2017!and!Beyond:!Using!the!ACA! Innovation!Waiver!to!Reach!Minnesota s! Triple!Aim!

Transcription

1 The$Woodrow$Wilson$School$ Graduate$Policy$Workshop$ 2017andBeyond:UsingtheACA InnovationWaivertoReachMinnesota s TripleAim Authors$ LaurenDunn,DanielEdelman,MaryamJanani,EmilyKing,AvitalLudomirsky,AbbyMcCartney, AnnaNinan,EleutheraSa,SethSamelson,RachelVanCleve Project$Advisors$ HeatherHowardandDanielMeuse January$2015

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3 Table$of$Contents$ Acknowledgements$...$2 List$of$Acronyms$...$4 Executive$Summary$...$5 Introduction$...$6 The$1332$Waiver$...$9 Backgroundon1332Waivers...9 OtherStatesandthe1332Waiver...11 Minnesota s$remaining$challenges$...$14 TheCoverageLandscape...14 OpportunitiesforImprovement...14 Using$the$1332$Waiver$to$Achieve$Minnesota s$goals$...$19 OpportunitiesforIncrementalChange...19 OptionA:DHSVDrivenConsolidationofPublicPrograms...28 OptionB:CoverageExpansionthroughtheMarketplace...32 OptionC:CoordinatedPurchasingPath...38 Comparative$Analysis$of$the$Options$...$45 SmoothingtheCoverageContinuum...45 Affordability...46 UniversalityandComprehensivenessofCoverage...46 FinancialFeasibility...47 FeasibilityofAdministrativeCoordination...47 LeveragingDeliverySystemReform...48 Recommendations$...$53 Conclusion$...$55 Endnotes$...$ andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 1

4 Acknowledgements$ Theauthorswouldliketothanktheindividualslistedbelow,whogenerouslyprovidedtheirtime, invaluableinsight,andexpertisethroughouttheresearchprocess.wearealsoindebtedtoandgrateful forworkshopadvisorsheatherhowardanddanielmeuse,whoprovidedguidance,education, mentorship,assistance,andlaughterduringthecourseofthisworkshop.finally,wethankthestaffsof MNsure,Minnesota sdepartmentofhumanservices,andprincetonuniversity swoodrowwilson School,whomadethisprojectpossible. Whilethisreportincorporatesinsightsfromnumerousindividuals,theanalysisandrecommendations aresolelytheviewsandresponsibilitiesofitsauthors. MNsure$ ScottLeitz,ChiefExecutiveOfficer KatieBurns,ChiefOperatingOfficer AllisonO Toole,DeputyDirectorofExternalAffairs DavidvanSant,NavigatorBrokerManager Minnesota$Department$of$Human$Services$ MarieZimmerman,MedicaidDirector NathanMoracco,AssistantCommissionerforHealthCareAdministration SusanHammersten,HealthCareReformImplementationManager AnnBerg,ActingStateMedicaidDirector KarenGibson,Director,HealthCareEligibilityandAccess Minnesota$Department$of$Commerce$ AlyssavonRuden,HealthPolicyAdvisor KristiBohn,HealthActuary Minnesota$Department$of$Health$ Dr.EdwardEhlinger,Commissioner MannyMunsenVRegala,AssistantCommissioner StefanGildemeister,EconomistandDirector,HealthEconomicsProgram AlishaSimon,SeniorResearcher Other$ JenniferDecubellis,AssistantCountyAdministratorforHealthinHennepinCounty,AreaDirectorof HennepinHealth JenniferLundblad,ChiefExecutiveOfficer,StratisHealth LynnBlewett,PrincipalInvestigatorandDirector,StateHealthAccessDataAssistanceCenter JulieSonier,SeniorResearchFellowandDeputyDirector,StateHealthAccessDataAssistanceCenter KelliJohnson,SeniorResearchFellowandCenterDirector,StateHealthAccessDataAssistanceCenter KristinDybdal,SeniorResearchFellow,StateHealthAccessDataAssistanceCenter DebraHolmgren,President,PorticoHealth 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 2

5 JaeYang,CoverageandCareManagementManager,PorticoHealth RebeccaLozano,OutreachProgramDirector,PorticoHealth LizDoyle,AssociateDirector,TakeActionMinnesota MattAnderson,SeniorVicePresidentofPolicyandStrategy,MinnesotaHospitalAssociation JanetSilversmith,DirectorofDepartmentofHealthPolicy,MinnesotaMedicalAssociation JulieBrunner,ExecutiveDirector,MinnesotaCouncilofHealthPlans EileenSmith,DirectorofCommunicationsandPublicRelations,MinnesotaCouncilofHealthPlans LawrenceJacobs,WalterF.andJoanMondaleChairforPoliticalStudiesandDirectoroftheCenterfor thestudyofpoliticsandgovernance,huberth.humphreyinstituteanddepartmentofpoliticalscience, UniversityofMinnesota JohnSelig,DirectorofDepartmentofHumanServices,Arkansas SenatorJoshuaMiller,RhodeIslandStateSenator Dr.JeffreyBrenner,ChiefExecutiveOfficer,CamdenCoalitionofHealthcareProviders;MedicalDirector, CooperAdvancedCareCenter KathleenStillo,ExecutiveDirector,CooperAdvancedCareCenter MarkHumowiecki,GeneralCounsel&DirectorofExternalAffairs,CamdenCoalitionofHealthcare Providers KerianneGuth,ProgramManager,CooperAdvancedCareCenter JonathanVogan,AssociateDirector,FinanceandPerformanceMeasurement,CooperAdvancedCare Center MarshaJohnson,ClinicalTherapist,CooperAdvancedCareCenter 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 3

6 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 4 List$of$Acronyms$ ACA PatientProtection&AffordableCare Act ACO$ AccountableCareOrganization APTC$ AdvancePremiumTaxCredit BHP$ BasicHealthPlan CCIIO CenterforConsumerInformation andinsuranceoversight CHIP$ Children shealthinsuranceprogram CMS CentersforMedicareandMedicaid Services DHS MinnesotaDepartmentofHuman Services DOC$ MinnesotaDepartmentof Commerce EPSDT$ EarlyandPeriodicScreening, Diagnostic,andTreatment ESI$ EmployerSponsoredInsurance FPG$ FederalPovertyGuidelines GMC Vermont sgreenmountaincare HHS U.S.DepartmentofHealthand HumanServices IRS InternalRevenueService IT InformationTechnology MA$ Minnesota smedicaidprogram: MedicalAssistance MAGI ModifiedAdjustedGrossIncome MC$ MinnesotaCare MCO ManagedCareOrganization MMB MinnesotaManagementandBudget QHP$ QualifiedHealthPlan SEGIP StateEmployeeGroupInsurance Plan SHADAC StateHealthAccessDataAssistance Center SIM StateInnovationModel $

7 Executive$Summary$ Section1332oftheAffordableCareActgivesstatestheopportunitytowaivecertainrequirementsofthelaw andbuildprogramsthatprovideaffordable,comprehensivehealthcareininnovativeways.minnesota s DepartmentofHumanServicesanditshealthinsuranceMarketplace,MNsure,haveexpressedinterestin usingthe1332waiverstoadvancehealthreformintheirstate.thisreport,draftedbygraduatestudentsat thewoodrowwilsonschoolofpublicandinternationalaffairsatprincetonuniversityandbasedupon extensiveinterviewswithhealthsystemstakeholdersinminnesotaaswellasindependentresearch,provides asetofrecommendationsforthedirectionhealthcarereformcouldtakeundera1332waiverprogram. WhileMinnesotaisanationalleaderonseveralhealthcareindicators,thereareanumberofareaswhereit coulduseawaivertoimprovetheprovisionofcare.theinsurancemarketforindividualsbetween0%and 400%ofthefederalpovertyguidelines(FPG)isapatchworkofprograms,andchangesinlifesituationcan leadanindividualto churn betweenprogramswithdifferenteligibilitycriteria,costs,providernetworks, andadministrativeprocedures.thestatehasmadeprogressondrivingdeliverysystemandpaymentreform, buthasyettoscaleupitspromisingpilotprograms.whileminnesota suninsuredrateisquitelow,hundreds ofthousandsofpeoplearestillwithoutcoverage.inevaluatingoptionsforreform,weasksixquestions:does theoptionsmooththecoveragecontinuumforindividuals?makecaremoreaffordable?helpthestateoffer comprehensive,universalcoverage?isitfinanciallyfeasible?administrativelyfeasible?doesitallowthe statetodrivedeliverysystemreform? Thestatecanbeginbymakinganumberofincrementalchangesthatarenotspecifictoanyparticularglobal visionofreform.itcanenhancecurrentprogramsbymakingfurtherinvestmentsinservicedelivery alternatives,webvbaseduserexperience,andnavigatorprograms.programalignmentcanbeimproved throughstandardizeddefinitionsofincomeandhouseholdandconsistentenrollmentproceduresandincome verificationsystems.thestatecanfixthefamilyglitchandcanexpandcoverageamongimmigrant communities.finally,minnesotacanshapechoicearchitectureonmnsuretonudgeindividualsintohigherv qualitycoverage. The1332waivercanalsobeusedmoreambitiously.Weoutlinethreepotentialpathsthatthestatecouldgo downinpursuingitsgoals.alloptionsaimtosmooththecostcontinuumforindividuals,mitigatechurn,and spurdeliverysystemreform,buttheytakeverydifferentapproaches. OptionA reliesonpublicprograms, andwouldrestoreminnesotacareto275%fpg,withdeliverysystemreformlargelydrivenbystate procurement. OptionB takesamoremnsurevcentricapproach,andwouldreplacethecurrentbasic HealthProgramforthe138%V200%FPGpopulationwithsubsidiesforqualifiedhealthplans.Additional subsidieswouldbeprovidedforpeopleupto275%fpg,anddeliverysystemreformandcostcontrolwould bedrivenbyactivepurchasing.finally, OptionC wouldmaintainthecurrentprogramboundariesat138% FPGand200%FPG,butwouldimplementvariouscarrierregulationstoeasetransitionsbetweenprograms. WeconcludethateitherOptionAorOptionBwouldbesthelpMinnesotaachieveitshealthcaregoals,and thatthedecisiontopursueapublicpathoraregulatedmarketpathshouldultimatelybeaphilosophicalone. Itiscrucialtochooseonepathortheother.OptionC,whichwouldinstitutionalizethecurrentcoverage patchwork,doesnotmaximizeleveragefordrivingreform. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 5

8 Introduction$$ HealthreformistraditioninMinnesota.Thestatehaslongbeenattheforefrontofeffortstoimprove quality,lowercosts,expandcoverage,andcoordinatecare.itishometothenation sfirsthealth maintenanceorganizationsandwasoneofthefirststatestotakeadvantageoffederaldemonstration waivers,creatingapioneeringpublicinsuranceprogramforworkingfamilies.in2008thelegislature passedasetofinitiativesthatlaidoutapathtopaymentreform,investedinpublichealth,and introducednewtransparencymeasures. 1 The2010AffordableCareAct(ACA)takesthesereforms nationwideandoffersnewtoolsforminnesotatopursueitstripleaimofimprovingpatientexperience andpopulationhealth,whilereducingpercapitacosts. Theyear2017bringsanotheropportunity.Section1332oftheACAmakesavailable innovationwaivers thatwillallowstatestowaivemanyofthelaw srequirementsanddeveloptheirowndeliveryand insurancesystems,allwhilereceivingthesameleveloffederalsubsidiesthatwouldhavegonetothe state sresidents.theminnesotadepartmentofhumanservices(dhs)andmnsurehaveexpressedan interestinusinga 1332 or 2017 waivertocarveoutauniquepathforhealthreforminminnesota. Thisreportexploresthepossibilitiesthatsuchawaivercouldunlock. Inourresearch,wespoketoindividualsrepresentingfourteenMinnesotaorganizations,including governmentagencies,advocacygroups,andresearchinstitutions.whileeachofferedaunique perspectiveonthecurrenthealthsystem,certaincommonthemesemerged.minnesota seffortsto providecomprehensiveanduniversalcoveragehaveledtoaverylowuninsuredrate,butalsocreateda patchworkofprogramswithnumerouschurnpoints.stakeholdersacrossthestatewantamore coherentandseamlesscontinuumofcoverage. Inaddition,werepeatedlyheardthatMinnesotaiscommittedtoreformingdeliveryandpayment systemstoimprovethequalityandlowerthecostsofcare.thestatehasdevelopedinnovativemodels ofcaredelivery,butthereisstillalongwaytogobeforethesenewmodelsarewidespread.many stakeholdersexpressedinterestinusingthenextroundofhealthreformtoexpandthedeliverysystem reformsnowunderwayinmedicalassistance(ma),minnesotacare,medicare,andprivateinsurance.at thesametime,theyremindedusthatanychangesmustpromotetheaffordability,comprehensiveness, anduniversalityofhealthcareinminnesota. ThisreportreflectsthegoalsandprioritiesofMinnesota shealthreformexpertsaswellasourown researchonminnesotaandotherstates.itbeginswithbackgroundonthe1332waiversanddiscusses otherstates waiverplans.itthengoesontooutlinewhatweheardfromstakeholdersinminnesota. Wesummarizetheweaknessesofthecurrentsystem,andwelistsixprinciplesthatwebelievetobethe prioritiesforminnesota shealthcaresystemgoingforward.thesixprinciplesserveasdecisioncriteria whenweweighoptionsforreformagainstoneanother. Wethenmakeourrecommendations.First,wepresentasetofreformsthatwebelieveMinnesota s leadersshouldmakeregardlessofwhetherorhowtheyusea1332waiver.thesefixesrangefrom 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 6

9 administrativereorganizationstoadjustmentsofthesubsidyscheduleforlowvtomiddlevincome families.manyofthesechangescanbefeasiblyaccomplishedwithouta1332waiver. Thethreeoptionsthatfollowaremoreambitious.Eachoptioninvolvessignificantchanges(and,we believe,improvements)tothestatusquo,andeachpositionsthestatetocontinuetoleadinhealth reformeffortsinthedecadestocome.finally,weusethedecisioncriteriageneratedfromour conversationswithminnesotastakeholderstoevaluateeachoptionandsuggestacourseofaction. ThisisanexcitingtimeforhealthreforminMinnesota.Duetothestate spioneeringandsustained investmentsovertheprecedingdecades,itshealthsystemisamongthebestinthenation.inthenext fewyears,minnesotawillhavetheopportunitytomakefurtherstridesinquality,efficiency,and innovation.thepathitchoosescoulddeterminethedirectionofamericanhealthcareforyearstocome. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 7

10 Part%I:%The$1332$Waiver 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 8

11 The$1332$Waiver$ Background$on$1332$Waivers$ Understanding$the$1332$Waiver$ Section1332oftheACAallowsstatestowaivecorerequirementsofhealthreformlegislationinorder toexperimentwithalternativepathstoachievingtheaca sgoals.thissectionreviewstheknown opportunitiesandconstraintsaffordedbythewaiver,theapplicationprocess,andpossibilitiesunder explorationbyotherstates. Provisions(that(may(be(waived( UnderSection1332,statescanproposemodificationstothefollowingelementsoftheACA: 2 The$qualified$health$plans.$Statesmaychangetherequirementsforqualifiedhealthplans(QHPs), includingthedefinitionofessentialhealthbenefits,limitsoncostvsharing,rulesforparticipating plans,andthemetallevels. 3 Forexample,astatemightexpandaccesstoleaninsuranceby introducinga copper planat50percentactuarialvalue. 4 Bycontrast,astatecould withouta waiver choosetolimitrelianceonlowvactuarialvvalueinsurancebyeliminatingbronzeplans. 5 The$health$insurance$Marketplaces.$StateshavetheoptiontomodifyoreliminatetheMarketplace system.forexample,statescouldwaivespecificrequirementsbyextendingaccessbeyondcitizens andlawfulresidentsorbycappingthesmallgroupmarketat50employees. 6,7 Theycouldalsomake broaderchanges,suchasreplacingthemarketplacewithaprivateexchange,allowingthepurchase ofsubsidizedcoverageoutsidethemarketplace,oreliminatingtheprivatemarketoutsidethe Marketplace. 8 Tax$credits$and$costZsharing$reductions.$Statesmightmodifytherulesconcerningtheprovisionof costvsharingandpremiumsubsidies.forexample,statescouldsmoothcostvsharing cliffs, tietax creditstoqualitymetrics,eliminatethefamilyglitch(seepage26),orchangetheincomelimitsfor subsidyeligibility.inconjunctionwithan1115medicaidwaiver,statescouldalterthepremiumand costvsharingscheduletosmoothdifferencesbetweenpubliccoverageandthemarketplace. 9 The$employer$mandate.Statesmayadjustoreliminatepenaltiesforlargeemployerswhodonot offercoveragetotheirfullvtimeemployees.forinstance,astatemightintroduceexemptionsfor midvsizedemployers,changethedefinitionofcoveredemployees,adjustthelevelofqualifying coverage,orpotentiallyeliminatethemandatealtogether. The$individual$mandate.Statesmayadjustoreliminatethetaxpenaltyforindividualswhogo withouthealthcoverage.forexample,astatemightexpandornarrowmandateexemptionsor implementlateenrollmentpenalties. 10 Waiver(Constraints( Generally,waiverproposalsneedtoprovidesimilarcoverageoutcomesintermsofbothqualityand quantityatequalorlessercost.specifically,proposalsundersection1332areconstrainedbythe followingcriteria: 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 9

