At Three Years, Opinion On ACA Remains Divided

At Three Years, Opinion On ACA Remains Divided

Web Briefing for Journalists: Repealing and Replacing Obamacare Presented by the Kaiser Family Foundation January 25, 2017 Larry Levitt Senior Vice President for Special Initiatives Kaiser Family Foundation Diane Rowland Usha Ranji Executive Vice President Associate Director for Womens Health Policy Kaiser Family Foundation Kaiser Family Foundation The Coming Debate Over The Future of the Affordable Care Act January 25, 2017 Kaiser Family Foundation Webinar

Larry Levitt Senior Vice President, Kaiser Family Foundation [email protected] @larry_levitt Possible avenues for repealing and replacing the ACA A budget reconciliation measure allows for changes in taxes and spending with a 51 vote majority in the Senate, but it cannot make changes to federal law that have only incidental effects on the budget. The House and Senate have passed budget resolutions paving the way for a reconciliation bill. One model is HR 3762, passed by Congress in early 2016 and vetoed by the President. Repeal of ACA premium subsidies and Medicaid expansion, with a delayed effective date. Immediate repeal of the individual mandate and ACA tax increases. No change to the ACAs insurance rules, including guaranteed access for people with pre-existing conditions. Continuing discussion about whether replacement proposals will be introduced and debated alongside a repeal measure. Potential executive actions by the Trump Administration (e.g., essential benefits, SEPs, grace periods, grandmothered plans, 1332 waivers). President Trumps executive order on the ACA The order does not have any immediate effect or grant new powers to federal agencies. But, it may signal the approach the Administration intends to take. waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden exercise all authority and discretion available to them to provide greater flexibility to States

Some possible administrative actions: Waive the individual mandate penalty using hardship authority. Defer enforcement of the employer requirement. Provide greater flexibility for required benefits. Extend transitional grandmothered plans. Provide greater state flexibility through section 1332 ACA waivers and Medicaid waivers. Consequences and risks of repeal and delay With no replacement in place, health coverage could be at risk for up to 32 million people. A replacement for the ACA would still likely require 60 votes in the Senate, which would need to be bipartisan based on the current partisan makeup. Repeal of the ACAs tax revenues would make development of a replacement more difficult, requiring scaled back benefits or new revenues or spending reductions. There is significant risk of a death spiral and insurer exits in the individual insurance market in the short-term. Insurers would be required to guarantee coverage to people with preexisting conditions, with no individual mandate to push healthy people to get covered. Insurers would also face uncertainty surrounding the future of the ACA, with an already fragile market in some states. Added risk: Potential for cost-sharing subsidies to end under House v. Burwell. Transitional relief could mitigate the risks. ACA replacement proposals Major proposals include: House GOP: A Better Way Representative Price: Empowering Patients First Act

Senators Burr and Hatch, Representative Upton: Patient Choice, Affordability, Responsibility, and Empowerment Act Senators Cassidy and Collins: The Patient Freedom Act of 2017 Senator Rand Paul: Obamacare Replacement Act None of these proposals have been voted on or analyzed by the Congressional Budget Office, and some have not been turned into legislative language. Details matter a lot! President Trump has not yet provided much detail on his plans for replacing the ACA, though said recently that his plan would provide insurance for everybody, while being much less expensive and providing much lower deductibles. Potential insurance market changes under ACA replacement proposals Preservation of the ACAs requirement for coverage of dependents up to age 26. Less federal regulation of health plan benefits. No individual or employer requirements. More modest protections for people with pre-existing conditions in the individual insurance market. Guaranteed access only for those with continuous coverage. Premium surcharges or late enrollment penalties for people with coverage gaps. Federal grants for state high-risk pools. More allowed variation in premiums based on age and gender. Refundable tax credits that vary by age, but not necessarily by income or local premiums. Expanded use of Health Savings Accounts. Sales of insurance across state lines. Capping the tax exemption for employer-provided health benefits. Some questions to consider under an ACA alternative Consumers:

What would be the impact on the number of people uninsured and on the adequacy of coverage people receive? Could low and middle income people afford health insurance and health care? How accessible is insurance for people with pre-existing conditions? The federal budget: How is the plan paid for and what is the impact on the federal budget? Does the plan address rising health care costs? States: Are there mechanisms and resources for states to go further if they wish? Insurers: How is the transition managed and how quickly do changes take effect? What is the effect of continuous coverage requirements and late enrollment penalties vs. an individual mandate? The Future of the ACA: What is at Stake for Medicaid? January 25, 2017 Kaiser Family Foundation Webinar Diane Rowland, Sc.D. Executive Vice President, Kaiser Family Foundation 32 states expanded coverage for adults through the ACA expansion. VT WA MT* ME

