Transcript Medicare: Past, Present, and Future

Planning for the Affordable Care Act:
Impact on Oncology
Gerald F. Kominski, Ph.D.
Professor, UCLA Fielding School of Public Health, and
Director, UCLA Center for Health Policy Research
April 15, 2014
March 23, 2010
President Obama Signing the ACA into Law
The Uninsured—As a Share of the Nonelderly Population, by Poverty
Levels and Family Type, 2011
Income
10%
EmployerSponsored
Insurance,
56%
39%
Family Type
400% +
139-399% FPL
(Subsidies)
16%
Children
25%
Parents
Uninsured,
18%
51%
≤ 138%
(Medicaid)
59%
Medicaid
*
21%
47.9 M Uninsured
Individual
Non-Group,
6%
266.4 M Nonelderly
SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS.
Adults
without
Dependent
Children
Basic Principles of the Affordable Care Act (ACA)
Too many Americans fall through the cracks of the current
health insurance “system.” Therefore, the ACA seeks to:
 Expand access to private insurance and Medicaid, rather than
redesign the entire insurance “system”
 Incremental, not fundamental, financing reform
 Provide federal funding to expand access, while allowing state
variation in implementation of the law
 New federalism
 Expand private health insurance markets, subject to extensive
federal regulations
 In exchange for steering millions of Americans into private insurance markets
Major Elements of the ACA Effective as of 2014
Most Americans are now subject to the “individual mandate” and will need to
demonstrate that they have qualified insurance, or pay a tax, next year
 Tax is being phased in over the next 3 years, and will be the higher of $695 per adult,
$2,085 per family, or 2.5% of household income, by 2016
To assist individuals and families to comply with the mandate, provides
subsidies for those with incomes from 100% and 400% FPL
 Requires out-of-pocket spending for premiums, ranging from 2.0% to 9.5% of income
 Creates state Marketplaces, as known as Exchanges, with standard, qualified health
plans, where subsidies can be used
Expands Medicaid coverage for anyone with income <139% FPL

Medicaid expansion is fully funded by the Federal government from 2014-16, then
Federal funding drops from 100% to 90% by 2020
Note: In 2014, FPL = $11,670 for a family of 1, $23,850 for a family of 4
What kinds of insurance policies can be sold
in the state Marketplaces?
 All policies must include:





