The Affordable Care Act: Seven Years Later

The Affordable Care Act: Seven Years Later Jason Furman Senior Fellow, PIIE The Century Foundation Washington, DC March 23, 217 Peterson Institute for International Economics 175 Massachusetts Ave., NW Washington, DC 236

Outline I. Coverage II. Cost III. Quality IV. Economic Performance V. Marketplace Stability

Uninsured Rate Has Fallen to the Lowest Level on Record Percent 25 2 Uninsured Rate, 1963 216 Creation of Medicare and Medicaid ACA First Open Enrollment 216 15 1 5 196 1965 197 1975 198 1985 199 1995 2 25 21 215 ACA = Affordable Care Act Note: Estimate for 216 reflects only the first three quarters. Other estimates are full-year. Sources: National Health Interview Survey and supplemental sources described in Council of Economic Advisers, 214, Methodological Appendix: Methods Used to Construct a Consistent Historical Time Series of Health Insurance Coverage (http://go.wh.gov/5orwjj).

Both Younger and Older Adults, as Well as Kids, Have Seen Substantial Coverage Gains Percent Uninsured 4 35 3 Uninsured Rates by Age, 1997 216 Young Adults (19-25) Yearof ACA Dependent Coverage Expansion Year Before First ACA Open Enollment 25 2 Non-Elderly Adults, Except Young Adults (26-64) 15 1 5 CHIP Created Children (<19) Year Prior to CHIPRA Enactment ACA = Affordable Care Act; CHIP = Children's Health Insurance Program; CHIPRA = Children's Health Insurance Program Reauthorization Act Note: Estimates for 216 reflect only the first three quarters. Estimates of the uninsured rate for -18 year olds have not yet been reported for 216, so the uninsured rate for -18 year olds reported in Figure 4-5 was calculated by extrapolating the 215 estimate using the percentage point change for -17 year olds, which has been reported. Similarly, estimates of the uninsured rate for 26-64 year olds were extrapolated using the percentage point change for the larger group consisting of 18 year olds and 26-64 year olds. Sources: National Health Interview Survey; Council of Economic Advisers calculations; author's calculations. 216 1997 1999 21 23 25 27 29 211 213 215

Uninsured Rate Has Fallen for All Income Levels Non-ElderlyUninsured Rate by Income Percent Uninsured 4 213 215 3 36% reduction 2 33% reduction 1 31% reduction < 138 138 to 4 > 4 Income as a Percentof the Federal Poverty Line Sources: National Health Interview Survey; Council of Economic Advisers calculations.

States that Expanded Medicaid Have Seen Much Larger Gains in Health Insurance Coverage 8 7 6 5 4 3 2 1 Decline in Uninsured Rate from 213 to 215 vs. Level of Uninsured Rate in 213, by State Decline in Uninsured Rate from 213 to 215 (Percentage Points) 1 CA 9 KY NV Medicaid Expansion States MA FL TX VA Medicaid Non-Expansion States 2 4 6 8 1 12 14 16 18 2 22 24 Uninsured Rate in 213 (Percent) Note: States are classified by Medicaid expansion status as of July 1, 215. Sources: American Community Survey; Council of Economic Advisers calculations.

Expanded Coverage is Improving Access to Care, Financial Security, and Health Decline in Share Not Seeing a Doctor Due to Cost vs. Decline in Uninsured Rate, by State, 213 215 Decline in Share Not Seeing a Doctor Due to Cost, 213 215 (p.p.) 7 6 5 4 3 2 1-1 2 4 6 8 1 12 14 Decline in Uninsured Rate, 213 215 (p.p.) Note: Sample limited to non-elderly adults. Percentage points denoted as p.p. Sources: Behavioral Risk Factor Surveillance System; Council of Economic Advisers calculations.

Millions More Workers Are Now Protected Against Unlimited Out-of-Pocket Spending 25 Share of Workers in Single Coverage Without an Out-of-Pocket Limit, 26 216 Percent of Enrolled Workers 3 216 2 15 1 5 26 27 28 29 21 211 212 213 214 215 216 Source: Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey 216.

Outline I. Coverage II. Cost III. Quality IV. Economic Performance V. Marketplace Stability

Projections of National Health Expenditures Have Fallen Sharply Projected National Health Expenditures, 21 219 National Health Expenditures as a Percent of GDP 21 2 Final Pre-ACA Projections 219 19 18 Actuals and Most Recent Projections 17 21 211 212 213 214 215 216 217 218 219 ACA = Affordable Care Act Note: Pre-ACA projections have been adjusted to reflect a permanent repeal of the sustainable growth rate following the methodology used by Stacey McMorrow and John Holahan (216, The Widespread Slowdown in Health Spending Growth Implications for Future Spending Projections and the Cost of the Affordable Care Act, An Update, Washington: Urban Institute, and Princeton: Robert Wood Johnson Foundation). For consistency, actuals reflect the current estimates as of the most recent projections release. Sources: National Health Expenditures Accounts and Projections; Council of Economic Advisers calculations.