ND NH* MN OR WI* SD ID WY NV PA IL UT CO CA MI* IA* NE IN* OH WV KS

MO KY OK NM TX AK AL GA LA FL HI DC SC AR* MS VA CT RI NJ DE MD NC TN

AZ* MA NY Democratic Governor (14 States + DC) Republican Governor (16 States) Independent Governor (1 State) States not Implementing Expansion (19 States) NOTES: Coverage under the Medicaid expansion became effective January 1, 2014 in all but seven expansion states: Michigan (4/1/2014), New Hampshire (8/15/2014), Pennsylvania (1/1/2015), Indiana (2/1/2015), Alaska (9/1/2015), Montana (1/1/2016), and Louisiana (7/1/2016). Seven states that will have Republican governors as of January 2017 originally implemented expansion under Democratic governors (AR, IL, KY, MA, MD, NH, VT), and one state has a Democratic governor but originally implemented expansion under a Republican governor (PA). *AR, AZ, IA, IN, MI, MT, and NH have approved Section 1115 expansion waivers. The uninsured rate in the United States has decreased, especially among Medicaid expansion states. 2013 as of June 2016 18% 15% 14% 8% Medicaid Expansion States

Non-Expansion States NOTE: Uninsured rates for 2016 are as of June 2016. SOURCE: Emily P Zammitti, Robin A Cohen, and Michael E Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January-June 2016, (Hyattsville, MD: National Center for Health Statistics, November 2016), https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201611.pdf. The ACA Medicaid expansion increased eligibility for adults, but adult eligibility remains low in non-expansion states. Median Medicaid Eligibility Levels for Adults as a Percent of the Federal Poverty Level, 2013 and 2017 2013 2017 138% 138% 90% 48% 44% 0% Parents Other Adults 0% Parents 0% Other Adults States that Have Implemented the States that Have Not Implemented the

Medicaid Expansion as of Jan. 2017 Medicaid Expansion as of Jan. 2017 (32levels states, DC) states) NOTE: 2017 areincluding based on state-reported eligibility levels as of January 2017. Eligibility (19 levels are based on 2016 federal poverty levels (FPLs) for a family of three for children, pregnant women, and parents, and for an individual for childless adults. In 2016,the FPL was $20,160 for a family of three and $11,880 for an individual. SOURCE: Based on results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown Center for Children and Families, 2013 and 2017 with data updates to reflect Medicaid expansion implementation. Key Issues for ACA Repeal and Medicaid Expansion 14.4 million adults in 32 states covered by Medicaid expansion in Q1 2016, of which 11.2 million are newly eligible 100% federal financing match from Jan 2014 September 2015 provided $93.3 billion to states; in 2017, match is 95% phasing down to 90% in 2020 and thereafter How will repeal address the expansion? remove eligibility for adults without dependent children? remove federal funds for expansion? fold expansion into broader Medicaid block grants? A block grant or per capita cap would be a fundamental change to Medicaid financing. Coverage

Federal Funding State Matching Payments Core Federal Standards Current Medicaid Program Guaranteed coverage, no waiting list or caps Block Grant Per Capita Cap No guarantee (can use wait lists or caps) May be guaranteed for

certain groups Capped Not based on enrollment, costs or program needs Fixed with pre-set growth Capped per enrollee Not based on health care costs and needs Fixed with pre-set growth per enrollee Required to draw down federal dollars Federal spending tied to state spending Unclear Federal spending not tied to state spending beyond cap Guaranteed, no cap Responds to program

needs (enrollment and health care costs) Can fluctuate Set in law with state flexibility to expand Unclear Federal spending not tied to state spending beyond per enrollee cap Uncertain what the requirements would be to obtain federal funds Medicaid is a major part of our health care system: covering 20% of people in the US in 2015. Chart Title Uninsured; 9% Other Public; 2% Medicaids 74.4 million beneficiaries include: Medicare; 14% Employer; 49% Medicaid/ CHIP; 20%

