Welcome! Partnerships: Closing the Gap in Rural Arizona 42 nd Annual Rural Health Conference 10 th Annual Performance Improvement Summit

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1 Partnerships: Closing the Gap in Rural Arizona 42 nd Annual Rural Health Conference 10 th Annual Performance Improvement Summit Welcome! Daniel Derksen MD August 4 th & 5 th, 2015 Sedona, Arizona

2 Arizona Marketplace Update Dan Derksen, M.D. Canyon de Chelly Photo: Ken Miller

3 BREAKING NEWS: THIS JUST IN

4 Federally Facilitated Marketplaces in States ACA Upheld 6-3 Federal Government Can Operate Exchanges in States Justice Alito Breyer Ginsburg Kagan Kennedy Roberts Scalia Sotomayor Thomas ACA Upheld No Yes Yes Yes Yes Yes No Yes No Total Y/N 6-3

5 What if SCOTUS Invalidated Federally Facilitated Marketplace (FFM) Subsidies? 6.4 Million Lose Coverage 34 States FFM: 5.8 M Enrollees in 27 states AL, AK, AZ, FL, GA, IN, KS, LA, ME, MS, MO, MT, NE, NJ, NC, ND, OH, OK, PA, SC, SD, TN, TX, UT, VA, WI, WY Partnership: 618,300 enrollees in 7 states AR, DE, IL, IA, MI, NH, WV CRH Analysis of FFM Subsidized Enrollee Data:

6 Act I Supremes vs Obamacare

7 Act I: Supreme Court Upholds ACA June 2012 Medicaid Expansion Tax Mandate Alito No No Breyer Yes Yes Ginsburg Yes Yes Kagan Yes Yes Kennedy No No Roberts Yes Yes Scalia No No Sotomayor Yes Yes Thomas No No Total Y/N Tax Mandate UPHELD Medicaid Expansion UPHELD* *States can choose not to expand Medicaid unduly coercive to lose all Medicaid funding if a state doesn t choose to expand Medicaid

8 The Unpopular ACA Tax Mandate 2015 tax penalty for those w/o coverage: 1% household income or $95 per person, whichever is greater 2016: 2% or $325 per person 2017: 2.5% or $695 per person

9 Employer sponsored health insurance costs excluded from taxable individual & payroll income, costing the U.S. $248 billion/yr These tax subsides have been in place for decades

10

11 Pre-ACA

12 STATUS QUO NOT A VIABLE OPTION Employee Share of Health Insurance Costs Rose at 4X the Rate of Their Income

13 Pre-ACA U.S. Health Coverage 2012 Private Health Insurance Employer Sponsored ESI Individual Purchase # covered (millions) Medicaid 51 Medicare 49 Uninsured 48 Total Population 311 Note: Some have dual coverage: e.g., Medicare + Medicaid US Census Bureau, page 22, accessed 08/02/15 at:

14 Categories of U.S. Health Spending 2012 Total = $2.8 Trillion Other 30% Hospital 32% Dental Nursing Home Rx 9% Physician & Clinic 20%

15 ACA in 2014 Created health insurance marketplaces Mandated coverage (levied a tax penalty) Expanded Medicaid: <138% FPL Subsidized premiums: % FPL Guaranteed issue (prohibits coverage denial) FPL Federal Poverty Level 2013 Household Size 100% 138% 400% 1 $11,490 $15,856 $45,960 2 $15,510 $21,404 $62,040 3 $19,530 $26,951 $78,120 4 $23,550 $32,499 $94,200 Accessed 08/02/15 at:

16 ACA Medicaid Expansion 31 States & Growing é 12.3 Million Medicaid Enrollees Accessed 08/02/15 at:

17 ACA Marketplace Decisions by State é 11.7 Mil Marketplace Enrollees 27 Fed-facilitated, 7 Partner 13 State, 3 Fed-supported State Accessed 08/02/15

18 18% 16% Avg. Annual Percent Increase in National Health Expenditures Last 5 years: Lowest spending 14% 12% 10% 8% 6% 4% 2% growth in 50 year history 13.1% 11.0% 10.6% 9.7% 8.6% 8.4% 7.1% 7.2% 6.7% 6.8% 6.4% 6.5% 6.3% 5.8% 4.7% % 3.8% 3.8% 3.6% 3.7% 0% SOURCE Accessed 08/02/15 at:

19 34% Waste $2.9 Trillion US Health Spending Confiscates Resources for Other Spending Quality Equals Meeting Health Needs We Must Reinvent Medical Education to Meet Our Nation s Health Needs Accessed 08/02/15 at:

20 The Rural Health Challenges Fewer providers Poorer outcomes Higher uninsured Higher poverty

21 Arizona vs New England Did you know? Arizona s 114,000 sq. mi. would encompass NY, CT, DE, ME, MA, NH, RI, VT, DC

22 Pre-ACA AZ, NM Health Coverage 2012 Payer Source # AZ #NM Medicaid 1,200, ,000 Uninsured 1,200, ,000 Medicare 800, ,000 Private Insurance 3,300, ,000 Total Pop. AZ 6,500,000 2,200,000 Medicaid + Uninsured Comprised 40-45% AZ and NM Population

23 Demand: Medicaid + Round 2 Marketplace Gain U.S. / AZ Enrollment Jan 2014-Mar 2015 Income < 138% Income 138% to 400% Medicaid Million AHCCCS AZ Medicaid <138% FPL ($32,500 Family of 4) Dec 2013-May 2015 Net Gain +365,129 UNITED STATES Age <26 Parents Plan +2.3 Million ARIZONA ACA ENROLLMENT AZ <26 Parents Plan +70,000 Marketplace Million 8.7M Subsidized AZ MARKETPLACE % FPL ($32,500-$94,200) Round 2 Enrollment thru Mar ,

24 ACA Enrollment (Participation Rate) AHCCCS AZ Medicaid +365,129 (74%) AZ MARKETPLACE # Enrollees with subsidy / # Eligible for subsidy 126,506 / 335,000 (38%)

25 Rural Hospital Margins Improved, but Thin

26 ACAs Prickly Coverage Disparities

27 ACA Marketplace: Oct Mar 2015 #Enrollees receiving subsidy / # Eligible for subsidy US 50% Participation Rate 64% 35% 38% Uninsured 2015 White 9% Latino 30% African Am 13% Pre-ACA: Half the Uninsured 47% in these 10 States 41% 33% Accessed 7/6/15at: % AL 41% 58% 51% 80%

28 Editorial June 11, 2012 By Dan Derksen Like civil rights legislation 50 years ago, decisions will soon be made whether each American can enjoy the rights of of a healthy citizenship.

29 Reverend Pinckney - he knew that the path of grace involves an open mind, but more importantly an open heart If we can find that grace anything is possible. If we can find that grace, everything can change. President Obama

30 There are no constraints on the human mind, no walls around the human spirit, no barriers to our progress except those we ourselves erect. Ronald Reagan Grand Canyon Photo: Ken Miller