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 CBPP.org


3 Reasons Why Oklahoma Decision Is Wrong About Health Subsidies

October 1, 2014 at 1:14 pm

A central piece of health reform authorizes the federal government to provide tax credits to help low- and moderate-income people buy coverage in the new health insurance marketplaces.  A federal district court judge in Oklahoma ruled yesterday that the law only authorizes the tax credits in states that have set up their own exchanges, not in states with a federally operated exchange.  (Other federal courts have split on the issue, which may eventually reach the Supreme Court.)  But this argument rests on a distorted reading of the law.  As I’ve explained:

  1. Section 1321 of health reform (the Affordable Care Act or ACA) says that if a state does not establish its own exchange or won’t be ready to operate its exchange in 2014, “the Secretary shall (directly or through agreement with a not-for-profit entity) establish and operate such Exchange within the State” (emphasis added).   In other words, the federal government will essentially “stand in the shoes” of a state that elects not to operate an exchange by establishing and operating the exchange on the state’s behalf.  That’s what the federal government has done in Oklahoma and other states that chose not to create their own exchange.
  2. Section 36B of the Internal Revenue Code, which section 1401 of the ACA added to the Code, specifically refers to federal exchanges in requiring all exchanges — state and federally operated — to report to the federal government on the amount of advance payments of premium credits that taxpayers receive.  That provision would make no sense if people buying coverage through a federally operated exchange weren’t eligible for credits.
  3. To help residents of states with state-run exchanges buy coverage but not residents of other states would clearly conflict with the ACA’s purpose, which is to ensure that all Americans have a path to affordable coverage, regardless of where they live.  As Chief Justice John Roberts noted in referring to the ACA’s Medicaid expansion, the exchanges are “an element of a comprehensive national plan to provide universal health insurance coverage.”

Lower Recidivism: Yet Another Good Reason for States to Expand Medicaid

June 25, 2014 at 2:54 pm

Some opponents of health reform’s Medicaid expansion have cited an estimate that 35 percent of adults newly eligible for Medicaid have been involved in the criminal justice system in the past year.  This figure is highly inflated.

In reality, only about 17 percent of newly eligible adults who enroll in Medicaid will have been in jail or prison.  But even though they will make up about one-sixth rather than one-third of new Medicaid enrollees, their number is significant — and connecting these low-income adults to the health care system can help them avoid returning to jail or prison, as we explain in a new paper.

On any given day, about 750,000 people are in jail; about 75 percent of them for nonviolent offenses.  As many as 90 percent of people in jail are uninsured.  This figure isn’t surprising; until health reform’s coverage expansions took effect this year, there was no pathway to health coverage for poor and low-income adults who weren’t parents living with their minor children, pregnant women, seniors, or people with disabilities.  Not many people with prison or jail stays fall into these categories.

Health reform opened up Medicaid eligibility for all adults with incomes below 138 percent of the poverty line.  So far, 26 states and the District of Columbia have decided to expand coverage.  In addition, adults who aren’t eligible for Medicaid or employer coverage and have incomes between 100 and 400 percent of the poverty line can qualify for premium tax credits to help them afford private coverage through the new health insurance marketplaces.  Roughly half of people leaving jail can qualify for coverage through Medicaid or the marketplaces.  (This figure takes into account that about half of the states have adopted the Medicaid expansion and half have not.)

A number of states and counties are working to connect people released from jail to health coverage for the first time, with a particular focus on people with mental illness and substance-use disorders, given the prevalence of these conditions in this population and the role of these conditions in increasing criminal activity.

States considering whether to expand Medicaid should consider the growing evidence that connecting the jail-involved population to treatment for mental illness and substance abuse can lower the rate at which they return to jail or prison.

For example, a study of a Michigan program to help recently released prisoners obtain community-based health care and social services found that it cut recidivism by more than half, from 46 percent to 21.8 percent.  Similarly, a study that the Justice Department funded in Florida and Washington found that “in both states, 16 percent fewer jail detainees with serious mental illnesses who had Medicaid benefits at the time of their release returned to jail the following year, compared to similar detainees who did not have Medicaid.”

