Eligibility for ACA Health Coverage Following Job Loss

Eligibility for ACA Health Coverage Following Job Loss

Eligibility for ACA Health Coverage Following Job Loss – Methods ...

The economic consequences of the coronavirus pandemic have led to historic level of job loss in the United States. Social distancing policies required to address the crisis have led many businesses to cut hours, cease operations, or close altogether. Between March 1st and May 2nd, 2020, more than 31 million people had filed for unemployment insurance. Actual loss of jobs and income are likely even higher, as some people may be only marginally employed or may not have filed for benefits. Some of these unemployed workers may go back to work as social distancing curbs are relaxed, though further job loss is also possible if the economic downturn continues or deepens.

In addition to loss of income, job loss carries the risk of loss of health insurance for people who were receiving health coverage as a benefit through their employer. People who lose employer-sponsored insurance (ESI) often can elect to continue it for a period by paying the full premium (called COBRA continuation) or may become eligible for Medicaid or subsidized coverage through the Affordable Care Act (ACA) marketplaces. Over time, as unemployment benefits end, some may fall into the “coverage gap” that exists in states that have not expanded Medicaid under the ACA.

In this analysis, we examine the potential loss of ESI among people in families where someone lost employment between March 1st, 2020 and May 2nd, 2020 and estimate their eligibility for ACA coverage, including Medicaid and marketplace subsidies, as well as private coverage as a dependent (see detailed Methods at the end of this brief). To illustrate eligibility as their state and federal unemployment insurance (UI) benefits cease, we show eligibility for this population as of May 2020 and January 2021, when most will have exhausted their UI benefits.

What are coverage options for people losing ESI?

Eligibility for health coverage for people who lose ESI depends on many factors, including income while working and family income while unemployed, state of residence, and family status. Some people may be ineligible for coverage options, and others may be eligible but opt not to enroll. Some employers may temporarily continue coverage after job loss (for example, through the end of the month), but such extensions of coverage are typically limited to short periods.

Medicaid: Some people who lose their jobs and health coverage—especially those who live in states that expanded Medicaid under the ACA— may become newly eligible1 for Medicaid if their income falls below state eligibility limits (138% of poverty in states that expanded under the ACA). For Medicaid eligibility, income is calculated based on other income in the family plus any state unemployment benefit received (though the $600 per week federal supplemental payment available through the end of July is excluded). Income is determined on a current basis, so prior wages for workers recently unemployed are not relevant. In states that have not expanded Medicaid under the ACA, eligibility is generally limited to parents with very low incomes (typically below 50% of poverty and in some states quite a bit less); thus many adults may fall into the “coverage gap” that exists for those with incomes above Medicaid limits but below poverty (which is the minimum eligibility threshold for marketplace subsidies under the ACA). Undocumented immigrants are ineligible for Medicaid, and recent immigrants (those here for fewer than five years) are ineligible in most cases.

Marketplace: ACA marketplace coverage is available to legal residents who are not eligible for Medicaid and do not have an affordable offer of ESI; subsidies for marketplace coverage are available to people with family income between 100% and 400% of poverty. Some people who lose ESI may be newly-eligible for income-based subsidies, based on other family income plus any state and new federal unemployment benefit received (including the $600 per week federal supplement, unlike for Medicaid).2 While current income is used for Medicaid eligibility, annual income for the calendar year is used for marketplace subsidy eligibility. Advance subsidies are available based on estimated annual income, but the subsidies are reconciled based on actual income on the tax return filed the following year. People who lose ESI due to job loss qualify for a special enrollment period (SEP) for marketplace coverage.3 As with Medicaid, undocumented immigrants are ineligible for marketplace coverage or subsidies. However, recent immigrants, including those whose income makes them otherwise eligible for Medicaid, can receive marketplace subsidies.

ESI Dependent Coverage: People who lose jobs may be eligible for ESI as a dependent under a spouse or parent’s job-based coverage. Some people may have been covered as a dependent prior to job loss, and some may switch from their own coverage to coverage as a dependent.