12 Affordability:$Proposalsmustprovidecoveragethatisatleastasaffordableasitwouldbeunderthe originalprovisions,includingprotectionsagainstexcessiveoutvofvpocketspending.theprecise measuresofaffordability(e.g.premiums,costvsharing,totalexpectedcost)havenotbeenspecified.$ Comprehensiveness:Proposalsmustprovidecoveragethatis,ataminimum,ascomprehensiveas Marketplacecoverage.ThechiefactuaryattheCentersforMedicare&MedicaidServices(CMS) mustcertifyestimatesofcomprehensiveness.whetherthiscalculationwillbebasedonbenefit categoryoractuarialequivalenceisstillunclear.$ Scope$of$coverage:ProposalsmustprovidecoveragetoatleastasmanypeopleastheACAwould haveintheabsenceofawaiver.themethodbywhichthiswillbecalculatedhasnotbeenspecified.$ Federal$deficit:Proposalscannotincreasethefederaldeficit. 11 $ ThefollowingprovisionsoftheACAcannotbewaived:guaranteedissue,communityrating,andnonV discriminationregulations. 12 Application(Process( Priortosubmittinganapplication,statesmustdemonstratethattheyhavetheauthoritytoenacta waiverandhavesolicitedpublicinputonthedesignoftheirwaiver.statescaneitherenactanewlaw thatprovidesforthewaiverorrefertoauthorityunderexistinglawintheirproposal. 13 Statesmust(1) holdapublichearingafterdraftingthewaiverproposal;(2)collectandrespondtocommentsafterthe applicationissubmitted;and(3)holdannualpublicforumsonthewaiverfollowingapproval. 14 Theapplicationitselfmustincludeactuarialandeconomicanalyses,animplementationtimeline,anda tenvyearbudgetplan.followingsubmissionofacompleteapplication,thedepartmentsofhealthand HumanServices(HHS)andtheTreasuryhave180daystoapproveorrejectthatapplication. Applicationscanbesubmittedatanytime,thoughproposalscannotbeimplementeduntilJanuary1, 2017.Ifawaiverisapproved,thestatemustsubmitquarterlyandannualreportsonthewaiverprogram tohhsandthetreasury.waiversarerenewable,buttheirinitialdurationcannotexceedfiveyears. Funding Fundsthatwouldotherwisegotowardssubsidizingresidents purchaseofinsurancethroughpremium taxcreditsandcostvsharingreductionsonthemarketplacecanberedirectedtothewaiverprogram. 15 Theprocessforcalculatingtheamountoffundingintheabsenceofthewaivedprovisionsisunclear,but willtakeintoaccounttheexperienceofotherstates. WaiverCoordination ThetextofSection1332callsforthecreationofacoordinatedstatewaiverapplicationprocessthat wouldenablestatestosubmitasingleapplicationformultiplewaivers.inotherwords,a1332 applicationcouldbecombinedwithsection1115medicaidwaiversaswellasmedicarewaivers.note that1332doesnotactuallyexpandwaiverauthorityovermedicaidormedicare,andexisting boundariesforwaiversstillapply. 16 Apotentialbenefitofasingleapplicationisthatstatesmaybeabletoestimatethecombinedfinancial impactoftwowaivers.hhscouldthenconsiderthewaiversintandemwhendeterminingwhetherthe 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 10

13 Section1115waiverisbudgetneutralandwhetherthesection1332waiverincreasesthefederal deficit. 17 UnansweredQuestions ManyquestionsremainunansweredbytheoriginaltextofSection1332.Someexpertsanticipatethat furtherinstructionsfortheapplicationprocesswillbereleasedinthespringof2015,butthefederal governmenthasyettoannouncesuchplans. Other$States$and$the$1332$Waiver$ HawaiiandVermontarebothtentativelyworkingtowardsa1332waiverapplicationtoachievetheir respectivehealthcoveragegoals.severalotherstates,includingarkansasandoregon,arealsowell positionedtoapplyforwaivers. Arkansas$ Arkansashasalsoestablisheditselfasaleaderinreforminnovationandiswellpositionedtoapplyfora 1332waiver.Arkansas sexisting1115waiverenablesittofundaprivateoptionmodelformedicaid users.a1332waivercouldincreaseaccesstoprivatehealthinsuranceandreducetheburdenonpublic programs.giventhepotentialforcombinedbudgetneutrality,a1332waivermayofferabipartisan approachtocoverageexpansionthroughaprivatevinsurancebasedapproach.underthearkansas HealthCarePaymentImprovementInitiative,thestatehasalreadymadeprogress,movingtowardsthe creationofpatientvcenteredmedicalhomes,healthhomesforindividualswithcomplexneeds,andan episodevbased paymentanddeliverymodel. 18 Hawaii$ Hawaiihasexpressedinterestinpursuinga1332waiver,inpartduetothedesiretopreserveits1974 employermandate,whichismoreexpansivethantheacaprovisionandhashelpedbringuninsured ratesbelow10percentinthestate.in2014,hawaiipassedlegislationcreatingastateinnovation WaiverTaskForcetoexploreoptions.InitsOctober2014meeting,theTaskForceagreedapotential waivershouldpursuethegoalofuniversalcoverageandaccessandshouldpreservehawaii semployer mandate.waiverdevelopmentsubcommitteeshavebeensetuptoexploreoptionsrelatedtopremium rating,stateagencyinformationtechnology(it)collaboration,resourceallocationforreform,and metrics. 19 Oregon$ Oregonisalsowellsituatedtopursuea1332waiverthroughitscreationofMedicaidcoordinatedcare organizations,withincentivestosupportpopulationhealthoutcomes. 20 In2009thelegislaturecreated theoregonhealthpolicyboardandtheoregonhealthauthority,whichhavetheabilitytocoordinate publicpurchasingofinsuranceforpublicemployees.thestateisseekingtodevelopcommon contractingstandardstoimprovequality,performance,andcostveffectiveness.ultimately,oregon intendstocreateuniformityinbenefitdesignsanddevelopaplanforvaluevbasedpurchasing andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 11

14 Vermont$ VermontwasconsideringusingthewaivertoachieveitsgoalofauniversalandunifiedsingleVpayer healthcaresystemundergreenmountaincare(gmc).aswasenvisioned,gmcwouldredirectaca subsidiestooffergoldvlevelbenefitplans,coveringapproximately90percentofstateresidents.gmc soughttolowercoststhroughreducedfraudandabuse,administrativesimplification,anddelivery systemreform,withsavingssupportinguniversalcoverage.medicare,medicaid,andchipweretobe foldedintoasingleadministrativesystemwhilemaintainingcurrentbenefits. 22 Legislationin2012called forthecreationofasinglevpayerplanandpursuitofa1332waiver,andvermonthasbeeninmeetings withcmssinceearly2013.untildecember2014,vermontwasworkingonamodeltodefinefederal fundingandrequiredstatefinancing,withthegoalofsubmittingafinalproposalbyearly2015and beginningconsultationswiththepublic. 23 Unfortunately,themodelrecentlyshowedthattheproposed planwouldrequireanadditional$2.5billioninrevenuewithinthefirstyearalone,necessitatingan increaseinpayrolltaxesof11.5percentandincometaxof9percent.withthesenumbersinmind,on December17,2014,GovernorPeterShumlinannouncedhewoulddelaysingleVpayerhealthcare system. 24 $ 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 12

15 Part%II:%Minnesota s*remaining(challenges 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 13

16 Minnesota s$remaining$challenges$ The$Coverage$Landscape$ Minnesota slongstandingcommitmenttothehealthofitsresidentshasledtooneofthehighestrates ofinsurancecoverageinthenation. 25 In2014,95percentofallMinnesotans,including93percentof adults,hadhealthinsurance. 26 Ofthetotalpopulation,56percentwereinsuredthroughtheiremployer, 16percenthadMedicare,15percenthadMA,andonepercenthadMinnesotaCare.Sixpercentofthe populationpurchasedprivate,individualinsurance,includinglessthanonepercentviamnsure. 27 EstimatesoftheearlyimpactoftheAffordableCareActfoundthatMinnesota suninsuredratefellby 41percentbetweenSeptember2013andMay2014,reachinganallVtimelow.Thisdeclinewaslargely drivenbyenrollmentinma,whichin2014extendedcoveragetoadultswithoutdependentchildrenand allowedeligibilitydeterminationviaashareditsystem. 28 Opportunities$for$Improvement$ Despiteprogressinexpandingaccesstoinsurance,expertswespokewithinMinnesotasawanumberof opportunitiestoimprovecontinuityandaffordabilityofcoverageandcare. Eligibility$Changes$ Minnesotansfacedisruptionsincoverageandcarewhentheirincomeandeligibilitychange.A patchworkoffreeorsubsidizedhealthinsuranceprogramsisavailabletominnesotansbetween0%and 400%FPG.Changesinincome,age,orpregnancystatuscancauseenrolleestoshiftbetweenMA, MinnesotaCare,andtheMarketplace.Asaresult,enrolleesmayfacesteeppremiumhikes,findthat theirpreferreddoctorsarenotpartoftheirnewnetworks,orfailtoreapplyforinsuranceandlose coveragealtogether. Inadditiontothepotentialforonepersontochangeeligibilityovertime,parentsandchildrenareoften coveredunderdifferentprograms.infamiliesearningbetween133%and275%fpg,childrenare eligibleforma,whileparentsmustpurchaseminnesotacareoraprivatemnsureplan. 29V30 Anationalstudyofpeopleearningbetween100%and200%FPGfoundthat38percentofthoseinitially belowthe138%fpgmedicaidcutoffhadincomesabovethecutoffoneyearlater.similarly,24percent ofthoseinitiallyabovethecutoffdroppedbelowitafteroneyear. 31 Althoughthestudylooksonlyatthe 100% 200%FPGrangeandMinnesotaVspecificdataisnotavailable,itseemslikelythatalargenumber ofminnesotanschangeprogrameligibilityfromyeartoyear.theseminnesotanswillbeaffectedby differencesinpremiumcostsandprovidernetworksbetweenprograms.$ Affordability$Cliffs$ Minnesotansalsofacesharpchangesinaffordabilityastheyshiftfromoneprogramtoanother.Before 2014,MinnesotaCarecoveredadultsupto250%FPGandparentsupto275%FPG.Inordertoaccess significantfundingundertheaca,thestatemodifiedminnesotacaretoconformtofederalstandards forabasichealthprogram(bhp),includingcappingeligibilityat200%fpg.minnesotansbetween200% and275%fpgmaynowshopforqhpsonmnsure;somewillqualifyfortaxcreditsandcostvsharing 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 14

17 reductionstohelppayforcoverage.evenwithfederalhelp,however,thosetransitioningfrom MinnesotaCaretotheMarketplacecanexpecthigherpremiumsandlessgenerouscostcoverage. MinnesotaCareenrolleesat200%FPGpaya$50monthlypremium,withnominalcopaysandmonthly deductibles. 32,33 Incontrast,Minnesotansat201%ofFPGareeligibleforplansonMNsurethathave higherpremiumsandcostvsharing.a40vyearvoldnonvsmokeratthisincomelevellivinginthetwin Citiescouldpurchaseasilverplanfor$125orabronzeplanfor$82permonthafterthefederal subsidy. 34 MinnesotaCare sactuarialvalue theportionofmedicalcoststheprogramwillpayforon average isestimatedatover96percent. 35 AsilverQHPhas70percentactuarialvalue(73percentwith costvsharingreductions)abronzeplan60percent. HighercostVsharingintheQHPsisarealconcern.Researchindicatesthatevenwhenpeoplehavehealth insurancecoverage,theymayfindthecostofcareunaffordable.inarecentsurvey,27percentof Minnesotansbetweenages18and64saidtheyhadforegoneneededhealthcareduetocost. 36 While theaca staxcreditshelplowvincomeconsumersaffordmonthlypremiums,costvsharingassistanceis onlyavailabletothosewhopurchasesilvervlevelplans. Provider$Networks$ Minnesotansmayfacedisruptionsinaccesstopreferredprovidersastheyshiftbetweenprograms. Unfortunately,statisticsontheextentofthesedisruptionsare,toourknowledge,unavailable.Toour knowledge,therearenostatisticsonthenumberofminnesotanswholoseaccesstotheirpreferred providerswhentheirprogrameligibilitychanges.minnesotahasfewnarrownetworkscomparedto otherstates,althoughsomeexist. 37,38 Atleasttwocarriers,UCareandMedica,createdMNsureplansto mirrortheirminnesotacareproducts,butmanyconsumersleavingminnesotacarein2014choseother, lowervcostplansinstead. 39 Inruralareaswithfewproviders,allhealthplansmayneedtocontractwith allproviderstomeetnetworkadequacyrequirements,andnetworksmayoverlapalmostcompletely. 40 InproviderVdenseareas,however,consumersmayhavetoresearchnetworksorchooseahigherVcost plantokeeptheirproviders. The$Remaining$Uninsured$$ AlthoughMinnesota suninsuredrateisalmost50percentlowerthanthenationalaverage,stakeholders remaincommittedtoexpandingcoverage. 41,42 In2014,6.7percentofadultsaged18to64and4.9 percentofallminnesotans,orapproximately264,000people,lackedhealthinsurance. 43,44 Although detaileddemographicinformationabouttheuninsuredisnotavailablefor2014,pastsurveysshowthat uninsuredminnesotansaremorelikelytobelowvincome,nonvwhite,nonvusvborn,unmarried,andin poorerhealthcomparedtothepopulationasawhole. 45 In2013,theuninsuredwere60.9percentwhite, 20.2percentHispanic,11.1percentblack,7.6percentAsian,and3.6percentAmericanIndian. 46 After ACAimplementation,upto12percentoftheremaininguninsuredmaybeundocumentedimmigrants withoutaccesstopublicinsuranceprogramsormnsurecoverage. 47 $ MNsure$and$BHP$Funding$ MNsureandMinnesotaCarewillbothseemajorshiftsandsomeuncertaintyintheirrevenuesources overthenextthreeyears.thefederalcciiograntthatprovidesover60percentofmnsure s andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 15

18 revenuewillexpirein2016.somewhatoffsettingthatloss,mnsure srevenuefrompremium assessmentswilltripleby2017duetoanincreaseinthepercentwithheld.toaccommodateitslower budget,mnsureplanstoreduceexpendituresacrosstheboard,mostsignificantlyontheitsystem. 48 MinnesotaCare,meanwhile,beginsreceivingfederalBHPfundingin2015asitsMedicaidwaiverfunding ends.expendituresnotcoveredbybhpfundingwillneedtocomefromenrolleepremiumsandthe state shealthcareaccessfund,whichisfundedlargelybythe2percentprovidertax.state expendituresonminnesotacareareprojectedtomorethandoubleby2017duetorisingenrollment andmanagedcarerates;asaresult,thehealthcareaccessfundwillbe$62millionindeficitin FederalBHPfundinghingesonthesecondlowestcostsilverplanonMNsure;lowpremiumsonMNsure meanlessfederalfundingandhigherstateoutlays.projectionsfor2015bhpfundingwererevised upwardwhenpremiumsincreased10percentover2014levels,butgainswereoffsetbythelarge numbersofnewenrolleesinthemetroregion,whereratesarelowest. 50 Delivery$System$Reform$ Minnesotaisanationalleaderandearlyadopterofmanydeliverysystemreforminitiatives. Publicandprivatepayersandprovidernetworksareexperimentingwithsharedsavings contractssuchasaccountablecareorganizations(acos),includingthreemedicareacosand ninemedicaidacos.suchcontractsnowapplytoaboutonevsixthofmaenrolleesandbetween onevthirdandtwovthirdsofcommercialplanenrollees. 51,52,53 StatelawrequiresallpayerstomakecoordinationVofVcarepaymentstoprimarycareclinics certifiedas healthcarehomes, encouragingclinicstafftotakeresponsibilityforthewellvbeing oftheirpatientsbetweenvisits,includingcoordinatingmentalhealthandsocialservices. 54 AllclinicsandhospitalsparticipateintheStatewideQualityReportingMonitoringSystem, makingclinicvbyvcliniccomparisonpossibleforcertainprocessandoutcomemeasures,suchas optimaldiabetescare. 55 HennepinHealth,aMedicaidHMO,isdemonstratinghowinvestmentsinhousing,social services,andpreventivementalhealthandmedicalcarecanimprovepatients healthandsave thestatemoneyoncareforhighvriskpatients. Minnesotahasoneofthehighestratesofelectronichealthrecordadoptionnationally,thanks toalegislativemandate. 56 Still,manyoftheseinitiativesareintheirinfancy.Althoughsharedsavingscontractsareinplacefora significantnumberofpatients,onlytwotosevenpercentofparticipatinghealthsystems revenuesare affected.differentpayersalsomeasureandrewarddifferenthealthoutcomes,creatingconfusing signalsforproviders. 57,58 Indeed,formostmedicalconditionsandprocedures,qualitymeasuresdonot yetexist. 59 WhileHennepinHealthhasbeensuccessfulatintegratingmedicalcare,behavioralhealth, andsocialservices,otherhealthsystemsareattheverybeginningofthelearningcurve. 60 Onehundred ninetyprimarycareclinicshavebeencertifiedashealthcarehomes,butthefirststudyoftheirimpact hasyettobereleased. 61 A2008initiativetoreportqualityandcostmeasuresforindividualdoctors(in additiontoclinics)wassuspendedduetoproviderconcernsthatratingsbasedondevidentifiedpatient recordscouldnotbeverified. 62 Finally,MNsurehasthestatutoryauthoritytoselectplansbasedon 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 16

19 criteriasuchasqualityandvalue,buthasyettotakethisstep. 63 $ Decision$Criteria$ Laterinthisreport,werateeachwaiveroptionaccordingtothefollowingsixcriteriabasedontheprioritieswe heardfromdhs,mnsure,andotherstakeholdersduringinterviews. 1.(A(smooth(continuum(of(coverage(from(0%(to(400%(FPG( Doestheoption(a)eliminatepremiumcliffs,(b)reducethenumberoftransitionpointsatwhichpeoplemaylose coverage,(c)allowpatientstokeepprovidernetworkswhentheirincomechanges,and(d)keepfamilymembers onthesameinsuranceplan? 2.(Affordability( Undereachwaiveroption,isthecostofinsurancecoverageaffordableforconsumers?Willinsuredconsumersbe abletoaffordtheoutvofvpocketcostsofcareundertheirplans? 3.(Universality(and(comprehensiveness(of(coverage( CantheoptionimproveinsuranceaccessfortheremainingfivepercentofMinnesotanswhoareuninsured?Canit improvethecomprehensivenessofthebenefitsoffered? 4.(Financial(feasibility( Istheoption(a)costVneutraltothefederalgovernment,and(b)affordablefortheStateofMinnesota? 5.(Administrative(feasibility( Doestheoptionrequireadifficultadministrativetransition,andonceestablished,willitbedifficulttosustain? 6.(Leveraging(delivery(system(reform( Howwilltheoptionaffectstateeffortstocontrolhealthcarecosts,improvequality,andpursuecurrentreform initiatives,includingaccountablecareorganizations,healthcarehomes,andeffortstointegratesocialservices andmentalhealthcareintothemedicalsystem?$$ 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 17

