Policy Brief: Affordable Care Act · 2014. 2015. 2016* Source: CDC/NCHS, National Health Interview...
Transcript of Policy Brief: Affordable Care Act · 2014. 2015. 2016* Source: CDC/NCHS, National Health Interview...
#NCG2017
Policy Brief:Affordable Care Act
The Future of the Affordable Care Act
Northern California GrantmakersApril 17, 2017
Larry LevittKaiser Family Foundation@larry_levitt
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Source: CDC/NCHS, National Health Interview Survey.
Uninsured rate among the non-elderly
Note: 2016 data is for Q1-Q3 only.
20 million more people covered
Source: National Health Interview Survey
Decrease in the share of the population uninsured, 2010-2016
45% nationally
62% in California
Estimated annual federal premium tax credits (2016):$4.6 billion
Federal funding for newly-eligible adults in Medicaid (January 2014 to September 2015):
$28.0 billion
Source: KFF analysis, http://kff.org/health-reform/state-indicator/average-monthly-advance-premium-tax-credit-aptc/?currentTimeframe=0 and http://files.kff.org/attachment/fact-sheet-medicaid-state-CA
Federal financial assistance under the ACA in California
• Repeal of the individual and employer mandates.• Guaranteed access to insurance for people with pre-existing conditions, with late
enrollment penalties for people with gaps in coverage.• Continuation of the ACA’s required insurance benefits.• 5-1 variation in premiums allowed for age.• Federal grants for state high-risk pools or other stabilization mechanisms.• Refundable tax credits that vary by age, but not income or local premiums
(phasing out above income of $75k for individuals).• Expanded use of Health Savings Accounts.• Scaled back Medicaid expansion and per capita cap on federal funding.• Repeal of almost all ACA tax increases (Cadillac plan tax remains but delayed until
2025).
Not in the plan: Sale of insurance across state lines, any drug pricing curbs.
American Health Care Act (House GOP health bill)
• 14 million more uninsured in 2018 and 24 million more by 2026, leaving 52 million non-elderly uninsured.
• Lower average premiums in the individual insurance market, as fewer older adults buy coverage and people shift to higher deductible plans.
• $839 billion decrease in projected Medicaid spending over the next decade. $306 billion decrease in tax credits for individual insurance.
• $150 billion decrease in the federal budget deficit.
Congressional Budget Office projections for the AHCA
Source: Kaiser Family Foundation analysis. Note: Data for Affordable Care Act represent the average tax credit available across all counties in the United States, at a given age.
How the House GOP plan shifts health insurance tax credits, based on income and age, in 2020
$3,225
$4,143
$9,874
$2,000
$3,000
$4,000
Age 27 Age 40 Age 60
Lower-Income ($20,000)
Affordable Care Act
American Health Care Act
$103
$1,021
$6,752
$2,000
$3,000
$4,000
Age 27 Age 40 Age 60
Middle-Income ($40,000)
Affordable Care Act
American Health Care Act
$0 $0 $0
$2,000
$3,000
$4,000
Age 27 Age 40 Age 60
Higher-Income ($75,000)
Affordable Care Act
American Health Care Act
• Medicaid is working fine, and if anything more states may start to expand. Over 4 million more people are enrolled in Medi-Cal.
• The ACA marketplaces have challenges.– A number of insurers have exited the marketplaces. 32% of counties (representing
21% of enrollees) have one insurer in 2017.– Benchmark premiums increased 22% on average in 2017.– There are fragile markets where premiums are high, have increased significantly,
there is only insurer participating, and/or enrollment has declined.• But, if left alone, the marketplaces are stable in the vast majority of the country.
– Most enrollees have a choice of insurers.– Insurer finances have been improving.– Marketplace enrollment basically held steady in 2017 at 12.2 million (a decline of half
a million). 1.6 million signed up in California, comparable to last year.– The structure of the ACA’s premium tax credits (which 83% of enrollees receive)
shield consumers from premium hikes and prevent a “death spiral.”
