Health Care Reform and the ACA: Now What? Matthew D. All Executive - - PowerPoint PPT Presentation

Health Care Reform and the ACA: Now What?

Matthew D. All

Executive Vice President and General Counsel Blue Cross and Blue Shield of Kansas

Source: Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group

Year after year, health care costs consume more and more of our economy

5.0% 6.9% 7.2% 7.9% 8.3% 9.2% 10.0% 10.6% 12.1% 13.3% 13.3% 13.2% 14.8% 15.5% 16.3% 17.4% 17.8% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%

1960 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 Total national health expenditures as a percent of Gross Domestic Product, 1970-2015

Source: Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group

Year after year, we spend substantially more per person

$355 Per capita $1,742 Per capita in constant 2015 dollars $9,990 Per capita $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Total National Health Expenditures Per Capita In Constant 2012 Dollars

Total national health expenditures, US $ per capita, 1970-2015

In Constant 2015 Dollars

$3,289 $3,493 $4,460 $8,745 $- $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 United Kingdom OECD Average Japan Australia Sweden France Belgium Comparable Country … Canada Germany Austria Netherlands Switzerland United States

Source: Kaiser Family Foundation analysis of 2013 OECD data: "OECD Health Data: Health expenditure and financing: Health expenditure indicators", OECD Health Statistics (database). doi: 10.1787/ data-00349-en (Accessed on June 25, 2014). Notes: Because 2012 data was unavailable, 2011 were used for Australia and the Netherlands. Data for Canada and Switzerland are estimated values.

We spend more on health than other advanced countries

Per Capita Total Current Health Care Expenditures, U.S. and Selected Countries, 2012

More of our health care spending come from some form of insurance than in previous decades

21.1% 22.2% 28.3% 33.2% 34.9% 35.3% 35.0% 34.3% 34.2% 34.8% 11.5% 16.7% 17.4% 18.6% 21.1% 22.0% 22.3% 22.8% 22.3% 8.0% 11.4% 11.3% 16.0% 15.7% 15.8% 16.7% 16.4% 17.9% 7.2% 5.2% 4.4% 3.4% 3.0% 3.7% 3.9% 4.1% 4.2% 4.2% 15.8% 13.5% 12.4% 12.1% 10.2% 8.9% 8.5% 8.6% 8.6% 8.4% 55.9% 39.6% 26.9% 22.5% 17.3% 15.3% 14.9% 13.9% 13.9% 12.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1960 1970 1980 1990 2000 2006 2008 2010 2012 2015

Private Health Insurance Medicare Medicaid Other Public Insurance Programs Other Third Party Payers Out-of- Pocket

SOURCE: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2012; file nhe2012.zip). NOTE: Medicare and Medicaid were enacted in 1965; by January 1970, all states but two were participating in Medicaid. Starting with 2009 NHE data, CMS revised the “Source of Funds” measure from a classification that was either public or private to one that is more program-based. CMS’s rational was that “financing arrangements have become more complex and the lines between public and private payers have become blurred as a single program may have federal, state, local, and private funding.” As a result, the category “Other Third Party Payers” includes both public and private programs and also some programs that receive funds from both public and private sources, such as Workers’ Compensation, Worksite Health Care, and School

• Health. “Other Pub. Ins. Programs” includes CHIP, the Department of Defense, and the Department of Veterans Affairs.

More of our health care spending come from some form of insurance than in previous decades

32.5% 36.4% 29.4% 45.7% 8.8% 44.4% 0.2% 7.9% 9.0% 3.4% 45.1% 9.7% 82.4% 17.8% 49.5% 28.6% 19.7% 27.2% 11.5% 22.7% 25.9% 3.5% 22.7% 9.7% 17.7% 4.5% 8.1% 7.6% 7.5% 23.3% 30.6% 29.0% 15.3% 9.5% 13.8% 1.2% 4.4% 23.4% 10.2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

• Priv. Health Ins.