Essential Health Benefits
Limits on annual out-of-pocket spending
No-cost coverage for “approved” preventive services
No annual or lifetime dollar caps on benefits
Premiums based only on age, geographic area, and
family size
 Cannot charge more for pre-existing conditions
 One of 4 approved “metal tiers” of coverage
What are Essential Health Benefits?
1. Ambulatory patient care
2. Emergency services
3. Hospitalization
4. Lab services
5. Prescription drugs
6. Maternity and newborn care
7. Mental health and substance abuse disorder treatment
8. Rehabilitation and habilitation services and devices
9. Preventive and wellness services and chronic disease support
10. Pediatric services, including dental and vision care
78
Monthly Premiums for All Metal Tiers, 2014
Before Subsidy, Region 16 (Los Angeles County), Couple (Ages 62 and 58)
Plan
Anthem EPO
Anthem HSA EPO
Anthem HMO
Blue Shield HSA PPO
Blue Shield PPO
HealthNet HMO
HealthNet PPO
Kaiser HSA HMO
Kaiser HMO
LA Care HMO
Molina HMO
Bronze
$957
$963
$1,001
$1,017
$1,041
$1,023
$1,038
$834
$866
Silver
$1,280
$1,110
$1,232
$1,036
$1,391
$1,137
$1,111
Gold
$1,538
$1,389
$1,450
$1,171
$1,691
$1,277
$1,210
ESI HealthNet HMO = $1,280 ($342 out-of-pocket premium)
Platinum
$1,784
$1,588
$1,662
$1,321
$1,819
$1,410
$1,452
Current Status of State Medicaid Expansion Decisions, 2014
VT
WA
MT
ME
ND
NH
MN
OR
WI*
SD
ID
WY
PA*
IL
UT
CO
CA
MI*
IA*
NE
NV
IN*
OH
WV
KS
MO
KY
OK
NM
TX
AK
AL
DC
SC
AR*
MS
VA
CT RI
NJ
DE
MD
NC
TN
AZ
MA
NY
GA
LA
FL
HI
Implementing Expansion in 2014 (26 States including DC)
Open Debate (6 States)
Not Moving Forward at this Time (19 States)
NOTES: Data are as of January 28, 2014. *AR and IA have approved waivers for Medicaid expansion; MI has an approved waiver for expansion
and plans to implement in Apr. 2014; IN and PA have pending waivers for alternative Medicaid expansions; WI amended its Medicaid state plan
and existing waiver to cover adults up to 100% FPL, but did not adopt the expansion.
Estimated Health Insurance Coverage in 2017
Total Nonelderly Population = 279 million
Uninsured
Medicaid/CHIP
Private
Non-Group/Other
Employersponsored
Insurance
19%
13%
10%
10%
Uninsured
16%
Medicaid/CHIP
9%
Exchange
8%
Private Non-Group
/ Other
Employersponsored
Insurance
58%
56%
Without Health Reform
(56 Million Uninsured)
With Health Reform
(29 Million Uninsured)
NOTE: This assumes that all states choose to expand Medicaid eligibility up to 138% FPL January 2014.
SOURCE: Congressional Budget Office, February 2013. Total may not equal 100% due to rounding
ACA’s Major Advantages for Oncology
 For patients:
 No pre-existing condition exclusions or higher premiums based
on health history
 Can never be denied coverage now or in the future
 No annual or lifetime dollar limits on covered benefits
 Comprehensive essential health benefits
 Reasonable limits on annual OOP liability
 Maximum $6,350/$12,700
 For centers:
 Patients cannot be denied coverage
 ~12 million newly insured according to CBO
Concerns for Oncology under the ACA
 Medicaid expansion
 Medicaid payments are low in many states
 In states not expanding Medicaid, 4.8 million low-income
adults will remain uninsured
 Narrow networks
 These have been used by insurers for decades (HMOs and
PPOs), but because of increased awareness of the use of
narrow networks in state Marketplaces, many consumers
seem to think they were created by the ACA
 Is your Center contracting with plans being offered in your
Exchange region?
Major Concerns for Oncology under the ACA
 Inclusion of preferred cancer treatments,
including specific specialty drugs
 Because every state is required to provide essential health
benefits (EHBs), and every state had to identify an actual
health policy offered in the state to serve as the benchmark
for (EHBs), this may not be a major issue
 However, whatever restrictions exist in your state are related
to limits imposed by insurers, not by the ACA
 Have you experienced problems with coverage before 2014?
Are there more problems in 2014?
Biased reporting on the ACA: “Nation’s elite
cancer centers off-limits under Obamacare”
From The NY Post, March 19, 2014: “The AP asked the centers how many
insurance companies in their state’s exchange included them as a network
provider. Of the 19 that responded, 4 reported access through all insurers: the
Kimmel Comprehensive Cancer Center at Johns Hopkins in Baltimore; Fox Chase
Cancer Center in Philadelphia; Duke Cancer Institute in Durham, NC; and
Vanderbilt-Ingram Cancer Center in Nashville, Tenn.”
Fact Check: Did the AP determine if all insurers provided coverage for these 19
Cancer Centers prior to the ACA? NO!
So, the AP is implying that the ACA has reduced access, without reporting a shred
of evidence from before the ACA.
As a professor, I would give the AP reporter an F, for failure to understand the
basics of pre-post study designs.
June 30, 2012
Mr. President, let’s
meet in the middle,
but you go first…
More Want Opponents To Work To Improve Law Rather Than
Continue Efforts To Repeal
Do you think opponents of the health care law should continue their efforts to repeal the law or should they accept that
it’s the law and work to improve it?
Accept that it is the law and work to improve it
Total public
Continue efforts to repeal
55%
Don't Know/Refused
38%
6%
By overall opinion of the health care law:
Among those with a
FAVORABLE opinion
Among those with an
UNFAVORABLE opinion
Don’t know/ Refused to
provide an opinion
88%
31%
8%
66%
59%
16%
2%
2%
23%
NOTE: “Opponents should leave the law as is (VOL.)” and “Neither of these/opponents should do something else (VOL.)” responses not shown
SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted January 14-21, 2014)
Medicare Part D Started Out With Little Support, but
is Now Highly Popular Among Seniors
AMONG THOSE AGES 65+: As you may know, Medicare provides a prescription drug benefit, known as Medicare Part D.
Given what you know about it, in general, do you have a favorable or unfavorable impression of the Medicare prescription
drug benefit?
80%
Favorable
Unfavorable
63%
60%
55
47
50
45
44
45 46
42
40%
34
37
20%
24 24
27
32
32
32 31
25
42
34
30 30
28
23
21
14%
17
0%
Feb Apr Jun
2004
Oct Dec
Apr
Aug Oct Dec Feb Apr Jun
2005
2006
Nov
Nov
2007 2008 2009 2010 2011 2012
NOTES: Question wording varied slightly in 2004-2006 surveys. Neither/neutral (VOL.) and Don’t know/Refused answers not shown.
SOURCE: Kaiser Family Foundation surveys
2013
Thank you!