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Health Policy Symposium
Elena Marks
Episcopal Health Foundation
June 11, 2016
Time for a Reality Check on Health Insurance
• Learn the basics of the coverage provisions of
the Affordable Care Act
• Le...
Health Insurance Coverage Provisions of
the ACA
History of Health Insurance in US
Source: PBS available at http://www.pbs.org/healthcarecrisis/history.htm
1910’s
Railroad...
ACA’s Initial Objective: Access
A Core Objective of the ACA was
to Expand Access to Health Care
In the US, Access to Healt...
Coverage Provisions in ACA:
Publicly Funded Plans
Medicaid
expansion to
138% FPL
($16K/year for
one; $34K/year
for 3)
Mark...
Coverage Provisions in the ACA:
None Out—All In
No pre-existing
condition exclusions
but
(almost) everyone
must have cover...
Coverage Provisions in the ACA:
New Health Plan Regulations
Changes to Private
Insurance
• Kids on parents’ plans til 26
•...
Texas and the ACA’s Coverage Provisions
Texas on the Eve of the ACA
Insured
19,564,000
76%
Undocumented
15%
ACA
Marketplace
Subsidy
Eligible
36%
No
Subsidy
11%
Un...
Texas on the Eve of the ACA:
Demographics of Uninsured Texans
Source: Current Population Survey, Annual Social and Economi...
Pre-2014 Experiences:
Affordability of Care by Insurance Status
7.2%
27.9%
17.9%
21.3%
13.4%
13.1%
14.4%
13.2%
40.6%
25.2%...
Pre-2014 Experiences:
Affordability of Care by Income
11.3%
40.6%
25.9%
30.1%
19.8%
31.5%
30.8%
11.5%
37.8%
23.5%
28.1%
19...
10.9% 9.0%
13.4%
13.4% 15.1%
17.7%
32.5% 30.6%
21.5%
16.6%
14.5%
11.8%
26.5%
30.2% 24.9%
0%
10%
20%
30%
40%
50%
60%
70%
80...
Pre-2014 Experiences:
Expectations about ACA
Texas Post-ACA Implementation
8.0
10.0
12.0
14.0
16.0
18.0
20.0
22.0
24.0
26.0
Q3 2013 Q1 2014 Q2 2014 Q1 2015 Q3 2015 Q1 2016
Percentage
U.S.
Texas
Sou...
Uninsured by Race/ethnicity and Age
Texans ages 18-64, 2013 to 2016
14.3
18.7
42.6
9.9
14.2
30.7
0 5 10 15 20 25 30 35 40 ...
Uninsured by Income and Gender
Texans ages 18-64, 2013 to 2016
54.1
46
22.7
13.1
0 10 20 30 40 50 60
1
2
Uninsured by Fami...
Texans Covered by ACA Marketplace Plans during
Open Enrollment Periods
733,757
918,890
1,306,208
0
200,000
400,000
600,000...
Texas Enrollment in Marketplace Plans by Income,
January 2016
48,279
4%
531,073
44%
277,606
23%
168,978
14%
84,489
7%
72,4...
Texas Enrollment in Marketplace Plans By
Race/Ethnicity, January 2016
0
0
8,531
1%
75,156
9%
125,261
15%
308,977
37%
317,3...
The Impact of Texas’ Refusal to Expand
Medicaid
Texas: Public Insurance pre-ACA
ACA’s Public Insurance Schema
Texas: Public Insurance post-ACA
~1 million
Texans
Trends in Uninsured Rates
2013 to 2016, Texas and US
Post-2014 Experiences:
Reasons for Remaining Uninsured, September 2015
Post-2014 Experiences:
Perceptions of Tax Penalties
22%
31%
26%
21%
Importance of the Possibility of a Fine to Uninsured
A...
Thorny Issues for Consumers, Providers,
and Payers
Consumer Concerns
Cost
Provider selection
Surprise bills
Provider Concerns
Panels Reimbursement rates What’s next?
Payer Concerns
Change
It takes two to tango
Cost control
Life Expectancy
Source: D. Squires and C. Anderson, U.S. Health Care from a Global Perspective: Spending, Use of Services,...
Infant Mortality
Source: D. Squires and C. Anderson, U.S. Health Care from a Global Perspective: Spending, Use of Services...
