AFFORDABLE CARE ACT: WHAT COMMUNITIES NEED

TO KNOWCINDY ZELDIN

EXECUTIVE DIRECTOR, GEORGIANS FOR A HEALTHY FUTUREPRESENTATION AT THE GEORGIA LEGISLATIVE BLACK CAUCUS

HEALTH SYMPOSIUMJULY 8, 2013

The Big Picture, The Big Opportunity: Covering the Uninsured

Overall, in Georgia: • Nearly two million uninsured (1.86 million); one-fifth of the population and one-fourth of working-age adults

• Georgia consistently ranks in the top 10 among the states in number and percentage of uninsured

• A majority of the uninsured are low-or moderate-income

• <100% FPL……. 43%• 100-138% FPL… 11%• 139-250% FPL… 23%• 251-399% FPL…. 12%• 400% FPL+......11%

*100% of FPL for an individual is $11,490 in annual income or $19,530 for a family of 3.

Source: CPS data, 2-year average ’10 – ‘11 (Kaiser State Health Facts)

<100% FPL

100-138% FPL

139-250% FPL

251-399% FPL

400% FPL+

Why Does Coverage Matter for

Individuals, Families, and Communities?

•Access to the health care system, usual source of care, and full spectrum of prevention and treatment

•Financial protection against high medical costs, peace of mind

•Increased productivity

•The health of parents can play an important role in the well-being of children; when parents gain coverage, their children are likely to enroll as well

•Spillover effects on communities; high numbers of uninsured can impact community providers and the economic vitality of communities

ACA: Overall Approach to Coverage

• Guiding principle: everyone is eligible for something (citizens and most legal immigrants)

•Maintain employment-based health insurance system

•Restructure the individual and small group health insurance marketplace through exchanges and market reforms

•Expand Medicaid for low-income individuals and families (made optional by SCOTUS)

•Individual mandate

The Health Insurance Marketplace (exchange)

• Transparency

• Competition & Accountability

• Navigation & Assistance

• Information & Tools

• Affordability

Who will be eligible for the Marketplace?• Individuals and families who don’t already have access to an affordable

health insurance plan through their workplace (or other coverage such as Medicare)

• Individuals with pre-existing conditions

• Individuals and families with incomes between 100% and 400% of the federal poverty level (FPL) will receive tax credits that can be applied directly to the plan premiums at the time of enrollment (note that individuals BELOW 100% FPL are ineligible for subsidies—we’ll return to this when we discuss Medicaid expansion)

• Children in families with incomes up to 235% of FPL will remain eligible for PeachCare for Kids or Medicaid, depending on their family income level

What will the marketplace do?• Enroll individuals and families into health insurance plans

• Provide information, services, and tools, including a web portal, to navigate consumers through the process of selecting and enrolling in a plan

• Provide an online calculator so consumers can calculate their premiums after factoring in a new tax credit that will be available to make coverage more affordable

• Display information about health plan costs, benefits, and quality and satisfaction ratings in a consumer friendly manner

What will the marketplace do (cont’d)?• Provide a toll-free consumer assistance hotline

• Certify that plans available on the exchange have adequate provider networks

• Certify that plans available on the exchange have at minimum a core set of benefits

• Present plan options in tiers (platinum, gold, silver, bronze) so that consumers can objectively identify which plans are more comprehensive than others and select a plan that best meets their needs

• Provide plain language information on enrollee rights, claims denials, and other consumer protections

Health Insurance Navigators• 78% of the uninsured don’t know about the health insurance exchange,

and when told about it most say they will need help navigating it

• 83% of people who could be eligible for the new Medicaid expansion don’t know about it

• Approximately 800,000 Georgians could be eligible for coverage through the exchange: if the goal were to get all signed up during the initial 6-month open-enrollment period, that would be thousands per day! If Georgia expands Medicaid, even more Georgians will need assistance

• The navigator program will serve as a source of unbiased information and assistance for uninsured consumers

Health Insurance Navigators• Because Georgia is a state with a federally facilitated marketplace, the U.S.

Department of Health and Human Services will operate a navigator program in Georgia

• Navigator functions include:

– Maintain expertise in eligibility, enrollment, and program specifications;– Conduct public education activities to raise awareness about the

Exchange;– Provide information and services in a fair, accurate, and impartial

manner;– Facilitate selection of a qualified health plan– Provide referrals for grievances, complaints, or questions– Provide information in a manner that is culturally and linguistically

appropriate

Medicaid Expansion

Medicaid Expansion

•Creates a new eligibility category for Medicaid based solely on income ; Congress did not intend for it to be optional for states (but SCOTUS decision made it so) •When a state expands, newly eligible individuals include those with incomes up to 138% FPL ($15,856 for an individual or $26,951 for a family of 3), Medicaid-eligible regardless of “category”

•Estimated 650,000 Georgians could gain coverage

•Expansion initially financed with 100% federal dollars (2014-2016) and then scales down such that by 2020 and thereafter the expansion population is 90% federally financed

Why Expand Medicaid?• People with low-incomes disproportionately lack access to job-based health insurance (nationally, 28% of predominately low-wage firms offer v. 77% of predominately high-wage firms)*

• Purchasing a private, individual policy is cost-prohibitive for people with very low incomes

•Medicaid is an existing program; many states have used it as a vehicle to expand coverage for low-income families over the past 20 years

* Source: Kaiser Family Foundation Employer Health Benefits 2012 Survey

Why Expand Medicaid, cont’d?• Improves health access and outcomes for individuals and families:

•Oregon health insurance experiment: Medicaid more likely to have a usual source of care than their uninsured counterparts

•New England Journal of Medicine study: states that expanded Medicaid saw lower mortality rates than neighboring states that did not, after controlling for a range of factors

• Strengthens the health care delivery system in communities:•Reduces the burden of uncompensated care

•Stimulates local economies:•Federal funds coming into the health care economy have a stimulative effect: Estimated 70,000 new jobs would be created, annual $8.2 billion in economic activity would be generated, an additional $276 million in tax revenue would be raised each year

Expanding Medicaid, cont’d

•The coverage gap: tax credits for health insurance through the exchange begin at 100% FPL because the lowest-income Americans were to be routed to Medicaid; if states don’t implement the Medicaid expansion, the poorest Georgians will have no affordable coverage options

•This complicates outreach and enrollment efforts: many consumers who knock on the door will be eligible for nothing; this violates the “no wrong door” spirit of the ACA

Georgia Medicaid Income Limits Today

235%

200% 200%224%

50%

29%

75%

Fede

ral P

over

ty L

evel

Can’t qualify

250%

200%

150%

100%

50%

Includes PeachCare

Family Size

Annual Income

1 $11,490

2 $15,510

3 $19,530

4 $23,550

100% Federal Poverty Level 2013

138% ACA Medicaid Expansion

Questions & Follow Up

Contact me at: czeldin@healthyfuturega.org or 404-418-6179