Creating a New Affordable Care Act Coverage Continuum

While the Patient Protection and Affordable Care Act (ACA) has contributed to an increase in the number of individuals with health care coverage, there are many who remain uninsured. As states seek solutions for addressing coverage gaps while managing budget pressures, Medicaid offers a valuable pool of expertise and a foundation to build a program that progressively supports the shift toward commercial insurance models for low-income populations.

By integrating state and federal funding streams to provide coverage for individuals whose income falls between zero and 400 percent of the Federal Poverty Level (FPL) on a single platform, states could maximize their purchasing power to influence and reform the health care system while providing coverage to a significant portion of the population.


Under this approach, states could leverage Section 1332 and 1115 waivers to segment eligibility, coverage and program design elements based on four income tiers:

  • For individuals whose income falls 0-100 percent below the FPL — Traditional (pre-ACA) Medicaid membership would receive benefits geared toward the individuals’ clinical profiles and health need, with funding provided from state and federal Medicaid dollars.
  • For individuals whose income falls 100-138 percent below the FPL – This group would be eligible for coverage and financial assistance using state and federal Medicaid funding. An important component of coverage is providing tools and support to increase this cohort’s financial literacy to create knowledgeable consumers of health care.
  • For individuals whose income falls 138-200 percent below the FPL — This cohort remains close to its current configuration, as enrollment in the marketplace in a commercial product combines federal funding for subsidies and personal financial responsibility for premiums.
  • For individuals whose income falls 200-400 percent below the FPL — This unit, while using the Medicaid platform within a reinsurance pool, could choose from benefits mirroring employer-based plans, assuming responsibility for paying premiums with assistance from repurposed federal funding.

We invite you to join us in leading the change. For more information on the proposed model and its access strategy, download the whitepaper in the sidebar.