QUESTION I – How will this proposal make health coverage affordable for people with low- and moderate-incomes?

Millions of Americans lack health insurance because they cannot afford it.  Any state that seeks to expand health care coverage must address the question of affordability.

The starting point for providing affordable coverage to a greater number of residents is through your state’s Medicaid and SCHIP programs.  Increasing eligibility levels in Medicaid and SCHIP will not only cover greater numbers of low-income residents, it will also draw down federal funding and decrease the number of uninsured your state will have to cover by other means.  States may also expand public coverage to populations that are not categorically eligible for Medicaid, such as childless, non-disabled adults or immigrants.  However, these programs generally require significant state funding.

It is also possible to make employer-sponsored health insurance more affordable to low- and moderate-income residents.  For example, some states pay part of the cost to enroll Medicaid-eligible individuals to make employer-sponsored coverage affordable while addressing concerns about crowd out.  States can also consider allowing employers to buy into public coverage.  This section will walk you through the options you have to increase affordability for low- and moderate-income people in your state.

1. Begin by expanding your state’s Medicaid and State Children’s Health Insurance Program (SCHIP). 
   Click here for more information on why and how to maximize Medicaid and SCHIP programs.
   1. To which populations?
      1. Children: A good place to start
         
      2. Parents
      3. Working disabled
      4. Disabled children
      5. Aged, blind and disabled
      6. Childless, non-disabled adults (Note: this will require a federal waiver.  See SPAs vs. Waivers.)
         
   2. Up to what income levels?
      1. What is politically and fiscally reasonable in your state?
      2. How will you address concerns that public coverage availability erodes employer-sponsored and private insurance (“crowd out”)? 
         Click here for more information on crowd out.
   3. Will your state need to submit a State Plan Amendment or apply for a  Medicaid waiver to cover these populations?
      
2. Will you establish or expand other public coverage programs to cover new populations?
   Click here for more information expanding public coverage to non-Medicaid populations.
   1. To which populations?
      1. Childless, non-disabled adults?
      2. To all adults, up to a certain income level? 
      3. Legal immigrant residents prior to meeting 5-year residency requirement?
      4. Immigrant children, regardless of status?
      5. Immigrants, regardless of status?
         
   2. To what income levels?
   3. What type of coverage?
      Will the program provide a standard plan offered by multiple insurers?
      For an example, click here for Vermont’s standard plan model.
      Will the program provide a single private plan or self-administered plan?
      For an example, click here for Maine’s single plan model.
3. How will you make employer-sponsored insurance more affordable and more widely available?  [Note:  this refers to people eligible for public coverage.  For a greater discussion of private market reforms, see Question II]
   1. For people who qualify for public programs, will you provide premium assistance?
      For more on decisions when considering premium assistance, click here.
      1. Which employers and employees would be eligible?  Employees to what income level?  What size employers?
      2. What constitutes meaningful employer-sponsored insurance?  Is meaningful employer coverage defined by the level of employer contribution?  Or by the benefits?  Both?
      3. When is it cost-effective to provide premium assistance for ESI rather than allowing people into Medicaid or SCHIP?
   2. Will you allow employers to buy into a public program?
      
   3. Will you use a state-sponsored reinsurance pool to stabilize or reduce premiums in the small group market?
      For an example, click here for New York’s reinsurance model.
   4. Will you offer tax credits to employers offering coverage?
      For an example, click here for Montana’s tax credit model.