Overview: Patient Protection and Affordable Care Act€¦ · $1.4 trillion over 10 years...
Transcript of Overview: Patient Protection and Affordable Care Act€¦ · $1.4 trillion over 10 years...
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Overview:Patient Protection
and Affordable Care Act
(and other Health Reform Initiatives)
Sheryl Garland, M.H.A.November 13, 2015
Objectives
• Provide an overview of the Patient Protection and Affordable Care Act (ACA)
• Review coverage options under the ACA
• Review recent legislative issues
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U.S. has been working on reforming its health care system for a long time….
Franklin Roosevelt outlines Economic Bill of
Rights that includesright to adequate
medical care
The Medicare and Medicaid programs
are signed into law by Lyndon Johnson
President Clinton asks the
First Lady to convene the White House
Task Force on Health Reform
Barack Obama signs the Patient
Protection and Affordable Care Act
Teddy Roosevelt endorses social
insurance as a part of his platform
President Truman calls for a National Health
Program in a message to Congress
1912 1944 1947 1993 20101965
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Why Is Health Reform An Issue?
• In 2014, there were nearly 36 million uninsuredAmericans*
• Since 2004, average health insurance premiums for family coverage have risen 69%**
• Average annual cost of employer‐sponsored family coverage in 2014 was $16,834**• Average employee contribution: $4,823
• In 2014, 55% of firms offered employer-sponsored coverage**
*Nation at a Glance: Uninsured Americans, CDC/NCHS National Health Interview Survey, 2013-2014, June 25, 2015. **The Kaiser Family Foundation and Health Research & Educational Trust, “Employer Health Benefits: 2014 - Summary of Findings”, September 10, 2014.
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On average, other wealthy countries spend about half as much per person on health than the U.S. spends
$3,289
$3,493
$4,460
$8,745
$‐ $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000
United Kingdom
OECD Average
Japan
Australia
Sweden
France
Belgium
Comparable Country…
Canada
Germany
Austria
Netherlands
Switzerland
United States
Total health expenditures per capita, U.S. dollars, PPP adjusted, 2012
Source: Kaiser Family Foundation analysis of 2013 OECD data: "OECD Health Data: Health expenditure and financing: Health expenditure indicators", OECD Health Statistics (database). doi: 10.1787/data-00349-en (Accessed on June 25, 2014). Notes: Because 2012 data was unavailable, 2011 were used for Australia and the Netherlands. Data for Canada and Switzerland are estimated values.
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Patient Protection and Affordable Care Act
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• Enacted in March, 2010 with the goals of:
• Ensuring access to quality health care• Providing affordable health insurance to the uninsured
• By 2024 will expand coverage to ≈ 26 million currently uninsured Americans
• Net cost of coverage expansion is $1.4 trillion over 10 years (2015-2024)
Source: Congressional Budget Office, Updated Estimates of the Effects of the Insurance Coverage Provisions of the Affordable Care Act, April, 2014
Patient Protection and Affordable Care Act (ACA)
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Impact of ACA on Children’s Health
• Prohibition on pre-existing condition exclusions
• Plans provide dependent coverage until a child turns 26
• Required coverage of preventive services without cost-sharing
• Authorization and funding for CHIP through September 30, 2015 (recently expanded to 2017)
• Established a new loan repayment program for certain medical, surgical, and behavioral health subspecialties
ACA Created Several Coverage Options
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• Established an Individual Mandate (Jan 1, 2014)
• Established an Employer Mandate(Jan 1, 2015 and Jan 1, 2016)
• Expanded Medicaid to non-elderly population with incomes at or below 138% FPL* (Jan 1, 2014)• (133% 2015 FPL = $15,654–single
person, $32,253 – family of 4)• OPTIONAL for States
• Created Health Insurance Exchange (Marketplace) (Jan 1, 2014)
* FPL = Federal Poverty Level
Nonelderly Uninsured byFederal Poverty Level
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Source: Diamond, D., “Thanks, Obamacare: America’s Uninsured Rate is Below 10% For the First Time Ever, Forbes, August 12, 2015,http://www.forbes.com/sites/dandiamond/2015/08/12/for-first-time-americans-uninsured-rate-is-below-10/
Individual and Employer Mandates
