Whats the Worst That Could Happen? Contingency Planning in a Time of - PowerPoint PPT Presentation

What’s the Worst That Could Happen? Contingency Planning in a Time of Health Market Changes March 22, 2017

Session Topics • Introduction: What would be the worst that could happen if the Affordable Care Act (ACA) were to be repealed with no replacement? • The Potential Impact of Repeal – Enrollment levels and the uninsured – Economic/employment impact – Rural/urban comparative impact • What the ACA Does : What could be repealed – Private Market – Medicaid – Medicare • Other Proposed Changes: The potential impact of other proposed market changes. • Contingency Planning : What can SORHs do ? 2

Change in Uninsured Population Under 65 Difference Number of Uninsured Population PCT Change Uninsured 2013-4 Under 65 - 2013 All 8,463,332 44,477,970 19.0% Rural 1,180,333 6,477,804 18.2% Urban 7,282,999 38,000,166 19.2% Medicaid Expansion 5,337,536 21,414,499 24.9% No Expansion 3,125,796 23,063,471 13.6% 3

Change in Uninsured Population Under 65 States Ranked - 2013-2014 TX 719,557 5,695,879 12.60% OK 82,601 659,369 12.50% LA 84,563 746,374 11.30% AL 70,402 637,841 11.00% VA 107,029 971,264 11.00% MO 80,423 762,811 10.50% WY 8,184 77,766 10.50% AK 12,153 135,757 9.00% SD 7,726 89,295 8.70% ME 12,101 143,651 8.40% UT 33,060 393,334 8.40% 4

Change in Rural Uninsured Population Under 65 States Ranked - 2013-2014 Difference Rural Number of Rural Uninsured Population Under State PCT Change Uninsured 2013-4 65 - 2013 KY 276,139 118,457 42.90% WV 102,899 39,624 38.50% OR 99,446 33,164 33.30% WA 110,251 34,746 31.50% VT 29,883 9,096 30.40% CT 14,952 4,495 30.10% AR 182,325 53,894 29.60% HI 22,059 6,526 29.60% CA 125,290 36,960 29.50% CO 115,426 32,589 28.20% VA 137,538 14,182 10.30% OK 239,079 24,478 10.20% ME 64,894 6,402 9.90% AK 52,619 4,144 7.90% MO 219,370 15,905 7.30% SD 49,942 3,207 6.40% UT 47,005 1,834 3.90% 5

Change in Uninsured Population Under 65 Expansion and Non-Expansion States - 2013-2014 Difference Number of Uninsured Population Under 65 - State PCT Change Uninsured 2013-4 2013 KY 41.50% 255,088 615,363 WV 98,184 254,261 38.60% RI 44,760 118,849 37.70% WA 33.00% 310,352 940,952 OR 181,245 560,102 32.40% VT 13,251 43,638 30.40% MN 124,838 433,829 28.80% CA 1,713,194 6,368,296 26.90% AR 122,161 458,780 26.60% CT 85,924 322,785 26.60% Difference Number of Uninsured Population Under 65 - State PCT Change Uninsured 2013-4 2013 WI 19.40% 97,844 505,462 KS 56,906 341,248 16.70% FL 602,677 3,778,848 15.90% MT 15.90% 26,416 166,184 NC 236,941 1,491,079 15.90% ID 40,029 256,305 15.60% MS 74,158 498,591 14.90% GA 261,320 1,810,621 14.40% NE 28,457 201,766 14.10% IN 118,871 887,375 13.40% 6

Sample State Profile Change in Uninsured Population Under 65 -- Washington Counties 2013-4 Population Under 65 - Difference Number PCT 2013 Uninsured With County Rural - Urban Uninsured - 2013 Uninsured 2013-2014 Coverage in 2014 Garfield County 265 119 44.9 RURAL Spokane County 66,107 27,621 41.8 URBAN Jefferson County 3,713 1,512 40.7 RURAL Whitman County 5,747 2,331 40.6 RURAL Kitsap County 28,238 11,161 39.5 URBAN Wahkiakum County 547 205 37.5 RURAL Chelan County 12,893 4,760 36.9 URBAN Kittitas County 6,549 2,387 36.4 RURAL Whatcom County 31,882 11,558 36.3 URBAN Skamania County 1,470 524 35.6 URBAN King County 241,577 85,763 35.5 URBAN Grays Harbor County 12,213 4,293 35.2 RURAL Cowlitz County 14,253 4,939 34.7 URBAN Lincoln County 1,226 422 34.4 RURAL San Juan County 2,513 858 34.1 RURAL Mason County 9,222 3,145 34.1 RURAL 7

Estimated Coverage Impact in Washington 8

Projected Economic Impact – Partial ACA Repeal Source: Commonwealth Fund – January 2017 9

