(aka Obamacare) and - ACA...

TheAffordableCareAct(ACA)(akaObamacare)

andTheAmericanHealthCareAct(AHCA)

(akaTrumpcare)WhereThingsStand

CharlesGaba•ACASignups.netRevised:6/01/17

NOTE:AlldatasourcesavailableatACASignups.net

TheHealthcareCoverageLandscapeasof2009

Mini-Medsaka“JunkPlans”

“McDonald’s“McCrewCare”benefits…requireemployeestopay$56/monthforbasiccoveragethatprovidesupto$2,000inbenefits/year…RubyTuesdaychargesworkers$18.43/week…forcoveragethatprovidesupto$1,250inoutpaDentcareand$3,000ininpaDenthospitalcare.Denny’sbasicplanforhourlyemployeesin2010providednocoverageforinpaDenthospitalcareandcappedcoveragefordoctorofficevisitsat$300/year.”

--KaiserFamilyFounda=on,2011

TheThree-LeggedStool

TheThree-LeggedStool:Leg1

•  GuaranteedIssue:Carriersmustselltoeveryoneregardlessofmedicalcondi=on,age,pre-exis=ngcondi=ons,etc(andinfactcannolongerevenaskaboutmedicalhistoryatall)

•  CommunityRaPng:Carrierscannotchargepeopledifferentratesforthesamepolicybasedonanyfactorsotherthan:–  age(withina3:1ra=o)–  locaPon(ra=ngarea)–  whethertheysmoke(50%surcharge)


•  EssenPalHealthBenefits(EHBs):AllACA-compliantpolicieshavetocover:1.  AmbulatoryServices2.  EmergencyServices

3.  Hospitaliza=on(includingsurgery,overnightstays,etc)

4.  Pregnancy/Maternity/NewbornCare(aswellasbirthcontrol/breasYeeing)

5.  MentalHealth/SubstanceAbuseTreatment

6.  Prescrip=onDrugs7.  RehabServices/Habilita=veDevices

8.  LaboratoryServices

9.  Preventa=ve/WellnessServices

10.  PediatricServices,includingoral/visioncareforchildren


•  EssenPalHealthBenefits(PreventaPveCare):AllACA-compliantpolicieshavetocover,ATNOOUTOFPOCKETCHARGE:

abdominalaor=caneurysmscreening;alcoholmisusescreening/counseling;asprinuse;bloodpressurescreening;cholesterolscreening;colorectalcancerscreening;depressionscreening;diabetesscreening;dietcounseling;hepa==sbscreening;hepa==scscreening;HIVscreening;immuniza=onvaccinesforadults,includingdiptheria,hepa==sa&b,herpeszoster,HPV,influenza,measles,meningococcal,mumps,pertussis,pneumococcal,rubella,tetanus,chickenpox;lungcancerscreening;obesityscreening/counseling;STIpreven=oncounceling;syphilisscreening&tobaccouse/cessa=onscreening/interven=on.


•  QualifiedHealthPlan(QHP)ActuarialValue:AllQHPshavetocoveratleast60%ofhealthcarecosts.Availablein4“MetalLevels”:–  BRONZE:60%AV(lowpremiums,highdeduc=ble)

–  SILVER:70%AV(mid-rangepremiums,mid-rangededuc=ble)*

–  GOLD:80%AV(higherpremiums,lowdeduc=ble)

–  PLATINUM:90%AV(highestpremiums,nodeduc=ble)–  Catastrophic:50%AV,verylowpremiums,insanelyhighdeducMbles,onlyavailableif

you’reunder30orotherrareexcepMons

•  *(SilverplansaretheonlyoneseligibleforCostSharingReducMonassistance)


•  IndividualMandate:Everyone(withexcep=ons)hastohaveanACA-complianthealthcarepolicyforatleast9monthsoftheyearortheyhavetopayataxpenaltyof:

–  $695.00/adult($347.50/child)or–  2.5%ofhouseholdincome(whicheverisgreater)–  maximumof$2,085/familyortheavg.annualpremiumforaBronze

plan

•  Penaltyisbymonth(6mouncovered=½penalty,etc)•  Excep=onsmadeforvariousreasons(expatriate,hardship,

domes=cviolencevic=m,naturaldisaster,etc)


•  TaxCredits(akaSubsidies):Twotypes,bothbasedonincomerelaPvetotheFederalPovertyLevel(FPL):

•  AdvancePremiumTaxCredits(APTC):Incomebetween100-400%FPL($12K-$48Kindividual;$24.6K-$98.4Kforafamilyof4)–  SubsidiesINCREASEasbenchmarkpremiums/deduc=blesincrease

(premiumgoesup20%?Subsidygoesup~20%)–  SubsidiesVARYbyRATINGAREA:

•  Avg.premiuminMassachuseps:$290/month•  Avg.premiuminAlaska:$1,041/month(3.6xashigh!)

