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TRANSCRIPT
TheAffordableCareAct(akaObamacare)
andRepeal/Replace:WhereThingsStand
CharlesGabaACASignups.net
Revised:3/15/17
TheHealthcareCoverageLandscapeasof2009
TheThree-LeggedStool
TheThree-LeggedStool:Leg1
• GuaranteedIssue:CarriersmustselltoeveryoneregardlessofmedicalcondiKon,age,pre-exisKngcondiKons,etc(andinfactcannolongerevenaskaboutmedicalhistoryatall)
• CommunityRaBng:Carrierscannotchargepeopledifferentratesforthesamepolicybasedonanyfactorsotherthanage(withina3:1raKo),locaKon(raKngarea)andwhethertheysmoke(50%surcharge)
• QualifiedHealthPlans(QHP):AllplanssoldhavetomeetACAstandards,includingatleast60%AV,all10EssenKalHealthBenefits,etc.(i.e.,theyhavetoberealhealthcarepolicies)
TheThree-LeggedStool:Leg1
• QHPActuarialValue:AllQHPshavetocoveratleast60%ofhealthcarecosts.Availablein4“MetalLevels”:– BRONZE:60%AV(lowpremiums,highdeducKble)– SILVER:70%AV(mid-rangepremiums,mid-rangededucKble)*
– GOLD:80%AV(higherpremiums,lowdeducKble)
– PLATINUM:90%AV(highestpremiums,nodeducKble)– Catastrophic:50%AV,verylowpremiums,insanelyhighdeduc=bles,onlyavailableif
you’reunder30orotherrareexcep=ons
• *(SilverplansaretheonlyoneseligibleforCostSharingReduc=onassistance)
TheThree-LeggedStool:Leg2
• IndividualMandate:Everyone(withexcepKons)hastohaveanACA-complianthealthcarepolicyforatleast9monthsoftheyearortheyhavetopayataxpenaltyof:
– $695.00/adult($347.50/child)or– 2.5%ofhouseholdincome(whicheverisgreater)– maximumof$2,085/familyortheavg.annualpremiumforaBronze
plan
• Penaltyisbymonth(6mouncovered=½penalty,etc)• ExcepKonsmadeforvariousreasons(expatriate,hardship,
domesKcviolencevicKm,naturaldisaster,etc)
TheThree-LeggedStool:Leg3
• TaxCredits(akaSubsidies):Twotypes,bothbasedonincomerelaBvetotheFederalPovertyLevel(FPL):
• AdvancePremiumTaxCredits(APTC):Incomebetween100-400%FPL($12K-$48Kindividual;$24.6K-$98.4Kforafamilyof4)– SubsidiesINCREASEasbenchmarkpremiums/deducKblesincrease
(premiumgoesup20%?Subsidygoesup~20%)– SubsidiesVARYbyRATINGAREA:
• Avg.premiuminMassachusels:$290/month• Avg.premiuminAlaska:$1,041/month(3.6xashigh!)
• CostSharingReducBon(CSR):Incomebetween100-250%FPL($12K-$30Kindividual,$24.6K-$61.5Kfamilyof4)
TheThree-LeggedStool:OpenEnrollment
• 2014:6months(+2weekoverBme)– 8.0Millionselectedplans;~7.0Millionpaid/effectuated– 44KviaMinnesotaBHPprogram
• 2015:3months(+1weekoverBme)– 11.7Millionselectedplans;~10.5Millionpaid/effectuated– 79KviaMinnesotaBHPprogram
• 2016:3months(+1dayoverBme)– 12.7Millionselectedplans;~11.4Millionpaid/effectuated– 121KviaMNBHPprogram;380KviaNYBHPprogram
• 2017:3months(nooverBme)– 12.2Millionselectedplans;~11.0Millionpaid/effectuated– 100KviaMNBHPprogram;665KviaNYBHPprogram
ACAOpenEnrollmentPeriods
MedicaidExpansion• ExpandsMedicaideligibilitytoEVERYONEupto138%FPL($16.6K/
yrforindividual)regardlessofpre-ACAeligibility• 31states+DCexpanded;19states(allGOPheld)sBllrefusing• ~2.6MILLIONpeoplecaughtinMedicaidGap:Don’tqualifyfor
Medicaid,butearntoolifletoqualifyforACAtaxcredits
• October2013:57.4millionenrolledinMedicaid• October2016:74.4millionenrolledinMedicaid• Netincreaseof17.0million• 13.0millionofthatduetoACAexpansion(+specialfromNY)• 3-4millionvia“Woodworkers”…peoplewhowerealreadyeligible
forMedicaidpre-ACAbuteitherdidn’tknowitorwerereluctanttounKltheACAwentintoeffect.
