ACA
101
for
Texas
Click to edit Master title style
and the Uninsured Coverage Gap
Click to edit Master subtitle style
Anne Dunkelberg, Associate Director – dunkelberg@cppp.org
Confused About The Affordable Care Act?
Tyler Area Chamber of Commerce
UT Tyler Ornelas Activity Center
Monday, August 12, 2013
CPPP.org
1
2013-14 Timeline
May
3
June
7
August
15
Navigator
applications
due
Plan details due
to federal
Marketplace
Navigator
awards
made.
Training
begins
October
January
1
1
OPEN
ENROLLMENT
BEGINS
Plan coverage
begins
March
31
Open
enrollment
ends
Texas Well and Healthy
• Collaborative campaign of 4 non-profits in TX
• Our goal: educate Texans about health care
options
• Website: www.texaswellandhealthy.org
• Facebook: www.facebook.com/KidsWellTexas
• Twitter: @TxWellHealthy
An ACA Primer
• The Patient Protection Affordable Care Act,
signed into law on March 23, 2010.
• Takes full effect January 1, 2014.
• Gradual roll-out of benefits.
• ACA, PPACA, Obamacare
• 2012 SCOTUS decision: all systems go, except
Medicaid Expansion is optional for states.
Health Reform’s Big Picture
1.
For the first time: a system making comprehensive care
available to all* Americans, at a cost they can afford.
2.
For the first time: health insurance marketplace
requires insurers to compete based on good care and
customer service, and not by avoiding covering people
or denying them care they need.
3.
Lays foundation for medical practice reforms based on
effective health care, not just rewarding volume; this is
ESSENTIAL to cost control and long-term deficit
reduction.
* Lawfully present in U.S.
5
No Lifetime or Annual Caps
• As of 2010, the lifetime caps on health insurance
benefits that used to hurt the sickest insured folks
are GONE.
• No more will a health insurance plan drop your
coverage when you get so sick that your
medical bills hit the roof.
• Also, annual caps on health benefits are being
phased out beginning in 2010.
No Pre-existing Conditions
• As of 2010: children (ages 0-18) can not be
denied coverage based on pre-existing
conditions.
• Starting in 2014: No one can be denied insurance
due to pre-existing conditions.
• Starting in 2014: No one can be charged more
because of health history or condition.
• Only 3 things lead to higher premiums: age,
tobacco use, and geography
Preventive Care with no Co-Payment
• Preventive Care: annual well check-ups, routine
care, vaccines, birth control, mammograms,
colonoscopy, screenings, etc.
• As of 2010: Kids, seniors, & disabled on Medicare
receive preventive care free (no co-pay)
• Aug 1, 2012: Women get contraceptives and
well woman care free (no co-pay)
• Starting in 2014: All insured adults and kids get
free preventive care (no co-pay)
Essential Health Benefits
The ACA is making sure
that in 2014, ALL
health insurance
policies will cover 10
Essential Health
Benefits.
This means all health
conditions should get
the coverage they
need!
1.
2.
3.
4.
5.
ambulatory patient services;
emergency services;
hospitalization;
maternity and newborn care;
mental health and substance
use disorder services,
including behavioral health
treatment;
6. prescription drugs;
7. rehabilitative and habilitative
services and devices;
8. laboratory services;
9. preventive and wellness
services and chronic disease
management
10. pediatric services, including
oral and vision care.
Seniors & People with Disabilities
• Seniors and those with disabilities in Medicare
are already receiving free screenings and
preventive care.
• Closing the Medicare prescription “doughnut
hole,” by making prescription drugs more
affordable.
o In Texas in 2011, the average savings was approximately
$639 for each person who fell into the doughnut hole.
o By 2020, the gap in drug coverage will be completely gone.
Small Business Owners
• Because of ACA, many small business owners
have access to new tax credits to help them buy
health insurance for their employees, if they want
to.
o 35% tax credit now
o Up to 50% tax credit in 2014
• No penalties or obligations for small business
owners (50 or fewer employees) who choose not
to provide insurance.
• For those who do, the ACA makes it easier to buy
and afford insurance through Small Business
Health Insurance Exchange (called SHOP).