Social Determinants of Health
Where We Invest
Social and Economic
Factors
- Education
- Employment
- Income
- Family and Social
Support
- Community Safe...
The Following Presenters Have Disclosed Relevant Financial Relationships:
Cedric Dark, MD MPH FAAEM FACEP
Community Health...
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Time for a Reality Check on Health Insurance

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Presentation by Elena Marks, JD, MPH for the Third Annual Policy Prescriptions® Symposium

Elena M. Marks is the president and chief executive officer of the Episcopal Health Foundation and a nonresident fellow in Health Policy at Rice University’s Baker Institute for Public Policy.

Marks previously served as the director of Health and Environmental Policy for the City of Houston. Prior to joining the mayor’s staff, Marks practiced trial and appellate law with major law firms, started and directed a successful legal placement firm, and developed strategic, long-range, and operating plans for service lines and system centers at a major health system.

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
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Time for a Reality Check on Health Insurance

  1. 1. Health Policy Symposium Elena Marks Episcopal Health Foundation June 11, 2016
  2. 2. Time for a Reality Check on Health Insurance • Learn the basics of the coverage provisions of the Affordable Care Act • Learn about the impact of the coverage provisions in Texas • Learn about particular features of ACA marketplace plans of concern to consumers and physicians
  3. 3. Health Insurance Coverage Provisions of the ACA
  4. 4. History of Health Insurance in US Source: PBS available at http://www.pbs.org/healthcarecrisis/history.htm 1910’s Railroads provide employee medical care 1930’s Social Security Act; Blue Cross offers hospital care insurance 1940’s Employer sponsored plans arise 1960’s Medicaid and Medicare enacted 1980’s Managed Care 1990’s Costs rise at 2X inflation; Clinton plan dies 2000’s Unsustainable cost curve; poor outcomes 2010 Affordable Care Act
  5. 5. ACA’s Initial Objective: Access A Core Objective of the ACA was to Expand Access to Health Care In the US, Access to Health Care = Access to Health Insurance 50 Million Americans Lacked Health Insurance in 2010
  6. 6. Coverage Provisions in ACA: Publicly Funded Plans Medicaid expansion to 138% FPL ($16K/year for one; $34K/year for 3) Marketplace with subsidized plans for 100% to 400% FPL (400%= $47K for one; $97K for 3)
  7. 7. Coverage Provisions in the ACA: None Out—All In No pre-existing condition exclusions but (almost) everyone must have coverage and large employers must offer affordable coverage
  8. 8. Coverage Provisions in the ACA: New Health Plan Regulations Changes to Private Insurance • Kids on parents’ plans til 26 • Premium rate bands limited to 3:1 based on age, tobacco, location • 80% medical loss ratio • Some preventive services covered without co-pays • Premium increases subject to review
  9. 9. Texas and the ACA’s Coverage Provisions
  10. 10. Texas on the Eve of the ACA Insured 19,564,000 76% Undocumented 15% ACA Marketplace Subsidy Eligible 36% No Subsidy 11% Uninsured 5,591,000 24% Medicaid Eligible but Unenrolled 14% Medicaid Expansion Adults 24% Note: Due to rounding, percents may not total 100% Sources: U.S. Census Bureau. March 2011 Current Population Survey (CPS), Texas Health and Human Services Commission, July 2012.