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Individual and Employer Mandates
• As of 2014, everyone is required to:1. Have health insurance coverage2. Have a coverage exemption3. Pay a penalty
• Beginning January 1, 2015, employers with 100 or more full-time or full-time equivalent employees had to offer affordable coverage
…to full-time employees and their dependent children
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Individual Mandate: Penalties
■Collected through tax returns
■Exempted: undocumented immigrants, Native Americans, and those who earn too little to file a tax return
2014 2015 2016 and beyond
$95 Per adult
$325Per adult
$695Per adult
OR OR OR
1% Of family income
2%Of family income
2.5%Of family income
Whichever is greater
Source: The Kaiser Family Foundation
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Medicaid Expansion
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0%
50%
100%
PregnantWomen
Children 0-5 Children 6-18
Elderly &Disabled
Parents ChildlessAdults
Current Elig Federal Reform
• Program created in 1965
• Helps states provide medical coverage for low-income families and other categorically-eligible individuals • Optional for states to participate
• Current Eligibility for Medicaid/FAMIS in Virginia
• Pregnant women and children (below 200% FPL)
• Adults with children (below 30% FPL)
• Aged, blind or disabled (below 80% FPL)
• Expansion provides coverage up to 138% FPL
138%
Medicaid in Virginia
Fed
eral
Po
ver
ty L
evel
*Coverage up to 200% FPL available through FAMIS
**
*
Medicaid Eligibility by FPL
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Year
Match by State Fiscal Year**
(July to June)
Federal State
2014 100% 0%
2015 100% 0%
2016 100% 0%
2017 95% 5%
2018 94% 6%
2019 93% 7%
2020 – beyond 90% 10%
Impact of Medicaid Expansion in Virginia
**http://cciio.cms.gov/resources/files/exchanges-faqs-12-10-2012.pdf.
• Approximately 400,000 Virginians would be eligible – Projected enrollment is
approximately 250,000
• Federal government pays 100% through 2017– Expanded enrollment is
estimated to result in a savings of $1.1 billion to the State through 2022*
*Medicaid DSH and Indigent Care, Presentation to the Senate Finance Committee, Health and Human Resources Subcommittee, Scott Crawford, Department of Medical Assistance Services, January 27, 2014,
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Health Insurance Exchange(Marketplace)
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ACA required the establishment of Health Insurance Exchanges (Marketplaces) in all States
• If a state-based Exchange/Marketplace is not created, the state defaults to the federal Marketplace
• 16 states and DC established State-based Marketplaces
• 34 states defaulted to the Federally-Facilitated Marketplaces (Exchanges) – including Virginia
• Marketplace plans provide• Premium Tax Credits for individuals 100% to 400% FPL• Cost-Sharing Reductions for individuals between 100% and
250% FPL
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Coverage Levels
• The ACA created four benefit levels of coverage (Metal Levels) based on how much of the cost is covered
• The levels define the split between what the consumer pays and what the health plan pays
Paid by PlanPaid by
Consumer
Platinum 90% 10%
Gold 80% 20%
Silver 70% 30%
Bronze 60% 40%
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Approximately 8 million people enrolled in the Marketplace plans nationwide in 2015
385,000 in Virginia
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Legislative Issues to Watch
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• 56 legislative attempts to repeal the ACA in the U.S. House of Representatives
• 2010 Lawsuit filed challenging the individual mandate• Supreme court rendered a decision in June 2012 stating
the Individual Mandate was constitutional
ACA Legislative and Legal Challenges
• King v. Burwell (June 2015)• Supreme Court ruled that subsidies are allowable for individuals in both
State and Federally Facilitated Marketplaces.
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Medicare Access and CHIP Reauthorization Act of 2015
• Repealed Sustainable Growth Rate (SGR) formula • Replaced with standard annual updates for 5 years (2015 –
2019)
• Transitions payment system from volume based to value based
• 2020 – 2026+ introduction of Merit Based Incentive Payment System and Alternative Payment Models
• Provides funding for the Children’s Health Insurance Program (CHIP)/FAMIS in Virginia through 2017
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Conclusion
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Questions