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TheAffordableCareAct(akaObamacare)

andRepeal/Replace:WhereThingsStand

CharlesGabaACASignups.net

Revised:3/15/17

TheHealthcareCoverageLandscapeasof2009

TheThree-LeggedStool

TheThree-LeggedStool:Leg1

•  GuaranteedIssue:CarriersmustselltoeveryoneregardlessofmedicalcondiKon,age,pre-exisKngcondiKons,etc(andinfactcannolongerevenaskaboutmedicalhistoryatall)

•  CommunityRaBng:Carrierscannotchargepeopledifferentratesforthesamepolicybasedonanyfactorsotherthanage(withina3:1raKo),locaKon(raKngarea)andwhethertheysmoke(50%surcharge)

•  QualifiedHealthPlans(QHP):AllplanssoldhavetomeetACAstandards,includingatleast60%AV,all10EssenKalHealthBenefits,etc.(i.e.,theyhavetoberealhealthcarepolicies)


•  QHPActuarialValue:AllQHPshavetocoveratleast60%ofhealthcarecosts.Availablein4“MetalLevels”:–  BRONZE:60%AV(lowpremiums,highdeducKble)–  SILVER:70%AV(mid-rangepremiums,mid-rangededucKble)*

–  GOLD:80%AV(higherpremiums,lowdeducKble)

–  PLATINUM:90%AV(highestpremiums,nodeducKble)–  Catastrophic:50%AV,verylowpremiums,insanelyhighdeduc=bles,onlyavailableif

you’reunder30orotherrareexcep=ons

•  *(SilverplansaretheonlyoneseligibleforCostSharingReduc=onassistance)


•  IndividualMandate:Everyone(withexcepKons)hastohaveanACA-complianthealthcarepolicyforatleast9monthsoftheyearortheyhavetopayataxpenaltyof:

–  $695.00/adult($347.50/child)or–  2.5%ofhouseholdincome(whicheverisgreater)–  maximumof$2,085/familyortheavg.annualpremiumforaBronze

plan

•  Penaltyisbymonth(6mouncovered=½penalty,etc)•  ExcepKonsmadeforvariousreasons(expatriate,hardship,

domesKcviolencevicKm,naturaldisaster,etc)


•  TaxCredits(akaSubsidies):Twotypes,bothbasedonincomerelaBvetotheFederalPovertyLevel(FPL):

•  AdvancePremiumTaxCredits(APTC):Incomebetween100-400%FPL($12K-$48Kindividual;$24.6K-$98.4Kforafamilyof4)–  SubsidiesINCREASEasbenchmarkpremiums/deducKblesincrease

(premiumgoesup20%?Subsidygoesup~20%)–  SubsidiesVARYbyRATINGAREA:

•  Avg.premiuminMassachusels:$290/month•  Avg.premiuminAlaska:$1,041/month(3.6xashigh!)

•  CostSharingReducBon(CSR):Incomebetween100-250%FPL($12K-$30Kindividual,$24.6K-$61.5Kfamilyof4)

TheThree-LeggedStool:OpenEnrollment

•  2014:6months(+2weekoverBme)–  8.0Millionselectedplans;~7.0Millionpaid/effectuated–  44KviaMinnesotaBHPprogram

•  2015:3months(+1weekoverBme)–  11.7Millionselectedplans;~10.5Millionpaid/effectuated–  79KviaMinnesotaBHPprogram

•  2016:3months(+1dayoverBme)–  12.7Millionselectedplans;~11.4Millionpaid/effectuated–  121KviaMNBHPprogram;380KviaNYBHPprogram

•  2017:3months(nooverBme)–  12.2Millionselectedplans;~11.0Millionpaid/effectuated–  100KviaMNBHPprogram;665KviaNYBHPprogram

ACAOpenEnrollmentPeriods

MedicaidExpansion•  ExpandsMedicaideligibilitytoEVERYONEupto138%FPL($16.6K/

yrforindividual)regardlessofpre-ACAeligibility•  31states+DCexpanded;19states(allGOPheld)sBllrefusing•  ~2.6MILLIONpeoplecaughtinMedicaidGap:Don’tqualifyfor

Medicaid,butearntoolifletoqualifyforACAtaxcredits

•  October2013:57.4millionenrolledinMedicaid•  October2016:74.4millionenrolledinMedicaid•  Netincreaseof17.0million•  13.0millionofthatduetoACAexpansion(+specialfromNY)•  3-4millionvia“Woodworkers”…peoplewhowerealreadyeligible

forMedicaidpre-ACAbuteitherdidn’tknowitorwerereluctanttounKltheACAwentintoeffect.

