time for a reality check on health insurance
TRANSCRIPT
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Health Policy SymposiumElena MarksEpiscopal Health FoundationJune 11, 2016
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Time for a Reality Check on Health Insurance
• Learn the basics of the coverage provisions of the Affordable Care Act
• Learn about the impact of the coverage provisions in Texas
• Learn about particular features of ACA marketplace plans of concern to consumers and physicians
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Health Insurance Coverage Provisions of the ACA
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History of Health Insurance in US
Source: PBS available at http://www.pbs.org/healthcarecrisis/history.htm
1910’sRailroads provide
employee medical care
1930’sSocial Security Act; Blue Cross offers hospital care insurance
1940’sEmployer
sponsored plans arise
1960’sMedicaid and
Medicare enacted
1980’sManaged Care
1990’sCosts rise at 2X
inflation; Clinton plan
dies
2000’sUnsustainable
cost curve; poor outcomes
2010Affordable Care
Act
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ACA’s Initial Objective: Access
A Core Objective of the ACA was to Expand Access to Health Care
In the US, Access to Health Care = Access to Health Insurance
50 Million Americans Lacked Health Insurance in 2010
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Coverage Provisions in ACA: Publicly Funded Plans
Medicaid expansion to 138%
FPL
($16K/year for one; $34K/year for
3)
Marketplace with subsidized plans for 100% to 400% FPL
(400%= $47K for one; $97K for 3)
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Coverage Provisions in the ACA:None Out—All In
No pre-existing condition exclusions
but (almost) everyone
must have coverage and
large employers must offer affordable
coverage
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Coverage Provisions in the ACA:New Health Plan Regulations
Changes to Private Insurance
• Kids on parents’ plans til 26• Premium rate bands limited to
3:1 based on age, tobacco, location
• 80% medical loss ratio • Some preventive services
covered without co-pays• Premium increases subject to
review
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Texas and the ACA’s Coverage Provisions
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Texas on the Eve of the ACA
Insured19,564,00076%
Undocumented15%
ACA Marketplace SubsidyEligible36%
No Subsidy11%
Uninsured5,591,00024%
Medicaid Eligible but Unenrolled14%
Medicaid Expansion Adults24%
Note: Due to rounding, percents may not total 100%Sources: U.S. Census Bureau. March 2011 Current Population Survey (CPS), Texas Health and Human Services Commission, July 2012.
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Texas on the Eve of the ACA:Demographics of Uninsured Texans
Source: Current Population Survey, Annual Social and Economic Supplement, 2012U.S. Census Bureau*Personal Income
1,606,00025%
610,0009%
190,0003%
3,956,00062%
50,0001%
Uninsured by Race/Ethnicity
White aloneBlack or African American aloneAmerican Indian and Alaska Native aloneAsian aloneHispanicTwo or more races
1,073,00018%
4,925,00081%
81,0001%
Uninsured by Age
00 to 17 18 to 64 65 to 80+
2,584,00040%
1,817,00028%
1,334,00021%
427,0007%
135,1352%53,000
1%75,000
1%
Uninsured by Income*
below$2,499 $2,500 to $19,999$20,000 to $39,999 $40,000 to $59,999$60,500 to $79,999 $80,000 to $99,999$100,000+
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Pre-2014 Experiences:Affordability of Care by Insurance Status
Mental health care or counseling
Dental care
Medical tests and treatment
Prescription drugs
Specialist care
General primary care
Medical Care
7.2%
27.9%
17.9%
21.3%
13.4%
13.1%
14.4%
13.2%
40.6%
25.2%
27.5%
21.2%
32.3%
29.7%
Skipped Care, September 2013 By Household Income as a Percent of the Federal Poverty Level (FPL)
Uninsured Insured
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Pre-2014 Experiences:Affordability of Care by Income
Mental health care or counseling
Dental care
Medical tests and treatment
Prescription drugs
Specialist care
General primary care
Medical Care
11.3%
40.6%
25.9%
30.1%
19.8%
31.5%
30.8%
11.5%
37.8%
23.5%
28.1%
19.0%
17.0%
20.4%
2.6%
14.3%
9.7%
10.6%
7.2%
5.4%
4.4%
Skipped Care, September 2013 By Household Income as a Percent of the Federal Poverty Level (FPL)
400+% FPL 139-399% FPL <=138% FPL
