More About Judy Solomon

Judy Solomon

Solomon is Vice President for Health Policy at the Center on Budget and Policy Priorities, where she focuses on Medicaid and the Children’s Health Insurance Program and issues related to the implementation of health reform, particularly policies to make coverage available and affordable for low-income people.

Full bio and recent public appearances | Research archive at

States Can Use Smart Strategies to Curb ER Visits

April 16, 2015 at 12:52 pm

We often hear that Medicaid beneficiaries use the emergency room (ER) for too much of their health care.  In response, some states have tried to reduce non-emergency use of the ER by charging beneficiaries co-pays.  As we explained in a recent paper, however, this approach is flawed — and other states have found better ways to connect beneficiaries with the care they need and avoid unnecessary ER use.

Medicaid beneficiaries do use the ER more frequently than adults with other health coverage, but their visits are almost always for serious medical problems.  Only about 10 percent of ER visits paid by Medicaid in 2008 were for non-emergency conditions — slightly more than the share of ER visits by people with private insurance (7 percent).  And a recent study shows that charging co-pays for non-emergency use of the ER didn’t change beneficiaries’ use of either the ER or primary care.

Several states have had significant success in curbing unnecessary ER use, however, by expanding access to primary care and targeting interventions at the people who frequently use the ER.  For example, New Mexico created a statewide 24/7 nurse advice hotline for all state residents, which diverted 65 percent of callers from the ER and has saved the state $68 million.  And in the year after Washington moved Medicaid beneficiaries to managed care and required hospitals to adopt seven best practices, non-emergency ER use fell by 14 percent and the state saved $34 million.

Indiana has also implemented a successful strategy, but curiously now is imposing co-pays for ER use.  Under the state’s Right Choices Program, which focuses on preventing unnecessary and inappropriate use of care by beneficiaries who use the most services, one of Indiana’s managed care plans has seen a 72 percent drop in ER use.  Despite this success, Indiana received approval in its recent Medicaid waiver to impose a $25 co-pay the second time a beneficiary uses the ER for non-emergency care in a 12-month period, purportedly to test whether the approach will reduce unnecessary ER use and increase use of health care in other settings — a theory that’s already been disproven, as I mentioned above.

It’s hard to see why Indiana wants to incur administrative costs for this experiment when we know that co-pays don’t work — and that targeted interventions like the Right Choices Program do.

Health Reform’s Success Grows; House Budget Chair Promises Repeal

March 17, 2015 at 12:48 pm

A day after the Administration announced that 16.4 million uninsured people have gained coverage under health reform, lowering the uninsured rate from 20.3 percent all the way to 13.2 percent, the House Republican Budget Chairman unveiled a budget that would reverse this remarkable progress by repealing health reform, including its Medicaid expansion.

In the run-up to Supreme Court arguments in King v. Burwell, in which plaintiffs seek to invalidate subsidies for health coverage for people in 34 states using the federal marketplace, House and Senate Republicans said they had plans to maintain coverage for the 8 million people at risk of losing it should the plaintiffs prevail.  Yet House Budget Committee Chairman Tom Price’s budget plan would repeal health reform entirely.

Among other things, that means repealing the requirement that insurers allow young adults to stay on their parents’ health plans until they turn 26.  That provision alone is responsible for 2.3 million of the 16.4 million coverage gain.

The Price plan’s vague statements about “starting over” on health reform and “expanding choices and flexibility” are empty promises for people who can’t afford health coverage without expanded Medicaid and subsidies. The Chairman’s budget eliminates the funding for their coverage, which would drive them back into the ranks of the uninsured.

Ruling Against Health Reform Subsidies Would Be Wrong — and Harmful

March 4, 2015 at 5:00 am

As the Supreme Court hears oral arguments in King v. Burwell this morning, it’s critical that the Court recognize that the Affordable Care Act (ACA) provides premium tax credits for consumers in all states, as we’ve explained.  Invalidating the credits for people in states that didn’t create their own exchanges would be wrong from a legal perspective and would harm millions of Americans.

The ACA clearly states that if a state elects not to establish its own exchange, “the Secretary [of Health and Human Services] shall . . . establish and operate such Exchange within the State.”  In other words, the federal government stands in the shoes of states that elect not to operate their own exchanges by establishing and operating the exchanges on their behalf.

As Chief Justice John Roberts has said, the exchanges are “an element of a comprehensive national plan to provide universal health insurance coverage” (emphasis added).  Leaving millions of people in 34 states unable to afford coverage is not a national plan — yet that’s exactly what would happen if residents of states with federally operated exchanges weren’t eligible for help buying coverage in the exchange.

If the Supreme Court invalidates premium credits in the federal exchange, the number of uninsured Americans would jump by roughly 8 million, as many people would find coverage unaffordable without subsidies, according to studies from the RAND Corporation and the Urban Institute.