OtherACAStuff(seelistatend):

•  NOAnnualorLifeKmelimitsoncoverageforANYONE(individualmarketANDgroupmarket

•  ALLPLANS(group&indy)mustmeetminimumcoveragerequirements

•  YOUNGADULTScanstayonparents’plansunKl26(indy&group)

•  CLOSESMEDICAREPARTDDONUTHOLE

•  Awholemessofotherstuff

TheHealthcareCoverageLandscapeasof2009

TheHealthcareCoverageLandscapeasofMarch2017

Whoaretheremaininguninsured?

WhoareIndyExchanges&MedicaidExpansionWorking/NotWorkingfor?

LegiBmateProblemsw/theACA:

•  MEDICAID:–  MEDICAIDGAP(2.6M):19stateshaven’texpanded(blameGOP)–  Dr./Hospitalreimbursementtoolow(~40%ofprivaterates)–  Fedscover90-95%ofexpansionMedicaidfundingbutonly50-75%of

tradiKonalMedicaid;statesconstantlyraidingtheirshareormessingw/programrequirements/coverage

•  GROUPCOVERAGE:–  Employermandateironicallyencourages“JobLock”whilealsoaddinga

bunchofpaperworkfortrackingemployees(butalsoprovidesparKalfundingforexchangesubsidies/Medicaidexpansion)

–  INELIGIBLEDUETOESIOFFER(4.5M):EmployerplansglitchallowsCatastrophic(Lead)plans“lewonthetable”todisqualifyemployeesforindividualexchangetaxcredits

•  RISKCORRIDORFUNDING:Thanks,MarcoRubio!!

LegiBmateProblemsw/theACA:

•  UNDOCUMENTEDIMMIGRANTS(5.4M):ACAdoesn’tallowundocumentedimmigrantsontoMedicaidorACA

exchangesevenatfullprice(unsubsidized).CAnearlypassedstatelawtoallowitbutrescindedawerTrumptookoffice.

•  MEDICAID/CHIPELIGIBLE(6.4M):OUTREACH,OUTREACH,OUTREACH…andobstrucKonbyGOPofficialsat

statelevel(remember,mostoftheseareeligiblefortrad.Medicaid)

•  TAXCREDITELIGIBLE/INCOMEINELIGIBLE(8.3M):–  APTCtooskimpy(400%FPLcut-off,notgenerousenough300-400%)–  CSRtooskimpy(250%FPLcut-off,notgenerousenough200-250%)–  ESIineligibilityallowsskinnyplanstobeconsidered“compliant”–  “FamilyGlitch”:If1memberonemployee-onlyESI,othersdon’t

qualifyforexchangesubsidies(~3Mpeople)

HowI’dFixtheACA’sProblems:1.   Fixthe“FamilyGlitch”:OtherfamilymembersshouldqualifyforAPTC/

CSRevenifsomeoneinthefamilyiscoveredbyESI.2.   Fixthe“SkinnyPlanGlitch”:RequireESIpoliciestobeatleastBronze-

strength(preferablySilver)beforeemployeesareineligibleforAPTC/CSR3.   RestoreRiskCorridorfunding(&extenditindefinitely).Themoneyis

legallyowedtothecarriersanyway,andtheprogramworksjustfinforMedicarePartD).

4.   GuaranteeCSRPayments.HouseGOPbroughtalawsuitchargingCSRpaymentsareunconsKtuKonaleventhoughthey’relegallymandated.Casepending;swordofDamoclescausingmonthlyuncertainty.

5.   RequireALLIndividualMarketplansbeofferedontheexchanges(beleryet,exclusivelyon-exchange,asDChasdonefor4years).Lessconfusion,noincome-basedcherry-picking,easiertrackingofenrollmenttrends.