•  CostSharingReducPon(CSR):Incomebetween100-250%FPL($12K-$30Kindividual,$24.6K-$61.5Kfamilyof4)

TheThree-LeggedStool:OpenEnrollment

•  2014:6months(+2weekoverPme)–  8.0Millionselectedplans;~7.0Millionpaid/effectuated–  44KviaMinnesotaBHPprogram

•  2015:3months(+1weekoverPme)–  11.7Millionselectedplans;~10.5Millionpaid/effectuated–  79KviaMinnesotaBHPprogram

•  2016:3months(+1dayoverPme)–  12.7Millionselectedplans;~11.4Millionpaid/effectuated–  121KviaMNBHPprogram;380KviaNYBHPprogram

•  2017:3months(nooverPme)–  12.2Millionselectedplans;~11.0Millionpaid/effectuated–  100KviaMNBHPprogram;665KviaNYBHPprogram

•  2018:45DAYS(11/01–12/15)

ACAOpenEnrollmentPeriods

BasicHealthPlan(BHP)program

•  OnlyMinnesota&NewYorkhaveadopteditsofar

•  Basicallyamountsto“MedicaidPlus”

•  Onlyavailabletothosebetween138%-200%FPL;costs$20/monthflat,availableyearround

•  Around100,000inMinnesota,665,000inNY

MedicaidExpansion•  ExpandsMedicaideligibilitytoEVERYONEupto138%FPL($16.6K/

yrforindividual)regardlessofpre-ACAeligibility•  31states+DCexpanded;19states(allGOPheld)sPllrefusing•  ~2.6MILLIONpeoplecaughtinMedicaidGap:Don’tqualifyfor

Medicaid,butearntoolihletoqualifyforACAtaxcredits

•  October2013:57.4millionenrolledinMedicaid•  October2016:74.4millionenrolledinMedicaid•  Netincreaseof17.0million•  13.0millionofthatduetoACAexpansion(+specialfromNY)•  3-4millionvia“Woodworkers”…peoplewhowerealreadyeligible

forMedicaidpre-ACAbuteitherdidn’tknowitorwerereluctanttoun=ltheACAwentintoeffect.

MEDICAID/CHIPELIGIBILITYLEVELS

Thereare8differentcategoriesineachstatewithdifferentincomeeligibilitylevels:•  PregnantWomen•  PregnantWomen(CHIP)•  Infants•  Children1-5•  Children6-18•  Children(CHIP)•  Parentsofchildrenunder18•  Adultswithoutchildrenunder18

•  Incomethresholdswerealloverthemap,from0%(noone)toashighas317%

•  ACAmade133%(138%)theminimumforallcategoriesinallstateswhichexpandedMedicaid

ACAImprovements:

•  Lg.Group,Sm.Group&IndividualMarket:

–  NOAnnualorLife=melimitsoncoverageforANYONE–  ALLplansmusthaveGuaranteedIssue,CommunityRa=ng,Essen=alHealthBenefits

–  ALLplansmustcoverarangeofpreventa=vecareservicesat$0outofpocketcost

–  YOUNGADULTScanstayonparents’plansun=l26•  Medicare:ClosesPartDDonuthole;extendsfundingby7

years

•  Awholemessofotherstuff

TheHealthcareCoverageLandscapeasof2009

TheHealthcareCoverageLandscapeasofMarch2017

Whoaretheremaininguninsured?

WhoareIndyExchanges&MedicaidExpansionWorking/NotWorkingfor?

LegiPmateProblemsw/theACA:

•  MEDICAID:–  MEDICAIDGAP(2.6M):19stateshaven’texpanded(blameGOP)–  Dr./Hospitalreimbursementtoolow(~40%ofprivaterates)–  Fedscover90-95%ofexpansionMedicaidfundingbutonly50-75%of

tradi=onalMedicaid;statesconstantlyraidingtheirshareormessingw/programrequirements/coverage

•  GROUPCOVERAGE:–  Employermandateironicallyencourages“JobLock”whilealsoaddinga

bunchofpaperworkfortrackingemployees(butalsoprovidespar=alfundingforexchangesubsidies/Medicaidexpansion)

–  INELIGIBLEDUETOESIOFFER(4.5M):EmployerplansglitchallowsCatastrophic(Lead)plans“leyonthetable”todisqualifyemployeesforindividualexchangetaxcredits

•  RISKCORRIDORFUNDING:Thanks,MarcoRubio!!(supplemental)

LegiPmateProblemsw/theACA:

•  UNDOCUMENTEDIMMIGRANTS(5.4M):ACAdoesn’tallowundocumentedimmigrantsontoMedicaidorACA

exchangesevenatfullprice(unsubsidized).CAnearlypassedstatelawtoallowitbutrescindedayerTrumptookoffice.

