ACA 101 for Texas and the Uninsured Click

ACA 101 for Texas and the Uninsured Click to edit Master title style Coverage Gap Click to edit Master subtitle style Anne Dunkelberg, Associate Director – dunkelberg@cppp. org Affordable Care Act: Where are we now? San Antonio Metropolitan Health District Thursday, August 8, 2013 CPPP. org 1

2013 -14 Timeline May 3 June 7 August 15 Plan details due to federal Marketplace Navigator awards made. Training begins January OPEN ENROLLMENT BEGINS Navigator applications due October Plan coverage begins 1 1 March 31 Open enrollment ends

Texas Well and Healthy • Collaborative campaign of 4 non-profits in TX • Our goal: educate Texans about health care options • Website: www. texaswellandhealthy. org • Facebook: www. facebook. com/Kids. Well. Texas • Twitter: @Tx. Well. Healthy

An ACA Primer • The Patient Protection Affordable Care Act, signed into law on March 23, 2010. • Takes full effect January 1, 2014. • Gradual roll-out of benefits. • ACA, PPACA, Obamacare • 2012 SCOTUS decision: all systems go, except Medicaid Expansion is optional for states.

Changing Our System • One step at a time… • incredibly complex law, over 1000 pages. • what we’re about to walk through together is a “top 10” of the Affordable Care Act, very stripped down. • please ask questions!

No Lifetime or Annual Caps • As of 2010, the lifetime caps on health insurance benefits that used to hurt the sickest insured folks are GONE. • No more will a health insurance plan drop your coverage when you get so sick that your medical bills hit the roof. • Also, annual caps on health benefits are being phased out beginning in 2010.

No Pre-existing Conditions • As of 2010: children (ages 0 -18) can not be denied coverage based on pre-existing conditions. • Starting in 2014: No one can be denied insurance due to pre-existing conditions. • Starting in 2014: No one can be charged more because of health history or condition. • Only 3 things lead to higher premiums: age, tobacco use, and geography

Free Preventive Care • Preventive Care: annual well check-ups, routine care, vaccines, birth control, mammograms, colonoscopy, screenings, etc. • As of 2010: Kids, seniors, & disabled on Medicare receive preventive care free (no co-pay) • Aug 1, 2012: Women get contraceptives and well woman care free (no co-pay) • Starting in 2014: All insured adults and kids get free preventive care (no co-pay)

Essential Health Benefits The ACA is making sure that in 2014, ALL health insurance policies will cover 10 Essential Health Benefits. This means all health conditions should get the coverage they need! 1. 2. 3. 4. 5. ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; 6. prescription drugs; 7. rehabilitative and habilitative services and devices; 8. laboratory services; 9. preventive and wellness services and chronic disease management 10. pediatric services, including oral and vision care.

Women & ACA Starting Aug. 1, 2012, NO CO-PAY for: • Well Woman Visits: Annual visits covered means women can receive preventive care when it matters most • Lactation Counseling: Pregnant and post-partum women have access to comprehensive lactation support and counseling from trained providers as well as breastfeeding equipment to give moms and little ones the best start • DNA Testing for Cervical Cancer: Women who are 30 or older will have access to HPV testing every 3 years, even if previous pap tests were normal • Contraceptive Counseling: Women will have access to all FDA approved contraceptive methods and patient education/counseling • STI and HIV Screenings & Counseling: Women will have access to annual testing and counseling on HIV and Sexually Transmitted Infections (STI) • Gestational Diabetes Screenings: Screenings will be preformed at 24 - 28 weeks pregnant and for those at high risk • Domestic Violence Screening: Screening and counseling for domestic and partner violence will be provided for all women

Seniors & Disabled • For seniors and the disabled on Medicare, you are already receiving free screenings and preventive care. • Closing the Medicare prescription “doughnut hole, ” by making prescription drugs more affordable. o In Texas in 2011, the average savings was approximately $639 for each person who fell into the doughnut hole. o By 2020, the gap in drug coverage will be completely gone.