20 Part%III:"Usingthe$1332Waiver'to'Achieve' Minnesota s*goals 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 18

21 Using$the$1332$Waiver$to$Achieve$Minnesota s$goals$ Opportunities$for$Incremental$Change$ ThissectiondescribesthreeareaswhereMinnesotacaninvestinshortVrunchanges:(1)enhancements tominnesota scurrentpoliciesandprograms;(2)technicalchangestobetteralignprograms;and(3) affordabilityimprovementsforcertainpopulations. Alloftheseincrementalchangescanbeimplementedalongsideanyofthethreeglobalreformoptions presentedinthefollowingthreesections(p.28v41).werecommendmakingtheseadjustments regardlessofwhich,ifany,ofthreereformoptionsminnesotachoosestopursue.someofthese changes,particularlyinthesecondtwocategories,willrequirea1332,1115,orjointwaiver.theyare thusbestconsideredinthecontextofamoreambitiousglobalwaiverapplication. Category$1:$Enhancements$to$Minnesota s$current$policies$and$programs$ Build(on(Successes(of(the(Minnesota(Accountable(Health(Model( MinnesotaisaleaderinservicedeliveryreformandisreceivingfundingfromtheStateInnovation ModelGrantthroughOctober2016totestitsgrowingaccountablehealthmodel. 64 Thestateshould continueprioritizingthetestingandexpansionofservicedeliveryalternatives.sinceitisuncertain whethercmswillprovideathirdroundoffunding,minnesotashouldconsiderintegratingitsservice deliveryreformneedsintoafuturefederalwaiverapplication. 65 Improve(the(DHS(and(MNsure(WebOBased(Consumer(Experiences( TheMNsurewebsiteexperiencedabumpystartduringthe2013launchoftheMarketplace. 66 In2014, thewebsitewasmarkedlyimproved,thoughsomeglitchesremained. 67,68 Regardlessofothermeasures takentoimprovethehealthinsurancesystem,mnsureshouldcontinuetoensureadequateitfunding, allowingforwebsiteenhancementsthatpromoteeaseofuse.examplesforadditionalimprovements includecreatingautomaticinformationtransferofmnsureenrolleestotheirinsurers,simplifyingtherev enrollmentprocessforbeneficiarieswhoseincomeorcircumstanceschange,andconductingcustomer satisfactionsurveysthatelicitadditionalfeedback. 69 Use(Navigators(for(Reenrollment(Processes(and(Health(Insurance(Literacy( TheAssisterNetworkisalreadyanimportantresourceinMinnesota.However,federalestablishment fundsandnavigatorvspecificgrantsthatfinancethisprogramaretemporary,anditwillbeuptothe statestocontinuefundingtheprogram.navigatorswereusedintheinitiallaunchoftheacatoassist individualsinthetransitiontothenewsystem.however,theyremainimportantgiventhat:(1)changes broughtbythe2017waivermayrequirenavigatorassistance;(2)newconsumersunfamiliarwith MNsuremayenterintothemarket(e.g.bygraduatingfromtheirparents insuranceatage26);(3) Consumersarestilladjustingtothenewsystemandmayneedassistanceinunderstandingreenrollment proceduresthroughthenearvterm;and(4)mnsurecanusenavigatorstoencourageconsumersto shop duringreenrollment. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 19

22 Togaugethesuccessofthenavigatorprogram,MNsureshouldconsiderconductingasurveysimilarto thehealthinsuranceliteracysurveybytheamericaninstituteforresearch. 70 Nationalsurveysalready indicatethatmanyconsumersarenotinformedaboutthevariousformsoffinancialassistancefor healthinsurance. 71 Thestudycouldidentifyareaswhereconsumerunderstandingisstilllackingand informnavigatortraining.forinstance,amultivtieredtrainingwouldgeneratenavigatorsatdifferent levels:newassisters,advancednavigatorswhohavedeeperexpertiseineligibilityissues,andexpertinv housenavigatorswhoprovidesupporttoassistersworkingdirectlywithfamilies. 72 Asindividualsbecomefamiliarwithreenrollmentprocedures,navigatorscanalsoexpandtheirservices andprovidecontinuingeducationaroundtheuseofhealthinsurance,includinghowtointerpreta healthplan sbenefitsandhowtoselectaprovider.continuingtheassisternetworkprogramand expandingtheroleofnavigatorswillrequireadditionalfundinginthecomingyears,and,giventhe unpredictabilityoffederalfinancing,itmaybenecessarytoseekstateandprivateresources. Active$Purchasing$Authority$and$Choice$Architecture$ MNsurecanuseactivepurchaserauthorityandchoicearchitecturetohelplowVincomeconsumerslookbeyond stickervpricepremiumsandpicktheplanthatisbestforthem. ThereisevidencethatconsumerstendtooverweightpremiumsandunderweightoutVofVpocketcostswhen consideringthecostofinsurance. 73 Therearetwobehavioralexplanationsforthis.First,whilepremiumsare relativelysimpletounderstand,deductibles,copays,andcoinsurancecanbeopaquetoconsumers. 74 Second, lowervpremiumplansallowconsumerstodeferhighpaymentsuntillater,whichisattractivegiventhehuman tendencytodiscountfuturelosses. 75 Whilethepreferenceofmanyconsumersforlowerlevelsofcoverageisunderstandable,itisfrequently suboptimalforthem.morecomprehensivecoverageallowsconsumerstosmooththecostofhealthcareoverthe courseofayearandavoidfinancialshocks particularlyimportantforfamilieswithoutsignificantsavings. Premiums(and(Metal(Level(Choice( Minnesota smarketplaceofferedthelowestpremiumsinthecountryin2014.despitesignificantrateincreasesin 2015,premiumsforbenchmarksilverandbronzeplansintheTwinCitiesremainamongthelowestforallmajor metropolitanareas. 76 InthefirstmonthofMNsure sopenenrollmentfor2015,34percentofqhpenrolleesoptedforbronzeplans, whichcarrythehighestoutvofvpocketcostsatanactuarialvalueof60percent.in2014,25percentofminnesotans enrollinginqhpschosebronzeplans,comparedto20percentnationwide. 77,78 Consumersbetween200%and 250%FPGareeligibleforfederalcostVsharingreductionsonlyiftheyenrollinsilverplans,butnotiftheyenrollin plansinothermetaltiers. Affordablepremiumsareattractivetoconsumers,butpremiumsareonlyonepieceofthetruecostofcoverage. OutVofVpocketcosts,whicharehigherinlowermetaltiers,offsetthebenefitsoflowpremiums. CostOSharing(Subject(to(a(Deductible( Inastudyof15states,Minnesota smarketplaceplansfor2014werefoundtohavethehighestdeductibles,at $4,061onaverage. 79 Furthermore,theplansonMinnesota smarketplacetendedtosubjectawidervarietyof servicesanddrugstothedeductiblethanthenationalaverage.in95percentofplansonmnsure,forexample, 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 20

23 consumerswouldhavetopaytheentirecostofallemergencydepartmentvisitsuntiltheymettheirdeductible, comparedto53percentofplansnationwide.highvdeductibleplansarenotinherentlybad,butconsumersneedto understandandplanforthepotentialcostsinordertoavoidfinancialhardship. 100% Figure$1.1:$Percent$of$2014$Silver$Plans$with$Cost$Sharing$Subject$to$ Deduc]ble$by$Type$of$Care/Drug,$Minnesota$and$US$ 80% 60% 40% 20% 0% MN US average Source: GeographicalPatternsinCostSharinginSilverPlans. RobertWoodJohnsonFoundation.November2014.Web. Implications(for(LowOIncome(Minnesotans( AMinnesotantransitioningfromMinnesotaCaretotheQHPsmightlookfortheplanonMNsurewiththelowest premium.atwincitiesresidentat201%fpgcouldpurchasethefairviewucarechoicesbronzeplanfor$82per monthafterapremiumsubsidyof$58andnocostvsharingassistance.ifthisconsumerendsupwithan unexpectedhospitalstay,shecouldenduppayingthefullinvnetworkdeductibleof$5,000.themostshemight havetopayoutofpocketoverthecourseoftheyearisthefederallimitof$6,600,or28percentofherincome. 80 HighVdeductibleplansrelyonconsumershavingafinancialcushion,whichmaynotbemanageableforlowVincome Minnesotans. Implications(for(MNsure(and(DHS(funding( TheACA sfinancingmechanismsmakeitadvantageousforstatestonudgeenrolleestowardadequatecoverage.in amarketwhereconsumersshopandplanscompetebasedonpremiumalone,minnesotamissesoutonanumber ofbenefitsoftheaca.forexample,whenlowvincomeconsumerschoosebronzeplans,theyforfeitthefederal costvsharingreductionsavailableforsilverplans. LowerVthanVexpectedpremiumandcostVsharingassistanceareparticularlyproblematicgivenMinnesota spursuit ofalternativecoverageprogramsundertheaca.minnesotacare sfederalfundingisbasedonthepremium assistancetheeligiblepopulationwouldhavereceivediftheyhadenrolledinthemarketplace.a1332waiver wouldbefinancedsimilarly. Strategies(for(MNsure:(Active(Purchaser(and(Choice(Architecture( MNsurecouldemploytwostrategiestohelpconsumerschooserealisticallyaffordableplansin2016open enrollment.activepurchaserandimprovedchoicearchitecturearealreadyontheboard sagendaforthecoming year,andwerecommendmovingforwardwithboth. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 21

24 A. First,MNsurecouldexerciseactive$purchaser$authoritytostandardizecostVsharingstructureswithin metallevelsandtoexcludeplansthatarejudgedunaffordableormisleadingtoconsumers.forexample, themassachusettshealthconnectorrequiresstandardizedcostvsharingstructuresforover80percentof itsplans.annualdeductibles,outvofvpocketmaximums,andcopaysareconstantacrossplansineachof sevenmetalcategories(platinuma/b,golda/b/c,silver,andbronze). 81 Thisstandardizationallows consumerstocompare applestoapples andusepremiumsasareliableindicatorofaffordability. 82 MNsurecouldtakeasimilarapproachtostandardization,excludingcostVsharingstructuresthathavehigh hiddencostsandposefinancialrisksforlowvincomeconsumers. B. Second,MNsurecouldstructureitschoice$architecturetohelpconsumersunderstandthetruecostof care,encouragethemtolookbeyondpremiums,andguidethemtowardsilverplansiftheywouldbenefit fromfederalcostvsharingreductions.ratherthanstandardizingcostvsharing,mnsurewouldemploywebv baseddecisiontoolstoguideconsumerstowardaffordableplansanddiscourageshoppingonpremiums alone. 83 MNsure scurrentdesigndoeshighlighttheimportanceofcostvsharingbyaskingconsumerstoindicate themaximumannualdeductibletheywouldbecomfortablewithandprovidingalinkformore information.atthesametime,amessageonthemnsurewebsite s Findaplan pagestates, Ifyouare lookingforalowerdeductibletheplanwillcostmore. 84 Thislanguagemayimplytoconsumersthattotal costisdeterminedbypremiumsratherthanbythecombinedpremiumandcostvsharingstructure,and maynudgethemtowardlowervpremiumplans.thewebsitecouldinsteademphasizethatthepremiumis onlyoneaspectoftotalcosts,flagtheriskofunexpectedspendingonhighvdeductibleplans,andmake premiumslessprominentintheinitialplanpresentation. Forconsumersbetween201%and250%FPGwhoareconsideringbronzeplans,MNsurecouldtakeextra caretohighlightanyoutvofvpocketcostssubjecttothedeductibleandindicatethatcostvsharing reductionsareonlyavailableforsilverplans. Category$2:$Technical$Changes$to$Better$Align$Programs$ AlthoughDHSandMNsurecoordinatewell,therearedifferencesbetweenthepublicandMarketplace insurancesystemsthatcauseconfusionforconsumers.thetechnicalchangesproposedherewould createasmootherconsumerexperienceatchurnpoints.somemayrequirea1332,1115,or coordinatedwaivertobeimplemented. Implement(Annual(Projected(Income(Across(All(Programs(for(Continuing(Eligibility(Determination( MAcurrentlyasksconsumerstodeterminepointVinVtimeincome,whileMinnesotaCareandthe Marketplaceuseannualprojectedincome. 85,86 Usingonestandardacrossprogramswillpromote continuityofcoverageandpredictabilityofhealthcarecostsforfamilies.betweenthetwooptions, annualprojectedincomemayprovideamoreaccuratepictureofafamily sfinancialstatus,especially forthosewhoseearningsareseasonal. 87 Asafirststep,Minnesotashouldconsiderusingprojectedannualincometoassesscontinuingeligibility forma,anoptionprovidedtostatesundertheaca. 88,89 Oncethisisimplemented,DHSwillbebetter positionedtojudgewhetherprojectedannualincomeshouldbeusedtoassesseligibilityforallma enrollees,achangethatmightrequireawaiver.questionstoconsiderwhenexpandingprojected 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 22

25 annualincomeinclude:(1)whatisthepotentialformiscalculationsorfraudwhenusingprojected income?(2)whatwillbethefinancialrecourseforindividualswhoundervcalculatetheirincomesand areeligibleforma?(3)arefamilieswithongoingmaeligibility,andthuspotentiallynewapplicants, abletoaccuratelyestimatetheirprojectedincome? Create(Consistent(Enrollment(Procedures(Across(Public(Programs( Thelagtimebetweenapplicationandenrollmentdatedifferbetweenprograms,causingconsumer confusionandgapsincoverageatthechurnpoints.medicalassistanceprovidescoverageretroactively tothefirstdayofthemonthandisavailableuptothreemonthsbeforethemonthoftheapplication, whileminnesotacarebeginsthemonthfollowingreceiptofthepremium. 90,91 MedicalAssistance s retroactiveapproachandlackofdelayregardingpremiumpaymentprovidescontinuouscoveragefor longer.thus,wesuggestthatminnesotacareconsideradoptingthisprocedure.itshouldbenotedthat shiftingminnesotacare sprocedurestowardsthegenerousretroactiveenrollmentofmawilllikely increasecosts.furthermore,neitherprogramisalignedwiththemarketplace,wherecoveragebegins onthefirstofthemonthafterenrollmentduringanopenorspecialenrollmentperiod. Implement(Uniform(PostOEligibility(Verification(of(Income(Across(Programs( MedicalAssistancerequiresthatconsumerssubmitalldocumentation,includingincome,citizenship, andimmigrationstatuses,beforedeterminationofeligibilitycanbemade. 92 MinnesotaCareandthe MarketplaceallowforpostVeligibilityverificationandprovideforagraceperiodof95daysforreceiptof documentation. 93 Aligningtheseverificationproceduresacrossprogramswouldpromoteadministrative easeanddecreaseconsumerconfusionatchurnpoints.werecommendanallowanceforpostveligibility verificationinmasothatconsumerscanreceivecoveragequicklyandexperiencesmoothtransitionsat churnpoints.inordertocontrollossesduetofraudanderror,themarketplaceallowanceperiodmay beshorterthanminnesotacare s:forinstance,60daysinsteadof95days. Utilize(Uniform(Household(Definition(Across(Programs( TheMarketplace,MA,andMinnesotaCareallusedifferenthouseholddefinitions.Ingeneral,the MarketplacedefinesahouseholdbasedontaxfilingstatusindeterminingAdvancePremiumTaxCredit (APTC)eligibility,whilethepublicprogramsalsoconsiderlivingarrangementsandtherelationshipsof memberswithinahousehold. 94 Dependingonthedefinitionused,familymembersmayhavedifferent FPGcalculations,makingthemeligiblefordifferentprogramsdependingonthedefinition. 95 Thisleads toconfusionforfamiliesandanadditionaladministrativeburdeninattemptingtomanagethree definitions. a Giventheproblemswithdifferingeligibilityandtheadditionaladministrativeworkthis a Thefollowingarethreeexamplesinwhichdefinitionsarenotaligned:MAaccountsfortheincomeofboth unmarriedparentsineligibilitydetermination,whilethemarketplaceonlyincludestheincomeoftheparentthat claimsthechildasadependent;minnesotacareconsiderstherelationshipofastepvparenttoastepvchildthatofa parentalrelationship,whilemaonlydoessounderspecificcircumstances;andminnesotacareistheonlystate healthprogramthatconsidersguardianshipindetermininghouseholdsize.[source:minnesotahealthcare ProgramsManual.MinnesotaDepartmentofHumanServices.December2014.Web.26December2014.] 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 23

26 creates,werecommendusingacoordinatedwaivertostandardizehouseholddefinitionacrossma, MinnesotaCare,andtheMarketplace. Category$3:$Affordability$Improvements$ Use(a(Waiver(to(Resolve(the( Family(Glitch ( UndertheACA,ifanindividualreceivesanofferofemployerVsponsoredinsurance(ESI),onlythecostof individualcoverageisconsideredintheirs sdefinitionof affordable. Thosewithan affordable ESI offerarenoteligibleforaptcsonthemarketplace.forsome,thecostofindividualesicoveragemaybe affordablebutthecostoffamilycoverageisnot.thesefamiliesarethenunabletopurchaseaffordable Marketplacecoverage.Thisproblemisreferredtoasthe familyglitch. 96 Minnesota s1332waiver applicationcouldincludea familywaiver, similartosenatoralfranken sproposedfamilycoverage ActofJune ThiswouldallowfamilymembersinthissituationtoreceiveAPTCsforwhichthey werepreviouslyineligible,ensuringthatchildrenandspouseswhodonothaveaccesstoaffordableesi throughafamilymembercanaccessaffordableinsurancethroughmnsure.suchanamendmentto currentregulationswouldrequireafederalwaiverandadditionalfundsforthesubsidies. Expand(Affordable(Coverage(for(Currently(Ineligible(Immigrants(( Inordertoexpandcoveragetothelastfivepercent,Minnesotamayneedtosupportthoseineligiblefor publicinsurance,includingundocumentedimmigrants. MostnonVcitizensareintheincomerangesrequiredtoqualifyforMAorAPTCs. 98 However,even lawfullypresentimmigrantsaresubjecttorestrictions,includingafivevyearwaitingperiodforma. Stateshavetheoptiontowaivethisprovisionforchildrenandpregnantwomen,butnotforother adults. 99 InMinnesota,lawfullypresentnoncitizensupto200%FPGareeligibleforMinnesotaCare, lawfullyvpresentpregnantwomenandchildrenregardlessofdateofentryintotheunitedstatesare eligibleforma,andundocumentedpregnantwomenareeligibleforcertainmaservices. 100,101 Lawfully presentimmigrantsareeligibletopurchaseqhpsandreceiveaptcswithoutawaitingperiod. UndocumentedimmigrantsareexcludedfromboththeMedicaidexpansionandMarketplacecoverage atanationallevel.somestates,however,usetheirownfundstoprovideexpandedcoveragefor noncitizens.forexample,illinois,newyork,andwashingtonallusestatefundstoprovideformsof medicalassistanceforchildrenregardlessofimmigrationstatus. 102 By2016,210,000individualsinMinnesotaareexpectedtoremainuninsured,with12percentbeing undocumentedimmigrants. 103 Thestatemaywanttoconsiderprovidingaffordablecoverageto noncitizensby:(1)expandingmaeligibilitytoalldocumentedimmigrantsregardlessofentrydate;(2) expandingfinancialsupportthroughma,minnesotacare,ormnsureaptcstochildrenwhoare undocumented;and/or(3)expandingfinancialsupportthroughma,minnesotacare,ormnsureaptcs toallundocumentedimmigrants. Minnesotamayneedtorequesta1332and/or1115waivertobypassthefederalrestrictionson undocumentedimmigrantparticipationinma,thebhp,andthemarketplace.fundingtosubsidize coverageforthispopulationwouldneedtocomefromthestate. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 24

