policy brief: affordable care act · 2014. 2015. 2016* source: cdc/nchs, national health interview...

#NCG2017

Policy Brief:Affordable Care Act

The Future of the Affordable Care Act

Northern California GrantmakersApril 17, 2017

Larry LevittKaiser Family Foundation@larry_levitt

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Source: CDC/NCHS, National Health Interview Survey.

Uninsured rate among the non-elderly

Note: 2016 data is for Q1-Q3 only.

20 million more people covered

Source: National Health Interview Survey

Decrease in the share of the population uninsured, 2010-2016

45% nationally

62% in California

Estimated annual federal premium tax credits (2016):$4.6 billion

Federal funding for newly-eligible adults in Medicaid (January 2014 to September 2015):

$28.0 billion

Source: KFF analysis, http://kff.org/health-reform/state-indicator/average-monthly-advance-premium-tax-credit-aptc/?currentTimeframe=0 and http://files.kff.org/attachment/fact-sheet-medicaid-state-CA

Federal financial assistance under the ACA in California

• Repeal of the individual and employer mandates.• Guaranteed access to insurance for people with pre-existing conditions, with late

enrollment penalties for people with gaps in coverage.• Continuation of the ACA’s required insurance benefits.• 5-1 variation in premiums allowed for age.• Federal grants for state high-risk pools or other stabilization mechanisms.• Refundable tax credits that vary by age, but not income or local premiums

(phasing out above income of $75k for individuals).• Expanded use of Health Savings Accounts.• Scaled back Medicaid expansion and per capita cap on federal funding.• Repeal of almost all ACA tax increases (Cadillac plan tax remains but delayed until

2025).

Not in the plan: Sale of insurance across state lines, any drug pricing curbs.

American Health Care Act (House GOP health bill)

• 14 million more uninsured in 2018 and 24 million more by 2026, leaving 52 million non-elderly uninsured.

• Lower average premiums in the individual insurance market, as fewer older adults buy coverage and people shift to higher deductible plans.

• $839 billion decrease in projected Medicaid spending over the next decade. $306 billion decrease in tax credits for individual insurance.

• $150 billion decrease in the federal budget deficit.

Congressional Budget Office projections for the AHCA

Source: Kaiser Family Foundation analysis. Note: Data for Affordable Care Act represent the average tax credit available across all counties in the United States, at a given age.

How the House GOP plan shifts health insurance tax credits, based on income and age, in 2020

$3,225

$4,143

$9,874

$2,000

$3,000

$4,000

Age 27 Age 40 Age 60

Lower-Income ($20,000)

Affordable Care Act

American Health Care Act

$103

$1,021

$6,752

$2,000

$3,000

$4,000


Middle-Income ($40,000)

Affordable Care Act


$0 $0 $0

$2,000

$3,000

$4,000


Higher-Income ($75,000)

Affordable Care Act


http://kff.org/interactive/tax-credits-under-the-affordable-care-act-vs-replacement-proposal-interactive-map/

http://kff.org/interactive/tax-credits-under-the-affordable-care-act-vs-replacement-proposal-interactive-map/

• Medicaid is working fine, and if anything more states may start to expand. Over 4 million more people are enrolled in Medi-Cal.

• The ACA marketplaces have challenges.– A number of insurers have exited the marketplaces. 32% of counties (representing

21% of enrollees) have one insurer in 2017.– Benchmark premiums increased 22% on average in 2017.– There are fragile markets where premiums are high, have increased significantly,

there is only insurer participating, and/or enrollment has declined.• But, if left alone, the marketplaces are stable in the vast majority of the country.

– Most enrollees have a choice of insurers.– Insurer finances have been improving.– Marketplace enrollment basically held steady in 2017 at 12.2 million (a decline of half

a million). 1.6 million signed up in California, comparable to last year.– The structure of the ACA’s premium tax credits (which 83% of enrollees receive)

shield consumers from premium hikes and prevent a “death spiral.”

Is the ACA collapsing?

12.9%

33.2%

California U.S.

