aca signups | healthcare policy data, analysis &...

WaystoPROTECT,REPAIRandSTRENGTHENtheACAatthefederalorstatelevel

•  PROTECT:LegislationtolockinexistingACApatientprotectionsintheeventhey’restrippedawayatthefederallevel

•  REPAIR:LegislationtorestoreACAprotections/regswhichhavealreadybeenstrippedawayatthefederalleveleitherlegislativelyorviaregulatorychangesbyTrump

•  STRENGTHEN:“ACA2.0”improvementstotakeittothenextlogicalstage.Implementingevenafewofthesecoulddramaticallyimprove/expandcoveragewhileloweringcostsforenrollees…manycanbedoneatthestatelevelwithoutfederalapproval.

“ACA2.0”HOUSE:H.R.1884:

“TheProtectingPre-ExistingConditionsandMakingHealthCareMoreAffordableActof2019”

“#PPECAMHCMAA”

SENATE:S.1213:ConsumerHealthInsuranceProtectionAct

“#CHIPA”

HouseACA2.0BillPackageH.R.1884:•  1.PROTECT:H.R.986:ReversesTrumpAdmin’smutationof1332

waiverdefinitionwhichwould’vemassivelyweakenedACAEssentialHealthBenefitprotections&more;Passed5/09

•  2.REPAIR:H.R.987(MOREAct):RestoresHC.govmarketingbudgetto$100M/yr;regulateshowit’sused;Passed5/17

•  3.REPAIR:H.R.1386(ENROLLAct):RestoresHC.gov’snavigator/outreachbudgetto$100M/yr;regulatesuse;Passed5/17

•  4.REPAIR:H.R.1010:ReversesTrumpAdmin’sexpansionofnon-ACAcompliant“short-termplans”;Passed5/17

•  5.STRENGTHEN:H.R.1385(SAVEAct):Providesstatesw/$200Minfederalfundstoestablishstate-basedACAexchanges;Passed5/17

•  6.STRENGTHEN:H.R.1425:ReinstatesfederalACAreinsuranceprogramw/$10B/year(wouldreducepremiums~11%onavg.)

HouseACA2.0BillPackageH.R.1884:•  7.STRENGTHEN:FixesACA“FamilyGlitch”whichpreventsfamilies

frombeingeligibleforsubsidiesif1memberiseligibleforanyemployer-sponsoredpolicy(couldincreaseenrollmentbyseveralmillionpeople)

•  8.REPAIR:ReversesTrumpAdmin’sexpansionofquasi-ACAcompliant“AssociationHealthPlans”

•  9.STRENGTHEN:StandardizedPlans/SilverSpamLoopholeFix:PreventsgamingofACAbenchmarkplanframework&reducesconfusionforenrollees

•  10.STRENGTHEN:StateEducation/EnrollmentInnovationProgramFunding:Provides$300M/yrtostatestohelpthemeducate/streamlineenrollmentintheindividual&smallgroupmarkets

•  11.PROTECT/REPAIR:AuditHealthCare.Gov’sbudget,whichTrumpAdminhasusedtoattacktheACAwhilesimultaneouslyslashingopenenrollmentadvertising,navigator/outreach&education,etc.

12.H.R.1868:#KillTheCliffs!•  CurrentACAsubsidies:

–  Thoseearning100-400%FPL•  SingleAdult:$12.5K-$50K•  Familyof4:$25K-$100K

–  Cappedatbetween2–10%ofincome

•  PROBLEM#1:–  Lower-endCliff:Thoseearningjustover

100%(non-expansionstates)or138%(expansionstates)havetopay2.1%or3.4%ofincometostart

–  UPPER-ENDCLIFF:Thoseearningjustover400%FPLhavetopayfullprice,whichaveragesover21%ofincomefor60-yearoldenrollees

•  PROBLEM#2:–  Subsidiesstillnotgenerousenougheven

formanyinthe100-400%range

12.H.R.1868:#KillTheCliffs!•  Proposed“ACA2.0”subsidiessolve

bothproblems:–  Removestheupper-endcliffcompletely–  Smoothsoutthelower-endcliff

–  Cappedatbetween0–8.5%ofincome

•  Likelyenrollmentincrease:4-6millionpeople

•  Eliminatesneedforconfusing“SilverSwitching”

•  Makesoff-exchangeACAenrollmentcompletelyunnecessary

•  Likelyadditionalcost:Just$10-$15billion/year

50-yearoldenrollee:Wouldsaveupto$2,800/year

60-yearoldenrollee:Wouldsaveupto$6,500/year!