Is the ACA collapsing?
12.9%
33.2%
California U.S.
Source: Kaiser Family Foundation analysis
Cumulative change in ACA marketplace benchmark premiums, 2014-2017
• The administration faces a choice of whether to undermine the individual insurance market or seek to make it work better and potentially move the ACA in a more conservative direction. So far, signals have been mixed.
• Potential steps to undermine the ACA marketplaces and insurance market:– End cost-sharing subsidy payments to insurers (about $7 billion in 2017, benefiting
58% of marketplace enrollees). Insurers would pull out or raise premiums by 19%.– Weaken the individual mandate.– Pull back on outreach.– Create uncertainty for insurers.
• Other areas of administrative discretion:– Settle lawsuits over the risk corridor program.– Give insurers or states more flexibility on required benefits and narrow range of
preventive benefits (e.g., contraception).– Grant waivers to states under section 1332.
• Medicaid: Likelihood of state waivers for higher premiums/copays and work requirements.
What the Trump Administration could do administratively on the ACA and Medicaid
Most say President Trump and Republicans in Congress are responsible for AC problemsAs you may know, the 2010 health care law, also known as Obamacare, remains the law of the land. Which comes closer to your view?
Other/Don’t know/Refused
7%
President Obama and Democrats in Congress
passed the law and they are responsible for
any problems with it moving forward
31%
President Trump and Republicans in Congress are now in control of the government and they are
responsible for any problems with it moving
forward61%
NOTE: “Other” includes the shares that say “Neither of these/someone else is responsible” (Vol.) and “Both are equally responsible” (Vol.). SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted March 28 – April 3, 2017)
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO14
Presentation to theNorthern California
Grantmakers Annual Conference
April 17, 2017
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO15
Contra Costa Health Plan (CCHP) IS: The oldest County-sponsored Federally Qualified Health Maintenance
Organization (HMO) in the country. Currently has multiple productlines – Medi-Cal, Medicare, Commercial, IHSS.
– 201,000 members.
Knox-Keene Licensed and NCQA approved Health Plan.
An integral entity within the Contra Costa County Heath ServicesDepartment and has 43 years of collaboration with the County PublicHospital and Federally Qualified Health Center (FQHC) AmbulatoryHealth Center, as well as the Public Health, Mental Heath, andSubstance Abuse Divisions within the Health Services Department.
Continued…..
.
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO16
Contra Costa Health Plan (CCHP) IS: CCHP Provides Direct Services of 24/7 Advice Nurse and case
management services.
CCHP has 3 choices of Provider Networks with 88% of all Medi-Cal Managed Care in County.
1. Contra Costa Regional Medical Center (CCRMC)
2. Community Provider Network (CPN)
3. Kaiser Permanente (for former Kaiser members in Medi-Cal.
CCHP is a third party administrator for uninsured programs of County Health Department and Pilot Program – Contra Costa CARES.
.