Health Care Prices Have Risen at the Slowest Rate in 5 Years Since the ACA Was Enacted 12 1 Health Care Price Inflation vs. Overall Inflation, 196 217 Year-Over-Year Inflation Rate 14 Health Care Goods and Services Jan-217 8 6 4 All Consumers Goods and Services 2-2 196 1965 197 1975 198 1985 199 1995 2 25 21 215 ACA = Affordable Care Act Sources: National Income and Product Accounts; author's calculations.

Health Care Spending Per Enrollee Has Grown Exceptionally Slowly in Public & Private Sectors Real Per Enrollee Spending Growth, By Payer, 2 215 Average Annual Percent Growth 8 7 6.5 2 25 6 25 21 4.7 5 21 215 4 3.4 3 2.4 2 1.5 1.5-1 -.3 -.2 -.3-2 -3 Private Insurance Medicare Medicaid Note: Medicare growth rate for 25 1 was calculated using the growth rate of non-drug Medicare spending in place of the growth rate of total Medicare spending for 26 to exclude effects of the creation of Medicare Part D. Inflation adjustments use the GDP price index. Sources: National Health Expenditure Accounts; National Income and Product Accounts; Council of Economic Advisers calculations.

The Pace of Deductible Growth Has Been Similar to the Pace Prior to the ACA Average Real Deductible in Employer-Based Single Coverage, 22 216 Average Real Deductible (216 Dollars) 1,5 1,2 Continuation of 22-21 Trend 216 9 6 Medical Expenditure Panel Survey, Insurance Component Continuation of 22-21 Trend 3 KFF/HRET Employer Health Benefits Survey 22 24 26 28 21 212 214 216 ACA = Affordable Care Act; KFF/HRET = Kaiser Family Foundation/Health Research and Educational Trust Note: Inflation adjustments use the GDP price index, including a Congressional Budget Office projection for 216. Sources: Medical Expenditure Panel Survey, Insurance Component; KFF/HRET Employer Health Benefits Survey 216; National Income and Product Accounts; Council of Economic Advisers calculations.

Cost Growth Has Slowed in Employer Coverage Even More When Out-of-Pocket Costs Are Included Average Annual Percent Growth 8 7.2 7 6 5.6 5 4 3 2 1 Growth in Real Costs for Employer-Based Family Coverage, 2 216 3.1 3.1 3.1 Total Premium Employee Contribution Employer Contribution Premiums for Family Coverage 21 216 5.1 5.2 5.1 Note: Out-of-pocket costs were estimated by first using the Medical Expenditure Panel Survey to estimate the out-of-pocket share in employer coverage for 2 214 and then applying that amount to the premium for each year to infer out-of-pocket spending. The out-of-pocket share for 215 and 216 was assumed to match 214. Inflation adjustments use the GDP price index. GDP price index for 216 is a Congressional Budget Office projection. Sources: Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey 216; Medical Expenditure Panel Survey, Household Component; Council of Economic Advisers calculations. 1.5 Worker Contribution + Estimated Out-of-Pocket Cost 2 21 2.4 Total Premium + Estimated Out-of-Pocket Cost

Alternative Payment Models Can Improve the Performance of the Health Care Delivery System Percent of Traditional Medicare Payments Tied to Alternative Payment Models, 21 219 Percent of Payments 6 5 4 Obama Administration Goals 3 2 Actual 1 21 211 212 213 214 215 216 217 218 219 Note: The dates and percentages for the actual series are approximate. Source: Centers for Medicare and Medicaid Services.

Outline I. Coverage II. Cost III. Quality IV. Economic Performance V. Marketplace Stability

The Quality of Care Received by Hospital Patients Has Improved Since 21-5 Cumulative Percent Change in Rate of Hospital- Acquired Conditions Since 21, 21 215 Cumulative Percent Change in Rate of Hospital-Acquired Conditions Since 21-2 -1-9 -15-2 -25-17 -17-21 21 211 212 213 214 215 Sources: Agency for Healthcare Research and Quality; Council of Economic Advisers calculations.

Hospital Readmission Rates Have Fallen Sharply in Recent Years Sources: Centers for Medicare and Medicaid Services; Council of Economic Advisers calculations.

Outline I. Coverage II. Cost III. Quality IV. Economic Performance V. Marketplace Stability

The Private Sector Has Added 16.2 Million Jobs in 84 Consecutive Months of Job Growth Since the Affordable Care Act Became Law Monthly Gain in Private-Sector Payroll Employment, 28 217 Job Gain/Loss 6, 4, Feb-217 2, -2, -4, Twelve-Month Moving Average -6, -8, -1,, 28 21 212 214 216 Sources: Bureau of Labor Statistics, Current Employment Statistics; author's calculations.

