Weathering the Perfect Storm Arizona s Rural Health in Peril House American Health Care Act Senate Better Care Reconciliation Act
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1 Weathering the Perfect Storm Arizona s Rural Health in Peril House American Health Care Act Senate Better Care Reconciliation Act June 26, 2017 House AHCA + Senate BCRA Analysis Daniel Derksen, M.D., Director University of Arizona Center for Rural Health
2 Arizona Center for Rural Health Mission: to improve the health & wellness of rural & underserved populations. AzCRH houses the: 1. State Office of Rural Health 2. Rural Hospital Flexibility Program 3. Small Hospital Improvement Program 4. Western Region Public Health Training Center 5. AzCRH Navigator Consortium
3 House: American Health Care Act Passed 05/04/2017 by 217 Yes to 213 No Votes CBO: AHCA would Increase uninsured by 14 million in 2018 Increase uninsured by 23 million by 2026 Cut $1.1 trillion fed funding over 10 years: (-$834B Medicaid, -$276 B Marketplace) Eliminate public health & prevention fund (Cut $1Billion/yr from CDC budget) 1. American Health Care Act Accessed 06/26/2017 at: 2. CBO-JCT Cost and Coverage Estimates of the American Health Care Act, released 05/24/2017: Dan Derksen MD
4 Senate H.R Better Care Reconciliation Act of 2017 Draft CBO: BCRA would Increase uninsured by 15 million in 2018 Increase uninsured by 22 million by 2026 Cut $1.2 trillion fed funding over 10 years: (-$772B Medicaid, -$408 B Marketplace) Eliminate public health & prevention fund (Cut $1Billion/yr from CDC budget) Senate BCRA draft 06/22/17: CBO-JCT Cost and Coverage Estimates of the Better Care Reconciliation Act, analysis 06/26/2017: Dan Derksen MD
5 Over 10 years would cut $2 trillion: $610 billion in federal Medicaid funding $193 billion SNAP (food stamps) $72 billion SSI disability support $87 billion NIH funding $18 billion CDC funding 1. Accessed 05/24/2017 at: 2. NYT Accessed 05/24/2017: Dan Derksen MD
6 House AHCA or Senate BCRA would: Repeal 1965 Social Security Act provision requiring the federal government to cover at least 50% of a state s Medicaid costs (federal medical assistance percentage or FMAP) Shift FMAP to per person cap or block grant Base cap on a state s 2016 Medicaid costs Adjusts annually based on consumer price index medical (House CPI-M) or urban (Senate CPI-U) Cut $770 to $834 Billion fed Medicaid funding Dan Derksen MD
7 Rural, Elderly, & Disabled at Risk Nurse, Physician, Hospital, Clinic - Charity Care Taxes You don t save money throwing people off coverage that just shifts costs to individuals, families, & health providers - and it worsens health outcomes Dan Derksen MD
8 Who is at risk? Rural, elderly, disabled Fewer providers Poorer outcomes Higher uninsured Higher poverty Older population Contribute to Disparities in: Access to Health Care Services Coverage Medicaid, Marketplace Especially for Rural, Border, Elderly, Latino pop.