Individual Mandate
• If you don’t have good, affordable coverage through
your job, Medicaid/CHIP, or Medicare, you must
purchase insurance for yourself, or pay a tax.
• If it costs more than 8% of your house-hold income,
you are exempt – pay no penalty. Also exempt below
tax filing income, or if uninsured because our state
fails to expand Medicaid.
• Why encourage healthy folks to sign up? It lowers the
average cost for all, saves money thru prevention.
We will all need care at some point and when
someone doesn’t have coverage we all pay for it in
higher premiums and taxes.
• You’d be eligible for Medicaid, but for the state’s decision to not expand
The ACA’s
Individual
Mandate to Have
Insurance in
2014
Individual Penalty Amounts
Regulating Insurers
The 80/20 Rule:
o Insurers have to spend 80% of your premiums on your
health care, only 20% can go to overhead and profits
o Because of this, millions of Texans got $167 million in
rebates during 2012 ($187 avg check)
Rate Review:
o Any health insurance increase 10% or more goes
through an automatic review process on whether or not
is justified.
o We still need “teeth” to stop unjustified rate hikes.
Marketplace Basics
• Terminology: Health Insurance Marketplace
(formerly known as the Exchange) and SHOP for
small employers
• Compare private insurance plans based on price,
benefits, quality, and other features
• Most people will get a break on costs
• “No wrong door” with Medicaid and CHIP
• Open enrollment starts October 1, 2013, and
coverage is effective beginning on January 1,
2014
Marketplace Administration
State-based
Partnership
Federally facilitated
Source: The Commonwealth Fund, www.commonwealthfund.org/Maps-and-Data/State-Exchange-Map.aspx
2014: ACA Provides Public Support Fitted to Income
>$89,400 for a
family of four;
>400% of FPL
Family Income
$67,100-$89,400;
300-400% of
FPL
$44,700-$67,100;
200-300% of
FPL
 Job-based coverage, or
 Full-cost coverage in the exchange
 Job-based coverage, or
 Subsidized exchange coverage: premiums capped
at 9.5% of income
 Job-based coverage, or
 Subsidized exchange coverage: premiums capped
at 6.3 – 9.5% of income
CHIP
• Job-based coverage, or
• Subsidized exchange coverage:
premiums capped at 3% - 6.3%
of income
Medicaid
???Medicaid???
Children
Adults
$29,700-$44,700;
133-200% of
FPL
<$29,700 for a
family of four;
< 133% FPL
Family income based on 2011 federal poverty income levels for a family of four
(non-disabled adults,
not eligible for Medicare)
18
Coverage Level Options in the Exchange
All plans will cover
essential benefits:
hospital, ER, mental health,
maternity, Rx, preventive
care, chronic disease
management and more.
% enrollee
cost share
% covered by plan
90%
Platinum
Gold
4 standard levels, (plus a
5th catastrophic plan for
people under age 30 or if
no other coverage is
affordable)
80%
70%
Silver
Bronze
0%
20%
60%
40%
60%
10%
20%
30%
40%
80%
100%
Options vary by % of covered benefits paid by the plan on average
vs % covered through out-of-pocket enrollee cost sharing
19
The Affordability Puzzle
1) Premium Credits
2) Help with Health Care Costs
 Preventive Services
 Out-of-Pocket Caps
 Cost-Sharing Subsidies
Premium Credits: Eligibility
Primary Group: Individuals and families
between 133* and 400 percent of
poverty
Two additional groups:
1) Legally present people below 133%* of poverty
who are not Medicaid eligible
2) People who would have to spend more than
9.5% of income to participate in employer plan or
whose employer plan has less coverage than the
“bronze” exchange plan
Premium Credits: Key Points




Sliding scale relative to income (premiums
capped at 2-9.5% of income)
Must be used to purchase coverage in
exchange
Value of credit linked to second lowest-cost
silver level plan (the “silver reference plan”)
People can choose any level of plan (e.g.
