Check a Box for Free Health Care

Brian Witte/AP Photo

Stan Dorn, director of the National Center for Coverage Innovation, speaks at a news conference in Annapolis with Delegate Joseline Pena-Melnyk and State Senator Brian Feldman. 

The Trump administration has spent the last two and a half years doggedly attacking the Affordable Care Act (ACA). From limiting advertising and outreach, shortening enrollment periods, and killing the individual mandate at the federal level, to approving state plans to eliminate health coverage for many Medicaid recipients, the administration has undermined and weakened the law even as a Republican-majority Congress failed to completely strike down the ACA. The national uninsured rate rose in the fourth quarter of 2018, according to Gallup data, from a historic low of 10.9 percent in 2016 to 13.7 percent. That increase represents an additional seven million adults left uninsured.

In response to these attacks, lawmakers in Maryland recently passed legislation that will make it easier for state residents to enroll in health care. The new program will not only widen the insurance pool and keep premiums down, but it is also a groundbreaking new way to ensure that nearly everyone who is eligible for assistance actually receives it. Yet very low-income people and the immigrant community may not benefit from the new program.

Starting next year, uninsured residents filing state taxes can check a box on their return to enroll in health coverage, and the state will use financial data from to tax record to determine eligibility for Medicaid or private insurance from the state health exchange. The Easy Enrollment Health Program was passed unanimously in the state Senate and with heavy bipartisan support in the House. Republican Governor Larry Hogan signed it into law in May.

“If you’re not insured, the state will help you get insured,” says Vinny DeMarco, president of the Maryland Citizens’ Health Initiative. Maryland had already seen success from the implementation of the ACA and the accompanying expansion of Medicaid: the uninsured rate in the state fell by nearly half and is currently about 6 percent.

“Maryland is going to be the first state in the country to actively use the tax system to get people enrolled in health care,” DeMarco adds, “which will benefit tens of thousands of Marylanders directly by getting them insurance and benefit all of us by keeping our premiums from going up as high.” 

Those eligible for Medicaid will be automatically enrolled in the program. Those who are eligible for federal premium tax credits to purchase health insurance on the state exchange will be contacted and guided through the process. An estimated 360,000 people in Maryland are uninsured, and this method could reach about 220,000 of them; 50,000 are eligible for Medicaid but aren’t on the program, 70,000 are eligible for premium tax credits that would cover the total cost of their premiums, and 100,000 are eligible for some level of premium assistance.

“A high percentage of people—particularly poor people—don’t even know there’s financial assistance available, don’t even know there’s a health insurance exchange,” says Stan Dorn, a senior fellow at Families USA, a national health advocacy organization. This has gone largely unnoticed while policy wonks debate new ideas like Medicare for All, which would obviously eliminate the need to solve this problem. But the fact remains that 20 million people nationally don’t have health coverage right now. Nearly half of the uninsured population lacks coverage due to costs—or at least, what they believe costs to be. 

The idea was to make the enrollment process as simple and as streamlined as possible. Beyond broadening health coverage in Maryland, the law’s supporters argue that it’s also essential to increase enrollment given the death of the individual mandate, killed upon the passage of 2017’s Tax Cuts and Jobs Act.

After the 2016 election, says State Senator Brian Feldman, Democratic state legislators presciently asked themselves: “What are we going to do in Maryland of there is action on the Hill to methodically dismantle the ACA?” 

So they created the Health Insurance Protection Commission to monitor how federal policies would affect Maryland. Chaired by Feldman and House Delegate Joseline A. Peña-Melnyk, the commission is made up of legislators, doctors, and advocates (including DeMarco). Last year, the commission recommended that Maryland enact a reinsurance program (in a nutshell, insurance for insurers, based on a similar program enacted in Oregon) in order to temporarily mitigate rising premiums. After the reinsurance program was enacted, Maryland saw a 13 percent deduction in premium costs.

But bureaucracy, rules, and regulations often get in the way of program enrollment. People must not only know they’re eligible for a program and how to apply, but must also have the time to deal with stressful paperwork and other red tape. In 2016, more than a quarter of the national uninsured population was eligible for Medicaid. 

Public policy scholar Pamela Herd says the new Maryland law is “exactly what we [are] talking about in terms of how to reduce administrative burden and make it easier for people to access programs for which they are eligible.” Herd, coauthor of Administrative Burden: Policy Making by Other Means, says that the program will perform two key functions. It will reduce “learning costs”—the fact that people have to know about a program in order to apply—and will also reduce “compliance costs”—or tedious tasks, like the forms one has to fill out, because the paperwork has already been gathered. You’re just checking a box.

The original bill introduced in the state legislature included a plan in which uninsured state residents would be required to pay a fee, like the original, federal individual mandate. However, departing from the federal mandate, Maryland’s plan was that residents could use that fee as a sort-of down payment for health insurance; the fee would be waived if a person then signed up for health coverage. Because of state IT modernization issues, as well as a way to avoid what Feldman calls “the political and partisan rancor,” that innovation was taken out of the final bill, likely contributing to the bipartisan success story of the law. It may be reintroduced in the coming years, depending on the success of the opt-in program.

Herd, however, is skeptical whether the tax penalty would have been as effective as the simple check-the-box-to-enroll method. Even if people qualified for Medicaid or a costless ACA plan, Herd says, it’s possible filers wouldn’t realize that—and would be hesitant to engage with the program at all, thinking they would end up paying more. 

Dorn says that he and the Maryland commission plan to soon publicize the program nationwide in hopes that other states will want to adopt it. And already, even before any sort of media push, Dorn says that Oregon, Virginia, New Mexico, and Massachusetts have each reached out to discuss possible replication.

Yet not all will be able to gain coverage through this program. Some people with extremely low incomes may not be required to file tax returns at all, and thus they may not file even if they are eligible for the Earned Income Tax Credit. Even to be eligible for the EITC, which would encourage a person to file a return, they must have, well, earned income. People who need Medicaid most—people with zero income or who earn too little to file a return—may not benefit.

However, because 20 to 25 percent of workers who areeligible for the EITC do not file a tax return and claim the credit, EITC outreach could encourage folks to file a tax return to claim the federal and state EITC—and also encourage them to enroll in health coverage.

Immigrant communities may not benefit from the new program. While the Trump administration has targeted health care, it’s also been targeted public assistance for immigrants. Specifically, new proposals surrounding “public charge” rules may punish immigrants who enroll in programs like Medicaid, even if they are eligible for them. And even if no such proposal is enacted, a climate of fear and hesitation has already kept many immigrants from applying for assistance.

“We have to use multiple tactics” to make sure that every person in the state has health care, says Ben Orr, executive director of the Maryland Center on Economic Policy, which supported the legislation. He describes how, in 2017, Maryland passed a law to cover the difference if the federal government defunded Planned Parenthood. States can also work to control costs of health services and prescription drugs, he says. “The bill we passed isn’t a magic bullet,” according to Orr, “and I’m not sure there is one out there.”

Supporters of single-payer health care might disagree. But for now, Maryland is doing what it can to cover as many people as possible.

Feldman says the commission is meeting again this year, and is inviting representatives from Massachusetts down to talk about their state health program (colloquially dubbed “RomneyCare”), as only 3 percent of Massachusetts residents are uninsured. 

The complexities of the U.S. health-care system bear out this simple truth: As long as the U.S. continues to work within its private insurer-dominated system instead of implementing something much easier, like single-payer, we will continue to need innovative reforms like Maryland’s new program to ensure that all have health care.

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