Transcript The Future of Health Policy Making

Implementation of the ACA:
Impact on Social Workers
Pam Silberman, JD, DrPH
Professor of the Practice
Department of Health Policy and Management
Gillings School of Global Public Health
Nov. 17, 2015
1
2
Overview


ACA intended to address four major problems with the US
health system
 1)
Coverage and access barriers
 2)
Overall population health
 3)
Quality
 4)
Costs
Implications for Social Workers
3
Problem #1: Uninsured

There were approximately 41 million
uninsured nonelderly in the US in 2013
(15% of the nonelderly population).


Percent of Uninsured by Family Income (% FPL)
(NC, 2013)
400%+
13%
Note: 49 million uninsured in 2010.
Approximately 1.6 million uninsured in
North Carolina in 2013 (19% of the
nonelderly population).

~187,000 uninsured children (<age 18)
in 2013

~1.4 million nonelderly adults
<100% FPL
35%
200-399%
22%
100-199%
29%
Kaiser Family Foundation. State Health Facts. US Census, Current Population Survey, American Community Survey
(2013)
4
Uninsured in the North Carolina (2013)
Percent of Nonelderly Uninsured
by Race/Ethnicity
Other
11%
Hispanic
24%
White,
nonHispanic
45%
Risk of Being Nonelderly
Uninsured by Race/Ethnicity
21%
Other
43%
Hispanic
18%
Black only
15%
White only
Black,
nonHispanic
20%
0%
Kaiser Family Foundation. State Health Facts.
20%
40%
60%
Being Uninsured Has An Adverse Impact on
Health and Financial Wellbeing


5
Being uninsured negatively impacts on the health of the uninsured

Less likely to get preventive services or help managing chronic illnesses

More likely to enter hospital for preventable conditions or with more severe
health problems

More likely to die prematurely
Being uninsured also impacts on financial wellbeing

More likely to report having trouble paying medical bills and having bills
turned over to collection agencies

At greater risk of going into bankruptcy
Kaiser Commission on Medicaid and the Uninsured. The Uninsured: A Primer. October 2013.
Coverage Provisions Pre-Supreme Court
Decision

6
Most people required to have health insurance coverage
beginning in 2014. The ACA built on our current system of
providing health insurance coverage.
 Public
coverage: Many low income people with incomes <138%
Federal Poverty Levels (FPL) would gain coverage through
Medicaid.
 Employer-based coverage: Most other people would get health
insurance through their employer.
 Individual (non-group) coverage: Some people would qualify for
subsidies to purchase coverage on their own through the Health
Insurance Marketplace.
Supreme Court Challenge to ACA

7
Supreme Court, in National Federation of Independent Businesses
vs. Sebelius:
 Upheld
the constitutionality of the individual mandate (under
Congress’ taxing authority).
 Struck
down the government’s enforcement mechanism for the
Medicaid expansion, essentially creating a voluntary Medicaid
expansion.
 Left
the rest of the ACA intact.
National Federation of Independent Businesses vs. Sebelius, 567 US ___ (2012)
Medicaid Eligibility Requirements
(Pre-ACA)
8
To qualify, four basic eligibility tests:


Citizenship or covered immigrant
Certain “type or category” of person, such as:







Pregnant woman
Child under age 19 (or 21 at state option)
Parents of dependent children (TANF/AFDC related)
Disabled (meet SSA disability definition)
 SSA disability definition: Having a physical or mental impairment that prevents a
person from engaging in substantial gainful activity, and which is expected to last
12 months or end in death
Elderly (65 or older)
Income limits, depends on program category
Resource (assets) limits, depends on program category
NC Medicaid Income Eligibility in Non
Expansion State (2015) (Percent of Federal Poverty Level,
9
based on new ACA-related income levels)
NC Health Choice
196%
210%
Medicaid
210%
138%
47%
100%
100%
•Currently, childless, nondisabled, non-elderly
adults can not qualify for
Medicaid
•Because of categorical
restrictions, Medicaid only
covers 26% of low-income
adults in North Carolina
CMS. State Medicaid and CHIP Income Eligibility Standards Effective January 1, 2015. Calculations for parents based
on a family of three. Note: 100% of the federal poverty levels (FPL) (2015) = $11,770/yr. (1 person), $15,930 (2
people), $20,090 (3 people), $24,250 (4 people).
9
10
NC Medicaid Income Eligibility if Expanded
Existing Medicaid Eligibles
Newly Medicaid Eligibles
Existing NCHC
Optional Coverage
196%
210%
138%
100%
•Approximately 560,000
uninsured adults would
have become income
eligible for Medicaid
expansion in 2014, if the
state had chosen to
expand Medicaid.
Note: 138% FPL (2014)= $16,243/yr (1 person), $21,983 (2 people), $27,724 (3 people),
$33,465 (4 people).
Medicaid Enrollment Growth Since
2013 Due to Enrollment Spillover
Parents
M’aid
Child*
NC
Health
Choice*
Total
Children
Pregnant Elderly,
Women
Blind,
Disabled
Dec.
2013
152,982
925,453
150,010
1,075,463 23,779
Oct.
2015
191,461
1,021,318
78,171
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Other**
Total
467,624
54,308
1,774,156
1,099,489 17,151
488,239
102,649
1,898,989
Change Dec. 2013-Oct. 2015
Number
38,479
95,865
(71,839)
24,026
(6,628)
20,615
48,341
124,833
Percent
25.2%
10.4%
-47.9%
2.2%
-27.9%
4.4%
89.0%
7.0%
*In January 2014, states were required to move children with incomes ≤138% FPL out of the CHIP program and into
Medicaid. Approximately 70,000 children were moved from NCHC to Medicaid.
**Other incomes Family Planning, Breast and Cervical Cancer Program, certain immigrant populations, and
refugees. Most of the growth was in the Family Planning program that offers coverage of limited services.
Current Status of State Medicaid Decisions
(Sept. 2015)
12
Employer Responsibilities


