Download Brian Colby Policy Director - Missouri Catholic Conference

Brian Colby
Policy Director
Who Am I?
Policy Director
Lobbyist
Analyst
Communicator/Reporter
Former Small Business Owner
What do we call it?
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Patient Protection and Affordable Care Act
PPACA
ACA
Obamacare
Health Reform
Whatever you call it, it is what it is.
What is the Status of the Law
• On March 23, 2010, President Obama signed into law the
Patient Protection and Affordable Care Act.
• In a June 28, 2012 decision, the U.S. Supreme Court
upheld much of the ACA, but struck down a requirement
that states expand their Medicaid program or face
financial penalties. The Medicaid expansion will now be
optional for the states.
• Medicaid is a joint federal and state program that
provides health coverage for certain low-income
individuals and families.
November Elections
• Changes in leadership in the Senate and at the
White House could see the repeal of the law
or major changes.
• For now, it is what it is until it changes.
Decisions for the MO Legislature
• 1. Should Missouri establish a “state based”
health insurance exchange or allow the federal
government create one for Missourians to
use?
• 2. Should Missouri expand its Medicaid
program?
What About Abortion in a possible
Medicaid Expansion?
• The Medicaid expansion is governed by the same
abortion restrictions as provided in the regular
Medicaid program. For many years Medicaid has
been subject to the Hyde Amendment, which
prohibits the use of Medicaid monies for abortions
or abortion coverage, except when necessary to save
the life of the mother or in cases of rape and incest.
The Hyde Amendment, however, is an annual rider to
the Medicaid appropriation.
– MO Catholic Conference Medicaid Fact Sheet 2012
Mandated Benefits, SB 749 and
Religious Liberty
• SB 749 passed, was vetoed and the veto was
overridden
• A lawsuit has been filed to challenge the
regulations.
• No more action in front of the state on this
issue for now.
What was Congress Thinking?
Employers
drop
coverage
Cost go up
More
employers
drop
coverage
Fewer
payers in
the
market
Causes
increases
in cost
Self Reinforcing Negative Feedback Loop
Cost Rising Faster than Income
• Health Care Cost have been going up 4 times our National
Income - GDP
• Since 1980 it has doubled every 10 years.
• The government pays a large share of over all health care
spending.
• Rising costs of health care is taking up a larger and larger
share of the budget
Really Smart People
• Jonathan Gruber, PhD at MIT
– adverse selection and the self reinforcing negative
feedback loop
• Len Nichols, PhD at George Washington U
-”If we can control the rising cost of health
care, we can’t pay back the Chinese.”
Why are Cost
Rising?
Good question:
-if you ask a health care economist he or she will likely
tell you that we do not have a Global Budget.
“If you don’t have a global budget, you might as well be
squeezing a balloon. If you try and squeeze cost at one
end it just pops out the other.”
- Uwe Reinhardt, PhD, Professor at Princeton
Health Insurance Coverage of
the Nonelderly Population, 2010
Private Nongroup 5.5%
266.0 Million
SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.
Nonelderly Uninsured by
Poverty Levels and Age, 2010
Adults
Children 8%
1%
Children
<138% FPL
139-399% FPL
10%
400%+ FPL
44%
Adults
32%
Adults
5%
Children
Total = 49.1 million uninsured
Note: Federal Poverty Level (FPL) for a family of four in 2010 is $22,050/year. Children includes all individuals under age 19.
SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.
Access to Insurance through the Workplace
by Income, 2005
Percent of employees not offered insurance
through own or spouse’s employer
55%
35%
13%
4%
<100%
100-199%
200-399%
Percent of Federal Poverty Level
Source: Urban Institute analysis of the February and March 2005 CPS Supplements, 2006, for the
Kaiser Commission on Medicaid and the Uninsured.
400% +
The Correlation
between Income and Employer
Sponsored Insurance
• The higher the income the more likely you will be offered
insurance at work.
• The lower the income the least likely you will be offered
insurance at work.
• There is an inverse correlation between your ability to pay
and your need to pay for your own insurance. In our system,
if you need insurance chances are you can’t afford it and if
you can afford it, chances are you don’t need it.
The Market is
Broken at the Low Income Scale
• If your customer has no money, you have no
market.
• The private marketplace is becoming out of
reach for low income workers.
Average Annual Premiums for Single and Family
Coverage, 1999-2012
$15,745*
* Estimate is statistically different from estimate for the previous year shown (p<.05).
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2012.
Establishment Offer Rates by Size and Average
Worker Earnings, 2000-2005
100%
90%
80%
Offer Rate
70%
60%
50%
1,000 or More Workers
100-999 Workers
40%
30%
25-99 Workers
20%
10-24 Workers
1-9 Workers
10%
0%
<15K
15K to
20K
20K to
25K
25K to
30K
30K to
35K
35K to
40K
40K to
50K
>=50K
Average Worker Earnings
Notes: Wages cutoffs are adjusted for inflation to 2005 dollars.
Source: Kaiser Family Foundation calculations based on data from the National Compensation Survey, 2000-2005, conducted by the Bureau of
Labor Statistics.
Who Cares?
• Why does coverage matter?
Barriers to Health Care Among Nonelderly Adults,
by Insurance Status, 2009
Percent of adults (age 18 – 64) reporting:
No Usual Source
of Care
No Preventive
Care
Went Without
Needed Care Due
to Cost*
Could Not Afford
Prescription
Drug*
* In past 12 months.