bronze, silver, etc), but MUST select a silver
plan to get cost-sharing subsidy
Out-of-Pocket Caps: Key Points
 All new health insurance plans will
have OOP caps beginning in 2014
 Caps apply only to covered services
% of FPL
100-200% 200-300% 300-400% 400%+
Annual Out- individual
$2,017
$3,025
$4,033
$6,050
of-pocket
family
$4,033
$6,050
$8,067 $12,100
Maximum
Cost-Sharing Subsidies: Key Points
 Families under 250% FPL receive extra
help with cost-sharing – lower
deductibles and copays
 Actuarial values increased to:
-
94% for families 100-150% FPL
87% for families 150-200% FPL
73% for families 200-250% FPL
 Must select a silver-level plan to qualify
In-Person Enrollment Assistance in 2014
In-person Assistance:
• Agents/Brokers
• Navigators
• Certified Application
Counselors
• Safety Net Providers
What is an ACA Navigator?
• Entities that will offer knowledgeable, in-person enrollment assistance to
consumers and small employers in the Health Insurance Marketplace.
• Will help people learn about their coverage options in the new Marketplace, and
to enroll in Medicaid, CHIP, or private coverage.
• Navigator duties:
• outreach/education;
• provide impartial information on plans;
• facilitate enrollment
• provide referrals; and
• provide that is culturally and linguistically
appropriate, and accessible to those with
disabilities
Types of ACA In-Person Enrollment Assistance
• Navigators – More broad based, comprehensive consumer
assistance. Grants funded by the Marketplace.
• Certified Application Counselors
•
•
•
•
Based in hospitals, clinics, or community
organizations.
Help enroll patients/individuals served by that
provider/org.
Provide info about coverage options, and assist
with computer process to enroll in
Medicaid/Exchange options; but no public
outreach/education.
Not funded by ACA
The Need for Navigators
Nationally, 75% of the newly eligible said that they wanted inperson assistance to learn about and enroll in coverage. (Enroll
America Research, 2012).
The profile of Marketplace enrollees is unique.
Nationally:
• 65% previously uninsured
• 77% have high school diploma or less
• Lower income than insured today
• 81% will receive subsidies
• Median income is 235% FPL ($54k for a family of 4)
• More racial and ethnic diversity
• 23% do not speak English at home
Kaiser Family Foundation, A Profile of Health Insurance Exchange Enrollees , March
2011
Marketplace and Medicaid: Building Blocks of
ACA’s 2014 Reforms
•
Build on current system: Most Americans still get coverage through their
employer.
•
Medicaid expansion: US citizens to 133% FPL ($14,856 individual; $30,657 for 4 in
2012). State option.
•
Reform private health insurance: standard minimum benefits, can’t charge more
based on health status, limits on premium differences by age, no denial of coverage,
no excluding pre-existing conditions, no annual or lifetime maximums.
•
New Health Insurance Marketplace where private insurers’ options can be
compared and purchased.
•
Sliding scale help with premiums in the exchange from 100% up to 400% of FPL
($92,200 for family of 4).
•
Sliding scale help with deductibles/co-pays and out-of-pocket caps in the
exchange
•
Individual mandate to have coverage (with major exemptions for lowest-income).
•
Employer penalties possible if employees get sliding-scale help in Marketplace,
but exemption for all employers with 50 or fewer FTE workers.
29
2014: ACA Provides Public Support Fitted to Income
>$89,400 for a
family of four;
>400% of FPL
Family Income
$67,100-$89,400;
300-400% of
FPL
$44,700-$67,100;
200-300% of
FPL
 Job-based coverage, or
 Full-cost coverage in the exchange
 Job-based coverage, or
 Subsidized exchange coverage: premiums capped
at 9.5% of income
 Job-based coverage, or
 Subsidized exchange coverage: premiums capped
at 6.3 – 9.5% of income
CHIP
• Job-based coverage, or
• Subsidized exchange coverage:
premiums capped at 3% - 6.3%
of income
Medicaid
???Medicaid???
