Affordable Care Act - The Decision Is In (What is included, what is not and how much does it all cost.) A presentation for the Palm Beach County Partnership for Aging by Paul Gionfriddo of Our Health Policy Matters. 705 South Palmway Lake Worth FL 33460 561-307-5588

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2.  What the Court Decided.
 The Effect of the Court’s Decision on You
and Me.
 What the Decision Means for the Future of
Medicare and Medicaid.
 A Gathering Storm – Public Policy and
Health in the Post-ACA World.
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7. 17
13.7 14.3
13 12.8
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8.  Is the individual mandate constitutional either
because it relates to interstate commerce or
because it is a tax?
 Is the Medicaid expansion to 133% of
poverty constitutional, or does it “coerce”
states into participating in Medicaid?
 If either answer is no, can the
unconstitutional part be “severed” from the
rest of the law?
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9.  Individual mandate is constitutional, but not
as a “command” under Commerce
Clause, but because it is a tax.
 Mandatory Medicaid expansion is
unconstitutional; states can opt out of
expansion and keep their existing Medicaid
programs.
 Unconstitutional portion is severable from
the rest of the law.
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10.  “It is estimated that four million people each
year will choose to pay the IRS rather than
buy insurance. … That Congress apparently
regards such extensive failure to comply with
the mandate as tolerable suggests that
Congress did not think it was creating four
million outlaws. It suggests instead that the
shared responsibility payment merely
imposes a tax citizens may lawfully choose
to pay in lieu of buying health insurance.”
Roberts Decision, p.37-38 10

11.  “Nothing in our opinion precludes Congress
from offering funds under the Affordable
Care Act to expand the availability of health
care, and requiring that States accepting
such funds comply with the conditions on
their use. What Congress is not free to do is
to penalize States that choose not to
participate in that new program by taking
away their existing Medicaid funding.”
Roberts Decision, p. 55
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13.  Subsidies for families earning up to
$91,000+.
 Medicaid eligibility up to 133% of poverty.
 Equitable pricing of mental health benefits.
 Consumer protections – pre-existing
condition coverage, no cancellations for
chronic illnesses, no annual/lifetime
caps, children stay on parents’ plan until age
26.
 Mandated minimum loss ratios of 80% to 13

14.  Medicare pays out 93-96 cents for every $1
in.
 $1.1 billion in ACA-mandated 2012 rebates
to private insurance company customers by
plans not meeting 80-85 cent MLR
requirements.
 Over $124 million in rebates to1.25 million
Florida residents.
 Average rebates in FL: $94 (large
group), $190 (small group), $240 (individual).
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15. Population Winner or Loser?
 You or your family  Winner – no
member has a chronic exclusions for pre-
disease or existing conditions for
condition, such as anyone as of 2014.
mental  Jury’s Out – newly
illness, cancer, heart Medicaid eligible
disease, or diabetes. people in a state
Affects 133 million thinking of opting out
people. of the Medicaid
expansion.
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16. Population Winner or Loser
 You are a Medicare  Winner. Donut hole
recipient. Affects 48 closes and prevention
million people. services are intact.
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17. Population Winner or Loser
 You want a single  Loser. Maybe next
payer, Medicare-for-all generation.
program or you want a
totally market-driven
insurance system with
little or no government
involvement.
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18. Source: CMS Projections, 2012
34% 33%
2011 2021
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20.  Assets as of 1/1/11: $344 billion
 2011 Income: $530 billion
 2011 Expenditures: $549 billion
 Assets as of 1/1/12: $325 billion
 Enrollment: 48.7 million (8.3 million disabled)
 Average benefit per enrollee: $12,042
 Part D (Drug) benefit only: $1,870
Source: Medicare Trustees Annual Report, 2012
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21.  Medicare did not contribute to the debt.
 Medicare funding deficit is a downstream
threat – trust fund has enough money for 12
more years.
 To keep Medicare as we know it solvent for
75 more years, Medicare taxes would have
to increase by 0.67% on Medicare taxpayers
and 0.67% on their employers.
Source: Medicare Trust Fund Trustees 2012 Report
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22. 12.0%
Source: Medicare
10.0% Trustees Annual
Report, 2012
8.0%
Current - With ACA
6.0%
ACA Provider Cuts
4.0% Overridden
All ACA Cuts Overridden
2.0%
0.0%
Current FY2040 FY2085
Year
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23.  3.6 million donut hole recipients saved drug
money in 2011.
› Florida: 238,362
 Total savings: $2.1 billion
› Florida: $142 million
 Savings per person: $604
› Florida: $596
Source: CMS Fact Sheet, 2/2/2012
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24.  14.3 million Medicare recipients received at
least one free preventive service during the
first 5+ months of 2012.
Source: CMS Release, June 11, 2012
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25. Current and Projected Medicare and
Medicaid Costs (Billions)
Medicare Medicaid
Source: CMS 2012 Projections $1,006.90 $957.30
$590.80 Federal
$458.90 61%
2012 2021
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26.  Florida family Medicaid eligibility limit 2012:
$23,052 for a family of four.
 Medicaid eligibility to 133% of poverty -
$30,700 for a family of four (2012).
 Fed pays 100% of the expansion cost first
three years, 90% thereafter.
 Affects 17 million people nationally.
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28. Source: FL Attorney General Pam Bondi, Supreme Court Brief, 2012
$574,000,000
$351,000,000
Currently Medicaid Newly Eligible Because
Eligible, But Not Enrolled of ACA
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29.  Effects on people with mental illnesses and
other chronic conditions.
 Affects basic benefits package – would not
have to cover all mandated services or
drugs.
 Affects single adults with chronic
conditions/disabilities, because single adults
are among those newly eligible for Medicaid.
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31. Prevention, not treatment, accounts
for half of our health gains over the
last century.
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33.  29,000 local public health employees were
lost between 2008 and 2010.
› NACCHO Survey, March 2011
 “Cuts to Essential Public Health Services
Jeopardize Americans’ Health”
› ASTHO Press Release, April 2011
 FL cut $55.6 million and 229 FTEs from
DOH in 2011.
› Health News Florida, August 2011
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34.  Started with $16 billion over ten years – less
than 2% of overall ACA funding.
 $5 billion cut in February 2012 to help fund
payroll tax cut, unemployment benefits, and
MD Medicare payments.
 House voted complete repeal in April 2012.
(Current U.S. Senate will not agree.)
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35.  The SCOTUS ruling doesn’t end the debate.
 According to an AP/GfK poll released in
June, 77% of the public still wanted the
President and Congress to work on health
reform.
 Will a market-based approach, including
Medicare privatization, get more traction in
Congress as it becomes a focal point of
Romney’s campaign for President?
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36.  High risk pools for  Adverse selection and
people with chronic high cost.
illnesses.  Would eventually
 Prevent discrimination affect nearly
against people with everyone, because
pre-existing conditions over 25% of us have a
only if they maintain lapse in coverage each
continuous coverage. year.
 Insurance sale  Plans to be regulated
across state lines. to the lowest state
 Medicaid block grant to standard.
states.  More uninsured and
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39. Thank you!
http://pgionfriddo.blogspot.co
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