I mean that that's you know really very much front of mind for people and although this is important there are other topics that understandably have we have gotten the limited bandwidth of short legislative session decision-makers that have come to the fore so we had some interest early on in this session we still have some interest in a number of states but I don't know how many states are going to be following America from Maryland sleep

01:20:23

this year question on Medicare in relevance which may not be relevant let me just read it Medicare enrollment process is extremely confusing complicated especially compared synthetic Kate or the marketplace how does Medicare auto enrollment fit into the conversation this is somewhat of a broadening which I think I know the answer but anyone would like to take a

01:20:57

crack well you're automatically enrolled into both Part A and Part B fee for service at age 65 unless you essentially opt out if you started applying for Social Security benefits by that point if you haven't applied for Social Security by that point and you have to find a way of paying your Part B premiums you can of course elect to take Medicare Advantage

01:21:28

as opposed to fee-for-service a and B coverage that require is an over opt-in and you have to go through the Medicare managed portal for looking at your options deciding which coverage you would like you also have to do similarly for Part D for prescription drugs so it's sort of a mix and in addition to all that if you go into Medicare fee-for-service which many people do about half of new enrollees are going

01:21:59

the fee-for-service half in to Medicare Advantage those who go into fee-for-service also at that time have to figure out if they want supplemental coverage and that is a different enrollment process through a different portal so I would agree with the questioner in the sense that this whole process needs to be reorganized to be a little bit clearer to people about what their choices are and what the implications of them are but this is that's a big topic that goes well beyond what we're talking about today Thanks yeah actually to me the Medicare autumn

01:22:31

enrollments we had a system but then as people started working longer beyond 65 and not needing Medicare Part B you know we kind of created it a new problem people who don't enroll you know because Medicare is a very powerful caller mandates where if you don't enroll in Part B when you're supposed to your

01:23:01

premium is higher for life and goes up based on the number of years but I think that's a very specific Medicare issue that probably is that side we've discussing that's about questions here what protections are being put in place to ensure personal data privacy is from Michelle again kulakowski US cultural business yeah so so data privacy is

01:23:32

really important here and and it obviously it's critical that whatever CD or federal agency is handling this information handled it with with care and is is you know subject to strict agreements about how the information is used and and you know certainly we we need to ensure that consumers personal information is not being exposed by state agencies that are assisting and health insurance enrollment or or anything else I don't think auto enrollment poses sort

01:24:03

of new or different challenges on data privacy issues than the underlying systems that exist state Medicaid agency state tax agencies the federal equivalent already have access to to a large amount of information that needs to be protected and so I agree that the protections are critical I don't think the questions here are different in kind from what we are what we're already dealing with it what the the statutory infrastructure is already set up to protect and in certain ways I think our

01:24:33

long-standing sensitivity about how and where tax data in particular gets shared have really hampered a lot of auto-enrollment activities are our attitude towards federal tax data in particular is that it can't go anywhere for any purpose absent an express statutory authorization with some nuance that we don't even get into here and so that that really makes it difficult to do something like the maryland experiment

01:25:06

as well as it could be done if there was more robust access to to federal tax data if we if we opened up the the situations in which data is who could use federal and state tax data and we we would we would be able to layer on the necessary privacy protections and really do a lot of good I think we also are similar there's another major database the national database of new hires which which is used for child support

01:25:36

enforcement today and very very few other things but it's similarly potentially really powerful in in facilitating enrollment and again I the the types of privacy protections we would need are the kind that already exist under current law and so sort of opening up those databases for this kind of project I think could go a could go a long way and put me down in a way that is absolutely respectful of consumer privacy I agree one point that sort of interesting in terms of data architecture the federal data services

01:26:08

hub which is the way that lots of different federal data sources have been made and private as well have been made available to exchanges and state Medicaid agencies it doesn't operate as a federal repository of data it's a federal doorway through which you can ping the underlying data sources maintained by separate agencies and that's an important element of the architecture that reduces the risks of security breaches and privacy losses Thanks we're nearing the end of our time and before signing off I'd like to give