27 Smooth$the$Premium$and$CostZSharing$Schedule$to$Minimize$Cliffs$ Foranyofthethreeoptionsthatfollow,werecommendthatMinnesotaincludeinitswaiverapplicationa proposaltosmoothpremiumandcostvsharingcliffsalongthe0% 275%FPGspectrum.Theeligibilitythresholds andvehiclesforsubsidizedinsurancewilldifferacrosstheoptions,butthecommitmenttoprovidinganaffordable, smoothcontinuumofcoverageisconstant. Table2.1showsthechangesinpremiumandactuarialvalueacrossthe138%and200%churnpointsfor2015.The mostsignificantcliffforbothpremiumsandcostvsharingisat200%fpg,betweenthecurrentminnesotacareand QHPguidelines.Thissectionpresentsafewalternativestothisdisjointedsystem.Thesesimplyservetoillustratea fewdirectionsthestatecouldpursueifitwouldliketocreateasmoothercontinuumofpremiumsandcostv sharingforlowvincomeresidents. Table$2.1.$2015$Premiums$and$actuarial$value$for$MA,$MinnesotaCare,$and$QHPs$$ for$a$25zyearzold$nonzsmoker$in$the$twin$cities$ 2015$ Silver$QHP$ Bronze$QHP$ Federal$Requirements$ %FPG$ Premium($) 104,105 AV (%) 106 Premium ($) AV (%) Premiumas percentofincome (%) 107 0$ $ $ $ $ $ $ AV (%) 108 TheshapeofarevisedpremiumandcostVsharingschedulewillhingeontheavailabilityofstateandfederal funding.minnesotacouldseek,forexample,tomaintaincurrentpremiumsandcostvsharingforthoseunder200% FPG,providingassistancetothoseabovetheclifftohelpeasethetransition.MinnesotaCarepremiumswere reducedeffectivejanuary2014inordertocomplywithanticipatedbhprequirementsandimproveaffordability. 109 Inordertopreservethislevelofaffordabilityinthepublicplanswhilealsoprovidingassistancetothoseunder 275%FPGcurrentlyshoppingontheMarketplace,Minnesotawouldneedtosecuresignificantadditionalfunding forpremiumassistancebeyondwhata1332waivercanprovide.onewayminnesotacouldpartiallyoffsetthe decreaseinpremiumsistoslightlyincreasecostvsharingforportionsofthepopulationcurrentlyonpublicplans withover96percentactuarialvalue. Premium(Smoothing( WerecommendthatMinnesotacreateamorelinearslidingscaleofpremiumsacrossthe0% 275%FPGspectrum. Inparticular,weproposehavingpremiumsincreasemoregraduallybetweenMAandMinnesotaCareandbetween MinnesotaCareandtheQHPs.Figure2.1mapsthecurrentpremiumschedulefora25V,40V,and60VyearVoldnonV smokerlivinginthetwincities,accordingtotheirincomelevelandeligibilityforma,minnesotacare,orasilver QHP. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 25

28 Figure$2.1.$Effective$2015$premiums$for$a$25Z,$40Z,$and$60ZyearZold$purchasing$a$ silver$plan$on$mnsure$ Figure$2.2.$Proposed$premium$schedule$relative$to$2015$effective$premiums$for$ a$25zyearzold$choosing$a$silver$qhp$ Figure2.2usesthe2015effectivepremiumsforthe25yearVoldchoosingasilverplanasthebenchmarkandoffers threealternatives:proposal1includespremiumsofroughly$2at139%fpg,$77at200%fpg,and$144at275% FPG.ItrequiresincreasingpremiumsforsomecurrentMinnesotaCareenrolleesinordertoslightlyoffsetpremium reductionsforthoseatbothlowerandhigherincomelevels.proposal2includespremiumsofroughly$2at139% FPG,$65at200%FPG,and$144at275%FPG.Italsorequiresincreasingpremiumsforsomecurrent MinnesotaCareenrollees,butlesssteeplythaninProposal1.Proposal3includespremiumsofroughly$2at139% FPG,$50at200%FPG,and$144at275%FPG.Itmaintainsthe$50maximumpremiuminMinnesotaCareand reducespremiumsforallothersbetween138%and275%fpg. UltimatelytheadjustedpremiumschedulewillneedtotakeintoaccountthevariationinMarketplacepremiums byageandgeographiclocation,andseektoharmonizethiswiththeagevandlocationvinvariantpremiumsfor MinnesotaCare.$ 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 26

29 CostOsharing(Adjustments( WealsorecommendprovidinggreatercostVsharingassistancetothosecurrentlywithoutaccesstopublic programs,whoaremostvulnerabletofinancialshocksduetohighoutvofvpocketspending.thisisaparticular concernforthoseinthe200% 275%FPGrangewhopurchasebronzeplans,makingthemineligibleforfederal costvsharingreductions.figure2.3showscurrentandproposedactuarialvalue,withtheaca srequirementsasa benchmark.proposal1requiresadditionalcostvsharingassistanceforthe200% 250%FPGpopulationtosmooth cliffsinoutvofvpocketspending.dependingontheglobalreformoptionpursued,thisassistancewouldbeprovided eitherthroughapublicplanwithlowcostvsharingrequirementsorthroughsubsidiesonmnsure.inordertooffset thecostofadditionalsubsidiesforthispopulation,minnesotacouldconsidergraduallyincreasingcostvsharingfor partofthe150% 200%populationtoprovidegraduallydecreasingactuarialvalue(Proposal2).However,thismay requireafederalwaiverifactuarialvaluedropsbelowfederalrequirements.aslidingscaleofdeductiblesand/or copayscouldalsobedifficulttoadministerifthispopulationremainsonapublicprogram. Figure$2.3.$Actuarial$Value$for$MA,$MinnesotaCare,$and$Bronze$and$Silver$QHPs 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 27

30 Option$A:$DHSZDriven$Consolidation$of$Public$Programs$ Vision$ ThisoptionexpandsMinnesota sexistinghighvqualitypublicprograms.asingle,consolidatedpublic planwillservemostfamiliesandindividualswithincomesbetween0%and275%fpg,eliminatingthe 138%FPGchurnpointandraisingthethresholdbetweenthepublicprogramsandprivateMarketplace toahigherincomelevel.thestatewillbeabletoleverageitsgreatermarketsharetodrivedelivery systemreformthroughtheprocurementprocess,ratherthanbyrelyingonindirectanduncertain marketmechanisms.sincethenumberofcustomersshoppingforsubsidizedprivateinsurancewill decline,mnsurewillplayasmallerroleinminnesota shealthreformprogram. Figure$1:$Coverage$Under$Option$A$ ParentsandNonV disabledadults MinnesotaCare APTCsMNsure Children MinnesotaCare APTCsMNsure PregnantWomen MinnesotaCare APTCsMNsure LegalPermanent Residentswith<5years MinnesotaCare APTCsMNsure 275% 400% Description$ OptionAwillenrollallnonV highvneed childrenandadultslivinginhouseholdsbetween0%and275% FPGinasingleprogramcalledMinnesotaCare.HighVneedpopulations,suchaslongVtermcareand disabledpatients,willremaininthetraditionalmaprogram,followingtheexampleofarkansas s Medicaidexpansion. 110 Forthesakeofalignment,theeligibilityceilingforpregnantwomenforthe publicprogramwillbedecreasedto275%fpgfromitscurrentpositionof280%fpg. b Institutinga275% FPGceilingforallindividualsrestoresMinnesotaCaretoitsformereligibilitycutoff,asrecommendedby thelegislature. 111 Byestablishingthesameceilingforchildrenandpregnantwomen,thesechangeswill allowfamiliestoreceivecareonthesameplan. Theconsolidationofprogramscouldtakeavarietyofforms.Ataminimum,DHScouldrebrandnonV highvneedmaasminnesotacare,takingadvantageoftheexistingunifiedapplicationprocesswhile maintainingseparatebackvendadministrationoftheprograms.amoreambitiousoptionwouldbeto fullyconsolidatetheprograms,creatingasinglesystemforprogramadministration,providerpayment, b OneconsiderationinshiftingpregnantwomenfromMAtoMinnesotaCareisthattheformeroffers transportationservicesthatthelatterdoesnot.dhsshouldconsidercarryingoverthoseservicesforpregnant womenduringtheintegrationoftheprograms. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 28

31 managedcarecontracting,andbeneficiarycontributions.inanyscenario,thestateshouldattemptto harmonizethebenefitspackagesofthetwoprograms,sothatallofthecoveredservicesavailableunder oneprogramareavailableintheother,albeitwithgreatercostvsharingamonghigherincomegroups. MedicalAssistanceandMinnesotaCarecurrentlyoperatewithanunwieldymixtureofintegrationand separation.theyrunonseparatefundingstreams,withtheformerrelyingonmedicaidandchip waiversandthelatterrelyingonthebhpfundingmechanismestablishedintheaca.furthermore,ma isoverseenatthestatelevelbydhsandimplementedbythecounties,whileminnesotacareis administeredbythedhsminnesotacareoffice. 112 Yetforseveralimportantfunctions,DHSisrequired bystatelawtocoordinatebetweentheprograms,asinapplicationprocedures,providerpayment, managedcare,andservicedelivery. 113,114,115,116 Theupcoming2016statewidemanagedcareprocurementisanopportunitytofurtherintegratethetwo programs. 117 CarriersprovidingplansinMinnesotaCarearerequiredtoprovideplansinMAaswell,but notineverycounty.minnesotacareenrolleesinsomecountiesarethereforevulnerabletodisruptions incareiftheybecomeeligibleforma. 118 DHScouldsetanewrequirementthatplanswishingto participateinpublicprogramsacceptenrolleesfrommaineverycounty.acoordinated1332and1115 waiverapplicationfor2017couldfurtherrationalizethisadministrativetangle,mergingprogram requirementsandconsolidatingadministration. Looking$Ahead$ TheimplementationofOptionAin2017couldsetthestageforseveraldifferentexpansionpathsafter thefirst1332waiverperiodendedin2022.wehighlighttwopaths,eachofwhichwouldfurther institutionalizehealthcareexpansionandwouldrepresentstrongprogressiveachievements. OnevisionwouldextendMinnesotaCareupto400%FPG.Thisoptionwouldeliminateallchurnpoints excepttheoneat400%fpgandwouldboostdhs sinfluenceoverdeliverysystemreform.however,it wouldalsoeliminatemuchofmnsure scustomerbase.mnsurewouldstillplayanimportantroleasa smallbusinessmarketplace,anindividualmarketplaceforthoseabove400%fpg,andaportaltopublic programs,butitwouldnotsellsubsidizedprivateinsurancetoindividuals.thiswouldperhaps underminetheinvestmentsminnesotahasmadeinestablishingastatevbasedmarketplace.evenmore problematicisthatthisplanwouldweakenminnesota sindividualprivateinsurancemarketandmay makeitmoredifficultforindividualsandfamiliesabove400%fpgtoobtaincoverage. AnalternativeexpansionvisionwouldcreateanoptionalMinnesotaCarebuyVinprogramfor Minnesotansbetween275%and400%FPG,orforanyoneabove275%FPG.Thisprogramwould virtuallyeliminatechurnamongenrollees;ashouseholdincomesshift,premiumsandcostvsharing wouldadjust,butprovidersandcoveragewouldstayconstant.thecongressionalbudgetoffice analyzedthebudgetaryeffectsofanationalcoveragebuyvinprogramandestimatedthattheprogram wouldhavepremiumsseventoeightpercentcheaperthanprivateplansofferedontheexchangefrom 2016V2023andwouldreduceoverallgovernmentoutlays.Nevertheless,therearepotentialdownsides tosuchapath.thebuyvinprogrammightcrowdoutprivatecarriersorattractadisproportionateshare 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 29

32 ofhighvcostindividuals.furthermore,therearepoliticalandpolicyrisksinimposingthelowerprovider reimbursementratesofpublicplansonalargersegmentofthemarket. 119 Evaluation$$ Smoothing(the(Coverage(Continuum( ByintegratingMAintoMinnesotaCare,thisplaneliminatesthe138%FPGchurnpointandhelpssmooth thecontinuumofcoveragecomparedtothestatusquo.furthermore,implementingthecostvsharing recommendationsdiscussedinthe OpportunitiesforIncrementalChange section(p.19)will significantlysmooththepaymentcontinuum. Anothercrucialaspectofcoveragecontinuityisthepossiblechangeinprovidernetworksbetween MinnesotaCareandtheQHPmarket.Inruralareaswithfewproviders,consumersmaybemorelikelyto keepthesameprovidernetwork,asallhealthplansmayhavetocontractwithnearlyallprovidersto meetnetworkadequacyrequirements.inurbanareaswithmorecareoptions,healthplanscan selectivelycontract.intheseareas,whenaconsumertransitionsbetweenminnesotacareandaqhp,it isgenerallypossibletochooseanewplanwithasimilarnetwork.however,peoplewithlowhealth insuranceliteracymayinadvertentlyloseaccesstotheircurrentprovidersiftheydonotfully understandtheplanstheyarechoosing.furthermore,thelowestvpriceqhpsmayhaveachievedthese lowcostsbycreatingmorenarrownetworksthanminnesotacare. Affordability( OptionAcouldofferincreasedaffordabilitytoconsumersupto275%FPGdependingontheformula adoptedtodeterminepremiums(andpossiblydeductibles)paid.see SmooththePremiumandCostV SharingScheduletoMinimizeCliffs (page25). Inthelongterm,ifMinnesotacontinuestoexpandpubliccoveragetoindividualsabove275%FPG,a higherpercentageofthestate spopulationwillbeenrolledinstatevrunprograms.intheory,greater consolidationinpublicprocurementcouldenablethestatetonegotiatelowerratesandreduceoverall administrativecosts. Universality(and(Comprehensiveness(of(Coverage( Reducingchurnalonecouldmarginallyincreasethepercentageofthepopulationwithhealthinsurance. Withfewercoveragegapsduetochurn,morepeoplewillbecoveredatanygiventime.However,since undocumentedimmigrantsremainineligibleforminnesotacare,thisexpansionalonedoeslittletocover theremaininguninsuredpopulationinminnesota.nevertheless,benefitswillbemorecomprehensive forthe200% 275%FPGpopulationifthestatemaintainsthecurrentservicepackageofferedby MinnesotaCare:severalbenefitscurrentlyofferedbyMinnesotaCarearenotofferedbyQHPs,suchas interpretersandmentalhealthcasemanagement. 120 Financial(Feasibility( See FinancialFeasibility:AComparativeAnalysis (page42). 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 30

33 Administrative(Feasibility( ThisoptionreliesheavilyonDHS,whichwillberesponsibleforprovidingcoveragetothe0% 275%FPG population.dhsalreadyparticipatesinprocurementformaandminnesotacare,sothisshouldnot requireanentirereworkingoftheagency soperations.however,iftheintendedbackvendintegration ofmaandminnesotacareissignificantasopposedtoamererebranding,implementationwillrequire greaterattentionandresourceswithindhs. Leveraging(Delivery(System(Reform( OptionAmaintainsDHS sprominentpositionasthepurchaserofhealthcareforoveronevsixthofthe state spopulation. 121 TheadditionalMinnesotaCareenrolleeswouldmarginallyincreaseDHS s purchasingpower.dhshasinitiatedseveralreformsinrecentyears,includingtheintroductionof competitivebiddingformedicaidmanagedcareplans,andacocontractswithnineprovidergroups covering145,000patients,demonstratingitswillingnesstousetheprocurementprocessfordelivery andpaymentreform. 122,123 Inthefuture,DHScouldpushfortheinclusionofManagedCareOrganization (MCO)andACOcontractprovisionsthatimprovethedeliverysystembeyondpaymentreform:for example,futurecontractscouldpromotecoordinationofprovidersandreducetheoccurrenceof patientsswitchingdoctors,expandingdhs sintegratedhealthpartnerships(medicaidacos),or incentivizingintegrationinfundingforsocialservices,behavioralhealth,andmedicalcare. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 31

34 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 32 Option$B:$Coverage$Expansion$through$the$Marketplace$ Vision$ ThisoptionusestheQHPMarketplace(MNsure)astheprimarytooltoexpandcoverageandleverage buyingpowerfordeliverysystemreform.ratherthanrelyingonthestatetoadministerthebasichealth Program(MinnesotaCare),itprovidespremiumsupportforeligibleindividualstopurchaseequivalent QHPsonMNsure,shiftingthestate srolefromservicedeliverytosubsidizationofprivateinsurance. ThisapproachempowersMNsuretouseitsregulatorypowertodemandlowerratesandmoreeffective servicedeliveryfromprivateinsurers.itprovidesgreaterconsumerchoiceandreliesonmarketplace competitiontodrivedownrates.practically,thisoptionallowsindividualsabovethemedicaideligibility linetostayontheexactsameplanatanyincomelevel,reducingchurnacrosstheincomespectrum. Figure$2:$Coverage$Under$Option$B$ Description$$ LikeOptionA,thisoptionwouldbeginbyrestoringeligibilityforMinnesotaCareto275%FPG.However, insteadofenrollingtheseindividualsinapublicplan,minnesotawouldusepublicfundstosubsidizethe purchaseofaprivateplanonthemnsuremarketplace.the200% 275%FPGpopulationwouldstayin themarketplacebutbenefitfromadditionalcostvsharingandservices,whilethe138% 200%FPGgroup wouldbemovedintothisreformedmarketplace. Consumersinthe138% 275%FPGincomerangefacelargejumpsinpremiumandoutVofVpocketcosts whentheymoveontotheprivatemarket(see OpportunitiesforIncrementalChange,"page19).Under OptionB,MinnesotawouldwrapQHPplanspurchasedonMNsurewithadditionalpremiumsubsidies andlowercostvsharingrequirementstomakethemfinanciallysimilartominnesotacare.medicallyfrail anddisabledindividualswouldcontinuetobeservedbyadhsvadministeredpublicplan,suchasma,to protectthemfrompotentiallyhighoutvofvpocketcosts. ForthenonVmedicallyVfrailpopulation,therequirementsforQHPsthatcanbesoldontheMarketplace wouldbecomeidenticaltotherequirementsforminnesotacareplans.asaresult,anysilverplan offeredonmnsurewouldbeeligibleforpurchasebyaminnesotacareenrollee,usingfederalandstate subsidies.currently,minnesotacareoffersseveralservicesnotincludedinqhps,suchasdentaland Medicaid(MA) Medicaid(MA) Medicaid(MA) PublicFundson MNsure PublicFundson MNsure APTCsMNsure APTCsMNsure APTCsMNsure APTCsMNsure ParentsandNonVdisabled Adults Children PregnantWomen LegalPermanent Residentswith<5years Residency 138% 275% 280% 400%