Children
Adults
$29,700-$44,700;
133-200% of
FPL
<$29,700 for a
family of four;
< 133% FPL
Family income based on 2011 federal poverty income levels for a family of four
(non-disabled adults,
not eligible for Medicare)
30
Texas Uninsured by Income 2011…
89% of the 6.1 million uninsured have incomes <400% FPL
>400% FPL
>$89,400
300-400% FPL
$67,050-$89,400
<100% FPL
<$22,350/yr for
family of four
656K
501K
6.1 million includes
1.7 million non-US
citizens; ~2/3 of these
(about 1.1 million)
likely undocumented
1.912 Million
250-300% FPL
$55,875-$67,050
421K
626K
614K
200-250% FPL
$44,700-$55,875
921K
150-200% FPL
$33,525-$44,700
100-125% FPL
$22,350-$27,938
525K
125-150% FPL
$27,938-$33,525
Annual income limits given for a family of four, 2011 federal poverty level
U.S. Census, 2012 CPS31
About 1.5 million Texans would gain
insurance with Medicaid expansion
• Experts and Texas HHSC estimate 1.3-1.8 million uninsured US
citizen adults in Texas will be eligible for the Medicaid option
in 2014,
• HHSC projects just over a million of these adults would
actually enroll by 2016 (note the difference between who is
eligible, versus who actually signs up).
• HHSC also estimates that over 400,000 more children—
already eligible today, but unenrolled—will sign up for
Medicaid by 2016 because of higher public awareness: called
the “welcome mat” effect.
32
But, If Texas Opts Out
• ACA sliding-scale premium help is available only to persons
above 100% FPL (exception: legal immigrants excluded from
Medicaid) , so:
– Uninsured Texas adults below 100% FPL would have NO assistance available in
2014.
– Those from 100-133% FPL would be eligible for premium assistance, but
because the system was designed assuming poorest would have Medicaid,
some of these near-poor will have difficulty affording the coverage even with
premiums capped at 2% of family income.
– So, costs of care for uninsured poor Texas adults will continue to be carried
primarily by local property taxpayers, secondarily by other charity care
providers, and without benefit of the 90%+ federal matching dollars.
33
There is significant variation in the share of the uninsured that is below the
Medicaid expansion limit across states
.
Share of Nonelderly Uninsured <138% FPL by State, 2010-2011:
VT
WA
ND
MT
NH
MN
OR
WY
CA
AZ
CO
NM
MI
PA
IA
NE
UT
NY
WI
SD
ID
NV
ME
IL
KS
OK
AK
WV
MO
KY
DC
SC
AR
AL
VA
NC
TN
MS
TX
53%
IN
OH
CT
NJ
DE
MD
GA
LA
FL
HI
United States:
51% Uninsured <138% FPL
34% – 47% (17 states)
48% – 51% (18 states, including DC)
52% - 61% (16 states)
SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census
Bureau's March 2011 and 2012 Current Population Survey (CPS: Annual Social and Economic Supplements).
MA
RI
Texas Uninsured: Without Medicaid Expansion,
Only half as many gain coverage
6.1 million
uninsured
Michael E. Cline, Ph.D., and Steve H. Murdock, Ph.D. , Rice University,
Estimates of the Impact of the Affordable Care Act on Counties in Texas, April
2012.
36
Texas Medicaid/CHIP: Who is Helped Today
CHIP,
591,756
January 2013, HHSC data
Disabled,
422,467
Elderly,
326,501
Poor Parents,
144,040
Medicaid
Children,
2,547,199
Total enrolled 1/1/2013:
3.6 million Medicaid;
TANF Parent,
83,772
Maternity
86,975
592,000 CHIP
1 in 7 Texans,
but 42% of Texas kids 37
37
Why So Few Poor Parents Covered in Texas
Medicaid
• Texas Medicaid has VERY low coverage of parents (must live
below 12% of poverty; work less than 10 hrs/wk @ min wage;
must be under $308 a month for family of 3).
– This dollar limit set by Texas legislature 1985 and never updated.
• Today, about 226,000 poor Texas parents get Medicaid, even
though there are about 2.6 million children enrolled.
• Medicaid Maternity coverage income limit is much higher, but
coverage ends 2 months after birth.
• Medicaid does not cover undocumented at any age.
