How the Affordable Care Act Affects Your Health Insurance Costs

Transcription

1 How the Affordable Care Act Affects Your Health Insurance Costs

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3 How the Affordable Care Act Affects Your Health Insurance Costs American Institute for Economic Research 250 Division Street Great Barrington, MA aier.org

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5 How the Affordable Care Act Affects Your Health Insurance Costs Contents Introduction 7 Understanding Health Insurance and the ACA 9 Why the ACA 9 How Health Insurance Works 10 How the ACA Affects Premiums, Deductibles, and Out-of-Pocket Costs Who is Affected by the ACA s Insurance Provisions? 23 Large Group Plans 26 Small Group Plans 27 Individual Market Plans 27 Medicaid-Eligible and the Coverage Gap 28 Medicare An Uncertain Path to Success Guide to the Affordable Care Act 35 Individual Market 35 Small Group Market 38 Large Group Market 40 Medicaid 42 Medicare 43 Glossary of ACA Terms and Definitions 45 Appendices A and B 51 Methods 61 Bibliography 67 How the Affordable Care Act Affects Your Health Insurance Costs 5

6 Authors: Stephen J. Adams, Acting Director of Research and Education; Jules Clark, Research Analyst; Luke Delorme, Research Fellow; Nicole Kreisberg, Senior Research Analyst Editor: Marcia Stamell Design: Patricia Rotondo Acknowledgements AIER benefited from the advice and cooperation of numerous individuals including Jeyaraj (Jay) Vadiveloo PhD, FSA, MAAA, CFA, Professor and Director, University of Connecticut Goldenson Center for Actuarial Research and his team: Mark Spong, Nehal Sapre, and Pete Camacho. AIER would also like to thank Nancy Trumbull, Harvard School of Public Health; Nancy Kane, Harvard Business School; Marilyn Tavenner and Teresa Miller, the Centers for Medicaid and Medicare Services of the U.S. Department of Health and Human Services; Ryan Lore, Towers Watson; and Daniel Okwaisie, AIER intern. All analysis and any errors or omissions are the responsibility of AIER.

7 01 Introduction The Patient Protection and Affordable Care Act, better known as the Affordable Care Act (ACA), has dominated the news unlike many other government initiatives in recent U.S. history. Even before its adoption by a Democratic-controlled Congress and President Barack Obama in March 2010, the ACA was generating a heated partisan debate about its likely costs and benefits. The act s largely Democrat supporters argue that the ACA will make affordable, quality health insurance available to all US citizens. They also claim that increased competition in the individual insurance market fostered by the ACA will reduce costs and improve the quality of health care. The act s largely Republican detractors view the ACA as an unwarranted government intrusion into individual choice and a deeply flawed program that will increase health insurance costs, reduce access to quality health care, and create unsustainable government entitlements. The ACA and Insurance Costs The ACA provisions that affect insurance costs for individuals are being implemented over a number of years. Many of the core elements of the law became effective in However, some provisions relating to employer mandates and some individual insurance requirements are being delayed by the Obama administration until 2015 and Other provisions do not become effective until The ACA affects health insurance premiums and out-of-pocket costs in three principal ways. The law imposes mandates on individuals, insurers, and employers. It requires minimum coverage standards and caps out-of-pocket costs across all 50 states. It provides federal subsidies for premiums, out-of-pocket costs, and Medicaid expansion. We expect the combined effect of these features to increase premiums for many millions of people and reduce premiums for many millions of others. Many people will be required to purchase more coverage than they prefer, potentially increasing their costs. Some people will pay more for the same amount of coverage before the ACA. Others will purchase coverage they could not buy at any price before the law because of a pre-existing condition. At the same time, the broader coverage and limitations on out-of-pocket costs will reduce the out-of-pocket costs many will pay in the event that they need health care services. Prior to the ACA, out-of-pocket costs could be very high under individual market plans. No One Knows How Many Will Benefit and How Many Will Not While a number of estimates have been published, there is no simple way to explain how the ACA affects the amount individuals will pay for insurance premiums and out-of-pocket How the Affordable Care Act Affects Your Health Insurance Costs 7

