Tax Credits + Medicaid. An Integrated Approach to Health Insurance Coverage. Lynn Etheredge

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1 4/8/05 Tax Credits + Medicaid An Integrated Approach to Health Insurance Coverage by Lynn Etheredge President Bush has recently proposed a major initiative for expanding health insurance coverage. It would use new federal tax credits -- plus new state supplements -- for individuals who do not participate in employer-based benefits or public programs. His budget includes $74 billion for individual tax credits, $23 billion for employer tax credits, and $4 billion for state purchasing pools ( ). 1 State Medicaid programs already assist more than 53 million low- income persons. However, federal laws now limit what states could do to supplement a new system of federal tax credits for individuals who fall in the gaps between employer-based benefits and Medicaid/SCHIP eligibility. An effective tax credits + Medicaid strategy would require state flexibility to re-design their Medicaid programs for this uninsured population. This paper suggests a framework for federal and state government discussions about how to design an integrated system of new federal tax credits and Medicaid reforms. It outlines eight major issue areas: eligibility, benefits and premium assistance, state purchasing pools, consumer choice, employer subsidies, enrollment and 1

2 administration, federal-state financing, and a safety net. It also suggests options for how these issues might be resolved. Eligibility An individual or family would be eligible for the new tax credits based on income. For example, individuals with incomes up to $15,000 would be eligible for a subsidy of up to 90 percent of premium, with a maximum $1,000 credit; families with incomes up to $25,000 would be eligible for a subsidy of 90 percent of premium, up to a maximum of $3,000 per family ($1,000 per adult and $500 per child). State Medicaid programs are not now able to determine eligibility only based on income. For archaic reasons, the federal Medicaid law still requires states to define eligibility in terms of categories of people. Over the years, these requirements have expanded to 28 federally-mandated categories; federal law now also permits states to cover persons in at least another 21 categories. The result is an extraordinarily complex eligibility system. Members of the same family may each have different Medicaid/SCHIP eligibility (young children, older children, pregnant women, nondisabled adults, disabled adults). Millions of very low-income individuals still cannot be covered by state Medicaid programs, simply because they do not fall into a federallyspecified eligible category. 2

3 A straightforward way to integrate federal tax credits and state Medicaid programs would be to allow states to make low income tax credit recipients eligible for some Medicaid assistance. For purposes of these Medicaid-paid supplements, states would be allowed to use the same income-based eligibility as used for determining the federal tax credits. More generally, states could also be given the option to use incomebased eligibility for all populations below some nationally-specified poverty level income. 2 Benefits and Premium Assistance The new tax credits would be a premium subsidy. Consumers would choose their own health benefits plan. The amount of government assistance would phase down with income. For example, there would be a 50 percent credit for individuals between $15,000 and $20,000 income, with a phase-out by $30,000. For families, tax credit assistance would phase out by $60,000. The administration proposes that state supplements work the same way. States could supplement the $1,000/adult federal tax credit with up to $2,000/adult of additional premium support for adults with incomes up to 133 percent of poverty. State supplements would phase out by 200 percent of poverty. The federal Medicaid law does not now give states this flexibility. States are required to have a single comprehensive health benefits package for all Medicaid enrollees. Although states have options, they must design Medicaid s benefit for their highest need and lowest income populations, with minimal enrollee premiums or costsharing. States are not now allowed to offer or subsidize less expensive health benefit 3

4 plans, such as health plans similar to those that employers and workers purchase. Nor can states adjust their subsidies for individuals based on income. Medicaid eligibility and benefits are now all or nothing. A small earnings increase beyond Medicaid s incomeeligibility threshold results in loss of all Medicaid benefits. With SCHIP, states were given flexibility to design new health benefits plans for children with incomes that were too high for Medicaid eligibility. The majority of states have used these options. With this new state flexibility, SCHIP has expanded coverage to more than 5.8 million lowincome children. Medicaid programs also lack authority and flexibility to assist in purchasing employer-offered and other private health insurance. Only about a third of states offer premium assistance options, e.g. through Section 1115 waivers, and only about 1 percent to 4 percent of enrollees now receive premium support for purchasing private health insurance plans. 3 Should tax credits and state supplements make a state-determined set of health benefits affordable for the eligible populations? Such benchmarks the SCHIP model could be pragmatically useful. If subsidies are too low to purchase desirable products, there will be little increase in insurance coverage. If subsidies are too high, there will be incentives for employers to drop coverage, raising the numbers of uninsured and driving up government costs. 4