Click here to read the full paper.

Medicaid Primary Care Payment Rate Bump Is Worth Extending

June 19, 2014 at 12:45 pm

An increase in Medicaid primary care payment rates that was included in health reform is scheduled to expire at the end of this year.  But with the need for cost-effective Medicaid primary care rising across the country, the current physician rates should be maintained — and expanded to additional providers — as the Obama Administration and a group of hospitals and doctors have recommended.

Medicaid enrollment has risen by 6 million since October, according to the Centers for Medicare and Medicaid Services, and total enrollment now tops 65 million.  With increased enrollment comes increased need for providers, particularly those providing primary care.  Connecting patients to primary care makes it more likely that they will receive the preventive care and other services to remain healthy and makes it less likely that they will later have to visit the emergency room.

Health reform required states to pay for primary care services at the Medicare rate, which is typically higher than the Medicaid rate, for 2013 and 2014; the federal government picked up 100 percent of the cost of the increase over the state’s regular Medicaid rate for those years.  In boosting physicians’ rates, policymakers intended to increase the number of primary care providers participating in Medicaid in order to ensure access to primary care for Medicaid beneficiaries — both those newly eligible and those who were eligible before 2014.  In Connecticut, the number of primary care providers enrolled in Medicaid has more than doubled since January 2012 and state officials are pushing for an extension of the temporary increase.

Twenty-one organizations representing physicians and hospitals recently wrote to Senate and House leaders to promote a two-year extension of the current payment rate.  The group also asked that policymakers extend the enhanced Medicaid rate to physicians practicing obstetrics and gynecology if their practices provide significant amounts of primary care.  The President’s budget included a one-year extension of the primary care rate increase that would also extend the enhanced rate to include physician assistants and nurse practitioners who provide primary care services.  Both the expansions of the payment increase to additional providers and an extension of the rate increase for at least another year deserve support.

Scare Tactics Shouldn’t Dissuade States From Expanding Medicaid

April 23, 2014 at 2:16 pm

The Foundation for Government Accountability (FGA), a Florida-based conservative think tank, is using scare tactics in its campaign against Medicaid expansion.  It claims that Arkansas taxpayers will have to pay tens of millions of dollars to the federal government in 2014 cost overruns in the state’s “private option” Medicaid expansion.  But that claim doesn’t hold up, and it shouldn’t keep other states from pursuing the private option to expand Medicaid.

The federal government approved Arkansas’ Medicaid expansion through a demonstration project, under which the state will use Medicaid funds to buy private health insurance plans for newly eligible adults through its Marketplace.  The per-person cost of covering these new Medicaid beneficiaries for the first four months of the demonstration project was slightly above projections incorporated in the terms and conditions to which the state agreed with the federal government, prompting FGA’s claim.

Demonstration projects (which are usually called “waivers”), like Arkansas’ private option, must not cost the federal government more than it would have otherwise spent.  If the project is not budget neutral over its entire duration, a state could have to repay excess federal spending.  This is extremely unlikely to happen in Arkansas, for several reasons:

  • Budget neutrality is determined over the entire term of the demonstration project —three years in this case — not what happens in 2014, as FGA claims.  Arkansas would only have to repay the federal government if total three-year spending on the private option exceeds the three-year limit.
  • The terms of the waiver recognize that the budget neutrality limit is a forecast, and like all estimates, it could be off in either direction.  Arkansas can ask for an upward adjustment if the limits underestimate the actual costs of covering the new beneficiaries.  At the same time, the state won’t share in any federal “savings” if costs are lower than projected.
  • Arkansas is taking steps that will likely keep spending within the three-year limit.  In 2014, some health plans offered extra benefits that increased premiums and hence per-beneficiary costs under the waiver.  Starting in 2015, insurers will have to offer plans without these extra benefits to private option participants, which should bring down premiums and per-person costs to stay below the budget neutrality limits.  Other states that pursue the private option model can prevent health plans from offering these more expensive plans to begin with, thus avoiding this problem altogether.