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Age 18-24 Age 35-49 Age 50-640%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
10.9% 9.0%13.4%
13.4% 15.1%
17.7%
32.5% 30.6%
21.5%
16.6%14.5%
11.8%
26.5% 30.2% 24.9%
General Opinion of the ACA in TX by Age, Sept 2013
<=138% 139-399% >=400%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
14.3%8.3% 11.2%
16.2%
15.7% 13.9%
37.9%
29.8%19.6%
8.2%
12.8%21.7%
23.1%33.0% 33.4%
General Opinion of the ACA in TX by Income, Sept 2013
White Black Hispanic0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
7.6%18.0%
13.6%
9.8%
38.2%
15.3%
19.3%
20.8%
42.7%18.4%
7.9%11.2%44.1%
14.7% 17.1%
General Opinion of the ACA in TX by Race/Ethnicity, Sept 2013
Pre-2014 Experiences:Opinion of the ACA by Age, Income, Race
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Pre-2014 Experiences: Expectations about ACA
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Texas Post-ACA Implementation
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Q3 2013 Q1 2014 Q2 2014 Q1 2015 Q3 2015 Q1 20168.0
10.0
12.0
14.0
16.0
18.0
20.0
22.0
24.0
26.0
U.S.Texas
Perc
enta
ge
Source: Health Reform Monitoring Survey and HRMS TX. Estimates are regression adjusted.
Uninsured by Race/ethnicity and AgeTexans ages 18-64, 2013 to 2016
Trends in Uninsurance for Texas Adults Ages 18-24
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Uninsured by Race/ethnicity and AgeTexans ages 18-64, 2013 to 2016
White, non-Hispanic
Black/other, non-Hispanic
Hispanic
0 5 10 15 20 25 30 35 40 45
14.3
18.7
42.6
9.9
14.2
30.7
Uninsured by Race/Ethnicity
18-30
31-49
50-64
0 5 10 15 20 25 30
26.4
28.1
21.1
20.7
21.6
10.3
Uninsured by Age Mar 2016 (%) Sep 2013 (%)
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Uninsured by Income and GenderTexans ages 18-64, 2013 to 2016
1
2
0 10 20 30 40 50 60
54.1
46
22.7
13.1
Uninsured by Family Income
Between 139% and 399% of FPL At or below 138% or FPL
1
2
0 5 10 15 20 25 30
22.3
14.9
28.4
20.7
Uninsured by Gender
Female Male
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Texans Covered by ACA Marketplace Plans during Open Enrollment Periods
Oct 2013-Mar 2014 Nov 2014-Jan 2015 Nov 2015-Jan 20160
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
733,757
918,890
1,306,208
Texas Enrollees from Open Enrollment
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Texas Enrollment in Marketplace Plans by Income, January 2016
<100% of FPL >100% to <150% of FPL
>150% to <200% of FPL
>200% to <250 %of FPL
>250% to <300% of FPL
>300% to <400% of FPL
> 400% of FPL -
100,000
200,000
300,000
400,000
500,000
600,000
48,279 4%
531,073 44%
277,606 23%
168,978 14%
84,489 7% 72,419
6%
24,140 2%
Fig. 8: Enrollment by Household Income
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Texas Enrollment in Marketplace Plans By Race/Ethnicity, January 2016
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Multiracial
African-American
Asian
Latino
White
0 50,000 100,000 150,000 200,000 250,000 300,000 350,000
0
0
85311%
751569%
12526115%
30897737%
31732738%
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The Impact of Texas’ Refusal to Expand Medicaid
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Texas: Public Insurance pre-ACA
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ACA’s Public Insurance Schema
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Texas: Public Insurance post-ACA
~1 million Texans
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Trends in Uninsured Rates 2013 to 2016, Texas and US
Sep 2013 Mar 2014 June 2014 Mar 2015 Sep 2015 Mar 20160
5
10
15
20
25
30
24.623.5
22.2
16.918.5 17.9
20.720 19.5
14.315.3
14.1
17.6
15.114
10.1 10.59.9
15.8
12.1
10.5
7.5 7.3 7.3
Texas States Not Expanding Medicaid All States States Expanding Medicaid
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Post-2014 Experiences:Reasons for Remaining Uninsured, September 2015
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Post-2014 Experiences:Perceptions of Tax Penalties
21%
31%26%
21%
Importance of the Possibility of a Fine to Uninsured Adult Texans, March 2015
Very important
Somewhat important
Not too important
Not at all important
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Thorny Issues for Consumers, Providers, and Payers
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Consumer Concerns
CostProvider selection
Surprise bills
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Provider Concerns
Panels Reimbursement rates What’s next?