S.1213:ConsumerHealthInsuranceProtectionAct(“CHIPA”)

•  Includes8majorprovisionsofHouseversion;inaddition…

•  UpgradesbenchmarkplanfromSilvertoGold,effectivelybeefingupCostSharingReductionassistancesignificantly

•  TiesMedicareAdvantagecontractstoexchangeparticipationinlow-competitionareas

•  Addsa$250/mocaponprescriptiondrugcosts•  IncreasesIndividual&Sm.GroupMLRfrom80%to85%•  Addressesmid-yearformularybait-n-switch,network

changes&treatmentdroppage•  RequiresOpenEnrollmenttolastatleast8weeks•  OutlawsSurpriseBilling(separatebillalreadyinprocess)•  Eliminates50%SmokerSurcharge(whichhasbeenfoundto

domoreharmthangood)

PresidentialCandidatesonACA2.0•  Senateversionprimarysponsor:Sen.Warren

•  Co-SponsoredbySen.Booker,Sen.Gillibrand,Sen.Harris&Sen.Klobuchar

•  Co-sponsoredbySen.Sandersin2018butnotin2019

•  Houseversionco-sponsoredbyRep.Moulton

•  Biden,Bullock,Delaney&Insleehaveindicatedstrongsupportofprotecting/improvingtheACA

•  AlltheothercandidatesseemtobeonboardwithACAimprovements

MOSTlikelytoWELCOMEasingle,mandatory,comprehensive,affordablehealthcareprogram:

•  ThosecurrentlyUNINSURED(~30million)•  ThosecurrentlyenrolledinJUNKPLANS(~5million)

•  ThosecurrentlyonINDIVIDUALMARKET(~15million)–  Especiallythosewhoareunsubsidizedorlightlysubsidized.

•  ThosecurrentlyenrolledinMEDICAID/CHIP(~73million)–  Tostopindividualstatesfromconstantlyscrewingaroundwithcoverage,eligibility,etc.

•  ThosecurrentlyenrolledinMEDICARE(~55million)–  Aslongastheyreceivebetterbenefitswithouthavingtopaymore

•  Total:~52%ofthetotalU.S.population

LEASTlikelytowelcomeasingle,mandatory,publiclyrunhealthcareprogram:

•  ThoseenrolledinEMPLOYER-SPONSOREDHEALTHCARE(~160million)–  IncludesFederal,State&Municipalemployees

–  IncludesUnionWorkerswhogaveupotherbenefitstoacquireGold-platedhealthcarecoverage

–  IncludesMilitaryTRICAREenrollees&theIndianHealthService

•  ~2/3areareatleastsatisfied(ifnotthrilled)w/currentcoverage

•  Potentialbacklashoverhavingcurrentcoveragereplaced•  ConcernaboutBig,UnknownProgram,etcetc.

•  Total:~48%ofthetotalU.S.population

“MedicareforAmerica”WHO’SCOVERED?

•  ENROLLEDAUTOMATICALLY:~52%ofthepopulation:–  EveryonecurrentlyUNINSURED–  EveryonecurrentlyenrolledintheINDIVIDUALMARKET–  EveryonecurrentlyenrolledinMEDICAIDorCHIP–  EveryonecurrentlyenrolledinMEDICARE–  AllNEWBORNCHILDREN–  AllNEWLYTURNING65

•  CANENROLLIFTHEYWANTTO:~48%ofthepopulation:–  AnyonewithEMPLOYERCOVERAGE,including:

•  EmployeesofLARGEBUSINESSES•  EmployeesofSMALLBUSINESSES•  FederalEmployees(FEHBP)•  State&MunicipalEmployees•  ActiveMilitaryMembers(TRICARE)•  EnrolleesintheIndianHealthService

“MedicareforAmerica”introducedbyReps.DeLauro&Schakowsky

“MedicareforAmerica”WHAT’SCOVERED?(justabouteverything)

•  Ambulatoryservices•  Emergencycare/urgentcare•  Hospitalization•  Maternity/newborncare•  Behaviorialhealthservices•  PrescriptiondrugsviaFDA•  Rehabilitative/habilitiveservices•  Laboratoryservices•  Preventative/wellness&chronic

diseasemanagement•  Pediatricservices•  Dentalcare•  Hearingservices/hearingaids•  Visionservices•  Home&Community-basedlong-

termsupportservices•  Chiropracticservices

•  Chiropracticservices•  Durablemedicalequipment•  FamilyPlanning(includingfull

maternity&reproductivecare)•  Gender-confirmingprocedures•  STD/HIVscreening,testing,

treatment&counseling•  Dietary/nutritioncounseling•  Medicallynecessaryfood/vitamins•  Nursingfacilities•  Acupuncture•  Digitalhealththerapeutics•  Telehealth•  Non-emergencymedical

transportation•  Carecoordination•  Palliativecare•  AnythingelsecoveredbyanyState

plan

“MedicareforAmerica”LONG-TERMSUPPORT&SERVICES

•  Homehealthaides&homemakers•  Directsupportprofessionalsand

personalattendantcareservices•  Hospice•  Nursingcare•  MedicalSocialServices•  Carecoordination,includingcase

management,fiscalintermediary,andsupportbrokerageservices

•  Short-terminpatientcare,includingrespitecareandcareforpaincontrol;

