February 5, 2014

Heather HowardDirector, State Health Reform Assistance

NetworkLecturer in Public Affairs, Princeton University

heatherh@princeton.edu 1/5/11

Public Health in Action: The ACA and Medicaid Expansion in PA and State by

State

1

Overview

2

The Affordable Care ActKey provisionsState implementation is critical to success

National LandscapeMedicaid expansionExchange implementation

Issues to Watch

3

4

Affordable Care Act (ACA): Key Provisions

Insurance reforms Requirement to purchase insurance

Coupled with subsidies for those with incomes up to 400% of the federal poverty level (FPL)

Health Insurance Exchanges Marketplace for individuals and small

businesses to compare policies and premiumsMedicaid eligibility expanded to 138% FPLSimplified Eligibility & Enrollment – “No Wrong

Door”Most provision went into effect in 2014

5

Why Focus on State Implementation?

States have central role in success or failure of ACARange of state requirements and options

States may choose to set up insurance exchangesState may opt to participate in delivery system reformsStates may expand Medicaid Most states are enforcing new insurance market rules

Context: state budget challenges, capacity constraints, politics

“New Federalism” -- carrot and stick approachMyriad Federal grants to fund health reform effortsIf states do not establish their own exchanges or

effectively enforce new insurance market reforms, federal government will step in

Supreme Court Decision on ACA

6

Medicaid expansion is optional Majority found the Medicaid expansion

unconstitutionally coercive of states“Gun to the head” because the

“threatened loss of over 10 percent of a State’s overall budget. . . is economic dragooning that leaves the States with no real option but to acquiesce”

Expansion is a “new program”; cannot withhold all Medicaid funds if state does not expand

Thus the violation can be remedied by making the expansion optional

Medicaid Fast Facts67 million People in the United States with Medicaid coverage.

$440 billion State and federal Medicaid spending for FY 2012.

9-12 million Additional Medicaid/CHIP beneficiaries between 2014-2019, pending state decisions on Medicaid expansion.

48% Births in the United States covered by Medicaid.

1 in 3 Children in the United States covered by Medicaid.

57% Medicaid beneficiaries under 65 who are from diverse racial/ethnic groups.

5% Medicaid beneficiaries, many with chronic illnesses and disabilities, accounting for 55% of total Medicaid spending.

49% Medicaid beneficiaries with disabilities diagnosed with mental illness.

43% Total long-term care costs in the United States financed by Medicaid.

39% Percentage of Medicaid dollars spent on Medicare-Medicaid enrollees.

72% Medicaid recipients who are enrolled in managed care.

8

9

Medicaid Expansion Challenges

10

Long-term Financing Newly eligible Medicaid populations 100%

federally funded through 2016Sliding scale brings federal portion down to 90% At risk during constant federal budget debates?

Woodworking/Welcome Mat Effect States only receive traditional lower FMAP for

currently eligible populations, not the enhanced FMAP for newly eligibles

Medicaid Expansion Challenges

11

How has expansion decision played out in states?State analysis of impactRole of stakeholders

States see opportunity (and leverage) to innovate through waiver processArkansas premium assistance or “private option”

model starts feeding frenzyMichigan – creation of health savings accounts,

premium and copay increases and four year “limit”Iowa

Traditional Medicaid for under 100% FPL, plus premiums and copays

Premium assistance to purchase QHPs for 100-138%Pennsylvania – Arkansas plus job search requirement

12

INSERT LATEST SLIDE ON STATE EXCHANGE DECISIONS – FROM KIDSWELL OR KAISER

13

Enrollment Observations

14

SBM enrollment generally outpacing FFMMost systems glitches worked out relatively

quicklyRobust consumer assistance and marketing

effortsMostly seamless eligibility between SBMs and

Medicaid Plan choice (metal tier) varies across states,

but overall 80% choosing silver or higherAge distribution varies as well, but overall 24%

of enrollees in the 18-34 age range

Challenges

15

Systems failuresSome vendors not able to deliverAudits = decisions to salvage or start over

WorkaroundsPaper processesContinuation of previous coverage options

(cancelled policies and high risk pools)Ongoing concerns from carriers about

enrollment and payment data connections

Consumer Assistance is Critical

16

ACA created three consumer enrollment and assistance roles:

Navigators and In-Person AssistersWill assist consumers and small employers with the

health insurance enrollment processConduct public education activities to raise

awareness about the Marketplace, help people apply for and enroll in plans, and provide referrals to more information

Certified Application Counselors

Other effortsPharmaciesEnroll America

17

Active Consumer Assis-tance States*

FFM States $-

$20,000,000 $40,000,000 $60,000,000 $80,000,000

$100,000,000 $120,000,000 $140,000,000 $160,000,000 $180,000,000 $200,000,000

Consumer Assistance Spending

*Includes Partnership states with state consumer assistance programs

Consumer Assistance: Tale of Three States

18

FFM: Navigator grantees in Pennsylvania– approximately $2.7 million awardedResources for Human Development, Pennsylvania

Association of Community Health Centers, Pennsylvania Mental Health Consumers’ Association, Mental Health America

SBE: New York has awarded $27 million for consumer assistance grants, will spend tens of millions on marketing

Partnership: Illinois has awarded $28 million to 1,200 certified navigators and is spending $35 million on marketing and public relations

19

20

DO WE HAVE A GOOD SLIDE SHOWING ENROLLMENT THUS FAR?

3/18/1121

Issues to Watch

22

Enrollment – overall numbers, but also mix by age, health status

Will state roles shift – accepting expansion or moving toward State-based marketplace?

ChurnImpact on broader insurance market

Rise of narrow networksPrivate exchangesAffordability

Further federal delays?

23

Questions?