8 Introduction expenses. There is no straightforward answer to the question of how many gain and how many lose in terms of premiums and out-of-pocket costs in the individual market. There is little reliable or meaningful data on premiums or out-of-pocket costs before the ACA to compare with post-aca costs. How much the law increases or reduces someone s costs depends largely on individual circumstances, especially one s health condition, state of residence, and how much health care an individual uses. It is unknown how many employers will drop or change their health insurance plans in response to the ACA. Companies are affected differently by the ACA depending on their size, location, and insurance plan. There are many theories, but until the law is in place, there is no way to know how many companies will respond or how insurance premiums and other costs will change. We can describe how the ACA affects insurance premiums and out-of-pocket expenses for individuals purchasing health insurance. We can also estimate the number of people in the categories likely to see cost increases or decreases or little impact at all. In this analysis, we examine the likely impacts of the ACA through Full implementation of the new law extends into 2018, and the impact of the ACA will be felt for years. There many important fiscal, economic, health care quality, and social implications of the ACA; however, these issues are not addressed here. There are many more questions than answers as to how the ACA will affect US citizens insurance costs. This report seeks to offer some context for understanding the shifting health insurance environment over the next two years. 8 American Institute for Economic Research

9 02 Understanding Health Insurance and the ACA Why the ACA The main provisions of the Affordable Care Act have less to do with the cost of health care than with trying to make health insurance more affordable for those with little or no coverage. Although the ACA includes some provisions intended to control costs, the most immediate impact to consumers will be on premiums and out-of-pocket costs for health care as well as on access to insurance. While the vast majority of people in the United States had health insurance before the ACA, the new law is aimed at people who would not or could not buy insurance. It is also aimed at those referred to as the underinsured, people who have health care coverage that does not adequately protect them from high medical expenses. Prior to the new ACA requirements, nearly 15 percent of the U.S. population, an estimated 46 million in 2012, had no health insurance during most of the calendar year. 1 Three quarters of these uninsured are in families with incomes near or below the federal poverty level ($11,670 for an individual and $23,850 for a family of four in 2014 within the continental U.S.). The remaining uninsured have annual incomes ranging from two-and-a-half to four times the poverty level (between $29,175 and $46,680 for an individual and between $59,625 and $95,400 for a family of four in 2014). Addressing underinsurance is more problematic. The notion of what is considered adequate coverage is inherently subjective. By one measure the number of insured people with outof-pocket costs that exceeded 10 percent of their family incomes there were an estimated 21 million underinsured in the U.S. in Like the uninsured, the underinsured either feel that better coverage is unaffordable, or they elect to take the chance that they will not have high health care expenses. Most of the population has health insurance Eighty-five percent of the people in the United States, 267 million people, had health insurance in 2012, as shown in Figure 1 on page 11. The largest share, 147 million in 2012, get their health coverage through group plans sponsored by their employers or that of their spouse or parent. These group plans are divided between large groups (firms with 51 or more employees, changing to 101 or more in 2016) and small groups (2-50 employees, increasing to in 2016). Large group insurance covered 131 million in 2012, while small group insurance covered approximately 16 million. 1 There are several ways to estimate the number of uninsured in America. Our figures are not a true count, but merely an estimate of the number of people who had no insurance at any time during the past year. For methodology see Methods in the back of this study. 2 Commonwealth Fund Biennial Health Insurance Survey 2007 cited in Cathy Schoen, Sara R. Collins, Jennifer L. Kriss and Michelle M. Doty How Many Are Underinsured? Trends Among U.S. Adults, 2003 And 2007, Health Affairs How the Affordable Care Act Affects Your Health Insurance Costs 9