Out-of-Pocket Medicare Medicaid Other NOTES: Medicare and Medicaid were enacted in 1965; by January 1970, all states but two were participating in Medicaid. “Out-of-Pocket” includes direct spending by consumers for all health care goods and services not covered by insurance, except for health care premiums. “Priv. Health Ins.” includes premiums paid to health insurance plans and the net cost of private health insurance (administrative costs, reserves, taxes, and profits or losses). “Other” includes Other Public Health Insurance Programs (CHIP, Depts. of Defense and of Veterans Affairs) and Other Third Party Payers (e.g., worksite health care, other private revenues, workers’ compensation, maternal/child health, other state and local programs, etc.). SOURCE: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group at https://www.cms.gov/NationalHealthExpendData/ (see Historical; NHE Web tables, Tables 7, 8, 15, 16).

1970 2012 1970 2012 1970 2012 1970 2012 Hospital Care Physician & Clinical Services Retail Prescription Drugs Nursing Care Facilities & Continuing Care Retirement Communities

The problems of health care, therefore, are the problems of insurance

• Adverse selection: those who expect to suffer a loss will buy

insurance more than those who don't.

• Moral hazard: the existence of insurance changes the

insured's (or his proxy's) behavior. – In fee-for-service health insurance, providers have an incentive to give more care and more expensive care. – You and I believe we're better off with more care and more expensive care.

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$5,277 $4,955 $4,823 $4,565 $4,316 $4,129 $3,997* $3,515 $3,354 $3,281* $2,973* $2,713 $2,661* $2,412* $2,137* $1,787* $1,619 $1,543 $12,865 $12,591* $12,011 $11,786 $11,429* $10,944* $9,773 $9,860* $9,325* $8,824 $8,508* $8,167* $7,289* $6,657* $5,866* $5,274* $4,819* $4,247

2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 Worker Contribution Employer Contribution

$18,142*

Higher health care costs translate into higher premiums

*Estimate is statistically different from estimate for the previous year shown (p < .05). SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2016. $5,791 $6,438* $7,061* $8,003* $9,068* $9,950* $10,880* $11,480* $12,106* $12,680* $13,375* $13,770* $15,073* $15,745* $16,351* $16,834* $17,545*

Premiums have outpaced workers' raises

98% 160% 213% 92% 167% 242% 24% 45% 60% 21% 35% 44% 0% 50% 100% 150% 200% 250% 300%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Health Insurance Premiums Workers' Contribution to Premiums Workers' Earnings Overall Inflation

SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2016. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2016; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2016 (April to April).

8.5% 12.1% 15.1% 16.9%

1990 2000 2010 2020

SOURCE: CBO Budget and Economic Outlook, January 2011 (for 1990-2010 data) and May 2013 (for 2020 data).

This is true for public programs, too. Medicare has grown as a percentage of the economy

1.9% 2.2% 3.6% 3.7%

1990 2000 2010 2020

Medicare Spending as a Share

• f Federal Budget Outlays

Medicare Spending as a Share

• f Gross Domestic Product (GDP)

Total Federal Outlays (trillions) $1.3 $1.8 $3.5 $5.0 Gross Domestic Product (trillions) $5.7 $9.8 $14.5 $22.9

2.9% 3.1% 3.4% 3.9% 4.4% 4.8%

0% 1% 2% 3% 4% 5% 6%

2015 2020 2025 2030 2035 2040

Medicare spending is projected to consume even more of the economy in the years to come

SOURCE: Congressional Budget Office, NOTE: Estimates are net Medicare spending as percentages of gross domestic product (GDP), based on the extended alternative fiscal scenario, under which Medicare’s physician payment rates would be maintained at current levels, rather than reduced. The 2014 Long-Term Budget Outlook (July 2014).

16.7 12.0 17.2 16.3 17.5 16.1 18.2 13.3 10.5 10.3 2 4 6 8 10 12 14 16 18 20

1972 1974 1976 1978 1980 1982 1983 1984 1986 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016*

Source: CDC/NCHS, National Health Interview Survey, reported in http://www.cdc.gov/nchs/health_policy/trends_hc_1968_2011.htm#table01 and https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf.

