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THE COMMONWEALTH FUND The Health Insurance Provisions of the 2009 Congressional Health Reform Bills: THE COMMONWEALTH FUND The Health Insurance Provisions of the 2009 Congressional Health Reform Bills: Coverage, Affordability and Costs Sara Collins, Ph. D. Vice President The Commonwealth Fund November 19, 2009

Congressional Health Reform Bills As Of Nov. 2009 Senate 11/19/09 House of Representatives 11/7/09 Congressional Health Reform Bills As Of Nov. 2009 Senate 11/19/09 House of Representatives 11/7/09 GI, adjusted CR 2: 1; 2010: meet 85% medical loss ratio; uninsured eligible for high-risk pools, no annual or lifetime limits or rescissions, dependent coverage to 27 Insurance Market Regulations GI, adjusted CR 3: 1; report medical loss ratio; in 2010: uninsured eligible for high risk pools; no annual or lifetime limits or rescissions, dependent coverage to 26 Individual mandate Penalty $750/year per adult in household phased in at $95 in 2014, $350 in 2015, $750 in 2016; exempts premiums >9. 8% of income Penalty: 2. 5% of the difference between MAGI and the tax filing threshold up to the average national premium of the “basic” benefit package Regional, state, or substate National or state Private, public, and co-op Individuals and small businesses 50– 100, 100 by 2015, 100+ at state option Individuals and small businesses <25 in 2013; <50 by 2014; <100 by 2015; 100+ after 2015 Minimum benefit standard, tiers Essential health benefits 60%– 90% actuarial value, Four tiers; catastrophic policy for young adults <30 and those exempt from individual mandate Essential health benefits 70%– 95% actuarial value, four tiers Premium / cost-sharing assistance Sliding scale 2%– 9. 8% of income up to 300% FPL/ flat cap at 9. 8% 300%– 400% FPL; cost-sharing subsidies for 100%– 200% FPL Sliding scale 1. 5%– 12% of income up to 400% FPL; cost-sharing subsidies and lower out of pocket max 133%– 350% FPL Up to 133% FPL Up to 150% FPL Exchange Plans offered Eligibility for exchange Medicaid / CHIP expansion Shared Responsibility / Employer Pay-or-play Play or pay; firms >$500, 000 payroll 72. 5% + prem. Firms >50 FTEs pay uncovered worker fee of $750 contribution for indiv/ Small employer tax credit; young adults can stay on 65% + for families; sliding scale phased-in from 2% to parent’s health plan to age 26 8% of payroll at $750, 000; Small-employer tax credit; young adults can stay on parent’s THE health plan to age 27 Source: SR Collins, K Davis, J Nicholson, S Rustgi, R Nuzum, The Health Insurance Provisions of the 2009 Congressional Health Reform Bills: Implications for Coverage, Affordability, and Costs, The Commonwealth Fund, Nov. 2009. COMMONWEALTH FUND

Major Sources of Savings and Revenues Compared with Projected Spending, Net Cumulative Effect on Major Sources of Savings and Revenues Compared with Projected Spending, Net Cumulative Effect on Federal Deficit, 2010– 2019 Dollars in billions CBO estimate of Senate Bill Total Net Impact on Federal Deficit, 2010– 2019 CBO estimate of House Bill –$130 –$109 $748 $891 • Medicaid/CHIP outlays 374 425 • Exchange subsidies 447 602 • Small employer subsidies 27 25 • Payments by uninsured individuals – 8 – 33 • Play-or-pay payments by employers – 28 – 135 • Associated effects on taxes and outlays – 64 6 –$491 –$427 • Productivity updates/provider payment changes – 154 – 177 • Other improvements and savings – 337 – 250 –$387 –$574 – 149 — — – 461 – 238 – 113 Total Federal Cost of Coverage Expansion and Improvement Total Savings from Payment and System Reforms Total Revenues • Excise tax on high premium insurance plans • Surtax on wealthy individuals and families • Other revenues Source: The Congressional Budget Office Preliminary Analysis of the Patient Protection and Affordable Care Act, Nov. 18, 2009, http: //www. cbo. gov/doc. cfm? index=10731. The Congressional Budget Office Analysis of H. R. 3962, The Affordable Health Care for America Act, Incorporating the Manager’s Amendment Offered by Representative Dingell, Nov. 6, 2009, http: //www. cbo. gov/doc. cfm? index=10710. THE COMMONWEALTH FUND

