How Would ACA Repeal Affect Frontier Communities? Potential Health Market Changes July 27, 2017
Session Topics Introduction: What would be the worst that could happen to frontier communities if the Affordable Care Act (ACA) were to be repealed with no replacement? The Potential Impact of ACA Repeal: Estimating the results of ACA repeal on frontier communities. What the ACA Does: What individual parts of the ACA could be repealed, moderating the impact of total repeal? Other Proposed Changes: What is the potential impact of other proposed health market changes? Goals for Frontier Communities: What specific targets would preserve health service access in frontier communities? NCFC Planning: What is NCFC s role in helping to preserve health service access in frontier communities? What specific steps could NCFC take? 2
Change in State Frontier County Uninsured Under 65-2013-2015 State Number of Frontier Counties Uninsured Frontier Population 2013 Difference Frontier Uninsured 2013-2015 PCT Difference of 2013 Frontier Uninsured Population MT 45 53,593 14,599 27.24 NV 11 29,446 11,322 38.45 AK 23 61,439 11,112 18.09 NM 14 24,230 11,059 45.64 TX 60 47,129 9,665 20.51 OR 10 14,174 7,152 50.46 ID 17 20,219 6,639 32.84 WY 16 31,534 5,378 17.05 KS 36 15,439 4,525 29.31 NE 35 11,978 3,835 32.02 ND 36 16,362 3,758 22.97 UT 13 16,050 2,288 14.26 WA 4 3,424 1,904 55.61 MN 6 4,039 1,887 46.72 SD 35 16,552 1,857 11.22 OK 8 5,686 1,371 24.11 LA 1 1,117 360 32.23 NY 1 472 218 46.19 VA 1 432 127 29.4 MS 1 200 41 20.5 Total 373 373,515 99,097 26.53% 3
Change in State Frontier County Uninsured Under 65-2013-2015 State Number of Frontier Counties Uninsured Frontier Population 2013 Difference Frontier Uninsured 2013-2015 PCT Difference of 2013 Frontier Uninsured Population WA 4 3,424 1,904 55.61 OR 10 14,174 7,152 50.46 MN 6 4,039 1,887 46.72 NY 1 472 218 46.19 NM 14 24,230 11,059 45.64 NV 11 29,446 11,322 38.45 ID 17 20,219 6,639 32.84 LA 1 1,117 360 32.23 NE 35 11,978 3,835 32.02 VA 1 432 127 29.4 KS 36 15,439 4,525 29.31 MT 45 53,593 14,599 27.24 OK 8 5,686 1,371 24.11 ND 36 16,362 3,758 22.97 TX 60 47,129 9,665 20.51 MS 1 200 41 20.5 AK 23 61,439 11,112 18.09 WY 16 31,534 5,378 17.05 UT 13 16,050 2,288 14.26 SD 35 16,552 1,857 11.22 Total 373 373,515 99,097 26.53% 4
Percent Uninsured 25% Change in Uninsured Population Under 65 20% 15% 10% 5% 0% FRONTIER RURAL URBAN ALL 2013 PCT Uninsured 20.95% 17.40% 16.67% 16.79% 2015 PCT Uninsured 15.53% 11.83% 10.75% 10.92% 5
Number Uninsured Change in Uninsured Population Under 65 45,000,000 40,000,000 35,000,000 30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 0 FRONTIER RURAL URBAN ALL 2013 Uninsured 373,515 6,139,566 37,964,221 44,477,302 2015 Uninsured 274,418 4,113,571 24,777,238 29,165,227 6
Percent Change in Uninsured 35% Change in Uninsured Population Under 65 30% 25% 20% 15% 10% 5% 0% FRONTIER RURAL URBAN ALL 2015 PCT Change in 2013 Uninsured 26.53% 33.00% 34.74% 34.43% 7
Change in Uninsured Population Under 65 All States - 2013-2015 The number of uninsured frontier county residents under the age of 65 dropped by about 100,000 between 2013-2015. The percentage of uninsured frontier county residents under the age of 65 fell from about 21% in 2013 to about 15.5% in 2015. Frontier counties in 2013 were at a higher rate of uninsured than rural or urban counties. The change in the uninsured percentage was generally commensurate with the change in rural and urban county populations. The reduction in the uninsured frontier population under 65 between 2013 and 2015 represents about 26.5% of the uninsured population in 2013. This relative reduction is smaller than similar reductions in other rural and urban areas. 8
Percent Uninsured 25% Change in Uninsured Population Under 65 - Expansion States 20% 15% 10% 5% 0% FRONTIER RURAL URBAN ALL 2013 PCT Uninsured 21.04% 15.16% 14.81% 14.88% 2015 PCT Uninsured 14.49% 8.57% 8.51% 8.54% 9
Number Uninsured Change in Uninsured Population Under 65 - Expansion States 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 0 FRONTIER RURAL URBAN ALL 2013 Uninsured 153,586 2,650,600 20,838,065 23,642,251 2015 Uninsured 105,174 1,473,822 12,051,375 13,630,371 10
