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Pres m nsure_jan14_blewettsonier

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  • 1. Lynn A. Blewett, Ph.D. Professor, Division of Health Policy and Management, University of Minnesota School of Public Health Julie J. Sonier, MPA Sr. Research Fellow and Deputy Director, SHADAC We are grateful to the State Health Reform Assistance Network, an initiative of the Robert Wood Johnson Foundation, for supporting this work.
  • 2. 1. What problem istext stylestrying to solve? Click to edit Master the ACA • Minnesota and National Context Second level 2. Access level Expansions in the Affordable Care Act Third • Medicaid Expansion Fourth level • Health Insurance Exchange Fifth level 3. Policy Issues for the Exchange 4. What’s next? 5. Q&A 2
  • 3. Click to edit Master text styles • 50 million uninsured Second level – Erosion of employer Third level sponsored insurance Fourth cost • Unsustainable level growth Fifth level • Adverse selection in insurance markets • Lack of consumer info to compare options • Increase access to affordable, comprehensive coverage through targeted subsidies • Improve overall affordability of coverage • Spread risk more broadly across the population • Organize/present plan comparisons 3
  • 4. Click to edit Master text styles 60 Second level Millions of uninsured people Third level Fourth level Fifth level 50 40 30 20 10 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 4
  • 5. Click to edit Master text styles Second level Third level Fourth level Fifth level 5
  • 6. Click toDistribution of Minnesota Population by Primary Source of edit Master text styles Second level Insurance Coverage Uninsured 9% Third level Fourth level Fifth level Public Coverage 28% EmployerSponsored Coverage 58% Non-Group Coverage 5% MDH Health Economics Program (data for 2010) 6
  • 7. Click to edit Master text styles 100% Second level 80% 60% Third level Fourth level Fifth level Minnesota U.S. 40% 20% 0% Fewer 10 - 24 than 10 25 - 99 100 999 1000+ All firm sizes Source: 2012 MEPS-IC, Table IIA2 7
  • 8. Click to edit Master text styles 100% Second level 80.4% Third level 80% Fourth level 60% Fifth level 69.7% 71.4% 59.5% Minnesota U.S. 40% 20% 0% 2000 2011 Source: SHADAC, State-Level Trends in Employer-Sponsored Health Insurance: A State-byState Analysis. April 2013. 8
  • 9. Click to edit Master text styles • Medicaid expansion Second level • Subsidies for private insurance – through health Third level Fourth level insurance exchanges Fifth level • Requirement for individuals to have health insurance (“individual mandate”) • Employer provisions – incentives and penalties • Changes to private insurance market rules 9
  • 10. Click to edit Master text styles Second level Third level Fourth level Fifth level 10
  • 11. • Peopleedit Master text below 138% of poverty guidelines* are Click to with family incomes styles eligible for Medicaid as of January 2014 Second level • 2012 Supreme Court decision made this optional for states Third level • Goal was to simplify eligibility – no more variation by family status, Fourth level age Fifth level • ACA expansion of eligibility mostly affects adults, since children are already eligible for Medicaid or CHIP at this income level in all states • Only applies to U.S. citizens and legal immigrants in the country for more than 5 years *The poverty level for a family of four is currently $23,550 11
  • 12. Click to edit Master text styles 250% 350% 300% Second 250% 200% level Third level Fourth level 185% Fifth level ACA Medicaid Expansion to 138% FPL 150% 22 million 63% Low-Income 37% Uninsured Adults 19-64 100% 50% 0% Children Pregnant Women Working Parents Jobless Parents 0 Childless Adults Source: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012. 12
  • 13. Click to edit Master text styles The following are differences across states that will affect Second level enrollment: Third level • • • • • Fourth level Fifth level Medicaid expansion is now optional for state Current Medicaid enrollment and eligibility Current Levels of Private Coverage Levels of outreach and enrollment activities Attitudes toward government programs 13
  • 14. Click to edit Master text styles Second level Third level Fourth level Fifth level 14
  • 15. Click to edit Master text styles Second level Third level Fourth level Fifth level 15
  • 16. ClickIndividuals are required to maintain minimum essential • to edit Master text styles Second level themselves and their dependents. coverage for Third level • Rationale: other changes to market rules (guaranteed issue,Fourthlifetime benefit limits, ect.) will not work unless no level Fifth level healthy people participate. • Those who do not meet the mandate will be required to pay a penalty for each month of noncompliance: Once fully phased in, annual penalty of $695 per person or 2.5% of income, whichever is greater 16