Almost All of the Net Increase In Employment Since the ACA Became Law Has Been in Full-Time Jobs Change in Number of Full-Time and Part-Time Workers Since March 21, 21 217 Millions of Workers 16 14 12 Feb-217 1 8 6 Full-Time Workers 4 2 Part-Time Workers -2 21 211 212 213 214 215 216 217 ACA = Affordable Care Act Sources: Bureau of Labor Statistics, Current Population Survey; author's calculations.

People Reporting Better Health Have Higher Employment Rates and Earnings Employment Outcomes for Prime Age Adults, by Health Status, 215 Panel A: Share with Any Wage or Salary Earnings Panel B: Average Earnings, People With Earnings Percent of Prime-Age Adults with Earnings Average Wage and Salary Earnings 1 7, 61, 9 82 82 6, 8 77 55, 7 5, 47, 6 52 4, 36, 39, 5 4 3, 3 22 2, 2 1 1, Poor Fair Good Very Good Excellent Poor Fair Good Very Good Excellent Self-Reported Health Status Self-Reported Health Status Sources: Current Population Survey; Council of Economic Advisers calculations.

The ACA, Along With Other Tax Policies, Has Contributed to Reducing After-Tax Inequality Change in Share of After-Tax Income by Income Percentile: Changes in Tax Policy Since 29 and ACA Coverage Provisions, 217 Change in Share of After-Tax Income (Percentage Points).8.6.4.2. -.2 -.4 -.6 -.8-1. Income Percentile ACA = Affordable Care Act Source: US Treasury, Office of Tax Analysis.

CBO Estimates that the Affordable Care Act Substantially Improved the Long-Term Budget Outlook Deficit Reduction Due to the Affordable Care Act, 216 235 Change in the Deficit (Billions) -1, -$353 Billion -2, -3, -4, Reduction of Around $3.5 Trillion -5, 216 225 226 235 CBO = Congressional Budget Office Note: CBO reports second-decade effects as a share of GDP. Amounts are converted to dollars using GDP projections from CBO's long-term budget projections. Sources: CBO; Council of Economic Advisers calculations.

The Life of the Medicare Trust Fund Has Been Extended by 11 Years Since the ACA Became Law Forecasted Year of Medicare Trust Fund Exhaustion, 2 216 Year of Exhaustion of the Medicare Hospital Insurance Trust Fund 232 23 228 226 224 222 22 218 216 216 2 22 24 26 28 21 212 214 216 Source: Medicare Trustees.

Outline I. Coverage II. Cost III. Quality IV. Economic Performance V. Marketplace Stability

Marketplace Premiums Have Converged to CBO s Prediction Actual Marketplace Premiums vs. CBO Projection Difference as a Percent of CBO Projection 1 5 1-5 -1-15 -2-16 214 217 CBO = Congressional Budget Office Source: Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (213; 216).

Some of the Large Premium Increases Likely Reflect Initial Underpricing by Insurers Annual Change in Benchmark Premium, by Quintile of 214 Benchmark Premium, 214 217 Median Annual Percent Change in Benchmark Premium, 214 217 18 15 12 9 6 3 1 (Lowest) 2 3 4 5 (Highest) Quintile of 214 Benchmark Premium Note: Premiums analyzed at the county level. Quintiles defined to have equal non-elderly populations. Data limited to states using HealthCare.gov in all years. Sources: Department of Health and Human Services; American Community Survey; Council of Economic Advisers calculations.

States With Larger Premium Increases Have Not Seen Larger Decreases in Enrollment Change in Marketplace Plan Selections vs. Change in Benchmark Premium, 216 217, by State Percent Change in Plan Selections 4 2-2 Observed Relationship -4-6 -8 Relationship Required to Permit a "Death Spiral" Under -1 Pessimistic Assumptions -1 1 2 3 4 5 6 7 8 9 1 11 12 Percent Change in Weighted Average Benchmark Premium Note: Figure includes states that used the HealthCare.gov platform in both 216 and 217. The black line portrays the estimated relationship from regressing the log change in plan selections on the log change in the benchmark premium. The red line portrays a relationship with the same intercept and a slope coefficient of -2. This slope coefficient would permit a death spiral if claims costs for enrollees discouraged by higher premiums were half or less the costs of other enrollees, a relatively extreme assumption. Sources: Department of Health and Human Services; Matt Fiedler, 217, New Data on Sign-ups Through the ACA s Marketplace Should Lay Death Spiral Claims to Rest, Washington: Brookings Institution (https://www.brookings.edu/blog/up-front/217/2/8/new-data-on-sign-ups-through-the-acas-marketplaces-should-lay-death-spiral-claims-torest/).

Most Marketplace Enrollees Are Fully Protected from Benchmark Premium Increases Premium for the Benchmark Plan for an Individual Making $25, Per Year, 217 Dollars per Month 35 3 25 2 $1 Premium Tax Credit $15 15 1 5 Individual Contribution $143 $143 Benchmark Premium = $243/Month Benchmark Premium = $293/Month Source: Council of Economic Advisers calculations.