5 In addition to flexibility to set benefits standards, States would also need Medicaid reforms to vary their supplements by income and for different rating factors included in premiums e.g. age, sex, geographic area. States also need new federal law to offer premium assistance and other forms of supplements, e.g. cost-sharing caps, services for special needs populations. State purchasing pools The administration s new proposals include $4 billion in state grants to develop purchasing pools, so that individuals would be better able to use their tax credits and state supplements. Federal and state governments have led the way in such arrangements, e.g. the Federal Employees Health Benefits Program (FEHBP), CalPERS, small firm purchasing alliances. States will need discretion in how to structure and manage their purchasing pools. Areas that states may want to address include health plan qualifications, underwriting and rating rules, marketing, enrollment procedures, premium payment, broker roles, state program participation, risk-adjustments and reinsurance. Pools could offer all of the health benefit options for which target populations may be eligible: private health plans, Medicaid, SCHIP and other state-sponsored health plans, COBRA options, Health Coverage Tax Credit (HCTC) plans, high-risk pools and innovative products such as Health Savings Accounts (HSAs). States will need authority to require that all tax credits be used to purchase coverage offered through the purchasing pools. (For employer tax credits, this may require an amendment to the federal ERISA statute that limits state 5

6 authority over employer health benefits.) A purchasing pool could greatly facilitate consumer choice, as well as administrative coordination of eligibility, enrollment, employer/employee contributions, tax credits and state supplements. Consumer Choice The tax credits would allow individuals to choose among private health insurance plans. State Medicaid programs now usually offer choices only among Medicaidcontracted health plans and providers. Consumers would be well-served if an integrated tax credits + Medicaid system were built around the principles of consumer choice and a level playing field. Changes in federal law needed for Medicaid to offer premium assistance options were discussed earlier. Some tax credit recipients may prefer public programs for low-income workers, e.g. MinnesotaCare, BadgerCare. Other individuals or families with special needs may be better served by being able to buy into Medicaid or SCHIP for services and provider networks that are not offered in private health insurance. Employer subsidies The current tax law provides generous subsidies for many workers enrolled in employer-paid health plans, but no assistance for tens of millions of other persons. Employer-paid premiums are excluded from taxable income of workers (for both the income and social security payroll tax) and from employer social security payroll taxes. As an example, a typical $8,000 employer contribution for family coverage would have a 6

7 $1,812 individual tax subsidy. (If the $8,000 had been taxable income, the worker would have paid 15 percent in federal income tax ($1,200) and 7.65 percent in social security taxes ($612). In addition, the employer tax subsidy would be $612. (If the $8,000 had been taxable income, the employer would have paid the 7.65 percent employer social security tax). Thus, in this example, the total worker and employer tax subsidy would be $2,424 (30.3 percent). For families with low incomes that do not pay income tax (but still must pay social security taxes), the combined subsidy would be $1,214 (15.3 percent), $612 each for worker and employer. 4 Because of their higher income tax rates, executives and senior employees would typically receive greater-than-average tax benefits. 5 The proposed tax credits would be a major step toward equity and expanded coverage. Should the new individual tax credits plus state supplements be too large, however, there is risk that some employers will drop employer-paid benefits. This could raise the numbers of uninsured, as well as government costs. States have some influence on these risks through regulation of premium setting in the small group and individual markets. New employer tax credits offer a way to reduce this potential erosion of employer-paid health benefits. They also can be used to encourage employers to offer health insurance. The administration s proposals include new employer credits of $200 per individual and $500 per family for small employers (up to 100 workers), at a cost of 7

8 $23 billion (over the period). The tax credits would be available, however, only for employer contributions to a Health Savings Account (HSA). Employers and consumers have shown little interest, so far, in high-deductible health plans, such as HSAs. Linking the success or failure of the expanded coverage initiative to an employer HSA plan deserves discussion. An employer tax credit that was available for all employer-offered health insurance could be more broadly effective. There are also other ways to target employer tax subsidies. Employer tax credits focused on small firms with lower-wage workers could be more cost-effective in buttressing employer-based coverage. However, there would still be issues of employer tax subsidies offering windfall benefits to firms that already provide coverage. Tax subsidies also could be shared with workers more broadly than through HSA accounts. 6 The federal government could provide states with $23 billion of grants, so that each state could design its own employer assistance programs. Enrollment and administration The federal and state governments will need to work together to design the new administrative system for this tax credits +Medicaid system. Such collaboration should occur early so that statutory authorities, discretion, and financing can be included in legislative proposals. 8

9 The Treasury Department is already operating a national administrative system for health insurance tax credits. It was developed to implement the Health Coverage Tax Credits (HCTC) enacted in the Trade Act of 2002 and to create a foundation for the new national tax credit initiative. The system is designed to verify eligibility, receive enrollee premium payments, supplement them with tax credits, and forward the combined payments electronically to health insurance plans each month. A successful national coverage initiative will need an effective enrollment system. The SCHIP programs, for example, have struggled to enroll low income children; the administration is requesting a $1 billion state grant initiative over the next two years, just to expand enrollments. In the individual insurance market, with high marketing costs, administrative charges can exceed 40 percent of benefits. Federal and state governments may wish to develop a workplace signup and payroll deduction system. An estimated 80 percent of the nearly 45 million uninsured are workers (and family members). Workplace signup would be a convenient, low-cost and effective way for workers to sign up for health insurance, tax credits, state supplements, SCHIP, and state purchasing pool options, and to make premium contributions through automatic payroll withholding. If an employer signup system is not used, it will be far more difficult and expensive to handle these functions. The effectiveness of enrollment systems also could be enhanced by use of automatic enrollment. An individual eligible for the new health insurance tax credits 9