35 visionservicesforadults,mentalhealthcasemanagement,andinterpreters. 124,125 Thesecanbe providedbythestateonafeevforvservicebasisas addvons toamarketplaceplan.while MinnesotaCareenrolleeswouldhavetheopportunitytoshoponMNsureandchoosetheirownplans, therewouldalsobeaprocedureforplacingthemintoa default planiftheydidnotmakeachoice. OnemodelforthisoptioncomesfromArkansas sapproachtomedicaidexpansion,althoughinthecase ofminnesotaitwouldapplytotheminnesotacarepopulationratherthanthemaprogram.arkansasis usingpremiumassistancetopurchaseqhpsforitsmedicaidenrollees,withtheexceptionofindividuals whoareconsidered medicallyfrail, disabled,orinneedoflongvtermservicesandsupports.because Medicaidoffersbenefitsthataretypicallynotcoveredbyprivateplans,suchasnonVemergency transportationandearlyandperiodicscreening,diagnostic,andtreatment(epsdt)benefitsfor19vand 20Vyearolds,Arkansascontinuestoofferthese wraparound servicesthroughtraditionalfeevforv servicemedicaid.inaddition,costvsharingiscappedatmedicaidstateplanamountsforenrollees between100%and138%offpgandeliminatedentirelyforenrolleesbelowthefederalpovertyline. 126 IowahastakenasimilarapproachtoMedicaidexpansion.Initsmodel,newlyeligibleMedicaid beneficiariesbetween100%and138%offpgwillreceivepremiumassistancetohelpthempurchase QHPsintheMarketplace,whilenewlyeligibleadultsbelow100%FPGwillbeenrolledinMedicaid managedcare.asinarkansas,servicesthatmedicaidcoversandqhpsdonot,suchasepsdtand transportation,willbeprovidedbytraditionalmedicaidonafeevforvservicebasis.inaddition,iowa beneficiariesearningmorethan50%offpgwillowesmall($5or$10)monthlypremiums,whichcanbe waivediftheycompletecertain healthybehavioractivities. However,theircoveragecannotbe terminatedforfailingtopaypremiumsiftheirincomeisbelow100%fpg. 127 Otherstateshave consideredsimilaroptionsformedicaidexpansion;however,toourknowledge,nootherstatehas consideredusingthevehicleofabhptoprovidesimilarsubsidiesandwraparoundservicestopeople above138%fpg. Leveraging(Delivery(System(Reform( UnderOptionB,MinnesotawouldbuildonArkansasandIowa sexamplestonotonlyexpandaccessto insurance,butalsotodrivedeliverysystemreform.mnsure sauthorizinglegislationgivesitthepower tobeselectiveabouttheplansofferedunderitsauspices,consideringfactorssuchasaffordability, quality,value,andadvancementofpaymentanddeliveryreform. c MNsurehasseveraltoolswithwhich toaccomplishthis: 128 c TheboardshallcertifyandselectahealthplanasaqualifiedhealthplantobeofferedthroughtheMinnesota InsuranceMarketplace,if:...(2)theboarddeterminesthatmakingthehealthplanavailablethroughthe MinnesotaInsuranceMarketplaceisintheinterestofqualifiedindividualsandqualifiedemployers. Theboard mayconsiderthefollowing: (1)affordability;(2)qualityandvalueofhealthplans;(3)promotionofprevention andwellness;(4)promotionofinitiativestoreducehealthdisparities;(5)marketstabilityandadverseselection; (6)meaningfulchoicesandaccess;(7)alignmentandcoordinationwithstateagencyandprivatesector purchasingstrategiesandpaymentreformefforts;and(8)othercriteriathattheboarddeterminesappropriate. TheexceptionsarethatMNsuremaynotexcludeahealthplanfromtheexchangeonthebasisthatitisfeeVforV 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 33

36 Settingadditionalcertificationcriteriathatreflectthestate sgoalsforsuchfactorsaspopulation health,planquality,accesstoproviders,deliverysystemreform,andtransparency UsingaselectivecontractingprocesstonegotiatebetterpricesandhigherVqualityplans ManagingproductchoicesandsettingparametersforcostVsharing Aligningwithotherlargepurchasersinthestate,suchaslargeemployercoalitionsorthestate governmentemployeebenefitsagencytosendconsistentpurchasingsignalstohealthinsurance carriersandproviders ProvidinginformationandwebVbaseddecisiontoolstoencouragebetterconsumerdecisionV making(see ActivePurchasingAuthorityandChoiceArchitecture, page20). WhileMNsurehastheauthoritytodoallthisnow,itcurrentlyservesarelativelysmallnumberof Minnesotans,justover100,000people,andthereforemaylacktheleveragetodrivemajorchangesin insurerbehavior. 129,130 (Bycomparison,MAcurrentlyservesover800,000Minnesotans.)Moving MinnesotaCareenrolleesontotheMarketplacewouldincreasethepotentialcustomerbasethat insurerscanreachandthereforeincentthemtochangetheirbehaviorinordertoreachthisdesirable market. Californiaprovidesamodelforleveraginginsurers interestinaccesstomarketplaceconsumerstodrive deliverysystemreform.coveredcalifornia,thestate smarketplace,usedanegotiationprocessto obtainlowercostsandhighervqualitynetworksfromthedozensofhealthplansthatexpressedinterest inofferingplans.workingwithproviders,healthplans,andregulators,theydevelopedselectioncriteria, standardizedbenefitdesigns,solicitationprocedures,andcontractstandardstocreateacompetitive mixof11healthinsurancecompaniesofferingvarioustypesofcoverage.duringnegotiations,some planswererejectedduetohighcostsorduplicativeorinadequateofferings,whileotherplanslowered theirpricesorrevisedtheirproposals.thestandardizedbenefitdesignsappliedtoplansofferedoutside ofthemarketplaceaswell,reducingopportunitiesforriskselectionandsimplifyingcomparisonsfor consumers.thestatealsousedamultiyearcontractingpolicytoencourageinsurerstoenterthemarket duringthefirstyearofopenenrollmentandprovidestabilitytoitsmarket.akaiserfamilyfoundation reportfoundthatcoveredcalifornia sworkimprovedthecompetitivenessofitsindividualinsurance marketrelativetothemarketthatexistedbeforetheaca,providinganexampleofthepotentialfor statemarketplacestoencouragecompetition,higherquality,andlowercosts. 131 MassachusettshasalsousedproactivetechniquestoimprovecostandqualityinitsConnector Marketplace.ThepartoftheConnectorthatofferssubsidizedinsurancehasbehavedasalarge employerwould,structuringthebiddingandenrollmentprocesstoencouragelowercostsand recruitingcarrierswithtighterprovidernetworksandlowercoststructures.theresultwasanannual increaseinpremiumsoflessthanfivepercent,whichwaslessthanhalftheannualincreaseinthe commercialinsurancemarket.inaddition,ontheunsubsidizedsectionofthemarketthatservessmall service,thatitimposespremiumpricecontrols,orthatitprovidestreatmentsnecessarytopreventpatients deathsthattheexchangedeterminesinappropriateortoocostly.minnesotastatutes2012,section , subdivision andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 34

37 businesses,theconnectorrequiredplanstomeeta SealofApproval beforebeingofferedinthe marketplace,encouragingqualityandefficiencyevenwhentheyhadlessleverageovercost. 132 Inadditiontotheoptionsoutlinedabove,theprocessofassigningenrolleestodefaultplanscanbeused toencouragecertaintypesofcompetitionorplandesign.forexample,arkansasencouragedmarket entryandcompetitionbyassigningdefaultenrolleesthroughamethodthatguaranteedacertain marketshareforsmallerinsurers,encouragingthemtoenternewmarketsandcompetewiththelarger andmoreestablishedplans.mnsurecanchooseanapproachtodefaultenrollmentthatsupportsthe marketbehaviorsitdesiresintheminnesotacontext. Looking$Ahead$ Ifthismodelissuccessfulinloweringpremiumcosts,spurringinnovationincaredelivery,andreducing churnforthepopulationabovethemaeligibilitycutoff,itcouldbeexpanded.forinstance,the populationcurrentlyservedbymamanagedcareprograms(about73percentofallmaenrollees 133 ) couldbeshiftedontotheqhpmarket,againwithsubsidizedoutvofvpocketcosts.thiswouldallowan enrolleetoremainontheexactsameinsuranceplanregardlessoftheirincome,withvaryingsubsidies from0%to400%fpg,unitingfamiliesonasingleplanandvirtuallyeliminatingchurn.becausethema populationislargerelativetothecurrentqhpmarket,thisextensionwoulddramaticallyincrease MNsure sleveragetoencouragedeliverysystemreform. Whilethismayseemlikearadicalchange,itwouldbelessdisruptivefromtheconsumerperspective thanonemightexpect.sincethemajorityofmaenrolleesarecurrentlyservedbyprivatemanagedcare plans,aqhpwithreducedcostvsharingwouldlikelyfeelquitesimilartothebeneficiary.however,the administrativeandphilosophicalshiftwouldbesubstantial.thisextensionisthereforealongvterm option,ratherthanonethatshouldbeattemptedinthefivevyeartimeframeofthe1332waiver. Evaluation$$ Smoothing(the(Coverage(Continuum( Thisoptionrepresentsamajorimprovementoverthestatusquoinsmoothingthecontinuumof coverage.iteliminatesthechurnpointat200%offpg,allowinganyoneover138%offpg(thema cutoff)toremainonthesameplan,withvaryingdegreesofsubsidiesandcostvsharing.inaddition, addedsubsidies,reducedcostvsharing,andactiveregulationofmnsureplanscanensurethat consumershavesimilarcoverageandcostsonbothsidesofthe138%fpgline,eliminatingthecliffsthat consumerscurrentlyfacewhentheirincomeschange. However,thisoptiondoesnotfullyeliminatecoveragetransitions.Thereisstilladangerofchurnatthe 138%FPGeligibilitycutoff,whichpresentsaparticularconcernbecausepeoplelivingclosertothe povertylinetendtohavelessstableincomesandlesstimeandcapacitytosurmountthebureaucratic hurdlesofrevenrollment.inaddition,althoughanyoneabovethiseligibilitylinecanremainonthesame plan,minnesotacareenrolleeswillloseaddvonservicesandcostvsharingsubsidieswhentheycrossthe 275%FPGlineandbecomeregularQHPcustomers,whichcouldmakeacomprehensiveplansuddenly costvprohibitive.finally,intheshortterm,thisoptiondoeslittletounifyfamiliesunderthesameplan. SincechildrenaregenerallyeligibleforMAupto275%FPG,movingtheirparentsfromMinnesotaCare 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 35

38 ontotheqhpmarketwillnotchangethefactthatparentsandchildrenoftenhavedifferentplanswith differentnetworksofproviders. Affordability(( Bydefinition,thisplanwillpreservethesamelevelsofaffordabilityforconsumersbetween138%and 200%ofFPG.ThesubsidiesandcostVsharingassistanceprovidedtothisgroupintheQHPmarketwillbe designedtoholdtheircostsroughlyconstantwiththosetheyarecurrentlypayingasminnesotacare enrollees.atthesametime,peoplebetween200%and275%offpg,whoarecurrentlyonlyeligiblefor federalsubsidies,wouldbecomeminnesotacarebeneficiariesandthuseligibleforadditionalsubsidies andcostvsharingreductions.thiswillhelptosmoothaffordability cliffs andassistlowvincomeworking adultswiththecostsoftheircoverage.asaresult,thisoptionrepresentsamodestbutclear improvementoverthestatusquo. Universality(and(Comprehensiveness(of(Coverage(( Sincethisoptionislikelytoreducechurn,itwouldalsobelikelytoslightlyincreasethepercentageof Minnesotanswhoarecoveredbyhealthinsuranceatanygiventime.Inaddition,theprovisionof addv on servicessuchasdentalandvisionbenefitsforqhpenrolleesbelow275%fpgwillincreasethe comprehensivenessoftheirplanstosomedegree.however,thisoptiondoeslittletoreachthesmall percentageofminnesotanswhoarecurrentlynotcoveredbyanyhealthinsurance.asnotedabove, manyoftheseuninsuredarebelievedtobeimmigrants;coveringthemwilllikelyrequireawillingnessto usestatefundstomakethemeligibleforsubsidizedinsurance,whetherpublicorprivate. Financial(Feasibility(( See FinancialFeasibility:AComparativeAnalysis (page42). Administrative(Feasibility(( Thisoptionpresentsasignificantadministrativelift.ItreliesheavilyonMNsuretonegotiatewith insurers,proposemodelcontracts,andholdcarriersandproviderstoqualitystandards.mnsuredoes notcurrentlyfulfillanyofthesefunctions,andasayoungagencywhoseroleisstillinflux,itisunclear howquicklyitcouldaddthisadditionalcapacity.inaddition,mnsurewouldhavetoworkcloselywith thedoconplanapproval,whiledhswouldhavetocoordinatewithinsurerstoadministercostvsharing subsidiesand addvon services.oncethissystemisestablished,ithasthepotentialtoworkeffectively, butthechallengeofsettingupthenecessaryinternalcapacitytonegotiateeffectivelywithinsurersand administerapublicvprivatehybridsystemissubstantialandrepresentsanimportantbarriertothis option ssuccess. Leveraging(Delivery(System(Reform(( Thisoption spotentialtodrivechangesinhealthcaredeliveryreliesonmnsure sabilityandpolitical willtoeffectivelysetahighbarforinsurers.byprovidingthetwinincentivesofcompetitiononcostand accesstoalargepoolofcustomersifqualitystandardsaremet,mnsurecanspurinnovationinthe privateinsurancemarket,buildingonminnesota slonghistoryofprivatesectorimprovementsinhealth careprovision.however,thispotentialmaynotberealizedifmnsurelacksthecapacitytoenforce toughcostandqualitystandards. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 36

39 Inaddition,itisnotclearthatthepoolofpeopleservedontheQHPmarketunderthisplanissufficiently largetodrivemajorchangesininsurerandproviderbehavior:duringlastyear sopenenrollment,only about91,000peopleenrolledineitherminnesotacareoraqhpthroughmnsure,comparedtoabout 109,000peoplewhoenrolledinMAduringthesametimeperiod. 134 Evenifthispoolisnotlargeenough toencouragemajorchangestoday,however,thisproposalleavesopentheoptionofcreatinganeven moreenticingpoolofcustomersbybringingmaenrolleesintotheqhpmarketinthelongterm,which wouldmorethandoublethesizeofthemarketif2014trendscontinue.inthislongrunscenario,the potentialtoencouragedeliverysystemchangeswouldbegreatlyenhanced. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 37

40 Option$C:$Coordinated$Purchasing$Path$ Vision$ ThisoptionbuildsontheshortVtermpolicyoptionspresentedinthesection Opportunitiesfor IncrementalChange (page19).itattemptstobringconsistencytotheconsumerexperienceandmore effectivelyharnessthestate spurchasingpowertodrivedeliverysystemreformwithoutradically alteringthecurrentsystem.ratherthanmovingeligibilityboundaries,thisoptionfavorsincremental improvementstotheexistingcontinuumofcare,suchasensuring(throughcarriermandatesor consumerincentives)thatsimilarplansareavailableregardlessofeligibilityforma,minnesotacare,or Marketplacesubsidies.Additionally,thisapproachcallsonDHSandMNsuretoworkcloselytogetherto defineandimplementstandardsforplansavailableinallpartsofthemarket.suchcoordinated purchasingwillhelpsupportthediffusionofdeliverysystemreformsthatwillcutcostsandincrease qualityofcarethroughoutthesystem. Figure$3:$Coverage$Under$Option$C$ ParentsandNonVdisabled Adults Medicaid(MA) Minnesota Care APTCs& CSRMNsure APTCsMNsure Children Medicaid(MA) APTCsMNsure PregnantWomen Medicaid(MA) APTCsMNsure LegalPermanentResidents with<5yearsresidency MinnesotaCare APTCs& CSRMNsure APTCsMNsure 138% 200% 275% 280% 400% Description$$ IncontrasttoOptionsAandB,thisoptionmaintainseachofthestateVsupportedhealthcare programs MA,MinnesotaCare,andtheMNsureQHPmarket asseparateanddistinctmarkets.the eligibilitylevelsformaandminnesotacarewillremainunchanged(0% 138%FPGand138% 200%FPG, respectively). InadditiontoimplementingmoreincrementalpremiumandcostVsharingchangesforthose transitioningbetweenprograms,thisoptionaimstofurthersmooththecarecontinuumbyrequiring insurancecarrierswhocoverconsumersintheqhpmarkettoalsoofferplansintheminnesotacareand MAmarkets.Currently,enrolleesinbothMinnesotaCareandMAprimarilyreceivecoveragethroughthe samegroupofmcos:blueplus,healthpartners,itascamedicalcare,medica,hennepinhealth, PrimeWestHealth,SouthCountyHealthAlliance,andUCare.Fortunately,alloftheseplansexcept HennepincoverbothMAandMinnesotaCareenrollees,andforthemostparttheyrelyonthesame networkofprovidersforbothprograms. 135 However,theseplansmay,insomecounties,chooseto coveronlyminnesotacareenrollees. 136 Forexample,thereare10countiesinwhichUCare snetwork 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 38

41 coversthoseeligibleforminnesotacare,butnotma.thoseenrolledinucare sminnesotacareplan whoseincomesfallbelow138%offplwouldneedtoswitchintoadifferentmcoformacoverage. ForthosetransitioningfromMAtoMinnesotaCareorfromMinnesotaCaretotheQHPmarket, consistencyincoverageispossible,butnotassured.toensurecontinuityofcare,thestatecould mandatethatallcarriersofferingmaandminnesotacareplansalsoofferplansintheqhpmarket. Alternately,ifthestatedoesnotwishtomandateactionbythecarriers,itcouldincentivizeconsumers topurchaseplansthatareavailableinallthreemarketsbyofferingadditionalsubsidiestolowerthe premiumcostsoftheseplans. Whetherthestatedecidestoimposeamandateorcreateanincentive,thegoalistoensureclientswith ongoingtreatmentsorchronicillnessesmaintainaccesstothesamesystemastheireligibilitychanges. Furthermore,familymemberswhoareeligiblefordifferentprogramscouldallhavethesameplan, shoulditsuittheirneeds.regardlessofthemechanismusedtoachievethesegoals,changestothe marketneednotbedrastic.currently,everycountystillhasatleastoneplanthatservesboth MinnesotaCareandMAenrollees. 137 Asnoted,fouroutoffiveofthecarriersintheQHPmarketalready offermaandminnesotacareplans. d,138 Inaddition,thestateshouldmandatethatcarriersalsooffersimilarplansineachofthethree markets/programs.theplansshouldprovidesimilarlevelsofcoverageandsimilar,ifnotthesame, providernetworkssothatthosetransitioningfromonemarkettoanotherwillbeabletomaintain continuityofcare.asabove,thesamegoalcouldbeachievedbyofferingadditionalsubsidiesto customerswhoselectacarrierwithconsistentnetworkcoverage. Finally,toenhancedeliverysystemreformefforts,MNsuremustcoordinateitsproductofferingswith DHS sprocurementstandardsforthemaandminnesotacareprograms.mnsurecaninvokeactive purchaserauthoritytobejustasprescriptivewiththecarriersinthemarketplaceasdhsiswithits procurementstandards.mnsureanddhsshouldworktogethertodevelopcommonstandardsfor procurementbydhsandapprovaltosellplansonmnsure.thesestandardsshouldbeincludedinboth DHS srequestforproposalsformanagedcareandmnsure sqhpguidelines,usingcommonlanguage.it maybeadvantageoustocoordinatewithminnesotamanagementandbudget(mmb)aswellto leveragethebuyingpowerassociatedwiththestateemployeegroupinsuranceplan(segip). Looking$Ahead$$ TheCoordinatedPurchasingPathoffersastreamlinedconsumerexperiencewithoutdrasticchangesto thestatusquo.whileitmaintainsmuchofthecurrentsystem,whichisworkingwellformany Minnesotans,itoffersincrementalimprovementstoensuregreatercontinuityofcareforthoseatthe churnpointsbetweenprograms.itfurthercapitalizesonthestate sexistingpurchasingauthoritiesto supportpromisingdeliverysystemreforms.althoughotheroptionsmaygenerategreatercontinuityof d ThefivecarriersofferingQHPsintheMNsuremarketin2015include:BlueCrossandBlueShield,BluePlus, HealthPartners,Medica,andUCare. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 39