Trend in the Number of Uninsured Non-elderly, 2012– 2019 Under Current Law and Senate Trend in the Number of Uninsured Non-elderly, 2012– 2019 Under Current Law and Senate and House Bills Millions Note: The uninsured includes unauthorized immigrants. With unauthorized immigrants excluded from the calculation, nearly 94% and 96% of legal nonelderly residents are projected to have insurance under the Senate and House proposals, respectively. Data: Estimates by The Congressional Budget Office. Source: SR Collins, K Davis, J Nicholson, S Rustgi, R Nuzum, The Health Insurance Provisions of the 2009 Congressional Health Reform Bills: Implications for Coverage, Affordability, and Costs, The Commonwealth Fund, Nov. 2009. THE COMMONWEALTH FUND

Source of Insurance Coverage Under Current Law and Two Proposals, 2019 Millions 18 M Source of Insurance Coverage Under Current Law and Two Proposals, 2019 Millions 18 M (6%) Among 282 million people under age 65 54 M (19%) Uninsured 35 M (12%) Medicaid 162 M (57%) ESI 24 M (9%) Uninsured 6 M (2%) Exchange (Public Plan)* 4 M (1%) Exchanges (Public Plans) 26 M (9%) Exchanges (Private Plans) 16 M (6%) Other 15 M (5%) 50 M 10 M (4%) Nongroup (18%) Nongroup Medicaid 152 M (54%) ESI Uninsured 24 M (9%) Exchange (Private Plans) 16 M (6%) Other 50 M (18%) Medicaid 9 M (3%) Nongroup 159 M (56%) ESI *CBO estimates 20% of people enrolled in exchange will choose the public plan under the House bill. Employees whose employers buy coverage through the exchange are counted as covered through the exchange. Source: Preliminary Analysis of the Patient Protection and Affordable Care Act, Congressional Budget Office Letter to THE the Honorable Harry Reid, November 18, 2009, http: //www. cbo. gov/doc. cfm? index=10731. Preliminary Analysis of the COMMONWEALTH FUND Affordable Health Care for America Act, Congressional Budget Office Letter to the Honorable Charles Rangel, October 29, 2009, http: //cbo. gov/doc. cfm? index=10688&zzz=39710.

Minimum Benefit Package Requirements Minimum Benefit Package Senate Four tiers 1 st tier (Bronze) Minimum Benefit Package Requirements Minimum Benefit Package Senate Four tiers 1 st tier (Bronze) actuarial value: 60% 2 nd tier (Silver) actuarial value: 70% 3 rd tier (Gold) actuarial value: 80% 4 th tier (Platinum) actuarial value: 90% Out-of-pocket maximum capped at HSA level of $5, 950 for individuals and $11, 200 for families Young adult catastrophic policy, covering preventive services, would be available House Essential health benefits package at four cost-sharing tiers 1 st tier (Basic) actuarial value: 70% 2 nd tier (Enhanced) actuarial value: 85% 3 rd tier (Premium) actuarial value: 95% 4 th tier (Premium-Plus) actuarial value: 95% plus oral health and vision care Annual out-of-pocket maximum $5, 000 for individuals, $10, 000 for families THE COMMONWEALTH FUND Source: Commonwealth Fund analysis of health reform proposals.