More than 150,000 low-income adults have gained Medicaid coverage in Arkansas in 2014, and enrollment continues to grow.  That’s the lesson that the 24 states that have not expanded — where 4.8 million uninsured adults fall into the coverage gap that results from not taking the Medicaid expansion — should take away from Arkansas.

Haven’t Enrolled in Marketplace Health Coverage? Three Things to Know

April 8, 2014 at 11:31 am

More than 7 million people had signed up for private coverage by the time open enrollment in health reform’s insurance marketplaces ended March 31.  But, what about those who are still trying to enroll — and those who don’t need coverage now but may need it later in the year when their circumstances change?  Here are three basic points on who can sign up between now and November 15, when the next open enrollment period begins:

First, people eligible for Medicaid can sign up any time — unlike private coverage, Medicaid has no limited enrollment period.  Medicaid eligibility varies by state but, in states that chose to expand Medicaid under health reform, people with income up to 138 percent of the poverty line (about $27,000 for a family of three) can enroll.

Second, people who began signing up in the federal marketplace at healthcare.gov by March 31 have until April 15 to finish and enroll in a plan.  And people who experienced problems with healthcare.gov or have other exceptional circumstances can get additional time.  In states with their own marketplaces, the deadlines vary, so check the marketplace website for details.

Third, many people who lose other coverage (such as Medicaid or job-based coverage) or experience other changes can enroll in marketplace coverage during “special enrollment periods” (SEPs).

Most major life changes trigger a SEP:

  • Losing other health coverage;
  • Moving to a different state, or even within a state if the move changes which plans are available;
  • Getting married; and
  • Having a baby or adopting a child.

But some significant life changes don’t trigger a SEP by themselves, such as getting divorced (unless the person getting divorced loses coverage or moves).  Losing a job without losing coverage also doesn’t trigger a SEP.

For more information on special enrollment periods and other health reform topics, check out CBPP’s special project Health Reform:  Beyond the Basics.

Obama Budget Would Improve Access to Health Care for Underserved Populations

March 14, 2014 at 2:07 pm

As health reform enables millions of uninsured Americans to gain health insurance, the need for preventive and primary care services and those who provide them will continue to grow.  The President’s 2015 budget includes a new initiative to strengthen the health workforce — particularly for underserved areas and populations with shortages of providers — and ensure adequate payments for primary care physicians, physician assistants, and nurse practitioners who see Medicaid patients.  It deserves Congress’ approval.

The initiative would:

  • Expand the National Health Service Corps, which boosts the number of health care providers in high-need communities through scholarships and other kinds of support.  The program would receive an extra $4 billion over fiscal years 2015 through 2020, allowing it to support 15,000 providers (up from the current 9,000) delivering care to more than 16 million people.
  • Provide $5.2 billion over ten years for a new competitive grant program for medical residency positions that would encourage primary care physicians to practice in rural and other underserved areas.
  • Continue Medicaid’s enhanced payment rate for primary care services, scheduled to end on December 31, 2014, through December 2015, at a total cost of $5.4 billion.  This provision requires states to pay providers at the Medicare rate; the federal government covers 100 percent of the boost from the state’s regular Medicaid rate. The President’s budget also would extend the enhanced Medicaid rate beyond primary care physicians to include physician assistants and nurse practitioners.

Addressing Confusion About Young Adults’ Coverage Options Under Health Reform

October 29, 2013 at 5:00 pm

Despite today’s suggestions to the contrary by House Budget Committee Chairman Paul Ryan, health reform offers young adults an unprecedented range of choices for affordable health insurance coverage.  It’s allowed more than 3 million young adults under age 26 to obtain coverage under their parents’ policies, and millions more have now gained access to coverage that will begin in January, when new, federally financed premium subsidies will help reduce what low- and moderate-income people will have to pay for coverage.

