1. Health Care Reform: What It Means for You Jewish Family Service Austin Alamo Breast Cancer Foundation December 16, Stacey Pogue, Senior Policy Analyst, Center for Public Policy Priorities 900 Lydia Street - Austin, Texas (512) – 1

2. Health Reform: The Big Picture
Establishes a system for making comprehensive care available to all lawfully present Americans at an affordable price
Competition in health insurance marketplace cannot be based on avoiding risk
Lays a foundation for controlling costs and improving quality of care

3. Timeline 2010: Early insurance market reforms begin.
: Start building new systems needed to support covering large numbers of uninsured.
2014: Big expansion of coverage starts.
2010
2011
2012
2013
2014

4. Health Reform Building Blocks
First Year Reforms
No lifetime limits
Parent’s coverage for young adults to age 26
No pre-existing condition denials for kids
More accountability for premiums
New federal high risk pool:
Small employer tax credits
Medicare improvements

5. Health Reform Building Blocks
Private Market
Can’t deny coverage
No pre-existing condition exclusions
Can’t charge more if you get sick
Limits on premium increases based on age
Minimum essential benefits and more standardized plans
Small business tax credits increase
2014

6. Health Reform Building Blocks
Medicaid Expansion
Eligibility up to 133% of the federal poverty level ($29,300/yr for family of four)
Adds ≈ 1.3 million adults in Texas
Need improved eligibility system
Full federal funding
Maximum state share of 10%
Significant new state costs
2014

7. Health Reform Building Blocks
Exchange & Affordability
Exchange = state-based, organized insurance market
Clear, comparable information on cost, coverage, value
Open to:
Individuals without job-based insurance
Small employer groups
Members of Congress
Premium assistance for <400% FPL
($88,000 for a family of four)
Sliding-scale deductibles/copays and
out-of-pocket caps
2014

8. Coverage Level Options in the Exchange
% enrollee cost share
4 standard levels, plus a catastrophic plan (for people under age 30 or if no other coverage is affordable)
Options vary by % of covered benefits paid by the plan on average vs % covered through out-of-pocket enrollee cost sharing
% covered by plan
Platinum
Gold
Silver
Bronze
All coverage has essential benefits, to be defined by HHS: hospital, ER, mental health, maternity, Rx, preventive care, chronic disease management and more.

9. >$88,400 for a family of four; <$29,300 for a family of four;
Health Reform Coverage Options by Income
>$88,400 for a family of four;
>400% of FPL
Job-based coverage, or
Full-cost coverage in the exchange
$66,200-$88,400;
% of FPL
Subsidized exchange coverage: premiums capped at 9.5% of income
$44,100-$66,200;
% of FPL
Subsidized exchange coverage: premiums capped at 6.3 – 9.5% of income
$29,300-$44,100;
% of FPL
CHIP
Subsidized exchange coverage: premiums capped at 3% - 6.3% of income
<$29,300 for a family of four;
< 133% FPL
Medicaid
Children
Adults
(non-disabled adults,
not eligible for Medicare)
Family Income
Family income based on 2009 federal poverty income levels for a family of four

10. Texas Uninsured by Income Today…
88% of 6.4 million uninsured <400% FPL
758K
1.8 Million
628K
6.4 million includes
1.6 million non-citizens; ~2/3 of ( just over
1 million) likely undocumented
1.2 Million
2.1 Million 10
Annual income limits given for a family of four, federal poverty level U.S. Census, CPS

11. Health Reform Building Blocks
Individual Mandate
Requirement to have coverage if you have an affordable option
Several exemptions
Needed for affordable coverage after market reforms
Penalty is 1/6 of the
cost of coverage
2014

12. Health Reform Building Blocks
Employer Responsibility
Larger employers face penalties if full-time workers get subsidized exchange coverage
Penalty is ≈1/4 of the cost of coverage
Small employers have no new obligations; won’t face penalties
May qualify for tax credits (2010)
Can purchase at a fair price in exchange
Or employees can directly get affordable exchange coverage
2014

13. 282 Million U.S. Residents Under Age 65
Americans’ Coverage in 2019: If nothing changed compared to health reform law
Private Exchanges
24 million 9%
Uninsured
54 million
19%
Medicaid/CHIP
35 million
12%
Medicaid/CHIP
51 million
18%
Uninsured
23 million 8%
Nongroup & Other
30 million 11%
Nongroup &
Other
26 million 9%
Employer
162 million
57%
Employer
159 million
56%
Without reform
282 Million U.S. Residents Under Age 65
Under Reform
Source: The Congressional Budget Office Cost Estimate of H.R. 4872, Reconciliation Act of 2010, Mar. 20, 2010

14. Which Texans would Gain Coverage If Reform were Fully Implemented Today?
Of the 6.4 Million Uninsured Texans today…
Exchange with help
Exchange at full cost
Medicaid adults: newly eligible
Medicaid/CHIP kids: eligible NOW but not enrolled
Remain uninsured 14
≈ 2 Texans gain private coverage for each 1 gaining through Medicaid

15. Who Will Still be Uninsured?
U.S. Citizens
Not subject to mandate; will not owe penalty
those with very low income
those who would pay more than 8% of income for most affordable exchange coverage
Subject to mandate; will owe penalty
Some may choose not to buy coverage
Others may still find coverage unaffordable
Undocumented:
not covered by the mandate
no Medicaid/CHIP (not before, not now),
no premium help, and cannot buy at full cost from exchange
Legal Permanent Residents:
Adults are excluded from Texas Medicaid under state law, but
Can purchase from exchange and qualify for help with premiums

16. New State Roles New State Roles
State Medicaid eligibility system must grow, improve performance
Create and run a health insurance exchange
New roles for Texas Department of Insurance
Rate review and regulation
New office of health insurance consumer ombudsman
Needed: aggressive initiative to expand health care workforce
Needed: sufficient revenue for state Medicaid match
Challenge: Texas needs real investments in these systems, but leadership is planning cuts 16 16

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