Even though we spend more, we leave many uninsured

Share of population uninsured:

Note: 2016 data is for Q1 – Q3 only.

Source: Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group

We spend most of our money on care by hospitals and physicians

Nursing Homes, 5% Prescriptions, 10% Other health, 30% Physicans/Clinics, 20% Hospitals, 32%

Relative contributions to total national health expenditures, 2014

Home Health Care, 3%

Source: Kaiser Family Foundation analysis of National Health Expenditure (NHE) Historical (1960-2015) and Projected (2016-2025) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group (Accessed on December 16, 2016) Note: 2015 to 2016 percent changes are calculated using 2015 and 2016 projected amounts.

Prescription costs are becoming a larger share of our health care spending

Average annual growth rate of prescription drug spending per capita for 1970’s – 1990’s; Annual change in actual prescription drug spending per capita 2000 – 2015 and projected prescription drug spending per capita 2016 - 2025

7.1% 11.8% 10.4% 13.8% 12.5% 10.9% 8.2% 5.5% 8.2% 4.1% 1.5% 3.8%

• 0.7%

1.5%

• 0.6%

1.6% 11.6% 8.0% 5.3% 5.1% 7.5% 5.4% 5.6% 5.4% 5.5% 5.8% 5.8% 5.9%

• 2%

0% 2% 4% 6% 8% 10% 12% 14% 1970s 1980s 1990s 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Prescription (Actual) Prescription (Projected) Total Health Per Capita (Actual) Total Health Per Capita (Projected)

Health care spending is highly concentrated

Contribution to total health expenditures by individuals, 2012

Source: Kaiser Family Foundation analysis of Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services

23% of total health spending 50% 66% 76% 82% 97% 3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Top 1% of health spenders Top 5% Top 10% Top 15% Top 20% Top 50% Lower 50%

Our health care finance quandary

• It's a quandary
• The core issue: health care costs are rising at

an unsustainable rate, year after year –Faster than other prices –Consuming more of the economy

Our health care finance quandary

• It's remains the most important domestic

public policy issue of our time

• It's becoming unaffordable
• It's crowding out other things
• It's the primary cause of our structural federal

deficit

• It's causing people to suffer

Many Americans put off care because of cost

• Percent who say they or another family member living in their household have done each of the following

in the past 12 months because of the cost: Not filled a prescription for a medicine Cut pills in half or skipped doses of medicine Skipped dental care or checkups Put off or postponed getting health care needed Had problems getting mental health care Relied on home remedies or over-the-counter drugs instead of going to see a doctor Skipped a recommended medical test or treatment

Source: Kaiser Family Foundation Health Tracking Poll (conducted August 10-15, 2011).

‘Yes’ to any of the above

The Affordable Care Act

• President Obama signed the Patient

Protection and Affordable Care Act ("PPACA"

• r "ACA") on March 23, 2010
• Passed after a long, tortuous legislative

process

• Since 2010, HHS, DOL, and Treasury have

issued a mountain of regulations and other guidance to implement the ACA

The Proverbial Three-Legged Stool

Available Mandatory Affordable

Consumer- Oriented Market

Available

• Guaranteed availability and renewability in all

markets

– A big change in the individual market

• No pre-existing condition limitations
• Modified community rating

– In small group and individual markets only – Allows rating variation only on four elements:

• Age, with a maximum 3:1 ratio
• Tobacco use, with a maximum 1.5:1 ratio
• Family size
• Geography

Mandatory

• Individual mandate

– Each person must have "minimum essential coverage" – Tax penalties for failure to comply

• 2014: Greater of $95 per adult and $47.50 per child (up to $285 for a

family) or 1.0% of family income.

• 2016: Greater of $695 per adult and $347.50 per child (up to $2,085 for a

family) or 2.5% of family income.