Small Business Owners • Because of ACA, many small business owners have access to new tax credits to help them buy health insurance for their employees, if they want to. o 35% tax credit now o Up to 50% tax credit in 2014 • No penalties or obligations for small business owners (50 or fewer employees) who choose not to provide insurance. • For those who do, the ACA makes it easier to buy and afford insurance through Small Business Health Insurance Exchange (called SHOP).

Individual Mandate • If you are uninsured through your job, Medicaid, or Medicare, you must purchase insurance for yourself, or pay a tax. • If it costs more than 8% of your house-hold income, you are exempt – pay no penalty. • Why is universal coverage important? We will all get sick at some point and when someone doesn’t have coverage we all pay for it in higher premiums.

Regulating Insurers The 80/20 Rule: o Insurers have to spend 80% of your premiums on your health care, only 20% can go to overhead and profits o Because of this, millions of Texans got $167 million in rebates during 2012 ($187 avg check) Rate Review: o Any health insurance increase 10% or more goes through an automatic review process on whether or not is justified. o We still need “teeth” to stop unjustified rate hikes.

Marketplace Basics • Terminology: Health Insurance Marketplace (formerly known as the Exchange) and SHOP for small employers • Compare private insurance plans based on price, benefits, quality, and other features • Most people will get a break on costs • “No wrong door” with Medicaid and CHIP • Open enrollment starts October 1, 2013, and coverage is effective beginning on January 1, 2014

The Affordability Puzzle 1) Premium Credits 2) Help with Health Care Costs ü Preventive Services ü Out-of-Pocket Caps ü Cost-Sharing Subsidies

Cost-Sharing Help 1) No Cost-Sharing for Recommended Preventive Services 2) Out-of-Pocket Caps 3) Cost-Sharing Subsidies

In-Person Enrollment Assistance in 2014 In-person Assistance: • Agents/Brokers • Navigators • Certified Application Counselors • Safety Net Providers

What is an ACA Navigator? • Entities that will offer knowledgeable, in-person enrollment assistance to consumers and small employers in the Health Insurance Marketplace. • Will help people learn about their coverage options in the new Marketplace, and to enroll in Medicaid, CHIP, or private coverage. • Navigator duties: • outreach/education; • provide impartial information on plans; • facilitate enrollment • provide referrals; and • provide that is culturally and linguistically appropriate, and accessible to those with disabilities

Types of ACA In-Person Enrollment Assistance • Navigators – More broad based, comprehensive consumer assistance. Grants funded by the Marketplace. • Certified Application Counselors • Based in hospitals, clinics, or community organizations. • Help enroll patients/individuals served by that provider/org. • Provide info about coverage options, and assist with computer process to enroll in Medicaid/Exchange options; but no public outreach/education. • Unfunded

The Need for Navigators Nationally, 75% of the newly eligible said that they wanted inperson assistance to learn about and enroll in coverage. (Enroll America Research, 2012). The profile of Marketplace enrollees is unique. Nationally: • 65% previously uninsured • 77% have high school diploma or less • Lower income than insured today • 81% will receive subsidies • Median income is 235% FPL ($54 k for a family of 4) • More racial and ethnic diversity • 23% do not speak English at home Kaiser Family Foundation, A Profile of Health Insurance Exchange Enrollees , March 2011

Marketplace and Medicaid: Building Blocks of ACA’s 2014 Reforms • Build on current system: Most Americans still get coverage through their employer. • Medicaid expansion: US citizens to 133% FPL ($14, 856 individual; $30, 657 for 4 in 2012). State option. • Reform private health insurance: standard minimum benefits, can’t charge more based on health status, limits on premium differences by age, no denial of coverage, no excluding pre-existing conditions, no annual or lifetime maximums. • New Health Insurance Marketplace where private insurers’ options can be compared and purchased. • Sliding scale help with premiums in the exchange from 100% up to 400% of FPL ($92, 200 for family of 4). • Sliding scale help with deductibles/co-pays and out-of-pocket caps in the exchange • Individual mandate to have coverage (with major exemptions for lowest-income). • Employer penalties possible if employees get sliding-scale help in Marketplace, but exemption for all employers with 50 or fewer FTE workers. 22

