On October 23rd, 2014, we updated our
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Medicaid eligibility for the poorest uninsured. If, e.g., up to 133% FPL, 17.0 million uninsured qualify.
Most important question:
State financial responsibility
BTW: What is the federal poverty level (FPL)? 22,050 4 3,740 Each additional person 18,310 3 14,570 2 $10,830 1 Annual income in 2009 Household size
New subsidies for those with incomes between Medicaid levels and 400% of FPL. Eligible would be, e.g., 16.3 million uninsured from 133% to 400% FPL. Questions:
How much of a subsidy, for premiums and out-of-pocket costs?
Is the subsidy provided as a tax credit? Or a “spending side” payment to health plans?
What “firewalls” prevent subsidies from funding abortions?
Do legal immigrants qualify during their first 5 years in the U.S.?
What happens to CHIP?
Affordability (4-person family; Dad, age 53) Note: shows 2009 costs as if proposal fully implemented. House (Tri-Cmt) HELP SFC $5,954 $5,226 $7,938 $66,150 300% FPL $2,205 $1,455 $3,087 $44,100 200% FPL $992 $0 $1,488 $33,075 150% FPL Premiums Annual income FPL
Health Insurance Exchange
Consumers not offered employer-sponsored insurance (ESI) can select from multiple plan options. Small firms can pay premiums so their workers buy through the exchange. Consumers picking costly plans pay higher premiums.
Is a public option available in the exchange?
Can large firms access the exchange?
Is the exchange run by the federal government? By a state-level entity?
Does the exchange negotiate with health plans for lower prices and higher quality?
Can undocumented immigrants or their employers buy coverage through the Exchange?
Individual and employer responsibility
Individual who lack health coverage are penalized, unless they cannot afford insurance
How is affordability determined?
Employers above a certain size must either offer coverage or pay the government
Payroll tax or free rider charge?
New rules for insurers
All health insurance must meet federal minimum benefit standards (e.g., preventive care, lifetime or annual caps, actuarial value minimum)
What rules apply to ESI?
How extensive are the standards? (E.g., medical loss ratio, cultural competence, etc.)
What happens to people who, today, have coverage that violates the new standards?
Insurers face new limits on their ability to discriminate against costly consumers
How much can premiums vary based on age? 2:1? 5:1?
What happens before the individual mandate and subsidies come on line?
Slowing cost growth
With Medicare, Medicaid [and a public plan], experiment with innovations that shift incentives from volume to value, better manage chronic care, etc.
Fund comparative effectiveness research to better inform decisions by insurers, providers, and patients
Transparency – more info from providers, more usable info from insurers, conflict-of-interest reports, etc.
New investment in Health Information Technology
Health reform legislation will not add to the deficit. Slowed cost growth in Medicare and Medicaid, along with new revenue, will pay for the new costs
What level of new costs is acceptable?
How will Medicare cost-growth be slowed?
Agreed: cut Medicare Advantage, change certain provider payment and drug rebate rules, reduce payments for uncompensated care
Question: A base-closing-type commission for Medicare?
How will revenue be raised?
Taxing unusually expensive insurance? Taxing the wealthy? Taxing the health care industry?
A final conundrum
Insurance reforms are wildly popular
For insurance reforms, individual mandate needed
For individual mandate, affordable coverage needed
For affordable coverage, costly subsidies needed
Bottom line: for insurance reforms, costly subsidies are needed