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CPPP.org Texas and Obamacare: A Status Update Texas Tribune Symposium on Health Care Huston-Tillotson University • Austin, Texas Anne Dunkelberg, Associate Director [email protected] Monday, February 16, 2015 1

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    CPPP.org

    Texas and Obamacare: A Status Update

    Texas Tribune Symposium on Health Care

    Huston-Tillotson University • Austin, Texas

    Anne Dunkelberg, Associate Director – [email protected]

    Monday, February 16, 2015

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    mailto:[email protected]

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    @CPPP_TX

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    CPPP is an independent public policy organization that uses data and analysis to advocate for solutions

    that enable Texans of all backgrounds to reach their full potential.

    We believe in a Texas that offers everyone the chance to compete and succeed in life.

    We envision a Texas where everyone is healthy, well-educated, and financially secure.

    OUR POLICY PRIORITIES

    • Expanding economic opportunity• Ensuring health and wellness• Investing in Texas

  • 27%

    15%

    10%

    11%

    24% 13%

    0.0 0.5 1.0 1.5 2.0 2.5

    Cost-Sharing Reductions PLUS Subsidies Subsidies Only

    Marketplace Subsidies & Cost-Sharing Reductions

    Kids’ Medicaid/CHIP (eligible today but not enrolled)

    Marketplace, No Assistance

    Coverage Gap:TX State Policy Decision

    Non-Citizens(Lawfully Present are eligible for

    assistance-about 1/3)

    Options for Coverage Starting 20146.4 million uninsured Texans, 24.6% of all ages

    Sources of Coverage by Age, Income, Immigration Status.

    Note: Authorized non-citizens may also eligible for financial assistance under a separate set of state and ACA eligibility rules; this analysis does not take into account uninsured families who may have an affordable offer of job-based coverage and who would therefore be ineligible for Marketplace subsidies.Source: CPPP Analysis of U.S. Census Bureau, CPS Annual Social and Economic Supplement, 2011 – 2013

    Uninsured Texans (Millions)

  • Texas Marketplace Enrolled: 1.2 million, up 38%

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    * Enrollment numbers based on data as of March 10, 2015, including SEP activity through 2-22-15**Includes all individuals eligible for tax credits as well as other legally-residing individuals who are uninsured or purchase non-group coverage, have incomes above Medicaid/CHIP eligibility levels, and who do not have access to employer-sponsored coverage. The estimate excludes uninsured individuals with in the coverage gap.

    Source: ASPE ISSUE BRIEF, HEALTH INSURANCE MARKETPLACES 2015 OPEN ENROLLMENT PERIOD: MARCH ENROLLMENT REPORT, and Kaiser Family Foundation, Marketplace Enrollment as a Share of the Potential Marketplace Population, accessed February 12, 2015.

    • 1,205,174 Texans selected a plan (up from 734,000 2014)

    • This is 39% of the estimated 3,061,000 eligible for Marketplace coverage– U.S. average is 42% of eligibles

    – FL has enrolled 64%

    • 57% were new enrollees (43% renewals)

    • 85% received financial assistance – $328 average premium before credit; $89 after credit; average subsidy 73%

    – 43% of enrolled Texans paying less than $50/month; 68% pay less than $100/month

    • 29% are ages of 18 to 34

    • Premiums increased average of 5% from 2014-2015 in TX, but credits eliminated impact.

    http://aspe.hhs.gov/health/reports/2015/MarketPlaceEnrollment/Mar2015/ib_2015mar_enrollment.pdfhttp://kff.org/health-reform/state-indicator/marketplace-enrollment-as-a-share-of-the-potential-marketplace-population-2015/

  • In 2014; 57% of Marketplace enrollees nationally were previously uninsured (no 2015 figures yet)

    New Rice University Report: Texas adult (18-64) uninsured rate down almost 8 points from 2013: dropped from 24.6% in 2013 to 16.9% Match 2015.

    Gallup:

    • Uninsured rate declined across all race/ethnicity categories since 2013

    • Greater % decline among African Americans and Latinos than among Whites.