1 in 2 low-income individuals 2 in 5 children 3 in 5 nursing home residents 2 in 5 people with disabilities 1 in 5 Medicare beneficiaries Non-Group; 7% SOURCE: Health insurance coverage: KCMU analysis of 2015 data from the 2016 ASEC Supplement to the CPS. Medicaid is a major purchaser of health care. Chart Title Disproportio nate Share Payments to Hospital Hospital*; 11% Medicare; 3% Payments; Physician & Rx Drugs*; 2% Outpatient*; 8% 3% Managed Care; 43% Other*; 8% Long-term Care*; 22% Over three quarters of Medicaid enrollees are children and adults, but over half

of spending is for seniors and people with disabilities. *Fee-for-service SOURCE: KFF estimates based on 2015 National Health Expenditure Accounts data from CMS, Office of $532.1B in FY 2015 the Actuary. Office of the Actuary, CMS, 2015 Actuarial Report on the Financial Outlook for Medicaid, (Baltimore, MD: CMS), https:// www.medicaid.gov/medicaid/financing-and-reimbursement/downloads/medicaid-actuarial-report-2015.pdf . The budget resolution from March 2016 would have reduced federal Medicaid spending by 41% over the 20172026 period. In Billions of Dollars ACA Repeal: -$1,063 B ACA Repeal: -$1,063 B Other Medicaid Cuts: -$1,028 $5,049 $3,986 $2,958 Current Law, Including ACA (CBO January 2016 Baseline) ACA Repeal ACA Repeal and Other Medicaid Cuts SOURCE: Kaiser Program on Medicaid and the Uninsured Estimates of the House Budget Committee Budget

Resolution from March 2016 using the CBO January 2016 Baseline and Estimates from the Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2016 to 2026 for the Medicaid ACA Estimates Total Cut: $2,091 B or 41% A per capita cap could lock in historical state differences or redistribute federal funds across states. Per capita spending by enrollment group $33,808 $5,214 $1,656 Children $6,928 $32,199 $10,142 $10,518 Individuals with Disabilities Aged $2,056 Adults SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2011 MSIS and CMS-64 reports. Because 2011 MSIS data were unavailable, 2010 MSIS & CMS-64 data were used for Florida, Kansas, Maine, Maryland, Montana, New Mexico, New Jersey, Oklahoma, Texas, and Utah.

The impact of a block grant or per capita cap will depend on how it is structured and the funding levels, but could include: Increases in the number of uninsured Reduced access and service utilization, decreased provider revenues (to hospitals, nursing homes, etc.), and increased uncompensated care costs Increased pressure on state budgets Decreased economic activity SOURCE: L. Antonisse, R. Garfield, R. Rudowitz, and S. Artiga, The Effects of Medicaid Expansion under the ACA: Findings from a Literature Review (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2016), http ://kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-findings-from-a-literature-review/ What to Watch What are options on the table? ACA Repeal / Replacement Financing Changes (Block Grant or Per Capita Cap) Waivers, administrative changes What are key questions? What happens with expansion dollars? What is the base year for setting caps? What are allowable growth rates or spending targets? What new flexibility would be granted / core requirements maintained? What are the targeted reductions in federal funding? What are the implications? Coverage / enrollees States (winners and losers) Providers The Future of the ACA: What is at Stake for Womens Health? January 25, 2017 Kaiser Family Foundation Webinar

Usha Ranji, M.S. Associate Director, Womens Health Policy Kaiser Family Foundation Changes in Womens Insurance Coverage Since Passage of the ACA Changes in health insurance coverage among women ages 18-64, 2010-2016 Private Health Insurance 64.7% 2011; 64.5% 19.3% 17.4% 2010 2011; 2011; 18.9% 18.0% 2011 2012 Public Health Insurance 2012; 64.2% 2013; 64.0% 2012; 18.6% 2013; 19.1% 18.3%

2013 Uninsured 2014; 66.9% 2014; 20.1% 2014; 14.3% 2014 NOTES: *Data for 2016 do not include the full year, only January-June. Among women ages 18 to 64. SOURCE: Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January-June 2016. 2015 2015; 69.5% 68.5% 2015; 21.2% 22.6% 2015; 10.8% 10.5% 2016* The ACA Made Many Insurance Reforms Affecting Women ACA At Risk Under Repeal No pre-existing condition exclusions At risk to be treated as pre-existing condition: Pregnancy (~ 4 million births per year) Prior C-section (1/3 births) Depression (1/10 women) History of domestic violence (1/3 women) Gender rating banned