6.  BeefupIndividualMandatePenalty(Notgonnahappen.Moveon.)7.   BEEFUPTHETAXCREDITS(bothAPTC&CSR)

Three-LeggedStoolFixes

HowwouldIfixtheACAtaxcredits?

•  RaisethecaponAPTCfrom400%to500%,beef‘emupbelowthat.

•  RaisethecaponCSRfrom250%to500%(sKlltaperingofftowardstop)

•  About$10B-$12B/yearshoulddoit.ChangeAPTCstructureasfollows

•  (somethingsimilarw/CSRstructure)

So,what’sinTrumpcare?(akathe“AmericanHealthCareAct”or“AHCA”)

So,what’sinTrumpcare?(akathe“AmericanHealthCareAct”or“AHCA”)•  DEFUNDSPlannedParenthood($530million/year…40%oftheirtotalbudget)•  DEFUNDSMedicaidExpansion(starKngin2020,viaalriKon…nonewenrollees,current

onescan’tcomebackoncetheyleave.•  DEFUNDSCostSharingReducKons(CSR)completelystarKngin2020.•  CHANGESnon-ACAMedicaidtoBLOCKGRANTS(kicksmoreofflater)•  CHANGESTaxCredits(APTC)fromINCOME-basedtoAGEbased

($2,000foryounger-->$4,000forolderenrollees)•  TaxcreditsNOLONGERINCREASEtomatchpremiumhikes,nordotheyvaryby

geography/raKngarea•  ChangesAGEBANDfrom3:1to5:1

(olderenrolleescanbecharge5xasmuchasyounger)•  ELIMINATEStheminimum60%AV(Bronze)requirement;HELLOJUNKPLANS!•  $100billionover9yearstostatesforHighRiskPools,Reinsuranceprograms,etc

(partofthisiseffecKvelyreplacingmoneytheystolefromtheRiskCorridorprogram)•  CHANGESMandatepenaltytoa30%,1-yrpremiumsurchargefornotmaintaining

conBnuouscoverage…w/penaltygoingtoCARRIER,notIRS•  WIPESOUToverhalftherevenuetofundACA…including3.8%investmenttaxonrich

people&0.9%Medicarepayrolltax.Replaceswith…notmuchofanything.•  Thiswouldgivetop1%avg.$33,000taxcut;top0.1%avg.$197,000taxcut;andtop

400richestAmericansanAVERAGETAXCUTOF$7MILLION.

So,what’sinTrumpcare?(akathe“AmericanHealthCareAct”or“AHCA”)•  DEFUNDSPlannedParenthood•  DEFUNDSMedicaidExpansion(starKngin2020,viaalriKon•  DEFUNDSCostSharingReducKons(CSR)•  CHANGESnon-ACAMedicaidtoBLOCKGRANTS(kicksmoreofflater)•  CHANGESTaxCredits(APTC)fromINCOME-basedtoAGEbased

($2,000foryounger-->$4,000forolderenrollees)•  TaxcreditsNOLONGERINCREASEtomatchpremiumhikes,nordotheyvaryby

geography/raKngarea•  ChangesAGEBANDfrom3:1to5:1

(olderenrolleescanbecharge5xasmuchasyounger)•  ELIMINATEStheminimum60%AV(Bronze)requirement;HELLOJUNKPLANS!•  $100billionover9yearstostatesforHighRiskPools,Reinsuranceprograms,etc

(partofthisiseffecKvelyreplacingmoneytheystolefromtheRiskCorridorprogram)•  CHANGES$695mandatepenaltytoa30%,1-yrpremiumsurchargefornot

maintainingconBnuouscoverage…w/penaltygoingtoCARRIER,notIRS•  WIPESOUToverhalftherevenuetofundACA…including3.8%investmenttaxonrich

people&0.9%Medicarepayrolltax.Replaceswith…notmuchofanything.•  Thiswouldgivetop1%avg.$33,000taxcut;top0.1%avg.$197,000taxcut;andtop

400richestAmericansanAVERAGETAXCUTOF$7MILLION.

