1. February 5, 2014 Heather Howard Director, State Health Reform Assistance Network Lecturer in Public Affairs, Princeton University heatherh@princeton.edu 1/5/11 Public Health in Action: The ACA and Medicaid Expansion in PA and State by State 1

2. Overview 2 The Affordable Care Act Key provisions State implementation is critical to success National Landscape Medicaid expansion Exchange implementation Issues to Watch

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4. 4 Affordable Care Act (ACA): Key Provisions Insurance reforms Requirement to purchase insurance Coupled with subsidies for those with incomes up to 400% of the federal poverty level (FPL) Health Insurance Exchanges Marketplace for individuals and small businesses to compare policies and premiums Medicaid eligibility expanded to 138% FPL Simplified Eligibility & Enrollment – “No Wrong Door” Most provision went into effect in 2014

5. 5 Why Focus on State Implementation? States have central role in success or failure of ACA Range of state requirements and options States may choose to set up insurance exchanges State may opt to participate in delivery system reforms States may expand Medicaid Most states are enforcing new insurance market rules Context: state budget challenges, capacity constraints, politics “New Federalism” -- carrot and stick approach Myriad Federal grants to fund health reform efforts If states do not establish their own exchanges or effectively enforce new insurance market reforms, federal government will step in

6. Supreme Court Decision on ACA 6 Medicaid expansion is optional Majority found the Medicaid expansion unconstitutionally coercive of states “Gun to the head” because the “threatened loss of over 10 percent of a State’s overall budget... is economic dragooning that leaves the States with no real option but to acquiesce” Expansion is a “new program”; cannot withhold all Medicaid funds if state does not expand Thus the violation can be remedied by making the expansion optional

7. Medicaid Fast Facts 67 million People in the United States with Medicaid coverage. $440 billion State and federal Medicaid spending for FY 2012. 9-12 million Additional Medicaid/CHIP beneficiaries between 2014-2019, pending state decisions on Medicaid expansion. 48% Births in the United States covered by Medicaid. 1 in 3 Children in the United States covered by Medicaid. 57% Medicaid beneficiaries under 65 who are from diverse racial/ethnic groups. 5% Medicaid beneficiaries, many with chronic illnesses and disabilities, accounting for 55% of total Medicaid spending. 49% Medicaid beneficiaries with disabilities diagnosed with mental illness. 43% Total long-term care costs in the United States financed by Medicaid. 39% Percentage of Medicaid dollars spent on Medicare-Medicaid enrollees. 72% Medicaid recipients who are enrolled in managed care.

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10. Medicaid Expansion Challenges 10 Long-term Financing Newly eligible Medicaid populations 100% federally funded through 2016 Sliding scale brings federal portion down to 90% At risk during constant federal budget debates? Woodworking/Welcome Mat Effect States only receive traditional lower FMAP for currently eligible populations, not the enhanced FMAP for newly eligibles

11. Medicaid Expansion Challenges 11 How has expansion decision played out in states? State analysis of impact Role of stakeholders States see opportunity (and leverage) to innovate through waiver process Arkansas premium assistance or “private option” model starts feeding frenzy Michigan – creation of health savings accounts, premium and copay increases and four year “limit” Iowa Traditional Medicaid for under 100% FPL, plus premiums and copays Premium assistance to purchase QHPs for 100-138% Pennsylvania – Arkansas plus job search requirement

12. 12 INSERT LATEST SLIDE ON STATE EXCHANGE DECISIONS – FROM KIDSWELL OR KAISER

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14. Enrollment Observations 14 SBM enrollment generally outpacing FFM Most systems glitches worked out relatively quickly Robust consumer assistance and marketing efforts Mostly seamless eligibility between SBMs and Medicaid Plan choice (metal tier) varies across states, but overall 80% choosing silver or higher Age distribution varies as well, but overall 24% of enrollees in the 18-34 age range

15. Challenges 15 Systems failures Some vendors not able to deliver Audits = decisions to salvage or start over Workarounds Paper processes Continuation of previous coverage options (cancelled policies and high risk pools) Ongoing concerns from carriers about enrollment and payment data connections

16. Consumer Assistance is Critical 16 ACA created three consumer enrollment and assistance roles: Navigators and In-Person Assisters Will assist consumers and small employers with the health insurance enrollment process Conduct public education activities to raise awareness about the Marketplace, help people apply for and enroll in plans, and provide referrals to more informatio n Certified Application Counselors Other efforts Pharmacies Enroll America

17. 17 *Includes Partnership states with state consumer assistance programs

18. Consumer Assistance: Tale of Three States 18 FFM: Navigator grantees in Pennsylvania– approximately $2.7 million awarded Resources for Human Development, Pennsylvania Association of Community Health Centers, Pennsylvania Mental Health Consumers’ Association, Mental Health America SBE: New York has awarded $27 million for consumer assistance grants, will spend tens of millions on marketing Partnership: Illinois has awarded $28 million to 1,200 certified navigators and is spending $35 million on marketing and public relations

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20. 20 DO WE HAVE A GOOD SLIDE SHOWING ENROLLMENT THUS FAR?

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22. Issues to Watch 22 Enrollment – overall numbers, but also mix by age, health status Will state roles shift – accepting expansion or moving toward State-based marketplace? Churn Impact on broader insurance market Rise of narrow networks Private exchanges Affordability Further federal delays?

23. 23 Questions?