COBRA: Many people who lose their job-based insurance can continue that coverage through COBRA, although it is typically quite expensive since unemployed workers generally have to pay the entire premium – employer premiums average $7,188 for a single person and $20,576 for a family of four – plus an additional 2%. People who are eligible for subsidized coverage through Medicaid or the marketplaces are likely to opt for that coverage over COBRA, though COBRA may be the only option available to some people who are income-ineligible for ACA coverage.

Short-term plans: Short-term plans, which can be offered for up to a year and can sometimes be renewed under revised rules from the Trump administration, are also a potential option for people losing their employer-sponsored insurance. These plans generally carry lower premiums than COBRA or ACA-compliant coverage, as they often provider more limited benefits and usually deny coverage to people with pre-existing conditions. Even when coverage is issued, insurers generally may challenge benefit claims that they believe resulted from pre-existing medical problems; given the long latency between initial infection and sickness with COVID-19, these plans are riskier than usual during the current pandemic. People cannot use ACA subsidies toward short-term plan premiums.

Our analysis examines eligibility for Medicaid, marketplace subsidies, and dependent ESI coverage. We do not estimate enrollment in COBRA, short-term plans, or temporary continuation of ESI. See Methods for more details.

How does coverage and eligibility change following job loss?

Between March 1st, 2020 and May 2nd, 2020, we estimate that nearly 78 million people lived in a family in which someone lost a job. Most people in these families (61%, or 47.5 million) were covered by ESI prior to job loss. Nearly one in five (17%) had Medicaid, and close to one in ten (9%) were uninsured. The remaining share either had direct purchase (marketplace) coverage (7%) or had other coverage such as Medicare or military coverage (6%) (Figure 1).

Eligibility for ACA Health Coverage Following Job Loss | The Henry ...

We estimate that, as of May 2nd, 2020, nearly 27 million people could potentially lose ESI and become uninsured following job loss (Figure 1). This total includes people who lost their own ESI and those who lost dependent coverage when a family member lost a job and ESI. Additionally, some people who otherwise would lose ESI are able to retain job-based coverage by switching to a plan offered to a family member: we estimate that 19 million people switch to coverage offered by the employer of a working spouse or parent. A very small number of people who lose ESI (1.6 million) also had another source of coverage at the same time (such as Medicare) and retain that other coverage. These coverage loss estimates are based on our assumptions about who likely filed for UI as of May 2nd, 2020 and the availability of other ESI options in their family (see Methods for more detail).

Among people who become uninsured after job loss, we estimate that nearly half (12.7 million) are eligible for Medicaid, and an additional 8.4 million are eligible for marketplace subsidies, as of May 2020 (Figure 2). In total, 79% of those losing ESI and becoming uninsured are eligible for publicly-subsidized coverage in May. Approximately 5.7 million people who lose ESI due to job loss are not eligible for subsidized coverage, including almost 150,000 people who fall into the coverage gap, 3.7 million people ineligible due to family income being above eligibility limits, 1.3 million people who we estimate have an affordable offer of ESI through another working family member, and about 530,000 people who do not meet citizenship or immigration requirements. We project that very few people fall into the coverage gap immediately after job loss (as of May 2020) because wages before job loss plus unemployment benefits (including the temporary $600 per week federal supplement added by Congress) push annual income for many unemployed workers in non-expansion states above the poverty level, making them eligibility for ACA marketplace subsidies for the rest of the calendar year.

By January 2021, when UI benefits cease for most people, we estimate that eligibility shifts to nearly 17 million being eligible for Medicaid and about 6 million being eligible for marketplace subsidies (Figure 2), assuming those who are recently unemployed have not found work. Many unemployed workers who are eligible for ACA marketplace subsidies during 2020 would instead be eligible for Medicaid or fall into the coverage gap during 2021. The number in the coverage gap grows to 1.9 million (an increase of more than 80% of its previous size), and the number ineligible for coverage due to income shrinks to 0.9 million.