10 Chapter 2 The government is the next largest source of health insurance in the U.S. Fully 49 million people, or 16 percent, are covered by Medicare, the federal health program for Americans who are aged 65 and older. Medicaid, a joint federal and state program for low-income people, provided health coverage for 46 million people, or 14 percent of the U.S. population, in Five percent of the people in the United States, 16 million people, purchased insurance directly from insurance providers in the individual market. This is where the ACA is likely to have most significant immediate effects on premiums and out-of-pocket costs. How Health Insurance Works Health insurance in America is exceedingly convoluted. Even before the ACA, health insurance was already heavily regulated by countless federal rules and is also subject to state regulation, resulting in different cost and benefit structures across the country. To understand how the ACA affects insurance costs, it is necessary to understand some of the basics of how health insurance works and how it was regulated before the new law took effect. The Basics Insurance is essentially a gamble. People who buy insurance pay a premium on the chance that they will need to use expensive health care services and that the cost of insurance will be far less than the cost of health services. People tend to buy the minimum amount of coverage they think that they will need. This, too, is a gamble because it is hard to predict how much health care someone will need in the course of a year. Insurance companies pool risks by covering a large number of people, calculating that premiums paid by the entire customer base will cover the costs of the few that actually need medical care. To further increase the chance that premiums will cover costs, insurers traditionally apply risk factors, or medical underwriting standards, to calculate premiums. People with factors that increase their chance of using health care services paid higher premiums than those who are less likely to use services. Young, healthy males, for instance, are less likely to use significant amounts of health services. All else being equal, these people paid lower premiums than older people, women, or those with existing health conditions. Some insurers further reduced their risk by limiting the type of health conditions they would cover, limiting their share of costs, and setting annual and lifetime caps on how much health costs they will cover. Prior to the ACA, insurance companies could and often did deny coverage altogether to individuals with some pre-existing conditions because they believed the cost of the services were certain to exceed the premium. Individual premiums were based on the health care services covered, the cost of those services, and the risk that the purchaser will need to use them. The more services that are covered, the larger the share covered by the insurance company; the higher the risk the individual will use services, the higher the premium. Group Insurance and Guaranteed Issue Most people in the United States get their insurance through employer-sponsored group plans. 3 Three percent of the U.S. population gets coverage through federal health care programs such as Child Health Insurance Program, TRICARE, Indian Health Service, and the Veterans Assistance Program. 10 American Institute for Economic Research

11 Understanding Health Insurance and the ACA FIGURE 1 Pre-ACA Health Care Coverage IHS 0.2% VA/TRICARE 3% Small Group 5% Large Group 42% Individual 5% Medicaid 14% Uninsured 15% 16% Medicare AIER Estimates of 2012 census and the 2012 Medical Expenditure Panel Survey. See Appendix A, Table 1a. How the Affordable Care Act Affects Your Health Insurance Costs 11

12 Chapter 2 In 2013, 96 percent of firms with more than 50 employees offered insurance and they paid an average of 71 percent of family plan premiums and 82 percent of individual plan premiums. 4 Because they share premium costs with their employer, most people pay much less towards premiums than those who purchase insurance directly from insurers. Under group plans, benefits are structured around the needs of the entire group rather than tailored to the individual. Group coverage, for example, will include maternity services even though some members of the group will never use them. Likewise, premiums are based on the average risk profile of the group rather than that of a single individual. This means that lower-risk group members and higher-risk members pay the same premiums and out-of-pocket costs to cover a broad set of benefits. Moreover, some state laws limited how aggressively insurers can apply medical underwriting to set group plan premiums. Small group plans were generally those with 50 or fewer employees, while large group plans are generally those with more than 50 employees. This will change in 2016, when small groups will include firms with 100 or fewer employees. Small and large group plans are treated differently by the insurance industry and by regulations. Large group premiums are based largely on how many employees participate in a plan and prior claims experiences of the firm. Small group premiums are more closely tied to the health conditions of employees. In general, small group plans are subject to more medical underwriting than large group plans. Depending on the state, premiums can be based on the average age of workers, their overall health conditions and the industry, for example. People covered by group plans enjoy a federal protection referred to as guaranteed issue, established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Guaranteed issue ensures that no small group company can be denied insurance because of a pre-existing condition of an employee, and no employee can be excluded from small group insurance because of a pre-existing condition. In the large group market, insurers could reject a company because of its medical history, but if it offered insurance to a large group employer, no employee can be excluded because of a pre-existing condition. State-by-state regulation Prior to the ACA most health insurance standards in the individual and small group markets were set by each state. As a result, the premiums and out-of-pocket cost of health insurance varied widely depending on the regulatory environment and each individual s health risk profile. The states will continue to regulate the individual and small-group markets under the ACA, but the ACA will place limits on what the states can regulate. On one end of the spectrum are 31 states with no underwriting rating structure for the individual market. In these states, insurance companies had great latitude in setting premiums based on the characteristics of each purchaser. Healthy male customers, for example, could pay much lower premiums than older or sicker or female customers. On the other end of the regulation spectrum, 8 states prohibited almost all medical underwriting and required that individual premiums be based on community rating or the experience of the entire population. Community rating requires that premiums be the same for everyone in the same geography, while adjusted community ratings allow insurers to adjust Medical Expenditure Panel Survey. Agency for healthcare research and quality (AHRQ) Employer Benefits Survey-Kaiser. 12 American Institute for Economic Research

