THE COMMONWEALTH

FUND

Women and the Affordable Care Act of 2010

Sara R. Collins, Ph.D.Vice President, Affordable Health Insurance

The Commonwealth Fund

Grantmakers In Health AudioconferenceWhat Effect Will the Affordable Care Act Have on Women’s Health?

December 8, 2010

Exhibit 1. 18.8 Million Uninsured Women Ages 19-64 in 2009,Up by 2 Million in Last Year

Millions uninsured, women ages 19-64

Source: Analysis of the 2001–2010 Current Population Surveys by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund.

14.3 14.815.6

16.515.6 16.2 16.7 16.4 16.8

18.8

0

2

4

6

8

10

12

14

16

18

20

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

THE COMMONWEALTH

FUND

2010 2011 2013 2014 2015-2017

Exhibit 2. Timeline for ACA Implementation• Small business

tax credit

• Prohibitions against lifetime benefit caps & rescissions

• Phased-in ban on annual limits

• Annual review of premium increases

• Public reporting by insurers on share of premiums spent on non-medical costs

• Preventive services coverage without cost-sharing

• Young adults on parents’ plans

Source: Commonwealth Fund Health Reform Resource Center: What’s In the Affordable Care Act? (Public Law 111-148 and 111-152), www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.

• Insurers must spend at least 85% of premiums (large group) or 80% (small group / individual) on medical costs or provide rebates to enrollees

• HHS must determine if states will have operational exchanges by 2014; if not, HHS will operate them

• State insurance exchanges

• Medicaid expansion up to 133% FPL

• Small business tax credit increases

• Insurance market reforms including no rating on health

• Essential benefit standard

• Premium and cost sharing credits for exchange plans

• Premium increases a criteria for carrier exchange participation

• Individual requirement to have insurance

• Employer shared responsibility penalties

• Penalty for individual requirement to have insurance phases in (2014-2016)

• Option for state waiver to design alternative coverage programs (2017)

•States adopt exchange legislation and begin implementing exchanges

•Phased-in ban on annual limits

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FUND

Exhibit 3. Source of Insurance Coverage Pre-Reform and Under Affordable Care Act, 2019

* Employees whose employers provide coverage through the exchange are shown as covered by their employers (5 million), thus about 29 million people would be enrolled through plans in the exchange. Note: ESI is Employer-Sponsored Insurance. Source: Congressional Budget Office, Letter to Honorable Nancy Pelosi, March 20, 2010 http://cbo.gov/doc.cfm?index=11379.

Among 282 million people under age 65

Pre-Reform

162 M(57%)ESI

35 M(12%)

Medicaid

54 M(19%)

Uninsured

16 M (6%)Other

15 M (5%)Nongroup

159 M(56%)ESI

51 M(18%)

Medicaid

24 M (9%)Exchanges

(Private Plans)

16 M (6%)Other

10 M (4%)Nongroup

23 M (8%)Uninsured

Affordable Care Act

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FUND

Exhibit 4. Early Provisions of the ACA That Will Benefit Women, 2010-13• Employers/insurers must allow adult children to remain on or join their parent’s health

plans (Sept. 2010): 1 million uninsured adult children to gain coverage.

• Ban on lifetime coverage limits (Sept 2010): About 102 million people have health plans with lifetime limits, 20,400 exceed limits and lose coverage each year, assuming women comprise half of population, 10,000 women would gain coverage.

• Phased-in restrictions on annual benefit limits (Sept. 2010): about 18 million people have plans with annual limits, 3500 people exceed limits each year, about 1750 women.

• Bans on rescissions of coverage (Sept 2010): Rescissions most common in the individual market where about 5.5 million women covered. About 10,700 people lose their coverage as a result each year, assume about half are women or 5,000.

• Preexisting condition insurance plans (PCIPs)(July-Aug 2010): Enrollment underway in 50 states/DC for people with health problems who have been uninsured for 6 months; 27 states running their own, 23 state plans run by HHS, eligibility is transferrable.

• Insurers must cover recommended preventive services without cost-sharing (Sept. 2010): Includes mammograms for women age 40+, cervical cancer screening, genetic counseling and testing for the breast cancer (BRCA) gene.

• $250 rebates to Medicare beneficiaries in the Rx doughnut hole (2010): About 16 percent of Medicare beneficiaries enter doughnut hole annually, women are among those most likely to.

Source: Commonwealth Fund Health Reform Resource Center: What’s In the Affordable Care Act? (Public Law 111-148 and 111-152), www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.

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FUND

Exhibit 5. Provisions of the ACA That Will Benefit Women, 2014+

• Expansion in Medicaid eligibility to cover adults with incomes under 133% poverty ($14,000 individual; $29,000 for family of four)

• New state insurance exchanges with premium and cost-sharing subsidies up to 400% poverty ($43,000 individual, $88,000 family of four): Premiums capped at 2%-9.5% of income between 100-400% poverty; spending capped at 6%-27% of total spending between 133-250% poverty

• Essential health benefit standards that include maternity and newborn care and limits on cost-sharing for plans sold in insurance exchanges and the in the individual and small group markets: Four different levels of benefits – bronze, silver, gold, platinum – that will vary only by cost sharing, benefits are the same at each level

• Prohibitions on insurance carriers from denying coverage or charging higher premiums on the basis of health or gender

Source: Commonwealth Fund Health Reform Resource Center: What’s In the Affordable Care Act? (Public Law 111-148 and 111-152), www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.