• LEGAL immigrant adults NOT covered in Texas Medicaid (state
choice, AL, VA, ,MS, ND, OH, WY also exclude). (Legal immigrant
kids through age 18 are covered in Texas Medicaid and CHIP)
38
Income Caps for Texas Medicaid and CHIP, 2012
250%
200%
$35,317/yr $35,317/yr
$25,390/yr
150%
100%
50%
0%
$25,128
185%
225%
$19,09
0
185
%
100%
133
%
Pregnant Newborns Age 1-5
Women
$8,376
$2,256
12%
Age 6-18
200
%
$3,696
19%
75%
TANF Working SSI (aged
parent of Parent of
or
2, no
2
disabled)
income
Mandatory
$38,180
Long
Term
Care
CHIP
Optional
indicates Texas Choices to go ABOVE federal minimum
Income Limit as Percentage of Federal Poverty Income
Annual Income is for a family of 3,
except Individual Incomes shown for SSI and Long Term Care
39
The Medicaid expansion will significantly increase
eligibility for parents in many states.
Medicaid Eligibility Levels for Parents, January 2013:
138%*
25%
NOTE: Ten states (CT, IL, ME, MA, MN, NJ, NY, RI, VT, WI) and DC already offer coverage to parents at or above 133% FPL; under the ACA an income
disregard of 5 percentage points will be applied to this limit increasing the effective income limit to 138% FPL .
SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University
Center for Children and Families, 2013.
Figure 41
In states that do not expand Medicaid, there will be large gaps
in coverage, leaving millions of low-income adults with no
affordable options.
NOTE: Applies to states that do not expand Medicaid. The current median state Medicaid eligibility limit for parents is 48% FPL in
the 21 states that are not moving forward with the Medicaid expansion at this time.
Status of State Action on the Medicaid Expansion
Decision, as of July 1, 2013
Source:
KFF.org
42
What does Texas pay, and what does federal
government pay if we expand Medicaid to
adults under the ACA?
• Federal government picks up 100% of the costs for
the first three years of Texas’ expansion to the
adults,
• 95% in 2017, 94% in 2018, 93% in 2019, and no less
than 90 percent every year after that.
• Texas will also see increased enrollment—known as
the “welcome mat” effect—by already-eligible but
currently uninsured children.
43
Range of Official Cost Estimates
• HHSC (Texas Medicaid agency) estimates the state-budget
(GR) Medicaid costs to cover these new adults at $1.3 billion
GR for the first 4 years, drawing another $23.9 billion in
federal match.
– HHSC projects in first 4 years, Texas would spend an average of $784
million a year, drawing over $6.8 BILLION federal match (net gain over
$6 billion/year)
• Legislative Budget Board (LBB) often has different opinion
of Medicaid caseload and cost per enrollee from THHSC;
projects only $482 million state GR costs for 4 years.
44
45
Large Urban Counties & Medicaid Expansion
2014-2017
El Paso
Dallas
$222
million
Uninsured
NOW
Estimated #
Gaining
Medicaid
Yearly Avg.
NEW Fed $
Harris
Lubbock
Travis
$580.1
million
$935.3 million
$77.7
million
$224.1
million
208,379
601,492
1,025,922
66,405
233,067
51,462
131,042
223,165
19,693
55,676
Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC
historical Medicaid spending by county, 2010. Cline & Murdock estimates of
ACA insurance gains by county.
46
Smith County and the ACA:
About 50% of Reduction in Uninsured depends on Medicaid
Expansion; Projected Federal Dollars Foregone
Total uninsured in Smith County (2010)
• 47,022 uninsured, 22.4% of county residents
• Uninsured children (under age 19): 9,908 uninsured, 17.7% of children in
county
Projected Smith County uninsured under ACA if Texas expands adult
Medicaid (moderate enrollment take-up, includes Medicaid expansion and
private insurance gains)
• 22,420 uninsured, 10.7% of county residents
Projected Smith County uninsured under ACA if Texas does NOT take
Medicaid option
• 34,475 uninsured, 16.4% of county residents (12,055 fewer gain coverage)
Projected new net annual gain in Medicaid funds for county (2014-2017
average) if Medicaid expanded
• $48,718,236 per year (2014-2017)
Michael E. Cline, Ph.D., and Steve H. Murdock, Ph.D., Hobby Center for the Study of Texas at Rice University 47
Largest South Texas Metro Counties
& Medicaid Expansion:
2014-2017
Bexar
Cameron
Hidalgo
Nueces
Webb
NEW Fed $
$ 503.5
million
$ 198.4
million
$ 404.7
million
$ 127.1
million
$92.0
million
Estimated
# Gaining
Medicaid
179,654
27,987
50,509
22,403
16,031
One-year
Avg.
Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC
historical Medicaid spending by county, 2010. Cline & Murdock estimates of ACA
insurance gains by county.
48
5 Tools on Medicaid Expansion and Texas:
1.
Choices and Challenges: How Texas County Uninsured Rates Will Drop Under Health Care
Reform Cline & Murdock, of Rice U. (former Texas State Demographer and Director of the
US Bureau of the Census) includes estimates of the much smaller reduction in uninsured
rates expected if Texas does not accept the Medicaid Expansion. (see www.cppp.org)
2.
Your County and the ACA Medicaid Expansion. CPPP compiled data for all 254 Texas
counties on impact of ACA on uninsured, and the new federal dollars by county, based on
Rice data above and the Texas Health and Human Services Commission’s latest official
Medicaid expansion estimates. (see www.cppp.org)
3.
Texas Has Only One Rational Choice: Expanding Medicaid Under the Affordable Care Act:
Study by The Perryman Group Finds that Expanding Medicaid More than Pays for Itself.
Analysis by The Perryman Group, every $1 spent by the State of Texas to expand Medicaid
coverage under the Affordable Care Act (ACA) returns $1.29 in dynamic State government
revenue over the first 10 years of the expansion. http://www.perrymangroup.com/
4.
Government Effectiveness and Efficiency Report 2013 (January 2013). This biennial report
to the Legislature by Legislative Budget Board staff includes a chapter analyzing the costs
and benefits of the ACA Medicaid expansion and recommending that counties be enabled
to finance and implement the expansion.
Smart, Affordable and Fair: Why Texas Should Extend Medicaid Coverage to Low-Income
Adults (January 2013). This new report from Billy Hamilton Consulting provides a
comprehensive model estimating the costs and benefits to local taxing authorities
(including cities, counties and hospital districts) and state government. Using the ClineMurdock model data, the authors conclude that state match needed for the Medicaid
expansion are far less than current state, local, and hospitals spending on health care for
low-income adults, and project $1.8 billion in new state revenue will be generated by the
expansion from 2014 through 2017, offsetting about half of the required state match.
5.
49
What’s Happened?
•
13 House and 6 Senate billed filed to expand Medicaid per ACA; each chamber
included a bill authored by a Republican in a leadership role (Rep. Zerwas; Senator
Deuell).
– Also Senate budget “rider” by Finance committee Chairman Tommy Williams
• Widespread Support, Executive Opposition. Statewide support
for Medicaid expansion from doctors, hospitals, county officials,
chambers of commerce, and even the Texas Association of
Business eventually supporting the Zerwas coverage option.
– Polling by Texas and national firms found 58-59% of Texas voters
support accepting federal ACA funds to cover the poorest uninsured
adults.
– Twenty-two chambers of commerce have called on the state to accept
this funding, and new chambers continue to add their names to the
list.
• Despite this support, the Legislature did not move the veryconservative, market-based “Texas Solution” alternative offered
by Rep. John Zerwas HB 3791.
– There was more than sufficient support by House members for
Zerwas’ “Texas Solution” bill. But the Governor’s office began to
communicate a veto threat
50
What’s Next?
Texas’ decision means that in January 2014:
• Texas adults above the poverty line will begin to get publicly funded
sliding-scale help with health insurance,
• but Texans below poverty will qualify for nothing.
Estimates of the number of uninsured Texas adults who will be
left without a coverage option in the near term range:
• from around 935,000 (HHSC, out of 1.1 million below 138% of
poverty)
• to as high as 1.3 million (Urban Institute/Kaiser Family Foundation,
out of about 1.7 million below 138% of poverty).
A Diverse network of Texans and Texas Organizations will keep
working to find health care for the Texans in the “Gap Group,” to
tell their stories, and to seek inclusion of Texas’ working poor in
the ACA’s health reform. www.texaswellandhealthy.org
51
INFORMATION NOW: HealthCare.gov
Available 24/7: 1-800-318-2596; TTY: 1-855-889-4325
Or, Chat Online
52
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53