    – Whites rate declined by 5.3 percentage points (from 14.3% percent): 6.6 million adults gaining coverage.

    – African Americans’ rate dropped 9.2 percentage points (from 22.%): 2.3 million adults gaining coverage.

    – Latino uninsured rate dropped 12.3 percentage points (from 41.8%): 4.2 million adults gaining coverage.

    (U.S. Census data will NOT be available until Sept. 2015)

    Uninsured Rates Decline

    Sources: Kaiser Family Foundation, Survey of Non-Group Health Insurance Enrollees, June 14, 2014. Rice University, Baker Institute, Issue Brief #11: Effects of the Affordable Care Act on health insurance coverage in Texas as of March 2015; April 30, 2015. Gallup: Office of the Assistant Secretary for Planning and Evaluation (ASPE) analysis of Gallup-Healthways Well-Being Index survey data through 3/4/15.

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    http://kff.org/private-insurance/report/survey-of-non-group-health-insurance-enrollees/http://bakerinstitute.org/media/files/Research/543b17ea/Pub-HPF-Study11-043015.pdfhttp://aspe.hhs.gov/health/reports/2015/uninsured_change/ib_uninsured_change.pdf

  • Texas Medicaid/CHIP: Who is Helped Today

    Medicaid Children, 3,007,976

    Maternity 138,060

    Poor Parents, 155,295

    Elderly, 374,160

    Disabled, 423,690

    CHIP, 335,120 December 2014, HHSC data

    Total enrolled 12/2014: 4.4 million

    Medicaid & CHIP:

    (44% of Texas kids)

    6Source: Center for Public Policy Priorities.

  • Nearly half of Texas Children Were Enrolledin Medicaid or CHIP in March 2014

    from a high of 77% to a low of 10%

    Note: Includes children less than 19 years of age.

    Sources: Medicaid: 8-Month Eligibility Databases, HHSC; CHIP: P10_dob_regular database , HHSC. Prepared by Data Quality & Dissemination,

    Strategic Decision Support, HHSC. Children

  • Texas Coverage Gap: Medicaid Hole in the ACA Coverage System

    Marketplace

    with

    Subsidies

    Marketplace

    with

    Subsidies

    Coverage

    Gap

    Coverage

    Gap

    Medicaid

    Childless* Adults Working Parents

    133% FPL

    $25,975 for

    family of 3

    19% FPL

    $3,696 for

    family of 3

    100% FPL

    $19,530 for

    family of 3

    States With Medicaid (AR, NM)

    Expansion

    Texas - Without Medicaid Expansion

    Marketplace

    with Subsidies

    Medicaid

    Parents and

    Childless* Adults

    Fam

    ily In

    com

    e

    $0

    vs.

    8“Childless” includes parents with grown children.

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    The Coverage Gap: 1 million Texans

    2 Parents with2 kids living on

    Kids get Medicaid

    Parents get sliding-scale Marketplace coverage for

    $43/month or less

    $24,500 per year

    2 Parents with 2 kids living on

    Kids get Medicaid

    Parents get no financial help and has no affordable options (must pay

    full price $440)

    $23,500 per year

  • NOTES: Under discussion indicates executive activity supporting adoption of the Medicaid expansion. **MT has passed legislation adopting the expansion; it requires federal waiver approval. *AR, IA, IN, MI, PA and NH have approved Section 1115 waivers. Coverage under the PA waiver went into effect 1/1/15, but it is transitioning coverage to a state plan amendment. Coverage under the IN waiver went into effect 2/1/15. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion.SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated April 29, 2015.http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

    Current Status of State Medicaid Expansion Decisions

    WY

    WI*

    WV

    WA

    VA

    VT

    UT

    TX

    TN

    SD

    SC

    RI

    PA*

    OR

    OK

    OH

    ND

    NC

    NY

    NM

    NJ

    NH*

    NVNE

    MT**

    MO

    MS

    MN

    MI*

    MA

    MD

    ME

    LA

    KYKS

    IA*

    IN*IL

    ID

    HI

    GA

    FL

    DC

    DE

    CT

    COCA

    AR*AZ

    AK

    AL

    Adopted (30 States including DC)

    Adoption under discussion (4 States)

    Not Adopting At This Time (17 States)

    http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

  • Cost Benefits of Closing the Gap

    • States with Medicaid expansion or Alternative Waiver report significant GR savings: AR and KY report savings are greater than costs.

