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Health Reform 101 The Road Ahead for Healthcare Policy in Utah
February 13, 2016
UAFP CME Conference
Key Terms
Private insurance plans sold on healthcare.gov with monthly premiums subsidized for some people
ACA or Obamacare Insurance
Why is the Affordable Care Act (ie. Obamacare) still viewed unfavorably by a majority of Utahns/Americans?
Who is benefiting from the Affordable Care Act now and in the future? Will the Affordable Care Act end up like the G.I. Bill, or “No Child Left Behind ?”
Three Key Questions
1
2
3
Open Enrollment
Open Enrollment
Special Enrollment
2016
JANUARY 1 FEBRUARY 1 NOVEMBER 1
The new health insurance calendar
Next Open Enrollment: Nov. 1, 2016 -- Jan. 31, 2017
OCTOBER 31
Open Enrollment
Open Enrollment
Special Enrollment
2017
JANUARY 1 FEBRUARY 1 NOVEMBER 1 OCTOBER 31
What is a Qualifying Life Event? ….that triggers a Special Enrollment Period
What is a Qualifying Life Event?
• Getting sick
• Forgetting to sign up for insurance before January 31, 2016
• Voluntarily ending insurance coverage
• Losing coverage that doesn’t qualify as minimum essential coverage under the ACA
What is a Complicated Case?
• A serious medical condition or natural disaster
• An unexpected hospitalization or temporary cognitive disability
• Medicaid/Marketplace transfer delays
• Misinformation or misrepresentation by brokers or assistors
• System errors related to immigration status
• Victims of domestic abuse
You couldn’t sign up for coverage before January 31st because of….
• A Marketplace system outage, such as Social Security Administration system outage
How the ACA changed healthcare (as we know it)
Adults under age 26 can stay on
their parents insurance
plan
Men and women pay the same for coverage
Insurance offers free preventative care like blood pressure checks, flu shots, and health screenings
No one can be denied or priced out of coverage for a
pre-existing condition
No lifetime caps on insurance payments
2010 2013
18.4%
29.0% Utah Uninsured Rate Ages 18-26:
Source: Utah DOH
www.healthcare.gov
Utah’s ACA sign-ups exceeded 151,000 in 2015
Sources: State-Level Data From from the ASPE January Health Insurance Marketplace Enrollment Report For The 2016 Open Enrollment Period; ; March 31, 2015 Effectuated Enrollment Snapshot; 15-06-02; http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-06-02.html HHS/CMS Health Insurance Marketplace; ASPE Issue Briefs: October 1, 2013 –April 19, 2014; November 15, 2014 – January 16, 2015; HHS News Release, “In Utah, 124,142 people are signed up for coverage through the Health Insurance Marketplaces,” 2/11/15 HHS News Release, “In Utah, 140,221 people are signed up for coverage through the Health Insurance Marketplaces,” 2/18/15 ASPE Issue Brief (3/10/15); http://aspe.hhs.gov/health/reports/2015/MarketPlaceEnrollment/Mar2015/ib_2015mar_enrollment.pdf Marketplace Plan Selection by Age in States Using the HealthCare.gov Platform, By State (1); 11-15-14 to 2-15-15 (including SEP activity through 2-22-15)
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
10
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151,058
Why are people dropping their coverage mid-year?