Percent Change in Uninsured Change in Uninsured Population Under 65 - Expansion States 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% FRONTIER RURAL URBAN ALL 2015 PCT Change in 2013 Uninsured 31.52% 44.40% 42.17% 42.35% 11
Change in Uninsured Population Under 65 Medicaid Expansion States - 2013-2015 The number of uninsured frontier county residents under the age of 65 in Medicaid expansion states dropped by about 50,000 between 2013-2015. The percentage of uninsured frontier county residents under the age of 65 in these states fell from about 21% in 2013 to about 14.5% in 2015. Frontier counties in 2013 were at a much higher rate of uninsured than rural or urban counties. The change in the uninsured percentage was generally greater than the change in rural and urban county populations. The reduction in the uninsured frontier population under 65 in these states between 2013 and 2015 represents about 31.5% of the uninsured population in 2013. This relative reduction is smaller than similar reductions in other rural and urban areas. 12
Percent Uninsured 25% Change in Uninsured Population Under 65 - Non-Expansion States 20% 15% 10% 5% 0% FRONTIER RURAL URBAN ALL 2013 PCT Uninsured 20.89% 19.59% 19.67% 19.67% 2015 PCT Uninsured 16.26% 15.02% 14.32% 14.45% 13
Number Uninsured Change in Uninsured Population Under 65 - Non-Expansion States 45,000,000 40,000,000 35,000,000 30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 0 FRONTIER RURAL URBAN ALL 2013 Uninsured 219,929 3,488,966 17,126,156 20,835,051 2015 Uninsured 169,244 2,639,749 12,725,863 15,534,856 14
Percent Change in Uninsured Change in Uninsured Population Under 65 - Non-Expansion States 30% 25% 20% 15% 10% 5% 0% FRONTIER RURAL URBAN ALL 2015 PCT Change in 2013 Uninsured 23.05% 24.34% 25.69% 25.44% 15
Change in Uninsured Population Under 65 Non-Expansion States - 2013-2015 The number of uninsured frontier county residents under the age of 65 in Medicaid non-expansion states dropped by about 50,000 between 2013-2015. The percentage of uninsured frontier county residents under the age of 65 in these states fell from about 21% in 2013 to about 16.25% in 2015. Frontier counties in 2013 were at a slightly higher rate of uninsured than rural or urban counties. The change in the uninsured percentage was generally lower than urban county populations. The reduction in the uninsured frontier population under 65 in these states between 2013 and 2015 represents about 23% of the uninsured population in 2013, slightly lower than rural and urban counties. 16
Estimated Coverage Impact in Washington 17
Projected Economic Impact Partial ACA Repeal Source: Commonwealth Fund January 2017 18
Key Areas of ACA Provisions Private Market Provisions Medicaid Provisions Medicare Provisions 19
Key ACA Private Market Provisions - 1 Establishes Coverage Mandates: creates health coverage purchase requirements. Individual mandates. Employer mandates. Creates Purchaser Subsidies: Premium tax credits for low and moderate income purchasers. Cost-sharing reductions for Silver plans for low and moderate income purchasers. Small business assistance program. 20
Key ACA Private Market Provisions - 2 Creates Marketplaces/Exchanges: Creates Individual/family and Small Business Health Options Program (SHOP) marketplaces for Qualified Health Plans (QHPs). State operated exchanges. Federally-facilitated exchanges. Hybrid exchanges. Sets QHP Standards: Essential QHP Benefits. Metal levels: including coverage, deduction limits and maximum out of pocket limits. Age Bands: sets premium ratios allowed for key age cohorts. 21
Key ACA Private Market Provisions - 3 Sets Nationwide QHP Operating Requirements: Pre-existing conditions. Coverage on parents plans for 26 and under. Loss ratios. Network adequacy. Essential community providers. Behavioral health parity. Requires Federal Approval of QHP Offerings. Establishes Insurer Risk Reduction and Stabilization Measures. State Demonstrations: Creates opportunity for state demonstrations. 22
Key ACA Medicaid Provisions Permits Medicaid Expansion: Permits, at state option, expansion of Medicaid eligibility to, among others, adults in higher income categories. Provides Enhanced Federal Support: Provides higher Federal matching for Medicaid expansions. Permits Expanded State Waivers: Provides expanded opportunity for state waivers for Medicaid expansion enrollees. Private option Cost-sharing [Training/Work requirements] 23