Employers with 50 or more full-time employees required to offer
insurance to the full-time employee and his/her dependents or
pay penalty (Sec. 1201, 1513, amended Sec. 1003 Reconciliation)
Employers with less than 50 full-time employees exempt from
penalties. (Sec. 1513(d)(2))


13
Employers with 25 or fewer employees and average annual wages of
less than $50,000 can receive a tax credit. (Sec. 1421, Sec. 10105)
Note: the requirement that employers offer health insurance
coverage to their employees was delayed until 2015 for employers
with 100+ employees or 2016 for employers with 50-100 employees.
14
Individual Mandate

Citizens and legal immigrants required to pay tax penalties if they
do not have qualified health insurance, unless exempt. (Sec. 1312(d),
1501, amended Sec. 1002 in Reconciliation)


Penalties: Must pay the greater of: $95/person or 1% taxable income (2014);
$325 or 2.0% (2015); or $695 or 2.5% (2016), increased by cost-of living
adjustment*
Certain groups are exempt from the penalties, including those who would
have to spend more than 8% of their income for the lowest cost premium,
people with incomes so low that they do not pay taxes, and those who
would have qualified for Medicaid (in non-expansion states).
*Families of 3 or more will pay the greater of the percentage of income, or three times the individual penalty amount. The
maximum penalty is equal to the amount the individual or family would have paid for the lowest cost bronze plan (minus any
allowable subsidy).
Federally Facilitated Marketplace


People can shop for coverage in the Marketplace
States were given the option of creating their own Health Insurance
Marketplaces (Exchanges). If they did not do so, the federal
government created a Marketplace.


15
34 states have Federally Facilitated Marketplaces (FFM).
The marketplace:
Provides standardized information (including quality and costs) to help
consumers choose between qualified health plans.
 Determines eligibility for the subsidy.
 Provides links to provider directories.
 www.healthcare.gov.

16
Subsidies to Individuals

Refundable, advanceable premium tax credits
are available to individuals to purchase
coverage through the Marketplace.

Eligible individuals include those with incomes
between 100-400% FPL on a sliding scale basis, if
not eligible for government coverage or
affordable employer-sponsored insurance (Sec.
Family
Size
100%
FPL/Yr.
250%
FPL/Yr.
400%
FPL/Yr.
1
$11,770
$29,425
$47,080
2
$15,930
$39,825
$63,720
3
Cost sharing subsidies also available if family income
4
between 100-250% FPL
$20,090
$50,225
$80,360
$24,250
$60,625
$97,000
$4,160
$10,400
$16,640
1401)


2015 Federal Poverty Level
(FPL)
Poor people (<100% FPL) not eligible for
subsidies to purchase coverage in the
Marketplace.
Each
add’l
person
Sliding Scale Subsidies (2015)
17
Individual or family
income
Maximum
premiums (%
family income)
Out-of-pocket Out-of-pocket cost sharing limits
cost sharing:* (2015)**
100-133% FPL
2% of income
6%
133-150% FPL
150-200% FPL
3-4%
4-6.3%
6%
13%
$2,250 (ind)/$4,500 (more than
one person)
$2,250 / $4,500
$2,250 / $4,500
200-250% FPL
250-300% FPL
300-400% FPL
6.3-8.05%
8.05-9.5%
9.5%
27%
30%
30%
$5,200 / $10,400
$6,600/ $13,200
$6,600/ $13,200
400% + FPL
No limit
30%
$6,600 / $13,200
*Out-of-pocket cost sharing includes deductibles, coinsurance, and copays, but does not include premiums, noncovered
services, or services obtained out of network. Subsidies tied to the second lowest cost silver plan in the market.
18
King vs. Burwell, 576 US ___ (2015)

Plaintiffs brought suit alleging that premium subsidies were not
available in states that had federally facilitated marketplaces
because the ACA limited subsidies to individuals who purchase
insurance on an exchange “established by the state.”
 If
subsidies were not available, health insurance coverage would
not be considered affordable to the plaintiffs, and therefore they
would not be required to purchase insurance.

