Transcript Coverage is Good Medicine Health Reform and Getting People Covered Last updated: 8/10/2014

Coverage is Good Medicine
Health Reform and Getting
People Covered
Last updated: 8/10/2014
Why We Needed Reform
Bankrupting
– Governments
(Medicare,
Medicaid)
– People
– Businesses
>50 Million people
uninsured
Market Broken
US Healthcare Costs Highest in World
Healthcare Costs Rising Fastest in US
USA
France
Denmark
Ireland
Outcomes vs. Costs
SUPPORT FROM DOCTORS AND NURSES
On March 23, 2010,
the Affordable Care Act
became law.
Health insurance for millions of
people
Largest expansion of coverage
since Medicare in 1965.
Affordable Care Act
2010-2013
•Young adults could stay on parent’s plan to age 26
•Medicare Rx doughnut hole started closing
•Small business tax credits
•Temporary High Risk Pools
•Preventive services without a deductible, co-pay or
coinsurance
•No lifetime limits
•80-85% of premium dollars on actual health care
services and quality improvements, not CEO pay,
advertising, etc or customers get rebates
•Increased funding for community health clinics
2014 - Expanding Affordability &
Access
•Expands
access to private health insurance
coverage for many Americans
•Provides
financial help to low-income individuals &
families
•Sliding-scale tax credits for premium and co-pays
available to individuals and families with incomes
between 100-400% of the Federal Poverty Level
•Caps
annual out-of-pocket spending for individuals
and families
Finally, an end to medical bankruptcy in America!
Three Ways to Get Coverage
Lowest Income
Expanded Medicaid*
Higher Income
Insurance Marketplace
Small Business
Small Business Marketplace
In participating states only
(private insurance)
(private insurance)
Health Insurance Marketplace
Health Insurance Marketplace
You CAN shop at the marketplace if you:
❑Live in the U.S.
❑Are a U.S. Citizen or legal resident
❑Are not in prison
Health Insurance Marketplace
You MUST shop at the marketplace if you:
❑Are a member of Congress or his/her staff
Health Insurance Marketplace
• Insurance companies have to offer you a
plan even if you’ve been denied before
• Only these will affect your premium:
• How old you are
• Where you live
• Number and age of people in your family
• Whether you smoke
Health Insurance Marketplace
All insurance plans must cover the basics – no more rip-off
policies that do not cover people when they get sick
Maternity
Doctor Visits
Hospital Stays
ER Visits
Blood Tests
Prescriptions
Pediatrics
Mental Health
with vision and dental
and Substance Abuse
Physical
Therapy
Prevention
(shots, cancer screenings)
and Newborn Care
Health Insurance Marketplace
All insurance plans must cover the basics.
But the amount they pay for each service, the
amount of your co-pays, the deductible, your
out-of-pocket costs, prescription co-pays and
drug coverage, which doctors & hospitals are
in their network, and the penalties for using
out of network providers vary a lot.
Most people get a tax credit
to help pay for health insurance
2014
Number of people in your family
You can get a tax credit if you make
1
$11,490 - $45,960
2
$15,510 - $62,040
3
$19,530 - $78,120
4
$23,550 - $94,200
5
$27,570 - $110,280
❑ Employer doesn’t offer affordable insurance (you would have
to pay more than 9.5% of your income)
❑ You’re not on Medicare, Medicaid or TRICARE
❑ Must buy insurance on the marketplace.
Special Enrollment Periods
Special Enrollment Periods
• Qualifying Life Events
– Marriage or divorce
– Having a baby or adopting a child
– Moving to another state
– Gaining citizenship
– Losing your coverage
• Job
• Turn 26 and age out of parents’ plan
• COBRA expires
Year-Round Enrollment
• Medicaid and CHIP
• Small businesses
• Members of federally recognized tribes
Next Open Enrollment Period
November 15, 2014
to
February 15, 2015
Medicaid & Supreme Court
• ACA: As originally passed, included the
marketplaces and expansion of Medicaid
• SCOTUS:
– ACA & individual mandate are constitutional
– Federal government cannot sanction states
that do not expand their Medicaid program to
cover the new mandatory population by
cutting off all Medicaid funds
Medicaid
• Expanded Medicaid eligibility to 133% of the
Federal Poverty Level
• Covers childless adults
• Cost of increase to States covered by Federal
dollars for those newly eligible
– 100% of the cost 2014-2016, gradually decreases to
90% by 2020 and beyond
• 26 states + DC moving forward with expansion, 25
states not moving forward at this time
Medicaid Expansion
• State-run, mostly federally-funded health
insurance for people with the lowest income.
