Health insurance auto-enrollment
Table of Contents
- Like to welcome you to this webinar on auto enrollments sponsored jointly by...
- Tax credits for that period of time second thing I think is to provide you...
- Low-cost silver you actually see that a significant number of silver plans could...
- They're thinking about their insurance markets that also frankly levels of...
- Them has an individual mandate and it's actually much more rigorously enforced...
- Email for the UI agency to send all of its UI applicants this seems to me like...
00:05
like to welcome you to this webinar on
auto enrollments sponsored jointly by
Brookings and the American Enterprise
Institute to begin persistence of
persisting 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 are not enrolled the
Urban Institute is estimated that 25% of
00:35
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 enrollment is critical
to achieving universal coverage in a
01:07
multi payer 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 a guy to 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 reflecting
their perspectives on how we can
01:39
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
audience if you have questions send them
02:10
either to events at Brookings don't need
to you or use Twitter and it's the
hashtag
auto enrollments 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 the
uninsured rate in half by enrolling
those who are eligible for coverage into
02:47
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
becomes fully enrolled into health
coverage with without having to take any
03:17
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 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
someone into coverage we need to know
who they are and then we need to have
03:49
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
challenge is that we have to collect a
premium some of the uninsured can
04:21
qualify for zero premium 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 and
bridge 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
robust to those kinds of errors so those
04:53
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 auto enrollment system both of which
I'll talk about a little bit more
the first is retroactive enrollment and
the second is strategies 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
population-wide auto enrollment the idea
05:25
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
back-up plan typically when they file
05:57
their taxes and the premium would be old
regardless of whether or not the person
used healthcare services in the year
this is obviously a big change from the
way we think about enrollment today and
that 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 tech towards universal
coverage that is that is in my view most
06:28
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 at
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 their as
the time they file their taxes look like
they are eligible for a zero premium
06:59
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
07:29
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
08:01
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 the
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
08:32
integrates the health coverage
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
damn 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
09:17
having me on the panel today this is a
very important and good topic for us to
discussing right now as lots of 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
09:48
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 Kristen 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
10:19
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
10:49
should try to put into place some kind
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 billion you
know a billion but not that much
11:21
certainly not in the context of money
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
11:53
be a grant to the HHS with funding to
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
12:23
access to insurance registries to be
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
12:55
an IT infrastructure to facilitate it
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 you
is when someone is auto-enrolled into a
program what happens if their income
13:25
changes sort of midstream and I think
one of the 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
13:56
enrolled into a program they're held
harmless for a period of time and given
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
14:26
explore this kind of program and I think
the first one is related to what I just
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
14:57
tax credits for that period of time
second thing I think is to provide you
know data sources really that allow them
to handle this in new responsibilities
better this is actually number three on
our list here would ask 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
15:32
data that has to be reported by the plan
health self-insured coverage data
through ERISA 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
16:02
states ought to be allowed to auto
enroll anyone into a catastrophic plan
right now the ACA limits that's two
people 30 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
16:34
reminded about options about health
insurance and allowed to auto enroll
into a program during that process
thanks thanks very much I think I'm 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
17:08
terrific so we're gonna talk about that
I'm going to talk about that using the
tax filing moment as an 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 third some
statements that are all policy
implications so to begin with why income
tax filing let me try so the why use
17:41
income tax filing as a place to start an
enrollment well to paraphrase the famous
saying associated with Willie Sutton
because 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
law also has all kinds of data
associated with it from which
eligibility can be determined so there's
18:12
obviously the information on the form
about income the previous year but
there's also a social security number
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
18:42
on largely voluntary compliance with tax
forms people need to feel comfortable
knowing that even illegal income
generating activities or unethical ones
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
19:12
easy enrollment bill in 2019 it garnered
enormous bipartisan support a unanimous
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
19:45
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
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
20:16
implementing it unbelievable unbelievabl
cooperation and effort on their part
it's a three phase approach 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
20:48
by using the standard procedures going
online to the portal or calling the the
1-800 number etc 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 who file 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
21:19
experience several states had tried
similar direct mail campaigns with
children based on state income tax
returns and gotten less than 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
checked the box on their tax return and
21:50
asked to have their information shared
with the exchange to determine
eligibility and nearly 3,000 have
enrolled into coverage really an a