In a 6-3 majority, Chief Justice Roberts held that the court
needed to look at the intent of the statute, and the intent was to
provide subsidies to enable people to afford coverage.
Enrollment Process


19
ACA creates a “no wrong door” enrollment system so people can
enroll in Medicaid, NC Health Choice, or private coverage
through the Marketplace.
Initial (2014) enrollment period ran from October 1, 2013 through
March 31, 2014. Second open enrollment period ran from Nov. 15,
2014-Feb. 15, 2015.
 If
you fail to enroll during an open enrollment period, you generally
will not be eligible until the next open enrollment period.

2016 open enrollment period runs from Nov. 1, 2015 – January
31, 2016
Enrolling into Marketplace
Coverage is Hard

20
Among uninsured adults in North Carolina (2014)
 46%
had less than a high school education and 24% had a high
school diploma or GED.
 31%
had never had health insurance coverage, and another 35%
had not had health insurance coverage in the last year.

Many people do not understand insurance design
components required or prevalent in most plans:
 Premiums,
deductibles, coinsurance, copayments, or out-of-pocket
limits, in-network or out-of-network services, tiered benefit plans
In Person Assisters Can Help





21
Center for Consumer Information and Insurance Oversight (CCIIO)
contracted with patient navigators in Federally Facilitated Marketplaces
to provide neutral information about the marketplace, and to help
people with the enrollment process.
Federally qualified health centers received separate funding to help
with education, outreach, and enrollment assistance
Agents and brokers can also help people enroll
Certified application counselors can also help people enroll (essentially
navigators that do not receive federal grants)
All in person assisters are required to be trained and certified by the
federal government
4th
NC Had
Highest Enrollment into the
Marketplace


22
By the end of the 2nd Open Enrollment Period, North Carolina
had enrolled 560,357 people into the Marketplace

4th highest number of people who enrolled into the marketplace

Only Florida (1,596,296), California (1,408,352) and Texas (1,205,174) had
higher enrollment
North Carolina tied for 7th in terms of the percent of potential
Marketplace population who enrolled (51%)

States with a higher proportion of their eligible population who selected
a plan included: Vermont (70%), Florida (64%), Maine (60%), DC (57%),
Delaware (53%), and Pennsylvania (53%). (NC tied with New Hampshire.)
Urban Institute Showed Decline in Uninsured
23
(Uninsured Adults 18-64 through second quarter 2014)

The decline is larger
in states that
expanded Medicaid

ASPE estimates that
the numbers of
uninsured dropped
by 16.4 million since
the ACA put in
place
Urban Institute. Health Reform Monitoring Survey. http://hrms.urban.org/quicktakes/Number-of-Uninsured-AdultsContinues-to-Fall.html. ASPE. Health Insurance Coverage and the Affordable Care Act. May 2015.
http://aspe.hhs.gov/health/reports/2015/uninsured_change/ib_uninsured_change.pdf
The ACA Expanded Coverage to
Millions of Americans
24

~7 million people selected a health plan in the first open
enrollment period (Oct. 1, 2013 – April 15, 2014)

More than 11 million people selected a health plan by the end of
the second open enrollment period (Nov. 15, 2014 – Feb. 15, 2014)

Of these people, we do not know how many actually paid their first month
premium and enrolled into coverage (estimates ~80%)

Further, we don’t know how many of these individuals were previously
uninsured
Covered Services

Qualified Health Plans offered to individuals and small businesses
must offer an essential health benefits package:* (Sec. 1302)


25
EHBs include: ambulatory patient services; emergency services;
hospitalization; maternity and newborn care; mental health and substance
use disorder services; prescription drugs; rehabilitation and habilitative
services; laboratory services; preventive and wellness services and chronic
disease management; and pediatric services, including oral and vision
care.
Plans must also cover mental health and substance abuse services
in parity with coverage of other medical conditions*
*Requirements do not apply to grandfathered plans in effect continuously, and not changed significantly since March 23, 2010.
Expansion of Preventive Services:
Private Plans

26
Most private insurance plans* are required to cover coverage of
certain preventive services with no cost sharing, including:
Clinical preventive services recommended by the US Preventive Services
Task Force (USPSTF) with an A or B recommendation
 Vaccines recommended by the Advisory Committee for Immunization
Practices (ACIP)
 Children’s preventive services that are part of the Bright Futures guidelines
 Separate set of women’s preventive services, including contraceptive
coverage.


