Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

The Affordable Care Act: An Evidence-Based Update

340 views

Published on

Presentation by Seth Trueger, MD, MPH for the Third Annual Policy Prescriptions® Symposium

Seth Trueger is an assistant professor at the University of Chicago, Section of Emergency Medicine.

The symposium is designed for clinicians, healthcare workers, and healthcare executives interested in exploring the major themes that will emerge in health policy throughout the year. This year, the symposium will emphasize value in healthcare, health information technology, gun violence, insurance choices, the Affordable Care Act, and the viewpoints of the Presidential candidates on health care.

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

The Affordable Care Act: An Evidence-Based Update

  1. 1. Seth Trueger MD MPH University of Chicago @MDaware ACA: Evidence-Based Update
  2. 2. DISCLOSURES Emergency Physicians Monthly
  3. 3. (bias?)
  4. 4. Plan ENROLLMENT stats, uninsured PLANS premiums, deductibles narrow networks, balance billing SCOTUS Zubik, House v Burwell PAY/QUALITY readmits v obs, MACRA
  5. 5. ENROLLMENT stolen mostly from Charles Gaba
  6. 6. Kaiser Family Foundation. Health Insurance Coverage in the US, 2011. Kaiser Slides. 19 October 2012. Medicaid, 13% VA/Other, 5% Medicare, 13% Private, Non- group, 5% Employer- Sponsored Insurance, 48% Uninsured 16% 2011
  7. 7. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart Medicaid, 19% VA/other, 6% Medicare, 17% Private, Non- group, 6% Employer- Sponsored Insurance, 43% Uninsured 9% 2016
  8. 8. Medicaid, 1319% VA/other, 6% Medicare, 1317%Private, Non- group, 56% Employer- Sponsored Insurance, 4843% Uninsured, 169%2011 2016
  9. 9. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart Medicaid, 19% VA/other, 6% Medicare, 17% Private, Non- group, 6% Employer- Sponsored Insurance, 43% Uninsured 9% 2016
  10. 10. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  11. 11. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  12. 12. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  13. 13. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  14. 14. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  15. 15. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  16. 16. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  17. 17. http://ccf.georgetown.edu/ccf- resources/medicaid_expansion_positive_impact_safety_net_hospitals_clinics/
  18. 18. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  19. 19. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  20. 20. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  21. 21. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  22. 22. Household 138% FPL 400% FPL 1 $16,242 $47,080 2 $21,983 $63,720 3 $27,724 $80,360 4 $33,465 $97,000 5 $39,205 $113,640
  23. 23. 2016 Enrollment Marketplaces Medicaid
  24. 24. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  25. 25. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  26. 26. 2015 Enrollment 11 million paid QHP 9 million off-Exchange QHP
  27. 27. 2015 Enrollment 11 million paid QHP 9 million off-Exchange QHP 2016 Enrollment 11 million Exchange QHP 6 million off-Exchange QHP 2 million off-Exchange grandfathered
  28. 28. 2015 Medicaid 9 million Medicaid expansion 3.4 million Medicaid woodworkers
  29. 29. 2015 Medicaid 9 million Medicaid expansion 3.4 million Medicaid woodworkers 2016 Medicaid 11 million Medicaid expansion 3.8 million Medicaid woodworkers 0.5 million Basic Health Plan
  30. 30. “Despite concerns about plan cancellations, only 600,000 people starting out with nongroup coverage became uninsured.
  31. 31. “Despite concerns about plan cancellations, only 600,000 people starting out with nongroup coverage became uninsured. Of the 155.8 million people with insurance in September 2013, 80 percent experienced no changes in the source of their insurance during the study period.
