the affordable care act: an evidence-based update
TRANSCRIPT
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Seth Trueger MD MPHUniversity of Chicago @MDaware
ACA: Evidence-Based Update
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DISCLOSURES
Emergency Physicians Monthly
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(bias?)
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PlanENROLLMENT stats, uninsured
PLANS premiums, deductiblesnarrow networks, balance
billing
SCOTUS Zubik, House v Burwell
PAY/QUALITY readmits v obs, MACRA
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ENROLLMENTstolen mostly from Charles Gaba
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Kaiser Family Foundation. Health Insurance Coverage in the US, 2011.Kaiser Slides. 19 October 2012.
Medicaid, 13%
VA/Other, 5%
Medicare, 13%
Private, Non-group, 5%
Employer-Sponsored Insurance,
49%
Uninsured, 16%2011
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Medicaid, 19%
VA/other, 6%
Medicare, 17%
Private, Non-group, 6%
Employer-Sponsored Insurance,
43%
Uninsured, 9%2016
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Medicaid, 13%
Medicare, 13%
Private, Non-group, 5%
Employer-Sponsored Insurance,
49%
Uninsured, 16%Medicaid, 1319% VA/other, 6%
Medicare, 1317%
Private, Non-group, 56%
Employer-Spon-sored Insurance,
4843%
Uninsured, 169%
20112016
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Medicaid, 19%
VA/other, 6%
Medicare, 17%
Private, Non-group, 6%
Employer-Sponsored Insurance,
43%
Uninsured, 9%2016
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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http://ccf.georgetown.edu/ccf-resources/medicaid_expansion_positive_impact_safety_net_hospitals_clinics/
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Household 138% FPL 400% FPL1 $16,242 $47,080 2 $21,983 $63,720 3 $27,724 $80,360 4 $33,465 $97,000 5 $39,205 $113,640
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2016 Enrollment
MarketplacesMedicaid
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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2015 Enrollment11 million paid QHP9 million off-Exchange QHP
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2015 Enrollment11 million paid QHP9 million off-Exchange QHP
2016 Enrollment11 million Exchange QHP6 million off-Exchange QHP2 million off-Exchange grandfathered
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2015 Medicaid9 million Medicaid expansion3.4 million Medicaid woodworkers
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2015 Medicaid9 million Medicaid expansion3.4 million Medicaid woodworkers
2016 Medicaid11 million Medicaid expansion3.8 million Medicaid woodworkers0.5 million Basic Health Plan
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“Despite concerns about plan cancellations, only 600,000 people starting out with nongroup coverage became uninsured.Of the 155.8 million people with insurance in September 2013, 80 percent experienced no changes in the source of their insurance during the study period.Among those who were uninsured at baseline, 47 percent remained uninsured at follow-up.”
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“Despite concerns about plan cancellations, only 600,000 people starting out with nongroup coverage became uninsured.Of the 155.8 million people with insurance in September 2013, 80 percent experienced no changes in the source of their insurance during the study period.Among those who were uninsured at baseline, 47 percent remained uninsured at follow-up.”
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“Despite concerns about plan cancellations, only 600,000 people starting out with nongroup coverage became uninsured.Of the 155.8 million people with insurance in September 2013, 80 percent experienced no changes in the source of their insurance during the study period.Among those who were uninsured at baseline, 47 percent remained uninsured at follow-up.”
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EMPLOYER SPONSORED INSURANCE
UNINSURED
MEDICAID
MARKETPLACES & OFF EXCHANGE
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UNINSURED
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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MEDICAID EXPANSION
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http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
Medicaid Expansion
WY
WI*
WV
WA
VA
VT
UT
TX
TN
SD
SC
RI PA*
OR
OK
OH
ND
NC
NY
NM
NJ
NH*
NV NE
MT*
MO
MS
MN
MI*MA
MD
ME
LA*
KY KS
IA* IN* IL
ID
HI
GA
FL
DC
DE
CT
CO CA
AR*AZ
AK
AL
Adopted (32 States including DC)
Not Adopting At This Time (19 States)
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
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http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf
Exchange enrollment by income
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http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf
Exchange enrollment by income
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http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf
Exchange enrollment by income
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20140%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
12%
38%
70%83%
56%
http://kff.org/slideshow/employer-sponsored-insurance-offer-and-coverage-rates/
<100FPL
100-250%
250-400%
>400%
<65yo
ESI by income
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PMID 27076474
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vs no ACA?18.1 million reduction in uninsured46% reduction (nonelderly)
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PLANSpremiums deductibles narrow networks oh my
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my take2014 rates were low
“subsidy equilibrium”rate increase requests ≠ rate increases
deductibles??
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lower premiums?
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“Under the law, no one can be denied coverage because of a pre-existing medical condition.”
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BAD THING OTHER BAD THING
NOT BECAUSE OF OBAMACARE
BECAUSEOBAMACARE
MAG
NITU
DE
TIME
OBAMACAREBEGAN
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narrow networks
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balance billing
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balance billingout of network ED
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balance billingout of network EDinsurance has to pay
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balance billingout of network EDinsurance has to payhow much?
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balance billingout of network EDinsurance has to payhow much?ED bill balance
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$?
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$?
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$?$
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$?$
$
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$?$
$
EMTALA
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$?$
$
EMTALA
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SCOTUSZubik v Burwell & House v Burwell
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Zubik v Burwell
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Zubik v BurwellLittle Sisters
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Zubik v BurwellLittle SistersOCPs
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Zubik v BurwellLittle SistersOCPs2 page form
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Zubik v BurwellLittle SistersOCPs2 page formduck
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House v Burwell
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CSRsCost Sharing Reductions
“the other subsidies”
(pork/chicken of the sea)
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above: premium subsidiesmonthly bill400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use250% FPLonly Silver+ (not cheaper
Bronze)
CSRs
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CSR uptake
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CSR uptake
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X
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X
X
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X
X
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¯\_(ツ )_/¯
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PAYING FOR QUALITYthe card says MIPS
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Readmissions
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Readmissions
outpatient networkincentives
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Readmissions
outpatient networkincentives
20%!
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PMID: 26910198
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Readmissions
outpatient networkincentives
21.5% 17.8%15.3% 13.1%
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penalties?2015: 80%all 3: 57% (!)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/
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penalties?2015: 80%all 3: 57% (!)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/
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penalties?average $100-300k2013: teaching & safety-net hospitals 2015: more broadly distributed (still gap)
improving teaching & safety net?surgical?https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/
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Readmission penalties?risk adjustment
socioeconomic status
¯\_(ツ )_/¯
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Readmission penalties?hiding in observation?
¯\_(ツ )_/¯
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PMID: 26910198
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MIPS APMFFS + P4P
ACO, CMMIbundles
2019 ±4% 5% bonus2020 ±5% 5% bonus2021 ±7% 5% bonus2022 ±9% 5% bonus2023 ±9% 5% bonus2024 ±9% 5% bonus2025 ±9% 5% bonus2026+ 0.25%+ baseline
annually0.75%+ baseline
annually
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¯\_(ツ )_/¯
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[email protected]@MDaware