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 those 71 percent most have been
low income fully 26 percent our children
most
young adults relatively few are in
high-income ranges so this suggests a
lot of promise if this is representative
22:20
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 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
22:52
legislation of stakeholders including
plans providers consumer groups tax
preparers have had a central role very
important to take their concerns into
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 having state
pilots that are supported by the federal
23:22
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 accord with the available
data and Jim talked about that as well
you might want to think about changing
the enrollment cycle so that 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
23:53
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
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 ago now's 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
24:23
off workers do not enroll income
for which they qualify it's just
overwhelming to be grappling with job
loss and therefore it becomes imperative
to make enrollment as 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
24:55
or detection of the disease and in terms
of the economy health care losses have
been enormous and if we see torrential
losses in 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 and economic half
health insurance is critical and
automatic enrollment is an important
recipe to any successful approach to
health insurance thanks very much
25:27
great to be with this group of people
and all of them have worked very hard on
on these important ideas and so what I
thought I would do today is to share
with you some thoughts about hopefully
everyone can see this about kind of
operationalizing auto enrollment in
thinking about some opportunities for
using and deploying auto enrollment
which I think Stan did a great job of
outlining at the state level how they've
25:58
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
about how to how to use auto enrollment
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 enrollment is is
26:30
sort of multifaceted identifying a
population figuring out who fits in
actually enrolling them activating them
effectuating coverage and
reconciling 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 a
useful sort of start in thinking about
27:02
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 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
27:33
the analysis you can start by defining
the problem a little bit so a lot of
this is drawn from in my presentation
from 2019 data and a lot of this comes
with the assistance of the of the Blue
Cross and Blue Shield 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
28:05
public health coverage and those who are
not lawfully present in the US which is
obviously three relatively significant
groups of people but let's just start
with this group of people to begin with
these numbers obviously are gonna look
different with the kovat 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
28:37
into the category below 133 percent of
FPL another million in that increment
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 were operating in okay
if we look then at what percentage of
the low-income uninsured can access free
bronze coverage under again 2019 data
29:06
what we see is that the vast majority of
rating areas in fact almost all rating
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 a hundred and thirty
three and two hundred percent of FPL
could have access to free bronze
coverage again using 2019 data which i
29:38
think is a really encouraging thing if
you're trying to figure out where you
start right because sometimes and think
about the problem it can be so 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 a 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
30:09
low-cost silver you actually see that a
significant number of silver 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 133 percent of FPL what you see is
that the vast majority of the country
30:41
offers access to silver plans for a
relatively low 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
31:15
smaller group of people even than those
group of people that we were talking
about and that is could you auto enroll
young people who are aging off their
parents plans whose incomes fall into
one hundred and thirty three to two
hundred scent 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
31:47
with with with an apt see with the tax
credits 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 stands
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
32:19
based on the needs and the situations
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 I I will
readily admit this is a and not that
significant percentage of people right
32:51
we're talking about 50,000 individuals
nationwide who are estimated to be
uninsured who are 27 years old and who
fall under this income Cadi okay 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 to
like like Texas
what you find is that the vast majority
33:22
of the this sort of pilot population
we're talking about could qualify for $0
bronze coverage after applying the apt
see and so there is some 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 and the panel
really elegantly outlined and try and
put it into effect for a small group of
people who could potentially really
33:53
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 strikes 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
gonna get a lot more into this there are
some political considerations to think
34:24
about namely that you know a 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
34:55
which obviously gets gets conservatives
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
35:28
from from the from the federal
government with the state governments
together
with that I will I will conclude that
was that was awesome I think my father's
battle 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
taking of the benefits and making them
36:01
so what I want to do is is basically
talk about why first of all why I like
the which is you know a lot of health
care policy is complicated and know and
you know Roman makes enrollment easier
to get coverage for people he creates a
safe default choice for consumers so
they can't go too far astray from when
36:33
it comes to their health care coverage
if somebody forgets to enroll or gets
overwhelmed by the choices they still
get coverage and today's discussions I
think has made it clear that as we're
grappling with our 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 you know we talked about
examples about our moment in current law
37:03
and then some of the political
challenges that despite the appeal heard
from a little bit so first let's look at
some key pieces of legislation that
include perhaps the most automatic of
all is the make hair Medicare for all
Act which has automatic enrollment
because everybody is automatically
entitled coverage and then automatically
Medicare for America Act is contains two
37:34
kinds of auto moment the first is a
default enrollment for a public plan for
the uninsured and the second is
automatic in a moment at birth and then
in the patient
senators Casting Collins composed
enabling states to do a woman is lon Ian
and Jim have talked about next to
amongst various think-tank or puzzles we
see a lot of ideological diversity as
