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Seth Trueger MD MPH
University of Chicago @MDaware
ACA: Evidence-Based Update
DISCLOSURES
Emergency Physicians Monthly
(bias?)
Plan
ENROLLMENT stats, uninsured
PLANS premiums, deductibles
narrow networks, balance billing
SCOTUS Zubik, House v Burwell
PAY/QUALITY readmits v obs, MACRA
ENROLLMENT
stolen mostly from Charles Gaba
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
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
Medicaid,
1319%
VA/other, 6%
Medicare,
1317%Private,
Non-
group,
56%
Employer-
Sponsored
Insurance,
4843%
Uninsured,
169%2011
2016
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
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
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
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
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
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
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
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
http://ccf.georgetown.edu/ccf-
resources/medicaid_expansion_positive_impact_safety_net_hospitals_clinics/
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
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
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
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
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
2016 Enrollment
Marketplaces
Medicaid
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
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
2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
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
2015 Medicaid
9 million Medicaid expansion
3.4 million Medicaid woodworkers
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
“Despite concerns about plan cancellations, only
600,000 people starting out with nongroup coverage
became uninsured.
“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.
“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.”
UNINSURED
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
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
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
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
EXPANSION
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)
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
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
http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf
Exchange enrollment by income
http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf
Exchange enrollment by income
http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf
Exchange enrollment by income
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
PMID 27076474
vs no ACA?
18.1 million reduction in uninsured
46% reduction (nonelderly)
PLANS
premiums deductibles narrow networks oh my
my take
2014 rates were low
“subsidy equilibrium”
rate increase requests ≠ rate increases
deductibles??
lower premiums?
“Under the law, no one can be denied
coverage because of a pre-existing medical
condition.”
BAD THING
OTHER BAD
THING
NOT BECAUSE
OF
OBAMACARE
BECAUSE
OBAMACARE
MAGNITUDE
TIME
OBAMACARE
BEGAN
narrow networks
balance billing
balance billing
out of network ED
balance billing
out of network ED
insurance has to pay
balance billing
out of network ED
insurance has to pay
how much?
balance billing
out of network ED
insurance has to pay
how much?
ED bill balance
SCOTUS
Zubik v Burwell & House v Burwell
Zubik v Burwell
Zubik v Burwell
Little Sisters
Zubik v Burwell
Little Sisters
OCPs
Zubik v Burwell
Little Sisters
OCPs
2 page form
Zubik v Burwell
Little Sisters
OCPs
2 page form
duck
House v Burwell
CSRs
Cost Sharing Reductions
“the other subsidies”
(pork/chicken of the sea)
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
CSR uptake
CSR uptake
¯_(ツ)_/¯
PAYING FOR QUALITY
the card says MIPS
Readmissions
Readmissions
outpatient network
incentives
Readmissions
outpatient network
incentives
20%!
PMID: 26910198
Readmissions
outpatient network
incentives
21.5%  17.8%
15.3%  13.1%
penalties?
2015: 80%
all 3: 57% (!)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-
are-we-doing/
penalties?
2015: 80%
all 3: 57% (!)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-
are-we-doing/
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/
Readmission penalties?
risk adjustment
socioeconomic status
¯_(ツ)_/¯
Readmission penalties?
hiding in observation?
¯_(ツ)_/¯
PMID: 26910198
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
¯_(ツ)_/¯
ntrueger@gmail.com @MDaware

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The Affordable Care Act: An Evidence-Based Update

Editor's Notes

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  3. compare about 11 million before
  4. compare about 11 million before
  5. compare about 11 million before
  6. compare about 11 million before
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