42 careorstrongerdeliverysystemreforms,thisoptionhastheadvantageofnotfurtherdisruptingthe markets,asmanysubstantialchangeshavebeenmadetotheminnesotahealthsysteminrecentyears. Shouldthestatepursuethispathandaimtodeepenitscommitmenttocoordinatedpurchasingdown theroad,itcouldpartnerwithmajoremployerstovoluntarilyembedthesamepurchasingstandards usedbydhsandmnsureintheemployervsponsoredinsurance(esi)market.thiswouldfurtherdrive deliverysystemreformgiventhereachandinfluenceofesi. Evaluation$ Smooth(Continuum(of(Coverage(( Thisoptionimprovesuponthecurrentsystembypromotingcontinuityofcarewhenindividualsmove betweenprograms.whileallthechurnpointswillremain,theirimpactwillbelessdrasticforconsumers. Themandatesthatcarriersparticipateinallthreemarketsandoffersimilarplansineachmarketwill allowfamiliestobeonsimilarorthesameplans,evenwhenprogrameligibilityvariesamongfamily members.however,consumersmaystillexperiencechurn,astheeligibilitythresholdsremainthesame acrossthecontinuum.furthermore,themandatethatcarriersofferingmaandminnesotacareplans alsoofferqhpswouldgivedhscompletecontroloverwhocanofferplansonmnsure,afeaturethat maynotbedesirableforthestate. Affordability( BeyondthecostVsharingandpremiumVsmoothingsuggestedin SmooththePremiumandCostVSharing ScheduletoMinimizeCliffs (page25),thisoptionisunlikelytosubstantiallyimpacthealthcarecostsin Minnesota.$ Universality(and(Comprehensiveness(of(Coverage( Whilethisoptiondoesnotaddressthegoalofcoveringthefinalfivepercentofuninsuredinthestate,it willincreasethecomprehensivenessofcoverageintheqhpmarketbyaligningmnsure sactive purchasingeffortswiththeprocurementstandardsofdhs. Financial(Feasibility( ( See FinancialFeasibility:AComparativeAnalysis (page42). Administrative(Feasibility( ByrelyingonthecoordinationofDHS procurementstandardsforma,minnesotacare,andsegipwith theactivepurchasingstrategiesofmnsure,thisoptionrequiresextensiveinterdepartmental coordinationinordertobesuccessful.evenbeyonddhsandmnsure,coordinationwouldberequired withotherentities,suchasmmbandthedoc,meaningthattherearemanypointsatwhich coordinationcouldbreakdown.theadministrativeburdentoensureeffectivecoordinationwillbequite high.additionally,itwillbeachallengetoinstitutionalizethesepracticesasstaffturnovermayimpact coordinationefforts. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 40

43 Leveraging(Delivery(System(Reform( Bybuildingoffofthestrengthsofthecurrentsystem,thisoptionavoidsinterferencewithexisting deliverysystemreformeffortsbutalsodoeslittletoenhancethem.assumingdhsandmnsureareable tocoordinatetheirpurchasingstandardseffectively,thisoptionwillsupportthediffusionofpromising deliverysystemreformeffortsthroughouttheminnesotanhealthsystem.however,becausedhsand MNsureremainseparateentitieswithdistinctmissionsandauthorities,coordinationalonemaybe insufficienttoharnessthefullpotentialofthestateorthemarkettorealizecostvsavingandqualityv enhancingreforms. Further,strengtheningcurrentdeliverysystemreformeffortsreliesonMNsurerealizingitsvisionasan activepurchaserfortheqhpmarket.thisgoalmaystillbemanyyearsoffasmnsurefocuseson providingeligibilityandenrollmentservicesthroughafullyfunctioningwebportal. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 41

44 Financial$Feasibility:$A$Comparative$Analysis$ Thefinancialimpactofhealthreformoptionsonstateandfederalbudgetswillbeacrucialconsiderationfor Minnesota.However,severalobstaclespreventusfromproducinganybutthemostrudimentaryprojections.For one,thecostofprogramsdependsonfuturepremiums,whichnoteventhecarriersthemselvesmayknowmore thanoneyearinadvance.foranother,welacktheactuarialexpertisethatwouldbenecessarytomakerigorous predictions.nevertheless,withagenerousapplicationofassumptionsandsimplifications,wecanmakesome educatedguessesabouttheimpactsofourproposalsonthesizeofvariousprogramsanddiscussthefinancial implicationsthereof.weconcludethattheoptionsthatdothemosttobroadencoverageanddrivereform, OptionsAandB,arealsomoreexpensiveintheshortterm. Enrollment( Wefirstattempttogiveprojectionsofnumberofenrolleesineachprogramin2016underourthreeoptions.For ourmaenrollmentfigures,whichremainconstantbetweenthethreeoptions,werelyupondhsprojections.for the138% 400%FPGadultpopulation,whichisdistributeddifferentlybetweenprogramsdependingontheoption, wedrawfromavarietyofsources:dhsbudgetprojections,economicandactuarialprojectionsoftheimpactof theacainminnesota,2013americancommunitysurveydata,andurbaninstitute/rwjfprojectionsfor enrollmentinstatevbasedmarketplaces. 139,140 UnderOptionC,theeligibilitycutoffsfortheBHPwillbeunchanged,andwecanrelyuponDHS sminnesotacare enrollmentprojections.optionsaandbbothfeatureabhpexpansion.weassumethat1)bhpenrollmentwillbe roughlythesameunderbothoptions,and2)theproportionoftheeligibleexpansionpopulationthatenrollswill approximatelyequaltheproportionoftheeligible138% 200%FPGpopulationprojectedtoenrollintheBHP. 141 Finally,weprojecttheMNsurepopulation.WeusetheUrbanInstitute/RWJFprojectionsforenrollmentinstateV basedmarketplacestopredictmnsure s2016enrollment.then,tocalculatethemnsureenrollmentforoptionsa andb,weassumethat70percentoftheprojectedmnsureenrollmentwillconsistofindividualsabove275% FPG aroughestimateextrapolatedfromtheproportionofmnsureenrolleeswhoreceivedcostvsharingsubsidies. Table$3.1.$2016$Enrollment$projections$for$MA,$BHP,$and$MNsure$under$each$option$ $ Option$A$ Option$B$ Option$C$ Medical$Assistance$ (administeredas MinnesotaCarein OptionA)$ BHP$ (administeredbydhsin OptionsAandC,orby MNsureinOptionB) 1,061,012 1,061,012 1,061, ,795 (138V275%FPG) 297,795 (138V275%FPG) 147,799 (138V200%FPG) MNsure$ 76,063 76, ,661 WhileOptionsAandBlookidenticalinTable3.1above,theycallforverydifferentdesignsoftheBHPprogram. Table3.2usesthesamedataasabove,butbreaksdownenrollmentineachofourscenariosbytheconcentration ofmarketpowerwithinstateagencies: $ $ 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 42

45 Table$4.2$2016$Enrollment$projections$by$controlling$state$agency$under$each$option$ $ $ $ Option$A$ Option$B$ Option$C$ Number 1,358,807 1,061,012 1,208,811 Enrollment$in$ DHSZled$ PercentageofnonVESI programs$ market,0%v400%fpg, 95% 74% 92% age0v64 Number 76, , ,661 Enrollment$in$ PercentageofnonVESI MNsureZled$ market,0%v400%fpg, 5% 26% 8% programs$ age0v64 Financials( BecausethefederalgovernmenthasalreadysignedoffonthecurrentstructureoftheproposedBHPexpansionto 200%FPG,OptionCleavesonlyafewlingeringfinancialproblems.Namely:howwillthestateplugthegapif federalbhprevenues,providedtothestatesunderthe95%formula,donotmeetthecostsofrunningthebhp? AndhowwillMNsurebecomefinanciallyselfVsustainingafteritsCenterforConsumerInformationandInsurance Oversight(CCIIO)grantexpiresin2016ifenrollmentdoesnotgrowsignificantlyoverthecomingyears? Thesetwoproblemsapplytotheotheroptionsaswell.Yet,forOptionsAandB,thecrucialfinancingquestions relatetothebhpexpansion.therewillbeafinancialcosttothestatetosubsidizingthecareofthe200% 275% FPGpopulation,especiallyiftheexpandedBHPadherestoMinnesotaCare sgenerousbenefitspackage,low premiums,andhighactuarialvalue.thefinancialburdenwillbeespeciallygreatiffederalsubsidiesremainlowas aresultoflowmarketplacepremiums.however,itbearsmentioningthatwhilea1332waiverproposalmustnot increasethefederaldeficitasawhole,thereisnoneedforeachcomponenttobebudgetvneutral.savingscould befoundelsewhereintheminnesotahealthsystemtocounterbalancethecostofthebhp.thecurrentdelivery systemreformpilotprogramsareapotentialsourceforsuchsavings. What smore,whileoptionsaandbcostmoreintheshortrun,theyhaveamuchgreaterpotentialforbending thelongvtermcostcurvethanoptionc.astable4.2showsabove,bothoptionswouldshiftenrolleestowardone stateagencywhosepurchasingpowertopursuecostsavingswouldbestrengthened,eitherthroughprocurement oractivepurchasing.butthisplanreliesuponthewillingnessandabilityoftheagenciestodrivepricesdown, whichisfarfromassured. ThebottomlineisthatOptionsAandBbothenhancecoverageforpopulationsthatarecurrentlyfinancingmuch oftheirowncare.theseplanswillcostmoney,andthefederalgovernmentmaynotbewillingtopayforallofit. Underaholisticapproachtothe2017waiverprocess,thestatemaybeabletocomeouteven.Butitisbeyondthe scopeofthisreporttotestthathypothesis.basedonwhatweknow,optioncisthesafestfinancialbet. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 43

46 Part%IV:"Comparative&Analysis of#the#options 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 44

47 Comparative$Analysis$of$the$Options$ Smoothing$the$Coverage$Continuum$ Most$Effective$$ Least$Effective$$ Option$A$ Option$C$ Smoothingthecontinuumofcoveragehasfourcomponents:(1)eliminatingpremiumcliffs;(2)reducing thenumberofchurnpointsatwhichpeoplemaylosecoverage;(3)allowingpatientstomaintain providernetworkswhentheirincomeschange;and(4)unitingfamiliesonthesameinsuranceplan. Sincepremiumcliffscanbeeliminatedunderalloptions,thiscomparisonwillfocusonthelatterthree criteria. Churn$Points$ OptionsAandBmosteffectivelyreducethenumberofchurnpointsacrossthecoveragecontinuum, whileoptioncmaintainsallexistingchurnpoints.bothoptionsaandbrequirejustonetransitionfrom MAorMinnesotaCaretotheQHPmarket.However,thetransitionoccursatahigherincomelevelunder OptionA(275%FPG)thanOptionB(138%FPG).ThisgivestheedgetoOptionA,asresearchshowsthat fluctuationsinincomearelesslikelytooccuramongthoseathigherincomelevels. 142 Similar$Provider$Networks$ Smoothingthecoveragecontinuumrequiresmaintainingsimilarprovidernetworksacrossdifferent typesofcoverage.underoptiona,individualsmaychangenetworkswhentheirincomessurpassthe 275%FPGthreshold.UnderOptionB,thisdifferencewilloccurat138%FPG,thoughthisoption promisesfinancialsupportsandactiveregulationofmnsureplanstoprovidebeneficiariessimilar coverageonbothsidesofthe138%fpgline.nevertheless,underoptionb,minnesotacareenrollees loseaddvonservicesandcostvsharingsubsidieswhentheycrossthe275%fpgline.intheshortterm, OptionCcouldhavethemostdirectimpactonincreasingcontinuityofcareifitmandatescarriersto participateinallthreemarkets(ma,minnesotacare,andmnsure),offeringsimilarplanswithsimilar networksineach.ifthismandateistooccur,optioncmaybesuccessfulinmaintainingsimilarprovider networks,butnotdiminishingchurn.thismandateiscompatiblewithoptionsaandbaswell,thoughit wouldbeadministrativelycomplextoimplementandwouldrequiremuchcooperationfromprivate insurers. Uniting$Families$ BothOptionsAandCensurefamiliesareonthesameorsimilarplans.UnderOptionA,allnonVelderly individualsupto275%fpgwillbeenrolledinminnesotacare,regardlessofageorpregnancystatus, keepingfamiliestogether.optioncalsoimprovesuponthestatusquobyrequiringcarrierstoprovide similarplansinallthreemarkets.whilefamilieswillnotbeonthesameplan,theywillhavethe opportunitytobeonsimilarplansofthesamecarrier.incontrast,optionbdoesnotallowfamiliestobe 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 45

48 onthesameplanasitmaintainscurrentmaeligibilitythresholds.toconclude,whilebothoptionsa andcmakeeffortstounifyfamilyinsurance,onlyoptionafullysucceeds. Affordability$ Most$Effective$$ Least$Effective$ Options$A$and$B$ Option$C$ ShortZRun$Affordability$ Thethreeoptions,bydesign,offercomparableshortVrunaffordabilityforconsumers.Minnesotans between0%and133%offpgwillcontinuetoreceivecomprehensive,lowvcostcoveragethrougha publicprogram.iftherecommendedcostvsmoothingmeasuresareimplemented,thosebetween133% and275%offpgwillhaveaffordablecoverageroughlycomparabletominnesotacare.whether consumersaccesscoveragethroughpublicprograms(optiona),ontheqhpmarketplace(optionb),or inamix(optionc),premiumsandcostvsharingwillgraduallyincreaseuptheincomespectrum. PremiumsmayvarybyageandsmokingstatusforthoseontheMarketplace;theactuarialvalueofplans willgraduallydecreasefrom90percentto73percentuptheincomespectrum.finally,inallthree optionsthoseabove275%offpgwillhaveaccesstothesamelevelsofcoveragetheyarecurrently eligibleforonmnsure. LongZRun$Affordability$ Thetwooptionsthatconsolidatepurchasingpowerultimatelyhavegreaterpotentialtoslowthegrowth inhealthcarecosts,leadingtogreateraffordabilityforconsumersinthelongrun.optiona,which increasesthepopulationindhsvadministeredpublicprograms,allowsthestatetocontinuetopromote thedeliverysysteminnovationsthatcurrentlyshowpromiseforcostcontainment.optionb,which bringsmoreconsumersintomnsure,allowsmnsuretostimulatecompetitionanddrivedowncostsin themarketplaceandpotentiallyinthebroaderprivatemarket.optioncmayhelppromotedelivery systemreformifdhsandmnsuresuccessfullycoordinatepurchasingstrategies,buthaslesspotential toimprovelongvrunaffordabilitythantheothertwooptions. Universality$and$Comprehensiveness$of$Coverage$ Most$Effective$ Least$Effective$ Options$A$and$B$ Option$C$ Universal$Coverage$$ UniversalityofcoveragereferstothegoalofexpandingaccesstohealthinsurancetoallMinnesotans. Noneofthethreeoptionsactivelypursuescoveragefortheremaininguninsured5percent. 143 Extending publicprogramandqhpeligibilitytoundocumentedimmigrants,asrecommendedin Opportunitiesfor IncrementalChange (page19),couldcoverupto12percentoftheremaininguninsuredpopulation. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 46

49 ByrestoringMinnesotaCareeligibility,bothOptionsAandBwoulddiminishthenumberofpeoplewho loseorchangecoverageatanygivenincomelevel,slightlyincreasingthepercentageofminnesotans coveredbyhealthinsuranceatanygiventime.incontrast,optioncdoesnotreducechurnenoughto meaningfullyimpactthenumberoftransitorilyuninsuredminnesotans.optionsaandbbothdomore thanoptionctoadvanceuniversalcoverage,withatakingtheleadduetothehigherchurnpointat 275%ratherthan138%FPG. Comprehensive$Coverage$$ EachoptionincreasesthecomprehensivenessofbenefitsofferedtocoveredMinnesotans.Byrestoring MinnesotaCaretopopulationsupto275%FPGunderOptionA,individualswithincomesbetween200% and275%fpgwillhavemorerobustbenefitsthantheywouldotherwisehaveintheqhpmarket. Similarly,OptionBaddsadditionalservices,suchasdentalandvisionbenefits,toplanssoldtoenrollees under275%fpg. OptionCcouldpotentiallyincreasethecomprehensivenessofcoveragebymandatingthatcarriersoffer similarplanswithsimilarnetworksinallthreemarkets.therefore,optionsaandbaresuperiorto OptionCintermsofincreasingbenefitsavailabletoenrolleesupto275%FPG. Financial$Feasibility$ Most$Effective$$ Least$Effective$$ Option$C$ Options$A$and$B$ See FinancialFeasibility:AComparativeAnalysis (page42). Feasibility$of$Administrative$Coordination$ Most$Effective$$ Options$A$ Least$Effective$$ Option$C$ Administrativefeasibilityinvolvestwoseparatequestions:(1)whichoptionswillbeeasiertoimplement and(2)whichoptionswillbeeasiertosustain.ouranalysissuggeststhattherearesignificanttradevoffs betweenthesetwoconcerns.theoptionwiththelowestimplementationhurdlesalsooffersthemost challenginglongvtermprospects,whereasthestatecouldreapsignificantlongvtermefficiencygainsifit takesonsomeupfrontcosts. OptionC,thecoordinatedpurchasingoption,isuniqueinthatitdoesnotreallocateresponsibilities betweendhsandmnsure.itcallsforstreamliningandcoordinationwithinthecurrentsystemand requiresnobureaucraticalterations.however,itrequirestwoagencieswithdifferentgoals,functions, cultures,andfundingstreamstoworkpermanentlyintandem.whilethecooperationbetweendhsand 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 47