In Burwell v. Hobby Lobby, the US Supreme Court held that closely held corporations do
not have to provide contraceptive coverage if they have a religious objection.
*“Grandfathered” plans—plans that have been in existence since March 2010 with few changes, are not subject to these
requirements.
ACA Includes Other Provisions to
Expand Access to Services

Expanded appropriations for National Health Service Corps (NHSC) by
$1.5 billion over 5 years.


27
Extended for one year as part of the SGR fix (“Doc fix”)
ACA appropriated $9.5 billion over 5 years to support federally qualified
health centers, plus $1.5 billion in new capital funds. (Sec. 10503, Sec. 2303 of
Reconciliation)


Funding was extended through FY 2018 as part of the Doc fix
ACA includes new efforts to expand and promote better training for
the health professional workforce.

Many of the workforce provisions were reauthorizations of existing programs. Other
workforce provisions were authorized but not funded.
http://www.hrsa.gov/about/organization/bureaus/bcrs/nhscoverview.html;
http://www.hhs.gov/healthcare/facts/bystate/nc.html
Problem #2: Population Health


28
The goal of any health system should be to improve individual and
population health
US is ranked near the bottom of OECD countries in most health status
comparisons. For example, in 2012 (or nearest year):

US ranks 27th out of 34 OECD countries on overall life expectancy at birth.

US ranks 31st out of 34 in infant mortality rates.

US ranks 32nd (female) and 29th (male) out of 34 in years of life lost per
100,000 (0-69 years old).

US ranks 29th out of 29 countries reporting in obesity rates.
OECD Health Statistics, 2014.
North Carolina Health Status
Indicators
North Carolina ranks 37th of the 50 states and DC in population health
measures in 2014. (America’s Health Rankings, 2014)
 North Carolina was ranked:
 41st in infant mortality rates
 36th in premature deaths
 25th in obesity and 43rd in adult diabetes
 33rd in adult smoking
 33rd in cancer deaths and 31st in cardiovascular deaths
 46th in children living in poverty and 30th in high school graduation
 8th in binge drinking

America’s Health Rankings. 2014. http://www.americashealthrankings.org/NC.
29
Affordable Care Act
•
30
Prevention and Public Health Trust Fund to invest in
prevention, wellness, and public health activities (Sec. 4002)
–
–
–
ACA initially appropriated $500 million in FY 2010 increasing to $2
billion by 2022.*
Creates a national prevention, health promotion, and public health
council to establish public health and prevention priorities for the
country (Sec. 4001)
Priority areas include: tobacco free living, preventing drug abuse or
excessive alcohol use, health eating, active living, injury and
violence free living, reproductive and sexual health, and mental and
emotional wellbeing.
* Will reach $2 billion in 2022.
http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf.
National Prevention Strategy

The National Prevention and Health
Promotion Strategy was released June
2011. It includes four domains and seven
priority areas:

Tobacco free living,

Preventing drug abuse and excessive
alcohol use;

Healthy eating;

Active living;

Injury and violence free living;

Reproductive and sexual health; mental and
emotional well-being; and

Mental and emotional wellbeing
http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf
31
Fed’l Prevention and Public Health
Funding (FY 2015)
32
FY 2015
Immunization grants
$210.3 M
Preventive Health and Health Services Block Grant
$160.0
National Media Campaign on Tobacco Use/Quit Lines
$111.0
Breast and Cervical Cancer
$104.0
Diabetes Prevention
$73.0
Heart Disease and Stroke Prevention & Million Hearts Campaign
$77.0
Nutrition, Physical Activity, & Obesity Prevention
$35.0
Racial and Ethnic Approaches to Community Health
$30.0
Workplace Wellness grants
$10
Other: Alzheimer’s prevention, chronic disease self-management, falls prevention, hospital
promoting breastfeeding, epidemiology and laboratory capacity grants, healthcare
associated infections, lead poisoning prevention, early care collaboratives, suicide prevention
$116.7
Prevention and Public Health Fund. http://www.hhs.gov/open/prevention/index.html. Accessed 6-2-15.
Maternal and Child Health

33
Support for pregnant and parenting teens and women (Sec.
10211-10214)
 Appropriates
$25 million in each fiscal year 2010-2019 in pregnancy
assistance grant funds for states to assist pregnant and parenting
teens and women.