•  MEDICAID/CHIPELIGIBLE(6.4M):OUTREACH,OUTREACH,OUTREACH…andobstruc=onbyGOPofficialsat

statelevel(remember,mostoftheseareeligiblefortrad.Medicaid)

•  TAXCREDITELIGIBLE/INCOMEINELIGIBLE(8.3M):–  APTCtooskimpy(400%FPLcut-off,notgenerousenough300-400%)–  CSRtooskimpy(250%FPLcut-off,notgenerousenough200-250%)–  ESIineligibilityallowsskinnyplanstobeconsidered“compliant”–  “FamilyGlitch”:If1memberonemployee-onlyESI,othersdon’t

qualifyforexchangesubsidies(~3Mpeople)

HowI’dFixtheACA’sProblems:1.   Fixthe“FamilyGlitch”:OtherfamilymembersshouldqualifyforAPTC/

CSRevenifsomeoneinthefamilyiscoveredbyESI.2.   Fixthe“SkinnyPlanGlitch”:RequireESIpoliciestobeatleastBronze-

strength(preferablySilver)beforeemployeesareineligibleforAPTC/CSR3.   RestoreRiskCorridorfunding(&extenditindefinitely).Themoneyis

legallyowedtothecarriersanyway,andtheprogramworksjustfinforMedicarePartD).

4.   GuaranteeCSRPayments.HouseGOPbroughtalawsuitchargingCSRpaymentsareuncons=tu=onaleventhoughthey’relegallymandated.Casepending;swordofDamoclescausingmonthlyuncertainty.

5.   RequireALLIndividualMarketplansbeofferedontheexchanges(beperyet,exclusivelyon-exchange,asDChasdonefor4years).Lessconfusion,noincome-basedcherry-picking,easiertrackingofenrollmenttrends.

6.  BeefupIndividualMandatePenalty(Notgonnahappen.Moveon.)7.   BEEFUPTHETAXCREDITS(bothAPTC&CSR)

Three-LeggedStoolFixes

HowwouldIfixtheACAtaxcredits?•  Remove100%minimumcaptoensureallnon-expansionresidents

qualify

•  Remove400%maximumcap(s=lltaperingoff),beef‘emupbelowthat.

•  RaisethecaponCSRfrom250%to500%(s=lltaperingofftowardstop)

•  $15B/yearshoulddoit.ChangeAPTCstructuretosomethinglikethis:

So,what’sinTrumpcare?(akathe“AmericanHealthCareAct”or“AHCA”)

So,what’sinTrumpcare?(akathe“AmericanHealthCareAct”or“AHCA”)•  DEFUNDSPlannedParenthood($530million/year…40%oftheirtotalbudget)•  DEFUNDSMedicaidExpansion(star=ngin2020,viaapri=on…nonewenrollees,current

onescan’tcomebackoncetheyleave.•  DEFUNDSCostSharingReduc=ons(CSR)completelystar=ngin2020.•  CUTSNON-ACAMEDICAIDFUNDING25%ANDCAPSIT(reducescareand/orkicks

moreofflater)•  CHANGESTaxCredits(APTC)fromINCOME-basedtoAGEbased

($2,000foryounger-->$4,000forolderenrollees)•  TaxcreditsNOLONGERINCREASEtomatchpremiumhikes,nordotheyvaryby

geography/ra=ngarea•  ChangesAGEBANDfrom3:1to5:1

(olderenrolleescanbecharge5xasmuchasyounger…andthat’sWITHOUTwaivers)•  ELIMINATEStheminimum60%AV(Bronze)requirement;HELLOJUNKPLANS!•  $138billionover9yearstostatesforHighRiskPools,Reinsuranceprograms,etc

(partofthisiseffec=velyreplacingmoneytheystolefromtheRiskCorridorprogram)•  CHANGESMandatepenaltytoa30%,1-yrpremiumsurchargefornotmaintaining

conPnuouscoverage…w/penaltygoingtoCARRIER,notIRS•  WIPESOUToverhalftherevenuetofundACA…including3.8%investmenttaxonrich

people&0.9%Medicarepayrolltax.Replaceswith…notmuchofanything.•  Thiswouldgivetop1%avg.$33,000taxcut;top0.1%avg.$197,000taxcut;andtop

400richestAmericansanAVERAGETAXCUTOF$7MILLION.