50 MNsurehasbeenlaudablethusfar,andanyoptionwillrequiresignificantcoordinationbetweenthe agenciesfortheforeseeablefuture,itmaybeunwisetoinstitutionalizeanarrangementwherecrucial policy,financing,andoperationdecisionsmustbereachedasaconsensusbetweenequals. Ontheotherhand,OptionsAandBbothpromisedifficulttransitions.Ineachscenario,oneagencywill havetoabsorbfunctionstraditionallyperformedbytheotherandimplementasignificantinternal reorganization.however,bothoptionswouldsimplifyadministrationinthelongrun.eachestablishesa leadingpartner thatwouldberesponsibleforalargersegmentofthenonvesi0% 400%FPG population.healthsystemintegrationwillbesimplerafteragencyintegration. However,OptionApromisestighterintegrationthanOptionB.EvenifOptionBisimplemented perfectly,therearestilllikelytobemorepeopleenrolledinmathaninthemnsuremarketplace,which meansthatcoordinationbetweenthetwoagencieswillneedtobealmostastightasunderoptionc. OptionAthereforehasasignificantadvantageinthiscategory,asithastheabilitytoconcentratemuch moreoftheadministrativeburdenwithinasingleagency.ofcourse,inanyscenario,dhsandmnsure aswellasthedocanddepartmentofhealth mustcontinuetoplayarole. Leveraging$Delivery$System$Reform$ Most$Effective$$ Options$A,$B,$and$C$ Least$Effective$ $ Stateagencieshavethreeprimaryleverstoinfluencethecostandqualityofhealthcare:(1)DHSandthe DepartmentofEmployeeRelationscannegotiatenewcontractswithhealthinsurers;(2)MNsurecan becomeanactivepurchaser;and(3)thedoccanreviewproposedinsuranceplanratesandnetworks. OptionAreliesonthefirstleverandOptionBonthesecondandthird;OptionCseekstopullthemallat thesametime.regardlessoftheoptionchosen,insurerscancontinuetodrivereformsintheprivate individualandgroupmarkets,whichcover61percentofminnesotans,andthelegislaturecaninitiate multivpayerinitiatives,asitdidwithhealthcarehomes. 144 OptionAreliesonDHSprocurementtodrivedeliverysystemreform.Underthisoption,DHSwill continuetopurchasehealthcareforitsexistingmarketofclosetoonemillionpeople,or17percentof thestate'spopulation. e,145,146 DHScancontinueleadingcostVcontainmentefforts,includingcompetitive MCObiddingandMedicaidACOs.Theestimatedadditionofnearly150,000MinnesotaCareenrollees between200%and275%fpgrepresentsa10v15percentincreasefordhs sinsuredpopulation,buta muchlargerlosstomnsure spopulation. 147 e AsofOctober2014,combinedaveragemonthlyenrollmentinMinnesotaCareandMedicalAssistancewas projectedtoreach939,000in2014and1,160,000in andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 48

51 OptionBreliesonactivepurchasing,DOCratereview,andprivatesectorinnovationtoagreaterdegree thanotheroptions.underoptionb,allindividualsbetween138%and275%offpgwouldshopon MNsure,alosstoDHSof10V15percentofitspopulation,butcouldincreaseMNsure senrollmentby threetimeswhatitwouldhavebeenunderthestatusquo(see FinancialFeasibility:AComparative Analysis, page42). 148 Thisadditionalpopulationwouldmakedeliverysystemreformthroughactive purchasingmorefeasible.sinceinsurersparticipatinginmnsurearerequiredtoofferthesameplans outsidethemarketplace,aportionofthe300,000peoplewhopurchaseindividualinsurancewithout subsidieswouldalsobenefitfromreformsinitiatedonmnsure. 149 TheadditionalMNsureplanswould alsofallunderdocratereview. UnderOptionC,DHSandMNsurewouldeachmaintainresponsibilityforthesamenumberofpeople theycurrentlycover.thecoordinationofpurchasingstrategiesbetweendhsandmnsure,ifsuccessful, couldalsopavethewayforfurtherreforms. Thechoicebetweenoptionsisinpartachoicebetweenpreferredleversforreform;namely,DHS procurementormnsureactivepurchasing.dhshasthusfarledthewayduetoitslongerhistory,larger population,andabilitytonegotiatespecificprovisionsofinsurancecontracts.however,thechoiceof optionisalsoachoiceoverwhoshouldholdtheleversinthelongterm:dhsormnsure,thedoc,and privateinsurers,anissueonwhichthisreportremainsagnostic. Insummary,alloptionsarecompatiblewithpaymentanddeliveryreform.OptionsAandCbenefitfrom therelativestrengthofdirectprocurementcomparedtoactivepurchasing.ultimately,thechoiceof optionsdependsonpreferenceforpublicorprivateleadership. Overall$Efficacy$of$Options$as$they$Relate$to$Decision$Criteria$ Smoothing the Coverage Continuum Affordability Universalityand Comprehensiveness ofcoverage Financial Feasibility Feasibilityof Administrative Coordination Leveraging Delivery System Reform Most Effective Option(s) OptionA OptionA OptionB OptionA OptionB OptionC OptionA OptionA OptionB OptionC Least Effective Option(s) OptionC OptionC OptionC OptionA OptionB OptionC 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 49

52 Additional$Concerns$ Reimbursement(Rates(( Underthe2014MinnesotaCarestatute,reimbursementratesunderMAandMinnesotaCareareessentiallythe same,withonlyafewexceptions. 150,151,152 Historically,however,QHPshavehadhigherreimbursementratesfor thesameservices.anymajorchangetominnesota sinsurancelandscapewillraisethequestionofhowproviders willbereimbursed. UnderOptionA,providersmaystronglyresistanexpansionofpublicinsuranceunlessDHSnegotiateshigherrates foratleastpartofthecoveredpopulationorcompensatesproviderswhoseeasignificantportiontheirpatients frompublicprograms.however,assumingthatoptionbleavesthestatusquoofhigherqhpratesunchanged,it willresultinhighercoststothetaxpayer,atleastintheshortterm,aspublicsubsidiescoverthehigherqhp reimbursements.optioncleavesthebasicstructureunchanged,butdoesnothingtoalleviatethecostvshifting thatcurrentlyhappenswhenpublicinsuranceratesaretoolowtocovercosts,leadingproviderstoshiftcostsonto patientswithprivateinsurance. RegardlessofwhichoptionMinnesotachoosestopursue,theissueofreimbursementrateswillneedtobe thoughtfullynegotiatedbetweenproviders,insurers,dhs,andthestatelegislature. Market(Dynamics(( Eachoftheproposedoptionsaffectsthestructureoftheinsurancemarketindifferentways.Movingmorepeople intoacertainsegmentoftheinsurancemarketnecessarilyaffectsthemarketdynamicsintheothersegments. 5% Figure 4.1: Marketshare Under Option A Figure 4.2: Marketshare Under Option B DHS-controlled 26% DHS-controlled 95% 74% Mnsurecontrolled MNSurecontrolled Figure 4.3: Marketshare Under Option C 8% DHS-controlled 92% MNSurecontrolled Forexample,underOptionA,moreofthepopulationwouldbecoveredbyMinnesotaCare,leavingonlypeople earningabove275%fpgintheqhpmarketonmnsure.thissmallermarketcouldresultinreducedcompetition andhigherpricesasfewerinsurerschoosetoofferplanstothispopulation. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 50

53 OptionB,bycontrast,wouldmovetheworkingadultswhocurrentlyqualifyforMinnesotaCareintotheQHP market,changingtheriskpoolforboththeqhpmarketanddhsprograms.inaddition,thesubsidiesusedto purchasethisinsurancecouldalterincentives,changingthepricingandstructureoftheplansoffered,aswellas thefrequencywithwhichpeopleuseservices. Byloweringthecostofindividualinsurance,eitheroftheseoptionscouldalsoleadto crowdvout, inwhich consumerswhowouldhaveotherwisebeenprivatelycovered(e.g.throughemployervsponsoredinsurance)would insteadenrollintheexpandedminnesotacareprogram.empiricalestimatesofcrowdvoutvarytremendously,and muchofthepriorresearchdemonstratingitsexistencewasdoneoninsurancemarketswithoutanindividual mandate,butitnonethelessafactortoconsidercarefully. 153 Active(Purchasing( WeheardfromvariousstakeholdersinMinnesotathattheyhadseriousconcernsaboutMNsure spotentialuseof activepurchasing.togeneralize,insurancecarriersandprovidersareskepticaloftheabilityofgovernment agenciestoaccuratelymeasurequalityandvalue,andtheyworrythatattemptstodosocouldcreateperverse incentivesandstifleinnovationinnewwaysofdeliveringcare.whileminnesotahasmadeimpressiveprogress towardconsensusmeasuresofqualityofcare,suchastheminnesotacommunitymeasurementstandards developedbytheminnesotamedicalassociationandtheminnesotacouncilofhealthplans,therearestillserious limitsonthestate sabilitytodistinguishbetweenhighvandlowvqualitycare.asaresult,attemptstoselectively contractwithinsurersandprovidersbasedonqualityandvaluewillbelikelytofacepoliticaloppositionfromthose affected. ThisbarrierisaseriousconcernforOptionB,whichreliesheavilyonMNsure sactivepurchasingabilitytopush deliverysystemreformsforward.withouteffectiveactivepurchasing,optionblosesitsmaintooltoimprove healthcarecostsandquality.however,thesameconcernsarelikelytoapplytodhs sprocurementprocessesif theyareusedtolimitinsurers accesstoalargesegmentofthepopulationonthebasisofqualityandvalue measures.likemnsure,dhshasthestatutoryauthoritytoconsidercostandqualitymeasuresinitscontracting decisions,butmaybehamperedinexercisingthosepowersbyimperfectmeasuresofthesegoalsandbypolitical oppositionfromkeystakeholders. Stigma( AnyexpansionofpublicinsuranceprogramsorsubsidieshastoconsidertheimpactofstigmaassociatedwithlowV incomeprogramsonthepotentialbeneficiaries.thisisaparticularconcernforoptiona,whichfolds MinnesotaCareandMedicalAssistanceintoasingleprogram.MiddleVincomeindividualswhoarenewlyeligiblefor thisprogrammaybedeterredfromenrollingduetothestigmaofparticipatinginameansvtestedgovernment program. However,evidenceofstigmaismixed:somestudiessuggestthatthegreatestdeterrenttoenrollinginMedicaid programsispooradministration,notthemeansvtestednatureoftheprogram. 154,155,156 Furthermore,sincethevast majorityofpublicinsurancebeneficiariesinminnesotaareenrolledinmanagedcare,fromtheperspectiveofthe consumer,theremaybelittleperceptualdifference:fortheenrollee,abluecrossminnesotacaremanagedcare planandabluecrossqhpsoldontheexchangeandboughtwithpublicsubsidieslookverymuchthesame. Technological(capacity(( AlloftheoptionsweoutlinerelyonDHSandMNsuredevelopingthetechnologicalcapacitytoimplementthem smoothly.asitcurrentlystands,theitsystemcreatedtofacilitatema,minnesotacare,andmnsureenrollmentis notcapableofcrucialtasksneededtosmoothtransitionsbetweentypesofcoverage,suchasrevassessingandrev enrollingconsumerswhoseincomeorcircumstanceshavechanged. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 51

54 ThisisaparticularbarrierforOptionC,whichreliesonsmoothcoordination,notonlybetweentheleadershipof thetwoagencies,butalsobetweentheirdayvtovdayoperations.smoothlymovingapersonfromminnesotacare intotheprivatemarket,forinstance,shouldincludeasimpleeligibilitydeterminationprocessandadefaultoption todirectthemtoaninsuranceplanwithasimilarnetworkofproviders;thesegoalsrelyonasmartitsystemthat canaccuratelyprocessthebackendofcomplexrulesandmakethechangeseemsimpletotheconsumer. However,OptionsAandBalsorelyonDHSandMNsure sitsystemtoprocessapplicationsquicklyandaccurately, directenrolleestothebestplanforthem,andcreateatrue onestopshop forconsumers.whicheveroption Minnesotachoosestopursue,continuingtoimproveitstechnologicalcapacitywillbeacrucialingredient. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 52

55 Recommendations$ Afterresearch,discussion,anddebate,wehavearrivedatthefollowingrecommendations.They representourbestevaluationofthesituationinminnesotabasedonthesixprinciplesoutlinedabove. 1. Do(Not(Let(Reform(Efforts(Stagnate(( ItmaysoundobvioustorecommendthatMinnesotacontinueitslongtraditionofhealthreform,butwe wanttoemphasizethatthishistoryisnotcomplete.bymanymeasures,minnesotahasoneofthebest healthcaresystemsinthecountry,andafterseveralroundsofmajorreformsoverthelastfewyears,it wouldbeeasyforthestatetobreatheasighofreliefandrestonitslaurels.however,whileminnesota hasastrongfoundationcomparedtomanyotherstates,itshealthcaresystemhasyettorealizeitsfull potential.thestatusquoisstillquitefragmented,whichisconfusingtofamilies,burdensometo administrators,andlesseffectivethanitcouldbeatreformingcaredeliveryandpaymentsystems. Meaningfullyreducingfragmentationwillrequireadministrativereorganization,sinceinthelongterm,a singleagencywillbebetterpositionedtonegotiateforlowerpricesandgreaterqualitythanmultiple agenciestryingtocoordinatetheirdifferentmissionsandgoals.forthisreason,webelievethatoption C,whichpreservesthecurrentadministrativestructureandmakesonlyincrementalchangestothe statusquo,wouldnotrepresentameaningfulimprovementinthelongterm. 2. Combine(Incremental(Changes(with(the(Option(Selected(( Asdescribedabove,therearevariousincrementalchangesthatcanbemadetoMinnesota scurrent programsandpolicies.thesechangescanbepursuedontheirownorcombinedwiththeotheroptions wehaveoutlined.theyincludecontinuedtechnologicalimprovement,expandedcommunityassistance, technicalfixestoeligibilityrules,familyaffordabilitywaivers,andamodifiedcostvsharingstructure. Whiletheseadjustmentsarelessambitiousinscopethanthemoresweepingchangesproposedby OptionsAandB,theycouldhaveanevengreaterimpactontheconsumerexperienceand administrativeburdenforprogramadministratorsintheshortterm. Insomecases,a1332waiverwouldeasetheway:forexample,underawaiver,federalfundingcouldbe redirectedtocontinuethenavigatorandassistorprograms,providesubsidiesforfamiliescurrently excludedbythe familyglitch, ormodifythepremiumsubsidiesforfamiliesunder275%fpg.however, statefundscouldalsobeusedtoaccomplishthesegoals,andmanyimportantchanges,includingthe costvsharingadjustments,couldbealsoaccomplishedbylayeringstatefundsoverfederalsubsidies. WhicheveroptionMinnesotachoosestopursue,andregardlessofthespecificfundingsource,we recommendthatanyreformproposalincludethesechanges. 3. Make(a(Philosophical(Choice(Between(Options(A(and(B(( Asnotedabove,webelievethatOptionClacksthepotentialtodrivemeaningfulchange.Despitetheir differingapproaches,however,optionsaandbbothrepresenthighvpotentialstepsforward.optiona doesthisbysimplifyingandexpandingpublicprograms,relyingondhs sprocurementprocessesto pushforlowercostsandhigherquality,whileoptionbshiftsminnesotacareenrolleesontotheprivate market,offeringadditionalsupportsfortheirtransitionandrelyingonmnsure sactivepurchasing 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 53

56 standardsandprivatecompetitiontoincentivizebettercareatalowercost.bothapproachesreduce churnbysimplifyingtheconstellationofprogramsforlowvandmiddlevincomeminnesotans.both optionsalsoconcentratemoreofthemarketunderasingleagency sumbrellaandthereforestrengthen thatagency shandinnegotiationswithinsurersandproviders.asaresult,bothprovidesignificant opportunitiestostreamlinethecontinuumofcoverageanddrivedeliverysystemreform. ThechoicebetweenOptionsAandBthereforedependslessontheirrelativepotentialtocreatelongV termchangethanonminnesota spreferredapproach.whetherapublicprogramoraprivate marketplaceisbetterpositionedtocreatelongvtermchangeisultimatelyaquestionofbeliefand experience,aswellasastate suniquehistory,politicalcircumstances,andadministrativecapacity. Minnesota sleadersarebestpositionedtojudgethesefactors.thelongvtermdirectionofthestate s healthcaresystemisadecisionthatmeritsinvdepthdiscussionanddebateamongminnesota svoters andthosetheychoosetorepresentthem.regardlessofwhichoptionismoreappropriatefor Minnesota,however,webelievethateitherOptionAorBhasthepotentialtodrivemeaningfuldelivery systemreformandgreatlyimprovetheconsumerexperience,representingasignificantimprovementto thestatusquoinboththeshortandlongterm. $ $ $ 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 54

57 Conclusion$ Minnesota shealthcaresystemisatacrossroads.bothitspublicprogramsanditsprivateplansare experimentingwithpaymentforqualityandothermeasurestocontaincostgrowth,while simultaneouslyextendingmoreaffordableandcomprehensivecoveragetoconsumersthaneverbefore. WecommendtheextensiveprogressMinnesotahasmadeuptothispointininsuringmorethan90 percentofitspopulationandprovidingincreasinglyhighqualitycare. IneveryconversationwehadwithstakeholdersinMinnesota,weheardadeepcommitmentto excellenceandcontinuousimprovement.asaresult,weareconfidentthatthestate sreformefforts willnotstagnate,despiteitsremarkableprogress.wehavepreparedthisreportinthehopesthatitwill assistminnesotainthesecontinuedefforts.webelievethatourtworecommendedoptionsrepresent variousroadstowardtheultimate tripleaim ofimprovedpatientexperienceandpopulationhealth, alongsidelowerpercapitacosts.whiletheroadsmayhavedifferentbumpsanddetours,webelieve thattheybothleadtothesamedestination:ahealthcaresystemthatworksbetterforallminnesotans. $ $ 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 55