Premium Subsidies Premium Subsidy Senate Sliding scale credits based on 2 nd lowest cost Premium Subsidies Premium Subsidy Senate Sliding scale credits based on 2 nd lowest cost silver plan such that premium contributions are no greater than 2% of income for 100% FPL or less to 9. 8% of income for 300– 400% FPL; If employer coverage contribution is <9. 8% of income, not eligible for subsidies House Premium subsidy for purchase through exchange so contribution is limited, as share of income, to: 133– 150% FPL: 1. 5– 3. 0% 150– 200% FPL: 3. 0– 5. 5% 200– 250% FPL: 5. 5– 8. 0% 250– 300% FPL: 8. 0– 10. 0% 300– 350% FPL: 10. 0– 11. 0% 350– 400% FPL: 11. 0– 12. 0% (based on average premium of 3 lowest cost plans) If employer coverage contribution is <12% of income, not eligible for subsidies THE COMMONWEALTH FUND Source: Commonwealth Fund analysis of health reform proposals.

Cost-Sharing Credits and Limits Senate House Cost-sharing subsidies limit cost-sharing thus increasing actuarial value Cost-Sharing Credits and Limits Senate House Cost-sharing subsidies limit cost-sharing thus increasing actuarial value of essential benefits to: 100– 150% FPL — 90% 150– 200% FPL — 80% Cost-sharing credits reduce limits on cost-sharing, thus increasing actuarial value of basic plan to: 133– 150% FPL: 97% 150– 200% FPL: 93% 200– 250% FPL: 85% 250– 300% FPL: 78% 300– 350% FPL: 72% 350– 400% FPL: 70% OOP limit for 100– 200% FPL is 1/3 HSA limit $1, 964 OOP limit for 200– 300% FPL is 1/2 HSA limit $2, 975 OOP limit for 300– 400% FPL is 2/3 HSA limit $3, 927 Cost-sharing is eliminated for preventive services Annual OOP limits (individual/family) 133– 150% FPL: $500/$1, 000 150– 200% FPL: $1, 000/$2, 000 200– 250% FPL: $2, 000/$4, 000 250– 300% FPL: $4, 000/$8, 000 300– 350% FPL: $4, 500/$9, 000 350– 400% FPL: $5, 000/$10, 000 Cost-sharing is eliminated for preventive services Note: OOP is defined as “out-of-pocket” costs. AV is defined as “actuarial value. ” Source: Commonwealth Fund analysis of health reform proposals. THE COMMONWEALTH FUND

Medicaid Premium Caps as a Share of Income Under Senate and House Bills Note: Medicaid Premium Caps as a Share of Income Under Senate and House Bills Note: Under the Senate bill, people are eligible for Medicaid up to 133% FPL; under the House bill, people are eligible for Medicaid THE COMMONWEALTH up to 150% FPL. FUND Source: SR Collins, K Davis, J Nicholson, S Rustgi, R Nuzum, The Health Insurance Provisions of the 2009 Congressional Health Reform Bills: Implications for Coverage, Affordability, and Costs, The Commonwealth Fund, Nov. 2009.

Percent of Income Spent on Premiums 2009– 2019 If the Percent of Total Premiums Percent of Income Spent on Premiums 2009– 2019 If the Percent of Total Premiums Paid by Families Remains Constant, Senate Bill and House Bill* Percent of income spent on premiums 150% FPL 200% FPL 300% FPL 400% FPL *For a family of four in a medium-cost area in 2009 (age 40). Premium estimates are based on Senate Silver Plan, AV = 0. 70, House Basic Plan, AV THE = 0. 70; 2009 premium estimates are from Kaiser Family Foundation Health Reform Subsidy Calculator – Premium Assistance for Coverage in COMMONWEALTH FUND Exchanges/Gateways, http: //healthreform. kff. org/Subsidycalculator. aspx. Source: SR Collins, K Davis, J Nicholson, S Rustgi, R Nuzum, The Health Insurance Provisions of the 2009 Congressional Health Reform Bills: Implications for Coverage, Affordability, and Costs, The Commonwealth Fund, Nov. 2009.