Key ACA Medicare Provisions Modifies Previous Payment Programs: Eliminates/reduces previous Medicare special payment arrangements. Disproportionate Share Hospitals (DSH)/SCH Home Health Creates Performance Payment Incentives: Establishes Medicare performance payment adjustments. Hospital Readmission Reduction Hospital Acquired Condition Value-Based Purchasing Provider Quality Adjustments [PQRS-MACRA-MIPS-Meaningful Use] Primary Care Incentive Payment Creates Alternative Payment Methodologies: Creates Medicare alternative payment demonstrations. Accountable Care Organizations (ACOs) Other Alternative Payment Methodologies (APMs) 24
Would Repeal Be a Pre-ACA Reset? It depends. Would repeal be a true reset or will it be limited to private market provisions? Private Coverage mandates. Marketplace and QHP requirements. Purchaser subsidies. High risk pool elimination. Would it rescind Medicare operational changes? Will it roll back payment reductions? DSH SCH Home health. 25
Pre-ACA Reset Considerations: 2 Will it repeal Medicare performance/quality payment modifiers? Hospital. Physician. Will it repeal mandated costs? Meaningful use. MACRA/MIPS/PQRS. Hospital Compare. Will it repeal Medicaid expansion? Will current Medicaid expansion be continued? Will additional states be permitted to expand Medicaid? Will FMAP for expanded Medicaid be continued at current rate or ratcheted back to basic Medicaid FMAP rates? 26
Pre-ACA Reset Considerations: 3 Will State waivers be expanded? Will they expand the private option with or without state marketplaces? Would it work if state marketplaces are eliminated? Will it meet Medicaid standards if plan benefit requirements are eliminated? Will they permit enrollee training/work requirements? Will they eliminate PPS and other special reimbursement rates? Will they permit enhanced enrollee cost-sharing? Will there be block granting or per capita caps applied to Medicaid expansion programs? Will it make supplemental, non ACA modifications, to the health market? 27
Other Potential Changes to the Health Care Market Medicaid Block Granting / Per Capita Caps. Privatization of Medicare Capped Benefit. Re-establish state high risk pools. Expand health savings accounts. Expand interstate availability of plans. Regulate medical liability. Modify MACRA and PQRS. Modify Hospital Star Rating. 28
What s the Bottom Line for Frontier? Increase in Uninsured: The number of uninsured will rise including those previously covered by Medicaid and private insurance. Increase in Underinsured: The number of underinsured will rise. Covered services will be narrowed. Co-pays and deductible levels will also increase. Premium Increases: Premiums for private insurance will rise for many. Subsidies for premiums will be reduced. Cost-Sharing Increases: Cost-sharing for private insurance will rise. Plans will cover a lower portion of medical costs and will be back-loaded. Costsharing subsidies will be reduced or eliminated. Cost-sharing for Medicaid will be expanded. 29
Bottom Line - 2 Reduction in Plan Choice: The number of plans in frontier areas will be reduced. Reduction in Frontier Market Competition: The number of insurers offering plans in frontier areas will be reduced. Essential Community Provider (ECP) Instability: ECPs will see more uncompensated care and a decrease in compensated care. This may threaten their sustainability. Curtailed Medicaid Enrollment: Outreach and enrollment for Medicaid will be reduced. Retroactive coverage and presumptive eligibility provisions will be eliminated. Narrower Provider Networks and Covered Services: These restrictions in both the private market an Medicaid could reduce access in Frontier areas. 30
Goals for Frontier Communities in the Face of ACA Repeal Medicaid Program Maintain existing Medicaid expansion. Permit states to expand Medicaid in future years. Maintain current levels of Federal contribution to Medicaid. Maintain retroactive coverage and presumptive eligibility provisions. Maintain support for outreach and enrollment. 31
