Partnerships: Closing the Gap in Rural Arizona 42nd Annual Rural Health Conference

10th Annual Performance Improvement Summit

Welcome!

Daniel Derksen MD August 4th & 5th, 2015 Sedona, Arizona

Canyon de Chelly Photo: Ken Miller

Arizona Marketplace Update Dan Derksen, M.D.

Dan Derksen MD

BREAKING NEWS: THIS JUST IN…

Federally Facilitated Marketplaces in States

Justice ACA

Upheld Alito No

Breyer Yes Ginsburg Yes

Kagan Yes Kennedy Yes Roberts Yes

Scalia No Sotomayor Yes

Thomas No Total Y/N 6-3

ACA Upheld 6-3 Federal Government Can

Operate Exchanges in States

Dan Derksen MD

6.4 Million Lose Coverage 34 States • FFM: 5.8 M Enrollees in 27 states

AL, AK, AZ, FL, GA, IN, KS, LA, ME, MS, MO, MT, NE, NJ, NC, ND, OH, OK, PA, SC, SD, TN, TX, UT, VA, WI, WY

• Partnership: 618,300 enrollees in 7 states AR, DE, IL, IA, MI, NH, WV

What if SCOTUS Invalidated Federally Facilitated Marketplace (FFM) Subsidies?

CRH Analysis of FFM Subsidized Enrollee Data: http://kff.org/health-reform/state-indicator/marketplace-enrollees-eligible-for-financial-assistance-as-a-share-of-subsidy-eligible-population/ http://www.rand.org/content/dam/rand/pubs/research_briefs/RB9800/RB9812z1/RAND_RB9812z1.pdf

Dan Derksen MD

Act I Supremes vs Obamacare

Dan Derksen MD

Act I: Supreme Court Upholds ACA June 2012

Medicaid Expansion

Tax Mandate

Alito No No Breyer Yes Yes

Ginsburg Yes Yes Kagan Yes Yes

Kennedy No No Roberts Yes Yes

Scalia No No Sotomayor Yes Yes

Thomas No No Total Y/N 5-4 5-4

Tax Mandate UPHELD

Medicaid Expansion UPHELD*

*States can choose not to expand Medicaid –

‘unduly coercive’ to lose all Medicaid funding if a

state doesn’t choose to expand Medicaid

Dan Derksen MD

• 2015 tax penalty for those w/o coverage: 1% household income or $95 per person, whichever is greater

• 2016: 2% or $325 per person • 2017: 2.5% or $695 per person

The Unpopular ACA Tax Mandate

Dan Derksen MD

http://www.cbpp.org/files/policybasics-taxexpenditures.pdf

Dan Derksen MD

Employer sponsored health insurance costs excluded from taxable individual & payroll

income, costing the U.S.

$248 billion/yr These tax

subsides have been in place for decades

Dan Derksen MD

Pre-ACA Dan Derksen MD

STATUS QUO NOT A VIABLE OPTION

Employee Share of Health Insurance Costs Rose at 4X the Rate of Their Income 1999-2011

Dan Derksen MD

Pre-ACA U.S. Health Coverage 2012

US Census Bureau, page 22, accessed 08/02/15 at: http://www.census.gov/prod/2013pubs/p60-245.pdf

# covered (millions) Private Health Insurance

Employer Sponsored ESI

Individual Purchase

202 171 31

Medicaid 51 Medicare 49

Uninsured 48 Total Population 311

Note: Some have dual coverage: e.g., Medicare + Medicaid

Dan Derksen MD

Categories of U.S. Health Spending 2012 Total = $2.8 Trillion

http://healthaffairs.org/blog/2014/01/06/national-health-spending-growth-remains-low-for-fourth-consecutive-year/

Physician & Clinic

20%

Hospital 32%

Other 30%

Rx 9%

Dental Nursing Home

Dan Derksen MD

ACA in 2014 • Created health insurance marketplaces • Mandated coverage (levied a tax penalty) • Expanded Medicaid: <138% FPL •  Subsidized premiums:100-400% FPL • Guaranteed issue (prohibits coverage denial)

Household Size 100% 138% 400%

1 $11,490 $15,856 $45,960 2 $15,510 $21,404 $62,040 3 $19,530 $26,951 $78,120 4 $23,550 $32,499 $94,200

FPL – Federal Poverty Level 2013

Accessed 08/02/15 at: http://aspe.hhs.gov/poverty/13poverty.cfm#thresholds

Dan Derksen MD

Accessed 08/02/15 at: http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/

ACA Medicaid Expansion – 31 States & Growing

é12.3 Million Medicaid Enrollees

Dan Derksen MD

Accessed 08/02/15 http://kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/#