  • 17. Click to edithardshiptext styles • Financial Master Second level Religious objections Third level American Indians and Alaska Natives Fourth level Incarcerated level individuals Fifth Those for whom the lowest cost plan option exceeds 8% of income, and • Those whose income is below the tax filing threshold • • • • And the Undocumented 17
  • 18. • Tax creditsMaster text styles (≤ 25 employees) and Click to edit for small employers average level wages below $40K who provide health Second annual insurance Third level • • For 2010-2013: Up to 35% of employer’s premium contribution, Fourth level depending on employer’s size and average annual wage Fifth level For 2014 and beyond: Up to 50% of employer’s premium contribution for employers that purchase coverage through Exchange, depending on employer’s size and annual wage • Can only receive credit for 2 years 18
  • 19. • Employers subject to penalties if no coverage offered and at least one Click to edit Master text styles employee receives tax credits through an Exchange Second level • $2,000 multiplied by the # of full-time workers employed (minus Third level first 30 workers) Fourth level • Does not apply to businesses with fewer than 50 full-time workers Fifth level • Delayed to 2015 • Employers with > 200 employees must automatically enroll them into health insurance • Employees can opt out of the coverage 19
  • 20. • Employers also have the option to buy insurance through an exchange Click to edit Master text styles • Limited to employers with fewer than 100 workers through 2016 Second level (States can choose to limit employer size to 50 initially) Third level • States can expand to all employers beginning in 2017 Fourth level • States can choose to combine the individual and employer Fifth level exchanges, and/or merge these 2 insurance markets • Beginning in 2014, small employer tax credits available only to employers that purchase through the exchange 20
  • 21. ClickReviewed nearly 6,000 health insurance plans • to edit Master text styles marketed Second level to individuals and families across US Third 285 • Out oflevel plans in Minnesota, no coverage for • • • Fourth level Labor and delivery Fifth level in 195 (apx 70%), Mental health services in 170, and Specialty drugs in 80 • The median deductible in Minnesota - $5,000, five times as high as in Massachusetts Source: US World News and Report http://bit.ly/TH1ldF 21
  • 22. • Ambulatory patient services Click to edit Master text styles • Emergency services •Second level Hospitalization Third level • Maternity and newborn care Fourth level • Mental health and substance use disorder services, includingFifth level health treatment behavioral • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management, and • Pediatric services, including oral and vision care 22
  • 23. • No pre-existing text styles Click to edit Mastercondition exclusions • Second levelor annual limits on coverage No lifetime Third level • First-dollarlevel coverage for preventive services Fourth Fifth level 23
  • 24. Click to edit Master text styles Second level Third level Fourth level Fifth level 24
  • 25. Click to edit an Exchange under the ACA? • What is Master text styles Second level web-based marketplace • A (primarily) • Third level information on health insurance coverage Organizes Fourth level options Fifth level • Provides comparison across plans with respect to premiums, cost-sharing, coverage and quality ratings • Consumers can select and enroll in coverage through the Exchange • Vehicle for administering premium tax credits and cost sharing subsidies 25
  • 26. Click to edit Master text styles • Those who purchase in coverage Second level in the individual and small group market Third level - <50Fourth level employees Fifth level • Don’t have same leverage as large employers when purchasing coverage • Apx 12% of MN population gets coverage in small group or non-group markets pre-ACA 26
  • 27. Click to edit Master text styles • Amount level Second of credit is a sliding scale based on income • Third level subsidies for families with incomes up to 400% Premium Fourth level of poverty Fifth level • In addition, cost sharing subsidies up to 250% of poverty • Reduces deductible and other enrollee out of pocket costs • Available in silver level plans only 27