2014: ACA Provides Public Support Fitted to Income >$89, 400 for a family of four; >400% of FPL Family Income $67, 100 -$89, 400; 300 -400% of FPL $44, 700 -$67, 100; 200 -300% of FPL Job-based coverage, or Full-cost coverage in the exchange Job-based coverage, or Subsidized exchange coverage: premiums capped at 9. 5% of income Job-based coverage, or Subsidized exchange coverage: premiums capped at 6. 3 – 9. 5% of income CHIP • Job-based coverage, or • Subsidized exchange coverage: premiums capped at 3% - 6. 3% of income Medicaid ? ? ? Medicaid? ? ? Children Adults $29, 700 -$44, 700; 133 -200% of FPL <$29, 700 for a family of four; < 133% FPL Family income based on 2011 federal poverty income levels for a family of four (non-disabled adults, not eligible for Medicare) 23

Texas Uninsured by Income 2011… 89% of the 6. 1 million uninsured have incomes <400% FPL 656 K 501 K 1. 912 Million 421 K 626 K 6. 1 million includes 1. 7 million non-US citizens; ~2/3 of these (about 1. 1 million) likely undocumented 614 K 921 K 525 K Annual income limits given for a family of four, 2011 federal poverty level U. S. Census, 2012 CPS 24

Texas Enrollment Opportunity As of 2010, 6. 2 million Texans were uninsured. This is how those individuals could gain coverage under the ACA: Marketplace with help Marketplace at full cost Medicaid adults: newly eligible Medicaid/CHIP kids: eligible now but not enrolled Left uninsured 25

About 1. 5 million Texans would gain insurance with Medicaid expansion • Experts and Texas HHSC estimate 1. 3 -1. 8 million uninsured US citizen adults in Texas will be eligible for the Medicaid option in 2014, • HHSC projects just over a million of these adults would actually enroll by 2016 (note the difference between who is eligible, versus who actually signs up). • HHSC also estimates that over 400, 000 more children— already eligible today, but unenrolled—will sign up for Medicaid by 2016 because of higher public awareness: called the “welcome mat” effect. 26

But, If Texas Opts Out • ACA sliding-scale premium help is available only to persons above 100% FPL (exception: legal immigrants excluded from Medicaid) , so: – Uninsured Texas adults below 100% FPL would have NO assistance available in 2014. – Those from 100 -133% FPL would be eligible for premium assistance, but because the system was designed assuming poorest would have Medicaid, some of these near-poor will have difficulty affording the coverage even with premiums capped at 2% of family income. – So, costs of care for uninsured poor Texas adults will continue to be carried primarily by local property taxpayers, secondarily by other charity care providers, and without benefit of the 90%+ federal matching dollars. 27

There is significant variation in the share of the uninsured that is below the Medicaid expansion limit across states . Share of Nonelderly Uninsured <138% FPL by State, 2010 -2011: VT WA ND MT OR WI WY UT CA AZ CO NM IL KS OK MO TX 53% HI United States: 51% Uninsured <138% FPL MI PA OH IN WV KY DC SC AR AL VA CT NJ DE MD NC TN MS AK NY IA NE NV NH MN SD ID ME GA LA FL 34% – 47% (17 states) 48% – 51% (18 states, including DC) 52% - 61% (16 states) SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2011 and 2012 Current Population Survey (CPS: Annual Social and Economic Supplements). MA RI

Texas Uninsured: Without Medicaid Expansion, Only half as many gain coverage 6. 1 million uninsured Michael E. Cline, Ph. D. , and Steve H. Murdock, Ph. D. , Rice University, Estimates of the Impact of the Affordable Care Act on Counties in Texas, April 2012. 30

Texas Medicaid/CHIP: Who is Helped Today January 2013, HHSC data Total enrolled 1/1/2013: 3. 6 million Medicaid; 592, 000 CHIP 1 in 7 Texans, but 42% of Texas kids 31 31