Estimates of coverage loss and eligibility vary by state, depending largely on underlying state employment by industry and Medicaid expansion status. Not surprisingly, states in which the largest number of people are estimated to lose ESI are large states with many people working in affected industries (Appendix Table 1). Eight states (California, Texas, Pennsylvania, New York, Georgia, Florida, Michigan, and Ohio) account for just under half (49%) of all people who lose ESI. Five of the top eight states have expanded Medicaid, and people eligible for Medicaid among the potentially newly uninsured as of May 2020 in these five states account for 40% of all people in that group nationally. Overall, patterns by state Medicaid expansion status show that people in expansion states are much more likely to be eligible for Medicaid, while those in non-expansion states are more likely to qualify for marketplace subsidies (Figure 3). However, the number of people qualifying for marketplace subsidies is similar across the two sets of states, as more people live in expansion states. Three states that have not expanded Medicaid, including Texas, Georgia, and Florida, account for 30% of people who become marketplace tax credit eligible nationally in May 2020. Assuming unemployment extends into 2021 when UI benefits would likely expire for most families, the proportion eligible for Medicaid would increase in expansion states while non-expansion states may see more nonelderly adults moving into the Medicaid coverage gap (Figure 4; Appendix Table 2).

Figure 3: May 2020 Eligibility for ACA Coverage among People Becoming Uninsured Due to Loss of Employer-Sponsored Insurance, by State Medicaid Expansion Status

Figure 4: January 2021 Eligibility for ACA Coverage among People Becoming Uninsured Due to Loss of Employer-Sponsored Insurance, by State Medicaid Expansion Status

Nearly 7 million people losing ESI and becoming uninsured are children, and the vast majority of them are eligible for coverage through Medicaid or CHIP. Within the 26.8 million people losing ESI and becoming uninsured in May 2020, 6.1 million are children. Because Medicaid/CHIP income eligibility limits for children are generally higher than they are for adults, the vast majority of these children are eligible for Medicaid/CHIP in May 2020 (5.5 million, or 89%) or January 2021 (5.8 million, or 95%).

Discussion

Given the health risks facing all Americans right now, access to health coverage after loss of employment provides important protection against catastrophic health costs and facilitates access to needed care. Unemployment Insurance filings continue to climb each week, and it is likely that people will continue to lose employment and accompanying ESI for some time, though some of them will return to work as social distancing curbs are loosened. The ACA expanded coverage options available to people, and we estimate that the vast majority of people who lose ESI due to job loss will be eligible for ACA assistance either through Medicaid or subsidized marketplace coverage. However, some people will fall outside the reach of the ACA, particularly in January 2021 when UI benefits cease for many and some adults fall into the Medicaid coverage gap due to state decisions not to expand coverage under the ACA.

Both ACA marketplace subsidies and Medicaid are counter-cyclical programs, expanding during economic downturns as people’s incomes fall. In return for additional federal funding to help states finance their share of Medicaid cost during the public health crisis, states must maintain eligibility standards and procedures that were in effect on January 1, 2020 and must provide continuous eligibility through the end of the public health emergency, among other requirements. These provisions may help eligible individuals enroll in and maintain Medicaid, particularly in light of state and federal actions prior to the crisis to increase eligibility verification requirements or transition people off Medicaid.

Our estimates only examine eligibility among people who lost ESI due to job loss and potentially became uninsured. Additional uninsured individuals—including some of the 9% of the 78 million individuals in families where someone lost employment—may also be eligible for Medicaid or subsidized coverage. It is possible that contact with state UI systems may lead them to seek and enroll in coverage, even if they were eligible for financial assistance before job loss but uninsured.

It is unclear whether people losing ESI and becoming uninsured will enroll in new coverage. We did not estimate take-up or enrollment in coverage options but rather only looked at eligibility for coverage. Even before the coronavirus crisis, there were millions of people eligible for Medicaid or marketplace subsidies who were uninsured. Eligible people may not know about coverage options and may not seek coverage; others may apply for coverage but face challenges in navigating the application and enrollment process. Still others may find marketplace coverage, in particular, unaffordable even with subsidies. As policymakers consider additional efforts to aid people, expanding outreach and enrollment assistance, which have been reduced dramatically by the Trump Administration, could help people maintain coverage as they lose jobs.

This is the first economic downturn during which the ACA will be in place as a safety net for people losing their jobs and health insurance. The Trump Administration is arguing in case before the Supreme Court that the ACA should be overturned; a decision is expected by next Spring. The ACA has gaps, and for many the coverage may be unaffordable. However, without it, many more people would likely end up uninsured as the U.S. heads into a recession.

