Using automatic enrollment to cover everyone

The Senate Should Build Automatic Enrollment Into Health Reform. Here’s How.

By Lanhee Chen and James Capretta
Health Affairs Blog, June 5, 2017

As the discussion over the future of health reform continues in the United States Senate, some Republicans are looking for ways to boost coverage levels, help stabilize insurance markets, and lower health costs. For years, the U.S. has had insurance enrollment levels below what was possible because of lower than desirable take-up of existing options.

Currently, under the ACA, the markets are less stable than they could be, or should be, because there are too few younger and healthier enrollees. Automatic enrollment would boost enrollment into insurance among this group of potential customers, and thus help create a more balanced risk pool.

We believe that automatically enrolling Americans eligible for tax credits into no-premium health plans should be an important component of a renewed effort at health reform. Many of the uninsured who do not make plan selections on their own can be enrolled into plans that provide true insurance against significant or catastrophic health events. Individuals who are auto-enrolled will have the opportunity to opt-out of that coverage if they prefer; they will also be given the opportunity to switch to a different plan during the next available open enrollment period.

Operationalizing The Idea

* Make State Participation A Condition Of Federal Funding Under Reform, And Provide Separate Funding For Administrative Costs

* Require Insurers To Offer Default Insurance Products In The Individual Insurance Market

* Establish Parameters For Default Insurance Plans

* Establish A Target Population For Automatic Enrollment Into No-Premium Coverage

* Repurpose And Supplement The IRS’ Income And Insurance Enrollment Data

* Establish A Process For Assigning Beneficiaries To Default Plans

* Provide Notification To Beneficiaries

* Recruit Hospital And Physician Cooperation

What Happens When The Tax Credits Exceed The Premiums Needed For Default Insurance?

In the event Congress adopts income-adjusted credits, there will be cases when people get placed into default plans with premiums that are less than the value of the credits for which they are eligible. In these cases, the person would forgo the balance of their credit until such time that they make a selection of a plan, or affirm the default option.

What Happens When The Credits Fall Short Of The Premiums For Default Coverage?

The system for identifying and placing individuals into coverage will be based on income and insurance enrollment data from two years prior to the placement into a plan. There will necessarily be cases when someone gets placed into coverage with a premium than ends up exceeding the value of the credit for which they are eligible. In these cases, the insurance plan receiving the credit, and the individual who was placed into coverage, should be held harmless for misestimated credit amounts. That is, the insurer should not be required to return the difference between the credit received for a default enrollee over the amount of the credit that should have been paid based on the person’s income. Nor should the default insurance enrollee be asked to cover the difference in a payment to the federal government or the insurance plan.

What Happens When A Person Has Had A Break In Coverage And Owes A Premium Surcharge?

In the House-passed AHCA, persons who experience a break in coverage are required to pay a surcharge equal to 30 percent of the premium of the plan which they are seeking to purchase. The main intent of an automatic enrollment process is to help people avoid breaks in coverage, and thus also the penalties associated with trying to re-enter the market. In that context, it would be best to provide some level of accommodation for people who end up being placed into default coverage after a spell of being uninsured. One approach would be to provide everyone who experiences a break in coverage a one-time waiver of the surcharge penalty when they first are placed into a default plan. After that first occasion, however, if someone experienced a break in coverage and then subsequently got placed into a default plan, the person would be required to pay the surcharge or would eventually be disenrolled from coverage.

The Value Of High-Deductible Insurance

Critics of this approach to automatically enrolling people into default insurance will argue that the coverage will be inadequate because the deductibles will be too high. It is certainly true that plans which require no premium payment from the enrollees are likely to have deductibles that are even higher than is typical in today’s marketplace. But, despite much criticism of high-deductible insurance from politicians in both parties, such coverage provides what consumers need most from these products, which is protection against major medical expenses.

From the Conclusion

For the most part, the uninsured do not have principled objections to enrolling in coverage; they remain without insurance out of inertia, or lack of information about their options or the financial assistance available to them. Automatic enrollment can give many of the uninsured coverage at no cost to themselves.


Reader Comment:

By Don McCanne M.D.

Obviously automatic enrollment is a great idea. But why put up with the administrative complexity of the authors’ model which still leaves so many out of the system, not to mention leaving too many exposed to excessive financial barriers to care? Why not, instead, automatically enroll everyone, only once, for life? The administrative simplicity would carry through to management of health care benefits, greatly reducing the administrative waste inherent in our system. A recent estimate indicates that we would save half a trillion dollars in recoverable administrative waste, which is enough to remove financial barriers to care through the reduction of excessive patient cost sharing (Annals of Internal Medicine, online, Feb. 21, 2017).

Yes, that would be a single payer system – an improved Medicare for all – but is that any reason to dismiss it? Considering our high costs, profound waste, and inherent inequities, single payer has become an imperative. Let’s automatically enroll everyone.



By Don McCanne, M.D.

Looking at policy options in isolation can be informative, but, as this article by Lanhee Chen and James Capretta demonstrates, it is crucial to understand how the particular policy meshes with the entire package of health care reform.

Automatic enrollment into the health care financing system is a great idea, assuming that we want everyone covered. When Medicare was established, everyone eligible at age 65 was automatically enrolled in Part A - the hospital coverage. That has worked very well, as far as it went. In fact, the Supreme Court has ruled that if a person were to decline enrollment in Part A they would have to relinquish their Social Security benefits as well. That is a very powerful incentive for the individual to accept automatic enrollment.

Medicare for All supporters would improve Medicare benefits and remove the financial barriers to care and then would expand it to include everyone - through automatic enrollment.

But what do Chen and Capretta propose? They would include automatic enrollment in the AHCA repeal and replace proposal currently under consideration in the Senate. For a person eligible for a premium subsidy (tax credit), they would use the subsidy to purchase a plan in which the individual would be enrolled automatically. This would fall short since it would cover only individuals eligible for subsidies, so the program would still not be universal.

Worse, they propose that the plan would, in essence, have an actuarial value based on what the tax credit would purchase. For most individuals, that would be very little insurance. They tout the benefit of very high deductibles, stating, “such coverage provides what consumers need most from these products, which is protection against major medical expenses.” But how is an individual going to cover a $40,000 deductible with an annual income of $35,000?

Automatic enrollment is a great policy concept but it needs to be an element of a system of melded beneficial policies - like a well designed single payer system - an improved Medicare for all. Let’s set that up and then automatically enroll everyone in it.