After the Affordable Care Act (ACA) ushered in years of a decline in the uninsured rate, recent data from the Census Bureau indicate a rise in the share of the population without health insurance for the first time since implementation of the ACA’s insurance reforms. The troubling trend follows a series of federal actions undermining the ACA, including policies that curtail the impact of Medicaid expansion and reduced funding for enrollment outreach.

As states look for ways to counter this uptick in the uninsured, Maryland is in the process of implementing a program that offers a new, easy way to enroll in comprehensive and affordable health insurance.

Maryland’s New Program to Address the Uninsured

Since Congress suspended the ACA’s individual mandate penalty, a number of states have considered or enacted state-level coverage requirements. Last year, Maryland lawmakers introduced legislation that would have established an innovative form of the individual mandate. Instead of paying an outright penalty for being uninsured, residents who failed to maintain coverage would instead be charged a “down payment” for a new health insurance plan. The state would use this down payment and tax information to automatically enroll residents in affordable coverage, either through marketplace plans with applicable federal subsidies, or through the state’s Medicaid program.

The bill ultimately failed, but was reintroduced and reworked this year. In May, Maryland enacted legislation establishing the Maryland Easy Enrollment Health Insurance Program, a state initiative that provides uninsured residents with a new avenue for enrolling in comprehensive health insurance.

Under the program, residents who lack coverage will be able to check boxes on their tax return indicating they are uninsured, and that they are interested in finding out their eligibility for state medical assistance programs or federal premium and cost-sharing subsidies. The Maryland exchange will use tax information to determine eligibility, and if applicable, enroll residents and qualifying household members in Medicaid or CHIP, or provide a special enrollment period for enrolling in a marketplace plan with subsidies. The enacted legislation also includes a directive to study the feasibility of instituting an individual mandate and automatic marketplace enrollment, indicating that the state may eventually move towards the innovative coverage requirement imagined in the initial proposal.

Maryland has taken numerous steps to protect access to quality and affordable coverage, including implementing a state reinsurance program that reduced individual market premiums. The Maryland Easy Enrollment Health Insurance Program is a first-in-the-nation attempt to use data collected on a tax form to provide consumers with a new opportunity to enroll in affordable health insurance. The Kaiser Family Foundation found that in 2017, half of Maryland’s uninsured population was eligible for a public insurance program or federal tax credits. By using the tax filing process to reach the uninsured, Maryland is tackling one of the largest barriers to enrollment: a lack of information about available low- or no-cost insurance options.

As Maryland Moves to Increase Access to Insurance, the Federal Government May Erect a New Barrier to Maintaining Coverage

While states are leading the way in innovative ways to improve access to health insurance, the federal government is considering ending a practice that facilitates millions of enrollments each year. Currently, automatic re-enrollment, also called automatic renewal, allows consumers who do not actively switch plans or leave the marketplace to stay covered and keep their federal subsidies. Auto renewal is a common practice in public programs like Medicare Advantage and in the employer group market. It eases administrative burdens for enrollees and insurers and helps maintain continuity of coverage and care.

However, earlier this year, the Centers for Medicare & Medicaid Services (CMS) asked for comments on the automatic re-enrollment process for possible rulemaking to address agency concerns about errors in eligibility and government waste. The comments they received on this topic unanimously supported preserving automatic re-enrollment, and with good reason: nearly a third of people who selected a marketplace plan in 2019 were automatically re-enrolled into previous coverage (see table). Despite this support, CMS is considering future rulemaking beginning as early as Plan Year 2021 that may eliminate automatic re-enrollment. Ending or significantly modifying the process may have disastrous consequences for consumers and market stability.

Marketplace Plan Selections During the Open Enrollment Period for Plan Years 2018 and 2019

Source: Centers for Medicare & Medicaid Services, “Health Insurance Exchanges 2019 Open Enrollment Report,” March 25, 2019, accessed at https://www.cms.gov/newsroom/fact-sheets/health-insurance-exchanges-2019-open-enrollment-report.

A recent study published in JAMA Internal Medicine highlights why automatic re-enrollment is critical to maintaining marketplace signups. Researchers at the University of Pittsburgh and Duke University evaluated enrollment data from the California marketplace, finding that between 2014 and 2017, losing the ability to automatically re-enroll in marketplace coverage due to an insurer exit was associated with a 30-percentage point decrease in enrollment. The authors suggest that eliminating automatic re-enrollment would be associated with fewer enrollees remaining insured through the marketplace.

The 2021 Notice of Benefit and Payment Parameters is currently under review at the White House Office of Management and Budget. It remains to be seen if CMS will propose changes to automatic re-enrollment, but evidence shows that the ability to automatically re-enroll is associated with better enrollment outcomes.

Takeaway

The rise in the uninsured rate should sound the alarm that the hard-won advances of the ACA have been eroded under the current federal administration. At the state level, policymakers should consider ways they can increase access to enrollment, be it through a Maryland-style program or taking advantage of increased opportunities to promote enrollment as a state-based marketplace. And as the federal government considers changes that may reduce plan renewals and coverage continuity, they should listen to the consumer advocates, insurers, and state regulators who are on the front lines of enrollment efforts when they voice opposition to changing established and valuable enrollment practices.