•  Behavioralhealthhomeandcommunitybasedlong-termservicesandsupports,includingassertivecommunitytreatment;peersupportservices

• Intensivecarecoordination,includingcasemanagement;supportedemployment;andsupportedhousingwraparound• Private-dutynursing• Respiteservicesprovidedintheindividual’shomeorbroadercommunity• Transitionalservicestosupportanindividual’stransitionfromaninstitutionalsettingtothecommunity.

“MedicareforAmerica”introducedbyReps.DeLauro&Schakowsky

“MedicareforAmerica”WHATABOUTEMPLOYER-SPONSOREDINSURANCE?

•  LARGEEMPLOYERS(>100employees)HAVEACHOICE:–  A.ProvideQUALITYPRIVATEINSURANCEfortheiremployees(mustbe

Gold-levelorhigherw/vision,dental&hearing:80%AVw/employercoveringatleast70%ofpremiums,includingfortheirfamily);OR

–  B.ShiftemployeesovertoMedicareforAmerica&payaflat8%payrolltax

•  SMALLEMPLOYERS(<100employees)HAVEACHOICE:–  A.ProvideQUALITYhealthinsurancefortheiremployees(mustbeGold-

levelorhigherw/vision,dental&hearing:80%AVw/employercoveringatleast70%ofpremiums,includingfortheirfamily);or

–  B.ShiftemployeesovertoMedicareforAmerica

–  IfanindividualemployeewantstomovetoMed4America,theycandoso&theiremployerhastocontinuetopaythesameamounttheywerebefore;employeepaysLESSERofwhattheywereorMed4Americarates

“MedicareforAmerica”WHATABOUTMEDICAREADVANTAGE?

•  IndividualswillhavetheoptiontoenrollinaMedicareAdvantageforAmericaplan

•  Theseplanswillneedtochargeaseparatepremiumiftheycoveradditionalbenefits.

•  MedicareAdvantageplanswouldalsopayMedicareforAmericaratesforbenefitsandservices.

•  IncludesMedicareAdvantageBillofRights,whichwouldprohibitplansfromdroppingprovidersduringthemiddleoftheplanyearw/outcause&improvesnoticetoplanenrolleesaboutannualchangestoprovidernetworks

•  Federalgov’tpaysMAadmin95%ofcosts;it’suptoMAadmintodecidewhatadditionalbenefitstooffer&howmuchmoretocharge.

“MedicareforAmerica”HOWISITPAIDFOR?

•  Sunsetthe2017TaxBill•  Adda5%surtaxonAGIover$500K/yr•  IncreaseMedicarepayrolltaxonincomeover$200K($250K)/yr

(from0.9%to4.0%overthoseamounts)

•  IncreaseNetInvestmenttaxonincomeover$200K($250K)/year(from3.8%to6.9%overthoseamounts)

•  Increaseexcisetaxesonalltobacco,alcohol&sugarydrinkproducts

•  StateswouldcontinuetomakemaintenanceofeffortpaymentsequaltotheirexistingMedicaid/CHIPfunding,adjustedtoaccountforwhetherthey’veexpandedMedicaidundertheACAornot

“MedicareforAmerica”OTHERIMPORTANTSTUFF

•  ABORTIONWOULDBECOVERED(alongw/completereproductive/maternitycare).TheHydeAmendment“shallnotapply”.

•  UNDOCUMENTEDIMMIGRANTSarecovered(“aresidentoftheUnitedStatesoraterritoryoftheUnitedStates”)

•  PROHIBITIONAGAINSTSTEPTHERAPY&PriorAuthorization•  CURRENTMEDICAREENROLLEESWOULDPAYCURRENT

PREMIUMS(i.e.,theypaythelesserofMed4AmratesorexistingMedicarerates)

•  MEDICALSTUDENTLOANFORGIVENESS:Doctors,nurses,directcareworkers,therapists,PAs,pharmacists,dentistsetc.willhave10%oftheirstudentloandebtforgivenforeachyeartheyparticipateinMedicareforAmerica

“MedicareforAmerica”OTHERIMPORTANTSTUFF

•  HEALTHCAREPROVIDERREIMBURSEMENTRATES:BasedonexistingMedicare/Medicaidbuthigherforsomeservices(atleast110%forhospitalinpatient/outpatient;higherforunderservedareas;atleast130%forprimarycare,mental&behavioralhealthservices)