13 Understanding Health Insurance and the ACA FIGURE 2 State Rules on Individual Market Premiums Pre-ACA No Rating Rating Bands Adjusted Community Rating Community Rating Source: National Association of Insurance Commissioners. See Appendix B, Table 3. How the Affordable Care Act Affects Your Health Insurance Costs 13

14 Chapter 2 FIGURE 3 Pre-ACA Small Group Premium Underwriting Standards by State No Rating Rating Bands Adjusted Community Rating Community Rating Source: National Association of Insurance Commissioners. 14 American Institute for Economic Research

15 Understanding Health Insurance and the ACA premiums for factors like age, gender, or smoking status. In these states, premiums were more equalized among people with different risk profiles. 5 Figure 2 on page 13 shows the variety of premium regulations in the U.S. prior to the ACA. Small group rating rules varied greatly by state as well, as shown in Figure 3 on page 14. Every state except Virginia, Hawaii, Pennsylvania, and the District of Columbia had some form of premium regulation in place before the ACA. These ranged from strict community rating requirements to broad limits on the amounts that insurers can vary premiums. Similarly, prior to the ACA, state requirements also varied for which services and benefits must be included in a health insurance plan. Some states allowed insurers to offer bare-bones plans while others specified a list of benefits that all plans must offer. Self-Funded Group Plans Many large employers self-insure. That is, they pay employee health care costs directly from funds set aside for that purpose rather than purchase a plan from an insurance company. The employer creates an employee pool, allocates and administers the health benefits, and assumes all payment and risk for the employee pool. These are called self-funded plans, and they covered 61 percent of workers who acquired insurance at work in Large employers typically self-insure some or all of their health plan offerings, while small employers are less likely to selfinsure. Small firms are more vulnerable than large firms to unexpectedly high medical claims incurred by a few employees, so small firms are more likely to purchase fully insured plans and reduce their financial risk. Self-funded plans are regulated differently than those purchased from insurance companies. They are regulated federally by the Department of Labor under the Employee Retirement Income Security Act of 1974 (ERISA), so they are sometimes known as ERISA plans. A selffunded plan does not have to meet all of the insurance laws and requirements imposed by the state. For example, before the ACA, if a state mandated coverage for a specific medical service or treatment, a self-funded plan may not have to provide coverage for that service. 7 How the ACA Affects Premiums, Deductibles, and Out-of-Pocket Costs To increase coverage among the uninsured and reduce the incidence of underinsurance, the ACA makes several changes to the way health insurance plans in the U.S. are structured. These changes include insurance plan standards, mandates, and federal subsidies. There are a number of factors beyond the ACA that will affect plan premiums. These include health care cost inflation and changes in company cost sharing. An analysis conducted for the State of California estimated that factors beyond the ACA will contribute to a 9 percent increase in premiums in that state in INSURANCE PLAN STANDARDS The ACA requires insurance companies to cover everyone, regardless of previous health conditions. Under the law, insurers can no longer set premiums on each individual s risk profile, 5 Consumer Guide to Group Health Insurance. National Association of Health Underwriters. Accessed at GroupInsurance.cfm Kaiser Employee Benefit Survey. 7 NAHU, 8 Factors Affecting Individual Premium Rates in 2014 for California. Cosway, R. and Abbott, B. Milliman. March 28, How the Affordable Care Act Affects Your Health Insurance Costs 15