OtherACAStuff(seelistatend):
• NOAnnualorLifeKmelimitsoncoverageforANYONE(individualmarketANDgroupmarket
• ALLPLANS(group&indy)mustmeetminimumcoveragerequirements
• YOUNGADULTScanstayonparents’plansunKl26(indy&group)
• CLOSESMEDICAREPARTDDONUTHOLE
• Awholemessofotherstuff
TheHealthcareCoverageLandscapeasof2009
TheHealthcareCoverageLandscapeasofMarch2017
Whoaretheremaininguninsured?
WhoareIndyExchanges&MedicaidExpansionWorking/NotWorkingfor?
WhoareIndyExchanges&MedicaidExpansionWorking/NotWorkingfor?
LegiBmateProblemsw/theACA:
• MEDICAID:– MEDICAIDGAP(2.6M):19stateshaven’texpanded(blameGOP)– Dr./Hospitalreimbursementtoolow(~40%ofprivaterates)– Fedscover90-95%ofexpansionMedicaidfundingbutonly50-75%of
tradiKonalMedicaid;statesconstantlyraidingtheirshareormessingw/programrequirements/coverage
• GROUPCOVERAGE:– Employermandateironicallyencourages“JobLock”whilealsoaddinga
bunchofpaperworkfortrackingemployees(butalsoprovidesparKalfundingforexchangesubsidies/Medicaidexpansion)
– INELIGIBLEDUETOESIOFFER(4.5M):EmployerplansglitchallowsCatastrophic(Lead)plans“lewonthetable”todisqualifyemployeesforindividualexchangetaxcredits
• RISKCORRIDORFUNDING:Thanks,MarcoRubio!!
LegiBmateProblemsw/theACA:
• UNDOCUMENTEDIMMIGRANTS(5.4M):ACAdoesn’tallowundocumentedimmigrantsontoMedicaidorACA
exchangesevenatfullprice(unsubsidized).CAnearlypassedstatelawtoallowitbutrescindedawerTrumptookoffice.
• MEDICAID/CHIPELIGIBLE(6.4M):OUTREACH,OUTREACH,OUTREACH…andobstrucKonbyGOPofficialsat
statelevel(remember,mostoftheseareeligiblefortrad.Medicaid)
• TAXCREDITELIGIBLE/INCOMEINELIGIBLE(8.3M):– APTCtooskimpy(400%FPLcut-off,notgenerousenough300-400%)– CSRtooskimpy(250%FPLcut-off,notgenerousenough200-250%)– ESIineligibilityallowsskinnyplanstobeconsidered“compliant”– “FamilyGlitch”:If1memberonemployee-onlyESI,othersdon’t
qualifyforexchangesubsidies(~3Mpeople)
HowI’dFixtheACA’sProblems:1. Fixthe“FamilyGlitch”:OtherfamilymembersshouldqualifyforAPTC/
CSRevenifsomeoneinthefamilyiscoveredbyESI.2. Fixthe“SkinnyPlanGlitch”:RequireESIpoliciestobeatleastBronze-
strength(preferablySilver)beforeemployeesareineligibleforAPTC/CSR3. RestoreRiskCorridorfunding(&extenditindefinitely).Themoneyis
legallyowedtothecarriersanyway,andtheprogramworksjustfinforMedicarePartD).
4. GuaranteeCSRPayments.HouseGOPbroughtalawsuitchargingCSRpaymentsareunconsKtuKonaleventhoughthey’relegallymandated.Casepending;swordofDamoclescausingmonthlyuncertainty.