Brookings and I admit it already clear
38:05
they're on the vanguard of making
automatic and woman a part of their
proposals Christians just Kristin just
discussed how the Brookings proposed
proposal was is retrospective so you get
automatically grown retrospectively in
coverage yeah I proposed a cluster as
much automatic enrollment as possible
doing it in their own 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 in
38:35
receiving food stamps or welfare and
then in Medicare for extra for all caps
plan it's a basis for the Dalaran
Schakowsky bill which concludes the
automatic enrollment for the uninsured
into fall public plan and automatic
enrollment at birth our third way
proposed the tab costs cost caps and
covers for all we kind of combined the
bookings and I approaches we have as
much upfront automatic enrollment as
possible in a private plan and then a
39:06
retrospective in the moment in a public
plan for anybody who's locked as a
backstop and lastly we all remember
finally when sort of bothered was at the
Heritage Foundation II proposed
automatic enrollment as an alternative
to the individual man
so the popularity of auto auto
enrollment has already become embodied
in the law 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
39:37
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
and minute renewal and Medicare
Advantage and exchange plans there's
also this thing called express lane
eligibility
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
40:07
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 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
we've heard that and I see three key
40:38
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 on what
the standard for default carbons is it a
health plan with essential benefits as
defined of the ACA or are a short-term
plan that doesn't have any protections
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
41:11
we would be increasing coverage quite a
bit that's going to have a big influence
now I know right now we're not supposed
to be worrying about you know cost
because we call the crisis and that's
appropriate but eventually we're gonna
have to start thinking about our
long-term sustainability of budgets and
you know des 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 big push in Congress to get this
done you know there's no organized
constituency for people who will forget
41:43
to do things and get overwhelmed by
their choices now they're great
advocates for consumers like family I
would say but it's going to be hard to
organize you're on automatic enrollment
Stan would love to do but it's gonna
have to be really coupling with broader
coverage in push for universal coverage
and the last challenge is implementation
as we kind of touched on already some
consumers will not only be confused
about their enrollment and what
getting and even if they can opt out
which they certainly should be able to
42:13
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
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
42:45
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 but simply to not take up
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 be
seen in such a letter after
auto-enrollment is enacted an American
spine that it has given them the
43:15
protection that they ended up eating
okay thanks I'm unmuted I 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 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 a state or
43:57
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 by doing things
in the state level we get it 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
44:29
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 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
44:58
wanted to write a federal statute I
think unless we did the retroactive
enrollment option sort of the the big
one you know where you just sort of
placed everybody into a plan of some
sort
it's not entirely clear to me that we
all would agree on or even know exactly
what it to put into a federal statute to
do auto enrolment easily at the moment
it's a pretty complex endeavor and I
think there's such differentiation
across the states in terms of how
45:31
they're thinking about their insurance
markets that also frankly levels of
capacity to
[Music]
engage in this that maybe that's an
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
46:03
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
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
46:33
of people proposing various programs to
do that but when you tell them as
locking slides indicates and everybody's
information is indicated that the
majority of people who are uninsured are
actually eligible for something and I
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
they're I think that means that you know
we're gonna maybe a little bit of a long
47:03
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 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
47:34
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 challenge and I think Jim has
come
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 national
whether that's with the Children's
48:05
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 outlined in terms of things that the
federal government can do to give a
boost the state efforts are absolutely
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
48:35
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
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 Jim talked about this
49:06
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 into coverage
and filing when they file their income
taxes whether into Medicaid or into your
premium marketplace coverage so I could
see some opportunities for federal
action as well so we're we're out
produced opportunistic and Families USA
whatever opportunities we see for
coverage gains we're going to seize them
and take and do the best we can
I just want to underscore that that last
49:39
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
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 Ellen
is a is a calculation that's made at the
50:10
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 kind of
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 turned in 27 and aging
50:40
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
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
51:11
you're eligible for and the following
calendar year is an eminently reasonable
thing to do and 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 snow upon tyne stability and the
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 we'll be using
to determine eligibility and does it
really make sense for this complicated
51:41
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
reconciling 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
Stan I'd be willing to look at both I
think that's the way to go let me just
add to that you know we are there is
52:13
lots of other areas of our policy the
federal policy which we used pressure
start to
qualifications like the student loans
all that is done and prior your taxes so
that's a good point to make as well let
me also have an echo you know both the
political motivation here it's going to
be the biggest thing that people worried
about our costs and running for
president say it's gonna come up and say
we're gonna protect everybody from high
costs well part of that has to be
52:44
coverage you can't protect people from
high costs unless they have carbon so so
I see this you know to be getting nicely
