Nowak Sarah A, Saltzman Evan, Cordova Amado
Rand Health Q. 2016 May 9;5(4):3.
The Affordable Care Act (ACA) was designed to increase health insurance coverage while limiting the disruption to individuals with existing sources of insurance coverage, particularly those with employer-sponsored insurance (ESI). To limit disruption to those with coverage, the ACA implements the employer mandate, which requires firms with more than 50 employees to offer health insurance or face penalties, and the individual "affordability firewall," which limits subsidies to individuals lacking access to alternative sources of coverage that are "affordable." This article examines the policy impacts of the affordability firewall and investigates two potential modifications. Option 1, which is the "entire family" scenario, involves allowing an exception to the firewall for anyone in a family where the ESI premium contribution exceeds 9.5 percent of the worker's household income. In Option 2, the "dependents only" scenario, only dependents (and not the worker) become eligible for Marketplace subsidies when the ESI premium contribution exceeds 9.5 percent of the worker's household income. Relative to the ACA, RAND researchers estimate that nongroup enrollment will increase by 4.1 million for Option 1 and by 1.4 million for Option 2. However, the number without insurance only declines by 1.5 million in Option 1 and 0.7 million in Option 2. The difference between the increase in nongroup enrollment and the decrease in uninsurance is primarily due to ESI crowd-out, which is more pronounced for Option 1. Researchers also estimated that about 1.3 million families who have ESI and unsubsidized nongroup coverage under current ACA policy would receive Marketplace subsidies under the alternative affordability firewall scenarios. For these families, health insurance coverage would become substantially more affordable; these families' risk of spending at least 20 percent of income on health care would drop by more than two thirds. We additionally estimated that federal spending will increase by $8.9 billion and $3.9 billion for Options 1 and 2, respectively, relative to the ACA.
《平价医疗法案》（ACA）旨在扩大医疗保险覆盖范围，同时尽量减少对已有保险覆盖的个人，特别是那些拥有雇主提供保险（ESI）的人的干扰。为了减少对有保险者的干扰，ACA实施了雇主强制规定，即要求拥有50名以上员工的公司提供医疗保险，否则将面临处罚；还实施了个人“可承受性防火墙”，限制对无法获得“可承受”的替代保险来源的个人的补贴。本文研究了可承受性防火墙的政策影响，并探讨了两种可能的修改方案。方案1是“整个家庭”的情况，即对于家庭中任何一名其ESI保费贡献超过工人家庭收入9.5%的成员，允许其不受防火墙限制。在方案2“仅受抚养人”的情况下，当ESI保费贡献超过工人家庭收入的9.5%时，只有受抚养人（而非工人）有资格获得市场补贴。与ACA相比，兰德公司的研究人员估计，方案1的非团体参保人数将增加410万，方案2将增加140万。然而，无保险人数在方案1中仅减少150万，在方案2中减少70万。非团体参保人数增加与未参保人数减少之间的差异主要是由于ESI挤出效应，方案1的这种效应更为明显。研究人员还估计，在当前ACA政策下拥有ESI和无补贴非团体保险的约130万个家庭，在替代的可承受性防火墙方案下将获得市场补贴。对于这些家庭来说，医疗保险将变得更加可承受；这些家庭将至少20%的收入用于医疗保健的风险将下降三分之二以上。我们还估计，相对于ACA，方案1和方案2的联邦支出将分别增加89亿美元和39亿美元。
