Objectives. Overview: Patient Protection and Affordable Care Act (and other Health Reform Initiatives)

Transcription

1 Overview: Patient Protection and Affordable Care Act (and other Health Reform Initiatives) Sheryl Garland, M.H.A. November 13, 2015 Objectives Provide an overview of the Patient Protection and Affordable Care Act (ACA) Review coverage options under the ACA Review recent legislative issues 2 1

2 U.S. has been working on reforming its health care system for a long time. Franklin Roosevelt outlines Economic Bill of Rights that includes right to adequate medical care The Medicare and Medicaid programs are signed into law by Lyndon Johnson Barack Obama signs the Patient Protection and Affordable Care Act Teddy Roosevelt endorses social insurance as a part of his platform President Truman calls for a National Health Program in a message to Congress President Clinton asks the First Lady to convene the White House Task Force on Health Reform 3 3 Why Is Health Reform An Issue? In 2014, there were nearly 36 million uninsured Americans* Since 2004, average health insurance premiums for family coverage have risen 69%** Average annual cost of employer sponsored family coverage in 2014 was $16,834** Average employee contribution: $4,823 In 2014, 55% of firms offered employer-sponsored coverage** *Nation at a Glance: Uninsured Americans, CDC/NCHS National Health Interview Survey, , June 25, **The Kaiser Family Foundation and Health Research & Educational Trust, Employer Health Benefits: Summary of Findings, September 10,

3 On average, other wealthy countries spend about half as much per person on health than the U.S. spends Total health expenditures per capita, U.S. dollars, PPP adjusted, 2012 United States Switzerland Netherlands Austria Germany Canada Comparable Country Belgium France Sweden Australia Japan OECD Average United Kingdom $3,493 $3,289 $4,460 $8,745 $ $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 Source: Kaiser Family Foundation analysis of 2013 OECD data: "OECD Health Data: Health expenditure and financing: Health expenditure indicators", OECD Health Statistics (database). doi: /data en (Accessed on June 25, 2014). Notes: Because 2012 data was unavailable, 2011 were used for Australia and the Netherlands. Data for Canada and Switzerland are estimated values. 5 3

4 Patient Protection and Affordable Care Act 7 Patient Protection and Affordable Care Act (ACA) Enacted in March, 2010 with the goals of: Ensuring access to quality health care Providing affordable health insurance to the uninsured By 2024 will expand coverage to 26 million currently uninsured Americans Net cost of coverage expansion is $1.4 trillion over 10 years ( ) Source: Congressional Budget Office, Updated Estimates of the Effects of the Insurance Coverage Provisions of the Affordable Care Act, April,

5 Impact of ACA on Children s Health Prohibition on pre-existing condition exclusions Plans provide dependent coverage until a child turns 26 Required coverage of preventive services without costsharing Authorization and funding for CHIP through September 30, 2015 (recently expanded to 2017) Established a new loan repayment program for certain medical, surgical, and behavioral health subspecialties 9 ACA Created Several Coverage Options Established an Individual Mandate (Jan 1, 2014) Nonelderly Uninsured by Federal Poverty Level Established an Employer Mandate (Jan 1, 2015 and Jan 1, 2016) Expanded Medicaid to non-elderly population with incomes at or below 138% FPL* (Jan 1, 2014) (133% 2015 FPL = $15,654 single person, $32,253 family of 4) OPTIONAL for States Created Health Insurance Exchange (Marketplace) (Jan 1, 2014) * FPL = Federal Poverty Level 10 5

6 Source: Diamond, D., Thanks, Obamacare: America s Uninsured Rate is Below 10% For the First Time Ever, Forbes, August 12, 2015, 11 Individual and Employer Mandates 12 6

7 Individual and Employer Mandates As of 2014, everyone is required to: 1. Have health insurance coverage 2. Have a coverage exemption 3. Pay a penalty Beginning January 1, 2015, employers with 100 or more full-time or full-time equivalent employees had to offer affordable coverage to full-time employees and their dependent children 13 Individual Mandate: Penalties and beyond $95 Per adult $325 Per adult $695 Per adult OR 1% Of family income OR 2% Of family income Whichever is greater OR 2.5% Of family income Collected through tax returns Exempted: undocumented immigrants, Native Americans, and those who earn too little to file a tax return Source: The Kaiser Family Foundation 14 7

8 Medicaid Expansion 15 Medicaid in Virginia Federal Poverty Level 138% 100% 50% 0% Pregnant Children 0-5 Children 6- Women 18 * Medicaid Eligibility by FPL * * Current Elig Elderly & Disabled Federal Reform Parents Childless Adults Program created in 1965 Helps states provide medical coverage for low-income families and other categorically-eligible individuals Optional for states to participate Current Eligibility for Medicaid/FAMIS in Virginia Pregnant women and children (below 200% FPL) Adults with children (below 30% FPL) Aged, blind or disabled (below 80% FPL) Expansion provides coverage up to 138% FPL *Coverage up to 200% FPL available through FAMIS 16 8

9 Impact of Medicaid Expansion in Virginia Approximately 400,000 Virginians would be eligible Projected enrollment is approximately 250,000 Federal government pays 100% through 2017 Expanded enrollment is estimated to result in a savings of $1.1 billion to the State through 2022* Match by State Fiscal Year** Year (July to June) Federal State % 0% % 0% % 0% % 5% % 6% % 7% 2020 beyond 90% 10% ** *Medicaid DSH and Indigent Care, Presentation to the Senate Finance Committee, Health and Human Resources Subcommittee, Scott Crawford, Department of Medical Assistance Services, January 27, 2014, 17 9

10 19 Health Insurance Exchange (Marketplace) 20 10

11 ACA required the establishment of Health Insurance Exchanges (Marketplaces) in all States If a state-based Exchange/Marketplace is not created, the state defaults to the federal Marketplace 16 states and DC established State-based Marketplaces 34 states defaulted to the Federally-Facilitated Marketplaces (Exchanges) including Virginia Marketplace plans provide Premium Tax Credits for individuals 100% to 400% FPL Cost-Sharing Reductions for individuals between 100% and 250% FPL 21 Coverage Levels The ACA created four benefit levels of coverage (Metal Levels) based on how much of the cost is covered The levels define the split between what the consumer pays and what the health plan pays Paid by Plan Paid by Consumer Platinum 90% 10% Gold 80% 20% Silver 70% 30% Bronze 60% 40% 22 11

12 Approximately 8 million people enrolled in the Marketplace plans nationwide in ,000 in Virginia 23 Legislative Issues to Watch 24 12

13 ACA Legislative and Legal Challenges 56 legislative attempts to repeal the ACA in the U.S. House of Representatives 2010 Lawsuit filed challenging the individual mandate Supreme court rendered a decision in June 2012 stating the Individual Mandate was constitutional King v. Burwell (June 2015) Supreme Court ruled that subsidies are allowable for individuals in both State and Federally Facilitated Marketplaces. 25 Medicare Access and CHIP Reauthorization Act of 2015 Repealed Sustainable Growth Rate (SGR) formula Replaced with standard annual updates for 5 years ( ) Transitions payment system from volume based to value based introduction of Merit Based Incentive Payment System and Alternative Payment Models Provides funding for the Children s Health Insurance Program (CHIP)/FAMIS in Virginia through

14 Conclusion 27 Questions 14