Chairman Ryan overlooked those features again today.  Similar to his assertions of earlier this year, he incorrectly claimed at a House Ways and Committee hearing today that under health reform, young adults under age 26 who earn between 100 and 400 percent of the poverty line will be ineligible for federal tax credits to help pay their premiums for plans through the new health insurance marketplaces (also known as exchanges) if they can get coverage under their parents’ plan.  (Unfortunately, Marilyn Tavenner, the Centers for Medicare and Medicaid Services’ administrator, incorrectly agreed at today’s hearing that these young adults would not qualify for subsidies.)

That’s simply not true.  Most young adults have multiple coverage options.  They can obtain coverage through their parents’ plan if available, or through their own employer if their job offers health coverage.  Young adults may also qualify for Medicaid depending on their income and on whether their state has chosen to adopt health reform’s Medicaid expansion to cover low-income adults.

For young adults who are ineligible for Medicaid, premium tax credits would be an option as well, as long as they have incomes in the subsidy-eligibility range (100 percent to 400 percent of poverty), their parents don’t claim them as dependents on their tax returns, and their employers haven’t offered them affordable and adequate coverage.  The fact that they also can enroll under their parents’ policy does not in and of itself preclude them from obtaining exchange coverage using the premium credits.

Young adults have to choose their coverage options carefully, considering, for example, each available option’s costs, benefits, and provider networks.  But the bottom line is that more young people have greater access to much-needed health insurance coverage.

“Coverage Gap” Could Narrow as More States Look to Expand Medicaid Under Health Reform

October 21, 2013 at 9:05 am

With 25 states already expanding Medicaid to low-income adults under health reform, governors in New Hampshire and Ohio want their states to expand their programs as well, which would extend coverage hundreds of thousands of currently uninsured adults, according to state estimates.

Last year’s Supreme Court decision upholding health reform gave states the choice of whether to implement the Medicaid expansion — which allows states to extend coverage to adults below 133 percent of the federal poverty line in 2014.  Expanding Medicaid is a very good financial deal for states.  The federal government will pick up 100 percent of the cost of the expansion to newly eligible individuals for the first three years and no less than 90 percent of the cost on a permanent basis.

In New Hampshire, a bipartisan panel endorsed a proposal to expand Medicaid last week. Governor Maggie Hassan has called a special session of the legislature in November to vote on the plan, which would cover as many as 50,000 adults in the state.  And in a potentially promising move for 275,000 Ohioans, Governor John Kasich is appealing to a state legislative panel to vote today to approve the expansion there.

These moves would help reduce the so-called “coverage gap” into which more than 5 million Americans may fall, because their incomes are below the thresholds to qualify for premium subsidies to help buy health insurance through the new marketplaces, their incomes are too high for the existing Medicaid programs, and they live in states that aren’t planning to adopt the Medicaid expansion.

Moreover, expansion would make good financial sense for New Hampshire and Ohio.  In the 25 states that have decided to expand Medicaid, a recent Kaiser Commission on Medicaid and the Uninsured’s survey showed that state spending on Medicaid will grow by 4.4 percent in 2014 — compared with 6.1 percent for the states that are not moving forward with expansion.

Shutdown Deal Won’t Affect Health Reform Subsidies

October 17, 2013 at 4:09 pm

Let’s clear up any confusion:  yesterday’s deal to reopen the government and raise the debt limit doesn’t change the procedures for verifying applicants’ eligibility for new federal health insurance subsidies under health reform.  That’s appropriate, since these procedures are perfectly adequate as they now stand.

Instead, a provision in yesterday’s deal requires the Health and Human Services (HHS) Secretary to certify that the new health insurance marketplaces (formerly called exchanges) are verifying eligibility in a manner that’s consistent with the requirements of health reform (i.e., the Affordable Care Act); at that point, the subsidies can start.  The Secretary must also provide a report to Congress by January 1 that describes the procedures used to verify eligibility.

The provision also requires HHS’ Inspector General (IG) to report to Congress on the effectiveness of those procedures, but that report isn’t due until July 1, giving the IG the time to make a fair assessment.

Here’s how the verification procedures work:

Under health reform, people who buy private coverage through the new marketplaces may qualify for subsidies to help make coverage affordable.  Contrary to critics’ claims that marketplaces will rely on the “honor system” to determine applicants’ eligibility for the subsidies, all marketplaces — both state- and federally run — will rigorously verify applicants’ income and require applicants to provide information on any coverage that employers offer.