into a federal debate about where we go
next with coverage now of course I
totally agree also money and you know
the states are going to be where the
action takes place so we've really got
to do both but it's Christmas that it's
gotta be you know I just thought of
53:16
something that's you know so much of the
work we've done on Ottoman Albans 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 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
53:48
start thinking about you know like prior
tax data you know will not help fast
enough to deal with something so I
almost wonder if there we need to have a
you know more than one approach to at
least be available during 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
54:19
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 a 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
major change in circumstances and
there's an 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 returns you the work and then
54:49
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
keep on Jeanette at scale whether that's
an estate or whether or you know when a
pilot program but it's actually
functional
across a group of people but you also
preserve some some complexity therefore
55:21
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
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 enrolment now having
55:52
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
easily be bridged into a marketplace
plan that would offer similar or
substantially similar coverage that
would also be available at a at a cost
point to them that's similar to what
56:23
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
bears thinking about whether in fact
there is some way of
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
56:55
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 Auto in a moment would be
an interesting and potentially
attractive alternative you know London
do you think it's feasible to that this
could actually show up that a federal
Kovach relief bill and the sense be one
more example of how responding to the
57:26
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 have had I think it's
only gonna be feasible if you can
identify a 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
57:58
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 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
58:29
deductible the spending toward
deductible and an employer plan to a
marketplace plan so in other words if
you've spent two hundred out of your
five hundred dollar deductible you would
get credit for that spend against your
deductible in a marketplace plan as if
it were your 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
59:00
clearly 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 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 or
59:31
countries with multi payer systems for
example Germany Switzerland Netherlands
how do they use auto enrollments to
achieve you know crystal coverage I
think I'll jump in here because actually
Paul and I talked about this in advance
and that I'm sure those 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
01:00:02
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 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
01:00:33
is just to put them into a plan and then
start trying to make sure that 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 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
01:01:05
insurance plans that are regulated by
the country in the state and if someone
sort of recalcitrant and not signing up
they actually Bend this place them into
the competing plans in the country on a
proportional basis 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 tasks should be a
01:01:38
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
aztlán 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
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
01:02:07
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
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
01:02:40
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
or should I go on I think you know why
don't we learn from Missha tips by
employers that use auto enrolment for
retirement plans are any employers using
such an approach for their health
benefit plans
01:03:09
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 on the employer
retirement site which is obviously a lot
easier
the basic story there is that it has
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
01:03:41
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
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
01:04:12
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
not just 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 Floral in kayes if we did a lot
01:04:42
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
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
01:05:14
an employer Auto enrolls you into a 401k
the employer is is largely spending your
money sometimes there's there's a
matching contribution but they are
primarily spending you
or money in enrolling in the 401k when
they're enrolling as a health insurance
plan they're primarily spending their
own money because of 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
01:05:44
important dynamic here is for 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 receive a premium
tax credit if they decide to forgo their
employer coverage and ox4 marketplace
coverage instead and so there's some
concern that employers by Auto enrolling
01:06:16
employees may be firewalling and
individuals from sort of better more
affordable coverage for their low-wage
workers in the marketplace and so and so
I think there that has sometimes been a
concern I think that has perhaps been
sort of overblown at times on the 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
01:06:48
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
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
01:07:20
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 by and large
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
01:07:52
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
this is under Bobby Jindal health
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
01:08:24
studies when I was at the Urban
Institute and we talked to these
families and they loved it people who
would not use the cards that 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 it
people just loved it so I think Jim is
right if we design it right people may
like that 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
01:08:54
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
coverage and care so so I think Jim it's
really good point there as usual good
actually I just wanted to ask that I
think you know almost you know profound
change in thinking in economics you know
01:09:26
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 Thaler
came up with it was a nudge that and
then I think it probably some of the
intellectual basis of auto enrollments
that you know
most people would actually be very
pleased that this happen to that and we
01:09:57
ought to help them but you know with the
gentle enough nudge that we're not
taking their freedom away you go to
another question huh I think we've done
a good job yeah any comments on the
political needs to avoid what terms
would turn out to be overpayments and
01:10:29
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
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
01:11:02
