Transcript Affordable Care Act

Transforming
Healthcare: Surfing
the Tsunami of
Change
October 24, 2014
Donna Orban
Certified Marketplace
Navigator
Affordable
Care Act
ABC’s of the
ACA
Learning Objectives
 Explain
the Health Insurance
Marketplace from consumer
perspective
 Describe demographics of
Marketplace consumers
 Look at enrollment by the numbers
Learning Objectives
Describe
key provisions of the
ACA.
Describe the history of the
Affordable Care Act (ACA).
Describe the implementation of
ACA beginning in 2009.
Marketplace
Exchange
It’s like a mall for health
insurance! What does is
mean for consumers?
The Health Insurance
Marketplace
Easier to Buy Insurance
• Insurance Exchanges allow people to
compare plans, apples to apples
• Families and individuals receive tax
credit, depending upon income, to
help pay for health insurance
coverage
• Marketplaces offer multiple Qualified
Health Plans from participating
providers
• Ability to find coverage to fit your
individual needs
• Marketplaces provide basic
information on:
• Plan premiums
• Deductibles
• Out-of-pocket costs
Premium Tax Credits
 Must
not be eligible
for “affordable”
job based
coverage that
meets Minimum
Essential Coverage
 Household
income
must be between
100% and 400% of
Federal Poverty
Level for household
size
Expansion of State Health
Insurance Programs
http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-theaffordable-care-act
Olympics of Healthcare
Coverage
Only Silver Plan = Cost Sharing
Reductions
The Silver plan is set up so that 70% of medical costs are covered
through the provider. With cost-sharing reductions the amount listed
below is what the provider and the government will pay for out-ofpocket health services:
If your income is 100-150% of the FPL, the actual coverage of a
Silver plan is 94%

If your income is 150-200% of the FPL, the actual coverage of a
Silver plan is 87%

If your income is 200-250% of the FPL, the actual coverage of a
Silver plan is 73%

Marketplace
Enrollment &
Demographics
How many individuals have
new comprehensive
insurance and what do
they look like?
Enrollment by the Numbers
From Oct 1, 2014 through the extension
deadline April 19, 2015:
 8,019,763 people selected Marketplace
plans
 More than 4.8 million additional individuals
enrolled in Medicaid and CHIP
 About 3.8 million people, including nearly
1.2 million young adults (18 – 34), enrolled
during the final reporting period, which
began March 2 and concluded on April
19
http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf
Marketplace Demographics
Of the more than 8 million who enrolled in
Marketplace plans:
 54
% are female and 46 % are male
 34% are under age 35
 28 % are between the ages of 18-34
 65 % selected a Silver Plan; 20% Bronze
 85% selected a plan with financial
assistance
http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf
Marketplace Demographics
 62.9
% of those reporting are white
 16.7 % are African American
 10.7% are Latino
 7.95 are Asian
 1.3% are multiracial
 0.3% American Indian/Alaska Native
 0.1% Native Hawaiian/Pacific Islander
http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf
Marketplace Demographics
Total Oklahoma Marketplace Enrollment =
69,221 (bottom 7 states for enrollment)
 70.1
% of those reporting are white
 9.0 % are African American
 7.5 % are Latino
 6.8% are Asian
 3.4 % are multiracial
 3.1 % American Indian/Alaska Native
 0.1% Native Hawaiian/Pacific Islander
http://quickfacts.census.gov/qfd/states/40000.html
Patient
Protection and
Affordable
Care Act
Transforming the Delivery
and Business of Healthcare
Major Tenants of ACA
 Payment
reform
 Quality
 Delivery
system redesign
Who does it impact?
o Everyone!
Changes that may impact families
o Financial Protection
o Easier Access to Health Insurance
o Tax Credits
Financial Protections
• No annual or lifetime limits
• Spending caps will limit the
amount consumers pay
out of pocket each year
• Insurance companies have
to spend at least 80% of
premiums on medical care
• Eligible Tax Credits and
cost sharing reductions to
lower cost of healthcare
Quality of Care and a
Focus on Prevention
•Women
•Children
•Native
Americans
•Individuals with Medical Conditions
•Legal Immigrants
Who and How the ACA
helps…

Women

Insurance companies can
no longer deny women
insurance because of a
pre-existing conditions
such as:
Breast or Cervical Cancer
 Pregnancy or C-Section
 Domestic Abuse


Insurers can no longer
charge women more than
men for the same
coverage
Who and How the ACA
helps…
 Native

Americans
Permanently authorizes
the Indian Health Care
Improvement Act and:
 Improves
access to 1.9
million Native Americans
served by Indian Health
Services
 Cost sharing reductions
avail 100-300% FPL
 AN/AI can enroll monthly
Who and How the ACA
helps…

People with medical
conditions



People with a disability or
mental illness can work
part-time and still qualify
for Medicaid
Mental healthcare must be
covered just like physical
health care
Insurers cannot refuse or
charge more to cover
those individuals with preexisting conditions
Who and How the ACA
helps…

Chronic Health Problems




No longer deny individuals
Insurance due to pre-existing
conditions or for participating in
a clinical trial
No yearly or lifetime limits on
coverage
All Marketplace insurance
plans will cover children’s vision
and dental
Young adults can stay on their
parents’ plan until age 26

Coverage is available even if
child is married or has own child
(child and spouse are not
covered)
Who and How the ACA
helps…
 Legal