Source: Kaiser Family Foundation analysis

Cumulative change in ACA marketplace benchmark premiums, 2014-2017

• The administration faces a choice of whether to undermine the individual insurance market or seek to make it work better and potentially move the ACA in a more conservative direction. So far, signals have been mixed.

• Potential steps to undermine the ACA marketplaces and insurance market:– End cost-sharing subsidy payments to insurers (about $7 billion in 2017, benefiting

58% of marketplace enrollees). Insurers would pull out or raise premiums by 19%.– Weaken the individual mandate.– Pull back on outreach.– Create uncertainty for insurers.

• Other areas of administrative discretion:– Settle lawsuits over the risk corridor program.– Give insurers or states more flexibility on required benefits and narrow range of

preventive benefits (e.g., contraception).– Grant waivers to states under section 1332.

• Medicaid: Likelihood of state waivers for higher premiums/copays and work requirements.

What the Trump Administration could do administratively on the ACA and Medicaid

Most say President Trump and Republicans in Congress are responsible for AC problemsAs you may know, the 2010 health care law, also known as Obamacare, remains the law of the land. Which comes closer to your view?

Other/Don’t know/Refused

7%

President Obama and Democrats in Congress

passed the law and they are responsible for

any problems with it moving forward

31%

President Trump and Republicans in Congress are now in control of the government and they are

responsible for any problems with it moving

forward61%

NOTE: “Other” includes the shares that say “Neither of these/someone else is responsible” (Vol.) and “Both are equally responsible” (Vol.). SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted March 28 – April 3, 2017)

Contra Costa Health Plan

Patricia Tanquary, MSSW, MPH, PhD, CEO14

Presentation to theNorthern California

Grantmakers Annual Conference

April 17, 2017



Contra Costa Health Plan (CCHP) IS: The oldest County-sponsored Federally Qualified Health Maintenance

Organization (HMO) in the country. Currently has multiple productlines – Medi-Cal, Medicare, Commercial, IHSS.

– 201,000 members.

Knox-Keene Licensed and NCQA approved Health Plan.

An integral entity within the Contra Costa County Heath ServicesDepartment and has 43 years of collaboration with the County PublicHospital and Federally Qualified Health Center (FQHC) AmbulatoryHealth Center, as well as the Public Health, Mental Heath, andSubstance Abuse Divisions within the Health Services Department.

Continued…..

.



Contra Costa Health Plan (CCHP) IS: CCHP Provides Direct Services of 24/7 Advice Nurse and case

management services.

CCHP has 3 choices of Provider Networks with 88% of all Medi-Cal Managed Care in County.

1. Contra Costa Regional Medical Center (CCRMC)

2. Community Provider Network (CPN)

3. Kaiser Permanente (for former Kaiser members in Medi-Cal.

CCHP is a third party administrator for uninsured programs of County Health Department and Pilot Program – Contra Costa CARES.

.



ACA Repeal/ReplaceImpacts Relating to Optional Expansion Elimination

THE ECONOMICSIMPACT OF ACA OPTIONAL EXPANSION TO LOCAL HEALTH PLAN

MEMBERSTOTAL EXPANSION

REVENUEPLAN EXPANSION REVENUE TO:

Health PlanTotal

Members# Expansion

Members To Plan Physicians Hospitals Pharmacies OtherAAH 255,848 106,000 $300,000,000 $60,000,000 $100,000,000 $53,000,000 $63,000,000 CalOptima 763,922 234,000 $1,100,000,000 $565,000,000 $227,000,000 CalViva 358,494 83,000 $525,000,000 CenCal 180,000 46,000 $141,000,000 $40,000,000 $42,000,000 $41,000,000 $18,000,000 CCAH 350,000 83,000 $344,000,000 $97,300,000 $157,900,000 $59,500,000 CHG 285,491 87,112 $159,807,851 $47,000,000 $70,000,000 $43,000,000 CCHP 184,860 54,720 $269,568,677 $50,450,005 $156,799,743 $25,718,060 $36,600,869 GCHP 206,251 0HPSJ 340,000 88,000 $330,000,000 $88,000,000 $137,000,000 $57,000,000 $4,000,000 HPSM 112,607 0IEHP 1,226,097 370,000 $1,080,000,000 $445,700,000 $443,000,000 $182,100,000 KHS 241,216 69,000 $208,000,000 $54,000,000 $112,600,000 $41,400,000 LA Care 1,960,219 410,473Partnership 566,000 163,000 $847,000,000 SFHP 134,587 0SCFHP 266,961 83,000 $330,000,000 $60,000,000 $202,000,000 $58,000,000