58 Endnotes$ 1 Minnesota.DepartmentofHealth.2008HealthCareReformSummary.St.Paul,MN:MinnesotaDepartmentofHealth Commissioner'sOffice,2008.Print. 2 "Application,Review,andReportingProcessforWaiversforStateInnovation."FederalRegister77.38(27February 2012):11700V11721.Print. 3 TheAffordableCareAct,SectionbySection. HHS.gov/HealthCare.U.S.DepartmentofHealth&HumanServices,2 January2015.Web.2January ManattHealthSolutions."Requirements,Benefits,andLimitationsofSection1332Waivers."StateHealthReform AssistanceNetwork(2014).Print. 5 Bachrach,Deborah,JoelArio,andMichaelKolber. ThinkingAhead:1332StateInnovationWaivers. Princeton,NJ: StateHealthReformAssistanceNetwork&ManattHealthSolutions.4December2014.Web. 6 TheAffordableCareAct,SectionbySection. 7 Bachrach,Ario,andKolber. 8 Bachrach,Ario,andKolber. 9 ManattHealthSolutions. 10 ManattHealthSolutions. 11 ManattHealthSolutions. 12 ManattHealthSolutions. 13 ManattHealthSolutions. 14 Bachrach,Ario,andKolber. 15 Bachrach,Ario,andKolber. 16 Bachrach,Ario,andKolber. 17 ManattHealthSolutions. 18 Bachrach,Deborah,LammotduPont,andMindyLipson.Arkansas:ALeadingLaboratoryforHealthCarePaymentand DeliverySystemReform.NewYork:TheCommonwealthFund,2014.Print. 19 Giesting,Beth,Chair.StateInnovationWaiverTaskForceMeeting2.9October2014,Honolulu,HI. 20 McDonough,JohnE. Wyden swaiver:stateinnovationonsteroids. JournalofHealthPolitics,PolicyandLaw39.4 (2014):1V Spaulding,JebandRobinLunge.VermontHealthCareReformAgencyofAdministration.HealthCareReformFinancing Plan:ReporttotheVermontLegislature.24January2013.Print. 22 Hsiao,William,etal."WhatOtherStatesCanLearnfromVermont sboldexperiment:embracingasinglevpayerhealth CareFinancingSystem."HealthAffairs30.7(2011):1232V1241.Print. 23 Bachrach,Ario,andKolber. 24 Kliff,Sarah. HowVermont ssinglevpayerhealthcaredreamfellapart. Vox.com,22December2014.Web.25 December "HealthInsuranceCoverageoftheTotalPopulation."KaiserFamilyFoundation.2014.Web.28December AssessingtheAffordableCareActinMinnesota:MoreAdultsinMinnesotaHaveHealthInsurance.IssueBrief.St.Paul: MinnesotaDepartmentofHealth,HealthEconomicsProgram, Sonier,Julie,ElizabethLukanen,andLynnBlewett. EarlyImpactsoftheAffordableCareActonHealthInsurance CoverageinMinnesota. StateHealthAccessDataAssistanceCenter,June2014.Print. 28 Sonier,Julie,ElizabethLukanen,andLynnBlewett. 29 Chun,Randall.MinnesotaHouseofRepresentativesResearchDepartment.MinnesotaCare.St.Paul:MinnesotaHouse ofrepresentatives.november2014.print. 30 Chun,Randall.MinnesotaHouseofRepresentativesResearchDepartment.MedicalAssistance.St.Paul:Minnesota HouseofRepresentatives.November2014.Print. 31 Sommers,BenjaminandSaraRosenbaum."IssuesinHealthReform:HowChangesinEligibilityMayMoveMillions BackandForthbetweenMedicaidandInsuranceExchanges."HealthAffairs30.2(2011):228V236.Print. 32 MinnesotaHealthCareProgramsSummaryofCoverage,CostSharing,andLimits.St.Paul:MinnesotaDepartmentof HumanServices,January2014.Web.29December "AdvancedPremiumTaxCredits."BridgetoBenefits.Children'sDefenseFundMinnesota.n.d.Web.December "HealthInsuranceMarketplaceCalculator."TheKaiserFamilyFoundation.2014.Web.December BasicHealthProgramBlueprint. Medicaid.gov.10December2014.Web.29December andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 56

59 36 AssessingtheAffordableCareActinMinnesota:MoreAdultsinMinnesotaHaveHealthInsurance. 37 Blewett,Lynn,ElizabethLukanen,JulieSonier,andKristinDybdal.StateHealthAccessDataAssistanceCenter.Personal Interview.29October Silversmith,Janet.MinnesotaMedicalAssociation.PersonalInterview.28October Brunner,JulieandEileenSmith.MinnesotaCouncilofHealthPlans.Personalinterview.29October Bohn,KristiandAlyssavonRuden.MinnesotaDepartmentofCommerce,InsuranceDivision.Personalinterview.28 October AssessingtheAffordableCareActinMinnesota:MoreAdultsinMinnesotaHaveHealthInsurance. 42 Burns,KatieandScottLeitz.MNsure.Personalinterview.27October AssessingtheAffordableCareActinMinnesota:MoreAdultsinMinnesotaHaveHealthInsurance. 44 Sonier,Julie,ElizabethLukanen,andLynnBlewett. 45 "DemographicCharacteristicsoftheUninsured,2011and2013."MinnesotaHealthAccessSurveyInteractiveDataTool. MinnesotaDepartmentofHealth,HealthEconomicsProgram,n.d.Web.24December DemographicCharacteristicsoftheUninsured,2011and MITDepartmentofEconomicsandGormanActuarial.TheImpactoftheACAandExchangeonMinnesota:Updated Estimates.Massachusetts,February2013.Web.28December MNsure. MNsureFY2015V17FinancialPlan Web.December2014.$ 49 MinnesotaDepartmentofHumanServices."HealthCareAccessFundNovember2014ForecastUpdate."2014.Web. December2014.$ 50 MinnesotaDepartmentofHumanServices. November2014Forecast Web.December "IntegratedHealthPartnerships."MinnesotaDepartmentofHumanServices.13May2014.Web.26Dec Sonier,Julie,ElizabethLukanen,andLynnBlewett. 53 MinnesotaDepartmentofHealthandMinnesotaDepartmentofHumanServices."StateHealthCareInnovationPlan." GrantapplicationtoCenterforMedicareandMedicaidInnovation,2012.PDFfile. 54 MinnesotaDepartmentofHealthandMinnesotaDepartmentofHumanServices."StateHealthCareInnovationPlan." GrantapplicationtoCenterforMedicareandMedicaidInnovation,2012.PDFfile. 55 "StateReporting."MinnesotaCommunityMeasurement.2014.Web.26Dec MinnesotaDepartmentofHealthandMinnesotaDepartmentofHumanServices."StateHealthCareInnovationPlan." GrantapplicationtoCenterforMedicareandMedicaidInnovation,2012.Page55.PDFfile. 57 Anderson,Matthew."Re:FollowVUpfromtheWoodrowWilsonSchool."MessagetoRachelVanCleve.3Dec.2014.EV mail. 58 Anderson,Matthew.MinnesotaHospitalAssociation.Personalinterview.29October Anderson,Matthew. 60 Anderson,Matthew. 61 "PatientVCenteredCare."HealthReformMinnesota.MinnesotaOfficeoftheGovernor.n.d.Web.26December Silversmith,Janet.MinnesotaMedicalAssociation.Interview.28October Burns,KatieandScottLeitz. 64 MinnesotaAccountableHealthModel StateInnovationModelGrant. HealthReformMinnesota.17November 2014,n.p.Web.26December StateInnovationModelsInitiative:FrequentlyAskedQuestions. CMS.gov.CentersforMedicare&MAServices,n.d. Web.26December Stawicki,ElizabethandCatharineRichert. WhatWentWrongwithMinnesota sinsuranceexchange. KaiserHealth News.12March2014.Web.19December Snowbeck,Christopher. MNsuresaysstablesitemeanssignVupscomingatfasterpace. StarTribune.19November 2014.Web.19December Snowbeck,Christopher. Mnsuretellsagentsglitchescontinuewithwebsite. StarTribune.13December2014.Web. 19December Snowbeck,Christopher. MNsureenrollmentsup,butgettingdatatoinsurerstroublesome. StarTribune.18 December2014.Web.26December Paez,KathrynandCorettaMallery.ALittleKnowledgeisaRiskyThing:WideGapinWhatPeopleThinkTheyKnow AboutHealthInsuranceandWhatTheyActuallyKnow.Washington,D.C.:AmericanInstitutesforResearch,(2014).Print. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 57

60 71 Volk,JoAnn,SabrinaCorlette,SandyAhn,andTriciaBrooks.ReportfromtheFirstYearofNavigatorTechnical AssistanceProject:LessonsLearnedandRecommendationsfortheNextYearofEnrollment.Washington,D.C.: GeorgetownUniversityHealthPolicyInstitute,2014.Print. 72 Volk,JoAnn,SabrinaCorlette,SandyAhn,andTriciaBrooks. 73 KleimannCommunicationGroupandConsumersUnion. ChoiceArchitecture:DesignDecisionsthatAffectConsumers HealthPlanChoices. 9July2012.Web. 74 KleimannCommunicationGroupandConsumersUnion. 75 Thaler,Richard. SomeEmpiricalEvidenceonDynamicInconsistency. EconomicsLetters8.3(1981):201V7.Print. 76 Cox,Cynthia,LarryLevitt,GaryClaxton,RosaMa,andRobinDuddyVTenbrunsel. Analysisof2015PremiumChangesin theaffordablecareact shealthinsurancemarketplaces. KaiserFamilyFoundation,September2014.Print. 77 MNsure. MNsureMetricsDashboard. Web.17December UnitedStates.DepartmentofHealthandHumanServices.HealthInsuranceMarketplace:SummaryEnrollmentReport fortheinitialannualopenenrollmentperiod.washington,dc:dhhs.1may2014.web. 79 BreakawayPolicy.LookingBeyondTechnicalGlitches:APreliminaryAnalysisofPremiumsandCostSharingintheNew HealthInsuranceMarketplaces.RobertWoodJohnsonFoundation,November2013.Web. 80 FindaPlan. MNsure.N.d,n.p.Web.22December Hague,Ashley,SarahBushold,andMichaelNorton. FinalAwardof2015SealofApproval. MassachusettsHealth Connector.11September2014.Web. 82 KleimannCommunicationGroupandConsumersUnion. 83 KleimannCommunicationGroupandConsumersUnion. 84 FindaPlan. MNsure. 85 ManattHealthSolutions.ConsumerAssistanceResourceGuide:MAGIHouseholdIncomeEligibilityRules.Issuebrief. Princeton:StateHealthReformAssistanceNetwork,2014.Print. 86 Mason,Ralonda. HouseholdIncomeandComposition. St.Paul:MNsure&MinnesotaDepartmentofHumanServices. Web.26December Sommers,BenjaminD.,JohnA.Graves,KatherineSwartz,andSaraRosenbaum. MedicaidandMarketplaceEligibility ChangesWillOccurOfteninallStates;PolicyOptionsCanEaseImpact. HealthAffairs33.4(2014):700V707.Print. 88 Sommers,BenjaminD.,JohnA.Graves,KatherineSwartz,andSaraRosenbaum. 89 KaiserCommissiononMedicaidandtheUninsured. MAEligibility,EnrollmentSimplification,andCoordinationunder theaffordablecareact:asummaryofcms smarch23,2012finalrule. KaiserFamilyFoundation.December2012. Web.26December Chun,Randall.MinnesotaHouseofRepresentativesResearchDepartment.MedicalAssistance.St.Paul:Minnesota HouseofRepresentatives.November2014.Print. 91 MinnesotaInsuranceAffordabilityProgramsManual2014,section Minnesota smagivbasedeligibilityverificationplan.medicaid.web.26december ACAImplementationandMNsure. MNsure.21July2013.Web.26December Angeles,JanuaryandTaraStraw.TheHealthCareAssister sguidetotaxrules.healthreform:beyondthebasics, CenteronBudgetandPolicyPriorities.October2014.Web.26December DeterminingHouseholdsforMedicaidandPremiumTaxCredits:BeyondtheBasics. CenteronBudgetandPolicy Priorities.7August2013.Web.27Dec Brooks,Tricia. HealthPolicyBriefs:TheFamilyGlitch. HealthAffairs.10November2014.Web.19December Franken,Al.SummaryoftheFamilyCoverageAct.Web.27December KaiserCommissiononMedicaidandtheUninsured.KeyFactsonHealthCoverageforLowYIncomeImmigrantsToday andundertheaffordablecareact.kaiserfamilyfoundation.march2013.web.28december KaiserCommissiononMedicaidandtheUninsured.KeyFactsonHealthCoverageforLowYIncomeImmigrantsToday andundertheaffordablecareact. 100 ACAImplementationandMNsure. MNsure.21July2013.Web.26December Chun,Randall&DanyellPunelli.MinnesotaHouseofRepresentativesResearchDepartment.EligibilityofNoncitizens forhealthcareandcashassistanceprograms.st.paul:minnesotahouseofrepresentatives.september2011.web.28 December MedicalAssistanceProgramsforImmigrantsinVariousStates. NationalImmigrationLawCenter.July2012.Web.28 December MITDepartmentofEconomicsandGormanActuarial. 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 58

61 104 "MinnesotaPremiumEstimatorTable."MinnesotaDepartmentofHumanServices.2014.Web.29December "HealthInsuranceMarketplaceCalculator."TheKaiserFamilyFoundation.2014.Web.December BasicHealthProgramBlueprint. Medicaid.gov.10December2014.Web.29December ExplainingHealthCareReform:QuestionsAboutHealthInsuranceSubsidies.IssueBrief.Washington,D.C.:Kaiser FamilyFoundation,2014.Web.29December Chun,Randall.MinnesotaHouseofRepresentativesResearchDepartment.EligibilityforSubsidizedHealthCoverage inminnesota:2013sessionchanges.st.paul:minnesotahouseofrepresentatives,2013.web.29december Demko,Paul."StaterollsoutMinnesotaCare2.0."PoliticsinMinnesota:CapitolReport.19June2013.Web.30 December KaiserCommissiononMedicaidandtheUninsured."MedicaidExpansioninArkansas."KaiserFamilyFoundation October2014.Print. 111 OfficeoftheRevisorofStatutes.2013MinnesotaSessionLaws.Chapter108H.F.No.1233Subd.35,2013.Print. 112 MinnesotaStatutes2014,section256L.02.,subdivision2(a). 113 MinnesotaStatutes2014,section256L.05.,subdivision1(a). 114 MinnesotaStatutes2014,section256L MinnesotaStatutes2014,section256L MinnesotaStatutes2014,section256L ManagedCareProcurementRequestforComment. MinnesotaDepartmentofHumanServices.2014.Web.20 December MinnesotaStatutes2014,section256L.121,subdivisions1, Adda PublicPlan tothehealthinsuranceexchanges. OptionsforReducingtheDeficit:2014to2023.Congressional BudgetOffice.13November2013.Web.28December Chun,Randall.MinnesotaHouseofRepresentativesResearchDepartment.MinnesotaCare.St.Paul:MinnesotaHouse ofrepresentatives.october2013.print. 121 MinnesotaDepartmentofHumanServices,ReportsandForecastsDivision.FamilySelfYSufficiencyandHealthCare ProgramStatistics.28November2014.Web.28December IntegratedHealthPartnerships. MinnesotaDepartmentofHumanServices.13May2014.Web.21December2014. Anderson,Matt. Re:FollowVupfromtheWoodrowWilsonSchool. MessagetoRachelVanCleve.3December2014.EV mail. 123 IntegratedHealthPartnerships. MinnesotaDepartmentofHumanServices.13May2014.Web.21December Chun,Randall.MinnesotaHouseofRepresentativesResearchDepartment.InformationBrief:MinnesotaCare.St.Paul, MN:MinnesotaHouseofRepresentatives.October2013.Print. 125 UnitedStates.CenterforMedicareandMedicaidServices.MinnesotaEHBBenchmarkPlan.CenterforMedicareand MedicaidServices,CenterforConsumerInformationandInsuranceOversight,2014.Print. 126 KaiserCommissiononMedicaidandtheUninsured."MedicaidExpansioninArkansas."KaiserFamilyFoundation October2014.Print. 127 KaiserCommissiononMedicaidandtheUninsured."MedicaidExpansioninIowa."KaiserFamilyFoundation,October 2014.Print. 128 Corlette,Sabrina,andJoanneVolk.ActivePurchasingforHealthInsuranceExchanges:AnAnalysisofOptions. GeorgetownUniversityHealthPolicyInstituteandNationalAcademyofSocialInsurance,June2011.Print. 129 Minnesota.DepartmentofHumanServices,ReportsandForecastsDivision. FamilySelfVSufficiencyandHealthCare ProgramStatistics. St.Paul,MN:MinnesotaDepartmentofHumanServices,October2014.Print. 130 Corlette,Sabrina,andJoanneVolk. 131 CoveredCaliforniaOpenEnrollment2013Y2014:LessonsLearned.CoveredCalifornia,October2014.Print. 132 Corlette,Sabrina,andJoanneVolk. 133 KaiserFamilyFoundation. StateHealthFacts:TotalMedicaidMCOEnrollment. KaiserFamilyFoundation, September2014.Web. 134 BowringVMcDonough,Jenni."Morethan200,000MinnesotansEnrollinQualityHealthCoveragethroughMNsure." MNsure,n.p,April2014.Web. 135 ManagedCareReporting:Contracts. MinnesotaDepartmentofHumanServices.7February2014,n.p.Web.27 December PrimaryCareNetworkList(PCNL)Guidelines:RequirementsforPCNLs. MinnesotaDepartmentofHumanServices. 16May2014,n.p.Web.27December andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 59

62 137 MapsofHealthPlanServicesbyCounty. MinnesotaDepartmentofHumanServices.10November2014.Web.27 December MoreFinancialHelpandMorePlansAvailableThroughMNsurethisYear. MNsure.1October2014,n.p.Web.27 December MITDepartmentofEconomicsandGormanActuarial. 140 Wishner,Jane,AnnaSpencer,andErikWengle.AnalyzingDifferentEnrollmentOutcomesinSelectStatesThatUsed TheFederallyYFacilitatedMarketplacein2014.TheUrbanInstitute,November2014.Web.1January MITDepartmentofEconomicsandGormanActuarial. 142 Sommers,BenjaminandSaraRosenbaum. Issuesinhealthreform:Howchangesineligibilitymaymovemillionsback andforthbetweenmedicaidandinsuranceexchanges. HealthAffairs30.2(2011):228V Sonier,Julie,ElizabethLukanen,andLynnBlewett. EarlyImpactsoftheAffordableCareActonHealthInsurance CoverageinMinnesota. StateHealthAccessDataAssistanceCenter,June2014.Print. 144 Sonier,Julie,ElizabethLukanen,andLynnBlewett. 145 Minnesota.DepartmentofHumanServices,ReportsandForecastsDivision.FamilySelfYSufficiencyandHealthCare ProgramStatistics.28November2014.Print. 146 PopulationData:OurEstimates. MinnesotaStateDemographicCenter.n.d.Web.20December Snowbeck,Christopher. MNsuretrims2015enrollmenttargetbyonethird. StarTribune.com3Dec.2014.Web.22 Dec MinnesotaDepartmentofHumanServices,ReportsandForecastsDivision.FamilySelfYSufficiencyandHealthCare ProgramStatistics.November28,2014.PDFfile. 149 Sonier,Julie,ElizabethLukanen,andLynnBlewett. 150 Chun,Randall.MinnesotaHouseofRepresentativesResearchDepartment.HouseResearchShortSubjects Medical Assistance:AnOverview.St.Paul:MinnesotaHouseofRepresentatives.2014.Print. 151 Chun,Randall.MinnesotaHouseofRepresentativesResearchDepartment.HouseResearchShortSubjects MinnesotaCare:AnOverview.St.Paul:MinnesotaHouseofRepresentatives.2014.Print. 152 MinnesotaStatutes2014,section256L Frakt,Austin. ExtrapolateMedicaidcrowdoutestimateswithcaution. TheIncidentalEconomist.11November2013. Web.28December Stuber,JenniferandMarkSchlesinger. SourcesofstigmaformeansVtestedgovernmentprograms. SocialScience andmedicine63.4(2006):933v945.web. 155 Stuber,JenniferP.,KathleenA.Maloy,SaraRosenbaum,andKarenC.Jones.BeyondStigma:WhatBarriersActually AffecttheDecisionsoftheLowYIncomeFamiliestoEnrollinMedicaid?IssueBrief.Washington,D.C.:CenterforHealth ServicesResearchandPolicy,TheGeorgeWashingtonUniversity,2000.Print. 156 KaiserCommissiononMedicaidandtheUninsured. KeyLessonsfromMedicaidandCHIPforOutreachand EnrollmentUndertheAffordableCareAct. KaiserFamilyFoundation.June2013.Web.28December2014.$ 2017andBeyond:UsingtheACAInnovationWaivertoReachMinnesota stripleaim 60

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