Individual plans may charge higher premiums to women for same coverage 1/3 of plans charged 25 and 40 year old women at least 30% more than men This practice costs women an estimated $1 billion more annually Maternity care required in all plans Individually purchased plans and small employerbased plans could exclude maternity care Included in only 12% of plans (2012) 7% of plans offered maternity riders (2012) Riders can cost more than $1000/month Plans must offer dependent coverage up to age 26 Women in their twenties had the highest uninsured rate before ACA 30% of women age 19-26 uninsured in 2009 SOURCES: Centers for Disease Control and Prevention (CDC), Births - Method of Delivery 2015, Depression in U.S. Household Population 2009-2012. National Coalition Against Domestic Violence (NCADV), National Statistics, 2010. National Womens Law Center (NWLC), Turning to Fairness Report, 2012. Kaiser Family Foundation/Urban Institute analysis of the March 2009 Current Population Survey, U.S. Bureau of the Census. Preventive Services Covered by Private Plans Without Cost Sharing for Women Cancer Chronic Conditions Vaccines Healthy Behaviors Pregnancy

Reproductive and Sexual Health Breast Cancer Cardiovascular health Hypertension screening Lipid disorders screenings Aspirin Td booster, Tdap Alcohol misuse STI and HIV counseling (adults at Mammography for women 40+* Genetic (BRCA) screening and counseling Preventive medication Cervical Cancer Pap testing (women 21+ ) High-risk HPV DNA testing Type 2 Diabetes

screening (adults w/ elevated blood pressure) Depression screening (adults, when follow up supports available) Osteoporosis Colorectal Cancer One of following: fecal occult blood testing, colonoscopy, sigmoidoscopy Lung Cancer Adults 55-80 with history of smoking Skin Cancer Counseling for fair-skinned adults 10-24 screening (all women 65+, women 60+ at high risk) Obesity Screening (all adults) Counseling and behavioral interventions (obese adults)

Hepatitis B, C screenings (adults at increased risk) screening and counseling (all adults) MMR Diet counseling Meningococcal Hepatitis A, B Pneumococcal Zoster Influenza, Varicella HPV (women and men 1926) (adults w/high cholesterol, CVD risk factors, diet-related chronic disease) Tobacco counseling and cessation interventions (all adults) Interpersonal and domestic violence screening and counseling (women 18-64)

Well-woman visits (women 18-64) Fall Prevention in Older Adults; physical therapy and vitamin D supplements Tobacco and cessation interventions Alcohol misuse screening/counseling Rh incompatibility screening Gestational diabetes screenings 24-28 weeks gestation First prenatal visit (women at high risk for diabetes) Screenings Hepatitis B Chlamydia (<24, hi risk)

Gonorrhea HIV Syphilis Bacteriurea Folic acid supplements (women w/repro capacity) Iron deficiency anemia screening Breastfeeding supports, counseling , consultations and equipment rental SOURCE: U.S. DHHS, Recommended Preventive Services. Available at http://www.healthcare.gov/center/regulations/prevention/recommendations.html. More information about each of the services in this table, including details on periodicity, risk factors, and specific test and procedures are available at the following websites: USPSTF: http://www.uspreventiveservicestaskforce.org/recommendations.htm ACIP: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm#comp HRSA Womens Preventive Services: http://www.hrsa.gov/womensguidelines/ high risk; all sexuallyactive women) Screenings: Chlamydia (sexually active women <24y/o, older women at high risk) Gonorrhea (sexually active women at high risk) Syphilis (adults at high risk) HIV (adults at high risk; all sexually active women) Contraception (women w/repro

capacity) All FDA approved methods as prescribed, Sterilization procedures Patient education and counseling Plans Must Offer Coverage of at least one of each of 18 FDA Approved Contraceptive Methods Contraceptive Duration of Contraceptives Surgical and Implant Sterilization Permanent Intrauterine devices Copper and Progestin 5-10 years Implantable Rods 3 years Ella (emergency contraception) Single use Levonorgestrel (aka Plan B) Single use Injection (Depo-Provera) Per injection (3 months each)

Oral Contraceptives (Combined, Progestin only, extended/continuous use) Birth Control Patch Per month Vaginal Ring (NuvaRing) Per month Diaphragm Per month 2 years Female Condom Single use Sponge 3 time uses Cervical Cap 2 years Spermicide Per package NOTE: A womans reproductive life spans approximately 30 years. SOURCE: Planned Parenthood, Birth Control. The Contraceptive Coverage Policy Has Had a Large Effect in a Short Amount of Time