ACA Marketplace Decisions by State

27 Fed-facilitated, 7 Partner 13 State, 3 Fed-supported State

Dan Derksen MD

é11.7 Mil Marketplace Enrollees

Avg. Annual Percent Increase in National Health Expenditures 1960-2012

10.6%

13.1%

11.0%

6.7%

5.8% 6.4%

7.1% 8.4%

9.7%

8.6%

7.2% 6.8%

6.5% 6.3%

4.7% 3.8% 3.8% 3.6% 3.7%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

1960 1970 1980 1990 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

2013 3.6%

SOURCE Accessed 08/02/15 at: http://content.healthaffairs.org/content/early/2014/11/25/hlthaff.2014.1107

Last 5 years: Lowest spending growth in 50 year history

Dan Derksen MD

34% Waste $2.9 Trillion US Health Spending Confiscates Resources for Other Spending

Accessed 08/02/15 at: http://beyondflexner.org/conferences/bf2015/presentations/

Dan Derksen MD

“Quality Equals Meeting Health

Needs – We Must Reinvent Medical Education to Meet

Our Nation’s Health Needs”

The Rural Health Challenges

Dan Derksen MD

Fewer providers Poorer outcomes Higher uninsured Higher poverty

Did you know? Arizona’s

114,000 sq. mi. would encompass NY, CT, DE, ME,

MA, NH, RI, VT, DC

Dan Derksen MD

Arizona vs New England

Pre-ACA AZ, NM Health Coverage 2012 Payer Source # AZ #NM Medicaid 1,200,000 550,000 Uninsured 1,200,000 450,000 Medicare 800,000 300,000 Private Insurance 3,300,000 900,000 Total Pop. AZ 6,500,000 2,200,000

http://quickfacts.census.gov; www.statehealthfacts.org http://www.azgovernor.gov/hix/documents/Grants/UpdatedBackgroundResearchReport.pdf

Medicaid + Uninsured Comprised 40-45% AZ and NM Population

Dan Derksen MD

Marketplace +11.7 Million

8.7M Subsidized

Income < 138% Income 138% to 400%

AHCCCS – AZ Medicaid <138% FPL ($32,500 Family of 4)

Dec 2013-May 2015 Net Gain

+365,129

AZ MARKETPLACE 138-400% FPL ($32,500-$94,200) Round 2 Enrollment thru Mar 2015

+205,000

Age <26 Parents’ Plan +2.3 Million

AZ <26 Parents’ Plan +70,000

Demand: Medicaid + Round 2 Marketplace Gain U.S. / AZ Enrollment Jan 2014-Mar 2015

UNITED STATES

ARIZONA ACA ENROLLMENT

Medicaid +12.3 Million

http://www.medicaid.gov/medicaid-chip-program-information/program-information/downloads/april-2015-enrollment-report.pdf http://aspe.hhs.gov/health/reports/2015/MarketPlaceEnrollment/Mar2015/ib_2015mar_enrollment.pdf http://kff.org/health-reform/state-indicator/marketplace-enrollment-as-a-share-of-the-potential-marketplace-population-2015/ http://kff.org/medicaid/issue-brief/recent-trends-in-medicaid-and-chip-enrollment-as-of-january-2015-early-findings-from-the-cms-performance-indicator-project/

Dan Derksen MD

AHCCCS – AZ Medicaid +365,129 (74%)

ACA Enrollment (Participation Rate)

Dan Derksen MD

AZ MARKETPLACE # Enrollees with subsidy / # Eligible for subsidy

126,506 / 335,000 (38%)

http://kff.org/health-reform/state-indicator/marketplace-enrollees-eligible-for-financial-assistance-as-a-share-of-subsidy-eligible-population/

Rural Hospital Margins Improved, but Thin

ACAs Prickly Coverage Disparities

Dan Derksen MD

35%

ACA Marketplace: Oct 2013 - Mar 2015 #Enrollees receiving subsidy / # Eligible for subsidy

US 50% Participation Rate

Accessed 7/6/15at: http://obamacarefacts.com/2015/03/16/obamacare-enrollment-numbers-as-of-march-2015/ http://kff.org/health-reform/state-indicator/marketplace-enrollees-eligible-for-financial-assistance-as-a-share-of-subsidy-eligible-population/

64%

38%

47%

41% 33% 39%

51%

80%

58%

Dan Derksen MD

Pre-ACA: Half the Uninsured in these 10 States

AL 41% Uninsured 2015

White 9% Latino 30%

African Am 13%

Editorial June 11, 2012 By Dan Derksen

Like civil rights legislation 50 years ago, decisions will

soon be made whether each American can

enjoy the rights of of a healthy citizenship.

Dan Derksen MD

Reverend Pinckney - he knew that the path of grace involves an open mind, but more importantly an open heart

If we can find that grace anything is possible.

If we can find that grace, everything can change. President Obama

Grand Canyon Photo: Ken Miller

There are no constraints on the human mind, no walls around the human spirit, no barriers to our progress except those we ourselves erect.

Ronald Reagan