Millions more would face dramatic premium increases because younger and healthier people would be especially likely to go without coverage, leaving those who continue to buy coverage older and less healthy, on average — and thus costlier to cover.  RAND estimates that premiums would jump by 47 percent; the Urban Institute estimates a 35 percent increase.

A diverse group of Americans would be hurt.  Most tellingly, 81 percent are full- or part-time workers who don’t get coverage at work.

While some health reform critics claim they have alternative reform plans in case the Supreme Court rules against the premium credits, their claims are hard to take seriously.  The recent “plan” from three Senate Republican leaders — Health, Education, Labor and Pensions Committee Chairman Lamar Alexander; Republican Policy Committee Chairman John Barrasso; and Finance Committee Chairman Orrin Hatch — is extremely vague and would likely undo consumer protections and market reforms that help millions of Americans get affordable coverage, as we’ve noted.

Similarly, the recent proposals from three House Republican leaders — Education and the Workforce Committee Chairman John Kline; Ways and Means Committee Chairman Paul Ryan; and Energy and Commerce Committee Chairman Fred Upton — lack essential details and would likely make marketplace coverage unaffordable for millions of Americans, especially people who are older or have pre-existing conditions, forcing many back to the ranks of the uninsured and underinsured.

Millions of Americans have benefited from the coverage they’ve received under the ACA. It’s imperative that the Supreme Court make the right decision on the merits and not turn back the clock on health reform.

Ending Subsidies in Marketplace States Would Hurt Diverse Group

January 26, 2015 at 1:31 pm

I recently cited studies from the Urban Institute and RAND Corporation showing that millions more Americans would be uninsured and premiums would rise significantly if the Supreme Court overturns health reform subsidies for people getting coverage through the federal marketplace.  A follow-up Urban report tells us more about the 8.2 million people estimated to lose coverage.  Of those losing subsidies and becoming uninsured:

  • 81 percent are full- or part-time workers;
  • 62 percent live in the South;
  • 61 percent are white, non-Hispanic; and
  • 60 percent have incomes below twice the poverty line.

Importantly, the report points out that “[e]stimates presented in this analysis reflect effects at a point in time, and therefore understate the number of people who would be affected over the course of a year and over multiple years, as individuals’ employment and income fluctuate.”  (Emphasis added.)

One reason why many of the people losing tax credits would end up uninsured is that they don’t have an offer of employer coverage.  Urban estimates that almost two-thirds of those now receiving tax credits have a family member who works at a small firm (fewer than 50 workers) and just over a quarter have a family member who is self-employed.  About 15 percent of those receiving tax credits are between ages 55 and 64, many of them likely early retirees.  These aren’t static categories, of course; people retire, start a business, and change jobs all the time.

Before health reform, many Americans found health coverage expensive or even unavailable — especially older people not yet eligible for Medicare and those with chronic conditions or a history of illness.  It’s critical that the Supreme Court not turn back the clock for millions of people who need help getting coverage, now and in the future.

More Uninsured, Higher Premiums if Subsidies End in Federal Marketplace

January 12, 2015 at 1:53 pm

Millions more Americans would be uninsured and premiums in the individual (nongroup) market would jump if the Supreme Court disallowed health reform subsidies for people getting coverage through the federal marketplace, new studies from the Urban Institute and RAND Corporation show.

These studies show why it’s critical for the Supreme Court to recognize that health reform provides subsidies in all states.

As we’ve explained, plaintiffs in a case before the Court claim that under the Affordable Care Act (ACA), premium credits to help eligible people afford marketplace coverage are supposed to be available only in states that set up their own marketplaces.

Invalidating the subsidies for people in states that didn’t create their own marketplaces would result in 8.2 million more people uninsured and 35 percent higher premiums for those who get coverage through the individual market, the Urban study finds.  Similarly, RAND finds that 8.0 million more would be uninsured and premiums would rise by 47 percent.

The number of uninsured would jump because many people would find coverage unaffordable without subsides.  Premiums would jump because younger and healthier people would be especially likely to do without coverage, leaving those who continued to buy coverage older and less healthy, on average — and thus costlier to cover.

Both studies show that premiums would rise for everyone in the individual market, including those who buy coverage outside the federal marketplace.  That’s because health reform requires insurers to base their premiums on a single risk pool for all coverage they offer, both inside and outside the marketplace.

These price increases would have a significant impact, even on people with incomes too high to qualify for subsidies.  The number of people with incomes above 400 percent of the poverty line — the maximum level to qualify for a subsidy — buying coverage through the federal marketplace would fall by 42 percent, Urban estimates.

Of course, the impact on lower-income people would be even greater, since they would face higher premiums plus the loss of subsidies (and have more limited budgets to start with).  Fully 91 percent of people with incomes below 200 percent of the poverty line would leave the federal marketplace, according to Urban.