Immigrants
Eligible for:
 Purchasing
health
insurance from the State
Exchange (2014) with no
waiting periods
 Premium tax credits,
cost-sharing reductions,
temporary high-risk
pools, and “basic health
plans” offered by a state
Reforming
Healthcare
How long has the U.S. been
seeking change in
healthcare?
This is not a new concept…
The Heritage Foundation was
one of the strongest early
backers of an individual
mandate.
The “central element in the
Heritage proposal is a two-way
commitment between
government and citizens.
Under this ‘social contract’ the
federal government would
agree to make it financially
possible… for every American
family to purchase at least a
basic package of medical
care including catastrophic
insurance. In return,
government would require, by
law, every head of household
acquire at least a basic health
plan for his or her family.”
Historical
Review
A Presidential Overview
 Franklin
Roosevelt- Healthcare is a fundamental
human right
 Harry
Truman- Single Payer Insurance System
 Dwight
Eisenhower- Allow small companies to
pool resources to expand coverage

John F. Kennedy- Universal single payer with national
health budget, no consumer cost-sharing
 Lyndon
B. Johnson- Medicare and Medicaid
Enacted
 Richard
 Gerald
Nixon- Minimum levels of coverage
Ford- Avoidance of duplicate services

Jimmy Carter- Focus on cost containment, minimum
package of benefits, new public corporation created
to sell coverage
 Ronald
Reagan- 1st major expansion of Medicare
benefits, ceiling on out-of-pocket costs
 George
Bush- Healthcare tax credits, purchasing
pools, manage fraud and abuse in Medicare
 Bill
Clinton- Universal coverage, employer and
individual mandates, managed competition
 George
W. Bush- Prescription drug coverage for
Medicare
 Barack
Obama- Patient Protection and
Affordable Care Act
Do these terms sound
familiar???










human right
pool resources
Single Payer
Universal single payer
Minimum levels
cost containment
ceiling on out-of-pocket
costs
tax credits, purchasing
pools
employer and individual
mandates
Prescription drug coverage
By the
numbers…
What does our health and
our healthcare cost???
Rising Healthcare Costs
Healthcare Spending
Healthcare Spending vs.
Health Outcomes
We spend so much… You think we’d be healthier…
How much do you go to the
Doctor???
Healthcare Spending Realities
Delivering Healthcare Services
You know we’re in the bottom…
Payment Reform
Individual Financial Protections
80/20 Rule
More Transparency of Healthcare Systems
More Financial Protections
•
•
•
Insurers must justify premium
increases
ACA limits insurance companies
overhead costs (administration and
marketing)
Allows individuals and small
businesses to get better rates
because they are in a bigger pool
Medical Loss Ratio: 80/20
 80
cents out of every dollar in premiums
must be paid out for policyholders
medical care
 If the full 80% is not paid out for medical
care, the insurance company must send
you a refund check every year
Protecting Women’s Health
Prevention and Wellness




No deductibles or
copayments for
preventative services
Grants for community
wellness programs
National standards
for restaurant
nutrition labeling
Incentives for doctors
to improve patient’s
health
The Patient and Doctor Have
Control

Insurance plans will have to cover essential
services:









Preventative care
Hospitals
Physicians
Prescription Drugs
Substance Abuse
Dental and Vision for:
Children
Maternity Care
Clear appeals process if your claim is denied
Delivery System Redesign
•Buying
Health Insurance
•Improving the Healthcare Workforce
•Local Efforts for Improvement
Changing the System of
Healthcare Delivery
 Physician
Incentives for quality
coordinated care
 Funding for pilot projects in evidencedbased medicine
 Enhanced payments for primary care
physicians and general surgeons
 Use of Health Informatics
 Expansion of State Medicaid services
Improving the Healthcare
Workforce


The ACA will provide loan
repayments and scholarships
for students who work in
underserved areas
The ACA offers grant
opportunities for health
programs at colleges and
universities to increase the
racial diversity of the
healthcare workforce
Shared Responsibilities of
the ACA
Federal, Business, and Individual Responsibilities
How do we pay for the ACA?


Multiple funding mechanisms are built into the ACA
legislation
The ACA does NOT add to the deficit!


$143 billion in savings this decade
Examples of funding mechanisms:




$2,000 per employee fine for large businesses (50+
employees) who do not provide health insurance for
employees
Higher taxes will be imposed on those earning more than
$200,000 individual/$250,000 couple
Medicare Advantage plans will be reimbursed at the
regular Medicare rate
Educational Reform on Student Loans
Federal Government
 Pays
for 100% of Medicaid expansion from
2014-2016
 Pays for 90%-95% of Medicaid expansion
in 2017 and beyond
 Shares in costs of tax credits and premium
subsidies
Businesses
 Large
employers (50+ employees) may
have to pay a penalty if they do not
provide coverage AND one or more of
their employees receives an insurance
premium subsidy
 Taxes on insurance companies that offer
very high cost plans “Cadillac plans”
 Fee or taxes on producers of some
medical equipment and pharmaceuticals
Individuals



U.S. citizens and legal residents must purchase health
insurance or pay a penalty
Penalties are phased in for those who do not
purchase health insurance
Exemptions granted for:








AI/AN Populations
Hardship Exemptions
Religious objections
Those without coverage for less than 3 months
Undocumented workers
Incarcerated individuals
Or, if the lowest cost plan exceeds 8% of income
Tax changes for some high-income individuals
Questions???
For more information contact:
Donna Orban, CRS [email protected]