TOTALS 7,432,553 1,877,305 $ 5,634,376,528 $ 1,507,450,005 $ 1,648,299,743 $ 560,718,060 $ 121,600,869



ACA Repeal/ReplaceImpacts Relating to Optional Expansion Elimination

THE PEOPLEDemographics of the OE Population

Ages Gender Physical Health (# OE with diagnoses)

Behavioral Health

(# OE with diagnoses)

19-40 41-64 Men Women Hyper-tension

Cardio-vascular Diabetes Asthma

Pain Manage-

ment

Other Common

depression, anxiety, etc.

30,096 24,624 27,385 27,335 8,926 1,283 4,496 3,984 4,153 238 11,294

Health Plan: CCHP



California Coverage of low-income Undocumented Children under Medi-Cal

CCHP, like other Safety Net Health Plans have added 1600

undocumented low-income children to our Medi-Cal population

since summer, 2016.

Currently working with Kaiser Permanente Health Plan, County

Social Services and DHCS to add 1,221 additional undocumented

low-income children previously covered by Kaiser Healthy

Children Program.



Current Covered CA Populations At Risk of Subsidy Repeals

PRICING REGION COUNTYCOVERED CALIFORNIA IN BAY AREA

2017 COVERAGE % SUBSIDIZED

REGION 2MARIN, NAPA, SOLANO

AND SONOMA54,708 87%

REGION 4 SAN FRANCISCO 38,775 81%

REGION 5 CONTRA COSTA 41,353 86%

REGION 6 ALAMEDA 66,920 86%

REGION 8 SAN MATEO 26,243 85%

CCHP has received most of those churning off Covered California as they then qualify for Medi-Cal.


Patricia Tanquary, MSSW, MPH, PhD, CEO 21

Contra Costa County Region 5 enrollment breakdown

Enrollment by Carrier Enrollment by Metal Tier



Contra Costa CARES The CARES program is a pilot to demonstrate the value of connecting uninsured

patients to a primary care medical home. It also highlights the effectiveness of a coordinated system that enables

community health centers (CHCs) to work with Contra Costa Health Plan (CCHP) to enroll Contra Costa residents in a primary care medical home.

Contra Costa CARES (CARES) enrolls low-income individuals who are ineligible for other healthcare programs, and live in Contra Costa County, into a primary care medical home.

Approximately 28,000 individuals in the county are estimated to qualify for the program.

All patients are assigned to a medical home, with the majority enrolled at La Clinica and Lifelong Medical locations.

The profile of enrolled participants shows that 97% are working age adults in family-size households. Most participants (54%) live in the west county region.

The vast majority (95%) of enrollees who transitioned out of the CARES program have become enrolled in full-scope Medi-Cal coverage due to changes in health status, gaining comprehensive coverage.



Figure 3. Enrollee age data shows the majority of enrollees are working age and from working households

95% are part of

Working Households



Figure 4. Patient visit data shows that diabetes and hypertension-related services are the most common type of care provided



Figure 5. Overall ER visits declines after individuals enrolled in CARES.



Sustainable Funding Contra Costa CARES was funded as a 12-month pilot primary care

program, in a partnership between Sutter, Kaiser and John Muir hospitals

splitting the funding with the County Health Department. CCHP is the

third party administrator who manages the program with the Community

Consortium assistance.

Funding was later secured to extend coverage for an additional 12

months ending in July, 2018. This year-to-year funding hampers the

ability to expand sustained primary care capacity. Community partners

are being engaged in order to identify sustainable funding sources that

expand access to health care for this population.