HowdoesTrumpcarechangetaxcredits?

HowACHA(Trumpcare)wouldchangepre-exisPngcondiPoncoverage

PARTIALLISTOFPRE-EXISTINGCONDITIONSasdefinedbymajorinsurancecarrierspre-ACA

• Acne• Acromegaly• AIDSorARC• Alzheimer'sDisease• AmyotrophicLateralSclerosis• Anemia(Aplas=c,Cooley's,Hemoly=c,MediterraneanorSickleCell)• Anxiety• Aor=corMitralValveStenosis• Arteriosclerosis• Arteri=s• Asbestosis• Asthma• Bipolardisease• Cancer• Cardiomyopathy• CerebralPalsy(infan=le)• ChronicObstruc=vePulmonaryDisease• CirrhosisoftheLiver

• Coagula=onDefects• Conges=veHeartFailure• Cys=cFibrosis• Demyelina=ngDisease• Depression• Dermatomyosi=s• Diabetes• Dialysis• EsophagealVaricosi=es• Friedreich'sAtaxia• Hepa==s(TypeB,CorChronic)• Menstrualirregulari=es• Mul=pleSclerosis• MuscularDystrophy• MyastheniaGravis• Obesity• Organtransplants• Paraplegia• Parkinson'sDisease• PolycythemiaVera

• Pregnancy• Psoria=cArthri=s• PulmonaryFibrosis• RenalFailure• Sarcoidosis• Scleroderma• Sexreassignment• Sjogren'sSyndrome• Sleepapnea• Transsexualism• Tuberculosis

HowACHA(Trumpcare)wouldchangepre-exisPngcondiPoncoverage

StateswithfullGuaranteedIssuepre-ACA:

MaineMassachusehsNewJerseyNewYork

RhodeIsland*Vermont

WashingtonState*

*RI/WA=someexcepPons

“105%RateHikeDuetoObamacare”?

•  OnlyincludedHC.govstates•  Doesn’tincludetaxsubsidiesfor50%ofthemarket

•  Apples/Orangessince44statesalloweddiscrimina=on/cherry-pickingofthosew/pre-exis=ngcondi=onspriortotheACA

•  Withtaxcreditsincluded,average4-yrincreasedropsto22%


•  Whenyouadd9morestates,unsubsidizedaveragedropstoa94%4-yrincrease

•  Whenyouadd9morestates,subsidizedaveragedropstoa19%4-yrincrease

•  (s=llmissingCA,NY,DC)


•  IfyouonlylookatstateswhichalreadyhadGuaranteedIssueinplacepre-ACA,itpaintsaverydifferentpicture(NYmissingbutNYDFSsays~50%lowerthanin2013evenayer3yrsofratehikes)

CBOScore?

CBOScore?•  14millionlosecoveragein2018•  Another9millionlosecoverageby2026(23milliontotal)•  Justaboutalllosingcoveragewouldbelower-incomeand/orelderly

•  By2026,totaluninsuredwouldbe~51million(upfromcurrent28million)

•  Age-basedtaxcreditswouldactuallybesomewhatbeperforsomeinthemiddleclass(300-600%FPL),butdevastaPngtolow-income/elderly.

•  PREMIUMSwouldINCREASEbyanaddiPonal15-20%peryearthru2020;wouldthengraduallydecreaseto~10%lowerthancurrentprojec=onsby2026…mainlyduetoforcing50-64yearoldsoffcoveragecompletely.

•  DEDUCTIBLESwouldINCREASEevenmorein2ways:a)LowerAVreqiurements;b)CSRassistancecutoffforlower-incomeenrollees

ForasingleadultEarning$26,500/yrtypicalpremiumschanges:

• Age21:26%lessoraboutthesame

• Age40:23%or70%increase

• Age64:800%-950%increase

Yes,uptoa9.5xashighAFTERreworkedtaxcredits.

HowmanypeopleDoestheCBO

projectWouldlosecoverageBy2026?

23MillionOr

7%oftheenPreU.S.PopulaPon:

14MviaMedicaid3millionvia

IndividualMarket6millionviaGroupPolicies

Plus913,000SENIORS

LosingMedicaid(notMedicare)

MICHIGAN:536,000peopleprojectedtolosecoverage(5.4%ofpop.)~343KMedicaid;98KEmployerSponsored;95KIndividualMarket.