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Payer Concerns
Change
It takes two to tango
Cost control
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Life Expectancy
Source: D. Squires and C. Anderson, U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries, The Commonwealth Fund, October 2015
9 1012 11 12
9 912 11
8
16
11 10
21
18 15
11
16
2120
15
9
82.2
81.5
82.3
80.981.4 81.4
81.8 82.0
82.9
81.1
78.8
75
76
77
78
79
80
81
82
83
84
85
0
5
10
15
20
25
30
35
40
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK USA
Life Expectancy at Birth in Years
Heal
th a
nd S
ocia
l Car
e Sp
endi
ng a
s a
Perc
enta
ge o
f GDP
Health Care Social Care Life Expectancy
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Infant Mortality
Source: D. Squires and C. Anderson, U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries, The Commonwealth Fund, October 2015
9 10 12 11 12 9 9 12 11 8 16
11
10
21
18
15
11
16
2120
15
9
3.6
4.8
3.63.3
3.8
5.2
2.42.7
3.9 3.8
6.1
2
3
4
5
6
7
8
0
5
10
15
20
25
30
35
40
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK USA
Infant Mortality per 1,000 Live BirthHe
alth
and
Soc
ial C
are
Spen
ding
as
a Pe
rcen
tage
of G
DP
Health Care Social Care Infant Mortality
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Social Determinants of Health
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Where We Invest
Social and Economic Factors- Education- Employment- Income- Family and Social
Support- Community Safety
Health Behaviors- Tobacco Use- Diet and Exercise- Alcohol and Drug Use- Sexual Activity
Physical Environment
Clinical Care- Access to Care- Quality of Care
- Hospital Care- Physician and Clinical
Services- Dental Services- Home Health Care- Nursing Care Facilities,
Continuing Care Communities
- Prescription Drugs- Durable Medical
Equipment- Government
Administration- Net Cost of Health
Insurance- Research- Structures and
Equipment
40%
30%
10%
20%
98%
Determinants of Health
2014 National Health Expenditures
Public Health
2%$79 billion
$2.9 trillion
Medical Services
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The Following Presenters Have Disclosed Relevant Financial Relationships:Cedric Dark, MD MPH FAAEM FACEPCommunity Health Choice, Event Sponsorship; Schumacher Clinical Partners, Event Sponsorship Seth Trueger, MD MPHEmergency Physicians Monthly, Employee, Salary The Following Presenters Have Disclosed No Financial Relationships:Megan Douglas, JDElena M. Marks, JD MPHLaura Medford-Davis, MDBich-May Nguyen, MD MPH The Following Planners Have Disclosed Relevant Financial Relationships:Cedric Dark, MD MPH FAAEM FACEPCommunity Health Choice, Event Sponsorship; Schumacher Clinical Partners, Event Sponsorship The Following Planning Committee Members and Staff Have Disclosed No Relevant Financial Relationships:Emily DeVillers, CAEKay Whalen, MBA CAEJanet Wilson, CAE
Disclosure