9 Medicaid Costs vs Enrollment MEDICAID Elderly Disabled Total $555 Billion COST $350 Fed+$205 State 21% 42% 63% 70 Million Americans ENROLLED 9% 15% 24% Park, H. NYT 03/07/17:
10 STATE State rank by increase in lowincome elderly population % Increase in Low Income Elderly 1. NV 54% 2. AK 42% 3. AZ 39% 4. WY 36% 5. UT 30% States with rapid increase in low income elderly populations will be punished by per capita or block grant Medicaid payment Park, H. NYT 03/07/17:
11 Federal Per Capita Medicaid Enrollee Spending by State, ,000 0,000 8,000 6,000 4,000 Arizona would be punished by the proposed AHCA and the President s budget because Arizona expanded AHCCCS coverage, and is cost efficient Arizona #8 lowest 2,000 0 DC NY WV RI CT OR VT MO MS DE KY MN AR TN MT OH ND PA ME MA ID LA MD IA IN US AK NC UT NM KS SC AL WI CA WY WA OK TX MI NJ GA FL VA AZ NE SD HI CO NV IL NH Data: J. Holahan and M. Buettgens, Block Grants and Per Capita Caps: The Problem of Funding Disparities Among States, Urban Institute, Sept. 2016, available at Rosenbaum S Commonwealth Fund Mar 2017:
12 Federal Per Capita Medicaid Enrollee Spending by State in 2017 STATE FMAP % 2018 Fed Medicaid Expenditures State Medicaid Expenditures 2017 Medicaid + CHIP 2017 Per Capita Fed Medicaid 2017 AZ 69% $8,391,000,000 $2,721,000,000 1,741,000 $4,253 CA 50% $52,523,000,000 $29,440,000,000 12,288,000 $4,595 NM 72% $4,260,000,000 1,104,000, ,000 $4,757 NV 66% $2,573,000,000 $791,000, ,000 $3,312 U.S. 57% $348,916,000,000 $204,538,000,000 75,000,000 $4,954 NYT 03/07/17:
13 2015 U.S. Health Spending $3.2 Trillion Dental Nursing Home Other 10% Out of Pocket 11% Rx 26% Medicaid 17% 33% Private Insurance Physician & Clinic 20% Medicare 20% Accessed 03/10/2017 at:
14 Medicaid Cuts in AHCA: Medicaid Spending in 2015 was 1 : $545 billion = $200 state fed Federal Medicaid cuts : $830B (>$150B/yr by 2026) Medicaid Enrollment 2 : -14M Accessed 05/23/17:
15 Medicaid, CHIP, Medicare: One in $3 U.S. Health Spending in 2015 Medicaid: $545 billion Medicare: $646 billion Total US: $3.2 trillion Accessed 03/10/17 at: Martin: Health Affairs Jan 2017:
16 2016 Publicly Sponsored Insurance Medicaid + CHIP + Medicare 38% US pop (123M/323M) 75 Million=Medicaid 70M + CHIP 5M 57 Million on Medicare 9 M dual on both Medicaid + Medicare CHIP = Children s Health Insurance Program Accessed 05/24/17 at:
17 Medicaid + Marketplace Gain Post-ACA Enrollment Gain from Sept 2013 thru 2016 UNITED STATES Medicaid+CHIP Million Age <26 Parents Plan Million Marketplace Million Effectuated Enrollment (paid premiums) 91.4% Americans with health insurance Million Gained Coverage 2 since % or 27 Million Uninsured in Accessed 05/17/2017: 1. Medicaid + CHIP Report thru Mar 2017: Coverage gains due to the ACA US DHHS: 3. Effectuated Marketplace Enrollment:
18 é16.8m Medicaid/CHIP Enrollees States + DC Expanded Medicaid >Half (16) That Expanded Are in Republican Governor States: AZ, AR, IL, IA, IN, KY, MD, MA, MI, ND, NH, NJ, NM, NV, OH, VT
19 Medicaid FMAP: Federal Medical Assistance Percentage: FMAP is the federal share of Medicaid costs, based on a state s per capita income (PCI) compared to US PCI Accessed 03/10/17: FMAP by state: kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?currenttimeframe=0&sortmodel=%7b%22colid%22:%22location%22,%22sort%22:%22asc%22%7d Congress Research Service Medicaid FMAP released 02/09/2016 at:
20 Medicaid FMAP 50% Statutory Minimum Federal Cost Share FMAP Share Averages 57% in the 50 States Example: Arizona 2018 FMAP = 69% 2018 FMAP by State:
21 Effects on Arizona Did you know? Arizona s 114,000 sq. mi. would encompass NY, CT, DE, ME, MA, NH, RI, VT, DC Dan Derksen MD
