Who is Insured?
Most people are insured through an employersponsored plan (177 million Americans, 62% of
people are under age 65)
99% of employers with 200 or more employees
offer health insurance
78% - 10 to 24 employees
49% - 3 to 9 employees
Who is Insured
About 70 million Americans are insured
under a “public plan”
Government spends about 42% of every
dollar spent on health care
Estimated 46 million Americans lack health
care insurance (15% of U.S. population)
Who Are The Uninsured?
27 million have personal income over $50,000
66% of uninsured have family incomes of $45 - $85,000
14 million are eligible for Medicaid on the Children‟s Health
10 million „illegal‟ aliens
1/3 are between 18 to 29 years of age
In New Jersey, 1,057,000 people (about 15% of the
About 650 New Jerseyans lose health care insurance every
Insurance Reform and
Dependent coverage to age 26 (2010)
Children with pre-existing conditions cannot be denied coverage (2010)
No denial for pre-existing conditions eliminated (2014)
No Charge for annual wellness visit (2014)
Guaranteed issue policy (2014)
Modified community ratio (2014)
80 – 85% medical loss ratio (2014)
All plans must provide
Essential Health Benefits
“Essential Health Benefits” requires minimum set of
benefits, with no lifetime of annual coverage limits
Ambulatory patient services
Maternity and newborn care
Mental health and substance abuse coverage
Rehab services and medical devices
Preventative and wellness/chronic disease management
“Free” Preventive Care
Health Delivery Reforms
Facilitating Accountable Care Organizations.
Research on best provider practices
Research on comparative evidence outcomes
Pilot program that pays for outcomes on flat fee
basis rather than fee for service for treatments
Standards for extended living arrangements
Hospice, home-health reimbursement
Health Care Clinics
Primary Care Training
Grants to States
Diversity and Cultural Competency
Education Curricula Development in Health Sciences
New Jersey‟s Cost Spiral
Premiums have increased on average 14%
per year, for 12 consecutive years
N.J. Employer-Plan Crisis
Premiums have grown 5-times faster than wages
2000 – 2010, cost of family policy has gone up
110% in New Jersey.
Average employee contribution has gone up 200%
Out-of-pocket and co-payments have gone up
115% since 2000.
N.J. Small Employer Benefits
2011 – 770,000 covered lives
Down 17% from 2000
(Affiliated Physicians and Employers
Health Plan has increased 48%)
Affordable Care Act will provide
subsidies and tax breaks to individuals
and small employers for the purchase
The Health Insurance Exchange
Uninsured individuals not eligible for Medicare or
Medicaid will be permitted to purchase insurance
through state Exchanges (purchasing pools).
Employers with fewer than 100 employees will be
permitted to enroll.
Employer eligibility may be expanded in 2017.
13 states and the District of Columbia,
have passed a heath care exchange law
On May 10, 2012 Governor Christie
vetoed the N.J. Health Exchange Act.
Minimum Essential Coverage
(the Individual Mandate 2014)
A federal requirement that individuals
purchase health care insurance or pay
penalty up to 2.5% of income as
penalty or capped at $95 in 2015 rising
to $695 in 2016.
Hospitals, physicians, insurance
companies and others agree that without
the Individual Mandate the consumer
protection and benefits reforms would
ruin the health care market
Will the U.S. Supreme Court declare the
Affordable Care Act constitutional?
Florida v. Dept. HHS
11th Cir. Court of Appeals (2011)
Individual Mandate is unconstitutional
Seven Sky v. Holder
U.S. Court of Appeals – DC (2011)
Individual Mandate is constitutional
Thomas Moore Center v. Oblama
6th Cir. Court of Appeals (2011)
Individual Mandate is constitutional
What will the Court do?
Uphold the Act in its entirety.
Invalidate the Individual Mandate but
leave the rest of the Act intact.
Invalidate the entire Act.
Dismiss case as premature