兰德-The-Effects-of-Iowas-Proposed-Stopgap-Measure-on-Health-Insurance-Costs-and-Coverage_35页_385kb

报告摘要

Summary of "The Effects of Iowa’s Proposed Stopgap Measure on Health Insurance Costs and Coverage"

Core Content

This report analyzes the potential effects of Iowa's proposed 1332 State Innovation Waiver, known as the Iowa Stopgap Measure (ISM), on health insurance costs, coverage, and the federal deficit. The study uses RAND's COMPARE microsimulation model to evaluate how the ISM might impact the state's ACA-compliant individual insurance market.

Main Points

Background

The ACA allows states to request a 1332 waiver to implement alternative reforms, provided they meet four criteria:
1. Coverage must be at least as comprehensive as under the ACA.
2. Coverage must be at least as affordable as under the ACA.
3. A comparable number of people must be insured.
4. The waiver must not increase the federal deficit.
In 2017, Iowa submitted an ISM application to address market instability caused by insurer exits, particularly from Medica, which had raised premiums significantly.

The Iowa Stopgap Measure

The ISM includes four key modifications to the ACA:
1. Single Standard Plan: All insurers in the ACA-compliant market would be required to offer only one standard plan with an actuarial value of 70% (similar to ACA silver plans).
2. CSR Subsidy Adjustment: Elimination of cost-sharing reduction (CSR) subsidies for individuals with incomes between 200% and 250% of the FPL. CSR subsidies are retained for those with incomes between 133% and 200% of the FPL.
3. Expanded Premium Tax Credits: Premium tax credits are available to individuals with incomes above 400% of the FPL, which is not the case under the ACA.
4. Reinsurance Program: Federal funds would provide reinsurance for claims above $100,000, supplementing the existing federal reinsurance program.

Key Impacts

Premiums: The ISM is likely to lower premiums in the ACA-compliant market.
Coverage: The ISM could decrease the number of uninsured individuals.
Federal Deficit: The ISM is estimated to increase the federal deficit, though per-enrollee costs may decrease.
Health Care Utilization: Individuals with incomes above 200% of the FPL may be at risk of foregoing necessary care due to the elimination of higher-actuarial value plans.

Alternative Scenarios

The report models five scenarios to assess the ISM's effects:

Status Quo (Medica Monopoly): Medica remains the sole insurer, with premiums set at 42% higher than 2017 levels.
ISM with Waiver Premiums: Premiums match those proposed in the ISM application, which are 30% lower than Medica's filings.
ISM with Competitive Premiums: Premiums are calculated endogenously within the model, assuming more competition and lower premiums.
ACA, No Grandfathered/Transitional Market: Assumes elimination of grandfathered and transitional plans, which may lower premiums.
ACA and Reinsurance: Models the ACA-compliant market with the ISM's reinsurance program, which could reduce insurer costs and premiums.

Key Findings

Coverage

The ISM is expected to reduce the number of uninsured individuals.
It could bring more people into the ACA-compliant market, including those from the grandfathered/transitional market and previously uninsured individuals.

Costs

Premiums: The ISM may lower premiums for all groups.
Federal Deficit: The ISM is projected to increase the federal deficit, but per-enrollee federal costs may decrease.
Family Spending: The ISM could reduce average family health care spending, including out-of-pocket costs.

Risk of Catastrophic Spending

The ISM may lower the risk of catastrophic health spending for families, as reinsurance covers a significant portion of high-cost claims.

Health Care Utilization

Higher-income individuals (above 200% of FPL) may face reduced access to high-actuarial value plans, potentially leading to delayed or foregone care.

Limitations

The report acknowledges that the ISM eliminates autoenrollment, which could overstate its coverage effects.
Some scenarios are counterfactual, as the 2018 marketplace participation deadline has passed.

Conclusion

The ISM is likely to stabilize the ACA-compliant market by attracting more enrollees and lowering premiums.
However, it may increase the federal deficit and risk the health of higher-income individuals by reducing access to high-value plans.
A reinsurance-only program, without the other ISM features, could achieve similar coverage without increasing the deficit.

Key Tables and Figures

Table 1: Compares individual market insurance design parameters under the ACA and ISM.
Table 2: Summarizes assumptions for each modeled scenario.
Table 3: Projects health insurance enrollment for the nonelderly in Iowa for 2018 under each scenario.
Table 4: Details ACA-compliant market enrollment by new enrollee type.
Table 5: Estimates federal deficit impacts under each scenario.
Table 6: Shows changes in family health care spending, risk of catastrophic spending, and health care consumption under the ISM waiver premium scenario.
Figure 1: Depicts the change in age-standardized individual-market premiums in 2018 relative to the status quo.