1. THE COMMONWEALTH FUND Achieving and Maintaining Near Universal Coverage Under the Affordable Care Act: Key Issues For Federal and State Policy Makers Sara R. Collins, Ph.D. Vice President, Affordable Health Insurance The Commonwealth Fund Alliance for Health Reform Briefing Keeping Coverage Continuous: Smoothing the Path Between Medicaid and the Exchange May 20, 2011

2. THE COMMONWEALTH FUND

3. THE COMMONWEALTH FUND Exhibit 2. Source of Insurance Coverage Pre-Reform and Under Affordable Care Act, 2020 * Employees whose employers provide coverage through the exchange are shown as covered by their employers. Note: ESI is employer- sponsored insurance; “Other” includes Medicare. Source: Testimony Statement of Douglas W. Elmendorf, Director, before the Subcommittee on Health Committee on Energy and Commerce U.S. House of Representatives, CBO’s Analysis of the Major Health Care Legislation Enacted in March 2010, March 30, 2011. http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf Among 284 million people under age 65 Under Prior Law 163 M (57%) ESI 36 M (13%) Medicaid 56 M (20%) Uninsured 15 M (5%) Other 14 M (5%) Nongroup 162 M (57%) ESI 52 M (18%) Medicaid 24 M (8%) Exchanges (Private Plans) 15 M (5%) Other 8 M (3%) Nongroup 23 M (8%) Uninsured Affordable Care Act

4. THE COMMONWEALTH FUND TX FL NM GA AZ CA WY** NV AK OK MS LA MT TN Exhibit 3. Status of State Legislation to Establish Exchanges, As of May 2011 *North Dakota pending legislation provides an appropriation for exchange creation (H 1126). **Wyoming legislation provides for a study of whether the state should establish and operate a Wyoming health insurance exchange or participate in a regional exchange, requires a report and specifying report requirements, provides an appropriation (H 50). *** Indiana Governor signed an Executive Order in Jan 2011 establishing an exchange (Executive Order 11-01). ****Wisconsin legislation is to study feasibility of exchange. Source: National Conference of State Legislatures, Federal Health Reform: State Legislative Tracking Database. http://www.ncsl.org/default.aspx?TabId=22122; Commonwealth Fund Analysis. http://www.ncsl.org/default.aspx?TabId=22122 WA OR ID SD ND* MN WI**** MI IA AR IL OH WV VA AL PA NY ME MA NH VT HI Legislation signed into law Legislation passed one or both houses Governors have pursued/considering non-legislative options Legislation signed, intent to est. or study exchange Legislation pending in one or both houses UT CO KS NE IA MO IL IN*** KY WV VA NC SC DC MD DE NJ CT RI Legislation has been vetoed

5. THE COMMONWEALTH FUND Exhibit 4. Seven States Awarded Early IT Innovator Grants from HHS StateDepartment or AgencyGrant Amount Kansas Kansas Insurance Department $31,537,465 Maryland Maryland Department of Health and Mental Hygiene $6,227,454 Multi-State Consortia University of Massachusetts Medical School $35,591,333 New York New York Department of Health $27,431,432 Oklahoma Oklahoma Health Care Authority $54,582,269-Declined OregonOregon Health Authority$48,096,307 Wisconsin Wisconsin Department of Health Services $37,757,266 Source: US Department of Health and Human Services News Release, States Leading the Way on Implementation: HHS Awards “Early Innovator” Grants to Seven States, February 16, 2011, http://www.hhs.gov/news/press/2011pres/02/20110216a.html

6. THE COMMONWEALTH FUND Four levels of cost-sharing 1st tier (Bronze) actuarial value: 60% 2nd tier (Silver) actuarial value: 70% 3rd tier (Gold) actuarial value: 80% 4th tier (Platinum) actuarial value: 90% Catastrophic policy with essential benefits package available to young adults and people who cannot find plan premium <=8% of income Annual OOP limits (individual/family) 100%–200% FPL: 1/3 HSA limit, $1,983/$3,967 200%–300% FPL: 1/2 HSA limit, $2,975/$5,950 300%–400% FPL: 2/3 HSA limit, $3,967/$7,933 Cost-sharing is eliminated for preventive services Exhibit 5. Subsidized Health Insurance Under the Affordable Care Act Federal poverty level Income for a family of four Premium tax credit cap as a share of income Average cost-sharing as share of medical costs <133%<$29,726Medicaid 133%–149%$29,726–<$33,5253.0%–4.0%6% 150%–199%$33,525–<$44,7004.0%–6.3%13% 200%–249%$44,700–<$55,8756.3%–8.05%27% 250%–299%$55,875–<$67,0508.05%–9.5%30% 300%–399%$67,050–<$89,4009.5%30% >400%>$89,400—— Note: FPL refers to Federal Poverty Level. OOP refers to out-of-pocket costs. Actuarial values are the average percent of medical costs covered by a health plan. Premium and cost-sharing credits are for silver plan. Source: Federal poverty levels are for 2011; Commonwealth Fund Health Reform Resource Center: What’s in the Affordable Care Act? (PL 111-148 and 111-152), http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.