Harold Pollack reports today on an issue with the healthcare reform law that seems trivial at first but turns out to be anything but on closer inspection. The problem is this: a certain number of poor and working class families have highly variable incomes, which means they might be eligible for Medicaid one month but healthcare exchanges the next. So do they ping pong back and forth between the two? Or what?
At first this might not seem like a big deal. How many of these kinds of families can there be? The answer, it turns out, is a lot. Nearly a third of all families have incomes less than 200% of the federal poverty level, and Benjamin Sommers and Sara Rosenbaum, using longitudinal survey data, conclude that a whole lot of them have highly variable incomes:
We estimate that within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will.
States need to account for this in their design health insurance exchanges, and to allow a more permeable boundary between the new exchanges and Medicaid. Sommers and Rosenbaum provide some pretty sensible policy suggestions. I’ll let you read their take and decide for yourself.
The Affordable Care Act is pretty silent about how these issues should be handled. For all the juvenile criticisms of passing a many-paged bill, a few-thousand pages provides only a basic structure and roadmap for health reform. Much of the hard work resides in the yet-to-be-written administrative and regulatory Midrash that goes along with it.
The policy suggestions Harold alludes to are behind a paywall, so I can't comment on them at the moment. But I don't doubt that they're pretty sensible. Hopefully state-level administrators will start thinking about this, even if their political masters are busy covering their ears, shouting "la la la," and trying to pretend that the healthcare reform law doesn't exist and will never go into effect. It will, and this is a problem every state will need to address.