 

 

 

 

Now Is the Time to Address Surprise Billing

https://www.medpagetoday.com/blogs/marty-makary/86455?xid=fb_o&trw=no&fbclid=IwAR1boFFgBZuSqJ9-1728UdSFeIK790TTXNeoJJ9mky9jCKbGyQ_G4jqwrfk

Tips to avoid surprise medical bills

The doctor-patient relationship is being undermined.

Private equity companies have spent millions in dark money to stall and effectively kill all versions of surprise billing reform. But this week, the issue will come before Congress again. Legislation was introduced Tuesday in the House that, among other things, would further assist hospitals with more relief funds. With this potential third disbursement of federal dollars comes an opportunity to finally address the embarrassing problem of surprise billing that has eroded the public trust in our great medical profession.

Physicians across the country are now signing a letter urging leaders of Congress to address surprise billing once and for all. I have already signed this letter and encourage you to consider doing so as well.

One reason the medical profession is the greatest profession in the world is that patients put their faith and trust in us. But 64% of Americans now say they have avoided or delayed medical care for fear of the bill. As more and more patients lose faith in the system, the doctor-patient relationship is being undermined by surprise billing and the modern-day business practices of price gouging and predatory billing. In fact, these egregious practices have become part of the business model of some private equity groups, which seek to replace physician autonomy with corporate medicine.

Our system today is unnecessarily complicated and works against patients’ interests by putting them in the middle of a finger-pointing blame game, which leaves them holding the bag. It doesn’t make sense for us to accept people with open arms, treat their ailment, and then ruin their lives financially. Medical science is a bastion of scientific and intellectual genius. We can fix this problem. Already, some efforts are advancing price transparency by creating a transparent marketplace for patients.

I’ve spent many years looking at the systematic cost issues that face our health system and patients. Simply put, the lack of fairness and transparency in pricing and billing practices has created financial toxicity and increased the general mistrust of the medical system for millions of Americans. No one designed it to be this bad. In fact, we have good people working in a bad system. When I explain details of pricing, billing, and collections with doctors and hospital leaders, they are invariably shocked and furious to learn how out of control their billing offices have gotten in overcharging patients and shaking people down for more than a reasonable amount for a service.

The current COVID-19 crisis is a stark reminder of the gaps in our health system that exacerbate the pressures facing providers and patients. Many Americans are getting crushed right now. Despite many years of debate in Washington and bipartisan agreement that something must be done, there is still no federal protection in place to safeguard consumers from an egregious surprise medical bill if they need emergency care or have limited options. The reality is that special interests — including the very private equity firms that stand to benefit financially from these exploitative business practices — continue to spend millions to maintain the status quo.

It’s time for a bipartisan compromise to end the non-transparent game of surprise medical billing. It’s time that Congress takes meaningful action to protect patients during this COVID-19 crisis and finally address this issue. Congress has solutions on the table that would bring much greater fairness and transparency to the healthcare system, protect patients from these predatory charges, and ensure that physicians are paid fairly for our services, as we deserve. It’s time we put an end to the cycle of financial toxicity and rebuild the great public trust in the medical profession.

 

 

 

 

COVID-19 Tracking Poll: Most Californians Continue to Favor Staying Home Despite Economic Consequences

COVID-19 Tracking Poll: Most Californians Continue to Favor Staying Home Despite Economic Consequences

COVID-19 Tracking Poll: Most Californians Continue to Favor ...

To help Californians and state policymakers understand evolving demands on the state’s health care system during the COVID-19 pandemic, CHCF is working with survey firms on two fronts. CHCF and global survey firm Ipsos are assessing residents’ desire for COVID-19 testing and their access to health care services. CHCF and Truth on Call, a physician market-research firm, are surveying hospital-based critical care, emergency department, and infectious disease physicians about staffing and the availability of testing, personal protective equipment (PPE), intensive care unit beds, and ventilators. Download the charts and data for your own presentations and analyses.

Californians’ support for sheltering in place to curb the spread of coronavirus remains strong, according to a new tracking poll from CHCF and survey firm Ipsos.

For the second time in two weeks, Californians were asked which of the following statements came “closest to your opinion” of the state’s pandemic response:

  • Californians should continue to shelter in place for as long as is needed to curb the spread of coronavirus, even if it means continued damage to the economy.
  • Californians should stop sheltering in place to stimulate the economy even if it means increasing the spread of coronavirus.

