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Measuring the Scope of Presidential Candidates’ Coverage Proposals

Summary

Avalere analysis finds that the candidates’ healthcare coverage reform proposals could impact a range of 23M to 153M individuals across insurance markets.

The 2020 presidential campaign platforms for both President Trump and former Vice President Biden include a range of healthcare proposals. While the policies differ in magnitude and the degree to which they disrupt existing coverage, millions of Americans could see different benefits, changes in insurance protections, shifts between forms of coverage, or loss of insurance as the result of these policies. Accordingly, Avalere estimated the number of individuals by insurance market who could be impacted by select coverage reforms if they were enacted today.

Between the candidates, Avalere has identified 6 of the key coverage reforms that could be a focal point of healthcare policy in 2021, including:

  • Expanding Medicare Eligibility to Age 60 (Biden): Expands Medicare eligibility to all adults aged 60 or older, regardless of current insurance status.
  • Public Option (Biden): Allows individuals who are not already enrolled in Medicaid or Medicare to buy into a national public option.
  • Affordable Care Act (ACA) Legislative Enhancements (Biden): Expands Advance Premium Tax Credit (APTC), provides additional funds for reinsurance programs and state-based insurance markets (SBMs), removes short-term limited duration insurance (STLDI) flexibilities, and sets national network adequacy standards.
  • Full ACA Repeal (Trump/US Supreme Court): Assumes key titles of the ACA are struck down, including the exchanges, Medicaid expansion, and protections for individuals with pre-existing conditions.
  • Health Reimbursement Arrangement (HRA) Flexibility Expansion (Trump): As established under the Health Reimbursement Arrangements and Other Account-Based Group Health Plans final rule, all employers are allowed to offer an HRA that employees can use to enroll in individual market plans or Medicare, rather than offer traditional employer-sponsored coverage. The rule also allows “limited excepted benefit” HRAs that employees can use to purchase coverage that is not considered a comprehensive individual plan (“alternative coverage”) outside of their employer-sponsored coverage.
  • State Block Grants (Trump): Replaces current open-ended Medicaid financing structure, premium tax credits, Basic Health Program (BHP) provisions, and cost sharing reduction (CSR) payment with block grants to fund state-designed health care reform programs.

Importantly, this analysis does not attempt to project the number of people who would shift between sources of coverage nor the qualitative impact on affordability or access of each policy. This analysis simply estimates the number of people, subject to the intricacies and details of each policy, that could see changes to their coverage if each individual coverage reform were enacted.

Table 1. Number of Lives Impacted by Priority Coverage Reforms, by Payer
Payer Category Medicare Eligibility Expansion Public Option ACA Legislative Enhancement Full ACA Repeal HRA Flexibility Expansion State Block Grants
Medicare To date, candidates’ major proposals would not shift coverage for current Medicare beneficiaries.
Medicaid 3.8M 15.3M 74.6M
Employer-Sponsored Insurance 13.4M 78.4M 78.4M 93.1M 153.4M
Individual Market 3.2M 13.9M 13.9M 10.7M 9.8M
Uninsured 1.7M 21.0M 17.0M 3.8M
Other Government* 600K
Total 22.7M 113.1M 109.3M 119.1M 153.4M 88.2M

*Includes Veteran’s Affairs, Indian Health Services, and TRICARE.

Methodology

To estimate the number of people that could be impacted by the 6 potential priority healthcare coverage reform proposals, Avalere analyzed the number of eligible individuals in each market using the American Community Survey 2018 1-year sample of health insurance coverage in the US and the Congressional Budget Office’s (CBO) Composition of the Uninsured Population report for 2021.

Medicare Expansion

To estimate the number of newly Medicare-eligible enrollees, Avalere analyzed the number of individuals aged 60–64 in each state, regardless of current insurance access, by using the American Community Survey 2018 1-year sample of health insurance coverage in the US.

ACA Repeal

To estimate the number of individuals impacted by a full ACA repeal, Avalere analyzed the number of individuals enrolled in the ACA exchanges using the Centers for Medicare & Medicaid Services (CMS) Early 2020 Effectuated Enrollment Snapshot, and in Medicaid, due to the ACA expansion, using CMS’s Quarterly Medicaid Enrollment Data for the New Adult Group. In addition, Avalere estimated the total number of individuals with preexisting conditions in the non-Medicare and non-Medicaid population. Specifically, Avalere used data from the 2015 Medical Expenditures Panel Survey, which includes information about health conditions, coverage sources, and health costs for a nationally representative sample of the US population. Individuals who received either Medicare or Medicaid at any point in 2015 were excluded.

ACA Enhancements

Avalere estimated the number of individuals impacted by legislative enhancements to the exchanges under the ACA—including expanding APTC to additional income levels and setting a lower affordability threshold, providing additional funds for reinsurance programs and SBMs, removing STLDI flexibilities, and setting national network adequacy standards. Specifically, Avalere analyzed the number of individuals that would be eligible for enhanced subsidization using the ACS 2018-year sample of individuals with employer-sponsored insurance from 138% to 500% of the federal poverty level, along with the current individual market population using Avalere’s Proprietary All-Payer Enrollment Model. In addition, Avalere assessed CBO’s Composition of the Uninsured Population report for 2021 to determine the number of uninsured individuals currently eligibility for marketplace subsidies or subsidized employer-based coverage or those with FPLs above state marketplace subsidy eligibility levels.

Public Option

Avalere estimated the number of individuals impacted by a public option proposal, as proposed by Vice President Biden, assuming all individuals between 138% and 500% FPL who are not already enrolled in Medicaid or Medicare could be eligible. Accordingly, similar to the analysis of ACA enhancements, Avalere analyzed the number of individuals that would be eligible for enhanced subsidization using the ACS 2018 1-year sample of individuals with employer-sponsored insurance above 138% of the federal poverty level, along with the current individual market population using Avalere’s Proprietary All-Payer Enrollment Model. In addition, Avalere assessed CBO’s Composition of the Uninsured Population report for 2021 to determine the number of uninsured individuals currently eligibility for marketplace subsidies or subsidized employer-based coverage or those with FPLs above state marketplace subsidy eligibility levels.

HRA Expansion

To estimate the number of individuals that could be impacted by HRA expansion, as finalized under the June 2019 Health Reimbursement Arrangements and Other Account-Based Group Health Plans final rule jointly released by the Department of Health and Human Services, the Treasury Department, and the Department of Labor, Avalere estimated the total current employer-sponsored insurance market using the ACS 2018 1-year sample and proprietary All-Payer Enrollment Model.

State Block Grant

To estimate the number of individuals impacted by a Medicaid and ACA block-grant proposal, Avalere analyzed the CMS Preliminary June 2020 Applications, Eligibility, and Enrollment Data monthly report to determine total national Medicaid enrollment, as well as the CMS Early 2020 Effectuated Enrollment Snapshot for the subsidized exchange population. Additionally, Avalere analyzed CBO’s Composition of the Uninsured Population report for 2021 to determine the number of individuals with an income below the FPL threshold to qualify for subsidized exchange coverage in a state that has not yet expanded Medicaid.

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