DavidTroh’sDistrict(MI-11):10.7KMedicaid;9KESI;7,400Individual

InaddiPon,27,500low-incomedual-enrolleeseniorsareprojectedtoloseMedicaid

HowmanyhavePre-Exis=ngCondi=ons?

•  MICHIGAN:4.1MILLIONnon-elderly(41%oftotalpop.)(226Kcurrentlyonindividualmarket)

•  MI-11:318,000non-elderly;18,000onindividualmarket

WHATHAPPENSIFMICHIGANRECEIVEDFULLWAIVER?

•  InsurancecarrierscouldrefusetocoversomeoftheEHBs,suchasmaternity/prenatalcare,mentalhealthservices,prescripPondrugs,etc.

•  InsurancecarrierscouldchargeFARmore($thousands)forcoveringvariouspre-exisPngcondiPons

•  Insurancecarrierscouldbringbackannual/lifePmelimits

•  InsurancecarrierscouldchargeolderenrolleesMOREthan5xasmuch

•  Womencouldonceagainbechargemoreforbeingwomen

GOPObstrucPon/Sabotage•  Co-Opswereshort-changedfromthestart

($10Bingrantswhipleddownto$2.4Binshort-termloans)

•  19StatesRefusedtotakeMedicaidExpansion(2.6millionpeopleleyw/nocoverageop=ons,higherpremiumsinthosestates)

•  GleefulObstrucPonofEnrollmentEfforts

--AtlantaJournal-Cons=tu=on,4/16/15

GOPObstrucPon/Sabotage?•  Ahemptedtokilltaxcreditsin2/3ofstates

(Kingv.Burwellapemptedtowipeoutsubsidiesusingalaughableclaimbasedonastupiddrayingglitch;shotdownbySCOTUS)

•  AhempPngtokillCostSharingReducPons(HouseGOPsuedObamaAdminoverCSRs,casepending)

•  TheRiskCorridorMassacre(MarcoRubio&Co.addedpoisonpilltomust-passCromnibusBillinDec.2014effec=velydefundingRiskCorridorprogram,helpingtocause2/3ofCo-Ops&atleast1privatecarriergoingbankrupt)

GOPObstrucPon/Sabotage?•  PulledAdverPsingduringcriPcalfinalweek

(Trump/HHSSec.Pricedeliberatelyyankedmarke=ng/outreachofHealthCare.Govoverfinal5daysof2017OpenEnrollmentPeriod.Result?HC.govenrollmentdown5%evenas12state-basedexchangesincreased2%)

•  DayOneExecuPveOrder(TrumpissuedanEOwithinhoursoftakingofficeinstruc=ngalldepartmentstodoeverythingpossibletoweaken/undermineACA…includingnotenforcingindividualmandate)

•  JerkingCarriersAroundre.CSRReimbursementPayments(Thisaloneisdirectlyresponsiblefor15-60%of2018ratehikes…accordingtothecarriersthemselves)

Who’sShouPngfromtheRoozops?

HealthInsuranceCarrierspinblamesquarelyondeliberateTrump/GOPCSR/etc.uncertainty:

•  CA,FL,MI,NM,OH,TX,UT,WA,WI:MolinaCEOMarioMolinadeliversul=matumtoTrumpre.CSRpayments.He&hisCFObrotheraresubsequentlyfiredfromcompanyfoundedbytheirfather.

HealthInsuranceCarrierspinblamesquarelyondeliberateTrump/GOPCSR/etcuncertainty:

•  Maryland:EvergreenHealth:CSR/otherTrump/GOPuncertainty=“PrimaryDriver”of27%hike

•  NewMexico:NewMexicoHealthConnec=ons“planstofilehigherpremiumsthatassumenoCSRpayments.”

•  Virginia,Maryland,DC:CareFirstCEO:15pointsof52%&39%ratehikes=duespecificallytoTrumpadminac=ons

•  IL,MT,NM,OK,TX:HealthCareServiceCorp(BCBS)CEOsays“It’shardtosay”whetherthey’lls=ckaroundnextyearduespecificallytoCSRpaymentuncertainty

HealthInsuranceCarrierspinblamesquarelyondeliberateTrump/GOPCSR/etc.uncertainty:•  NorthCarolina:BCBSNCCEOspecificallypins60%(14points)

oftheir23%ratehikerequestonlackofCSRfunding:

PennsylvaniaInsuranceCommissioner:8.8%withoutTrump/GOPsabotage,36%with

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