The Affordable Care Act Where Do We Go from Here? Elisabeth Wright Burak NALEO Legislative Summit on Health October 20, 2017

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1 The Affordable Care Act Where Do We Go from Here? Elisabeth Wright Burak NALEO Legislative Summit on Health October 20, 2017

2 Declines in U.S. Uninsured 31.0% 30.9% 29.8% 29.0% 28.4% 23.5% 19.5% 18.0% 15.1% 15.5% 15.1% 14.8% 14.5% 11.7% 9.4% 8.6% Total Population Total Latino Population Source: CCF analysis of 2016 ACS data, single year estimates 2

3 Adult (Non-Elderly) Uninsurance Rate 42.4% 42.9% 41.6% 40.8% 39.9% 32.8% 27.5% 25.4% 20.6% 21.4% 21.0% 20.6% 20.3% 16.3% 13.1% 12.0% Non-elderly Adults Non-elderly Latino Adults Source: CCF analysis of 2016 ACS data, single year estimates 3

4 Uninsurance Rate Among Latino and All Children, % 14.1% 12.8% 12.1% 11.5% 9.7% 7.5% 7.2% 8.6% 8.0% 7.5% 7.2% 7.1% 6.0% 4.8% 4.5% All Children Latino Children Source: CCF analysis of 2016 ACS data, single year estimates 4

5 Latino Children are Disproportionately Represented Among the Uninsured (2015) Source: S. Schwartz, S. Lopez, and S. Vargas Poppe. Latino Children s Coverage Reaches Historic High, But too Many Remain Uninsured. Georgetown University Center for Children and Families and National Council of La Raza. December

6 Public Coverage Sources Medicaid (1965) federal/state partnership, guaranteed federal funding between 50-75% of costs Serves: low-income kids, seniors, people with disabilities, pregnant women required; other populations at state option. ACA allowed states to expand Medicaid to all lowincome adults up to 138% of the poverty line starting in 2014 (31 states and DC) Children s Health Insurance Program (CHIP, 1997) Federal/state partnership, block grant federal match 65-85%++ of costs up to federal cap Serves: low-income kids that do not qualify for Medicaid. Affordable Care Act (ACA, 2010 fully implemented 2014) New marketplaces, financial support to purchase coverage for those without access to affordable employer insurance or Medicaid/CHIP Medicare (1965) 65+ federally administered Source: ASPE FMAP 2017 Report. Valid October 1, 2016-September 30,

7 Coverage Sources (2015) All People All Hispanic/Latino 2.90% Uninsured 1.80% Uninsured 18.40% 10.80% Employer 30.00% 20.40% Employer 8.20% Individual Individual 59.70% Medicaid/CHI P Medicare 5.80% 41.90% Medicaid/CHI P Medicare Source: SHADAC analysis of the 2015 American Community Survey (ACS) Public Use Microdata Sample (PUMS) files, State Health Compare, SHADAC, University of Minnesota, statehealthcompare.shadac.org, Accessed 6/9/17. 7

8 Coverage Under 138% FPL All People Hispanic/Latino 5.3% Uninsured Uninsured 9.3% 18.5% Employer 23.9% Employer 42.8% 26.3% Individual Medicaid/CH IP 45.4% 17.2% Individual Medicaid/CHI P 7.1% Medicare Medicare 4.2% Source: SHADAC analysis of the 2015 American Community Survey (ACS) Public Use Microdata Sample (PUMS) files, State Health Compare, SHADAC, University of Minnesota, statehealthcompare.shadac.org, Accessed 6/9/17. 8

9 Sources of Children s Coverage All Children Latino Children 0.3% 5.1% Uninsured 0.5% Uninsured Employer 8.0% Employer 35.7% 53.1% Individual Medicaid/CH IP 53.4% 34.2% Individual Medicaid/CH IP 5.8% Medicare 3.9% Medicare Source: SHADAC analysis of the 2015 American Community Survey (ACS) Public Use Microdata Sample (PUMS) files, State Health Compare, SHADAC, University of Minnesota, statehealthcompare.shadac.org, Accessed 6/9/17. 9

10 Percentage-point reductions in health-inclusive poverty rates from various programs, by selected characteristics. Dahlia K. Remler et al. Health Aff 2017;36: by Project HOPE - The People-to-People Health Foundation, Inc.