• Open enrollment, individual market

– For 2014 policy year: October 1, 2013 through March 31, 2014 – For 2018 policy year: November 1, 2017 through December 15, 2017

Affordable

• Advance premium tax credits

– Available in the exchange only (individual coverage) – Paid in advance, applied to monthly premium – Available to workers offered employer-based coverage only if the coverage offered is below "minimum value" or is "unaffordable"

Affordable

• Advance Premium Tax credits

– Available to individuals and families with incomes between 100-400% FPL – Makes up the difference between the premium amount (based on the second-lowest cost silver plan) and a maximum percentage of income:

• 100-133% FPL: 2% of income
• 133-150% FPL: 3-4% of income
• 150-200% FPL: 4-6.3% of income
• 200-250% FPL: 6.3-8.05% of income
• 250-300% FPL: 8.05-9.5% of income
• 300-400% FPL: 9.5% of income

Affordable

Family Size 100% 133% 175% 200% 250% 300% 400% 1 $11,490 $15,282 $20,108 $22,980 $28,725 $34,470 $45,960 2 $15,510 $20,628 $27,143 $31,020 $38,775 $46,530 $62,040 3 $19,530 $25,975 $34,178 $39,060 $48,825 $58,590 $78,120 4 $23,550 $31,322 $41,213 $47,100 $58,875 $70,650 $94,200 5 $27,570 $36,668 $48,248 $55,140 $68,925 $82,710 $110,280 6 $31,590 $42,015 $55,283 $63,180 $78,975 $94,770 $126,360 7 $35,610 $47,361 $62,318 $71,220 $89,025 $106,830 $142,440 8 $39,630 $52,708 $69,353 $79,260 $99,075 $118,890 $158,520

Affordable

• Cost-sharing reductions

– Available in silver plans only – Available for consumers with incomes less than 250% FPL – Lowers deductibles, cost sharing, copays

Average Out-Of-Pocket Limit In Plans with Combined Limit for Medical and Prescription Drug Cost Sharing

$6,160 $4,850 $1,795 $874 $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 Silver CSR 73 CSR 87 CSR 94

NOTES: CSR 73 refers to a reduced cost-sharing plan with an actuarial value of 73%. CSR 87 and CSR 94 have actuarial values of 87% and 94%, respectively. SOURCE: Kaiser Family Foundation analysis of Marketplace plans in the 38 states with Federally Facilitated or Partnership exchanges in 2016 (including Hawaii, New Mexico, Oregon, and Nevada). Data are from Healthcare.gov. Health plan information for individuals and families available here: https://www.healthcare.gov/health-plan-information/

Affordable

• Medicaid supposed to be expanded up to 138% FPL
• Enhanced federal funding

– 2014-16: 100% federal funding of newly eligible – 2017: 95% federal funding – 2018: 94% federal funding – 2019: 93% federal funding – 2020 – beyond: 90% federal funding

• Supreme Court made it optional, state by state

– Many states, including Kansas, have not expanded Medicaid

NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. *AR, AZ, IA, IN, MI, MT, and NH have approved Section 1115 waivers. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion. SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated January 1, 2017. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

Current Status of State Medicaid Expansion Decisions

WY WI* WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH* NV NE MT* MO MS MN MI* MA MD ME LA KY KS IA* IN* IL ID HI GA FL DC DE CT CO CA AR* AZ* AK AL

Adopted (32 States including DC) Not Adopting At This Time (19 States)

Consumer-Oriented Market

• The ACA market is meant to be more consumer-
• riented

– More standardized policies: "essential health benefits" – Standardized richness of policies: "metallic plans"

• Platinum (90% AV)
• Gold (80% AV)
• Silver (70% AV)
• Bronze (60% AV)

– A single place to compare products: the Exchange or "Marketplace"

What has the ACA accomplished?

• Extremely rocky start to open enrollment

period in 2013-14, which undermined confidence in the law.

• Much better experience for consumers in

2015-17.

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What has the ACA accomplished?

• More than 8 million consumers enrolled in the

Marketplaces in 2014.

• 11.4 million are estimated to have enrolled in

the Marketplaces in 2015.

• 12.7 million are estimated to have enrolled in

the Marketplaces in 2016.

• 12.2 million are estimated to have enrolled in

the Marketplaces in 2017.

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What has the ACA accomplished?