This week, 71% of Californians want to continue the statewide order, compared to 75% two weeks ago. The change is within the statistical margin of error. This week, 17% say to stop sheltering in place, and 12% say they don’t know or have no opinion. Seventy-three percent of Californians with incomes at or below 138% of the federal poverty guidelines (PDF) support the stay-at-home orders.

Support for sheltering in place is strong among Californians no matter the setting in which they live. Seventy-three percent of urban residents support continuing to stay at home compared to 72% of rural Californians, and 68% of suburban residents.

As public officials plan greater use of “contact tracing” in future phases of COVID-19 containment efforts, Californians were asked which of the following came closest to their opinion about sharing personal information with public health officials:

  • I am willing to share personal information about my health, movements, and contacts with local and state public health officials in order to help them understand and combat the spread of coronavirus.
  • I am not willing to share personal information about my health, movements, and contacts with local and state public health officials under any circumstances.

Sixty percent of state residents are willing to share personal information to help stop the spread of the coronavirus, while 21% are unwilling to share information under any circumstances, and 18% don’t know or have no opinion. These results have changed little in two weeks. Forty-nine percent of Black Californians (not shown) and 50% of Californians with low incomes are willing to share information.

Public officials are discussing moving from broad shelter-in-place strategies to more targeted quarantine-and-isolate approaches to COVID-19 containment. In this week’s tracking survey, CHCF and Ipsos asked Californians who live with at least one other person about their capacity to physically separate themselves from others in their home. According to the most recent US Census data, 11% of Californians live alone.

Eighty-one percent of those who live with at least one other person say they have access to a separate bedroom at home, and 58% say they have access to both a separate bedroom and a separate bathroom. Among Californians with low incomes, 74% of those who live with at least one other person have access to a separate bedroom, and 38% have access to a separate bedroom and a separate bathroom. Sixteen percent of all Californians surveyed and 22% of Californians with low incomes do not have access to a separate bedroom.

Californians say they continue to engage in recommended behaviors to slow the spread of the new coronavirus. Eighty-four percent say they avoid unnecessary trips out of the home “all of the time” or “most of the time.” With regard to other public health behaviors:

  • 81% of Californians say they routinely wear a mask in public spaces all or most of the time.
  • 93% say they stay at least six feet away from others in public spaces all or most of the time.
  • 93% say they wash their hands frequently with soap and water all or most of the time.

Compared with previous editions of the tracking survey, the percentage of Californians who would like to get tested increased. This week, 17% of those surveyed say they haven’t sought a test but would like to get one, up from 11% in the first survey in March.

As in findings in previous rounds of the tracking survey, 2.7% of Californians report they were tested in the preceding seven days. More Californians with low incomes report trying and failing to get tested than those overall (5.8% vs. 2.4%).

The share of Californians seeing health care providers by phone or video continues to rise. This week, 8% of Californians report seeing a provider by phone or video. The portion of Californians seeing a health care provider in person in the previous week has fallen by half, from 10% to 5% since this poll began in March.

The growth in telehealth appointments is more pronounced for Californians with low incomes, with 11% reporting that they saw a provider by phone or video in the previous seven days compared to 1.7% in late March.

Over the previous seven days, 70% of Californians say their mental health is “about the same” as before. This response is unchanged from two weeks ago. The percentage of respondents saying their mental health has gotten “a little” or “a lot” worse declined from 22% to 18%. This change is within the margin of error.

Less than 1% of Californians say they have lost health insurance coverage in the last month. Fifteen percent are “very” or “somewhat” worried about losing coverage, and among Californians with low incomes, 27% are worried about losing health insurance coverage.

 

 

 

Cartoon – Market Cure

Cartoon – Your tumor is still growing | HENRY KOTULA

Cartoon – U.S Healthcare Options

Cartoon – US Healthcare Options | HENRY KOTULA

Even health care jobs aren’t safe

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Unemployment rate soars to 14.7% in April - Axios

The coronavirus pandemic is a health care crisis, but health care still isn’t immune from the rampant job losses the pandemic has wrought, Axios’ Bob Herman reports.

By the numbers: The health care industry lost more than 1.4 million jobs in April.