Patricia Tanquary, MSSW, MPH, PhD 14

Questions?Patricia Tanquary, MSSW, MPH, PhD

Chief Executive Officer


595 Center Avenue, Suite 100

Martinez, CA 94553

Office Phone: 925--313-6004

Email: [email protected]

mailto:[email protected]

Chris PerroneDirector, Improving Access

NCG Annual ConferenceApril 17, 2017

Potential Changes to the ACA: Responding in Uncertain Times

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Rapid Response: California FocusTimely Information & Analysis Key Partnerships

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Rapid Response: National DebateState-Specific Policy Briefs National Analyses

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How best to: • Maintain a healthy risk mix?• Improve affordability for consumers?• Ensure adequate plan choice in every region?• Improve continuity of coverage through transitions?• Finance state spending?

Policy Issues Ahead

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• Delivery System Reform in Medi-Cal Alternative Payment

Models & Capitation Reform

Behavioral Health/ Complex Care Integration

Team-based Care• High Value Care Opioid Treatment Maternity Care End of Life Care

Staying The Course: Getting Better Value

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Cumulative Percentage of Enrollees

5% of enrollees generated 52% of spending($34,480 per person)

Distribution of Medi-Cal Spending, 2011

Source: DHCS, 2015.Note: Among Medi-Cal-only enrollees in managed care, FFS or both

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Medi-Cal 2020: Whole Person Care Pilots

• Coordinate health, behavioral health, and social services for Medi-Cal beneficiaries who are frequent users of multiple systems

• County agencies, designated public hospitals, district municipal public hospitals

• $3 billion over 5 years (50% federal; 50% local)

Source: Harbage Consulting

Housing Services • Housing and tenancy

sustaining services• Housing education

and legal assistance• SNF Housing

Transitions• Street Outreach

Care Coordination/ Wrap-Around Services• Recuperative Care• Sobering Centers• Mobile/Service

Integration Teams• Peer Support

Specialists

Examples

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Other Opportunities to Promote Reforms Medi-Cal PRIME Medi-Cal FQHC

APMMedi-Cal Health Home Program

Accountable Communities for Health

Goal Transform public hospitals into entities that take responsibility for the quality and cost of their patients inside the hospitals and in the community and move toward alternative payment models

Establish payment system for FQHCs that fosters greater accountability for performance (cost and quality) and provides greater flexibility in how care is provided

To coordinate the full range of physical health, behavioral health, and community-based long term services and supports needed by beneficiaries with chronic conditions.

Improve personal and community-wide health outcomes and reduce disparities with regard to particular chronic diseases or health needs; control costs associated with ill health; and develop financing mechanisms to sustain the ACH.

Funding Up to $3.7 billion in Federal funding over 5 years

NA 90% Federal match $5.1 million over three years from four foundations

Partners Designated public, district and municipal hospitals

Federally Qualified Health Centers

Medi-Cal plans and community-based care management entities

Multi-sector, typically led by county department of public health

Locations Statewide Participants TBD 29 counties Imperial, Merced, San Diego, San Joaquin, Santa Clara, Sonoma

Start 2016 2018 2018 2016

Link http://www.dhcs.ca.gov/provgovpart/Pages/PRIME.aspx

http://www.dhcs.ca.gov/services/Pages/FQHC_APM.aspx

http://www.careinnovations.org/programs-grants/payment-redesign

http://www.dhcs.ca.gov/services/Pages/HealthHomesProgram.aspx

http://www.communitypartners.org/cachi

http://www.dhcs.ca.gov/provgovpart/Pages/PRIME.aspx

http://www.dhcs.ca.gov/services/Pages/FQHC_APM.aspx

http://www.careinnovations.org/programs-grants/payment-redesign

http://www.dhcs.ca.gov/services/Pages/HealthHomesProgram.aspx

http://www.communitypartners.org/cachi

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The Sands of Time?Then…

Next?

Now…

policy brief: affordable care act · 2014. 2015. 2016* source: cdc/nchs, national health interview...

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