•  ALLOWSHHSTONEGOTIATEPRESCRIPTIONDRUGPRICES

•  NoBalanceBilling/SurpriseBilling•  NoPrivateContracting•  MentalHealthParityRequirement•  SAFESTAFFINGREQUIREMENTSforhospitals(musthaveastrictly-

definedadequatenumberofnurses,orderlies,etc.perpatient)

•  EliminatesStateMedicaidwaitinglists•  Eliminates2-yearSSDIMedicarewaitinglist

Medicare For All Sen. Sanders Rep. Jayapal

14 Co-sponsors for S. 1129 114 Co-sponsors for HR. 1384

•  48% of House Dems (and growing)

•  Some differences but LOTS of overlap

Warren Merkley Harris Leahy Gillibrand Markey Booker Schatz Baldwin Whitehouse Blumenthal Udall Heinrich Hirono

Medicare For All •  Covers all US residents •  Transitions current

Medicare, Medicaid/CHIP, FEHB into MFA. –  VA & IHS continue as is.

•  HR.1384 timeline: –  Year 1: enroll everyone

under 19 and over 55 –  Year 2: everyone else

•  S.1129 timeline: –  Year 1: Medicare eligibility

age lowered to 55 •  everyone under age 19

can also enroll. •  workers can buy in.

–  Year 2: eligibility age = 45 –  Year 3: eligibility age = 35 –  Year 4: every US resident

auto-enrolled

Medicare For All •  Paying hospitals & doctors:

–  HR.1384 sets global budgets –  S.1129 sets payment rates

•  Medicare would negotiate prices for drugs & devices.

•  Eliminates nearly all out-of-pocket expenses –  No deductibles or copays for

medical services. –  Limited copays for rx drugs to

encourage use of generics.

•  Upgrades Medicare to cover comprehensive benefits: –  all of the ACA’s essential

benefits –  abortion & repro health –  dental, vision, & hearing –  long-term services &

supports (home and community-based)

–  states can add benefits

IfTexasvs.Azar(TXvUS)isultimatelysuccessful&theACAiscompletelystruckdown…

Medicaidexpansionforover16millionpeople?

GONE.Premiumsubsidiesforover9millionpeople?

GONE.CostSharingsubsidiesforover7millionpeople?

GONE.

BasicHealthPlancoveragefor800,000inMinnesota&NewYork?GONE.

Discriminationagainstupto130millionw/pre-existingconditions?

BACK.

Chargingwomenmoreforthesamepolicyduetotheirgender?

BACK.


Chargingolderpeople5to6timesasmuchasyoungerpeople?

BACK.Policiesrequiredtocoveraminimumof60%ofmedicalexpenses?

GONE.Policiesrequiredtocovermaternitycare&mentalhealthservices?

GONE.

Adultchildrenallowedtostayontheirparentsplansuntilage26?GONE.

Annualandlifetimelimitsonhealthcarecoverageclaims?BACK.

Policiesrequiredtocoverpreventativeservicesatnoout-of-pocketcost?

GONE.


Taxcreditstoreducepremiumsforlow/moderate-incomeenrollees?

GONE.Financialhelptoreduceout-of-pocketexpensesforlow-incomeenrollees?

GONE.

Hardmaximumcaponin-networkout-of-pocketexpenses?GONE.

ClosureofMedicarePartDprescriptiondrug“donuthole”?REOPENED.

ANDMUCH,MUCHMORE.

Texasvs.AzarCALLTOACTION:WhatcanYOUdo,NOW?

•  Youcan’tdomuchabouthowthecourtsrule.HOWEVER,there’stwothingsyouCANdo:

•  1.DOEVERYTHINGPOSSIBLEtoelectDemocratsup&downtheticketin2019&2020(duh!)

•  2.LOBBYYOURSTATEREPRESENTATIVES,STATESENATORS&GOVERNORStoREPLICATEasmanyoftheACA’sprotections/provisionsatthestatelevelaspossible,including…

HowmuchhasYOURstatedonetoprotect/improvetheACA?

•  · California: 12 measures enacted •  · New Jersey: 9 measures enacted •  · Massachusetts: 17 measures enacted •  · Rhode Island: 7 measures enacted •  · Connecticut: 12 measures enacted •  · New York: 16 measures enacted •  · Washington State: 18 measures enacted •  · Colorado: 13 measures enacted •  · Vermont: 14 measures enacted •  · New Mexico: 10 measures enacted •  · Washington, DC: 11 measures enacted •  · Maryland: 11 measures enacted •  · Minnesota: 11 measures enacted •  · Nevada: 10 measures enacted

aca signups | healthcare policy data, analysis &...

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