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We estimate that 16 million people would receive health coverage in 2019 through the newly
created Exchanges under the PPACA. (Another 15 million, who currently have individual health
insurance policies, are also expected to switch to Exchange plans.) We modeled the choice to
purchase coverage from the Exchanges as a function of individuals’ and families’ expected
health expenditures relative to the cost of coverage if they were insured (taking into account
applicable premium subsidies). We also considered the required penalty associated with the
individual mandate if they chose to remain uninsured, along with other factors.
5
Our model
indicated that roughly 63 percent of those eligible for the Exchanges would choose to take such
coverage, with the principal incentive being the level of premium assistance available. For many
individuals, the penalty amounts for not having insurance coverage were not sufficiently large to
have a sizable impact on the coverage decision. Also, in this regard, individuals or families
would not be subject to a penalty for failing to enroll in an Exchange plan if the “bronze”
premium level (reduced by the premium tax credit, if applicable) would exceed 8 percent of
income. We estimate that this provision would exempt individuals and families with incomes
between about 400 percent and 542 percent of the FPL, representing about 16 percent of the non-
aged population.
The new legislation would require the Office of Personnel Management to arrange for at least
two private, multi-State health plans to be offered through each health insurance Exchange. The
multi-State plans would generally meet the same benefit, cost-sharing, network, and other
requirements applicable to private Exchange plans and would negotiate payment rates with
providers. (A State could enact a requirement for additional benefits in the multi-State plans,
beyond the essential benefits specified for a qualified plan, but would have to make payments on
behalf of eligible individuals to defray the cost of the additional benefits.) We estimate that the
multi-State plans would have costs that were very similar to those for other Exchange plans.
Employer-sponsored health insurance has traditionally been the largest source of coverage in the
U.S., and we anticipate that it would continue to be so under the PPACA. By 2019, an estimated
13 million workers and family members would become newly covered as a result of additional
employers offering health coverage, a greater proportion of workers enrolling in employer plans,
and an extension of dependent coverage up to age 26. However, a number of workers who
currently have employer coverage would likely become enrolled in the expanded Medicaid
program or receive subsidized coverage through the Exchanges. For example, some smaller
employers would be inclined to terminate their existing coverage, and companies with low
average salaries might find it to their—and their employees’—advantage to end their plans,
thereby allowing their workers to qualify for heavily subsidized coverage through the
Exchanges. Somewhat similarly, many part-time workers could obtain coverage more
inexpensively through the Exchanges or by enrolling in the expanded Medicaid program.
Finally, as mentioned previously, the per-worker penalties assessed on nonparticipating
employers are relatively low compared to prevailing health insurance costs. As a result, the
penalties would not be a substantial deterrent to dropping or forgoing coverage. We estimate
that such actions would collectively reduce the number of people with employer-sponsored
health coverage by about 14 million, or slightly more than the number newly covered through
5
Such other factors include age, gender of head of household, race, children, marital status, health status, and
employment status (for both the head of household and the spouse), as well as adjustments to reflect the availability
of health insurance on a guaranteed-issue basis and at community-rated, group insurance premium rates. Finally, we
also considered the general desire to comply with the intent of the law, even in the significant number of cases in
which the penalty amount would be small or would not apply.