11 Medicaid Helps Kids Succeed in School and Life Source: Georgetown University Center for Children and Families. Medicaid is a Smart Investment in Children. March 13,

12 ACA Repeal and Medicaid Reform Efforts Common Themes 12

13 Marketplaces, Private Plans in Recent ACA Repeal Marketplaces and Private Insurance Eliminate or Weaken Essential Health Benefits Preventive Maternity Habilitative Mental health Pediatric oral health/vision Allow lifetime or annual limits Eliminate out-of-pocket consumer maximum Reverse coverage protections for preexisting conditions Marketplaces Eliminate or weaken financial support to families to purchase coverage on the marketplaces Impact: Increase deductibles and other out-of-pocket costs for families 13

14 Proposed Medicaid Changes in Recent ACA Repeal Restructure Medicaid financing through a cap and/or block grant Phase out, effectively end, ACA Medicaid expansion adult End or decrease 90-day retroactive coverage Work requirements as condition for Medicaid eligibility at state option 14

15 Proposed Medicaid Changes Would End 50+ Year Federal-State Medicaid Partnership Complicated percapita formula to create an annual federal cap on federal Medicaid spending State choice to block grant services for certain populations (varies by proposal) 15

16 Medicaid Caps Shift Costs to Current Medicaid Financing System $100 $44 $56 Texas Federal Share $130 $43 $87 Higher spending (unexpected cost growth) State Share States V S Capped Federal Medicaid Funding $100 $44 $56 Texas $100 $60 $90 $40 $40 Expected spending with cap Federal Share Federal cap Higher spending (unexpected cost growth) State Share $130 Chart by the Center on Budget and Policy Priorities, CCF Back to the Basics webinar series: Medicaid Financing FMAP from ASPE FY 2017 Federal Medical Assistance Percentages. Texas s FMAP is 56.18%-- we rounded to 56% for this presentation 16

17 Medicaid is the Largest Source of Federal Funds to States, FY 2015 Medicaid 7.2% 9.0% 21.7% 56.1% Public Assistance Higher Education Elementary & Seconday Education Transportation 3.6% 2.5% All Other Source: National Association of State Budget Officers. State Expenditure Report: Examining Fiscal State Spending. Published

18 State Choices to Offset Capped Federal Funding Boost State Spending Impose more red tape to suppress enrollment and retention X Cut Benefits Lower Reimburseme nt for Providers Close or cap enrollment Reduce Eligibility Increase Enrollee Costs 18

19 Children s Health Insurance Program (CHIP) + other unknowns Federal CHIP funding expired September 30, 2017 (SEE ALSO: Maternal, Infant, Early Childhood Home Visiting Program [MIECHV] and Community Health Center Funding) Together, Medicaid and CHIP have driven our success in covering children At least 10 states projected to run out of funds by year s end States announcing plans to send notices to families, freeze programs (e.g. UT, WA). States need time to make plans for eligibility determinations/transfers, payment closures, contracts CHIP is popular program that has bipartisan support a long-term, clean, bi-partisan extension could be a win for both sides and ensure kids coverage remains stable during broader uncertainty in the health system. 19

20 Bipartisan CHIP Progress Senate and House CHIP policy agreements would: o Extend CHIP funding for 5 years o Keep enhanced + 23% matching rate through 2019, phase down to regular CHIP match o Keep/extend requirement for states to maintain the children s coverage eligibility levels, with some flexibility for children > 300%FPL o Extend outreach, quality, demonstration initiatives o Extend Express Lane Enrollment (ELE) for children 20

21 o o o Recent Trump Administration Cuts to outreach/enrollment assistance/funds 10/12 Executive Order Seek to extend access to short-term and association health plans largely uncovered by ACA consumer protections Discontinuation of marketplace cost-sharing reductions (CSRs) subsidies to plans for covering low-income marketplace enrollees Actions 21

22 Bipartisan Market Stabilization Agreement? o Alexander-Murray move to stabilize marketplaces, ACA: o 2 year continuation of cost-sharing reductions (CSRs) o Outreach/enrollment funding for states o New state flexibilities (1332 waivers) o Expanded age eligibility for catastrophic plans (currently under 30 only 22

23 Additional HHS Administrative Actions: What to expect? Source: HHS letter to the Nation s Governors from Sec. Thomas Price and CMS Administrator Seema Verma, March 14,

24 Medicaid 1115 Waivers Source: E. Hinton et. al. Section 1115 Medicaid Demonstration Waivers: A Look at the Current Landscape of Approved and Pending Waivers, Kaiser Family Foundation, September

25 Questions Moving Forward o Future of the ACA Marketplaces? Stability, continuity? Outreach/enrollment support? Fate of Senate bipartisan effort? o Will CHIP be extended before we create additional uncertainty for children, families, and states? o Medicaid changes: Cuts or financing changes in next budget process? o New attempts at ACA repeal? o Will more states adopt Medicaid expansion? 25

26 Additional Resources Go to ccf.georgetown.edu to sign up for our newsletter, visit our Say Ahhh! blog State Coverage Data: Follow us Facebook: Georgetown University Center for Children and Families u 26