• The vast majority of consumers are receiving

some type of financial assistance.

• Lots of previously uninsured now have

insurance.

• Dramatic rate increases in some states in

some years

• Costs remain a serious, fundamental problem.

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75% 61% 58% 54% 51% 46% 41% 29% 19% 30% 34% 35% 36% 43% 40% 57%

People in ACA Marketplaces Who Say They Benefited or Were Negatively Affected By ACA

Republicans

Benefited Negatively affected

NOTE: The share who say they neither benefited nor were negatively affected is not shown. SOURCE: Analysis of Kaiser Family Foundation Survey of Non-Group Health Insurance Enrollees, Wave 3 (Feb. 9-Mar. 31, 2016)

Lower-deductible plans Receiving tax credit Not receiving tax credit TOTAL MARKETPLACE ENROLLEES Independents Democrats High-deductible plans

AMONG NON-GROUP ENROLLEES WITH MARKETPLACE PLANS: So far, would you say you and your family have personally benefited from the health reform law, or not?/ So far, would you say you and your family have been negatively affected by the health reform law, or not?

What has the ACA accomplished?

Uninsured 57% Different individual plan 16% Don't know 4% Medicaid, other public 9% Employer or COBRA 14%

Previous insurance status of Exchange consumers, 2014

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SOURCE: Kaiser Family Foundation Survey of Non-Group Insurance Enrollees (conducted April 3 – May 11, 2014)

What has the ACA accomplished?

Too expensive 51% Job-related reasons 21% Didn't think you needed coverage 10% Didn't know how to get it 5% Couldn't get it because of poor health/illness/age 4% Other 9%

Reason previously uninsured exchange consumers were uninsured, 2014

36

SOURCE: Kaiser Family Foundation Survey of Non-Group Insurance Enrollees (conducted April 3 – May 11, 2014)

What has the ACA accomplished?

With financial assistance 82% Without financial assistance 18%

2016 Exchange enrollment and financial assistance

With financial assistance Without financial assistance

37

What has the ACA accomplished?

Platinum 2% Gold 6% Silver 68% Bronze 23% Catastrophic 1%

2016 Exchange enrollment by metallic level

Platinum Gold Silver Bronze Catastrophic

38

What has the ACA accomplished?

4 1 11 5 28 27 33 34 24 33

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Full-ACA Other Individual Covg.

Reported health status in individual market, 2015

Excellent Very good Good Fair Poor

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SOURCE: Kaiser Family Foundation Survey of Non-Group Insurance Enrollees, Wave 2 (conducted February 18 – April 5, 2015)

Price increases in the exchange

• Two things happened:

– The pool was sicker than expected

• Insurers had to file rates 8-9 months in advance
• The hope that the first year was just "pent-up demand"

didn't materialize

– The pool was more porous than intended

• Too easy to jump in, drop out, jump back in

Notes: The premium changes shown are for the second-lowest cost silver (“benchmark”) plan available to a 40-year-old in a given county or region. Source: Kaiser Family Foundation analysis of insurer rate filings to state regulators and premium data published by HealthCare.gov, available at https://www.healthcare.gov/health-plan-information-2015/

The difference in premiums Americans pay for the second-lowest cost silver plan from 2014 to 2015, before tax credits

Prior to the application of tax credits, changes in premiums for the benchmark silver plan vary dramatically from county to county across the nation

Notes: The premium changes shown are for the second-lowest cost silver (“benchmark”) plan available to a 40-year-old making $30,000 per year in a given county or region. A notable increase or decrease in the benchmark premium of a county from 2014 to 2015 can generally be attributed to premiums falling below the limit that the ACA sets for low- to moderate-income Americans as a percentage of income. Under the income and age scenario used in the map above, the 2015 benchmark premium is low enough in parts of Minnesota that a 40-year-old making $30,000 would not qualify for a tax credit. Source: Kaiser Family Foundation analysis of insurer rate filings to state regulators and premium data published by HealthCare.gov, available at https://www.healthcare.gov/health-plan-information-2015/

The difference in premiums Americans pay for the second-lowest cost silver plan from 2014 to 2015, after tax credits