Insurance Dropouts Present a Challenge for Health Law New York Times By Abby Goodnough October 11, 2015
Link: http://www.nytimes.com/2015/10/12/us/insurance-dropouts-present-a-challenge-for-health-law.html
1) Premium cost
2) Under utilization
3) Paperwork errors
16.7%
15.7%
16.3%
15.9%
16.7%
16.6%
15.7%
14.0%
12.5%
9.1%
10.2%
11.6%
11.9%
10.6% 10.7%
11.2%
10.6%
13.4%
13.2%
11.6%
10.3%
15.6%
13.3% 13.2%
8%
9%
10%
11%
12%
13%
14%
15%
16%
17%
18%
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015Q2
UT:Census/SAHIE
UT:DOH(BRFSS)
UT: Gallup-Healthways
Utah’s uninsured rate is decreasing… …but the most recent data indicates a slowdown
Census SAHIE: https://www.census.gov/library/publications/2015/demo/P60-253.html DOH (BRFSS): http://ibis.health.utah.gov/pdf/opha/publication/ins/InsHighlights_2014.pdf Gallup Healthways: http://www.gallup.com/poll/184514/uninsured-rates-continue-drop-states.aspx?utm_source=Well-Being&utm_medium=newsfeed&utm_campaign=tiles
Sources: [2014] https://https://insurance.utah.gov/health/Health%20Refrom/ACA_Rate_Individual_20131007_OnExchange.pdf [2015] Utah – On Exchange Rates (accurate as of 10/15/14) https://insurance.utah.gov/health/Health%20Refrom/2015IndividualOnExchange20141016.pdf [2016] www.hea;thcare.gov; See Plans and Premiums (October 2015)
Altius Health Plans Arches BridgeSpan Humana Molina Healthcare Select Health
6 plans
26 plans
34 plans
24 plans
1 plan
Humana (6) Molina Healthcare (3) Select Health (60) University of Utah (5) Arches
2015: 101 Plans 2016: 74 Plans
Altius Health Plans Arches BridgeSpan Humana Molina Healthcare Select Health
2014: 91 Plans
Gold
Silver
Bronze
Catastrophic
Platinum
5 plans
19 plans
27 plans
21 plans
2 plans
5 plans
29 plans
40 plans
27 plans
0 plans
2014-16 Individual Marketplace Comparison Salt Lake County
60% 70%
80% 90%
Bronze Silver Gold Platinum
Costs for health plans will differ by metal tier
Higher Premiums Lower Premiums
Lower cost-sharing Higher cost-sharing
Catastrophic
<60%
What are the penalties for remaining uninsured in 2016?
[Chart] Kaiser Family Foundation
$285 $975 $2,085 Max per family
$95/adult, $47.50/child
$325/adult $162.50/child
$695/adult $347.50/child
We Are Here
(*) Premium costs do not include subsidies
Sources: [2014] https://https://insurance.utah.gov/health/Health%20Refrom/ACA_Rate_Individual_20131007_OnExchange.pdf [2015] Utah – On Exchange Rates (accurate as of 10/15/14) https://insurance.utah.gov/health/Health%20Refrom/2015IndividualOnExchange20141016.pdf [2016] Utah 2016 ACA Individual & Small Group Enrollment and Premium Rates; Utah Dept. of Insurance (October 2015)
In Salt Lake County, benchmark premiums rose 13% in 2016
$112
$197 $209
$301
$424
$115
$202 $215
$309
$436
$131
$229 $244
$350
$494
$-
$100
$200
$300
$400
$500
$600
20 30 40 50 60
Monthly Premiums* for Benchmark Silver Plan by Age (2014-15-16) Salt Lake County
Age
2014 2015 2016
(*) Premium costs do not include subsidies
[2015] Utah – On Exchange Rates (accurate as of 10/15/14) https://insurance.utah.gov/health/Health%20Refrom/2015IndividualOnExchange20141016.pdf [2016] Utah 2016 ACA Individual & Small Group Enrollment and Premium Rates; Utah Dept. of Insurance (October 2015)
Premium “spread” is higher in 2016 than in 2015
$120
$140
$160
$180
$200
$220
$240
$260
2016
2015
Salt Lake County Silver Plan Premiums for 21 year-olds (2015-16)
Benchmark Plans (Second- lowest Silver plan)
$74
$47
How can premium prices vary?
(in billions) 1) Age (new ratio of 3:1)
2) Tobacco use (ratio of 1.5:1)
3) Geography (by counties)
Area 1: Cache and Rich Area 2: Box Elder, Morgan, and Weber Area 3: Davis, Salt Lake, Summit, Tooele, and Wasatch Area 4: Utah Area 5: Iron and Washington Area 6: Beaver, Carbon, Daggett, Duchesne, Emery, Garfield, Grand, Juab, Kane, Millard, Piute, San Juan, Sanpete, Sevier, Uintah, and Wayne
0% 101% 400% 100%
Who is eligible for premium subsidies?