55%
11%
11%
42%
6%
6%
26%
4%
9%
6%
Uninsured
Medicaid/Other Public
Employer/Other Private
13%
27%
Respondents who said usual source of care was the emergency room were included among those not having a usual
source of care.
SOURCE: KCMU analysis of 2009 NHIS data.
Diagnosis of Late-Stage Cancer
Uninsured vs. Privately Insured
3.0
2.5
Ratio of probability of diagnosis of late vs. early
stage cancer, Uninsured/private insurance
2.0
2.2
Colorectal
Cancer
Lung Cancer
2.9
2.3
Equal likelihood
between
Uninsured and
Insured
2.0
1.5
1.0
0.5
0.0
Melanoma
Breast Cancer
NOTE: Odds ratios were adjusted for age, sex, race/ethnicity, facility type, region, and income and education on basis
of postal code. They represent the odds of being diagnosed with stage III or state IV cancer vs. stage I cancer.
Analysis based on cases occurring between 1998-2004.
SOURCE: Kaiser Family Foundation, based on Halpern MT et al, Association of insurance status and ethnicity with
cancer stage at diagnosis for 12 cancer sites: a retrospective analysis." The Lancet Oncology. March 2008.
Hospitals’ Role
• EMTALA
• Emergency Medical Transportation and Active Labor
Act
– Passed 1986 signed into law by President Ronald Reagan
– mandates that hospitals treat and stabilize patients with
emergency medical conditions regardless of their ability to
pay.
– Hospitals agreed to take on this role in part because of a
federal promise to pay disproportionate share hospital
(DSH) payments to hospitals that saw the uninsured.
These payments will phase down with the anticipation of
health reform increasing coverage for more people. This
will be important.
Emergency Room Care is the Most
Expensive
• $1000 versus $100
• People without insurance utilizing this system
puts burdens on hospitals that forces hospitals
to raise prices for everybody.
• Health reform said we need to cover people to
start to bring down cost.
How do we bring everyone into the
System?
• Cover the very low income workers with
publicly financed insurance via Medicaid.
• Cover the middle income folks not covered at
work, including small businesses, family
farmers and sole proprietors on to the
exchange that provides affordable insurance.
New Requirements
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Everybody needs to find coverage somehow
Medicare – disabled and over 65
Medicaid for lowest income
Dependents – on parents until 26
Exchange – some small business, family
farmers, sole proprietors of modest income
• Traditional Employer based coverage
Expanding Coverage Under the Affordable Care Act
Federal Poverty Level
56%
EmployerSponsored
Insurance
10%
400%+
37%
139-399%
(Subsidies)
18%
Uninsured
20%
54%
Medicaid*
<139%
(Medicaid)
6%
Private NonGroup
266 M Nonelderly
49.1 M Uninsured
* Medicaid also includes other public programs: CHIP, other state programs, Medicare and military-related coverage.
The federal poverty level for a family of three in 2012 is $19,090. Numbers may not add to 100 due to rounding.
SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.
The new voluntary marketplace
The Exchange
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Web-based shopping tool or store
Compares coverage and price
Set up by state or federal government
Voluntary individuals and business can buy
insurance inside and outside the Exchange
• Individuals will be provided tax credits only
inside the exchange.
Question #1
• 1. Should Missouri establish a “state based”
health insurance exchange or allow the federal
government create one for Missourians to
use?
Pro and Cons?
Proponents say exchanges…
– Pools risks inside the individual and small group
markets making individual ins. more like group ins.
– Brings down cost because of price transparency,
competition and choice
Opponents say exchanges…
-are unnecessary
-will drive up costs
Question #2
• 2. Should Missouri expand its Medicaid
program?
What is Medicaid?
• President Lyndon Johnson signed Medicare and Medicaid
into law on July 30, 1965, in Independence, Missouri in a
ceremony attended by former President Harry Truman.
Medicaid is a joint federal-state program offers health
coverage for low-income people of specific populations
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children up to age 19
parents of very low income
pregnant women
disabled individuals
Long term care for seniors age 65 of low income and few assets
How the New Medicaid Program
would change MO current program.
• Moves income eligibility from 17% to 138% FPL for
families with dependent children.
– Family of 3 at 17% of FPL has an income of $3504
– Family of 3 at 138% FPL has an income of $25,390
• For the first time will include adults without
dependent children.
– Individual at 138% of FPL has an income of $15,415
Coverage and Cost
• 255,000 people would gain coverage
• The feds pay 100% of newly eligible cover for
the first 3 years calendar years starting 20142016 then fed share phases down 95% in
2017, 94% in 2018 and 90% in 2019 and
beyond.
State Share of Cost
• Urban Institute and the Department of Social Services did
some projections in 2010 that estimated the cost to the state
in the first three years would be negligible but in 2017 the
cost could be $50 million rising to $189 million in 2020 and
$253 million in 2022.
• New analysis is being done so those numbers may change.
• Some folks believe a “woodwork” effect could cost the state
more. No woodwork effect factored into DSS est.
• DSH payment begin to dramatically reduce in 2017, many
argue that it could cause major disruption in our hospital
system.
Estimates # of People Covered
• Health Insurance Exchange 305,000
• Medicaid Expansion 255,000
Thank You
• Brian Colby
• [email protected]