Share of women reporting any out-of-pocket spending on oral contraceptives: 22.5% 22.6% 22.2% 22.3% 22.6% 22.5% 22.0% 21.8% 20.9% ACA Contraceptive Provision 6.5% 3.6% 2004 2005 2006 2007 2008

2009 2010 2011 2012 2013 2014 NOTE: Share of women age 15-44 with health coverage from a large employer who have any out-of-pocket spending on oral contraceptive pills, 2004-2014. SOURCE: Peterson-Kaiser Health System Tracker. Kaiser Family Foundation analysis of Truven Health Analytics MarketScan Commercial Claims and Encounters Database, 2004-2014. What Will Happen to Contraceptive Coverage? There are Options for Administrative Action without Full Repeal HHS could drop requirement (Under President Trump, HRSA could have different recommendations) Scale back the requirement (fewer methods, more medical management permitted) Broaden the qualifications for exemption to all employers who object Hobby Lobby and Zubik SCOTUS cases - plaintiffs sought exemption Obamas HHS : women workers & dependents entitled to contraception Trumps HHS could give employers the right to be exempt if they object to contraception on moral or religious grounds State Requirements for Contraceptive Coverage 28 states require insurance to cover prescription contraceptives to some extent, but only 4 include no cost-sharing and require all FDA-approved contraceptives Do not apply to self-insured plans VT

WA MT ME ND NH MN OR ID MI WY NV UT CA PA IA NE IL CO IN OH WV

KS MO KY OK NM TX AL DC SC AR MS VA CT RI NJ DE MD NC TN AZ MA NY

WI SD GA LA FL AK HI Contraceptive coverage required with no cost-sharing Contraceptive coverage requirement SOURCE: Guttmacher Institute, Insurance Coverage of Contraceptives, January 2017. ACA Reforms Also Improved Availability of Maternity Care Pregnancy no longer a pre-existing condition Maternity and newborn care are essential health benefits No cost prenatal visits and recommended screening services Medicaid expansion provides pathway to coverage for mothers who previously may have lost coverage post partum Breastfeeding supports for nursing mothers Breast pumps and lactation consultation now covered without cost-sharing Breaks and private area to express milk in workplace ACA Repeal Will Place Additional Demands on the Family Planning Safety Net if Medicaid Expansion and Subsidies are Eliminated Distribution of Title X Family Planning Clinics Revenue Sources: Other

25.00% State/ Local Government 16.00% Medicaid 40.00% Title X 19.00% SOURCE: Office of Population Affairs, Title X Family Planning Annual Report 2015 National Summary, August 2016. Funding Threats to Planned Parenthood Could Eliminate Access to a Major Provider of Subsidized Family Planning Services to Women Health centers make up a greater share of providers, but Planned Parenthood Clinics serve a disproportionate share of clients 38% 36% % Share of all Clinics All Clinics % Share of all Clients Served 29% 16% 27% 16% 13% 10% lth

a e H ity n u m m Co s er t n Ce ed n an Pl od o th n re Pa 8% 8% l ta i sp o H

lth a He De t en rtm a p SOURCE: Frost JJ, Zolna MR, & Frohwirth L. (2013). Contraceptive Needs and Services, 2010. New York: Guttmacher Institute, Table 3 on pg. 15. er h Ot Kaiser Family Foundation Resources ACA Repeal kff.org/tag/aca-repeal/ Medicaids Future kff.org/tag/medicaids-future/ Reproductive Health kff.org/tag/reproductive-health/ Interactive Maps: Estimates of Enrollment in ACA Marketplaces and Medicaid Expansion http://kff.org/interactive/interactive-mapsestimates-of-enrollment-in-aca-marketplaces-andmedicaid-expansion/ Contact Information Amy Jeter, Communications Officer Kaiser Family Foundation | Washington, D.C. Email: [email protected] Phone: (650) 854-9400 Facebook: /KaiserFamilyFoundation Twitter:

@KaiserFamFound Email alerts: kff.org/email Todays Web Briefing Will Be Recorded The webcast will be available later today. Slides are available for download. kff.org/health-reform/event/web-briefing-forjournalists-repealing-and-replacing-obamacare/

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