Income as % of the Federal Poverty Level (FPL)
NO YES 53,000 Utahns
in the Gap
Sliding-scale subsidies make insurance more affordable
Source: http://www.coloradohealthinsurancebrokers.com/wp-content/uploads/2013/08/2015-2016-FPL-Chart-1024x314.jpg
For 2016, a family of four can earn $97,000 a year and receive a premium subsidy
If your income/family size is on this chart, you qualify for a subsidy
The Hernandez Family Income: $26,000 Residence: Salt Lake City, Utah Ages: Dad : 33 Mom: 29 Kids: 11, 7
Annual income: $26,000
% of poverty level: 109%
Monthly premium: $458
Subsidy pays: $410 per month
The Hernandez’s pay: $48 per month
Benchmark Silver Plan
Primary doctor: $5 Specialist doctor: $15 Emergency room care: $150 Generic drugs: $6
Plan Details
2016 rate change: + $4/month
Deductible: $1000 Out-of-pocket maximum: $1,500 Source: https://www.healthcare.gov/see-plans/; Image source: Moodboard
Annual income: $44,000
% of poverty level: 222%
Monthly premium: $537
Subsidy pays: $274 per month
The Shumways pay: $262 per month
Benchmark Silver Plan
Primary doctor: $35 Specialist doctor: $60 Emergency room care: $500 Generic drugs: $10
Plan Details
Deductible: $2,300 Out-of-pocket maximum: $10,900
2016 rate change: +$1/month
The Shumways Income: $44,000 Residence: American Fork, UT Ages: Dad : 24 Mom: 23 Kid: Newborn
Source: https://www.healthcare.gov/see-plans/
Mr. and Mrs. Smith Income: $42,000 Residence: Santa Clara, Utah Ages: 60, 62
Annual income: $42,000
% of poverty level: 267%
Monthly premium: $1,188
Subsidy pays: $865 per month
The Smiths pay: $323 per month
Benchmark Silver Plan
Primary doctor: $35 Specialist doctor: $60 Emergency room care: $600 Generic drugs: $10
Plan Details
Deductible: $2,500 Out-of-pocket maximum: $13,700
2016 rate change: + $13/month
Source: https://www.healthcare.gov/see-plans/; Image source: Moodboard
Annual income: $21,000
% of poverty level: 89%
Expected contribution: 100%
Monthly premium (for 2): $482
The Smith’s pay: $482
Subsidy pays $0
The Smith Family Income: $21,000 Residence: Orem, Utah Ages: Dad : 35 Mom: 33 Child: 7 Child: 11
No Subsidy
The Smith’s healthcare costs would be 27% of their total income
Who lives in the Coverage Gap?
Source: https://www.healthcare.gov/see-plans/; Image source: TVZ Design
Window-shop for insurance
https://www.healthcare.gov/see-plans
Who is signing up for the ACA in Utah?
Image source: WarrenFree
In 2016, 13 of Utah’s top 20 ZIP codes for ACA enrollment were outside of Salt Lake
County
Source: 2016 Health Insurance Marketplace Plan Selections by ZIP Code; (Nov. 1, 2015 — Jan. 9, 2016); https://aspe.hhs.gov/basic-report/plan-selections-zip-code-health-insurance-marketplace-january-2016
RANK CITY SELECTIONS % INCREASE 1 Lehi (84043) 3,501 19% 2 South Jordan (84095) 3,346 12% 3 American Fork (84003) 2,948 17% 4 Pleasant Grove (84062) 2,931 20% 5 St. George (84790) 2,829 10% 6 St. George (84770) 2,742 11% 7 Draper (84020) 2,624 13% 8 Bountiful (84010) 2,455 5% 9 Spanish Fork (84660) 2,377 24%
10 West Valley City (84119) 2,368 3% 11 West Valley City (84120) 2,345 13% 12 Provo (84604) 2,289 22% 13 Herriman (84096) 2,276 20% 14 Clearfield (84015) 2,258 3% 15 Riverton (84065) 2,255 23% 16 Cottonwood Heights (84121) 2,254 6% 17 Orem (84058) 2,196 24% 18 Orem (84057) 2,193 16% 19 Ogden (84404) 2,189 1% 20 Layton (84041) 2,110 12%
Enrollment by Age
Utah children are enrolling in ACA insurance at 2.67x the national average
Utah
U.S.