  11. 11. Texas on the Eve of the ACA: Demographics of Uninsured Texans Source: Current Population Survey, Annual Social and Economic Supplement, 2012 U.S. Census Bureau *Personal Income 1,606,000 25% 610,000 9% 14,000 0% 190,000 3% 3,956,000 62% 50,000 1% Uninsured by Race/Ethnicity White alone Black or African American alone American Indian and Alaska Native alone Asian alone Hispanic Two or more races 1,073,000 18% 4,925,000 81% 81,000 1% Uninsured by Age 00 to 17 18 to 64 65 to 80+ 2,584,000 40% 1,817,000 28% 1,334,000 21% 427,000 7% 135,135 2%53,000 1% 75,000 1% Uninsured by Income* below$2,499 $2,500 to $19,999 $20,000 to $39,999 $40,000 to $59,999 $60,500 to $79,999 $80,000 to $99,999 $100,000+
  12. 12. Pre-2014 Experiences: Affordability of Care by Insurance Status 7.2% 27.9% 17.9% 21.3% 13.4% 13.1% 14.4% 13.2% 40.6% 25.2% 27.5% 21.2% 32.3% 29.7% Mental health care or counseling Dental care Medical tests and treatment Prescription drugs Specialist care General primary care Medical Care Skipped Care, September 2013 By Household Income as a Percent of the Federal Poverty Level (FPL) Uninsured Insured
  13. 13. Pre-2014 Experiences: Affordability of Care by Income 11.3% 40.6% 25.9% 30.1% 19.8% 31.5% 30.8% 11.5% 37.8% 23.5% 28.1% 19.0% 17.0% 20.4% 2.6% 14.3% 9.7% 10.6% 7.2% 5.4% 4.4% Mental health care or counseling Dental care Medical tests and treatment Prescription drugs Specialist care General primary care Medical Care Skipped Care, September 2013 By Household Income as a Percent of the Federal Poverty Level (FPL) 400+% FPL 139-399% FPL <=138% FPL
  14. 14. 10.9% 9.0% 13.4% 13.4% 15.1% 17.7% 32.5% 30.6% 21.5% 16.6% 14.5% 11.8% 26.5% 30.2% 24.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Age 18-24 Age 35-49 Age 50-64 General Opinion of the ACA in TX by Age, Sept 2013 14.3% 8.3% 11.2% 16.2% 15.7% 13.9% 37.9% 29.9% 19.6% 8.2% 12.8% 21.7% 23.1% 33.0% 33.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <=138% 139-399% >=400% General Opinion of the ACA in TX by Income, Sept 2013 7.6% 18.0% 13.6% 9.8% 38.2% 15.3% 19.3% 20.8% 42.7% 18.4% 7.9% 11.2%44.1% 14.7% 17.1% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% White Black Hispanic General Opinion of the ACA in TX by Race/Ethnicity, Sept 2013 Pre-2014 Experiences: Opinion of the ACA by Age, Income, Race
  15. 15. Pre-2014 Experiences: Expectations about ACA
  16. 16. Texas Post-ACA Implementation
  17. 17. 8.0 10.0 12.0 14.0 16.0 18.0 20.0 22.0 24.0 26.0 Q3 2013 Q1 2014 Q2 2014 Q1 2015 Q3 2015 Q1 2016 Percentage U.S. Texas Source: Health Reform Monitoring Survey and HRMS TX. Estimates are regression adjusted. Uninsured by Race/ethnicity and Age Texans ages 18-64, 2013 to 2016 Trends in Uninsurance for Texas Adults Ages 18-24
  18. 18. Uninsured by Race/ethnicity and Age Texans ages 18-64, 2013 to 2016 14.3 18.7 42.6 9.9 14.2 30.7 0 5 10 15 20 25 30 35 40 45 White, non-Hispanic Black/other, non-Hispanic Hispanic Uninsured by Race/Ethnicity 26.4 28.1 21.1 20.7 21.6 10.3 0 5 10 15 20 25 30 18-30 31-49 50-64 Uninsured by Age Mar 2016 (%) Sep 2013 (%)
  19. 19. Uninsured by Income and Gender Texans ages 18-64, 2013 to 2016 54.1 46 22.7 13.1 0 10 20 30 40 50 60 1 2 Uninsured by Family Income Between 139% and 399% of FPL At or below 138% or FPL 22.3 14.9 28.4 20.7 0 5 10 15 20 25 30 1 2 Uninsured by Gender Female Male
  20. 20. Texans Covered by ACA Marketplace Plans during Open Enrollment Periods 733,757 918,890 1,306,208 0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 1,400,000 Oct 2013-Mar 2014 Nov 2014-Jan 2015 Nov 2015-Jan 2016 Texas Enrollees from Open Enrollment
  21. 21. Texas Enrollment in Marketplace Plans by Income, January 2016 48,279 4% 531,073 44% 277,606 23% 168,978 14% 84,489 7% 72,419 6% 24,140 2% - 100,000 200,000 300,000 400,000 500,000 600,000 <100% of FPL >100% to <150% of FPL >150% to <200% of FPL >200% to <250 %of FPL >250% to <300% of FPL >300% to <400% of FPL > 400% of FPL Fig. 8: Enrollment by Household Income
  22. 22. Texas Enrollment in Marketplace Plans By Race/Ethnicity, January 2016 0 0 8,531 1% 75,156 9% 125,261 15% 308,977 37% 317,327 38% 0 50,000 100,000 150,000 200,000 250,000 300,000 350,000 Native Hawaiian/Pacific Islander American Indian/Alaska Native Multiracial African-American Asian Latino White
  23. 23. The Impact of Texas’ Refusal to Expand Medicaid
  24. 24. Texas: Public Insurance pre-ACA
  25. 25. ACA’s Public Insurance Schema
  26. 26. Texas: Public Insurance post-ACA ~1 million Texans
  27. 27. Trends in Uninsured Rates 2013 to 2016, Texas and US
  28. 28. Post-2014 Experiences: Reasons for Remaining Uninsured, September 2015
  29. 29. Post-2014 Experiences: Perceptions of Tax Penalties 22% 31% 26% 21% Importance of the Possibility of a Fine to Uninsured Adult Texans, March 2015 Very important Somewhat important Not too important Not at all important
  30. 30. Thorny Issues for Consumers, Providers, and Payers
  31. 31. Consumer Concerns Cost Provider selection Surprise bills
  32. 32. Provider Concerns Panels Reimbursement rates What’s next?