22 Governor Brewer Medicaid Expansion Weigh the evidence and do the math $2 billion per year 20,000 jobs 250,000 uninsured covered Governor Brewer restored Medicaid coverage to 100% FPL for childless adults in 2014, and expanded it from 100% to 138% FPL as the ACA allows Dan Derksen MD
23 Pre-ACA 2012 AZ Health Coverage Payer Source # Arizonans %AZ Pop Employer Sponsored Insurance 3,300, % Medicaid (AHCCCS)/CHIP (KidsCare) 1,200, % Medicare 800, % Uninsured 1,200, % Total Pop. Arizona 6,500, % Adapted by
24 How Arizona Cut Its Uninsured AHCCCS AZ Medicaid <138% FPL ($33,948 for a Family of 4) July-Sep 2013 to Oct 2016 Net Gain AZ MARKETPLACE % FPL ($33,948 - $98,400 Family of 4) OE-3 Effectuated Enrollment* Mar 31, ,000 AZ <26 Parents Plan +70, ,000 Arizona Total: +850,000 KidsCare/CHIP restored 09/2016: +20,000 Eligible Arizona Children Age <19 years with family incomes between % FPL *Effectuated enrollment are those enrolled and paying premiums. CHIP = Children s Health Insurance Program, called KidsCare in Arizona Accessed 05/29/17 at: 1. AZ KidsCare/CHIP: 2. AHCCCS/Medicaid: 3. Effectuated Enrollment (pd premium):
25 YES from Premiums Doubled (ex. 25 y.o. Non-Smoker, Silver Plan AZ) AZ County Avg. Monthly Rate Increase Average %Increase Maricopa $206 $386 $180 87% Pima $190 $274 $84 44% Gila, Pinal $219 $453 $ % Apache, Navajo, Coconino, Mohave $275 $501 $226 82% Yavapai $294 $586 $292 99% Yuma, La Paz $261 $593 $ % Santa Cruz $190 $395 $ % Cochise, Graham, Greenlee $238 $486 $ % 2016 AZ Marketplace Plan Rates: AZ Marketplace Plan Rates:
26 Total # Selected Market Plans Avg. Ttl Prem/Mo (Insurer Gets) Avg APTC Mo (Fed Subsidy Pays) Avg Prem Mo after APTC (Enrollee Pays) #Received APTC Subsidies (% of Ttl Enrollees) #Received APTC + CSR Subsidies (% Ttl Enrollees) # Paid Full Premium (% Total Enrollees) AZ 2016 AZ 2017 US 2016 US ,066 $324/mo $204/mo $120/mo 196,291 $611/mo $521/mo $104/mo 150,269 (74%) 155,754 (79%) 11,081,330 $397/mo $291/mo $106/mo 9,389,609 (85%) 12,216,000 $476/mo $383/mo $106/mo 10,101,808 (83%) 94,463 (47%) 100,316 (51%) 6,400,000 (57%) 7,500,000 (61%) 52,797 (26%) 40,537 (20%) 1,691,721 (15%) 2,114,192 (17%) But low-income Arizonans were shielded from total premium increases because of the ACA subsidies! APTC = Advance Premium Tax Credit Subsidy CSR = Cost Sharing Reduction Subsidy Dan Derksen MD
27 Low income Arizonans shielded from total premium increases because of the ACA subsidies 4% enrollment increase 2016 to 2017 in those getting APTC 6% enrollment increase for those getting APTC + CSR 23% enrollment decrease for those not receiving subsidies APTC = Advance Premium Tax Credit Subsidy CSR = Cost Sharing Reduction Subsidy Sharply cutting subsidies for the poor, by $1.5 trillion over 10 years as per the AHCA, will increase the uninsured, shift costs to individuals, families, & health providers, and worsen health outcomes Dan Derksen MD
28 The House American Health Care Act or Senate Better Care Reconciliation Act would: Repeal SSA provision requiring feds cover at least 50% of a state Medicaid program AZ income is lower than US, feds cover 70% costs of AHCCCS Create per person cap, vulnerable to yearly cuts End AHCCCS/Medicaid for 400,000 in AZ Cut >$7 billion in fed funding to Arizona Double uninsured to 1.2 million Arizonans Double uncompensated/charity care costs
29 Senate BCRA uses CPI-Urban rate that over the last 10 years averaged half the CPI-M increases Years 2008 to 2017 CPI-M Medical CPI-U Urban Avg / Yr 3.2% 1.7% House: $345,000,000,000 X 3.2% = $11,040,000,000 Senate: $345,000,000,000 X 1.7% = $5,865,000,000 $5,175,000,000 Senate version uses CPI-U, means smaller annual federal increases to states, compounded each year
30 Dan Derksen Time repeals our boastful leaders and their golden towers tumble Lies unmask these poison-feeders truth reveals and renders humble
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