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Exhibit 6. Interim Final Regulations and Requests for Comments Issued by HHS, DOL, Treasury as of December 2010

INTERIM FINAL REGULATIONS ISSUED: • Dependent coverage of children to age 26 – May 2010• Early retiree reinsurance program – May 2010• Preexisting condition exclusions for children, lifetime and annual

limits, rescissions, patient protections – June 2010• Grandfathered plans - June 2010• Coverage of preventive services without cost-sharing - July 2010• Preexisting Condition Insurance Plans (PCIPs) – July 2010• Medical loss ratio reporting and rebates - November 2010

REQUEST FOR COMMENTS: • Premium review – April 2010• Insurance exchanges – August 2010

See Office of Consumer Information and Insurance Oversighthttp://www.hhs.gov/ociio/index.html

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FUND

Exhibit 7. Estimated Change in Medicaid Enrollment, Uninsured Adults <133% FPL and Spending Over 2014-2019 as a Result of ACA Medicaid

Expansion*

0

20

40

60

80

Increase inMedicaid

Enrollment2019

Reduction inUninsured

Adults <133%FPL

State Spending FederalSpending

Total Spending

27.4%

1.4%

22.1%

13.2%

*Projections based on a 57% participation rate among newly eligible uninsured and lower rates across other coverage groups. Scenario assumes moderate levels of participation similar to current experience among those newly eligible and little additional participation among currently eligible individuals.

Source: J. Holahan, I. Headen, Medicaid Coverage and Spending in Health Reform. Kaiser Family Foundation. May 2010.

44.5%

Percent

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FUND

Exhibit 8. Changes in Spending from Medicaid Expansion in the ACA, 2014-2019

$21.2 Billion (5%) State

$443.5 Billion (95%)

Federal

Total Change in Medicaid Spending

$464.7 Billion

Source: J Holahan, I Headen. Medicaid Coverage and Spending in Health Reform: National and State-by-State Results for Adults at or Below 133% FPL. May 2010. Kaiser Family Foundation. *Projections based a 57% participation rate among newly eligible uninsured and lower rates across other coverage groups. Scenario assumes moderate levels of participation similar to current experience among those newly eligible and little additional participation among currently eligible individuals.

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FUND

Federal Poverty Level

Percent Number Uninsured

Premium Cap As A Share of Income

Cost Sharing Cap

<133% FPL 51% 9,480,576 Medicaid Medicaid

133%–149% FPL 5% 1,009,244 3.0%–4.0% 6%

150%–199% FPL 12% 2,331,821 4.0%–6.3% 13%

200%–249% FPL 9% 1,701,066 6.3%–8.05% 27%

250%–299% FPL 6% 1,141,312 8.05%–9.5% 30%

300%–399% FPL 7% 1,282,853 9.5% 30%

Subtotal (133%-400%FPL) 40% 7,466,296 3.0%–9.5% 6%–30%

>400% FPL 10% 1,812,800 -- --

Total 100% 18,759,672 -- --

Exhibit 9. Distribution of 18.8 Million Uninsured Women by Federal Poverty Level and Provisions of the Affordable Care Act

Note: Percentages may not sum to 100 due to rounding.Source: Analysis of the March 2010 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund; Commonwealth Fund analysis of Affordable Care Act (Public Law 111-148 and 111-152).

Uninsured Women ages 19-64

THE COMMONWEALTH

FUND

Exhibit 10. Most of the 18.8 Million Currently Uninsured Women Ages 19-64 Will Gain Coverage Beginning in 2014

Note: Percentages may not sum to 100 due to rounding.Source: Analysis of the March 2010 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund

Medicaid 9.5 million

51%

Subsidized Private Insurance with

Consumer Protections 7.5 million

40%

Non-Subsidized Private Insurance with Consumer Protections

1.8 million 10%

18.8 Million Uninsured Women Ages 19-64 in 2009

THE COMMONWEALTH

FUND

TX

30.8% FL

26.0%

NM

27.6%GA

22.7%

AZ

21.3%

CA

22.7%

WY

NV

22.9%

AK

OK

20.7%MS

21.7%LA

23.7%

MT

TN

Exhibit 11. Women Ages 19-64 in 16 States With Uninsured Rates Higher Than the National Average Will Particularly Benefit From the Health

Reform Law

Note: Uninsured rates are two-year averages, 2008-2009.Source: Health Insurance Coverage of Women 19–64, states (2008–2009), Kaiser Family Foundation, statehealthfacts.org. Estimates based on the Census Bureau's March 2009 and 2010 Current Population Survey

WA

ORID 20.2%

UTCO

KS

NE

SD

ND

MNWI

MI

IA

MO

AR 24.9%

IL INOH

KY 21.0%

WV 21.0% VA

NC 20.2%

SC

AL

PA

NY

ME

DCMD

DE

NJCT

RIMA

NHVT

HI

States with uninsured rate higher than national average of 20%, women ages 19-64, 2008-2009

21.7%