Personal Responsibility Education (Sec. 2953)
 Each
state is eligible for an allotment of at least $250,000 to reduce
pregnancy and birth rates among youth ages 10-19 years.
 Appropriated $75 million in each FY 2010-2014 to states to carry out
personal responsibility education programs (PREP) designed to
educate adolescents on abstinence, contraception, and
preparation for adulthood.
Maternal and Child Health

34
Maternal, infant, and early childhood home visiting
programs (Sec. 2951)
 Funding
to states, tribes, and territories to develop and implement
one or more evidence-based Maternal, Infant, and Early Childhood
Visitation model(s), which aim to reduce infant and maternal
mortality and its related causes by producing improvements in
prenatal, maternal, and newborn health, child health and
development, parenting skills, school readiness, juvenile
delinquency, and family economic self-sufficiency.
 Authorized and funded for $1.5B over 5 years.
HRSA. Home Visiting Grants and Grantees. http://mchb.hrsa.gov/programs/homevisiting/grants.html
Problem #3: Quality

To Err is Human estimated that preventable medical errors in
hospitals led to between 44,000-98,000 deaths in 1997. (Institute of
Medicine, 1999)

35
People only receive about half of all recommended
ambulatory care treatments.
(E. McGlynn, et. al. NEJM, 2003; Mangione-Smith, et. al. NEJM, 2007)
Affordable Care Act: Quality
Overview

36
The ACA directs the HHS Secretary to establish national
strategy to improve health care quality. (Sec. 3011, 3012)
 Funding
to CMS to develop quality measures.
(Authorizes $75M for each FY 2010-
2014; Sec. 3013-3014)
 Collection
and public reporting of quality data. (Sec. 3015, 10305, 10331)
 Moving towards paying providers on the basis of quality of care
provided, not just volume (called “value-based purchasing”).
Example: Hospital Penalties for
Excess Readmissions


37
Hospitals with excess readmissions (risk-adjusted 30-day readmission
rates) are receiving lower Medicare payments (Sec. 3025)

Initially, CMS tracked readmissions for pneumonia, heart failure, and heart attacks.
Elective hip or knee replacement and congestive obstructive pulmonary disease
were added in FY 2015

2,610 hospitals were penalized in FY 2015.

DRGs reduced by up to 1% (FFY 2013), 2% (2014), and 3% (2015)
Greater emphasis on care transitions—linking patients to primary care providers
and other resources in the community to prevent readmissions
Kaiser Health News. Readmission Penalties by State: Year Three. Oct. 2014.; Press M. Limits of Readmission Rates in Measuring Quality
Suggest the Need for Added Metric. Health Affairs. 2013:32(6). James J. Medicare Hospital Readmissions Reduction Program. Health Affairs
Policy Brief. Nov. 2013; Boccuti C, Casillas G. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Program. KFF. Jan.
2015 Issue brief.
Problem #4: Costs

38
US spending on health care rising far more rapidly than other
costs in our society.
 US
spends more on health care than any other industrialized nation.
 Health
care costs rising faster than general inflation.
Increases in Health Insurance Premiums,
Inflation, and Workers’ Earnings (1999-2015)
39
250%
Health Insurance Premiums
Workers' Contribution to Premiums
Workers' Earnings
Overall Inflation
200%
221%
203%
158%
150%
138%
88%
100%
75%
50%
20%
17%
0%
1999
2000
2001
2002
2003
2004
2005
56%
42%
42%
31%
2006
2007
2008
2009
2010
2011
2012
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2015. Bureau of Labor Statistics, Consumer Price
Index, U.S. City Average of Annual Inflation (April to April), 1999-2015; Bureau of Labor Statistics, Seasonally Adjusted Data
from the Current Employment Statistics Survey, 1999-2015 (April to April).
2013
2014
2015
Reducing Rate of Increase in Health
Care Spending: ACA


No “magic bullets” to reduce rising health care costs
ACA includes new opportunities to test new models of care delivery and
payment models in Medicare and Medicaid to:




Improve patients’ experience with health care system (quality, access)
Improve population health
Reduce unnecessary health care expenditures
Testing different models including:


40
Patient centered medical homes, episodes of care, Accountable Care Organizations
(ACOs)
Once new models are shown to work in different communities and with
different delivery systems, Secretary of HHS has the authority to
implement broadly in other communities.
Patient Centered Medical Homes
41

Primary care that is comprehensive and covers care across the
lifespan, incorporates a team of health professionals, is patient
centered, incorporates information support to improve quality and
outcomes, and includes payment mechanisms to promote better
care coordination across professionals.

Social workers can play a critical role in the new patient centered
medical homes:

Licensed clinical social workers can provide integrated behavioral health services

Social workers can help with care coordination and disease management
services for people with complex or chronic health problems
42
Accountable Care Organizations

An ACO is an organization of eligible providers and suppliers who are
accountable for the quality, cost, and overall care of the an assigned
group of enrollees (eg, Medicare beneficiaries).