16 Chapter 2 and they cannot deny coverage to high-risk individuals. Instead, they are required to cover everyone who applies in the geography they serve. Insurers can no longer apply medical underwriting standards to set premiums for individual or small group plans. In essence, the ACA applies adjusted community ratings to all states. All providers of individual or small group insurance are now required to set premiums according to the average risk in the overall individual and small group markets of the region in which they sell insurance, adjusted for age, smoking status, and family size. The new law requires all individual plans and small group plans, at a minimum, to include 10 essential benefits. In addition to these specified benefits, these plans must include annual and lifetime caps on out-of-pocket costs for these benefits, described in Chapter 5. The 10 essential benefits are: 1 Ambulatory patient services (outpatient services) 2 Prescription drug coverage 3 Emergency care 4 Mental health services 5 Hospitalization 6 Rehabilitation and habilitation services 7 Preventative and wellness services 8 Laboratory services 9 Pediatric care, including oral and vision care for children under 19 years of age 10 Maternity and newborn care IMPACTS OF NEW STANDARDS ON PREMIUM AND OUT-OF-POCKET COSTS The new requirements to cover everyone and to apply average risk factors are an attempt to increase the benefits of risk pooling for consumers in the individual and small group markets. One result of this risk pooling is that those who benefited from medical underwriting before the ACA, people with low health risk profiles, will likely see higher premiums after the ACA, all else equal. By the same token, those who were disadvantaged by underwriting, people with higher risk health profiles, will see lower premiums. The elimination of medical underwriting means that premiums could change dramatically for many, if not most, purchasers in the individual market. More than 13 million of the 16 million people in the individual market in 2012 and 40 million of the 46 million uninsured live in states that had very limited restrictions on medical underwriting prior to the ACA. 9 These people will see higher or lower premiums depending on their health status and the level of coverage they elect to purchase. The new minimum benefits requirement will also likely cause insurance companies to raise some premiums in the individual and small group markets to account for broader benefit 9 AIER estimates. See Methods. 16 American Institute for Economic Research

17 Understanding Health Insurance and the ACA coverage. Before 2014, many plans in the individual market were bare-bones plans or plans that did not cover certain services. For example, few small group and individual plans included dental and vision care for children or mental health services, both of which are mandated by the ACA. Insurers will also raise premiums to account for the cost of caps on out-of-pocket costs. Large group plans do not face the same requirements, and large firms have historically offered plans with a broad range of benefits. So they are much less affected by changes in plan standards. However, many people who use health care services for which they now have new coverage, or more generous coverage, will see lower out-of-pocket costs than before the ACA because of minimum benefits and caps on out-of-pocket costs. Because insurers that serve the small group market are no longer allowed to set premiums based on the health status or gender of the employees in covered firms, premiums will see upward pressure in firms with more low-risk workers. At the same time, firms with high-risk workers will see downward pressure on premiums. The degree to which premiums will be affected by these new standards will vary by state because of the range of states regulatory structures in place before the ACA. States with few requirements prior to the ACA are likely to see greater premium increases than those with more controls on premiums and out-of-pocket cost already in place. INDIVIDUAL AND EMPLOYER MANDATES Individual mandate. Under the ACA, everyone not eligible for public programs must now purchase health insurance or pay an annual penalty. Most people will not be affected by this individual mandate because 85 percent already have insurance. Those directly affected include the previously uninsured, those who are dropped from their group plans because their employer decides to eliminate insurance altogether, and the previously insured who decide to drop coverage. 10 Employer mandate. Beginning in , all employers with more than 50 workers must offer health insurance to their full-time employees or pay a penalty. The penalty is equal to $2,000 multiplied by the total number of full-time equivalent employees. 12 This mandate will affect smaller firms more than larger firms, because 96 percent of larger firms offered insurance voluntarily prior to the ACA. 13 The ACA expands the small group market in 2016 to include firms with up to 100 employees, and requires that firms with between 51 and 100 full-time equivalent employees offer insurance and include the 10 essential benefits. The combined effect of this change and the mandate for benefits creates a special class of small group employers facing a one-two punch from the ACA. Prior to the ACA, there were approximately 35,000 firms with employees, providing coverage to about 13 million individuals. 14 Another 65,000 firms in this category did not provide insurance, but must offer it in 2016 or pay a penalty. The penalty is the same as it is for large employers: $2,000 times the number of full-time equivalent employees The penalty increases over time: 2014 $95 or 1 percent of income, whichever is higher; 2015 $325 or 2 percent of income, whichever is higher; and in 2016 and beyond $695 or 3 percent of income, whichever is higher. 11 The Obama administration has delayed this requirement until 2016 for employers with between 51 and 100 employees. 12 In calculating the employer penalty, the number of employees is reduced by Medical Expenditure Panel Survey, 14 AIER estimate. Number-of-firms estimate is based on 2011 Small Business Administration data on firm size. The 115,000 employer firms with between 50 and 100 employees was discounted by 10,000 to account for full-time equivalent calculation. 15 In calculating the penalty the number of full-time employees is reduced by 30. How the Affordable Care Act Affects Your Health Insurance Costs 17

