1. The Patient Protection and Affordable Care Act (ACA) and Health Coverage Stan Dorn December 6, 2015 Tifereth Israel Congregation ◊ Washington, DC

2. What has happened thus far?

3. 3 Timing of selected ACA coverage provisions 20102011201220132014 March: ACA passes. September: 1. Dependents up to age 26 can enroll on parents’ plans. 2. No preexisting condition exclusions for children. June: U.S. Supreme Court rules that each state can choose whether to implement the ACA’s Medicaid expansion to low-income adults up to 138% of federal poverty level (FPL). Note: FPL is $11,770 for a single person and $24,250 for a family of four in 2015. October: Open enrollment begins, for coverage starting in January 2014. January: 1. Medicaid expansion becomes effective in states that choose to implement it. 2. Marketplaces offer plans, with financial assistance for people 100-400% FPL who are not offered Medicaid or employer coverage. 3. Individual coverage required. 4. Insurance reforms become effective, including bar on preexisting-condition exclusions for adults.

4. 4 Maximum financial eligibility for health assistance: people without disabilities under age 65, before and after 2014 Source: Martha Heberlein, et al., Georgetown Center for Children and Families and Kaiser Commission on Medicaid and the Uninsured, 2013, https://kaiserfamilyfoundation.files.wordpress.com/2013/05/8401.pdfhttps://kaiserfamilyfoundation.files.wordpress.com/2013/05/8401.pdf Note: CHIP is the children’s health insurance program. For Medicaid/CHIP coverage pre-2014, figure shows financial eligibility threshold in median state; parental coverage is for working parents. Figure does not show (1) non-financial eligibility criteria or (2) changed children’s eligibility due to shift to modified adjusted gross income. 2014 eligibility is for states expanding Medicaid. Federal Poverty Level

5. 5 The percentage of U.S. residents without insurance, by age, 2010-2015 Source: Centers for Disease Control and Prevention, National Center for Health Statistics, 2015, http://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly_estimates_2010_2015_Q12.pdf. http://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly_estimates_2010_2015_Q12.pdf Note: Estimates are annual averages, except for 2015, which is an average for January-June.

6. 6 From Sept. 2013 to Sept. 2015, the number of uninsured adults under age 65 fell by 14.3 million Source: Karpman and Long, Urban Institute, 2015, http://hrms.urban.org/quicktakes/Gains-in-Health-Insurance- Coverage-under-the-ACA-Continue-as-of-September-2015-but-Many-Remain-Uninsured.html.http://hrms.urban.org/quicktakes/Gains-in-Health-Insurance- Coverage-under-the-ACA-Continue-as-of-September-2015-but-Many-Remain-Uninsured.html Note: FPL = federal poverty level,

7. 7 Percentage of U.S. residents under age 65 with various forms of coverage, 2013-2015 Source: Centers for Disease Control and Prevention, National Center for Health Statistics, 2015, http://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly_estimates_2010_2015_Q12.pdf http://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly_estimates_2010_2015_Q12.pdf Note: Public coverage includes Medicaid, Medicare, military, and veterans health care. Estimates are annual averages, except for 2015, which is an average for January-June.

8. Prospects for further progress

9. 9 Who are the remaining 32.3 million uninsured in 2015? Source: Rachel Garfield, et al., Kaiser Family Foundation, 2015, http://files.kff.org/attachment/issue-brief-new- estimates-of-eligibility-for-aca-coverage-among-the-uninsured/http://files.kff.org/attachment/issue-brief-new- estimates-of-eligibility-for-aca-coverage-among-the-uninsured/ Note: CHIP is the children’s health insurance program.

10. 10 In non-expanding states, how would Medicaid expansion change the number of uninsured? Impact on number of uninsured ThousandsPercentage U.S.-4,250-30% Alabama-177-41% Florida-750-29% Georgia-389-31% Idaho-59-36% Kansas-77-33% Louisiana-193-40% Maine-40-44% Mississippi-139-42% Missouri-191-39% Nebraska-42-33% Source: Buettgens, et al, Urban Institute, 2015, http://files.kff.org/attachment/issue-brief-medicaid-expansion-health- coverage-and-spending-an-update-for-the-21-states-that-have-not-expanded-eligibilityhttp://files.kff.org/attachment/issue-brief-medicaid-expansion-health- coverage-and-spending-an-update-for-the-21-states-that-have-not-expanded-eligibility

11. 11 In non-expanding states, how would Medicaid expansion change the number of uninsured (cont.)? Impact on number of uninsured ThousandsPercentage North Carolina-313-31% Oklahoma-127-30% South Carolina-160-33% South Dakota-25-43% Tennessee-179-32% Texas-1107-27% Utah-68-26% Virginia-179-29% Wisconsin-21-9% Wyoming-14-30% Source: Buettgens, et al, Urban Institute, 2015, http://files.kff.org/attachment/issue-brief-medicaid-expansion-health- coverage-and-spending-an-update-for-the-21-states-that-have-not-expanded-eligibilityhttp://files.kff.org/attachment/issue-brief-medicaid-expansion-health- coverage-and-spending-an-update-for-the-21-states-that-have-not-expanded-eligibility

12. 12 What do the uninsured say in 2015? “ Of uninsured individuals, 43 percent say they have looked to get health insurance on their own in the last 12 months and a similar number (41%) report they went to the marketplace to find a health plan. Almost 8 in 10 (79%) of the uninsured who looked for insurance say that after weighing everything, they could not afford a plan. Six in 10 are confused about or have not heard of the tax credit, and more than 7 in 10 want one-on-one help understanding their insurance options. After learning about the increasing penalty amounts for 2015 and 2016, 26 percent say this information makes them more likely to get insurance.” Source: Robert Wood Johnson Foundation, 2015, http://www.rwjf.org/content/dam/farm/reports/surveys_and_polls/2015/rwjf420854 http://www.rwjf.org/content/dam/farm/reports/surveys_and_polls/2015/rwjf420854

13. 13 Penalties for an adult who lacks coverage Note: Penalties shown are for year-round uninsurance. Many uninsured are exempt from penalty. Examples include people under 138 percent of poverty in states that have not expanded Medicaid, people who would need to pay more than a specified percentage of income for health insurance, people subject to religious prohibitions of insurance coverage, etc.

14. 14 An historical perspective Sources: Hoag, et al., Mathematica, 2011, for 1998-2010 estimates, http://aspe.hhs.gov/health/reports/2012/chipra- irtc/index.pdf; U.S. Dept. of HHS 2012 for 2011 estimate, http://www.insurekidsnow.gov/chipraannualreport.pdf; MACPAC 2013 for 2012 estimate. http://www.macpac.gov/reports/2013-03- 15_MACPAC_Report.pdf?attredirects=0&d=1http://aspe.hhs.gov/health/reports/2012/chipra- irtc/index.pdfhttp://www.insurekidsnow.gov/chipraannualreport.pdfhttp://www.macpac.gov/reports/2013-03- 15_MACPAC_Report.pdf?attredirects=0&d=1

15. 15 Conclusion Significant gains in insurance coverage thus far To quickly achieve major additional gains, important challenges need to be overcome