Goals for Frontier Communities - 2 Direct Purchase of Individual/Family Insurance Maintain multiple insurers and plan offerings in frontier counties. Maintaining plan offerings with: Comprehensive health benefits, Affordable premiums, Reasonable cost-sharing (co-pays, co-insurance and deductibles), Appropriate pre-deductible benefits, Appropriate subsidies for lower income consumers, and Provider network adequacy. 32
How to Respond to ACA Repeal What is NCFC s role in achieving these or other goals? What specific things should NCFC do to help? Policy development and advocacy? Education? What else? 33
Important State Responses for Frontier Areas Mandated Statewide Insurance Offerings NM requires states which offer a plan at any metal level to assure that at least one plan at that level including all essential health benefits is offered statewide. Redefined Health Insurance Rating Areas CA, CO and other states have defined Health Insurance Rating Areas to include frontier counties in regions which include other urban and rural counties. This puts frontier populations in a larger risk pool which keeps premiums lower. Linked Medicaid and Private Insurance Market NY prevents insurance companies exiting the private insurance market from getting Medicaid managed care contracts. NV gives preference in Medicaid managed care markets to those companies who also participate in private insurance market. 34
State Responses - 2 High Risk / High Cost Patient Underwriting AK designed a system which will allow it to underwrite, using public funds, the high cost patients enrolled in health insurance exchange plans. This will provide incentive to insurers to offer plans and should reduce premiums. State and federal funds will be used. Defined Pre-Deductible Health Benefits NY has established maximum enrollee pre-deductible cost-sharing amounts for defined set of health benefits, including primary care visits, generic drugs and emergency room visits. These amounts are specific to plan metal levels. This assures that all purchasers of health plans receive some level of plan coverage immediately. 35
State Responses - 2 Network Adequacy Standards CA, NV, NM and several other states have established health provider network requirements for private insurance and Medicaid managed care programs. These standards include minimum provider to population ratios, maximum distances/travel times, and maximum wait times. Though limited, these standards provide a guarantee of access for frontier residents. Medicaid Buy-In The NV Legislature passed legislation which would have permitted individuals with incomes above Medicaid maximums to purchase Medicaid coverage. Premiums would be adjusted according to an income-based sliding fee scale. This would assure affordable coverage in a public option for frontier areas, whether or not private insurers offer alternatives. 36
Additional Resources - 1 Commonwealth Fund, Repealing Federal Health Reform: Economic and Employment Consequences for States, January 2017 http://www.commonwealthfund.org/publications/issue-briefs/2017/jan/repealingfederal-health-reform Urban Institute, Partial Repeal of the ACA through Reconciliation: Coverage Implications for Your State, January 2017 http://www.urban.org/policy-centers/health-policy-center/projects/partial-repeal-acathrough-reconciliation US Census Bureau, Small Area Health Insurance Estimates, February 2017. http://www.census.gov/did/www/sahie/data/interactive/sahie.html Kaiser Family Foundation, Compare Proposals to Replace The Affordable Care Act, February 2017. http://kff.org/interactive/proposals-to-replace-the-affordable-care-act/ 37
Additional Resources - 2 Rosenbaum et al., What Would Block Grants or Limits on Per Capita Spending Mean for Medicaid?, Commonwealth Fund, November 2016. http://www.commonwealthfund.org/publications/issue-briefs/2016/nov/medicaidblock-grants Talking Points Memo, Your Road Map To Paul Ryan's Plan To Privatize Medicare, December 2016. http://talkingpointsmemo.com/dc/your-road-map-to-paul-ryan-s-plan-to-privatizemedicare State Data Resources: Urban Institute State Profiles: http://bit.ly/2njvo24 Commonwealth Fund State Factsheets ACA Economic Impact: http://bit.ly/2njvw1f County Health Coverage Changes State Profiles: http://bit.ly/2mm5zsh 38