Health Policy SymposiumElena MarksEpiscopal Health FoundationJune 11, 2016

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

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’sRailroads provide

employee medical care

1930’sSocial Security Act; Blue Cross offers hospital care insurance

1940’sEmployer

sponsored plans arise

1960’sMedicaid and

Medicare enacted

1980’sManaged Care

1990’sCosts rise at 2X

inflation; Clinton plan

dies

2000’sUnsustainable

cost curve; poor outcomes

2010Affordable Care

Act

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

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)

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

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

Texas and the ACA’s Coverage Provisions

Texas on the Eve of the ACA

Insured19,564,00076%

Undocumented15%

ACA Marketplace SubsidyEligible36%

No Subsidy11%

Uninsured5,591,00024%

Medicaid Eligible but Unenrolled14%

Medicaid Expansion Adults24%

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.

Texas on the Eve of the ACA:Demographics of Uninsured Texans

Source: Current Population Survey, Annual Social and Economic Supplement, 2012U.S. Census Bureau*Personal Income

1,606,00025%

610,0009%

190,0003%

3,956,00062%

50,0001%

Uninsured by Race/Ethnicity

White aloneBlack or African American aloneAmerican Indian and Alaska Native aloneAsian aloneHispanicTwo or more races

1,073,00018%

4,925,00081%

81,0001%

Uninsured by Age

00 to 17 18 to 64 65 to 80+

2,584,00040%

1,817,00028%

1,334,00021%

427,0007%

135,1352%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+

Pre-2014 Experiences:Affordability of Care by Insurance Status

Mental health care or counseling

Dental care

Medical tests and treatment

Prescription drugs

Specialist care

General primary care

Medical Care

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%

Skipped Care, September 2013 By Household Income as a Percent of the Federal Poverty Level (FPL)

Uninsured Insured

Pre-2014 Experiences:Affordability of Care by Income

Mental health care or counseling

Dental care

Medical tests and treatment

Prescription drugs

Specialist care

General primary care

Medical Care

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%

Skipped Care, September 2013 By Household Income as a Percent of the Federal Poverty Level (FPL)

400+% FPL 139-399% FPL <=138% FPL

Age 18-24 Age 35-49 Age 50-640%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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%

General Opinion of the ACA in TX by Age, Sept 2013

<=138% 139-399% >=400%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

14.3%8.3% 11.2%

16.2%

15.7% 13.9%

37.9%

29.8%19.6%

8.2%

12.8%21.7%

23.1%33.0% 33.4%

General Opinion of the ACA in TX by Income, Sept 2013

White Black Hispanic0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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%

General Opinion of the ACA in TX by Race/Ethnicity, Sept 2013

Pre-2014 Experiences:Opinion of the ACA by Age, Income, Race

Pre-2014 Experiences: Expectations about ACA

Texas Post-ACA Implementation

Q3 2013 Q1 2014 Q2 2014 Q1 2015 Q3 2015 Q1 20168.0

10.0

12.0

14.0

16.0

18.0

20.0

22.0

24.0

26.0

U.S.Texas

Perc

enta

ge

Source: Health Reform Monitoring Survey and HRMS TX. Estimates are regression adjusted.

Uninsured by Race/ethnicity and AgeTexans ages 18-64, 2013 to 2016

Trends in Uninsurance for Texas Adults Ages 18-24

Uninsured by Race/ethnicity and AgeTexans ages 18-64, 2013 to 2016

White, non-Hispanic

Black/other, non-Hispanic

Hispanic

0 5 10 15 20 25 30 35 40 45

14.3

18.7

42.6

9.9

14.2

30.7

Uninsured by Race/Ethnicity

18-30

31-49

50-64

0 5 10 15 20 25 30

26.4

28.1

21.1

20.7

21.6

10.3

Uninsured by Age Mar 2016 (%) Sep 2013 (%)

Uninsured by Income and GenderTexans ages 18-64, 2013 to 2016

1

2

0 10 20 30 40 50 60

54.1

46

22.7

13.1

Uninsured by Family Income

Between 139% and 399% of FPL At or below 138% or FPL

1

2

0 5 10 15 20 25 30

22.3

14.9

28.4

20.7

Uninsured by Gender

Female Male

Texans Covered by ACA Marketplace Plans during Open Enrollment Periods

Oct 2013-Mar 2014 Nov 2014-Jan 2015 Nov 2015-Jan 20160

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

733,757

918,890

1,306,208

Texas Enrollees from Open Enrollment

Texas Enrollment in Marketplace Plans by Income, January 2016

<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 -

100,000

200,000

300,000

400,000

500,000

600,000

48,279 4%

531,073 44%

277,606 23%

168,978 14%

84,489 7% 72,419

6%

24,140 2%

Fig. 8: Enrollment by Household Income

Texas Enrollment in Marketplace Plans By Race/Ethnicity, January 2016

Native Hawaiian/Pacific Islander

American Indian/Alaska Native

Multiracial

African-American

Asian

Latino

White

0 50,000 100,000 150,000 200,000 250,000 300,000 350,000

0

0

85311%

751569%

12526115%

30897737%

31732738%

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

Sep 2013 Mar 2014 June 2014 Mar 2015 Sep 2015 Mar 20160

5

10

15

20

25

30

24.623.5

22.2

16.918.5 17.9

20.720 19.5

14.315.3

14.1

17.6

15.114

10.1 10.59.9

15.8

12.1

10.5

7.5 7.3 7.3

Texas States Not Expanding Medicaid All States States Expanding Medicaid

Post-2014 Experiences:Reasons for Remaining Uninsured, September 2015

Post-2014 Experiences:Perceptions of Tax Penalties

21%

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

Thorny Issues for Consumers, Providers, and Payers

Consumer Concerns

CostProvider 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, Prices, and Health in 13 Countries, The Commonwealth Fund, October 2015

9 1012 11 12

9 912 11

8

16

11 10

21

18 15

11

16

2120

15

9

82.2

81.5

82.3

80.981.4 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

Life Expectancy at Birth in Years

Heal

th a

nd S

ocia

l Car

e Sp

endi

ng a

s a

Perc

enta

ge o

f GDP

Health Care Social Care Life Expectancy

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

2120

15

9

3.6

4.8

3.63.3

3.8

5.2

2.42.7

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

Infant Mortality per 1,000 Live BirthHe

alth

and

Soc

ial C

are

Spen

ding

as

a Pe

rcen

tage

of G

DP

Health Care Social Care Infant Mortality

Social Determinants of Health

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

The Following Presenters Have Disclosed Relevant Financial Relationships:Cedric Dark, MD MPH FAAEM FACEPCommunity Health Choice, Event Sponsorship; Schumacher Clinical Partners, Event Sponsorship Seth Trueger, MD MPHEmergency Physicians Monthly, Employee, Salary The Following Presenters Have Disclosed No Financial Relationships:Megan Douglas, JDElena M. Marks, JD MPHLaura Medford-Davis, MDBich-May Nguyen, MD MPH The Following Planners Have Disclosed Relevant Financial Relationships:Cedric Dark, MD MPH FAAEM FACEPCommunity Health Choice, Event Sponsorship; Schumacher Clinical Partners, Event Sponsorship The Following Planning Committee Members and Staff Have Disclosed No Relevant Financial Relationships:Emily DeVillers, CAEKay Whalen, MBA CAEJanet Wilson, CAE

Disclosure