The Perfect Storm - Putting America s Health Care in Peril American Health Care Act + President s Budget May 24, 2017 CBO AHCA Analysis Daniel Derksen, M.D., Director University of Arizona Center for Rural Health
Arizona Center for Rural Health Mission: to improve the health & wellness of rural & underserved populations. AzCRH houses the: http://crh.arizona.edu 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
American Health Care Act CBO: AHCA over 10 years would: Cut $1.5 Trillion in federal funding Cut $830 Billion Medicaid funding to States Cut $665 B in fed subsidies for individuals Increase uninsured Americans by 23 million 1. American Health Care Act Accessed 05/24/2017 at: https://housegop.leadpages.co/healthcare/ 2. CBO-JCT Cost and Coverage Estimates of the American Health Care Act, 05/24/2017: https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628aspassed.pdf Dan Derksen MD
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: https://www.hhs.gov/sites/default/files/fy2018-budget-in-brief.pdf 2. NYT Accessed 05/24/2017: https://www.nytimes.com/interactive/2017/05/23/us/politics/trump-budgetdetails.html?q=medicaid Dan Derksen MD
American Health Care Act Eliminates fed. min. 50% of total Medicaid costs Shifts FMAP to per capita amt. or block grant Bases cap/grant on 2016 state s total expenses Adjusts annually based on CPI-M Cuts $830B over 10 yrs Medicaid funding to states 1. CBO-JCT Cost and Coverage Estimates of the American Health Care Act, 05/24/2017: https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628aspassed.pdf 2. American Health Care Act Accessed 05/24/2017 at: https://housegop.leadpages.co/healthcare/ Dan Derksen MD
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
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: http://content.healthaffairs.org/content/36/1/166.full.pdf+html
Medicaid Cuts in AHCA: Medicaid Spending in 2015 was 1 : $545 billion = $200 state + 345 fed Federal Medicaid cuts 2 2017-26: $830B (>$150B/yr by 2026) Medicaid Enrollment 2 : -14M Accessed 05/23/17: 1. http://content.healthaffairs.org/content/36/1/166.full.pdf+html 2. https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628aspassed.pdf
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: http://content.healthaffairs.org/content/36/1/166.full.pdf+html
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: http://content.healthaffairs.org/content/36/1/166.full.pdf+html https://aspe.hhs.gov/system/files/pdf/255516/medicaidexpansion.pdf https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html
Medicaid + Marketplace Gain Post-ACA Enrollment Gain from Sept 2013 thru 2016 UNITED STATES Medicaid+CHIP 1 +16.8 Million Age <26 Parents Plan 2 +2.3 Million Marketplace 3 +10.4 Million Effectuated Enrollment (paid premiums) 91.4% Americans with health insurance 2016 20 Million Gained Coverage 2 since 2010 8.6% or 27 Million Uninsured in 2016 https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf Accessed 05/17/2017: 1. Medicaid + CHIP Report thru Mar 2017: https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html2. Coverage gains 2010-2016 due to the ACA US DHHS: https://aspe.hhs.gov/sites/default/files/pdf/187551/aca2010-2016.pdf 3. Effectuated Marketplace Enrollment: https://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2016-fact-sheets-items/2016-10-19.html
é16.8m Medicaid/CHIP Enrollees 2013-16 31 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 https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html
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: https://fas.org/sgp/crs/misc/r43847.pdf
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: http://kff.org/medicaid/state-indicator/federal-matching-rate-andmultiplier/?currenttimeframe=0&sortmodel=%7b%22colid%22:%22location%22,%22sort%22:%22asc%22%7d
Federal Per Capita Medicaid Enrollee Spending by State, 2017 2,000 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 http://www.urban.org/research/publication/block-grants-and-capita-caps. Rosenbaum S Commonwealth Fund Mar 2017: http://www.commonwealthfund.org/publications/issue-briefs/2017/jan/medicaids-future-aca-repeal
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 http://www.huffingtonpost.com/2013/01/14/arizona-medicaid-expansion_n_2474726.html Dan Derksen MD
Pre-ACA 2012 AZ Health Coverage Payer Source # Arizonans %AZ Pop Employer Sponsored Insurance 3,300,000 50.7% Medicaid (AHCCCS)/CHIP (KidsCare) 1,200,000 18.5% Medicare 800,000 12.3% Uninsured 1,200,000 18.5% Total Pop. Arizona 6,500,000 100.0% Adapted by
How Arizona Cut Its Uninsured 2013-16 AHCCCS AZ Medicaid <138% FPL ($33,948 for a Family of 4) July-Sep 2013 to Oct 2016 Net Gain AZ MARKETPLACE 133-400% FPL ($33,948 - $98,400 Family of 4) OE-3 Effectuated Enrollment* Mar 31, 2016 +600,000 AZ <26 Parents Plan +70,000 +180,000 Arizona Total: +850,000 KidsCare/CHIP restored 09/2016: +15,000 Eligible Arizona Children Age <19 years with family incomes between 138-200% FPL *Effectuated enrollment are those enrolled and paying premiums. CHIP = Children s Health Insurance Program, called KidsCare in Arizona Accessed 04/26/17 at: 1. AZ KidsCare/CHIP: https://www.azahcccs.gov/resources/downloads/populationstatistics/2017/mar/ahcccs_population_highlights.pdf 2. AHCCCS/Medicaid: https://www.azahcccs.gov/resources/reports/population.html 3. Effectuated Enrollment (pd premium): https://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2016-fact-sheets-items/2016-06-30.html
YES from 2016-17 Premiums Doubled (ex. 25 y.o. Non-Smoker, Silver Plan AZ) AZ County 2016 2017 Avg. Monthly Rate Increase Average %Increase Maricopa $206 $386 $180 87% Pima $190 $274 $84 44% Gila, Pinal $219 $453 $234 107% Apache, Navajo, Coconino, Mohave $275 $501 $226 82% Yavapai $294 $586 $292 99% Yuma, La Paz $261 $593 $332 127% Santa Cruz $190 $395 $200 108% Cochise, Graham, Greenlee $238 $486 $248 104% 2016 AZ Marketplace Plan Rates: https://insurance.az.gov/sites/default/files/documents/files/individual_ppo_hmo_minimum_maximum_average_premiums.pdf 2017 AZ Marketplace Plan Rates: https://insurance.az.gov/sites/default/files/documents/files/2017%20individual%20qhp%20min%20max%20average%20sample%20rates.pdf
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 2017 203,066 $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
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
If the American Health Care Act were enacted as is, it would End Medicaid/AHCCCS for 380,000 in AZ Cut $2.5 billion in federal funding to Arizona Shift $0.5 billion/yr federal costs to AZ to cover 300,000 childless adults (<100% FPL) Force 80,000 off AHCCCS (100-138% FPL) Increase Arizona uninsured to pre-aca levels (to 1.2 million uninsured from 750,000) 05/24/2017 Bob Christie AP, Arizona Daily Star published 03/18/17: http://tucson.com/news/state-and-regional/analysis-arizonans-may-lose-medicaid/article_404d3ae0-0bef-11e7-bd41-5b4190aad6d3.html Dan Derksen MD