ACOs can share Medicare savings with the federal government IF:


The ACO complies with all the ACO requirements, AND

The ACO meets quality standards, AND

The ACO has measured savings below a calculated threshold
Also ACO models in Medicaid and private insurance.
Heiser S, et. Al. Unpacking the Medicare Shared Savings Proposed Rule: Geography and Policy. Health Affairs Blog. Jan
22, 2015. http://healthaffairs.org/blog/2015/01/22/unpacking-the-medicare-shared-savings-proposed-rule-geography-andpolicy/
Number of ACOs and Populations
Covered (2015)
Estimated Number of ACOs
Operating within State
43
Estimated Percent of
Population Covered by ACO
Muhlesein D. Growth and Dispersion of Accountable Care Organizations in 2015. Health Affairs Blog. March 31, 2015.
Many of the New Models Focused on
Improved Population Health

To improve population health,
also need to focus on mental
health and substance abuse
problems.

Need to focus on social
determinants of health, as well
as medical care.
44
Boyd C, et. al. Clarifying Multimorbidity Patterns to Improve Targeting and
Delivery of Clinical Services for Medicaid Populations. Center for Health Care
Strategies. Dec. 2010.
45
Effective ACOs Serving Vulnerable
Populations Address Social Determinants

Hennepin Health is a county-based safety net ACO serving the
Medicaid population in Minneapolis, MN.




Developed an ACO that integrates medical, behavioral, and social services for
Medicaid recipients in order to reduce social determinants of health that impair
health.
Interdisciplinary care coordination provided by teams which include RN care
coordinators, social workers, and community health workers. Also offer nonclinical
support for high-risk individuals (such as vocational and housing support).
Social workers offer behavioral health services, and help patients navigate health
and social services systems.
Model was shown to decrease ED use, improve care, and save money.
Sandberg et. al. Hennepin Health: A Safety-Net Accountable Care Organization for the Expanded Medicaid Population. Health Affairs.
2014;33(11).
Increasing Roles for Social Workers
in ACA

46
Social workers can:
 Help
people enroll into coverage in Medicaid or the Marketplaces
 Provide
behavioral health services to newly insured individuals or
others with better coverage for mental health and substance abuse
services (due to behavioral health parity provisions)
 Also
may be more options to offer behavioral health services in integrated,
primary care medical homes
 Help
people navigate the health care system and link to resources
in the community (to reduce preventable readmissions and
improve health outcomes)
ACA: Outstanding Challenges

47
The ACA presents many new challenges to the state.






In states (like NC) that chose not to expand Medicaid, the poorest people
will lack insurance coverage and they will be ineligible for subsidies.
The ACA did not invest significantly in expanding the health care
workforce, and does not adequately address maldistribution issues.
Coverage of preventive services is not as comprehensive as it should be.
Some providers and higher income individuals will pay more in taxes.
Did not address long-term care issues for the frail elderly and people with
disabilities
We do not yet have the “magic bullet” that will ensure better quality and
reduced health care costs.
ACA: New Opportunities

48
However, ACA offers many opportunities, including:
 Expands
coverage to more of the uninsured.
 Makes health insurance coverage more affordable to many
(although some people may have to pay more for coverage).
 Expands coverage of preventive services
 Greater emphasis on improving overall population health.
 Greater emphasis on quality of care.
 We are still in early stages, but some of the early models suggest
potential to reduce longer term cost escalation.
For More Information

Pam Silberman, JD, DrPH
Professor of the Practice
Department of Health Policy and Management
Gillings School of Global Public Health
University of North Carolina at Chapel Hill
[email protected]
919-966-4525
49
50
Important Contact Information

Federal website to apply:


North Carolina website to apply


www.healthcare.gov
cuidadodesalud.gov (for Spanish)
Epass.nc.gov
To make appointment with NC navigators, Certified Application
Counselors, or other in-person assisters


1-855-733-3711
NC Get Covered: www.ncgetcovered.org.
 NC Get Covered is the statewide coalition of navigators, FQHCs (community
health centers), and other in-person assisters helping people obtain coverage
through the Marketplace
Questions
51
National Health Reform
Resources
52

Patient Protection and Affordable Care Act. Consolidated Bill Text

US Health Reform website

National Federation of Independent Business v. Sebelius

Congressional Budget Office. Selected CBO Publications Related to Health
Care Legislation, 2009-2010.
http://docs.house.gov/energycommerce/ppacacon.pdf
www.healthcare.gov
http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf
http://www.cbo.gov/ftpdocs/120xx/doc12033/12-23-SelectedHealthcarePublications.pdf

Kaiser Family Foundation
http://healthreform.kff.org/
Subsidies Make Coverage More
Affordable

Nationally, 87% of people who purchased insurance in states using the
healthcare.gov platform received a subsidy