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
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
01:11:35
but rather as kind of 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
underpayments because an overpayment is
what you define an overpayment to be
which brings me to 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
experiment
Haitian program I could imagine the
01:12:06
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 have it in the fall
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
01:12:37
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
the 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
01:13:09
I see two mental is not a handsome black
TV the opportunity to follow up on what
Jim said just to say I agree yeah but
Stan don't you have a problem with July
first don't you want to do a little
earlier yeah those are small details
yes I agree I just want to make sure
those states had time to you know
process all that tax data good point I
01:13:39
some questions have come in the two ways
I mentioned remember events at Brookings
ddu or Twitter auto enrollments and just
keep coming in so I moved my screen
several states do not have broad-based
income tax
how would auto enrollment if it all work
in those states from Chris Barrow
Stan do you want to take that one so a
couple possibilities one is particularly
01:14:11
in the current environment State
Workforce agencies which run
unemployment insurance programs
I can't are too critical
important place to look as I mentioned
earlier you know we've tried many times
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
01:14:42
practically I've I've lost my job with
is 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 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
01:15:14
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
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 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
01:15:44
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
is driver's licenses particularly now
that we're doing Real ID you know good
bad or indifferent 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 and that
01:16:16
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 couldn't have access to the federal
income tax data but 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
01:16:52
anyone could speak to
besides Maryland's which states have
been most active in pursuing our
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
lung instruction strategies work um
we've gotten enquiries from states like
01:17:25
Colorado New Mexico Virginia Maine
Pennsylvania but a 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
01:17:58
I don't know how many states are going
to be following America from Maryland
sleep this year question on Medicare
enrollments which may not be relevant
let me just read it Medicare enrollment
process is extremely confusing and
complicated especially compared to make
Kate or the marketplace
how does Medicare auto enrollment fit
01:18:27
into the conversation this is somewhat
of a broadening which I think I know the
answer but anyone would like to take a
crack well you're automatically enrolled
into both Part A and Part B fee for
service at age six
five 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
01:18:59
paying your Part B premiums you can of
course elect to take Medicare Advantage
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 a mix and in addition to
01:19:32
all that if you go into Medicare
fee-for-service which many people do
about half of new enrollees are going
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
01:20:03
that's a big topic that goes well beyond
what we're talking about today Thanks
yeah actually to me the Medicare autumn
enrollments we had a system but then as
people started working longer beyond 65
and not meeting Medicare Part B you know
we kind of created it a new problem
people who don't enroll you know because
Medicare has a very powerful caller
01:20:34
mandate where if you don't enroll in
Part B when you're supposed to your
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 been
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
01:21:07
vistas yeah so so data privacy is 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
01:21:39
I don't think auto enrollment poses sort
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
01:22:12
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 anything get into here and so that
that really makes it difficult to do
something like the Maryland experiment
01:22:45
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's who could use
federal and state tax status 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
are similarly there's another major
database the national database of new
hires which which is used for child
01:23:15
support 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 of 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 could be done 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
01:23:47
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
01:24:18
each of the panelists an opportunity to
say 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 in 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
01:24:49
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 auto
enrollment and so I think that is that
is one of my two main takeaways from
from the conversation but there are lots
of different ways to tackle this problem
01:25:19
but they almost all start
with some reimagining of the way we do
eligibility for health care 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
01:25:50
approach to trying to figure out how we
can facilitate enrollment in this way
because I 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
01:26:23
technical technocracy and simplification
and all that you know Dave's point about
making it simple it's I think about it
in terms of the things were 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
01:26:54
really easy driving experience that's
what we want to do for health coverage
and 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
01:27:22
what I know I echo what it 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
01:27:57
circumstances and you know given the ACA
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
01:28:31
general bipartisan agreement about you
know what happens when and you know what
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 where we
are right now if you'd like you've got
the last word
sure just real quick I tremendous
thought and ideas that we've heard today
are good sign for the future policy even
01:29:02
if we end up having a fight over health
policy like we seem to have there will
be a lot underneath that Gerdes that
efforts like auto Roma to make system
better so yes regardless of the politics
no matter how cynically you are about
the politics this discussion is going to
be essential to like moving forward as I
guess me 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
01:29:33
of we can sort healthcare policy issues
and there are some where partisan
differences don't come in doesn't mean
that they're easy often stay call their
differences
limits what we can do but anyway that's
very encouraging that auto-enrollment
might be in concept and multi-layer
systems might be in that nonpartisan
category I want to thank all of you your
01:30:07
presentations and your discussion
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
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