  • 28. Click to premium contribution, based on income for family of four in 2013: Maximum edit Master text styles Second level 300-400% FPL Third level 9% of income Fourth level 250-300% FPL 8.05-9% of income Fifth level 6.3-8.05% of income 200-250% FPL 4-6.3% of income 150-200% FPL 3-4% of income 138-150% FPL <138% FPL 2% of income $0 $2,000 $4,000 $6,000 $8,000 $10,000 28
  • 29. Click to edit Master text styles Second level Third level Fourth level Fifth level 29
  • 30. • States have a lot oftext styles how to establish and run the Click to edit Master control over exchange – for example, whether to be selective about what Second level health plans can be sold through the exchange Third level • In states that do not establish their own exchanges, the Fourth level Fifth level federal government will establish and operate an exchange 30
  • 31. Click to edit Master text styles Second level Third level Fourth level Fifth level 31
  • 32. • Levels of coverage (bronze, Click to edit Master text styles silver, gold, platinum) correspond to enrollee cost sharing requirements Second level • • • Third level Deductibles Fourth level Coinsurance Fifth level Rx copays, etc. • Tradeoffs between premiums and cost sharing depend on individuals’ expectations about how much care they will need 32
  • 33. Monthly Exchange Premium for Second-Lowest Cost Silver Plan Click to edit Master text styles 450 400 Second 350 300 250 level Third level Fourth level Fifth level 200 150 100 50 0 CA CO CT KY MA ME MN MS MT NH NY NV RI VT WA Source: Breakaway Policy Strategies and the Robert Wood Johnson Foundation, “Looking Beyond Technical Glitches: A Preliminary Analysis of Premiums and Cost Sharing in the New Health Insurance Marketplaces,” November 2013. 33
  • 34. Average Annual Integrated Deductibles Click to edit Master text styles 4500 4000 Second 3500 level Third level 3000 Fourth level Fifth level 2500 2000 1500 1000 500 0 CO KY MA ME MN MS MT NV RI WA Source: Breakaway Policy Strategies and the Robert Wood Johnson Foundation, “Looking Beyond Technical Glitches: A Preliminary Analysis of Premiums and Cost Sharing in the New Health Insurance Marketplaces,” November 2013. (Policies with a single deductible for medical and rx expenses combined 34
  • 35. Click to edit Master text styles • Too early to draw conclusions from this preliminary Second level data onlevel Third premiums and cost sharing • Fourth level Need to know what consumers actually buy in the Fifth level exchanges vs. what is being offered for sale • Will likely take some time for markets to sort out in both Minnesota and other states over the next couple of years 35
  • 36. Click to edit Master text styles • Churn & continuity of providers Second level • Third level especially concerned about churn between States are Fourth and Medicaidlevel the exchange Fifth level • Breadth of provider networks (related to continuity of providers) • Demographics of exchange population and market stability • Degree of standardization in health plan choice/design 36
  • 37. 100% Click to edit Master text styles 90% 80% Second 70% 60% 50% level Third level Fourth level Fifth level 40% 30% Eligible for Medicaid/CHIP Eligible for financial assistance Not eligible for financial assistance 20% 10% 0% CA CT HI KY MDMN NV NY OR RI VT WA Source: Department of Health and Human Services, Office of the Assistance Secretary for Planning and Evaluation, “Health Insurance Marketplace: December Enrollment Report for the period: October 1 – November 30,” December 11, 2013. 37
  • 38. Click to edit Master text styles Second level Third level Fourth level Fifth level 38
  • 39. Access expansions of the ACA are targeted to a relatively Click to edit Master text styles small segment of the population in Minnesota Second level low incomes • Those with • • Third level Those without employer-sponsored insurance Fourth level • Small employers • • Fifth level Comprehensiveness of benefits in the individual market has improved – but comes at an additional cost Tradeoffs between premium cost, enrollee cost sharing, and provider networks are an issue that warrants attention and monitoring 39
  • 40. • Payment reform Click to edit Master text styles • Transforming the way we receive and pay for care Second level Third level • Immigrant Populations • Fourth level Not covered by Fifth level Medicaid expansion but represent almost 1/5 low-income non-elderly adult • Baby boomers retiring • Growth of federal entitlements with continued deficit spending • Incremental reform in political battlefield 40
  • 41. Click to edit Master text styles Lynn Second level Blewett Julie Sonier jsonier@umn.edu blewe001@umn.edu Third level Fourth level Fifth level www.shadac.org @shadac