87% had Advanced Premium Tax Credit (NC: 92%)
Average premium for an individual after the subsidy was $101 ($95 in
NC)


53
Subsidies reduced the premiums by 72% (77% in NC)
Average annual medical and drug deductible was $2,556 for a silver
plan in 2015

Cost sharing subsidies for people with incomes ≤150% FPL decreased annual
deductible to $229.
ASPE. Health Insurance Marketplaces 2015 Open Enrollment Period: March Enrollment Report. March 10, 2015.
http://aspe.hhs.gov/health/reports/2015/MarketPlaceEnrollment/Mar2015/ib_2015mar_enrollment.pdf. Kaiser Family
Foundation. New Reports Analyze Cost Sharing in 2015 ACA Marketplace Plans in 37 States. Feb. 11, 2015.
Example of Subsidies: Smith Family

54
Assume Smith family of 4 earns $51,410/year (212% FPL) and lives in
Greenville (Region 14).

Mike (age 40), Sally (age 35), Tim (age 13), Becky (age 6)

Second lowest cost silver plan will cost: Mike ($346/mo), Sally ($331/mo.), Tim and
Becky ($172/mo. each) for a total of $1,021/mo. (This assumes no one is a smoker.)

They are required to pay $3,455/yr. or ~$288/month (6.72% of their income) for the
second lowest cost silver plan

Therefore, the amount of subsidy that is available is: ~$733/mo.

In addition, the Smith family is eligible for a cost sharing subsidy, which would reduce
the amount they pay out of pocket to 27% on average (from 30%), and would
reduce the out-of-pocket limits to $5,200/ind. or $10,400 for a family.
Smith Family

55
Smiths can take the $733 subsidy and purchase:
 Lowest
cost silver plan ($1,005/mo), which would reduce their
premium from $288/mo. to $272.
 Lowest
to: $87.
cost bronze plan ($820) which would reduce their premium
 However,
if they use their subsidy to purchase a bronze plan, they will
not be eligible for a cost sharing subsidy.
 Lowest
cost gold plan ($1,263) which would increase their premium
to $530/mo. but decrease their out of pocket costs to 20%.
ACA Estimated to Increase Overall
Health Spending
56

While the ACA reduces the federal deficit, CMS actuaries
estimated that the ACA would increase overall health
spending

By 2022, the ACA is projected to reduce the uninsured by 30
million, but add approximately 0.1 percentage point to average
annual health care spending ($621 billion over the 10 year period).
CMS, National Health Expenditure Projections 2012-2022. http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/proj2012.pdf)
Health Insurance: Key Concepts