Key Areas of ACA Provisions Private Market Medicaid Medicare Provisions Provisions Provisions 10

Key ACA Private Market Provisions - 1 • Establishes Coverage Mandates: creates health coverage purchase requirements. – Individual mandates. – Employer mandates. • Creates Purchaser Subsidies: – Premium tax credits for low and moderate income purchasers. – Cost-sharing reductions for Silver plans for low and moderate income purchasers. – Small business assistance program. 11

Key ACA Private Market Provisions - 2 • Creates Marketplaces/Exchanges : Creates Individual/family and Small Business Health Options Program (SHOP) marketplaces for Qualified Health Plans (QHPs). – State operated exchanges. – Federally-facilitated exchanges. – Hybrid exchanges. • Sets QHP Standards: – Essential QHP Benefits. – Metal levels: including coverage, deduction limits and maximum out of pocket limits. – Age Bands: sets premium ratios allowed for key age cohorts. 12

Key ACA Private Market Provisions - 3 • Sets Nationwide QHP Operating Requirements : – Pre-existing conditions. – Coverage on parents’ plans for 26 and under. – Loss ratios. – Network adequacy. – Essential community providers. – Behavioral health parity. • Requires Federal Approval of QHP Offerings . • Establishes Insurer Risk Reduction and Stabilization Measures . • State Demonstrations : Creates opportunity for state demonstrations. 13

Key ACA Medicaid Provisions • Permits Medicaid Expansion: Permits, at state option, expansion of Medicaid eligibility to, among others, adults in higher income categories. • Provides Enhanced Federal Support: Provides higher Federal matching for Medicaid expansions. • Permits Expanded State Waivers: Provides expanded opportunity for state waivers for Medicaid expansion enrollees. – Private option – Cost-sharing – [Training/Work requirements] 14

Key ACA Medicare Provisions • Modifies Previous Payment Programs: Eliminates/reduces previous Medicare special payment arrangements. – Disproportionate Share Hospitals (DSH)/SCH – Home Health • Creates Performance Payment Incentives: Establishes Medicare performance payment adjustments. – Hospital Readmission Reduction – Hospital Acquired Condition – Value-Based Purchasing – Provider Quality Adjustments [PQRS-MACRA-MIPS-Meaningful Use] – Primary Care Incentive Payment • Creates Alternative Payment Methodologies: Creates Medicare alternative payment demonstrations. – Accountable Care Organizations (ACOs) – Other Alternative Payment Methodologies (APMs) 15

Would Repeal Be a Pre-ACA Reset? • It depends. • Would repeal be a true reset or will it be limited to private market provisions? – Private Coverage mandates. – Marketplace and QHP requirements. – Purchaser subsidies. – High risk pool elimination. • Would it rescind Medicare operational changes? – Will it roll back payment reductions? • DSH • SCH • Home health. 16

Pre-ACA Reset Considerations: 2 – Will it repeal Medicare performance/quality payment modifiers ? • Hospital. • Physician. – Will it repeal mandated costs? • Meaningful use. • MACRA/MIPS/PQRS. • Hospital Compare. • Will it repeal Medicaid expansion? – Will current Medicaid expansion be continued? – Will additional states be permitted to expand Medicaid? – Will FMAP for expanded Medicaid be continued at current rate or ratcheted back to basic Medicaid FMAP rates? 17

Pre-ACA Reset Considerations: 3 – Will State waivers be expanded? • Will they expand the private option – with or without state marketplaces? – Would it work if state marketplaces are eliminated? – Will it meet Medicaid standards if plan benefit requirements are eliminated? • Will they permit enrollee training/work requirements? • Will they eliminate PPS and other special reimbursement rates? • Will they permit enhanced enrollee cost-sharing? – Will there be block granting or per capita caps applied to Medicaid expansion programs? • Will it make supplemental, non ACA modifications, to the health market? 18

Other Potential Changes to the Health Care Market • Medicaid Block Granting / Per Capita Caps. • Privatization of Medicare – Capped Benefit. • Re-establish state high risk pools. • Expand health savings accounts. • Expand interstate availability of plans. • Regulate medical liability. • Modify MACRA and PQRS. • Modify Hospital Star Rating. 19

ACA Repeal: What’s the bottom line? • Fewer people will be insured. – Medicaid Enrollment Reductions. • Medicaid expansion rollbacks. • Basic Medicaid rollbacks under waivers and block granting. – Private Insurance Enrollment Reductions. • Individual/family and employer mandate eliminated. • Premiums will have no/low subsidies and will rise, making plans less affordable. • Cost-sharing subsidy of Silver plans will be eliminated, making plans less attractive. • Plans will cover less, making plans less appealing. – Impact: Greater demand of charity/sliding fee care and higher levels of uncompensated care. 20