10 would be automatically enrolled in an employer-offered health plan or HSA, unless he or she made another choice. Automatic enrollment sharply increases take-up rates. The federal government could provide states with a number of options for a large state role in administration of the new tax credits + Medicaid system, either as automatic flexibility or as waivers. For example, an estimate of the federal tax credit expenditures could be paid to a state government each year (a form of capitation grant) for assisting the eligible population. A state could combine these funds with its own supplements, as part of an overall financing package for the eligible population. (one-third federal/state, onethird employer, and one-third worker premium sharing arrangement is one possibility). Such flexible options would make it easier for states to adjust the total federal/state assistance for individuals to more closely match their premium rates, which will vary depending on state rating rules in the individual and small group markets. Federal-State Financing Shares The Medicaid program is financed jointly by the federal and state governments using a formula based on each state s per capita income. There is a minimum 50 percent federal match, which increases to more than 75 percent in the lowest income state. In the SCHIP program, the federal matching rates are higher, from 65 percent to 85 percent, but there is a capped federal allotment. In the HCTC program, the federal government s tax credits pay for 65 precent of premiums. 10

11 The new tax credit + supplements proposal suggests a lower federal share than under current programs; a $1,000 federal tax credit, with a $2,000 state supplement, would be a 33 percent federal share. This per capita tax credit improves on the Medicaid matching formula in one respect: more federal payments would automatically go into areas with more eligible persons; however, a flat federal payment has the drawbacks of not providing higher match rates to lower income states and of not sharing in the costs of supplemental benefits. If the new tax credits + Medicaid system has a lower federal share than the current Medicaid and SCHIP programs, states will have a greater incentive to finance supplemental benefits in those programs. There are several options, based on precedents, for discussing federal/state financing shares: (1) the federal tax credit could be raised to reduce the need for state supplements, to a higher dollar amount or to a 65 percent premium share (per HCTC); (2) new state supplements could receive the Medicaid matching rates (per Medicaid s supplements for Medicare s enrollees); (3) new state supplements could be matched at the SCHIP matching rates, perhaps with a capped allotment (per SCHIP); or (4) new state supplements for adults could be matched at the Medicaid rates, and new state supplements for children could be matched at the SCHIP rates. 11

12 An enhanced federal match could be offered for states new administrative expenses. Since Medicaid DSH (disproportionate share hospital) payments are intended to assist uninsured populations, states could also be allowed to use these Medicaid funds to help finance new state supplements. A Safety Net The experience of employer benefits and health insurance tax credits is that some persons may decline to purchase coverage. They will need to rely on a safety net. This safety net could be more fairly financed with transferable tax credits, i.e. if an individual turned down a tax credit, it would be transferred to state government to help finance his/her safety net expenses. This tax credit could be tied to a very basic benefit package, e.g. limited ambulatory care and a modest drug benefit, to assure there was a definite benefit for the individuals. In this way, a tax credits + Medicaid system could assure that all eligible persons would have some coverage through health insurance benefits of their choice, as a preferred option or through a safety net partially financed by their unused tax benefits. Conclusion Most of the nearly 45 million persons without health insurance coverage now fall in the gap between tax-subsidized employer benefits and Medicaid eligibility. With federal and state government cooperation, an integrated tax credits + Medicaid approach could be an effective strategy for halting the erosion of health insurance benefits and for covering many of these individuals. 12

13 1 General Explanations of the Administration s Fiscal Year 2006 Revenue Proposals (2005 Blue Book), Department of the Treasury, February 2005 (pp 19-28); Budget In Brief Fiscal Year 2006 Department of Health and Human Service, February 2005, pp For recent proposals along these lines, see Making Medicaid Work for the 21 st Century, National Academy for State Health Policy (NASHP), January 2005; L. Etheredge, J. Moore A New Medicaid Program Health Affairs Web Exclusive, August Asset tests could still be retained for long-term care institutional care. Categorical eligibility and income levels would remain unchanged for other Medicaid populations, such as pregnant women and children, disabled persons returning to work, medically needy persons, and spend-down eligibility 3 NASHP, op. cit. pp For an employer-paid $3,000 individual premium, the individual s tax benefit, in a 15% income tax bracket, would be $680 ($450 income tax, $230 OASDHI tax), and the employer OASDHI tax benefit would be $230, a combined $910 (30.3%). 5 For the 25% income tax bracket, with the OASDHI tax, the combined federal tax benefits would rise to 40.3%, i.e. about $3200 for a $8000 family premium contribution, $1200 for a $3000 individual contribution.. 6 For example, through contributions to multi-purpose Lifetime Savings Accounts (Treasury, op. cit. pp 5-18); L. Etheredge A Flexible Benefits Tax Credit for Health Insurance and More Health Affairs Web Exclusive, March

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