5. RequireALLIndividualMarketplansbeofferedontheexchanges(beleryet,exclusivelyon-exchange,asDChasdonefor4years).Lessconfusion,noincome-basedcherry-picking,easiertrackingofenrollmenttrends.
6. BeefupIndividualMandatePenalty(Notgonnahappen.Moveon.)7. BEEFUPTHETAXCREDITS(bothAPTC&CSR)
Three-LeggedStoolFixes
Three-LeggedStoolFixes
HowwouldIfixtheACAtaxcredits?
• RaisethecaponAPTCfrom400%to500%,beef‘emupbelowthat.
• RaisethecaponCSRfrom250%to500%(sKlltaperingofftowardstop)
• About$10B-$12B/yearshoulddoit.ChangeAPTCstructureasfollows
• (somethingsimilarw/CSRstructure)
So,what’sinTrumpcare?(akathe“AmericanHealthCareAct”or“AHCA”)
So,what’sinTrumpcare?(akathe“AmericanHealthCareAct”or“AHCA”)• DEFUNDSPlannedParenthood($530million/year…40%oftheirtotalbudget)• DEFUNDSMedicaidExpansion(starKngin2020,viaalriKon…nonewenrollees,current
onescan’tcomebackoncetheyleave.• DEFUNDSCostSharingReducKons(CSR)completelystarKngin2020.• CHANGESnon-ACAMedicaidtoBLOCKGRANTS(kicksmoreofflater)• CHANGESTaxCredits(APTC)fromINCOME-basedtoAGEbased
($2,000foryounger-->$4,000forolderenrollees)• TaxcreditsNOLONGERINCREASEtomatchpremiumhikes,nordotheyvaryby
geography/raKngarea• ChangesAGEBANDfrom3:1to5:1
(olderenrolleescanbecharge5xasmuchasyounger)• ELIMINATEStheminimum60%AV(Bronze)requirement;HELLOJUNKPLANS!• $100billionover9yearstostatesforHighRiskPools,Reinsuranceprograms,etc
(partofthisiseffecKvelyreplacingmoneytheystolefromtheRiskCorridorprogram)• CHANGESMandatepenaltytoa30%,1-yrpremiumsurchargefornotmaintaining
conBnuouscoverage…w/penaltygoingtoCARRIER,notIRS• WIPESOUToverhalftherevenuetofundACA…including3.8%investmenttaxonrich
people&0.9%Medicarepayrolltax.Replaceswith…notmuchofanything.• Thiswouldgivetop1%avg.$33,000taxcut;top0.1%avg.$197,000taxcut;andtop
400richestAmericansanAVERAGETAXCUTOF$7MILLION.
So,what’sinTrumpcare?(akathe“AmericanHealthCareAct”or“AHCA”)• DEFUNDSPlannedParenthood• DEFUNDSMedicaidExpansion(starKngin2020,viaalriKon• DEFUNDSCostSharingReducKons(CSR)• CHANGESnon-ACAMedicaidtoBLOCKGRANTS(kicksmoreofflater)• CHANGESTaxCredits(APTC)fromINCOME-basedtoAGEbased
($2,000foryounger-->$4,000forolderenrollees)• TaxcreditsNOLONGERINCREASEtomatchpremiumhikes,nordotheyvaryby
geography/raKngarea• ChangesAGEBANDfrom3:1to5:1
(olderenrolleescanbecharge5xasmuchasyounger)• ELIMINATEStheminimum60%AV(Bronze)requirement;HELLOJUNKPLANS!• $100billionover9yearstostatesforHighRiskPools,Reinsuranceprograms,etc
(partofthisiseffecKvelyreplacingmoneytheystolefromtheRiskCorridorprogram)• CHANGES$695mandatepenaltytoa30%,1-yrpremiumsurchargefornot
maintainingconBnuouscoverage…w/penaltygoingtoCARRIER,notIRS• WIPESOUToverhalftherevenuetofundACA…including3.8%investmenttaxonrich
people&0.9%Medicarepayrolltax.Replaceswith…notmuchofanything.• Thiswouldgivetop1%avg.$33,000taxcut;top0.1%avg.$197,000taxcut;andtop
400richestAmericansanAVERAGETAXCUTOF$7MILLION.