57
Individuals will be required to pay monthly premiums to pay for health
insurance.
Out-of-pocket cost sharing can include:
–
Deductibles: The amount you must pay first, before insurance begins paying
for covered services.
–
For example, a plan with a $2,000 deductible means that the insured individual is
responsible for the first $2,000 in medical bills before the health plan pays any bills.
–
Certain services are not be subject to the deductible, such as clinical preventive
services or immunizations. (The ACA requires insurers to cover these services without
cost sharing.)
–
Some carriers exempt other services from the deductible. For example, some plans
allow people to see the doctor for outpatient services without being subject to the
deductible. In these plans, the individual pays the copayment for the doctor’s visit and
the insurer pays the balance after the copayment. Depending on the plan design, the
deductible might only apply for higher-cost services, such as hospitalizations or
ambulatory surgery.
57
Health Insurance: Key Concepts
 Co-insurance:
58
The proportion (percentage) of the health care costs
you may need to pay, after you meet your deductible.
 For example, if you have a $100 doctor’s bill and you have an
insurance plan with 30% coinsurance, you will be responsible for
paying $30 and the insurance company will pay $70.If you have a
$1,000 doctor’s bill, you would be responsible for paying $300 (30% of
$1,000) and the insurance company would pay $700.
 Co-payments: A fixed dollar amount you need to pay for certain
services. It does not vary based on the underlying health bill.
 For example, if you have a $40 copay to see a doctor, you will pay
$40 regardless of whether the underlying bill is $100 or $1,000.
Health Insurance: Key Concepts
•
59
In addition, the health law includes a maximum amount you will have to
pay out-of-pocket for covered services (Out-of-pocket maximum).
•
•
•
•
The current out-of-pocket limit is $6,600 for an individual or $13,200 for a family
(2015).
The amount the insured person pays towards deductible, coinsurance, and
copayments for covered services counts towards the out-of-pocket maximum.
Once the person’s total out-of-pocket payments for covered services reaches the
out-of-pocket maximum, then the insurance company will pay 100% of all the
remaining expenses for covered services for the remainder of the plan year.
Note: premiums do NOT count towards the out-of-pocket limit. Additionally,
services received outside of network may not count towards the out-of-pocket
maximum.
Note: Some people who have lower incomes and purchase coverage in the
marketplace may have lower out-of-pocket limits.
4
Example: Two BCBSNC Plans
60
Blue Advantage Silver 2800
Blue Advantage Silver 0
Primary Care Physician Office
Visit
In network: $30 copay
Out-of-network (OON): 60% after
deductible
In network: 50% visit cost
OON: 60% after deductible
Specialist Office Visit
In network: $60 copay
OON: 60% after deductible
In network: 50% visit cost
OON: 60% after deduct.
Urgent Care Visit
$75 copay
50% of visit cost
Emergency room visit
$150/$500 copay (first
visit/subsequent visit)
50% of visit cost
In Network Deductible
$2,800 ind./$5,600 family
$0/$0
Out-of-Network Deductible
$5,600 ind./$11,200 family
$250 ind./$750 family
Out-of-pocket limit in network
$6,350 ind./$12,700 family
$6,350 ind./$12,700 family
Out-of-pocket limit OON*
$12,700 ind./$25,400 family
$12,700 ind./ $25,400 family
Coinsurance for other services
(different rules apply to drugs)
In network: 30%
Out-of-network: 60%
In network: 50%
Out-of-network: 60%
*The ACA does not require health plans to have out-of-pocket maximums for services received from out-of-network providers.
Example: BCBSNC Plans
Insured pays $30 for office visit
in network, not subject to
deductible. If OON, pays 60%
after a $5,600 out-of-network
Blue Advantage Silver 2800
Blue Advantage Silver 0
deductible.
61
Primary Care Physician Office
Visit
In network: $30 copay
Out-of-network (OON): 60% after
deductible
In network: 50% visit cost
OON: 60% after deductible
Specialist Office Visit
In network: $60 copay
OON: 60% after deductible
In network: 50% visit cost
OON: 60% after deduct.
Urgent Care Visit
$75 copay
50% visit cost
Emergency room visit
$150/$500 copay (first
visit/subsequent visit)
50% visit cost
In Network Deductible
$2,800 ind./$5,600 family
$0/$0
Out-of-Network Deductible
$5,600 ind./$11,200 family
Out-of-pocket limit in network
$6,350 ind./$12,700 family
Out-of-pocket limit OON
$12,700 ind./$25,400 family
Coinsurance for other services
(different rules apply to drugs)
In network: 30%
Out-of-network: 60%
Insured pays 30%
$250 ind./$750 family
coinsurance for other
services
after
$2800
$6,350
ind./$12,700
family
deductible (in network), or
$12,700
$25,400 family
60% after
a $5600ind./
deductible
out-of-network
In network: 50%
Out-of-network: 60%
62
Percentage of Covered Workers Enrolled in
Grandfathered Plans, 2011-2014
70%
63%
60%
53%
50%
56%
54%*
46%
48%*
49%
All Small Firms (3-199 Workers)
All Large Firms (200 or More Workers)
ALL FIRMS
40%
36%*
35%*
30%*
30%
26%*
22%*
20%
10%
0%
2011
2012
2013
* Estimate is statistically different from estimate for the previous year shown (p<.05).
NOTE: For definitions of Grandfathered health plans, see the introduction to Section 13.
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2011-2014.
2014
63
Most People in Marketplace
Satisfied with Plans
Annual deductible
23%
37%
19%
Choice of specialists
30%
34%
Monthly premium
30%
35%
Prescsription copay
32%
Doctor visit copay
Choice of hospitals
10%
Somewhat satisfied
20%
40%
Somewhat dissatisfied
50%
11%
8%
33%
30%
19%
12%
35%
60%
Very dissatisfied
70%
3%
17%
10%
43%
42%
0%
5%
15%
40%
Choice of primary care doctors
Very satisfied
11%
38%
30%
17%
4%
8%
9%
6%
6%
11%
11%
9%
80%
90%
5%
Don't know/refused
KFF. News Release. May 21, 2015. http://kff.org/health-reform/press-release/most-people-enrolled-in-marketplacecoverage-are-satisfied-with-plans-premiums-cost-sharing-and-provider-networks-new-survey-finds/
100%
Cost Projections if Congress
Repeals ACA

64
Repeal of the ACA would increase the federal deficit by $137B
(2016-2025).
 Would
save $1,658 billion in net savings from eliminating coverage
expansion.
 Would reduce new federal revenues by $502 billion from coverage
provisions (penalties) and $631B in noncoverage income.
 Would increase federal spending by $879 B in ACA provisions that
reduced federal spending (primarily in Medicare).
 Would increase GDP by .7% ($216B)
CBO. Budgetary and Economic Effects of Repealing the Affordable Care Act. June 2015.