• Who Would
Qualify:
Family Size
Household income is less than
1
$15,281.70
2
$20,628.30
3
$25,974.90
4
$31,321.50
5
$36,668.10
6
$42,014.70
7
$47,361.30
8
$52,707.90
Governors & state legislators can choose to expand Medicaid any time.
http://kaiserfamilyfoundation.files.wordpress.com/2013/07/8458-analyzing-the-impact-of-state-medicaid-expansiondecisions2.pdf (accessed 8/5/2013)
Expansion Status as of June 2014
500 new doctors and 600 new nurses are being
trained, including a focus on primary care
Hospitals have incentives to coordinate care, decrease
complications, and improve quality.
Increases Regulation of Private
Health Insurance Companies
• Creates Policies that Encourage Wellness – Requires
Full Coverage for Preventive Services
• All new group and individual plans must eliminate copays and deductibles for preventative care
• Ends “Pre-existing Condition” Denials – eliminated for
children on 9/23/10, for adults in 2014
• Prohibits Caps on Coverage Benefits – lifetime caps on
benefits eliminated 9/23/10, annual caps end in 2014
Increases Regulation of Private
Health Insurance Companies
• Allows Young Adults to Stay on Parent Policies Until
Age 26
• Prevents Coverage Rescissions
• Sets Medical Loss Ratios: 80-85% of premiums on
“real” health care
• Prohibits charging higher premiums based on health
status or gender
• Premiums only allowed to vary for age by no more
than 3 to 1, smokers by no more than 1.5 to 1
Provides Small Business Tax
Credits to Help Cover Employees
• Businesses with ≤25 employees, average wage
<$50,000
• Tax credits up to 35% of employer’s
contribution to premium in 2010, went up to
50% in 2014
• SHOP Online Marketplace delayed to 2015
• Employer mandate delayed to 2015/2016
Personal Responsibility to Purchase
Health Insurance
• Applies U.S. citizens and legal immigrants
• Exemptions for religious objection, American
Indians, those without coverage < 3 months,
undocumented immigrants, incarcerated individuals,
lowest cost plan is >8% of income, or income below
tax filing threshold
• Penalty total is the greater of:
– in 2014 = $95 or 1% taxable income
– in 2015 = $325 or 2% taxable income
– in 2016 = $695 or 2.5% taxable income
Requirement to buy Health
Insurance
Not required:
•Veterans
enrolled in VA Healthcare System
•Anyone with Medicare, Medicaid or TRICARE
•Individuals with a religious conscience exemption (applies
only to certain faiths)
•Incarcerated individuals
•Undocumented immigrant (not eligible, except employer plan)
•Individuals who cannot afford coverage or hardship
•Individuals with income below the tax filing threshold;
•Members of Indian tribes
What If You Don’t Get Insured?
You’ll pay a fine:
•In 2014: $95 (or 1% of your
income)
•In 2016: $695 (or 2.5% of your
income)
•Plus the cost of health care
($2500 for a broken ankle)
Exceptions:
•Uninsured for less than 3
months in a row
•All available insurance
options cost more than 9.8%
of your income
•Undocumented immigrant
•Belong to an exempt
religious sect
Why? Hospitals will save your life in an emergency – even if you
have no insurance. If you can’t pay your hospital bills, people with
insurance and the government (taxpayers) get charged more.
ACA Strengthens Medicare Benefits
• Gradually ends Medicare Part D Rx Drug
“Doughnut-hole”
– Totally closed by 2020
• Now covers
– Annual wellness visits & personalized
prevention plans with no co-pays for
preventive services
• Improving quality through payment reforms
ACA’s Amazing Success
Goals
(1) Improve health care security
(2) Improve health care quality
(3) Improve health care access
Expanding Access - Enrollment
ACA Success: Affordability
Those who signed up through the federal
marketplace:
•Almost 90 percent received tax credits to
help them afford coverage.
•Nearly 7 in 10 enrollees are paying $100 or
less per month
•Nearly half are paying $50 or less per
month.
•Average premium after tax credits is $82
per month
Expanding Access - Uninsured
ACA Success: Access
Access to Appointments
Satisfaction with Coverage
• 73 percent of people who bought health plans
and 87 percent of those who signed up for
Medicaid said they were somewhat or very
satisfied with their new health insurance.
• Seventy-four percent of newly insured
Republicans liked their plans
• 77 percent of people who had insurance
before — including members of the group
whose plans got canceled last year — were
happy with their new coverage.
Source: Commonwealth Fund poll
Costs Lower Than Expected
Projected savings in federal health spending
since the 2009 estimate = $7.9 trillion
Since ACA, 13 Years Added to
Life of Medicare Part A Trust Fund
Number of years from 2014 to exhaustion of
Hospital Insurance Trust Fund
ACA Success
• Healthcare costs rising at slowest rate in
50 years
• Insurance rates in states that have their
own exchanges much lower than predicted
• 8.2 million seniors have already saved
more than $11.5 billion from closing of
donut hole
• 360,000 small businesses have used tax
credits to insure over 2 million workers
ACA Success: Affordability
Those who signed up through the federal
marketplace:
•Almost 90 percent received tax credits to
help them afford coverage.