18 Chapter 2 Small employer mandate. Beginning in 2016, small group employers with 50 or fewer employees are not required to provide insurance, but those that do must comply with the ACA s minimum essential benefits requirement. Only 35 percent of the approximately 5 million firms in this category offered insurance to their employees before the ACA. 16 This mandate will cause many firms to expand their offerings to include dental and vision care for children. The ACA reporting requirements may cause some firms to drop insurance altogether. IMPACTS OF MANDATES ON PREMIUM AND OUT-OF-POCKET COSTS The individual mandate is important to holding down overall premium costs in the individual market. It is designed to ensure that insurance companies gain a large number of new premiumpaying customers from a broad pool of risk profiles. This large pool of additional customers is intended to allow insurers to offer reasonable premiums and still cover their costs. 17 Most large group plans (firms with more than 100 employees after 2016) where the largest number of people in the U.S. get their insurance avoid many of the ACA requirements that affect premiums. They are not subject to the 10 essential benefits requirements, for example. Self-funded plans are further exempt from many other ACA requirements. Sixty-one percent of people in large group plans are in self-funded plans, according to Kaiser s 2013 Employer Benefits Survey. Another category of large group plans that are exempt from most ACA requirements are those considered grandfathered. These are plans in place before 2010 that were not significantly changed thereafter. Because employers tend to change plans or carriers over time to keep costs down, the number of grandfathered plans is decreasing. In 2013, 30 percent of workers in firms with 200 or more employees were in grandfathered plans, a significant drop from 53 percent in Firms with fewer than 200 workers insure 49 percent of their covered employees with grandfathered plans in 2013, a drop from 63 percent in The cost of large and small group plans will be affected by the individual mandate. Many of the previously uninsured will join their employer s plan to avoid the federal penalty. This will increase their employer s total benefits costs, some of which are likely to be passed on to employees in their share of premiums. At the same time, some employers are removing part-time workers from their group plans to reduce business costs and to make low-income employees eligible for subsidized insurance through the public exchanges. Premiums for insurance offered through most small group plans will see additional increased pressure from the new minimum benefits requirements of the ACA to cover the cost of expanding benefits. Some employers may decide to drop insurance altogether. Affected employees will be forced into the individual market, where their premiums are likely to be significantly higher. FEDERAL SUBSIDIES Tax credits and subsidies were created to help make premiums and out-of-pocket cost more affordable for low-income U.S. citizens. There are two types of subsidies to help with private 16 Medical Expenditure Panel Survey. 17 The ACA includes a program to protect insurance companies in each state from adverse selection. The risk-adjustment program is intended to transfer funds from plans with a high proportion of low-risk enrollees to those with a high proportion of high-risk enrollees. 18 According to the Kaiser s Employer Benefits Survey, the number of firms with at least one grandfathered plan fell to 54 percent in 2013 from 64 percent in American Institute for Economic Research