Why So Few Poor Parents Covered in Texas Medicaid • Texas Medicaid has VERY low coverage of parents (must live below 12% of poverty; work less than 10 hrs/wk @ min wage; must be under $308 a month for family of 3). – This dollar limit set by Texas legislature 1985 and never updated. • Today, about 226, 000 poor Texas parents get Medicaid, even though there about 2. 6 million children enrolled. • Medicaid Maternity coverage income limit is much higher, but coverage ends 2 months after birth. • Medicaid does not cover undocumented at any age. • LEGAL immigrant adults NOT covered in Texas Medicaid (state choice, AL, VA, , MS, ND, OH, WY also exclude). (Legal immigrant kids through age 18 are covered in Texas Medicaid and CHIP) 32

Income Caps for Texas Medicaid and CHIP, 2012 $25, 128 $35, 317/yr $25, 390/yr 185% 225% $19, 090 $38, 180 200% $8, 376 185% 133% 100% $2, 256 12% $3, 696 19% 75% “Optional” indicates Texas Choices to go ABOVE federal minimum Income Limit as Percentage of Federal Poverty Income Annual Income is for a family of 3, except Individual Incomes shown for SSI and Long Term Care 33

The Medicaid expansion will significantly increase eligibility for parents in many states. Medicaid Eligibility Levels for Parents, January 2013: 138%* 25% NOTE: Ten states (CT, IL, ME, MA, MN, NJ, NY, RI, VT, WI) and DC already offer coverage to parents at or above 133% FPL; under the ACA an income disregard of 5 percentage points will be applied to this limit increasing the effective income limit to 138% FPL. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2013.

Figure 35 In states that do not expand Medicaid, there will be large gaps in coverage, leaving millions of low-income adults with no affordable options. NOTE: Applies to states that do not expand Medicaid. The current median state Medicaid eligibility limit for parents is 48% FPL in the 21 states that are not moving forward with the Medicaid expansion at this time.

Status of State Action on the Medicaid Expansion Decision, as of July 1, 2013 Source: KFF. org 36

What does Texas pay, and what does federal government pay if we expand Medicaid to adults under the ACA? • Federal government picks up 100% of the costs for the first three years of Texas’ expansion to the adults, • 95% in 2017, 94% in 2018, 93% in 2019, and no less than 90 percent every year after that. • Texas will also see increased enrollment—known as the “welcome mat” effect—by already-eligible but currently uninsured children. 37

Range of Official Cost Estimates • HHSC (Texas Medicaid agency) estimates the state-budget (GR) Medicaid costs to cover these new adults at $1. 3 billion GR for the first 4 years, drawing another $23. 9 billion in federal match. – HHSC projects in first 4 years, Texas would spend an average of $784 million a year, drawing over $6. 8 BILLION federal match (net gain over $6 billion/year) • Legislative Budget Board (LBB) often has different opinion of Medicaid caseload and cost per enrollee from THHSC; projects only $482 million state GR costs for 4 years. 38

5 Tools on Medicaid Expansion and Texas: 1. Choices and Challenges: How Texas County Uninsured Rates Will Drop Under Health Care Reform Cline & Murdock, of Rice U. (former Texas State Demographer and Director of the US Bureau of the Census) includes estimates of the much smaller reduction in uninsured rates expected if Texas does not accept the Medicaid Expansion. (see www. cppp. org) 2. Your County and the ACA Medicaid Expansion. CPPP compiled data for all 254 Texas counties on impact of ACA on uninsured, and the new federal dollars by county, based on Rice data above and the Texas Health and Human Services Commission’s latest official Medicaid expansion estimates. (see www. cppp. org) 3. Texas Has Only One Rational Choice: Expanding Medicaid Under the Affordable Care Act: Study by The Perryman Group Finds that Expanding Medicaid More than Pays for Itself. Analysis by The Perryman Group, every $1 spent by the State of Texas to expand Medicaid coverage under the Affordable Care Act (ACA) returns $1. 29 in dynamic State government revenue over the first 10 years of the expansion. http: //www. perrymangroup. com/ 4. Government Effectiveness and Efficiency Report 2013 (January 2013). This biennial report to the Legislature by Legislative Budget Board staff includes a chapter analyzing the costs and benefits of the ACA Medicaid expansion and recommending that counties be enabled to finance and implement the expansion. Smart, Affordable and Fair: Why Texas Should Extend Medicaid Coverage to Low-Income Adults (January 2013). This new report from Billy Hamilton Consulting provides a comprehensive model estimating the costs and benefits to local taxing authorities (including cities, counties and hospital districts) and state government. Using the Cline. Murdock model data, the authors conclude that state match needed for the Medicaid expansion are far less than current state, local, and hospitals spending on health care for low-income adults, and project $1. 8 billion in new state revenue will be generated by the expansion from 2014 through 2017, offsetting about half of the required state match. 5. 39