24%
31% 16%
13%
16% Under 18
18-34
35-44
45-54
55-64
9%
26%
16% 21%
27% Under 18
18-34
35-44
45-54
55-64
Source: "State-Level Data From the ASPE January Health Insurance Marketplace Enrollment Report For The 2016 Open Enrollment Period; For the period: November 1, 2015 - December 26, 2015.“ https://aspe.hhs.gov/health-insurance-marketplaces-2016-open-enrollment-period-january-enrollment-report.
Premium subsidies make health insurance more affordable
Impact of subsidies on actual consumer costs
ACA enrollment by % poverty level
Source: Reduction in Average Monthly Premiums from Advance Premium Tax Credits in States Using the HealthCare.gov Platform (1) 11-15-14 to 2-15-15 (including SEP activity through 2-22-15)
Consumer
Cost
$248
Source: "State-Level Data From the ASPE January Health Insurance Marketplace Enrollment Report For The 2016 Open Enrollment Period; For the period: November 1, 2015 - December 26, 2015.”
1%
33%
25%
21%
18% Under 100%
100% to 150%
150% to 200%
200% to 250%
250% to 400%
Half of existing ACA consumers switched health plans in 2016
Origin of all consumers
Plan selection by re-enrolled consumers
Source: "State-Level Data From the ASPE January Health Insurance Marketplace Enrollment Report For The 2016 Open Enrollment Period; For the period: November 1, 2015 - December 26, 2015.”
Source: "State-Level Data From the ASPE January Health Insurance Marketplace Enrollment Report For The 2016 Open Enrollment Period; For the period: November 1, 2015 - December 26, 2015.”
70%
30%
51%
49%
Newly enrolled
Re-enrolled
Switched plan
Same plan
Recent data suggests that Utah is falling behind other states in key health reform metrics
Sources: 2013, 2014; Gallup Healthways Well-Being Index (2/24/15); 2Q 2015 US: Gallup Healthways Well-Being Index (7/10/15); 2Q 2015 UT: Gallup Healthways Well-Being Index (8/10/15) ; Smith, Jessica C. and Carla Medalia, U.S. Census Bureau, Current Population Reports, P60-253, Health Insurance Coverage in the United States: 2014, U.S. Government Printing Office, Washington, DC,2015.
What ACA enrollment looks like
Who are the helpers? Navigator
Certified Application Counselor
Experts trained to help others evaluate their insurance options on the new insurance marketplace.
Image: Paramount Pictures Corporation
www.takecareutah.org | call 2-1-1
TCU’s trained counselors are ready to help you understand your new options to find affordable
health care coverage today
Where can Utahns find help applying for health insurance?
Utahans are still falling through the cracks
Source: “Utahns brace for Obamacare enrollment, year 2,” by Kristen Moulton, Salt Lake Tribune, 11/11/14; http://www.sltrib.com/news/1812058-155/insurance-hobson-says-utah-gov-plans?page=1
“First, the HealthCare.gov website had her application "processing" for two months. Then the exchange needed a
form from her employer. When she finally got insurance, it was at a rate far higher than it should have been and she was never given a card or even an address for sending a payment.” …. It’s irritating, because I really tried.”
November 11, 2014
Predictions for the Future
1) Fixing Utah’s Medicaid coverage gap
2) Sustainability of ACA marketplaces beyond 2016
3) Trends in plan deductibles and cost-sharing
4) Impact of elections on healthcare reform
5) Trends in Utah morbidity/mortality metrics
6) How healthcare reform affects providers
The Role of Providers and Professionals in Health Reform
[Chart] Kaiser Health Tracking Poll, August 2013
Providers are a trusted source for patients
[Chart] Kaiser Health Tracking Poll, August 2013
Providers are a trusted source for patients
What health professionals can do…
(in billions)
No one can be denied or priced out of
coverage for a pre-existing condition
(1) healthcare.gov
(2) Being sick doesn’t matter
anymore
(4) Subsidies will make premiums
more affordable
60% 70%
80% 90%
(3) It’s private insurance
(and it’s good insurance) (5) Navigators will
help you sign up
Coverage Gap 101 Fixing Utah’s Persistent Healthcare Challenge
405,000 Utahns received Medicaid in 2014
The largest Medicaid recipient category in Utah are children under age 19 (238,950 recipients)
Utah adults without children aren’t eligible for Medicaid at any income level
59.0% 13.8%
11.8%
4.0%
6.4% 5.0%
Children (age 0-18)
Parents
Visually Impaired and People with Disabilities
Elderly (age 65+)
Pregnant Women
Primary Care Network (PCN)
Source: Utah Dept. of Health 2014 Medicaid Report (p. 29); http://health.utah.gov/medicaid/stplan/LegReports/MedicaidAnnualReport_2014.pdf
In June 2012, the Supreme Court declared Medicaid expansion optional. Utah is among 22 states that
have not expanded coverage.