19 Understanding Health Insurance and the ACA insurance available beginning in To receive the subsidies, insurance must be purchased on the public exchanges, state-based insurance market places created by the ACA. Premium tax credits reduce the cost of premiums for people with incomes between 100 and 400 percent of the federal poverty level ($11,490 for an individual and $23,050 for a family of four). These tax credits are on a sliding scale so that their value decreases as income increases. People with incomes at 300 percent or above poverty will be eligible for smaller subsidies than lower-income people. Out-of-pocket cost-sharing subsidies are payments directly to insurers that reduce the cost of co-pays and deductibles for people with incomes between 100 and 250 percent of the federal poverty level. Medicaid eligibility. The ACA provides federal dollars to pay states 100 percent of the expansion costs of Medicaid for three years and 90 percent of the costs thereafter. The law anticipated that all 50 states and the District of Columbia would set eligibility for Medicaid insurance to individuals under the age of 65 at or below 133 percent of the federal poverty level. 19 However, the U.S. Supreme Court ruled that states have the option of expanding eligibility or continuing with their existing eligibility standards. As of March 2014, 25 states and the District of Columbia have expanded Medicaid eligibility, while 25 states have not. THE COVERAGE GAP A quirk in the new law and the refusal of some states to expand Medicaid has created a coverage gap for millions of Americans. Because the ACA anticipated that all states would expand Medicaid eligibility, it sets a minimum income level to receive premium subsidies through the public exchanges. As detailed below, in 25 states the maximum income for Medicaid eligibility still falls below the subsidy eligibility level. As a result, approximately 6 million people have incomes that are too low to qualify for insurance subsidies and too high to qualify for Medicaid in their state. 19 The federal poverty level is set by the federal government to indicate the minimum level of income necessary to maintain the basic cost of living. The threshold is 100 percent of the poverty level. According to federal guidelines, any person living below this line is living in poverty. hhs.gov/poverty/13poverty.cfm#thresholds. How the Affordable Care Act Affects Your Health Insurance Costs 19

20 Chapter 2 Summary of Affordable Care Act Impacts on Insurance Costs BEFORE THE ACA General inflation in the cost of health care services unrelated to the ACA was contributing to rising premiums. Most people in the U.S, 80 percent (251 million) were covered by an employer group plan or a public program. 42 percent (131 million) of people get health insurance through a large group plan. One in three people (104 million) were covered by Medicaid, Medicare, or another government program. Another 5 percent (16 million) bought insurance from their or their spouse s employer s small group plan. 5 percent of people in the U.S. (16 million) bought insurance directly from insurers in the individual market. 15 percent of people in the U.S. (46 million) had no health insurance in Some felt they could not afford it; some could not purchase it at any price because of a pre-existing condition; and some preferred not to purchase it. About 21 million people had insurance that might be considered inadequate to protect them from catastrophic health care costs percent of all firms with more than 200 employers offer insurance and between 45 and 91 percent of smaller firms offer insurance. 21 AFTER THE ACA General inflation in the cost of health care services and other costs unrelated to the ACA will drive premiums higher. LARGE GROUP PLANS Most people, 89 percent, will continue to get health insurance through an employer s group plan or a government program. This also includes people newly eligible for Medicaid. 13 million will be moved from the large group into the small group market by the ACA, where premiums and costs are more directly affected by the new law. 22 Premiums for most large group plans are likely to experience some increased price pressure related to the ACA. Higher premiums are reflecting the cost of additional employees joining the group plan because of the individual mandate to have insurance. Many part-time workers in large firms, who were eligible for insurance through work, may be dropped from their employer plan. Some will see lower premiums through the individual market with federal subsidies and broader coverage, but the employee will need to pay the full premium without employer share. In 2012, 24 percent of workers (28 million) were part-time Commonwealth Fund Biennial Health Insurance Survey 2007 cited in Cathy Schoen, Sara R. Collins, Jennifer L. Kriss, and Michelle M. Doty How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007, Health Affairs Employer Benefits Survey-Kaiser.Offer Rates. P AIER estimates. See Methods. 23 CPS Table 8 accessed at /cps/cpsaat08.pdf. 20 American Institute for Economic Research