Percent of Total Annual Medical Costs, Excluding Premiums, Paid by Enrollee Net of Subsidies Percent of Total Annual Medical Costs, Excluding Premiums, Paid by Enrollee Net of Subsidies Under Senate and House Bills* Medicaid Percent *For a family of four in a medium-cost area in 2009 (age 40). Cost-sharing estimates are based on: Senate Silver Plan, AV = 0. 70; THE House Basic Plan, AV = 0. 70. COMMONWEALTH FUND Under the Senate bill, people are eligible for Medicaid up to 133% FPL; under the House bill, people are eligible for Medicaid up to 150% FPL. Source: Commonwealth Fund analysis of proposals. Premium estimates are from Kaiser Family Foundation Health Reform Subsidy Calculator – Premium Assistance for Coverage in Exchanges/Gateways, http: //healthreform. kff. org/Subsidycalculator. aspx.

Penalties for Non-Compliance With the Individual Mandate Under Senate and House Bills on pti Penalties for Non-Compliance With the Individual Mandate Under Senate and House Bills on pti e em m Ex nco hip f i ds % o ar. 8 e. H >9 at en ium S em Pr Penalty per Person Estimated family premium, Senate & House = $9, 435 Estimated single premium, Senate & House = $3, 500 House Senate (2016) = $750 Senate (2015) = $350 Senate (2014) = $95 Income Note: The penalty under the Senate bill is implemented at $95 in 2014 and increases to $750 in 2016. The House penalty is calculated as 2. 5% of the difference between average modified adjusted gross income (MAGI) and the tax filing threshold. Calculations begin at $20, 000 because that is the point where MAGI exceeds the tax filing threshold. People are exempt if they have household incomes under 133% FPL or if premiums are greater than 9. 8% (Senate). Projected premiums are under House and Senate proposals. THE COMMONWEALTH Source: Commonwealth Fund analysis of the proposals; Urban-Brookings Tax Policy Center, “Average Modified Gross Income FUND and Average Modified Adjusted Gross Income Across Cash Income Levels, 2009”, Oct 15, 2009 available at www. taxpolicycenter. org/numbers/displayatab. cfm? Docid=2486&Doc. Type. ID=1.

Small Business Tax Credits Under Senate and House Bills for Family Premiums Credit per Small Business Tax Credits Under Senate and House Bills for Family Premiums Credit per Employee $9, 435 – projected family premium under Senate & House 50% employer contribution $4, 718* 65% employer contribution $6, 133* $4, 718* *To be eligible for tax credits, firms must contribute 50% of premiums per family under the Senate plan, and 65% under the House plan. Firms receive 35% and later 50% of their contribution in tax credits under Senate, and 50% of contribution under House. Note: Projected premium for a family of four in a medium-cost area in 2009 (age 40). Premium estimates are based on: Senate Silver Plan, AV = 0. 70; House Basic Plan, AV = 0. 70. Senate defines small firms as those with fewer than 25 employees with average wages below $40, 000. House defines small firms as those THE with average wage less than $20, 000 or fewer than 10 employees; credits phase out until average wage equals $40, 000 or up to 25 COMMONWEALTH FUND employees. Source: Commonwealth Fund analysis of proposals. Premium estimates are from Kaiser Family Foundation Health Reform Subsidy Calculator, http: //healthreform. kff. org/Subsidycalculator. aspx.

Acknowledgements Karen Davis, President Jennifer Nicholson, Associate Program Officer, Affordable Health Insurance www. commonwealthfund. Acknowledgements Karen Davis, President Jennifer Nicholson, Associate Program Officer, Affordable Health Insurance www. commonwealthfund. org Rachel Nuzum, Senior Policy Director Sheila Rustgi, Program Associate, Affordable Health Insurance THE COMMONWEALTH FUND