HowdoesTrumpcarechangetaxcredits?

CBOScore?

CBOScore?•  14millionlosecoveragein2018•  Another10millionlosecoverageby2026(24milliontotal)•  Justaboutalllosingcoveragewouldbelow-income(Medicaid/elderly/

etc)•  By2026,totaluninsuredwouldbe~52million(upfromcurrent28

million)•  Age-basedtaxcreditswouldactuallybesomewhatbelerforsomein

themiddleclass(300-600%FPL),butdevastaBngtolow-income/elderly.

•  PREMIUMswouldINCREASEbyanaddiKonal15-20%peryearthru2020;wouldthengraduallydecreaseto~10%lowerthancurrentprojecKonsby2026…mainlyduetoforcing50-64yearoldsoffcoveragecompletely.

•  DEDUCTIBLESwouldINCREASEevenmorein2ways:a)LowerAVreqiurements;b)CSRassistancecutoffforlower-incomeenrollees

CBOScore?

Howmanyareatriskpost-

repealnaBonally?

Upto24MILLION.

Howmanyareatriskpost-repeal?MICHIGAN:~210Kexchange*,~658KMedicaid=~868KTotal

(*outof~321Ktotalexchangeenrollees)OAKLANDCOUNTY:~30Kexchange,~55KMedicaid=~85KTotal(7.0%pop)

Howmanyareatriskpost-repeal?MICHIGAN:~210Kexchange*,~658KMedicaid=~868KTotal

(*outof~321Ktotalexchangeenrollees)ST.CLAIRCOUNTY:~4,200exchange,~10.5KMedicaid=~14.7KTotal(9.4%pop)

Howmanyareatriskpost-repeal?MI-11(Trof):~16Kexchange~59KMedicaid=~75KTotal

MI-14(Lawrence):~14Kexchange+~59KMedicaid=~73KTotal

Howmanyareatriskpost-repeal?MI-10(Mitchell):~18Kexchange~49KMedicaid=~67KTotal

(9.5%ofpopulaBon)

WhatElseWouldBeLostif“Phase3”goesthrough?•  80/20MedicalLossRaKo•  COVERAGEOFPRE-EXISTINGCONDITIONS•  NoPre-ExisKngWaiKngPeriodforIndymkt.•  Nomorethan90-daywaiKngperiodforESI•  COVERAGEOFESSENTIALSERVICES•  NomorepricyCOBRA•  EscapefromJobLock•  CoalMinerbenefitsforBlackLungDisease/survivors•  ELIMINATIONOFANNUAL/LIFETIMELIMITS•  Levelplayingfieldforwomen•  Freecolonoscopies,cholesterolchecks,bloodpressurechecks,general

physicals•  MEDICAREPARTDDONUTHOLEFILLED•  OpKontoleaveMedicareAdvantage&SignupforPartDannually•  PrescripKondrugcoverage(mandatory)•  Maternitycare,freebirthcontrol,freebreas|eedingsupplies&

breas|eedingprivacy

WhatElseWouldBeLostif“Phase3”goesthrough?•  ProtecKonfromLGBTdiscriminaKon•  FreerouKnevaccinaKons•  FreegestaKonaldiabetesscreenings•  Freepapsmears&HPVtests•  FreeHIV,Gonorrhea&Herpesscreenings•  FreeTobaccocessaKonprograms•  Substanceabusetreatment•  MandatoryMentalHealthcoverage•  RECORDLOWUNINSUREDRATE•  PREMIUMSUBSIDIES•  ImprovedCollegeStudentplans•  EaseofClaimsAppeals•  EasiertounderstandbenefitdescripKons•  EFFECTIVERATEREVIEW•  CAPSONOUTOFPOCKETCOSTS•  HealthplanopKonsforsmallbusinesses(150K)•  Pediatricdentalinsurance

GOPObstrucKon/Sabotage?

•  RiskCorridorMassacre(R.I.P.Co-Ops)–  Changedlawinmiddleof2015OEP,announcedAugust2015;

12.6¢onthedollar,$300M/$2.5Bpaid;upto$10B+now

•  NavigatorObstrucBon/Blockades

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