All marketplaces must first check the applicant’s reported income against a federal database that contains data on the applicant’s federal income tax returns, as well as information on any Social Security benefits that the applicant claims.  Marketplaces also will compare the applicant’s information with employers’ wage information provided by Equifax, a major credit reporting agency.  If the information that the applicant provides conflicts with the electronic data, the applicant must explain the discrepancy, provide additional documentation, or both.

Complaints about gaps in the income verification process surfaced in July, when HHS simplified the verification process for the small number of cases in which (1) an applicant’s reported income is much lower than the income reported on his or her last tax return, (2) information from electronic data sources isn’t available, and (3) the applicant doesn’t provide a reasonable explanation for the inconsistency.  HHS gave state-run marketplaces the option for 2014 only of accepting the applicant’s “attestation” and requesting further documentation in some rather than all of these cases.  (HHS issued guidance in August explaining that the federal marketplace, which will operate in 34 states, will request followup documentation in all cases.)

For any inaccuracies for a small share of subsidy recipients that could result, a back-up system will come into play in virtually all such cases.  The marketplaces only determine the amount of advance payments of the premium tax credits. The final amount of an individual’s premium credit is determined based on an individual’s actual income for the year that the person reported on his or her tax return, which the person files after the year is over.  Individuals who underreport their income will have to pay back excess advance payments of premium credits when they file their taxes.

Some Republicans sought to include in the budget deal a House-passed bill to bar the federal government from providing any subsidies until HHS’ IG certifies to Congress that “there is in place a program that successfully and consistently verifies” applicants’ information.  But as we have explained, the IG told Congress that it can’t evaluate whether the marketplaces are “successfully and consistently” verifying this information until they’re up and running and there are real cases to audit.

Potential GOP Demand to End Shutdown Would Undermine Health Reform

October 11, 2013 at 9:49 am

Some Republican senators reportedly will seek to include a House-passed bill to delay health reform’s premium and cost-sharing subsidies in legislation that (among other things) would reopen the government.  Proponents claim this House bill is an anti-fraud measure, but its real effect would be to undermine health reform.  The bill would prevent the new insurance marketplaces (or exchanges) from operating effectively starting on January 1 by keeping millions of lower- and middle-income uninsured Americans from obtaining subsidies for which they qualify — and which they need to afford coverage.

The House bill would bar the federal government from providing any subsidies for coverage bought through the exchanges until the Department of Health and Human Services’ Inspector General certifies to Congress that “there is in place a program that successfully and consistently verifies” applicants’ information regarding their household income and any coverage their employers offer.

But the Office of the Inspector General (OIG) itself has told Congress that it can’t evaluate whether the new marketplaces are “successfully and consistently” verifying this information until after the marketplaces are up and running and there are real cases to audit.  When OIG reviews or audits a program’s operations, it typically requires more than three months of data from actual program operations, which won’t be available until well into 2014, OIG noted in an analysis for the House Energy and Commerce Committee.

Ignoring that basic reality, the House bill would bar the marketplaces from providing subsidies to help people buy insurance until after the Inspector General issues a certification.

Thus, while the bill may sound innocuous, it would effectively blow up the operations of the new exchanges by preventing subsidies from starting on January 1.  It also would discourage people from enrolling now, because they wouldn’t know if they would actually receive the subsidies for which they qualify.

The Inspector General has been clear that the legislation is deeply problematic.  “The certification function described in the legislation is substantially outside a traditional IG oversight role,” its analysis for the Energy and Commerce Committee explained.  To carry out that function, OIG “would need to develop additional programmatic and technical expertise in a new program area” as well as substantial new financial resources and staff, OIG noted.

Finally, OIG pointed out that the House bill is vague and that “there is no generally accepted auditing definition or standard for a ‘certification’ of the type that the bill would require.”  In short, OIG found the proposal unworkable.