HowdoesTrumpcarechangetaxcredits?
CBOScore?
CBOScore?• 14millionlosecoveragein2018• Another10millionlosecoverageby2026(24milliontotal)• Justaboutalllosingcoveragewouldbelow-income(Medicaid/elderly/
etc)• By2026,totaluninsuredwouldbe~52million(upfromcurrent28
million)• Age-basedtaxcreditswouldactuallybesomewhatbelerforsomein
themiddleclass(300-600%FPL),butdevastaBngtolow-income/elderly.
• PREMIUMswouldINCREASEbyanaddiKonal15-20%peryearthru2020;wouldthengraduallydecreaseto~10%lowerthancurrentprojecKonsby2026…mainlyduetoforcing50-64yearoldsoffcoveragecompletely.
• DEDUCTIBLESwouldINCREASEevenmorein2ways:a)LowerAVreqiurements;b)CSRassistancecutoffforlower-incomeenrollees
CBOScore?
CBOScore?
CBOScore?
Howmanyareatriskpost-
repealnaBonally?
Upto24MILLION.
Howmanyareatriskpost-repeal?MICHIGAN:~210Kexchange*,~658KMedicaid=~868KTotal
(*outof~321Ktotalexchangeenrollees)OAKLANDCOUNTY:~30Kexchange,~55KMedicaid=~85KTotal(7.0%pop)
Howmanyareatriskpost-repeal?MICHIGAN:~210Kexchange*,~658KMedicaid=~868KTotal
(*outof~321Ktotalexchangeenrollees)ST.CLAIRCOUNTY:~4,200exchange,~10.5KMedicaid=~14.7KTotal(9.4%pop)
Howmanyareatriskpost-repeal?MI-11(Trof):~16Kexchange~59KMedicaid=~75KTotal
MI-14(Lawrence):~14Kexchange+~59KMedicaid=~73KTotal
Howmanyareatriskpost-repeal?MI-10(Mitchell):~18Kexchange~49KMedicaid=~67KTotal
(9.5%ofpopulaBon)
WhatElseWouldBeLostif“Phase3”goesthrough?• 80/20MedicalLossRaKo• COVERAGEOFPRE-EXISTINGCONDITIONS• NoPre-ExisKngWaiKngPeriodforIndymkt.• Nomorethan90-daywaiKngperiodforESI• COVERAGEOFESSENTIALSERVICES• NomorepricyCOBRA• EscapefromJobLock• CoalMinerbenefitsforBlackLungDisease/survivors• ELIMINATIONOFANNUAL/LIFETIMELIMITS• Levelplayingfieldforwomen• Freecolonoscopies,cholesterolchecks,bloodpressurechecks,general
physicals• MEDICAREPARTDDONUTHOLEFILLED• OpKontoleaveMedicareAdvantage&SignupforPartDannually• PrescripKondrugcoverage(mandatory)• Maternitycare,freebirthcontrol,freebreas|eedingsupplies&
breas|eedingprivacy
WhatElseWouldBeLostif“Phase3”goesthrough?• ProtecKonfromLGBTdiscriminaKon• FreerouKnevaccinaKons• FreegestaKonaldiabetesscreenings• Freepapsmears&HPVtests• FreeHIV,Gonorrhea&Herpesscreenings• FreeTobaccocessaKonprograms• Substanceabusetreatment• MandatoryMentalHealthcoverage• RECORDLOWUNINSUREDRATE• PREMIUMSUBSIDIES• ImprovedCollegeStudentplans• EaseofClaimsAppeals• EasiertounderstandbenefitdescripKons• EFFECTIVERATEREVIEW• CAPSONOUTOFPOCKETCOSTS• HealthplanopKonsforsmallbusinesses(150K)• Pediatricdentalinsurance
GOPObstrucKon/Sabotage?
• RiskCorridorMassacre(R.I.P.Co-Ops)– Changedlawinmiddleof2015OEP,announcedAugust2015;
12.6¢onthedollar,$300M/$2.5Bpaid;upto$10B+now
• NavigatorObstrucBon/Blockades