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO17
ACA Repeal/ReplaceImpacts Relating to Optional Expansion Elimination
THE ECONOMICSIMPACT OF ACA OPTIONAL EXPANSION TO LOCAL HEALTH PLAN
MEMBERSTOTAL EXPANSION
REVENUEPLAN EXPANSION REVENUE TO:
Health PlanTotal
Members# Expansion
Members To Plan Physicians Hospitals Pharmacies OtherAAH 255,848 106,000 $300,000,000 $60,000,000 $100,000,000 $53,000,000 $63,000,000 CalOptima 763,922 234,000 $1,100,000,000 $565,000,000 $227,000,000 CalViva 358,494 83,000 $525,000,000 CenCal 180,000 46,000 $141,000,000 $40,000,000 $42,000,000 $41,000,000 $18,000,000 CCAH 350,000 83,000 $344,000,000 $97,300,000 $157,900,000 $59,500,000 CHG 285,491 87,112 $159,807,851 $47,000,000 $70,000,000 $43,000,000 CCHP 184,860 54,720 $269,568,677 $50,450,005 $156,799,743 $25,718,060 $36,600,869 GCHP 206,251 0HPSJ 340,000 88,000 $330,000,000 $88,000,000 $137,000,000 $57,000,000 $4,000,000 HPSM 112,607 0IEHP 1,226,097 370,000 $1,080,000,000 $445,700,000 $443,000,000 $182,100,000 KHS 241,216 69,000 $208,000,000 $54,000,000 $112,600,000 $41,400,000 LA Care 1,960,219 410,473Partnership 566,000 163,000 $847,000,000 SFHP 134,587 0SCFHP 266,961 83,000 $330,000,000 $60,000,000 $202,000,000 $58,000,000
TOTALS 7,432,553 1,877,305 $ 5,634,376,528 $ 1,507,450,005 $ 1,648,299,743 $ 560,718,060 $ 121,600,869
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO18
ACA Repeal/ReplaceImpacts Relating to Optional Expansion Elimination
THE PEOPLEDemographics of the OE Population
Ages Gender Physical Health (# OE with diagnoses)
Behavioral Health
(# OE with diagnoses)
19-40 41-64 Men Women Hyper-tension
Cardio-vascular Diabetes Asthma
Pain Manage-
ment
Other Common
depression, anxiety, etc.
30,096 24,624 27,385 27,335 8,926 1,283 4,496 3,984 4,153 238 11,294
Health Plan: CCHP
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO19
California Coverage of low-income Undocumented Children under Medi-Cal
CCHP, like other Safety Net Health Plans have added 1600
undocumented low-income children to our Medi-Cal population
since summer, 2016.
Currently working with Kaiser Permanente Health Plan, County
Social Services and DHCS to add 1,221 additional undocumented
low-income children previously covered by Kaiser Healthy
Children Program.
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO20
Current Covered CA Populations At Risk of Subsidy Repeals
PRICING REGION COUNTYCOVERED CALIFORNIA IN BAY AREA
2017 COVERAGE % SUBSIDIZED
REGION 2MARIN, NAPA, SOLANO
AND SONOMA54,708 87%
REGION 4 SAN FRANCISCO 38,775 81%
REGION 5 CONTRA COSTA 41,353 86%
REGION 6 ALAMEDA 66,920 86%
REGION 8 SAN MATEO 26,243 85%
CCHP has received most of those churning off Covered California as they then qualify for Medi-Cal.
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO 21
Contra Costa County Region 5 enrollment breakdown
Enrollment by Carrier Enrollment by Metal Tier
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO 22
Contra Costa CARES The CARES program is a pilot to demonstrate the value of connecting uninsured
patients to a primary care medical home. It also highlights the effectiveness of a coordinated system that enables
community health centers (CHCs) to work with Contra Costa Health Plan (CCHP) to enroll Contra Costa residents in a primary care medical home.
Contra Costa CARES (CARES) enrolls low-income individuals who are ineligible for other healthcare programs, and live in Contra Costa County, into a primary care medical home.
Approximately 28,000 individuals in the county are estimated to qualify for the program.
All patients are assigned to a medical home, with the majority enrolled at La Clinica and Lifelong Medical locations.
The profile of enrolled participants shows that 97% are working age adults in family-size households. Most participants (54%) live in the west county region.
The vast majority (95%) of enrollees who transitioned out of the CARES program have become enrolled in full-scope Medi-Cal coverage due to changes in health status, gaining comprehensive coverage.
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO 23
Figure 3. Enrollee age data shows the majority of enrollees are working age and from working households
95% are part of
Working Households
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO 24
Figure 4. Patient visit data shows that diabetes and hypertension-related services are the most common type of care provided
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO 25
Figure 5. Overall ER visits declines after individuals enrolled in CARES.
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD, CEO 26
Sustainable Funding Contra Costa CARES was funded as a 12-month pilot primary care
program, in a partnership between Sutter, Kaiser and John Muir hospitals
splitting the funding with the County Health Department. CCHP is the
third party administrator who manages the program with the Community
Consortium assistance.
