A pathway to universal health care coverage


The Affordable Care Act helped more than 20 million Americans get health insurance. But despite these gains, we still have a long way to reach universal coverage. Today, more than 27 million Americans remain uninsured, despite the fact that many are eligible for coverage at very little or no cost to them. In fact for the calendar year 2017, more than half of all uninsured people who were eligible for tax credit assistance could have enrolled in a plan that required no premium. Another 1 million people were eligible to buy a plan that cost less than the individual mandate penalty. So why did these Americans not sign up for coverage? What was stopping them?

The bottom line is that health insurance is complicated and people are busy. Likely, many of these people didn’t know they were eligible for affordable and possibly free coverage. One way to solve this problem would be to intensify outreach efforts during the open enrollment period. Based on California’s experience, we know that targeted promotion works; it moves healthy people on the fence into coverage and saves everyone money in the long run. But the Trump administration has moved in the opposite direction, reducing spending on outreach and shortening open-enrollment period. An alternative and complimentary approach is to simply make the enrollment process as painless as possible: make it automatic!

{mosads}Research in behavioral economics has shown that paying attention to the design of programs can increase participation dramatically at almost no cost. One way to accomplish this is to simply change the default options.  We know that automatically enrolling those eligible for a program such as school lunches unless they opt out gets participation rates up to nearly 100 percent. In the case of health insurance, by flipping the choice that consumers make from “do I enroll in coverage and if so how?” to “do I choose to turn down coverage?” we know that a significant amount of people will use the default option – and choose to be enrolled. In fact, retirement plans that switched to opt-out models saw participation jump from just 33 percent to 90 percent. Automatic enrollment also helped enroll three-quarters of low-income seniors in Medicare Part D prescription coverage in just 6 months. These are staggering improvements for such a simple change.

Furthermore, we know that America currently has millions of financially eligible people who can receive affordable health care for virtually no upfront cost, but they just haven’t signed up. More than one third of those 27 million uninsured Americans are between the ages of 19 and 34, and the vast majority are very healthy. It’s clear that America’s health care system is in dire need of an easy, effective way to boost enrollment rates. What America needs is an opt-out model.

This week I am introducing the Pathway to Universal Coverage Act. This bill would help states expand health care coverage to millions of Americans and experiment with auto-enrollment for those eligible for coverage with no monthly premium, either through premium assistance on the ACA exchanges or Medicaid. The bill offers states that agree to participate in the program some money to cover their startup costs. States that establish an auto-enrollment system for eligible citizens of their state would be required to give individuals 60 days to opt out. This preserves total consumer choice in their own health care decisions as well as preserving the right of states to determine their own policies. It would also help states expand coverage by providing them with better access to federal data, including identifying who is both uninsured and eligible for a subsidy. It would also greatly streamline enrollment requirements. Finally, it would hold individuals who are auto-enrolled harmless from recoupment if their income later changes.

I understand that health care is extremely personal. Nearly 90 percent of Americans already have health insurance, but we have an opportunity to do better. Americans deserve an easy, effective way to enroll in affordable coverage. Piloting opt-out programs at the state level gives states the flexibility to address their own unique situation, rather than impose a one-size-fits-all model. Getting more young and healthy people in the marketplace would also lower costs for everyone. An auto-enrollment model has the potential to expand health care coverage to at least 4 million Americans right now. It’s an easy solution that would give millions of Americans health care, as well as financial piece of mind. What are we waiting for?

Rep. Ami Bera, M.D. is a physician representing California’s 7th District.

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