0% 138% 400%
Income as % of the Federal Poverty Level
101% 400% 0% 100%
AC A in 2 0 1 0 AC A af ter 2 0 1 2
Originally, the ACA required Medicaid Expansion
Income as % of the Federal Poverty Level
What is the Coverage Gap?
Utahns in the Gap 63,000
0% 101% 400% 100%
Premium subsidies aren’t available for people earning under the poverty line
Income as % of the Federal Poverty Level (FPL)
NO YES 53,000 Utahns
in the Gap
• People who can’t receive Medicaid include adults without kids, parents who earn more than 50% of poverty, and people with unqualified disabilities
• Many people who don’t quality for Medicaid are uninsured and live in Utah’s “Coverage Gap”
Who isn’t eligible for Medicaid?
Who is in the Coverage Gap?
Parents… students… full-time workers… family care-givers… people with disabilities… part-time workers… veterans… women who just gave birth
Todd Dad… grad student… has two part-time jobs
Wendy Single-mom… student… child on LDS mission
Rachel Mom… employee… in long-term recovery
FYI: People in the coverage gap work
The national picture...
Source: The Advisory Board Daily Briefing (11/3/15); https://www.advisory.com/daily-briefing/resources/primers/medicaidmap
Utah is one of three states considering expansion
30 states, D.C. expanding Medicaid
Who could be covered in Utah?
Utah’s coverage gap costs lives each year
0% 100%
How does full expansion differ from partial?
0% 100% 138%
70%
30%
10%
90%
STATE
FEDERAL
WHO PAYS
$82 million/year $513 million/year
Partial Expansion Full Expansion TYPE
PEOPLE COVERED
TAXES RETURNED*
Source Cost estimates based on Milliman Numbers Revised 12 /17/14 and Dept. of Health Estimates 03/03/15; Taxes Returned data for 2017.
Utah voters support a coverage gap solution
RyLee Curtis
Utah Health Policy Project 801.433.2299 x8 [email protected]
Jason Stevenson
Utah Health Policy Project 801.433.2299 x7 [email protected]
Got Questions?
How do I calculate my MAGI? (in billions)
Step #1) Start with gross income (GI)
Your adjusted gross income is the money you earned through wages, interests, dividends, rental and royalty income, capital gains, business income, farm income, unemployment and alimony.
Adjustments can include items like some contributions to IRAs, moving expenses, alimony paid, self-employment taxes, and student loan interest.
Step #2) Calculate Adjusted Gross Income (AGI) by subtracting qualified deductions from gross income. AGI is used to determine your tax liability
Source: Zane Benefits - http://www.zanebenefits.com/blog/bid/271272/How-Do-I-Calculate-My-Health-Insurance-Tax-...2
How do I calculate my MAGI? (in billions)
Step #3) Add back items excluded from AGI
• Deductions for IRA contributions. • Deductions for student loan interest or tuition. • Excluded foreign income. • Interest from EE (employee) savings bonds used to pay
higher education expenses. • Employer-paid adoption expenses.
For most people, MAGI is the same as AGI.
Step #4) The result is your Modified Adjusted Gross Income (MAGI) – used to calculate eligibility for premium subsidies on the new insurance marketplaces
Source: Zane Benefits - http://www.zanebenefits.com/blog/bid/271272/How-Do-I-Calculate-My-Health-Insurance-Tax-...2