Funding was later secured to extend coverage for an additional 12
months ending in July, 2018. This year-to-year funding hampers the
ability to expand sustained primary care capacity. Community partners
are being engaged in order to identify sustainable funding sources that
expand access to health care for this population.
Contra Costa Health Plan
Patricia Tanquary, MSSW, MPH, PhD 14
Questions?Patricia Tanquary, MSSW, MPH, PhD
Chief Executive Officer
Contra Costa Health Plan
595 Center Avenue, Suite 100
Martinez, CA 94553
Office Phone: 925--313-6004
Email: [email protected]
Chris PerroneDirector, Improving Access
NCG Annual ConferenceApril 17, 2017
Potential Changes to the ACA: Responding in Uncertain Times
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Rapid Response: California FocusTimely Information & Analysis Key Partnerships
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Rapid Response: National DebateState-Specific Policy Briefs National Analyses
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How best to: • Maintain a healthy risk mix?• Improve affordability for consumers?• Ensure adequate plan choice in every region?• Improve continuity of coverage through transitions?• Finance state spending?
Policy Issues Ahead
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• Delivery System Reform in Medi-Cal Alternative Payment
Models & Capitation Reform
Behavioral Health/ Complex Care Integration
Team-based Care• High Value Care Opioid Treatment Maternity Care End of Life Care
Staying The Course: Getting Better Value
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1 8 15 22 29 36 43 50 57 64 71 78 85 92 99
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Cumulative Percentage of Enrollees
5% of enrollees generated 52% of spending($34,480 per person)
Distribution of Medi-Cal Spending, 2011
Source: DHCS, 2015.Note: Among Medi-Cal-only enrollees in managed care, FFS or both
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Medi-Cal 2020: Whole Person Care Pilots
• Coordinate health, behavioral health, and social services for Medi-Cal beneficiaries who are frequent users of multiple systems
• County agencies, designated public hospitals, district municipal public hospitals
• $3 billion over 5 years (50% federal; 50% local)
Source: Harbage Consulting
Housing Services • Housing and tenancy
sustaining services• Housing education
and legal assistance• SNF Housing
Transitions• Street Outreach
Care Coordination/ Wrap-Around Services• Recuperative Care• Sobering Centers• Mobile/Service
Integration Teams• Peer Support
Specialists
Examples
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Other Opportunities to Promote Reforms Medi-Cal PRIME Medi-Cal FQHC
APMMedi-Cal Health Home Program
Accountable Communities for Health
Goal Transform public hospitals into entities that take responsibility for the quality and cost of their patients inside the hospitals and in the community and move toward alternative payment models
Establish payment system for FQHCs that fosters greater accountability for performance (cost and quality) and provides greater flexibility in how care is provided
To coordinate the full range of physical health, behavioral health, and community-based long term services and supports needed by beneficiaries with chronic conditions.
Improve personal and community-wide health outcomes and reduce disparities with regard to particular chronic diseases or health needs; control costs associated with ill health; and develop financing mechanisms to sustain the ACH.
Funding Up to $3.7 billion in Federal funding over 5 years
NA 90% Federal match $5.1 million over three years from four foundations
Partners Designated public, district and municipal hospitals
Federally Qualified Health Centers
Medi-Cal plans and community-based care management entities
Multi-sector, typically led by county department of public health
Locations Statewide Participants TBD 29 counties Imperial, Merced, San Diego, San Joaquin, Santa Clara, Sonoma
Start 2016 2018 2018 2016
Link http://www.dhcs.ca.gov/provgovpart/Pages/PRIME.aspx
http://www.dhcs.ca.gov/services/Pages/FQHC_APM.aspx
http://www.careinnovations.org/programs-grants/payment-redesign
http://www.dhcs.ca.gov/services/Pages/HealthHomesProgram.aspx
http://www.communitypartners.org/cachi
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The Sands of Time?Then…
Next?
Now…