  33. 33. Payer Concerns Change It takes two to tango Cost control
  34. 34. Life Expectancy Source: D. Squires and C. Anderson, U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries, The Commonwealth Fund, October 2015 9 10 12 11 12 9 9 12 11 8 16 11 10 21 18 15 11 16 21 20 15 9 82.2 81.5 82.3 80.9 81.4 81.4 81.8 82.0 82.9 81.1 78.8 75 76 77 78 79 80 81 82 83 84 85 0 5 10 15 20 25 30 35 40 AUS CAN FR GER NETH NZ NOR SWE SWIZ UK USA LifeExpectancyatBirthinYears HealthandSocialCareSpendingasaPercentageofGDP Health Care Social Care Life Expectancy
  35. 35. Infant Mortality Source: D. Squires and C. Anderson, U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries, The Commonwealth Fund, October 2015 9 10 12 11 12 9 9 12 11 8 16 11 10 21 18 15 11 16 21 20 15 9 3.6 4.8 3.6 3.3 3.8 5.2 2.4 2.7 3.9 3.8 6.1 2 3 4 5 6 7 8 0 5 10 15 20 25 30 35 40 AUS CAN FR GER NETH NZ NOR SWE SWIZ UK USA InfantMortalityper1,000LiveBirth HealthandSocialCareSpendingasaPercentageofGDP Health Care Social Care Infant Mortality
  36. 36. Social Determinants of Health
  37. 37. Where We Invest Social and Economic Factors - Education - Employment - Income - Family and Social Support - Community Safety Health Behaviors - Tobacco Use - Diet and Exercise - Alcohol and Drug Use - Sexual Activity Physical Environment Clinical Care - Access to Care - Quality of Care - Hospital Care - Physician and Clinical Services - Dental Services - Home Health Care - Nursing Care Facilities, Continuing Care Communities - Prescription Drugs - Durable Medical Equipment - Government Administration - Net Cost of Health Insurance - Research - Structures and Equipment 40% 30% 10% 20% 98% Determinants of Health 2014 National Health Expenditures Public Health 2% $79 billion $2.9 trillion Medical Services
  38. 38. The Following Presenters Have Disclosed Relevant Financial Relationships: Cedric Dark, MD MPH FAAEM FACEP Community Health Choice, Event Sponsorship; Schumacher Clinical Partners, Event Sponsorship Seth Trueger, MD MPH Emergency Physicians Monthly, Employee, Salary The Following Presenters Have Disclosed No Financial Relationships: Megan Douglas, JD Elena M. Marks, JD MPH Laura Medford-Davis, MD Bich-May Nguyen, MD MPH The Following Planners Have Disclosed Relevant Financial Relationships: Cedric Dark, MD MPH FAAEM FACEP Community Health Choice, Event Sponsorship; Schumacher Clinical Partners, Event Sponsorship The Following Planning Committee Members and Staff Have Disclosed No Relevant Financial Relationships: Emily DeVillers, CAE Kay Whalen, MBA CAE Janet Wilson, CAE Disclosure

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