  32. 32. “Despite concerns about plan cancellations, only 600,000 people starting out with nongroup coverage became uninsured. Of the 155.8 million people with insurance in September 2013, 80 percent experienced no changes in the source of their insurance during the study period. Among those who were uninsured at baseline, 47 percent remained uninsured at follow-up.”
  33. 33. UNINSURED
  34. 34. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  35. 35. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  36. 36. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  37. 37. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  38. 38. MEDICAID EXPANSION
  39. 39. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/ Medicaid Expansion WY WI* WV WA VA VT UT TX TN SD SC RI PA* OR OK OH ND NC NY NM NJ NH* NV NE MT* MO MS MN MI* MA MD ME LA* KYKS IA* IN*IL ID HI GA FL DC DE CT CO CA AR*AZ AK AL Adopted (32 States including DC) Not Adopting AtThisTime (19 States)
  40. 40. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  41. 41. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
  42. 42. http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf Exchange enrollment by income
  43. 43. http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf Exchange enrollment by income
  44. 44. http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf Exchange enrollment by income
  45. 45. 12% 38% 70% 83% 56% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2014 http://kff.org/slideshow/employer-sponsored-insurance-offer-and-coverage-rates/ <100FPL 100- 250% 250- 400% >400% <65yo ESI by income
  46. 46. PMID 27076474
  47. 47. vs no ACA? 18.1 million reduction in uninsured 46% reduction (nonelderly)
  48. 48. PLANS premiums deductibles narrow networks oh my
  49. 49. my take 2014 rates were low “subsidy equilibrium” rate increase requests ≠ rate increases deductibles??
  50. 50. lower premiums?
  51. 51. “Under the law, no one can be denied coverage because of a pre-existing medical condition.”
  52. 52. BAD THING OTHER BAD THING NOT BECAUSE OF OBAMACARE BECAUSE OBAMACARE MAGNITUDE TIME OBAMACARE BEGAN
  53. 53. narrow networks
  54. 54. balance billing
  55. 55. balance billing out of network ED
  56. 56. balance billing out of network ED insurance has to pay
  57. 57. balance billing out of network ED insurance has to pay how much?
  58. 58. balance billing out of network ED insurance has to pay how much? ED bill balance
  59. 59. SCOTUS Zubik v Burwell & House v Burwell
  60. 60. Zubik v Burwell
  61. 61. Zubik v Burwell Little Sisters
  62. 62. Zubik v Burwell Little Sisters OCPs
  63. 63. Zubik v Burwell Little Sisters OCPs 2 page form
  64. 64. Zubik v Burwell Little Sisters OCPs 2 page form duck
  65. 65. House v Burwell
  66. 66. CSRs Cost Sharing Reductions “the other subsidies” (pork/chicken of the sea)
  67. 67. above: premium subsidies monthly bill 400% FPL CSR: deductibles, copays, coinsurance out of pocket, based on use 250% FPL only Silver+ (not cheaper Bronze) CSRs
  68. 68. CSR uptake
  69. 69. CSR uptake
  70. 70. ¯_(ツ)_/¯
  71. 71. PAYING FOR QUALITY the card says MIPS
  72. 72. Readmissions
  73. 73. Readmissions outpatient network incentives
  74. 74. Readmissions outpatient network incentives 20%!
  75. 75. PMID: 26910198
  76. 76. Readmissions outpatient network incentives 21.5%  17.8% 15.3%  13.1%
  77. 77. penalties? 2015: 80% all 3: 57% (!) https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how- are-we-doing/
  78. 78. penalties? 2015: 80% all 3: 57% (!) https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how- are-we-doing/
  79. 79. penalties? average $100-300k 2013: teaching & safety-net hospitals 2015: more broadly distributed (still gap) https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how- are-we-doing/
  80. 80. Readmission penalties? risk adjustment socioeconomic status ¯_(ツ)_/¯
  81. 81. Readmission penalties? hiding in observation? ¯_(ツ)_/¯
  82. 82. PMID: 26910198
  83. 83. MIPS APM FFS + P4P ACO, CMMI bundles 2019 ±4% 5% bonus 2020 ±5% 5% bonus 2021 ±7% 5% bonus 2022 ±9% 5% bonus 2023 ±9% 5% bonus 2024 ±9% 5% bonus 2025 ±9% 5% bonus 2026+ 0.25%+ baseline annually 0.75%+ baseline annually
  84. 84. ¯_(ツ)_/¯
  85. 85. ntrueger@gmail.com @MDaware

×