Following the application of tax credits for a 40-year-old making $30,000 per year, premiums for the benchmark silver plan generally show little change

Jul 50% Jan 41% Oct 34% Sep 45% Oct 38% Nov 33% Jul 37% Jan 40% Dec 43% Mar 49% Jul 35% Jan 50% Oct 51% Sep 40% Oct 44% Nov 49% Jul 53% Jan 46% Mar 44% 0% 20% 40% 60% 80%

Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Mar 2010 2011 2012 2013 2014 2015 2016 2017

Favorable Unfavorable Don't know/Refused

More of the Public Now Views ACA Favorably

As you may know, a health reform bill was signed into law in 2010. Given what you know about the health reform law, do you have a generally favorable or generally unfavorable opinion of it?

ACA signed into law

• n March 23, 2010

NOTE: Data not collected for Dec 2012, Jan 2013, May 2013, Jul 2013, Aug 2014, Feb 2015, May 2015, Jul 2015, May 2016, and Jan 2017. SOURCE: Kaiser Family Foundation Health Tracking Polls

American Health Care Act

• Proposed by House Republicans earlier this

year as their plan to "repeal and replace"

– Perhaps intended to be the first of several parts

• Caused rancor with both ends of the spectrum

in the House Republican caucus

– No support at all from Democrats

• Pulled in late March, no vote taken

– White House, Speaker seemed to indicate they were moving on

American Health Care Act –Highlights

• Market Rules

– Maintains most current rules, including:

• Guaranteed availability
• Ban on pre-existing condition limitations
• Community rating

– Loosens age rating bands to a ratio of 5:1.

American Health Care Act –Highlights

• Mandates

– Eliminates both the individual and employer mandates – Requires insurers to impose a 30% penalty on consumers without "continuous coverage."

American Health Care Act – Proposed

• Tax Credits and CSRs

– Starting in 2020, provides an age-adjusted flat tax credit ranging from $2,000-$4,000 per year.

• Phased out for incomes above $75,000.
• Can be used off-exchange.
• Eliminates CSRs in 2020.

American Health Care Act – Proposed

• Patient and State Stability Fund

– Provides $15 billion/year in 2018 and 2019 for a "Patient and State Stability Fund." – Starting in 2020, the bill provides $10 billion/year for the fund, with a state match required.

American Health Care Act – Proposed

• Health Savings Accounts

– Increases contribution limits for HSAs and relaxes requirements.

American Health Care Act – Proposed

• Medicaid

– Allows states to continue the Medicaid expansion for people that were enrolled in Medicaid as of December 31, 2019. – Starting in 2020, per capita caps would be implemented, increasing in future years using the medical care component of the consumer price index. – Over time, would shrink program compared to current law.

American Health Care Act – CBO Analysis

• Health Insurance Coverage

– CBO estimates that 14 million more people would be uninsured in 2018 (comparing the bill to current law). – CBO estimates that 21 million more people would be uninsured in 2020. – CBO estimates that 24 million more people would be uninsured in 2026 .

American Health Care Act – CBO Analysis

• Premiums (all figures are comparing bill to

current law).

– CBO estimates average individual premiums in 2018 and 2019 would be 15 percent to 20 percent higher. – CBO estimates that premiums would be lower beginning in 2020.

• Caused by grants to states, elimination of actuarial value

requirements, younger mix of enrollees, etc.

– CBO estimates average premiums would be 10 percent lower in 2026.

American Health Care Act – Overall Effect on Consumers, Put Simply

• Would be more attractive than the ACA to

many richer, younger consumers.

• Would be less attractive than the ACA to many

poorer, older consumers.

Looking forward

• How will the Trump Administration administer

the ACA?

• Will the Republicans really try again?
• What does the Freedom Caucus want?

– All the way back to pre-ACA conditions? – "Invisible high risk pool"?

Looking forward

• Will the ACA individual risk pool stabilize?
• How will voters' views on the ACA change

from here?

• If the Democrats return to power, how will

they view the ACA and other potential

• ptions?