The Affordable Care Act: Progress & Peril John E McDonough November 2015
Presentation Outline Good News Not So Good News What I Tell Foreigners about ObamaCare Hope for the Future
# Title Name Detail The Affordable Care Act by Title 1 Quality, Affordable Health Care for All Americans Private Insurance Reform and coverage expansion 2 Role of Public Programs Medicaid expansion/chip 3 Improving the Quality and Efficiency of Health Care Medicare/delivery system reform 4 Prevention of Chronic Disease and Improving Public Health 5 Health Care Workforce Workforce Prevention/wellness/public health 6 Transparency and Program Integrity Fraud, comp. effectiveness 7 Improving Access to Innovative Medical Therapies Biosimilars 8 Community Living Assistance Services & Supports CLASS (repealed) 9 Revenue Measures New taxes and fees 10 Reauthorization of Indian Health Care Improvement Act plus Health Care Education & Reconciliation Act Manager s Amendment plus HCERA
1. Good News about the ACA Real progress on coverage/access US health spending at lowest growth rate ever ACA costing far less than projected Real progress on health system transformation Dynamic period of experimentation federal, state, county/local, health sector Advancing the Triple Aim
US Adult Uninsurance Rate Down to 11.4% Source: Gallup Surveys 5
People Getting Help Need It the Most Help the Most Hitting the Right Targets 6
Source: US Census Current Population Survey, October 2015; slide from Commonwealth Fund Uninsured Rate Dropped in All 50 States: 2013-14
ACA s Impact on Uninsurance in Kentucky Source: Kentucky Department for Medicaid Services 8
CBO Net Estimates of ACA Coverage Costs
All payers have seen lower spending increases Commonwealth Fund. Note: Figures for 2013 are projections. Source: Based on data from Bureau of Economic Analysis, National Income and Product Accounts; Centers for Medicare and Medicaid Services; Council of Economic Advisors. (Presented by Peter Orszag, Citigroup, at Altarum Institute Symposium on Sustainable U.S. Health Spending: The Quest for Value, July 15, 2014).
ACA Tax Increases in Context Source: Incidental Economist 11
The Delivery System Reform Toolbox Reduced Payments for Avoidable Complications Value Based Purchasing Medicare Advantage Plan Bonuses Accountable Care Organizations Bundled Payments Hospital Inpatient Quality Reporting Physician Quality Reporting System Medical Homes Source: D. Blumenthal, Commonwealth Fund Meaningful Use 12
30-Day, All-Condition Medicare Readmission Rates ACA passed Penalties start Source: Niall Brennan, CMMS, Findings from Recent CMS Research on Medicare, Presentation at AcademyHealth Annual Research Meeting session on The Centers for Medicare and Medicaid Services Data and Information Products, June 9, 2014. Available at http://www.academyhealth.org/files/2014/monday/brennan.pdf Adapted from Commonwealth Fund.
50,000 Deaths Averted, by HAC: 2011-2013 14 Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System, National Healthcare Safety Network, and Healthcare Cost and Utilization Project. 2014
Pre-ACA US Health System Care s Changing ACA System Paradigms Fee for service Pay for performance No underlying system ethos beyond professional autonomy and licensure Where Are We Going? Fee for Value Pay for Outcomes Accountable Care and The IHI Triple Aim to: Improve patient experience of care Lower per capita costs Improve population health 15
2. Not So Good News 20 states struggling to expand Medicaid Inadequate support for the hard work of access expansion Growing recognition that the Affordable Care Act is not affordable enough Urban Institute Premiums and Cost Sharing Political threats not over continuing lawsuits, 2016 federal elections Much more money for opponents than for ACA supporters on political mobilization Don t believe the silence on ACA in debates
State Medicaid Expansion Decisions 17
ACA Title Covered (#M) ACA Financial/Coverage Impacts: 2010-2019 vs. 2016-2025 $ Spent ($B) $ Raised /Saved ($B) 1. Private Sector Coverage 16/10 $509 $833 $80.6 $210 2. Medicaid/CHIP 16/14 $458.8 $824 $52.7 $66 3. Medicare/Delivery Reform $54 $449.9 $879 4. Prevention/Public Health $18 $.8 5. Workforce $18.2 -- 6. M&M Fraud & Abuse $2.8 $7 7. Biologic Similars -- $7 8. CLASS -- $70.2 $0 9. Revenues -- $437.8 $718 Others (Interactions etc) 14.8 $92.8 $204 Ten Year Deficit Reduction -$124 -$137/353
Income relative to federal poverty line Massachusetts required enrollee contributions as percent of income 100% 0% 2.01% 150 0 4.02 200 2.1 6.30 250 3-4 8.10 300 4.2 9.56 350 No cap 9.56 400 No cap 9.56 Over 400 No cap No cap Source: Urban Institute 2015 The ACA Is Not Affordable Enough ACA required enrollee contributions as percent of income
The Growing Cost Sharing Culture in US Health Care
CBO Net Estimates of ACA Coverage Costs
Urban Institute Recommendations Improve premium tax credits and cost-sharing reductions i.e.: Move Silver from 70% to 80% actuarial value Ease access to marketplace financial assistance for those affected by the family glitch Allow states the option to expand Medicaid to 100 percent of the federal poverty level instead of 138 percent Increase federal grants for information technology development and operation; education, outreach, and enrollment activities; and oversight and enforcement of insurance regulations
Still a Sharp Partisan Divide over the ACA
Consider: What if ACA Opponents Really Mean Full Repeal? Congress getting ready to move legislation to repeal key parts of the ACA for the 61 st time 1 st time possible to reach Obama s desk» Reconciliation bill would eliminate coverage for 14 million covered lives including 3 million children according to the CBO Every Republican Presidential Candidate has publicly endorsed ACT repeal» Candidate Jeb Bush! promises a transition plan for the 17 million who would lose their current coverage under his plan with zero details The Republican base still overwhelmingly backs repeal and demands that commitment from candidates How inconceivable is it that in January 2017, Republicans control the White House, the Senate, and the House of Representatives? How would they do it? Think: $879 billion
Knowledge of ACA Increases Its Favorability Source: Wendy Gross et al: Americans Attitudes Toward the Affordable Care Act. 2014 https://pprg.stanford.edu/wp-content/uploads/health-care-2012-knowledge-and-favorability.pdf 25
4. Hope for the Future The entire history of the ACA has been surviving one near-death experience after another Scott Brown election in January 2010 NFIB v. Sebelius, King v. Burwell 2012 federal elections Universal health insurance is a global movement picking up steam new World Bank report highlights 24 nations We/you are all part of a movement the health justice movement The delivery system reforms are not just concerns within the USA this is a global movement toward paying for value and pursuing the Triple Aim
ACA & disparities/inequities, Mental health, women, more Cong. Jim Clyburn: the Civil Rights Act of the 21 st century More than half of U.S. uninsured are non-white and lower income Mental Health: the largest expansion of behavioral health coverage in a generation Sebelius Women s Health: greatest advance for women s health in a generation National Partnership for W&F Addiction-Substance Abuse: I don t think there s another illness that will be more affected by the ACA. McClellan Disability: The ACA undeniably changes the paradigm for working-age people with disabilities, who now do not need to choose between healthcare and a job. B. Otto 27
Two things: On Coverage On Delivery System Reform What I Tell Foreigners About the ACA
We re almost there 29