    • 4 of the largest hospital chains (CHS, HCA Tenet, LifePoint), studied by pwc, found dramatic reductions in uncompensated care in Medicaid expansion states, but only small decreases on states with Coverage gaps.

    • Texas leads nation in hospital closures: 25% of total US since 2010 (we are less than 9% of population). Rural and urban hospitals point to Texas Coverage Gap as major culprit/potential solution.

    • Texas’ Coverage Gap threatens to weaken our Medicaid 1115 “Transformation waiver”, adding further injury to hospital viability.

    • Job creation estimates (Ray Perryman, Billy Hamilton) range from 200,000-300,000.

    • This is why TAB and 24 Texas Chambers of Commerce have endorsed Closing the Gap, as have the County Judges of the 6 largest counties, and a growing list of other elected officials, city councils, and county commissions.

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  • Red State AlternativesConservative States, Republican Governors have Negotiated Coverage

    Ex: Arizona, Arkansas, Indiana, Iowa, Michigan, Nevada, New Jersey, New Mexico, North Dakota, Ohio, and Pennsylvania.

    Texas can look to other “red states” for a menu of alternative approaches to insuring the Coverage Gap adults:• Benefits for the newly-covered adults based on commercial & small business plan standards;

    • Personal Responsibility Provisions: Cost-Sharing for the newly-covered adults is allowed, including premiums under “1115 waivers.”

    • Financial incentives for wellness behaviors like check-ups, immunizations, and participation in chronic disease management programs

    • Integration with Marketplace, maximizing use of private insurers and HMO-style managed care. Some states combine Medicaid Managed Care below poverty, and Marketplace for adults 100-138% of the federal poverty line (FPL).

    • Flexibility Exists, but within Limits. Under federal law, 1115 waivers must “further purposes of Medicaid.”

  • King v. Burwell• This summer the Supreme Court will

    decide whether subsidies can be provided through the federal Marketplace.

    • 37 states have federal exchanges.

    • A decision for the plaintiffs would deny financial assistance for insurance premiums to approximately 13 million Americans, of which 1.7 million are Texans.

    • Urban Institute model predicts over 1.4 million insured Texans would lose coverage in 2016 if the Marketplace subsidies are eliminated.

    – Includes subsidized, plus higher- income consumers whose premiums would increase by an estimated 35%-47% (Urban Institute, RAND Corporation)

    • Over 2/3 of Texans have incomes below 400% FPL, the upper limit for subsidies in the Marketplace.

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  • Total health expenditure per capita, public and private, 2009

    U.S. spends far more per capita on health care than all other developed countries.

    Total expenditure excluding investments.Source: OECD Health Data 2011; WHO Global Health Expenditure Database.

  • US Health Spending (CBO, The 2014 Long Term Budget Outlook , July 2014).

    http://www.cbo.gov/publication/45471

  • Controlling Medicaid and CHIP Costs

    • The Texas Legislature has aggressively pursued cost-containment in Texas Medicaid over the last 15 years.

    • When adjusted for inflation, Texas is spending less per Medicaid enrollee today than the state did in 2001.

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  • Center on Budget and Policy Priorities

    cbpp.org6

    Medicare and Medicaid Controlled Costs Better than

    Private Insurance Over the Last Decade

    Average Annual Growth Rate, 2000-2009

    4.6%5.1%

    7.2%7.7%

    0%

    1%

    2%

    3%

    4%

    5%

    6%

    7%

    8%

    9%

    Medicaid Per

    Beneficiary

    Medicare Per

    Beneficiary

    Private Per

    Capita,

    Comparable

    to Medicare

    Private Employer

    Insurance

    Premiums

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  • Title

    Medicaid as a share of Texas’ State-Dollar Spending = 23.3%

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