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