The reason: These jobs have gone away because outpatient care has dried up, as providers postponed elective procedures.

  • More than four out of five of those lost jobs were at dentists, doctors’ offices, chiropractors and other outpatient settings.
  • Technicians, billing clerks and medical assistants who work in outpatient settings — many of whom are not highly paid — have felt the brunt of the job losses.

What’s next: Don’t expect a quick return, even as elective procedures are able to come back online.

  • Patients who have lost their insurance or are worried about catching the coronavirus in a waiting room will likely stay away even from outpatient facilities.
  • “Of all the places people want to come back to quickly, a health care setting is probably not at the top of the list,” said Ani Turner, a health economist at Altarum.

What we’re watching: All of these delays in elective care a boon to insurers, who are saving a lot of money while outpatient procedures are on ice.

  • Some insurers will likely have to pay big rebates to their customers as a result. UnitedHealth Group is getting a jump start on that process, announcing $1.5 billion worth of voluntary premium credits and waived fees.

 

 

 

 

Cartoon – Sign of Coronavirus Times

The Coronavirus Scream - Truthdig: Expert Reporting, Current News ...

Minneapolis Fed president: ‘The worst is yet to come on the job front’

https://thehill.com/homenews/sunday-talk-shows/497006-minneapolis-fed-president-the-worst-is-yet-to-come-on-the-job?rnd=1589121753

Minneapolis Fed president: 'The worst is yet to come on the job ...

The president of the Federal Reserve Bank of Minneapolis said Sunday that the “worst is yet to come” after a record of 20 million people lost their jobs amid furloughs and layoffs sparked by the coronavirus pandemic in April. 

“I mean the worst is yet to come on the job front, unfortunately,” Neel Kashkari said on ABC’s “This Week.”

“We may be in an environment of gradual relaxing and then having to clamp back down again around the country as the virus continues to spread,” he added. “To solve the economy, we must solve the virus. Let’s never lose sight of that fact.”

Kashkari also contradicted White House economic adviser Larry Kudlow’s prediction for a financially strong half of 2020 and full 2021 when ABC’s George Stephanopoulos asked if that was realistic.

“You know, I wish it were,” he responded. “What I’ve learned in the last few months, unfortunately, this is more likely to be a slow, more gradual recovery.”

The Minneapolis Fed president said a “robust economy” would require a breakthrough in vaccines, testing and therapies. 

“I don’t know when we’re going to have that confidence,” he said, adding, “and ultimately, the American people are going to decide how long the shutdown is.”

The Department of Labor reported last week that the unemployment rate had reached 14.7 percent, which is the highest since the U.S. began tracking in 1948. More than 33 million people have applied for unemployment claims since mid-March. 

Speaking earlier Sunday on “This Week,” Kudlow acknowledged that “very difficult” unemployment numbers could likely be reported in May. But he added that there is a “glimmer of hope” within the unemployment data, with 80 percent of the claims involving those who were furloughed or going through temporary layoffs. 

 

 

 

 

Most consumers nervous about returning to care settings

https://mailchi.mp/aa7806a422dd/the-weekly-gist-may-8-2020?e=d1e747d2d8

As non-essential businesses begin to reopen, there’s no guarantee that merely opening the doors will make customers return. A recent Morning Consult poll provides an assessment of the impact of COVID-19 on consumer confidence: fewer than one in five US adults are currently comfortable doing (formerly) everyday activities like eating at a restaurant or going to a shopping mall.

The graphic below provides similar data for healthcare. Consumers’ willingness to visit healthcare providers in person for non-COVID care is only slightly better, at 21 percent. Which providers might see patients return most quickly?

Consumers say they are about twice as likely to visit their primary care doctor’s office than other healthcare facilities, including hospitals, specialists, and walk-in clinics. And when it comes to scheduling a routine in-office visit, nearly half say they will wait two to six months, with almost one in ten not comfortable going to a doctor’s office in person for a year or more.

Healthcare facilities face an uphill battle in bringing back patients—many of whom have ongoing chronic diseases that necessitate care now. Reaching patients through telemedicine and providing concrete messages about how they can safely see their doctor will be critical to staving off a tide of disease exacerbations that will mount as fear delays much-needed care.