01:26:39

each of the panelists an opportunity to stay any final thoughts they have reflecting on our conversation so I'll start I have really enjoyed this this discussion the one of the things that is most striking for me and in conversations like like this one or others that I've had privately with with you all and others is that anybody who thinks seriously about operationalizing auto-enrollment occur at any meaningful

01:27:10

scale is thinking about changes to our eligibility rules that it's not possible to tackle this policy problem without reimagining the way we do eligibility to to make it more stable and more predictable over time and that's coming from the left and from the right it is a it is a prerequisite to two serious efforts in our know enrollment and so I think that is that is one of my team's main takeaways from from the conversation but there are lots of different ways to tackle this problem but they almost all start with some

01:27:43

summary imagining of the way we do eligibility for healthcare coverage program I would just add I think it speaks volumes about the promise in the kinds of policy solutions that we've all talked about that you see the kind of ideological diversity that's represented here as well as the the kind of really what I think is technocratic I mean that in the kind of sense of the word you know our sort of technocratic approach to trying to figure out how we

01:28:14

can facilitate enrollment in this way because I do think it speaks to one of those rare opportunities when when right and left might work together to make something happen in a really meaningful way yeah I completely agree it's just such a joy to see at a time of tremendous partisan strife that people with different perspectives can work together and figure out a way to solve problems that help people's everyday lives and in terms of the notion of technical technocracy and simplification

01:28:45

and all that you know davis point about making it simple it's i think about it in terms of the things are talking about are complicated and yet the goal is to make it simple to computers I think about like a car I have no idea what happens on my car I know there's a carburetor it's run by a computer all I know about all I care about as I push one thing and I go I push another thing and I stop and I turn the wheel and it's easy for me a lot of complicated engineering beneath the hood makes it possible for me as a person to make it a really easy driving experience that's

01:29:17

what we want to do for health coverage and we and it may take a lot of engineering and work behind the hood we may have to get our hands greasy and Lord knows what we're gonna have to do but the goal is to make it really simple it's a complicated system we have now whatever we can do to make it simpler for people we're gonna get a lot more people health coverage and that that'll be that'll be good for them and for the country exactly I think carburetors went out of cars a couple of decades ago shows you what I know I echo what it

01:29:49

already has been said I think if the United States is going to have a multi payer system which we probably will you know absence of other things happening I think we probably will have a multi payer system for some time there's only one you know way to move forward which is to try to make that multi payer system work a little bit better in terms of getting people into what they're supposed to be in based on their current life circumstances and you know given the ACA

01:30:24

and what it's setup attached to the employer system attached to Medicaid attached to our retirement Medicare program you know how do we make all of that work a little bit better with each other as people move around and have different changes in their life circumstances I think auto enrollment could be a very big part of that and I very much agree simplicity you know complicated engineering out of sight simplicity for the consumer getting general bipartisan agreement about you know what happens when and you know what

01:30:56

are the options for people at what point in time and you know getting the employer community also to participate in all this I think all that could go a long way toward being in a better place five years from now than one there we are right now if you'd like you've got the last word sure just real quick I tremendous thought and I use that we've heard today are good signs for the future policy even if we end up having a fight over health policy like we seem to

01:31:26

have there will be a lot underneath that Gerdes that efforts like out of enrollment to make this system better so yes regardless of the politics no matter how cynical you are about the politics this discussion is going to be essential to like moving forward isn't guessing yeah try to get covered people covered and protected from high costs thanks like you know my long experience in health policies have always thought of we can sort healthcare policy issues and

01:31:58

there are some where partisan differences don't come in doesn't mean that they're easy often stake all their differences are limits what we can do but anyway that's very encouraging that auto-enrolment might be in concept and multi-layer systems might be in that nonpartisan category I want to thank all of you your presentations and your discussion

01:32:30

comments were all very very valuable and I'm really glad we could get together on Zoom to do this and look forward to seeing you at least virtually again soon but thank you very much to Brookings and AEI for sponsoring this event really kudos yeah thanks for thank you to all of you who participated thank you and thanks to Paul for stepping up and moderating it was absolutely really great thank you max thank you thank you

01:33:00

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Webinar: Health insurance auto-enrollment

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