•Nearly 7 in 10 enrollees are paying $100 or
less per month
•Nearly half are paying $50 or less per
month.
•Average premium after tax credits is $82
per month
Challenges Ahead
• Medicaid expansion
• Lawsuits
• Network Adequacy
Impact of Failure to Expand Medicaid
• State loses Federal funding - $$$ Billions over 10 yrs
• People < 100% FPL have no options if they don’t have
employer insurance
• 100 - 138% FPL will get subsidies for marketplace
• Millions of people won’t get coverage
• Rural and safety net hospitals that care for many uninsured
will close, leading to worsening care for all people in rural and
underserved areas
• Lose the thousands of new jobs expansion would create
Legal Challenges
Hobby Lobby Case
•The Supreme Court decision allows "closely-held"
corporations (those where five or fewer people own the
majority of the business) to opt-out of the contraceptive
mandate if they have a “sincere religious objection” to
birth control.
• Does not rollback many of the other ways that
Obamacare expands birth control access
• Opens the door for more challenges to the Affordable
Care Act — and other federal laws — on the grounds of
religious liberty.
Halbig v Burwell & King v Burwell
• Issue is whether subsidies are available on Federal
marketplaces as well as ones established by states
• July 22, 2014, the U.S. Court of Appeals of the D.C.
Circuit ruled 2–1 in Halbig that subsidies only
available on state exchanges
• On the same day, in the similar case of King v.
Burwell, the U.S. Court of Appeals for the Fourth
Circuit ruled 3-0 that subsidies apply to all
marketplaces
Halbig v Burwell & King v Burwell
• These cases, and 2 other cases brought by state AGs
& pending in the federal district courts in Oklahoma
and Indiana, were brought to destroy the ACA
• An unfavorable ruling would bar millions of Americans
who live in states with federal exchanges from
receiving premium tax credits, making their health
insurance unaffordable
• Employer mandate would be unenforceable (no
subsidies)
• Insurance rates would rise significantly in these states
QUESTIONS?
“Of all the forms of inequality, injustice in health care is the
most shocking and inhumane.”― Martin Luther King Jr.
“This is the Civil Rights Act of the 21st Century” ― Rep James
Clyburn (D-SC)
SUPPLEMENTAL SLIDES
Federal Poverty Levels
Paying for Reform
1st 10-year net deficit reduction = $140 billion
Taxes
• Industry (insurance, pharmaceutical, medical devices)
• On individuals
– Payroll: additional 0.9% Medicare payroll take on wages
>$250,000 (couple), >$200,000 (individual)
– Capital gains: 3.8% tax on unearned income (interest,
dividends) ONLY for those w/ income >$250,000
– “Cadillac Tax”: insurance plans >$27,500 (family) and
>$10,200 (individual) taxed starting in 2018
– Tanning tax 10%
Small Business Marketplace (SHOP)
How Many Employees Do You Have?
1 to 49
50 or More
Shop on the
small business
marketplace.
Buy insurance
the way you
always did.
More information at BusinessUSA.gov
Small Business Marketplace (SHOP)
Shop on the
Small Business
Marketplace
1 to 49
employees
Coming
Soon
2014
Pick ONE plan for all
employees.
Pick a VARIETY of plans
for all employees.
Pay one lump sum to
the SHOP exchange
Note: website for small businesses starts in November.
Small Business Marketplace
Tax Credits
❑2-24 full-time equivalent employees
❑You pay at least 50% of premiums
❑Average wages less than
$50,000/year
Up to 50% tax credit for premiums
Large Employer Penalties
(delayed till 2015)
•More than 50 full-time equivalent employees
•You don’t offer insurance OR employees can’t
afford the insurance you offer (they have to pay
more than 9.5% of their income)
•One employee needs help from taxpayers
(Medicaid or a tax credit) to be able to afford
health care
You pay ($2000-$3000 per year) x (# of fulltime employees)
*Would affect 1% of all employers.
Access Issues Ahead
• Reaching more of the uninsured
• Expanding Medicaid in those state that
have not expanded
• Network adequacy
• Workforce
• Cost of premiums, deductibles, copays,
coinsurance
Beyond Access
• ACA Prevention Provisions
– National Prevention Council
– Prevention Fund
• ACA Delivery System Reform Provisions
– Medicare 30-day Readmission Policy
– ACO’s, bundled payments, and more
• And Beyond!