Moreover, the provision is unnecessary.  Health reform already has reasonable verification procedures.

As we have explained (here and here), the marketplaces will verify applicants’ incomes and coverage through electronic data, including prior tax returns and wage reports.  When electronic data are not available or are inconsistent with the applications, the marketplaces will require further documentation.

Furthermore, the marketplaces will determine advance payments of premium tax credits so people can get immediate help paying monthly premiums, not the final premium credit amount that people will receive for the year.  The final amount will be based on the family’s actual income for the year as reported on its tax return.  If the advance payment turns out to be too high, the household will have to repay some or all of the difference when it files its taxes.  That is the ultimate verification system.

The Administration has said it would veto the House bill, and with good reason.  Policymakers should see the proposal for what it is — a thinly disguised attempt to delay and disrupt health reform.

Early Results From Connecticut Show Health Reform Is Helping Young Adults Get Coverage

October 9, 2013 at 3:53 pm

Enrollment in health reform’s new marketplaces (sometimes called exchanges) began last week, and Connecticut already has reported encouraging results about young adults signing up for the coverage that will take effect on January 1.

Almost one-third of those who applied for coverage through Access Health CT, Connecticut’s state-run marketplace, in the first five days are under 35, according to Kevin Counihan, the exchange’s CEO.  (Connecticut is one of 17 states operating its own marketplace; the rest of the states are partnering with the federal government on their marketplace or having the federal government operate the marketplace for them.)

This is an early report, but it’s a promising indicator of health reform’s potential to reduce the rate of uninsurance among young adults — and address this group’s need for greater coverage options.  A recent Kaiser Family Foundation poll found that more than 75 percent of all young adults want and need health insurance.

Health reform has already benefitted young adults by allowing those under age 26 to obtain health insurance coverage under their parents’ policies — a feature that is providing coverage to more than 3 million young adults.

Recent Census data showed that the share of 18- to 24-year-olds without health insurance coverage fell from 25.8 percent in 2011 to 24.3 percent in 2012.  This marked the second straight year that the uninsured rate for this group has fallen, and it’s now down 5.2 percentage points since 2010.

This leaves 25- to 34-year-olds as the age group with the highest rate of uninsurance, at 27.3 percent in 2012 (see chart).  But, we expect this rate to fall considerably in 2014 as young adults continue to sign up for coverage in Connecticut — and across the country.

Kaiser: Costs Will Grow More Slowly in States Expanding Medicaid

October 8, 2013 at 3:20 pm

The Kaiser Commission on Medicaid and the Uninsured’s annual survey of states on their Medicaid budgets, released yesterday, shows why states should expand Medicaid to adults with incomes below 133 percent of the federal poverty line, as health reform makes possible:  in the 25 states that have decided to expand Medicaid, Kaiser projects that state spending on Medicaid will grow by 4.4 percent in 2014 — compared with 6.1 percent for the states that are not moving forward with expansion (see chart).

Medicaid enrollment will grow in all states in 2014 as people who are already eligible enroll for the first time — spurred by health reform’s individual mandate that most Americans have health insurance or pay a penalty, as well as by significant outreach and new simplified enrollment procedures.  The federal government will pick up the costs of this increased enrollment at the state’s regular matching rate, which averages 57 percent, leaving the state to pay 43 percent on average.

So, how can Medicaid budgets grow more slowly in states adding tens or hundreds of thousands of newly eligible adults?

The states expanding Medicaid reported to Kaiser that they expect to achieve savings in state-funded services such as mental health care, corrections-related health care, and uncompensated care that they now provide to uninsured individuals who will become newly eligible for Medicaid.  And, the federal government will pick up all the costs of covering these newly insured adults in 2014, including 100 percent of the costs of state-funded services they have received until now.

To be sure, total federal and state Medicaid spending will grow faster in expansion states next year — by 13 percent in expansion states, compared with 6.8 percent in non-expansion states.  But, that’s due to the federal government paying all the costs of the expansion in 2014.

Expanding Medicaid will help low-income adults get the coverage they need.  Kaiser’s survey confirms that it will help state budgets, too.