40

Large Urban Counties & Medicaid Expansion 2014 -2017 El Paso Dallas Yearly Avg. $222 million Uninsured NOW Estimated # Gaining Medicaid NEW Fed $ Harris Lubbock Travis $580. 1 million $935. 3 million $77. 7 million $224. 1 million 208, 379 601, 492 1, 025, 922 66, 405 233, 067 51, 462 131, 042 223, 165 19, 693 55, 676 Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC historical Medicaid spending by county, 2010. Cline & Murdock estimates of ACA insurance gains by county. 41

Largest South Texas Metro Counties & Medicaid Expansion: 2014 -2017 Bexar Cameron Hidalgo Nueces Webb NEW Fed $ $ 503. 5 million $ 198. 4 million $ 404. 7 million $ 127. 1 million $92. 0 million Estimated # Gaining Medicaid 1 79, 654 27, 987 50, 509 22, 403 16, 031 One-year Avg. Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC historical Medicaid spending by county, 2010. Cline & Murdock estimates of ACA insurance gains by county. 42

What’s Happened? • 13 House and 6 Senate billed filed to expand Medicaid per ACA; each chamber included a bill authored by a Republican in a leadership role (Rep. Zerwas; Senator Deuell). – Also Senate budget “rider” by Finance committee Chairman Tommy Williams • Widespread Support, Executive Opposition. Statewide support for Medicaid expansion from doctors, hospitals, county officials, chambers of commerce, and even the Texas Association of Business eventually supporting the Zerwas coverage option. – Polling by Texas and national firms found 58 -59% of Texas voters support accepting federal ACA funds to cover the poorest uninsured adults. – Twenty-two chambers of commerce have called on the state to accept this funding, and new chambers continue to add their names to the list. • Despite this support, the Legislature did not move the veryconservative, market-based “Texas Solution” alternative offered by Rep. John Zerwas HB 3791. – There was more than sufficient support by House members for Zerwas’ “Texas Solution” bill. But the Governor’s office began to communicate a veto threat 43

What’s Next? Texas’ decision means that in January 2014: • Texas adults above the poverty line will begin to get publicly funded sliding-scale help with health insurance, • but Texans below poverty will qualify for nothing. Estimates of the number of uninsured Texas adults who will be left without a coverage option in the near term range: • from around 935, 000 (HHSC, out of 1. 1 million below 138% of poverty) • to as high as 1. 3 million (Urban Institute/Kaiser Family Foundation, out of about 1. 7 million below 138% of poverty). A Diverse network of Texans and Texas Organizations will keep working to find health care for the Texans in the “Gap Group, ” to tell their stories, and to seek inclusion of Texas’ working poor in the ACA’s health reform. www. texaswellandhealthy. org 44

INFORMATION NOW: Health. Care. gov Available 24/7: 1 -800 -318 -2596; TTY: 1 -855 -889 -4325 Or, Chat Online 45

FAMILY BUDGETS Use of This Presentation The Center for Public Policy Priorities encourages you to reproduce and distribute these slides, which were developed for use in making public presentations. If you reproduce these slides, please give appropriate credit to CPPP. The data presented here may become outdated. For the most recent information or to sign up for our email updates, visit our website. © CPPP Center for Public Policy Priorities 7020 Easy Wind Drive, Suite 200 Austin, TX 78752 P 512. 320. 0222 F 512. 320. 0227 Methodist Healthcare Ministries 4507 Medical Drive San Antonio, TX 78229 Toll-Free: 800. 959. 6673 P 210. 692. 0234 F 210. 614. 7563 www. MHM. org CPPP. org 46